700346981

240229

[MedRec]

  • 2024-01-28 ~ 2024-02-02 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Gastric cancer adenocarcinoma, with suspect left adrenal metastasis, stage IV, s/p FOLFOX
      • Chronic viral hepatitis B without delta-agent
      • xerotic dermatitis with lichen simplex cohronicus
      • suspect lichen amyloidosis
    • CC
      • for chemotherapy with C1D1 FOLFOX Q2W.
    • Present illness
      • This is a 75 year-old man who has the history of hypertension for 7 years without medication control.
      • According to the statement of the patient’s families record. He suffered from epigastric fullness, general maliaise, and hemopty for two days, so he came to GI OPD at Cardinal Tien Hospital on 2023-08. The endoscopic was done on 2023/08/22, the report showed: Gastroesophageal reflux disease, Rule Out cancer of stomach hight body ulcer in tumor. The stomach biopasy (2023/08/24) revealed Adenocarcinoma, Immunostains: CK(+) for stromal invasion p53: (-) mCEA: (+) CDX-2: (+) Her-2: Negative (1+, Incomplete membrane staining > 10%), Mucin: Few cells (+) Giemsa stain: (-) for Helicobacter Pylori PAS: (-) for neoplastic cells infiltration). He denide have the body weight loss, fever, weakness.
      • He came to our Hema OPD for cancer evaluation due to personal reason. The port-a catheter was insertion on 2024/01/25. Anti-HBc: reactive on 2024/01/29, s/p Vemlidy.
      • This time, he is admitted for C1D1 chemotherapy with FOLFOX on 2024/01/28.
    • Course of inpatient treatment
      • After be admitted, he suffered from cough with white sputum noted, so gave antitussive treatment. Then, he complaints skin rash, itchy, and skin tag at abdomen, back, limbs for 2-3 months, and the symptom not become better, so consulted dermatology, and suggested Biomycin onit for wound lesions.
      • Clobestol onit for itchy papules.
      • Sinphraderm cream mix-up with CB.
      • Orolisin 1# tid po for pruritus control.
      • Consideer further NB-UVB at Dermatology OPD after patient discharge.
      • After treatment, the symptom improved, so he received C1D1 chemotherapy with FOLFOX on 2024/01/31-02/02, hydration, Vemlidy for Anti-HBC: reactive, Imperan for vomiting.
      • After chemotherapy, he denide having a fever, vomiting, diarrhea, or any complaints. He can be discharged on 2024/02/02, the OPD follow-up will be arranged.
    • Discharge prescription
      • Cough Mixture (platycodon) 5mL TID
      • Actein (acetylcysteine 200mg) 1# TID
      • Norvasc (amlodipine 5mg) 1# QD
      • Orolisin (chlorpheniramine maleate 5mg, orotic acid 30mg, glycyrrhizic acid 50mg) 1# TID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD

[consultation]

  • 2024-02-27 Orthopedics
    • Q
      • for suspect degenerative arthritis.
      • He suffered from right knee pain and swelling for 2-3 days, then the symptom become worse, so we need your help, thanks a lot!!
    • A
      • This is a case r/o OA knee, please check knee standing x-ray first and i will check osteoarthritis stage and discuss treatment and education to Paitnet, Thanks alot.
  • 2024-01-30 Dermatology
    • Q
      • He suffered from skin rash, itchy, and skin tag at abdomen, back, limbs for 2-3 months, and the symptom become worse, so we need your help, thanks a lot!!
    • A
      • The patient had sufferred from diffuse verrucous leisons with lichenificaiton over expose area.
      • Under the impression of xerotic dermatitis with lichen simplex cohronicus r/o lcihen amyloidosis.
      • The following sugeetion:
        • for wound lesions, biomycin onit 1 tube topical bid use first.
        • for itchy papules, Clobestol onit 3 tube otpical bid use.
        • for dry scaling lesions, SInphraderm cream 1 tube mix-up with CB. Strong 4 tube topical bid use.
        • Orolisin 1# tid po for pruritus control.
        • consideer further NB-UVB at Dermatology OPD after patient discharge.
  • 2023-12-24 Ophthalmology
    • Q: right eye pain for 3 days
      • Chief Complaint: FBS OD for 3 days
      • denied BV, stinging pain, itchy, discharge(-)
      • stated that just came back from taitung, may contact with
      • dirty bed sheet
      • NKDA
      • Medication: antihypertensive
      • OPH hx: cata s/p OP OU 10+ yrs ago
      • Past history: HTN under meds control
      • Surgical history: BPH s/p TURP
      • Exposure (TOCC): nil
    • A
      • O
        • VAcNC od 20/30
        • IOP soft by digit
        • Pupil 3/3 +/+
        • No periorbital swelling
        • conj od upper tarsal injected and tender when palpate, inf tarsal cyst and multiple lithiasis os multiple non-protruded lithiasis
        • K clear ou peripheral thinning ou, dellen??, Pooling at thinning site, Staining negative
        • AC D/cl ou
        • PCIOL ou
      • A
        • Internal hordeolum od
      • P
        • Cravit 1gtt qid + tetracycline ointment 1qs bid od
        • inform the risk of infection progression, if increased pain/swelling, come back asap
        • opd f/u on W2

[chemotherapy]

  • 2024-02-27 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 450mg NS 250mL 2hr + fluorouracil 2800mg/m2 3190mg NS 500mL 46hr (70% FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2024-01-31 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (70% FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO

==========

2024-02-29

[reconciliation]

The FOLFOX regimen was initiated on 2024-01-31. A subsequent evaluation on 2024-02-27 revealed an elevated CA-199 level. This finding might suggest the possibility of disease in the distal stomach (closer to the small intestine).

  • 2024-02-27 CA-199 (NM) 85.264 U/ml
  • 2024-01-22 CA-199 20.66 U/mL

Additionally, the CRP level on 2024-02-27 was 15.5 mg/dL, while the PCT level was within normal limits. Elevated CRP can indicate various conditions, including inflammation, autoimmune disorders, tissue injury, or even certain cancers. Therefore, further monitoring or investigations may be prudent to elucidate the cause of the elevated CRP.

No medication discrepancies were found after review of HIS5 and PharmaCloud records.

700801871

240229

==========

2024-02-29

[reconciliation - potential medication discrepancy: refills not aligned with active list]

A potential medication discrepancy has been identified for this patient. While the patient has recently refilled a 28-day supply of lorazepam, escitalopram, and ginkgo biloba extract (ginkgoflavonglycosides) on 2024-02-26 according to the PharmaCloud database, these medications are not currently included in the active medication list. Please verify if these refilled medications are still deemed necessary and consider updating the active medication list accordingly.

700995209

240229

[exam findings]

  • 2024-01-24 SONO - neurology
    • Chronic parenchymal renal disease
    • Right renal stone
  • 2024-01-08 CXR
    • multifocal areas of GGOs in both lungs further in regression
  • 2024-01-02 CXR
    • multifocal areas of GGOs in both lungs in regression as compared with previous chest image
  • 2023-12-29 CT - chest
    • Indication
      • Other pneumonia, unspecified organism
      • Malignant neoplasm of unspecified site of left female breast
      • Fever, unspecified
      • suspected Pneumonia
    • Chest CT without IV contrast ehnancement shows:
      • Diffuse mosaic ground glass opacities scattered at both lungs is found.
      • S/p port-A placement with its tip at Superior vena cava
      • No evidence of bilateral pleural effusion.
      • Patent airway is found.
      • There is no evidence of mediastinal LAP
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Diffuse mosaic ground glass opacities scattered at both lungs is found. Pneumonia is considered.
  • 2023-12-29 CXR erect
    • Diffuse opacities over both lungs is found.
  • 2023-12-08 CXR erect
    • patchy consolidation and ground-glass opacities over RUL
    • recticular opacities over left lung and Rt midlung zone?
    • Surgical clips over the Lt lower chest
  • 2023-09-06 Patho - breast mastectomy with regional lymph nodes
    • PATHOLOGIC DIAGNOSIS
      • Breast, left, partial mastectomy — Mixed invasive carcinoma of no special type and mucinous carcinoma
      • Resection margin, breast, left, partial mastectomy — Free
      • Lymph node, axillary sentinel and axillary, left, axillary LN dissection — Metastatic carcinoma (1/4)
      • AJCC 8 th edition, Pathology stage: pT2N1(cM0); Anatomic stage IIB; Prognostic stage IB
    • MACROSCOPIC EXAMINATION
      • Breast Size: 7.3 x 4.2 x 2.4 cm and 2.5 x 2.0 x 1.5 cm (4’-6’ re-excision)
      • Skin Size: 5.8 x 1.2 cm
      • Nipple: Not included
      • Tumor Size: 2.5 x 2.0 x 1.5 cm
      • Resection Margin: Free
      • Lymph node: Axillary
      • Representative parts are taken for section and labeled: F2023-00398: FSA1= 12’ 3’, 6’ margins, FSA2= 9’ and deep margins, A1= skin, A2-A5= tumor, A6= non-tumor, FSB= sentinel LNs, FSC and C= 4’-6’ re-excision. S2023-17825: A1-A3= axillary lymph nodes
    • MICROSCOPIC EXAMINATION
      • Histology
        • Histologic type: Mixed invasive carcinoma of no special type (60%) and mucinous carcinoma (40%)
        • Size of invasive carcinoma: 2.5 x 2.0 x 1.5 cm
        • Histologic grade (Nottingham histologic score): Grade 2 (score= 6)
        • Skin involvement: Absent
        • Ductal carcinoma in situ: Present; Extensive DCIS: Negative
      • Margins: Negative, Closest margin: > 10 mm
        • 6” margin invovlved by carcinoma (frozen section specimen A), and free of carcinoma in “4’-6’ re-excision” (frozen section specimen C)
      • Nodal status: Metastatic carcinoma (1/4)
        • number of lymph node examined: 2 (sentinel), 2 (axillary)
        • number with macrometastases (>2mm): 1 (sentinel)
        • number with micrometastases (>0.2~2mm and/or >200 cells): 0
        • number with isolated tumor cells (<=0.2mm and <=200 cells): 0
      • Treatment Effect: No presurgical therapy received
      • Lymphovascular invasion: Present
      • Perineural invasion: Absent
    • IMMUNOHISTOCHEMICAL STUDY (S2023-16485)
      • ER (Ab): Positive (95%, strong intensity)
      • PR (Ab): Positive (2%, moderate intensity)
      • HER-2/Neu (Ab): Negative (score = 1+ in both mucinous carcinoma component and invasive carcinoma of no special type component) (F2023-00398A1)
      • Ki-67: 10%
      • E-cadherin: Positive (F2023-00398A1)
  • 2023-09-04 SONO - abdomen
    • mild fatty liver
    • fatty infiltration of pancreas
  • 2023-08-25 Tc-99m MDP bone scan
    • Mildly increased activity in the middle T-spines and L3-4 spines. Degenerative change may show this picture.
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2023-08-18 Patho - breast biopsy (no need margin)
    • Breast, left, core neddle biopsy — Mucinous carcinoma
    • The sections show a picture of mucinous carcinoma, composed of breast tissue with nests and cords of polygonal neoplastic cells with focal micropapillary pattern, floating in mucinous pools. Focal calcification is present.
    • IHC shows following features:
      • ER (Ab): Positive (95%, strong intensity)
      • PR (Ab): Positive (2%, moderate intensity)
      • HER-2/Neu (Ab): Negative (score = 0)
      • Ki-67: 10%
  • 2023-08-18 SONO - breast
    • Left breast 4’ region tumor, suggest biopsy.
    • BI-RADS: Category 4b: suspicious abnormality-biopsy should be considered.
  • 2023-08-18 Mammography
    • Digital mammography of both breasts with MLO and CC views:
    • Old mammographic study: 2015-12-30 (BIRADS 1)
      • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
      • Focal asymmetry in LOQ of left breast, suggest sonographic correlation.
      • No obvious architectural distortion.
      • No periareolar skin thickening.
      • Non-specific bilateral axillary lymph nodes.
    • Impression:
      • Dense breast. Focal asymmetry in LOQ of left breast, suggest sonographic correlation.
    • BI-RADS: Category 0 (incomplete. Need additional imaging evaluation.)

[MedRec]

  • 2023-12-29 ~ 2024-01-08 POMR Chest Medicine Wu YaoGuang
    • Discharge diagnosis
      • Bilateral pneumonia, sputum culture pending
      • Interstitial pulmonary disease, unspecified
      • Left breast invasive carcinoma with axillary lymph nodes metastasis. pT2N1M0, stage IIB. ER (95%), PR (5%), Ki67 10%, ECOG 0.
    • CC
      • dyspnea for two days
    • Present illness
      • This is a 55 years old female patient with past history of Left breast invasive carcinoma with axillary lymph nodes metastasis. pT2N1M0, stage IIB. ER (95%), PR (5%), Ki67 10%, ECOG 0.
      • She denied other systemic diseases including DM, HTN,or heart disease. HBV was noted since 2023/08. She denied any drug use recently.
      • She suferred from dyspnea for two days accompanied with productive cough. Fever up to 38.9’C was noted. No rhinorrhea or sorethroat. Due to above symptoms, she came to our ER for help.
      • At ER, the temperature was 40’C, pulse beats 150 per minute, blood pressure 140/79 mmHg, respiratory rate 18 breaths per minute, and the oxygen saturation 91%, consciousness was E4V5M6.
      • The laboratory data showed leukocytosis (12290/ul) with bandemia and elevated CRP level (28.9mg/dl).
      • Chest CT revealed diffuse mosaic ground glass opacities scattered at both lungs is found. Pneumonia is considered.
      • Under the impression of pneumonia, she was admitted for further evaluation and management.
    • Course of inpatient treatment
      • After admission, antibiotics with brosym, her underlying medication or other symptomatic drugs were kept using.
      • She developed fever on 2024/01/03 and the fever last two days to 01/04.
      • We checked two set of blood cultures and check sputum culture. We also prescribed Targocid for infection control.
      • We also checked Aspergillus serum antigen on 01/04 and the result showed negative.
      • Recent lab data results of autoimmune related all showed no abnormalities.
      • Pathogen like HSV, mycoplasma IgM showed negatuve results. We titrated Codeine use from TID to Q6H due to her more frequent cough on 2024/01/03 night.
      • We also Swicth Hydrocortisone to oral Compesolon due to his improving chest CXR on 01/02 compared with last film on 2023/12/29.
      • Lab datas and chest CXR followed on 2024/01/08 showed improving,acceptable results.
      • Her O2 saturation were stable during this hospitalization.
      • Due to her much improving clinical condtions, improving lab datas and CXR, she was allowed discharge today.
    • Discharge prescription
      • Actein Effervescent (acetylcysteine 600mg) 1# BID
      • Pariet (rabeprazole 20mg) 1# QDAC
      • Compesolon (prednisolone 5mg) 1# BID
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
  • 2023-12-29 SOAP Medical Emergency
    • S: Self-reported fever, upper respiratory tract symptoms, and shortness of breath for 2 days, denied TOCC
      • fever was noted for 2 days
      • cough with sputums
      • Hx of Lt breast ca (mucinous ca) proved by CNB on 2023-08-18
      • Lt breast ca s/p partial mastectomy+ALND on 2023-09-05
      • adjuvant C/T with E(Lipodox) C -> T since on 2023-09-19
    • O: Vital signs: BP 140/79; HR: 150; BT 40’C; RR 18;
      • Con’s: E4V5M6
      • SpO2: 91%
      • General appearance: not in distress
      • Conj: not pale
      • Sclera: not icteric
      • BS: clear and bil. symmetrical breathing sound, no tender over chest wall, no obvious skin rash
      • Heart: RHB, no JVE
      • Abdomen: soft and oviod, no obvioius tenderness, no muscle guarding,
      • Extremities: freely movable,
    • Preliminary Impression
      • J18.8 Other pneumonia, unspecified organism
      • PN, bil, fever, SOB, Hx Lt breast Ca s/p op, C/T, WBC 12.3K, CRP 29, U/A(-), COVID, Flu(-), Brosym, OA CM
    • Prescription
      • Acetal (acetaminophen 500mg) 1# ST
      • Brosym (cefoperazone, sulbactam) 4g ST IVD
      • Brosym (cefoperazone, sulbactam) 4g Q12H IVD
      • NS 500mL ST IVD
      • Lyacety (lysine acetylsalicylate) 500mg ST IVD

[consultation]

  • 2024-01-17 Nephrology
    • Q
      • poor renal function
      • This is a 55 years old female patient. She denied any underlying systemic diseases including DM, HTN or heart disease. HBV was noted since 2023/08. She denied any drug use recently.
      • Under the impression of left breast invasive carcinoma with axillary lymph nodes metastasis. She was admission for 6th adjuvant chemotherapy with nab Taxol.
      • She just discharged from chest ward due to ILD. However, BUN:27mg/dl, Cr:1.62 mg/dl, eGFR: 35.06ml/min were noted on 2023/01/17. We need your help for renal function assessment. Thank you so much!!
    • A
      • This 55 y/o female was admitted to GS ward due to left breast invasive carcinoma with axillary lymph nodes metastasis for 6th adjuvant chemotherapy.
      • Hx: DM, HTN or heart disease. HBV was noted since 2023/08.
      • BW 53.8 kg
      • Lab
        • 2024-01-17 BUN 27 mg/dL
        • 2024-01-17 Creatinine 1.62 mg/dL
        • 2024-01-17 eGFR 35.06 ml/min/1.73m^2
        • 2024-01-17 Alkaline phosphatase 131 U/L
        • 2024-01-17 K (Potassium) 4.4 mmol/L
        • 2024-01-17 Na (Sodium) 139 mmol/L
        • 2024-01-17 WBC 12.97 x10^3/uL
        • 2024-01-17 HGB 11.7 g/dL
      • Urinalysis ??
      • Renal echo ??
      • Medication history:
        • Chemo: Nab-paclitaxel, pending 6th course
      • Consciousness: E4V5M6
      • Previously admitted to CM due to aspergillosis
      • Baseline renal function was normal
      • Impression: Pre-renal AKI may due to dehydration
      • Recommendation:
        • Please titrate fluid supplement (e.g. N/S, D5W) slightly more than maintainence dosage (> 25-30 ml/kg/Day), that is at least around 1500 mL/day, or divided separately via mouth and IV, avoid dehydration especially in the scenario of active cancer under chemotherapy susceptible to infection
        • Please record U/O on a daily basis, and check body weight BIW or TIW if necessary
        • Please obtain URINALYSIS and LIPID profile given lipemia
        • Regular f/u BUN/CRE, electrolyte, VBG, CXR
        • Arrange renal echo to r/o post-renal factor
        • Please feel free to contact us if any inquiries.
        • Thanks for consultation.
  • 2023-09-18 Gastroenterology
    • Q
      • This is a 55 years old woman patient. Due to left breast cancer, she was admitted for chemotherapy. However, Anti-HBc and Anti-HBs positive. We need your help for medicine. Thank you so much!
      • First adjuvant chemotherapy on 2023/09/20
      • MBD on 2023/09/20
      • arrange OPD on 2023/09/27
    • A
      • 55 years old female with breast cancer and admitted for chemotherapy. For anti-HBc(+), we are consulted.
      • Lab
        • 2023-09-18 S-GPT/ALT 17 U/L
        • 2023-09-18 S-GOT/AST 16 U/L
        • 2023-09-18 Bilirubin total 0.26 mg/dL
        • 2023-09-12 Anti-HCV (NM) Negative
        • 2023-09-12 Anti-HBs (NM) Positive
        • 2023-09-12 HBsAg (NM) Negative
        • 2023-09-04 Alkaline phosphatase 121 U/L
        • 2023-09-04 Albumin 4.0 g/dL
      • impression
        • Resolved HBV infection
        • Left breast cancer, plan for chemotherapy
      • suggestion
        • The prophylactive antiviral treatment of HBV is indicated during the chemotherapy
        • Arrange abdominal sonography and check HBV DNA
        • GI OPD follow-up is indicated
        • We would prescribe the antiviral agent when the chemotherapy is to be launched
  • 2023-09-04 Rehabilitation
    • A
      • Rehabilitation programs: arrange bedside PT rehabilitation (passive ROM, massage, therapeutic exercise) and home program education.
      • Goal: Functional ability ID, maintain ROM, prevent post-OP complications

[surgical operation]

  • 2023-09-05
    • Surgery
      • Partial mastectomy + axillary lymphnode dissection        
    • Finding
      • a 2.5x2x1.5 cm slight firm mass in lt breast
      • SLN 1/2 (+) 

[chemotherapy]

  • 2024-02-29 - nab-paclitaxel 260mg/m2 390mg 30min (Abraxane)
    • diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2024-02-07 - nab-paclitaxel 260mg/m2 390mg 30min (Abraxane)
    • diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2024-01-17 - nab-paclitaxel 260mg/m2 390mg 30min (Abraxane)
    • diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-12-14 - docetaxel 75mg/m2 110mg NS 250mL 1hr (D Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-11-22 - cyclophosphamide 600mg/m2 885mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr (AC(Lipo) Q3W)
    • Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2023-11-01 - cyclophosphamide 600mg/m2 870mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr (AC(Lipo) Q3W)
    • Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2023-10-11 - cyclophosphamide 600mg/m2 860mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr (AC(Lipo) Q3W)
    • Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2023-09-20 - cyclophosphamide 600mg/m2 835mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr (AC(Lipo) Q3W)
    • Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + betamethasone 8mg + diphenhydramine 30mg + NS 250mL

700999655

240229

[exam findings]

  • 2024-02-21 Patho - breast simple/partial mastectomy
    • PATHOLOGIC DIAGNOSIS
      • Breast tumor, left, simple mastectomy (s/p neoadjuvant C/T) —- Residual ductal carcinoma in situ, high grade
      • Resection margins, ditto — Free of tumor invasion
      • Sentinel lymph nodes, L’t axillary, frozen section — Free of tumor metastasis (0/3)
      • Nipple and skin, left breast — Free of tumor invasion
      • AJCC Pathologic Anatomic Stage — ypTisN0, if cM0, stage 0; Prognostic Stage — Stage 0
    • MACROSCOPIC EXAMINATION
      • Breast: 20 x 15 x 5.3 cm
      • Skin: 19.5 x 5.1 cm, no ulcer
      • Nipple: 1.3 x 0.9 cm, retracted
      • Tumor: 1.1 x 0.7 cm
      • Resection Margins: free
      • Lymph node: left axillar sentinel lymph nodes for frozen (F2024-00060)
      • Representatively embedded for sections as A1: unlabelled four peripheral margins, A2: lesion 1, A3-A5: lesion 2, A6-A7: lesion 3, A8: lesion 4, A9: lesion 5, A10: lesion 6, A11: lesion 7 and A12-A16: nipple + skin + breast tissue and X1-X20: breast tissue [Reference: F2024-00060 FSA1 and FSA2: L’t axillary SLNs]
    • MICROSCOPIC EXAMINATION
      • Histologic type: residual ductal carcinoma in situ with central necrosis
      • Histologic grade: grade 3, high grade
      • Margins: free of tumor invasion
      • Nodal status: free of tumor metastasis (0/3)
      • Treatment Effect:
        • In the Breast: no residual invasive carcinoma is present in the breast after presurgical therapy
        • In the Lymph nodes: no lymph node metastases and no prominent fibrous scar
      • Lymphovascular invasion: absent
      • Perineural invasion: absent
      • Non-tumor breast: fibrocystic change with adenosis, microcalcification, usual ductal hyperplasia, intraductal papillomas, fibroadenomas and sclerosing adenosis
    • IMMUNOHISTOCHEMISTRY
      • For DCIS (S2024-03260X17): P63 shows preserved outer myoepithelial cell
      • For UDH (S2024-03260A8): CK5/6 and P63 show positive for myoepithelial cell
  • 2024-02-16 MRI - breast
    • Clinical history: 61 y/o female patient with Rt breast microcalcification s/p needle localization excision on 2013-04-16, pathology showed DCIS with positive margin.
      • Rt breast DCIS s/p simple mastectomy on 2013-05-07
      • Lt breast mass noted for days on 2023-08-09
      • Lt breast ca proved by CNB on 2023-08-11
      • NEOADJUVANT C/T WITH EC -> THP SINCE 2023-08-22
      • Changed to VNB + H + P since 6th C/T due to ILD.
    • With and without enhancement MRI of breast (axial T1, T1FS, sagittal T2, T2FS, axial and sagittal T1FS contrast, dynamic study):
      • S/P right mastectomy.
      • Regression of left breast malignancy.
      • No periareolar skin thickening.
      • Small right axillary lymph nodes.
    • Impression:
      • S/P right mastectomy.
      • Left breat malignancy with axillary lymph node s/p neoadjuvant, moderate regression.
    • BI-RADS: Category 6 - proven malignancy.
  • 2023-11-26 CT - abdomen
    • Findings
      • S/P right breast operation.
      • Mild small bowel ileus.
      • A lipoma (2.0cm) at left thigh.
      • Retroversion of uterus.
      • Grade 4 fatty liver.
      • Atherosclerosis of aorta, iliac arteries.
      • Compression fracture of L1.
    • IMP:
      • S/P right breast operation.
      • Mild small bowel ileus.
  • 2023-08-23 MRI - breast
    • Clinical history: 60 y/o female patient with left breast cancer
    • With and without enhancement MRI of breast:
      • S/P right mastectomy.
      • There is large irregular tumor, 6.5cm in left breast, with prominent enhancement, c/w malignancy.
      • Presence of left periareolar skin thickening.
      • Enlarged left axillary and internal mammary lymph nodes, could be due to metastatic lymph nodes.
    • Impression:
      • S/P right mastectomy.
      • Left breast malignancy with axillary and internal mammary lymph nodes metastasis.
    • BI-RADS: Category 6: proven malignancy.
  • 2023-08-22 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (100 - 28) / 100 = 77.00%
      • M-mode (Teichholz) = 72
    • Conclusion:
      • Indeterminated LV filling pressure; severely dilated LA.
      • Normal LV and RV systolic function.
      • Trivial MR.
      • Prominent epicardial fat.
  • 2023-08-21 PET
    • Glucose hypermetablic lesions in the left breast, left axilla, and bilateral SCF lymph nodes, compatible with left breast cancer with regional lymph nodes metastases.
    • Glucose hypermetablic lesions in bilateral lower neck and bilateral mediastinal lymph nodes, T6 spine and left humeral shaft, highly suspected breast cancer with distant metastases.
    • Increased FDG uptake in the right lobe of the thyroid gland, highly suspected the other primary malignancy, suggesting biopsy, if necessary, for further evaluation.
    • Left breast cancer, cTxN3cM1, stage IV (AJCC 8th ed.); highly suspected the other primary thyroid cancer in the right lobe, by this F-18 FDG PET scan.
  • 2023-08-11 Patho - lymphnode biopsy
    • Lymph node axillary, left, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (-, 0%), PR (-, 0%), Her2/neu: positive (score = 3+), Ki-67 (40%), E-cadherin (+).
    • Section shows fragments of lymph node tissue with irregular neoplastic ducts infiltration.
  • 2023-08-11 Patho - breast biopsy
    • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (-, 0%), PR (-, 0%), Her2/neu: positive (score = 3+), Ki-67 (80%), E-cadherin (+).
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • 2023-08-11 Mammography
    • Dense breast.
    • S/P right mastectomy.
    • Left breast plemorphic microcalcifications with enlarged left axillary lymph nodes, r/o malignancy.
    • BI-RADS: Category 5: highly suggestive of malignancy-appropriate action should be taken.
  • 2023-08-10 Tc-99m MDP bone scan
    • Increased activity in some L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, elbows, wrists, hips, knees and feet, compatible with benign joint lesions.
  • 2019-04-23 SONO - abdomen
    • Mild fatty liver
    • A hepatic hemangioma measuring 1.08 cm in S8 is noted.

[MedRec]

  • 2023-11-26 ~ 2023-12-06 POMR Integrative Medicine Rao LunYu
    • Discharge diagnosis
      • Left breast invasive carcinoma with axillary lymph nodes, cT3N1M0, stage IIIA. IHC stains: ER (-, 0%), PR (-, 0%), Her2/neu: positive (score = 3+), Ki-67 (80%). ECOG: 0.
      • Acute respiratory failure with hypoxia
      • Pneumonia, unspecified organism
      • Urinary tract infection, urine culture:Escherichia coli
      • Agranulocytosis secondary to cancer chemotherapy
      • Interstitial pulmonary disease, suspect Taxotere related
      • Type 2 diabetes mellitus
      • Hypertension
      • Carrier of viral hepatitis B
    • CC
      • fever up to 39.5 degree since this today
    • Present illness
      • This is a 61-year-old male/female with past history of (1) Left breast invasive carcinoma with multiple lymph nodes metatstais, cT3N3cM1, stage IV, under neoadjuvant chemotherapy (2) HBV (3) DM (4) HTN .
      • This time, according to patient statement, she was suffered from fever up to 39.5 degree since this today. Diarrhea was her chronic problem after chemotherapy.
      • She denied URI symptoms(-), dyspnea(-), decrease urine output(-).
      • Due to the symptom, she went to our ER for help. In ER, her vital sign was showed BP:140/71 mmHg, HR: 108bpm, BT:39.5’C, RR:18/min, conscious E4V5M6, and SpO2:98% under room air. Physical examination showed bilateral clear breathing sound and no abdominal tenderness, no CV angle knocking pain(-). Laboratory data revealed leukopenia, hypokelamia, hyponatremia and elevated CRP level. The urinalysis showed pyuria and bacteriuria. Under the impression of neutropenic fever, chemotherapy related, she was admitted for further management. 
    • Course of inpatient treatment
      • After admission, empiric antibiotics with Tapimycin was administered on 2023/11/26-28 due to neutropenic fever, add Targocid on 11/27-12/06.
      • However, desaturation was noted on 11/30 night and followed the chest film disclosed suspect interstitial lung disease.
      • We add the Dexamethasone on 11/30-12/06 and shifted the antibiotics to Mepem on 11/30-12/06 for suspect interstitial lung disease, blood culture no growth.
      • Add Baktar 2 tab Q12H for PJP prevention.
      • Patient become better after the medication treatment. With the relatively stable condition,she was discharged on 2023/12/06 and will OPD follow up
    • Discharge prescription
      • loperamide 2mg 2# PRNQ8H if watery diarrhea
      • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
      • Ulstop (famotidine 20mg) 1# BID
      • ZCough (benzonatate 100mg) 1# TID
      • Morcasin (sulfamethoxazole 400mg, trimethoprim 80mg) 2# Q12H
      • Ceficin (cefixime 100mg) 2# Q12H
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Limeson (dexamethasone 4mg) 1# BID
  • 2023-08-21 ~ 2023-08-23 POMR General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Left breast invasive carcinoma with axillary lymph nodes status post port A insertion on 2023/08/22. cT3N1M0, stage IIIA.ECOG:0.
      • Encounter for antineoplastic chemotherapy
      • Intraductal carcinoma in situ of right breast status post simple mastectomy on 2013/05/07
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
      • Carrier of viral hepatitis B
    • CC
      • noted a palpable mass at left breast on 2023/08/09.
    • Present illness
      • This 61-year-old female patient has past history of hypertension over 10 years with regular medicine control. DM over 5 years with regular medicine control. HBV was noted on 2023/08. Right breast DCIS status post simple mastectomy on 2013/05/07. She denied any TOCC histories in recent 3 months.
      • She noted a palpable mass at left breast on 2023/08/09. She came to our OPD for help. Breast sono showed a lesion, Left 10/0.62 cm , size: 3.76x1.4 cm, r/o malignancy with left axillary lymph nodes metastasis suggest biopsy. Left breast and axillary lymph nodes core needle biopsy revealed invasive carcinoma, ER (-, 0%), PR(-, 0%), Her2/neu positive (score= 3+), Ki-67(80 %), CA-153 10.768 U/ml, CEA 2.393 ng/ml.
      • Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis. She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss. PE: symmetrical of bilateral breasts. A hard, nontender, movable mass and irregular margin at left breast around 9x9 cm without discharge. The nipple was dimping without exudative nor bloody discharge and no retraction. The left breast skin had no cellulitis change.
      • SDM for this patient in OPD. Neo-adjuvant chemotherapy was her choose. Lipo dox 35mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 + Herceptin 600mg SC + Perjeta 420mg for 4 cycles was plan.
      • Under the impression of left breast invasive carcinoma with axillary lymph nodes metastasis, she was admitted for surgery of port A insertion. Arrange 1st neoadjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 on 2023/08/23. 
    • Course of inpatient treatment
      • After admission, port A insertion was performed on 2023/08/22. 1st neo-adjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 were given. The wound is clean and dry. No discomfort after chemotherapy.
      • Under the stable condition, she was discharged today, wound will be follow up on 2023/08/30. And arrange next admission three weeks later.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Emend (aprepitant 125mg) 1# QD on 8/24, 8/25
      • Promeran (metoclopramide 3.84mg) 1# TIDAC on 8/26, 8/27, 8/28
      • loperamide 2mg 2# PRNQ8H if watery stool > 2 per day

[surgical operation]

  • 2024-02-20
    • Surgery
      • left breast simple mastectomy and sentinel lymph node biopsy
    • Finding
      • lef breast tumor 1.5cm, 10”/1.5cm
      • left axillary sentinel lymph nodes biopsy: 3, all negative

[chemotherapy]

  • 2024-02-19 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr
  • 2024-01-29 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + vinorelbine 30mg/kg 45mg NS 50mL 10min
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2024-01-08 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + vinorelbine 30mg/kg 45mg NS 50mL 10min
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-12-18 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + vinorelbine 30mg/kg 40mg NS 50mL 10min
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-11-16 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 60min + docetaxel 75mg/m2 113mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-10-25 - cyclophosphamide 600mg/m2 910mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 53mg D5W 250mL 2hr (AC(Lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-10-04 - cyclophosphamide 600mg/m2 905mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 53mg D5W 250mL 2hr (AC(Lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-09-13 - cyclophosphamide 600mg/m2 908mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 53mg D5W 250mL 2hr (AC(Lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-08-22 - cyclophosphamide 600mg/m2 919mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr (AC(Lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

701269031

240229

      

[allergy]

  • NKDA         

[Family History]

  • Father had DM
  • She denied cancer history in her family

[lab data]

  • 2023-01-11 Anti-HBc Nonreactive
  • 2023-01-11 Anti-HBc-Value 0.13 S/CO
  • 2023-01-11 Anti-HBs 3.73 mIU/mL
  • 2023-01-11 HBsAg Nonreactive
  • 2023-01-11 HBsAg (Value) 0.39 S/CO
  • 2023-01-11 Anti-HCV Nonreactive
  • 2023-01-11 Anti-HCV Value 0.08 S/CO

[exam findings]

  • 2024-02-17 CT - abdomen
    • Indication: Bilateral high grade serous ovarian carcinoma, cT3N1bM1, stage IV s/p bilateral oophorectomy, hysterectomy and chemotherapy, recurrent with peritoneal seeding s/p chemotherapy with Taxol/Carboplatin 2023/2/10, 3/3, 3/25, 4/18, progression (2023-05-03 CT: multiple metastatic nodes in the mediastinum and abdominal para-aortic space and para-cava space show progressive disease.) s/p lipodox + carboplatin 2023/5/9, 5/30, 6/27, 7/25, HER-2 negative (1+), s/p Enhertu 2023/8/22, 9/12, 10/3, 10/31, 11/21, 12/12
    • With and without contrast enhancement CT of abdomen shows:
      • s/p hystero-oophorectomy .
      • Progression of lymph nodes in left laxillary, mediastinal, and para-aortic regions.
      • A mass lesion with heterogeneous enhancement, 2.2cm, in S8 of liver.
    • Impression
      • Ovarian carcinoma, s/p operation
      • Metastatic lymph nodes, in progression
      • Liver metastasis
  • 2024-02-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (76 - 24) / 76 = 68.42%
      • M-mode (Teichholz) = 69
    • Conclusion:
      • Normal LV filling pressure.
      • Normal LV and RV systolic function.
      • Trivial MR; trivial TR.
  • 2023-11-07 CT - abdomen
    • S/P hysterectomy.
    • GB stones.
    • Regression size of metastatic lymph nodes in paraaortic, mediastinum and left axillary regions.
  • 2023-08-17 - abdomen
    • S/P hysterectomy.
    • Some LNs (up to 2.8cm, progression) at mediastinum, left axillary region and retroperitoneum.
    • Right thyroid nodule (8mm).
  • 2023-08-17 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 24) / 93 = 74.19%
      • M-mode (Teichholz) = 74.1
    • Conclusion:
      • Adequate LV, RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Trivial MR
  • 2023-07-26 Her-2/neu DISH
    • RESULT OF HER2/NEU IN SITU HYBRIDIZATION
      • There is NO amplification of HER2 gene is detected
    • METHOD AND DETAILS:
      • Number of observers: 1
      • Number of invasive tumor cells counted: 20
      • Average number of HER2 gene copy signal per cell: 1.9
      • Average number of CEP17 gene copy signal per cell: 1.9
      • HER2/CEP17 ratio: 1
      • Heterogeneous signals: Absent
      • Origin slide and block number:S2023-14060
      • Specimen: Formalin-fixed paraffin embedded metastatic ovary serous carcinoma
      • Adequacy of sample for evaluation: Yes
      • Method of in situ hydridization: CISH (Ventana HER2 dual ISH DNA probe cocktail assay, Roche compancy)
    • INTERPRETATION CRITERIA (ASCO/CAP scoring criteria 2018)
      • Amplified:
        • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number >=4.0
        • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=6.0 signals/cell
      • Not amplified:
        • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number <4.0
        • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=4.0 and <6.0 signals/cell
        • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number <4.0
  • 2023-07-17 Patho - lymphnode biopsy
    • Lymph node, left axillary, sono-guide biopsy — Compatible with metastatic ovarian serous carcinoma
    • Microscopically, the sections show a picture of metastatic adenocarcinoma characterized by tumor cells arranged in cribriform pattern infiltrating in parenchyma.
    • Immunohistochemistry of PAX-8(+), CK7(+, scatter), CK20(-), WT-1(+) and P53(scant +, aberrant expression), compatible with metastatic ovarian serous carcinoma.
    • 2023-07-28 Immunohistochemistry of Her-2/neu show negative, Dako score 1+
  • 2023-05-10 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (64 - 14) / 64 = 78.13%
      • M-mode (Teichholz) = 79
    • Conclusion:
      • Normal LV filling pressure.
      • Normal LV and RV systolic function.
      • Degenerative changes of mitral valve with trivial mitral regurgitation; trivial tricuspid regurgitation; mild pulmonary regurgitation.
  • 2023-05-03 CT - abdomen
    • Findings:
      • There is a newly developed soft tissue mass in mediastinum para-aortic space, measuring 1.9 x 1.1 cm (Srs:302 Img:24).
        • Metastasis is suspected.
      • Prior CT identified multiple metastatic nodes in abdominal para-aortic space and para-cava space are noted again, increasing in size (Srs:302 Img:61-68).
      • Prior CT identified soft tissue lesions in right anterior subphrenic space is noted again, mild increasing in size (Srs:302 Img:55) that may be tumor seeding.
      • Prior CT identified a poor enhancing lesion 0.7 cm in S4/8 of the liver dome is noted again, stationary but poor margination.
      • Prior CT identified soft tissue lesions in bilateral cardiac-phrenic angle (Srs:302 Img:53,55) are noted again, mild increasing in size.
      • Soft tissue mass-like lesions in bilateral adnexa (Srs:302 Img:110) are suspected that may be tumor recurrence.
        • The differential diagnosis includes post-operative change.
        • Please correlate with GYN. sonography or MRI.
      • S/P hysterectomy and oophorectomy.
      • Presence of gallbladder stone.
    • Impression:
      • Multiple metastatic nodes in the mediastinum and abdominal para-aortic space and para-cava space show progressive disease.
  • 2023-02-09 Hearing Test
    • Reliabilty Fair
    • PTA
      • R’t : 16 dB HL
      • L’t : 15 dB HL
      • Bil WNL except 8k Hz.
  • 2023-01-20 MRI - brain
    • Indication: Ovarian cancer s/p OP and chemotherapy, with recurrence over peritoneum seeding
    • IMP: No evidence of intracranial lesion.
  • 2023-01-19 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the nasal bone, L3-4 spines, bilateral shoulders, left elbow and bilateral hips in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the L3-4 spines. Degenerative change may show this picture.
      • Increased activity in the nasal bone. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, left elbow and bilateral hips, compatible with benign joint lesions.
  • 2023-01-18 PET scan
    • There was increased FDG uptake in the surface of the right lobe of liver (SUVmax early: 7.24, delay: 7.37), in the surface or sub-diaphragm of the left lobe of liver (SUVmax early: 10.73, delay: 11.82), celiac lymph nodes (SUVmax early: 5.60, delay: 7.06), left para-aortic space lymph nodes (SUVmax early: 10.31, delay: 11.92), lymph nodes in the LLQ (SUVmax early: 11.90, delay: 12.74) and RLQ (SUVmax early: 10.59, delay: 11.47) of abdomen, and spleen (SUVmax early: 4.63, delay: 4.89). In addition, increased FDG uptake was also noted in several left mediastinal lymph nodes (SUVmax early: 7.27, delay: 6.51), and bilateral pulmonary hilar lymph nodes (SUVmax early: 3.74, delay: 6.05).
    • IMPRESSION:
      • Glucose hypermetabolism lesions in n the surface of the right lobe of liver, in the surface or sub-diaphragm of the left lobe of liver, celiac lymph nodes, left para-aortic space lymph nodes, lymph nodes in the LLQ and RLQ of abdomen, and spleen, highly suspected recurrent tumor with peritoneal seeding, suggesting further investigation and follow-up.
      • Glucose hypermetabolism in the left mediastinal lymph nodes, the nature is to be determined (reactive or metastatic lymph nodes or other nature ?), suggesting further investigation.
      • Glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, probably reactive nodes.
      • Ovarian cancer s/p treatment with tumor recurrence and peritoneal seeding, rc-stage IVB, by this F-18 FDG PET scan.
  • 2023-01-17 CT - abdomen
    • S/P hysterectomy and oophorectomy.
    • GB stone.
    • Hypodense nodule, 0.68cm in the liver dome, suspected liver metastasis. DDx: subphirenic seeding.

[MedRec]

  • 2024-02-21 SOAP Hemato-Oncology Xia HeXiong
    • O:
      • s/p paclitaxel and carboplatin, C1D1 on 2023-02-10 to 2023-04-18, PD
        • AE: Stiffness of hand joint; Neutropenia Gr 3 -> Improved
      • s/p Lipo-Dox +/- Carboplatin, C1D1 on 2023-05-09 to 2024-07-25, PD
        • AE: Gr 1 Leukopenia.
      • s/p Enhertu, C1D1 on 2023-08-22 to 2024-01-23 best response PR
    • P
      • Thyroid function Q3M, next on 2024-03
      • Arrange CT Q3M, next on 2024-02-17
    • Prescription
      • Dulcolax (bisacodyl 5mg) 1# QN
      • Through (sennoside 12mg) 1# HS

[immunochemotherapy]

  • 2024-02-28 - topotecan 1.5mg/m2 2.1mg NS 70mL 30min D1-5
    • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-5
  • 2024-01-23 - trastuzumab deruxtecan 5.4mg/kg 250mg D5W 100mL 90min (Enhertu)
    • dexamethasone 8mg + palonosetron 250ug + NS 250mL + MgSO4 10% 20mL
  • 2024-01-02 - trastuzumab deruxtecan 5.4mg/kg 250mg D5W 100mL 90min (Enhertu)
    • dexamethasone 8mg + palonosetron 250ug + NS 250mL + MgSO4 10% 20mL
  • 2023-12-12 - trastuzumab deruxtecan 5.4mg/kg 250mg D5W 100mL 90min (Enhertu)
    • dexamethasone 8mg + palonosetron 250ug + NS 250mL
  • 2023-11-21 - trastuzumab deruxtecan 5.4mg/kg 250mg D5W 100mL 90min (Enhertu)
    • dexamethasone 8mg + palonosetron 250ug + NS 250mL
  • 2023-10-31 - trastuzumab deruxtecan 5.4mg/kg 250mg D5W 100mL 90min (Enhertu)
    • dexamethasone 8mg + palonosetron 250ug + NS 250mL
  • 2023-10-03 - trastuzumab deruxtecan 5.4mg/kg 250mg D5W 100mL 90min (Enhertu)
    • dexamethasone 8mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-12 - trastuzumab deruxtecan 5.4mg/kg 200mg D5W 100mL 90min (Enhertu)
    • dexamethasone 8mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-22 - trastuzumab deruxtecan 5.4mg/kg 200mg D5W 100mL 90min (Enhertu)
    • dexamethasone 8mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-25 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr + carboplatin AUC 4 540mg D5W 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-27 - liposome doxorubicin 40mg/m2 50mg D5W 250mL 1hr + carboplatin AUC 4 500mg D5W 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-30 - liposome doxorubicin 40mg/m2 50mg D5W 250mL 1hr + carboplatin AUC 4 500mg D5W 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-09 - liposome doxorubicin 50mg/m2 60mg D5W 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-18 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-03-25 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-03-02 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-02-10 - paclitaxel 140mg/m2 200mg NS 250mL 3hr + carboplatin AUC 4 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

Topotecan - 2024-02-29 - https://www.uptodate.com/contents/topotecan-drug-information

  • Ovarian cancer, metastatic: IV:
    • 1.5 mg/m2/day for 5 consecutive days every 21 days, continue until disease progression or unacceptable toxicity or
    • (off-label dosing) 1.25 mg/m2/day for 5 days every 21 days until disease progression or unacceptable toxicity or a maximum of 12 months or
    • (weekly administration; off-label dosing) 4 mg/m2 on days 1, 8, and 15 every 28 days until disease progression or unacceptable toxicity or a maximum of 12 months.

==========

2024-02-29

[disease progression after multiple regimens: Enhertu partial response & topotecan consideration]

The patient’s disease progressed after receiving paclitaxel and carboplatin, followed by liposomal doxorubicin and carboplatin. However, a partial response was observed with Enhertu (fam-trastuzumab deruxtecan-nxki. There was NO amplification of HER2 gene detected on 2023-07-26).

Enhertu is an antibody-drug conjugate (ADC) that delivers the topoisomerase I inhibitor payload deruxtecan (DXd). Topotecan, which is currently being used, is also a topoisomerase I inhibitor. Therefore, it is expected that there may still be a response, but with potentially higher adverse reactions.

Neutropenia was observed when Enhertu was previously administered, so close monitoring is recommended.

2023-03-03

  • Although most patients with high-grade serous carcinoma (HGSC) initially respond to platinum-based chemotherapy, the large majority of patients will relapse. ref: ESMO-ESGO consensus conference recommendations on ovarian cancer: pathology and molecular biology, early and advanced stages, borderline tumours and recurrent disease†. Ann Oncol. 2019;30(5):672-705. doi:10.1093/annonc/mdz062
    • There are no validated predictive markers of primary platinum refractory or resistant disease.
    • Defects in HR repair are associated with improved outcome/PFS following platinum-based chemotherapy.
    • The time elapsed since last platinum chemotherapy represents a continuum of probability of response to further chemotherapy.
  • In potentially platinum-responsive patients previously exposed to bevacizumab, platinum-based rechallenge followed by PARPi maintenance therapy is effective irrespective of BRCA mutation and HRD status. Olaparib, niraparib and rucaparib can also be considered for use as monotherapy in patients with recurrent disease who have received several previous lines of treatment. ref: How to sequence treatment in relapsed ovarian cancer. Future Oncol. 2021;17(3s):1-8. doi:10.2217/fon-2020-1122
    • The patient initiated a new series of cycles with paclitaxel and carboplatin from 2023-02-10.
  • According to the National Health Insurance drug reimbursement regulations, PARP inhibitors (olaparib, niraparib) can be used for maintenance therapy in patients with ovarian, tubal, or primary peritoneal cancer who meet all of the following conditions for up to two years:
    • Used after responding to first-line platinum-based chemotherapy.
    • Patients have germline or somatic BRCA1/2 pathogenic or suspected pathogenic mutations.
    • FIGO stage III or IV disease.
  • According to the National Health Insurance drug reimbursement regulations, patients with malignancies who have experienced leukopenia with a white blood cell count less than 1000/uL or neutrophil count (ANC) less than 500/uL after receiving chemotherapy, can use short-acting injection of granulocyte colony-stimulating factor (G-CSF) such as filgrastim or lenograstim.
    • It has been planned to administer Granocyte (lenograstim) once daily for 3 consecutive days, starting from 2023-03-03.

2023-03-02

  • The condition of leukopenia has been resolved after administering lenograstim for 3 consecutive days (2023-02-21 ~ 2023-02-23)
    • 2023-03-01 WBC 4.19 x10^3/uL
    • 2023-02-20 WBC 1.48 x10^3/uL

701480646

240229

[exam findings]

  • 2024-02-28 CXR
    • Ground glass opacities in bil. lungs.
    • Deviation of trachea.
    • Fracture of left clavicle.
  • 2024-02-28 KUB
    • A calcification at left sacral region.
    • Stool retention in the bowel.
    • Fracture of left 12th rib.
  • 2024-02-02 SONO - abdomen
    • Diagnosis
      • Suspected chronic liver parenchyma disease
      • Suspected GB stones
      • Mild CBD dilatation
      • Ileus, bilateral LLQ
      • Pancreas not shown
      • Suboptimal examination of liver,especially the subcostal view due to poor echo window(disruption of the transmission of US waves by bowel gas and patient’s body habitus)
    • Suggestion:
      • CT of abd was suggested for ileus workup
      • Please correlate with liver function test and follow AFP
      • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
      • Because of poor echo window,please follow sono abd 3-6 months later if clinical needs
  • 2024-01-31 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Left axis deviation
    • Low voltage QRS of precordial leads
    • Possible septal infarct, age undetermined
    • Abnormal ECG
  • 2024-01-15 CXR erect
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • The trachea shows right lateral deviation in thoracic inlet level that may be intrathoracic goiter. Please correlate with CT.
    • A nodular opacity projecting in the right upper lung is suspected. Please correlate with CT.
  • 2023-12-20 CT - abdomen
    • Findings:
      • Prior CT identified lobulated wall thickening of the gastric body and antrum with irregular contour is noted again, mild increasing in size that is c/w adenocarcinoma of the stomach with stable disease or progressive disease.
        • In addition, Prior CT identified four enlarged nodes in peri-gastric area are noted again, mild decreasing in size that are c/w metastatic nodes S/P C/T with partial response.
        • Prior CT identified multiple metastases on both hepatic lobes are noted again. Some of them show stable in size. Some of them show mild increasing in size.
        • Liver metastases S/P C/T with stable disease is highly suspected.
      • There is ascites and soft tissue lesions in the omentum. Carcinomatosis is highly suspected. Please correlate with ascites cytology.
      • There is a lobulated poor enhancing mass in the cul-de-sac with directly invasion the rectum, measuring 4.3 cm in size (Srs:301 Img:69) that is c/w tumor seeding (Krukenberg tumor).
      • The gallbladder shows stones and wall thickening at the fundus that may be adenocarcinoma. The differential diagnosis includes chronic cholecystitis and tumor seeding.
      • Prior CT identified a well-defined poor enhancing mass with suggestive fat component in left kidney, 2.7 x 2.1 cm in size, is noted again, mild increasing in size to 3 x 2.3 cm.
        • Renal cell carcinoma is highly suspected.
        • The differential diagnosis includes angiomyolipoma.
        • Follow up is indicated.
      • There are multiple osteopenic defects in the T-and L-spine, sacrum and bilateral ilium. Bony metastases are highly suspected.
        • Please correlate with bone scan.
      • S/P esophagectomy with colonic gastrostomy?
        • please correlate with clinical history.
    • Impression:
      • Adenocarcinoma of the stomach S/P C/T with stable disease or progressive disease is highly suspected. please correlate with clinical condition.
  • 2023-09-16 CT - abdomen
    • History and indication: Gastric cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P esophageal operation with reconstruction. Wall thickening of stomach.
      • Fat stranding at pelvic cavity.
      • Some LNs at upper abodmen.
      • Some poor enhancing nodules in liver.
      • Mild splenomegaly.
      • Atherosclerosis of aorta, iliac arteries.
      • Some GGO at bilateral lungs.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P operation. Gastric cancer with LNs and liver metastases.
      • Fat stranding at pelvic cavity.
  • 2023-05-02 Tc-99m MDP bone scan
    • Mildly inhomogenously increased activity in some T- and L-spines and sacrum and diffusely increased activity in bilateral iliac bones. The nature is to be determined. Please correlate with other imaging modalities and follow up bone scan to rule out the possibility of bone metastases.
    • Some hot spots in the skull. Please also follow up bone scan for further evaluation.
  • 2023-04-27 Patho - colon biopsy (Y1)
    • Colorectum, rectum, biopsy — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+), CK7 (-).
  • 2023-04-27 Patho - stomach biopsy (Y1)
    • Labeled as “anstomosis and saddle portion of subtotal gastrectomy”, biopsy (A) — Adenocarcinoma.
    • Section shows pieces of bland gastric type mucosa and neoiplastic intestinal type tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+), Her2/neu: Negative (score=0+).
  • 2023-04-27 Sigmoidoscopy
    • Finding
      • A large tumor with friable mucosa in upper rectum and RS colon, resulting in luminal stenosis and difficulty in manipulation of scope. The scope could not pass through the RS junction. Biopsy was taken at the tumor
    • Diagnosis:
      • Highly supsected colorectal malignancy, upper rectum and RS colon, s/p biopsy
      • Incomplete colonosocpy
    • Suggestion:
      • Pursue pathology result
      • Correlate with CT scan
    • Complication:
      • No immediate complication
  • 2023-04-27 EGD
    • Diagnosis:
      • Large gastrojejunal ulcer, r/o malignancy, s/p biopsy (A)
      • Ulcer on the colon mucosa (esophageal reconstruction) near the esophageal orifice, s/p biopsy (B)
      • Status of total esophagectomy and esophageal reconstruction with colon
      • Status post radical subtotal gastrectomy with BII anastomosis
    • Suggestion:
      • Suggest high-dose PPI therapy
      • Pursue pathology result
      • Correlate with CT scan
  • 2023-04-26 CT - abdomen
    • Indication:
      • CC: abdominal pain for 2 weeks. RLQ abdominal pain for 1 week and progressed last night
      • PI: RLQ abdominal cramping pain, especially after meal, mild epigastric dull pain, mild nausea, diarrhea
      • PH: esophageal surgery 40 years ago
    • Findings:
      • There is lobulated wall thickening of the gastric body and antrum with irregular contour, measuring 7 cm in size, that may be adenocarcinoma (T4a). Please correlate with gastroscopy.
        • In addition, there are four enlarged nodes in peri-gastric area that are c/w metastatic nodes (N2).
        • There are multiple poor enhancing masses on both hepatic lobes that are c/w liver metastases (M1). The largest one measuring 2.2 cm in S4.
      • There is ascites and soft tissue lesions in the omentum. Carcinomatosis is highly suspected. Please correlate with ascites cytology.
      • There is a lobulated poor enhancing mass in the cul-de-sac with directly invasion the rectum, measuring 4.3 cm in size (Srs:301 Img:69) that is c/w tumor seeding (Krukenberg tumor).
      • The gallbladder shows stones and wall thickening at the fundus that may be adenocarcinoma. The differential diagnosis includes chronic cholecystitis and tumor seeding.
      • There is a well-defined poor enhancing mass with suggestive fat component in left kidney, measuring 2.7 x 2.1 cm in size.
        • Renal cell carcinoma is highly suspected.
        • The differential diagnosis includes angiomyolipoma.
        • Please correlate with contrast enhanced dynamic CT.
      • There are multiple osteopenic defects in the T-and L-spine, sacrum and bilateral ilium. Bony metastases are highly suspected.
        • Please correlate with bone scan.
      • S/P esophagectomy with colonic gastrostomy?
        • please correlate with clinical history.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2(N_value) M:M1(M_value) STAGE:IVB(Stage_value)

[MedRec]

  • 2024-01-26 SOAP Hemato-Oncology Gao WeiYao
    • P: Start taxol weekly and plan to apply ramucirumab.
  • 2024-01-15 SOAP Hemato-Oncology Gao WeiYao
    • P: The last chemo folfox6 done in Nov 2023. Plan to switch to taxotere plus ramucirumab self-paid.
  • 2023-04-27 ~ 2023-05-19 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Adenocarcinoma of the gastric body and antrum, carcinomatosis and multiple bony metastases and colon metastases, cT4aN2M1, stageIVB
      • Other Gram-negative sepsis, blood culture yielded Acinetobacter ursingii
      • Iron deficiency anemia, unspecified
      • Microcytic anemia
    • CC
      • RLQ abdominal cramping pain, especially after meal for 2 weeks
    • Present illness
      • This 70 year old women has history of esophageal surgery 40 years ago, esophageal perforation s/p right half colectomy for esophageal reconstruction.
      • She presented to our hospital with RLQ abdominal cramping pain, especially after meal for 2 weeks with body weight loss for 3-4 kg in one month. Therefore, she came to our ER for help. At ER, there were no fever, no chest pain nor dysuria.
      • CT of abdominal was performed on 2023/4/27 revealed:
        • Adenocarcinoma of the gastric body and antrum is highly suspected. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for gastric cancer: T4aN2M1, stage: IVB.
        • Carcinomatosis is highly suspected.
        • Krukenberg tumor in the cul-de-sac with direct invasion the rectum.
        • Adenocarcinoma of the gallbladder fundus is highly suspected.
        • Renal cell carcinoma in left kidney is highly suspected.
        • Multiple bony metastases are suspected.
      • EKG showed
        • Large gastrojejunal ulcer, r/o malignancy, s/p biopsy (A).
        • Ulcer on the colon mucosa (esophageal reconstruction) near the esophageal orifice, s/p biopsy (B).
        • Status of total esophagectomy and esophageal reconstruction with colon.
        • Status post radical subtotal gastrectomy with BII anastomosis.
      • Colonscopy showed Highly supsected colorectal malignancy, upper rectum and RS colon, s/p biopsy.
      • Laboratory test revealed anemia (Hb: 7.7g/dl) and elevated tumor marker of CEA (28.09ng/mL), CA199 (260.84 U/mL) and CA125 (53.8 U/mL).
      • Blood transfusion with LPRBC.
      • Empiric antibiotics with Cefuroxime was administered.
      • Under the impression of Adenocarcinoma of the gastric body and antrum, carcinomatosis and multiple bony metastases are suspected, cT4aN2M1, stageIVB. She was admitted for further management
    • Course of inpatient treatment
      • After admission, high dose PPI with pantoloc 20mg in N/S 500ml run 20ml/hr on 4/27-29 and Blood transfusion with LPRBC 2U for correct anemia.
      • Foliromin 1tab BID for Iron deficiency anemia.
      • Arrange the bone scan on 2023/5/2 showed:
        • Mildly inhomogenously increased activity in some T- and L-spines and sacrum and diffusely increased activity in bilateral iliac bones. The nature is to be determined. Please correlate with other imaging modalities and follow up bone scan to rule out the possibility of bone metastases.
        • Some hot spots in the skull. Please also follow up bone scan for further evaluation.
      • GS was consulted for port-A insertion on 5/4.
      • Empiric antibiotics with Cefuroxime 1500mg Q8H on 4/27-5/5 and shifted to Tapimycin, owing to watery diarrhea we shifted to antibiotics with Cravit on 5/12-19.
      • B/C yield Acinetobacter ursingii, we repeated the blood culture on 5/16 and pending.
      • Chemotherapy with C1D1 FOLFOX6 was administered on 2023/5/10-5/12. Patient tolerated the chemotherapy.
      • With the relatively stable condition,she was discharged on 2023/5/19 and will arrange next admission on 5/25
    • Course of inpatient treatment
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • Nexium (esomeprazole 40mg) 1# QDAC for 4/27 EGD
      • Foliromin (ferrous sodium citrate 50mg) 1# BID
      • Zandip (lercanidipine 10mg) 1# QD
      • Cravit (levofloxacin 500mg) 1.5# QDAC
      • Smecta (dioctahedral smectite 3g) 1# PRNTIDAC if diarrhea

[consultation]

  • 2023-05-16 Psychosomatic Medicine
    • Q
      • Suicidal ideation in cancer inpatients >=2 points.
    • A
      • This 70 y/o lady has been admitted for gastric adenocarcinoma, with severe gastric pain, nausea, poor intake. The patient wants to eat, but she vomits after eating even a little bit. In recent few months, she also developed low and anxious mood, disruptive sleep, hopelessness and worthlessness feelings, guilty feelings, death thoughts. She is worried that her continued treatment will be a drag on my family, and she wants to have euthanasia. However she had fine support from her family and could perceive pleasure when her son and husband came to acompany her, and she accept the current therapautic planning. I have discussed the treatment plan with the patient and her husband.
      • IMP: adjustment disorder with depressed and anxious mood.
      • Suggestion: brintellix 10mg 0.5# HS, alprazolam 0.5mg 0.5# HSPRN if insomnia
      • Arrange PSY OPD follow up.

[chemotherapy]

  • 2024-02-23 - paclitaxel 80mg/m2 90mg NS 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2024-02-16 - paclitaxel 80mg/m2 90mg NS 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2024-02-02 - paclitaxel 80mg/m2 90mg NS 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2024-01-26 - paclitaxel 80mg/m2 90mg NS 250mL 3hr
    • dexamethasone 20mg PO + dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
  • 2023-11-28 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-14 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-10-24 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-10-04 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-09-13 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-30 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-15 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-07-26 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-07-11 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-06-21 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-06-06 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-05-23 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 166mL 46hr (Baxter Infusor) (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-05-10 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

Paclitaxel - 2024-02-29 - https://www.uptodate.com/contents/paclitaxel-conventional-drug-information

  • Gastric cancer, metastatic or unresectable locally advanced (off-label use) IV:
    • 80 mg/m2 on days 1, 8, and 15 every 28 days (in combination with ramucirumab) until disease progression or unacceptable toxicity or
    • 80 mg/m2 on days 1, 8, and 15 every 28 days (as a single agent) until disease progression or unacceptable toxicity or
    • 200 mg/m2 (cycle 1; escalated to 225 mg/m2 in cycle 2 if acceptable ANC and platelets) over 3 hours on day 1 every 3 weeks (in combination with carboplatin); evaluate for response every 2 cycles.

==========

2024-02-29

[FOLFOX followed by paclitaxel: rising tumor markers & hypokalemia]

The patient’s treatment was initiated with the FOLFOX regimen in May 2023. Both CEA and CA199 tumor markers reached their nadir (lowest point) in Sep 2023, but still remained out of the normal reference range. Subsequently, the markers began to rise, and the last dose of FOLFOX was administered in late Nov 2023.

  • 2024-02-27 CEA (NM) 30.060 ng/ml

  • 2024-02-20 CEA (NM) 26.790 ng/ml

  • 2024-01-30 CEA (NM) 24.157 ng/ml

  • 2024-01-19 CEA (NM) 23.317 ng/ml

  • 2023-12-29 CEA (NM) 22.383 ng/ml

  • 2023-12-22 CEA (NM) 17.894 ng/ml

  • 2023-12-15 CEA (NM) 14.477 ng/ml

  • 2023-12-08 CEA (NM) 15.861 ng/ml

  • 2023-12-01 CEA (NM) 14.718 ng/ml

  • 2023-11-17 CEA (NM) 12.991 ng/ml

  • 2023-10-24 CEA (NM) 10.527 ng/ml

  • 2023-10-06 CEA (NM) 8.849 ng/ml

  • 2023-09-28 CEA (NM) 8.549 ng/ml

  • 2023-09-15 CEA (NM) 7.623 ng/ml

  • 2023-09-01 CEA (NM) 7.170 ng/ml

  • 2023-07-07 CEA (NM) 9.071 ng/ml

  • 2023-06-23 CEA (NM) 10.524 ng/ml

  • 2023-06-12 CEA (NM) 11.251 ng/ml

  • 2023-06-02 CEA (NM) 14.962 ng/ml

  • 2023-05-30 CEA (NM) 15.930 ng/ml

  • 2023-04-27 CEA 28.09 ng/mL

  • 2024-02-27 CA-199 (NM) 735.100 U/ml

  • 2024-02-20 CA-199 (NM) 669.050 U/ml

  • 2024-01-30 CA-199 (NM) 754.580 U/ml

  • 2024-01-19 CA-199 (NM) 598.990 U/ml

  • 2023-12-29 CA-199 (NM) 382.890 U/ml

  • 2023-12-22 CA-199 (NM) 202.647 U/ml

  • 2023-12-15 CA-199 (NM) 178.155 U/ml

  • 2023-12-08 CA-199 (NM) 203.365 U/ml

  • 2023-12-01 CA-199 (NM) 171.744 U/ml

  • 2023-11-17 CA-199 (NM) 156.577 U/ml

  • 2023-10-24 CA-199 (NM) 126.428 U/ml

  • 2023-10-06 CA-199 (NM) 96.780 U/ml

  • 2023-09-28 CA-199 (NM) 84.503 U/ml

  • 2023-09-15 CA-199 (NM) 93.263 U/ml

  • 2023-09-01 CA-199 (NM) 89.666 U/ml

  • 2023-07-07 CA-199 (NM) 122.765 U/ml

  • 2023-06-23 CA-199 (NM) 147.885 U/ml

  • 2023-06-12 CA-199 (NM) 197.215 U/ml

  • 2023-06-02 CA-199 (NM) 250.810 U/ml

  • 2023-05-30 CA-199 (NM) 363.860 U/ml

  • 2023-04-27 CA-199 260.84 U/mL

Paclitaxel was initiated on 2024-01-26. Ramucirumab, originally planned as a co-administered drug, has not yet been commenced. The paclitaxel treatment has not shown a clear trend of decreasing tumor marker levels.

Hypokalemia was identified on 2024-02-28, with a value of 2.9 mmol/L. Const-K and Spiron (spironolactone) are currently being administered, and no medication discrepancies were found.

701492916

240229

[exam findings]

  • 2023-12-13 CT - chest
    • Indication
      • breast lump Lt breast ca proved by CNB on 2023-07-14 at ZhongXiao Hospital
      • Lt breast ca (TNBC) and NACT with E(Lipodox)C -> T since 2023-08-16 and adding Keytruda since 2023-08-16.
    • Findings: Comparison was made with CT on 2023/12/03
      • Lungs: inferior lingular segment atelectasis with bronchiectasis. patchy ground-glass opacities at both upper lobes and interlobular septal thickening at both lungs.
        • ground glass solid nodule at RUL RML RLL LUL LLL (mm in largest
      • Mediastinum and hila: no enlarged LN or mass.
      • Thoracic aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal size of cardiac chambers.
      • Pleura: unremarkable.
      • Chest wall and visible lower neck: a 5mm dense calcification
      • at left breast, and no abnormal enhancing nodule and no enlarged LN at axilla.
      • marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • residual interstitial fibrosis sequela of prior drug-related toxicity? lingula collapse with bronchiectasis
  • 2023-12-08 Bronchodilator Test
    • Normal pulmonary function
  • 2023-12-06 CXR
    • Presence of ileus.
    • S/P Port-A infusion catheter insertion.
    • Ground glass opacity in LLL.
    • Normal appearance of trachea and bil. main bronchus.
    • Normal size of heart.
    • Suggest clinical correlation.
  • 2023-12-03 CTA - chest
    • Findings
      • No intimal flap, nor intramural hematoma of aorta.
      • No filling defect of pulmonary artery.
      • Ground-glass opacities with superimposed interlobular septal thickening of both lung fields, more severe at upper lobes.
      • No enlarged mediastinal lymph node.
      • No pleural lesion.
      • Unremarkable change of the visible liver, spleen, pancreas, adrenal glands, and kidneys.
      • No bony destructive lesion on these images.
    • Impression
      • No CT-evidence of aortic dissection or pulmonary embolism
      • Crazy paving of both lung fields. The differential diagnosis includes, but is not limited to pulmonary edema, ARDS, and acute interstitial pneumonia.
  • 2023-11-07 CT - chest
    • Indication: fever, cause unknown, ILD???
    • Findings
      • Lungs: partial atelectasis of inferior lingular segment and RML.
      • several lobular ground glass opacities at RUL.
      • normal appearance of both lower lobes.
      • Mediastinum and hila: no enlarged LN or mass.
      • Thoracic aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal size of cardiac chambers.
      • Pleura: unremarkable.
      • Chest wall and visible lower neck: an enhancing lesion (22mm) in left breast with a central high density focus.
      • suspect duodenal diverticuulm, 2nd portion.
      • marginal spurs of multiple vertebrae due to spondylosis. no destructive lytic or blastic lesion.
    • Impression:
      • no evidence of interstitial lung disease or pneumonia.
  • 2023-11-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (46 - 15) / 46 = 67.39%
      • M-mode (Teichholz) = 65
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Trivial MR and trivial TR
      • LV diastolic dysfunction, Gr 1
      • Preserved RV systolic function
  • 2023-08-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (49.8 - 17.3) / 49.8 = 65.26%
      • M-mode (Teichholz) = 65.3
      • 2D (M-Simpson) = 73.7
    • Conclusion:
      • Normal AV with no AR
      • Normal MV with mild MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, normal IVC size
  • 2023-08-14 SONO - abdomen
    • Findings
      • Liver: Increased brightness of liver parenchyma was noted. A sonolucent lesion was noted in S6-S6, with posteriore enhancement, in S6-S7: size about 0.5cm.
      • Pancreas: Some parts of pancreas blocked by bowel gas, especially head and tail; increased brightness of pancreas parenchyma
    • Diagnosis:
      • mild fatty liver
      • liver cyst
      • fatty infiltration of pancreas
  • 2023-08-11 MRI - breast
    • Clinical history: 71 y/o female patient with breast lump, Lt breast ca proved by CNB on 2023-07-14 at ZhongXiao Hospital.
    • With and without enhancement MRI of breast (axial T1, T1FS, sagittal T2, T2FS, axial and sagittal T1FS contrast, dynamic study):
      • There is irregular tumor,, 2.5cm in left subareolar region, with prominent enhancement, c/w malignancy.
      • Irregular tumor, 1.5cm in deep breast of 10-11’region of left breast.
      • No periareolar skin thickening.
      • No enlarged axillary lymph node.
    • Impression:
      • Left breast subareolar and 10-11region tumors, r/o malignancy.
    • BI-RADS: Category 6 - proven malignancy.
  • 2023-08-07 PD-L1 (22C3)
    • Cellblock No. STQ2304637 (Taipei City Hospital ZhongXiao Branch)
    • RESULTS:
      • Combined Positive Score (CPS) assessment: CPS >= 1 and <10
      • Combined Positive Score (CPS): 1
  • 2023-08-04 Tc-99m MDP bone scan
    • Increased activity in the lower C-spine, lower T-spine and L4-5 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, elbows, wrists, hips and knees, compatible with benign joint lesions.
  • 2023-08-04 SONO - breast
    • Diagnosis:
      • Bil. fibroadenomas as described
      • Left breast cancer
    • BI-RADS: 6. known biopsy-proven malignancy
  • 2023-08-04 Mammography
    • Digital mammography of both breasts with MLO and CC views:
      • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
      • Focal asymmetry in subareolar region of left breast.
    • Impression:
      • Dense breast. Focal asymmetry in subareolar region of left breast.
    • BI-RADS: Category 6 - proven malignancy.

[MedRec]

  • 2024-02-06, 2023-11-17, -08-25 SOAP Gastroenterology Zhan WeiYu
    • O: 2023/08/07 HBsAg (NM) = Positive;
    • A: HBV carrier under chemotherapy
    • Prescription x3
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
  • 2023-12-03 ~ 2023-12-09 General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Left breast cancer, cT2N0M0, stage IIA. ER(-), PR(-), HER-2(1+), Ki-67:40%. ECOG:1.
      • Immune-Related Adverse Events with bilateral pneumonitis
    • CC
      • Dry cough with mild dyspnea at last night, SpO2 measured 70-80% at home.
    • Present illness
      • This 71-year-old female patient has past history of insomnia and hyperdislipidemia with regular medicine control at ZhongXiao Hospital. She is a HBV carrier. Her TOCC history was travel to Okinawa from 7/24 to 7/29.
      • Under the impression of left breast invasive carcinoma, chemotherapy with weekly Taxotere on 11/22. However, dry cough with mild dyspnea at last night, SpO2 measured 70-80% at home. Cough started 2-3 days ago.
      • She was came to our EF for help. In ER, vital sign BP:109/59mmhg; PR:131 bpm/min; BT:37.1’C; RR:24;
      • Con’s:E4V5M6, SPO2:94%.
      • Chest CTA reaveled ground-glass opacities with superimposed interlobular septal thickening of both lung fields, more severe at upper lobes, suspect ILD (caused by chemotherapy). Respiratory patten shallow and minimal of yellow sputum.
      • Under the impression of pneumonitis suspect ILD, she was admitted for further survey and management.
    • Course of inpatient treatment
      • After admission, Medason 40mg IVD Q12H and A+B INHL for ILD. (why “A+B” stands for Ipratran (ipratropium bromide) and Butanyl (terbutaline)?)
      • Cravit for pneumonia.
      • O2 N/C 3L support.
      • Under staable condition, she was discharged today, OPD will be arrange.
      • Chemotherapy change to weekly nab-Taxol + Carboplatin 450mg at next time.
    • Discharge prescription
      • Cravit (levofloxacin 500mg) 1.5# QDAC 7D
      • Trimbow (beclometasone 100ug, formoterol 5ug, glycopyrronium 12.5ug; per dose) 2 puff BID INHL
      • Methylone (methylprednisolone 4mg) 1# TID 2D 12/9-10
      • Methylone (methylprednisolone 4mg) 1# BID 2D 12/11-12
  • 2023-08-14 ~ 2023-08-16 General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Left breast cancer, cT2N0M0, stage IIA status post port A insertion on 2023/08/15. ER(-), PR(-), HER-2(1+), Ki-67:40%. ECOG:0.
      • Encounter for antineoplastic chemotherapy
      • Hyperlipidemia
      • Other insomnia
      • Type 2 diabetes mellitus without complications
      • Chronic viral hepatitis B without delta-agent
    • CC
      • Palpable breast lump for 1 month
    • Present illness
      • This 71-year-old female patient has past history of insomnia and hyperdislipidemia with regular medicine control at ZhongXiao Hospital. She is a HBV carrier. She denied cancer history. Her TOCC history was travel to Okinawa from 7/24 to 7/29.
      • She noted a palpable mass at left breast for 1 month. A hard, nontender, movable mass with irregular margin at left breast around 5x5 cm without discharge. Her body weight was decreased from 51.5kg in January to 49kg in August. She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, nor bowel habit change. physical exmaination showed symmetrical of bilateral breasts. There were no thickening or swelling of part of the breast, irritation or dimpling of breast skin, redness or flaky skin in the nipple area or the breast, pulling in of the nipple, nipple discharge other than breast milk or blood, or change in the size or the shape of the breast.
      • She came to local ObGyn OPD for help and was told a left irregular 2x3cm lesion by breast sonography. Therefore, she went to ZhongXiao Hospital for further management. Core needle biopsy was done on 2023/07/14 and breast cancer was proved by pathological report. Then, the patient came to Doctor Zhang’s out patient clinic for help. Mammography on 8/4 showed focal asymmetry in subareolar region of left breast with BI-RADS: Category6-proven malignancy. Breast sonography on 8/4 showed bilateral fibroadenomas as described and left breast cancer. Tc-99m MDP whole body bone scan on 8/4 showed no obvious lesion for metastasis. Breast MRI on 8/11 showed left breast subareolar and 10-11region tumors, r/o malignancy. CA-153:8.704 U/ml, CEA:2.088 ng/ml.
      • Under the impression of left breast invasive carcinoma, she was admitted for surgery of abdominal sonography, port-A insertion, and chemotherapy.        
    • Course of inpatient treatment
      • After admission, port A insertion was performed on 2023/08/15. 1st neo-adjuvant chemotherapy with Lipo dox + Endoxan + Keytruda were given. The wound is clean and dry. No discomfort after chemotherapy. Under the stable condition, she was discharged today, wound will be follow up on 8/23. And arrange next admission three weeks later.
    • Discharge prescription
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Acetal (acetaminophen 500mg) 1# QID
      • Emend (aprepitant 125mg) 1# QD for 8/17, 8/18
      • Lemeson (dexamethasone 4mg) 1# BID for 8/17 ~ 8/19
      • loperamide 2mg 2# PRNQ8H if watery diarrhea > 2

[immunochemotherapy]

  • 2024-02-29 - nab-paclitaxel 100mg 30min
    • diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2024-02-21 - nab-paclitaxel 100mg 30min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2024-02-15 - nab-paclitaxel 100mg 30min + carboplatin AUC 2 450mg NS 250mL 2hr
    • Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2024-01-31 - nab-paclitaxel 100mg 30min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2024-01-24 - nab-paclitaxel 100mg 30min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2024-01-17 - nab-paclitaxel 100mg 30min + carboplatin AUC 2 450mg NS 250mL 2hr
    • Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2024-01-03 - nab-paclitaxel 100mg 30min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-12-27 - nab-paclitaxel 100mg 30min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-12-20 - nab-paclitaxel 100mg 30min + carboplatin AUC 2 450mg NS 250mL 2hr
    • Akynzeo (netupitant 300mg, palonosetron 0.5mg) 1# PO + betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-11-22 - ……………………………… docetaxel 40mg/m2 58mg NS 150mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-11-15 - pembrolizumab 200mg NS 100mL 30min + docetaxel 40mg/m2 58mg NS 150mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-10-18 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 875mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr (AC(Lipo) Q3W) Zhang YaoRen
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg + NS 250mL
  • 2023-09-28 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr (AC(Lipo) Q3W) Zhang YaoRen
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg + NS 250mL
  • 2023-09-06 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr (AC(Lipo) Q3W) Zhang YaoRen
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg + NS 250mL
  • 2023-08-15 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr (AC(Lipo) Q3W) Zhang YaoRen
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg + NS 250mL

==========

2023-11-06

[leukopenia]

The patient received the Keytruda (pembrolizumab) with AC(Lipo) regimen on 2023-08-15, 2023-09-06, 2023-09-28, and 2023-10-18, with episodes of leukopenia noted in early Sep and early Oct.

  • 2023-11-06 WBC 1.70 x10^3/uL **
  • 2023-11-04 WBC 1.50 x10^3/uL **
  • 2023-11-03 WBC 1.91 x10^3/uL **
  • 2023-10-18 WBC 4.06 x10^3/uL
  • 2023-09-28 WBC 4.50 x10^3/uL
  • 2023-09-06 WBC 2.89 x10^3/uL *
  • 2023-08-23 WBC 8.61 x10^3/uL
  • 2023-08-09 WBC 9.17 x10^3/uL

The frequency of the immunochemotherapy was Q3W, and the second episode of leukopenia was more severe than the first. This may indicate that the patient’s recovery capacity is not keeping pace with the immunosuppressive effects of the medication.

Under the National Health Insurance drug reimbursement regulations, short-acting injectables G-CSF such as filgrastim and lenograstim can be used in non-hematologic malignancy patients post-chemotherapy if they have experienced white blood cell counts below 1000/cumm or absolute neutrophil counts (ANC) below 500/cumm. The patient’s lab values have not yet reached these thresholds. If there is a consideration of increased risk of infection, it may be advisable for the patient to use these medications at their own expense.

Compared to other options such as lowering the dose of chemotherapy or increasing the administration interval, the use of G-CSF appears to be a more effective approach in managing neutropenia caused by chemotherapy. Lowering the dose of chemotherapy may reduce the occurrence of neutropenic complications, but it can also compromise the effectiveness of the treatment (Lyman et al., 2005). Similarly, increasing the administration interval of chemotherapy may reduce the frequency of neutropenia, but it can also lead to delays in treatment and potentially compromise treatment outcomes (Okera et al., 2010). On the other hand, the use of G-CSF has been shown to effectively prevent and manage neutropenia, reducing the risk of febrile neutropenia, infections, and the need for dose reductions or delays in treatment (Ar, 2004; Crawford, 2003; Mizuno et al., 2017; Flores & Ershler, 2010).

  • Ref:
    • Lyman, G. H., Lyman, C., & Agboola, O. (2005). Risk models for predicting chemotherapy-induced neutropenia. The Oncologist, 10(6), 427-437. https://doi.org/10.1634/theoncologist.10-6-427
    • Okera, M., Chan, S. Y., Dernede, U., Larkin, J., Popat, S., Gilbert, D. C., … & Chowdhury, S. (2010). A prospective study of chemotherapy-induced febrile neutropenia in the south west london cancer network. interpretation of study results in light of ncag/ncepod findings. British Journal of Cancer, 104(3), 407-412. https://doi.org/10.1038/sj.bjc.6606059
    • Ar, W. (2004). Pegfilgrastim: a recent advance in the prophylaxis of chemotherapy-induced neutropenia. European Journal of Cancer Care, 13(4), 371-379. https://doi.org/10.1111/j.1365-2354.2004.00503.x
    • Crawford, J. (2003). Safety and efficacy of pegfilgrastim in patients receiving myelosuppressive chemotherapy. Pharmacotherapy, 23(8 Part 2), 15S-19S. https://doi.org/10.1592/phco.23.9.15s.32889
    • Mizuno, Y., Fuchikami, H., Takeda, N., Iwai, M., & Sato, K. (2017). Efficacy of reduced dose of pegfilgrastim in japanese breast cancer patients receiving dose-dense doxorubicin and cyclophosphamide therapy. Japanese Journal of Clinical Oncology, 47(1), 12-17. https://doi.org/10.1093/jjco/hyw152
    • Flores, I. Q. and Ershler, W. B. (2010). Managing neutropenia in older patients with cancer receiving chemotherapy in a community setting. Clinical Journal of Oncology Nursing, 14(1), 81-86. https://doi.org/10.1188/10.cjon.81-86

700022241

240227

[exam findings]

  • 2024-02-26 CT - abdomen
    • History and indication: gastric cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Gastric cancer (low body and antrum) with adjacent liver, pancreas, hepatic artery, portal vein and SMV invasion. Some LNs around stomach. Some soft tissue in peritoneal cavity with ascites. S/P CBD stenting.
      • Patchy densities (up to 2.9cm) at RLL.
      • Liver and renal cysts (up to 2.8cm).
      • Atherosclerosis of aorta, iliac arteries.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Progression of gastric cancer (low body and antrum) with adjacent liver, pancreas, hepatic artery, portal vein and SMV invasion. Some LNs around stomach. Peritoneal carcinomatosis with ascites. S/P CBD stenting.
      • Patchy densities (up to 2.9cm) at RLL (stable).
  • 2023-11-28 CT - abdomen
    • History and indication: Malignant neoplasm of stomach
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Gastric cancer (low body and antrum) with adjacent liver, pancreas, hepatic artery, portal vein and SMV invasion. Some LNs around stomach. Some soft tissue in peritoneal cavity. S/P CBD stenting.
      • Patchy densities (up to 2.9cm) at RLL.
      • Liver and renal cysts (up to 2.8cm).
      • Distention of gallbladder.
      • Atherosclerosis of aorta, iliac arteries.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Gastric cancer (low body and antrum) with adjacent liver, pancreas, hepatic artery, portal vein and SMV invasion (stable). Some LNs around stomach. Some soft tissue in peritoneal cavity. S/P CBD stenting.
      • Patchy densities (up to 2.9cm) at RLL (stable).
  • 2023-08-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (87.2 - 10.1) / 87.2 = 88.42%
      • M-mode (Teichholz) = 88.4-78.4
  • 2023-08-23 CT - abdomen
    • Findings: Comparison prior CT dated 2023/05/29.
      • Prior CT identified lobulated circumferential irregular wall thickening at the gastric low body and antrum is noted again, stable in size that is c/w adenocarcinoma S/P C/T with stable disease.
        • Prior CT identified the stomach lesion direct invasion the liver and pancreas is noted again, stationary.
        • There is smudgy appearance of the omentum that may be metastases (tumor seeding).
      • S/P biliary stent implantation in between IHD and duodenum.
        • However, mild IHDs dilatation is still noted.
      • Prior CT identified three calcified masses in RLL of the lung are noted again, stationary. Old granulomas are highly suspected.
      • Prior CT identified bilateral renal cysts (up to 2.8cm) are noted again, stationary.
    • Impression:
      • Adenocarcinoma of the stomach S/P C/T show stable disease.
      • There is smudgy appearance of the omentum that may be metastases (tumor seeding).
  • 2023-08-15 ECG 24hr
    • Baseline was sinus rhythm
    • A few isolated VPCs
    • Rare isolated APCs / burst APCs
    • No long pause
    • No significant tachyarrhythmia
  • 2023-06-08 All-RAS + BRAF mutation
    • Cellblock No. S2023-10706
    • RESULTS:
      • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-06-08 PD-L1 IHC
    • Cellblock No. S2023-10706
    • RESULTS:
      • Combined Positive Score (CPS) assessment: CPS >= 1 and <10
      • Combined Positive Score (CPS): 1
  • 2023-06-08 PD-L1 22C3
    • Cellblock No. S2023-10706
    • RESULTS:
      • Combined Positive Score (CPS) assessment: CPS < 1
      • Combined Positive Score (CPS): 0
  • 2023-06-08 PD-L1 SP142
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
      • S2023-10706
      • Tumor type: signet-ring cell carcinoma
      • Tumor location: stomach
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark XT
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: Pass,
      • Adequate tumor cells present (>=50 viable tumor cells): Yes
    • Result:
      • Tumor cell (TC) staining assessment: TC category: TC < 1%
      • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2023-06-02 CT - chest
    • Indication: gastric cancer favor lung metastasis
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lobulated calcified mass at right lower lobe measuring 2.8cm in largest dimension is found. Old insult is considered.
        • Small lymph nodes are found at paratracheal region.
      • Visible abdomen:
        • Huge mass lesion at gastric body measuring 11.6cm with liver invasion is found. Gastric cancer is considered. Some lymph nodes are found around the gastric body.
        • s/p biliary stent placement.
        • Dilated IHDs and CBD is found.
        • Mild pneumobilia is found.
    • Imp:
      • Huge gastric cancer with biliary tree obstruction s/p biliary stent placement.
      • Right lower lobe calcified mass. Old insult is considered.
  • 2023-05-31 Patho - stomach biopsy
    • Stomach, antrum, biopsy — Signet-ring cell carcinoma
    • Section shows fragments of gastric tissue infiltrated by signet-ring cells.
    • The immunohistochemical stains reveal CK(+) and Her-2/neu (Ab): Negative (0).
  • 2023-05-31 Endoscopic Retrograde Cholangiopancreatography, ERCP
    • Indication: Gastric cancer, obstructive jaundice, rule out metastic tumor with hepatic hilar compression
    • Symptoms: Jaundice
    • Premedication: Buscopan IV + Gascon po
    • Anesthesia: IV anesthesia
    • Findings
      • Duodenum
        • Since advanced gastric cancer involve gastric body and antrum had been known from previous study, upper GI endoscopic GIF-H260 was used before ERCP to exam the route from gastric body to 2nd portion. A huge ulcerative mass was noted from lower body to pyloric ring. Juxtapapillary diverticulum (type 2) was noted.
      • Common bile duct
        • Cholangiogram showed dilated proximal CBD measured 1.5 cm in max diameter. About 2.5 cm stricture was noted middle CBD
    • Management during examination
      • Unintended pancreatic duct guide wire cannulation happened on initial cannulation. After 45 minute trial to stanadard cannulation, needle knief precut fistulotomy (Boston) was applied followed by successful bile duct cannulation. About 10 ml yellowish bile was aspirated. ERBD (Boston, Advenix,8.5 Fr. 9 cm) was inserted with good bile drainage
    • Diagnosis
      • Middle common bile duct stricture, status post needle knife precut fistulotomy + ERBD
      • Non-visualized GB
      • Juxtapapillary diveritculum
      • Advanced gastric cancer, type IV, lower body to pylorus
    • Suggestion
      • NSAID (Voltaren 100mg supp) was used to post ERCP pancreatitis prevention
  • 2023-05-30 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Gastric lesion, suspect gastric cancer, Borrmann type IV (infiltration type), s/p biopsy
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
    • Suggestion
      • Pursue pathology report
      • PPI use
  • 2023-05-29 CT - abdomen
    • History and indication: favor a tumor in upper abdomen
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of stomach (low body and antrum) with adjacent liver, pancreas, CBD, hepatic artery, portal vein and SMV invasion causing biliary dilatation. Some LNs around stomach. Some soft tissue in peritoneal cavity.
      • Nodules (6.4mm, 7.2mm) at RLL.
      • Liver and renal cysts (up to 2.8cm).
      • Distention of gallbladder.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • In favor of gastric cancer with adjacent structures invasion, peritoenal seeding, LNs and lung metastases.
  • 2023-05-29 CXR
    • Multiple nodules at bil. lower lung zones.
  • 2023-05-27 SONO - abdomen
    • Diagnosis
      • favor a tumor in upper abdomen (origin to be determined: pancreas or stomach?)
      • suspected liver parenchymal disease
      • gallbladder distention, dilatation of CBD and bilateral IHD
      • gallbladder sludge, sludge in left IHD
      • bilateral renal cysts
    • Suggestion
      • 4 phase CT scan

[MedRec]

  • 2024-01-16 SOAP Hemato-Oncology He JingLiang
    • Prescription x2
      • NS 10mL ST IVD
      • Hepac Lock Flush 100 USP units/mL 10mL ST IRRI
      • Xeloda (capecitabine 500mg) 2# BID
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Nexium (esomeprazole 40mg) 1# QDAC

[consultation]

  • 2023-06-05 Hemato-Oncology
    • Q
      • for management of gastric cancer with adjacent structures invasion, peritoenal seeding, LNs and lung metastases.
      • This 67-year-old male denied systemic disease in the past.
      • This time, due to favor gastric cancer with adjacent structures invasion, peritoenal seeding, LNs and lung metastases. He was admitted to our GI ward for management and further survey
        • Abdominal CT:gastric cancer with adjacent structures invasion, peritoenal seeding, LNs and lung metastases.
        • upper GI endoscopy was performed that showed Gastric lesion, suspect gastric cancer, Borrmann type IV(infiltration type), s/p biopsy. NGS was also done *
      • ERCP was also done revealed Middle common bile duct stricture, status post needle knife precut fistulotomy + ERBD; Non-visualized GB; Juxtapapillary diveritculum and Advanced gastric cancer, type IV, lower body to pylorus.
      • AFP: 3.3 ng/mL; CA199: 3.37 U/mL; CEA: 149.83 ng/mL      
      • Now, we pending pathology and need your further survey.
      • Thanks a lot!
    • A
      • Dear doctor: This 67 year old is a case of suspect gastric cancer with adjacent structures invasion, peritoenal seeding, LNs and lung metastases, pending gastric lesion biopsy result.
      • Please check HBsAg, Anti HBc, Anti HBs, Anti HCV and arrange chest CT (+/- contrast). Check HER2 and PD-L1 testing if metastatic adenocarcinoma is documented/suspected. Testing for MSI by PCR/nextgeneration sequencing (NGS) or MMR by IHC. Arrange port A insertion. We will take over this case if you agree. Thanks for your consultation.
    • A1 2023/06/02 10:42
      • The patient lives in Banqiao. He is a CiCheng member. He has a wife and a daughter. His niece is a nurse at Cathay General Hospital.
      • Initial presentation: palpable upper abdominal mass, abdominal fullness, body weight loss 3kg in one month, bilirubin noted
      • ERCP show middle common bile duct stricture, tumor compression related s/p status post needle knife precut fistulotomy + ERBD

[chemotherapy]

  • 2023-11-14 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-10-31 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-10-11 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-09-26 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-09-12 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-29 - nivolumab 100mg NS 100mL 30min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (Opdivo + FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-15 - nivolumab 100mg NS 100mL 30min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (Opdivo + FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-02 - nivolumab 100mg NS 100mL 30min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (Opdivo + FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-18 - nivolumab 100mg NS 100mL 30min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (Opdivo + FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-04 - nivolumab 100mg NS 100mL 30min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (Opdivo + FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-20 - nivolumab 100mg NS 100mL 30min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr (Y-sited with Covorin) + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited with Oxalip) + fluorouracil 2400mg/m2 3500mg NS 180mL 48hr (in infusor) (Opdivo + FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-08 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-02-27

[Xeloda (capecitabine) tube feeding]

Steps to dissolve the Xeloda tablets (Ref: https://www.enherts-tr.nhs.uk/wp-content/uploads/2019/10/Capecitabine-v1-final.pdf)

  • Fill a cup with approximately 200ml of warm (not hot) water. Ensure that this cup, as well as the spoon, are not used by anyone else or for anything else.
  • The exact number of capecitabine tablets needed should be popped out from the blister and added to the water.
  • Allow the tablets to dissolve in the water and use the spoon to mix the solution periodically. This process takes around 15 minutes.
  • Once the tablets have completely dissolved, you may add raspberry squash or other strong flavouring (not fruit juice) to disguise the bitter taste.
  • The whole contents of the cup must be drunk immediately. It is advisable to rinse the cup with water and drink this to ensure the entire contents are ingested.

Important - Capecitabine tablets should never be crushed - this creates a dangerous dust.

Protection - The person preparing the solution should wear non-sterile gloves and a non-sterile plastic apron (supplied by the hospital).

Capecitabine can be slowly but completely dissolved. It can be used with a gastric or jejunal feeding tube. (Ref: Developing guidance for feeding tube administration of oral medications. JPEN J Parenter Enteral Nutr. 2023 May;47(4):519-540. doi: 10.1002/jpen.2490)

2023-06-09

  • Trastuzumab is recommended to be included in the first-line chemotherapy for advanced gastric adenocarcinoma with HER2 overexpression. The National Health Insurance (NHI) covers the use of trastuzumab (specifically the IV formulation) in metastatic gastric cancer when used in conjunction with capecitabine (or 5-fluorouracil) and cisplatin for the treatment of HER2 overexpressing (IHC3+ or FISH+) metastatic gastric adenocarcinoma that hasn’t been previously treated with chemotherapy.
  • However, the patient’s stomach biopsy pathology dated 2023-05-31 showed negative results for Her-2/neu(Ab)(0). Therefore, this patient does not meet the criteria for the use of trastuzumab covered by NHI.
  • The patient has begun his initial dose of the FOLFOX regimen today, without a bolus of 5-FU and with a reduced dosage of oxaliplatin. As of the current moment, there have been no complaints of adverse reactions. The patient’s TPR readings are stable, and there are no concerns with the currently active prescription.

2023-06-08

[patient education]

After attending a family meeting with the patient’s relatives at 11:00 this morning, I visited the patient at 12:30. At that time, the patient and his wife had left the bed to walk nearby, only the patient’s daughter was present. I told the patient’s daughter that if immunotherapy is to be used, it is better to use it sooner rather than later. The patient’s daughter also asked about the possible prognosis of the disease and the possible side effects of the drugs. I elaborated based on the content of this morning’s family meeting. The patient’s daughter indicated that she will decide whether to use immunotherapy in the near future.

700557035

240227

[exam findings]

  • 2023-11-01 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (75.5 - 20.0) / 75.5 = 73.51%
      • M-mode (Teichholz) = 73.5
    • Conclusion:
      • Normal chamber size
      • Thickening of IVS and LVPW
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • Mild MR, TR and PR
      • No regional wall motion abnormalities
  • 2023-10-05 Patho - breast simple/partial mastectomy
    • PATHOLOGIC DIAGNOSIS
      • Tumor, right breast, frozen + partial mastectomy —- Invasive carcinoma of no special type with focal ductal carcinoma in situ, intermediate grade
      • Resection margins, frozen — Tumor involved at upper margin, other margins are free
      • Margin, 9 o’colck, re-excision — Free of tumor invasion
      • Sentinel lymph node, R’t axillary, frozen — Micrometastasis (1/2)
      • Lymph node, R’t axillary level I and II, dissection — Free of tumor metastasis (0/15)
      • Skin of R’t breast — Free of tumor invasion
      • AJCC Pathologic Anatomic Stage — pT1cN1mi, if cM0, stage IB; Prognostic Stage — Stage IA
    • MACROSCOPIC EXAMINATION
      • Breast size: 7 x 6.2 x 3 cm
      • Skin size: 2.8 x 0.6 cm
      • Nipple: Not received
      • Tumor: 1.4 x 1.2 cm
      • Resection margins: Free, tumor involved at upper margin, 2.3 cm from base and at least 1.2 cm from peripheral margins
      • Lymph node: R’t axillary sentinel and non-sentinel (level I + II) lymph nodes
      • 9 o’clock recut breast margin: 3.9 x 2.3 x 1.5 cm with ink
      • All embedded for sections as A1-A4: 9 o’clock margin re-excision, B1-B3: R’t axillary level I and II LNs [Reference: F2023-00441 frozen section, FSA: R’t axillary sentinel lymph nodes, FSB: tumor + upper margin (ink), A1: 3 (blue ink) + 6 (green ink) + 9 (orange ink) + 12 o’clock + base (yellow) margins, A2 -A3: tumor, A4: tumor + skin]
    • MICROSCOPIC EXAMINATION
      • Histologic type: invasive carcinoma of no special type with focal ductal carcinoma in situ, intermediate grade
      • Size of invasive carcinoma: 1.4 x 1.2 cm
      • Histologic grade (Nottingham histologic score): Grade III (score 8) including [(A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 3 and (C) Mitotic count: score 2]
      • Margins (frozen + re-excision): free of tumor invasion, 2.3 cm from base and at least 1.2 cm from peripheral margins
      • Nodal status:
        • R’t axillary sentinel lymph node: micrometastasis (1/2)
        • R’t axillary level I and II lymph node: free of tumor metastasis (0/15)
      • Treatment Effect: N/A
      • Lymphovascular space invasion: identified
      • Perineural invasion: identified
      • Immunohistochemistry: please refer to S2023-17624
      • Stromal tumor-infiltrating lymphocytes (TILs): 10%
  • 2023-10-04 Lymphoscintigraphy
    • Probably one sentinel lymph node at the right axillary region.
  • 2023-09-19 Tc-99m MDP bone scan
    • Increased activity in the L4 spine. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Prominently increased activity in the right knee. The nature is to be determined (severe degenerative change? other nature?). Please correlate with other clinical findings and follow up bone scan for further evaluation.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and feet, compatible with benign joint lesions.
  • 2023-09-15 CT - chest
    • Spiculated nodule at right outer breast measuring 1.15cm in largest dimension. (Se301 Im32). Breast cancer is considered.
    • Non-specific lymph nodes are found at right axillary region.
  • 2023-09-04 Patho - breast biopsy (no need margin)
    • Breast, right, 9/2, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (+, 100%, STRONG intensity), PR (+, 70 %, STRONG intensity), Her2/neu: positive (score=3+), Ki-67 (20%), P63 (-), E-cadherin (+).
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • 2023-08-25 SONO - breast
    • Diagnosis: Highly suspicious of malignancy, with sonographic negative axillary LNs
    • Treatment: Core-needle biopsy
    • Suggestion: Regular OPD follow-up
    • BI-RADS: 4A - low suspicion for malignancy Biopsy Should Be Considered
  • 2023-08-17 Mammography
    • Hyperdense spiculated tumor, 1.6cm in UOQ of right breast(anterior third portion), r/o malignancy, suggest biopsy.
    • BI-RADS: Category 4c: highly suspicious abnormality-biopsy should be considered.

[MedRec]

  • 2023-10-27 SOAP Cardiology Duan DeMin
    • Prescription x3
      • Exforge (amlodipine 5mg, valsartan 160mg)
      • Syntrend (carvedilol 25mg)
  • 2023-10-19 SOAP Hemato-Oncology
    • S
      • For further managemenet of breast cancer
      • Hx of ovary cancer s/p OP 44 y/o
      • Anti-HBs (+), Anti-HBc (+), HBs (-), Anti-HCV (-)
    • A/P
      • right breas cancer, HER-2 type, pT1cN1miM0, stage IB
      • refer to oncologist for following R/T and C/T
      • Plan:
        • AC x 4 -> TH(P)
        • R/T
      • Hormonal therapy and H(P) upto 1 year
      • Admission for heart echo -> C/T AC x 4 then TH(P)
      • OP for Port-A on 2023-10-31
  • 2023-10-03 ~ 2023-10-09 POMR General and Digestive Surgery
    • Discharge diagnosis
      • Right beast cancer, cT1cN0M0, stage IA. IHC stains: ER (+, 100%), PR (+, 70 %), Her2/neu: positive (score=3+), Ki-67(20%) status post partial mastectomy and axillary lymph node dissection on 2023/10/04. ECOG:0
      • Hypertension
    • CC
      • diagnosed with abnormal under mammography by health examination.
    • Presnet illness
      • This 57-year-old female patient has past history of
        • hypertension over 4-5 years without irregular medicine control about for 1 years
        • ovarian cancer, stage 0 post abdominal total hysterectomy for 11-12 years ago.
      • She denied any TOCC histories in recent 3 months.
      • She was diagnosed with abnormal under mammography by health examination. She came to our OPD for help on 2023/08/25. Breast sono showed highly suspicious of malignancy with sonographic negative axillary LNs, Right 9 o’clock / 2 cm, size:1.01 x 1.19 x 1.37 cm.
      • Guide biopsy was performed. Pathology revealed invasive carcinoma, ER (+, 100%), PR (+, 70 %), Her2/neu: positive (score=3+), Ki-67 (20%).
      • The tumor marker showed CA-153:34.844 U/ml, CEA:1.972 ng/ml.
      • Tc-99m MDP whole body bone scan and chest CT showed no obvious lesion for metastasis.
      • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
      • PE: symmetrical of bilateral breasts. A hard, non-tender, fixed mass and irregular margin at right breast around 2x2 cm without discharge. The nipple was no dimping without exudative nor bloody discharge and no retraction. The right breast skin had no cellulitis change, no lymph nodes at right axilla.
      • Under the impression of right breast invasive carcinoma. After fully explaination the treatment of surgical method at OPD.
      • This time, she was admission for surgery of partial mastectomy + sentinel lymph node biopsy.
    • Course of inpatient treatment
      • After admission, right breast partial mastectomy and ALND was perfromed on 2023/10/04. The post-operative course was relatively smooth without complication. The wound is clean and dry and the wound pain was tolerable. The final pathology report is pending.
      • Under the stable condition, she was discharged with remove jp drain x2 today and re-follow at OPD.
    • Discharge diagnosis
      • Acetal (acetaminophen 500mg) 1# QID
      • Norvasc (amlodipine 5mg) 1# QD
      • Diovan (valsartan 160mg) 0.5# QD

[surgical operation]

  • 2023-10-04
    • Surgery
      • partial mastectomy and ALND      
    • Finding
      • right 9/2 tumor, CNB: IDC
      • SLNB: micrometastasis, 1/2

[immunochemotherapy]

  • 2024-02-27 - trastuzumab 600mg SC 5min + docetaxel 75mg/m2 130mg NS 250mL 1hr
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2024-02-03 - trastuzumab 600mg SC 5min + docetaxel 75mg/m2 130mg NS 250mL 1hr
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2024-01-12 - epirubicin 90mg/m2 150mg NS 100mL 30min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-12-22 - epirubicin 90mg/m2 150mg NS 100mL 30min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-24 - epirubicin 90mg/m2 150mg NS 100mL 30min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-01 - epirubicin 90mg/m2 150mg NS 100mL 30min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-02-27

[reconciliation]

Throughout this hospitalization, the patient has maintained stable vital signs. Lab tests obrained on 2024-02-26 revealed grossly normal readings. Based on these findings, no contraindications to the administration of trastuzumab plus docetaxel were identified. Additionally, a review of the HIS5 and PharmaCloud revealed no discrepancies.

700877253

240227

[exam findings]

  • 2023-12-02 CT - abdomen
    • Indication: High-grade B-cell lymphoma, stage IV, over left pelvis, extending to L5 level and compression of nerve root of left sacrum, swelling and paralysis of left lower limb; osteolytic lesion over left sacrum and SI joint, ECOG 2.
    • Abdominal CT with and without enhancement revealed:
      • Thickening of pyriformis muscle is found. Recurrent/residual lymphoma is compatible. In comparison with CT dated on 2023-08-25, the lesion regressed.
      • Tiny GB polyp measuring 0.3cm is found. There is no evidence of paraarotic LAPs.
    • Imp:
      • Recurrent/residual left pyriformis muscle soft tissue mass. Residual lymphoma is compatible. Suggest further treatment.
  • 2023-10-24 MRI - pelvis
    • History and indication: High-grade B-cell lymphoma
    • With and without contrast MRI of pelvis revealed:
      • Mild regression of left pelvic lymphom with adjcent structures invasion and central necrosis.
      • No ascites. Small lymph nodes at retroperitoneum.
      • Mild left hydronephrosis.
    • IMP:
      • Mild regression of left pelvic lymphom with adjcent structures invasion and central necrosis.
  • 2023-10-13 Motor Nerve Conduction Velocity (MNCV) & Sensory Nerve Conduction Velocity (SNCV)
    • Lower limb MNCV study:
      • Absence of signal in Lt peroneal nerve & Lt tibial nerve.
      • Normal distal latency, Normal CMAP amplitude & Normal MNCV in Rt peroneal nerve & Rt tibial nerve.
    • SNCV study:
      • Absence of signal in Lt sural nerve.
      • Prolonged distal latency, Normal SNAP amplitude & Normal SNCV in Rt sural nerve.
    • F wave study:
      • Prolonged F wave-latency in Rt peroneal nerve & Rt tibial nerve.
      • Absence of signal in Lt peroneal nerve & Lt tibial nerve.
    • H reflex study:
      • Normal H reflex latency in Rt tibial nerve.
      • Absence of signal in Lt tibial nerve.
    • These findings suggest
      • Absence of signal in left peroneal, tibial & sural nerve, in favor of left Lumbosacral plexopathy
      • Lumbosacral radiculopathy, right side.
      • Advise clinical correlation.
  • 2023-08-25 CTA - abdomen
    • CC: left lower leg pain since 8/8 23
      • Sudden onset of Lt lower leg pain & unable to walk, she went to FuJen Catholic University Hospital ER 20230809 CT: soft tissue mass in left pelvic side wall with total encasement of left common and internal iliac artery and vein.
      • Explorative laparoscopic surgery pathology: high-grade B-cell lymphoma.
    • Findings - Comparison: prior CT from FuJen Catholic University Hospital dated 2023/08/09.
      • Prior CT identified lobulated soft tissue masses in left side pelvis with total encasement of left common, internal, and external iliac artery and vein is noted again, mild increasing in size that is c/w malignant lymphoma.
        • In addition, there is filling defects at left common iliac vein, left external iliac vein, and left superficial femoral vein that are c/w thrombosis.
      • There is mild left side hydroureteronephrosis that is c/w malignant lymphoma with left M3 ureter encasement.
      • There are enlarged nodes in para-aortic space and para-cava space that are c/w malignant lymphoma.
      • There is mild ascites and smudgy appearance of the omentum.
        • Please correlate with ascites cytology.
      • The urinary bladder shows mild right lateral deviation and S/P Foley’s catheter insertion.
      • The gallbladder shows distension and a linear calcification (1 cm in length) within the wall.
      • There is small amount right side Pleura effusion.
    • Impression:
      • Malignant lymphoma in left side pelvis.
      • There is mild left side hydroureteronephrosis that is c/w malignant lymphoma with left M3 ureter encasement.
      • There are enlarged nodes in para-aortic space and para-cava space that are c/w malignant lymphoma.
      • There is mild ascites and smudgy appearance of the omentum. Please correlate with ascites cytology.
  • 2023-08-24 CXR (erect)
    • Hypo-inflation of both lung is noted.
    • Atherosclerotic change of aortic arch
  • 2023-08-24 ECG
    • Sinus tachycardia
    • Nonspecific ST and T wave abnormality
  • 2023-08-24 CXR (erect)
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
  • 2023-08-24 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (70 - 27) / 70 = 61.43%
      • M-mode (Teichholz) = 61
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Mild MR, trivial TR
      • Preserved RV systolic function
  • 2023-08-22 PET scan
    • A large glucose hypermetabolic lesion in the pelvic cavity with extension to the sacrum and the soft tissue of left upper thigh, compatible with lymphoma.
    • Glucose hypermetabolism in some paraaortic and common iliac lymph nodes, in a focal area in the right anterior upper abdominal cavity and in the T9 spine. Lymphoma should be considered first.
    • Mild glucose hypermetabolism in the right anterior pelvic wall. The nature is to be determined (inflammatory process? lymphoma? other nature?). Please correlate with other clinical findings for further evaluation.
  • 2023-08-21 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
    • Specimen submitted in B5 fixative consists of 1 piece(s) of tan, rod shape bone marrow tissue measuring 2.3 x 0.2 x 0.2 cm. All for section in one cassette after decalcification.
    • Section shows piece(s) of bone marrow with 45% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.

[MedRec]

  • 2023-10-21 SOAP Neurology Zou ChuYin
    • S: CC: tingling senssation and numbness for 3 weeks
    • O: NCV:
      • Absence of signal in left peroneal, tibial & sural nerve, in favor of left Lumbosacral plexopathy
      • lumbosacral radiculopathy, right side.
  • 2023-10-14 SOAP Dermatology Wang ChunHua
    • S
      • dyskeratotic nails on bil feet and hands for yrs, scaling(+), itching(+), local painful(+)
      • Erythematous patches on trunk and inguinal area for yrs, ringwarm(+)
      • T unguin was Dx and Tx at LMD for yrs, poor response to topical drugs
      • Heavy scaling over erythematous patchs on scalp, and eyelid and nasolabial fold with moderate itching
    • Prescription
      • Asthan (ketotifen 1mg) 1# BID
      • Zalain Cream (sertaconazole nitrate) BID TOPI
  • 2023-10-06 ~ 2023-10-14 POMR Hemato-Oncology He JingLiang
    • Course of inpatient treatment
      • After be admitted, she received C1 R-DA-EPOCH Q3W on 2023/10/06-10/10, Imperan for vomiting, Vemlidy for Anti-HBc: positive, the lab of GPT level elevation (GPT: 54 U/L), so gave Bao-gan treatment.
      • She suffered from fever without chillness (BT: 38’C), CRP level elevation (CRP: 9.1 mg/dl) before chemotherapy, so inform to the visiting staff about the patient’s condition, CRP level elevation, and fever noted, then the visiting staff expressed tumor fever high likely, so the chemotherapy kept going.
      • Followed-up urine routine not urinary tract infection signs. After chemotherapy, she denied having a fever, chillness, vomiting, or diarrhea. Consulted Chinese Medicine for Comprehensive protocol of integrated Chinese and western medicine. She suffered from hoarseness, and left foot walk lamely noted, so eduation to drink more water, and consulted Rehabilitation Department for rehabilitation, Neurology for Neurological physical examination, followed-up MNCV (lower limbs), SNCV, F wave, H reflex was done on 2023/10/13, the report pending.
      • The symptom of hoarseness improved. The lab of BSC showed poor liver function (ALT: 67U/L), so gave Bao-gan treatment. After treatment, the symptom of poor liver function improved (ALT: 67 -> 48U/L).
      • She suffered from pustules around anus, so gave Excelderm plus Mycomb using.
      • The GCSF 250mcg will given for 3 days (2023/10/14-10/16) due to prevention leukocytopenia.
      • Under the stable stable, she can be discharged on 2023/10/14, the OPD follow-up will be arranged.
    • Discharge prescription
      • Exelderm Cream (sulconazole nitrate) BID EXT
      • Mycomb Cream (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
      • Ulstop (famotidine 20mg) 1# BID
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Through (sennoside 12mg) 2# HS
      • Gasmin (dimethylpolysiloxane 40mg) 1# TID
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
      • diphenidol 25mg 1# TID
      • Eurodin (estazolam 2mg) 1# HS
      • BaoGan (silymarin 150mg) 1# TID
  • 2023-08-19 ~ 2023-09-22 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • High-grade B-cell lymphoma over left pelvis, extending to L5 level and compression of nerve root of left sacrum, swelling and paralysis of left lower limb; osteolytic lesion over left sacrum and SI joint, ECOG 2.
      • Other bacterial infections of unspecified site
      • Tinea corporis
      • port-a catheter insertion at left subclavicular on 2023/8/24.
      • hypokalemia
      • hypomagnesemia
      • Port-a insertion at left superior vena cava on 2023/8/24
    • CC
      • left lower leg pain since 2023-08-08
    • Present illness
      • This is a 65 years old female patient, denied any systemic disease.
      • Beacuse of sudden onset of left lower leg pain and unable to walk, she went to see FuRen Univ Hospital ER and suspected of abdominal abscess and she was admitted.
      • 2023/08/18 lab data at FuRen U Hospital: WBC 11.25k, Hb: 9.6, Plt: 324k, ALT: 22, Bil: 0.49, LDH: 607, Cr: 0.8, Na: 133, K: 3.6, Ca: 8.2, CRP 16
      • Patho S2310863 (at FuRen U Hospital)
        • DIAGNOSIS
          • Soft tissue, pelvis, left side, explorative laparoscopic surgery, high-grade B-cell lymphoma
        • MACROSCOPY
          • Specimen size: 5 fragments, up to 1.4 x 1 x 0.6 cm
          • Specimen features: brown and soft All for section.
          • Jar 0 Immunostain for CD3, CD20, Ki-67, CD10, BCL6, Mum1, BCL2, c-Myc, CD5, CD30, cyclin D1, TdT are performed.
        • MICROSCOPY
          • Sections show fibroadipose tissue diffusely infiltrated by abnormal lymphoid cells. There is prominent and extensive crush artifact. In the areas where cellular morphology are better preserved, the abnormal cells are found to be medium to large sized, moderately pleomorphic, with fine to vesicular chromatin and one to three nucleoli.
          • The tumor cells are positive for CD20 while negative for CD3, and Ki-67 labeling index is 95%. It is consistent with high-grade B-cell lymphoma.
          • The tumor cells are positive for CD10, while a few cells are positive for BCL6 or Mum1. It is consistent with germinal center phenotype.
          • The tumor cells are positive for BCL2, and 90% of the tumor cells are positive for c-Myc. Considering the high grade feature, germinal center phenotype, high Ki-67 and c-Myc labeling, some Burkitt-like features are present; however, the cells are not typical blastoid in morphology, and they are BCL2 positive, favoring DLBCL. A high-grade B-cell lymphoma with MYC and BCL2 rearrangements cannot be excluded.
          • FISH analysis for BCL2, BCL6 and MYC are performed, and the result will be sissued in an addendum.
          • The tumor cells are negative for CD5, CD30, cyclin D1 and TdT.
      • She had intermittent low grade fever during admission there. Because of difficult urination, foley was indwelled at that time. She denied abdominal pain, nausea, vomiting nor changes in stool color. She had loss of appetite but currently no weight loss. She also had a habit of constipation and need to use laxative.
      • After doing laparoscopic exploration, B-cell lymphoma was diagnosed at the pathology report. So, she was transferred to our hospital. She denied At our ER, vital signs showed BP 178/98 mmHg; HR 125 bpm; BT 37.5’C; RR 20 bpm; Con’s: E4V5M6, SPO2 96%, antibiotic treatment with Brosym.
      • Under the impression of B-cell lymphoma. she was admitted to our ward for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, Brosym was administered as prophylaxis due to high CRP level. Then, check blood tests and imaging tests including Cardiac echo and PET scan.
      • PET (2023/08/22) revealed
        • A large glucose hypermetabolic lesion in the pelvic cavity with extension to the sacrum and the soft tissue of left upper thigh, compatible with lymphoma.
        • Glucose hypermetabolism in some paraaortic and common iliac lymph nodes, in a focal area in the right anterior upper abdominal cavity and in the T9 spine. Lymphoma should be considered first.
        • Mild glucose hypermetabolism in the right anterior pelvic wall. The nature is to be determined (inflammatory process? lymphoma? other nature?).
        • Please correlate with other clinical findings for further evaluation.
      • Heart echo (2023/08/24): LVEF(%): 61%.
        • Adequate LV systolic function with normal resting wall motion.
        • Mild MR, trivial TR.
        • Preserved RV systolic function.
      • Then, palliative radiotherapy to left pelvic mass, left sacrum and SI joint for 2500cGy/10 fx was started 2023-08-23 for pain and symptom control. CT simulation is arranged on Aug 21 13:30. Possible side effect is told.
      • Self-paid Calcium carbonate 1# TID, self-paid Febuxostat 1# QD, Calgon 1 vial stat and supplement hydration NS 1# QD to 1# BID were given for prophylactic tumor lysis syndrome.
      • Record lower legs circumference daily.
      • Vemlidy 1# QD was added due to anti-HBc reactive.
      • Port-A installation was done on 2023-08-24.
      • Then, Chemotherapy R-CEOP regimen was started on 2023-08-25.
      • After first cylce, a sudden onset of abdominal pain, chills during mabthera infusion occurred.
      • The emergent CT abdomen revealed malignant lymphoma in left side pelvis.
        • There is mild left side hydroureteronephrosis that is c/w malignant lymphoma with left M3 ureter encasement.
        • There are enlarged nodes in para-aortic space and para-cava space that are c/w malignant lymphoma.
        • There is mild ascites and smudgy appearance of the omentum.
      • Therefore, acute infusion reaction ws noted. The mabthera infusion was stopped. The chemotherapy was still ongoing.
      • Due to elevation of D-dimer, we added Lixiana (edoxaban) 1# QD on 2023/08/26-08/31.
      • Febuxostat was discontiuned on 2023-08-28 after urine acid dropped.
      • Bed-side PT rehabilitation was consulted.
      • The lab of CBC/DC showed neutropenia, and anemia (WBC: 450/uL, band: 2.4%, neutrophil: 28.1%, ANC: 137.25, Hb:8.6mg/dL), so gave blood transfusion with LPRBC, Granocyte 250mcg SC QD x3 days (9/5-9/7 23), Cefim 2000 mg IVD Q8H for prevention infection, and protective isolation.
      • The complaints abdomen bloating, so the radiotherapy (2500cGy, 8/10 fx) was stopped due to severe gastrointestinal discomfort, and neutropenia on 2023/09/05.
      • The lab of eletrolecty showed imblance (K: 3.1mmol/L, Mg: 1.8mg/dL), so gave 0.298% KCL in N/S 500ml QD, Const-K 1# QD. MgO 1# TID. Education diet with orange juice, banana.
      • She complaints dry cough, gave Z-cough plus Cough Mixture 5ml PRNQ8H.
      • After treatment, the symptom of neutropenia, and anemia improved (BC: 450 -> 4600/uL, band: 2.4 -> 4.2%, neutrophil: 28.1 -> 48.90%, ANC: 137.25 -> 2442, Hb:8.6 -> 9.9mg/dL), and the gastrointestinal discomfort became better.
      • She received C2 R-CHOP on 2023/09/12, and gave GCSF 250mcg x3 days (9/14-9/16 23).
      • When the GCSF 250mcg was given once, the lab of WBC level up to 41140/uL (9/15 23), so stopped to give GCSF.
      • And she complaints dry cough, so gave antitussives treatment. After treatment, the symptom of dry cough improved.
      • Then, re followed-up the lab of WBC level drop to 1530/uL (9/20 23), so gave GCSF 250mcg x3 days on 2023/9/20-9/22.
      • Now, the lab of WBC level up to 2110/uL (9/22 23), and complaints shortness of breathing when she is walking hard, but take a rest, the respiratory pattern become smooth, followed-up chest x-ray not pneumonia, not pleural effusion.
      • The patient, family request to discharge. Under the condition become smooth, she can be discharged on 2023/09/22, the OPD follow-up will be arranged.
    • Discharge prescription
      • Cardiolol (propranolol 10mg) 0.5# QD
      • Cough Mixture (platycodon) 5mL PRNQ8H
      • diphenidol 25mg 1# TID
      • Eurodin (estazolam 2mg) 1# PRNHS
      • Gaslan (dimethylpolysiloxane 40mg) 2# TID
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
      • Lactul (lactulose 666mg/mL) 10mL QD
      • Through (sennoside 12mg) 2# HS
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Norvasc (amlodipine 5mg) 1# QN
      • Ulstop (famotidine 20mg) 1# BID
  • 2023-08-18 SOAP Medical Emergency Wu MengYu
    • S: 8/18 lab data at FuRen Uni Hosp: WBC 11.25k, Hb: 9.6, Plt: 324k, ALT: 22, Bil: 0.49, LDH: 607, Cr: 0.8, Na: 133, K: 3.6, Ca: 8.2, CRP 16
      • Pathology S2310863
        • DIAGNOSIS
          • Soft tissue, pelvis, left side, explorative laparoscopic surgery, high-grade B-cell lymphoma
        • MACROSCOPY
          • Specimen size: 5 fragments, up to 1.4 x 1 x 0.6 cm
          • Specimen features: brown and soft All for section.
          • Jar 0 Immunostain for CD3, CD20, Ki-67, CD10, BCL6, Mum1, BCL2, c-Myc, CD5, CD30, cyclin D1, TdT are performed.
        • MICROSCOPY
          • Sections show fibroadipose tissue diffusely infiltrated by abnormal lymphoid cells. There is prominent and extensive crush artifact. In the areas where cellular morphology are better preserved, the abnormal cells are found to be medium to large sized, moderately pleomorphic, with fine to vesicular chromatin and one to three nucleoli.
          • The tumor cells are positive for CD20 while negative for CD3, and Ki-67 labeling index is 95%. It is consistent with high-grade B-cell lymphoma.
          • The tumor cells are positive for CD10, while a few cells are positive for BCL6 or Mum1. It is consistent with germinal center phenotype.
          • The tumor cells are positive for BCL2, and 90% of the tumor cells are positive for c-Myc. Considering the high grade feature, germinal center phenotype, high Ki-67 and c-Myc labeling, some Burkitt-like features are present; however, the cells are not typical blastoid in morphology, and they are BCL2 positive, favoring DLBCL. A high-grade B-cell lymphoma with MYC and BCL2 rearrangements cannot be excluded.
          • FISH analysis for BCL2, BCL6 and MYC are performed, and the result will be sissued in an addendum.
          • The tumor cells are negative for CD5, CD30, cyclin D1 and TdT.
    • A: Preliminary Impression: C85.10 Unspecified B-cell lymphoma, unspecified site

[consultation]

  • 2023-10-12 Neurology
    • Q
      • for Neurological physical examination
      • This is a 65 years old female patient with diagnosis of high grade B lymphoma, s/p chemotherapy, radiotherapy. Due to tumor on pelvis, so her left leg swelling, and muscle power: RL/LL 5/4+, she can walk with walker. But left foot walk lamely. Therefore, please kindly refer this patient for Neurological physical examination.
    • A
      • left leg weakness since 2023/08/08, partially improved
        • Muscle power of left leg: proximal:3, distal:0
        • DTR: (-)
      • Plan:
        • arrange MNCV (lower limb), SNCV, F wave, H reflex
  • 2023-09-01 Dermatology
    • Q
      • for skin impetigo over left knee & buttock
      • This 65-year-old woman, a patient of large B cell lymphoma S/P C/T. She complained of skin impetigo over left knee & buttock for days. We need expertise to evaluate her condition thanks !
    • A
      • This patient suffered from multiple erytehamtous papules on buttock and limbs for days.
      • Imp:
        • Tinea corporis
      • Suggestion:
        • Excelderm x 1 tubes/bid
        • Mycomb x 2 tubes/bid

[immunochemotherapy]

  • 2024-02-27 - rituximab 375mg/m2 550mg NS 500mL 8hr D1 + etoposide 50mg/m2 70mg doxorubicin 10mg/m2 14mg vincrestine 0.4mg/m2 0.5mg NS 1000mL 24hr D1-4 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D5 + prednisolone 60mg/m2 40mb BID PO D1-5 (R-da-EPOCH Q3W)
    • dexamethasone 4mg D1 + diphenhydramine 30mg D1,4 + palonosetron 250ug D1,4 + aprepitant 125mg PO D1 + acetaminophen 500mg PO D1 + NS 250mL D1,4
  • 2024-01-24 - rituximab 375mg/m2 550mg NS 500mL 8hr D1 + etoposide 50mg/m2 70mg doxorubicin 10mg/m2 14mg vincrestine 0.4mg/m2 0.5mg NS 1000mL 24hr D1-4 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D5 + prednisolone 60mg/m2 40mb BID PO D1-5 (R-da-EPOCH Q3W)
    • dexamethasone 4mg D1 + diphenhydramine 30mg D1,4 + palonosetron 250ug D1,4 + aprepitant 125mg PO D1 + acetaminophen 500mg PO D1 + NS 250mL D1,4
  • 2023-12-26 - rituximab 375mg/m2 550mg NS 500mL 8hr D1 + etoposide 50mg/m2 70mg doxorubicin 10mg/m2 14mg vincristine 0.4mg/m2 0.5mg NS 1000mL 24hr D1-4 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D5 + prednisolone 60mg/m2 40mb BID PO D1-5 (R-da-EPOCH Q3W)
    • dexamethasone 4mg D1 + diphenhydramine 30mg D1,4 + palonosetron 250ug D1,4 + aprepitant 125mg PO D1 + acetaminophen 500mg PO D1 + NS 250mL D1
  • 2023-11-27 - rituximab 375mg/m2 550mg NS 500mL 8hr D1 + etoposide 50mg/m2 70mg doxorubicin 10mg/m2 14mg vincristine 0.4mg/m2 0.5mg NS 1000mL 24hr D1-4 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D5 + prednisolone 60mg/m2 40mb BID PO D1-5 (R-da-EPOCH Q3W)
    • dexamethasone 4mg D1 + diphenhydramine 30mg D1,4 + palonosetron 250ug D1,4 + aprepitant 125mg PO D1 + acetaminophen 500mg PO D1 + NS 250mL D1
  • 2023-11-02 - rituximab 375mg/m2 540mg NS 500mL 6hr D1 + etoposide 50mg/m2 70mg doxorubicin 10mg/m2 14mg vincristine 0.4mg/m2 0.5mg NS 1000mL 24hr D1-4 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D5 + prednisolone 60mg/m2 40mg BID PO D1-5 (R-da-EPOCH Q3W)
    • dexamethasone 4mg D1 + diphenhydramine 30mg D1,4,5 + palonosetron 250ug D1,4,5 + aprepitant 125mg PO D1 + acetaminophen 500mg PO D1 + NS 250mL D1,5
  • 2023-10-06 - rituximab 375mg/m2 540mg NS 500mL 6hr D1 + etoposide 50mg/m2 70mg doxorubicin 10mg/m2 14mg vincristine 0.4mg/m2 0.5mg NS 1000mL 24hr D1-4 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D5 + prednisolone 60mg/m2 40mg BID PO D1-5 (R-da-EPOCH Q3W)
    • dexamethasone 4mg D1 + diphenhydramine 30mg D1-5 + palonosetron 250ug D1-5 + aprepitant 125mg PO D1 + acetaminophen 500mg PO D1 + NS 250mL D1,5
  • 2023-09-12 - rituximab 375mg/m2 530mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + epirubicin 60mg/m2 80mg NS 100mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (RCHOP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL
  • 2023-08-24 - rituximab 375mg/m2 530mg NS 500mL 8hr + cyclophosphamide 750mg/m2 900mg NS 250mL 30min + epirubicin 60mg/m2 70mg NS 100mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (RCHOP Q3W, Endoxan and Epicin 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL

dose-adjusted (da)-R-EPOCH - Infusional etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R) for non-Hodgkin lymphoma - 2024-01-25 - https://www.uptodate.com/contents/image?imageKey=ONC%2F88411

  • Cycle length:
    • 21 days.
  • Regimen
    • Rituximab
      • 375 mg/m2 IV
      • Dilute in NS or D5W to a final concentration of 1 to 4 mg/mL. Initial infusion: Start at 50 mg/hour; escalate in 50 mg/hour increments every 30 minutes to a maximum of 400 mg/hour, as tolerated. In the absence of an initial infusion reaction, for subsequent infusions, administer 20% of the total dose over the first 30 minutes and the remaining 80% over 60 minutes, as tolerated. The 90-minute infusion schedule should NOT be used in patients who have clinically significant cardiovascular disease or have a circulating lymphocyte count ≥5000/microL.
      • Day 0 or 1
    • Etoposide
      • 50 mg/m2 per day IV
      • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
      • Days 1 to 4 (96 hours)
    • Doxorubicin
      • 10 mg/m2 per day IV
      • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
      • Days 1 to 4 (96 hours)
    • Vincristine
      • 0.4 mg/m2 per day IV (dose not capped)
      • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
      • Days 1 to 4 (96 hours)
    • Cyclophosphamide
      • 750 mg/m2 IV
      • Dilute with 250 mL NS or D5W and administer over 30 minutes.
      • Day 5
    • Prednisone
      • 60 mg/m2 orally twice daily
      • Administer first dose 30 minutes prior to chemotherapy on day 1.
      • Days 1 to 5
    • Granulocyte colony stimulating factor (G-CSF)
      • Start day 6

==========

2024-02-27

[anemia]

Lab results obtained on 2024-02-26 were unremarkable except for a stool occult blood test 1+ and anemia (HGB 7.7 g/dL). The anemia was subsequently addressed with a LPRBC transfusion.

No lab findings were identified that would preclude administration of the R-da-EPOCH regimen.

2024-01-25

[monitoring iron levels in this frequent transfusion patient]

The laboratory results suggest a consistent pattern of microcytosis/microcytic anemia. This patient has been receiving multiple blood transfusions approximately monthly since Sep 2023. Given this history, it is advisable to assess iron storage to evaluate for potential iron overload if clinically necessary.

  • 2024-01-24 RBC 3.67 x10^6/uL
  • 2024-01-24 HGB 8.8 g/dL
  • 2024-01-24 HCT 28.1 %
  • 2024-01-24 MCV 76.6 fL

2023-12-27

[reconciliation]

Lab results obtained on 2023-12-26 revealed no significant abnormalities that would contraindicate the continuation of the R-da-EPOCH regimen. Additionally, comprehensive medication reviews using HIS5 and PharmaCloud identified no discrepancies in the current medication list.

2023-11-28

[prophylactic G-CSF for post-chemotherapy leukopenia]

The patient was admitted to begin the 3rd cycle of R-da-EPOCH chemotherapy on 2023-11-27. Based on the experiences from cycles 1 and 2 of this regimen, leukopenia may occur following this administration. Prophylactic G-CSF can be prescribed for standby use.

  • 2023-11-27 WBC 4.93 x10^3/uL
  • 2023-11-15 WBC 0.46 x10^3/uL ** R-da-EPOCH C2 on 11/02
  • 2023-11-09 WBC 3.51 x10^3/uL
  • 2023-11-02 WBC 6.38 x10^3/uL
  • 2023-10-24 WBC 8.79 x10^3/uL
  • 2023-10-17 WBC 0.83 x10^3/uL ** R-da-EPOCH C1 on 10/06
  • 2023-10-13 WBC 6.96 x10^3/uL
  • 2023-10-11 WBC 4.58 x10^3/uL

2023-10-09

There are no medication reconciliation issues after review of PhamaCloud and HIS5 records.

The patient has received two cycles of R-CHOP treatment and has then transitioned to DA-R-EPOCH treatment as of 2023-10-06. It is believed that the new treatment, R-DA-EPOCH, is more effective but also carries a higher risk of toxicity. As the patient has recently started this new regimen, please closely monitor for any signs of adverse reactions. Ref: DA-R-EPOCH vs R-CHOP in DLBCL: How do we choose? Clin Adv Hematol Oncol. 2021 Nov;19(11):698-709. PMID: 34807015; PMCID: PMC9036549.

2023-09-12

An episode of leukopenia was observed on 2023-09-05, approximately two weeks after the patient’s initial R-CHOP regimen administered on 2023-08-24. Prompt intervention with a consecutive 3-day course of G-CSF was initiated, and since then, no further instances of leukopenia have been detected.

  • 2023-09-11 WBC 6.10 x10^3/uL
  • 2023-09-08 WBC 4.60 x10^3/uL
  • 2023-09-05 WBC 0.45 x10^3/uL * Granocyte (lenograstim 250ug) x 3 days
  • 2023-09-01 WBC 4.23 x10^3/uL
  • 2023-08-28 WBC 4.91 x10^3/uL
  • 2023-08-25 WBC 15.59 x10^3/uL
  • 2023-08-24 WBC 15.94 x10^3/uL
  • 2023-08-21 WBC 20.57 x10^3/uL

701025993

240227

[lab data]

2023-12-06 P.jiroveci DNA-Sp Positive
2023-12-04 CMV viral load assay Target not detecetedIU/mL
2023-11-30 Aspergillus Ag Negative
2023-11-30 Aspergillus Ag Value 0.1 Ratio
2023-11-29 ANA Negative
2023-11-29 Mycoplasma pneumonia IgG Negative AU/mL
2023-11-29 Mycoplasma IgG Valu <10 AU/ml
2023-11-28 Anti-ds DNA Antibody <0.6 IU/ml
2023-11-28 Anti-ENA SS-A (Ro) <0.4 EliA U/ml
2023-11-28 Anti-ENA SS-B (La) <0.3 EliA U/ml
2023-11-28 Anti Jo-1 antibody <0.3 EliA U/ml
2023-11-28 Anti-ENA Scl-70 Ab <0.6 EliA U/ml
2023-11-28 Anti-ENA Sm <0.8 EliA U/ml
2023-11-28 Anti-ENA RNP <0.5 EliA U/ml
2023-11-28 Cryptococcus Ag Negative
2023-11-28 RF <10 IU/mL
2023-11-26 COVID19新冠肺炎病毒抗原快篩 Negative
2023-11-26 Influenza A Ag Negative
2023-11-26 Influenza B Ag Negative

2023-08-08 Anti-HCV (NM) Negative
2023-08-08 Anti-HCV Value (NM) 0.042
2023-08-08 Anti-HBc (NM) Negative
2023-08-08 Anti-HBc Value (NM) 2.360
2023-08-08 Anti-HBs (NM) Positive
2023-08-08 Anti-HBs value (NM) 210.000 mIU/mL
2023-08-08 HBsAg (NM) Negative
2023-08-08 HBsAg Value (NM) 0.432

[exam findings]

  • 2024-02-19 Bone densitometry - spine
    • L-spines BMD performed by DXA revealed:
      • AP L-spines, BMD of L1-4 is 0.900 gms/cm2, about 1.1 SD below the peak bone mass (88%) and 0.3 SD below the mean of age-matched people (95%).
    • Impression:
      • Osteopenia
  • 2024-01-22 Bone densitometry - spine
    • L-spines BMD (AP view) performed by DXA revealed:
      • AP L-spines, BMD of L1-4 0.880 gms/cm2, about 1.3 SD below the peak bone mass (86%) and 0.5 SD below the mean of age-matched people (93%).
    • IMP: osteopenia
  • 2024-01-16 Gynecologic Ultrasonography
    • IMP: Uterine myoma
  • 2024-01-03 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 19) / 80 = 76.25%
      • M-mode (Teichholz) = 77
    • Conclusion:
      • Adequate LV, RV systolic function with normal wall motion
      • Impaired LV relaxation
  • 2023-12-14 CXR + Lat Rt
    • Scoliotic alignment of the thoracolumbar spine is noted.
  • 2023-12-12 CT - chest
    • Indication
      • Lt breast ca s/p partial mastectomy + ALND on 2023-07-28
      • adjuvant C/T with E(lipodox)C ->T, since 2023-08-16
    • Findings: comparison prior CT on 2023/11/26
      • lungs: normal appearance of both lungs.
      • Mediastinum and hila: no enlarged LNs or mass.
      • Thoracic aorta: normal caliber,Central pulmonary arteries: normal caliber.
      • Heart: normal size of cardiac chambers. well myocardial enhancement.
      • Pleura: no effusion.
      • Chest wall and visible lower neck: no abnormal enhancing lesion in the breasts. no enlarged LN.
      • Visible abdominal contents: unremarkable of the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys.
      • no enlarged lymph node. no ascites.
      • marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • no abnormality of both lungs in this F/U CT.
  • 2023-12-02, -11-29, -11-26 CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2023-11-29 Bronchodilator Test
    • Mild restrictive ventilatory impairment
    • without significant bronchodilator response
    • please correlated with clinical condition
  • 2023-11-27 CT - chest
    • Indication: left breast cancer s/p chemotherapyr/o ILD
    • Findings
      • lungs: extensive, upper lung predominant, extensive ground glass opacity and consolidation, in both lungs, assoicated septal thickening.
      • Mediastinum and hila: a few slighlty enlarged LNs in the visceral space.
      • Thoracic aorta: normal caliber,Central pulmonary arteries: normal caliber.
      • Heart: normal size of cardiac chambers. well myocardial enhancement.
      • Pleura: trace Rt-sided effusion.
      • Chest wall and visible lower neck: abnormal enhancing lesion in the breasts
      • unremarkable of the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys.
      • arginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • Lung parenchymal and interstial proces, drug-related toxicity r/o infection.
  • 2023-11-26 ECG
    • Sinus tachycardia
    • Possible Left atrial enlargement
  • 2023-10-16 Patho - endometrium curretage/biopsy
    • Uterus, endometrium, D&C — endometrial hyperplasia,without atypia
  • 2023-10-05 ECG
    • Normal sinus rhythm
    • Increased R/S ratio in V1, consider early transition or posterior infarct
    • Abnormal ECG
  • 2023-09-27, -09-02 Gynecologic Ultrasonography
    • IMP: Uterine myoma
  • 2023-07-28 Patho - breast mastectomy with regional lymph nodes
    • PATHOLOGIC DIAGNOSIS
      • Tumor, left breast, frozen + partial mastectomy —- Invasive carcinoma of no special type, multifocal
        • Resection margins, ditto — Free of tumor invasion
      • Sentinel lymph node, L’t axilla, frozen — Tumor metastasis (1/6)
        • Non-sentinel lymph node, L’t axilla, frozen — Fat only
      • Left axilla LNs, dissection — Free of tumor metastasis (0/5)
      • AJCC Pathologic Anatomic Stage — pT2N1a, if cM0, stage IIB and Prognostic Stage — Stage IB
    • MACROSCOPIC EXAMINATION
      • Breast size: 7.2 x 4.8 x 3.0 cm
      • Skin size: 5.4 x 1.3 cm
      • Nipple: Not received
      • Tumor: 2.1 x 2.0 cm
      • Resection margins: Free, 0.9 cm from closest 6 o’clock margin
      • Lymph node: L’t axillary lymph nodes
      • All embedded for sections as A1-A2: L’t axillary LNs [Reference: F2023-00339 frozen, FSA: 6 o’clock margin (ink) + base and A1-A3: tumor, A4: non-tumor, A5: skin and X: 12 o’clock (blue ink) + 3 o’clock + 9 o’clock (yellow ink) margin, FSB: L’t axillary sentinel lymph node, FSC: L’t axillary non-sentinel lymph node]
    • MICROSCOPIC EXAMINATION
      • Histologic type: multifocal invasive carcinomas of no special type
      • Size of invasive carcinoma: up to 2.1 x 2.0 cm
      • Histologic grade (Nottingham histologic score): Grade II (score 6) including [(A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1]
      • Margins: Free of tumor invasion
      • Nodal status: tumor metastasis (1/11) in total number, without extracapsular extension (0/1)
      • Treatment Effect: N/A
      • Lymphovascular space invasion: Present
      • Perineural invasion: Present
      • Immunohistochemistry: ER(2~3+, 90%), PR(1~2+, 30-40%), HER2/neu(-, Dako score 1+) and Ki-67: 5-10% and P63(-) for tumor
  • 2023-07-08 Frozen Section
    • Margins, left breast, frozen — Free of tumor invasion, 0.9 cm from closest 6 o’clock margin
    • Sentinel lymph node, frozen — Tumor metastasis (1/6)
    • Non-sentinel lymph node, frozen — Fat only
  • 2023-07-28 Lymphoscintigraphy
    • Probably two sentinel lymph nodes at the left axillary region.
  • 2023-07-27 MRI - breast
    • Left breast malignancy.
    • Left internal mammary lymph node, r/o lymph node metastasis.
      • Round right axillary lymph nodes, suggest further study.
    • Right breast subareolar region oval shaped cystic tmor, 3x1.6cm.
    • Round right axillary lymph nodes, suggest further study.
    • BI-RADS: Category 6-proven malignancy.
  • 2023-07-27 SONO - abdomen
    • Diagnosis:
      • Fatty liver, mild
      • Suspected fatty infiltration of pancreas
    • Suggestion:
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • 2023-07-25 Tc-99m MDP bone scan
    • Increased activity in the lower L-spines and bilateral S-I joints. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips, knees and feet, compatible with benign joint lesions.

[MedRec]

  • 2024-02-21 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • Prescription x3
      • NS 10mL ST IVD
      • Hepac Lock Flush 100 USP units/mL 10mL ST IRRI
      • Evista (raloxifen 60mg) 1# QD
      • MgO 250mg 1# TID
      • Stilnox (zolpidem 10mg) 1# HS
  • 2024-01-31 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • S: consider TAM 5 years (raloxifen since today)
    • Prescription
      • Evista (raloxifen 60mg) 1# QD
      • MgO 250mg 1# TID
      • Stilnox (zolpidem 10mg) 1# HS
  • 2023-12-13 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • S:
      • breast lump
      • Lt breast ca(4/2) proved by CNB at ZhongShan Hospital on 2023-07-05
      • VABB for rt breast tumor (atypical ductal papilloma) at ZhongShan Hospital on 2023-07-14
      • Lt breast ca s/p partial mastectomy + ALND on 2023-07-28
      • adjuvant C/T with E(lipodox)C then T, since 2023-08-16
      • ILD after 5th adjuvant C/T
  • 2023-12-07 SOAP Chest Medicine
    • S: just discharge, still dyspean, cough, DOE less but not subsided, itching thorat few, lump thorat, GERD, rhirnohea few
    • O:
      • 2023/11/27 CT: Lung/Mediastinum/Pleura
        • Lung parenchymal and interstial proces, drug-related toxicity r/o infection.
      • 2023/11/29 Bronchodilator Test
        • Mild restrictive ventilatory impairmentwithout significant bronchodilator response (FVC 62%, FEV1 62%)
      • 2023/12/06 P.jiroveci DNA-Sp = Positive;
      • 2023/12/04 CMV viral load assay = Target not deteceted IU/mL;
      • 2023/11/30 Aspergillus Ag = Negative;
      • 2023/11/30 Aspergillus Ag Value = 0.1 Ratio;
      • 2023/11/29 ANA = Negative;
      • 2023/11/28 Anti-ds DNA Antibody = <0.6 IU/ml;
      • 2023/11/28 Anti ENA (Ro,La): Anti-ENA SS-A(Ro) = <0.4 EliA U/ml; Anti-ENA SS-B(La) = <0.3 EliA U/ml;
      • 2023/11/28 Anti-ENA (Jo-1): Anti Jo-1 antibody = <0.3 EliA U/ml;
      • 2023/11/28 Anti-ENA (Scl-70): Anti-ENA Scl-70 Ab = <0.6 EliA U/ml;
      • 2023/11/28 Anti-ENA (Sm/RNP): Anti-ENA Sm = <0.8 EliA U/ml; Anti-ENA RNP = <0.5 EliA U/ml;
      • 2023/11/28 Cryptococcus Ag = Negative;
      • 2023/11/28 RF = <10 IU/mL;
      • 2023/11/27 ESR = 15 mm/hr;
    • Prescription
      • Methylone (methylprednisolone 4mg) 1# BID
      • Allegra (fexofenadine 60mg) 1# BID
      • Actein Effervescent (acetylcysteine 600mg) 1# BID
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
      • Gasmin (dimethylpolysiloxane 40mg) 1# TID
      • Morcasin (sulfamethoxazole 400mg, trimethoprim 80mg) 2# BID
      • Stilnox (zolpidem 10mg) 1# HS
  • 2023-11-27 ~ 2023-12-04 POMR General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Left breast invasive carcinoma with left axillary lymph node metastasis. pT2N1a, if cM0, stage IB. ER(90%), PR(30-40%), HER2/neu( 1+) and Ki-67: 5-10%. ECOG:1.
      • Interstitial pulmonary disease due to chemotherapy
    • CC
      • dyspnea and severe dry cough for 3 days.
    • Present illness
      • This 44-year-old female patient denied any past history including hypertension, diabetes mellitus, hepatitis B virus or heart disease. She denied any TOCC histories in recent 3 months.
      • She was under 5th adjuvant chemotherapy on 11/16 due to left breast invasive carcinoma with left axillary lymph node metastasis. However, dyspnea and severe dry cough for 3 days. She went to ER for help. In ER, vital sign: BP:154/76mmhg; PR:151 bpm/min; BT:37.6 ℃; RR:26 bpm/min; Con’s:E4V5M6, Spo2:93%. CXR revealed ground glass opacities in bilateral lungs.
      • Under impression of pneumonia suspect interstitial pulmonary disease after chemotheray. She was admitted for treatment. Lung CT will be arrange.
    • Course of inpatient treatment
      • After admission, lung CT revealed lung parenchymal and interstial proces, drug-related toxicity r/o infection. Medason 40mg IVD Q12H and Cravit was given. O2 support due to dyspnea.
      • After condition improved, she was discharged today. OPD will be follow up.
    • Discharge prescription
      • Actein (acetylcysteine 200mg) 1# TID 7D
      • Fudecough (dextromethorphan 15mg) 1# TID 7D
      • Stilnox (zolpidem 10mg) 1# HS 7D
      • Methylone (methylprednisolone 4mg) 1# TID 2D
      • Methylone (methylprednisolone 4mg) 1# BID 2D since 2023-12-06
      • Cravit (levofloxacin 500mg) 1.5# QDAC 7D
      • Trimbow (beclometasone 100ug, formoterol 6ug, glycopyrronium 12.5ug; per dose) 2 pull BID INHL
  • 2023-11-26 SOAP Medical Emergency Li XuanQing
    • S: Triage: 2 Shortness of breath > Fever (immune function deficiency) the patient had chemotherapy last Thursday and had fever, shortness of breath, and general malaise for days.
    • O: Vital signs: BP:154/76; HR:151; BT:37.6’C; RR:26;
      • Con’s:E4V5M6
      • SpO2:93%
    • A: Preliminary impression: R50.9 Fever, unspecified
    • Prescription
      • Actein (acetylcysteine 200mg) 1# TID
      • Cravit (levofloxacin) 750mg ST & QD IVD
      • NS 500mL ST IVD run 100cc/hr
      • Acetal (acetaminophen 500mg) 1# ST
  • 2023-08-23 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • O: Conclusion of the Multidisciplinary Cancer Team Meeting, Meeting Date: 2023-08-11
      • Recommendation: Initiate treatment with EC followed by T, then R/T + H/T.
  • 2023-07-27 ~ 2023-07-29 POMR General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Left breast invasive carcinoma status post Partial mastectomy + axillary lymph node dissection  on 2023/07/28. cT2N1M0, stage IIA.ECOG:0
    • CC
      • noted a palpable mass at left breast over 2 months.
    • Present illness
      • This 44-year-old female patient denied any past history including hypertension, diabetes mellitus, hepatitis B virus or heart disease. She denied any TOCC histories in recent 3 months.
      • She noted a palpable mass at left breast over 2 months. She went to ZhongShan hospital for help. Left breast core neddle biopsy showed invasive carcinoma on 2023/07/05. ER(90%), PR(70%), HER(-),Ki67:5%. Right breast papilloma status post Vacuum-assisted breast biopsy on 2023/07/14.
      • Due to personal reason, she came to our OPD for help. Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis.
      • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
      • PE: symmetrical of bilateral breasts. Old op scar at right breast. A hard, nontender, movable mass and irregular margin at left breast around 2x2 cm without discharge. The nipple was dimping without exudative nor bloody discharge and no retraction. The left breast skin had no cellulitis change.
      • Under the impression of left breast invasive carcinoma, she was admitted for surgery of partial mastectomy + SLNB.
    • Course of inpatient treatment
      • After admission, left breast partial mastectomy + ALND was performed on 2023/07/28. The wound is clean and dry.
      • Under the stable condition, she was discharged today, wound will be follow up in OPD.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Ulstop (famotidine 20mg) 1# BID

[consultation]

  • 2024-01-03 Radiation Oncology
    • Q
      • Under impression of left breast invasive carcinoma with axillary lymph node metastasis, she was admitted for 7th adjuvant chemotherapy with 5FU 500mg/m2 + Lipo dox 35mg/m2 + Endoxan 600mg/m2. We need your help for radiotherapy schedule. Thank you so much!!
    • A
      • Objective:
        • General Condition-ECOG: 1.
        • PE, 2024/1/03: No SCF LAPs.
        • Pathology, 2023/07/28: Tumor, left breast, frozen + partial mastectomy —- Invasive carcinoma of no special type, multifocal, 2.1 x 2.0 cm, LVSI(+), PNI(+), ER(2~3+, 90%), PR(1~2+, 30-40%), HER2/neu(-, Dako score 1+) and Ki-67: 5-10%.
          • Resection margins, ditto — Free of tumor invasion; 0.9cm form 6 o’clock margin.
          • Sentinel lymph node, L’t axilla, frozen — Tumor metastasis (1/6);
          • Left axilla LNs, dissection — Free of tumor metastasis (0/5);
          • AJCC Pathologic Anatomic Stage — pT2N1a, if cM0, stage IIB and Prognostic Stage — Stage IB.
        • Images:
          • Breast MRI, 2023/07/27: There are irregular hypervascular tumor (2x1.7cm) in LOQ of left breast, 5cm from the nipple near chest wall, c/w breast malignancy. There are oval shaped tumors, 1.2cm in UIQ of left breast and 1.4cm in LIQ of left breast, suggest close follow up. Right breast subareolar region oval shaped cystic tumor, 3x1.6cm. Presence of left internal mammary lymph node (1.8cm), r/o lymph node metastasis. Left axillary lymph node. Round right axillary lymph nodes, suggest further study. IMP: 1. Left breast malignancy. 2. Left internal mammary lymph node, r/o lymph node metastasis. Round right axillary lymph nodes, suggest further study. 3. Right breast subareolar region oval shaped cystic tmor, 3x1.6cm. 4. Round right axillary lymph nodes, suggest further study.
          • CXR, Liver sonogram & Bone scan, 2023/07: negative for metastases.
          • Chest CT, 2023/11/27: Lung parenchymal and interstitial process, drug-related toxicity.
          • CA-153: 9.143 U/ml, CEA: 0.857 ng/ml. (2023/07/25)
      • Diagnosis: Left breast cancer, invasive carcinoma, pT2N1a cM0, s/p partial mastectomy + axillary lymph node dissection on 2023/07/28 s/p adjuvant C Lipo-Dox F x 4; Taxotere x 1, C Lipo-Dox F x 2, ECOG 1.
        • Interstitial lung disease due to Taxotere in 2023/11.
      • Plan: I suggested adjuvant RT to left breast & SCF lymphatics for 5000cGy/25 fx, boost scar for 1000cGy/5 fx for locoregional control.
        • CT simulation on 2024/01/16 08:30 (if chemotherapy is delayed, it will be postponed); RT will be started 2 days later. Psychosocial support and diet education.
  • 2023-11-28 Chest Medicine
    • Q
      • Surgery of left breast invasive carcinoma status post partial mastectomy + axillary lymph node dissection on 2023/07/28. Pathology report showed left breast invasive carcinoma, left axillary lymph node metastasis, Grade II, pT2N1a, if cM0, Stage IB. ER(2~3+, 90%), PR(1~2+, 30-40%), HER2/neu(-, Dako score 1+) and Ki-67: 5-10%. Adjuvant chemotherapy with Lipo dox 35mg/m2+ Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 for 4 cycles were suggest. 5th adjuvant chemotherapy with Taxotere 75mg/m2 on 11/16.
      • However, dyspnea and severe dry cough for 3 days. She went to ER for help. Arrange lung CT revealed pneumonia, suspect ILD?? We need your help for assessment. Thank you so much!!
    • A
      • Suggestions:
        • Survey:
          • Chest CT scan (done) and c/w ILD, DDX including drug related, infection and pulmonary edema.
          • Arrange pulmonary function test if condition permit
          • Survey other cause of ILD such as autoimmune: ANA, dsDNA, SSA, SSB, Scl70, Jo-1, smRNP, RF. If positive, suggest to consult Rheumatologits
          • Survey possibility of infection such as bacteria, aspergillus, Cryptococcus, PJP, CMV
          • f/u routine blood test (CBC and biochemistry) + ESR
        • Treatment:
          • Treat underlying condition as your expert
          • Oxygen therapy to keep adequate SpO2.
          • Corticosteroids: parental methylprednisolone during acute phase. Shift to oral steroid after stable condition.
          • Bronchodilator with A+B to treat dyspnea. Shift to trimbow after stable condition and maintain during OPD treatment.
          • Prevent fluid overload
  • 2023-09-27 Obstetrics and Gynecology
    • Q
      • This 44-year-old female patient under the impression of left breast invasive carcinoma, she was admitted for chemotherapy. Due to vaginal bleeding was noted for days, we need your help for assessment. Thank you so much!!      
    • A
      • This 44-year-old menopaused woman was admitted for chemotherapy under the impression of left breast invasive carcinoma. No Tamoxifen used. We were consulted for vaginal bleeding was noted for days.
      • PV: bloody vaginal discharge, cervix: grossly normal, no mass lesion
      • TVUS IMP: Multiple myomas, Endometrium Thickness: 6.6 mm
      • Suggestion:
        • Symptomatic treatment firstly: Transamin 500mg Q8H till symptom improve
        • GYM OPD f/u after discharged.
        • Diagnostic D&C may be considered if persistent symptoms.
  • 2023-08-14 Dentistry
    • Q
      • This 44-year-old female patient under the impression of left breast invasive carcinoma, she was admitted for chemotherapy.
      • Complaint of upper gum pain. We need your help for assessment before chemotherapy. Thank you so much!!
    • A
      • S: complaint gum boil over UA area off and on.
      • O:
        • FM chrinic periodontiutis with calculus deposition,
        • #22: post endo-tx without crown protection,
        • #26: ill-fitting crown.
      • A: 522.6
      • P:
        • take panox1 for check up.
        • #22: suggest micro-re-endo-tx at endo-OPD.
        • #26: suggest remove and further evalaution and tx.
        • suggest keep f/u every 6 months.

[chemotherapy]

  • 2024-01-04 - fluorouracil 500mg/m2 870mg NS 100mL 30min + liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 500mg/m2 870mg NS 500mL 1hr (FAC(lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL + Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO
  • 2023-12-13 - fluorouracil 500mg/m2 870mg NS 100mL 30min + liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 500mg/m2 870mg NS 500mL 1hr (FAC(lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL + Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO
  • 2023-11-16 - docetaxel 75mg/m2 129mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + famotidine 20mg + NS 250mL (D Q3W)
  • 2023-10-25 - cyclophosphamide 600mg/m2 1025mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 59mg D5W 250mL 2hr (AC(Lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-09-27 - cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr (AC(Lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-09-06 - cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr (AC(Lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-08-16 - cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr (AC(Lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

2023-11-30

[addressing post-chemotherapy respiratory distress and leukopenia]

Currently, there are no recent daily progress notes in HIS5 found.

Should there be recent occurrences of dyspnea, respiratory distress, or shortness of breath, it’s important to note that the last chemotherapy session with docetaxel was on 2023-11-16, about two weeks ago. Therefore, it is less probable that these symptoms are directly caused by the chemotherapy (hypersensitivity). However, docetaxel has also been linked to pulmonary disease, unspecified, with a reported incidence rate of 41% (Ref: UpToDate).

Another potential cause that cannot be overlooked is the earlier administration of cyclophosphamide, a component of the AC(Lipo) regimen. This drug has been associated with pulmonary toxicity, manifesting in various forms such as pneumonitis, pulmonary fibrosis, pulmonary veno-occlusive disease, and acute respiratory distress syndrome. Identifying pulmonary toxicity can be challenging due to overlapping pulmonary conditions in the same patient population, including infections and pulmonary malignancies. Symptoms of this toxicity typically include dyspnea, fever, cough, parenchymal infiltrates, abnormal pulmonary function tests, and pleural thickening.

If nonspecific interstitial pneumonia (NSIP) has been confirmed (and assuming that infection has been completely excluded as a cause), it is recommended to begin with prednisone 0.5 to 1 mg/kg ideal body weight per day up to a maximum of 60 mg/day for one month followed by 30 to 40 mg/day for an additional two months.

For patients with severe NSIP, pulse intravenous methylprednisolone may be preferred for initial therapy. A typical regimen is 1000 mg/day for three days followed by oral prednisone as dosed above. Rarely, patients need additional pulse doses.

Additionally, there was an episode of leukopenia in late Nov (WBC counts 1.69K/uL on 2023-11-22 and 2.84K/uL on 2023-11-26), which might have been caused by the administration of docetaxel. It may be an option to prepare prophylactic G-CSF for use after the next chemotherapy session.

701343379

240227

[exam findings]

  • 2024-02-15 Gynecologic Ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2024-01-17 CT - abdomen
    • Findings: Comparison prior CT dated 2023/08/01.
      • Prior CT identified a soft tissue nodule 6 mm in the omentum at left middle pelvis is noted again, mild increasing in size to 9 mm (Srs:301 Img:91). Follow up is indicated.
      • S/P hysterectomy
      • Prior CT identified a well-defined homogeneous soft tissue mass 2.4 x 1.8 cm in left adrenal gland is noted again, stationary.
        • Adenoma is highly suspected. Follow up is indicated.
    • Impression:
      • Prior CT identified a soft tissue nodule 6 mm in the omentum at left middle pelvis is noted again, mild increasing in size to 9 mm. Follow up is indicated.
  • 2023-08-30 All-RAS + BRAF mutation
    • Cellblock No.: F2023-00362 Fs
    • RESULTS:
      • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-08-16 CXR erect
    • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
    • s/p left chest tube in place,its tip directed superiorly projecting over 4th intercostal space
    • small Lt hemithorax, decreased pulmonary vascularity, small hilum, due to post operative change of LUL lobectomy
    • Linear band subsegmental atelectasis at Rt lower lung zone
  • 2023-08-14 Patho - lung total/lobe/segmental
    • Diagnosis
      • Lung, left lower lobe, 3D VATS lobectom — Moderately differentiated squamous cell carcinoma, HPV-associated, metastatic
      • Lymph node, LN 5, RLND — Negative for malignancy
      • Lymph node, LN 7, RLND — Negative for malignancy
      • Lymph node, LN 9, RLND — Negative for malignancy
      • Lymph node, LN 10, RLND — Negative for malignancy
      • Lymph node, LN 11, RLND — Negative for malignancy
      • Lymph node, LN 12, RLND — Negative for malignancy
      • AJCC 8th edition pathology stage for Cervix Uteri: pTxN0M1; AJCC stage IVB
    • Gross Description
      • Specimen received:
        • Lung, size:16 x 8 x 2.5 cm and 186 gm in weight 
        • Lymph nodes, 6 bottles, maximal size: 0.8 cm
      • Tumor Site: Near hilar of left lower lobe
      • Gross Tumor Size: Solitary 1.7x 1.5 cm     - Gross tumor patterns: poorly defined
      • Representative sections are taken and labeled as: FS: frozen control, A1: margin, A2-4: tumor, A5: non-tumor, A6: hilar, A7: LN 5, A8: LN 7, A9: LN 9, A10: LN 10, A11: LN 11, A12: LN 12
    • Microscopic Description
      • Tumor Size: Greatest dimension (centimeters): 1.7 cm + Additional dimensions (centimeters): 1.5 x 1.3 cm
      • Tumor Focality - Single tumor
      • Histologic Type (select all that apply) — squamous cell carcinoma, HPV-associated, metastatic
      • Histologic Grade (according to the main histological type) — G2: Moderately differentiated
      • Visceral Pleura Invasion — Not identified
      • Lymphovascular Invasion (select all that apply) — Not identified
      • Margins (select all that apply)
      • Note: Use this section only if all margins are uninvolved and all margins can be assessed. — All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin (centimeters): 0.7 cm from closest bronchial Margin
      • Regional Lymph Nodes
        • Lymph Node Examination (required only if the lymph nodes present in the specimen) - N1 (Number involved / Number examined)           - group 10 (Hilar), left:  0 / 5           - group 11 (Interlobar): 0 / 6           - group 12 (lobar): 0 / 2     - N2 (Number involved / Number examined)          - group 5: 0 / 8           - group 7: 0 / 1
          • group 9:  0 / 3
      • Additional Pathologic Findings (select all that apply) — None identified
      • Ancillary Studies: Immunostains — TTF-1 (-), CD56 (-), P40 (+), P16 (+, strong, diffuse, >80%)
  • 2023-08-13 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Left axis deviation
    • Abnormal ECG
  • 2023-08-07 Nasopharyngoscopy
    • smooth nasopharynx, oropharynx and hypopharynx, no finding of lesion over bilateral palatine tonsils.
  • 2023-08-04 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 13 dB HL; LE 13 dB HL.
    • Bil normal to mild SNHL.
  • 2023-08-02 MRI - larynx
    • Indication: increased FDG uptake in bilateral palatine tonsils, for survey
    • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed showed:
      • susceptibility artifacts in the left oral cavity
      • a smooth-margined nodular lesion, about 31mm, in the right thyroid gland.
      • symmetric increased soft tissue in the bilateral oropharyngeal tonsils. Homogeneous enhancement was noted.
      • no neck LAP.
    • IMP:
      • prominent soft tissue in the bilateral oropharyngeal tonsils
  • 2023-08-01 CT - abdomen
    • Findings
      • Post-op change at right abdominal wall.
      • S/P hysterectomy.
      • Peritoneal nodules in the peritoneum, r/o carinomatosis.
      • Left adrenal tumor, 2.3cm, stationary.
      • Left lower lung tumor, 1.7cm near hilar region, r/o malignancy.
    • Impression:
      • Post-op change at right abdominal wall.
      • S/P hysterectomy.
      • Peritoneal nodules in the peritoneum, r/o carinomatosis.
      • Left lower lung tumor, 1.7cm near hilar region, r/o malignancy, primary or metastasis?
  • 2023-07-19 PET scan
    • Increased FDG uptake in the peritoneum of the right abdomen, compatible with the recurrent tumor.
    • Increased FDG uptake in the left adrenal region, probably benign in nature.
    • Increased FDG uptake in a focal lesion in the left upper lung, highly suspected the other primary (lung) or seconary (from cervical cancer) cancer, suggesting biopsy for investigation.
    • Increased FDG uptake in bilateral pulmonary hilar and mediastinal lymph nodes, probably reactive (priority) or metastatic nodes.
    • Increased FDG uptake in the left 4th rib, probably post-traumatic change (priority) or cancer with bone mets.
    • increased FDG uptake in bilateral palatine tonsils, probably inflammation process.
    • Cervical cancer s/p treatment with tumor recurrence and highly suspected the other primary cancer in the left upper lung, by this F-18 FDG PET scan.
  • 2023-07-03 Patho - soft tissue tumor, extensive resection
    • Soft tissue, anterior peritoneum, debulking surgery —- metastatic squamous cell carcinoma, moderately differentiated, consistent with cervical origin
    • Sections show fibroadipose tissue with metastatic keratinized squamous cell carcinoma.
    • The immunohistochemical stains reveal p16(+) and p40(+). The results are consistent with metastatic cervical squamous cell carcinoma. The tumor is 0.1 cm away from the closest peripheral resection margin. The small piece of fibroadipose tissue is free of malignancy.
  • 2023-06-29 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Left axis deviation
    • Abnormal ECG
  • 2023-05-09 MRI - pelvis
    • Findings
      • S/P hysterectomy.
      • Focal enhanced soft tissue, 2.9cm in right abdominal wall, r/o recurrent tumor.
      • Presence of gallbladder stone.
      • Minimal ascites in the pelvic cavity.
      • Left adrenal tumor, 2cm.
    • Impression:
      • S/P hysterectomy.
      • GB stone.
      • Left adrenal tumor, 2cm.
      • R/O recurrent tumor in right abdominal wall.
  • 2023-02-20 Gynecologic ultrasonography
    • No obvious uterine or ovarian lesion
  • 2023-02-01 CT - abdomen
    • S/P hysterectomy. There is no evidence of tumor recurrence.
    • Adenoma measuring 2.4 x 1.8 cm in left adrenal gland is suspected. please correlate with clinical condition.
  • 2022-11-21 Gynecologic ultrasonography
    • No obvious uterine or ovarian lesion
  • 2022-10-27 MRI - pelvis
    • Findings
      • S/P hysterectomy.
      • Non-enhancing nodule, 0.6cm in left kidney, r/o renal cyst.
      • Unremarkable change of the liver, spleen, pancreas and right kidney.
      • Presence of gallbladder stone.
      • Left adrenl tumor, 2.2cm, stationary.
    • Impression:
      • S/P hysterectomy, suggest follow up.
      • Left adrenal tumor, stationary.
      • R/O left renal cyst.
      • Gallbladder stone.
  • 2022-08-31 CT - abdomen
    • S/P hysterectomy. There is no evidence of tumor recurrence.
    • Adenoma measuring 2.4 x 1.8 cm in left adrenal gland is suspected. please correlate with clinical condition.
  • 2022-08-29 Gynecologic ultrasonography
    • No obvious uterine or ovarian lesion
  • 2022-06-25 SONO - abdomen
    • Findings
      • Increase brightness of liver parenchyma with fat attenuation. No focal lesion is found.
      • A 0.77 cm hyperechoic lesion with acoustic shadow was noted in the gallbladder.
    • Dignosis
      • GB stone
      • Fatty liver, moderate
  • 2022-06-09 MRI - pelvis
    • Findings
      • S/P hysterectomy.
      • Non-enhancing nodule, 0.58cm in left kidney, r/o renal cyst.
      • Diffuse thickening wall at superior wall of urinary bladder, suggest clinical correlation.
      • Left adrenl tumor, 2.2cm, stationary.
    • Impression
      • S/P hysterectomy, suggest follow up.
      • Left adrenal tumor, stationary.
      • R/O left renal cyst.
      • Diffuse thickening wall at superior wall of urinary bladder, cystitis? suggest clinical correlation.
  • 2022-05-30 Gynecologic ultrasonography
    • No obvious uterine or ovarian lesion
  • 2022-03-02 CT - abdomen
    • S/P hysterectomy. There is no evidence of tumor recurrence.
    • Adenoma measuring 2.4 x 1.8 cm in left adrenal gland is suspected. please correlate with clinical condition.
  • 2021-11-08 Patho - uterus (with or without SO) neoplastic
    • PATHOLOGIC DIAGNOSIS
      • Uterus, cervix, laparoscopic radical hysterectomy — squamous cell carcinoma, HPV-associated
      • Uterus, endometrium, laparoscopic radical hysterectomy — squamous cell carcinoma, by direct invasion
      • Uterus, myometrium, laparoscopic radical hysterectomy — squamous cell carcinoma, by direct invasion
      • Ovaries and fallopian tubes, bilateral, BSO — Negative for malignancy
      • Lymph nodes, left ilac, lymphadenectomy — Negative for malignancy (0/5)
      • Lymph nodes, left obturator, lymphadenectomy — Negative for malignancy (0/9)
      • Lymph nodes, right ilac, lymphadenectomy — Negative for malignancy (0/3)
      • Lymph nodes, right obturator, lymphadenectomy — Negative for malignancy (0/10)
      • AJCC 9th edition: pStage IIB, pT2bN0(if cM0); FIGO Stage: IIB
    • MACROSCOPIC EXAMINATION
      • Size of uterus: 9.5 x 5.5 x 4.0 cm
      • Tumor size: 4.5 x 3.0 x 2.5 cm; involving the whole cervix and invasion to endometrium, myometrium, upper vagina
      • Tumor depth: 1.5 cm
      • Parametrium: Microscopically, tumor invasion is seen.
      • Endometrium: 4.0 x 3.5 x 0.4 cm; invaded by tumor
      • Myometrial wall: several leiomyomas, measuring up to 4.5 x 3.8 x 2.7 cm, adenomyosis, and invaded by tumor
      • Adnexa: Included
      • Right ovary: 2.4 x 1.4 x 0.8 cm,
      • Left ovary: 1.8 x 1.2 x 0.5 cm,
      • Right fallopian tube: 6.5 cm in length and 0.3 cm in diameter
      • Left tube: 5.8 cm in length and 0.3 cm in diameter
      • Bilateral adnexa appear unremarkable.
      • Lymph nodes: 4 groups of lymph nodes, labeled right iliac, obturator and left iliac, obturator
      • Representative sections are taken and labeled as: A1: right ovary and fallopian tube; A2: left ovary and fallopian tube; A3-4: leiomyoma and adenomyosis; A5: endometrium, non-tumor; A6-14: tumor (A7-8; A9-10: the same level); B: lymph node, left iliac; C: lymph node, left obturator; D: lymph node, right iliac; E: lymph node, right obturator.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Squamous cell carcinoma, HPV-associated
      • Histologic Grade: G2: Moderately differentiated
      • Stromal invasion: Depth of stromal invasion: 15 mm, entire cervical wall
      • Silva Pattern of Invasion (applicable only to invasive endocervical adenocarcinomas): Not applicable
      • Other Tissue/ Organ Involvement (select all that apply):
        • Parametrium, side not specified
        • Vagina: location not specified
      • Margins:
        • Ectocervical/Vaginal cuff Margin: Not Free (Cancer present)
        • Radial (Circumferential) Margin: Not Free
      • Lymphovascular Invasion: Present
      • Regional Lymph Nodes:
        • Pelvic Lymph Nodes:
        • Right iliac: Negative: 0/ 3
        • Left iliac: Negative: 0/ 5
        • Right obturator: Negative: 0/ 10
        • Left obturator: Negative: 0/ 9
        • Para-aortic Lymph Nodes: not received
      • Distant Metastasis: Not applicable
      • Additional Pathologic Findings: None identified
      • Special Study: p16 immunohistochemistry: Positive (S2021-16493)
      • Several leiomyoma with calcification and adenomyosis are seen in myometrium.
  • 2021-10-21 Patho - cervix biopsy
    • Labeled as “cervix”, biopsy — carcinoma.
    • Section shows nests of neoplastic epithelium with polygonal appearance.
    • IHC stain: p16 (+, 100%), Ki-67: 95%, p40 (+). GATA-3 (+).
    • NOTE: Although the pattern p16 (+) and p40 (+) is compatible with cervical squamous cell carcinoma. A normal serum level of SCC marker and IHC stain of GATA-3 (+) is not typical. Please check urinary bladder to exclude other possibility.
  • 2021-10-18 Gynecologic ultrasonography
    • cervical mass 35 x 32 mm (blood flow)
    • Uterine myoma
    • EM 11.6mm (+fluid)

[MedRec]

  • 2023-06-29 ~ 2023-07-05 POMR Obstetrics and Gynecology Chen GuoHu
    • Discharge diagnosis
      • cervical cancer (squamous cell carcinoma, stage II), post radical hysterectomy + BSO + BPLND and CCRT –> right abdominal tumor 4.5x4cm at ant peritoneum, suspected cervical cancer recurrence
      • right abdominal tumor 4.5x4cm at ant peritoneum, suspected cervical cancer recurrence s/p debulking surgery (abdominal tumor excision for suspected cervical cancer recurrence) and enterolysis on 2023-06-30
      • cervical cancer (squamous cell carcinoma, stage IIb), post radical hysterectomy + BSO + BPLND and CCRT –> right abdominal tumor 4.5x4cm at ant peritoneum, suspected cervical cancer recurrence s/p debulking surgery (abdominal tumor excision for suspected cervical cancer recurrence) and enterolysis on 6/30/2023
    • CC
      • She found a mass at right abdominal wall WITH PELVIC MRI FINDINGS OF RIGHT ABDOMINAL TUMOR, SUSPECTED CANCER RECURRENCE when UNDERGOING regular f/u on 2023/05/09     
    • Present illness
      • This 58 y/o woman, G1P0AA1, menopauseD at 53 y/o, menstral cycle regular with duration/interval of 5/28 days, had no dysmenorrhagia. She had a past history of CERVICAL CANCER, STAGE II (squamous cell carcinoma of cervix) POST RADICAL HYSTERECTOMY + BSO + BPLND + adhesiolysis on 2021/11/05, AND POST-OP CCRT (C/T on 2021/12/2, 9, 16, 23, 29, 2022/1/5 and RT on 2021/12/3~2022-1-27 WITH 4500cGy/25 fractions of the pelvic, 4860cGy/27 fractions of the cuff to parametrium, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT. SHE Denied any food or drug allergy, and denied anticoagulants or hormone use.
      • AFTER THE SURGERY AND CCRT, No palpable mass was noted UNTIL THIS MAY, AND THERE WAS no significant body weight change, no abdominal discomfort, no constipation, no diarrhea, no urinary frequency, no nausea or vomitting, no decreased appetite. She turned to our GYN OPD for help because of a mass was noted in her right abdominal wall, and some examinations were done. She found a mass at right abdominal wall WITH PELVIC MRI FINDINGS OF RIGHT ABDOMINAL TUMOR 3X3CM, SUSPECTED CANCER RECURRENCE when UNDERGOING regular f/u on 2023/05/09. The transabdominal sono on 2023.06.26 revealed no ascites, BUR right abd mass 2.9cm -> 3.5cm. THE Tumor marker was examinated on the same day and showd SCC LEVEL 0.8~1.0 ng/ml; CEA LEVEL 1.88 ng/mL.
      • Under the impression of RIGHT ABDOMINAL TUMOR, SUSPECTED recurrent cervical cancer WITH POSSIBLE PELVIC ADHESION, she was admitted on 2023/06/29 for exploratory laparotomy (TUMOR DEBULKING SURGERY), ENTEROLYSIS and postoperative care.      
    • Course of inpatient treatment
      • The patient was admitted on 2023-06-29 and underwent debulking surgery (abdominal tumor excision for suspected cervical cancer recurrence) and enterolysis the next day. Her postoperative course was uneventful. After flatus, her eating and urination by self voiding, defecation was smooth. The vital sign was stable after surgery. She is discharged on 2023-07-05 and her followup appointment is scheduled on next week.
    • Discharge prescription
      • MgO 250mg 2# QID
      • Acetal (acetaminophen 500mg) 1# QID
      • cephalexin 500mg 1# QID
  • 2023-05-10 SOAP Hemato-Oncology Xia HeXiong
    • P: Already discuss with Chief Chen for the possibility of recurrence over right abdominal wall based on MRI on 2023-05-09
  • 2022-03-03 SOAP Hemato-Oncology Xia HeXiong
    • A/P
      • CCRT with weekly CDDP on 2021-12-30 followed by C/T with PF later
      • Encourage respiratory exercise
      • RTC on 2022-02-09, then discuss with adjuvant C/T (margin not free)
      • After discussion with patient about adjuvant TP, patient trend not to receive adjuvant chemotherapy.
      • Port-A flush Q3M, next on 2022-04-05
  • 2021-11-25 SOAP Radiation Oncology Huang JingMin
    • A: Squamous cell carcinoma, HPV-associated, of the uterine cervix, AJCC 8th edition: pStage IIB, pT2bN0(cM0); FIGO Stage: IIB, s/p 3D laparoscopic radical hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + adhesiolysis.
    • P: Postoperative CCRT is indicated for this patient with the following indicators: stage IIB, margin involed.
      • Goal: curative
      • Treatment target and volume: pelvis
      • Technique: VMAT/IGRT and IVRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, 4860cGy/27 frcations of the parametrium, and another 1200cGy/3 fractions to vagnal cuff mucosa surface.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient. She understand and would like to receive radiotherapy, The treatment planning of ardiotherapy will be started at 2:30 PM, 2021-11-30.
  • 2021-11-25 SOAP Hemato-Oncology Xia HeXiong
    • P
      • CCRT with weekly CDDP followed by C/T with PF
      • Encourage respiratory excersie
      • Port-A insertion
  • 2021-11-25 SOAP Obstetrics and Gynecology Chen GuoHu
    • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 20210118
      • CCRT and C/T
  • 2021-11-04 POMR Obstetrics and Gynecology Chen GuoHu
    • Discharge diagnosis
      • Cervical cancer (C53.9) post laparoscopic radical hysterectomy + bilateral salpingo-oophorectomy + bilateral lymph node dissection on 2021/11/05
      • Malignant neoplasm of endometrium
      • Myoma uteri
      • Female pelvic peritoneal adhesions (postinfective)
    • CC
      • intermittent menopausal bleeding for almost 2 years.  
    • Present illness
      • This is a 56 year-old female, G0P0, SEX(+), AND she denied any medical history and surgical history. Her menstral cycle was in interval of 28 days and in duration of 5 days. Menopause was NOTED on her age of 52 y/o. SHE Ever took estrogen by herself in 2019.
      • This time, she complained of intermittent menopausal bleeding for almost 2 years, but she didn’t pay attention to it. However, the vaginal bleeding got more frequent and the blood loss amount also got more and more, blood clot was also noted in recent monthS. Anemic symptoms, such as general malaise, dizziness and tachycardia were noted since 2021.09. Thus, she turned to ShuangHe hostpital on 2021.10, andD lab data of Hb 7 was noted, ferrous agent was also perscribed and the symptoms improved. Some work-out was done there.
      • She then brought the examination results found in ShuangHe hostpital to our OPD for second opinion. The GYN sonar on 110.10.18 revealed EM 1.16cm with fluid, 3 myomas (3x3cm ; 2.8x2.5cm ; 2.3x2cm), and A cervical mass 3.5x3cm, with abduantWITH abundant flow(+), The abdominal CT scan (done in ShuangHe) revealed endometrium thickening with irregular marginS, SUSPECTED ENDOMETRIAL CANCER with extending to cervix. A 2.4 cm adrenal nodule was also noted. The lab data on 110.10.18 revealed SCC level was 1.5, and CEA level was 4.93 ng/mL. The cervical biopsy showed carcinoma, nature to be determined. with IHC stain: p16 (+, 100%), Ki-67: 95%, p40 (+), GATA-3 (+). The endocervical biopsy, ECC revealed high grade dysplastic epidermoid.
      • Under the impression of cervical cancer with endometrial involvement or suspected endometrial cancer with extending to cervix, she was admitted for 3D laparoscopic radical hysterectomy, BSO and BPLND. Cystoscope + DBJ insertion will be arranged prior to the major surgery.
    • Course of inpatient treatment
      • The patient was admitted on 2021/11/04 and underwent 3D laparoscopic radical hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + adhesiolysis (by Prof. Chen) + cystoscopy + Bilateral DBJ insertion by GU Dr. on 2021/11/05.
      • We gave her Cefazolin and Gentamycin IV form for 3 days and then shifted her antibiotics to Cephalexin oral form. Post-operation wound was dry and clean without dehiscence, discharge, or oozing. Her lab data on 2021/11/06 also showed no specific positive findings. There was no special complaint nor fever, with improved condition 3 days after the LSC radical hysterectomy surgery. After flatus, her eating and self voiding, defecation were all ok. JP drain was removed on 11/12 with stable condition. Since all her general conditions were all improved and relatively stable, we arranged discharge for her on 2021-11-13 for further OPD follow up of her recovery status and surgical wound conditions.     
    • Discharge prescription
      • Anxiedin (lorazepam 0.5mg) 1# PRNHS
      • Gaslan (dimethylpolysiloxane 40mg) 2# TID
      • cephalexin 500mg 1# QID
      • Acetal (acetaminophen 500mg) 1# QID

[surgical operation]

  • 2023-08-14
    • Surgery
      • 3D VATS LUL lobectomy + RLND.
    • Finding
      • One tumor was noted over LUL, central located, size about 1.5cm in diameter.
      • Frozen section: squamous cell carcinoma.
      • One 24 Fr. straight chest tube was inserted via left 8th ICS.
  • 2023-06-30
    • Surgery
      • debulking surgery (abdominal tumor excision for suspected cervical cancer recurrence) and enterolysis
    • Finding
      • prevical cervical cancer (SCC, stage II), post radical hysterectomy + BSO + BPLND and CCRT
        • -> right abdominal tumor 4.5x4cm at ant peritoneum (5cm distance to umbulicus), suspected cervical cancer recurrence
        • -> abdominal tumor excision
      • abdominal cavity:
        • no ascites, but pelvic adhesion (due to previous radical hysterectomy + BSO + BPLND?) was noted between ant peritoneum, abdominal tumor, omentum and bowels s/p enterolysis
  • 2021-11-05
    • Surgery
      • 3D laparoscopic radical hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + adhesiolysis
    • Finding
      • Uterus: 12x8x5 cm, corpus – multile myomas 2~4cm
      • prev cervical biopsy – carcinoma, nature?
      • cervix – eroded with cauderflower mass 3x3cm, suspected residual cancer
      • endometrium – multiple soft fungating mass, suspected cancer
        • -> R/O endometrial cancer with isthmus and cervical invasion, or cervical cancer with endometrial invasion?
      • vagina (upper 1/2) – eorded with soft, necrotic mass, suspected cancer invasion
      • parametrium (including uterus artery) – seemed free of invasion
      • bil adnexa: normal-looking
      • bowels, omentum – seemed free of cancer invasion
      • cystoscopy – smooth bladder and ureter contour
      • Bilateral pelvic iliac and obturator LNs was removed
      • CDS: 20c.c ascites (washing cytology was sent), some pelvic adhesion was noted between US ligaments and rectum s/p lysis
      • A 7mm JP drain was placed in CDS

[radiotherapy]

  • 2021-12-03 ~ 2022-01-27 - 4500cGy/25 fractions of the pelvic, 4860cGy/27 fractions of the cuff to parametrium, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT.

[chemotherapy]

  • 2024-02-27 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2024-02-01 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2024-01-09 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-12-12 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-11-14 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-16 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr (Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-20 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL + NS 1000mL 2hr
  • 2023-09-13 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL + NS 1000mL 2hr
  • 2023-09-06 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL + NS 1000mL 2hr
  • 2023-08-30 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL + NS 1000mL 2hr
  • 2022-01-06 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL + NS 1000mL 2hr
  • 2021-12-30 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL + NS 1000mL 2hr
  • 2021-12-24 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL + NS 1000mL 2hr
  • 2021-12-17 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 1000mL 2hr
  • 2021-12-09 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 1000mL 2hr
  • 2021-12-02 - cisplatin 40mg/m2 70mg NS 500mL (QW CCRT)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL + NS 1000mL 2hr

==========

2024-02-27

[reconciliation]

Vital signs during this hospital stay and labs on 2024-02-27 showed stable and normal values, no medication discrepancy found after reviewing HIS5 and PharmaCloud.

2024-02-02

[reconciliation]

Lab data from 2024-02-01 and vital signs assessed through the TPR panel during this hospital stay were overall within normal limits. A thorough review of the HIS5 and PharmaCloud databases did not reveal any discrepancies in medication.

2024-01-09

[gradual eGFR change: current dose safe, continued monitoring]

There appears to be a gradual downward trend in eGFR in this patient, and no dose adjustment is required at this time.

  • 2024-01-08 eGFR 66.41 ml/min/1.73m^2
  • 2023-12-11 eGFR 78.03 ml/min/1.73m^2
  • 2023-11-09 eGFR 55.38 ml/min/1.73m^2
  • 2023-10-16 eGFR 65.01 ml/min/1.73m^2
  • 2023-09-25 eGFR 69.24 ml/min/1.73m^2
  • 2023-09-19 eGFR 72.03 ml/min/1.73m^2
  • 2023-09-12 eGFR 68.35 ml/min/1.73m^2
  • 2023-09-05 eGFR 67.48 ml/min/1.73m^2
  • 2023-08-28 eGFR 84.36 ml/min/1.73m^2
  • 2023-08-13 eGFR 77.19 ml/min/1.73m^2
  • 2023-08-03 eGFR 91.35 ml/min/1.73m^2

700029486

240226

==========

2024-02-26

[tube feeding: Const-K extended-release tab 750mg/10mEq/tab (KCl); Detrusitol SR 4mg prolonged-release cap (tolterodine); Wellbutrin XL 150mg/tab (bupropion)]

Const-K is an extended-release potassium supplement tablet that is not intended to be crushed, as this would compromise its slow-release properties. However, in situations where oral administration is not feasible and intravenous potassium is not preferred, crushing the tablet for tube feeding might be considered the only option, despite the loss of extended-release functionality.

Each Const-K tablet delivers 10 mEq of potassium, equating to the potassium content of approximately a 10 cm banana, which contains about 2.2 mEq/inch (0.9 mEq/cm) in bananas (N Engl J Med. 1985;313(9):582.)

Similarly, other extended-release medications such as Detrusitol SR and Wellbutrin XL are not recommended to be crushed. Disrupting their extended-release mechanism can lead to more variable serum concentrations, potentially affecting their efficacy and safety.

700165811

240226

[exam findings]

[MedRec]

  • 2024-01-04 ~ 2024-01-06 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Adenocarcinoma of the vagina with severe adhesion to bladder, status post staging operation (BSO + BPLND + vaginal tumor excision), with bladder injury status post repair,  pT2bN1, stage III, if cM0/FIGO stage III with progression.
      • Postive of anti-HBc
    • CC
      • for C4 chemotherapy with Abraxance (self-paid) Q3W
    • Present illness
      • This is a 56-year-old female, G2P2, with past history of
        • adenomyosis and uterine myoma s/p laparoscopic hysterectomy in Tzu Chi Hospital in 2012/03
        • bilateral ureter obstruction s/p extracorporeal shock wave lithotripsy (ESWL) in Carinal Tien Hospital (CTH) in 2020
        • left hydronephrosis and ureteral stricture s/p double J-stent placement in CTH in 2021/10
        • right hydronephrosis and ureteral stricture s/p double J-stent placement in CTH in 2021/11
        • endometriosis related recurrent bilateral ureteral stricture and hydronephrosis s/p right laparoscopic ureteroneocystostomy (UNC), laparoscopic ureterolysis and laparoscopic adhesionolysis in CTH on 2022/01/06
      • She denied systemic disease, including DM, hypertension or allergic history. Her father has pancreatic cancer and DM, her mother had no underlined diseases.
      • According to her statement, she had adenomyosis and leiomyoma s/p laparoscopic hysterectomy, laparoscopic pelvic adhesion lysis and P repair in Tzu Chi Hospital on 2012/03. She had regular OPD follow-up but stopped a few years later. She had intermittent lower abdominal pain since 2020, and she visited GU OPD for treatment. Bilateral ureter obstruction was noted, and ESWL was done in CTH in 2020. Her lower abdominal and back pain recurred in 2021/10, so she visited ER in CTH for treatment.
      • Left hydronephrosis and ureteral stricture was noted, and left double J-stent placement was done in 2021/10. Left double J-stent was removed 1 week after discharge. However, her lower abdominal and back pain recurred again in 2021/11, so she still visited ER in CTH for treatment. Right hydronephrosis and ureteral stricture was noted, and right double J-stent placement was done in 2021/10. right double J-stent was removed 1 week after discharge. After discharge, she still have intermittent lower abdominal pain and and visited ER in CTH in 2021/12.
      • The GU doctor noted a mass attached to bladder, suspected causing recurrent bilateral ureteral stricture and hydronephrosis, so right laparoscopic ureteroneocystostomy (UNC), laparoscopic ureterolysis and laparoscopic adhesionolysis was done in CTH on 2022/01/06. The mass was suspected endometiosis related.
      • During operation, a mass around vagina was noted, and biopsy was suggested. Then, colposcopic was done and adnenocarcinoma was suspected, origin unspecified.
      • Immunostain of vagina biopsy showed CK7, p53 positive, PAX8 weakly positive and MIB-1 increased.
      • Thus, colonoscopy was done to exclude colonorectal cancer, but there was no tumor noted except colitis at a-colon s/p biposy and hemorrhoid.
      • PET scan was done on 2022/03/22 and revealed undertemined lesion in proximal rectum. Surgery was not suggested by gynecologist in CTH.
      • Thus, she visited Gynecologist Dr. Hung in Tzu Chi Hospital for second opinion. Endometriosis was suspected and medication was prescribed. However, her lower abdominal pain and low back pain persisted. Then, she visited NTUH for further evaluation of her diseases. Viginal biopsy, MRI and lab data were done. Vaginal biopsy showed adenocarcinoma, PAC8 positive and increased Ki-67 index. MRI revealed a 2.2cm focal enhancing lesion at the vaginal stump or cervix with diffusion restrition, neoplasm cannot be excluded. Gynecologist in NTUH suggested that radiotherapy had poorer effect to adenocarcinoma than squamous cell carcinoma (SCC), and the bladder impairment of radiotherapy complication should be considered as well. Thus, she visited radiologist in NTUH, but the radiologist in NTUH had different opinion with Gynecologist in NTUH.
      • She then visited Dr. Huang in Tzu Chi Hospital for second opinion, and Dr. Huang decided to discuss this patient’s management in gynecologic cancer meeting. After the meeting, CCRT was suggested. However, the patient was concern about poor radiotherapy effect to adenocarcinoma and bladder impairment caused by radiotherapy. So gynecologist Dr. Huang suggested her to visit our radiologist Dr. Huang for treatment evaluation. Radiologist Dr. Huang suggested vaginectomy and lymphadenectomy, combined with radiotherapy for consolidation later.
      • She underwent staging surgery (BSO + BPLND + vaginal tumor excision) and bilatearl neocystostomy orifice s/p DBJ insertion & bladder injury s/p repair on 2022/6/15.The pathology showed pT2bN1,stage III, if cM0 / FIGO stage III.Port-A insertion on 2022/7/7.
      • Under th diagnosis of Adenocarcinoma of the vagina with severe adhesion to bladder, status post staging operation (BSO + BPLND + vaginal tumor excision), with bladder injury status post repair, pT2bN1, stage III, if cM0/FIGO stage III. DBJ removal on 2022/7/11.
      • CCRT with selfpaid of C1 Taxol (selfpaid) plus Cisplatin was administered on 2022/7/19. Weekly cisplatin on 2022/8/16-9/13.
      • Radiotherapy started on 2022/08/01 with 4500cGy/25 fractions of the pelvic, 5040cGy/28 fractions of the vaginal tumor bed, and 5400cGy/30 fractions of the reduced vaginal tumor bed.
      • After completion of CCRT, she received chemotherapy with Avastin (selfpay) + Taxol (selfpaid) + Cisplatin since 2022/09-2023/04.
      • Follow up CT showed 1. Prior CT identified a soft tissue mass-like lesion in the vagina, measuring 5 x 3.3 cm, is noted again, stationary, 2. Prior CT identified diffuse mild wall thickening of the urinary bladder is not noted again and 3. Prior CT identified small size and mild hydroureteronephrosis but no delayed contrast excretion of left kidney is noted again, stationary.
      • Last time. she received hydronephrosis /p bilateral tumor stent insertion on 2023/11/23, without complication during hospitalization. Newly chemotherapy as C1 Abraxane by selfpay QW for diaease progress on 2023/11/24, C2 Abraxane on 2023/12/08, C3 on 2023/12/22.
      • This time, she she was admitted for C4 Abraxane on 2024/01/04.
    • Course of inpatient treatment
      • After admission, chemotherapy with Abraxance (125mg/m2, self-paid) was given on 2024-01-05, smoothly without obvious side effect.
      • She was discharged on 2024-01-06 under stable condition and will follow-up at OPD.
    • Discharge prescription
      • none

[chemotherapy]

  • 2024-02-26 - nab-paclitaxel 125mg/m2 200mg (QW. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2024-02-02 - nab-paclitaxel 125mg/m2 200mg (QW. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2024-01-25 - nab-paclitaxel 125mg/m2 200mg (QW. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2024-01-05 - nab-paclitaxel 125mg/m2 200mg (QW. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-12-22 - nab-paclitaxel 125mg/m2 200mg (QW. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-12-08 - nab-paclitaxel 125mg/m2 200mg (QW. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-11-24 - nab-paclitaxel 125mg/m2 200mg (QW. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-04-07 - bevacizumab 15mg/kg 800mg NS 250mL 90min + paclitaxel 175mg/m2 280mg NS 250mL 3hr + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 120mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-03-16 - bevacizumab 15mg/kg 800mg NS 250mL 90min + paclitaxel 175mg/m2 280mg NS 250mL 3hr + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 118mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-02-07 - bevacizumab 15mg/kg 800mg NS 250mL 90min + paclitaxel 175mg/m2 280mg NS 250mL 3hr + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 118mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-12-20 - bevacizumab 15mg/kg 800mg NS 250mL 90min D1 + paclitaxel 175mg/m2 280mg NS 250mL 3hr D2 + NS 500mL 1hr D2 (before cisplatin) + cisplatin 75mg/m2 118mg NS 500mL 2hr D2 + NS 500mL 1hr D2 (after cisplatin)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D2 + famotidine 20mg D2+ palonosetron 250ug D2 + NS 250mL D1-2
  • 2022-11-01 - paclitaxel 175mg/m2 275mg NS 250mL 3hr + NS 500mL (before cisplatin) + cisplatin 75mg/m2 118mg NS 500mL 2hr + NS 500mL (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-10-04 - paclitaxel 175mg/m2 275mg NS 250mL 3hr + NS 500mL (before cisplatin) + cisplatin 75mg/m2 118mg NS 500mL 2hr + NS 500mL (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-09-14 - NS 500mL (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)
    • diphenhydramine 30mg + granisetron 2mg + metoclopramide 10mg + NS 250mL
  • 2022-09-07 - NS 500mL (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)
    • diphenhydramine 30mg + granisetron 2mg + metoclopramide 10mg + NS 250mL
  • 2022-08-31 - NS 500mL (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)
    • diphenhydramine 30mg + granisetron 2mg + metoclopramide 10mg + NS 250mL
  • 2022-08-24 - NS 500mL (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)
    • diphenhydramine 30mg + granisetron 2mg + metoclopramide 10mg + NS 250mL
  • 2022-08-17 - NS 500mL (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)
    • diphenhydramine 30mg + granisetron 2mg + metoclopramide 10mg + NS 250mL
  • 2022-08-10 - NS 500mL (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)
    • diphenhydramine 30mg + granisetron 2mg + metoclopramide 10mg + NS 250mL
  • 2022-07-19 - paclitaxel 175mg/m2 275mg NS 250mL 3hr + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 118mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-02-26

[nab-paclitaxel and renal function]

Post-administration of nab-paclitaxel, serum creatinine levels have consistently remained above 1.5 mg/dL. Although there hasn’t been a rapid increase, continuous monitoring is still advised.

  • 2024-01-12 Creatinine 1.64 mg/dL
  • 2024-01-04 Creatinine 1.60 mg/dL
  • 2023-12-29 Creatinine 1.52 mg/dL
  • 2023-12-22 Creatinine 1.77 mg/dL
  • 2023-12-14 Creatinine 1.56 mg/dL
  • 2023-12-08 Creatinine 1.54 mg/dL
  • 2023-11-30 Creatinine 1.58 mg/dL nab-paclitaxel 20231124 initialized
  • 2023-11-22 Creatinine 1.36 mg/dL
  • 2023-11-17 Creatinine 1.66 mg/dL
  • 2023-10-20 Creatinine 1.24 mg/dL
  • 2023-10-06 Creatinine 1.21 mg/dL
  • 2023-09-15 Creatinine 1.18 mg/dL
  • 2023-09-08 Creatinine 1.00 mg/dL
  • 2023-09-01 Creatinine 1.12 mg/dL
  • 2023-08-11 Creatinine 1.01 mg/dL

Nab-Paclitaxel for patients with altered kidney function, there are no dosage adjustment recommendations for those with a Creatinine Clearance (CrCl) ≥30 mL/minute. Furthermore, there are no pharmacokinetic studies available for severe kidney impairment in patients with a CrCl <30 mL/minute.

700184828

240226

[past history]

  • Medical history:
    • Hypertension
    • Goiter
    • Gall bladder stone
    • Mixed hyperlipidemia
    • Left adrenal hemanigioma status post laparoscopic adrenalectomy
    • Diabetes, suspicious subclinical Cushing.
    • Acom aneurysm rupture s/p TAE at ShuGuang Hospital in ShangHai, 20160326
    • Non rupture right MCA aneurysm.
  • Operative history:
    • Left adrenal hemanigioma status post laparoscopic adrenalectomy
    • Acom aneurysm rupture s/p TAE at ShuGuang Hospital in ShangHai, 20160326
    • Port-A insertion on 2022-10-13
  • Neoadjuvent chemotherapy with
    • Lipo-dox 35mg/m2 + Endoxan 600mg/m2 since 2022/10/22~2022/12/26.
    • Taxotere 75mg/m2 since 2023/01/31~ .
    • Herceptin 600mg SC + Perjeta 420mg for 6 cycles since 2023/01/31~

[allergy]

  • NKDA                 

[family history]

  • There is no family history of mental diseases or asthma.
  • Father: lung cancer; Mother: hypertension.

[exam findings]

  • 2023-01-31 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 21) / 80 = 73.75%
      • M-mode (Teichholz) = 73
    • Preserved LV and RV systolic function with normal wall motion
    • Mildly dilated LA, grade 1 LV diastolic dysfunction
    • Mild MR, TR
  • 2022-10-14 Patho - breast biopsy (no need margin)
    • Breast, left, biopsy — fibroadenoma
    • Microscopically, the breast shows fibroadenoma composed of intracanalicular growth pattern of elongated and branching mammary ductules surrounded by fibrous stroma.
  • 2022-10-13 SONO - neck (lymph node)
    • Sonography of neck revealed some LNs in bil. neck.
  • 2022-10-12 SONO - breast
    • Diagnosis
      • uncertain breast tumor, in favor of benign
      • fibroadenoma (FA) suspect malignancy from PET
    • Suggestion and Plan
      • regular OPD follow-up.
      • A breast tumor located at L’t (1, 0) noted from sonography.
      • We use 16 guage needle to puncture the tumor for 3 times.
  • 2022-09-30 Whole body PET scan
    • There was increased FDG uptake in multiple focal areas in the right breast (SUVmax early: 18.22, delay: 20.27), in multiple right axillary lymph nodes (SUVmax early: 17.81, delay: 24.89), in a small focal area in the left breast (SUVmax early: 17.33, delay: 23.16), in a focal area in the right parotid gland (SUVmax early: 7.93, delay: 7.69), in some bilateral neck lymph nodes (SUVmax early: 5.17, delay: 6.25) and in the right adrenal gland (SUVmax early: 7.32, delay: 9.92).
    • IMPRESSION:
      • Multiple glucose hypermetabolic lesions in the right breast, compatible with multiple malignant breast tumors.
      • A small glucose hypermetabolic lesion in the left breast. Breast malignancy should be watched out. Please correlate with other clinical findings for further evaluation.
      • Glucose hypermetabolism in multiple right axillary lymph nodes, suggesting metastatic lymph nodes.
      • A glucose hypermetabolic lesion in the right parotid gland. Some kind of parotid lesion may show this picture. Please correlate with other clinical findings for further evaluation
      • Mild glucose hypermetabolism in some bilateral neck lymph nodes. Inflammation is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
      • Glucose hypermetabolism in the right adrenal gland. Either hyperplasia or adenoma may show this picture. Please also correlate with other clinical findings for further evaluation
  • 2022-09-29 Patho - breast biopsy (no need margin)
    • Lymph node, right axillary, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains (using block: S2022-16632): ER (-, 0%), PR(-, 0%), Her2/neu: positive (score=3+), Ki-67( 70%), E-cadherin (+).
    • Section shows fragments of lymph node tissue with irregular neoplastic ducts infiltration.
  • 2022-09-29 Patho - breast biopsy (no need margin)
    • Breast, right, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains (using block: S2022-16631): ER (-, 0%), PR(-, 0%), Her2/neu: positive (score=3+), Ki-67( 70%), E-cadherin (+).
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • 2022-09-27 Mammography
    • Screening digital mammography of both breasts with MLO and CC views:
    • Old mammographic study: 2013-08-09 (BIRADS 1)
    • Impression:
      • Dense breast. Right breast tumors with enlarged right axillary lymph nodes, suspected malignancy with lymph nodes metastasis.
    • BI-RADS: Category 5: highly suggestive of malignancy-appropriate action should be taken.

[chemoimmunotherapy]

  • 2024-01-02 - trastuzumab emtansine 3.6mg/kg 243mg NS 250mL 90min
    • diphenhydramine 30mg + NS 250mL
  • 2023-12-13 - trastuzumab emtansine 3.6mg/kg 243mg NS 250mL 90min
    • diphenhydramine 30mg + NS 250mL
  • 2023-11-06 - trastuzumab emtansine 3.6mg/kg 244mg NS 250mL 90min
    • diphenhydramine 30mg + NS 250mL
  • 2023-10-16 - trastuzumab emtansine 3.6mg/kg 251mg NS 250mL 90min
    • diphenhydramine 30mg + NS 250mL
  • 2023-09-25 - trastuzumab emtansine 3.6mg/kg 251mg NS 250mL 90min
    • diphenhydramine 30mg + NS 250mL
  • 2023-09-04 - trastuzumab emtansine 3.6mg/kg 254mg NS 250mL 90min
    • diphenhydramine 30mg + NS 250mL
  • 2023-08-14 - trastuzumab emtansine 3.6mg/kg 255mg NS 250mL 90min
    • diphenhydramine 30mg + NS 250mL
  • 2023-07-24 - trastuzumab emtansine 3.6mg/kg 256mg NS 250mL 90min
    • diphenhydramine 30mg + NS 250mL
  • 2023-06-26 - trastuzumab emtansine 3.6mg/kg 256mg NS 250mL 90min
    • diphenhydramine 30mg + NS 250mL
  • 2023-05-17 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr
  • 2023-04-27 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr
  • 2023-04-06 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 133mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-14 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 133mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-02-21 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 133mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-01-31 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 1hr + docetaxel 75mg/m2 132mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-12-26 - cyclophosphamide 600mg/m2 1046mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg NS 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2022-12-05 - cyclophosphamide 600mg/m2 1048mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg NS 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2022-11-14 - cyclophosphamide 600mg/m2 1048mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg NS 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2022-10-22 - cyclophosphamide 600mg/m2 1053mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg NS 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO

==========

2024-02-26

[guidelines for platelet transfusion addressing thrombocytopenia in Kadcyla therapy]

The patient has been on Kadcyla (trastuzumab emtansine) therapy since 2023-06-26, following a previous regimen that included Herceptin (trastuzumab) and Perjeta (pertuzumab), with the last dose administered on 2023-05-17.

Post-initiation of Kadcyla, there has been a temporal association with an increase in both the frequency and severity of thrombocytopenia episodes, indicating that the thrombocytopenia could be attributed to Kadcyla. Literature indicates that trastuzumab emtansine is associated with thrombocytopenia, with incidences ranging from 29% to 31%, and grades 3/4 thrombocytopenia occurring in 6% to 15% of cases, including a higher incidence in patients of Asian descent, where grades 3/4 thrombocytopenia ranges from 19% to 45%.

  • 2024-02-23 PLT 87 x10^3/uL **
  • 2024-02-22 PLT 44 x10^3/uL ***
  • 2024-01-16 PLT 55 x10^3/uL **
  • 2024-01-06 PLT 51 x10^3/uL **
  • 2024-01-02 PLT 61 x10^3/uL **
  • 2023-12-13 PLT 116 x10^3/uL *
  • 2023-11-27 PLT 69 x10^3/uL **
  • 2023-11-06 PLT 95 x10^3/uL **
  • 2023-10-16 PLT 110 x10^3/uL *
  • 2023-09-25 PLT 144 x10^3/uL *
  • 2023-09-04 PLT 177 x10^3/uL
  • 2023-08-14 PLT 248 x10^3/uL
  • 2023-07-24 PLT 251 x10^3/uL
  • 2023-07-04 PLT 84 x10^3/uL **
  • 2023-06-26 PLT 239 x10^3/uL
  • 2023-05-25 PLT 212 x10^3/uL
  • 2023-04-27 PLT 285 x10^3/uL
  • 2023-04-06 PLT 232 x10^3/uL
  • 2023-03-14 PLT 284 x10^3/uL
  • 2023-02-21 PLT 264 x10^3/uL
  • 2023-02-07 PLT 273 x10^3/uL
  • 2023-01-31 PLT 243 x10^3/uL

Prophylactic platelet transfusions are recommended to prevent spontaneous bleeding in afebrile patients with platelet counts below 10K/uL due to bone marrow suppression. This recommendation aligns with guidelines from the International Society on Thrombosis and Haemostasis published in 2023 (Reference: J Thromb Haemost. 2024;22(1):53).

In patients presenting with fever, infection, or inflammation, platelet transfusions are generally advised at counts of ≤ 15K to 20K/uL due to the heightened risk of bleeding (Reference: Clin Lab Med. 2021;41(4):621).

2023-02-22

There are currently no bowel movement records for this hospital stay in HIS5. However, the records from the patient’s previous hospital stay (between 2023-01-31 and 2023-02-01) indicated that the patient had one bowel movement per day.

According to the review of systems in the admission note for this hospital stay, the patient experienced diarrhea and had 8 to 9 bowel movements per day.

It might be noted that docetaxel is known to cause gastrointestinal adverse reactions, including diarrhea (with a frequency of 23% to 43%, and severe diarrhea occurring in 6% or less of cases), and the incidence of diarrhea with pertuzumab and trastuzumab is 60% (ref: UpToDate).

The use of loperamide is recommended as a means of alleviating diarrhea and Loperamide (2mg/cap) is available in this hospital.

Loperamide usage: Oral, Initial: 4 mg, followed by 2 mg every 2 to 4 hours or after each loose stool; for diarrhea persisting >24 hours, administer 2 mg every 2 hours (or 4 mg every 4 hours). Continue until 12 hours have passed without a loose bowel movement. Doses >16 mg/day may not provide benefit; consider alternative therapy for diarrhea persisting >=48 hours.

700738641

240226

[MedRec]

  • 2024-02-22 SOAP Metabolism and Endocrinology Liao YuHuang
    • Prescription x3
      • Relinide (repaglinide 1mg) 0.5# TIDAC15
      • Januvia (sitagliptin 100mg) 1# QD
      • Zulitor (pitavastatin 4mg) 0.5# QD
      • Doxaben (doxazosin 4mg) 1# QD
  • 2024-01-25 SOAP Orthopedics Zen XiaoZu
    • Prescription x3
      • TieShrShuPap (flurbiprofen 40mg/patch) 1# QD EXT
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# BID
  • 2023-12-07 SOAP Urology Wu ShuYu
    • A: BPH, OAB, urolithiasis
    • Prescription x2
      • Minirin Melt (desmopressin 60ug) 1# HS
      • Avodart (dutasteride 0.5mg) 1# QD

==========

2024-02-26

[reconciliation]

According to the PharmaCloud database, there are no outstanding prescriptions issued by other healthcare provider.

Two drugs, Relinide (repaglinide) and Januvia (sitagliptin), prescribed by our endocrinologist on 2024-02-22, are not reflected in the active medication list. It is recommended to verify whether these medications are no longer required.

700887413

240226

[exam findings]

  • 2024-02-23 CXR
    • S/P tracheostomy.
    • Fibrotic infiltrate in left upper lung.
    • Blunting of costophrenic angle, left side, could be due to pleural effusion.
  • 2024-02-23 ECG (emergency)
    • Sinus tachycardia
    • ST elevation, consider early repolarization, pericarditis, or injury
    • Abnormal ECG
  • 2024-02-23 CT - brain
    • Without-contrast CT scan of the brain with 4-mm axial and sagittal images reveals:
      • Mild degree of general enlargement of ventricles, cisterns and cortical sulci indicating general brain atrophy.
      • No intracranial hemorrhage, nor space-occupying lesion.
      • No midline shift, nor mass effect.
      • No skull fracture.
      • S/P NG tube and tracheostomy.
    • IMP:
      • Mild general brain atrophy.

[MedRec]

  • 2024-02-23 Surgical Emergency He YaoCan
    • S: Blunt trauma to the head > Acute moderate central pain (4-7): Fall, blunt trauma to the head
      • Weakness and dizziness
      • Deny tarry stool
      • Hx of hypophayngeal ca post CT in NTUH
      • TRACHEOSTOMY (+)
    • O: Vital signs: BP:129/59; HR:113; BT:36.6’C; RR:20;
      • Con’s:E4VTM6
      • SpO2:95%
      • Alert consciousness
      • mild pale, S/P TRACHEOSTOMY
      • Mild deformity of occpital region
      • Free motion of four limbs
    • A: Preliminary impression S00.93XA Contusion of unspecified part of head, initial encounter
      • H.I, brain CT: no ICH. bil. PN, Brosym, CRP:9.1, COVID/FLU-. Hb:7.0. BT 2U, Hb8
      • Hx of hypophayngeal ca s/p C/T, f/u at NTUH, oa Onco.

700901494

240226

[MedRec]

  • 2024-02-01, 2023-11-09, -08-17 SOAP Cardiology Xie JianAn
    • Prescription x3
      • Micardis (telmisartan 80mg) 1# QD
      • Norvasc (amlodipine 5mg) 0.5# QD
      • carvedilol 6.25mg 1# QD
      • Natrilix (indapamide 1.5mg) 1# QD
  • 2023-12-27 SOAP Radiation Oncology Huang JingMin
    • S: Completion of radiotherapy on 2022-10-14. Lung metastases.
      • PI: Endometrioid adenocarcinoma, grade 2, of the uterine endometrium, stage pT1b pN0 (cM0); AJCC 8th edition/FIGO Pathology stage: IB, s/p Laparoscopic gynecologic oncology staging surgery on 2022-07-27.
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM(-); HTN(-)
      • Allergy(+)
    • A: Endometrioid adenocarcinoma, grade 2, of the uterine endometrium, stage pT1b pN0 (cM0); AJCC 8th edition/FIGO Pathology stage: IB, s/p Laparoscopic gynecologic oncology staging surgery and s/p radiotherapy, with lung metastases.
    • P: Refer to medical oncology for further treatment.
      • RTC: after chemotherapy or if indicated.
  • 2023-12-21 SOAP Hemato-Oncology Gao WeiYao
    • S: menopaused at 55 y/o
      • Endometrioid adenocarcinoma, grade 2, FIGO Pathology stage: IB, at least.
      • post Laparoscopic gynecologic oncology staging surgery on 2022/07/27
      • Recurrent 2023/12/11 PATHO - lung transbronchial biopsy, Lung, right, CT-guide biopsy — consistent with metastatic endometrioid carcinoma
    • A:
      • Conclusions of Cancer Multi-specialty Team Meeting, Meeting date: 20231214
        • Treatment plan: Transfer to the HemaOnco department for systemic chemotherapy (for relapse with lung metastasis).
      • The patient and her daughter is hesitating about chemotherapy. I have planned to refer her to port-A by GS Chen YJ but she is still hesitating about it.
      • Conclusions of Cancer Multi-specialty Team Meeting, Meeting date: 20231207
        • Treatment plan: If recurrence of lung metastasis is suspected, it is recommended to arrange chest CT quided biopsy for tissue prove.
  • 2023-05-25, -03-02 SOAP Cardiology Xie JianAn
    • Prescription x3
      • Micardis (telmisartan 80mg) 1# QD
      • Norvasc (amlodipine 5mg) 1# QD
      • carvedilol 6.25mg 1# QD
      • Tricozide (trichlormethiazide 2mg) 0.5# QD
  • 2023-05-25 SOAP Gastroenterology Chen ZhiXiang
    • Prescription x3
      • Gaslan (dimethylpolysiloxane 40mg) 2# TID
      • Alpraline (alprazolam 0.5mg) 1# HS
      • Algitab (alginic acid, MgCO3, Al(OH)3; 200mg) 1# TID
      • Tone (imipramine 25mg) 0.5# TID
      • Ulstop (famotidine 20mg) 1# BID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
  • 2023-02-23 SOAP Gastroenterology Chen ZhiXiang
    • Prescription x3
      • Gaslan (dimethylpolysiloxane 40mg) 2# TID
      • Alpraline (alprazolam 0.5mg) 1# HS
      • Synpylon (sulpiride 50mg) 1# TID
      • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC

[surgical operation]

  • 2022-07-27
    • Surgery
      • Operation: Laparoscopic gynecologic oncology staging surgery        
    • Finding
      • Uterus: normal size, smooth surface, papillary mass in uterus cavity, myometrium invasion depth <1/2
      • Bilateral adnexa: grossly normal
      • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(+)
      • CDS: free
      • Estimated blood loss: 50ml
      • Blood transfusion: nil
      • Complication: nil
  • 2022-07-20
    • Surgery
      • D&C, diagnostic
      • MRI: Soft tissue in the uterine cavity, r/o endometrial malignancy, if proven malignancy, cstage T1bN0M0.
    • Finding
      • Uterus: Anteversion, 9 cm.
      • Some endometrial tissue were curetted out.
      • Estimated blood loss: 5 mL, Blood transfusion: nil, complication: nil.  

[radiotherapy]

[chemotherapy]

  • 2024-02-26 - paclitaxel 175mg/m2 300mg NS 250mL + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

Why give Taxol (Paxel) before carboplatin? - 2024-02-26 - https://www.drugs.com/medical-answers/give-taxol-paxil-before-carboplatin-3562689/

  • Medically reviewed by Carmen Pope, BPharm. Last updated on Oct 2, 2023.

  • Official answer by Drugs.com

    • Taxol (paclitaxel, Paxel) must be given before carboplatin because if carboplatin is given before Taxol, it stops Taxol from having an effect on cancer cells. This is called a scheduling interaction because when Taxol is given before carboplatin, there is little interaction and both agents work as intended.
    • The combination of carboplatin and paclitaxel is widely used to treat multiple solid tumors including ovarian, lung, and breast cancer. Research has shown that the pretreatment or simultaneous treatment with carboplatin inhibited Taxol-induced I-kappa, B-alpha degradation, and BCL-2 phosphorylation. Further analyses demonstrated that carboplatin could significantly interfere with the cytotoxic effects of Taxol on both mitotic arrest and apoptotic cell death unless Taxol was administered before carboplatin. These results indicate that the interaction between paclitaxel and carboplatin is highly schedule-dependent and the optimal schedule is Taxol (paclitaxel, Paxel) followed by carboplatin.
  • Why is Taxol and carboplatin used together?

    • A landmark study in 1996 showed that Taxol and carboplatin in combination was better for the treatment of advanced ovarian cancer because it was less toxic than the combination used at the time, Taxol and cisplatin. Carboplatin-Taxol in combination were also just as effective as cisplatin-Taxol. Carboplatin-Taxol have been a standard chemotherapy combination used for more than 25 years for the treatment of ovarian cancer. The combination is also used to treat many other solid tumors.
  • How effective is Taxol and carboplatin?

    • The combination of carboplatin-Taxol is well tolerated and achieves a clinical response rate of 50% to 81% and an average progression free survival (PFS) of 13.6 to 19.3 months. Other findings include:
      • For patients with optimally debulked advanced ovarian cancer revealed the median PFS for carboplatin-Taxol was 20.7 months compared to 19.4 with cisplatin-Taxol
      • Overall survival was 57.4 months with carboplatin-Taxol compared to 48.7 months with cisplatin-Taxol
      • Gastrointestinal, renal, metabolic toxicity and leukopenia were significantly more in cisplatin-Taxol group compared with carboplatin-Taxol
      • Quality-of-life scores at the end of treatment were significantly better with carboplatin-Taxol (65.25) compared with cisplatin-Taxol (51.97).
      • Toxic side effects, such as nausea and weight loss, are less with carboplatin-Taxol
      • Carboplatin-Taxol can be administered safely and effectively over a 3-hour infusion period. Previously, cisplatin-Taxol was administered over 24 hours, requiring a hospital stay.

==========

2024-02-26

No repeat prescriptions have been issued by any healthcare provider other than ours according the the PharmaCloud database. Furthermore, the medications prescribed by our cardiologist on 2024-02-01 have been incorporated into the active medication list without any discrepancies.

The patient’s vital signs have remained stable throughout this hospital stay, and laboratory results from 2024-02-26 did not reveal any significant findings. There is no evidence to suggest any contraindications for the administration of the paclitaxel and carboplatin regimen.

700335981

240223

[exam findings]

  • 2023-12-28 CT - chest
    • Chest CT with and without IV contrast ehnancement shows:
      • Consolidation of left lower lobe and posterior segment of left upper lobe is found.
      • S/p port-A placement with its tip at Superior vena cava.
      • There is stone at dependent portion of GB. GB stone(s) are noted.
      • Loculated cystic change at pancreatic body measuring 2.8cm in largest dimension. Suggest follow up.
    • Imp:
      • Consolidation of left lower lobe and posterior segment of left upper lobe is found. Suggest closely follow up.
  • 2023-11-13 CXR (erect)
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Increased lung markings on left middle lung and both lower lung are noted.
  • 2023-10-26 Bladder Sonography
    • PVR 26.88mL
  • 2023-07-27 SONO - abdomen
    • Diagnosis:
      • Suspected chronic liver parenchyma disease
      • Suspected GB stone
      • Pancreas not shown
      • Suboptimal examination of liver, especially the subcostal view due to poor echo window
    • Suggestion:
      • OPD f/u
      • Please correlate with liver function test and follow AFP
      • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
  • 2023-07-11 Neurosonology
    • Occlusion in R proximal CCA to CCA bifurcation; tight stenosis with trace flow in R ICA; reversed R ECA flow; mild to moderate atheromatous lesions in L CCA bifurcation and ICA; mild atheromatous lesions in L proximal to distal CCA.
    • Normal extracranial L carotid, vertebral, and intracranial vertebral, basilar arterial flows.
    • Poor bilateral temporal windows for transcranial insonation.
    • Normal bilateral ophthalmic arterial flows.
    • Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
  • 2023-06-17 CT - chest
    • LLL small cell carcinoma with lung to lung metastases, T2N2M0, stage IIIA s/p radiotherapy to the Lt lung tumor and LAPs from 2023/03/22~ and chemotherapy with EP (Etoposide 80mg/m2(D1~D3), Carboplatin AUC:4(D1)) from 2023/03/27~
    • Chest CT with and without IV contrast ehnancement shows:
      • Centrilobular Emphysematous change over both lungs is found.
      • Interstitial change at both lungs more on the dependent lung is found.
      • Minimal infiltration over left lower lobe is found. In comparison with CT dated on 2023-01-28, the lesion decreased in size markedly.
      • There is mild bilateral pleural effusion.
      • Calcified coronary arteries is found.
    • Imp:
      • left lower lobe lung cancer s/p C/T with almost complete remission.
      • COPD
      • Interstitial change at both lungs. Cancer Treatment related change cannot be fully excluded.
  • 2023-05-11, -04-20 CXR
    • Atherosclerotic change of aortic arch
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-03-22 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 28 dB HL; LE 59 dB HL.
    • RE normal to severe SNHL. (BC masking dilemma at 4k Hz)
    • LE moderate to profound mixed type HL.
  • 2023-03-16 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopharynx, right, biopsy — Lymphoid hyperplasia
    • Section shows a piece of respiratory epithelium lined tissue with lymphoid hyperplasia.
    • The immunohistochemical stain of CK reveals no invasive tumor. The immunohistochemical stains of CD3 and CD20 show relatively preserved lymphoid architecture. The immunohistochemical stain of CD56 is negative.
  • 2023-03-16 Nasopharyngoscopy
    • Bx of R NP PET + lesion
    • smooth bulging
    • CT-guided Bx = L poor diff ca, favor small cell ca
  • 2023-03-06 PET
    • Glucose hypermetabolism in the left lower lung with left pulmonary lymph nodes involvement, highly suspected the primary lung cancer with regional lymph nodes metastases. Some small nodular lesions in the right lower lung, however, show no increased FDG uptake.
    • Increased FDG uptake in bilateral mediastinal and right pulmonary hilar lymph nodes, probably reactive or metastatic nodes, suggesting further evaluation.
    • Increased FDG uptake in the in the post. wall (submucosa layrer ?) of the right nasopharynx, the nature is to be determined (another NPC, inflammation process or other nature ?), suggesting biopsy for investigation.
    • Increased FDG uptake in soft tissue of bilateral buccal regions, inflammation process may show this picture.
    • Decreased FDG uptake in the left fronto-parieto-temporal regions of the cerebral cortex, compatible with cerebral infarction.
    • Left lower lung cancer, cTxN1-3M0 (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-02-13 Portable 24hr ECG
    • Baseline was sinus rhythm with paroxysmal AFIB
    • 2 episodes of sustained pAFIB noted (13~16PM, 8~12AM)
    • Rare isolated VPCs / VPC couplet
    • Frequent isolated APCs / APC couplets (Burden 2%)
    • 19 episodes of short-run AT, max 6 beats
  • 2023-02-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (95 - 25) / 95 = 73.68%
      • M-mode (Teichholz) = 73
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Trivial MR, mild AR, trivial TR
      • Impaired LV relexation
      • Preserved RV systolic function
  • 2023-02-10 Tc-99m MDP bone scan
    • Increased activity in some L-spines and sacrum. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Some hot and faint hot spots in the posterior aspect of bilateral rib cages and increased activity in the left frontal area of the skull and left tibia. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions and knees, compatible with benign joint lesions.
  • 2023-02-06 CXR
    • Lung markings: a nodular lesion in the left perihilar lung field
  • 2023-02-06 Patho - lung transbronchial biopsy
    • Lung, left, CT-guide biopsy — poorly differentiated carcinoma, in favor of small cell carcinoma
    • Sections show large nests of small hyperchromatic tumor cells with scanty cytoplasm and crushing artifact.
    • The immunohistochemical stains reveal CK(+), CK7(focal +), CK20(-), CD56(focal +), Synaptophysin(-), Chromogranin A(-), TTF-1(-), Napsin A(-), p40(-), GATA3(-), and CDX2(-). The Ki-67 is about 80%. The results and morphology are in favor of small cell carcinoma. Please correlate with the clinical presentation and image study.
  • 2023-01-31 CT - abdomen
    • With and without contrast enhancement CT of abdomen:
      • Presence of gallbladder stone.
      • Left upper lung tumor (3.1cm), r/o lung malignancy.
      • Right lower lung nodule, r/o lung to lung metastasis.
      • Emphysematous change of lungs.
    • Impression:
      • GB stone.
      • Left upper lung tumor, r/o lung malignancy.
      • RLL nodule, r/o lung to lung metastasis.
      • Emphysematous change of lungs.
  • 2023-01-31 Electroencephalography, EEG
    • This EEG study recorded background alpha rhythm (8-9) and beta activity with intermittent transient diffuse slow waves. more on the left.
    • No epileptiform discharges.
    • Please correlate with clinical features.
  • 2023-01-28 CT - chest
    • Indication: for left lung nodular?
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Moderate to severe Emphysematous change over both lungs is found.
        • Mass like lesion at left upper lobe measuring 3.33cm in largest dimension. r/o lung cancer.
        • Minimal peribronchial opacity oveer right lower lobe and left lower lobe is found.
        • Some lymph nodes are found at bialteral paratracheal region.
      • Visible abdomen:
        • There is stone at dependent portion of GB. GB stone(s) are noted.
    • IMP:
      • COPD with one mass at left upper lobe measuring 3.33cm. Lung cancer is suspected.
      • Mediatinal lymphadenopathy
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T2(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-01-27 Neurosonology
    • Occlusion in R proximal CCA to CCA bifurcation; tight stenosis with trace flow in R ICA; reversed R ECA flow; mild atheromatous lesions in L CCA bifurcation and ICA.
    • Normal extracranial L carotid, vertebral, and intracranial vertebral, basilar arterial flows.
    • Poor bilateral temporal windows for transcranial insonation.
    • Reversed R ophthalmic arterial flows.
    • Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
  • 2023-01-26 MRA - brain
    • Subacute infarcts involving left frontotemporal lobe and basal ganglion as described. Stenosis of right ICA. Mild general brain atrophy.
  • 2023-01-23, -01-19 CXR
    • Lung markings: a nodular lesion in the left perihilar lung field

[MedRec]

  • 2024-02-22 SOAP Chest Medicine Lan ZhouJin
    • Prescription x3
      • Xanthium (theophylline 200mg) 1# BID
      • Mecater (procaterol 25ug) 1# QD
      • Concor (bisoprolol 1.25mg) 1# PRNQD if SBP > 140
      • Berotec-N (fenoterol 0.1mg/pull) 1 puff PRNQID INHL
      • Spiolto (tiotropium 2.5ug, olodaterol 2.5ug; per puff) 2 puff QD INHL
  • 2024-02-02 SOAP Neurology Chen PeiYa
    • Prescription x3
      • Syntam (piracetam 1200mg) 1# QD
      • Lixiana (edoxaban 30mg) 1# QD
      • Mesyrel (trazodone 50mg) 1# HS
  • 2024-01-24 SOAP Cardiology Zhan ShiRong
    • Prescription x3
      • Cartil (diltiazem 30mg) 1# BID hold if SBP < 100
      • Cordaron (amiodarone 200mg) 1# QD
  • 2024-01-18 SOAP Urology Wu ZhuYu
    • A: NVD (Bard: Neurogenic? or Night? Voiding Dysfunction), urine retention
    • Prescription x3
      • Urief (silodosin 8mg) 1# QD
      • Wecoli (bethanechol 25mg) 1# TIDAC
  • 2023-11-23 SOAP Neurology Chen PeiYa
    • Prescription x3
      • Syntam (piracetam 1200mg) 1# QD
      • Lixiana (edoxaban 30mg) 1# QD
      • Mesyrel (trazodone 50mg) 0.5# HS
  • 2023-10-11 ~ 2023-10-13 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Left lower lung small cell carcinoma with lung to lung metastases, T2N2M0, stage IIIA s/p radiotherapy to deliver 66~70 Gy/ 33~35 fx to the Lt lung tumor and LAPs from 2023/03/22~06/20 and chemotherapy with EP (Etoposide 80mg/m2(D1~D3), Carboplatin AUC:4(D1)) from 2023/03/27~
      • Chronic obstructive pulmonary disease, unspecified
      • Left distal ICA and left MCA occlusion with infarction s/p IV rt-PA therapy and EVT
      • Atrial fibrillation
      • Constipation, unspecified
      • Chronic viral hepatitis B without delta-agent
      • Anxiety disorder, unspecified
      • Hyperlipidemia, unspecified
      • Hypomagnesemia
      • Hypokalemia
      • Enlarged prostate with lower urinary tract symptoms
      • Other difficulties with micturition
      • Neuromuscular dysfunction of bladder, unspecified
      • Cachexia
    • CC
      • for chemotherapy plus immunity therapy
    • Present illness
      • This 74 year-old man suffered found lying on the ground with speechlessness on 2023/01/14.
      • Brain CT on 2023/01/14 was performed revealed suspect hyperdensity at left distal ICA and proximal MCA, suggest CTA study to clarify.
      • The neurology was consulted. Who suggest r-tPA was indication.
      • After Brain CTA on 2023/01/14 was performed revealed occlusion of left ICA and proximal MCA, r/o ICA dissectio and suspect occlusion of right CCA.
      • Impression of left distal ICA and left MCA occlusion with infarction s/p r-tPA, EVT + IA thrombectomy on 2023/01/14.
      • Brain VT on 2023/01/15 showed no definite intracranial hemorrhage and acute infarct in left insular cortex and frontal lobe.
      • Brain MRA on 2023/01/26 showed subacute infarcts involving left frontotemporal lobe and basal ganglion as described, stenosis of right ICA and mild general brain atrophy.
      • Dopscan + CPA on 2023/01/27 showed 1) Occlusion in R proximal CCA to CCA bifurcation; tight stenosis with trace flow in R ICA; reversed R ECA flow; mild atheromatous lesions in L CCA bifurcation and ICA. 2) Normal extracranial L carotid, vertebral, and intracranial vertebral, basilar arterial flows. 3) Poor bilateral temporal windows for transcranial insonation. 4) Reversed R ophthalmic arterial flows. 5) Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
      • Chest CT on 2023/01/28 showed COPD with one mass at left upper lobe measuring 3.33cm, Lung cancer is suspected and mediatinal lymphadenopathy, T2N2M0, stage IIIA.
      • Abdominal CT on 2023/01/31 showed GB stone, left upper lung tumor, R/O lung malignancy, RLL nodule, R/O lung to lung metastasis and emphysematous change of lungs.
      • Awake or Sleep EEG on 2023/01/31 showed this EEG study recorded background alpha rhythm (8-9) and beta activity with intermittent transient diffuse slow waves. more on the left, no epileptiform discharges and please correlate with clinical features.
      • LLL lung mass CT-guided biopsy on 2023/02/06 and pathology showed poorly differentiated carcinoma, in favor of small cell carcinoma, immunohistochemical stains reveal CK(+), CK7(focal +), CK20(-), CD56(focal +), Synaptophysin(-), Chromogranin A(-), TTF-1(-), Napsin A(-), p40(-), GATA3(-), and CDX2(-), the Ki-67 is about 80% and the results and morphology are in favor of small cell carcinoma.
      • Whole body bone scan on 2023/02/10 showed degenerative of L-spines and sacrum, no bone metastasis. 2D echo on 2023/02/13 showed M-mode (Teichholz) = 73, 1. Adequate LV systolic function with normal resting wall motion 2. Trivial MR, mild AR, trivial TR 3. Impaired LV relexation 4. Preserved RV systolic function.
      • Whole body PET scan on 2023/03/06 showed left lower lung with left pulmonary lymph nodes involvement, highly suspected the primary lung cancer with regional lymph nodes metastases, some small nodular lesions in the right lower lung, bilateral mediastinal and right pulmonary hilar lymph nodes, probably reactive or metastatic nodes, left lower lung cancer, cTxN1-3M0.
      • Port-A catheter implantation on 2023/03/06.
      • Nasopharyngoscopy on 2023/03/16 with nasopharynx right biopsy lymphoid hyperplasia.
      • He received PTA on 2023/03/22 showed Reliability FAIR, Average RE 28 dB HL; LE 59 dB HL, RE normal to severe SNHL. (BC masking dilemma at 4k Hz) and LE moderate to profound mixed type HL.
      • 24hrs CCr. on 2023/03/23 showed 54.5ml/min.
      • Radiotherapy to deliver 66~70 Gy/ 33~35 fx to the Lt lung tumor and LAPs from 2023/03/22~2023/03/23, 2023/03/29~.
      • Chemotherapy with EP(Etoposide 80mg/m2(D1~D3), Carboplatin AUC:4(D1)) was given on 2023/03/27(C1), on 2023/06/01(C2).
      • Follow up Chest CT on 2023/06/17 showed left lower lobe lung cancer s/p C/T with almost complete remission, COPD, interstitial change at both lungs. Cancer Treatment related change cannot be fully excluded.
      • Extensive discussion with treatment strategy, suggest IO plus C/T.
      • Chemotherapy plus immunity therapy with Carboplatin + Etoposide + Durvalumab (C1) on 2023/09/11.
      • This time, he was admitted to our ward for chemotherapy plus immunity therapy with Carboplatin + Etoposide + Durvalumab (free) (C2).
    • Course of inpatient treatment
      • After admission, he received chemitherapy with Carboplatin (AUC:4)/ Etoposide(100mg/m2, D1-D3)/ Durvalumab(1500mg, C2 Free(Buy one Free one)), post last chemotherapy, weakness still noted, discussion with wife, reduce Etoposide(100mg/m2, D1-D3), and decrease Carboplatin (AUC:4->2) on 2023/10/12.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
      • Chronic obstructive pulmonary disease with Mecater 25mcg/tab 1# PO QD, ROMICON-A 20,20,90mg/cap 1# PO QD for cough, Xanthium 200mg/cap 1# PO BID, Shitan 8mg/tab 1# PO BID, Spiolto 60 puff/box 2puff INHL QD.
      • Left distal ICA and left MCA occlusion with infarction s/p IV rt-PA therapy and EVT with Syntam Granules 1200mg/pk 1pk PO QD.
      • Atrial fibrillation with Lixiana F.C. 30mg 1# po QD, Concor 1.25mg/tab 1# PO PRNQD if SBP > 140mmHg and Cartil 30 mg/tab 1# PO BID Hold if SBP < 100mmHg.
      • For chemotherapy, Baraclude 0.5mg 1# po QDAC was given for Anti-HBc showed Reactive.
      • Hyperlipidemia with CRESTOR 10mg/tab 1# PO QD.
      • Hypomagnesemia with Magnesium Sulfate 10%, 20mL/amp 1amp IVD for support.
      • Hypokalemia with 0.298% KCl in 0.9% NaCl Injection 500mL/bot IVD for support.
      • Neuromuscular dysfunction of bladder, Uro OPD follow up, was treated with Urief F.C 8mg/tab 1# PO QD, Wecoli 25mg/tab 1# PO TIDAC.
      • Constipation with Through 12mg/tab 1# PO HS.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/10/13 and OPD followed up later.
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QLAC
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • BaoGan (silymarin 150mg) 2# BID
      • Crestor (rosuvastatin 10mg) 1# QD
      • Actein Effervescent (acetylcisteine 600mg) 1# BID
      • Through (sennoside 12mg) 1# HS
      • Megest (megestrol 40mg/mL) 10mL QD
  • 2023-08-31 SOAP Neurology Chen PeiYa
    • Prescription x3
      • Syntam (piracetam 1200mg) 1# QD
      • Lixiana (edoxaban 30mg) 1# QD
      • Mesyrel (trazodone 50mg) 0.5# QODHS
  • 2023-08-31 SOAP Chest Medicine Lan ZhouJin
    • Prescription x3
      • Xanthium (theophylline 200mg) 1# BID
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# BID
      • Mecater (procaterol 25ug) 1# QD
  • 2023-08-09 SOAP Cardiology Zhan ShiRong
    • Prescription x3
      • Cartil (diltiazem 30mg) 1# BID
  • 2023-05-25 SOAP Psychosomatic Medicine
    • S: The patient comes with son and wife. Less anxiety, less dysphoria, and more speech. It seems response to the additional sertraline.
  • 2023-05-11 SOAP Psychosomatic Medicine
    • S: MAJOR ILLNESS CARD: [Diagnostic interview 45085] C.C. & P.I.: The first time visit, the patient comes with wife and son. He initilally focus on left lower leg and ankle area. He then hesitately to talk about something wrong, about his wife and son. left cerebral stroke. In addition, lung cancer diagnosis at the same time. Low self-esteem, hypotalkativeness.
  • 2023-02-23 SOAP Chest Medicine
    • A/P
      • visit for asking about cancer Tx, for his stage III and poor performance, surgey was not suggested, refer to Oncology for possible clinical trial of IO
      • Tx COPD with Mx,
      • P: ultibro, xanthium, medicon
    • Prescription
      • Xanthium (theophylline 200mg) 1# QD
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
      • Ultibro Breezhaler (indacaterol 100ug, glycopyrronium 50ug) 1# QD INHL

[consultation]

  • 2024-01-03 Radiation Oncology
    • Q
      • for increase infiltration of lung after radiotherapy
    • A
      • The consolidation of left lower lobe and posterior segment of left upper lobe shown on the latest chest CT are comparable to the irradiated volume (2023-03-23 ~ 2023-06-20: 66 Gy/ 33 fx), which indicates fibrotic change. The fibrotic change is less likely to interfere systemic Tx such as IO if active infection has been ruled out.
  • 2023-06-23 Cardiology
    • Q
      • The patient is an 74-year-old male with a history of Left lower lung small cell carcinoma with lung to lung metastases, T2N2M0, stage IIIA s/p radiotherapy to deliver 66~70 Gy/ 33~35 fx to the Lt lung tumor and LAPs from 2023/03/22~ and chemotherapy with EP (Etoposide 80mg/m2(D1~D3), Carboplatin AUC:4(D1)) from 2023/03/27~, last time C/T on 2023/06/01, now under R/T.
      • For heart disease history, he presented with tachycardia for days, we need your further evaluation and management.
    • A
      • S: 74 year-old male had the history of Left distal internal carotid artery and left middle cerebral artery occlusion with infarction post intravenous recombinant tissue plasminogen activator and endovascular thrombectomy on 2023-01-14, atrial fibrillation and left lung cancer stage IIIA.
        • The patient just had the recovery of pancytopenia after chemotherapy.
      • O
        • LAB 6/23 Hb10.9 PLT231l Cre0.90 ALT54 K4.6; 6/15 albumin 3.0
        • ECG 20230612 Af, VR118bpm
        • CXR 230616 no cardiomegaly,
        • CT of chest 20230617
          • Centrilobular Emphysematous change over both lungs is found.
          • Interstitial change at both lungs more on the dependent lung is found.
          • Minimal infiltration over left lower lobe is found. In comparison with CT dated on 2023-01-28, the lesion decreased in size markedly.
          • There is mild bilateral pleural effusion.
          • Calcified coronary arteries is found.
        • Echocardiogram 20230213
          • Findings
            • AO(mm) = 34; LA(mm) = 35
            • IVS(mm) = 10; LVPW(mm) = 7
            • LVEDD(mm) = 45; LVESD(mm) = 26
            • TAPSE(mm) = 19
            • M-mode(Teichholz) = 73
            • TR: Trivial; Max pressure gradient = 21 mmHg
            • IVC size 7 mm with respiratory collapse > 50%
          • Conclusion:
            • Adequate LV systolic function with normal resting wall motion
            • Trivial MR, mild AR, trivial TR
            • Impaired LV relexation
            • Preserved RV systolic function
      • Impression
        • Atrial fibrillation
      • Suggestion
        • Give regular bisoprolol 1.25mg QD if no bronchospasm
        • Keep rosuvastatin, edoxaban 30mg QD
        • Watch fluid status and any sepsis (might induce HR increasing)
        • Holter ECG evaluation
        • Consider diltiazem 30mg QD or BID for ventricular rate control
  • 2023-06-20 Infectious Disease
    • Q
      • The patient is an 74-year-old male with a history of Left lower lung small cell carcinoma with lung to lung metastases, T2N2M0, stage IIIA s/p radiotherapy to deliver 66~70 Gy/ 33~35 fx to the Lt lung tumor and LAPs from 2023/03/22~ and chemotherapy with EP (Etoposide 80mg/m2(D1~D3), Carboplatin AUC:4(D1)) from 2023/03/27~, last time C/T on 2023/06/01, now under R/T.
      • he presented with herpes of lip since 6/17 night, we need your further evaluation and management.
    • A
      • Hx review as mentioned above and Lab data
      • Suggestion: keep topic acyclovir ointment for lip herpes and follow-up
  • 2023-02-02 Diagnostic Radiology
    • A: This 74-year-old patient is a case of LLL lung mass, r/o malignancy. CT-guided biopsy is indicated. Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.
  • 2023-01-30 Chest Medicine
    • Q
      • This 74 y/o man has a history of HTN and hyperuricemia. He was normal at 6pm when going to toilet but was found lying on the ground with speechlessness at 6:30pm. He denied of any aura, urinary or faecal incontinence, history of recent URI symptoms, headaceh, taking OC pills, unknown medications, similar disease in family history. He was sent to our ER for help. Arrival our ER around 19PM. Initail GCS E4V2M6. Physical examination shoed right limb weakness (muscle power 0), left gaze deviation, right hemianopia and right central facial palsy. Brain CT was performed revealed suspect hyperdensity at left distal ICA and proximal MCA. The neurology was consulted. Who suggest r-tPA was indication. After Brain CTA was performed revealed occlusion of left ICA and proximal MCA, r/o ICA dissectio and suspect occlusion of right CCA. Impression of left distal ICA and left MCA occlusion with infarction s/p r-tPA + IA thrombectomy then admission to SICU for neurologicalo monitor.
      • After admission, the brain CT was follow-up on 2023-01-15, it revealed No definite intracranial hemorrhage, acute infarct in left insular cortex and frontal lobe. The Plavix was added at that time. After general condition stable, he will transfer to ward on 2023/01/19. at ward, his conscious E4VA(dysarthria + breathy sound)M6. motor aphasia, MP general 4-5. s/p NG with Foley and remove sucess. the bronchdilator for wheezing.
      • Brain MRA showed Subacute infarcts involving left frontotemporal lobe and basal ganglion as described. Stenosis of right ICA. Mild general brain atrophy. For chest x-ray found a nodular lesion in the left perihilar region. chest CT was done and showed COPD with one mass at left upper lobe measuring 3.33cm. Lung cancer is suspected. Mediatinal lymphadenopathy. we arranged Abdomen CT+C afternoon, so your was consulted.
    • A
      • For his CT scan with emphysema with one mass at left upper lobe measuring 3.33cm. Lung cancer is suspected. Suggested to perform CT guided biospy. If he is proved to be case of lung cancer, further study of brain MRI and bone scan should be done.
      • For his emphysema, Spiolto inhaler is suggested.
      • I will like to follow this case if pathology available.
  • 2023-01-14 Neurology
    • Q
      • CVA Call
      • Triage Level: 2, Limb Weakness > Symptom onset time <4.5 hours. At 18 PM, patient was normally using the toilet. At 18:30 PM, patient was unable to move in the toilet, exhibiting right side limb weakness and both eyes looking to the left. Fasting sugar is 74 mg/dL by EMT. Denies TOCC (Time of onset, Characteristics, Circumstances).
    • A1
      • This 74 y/o man has a history of HTN and hyperuricemia. He was normal at 6pm when going to toilet but was found lying on the ground with speechlessness at 6:30pm.
      • NE E4VaM5 aphasia
        • CNs:
          • left gaze deviation, right hemianopia
          • right central facial palsy
        • MP upper 0/5 lower 2-3 /5
        • sensation: poor response of right limbs
        • NIHSS 022 111 0402 01320 (18) at 19:25
      • brain CT: no ICH, left dense MCA sign
      • impression: acute left MCA territory infarct
      • suggestion:
        • rt-PA therapy was indicated (71.2kg, 0.9mg/kg, total 64mg, loading 6.4mg)
        • arrange CTA to rule out LVO and consider EVT if indicated
        • neurology ICU admission
    • A2 2023-01-14 20:46:44
      • s/p rt-PA therapy (loading at 19:53)
      • NIHSS 122 111 0302 01220 (18) at 20:40
      • brain CTA: left ICA/MCA occlusion; right CCA occlusion
      • EVT is indicated after discussion with intervention radiologist
      • explained to the family about the EVT and the family agreed
      • tight control BP and arrange EVT

[chemotherapy]

  • 2024-01-31 - durvalumab 1500mg NS 250mL 1hr + carboplatin AUC 2 150mg NS 250mL 2hr (Carbo AUC 4 -> 2. Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2024-01-03 - durvalumab 1500mg NS 250mL 1hr + carboplatin AUC 2 150mg NS 250mL 2hr (Carbo AUC 4 -> 2. Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-12-11 - durvalumab 1500mg NS 250mL 1hr + carboplatin AUC 2 150mg NS 250mL 2hr (Carbo AUC 4 -> 2. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-14 - durvalumab 1500mg NS 250mL 1hr + carboplatin AUC 2 150mg NS 250mL 2hr (Carbo AUC 4 -> 2. Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-12 - durvalumab 1500mg NS 250mL 1hr + carboplatin AUC 2 150mg NS 250mL 2hr (Carbo AUC 4 -> 2. Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-11 - durvalumab 1500mg NS 250mL 1hr + etoposide 100mg/m2 135mg NS 500mL 2hr D1-3 + carboplatin AUC 4 300mg NS 250mL 2hr D1 (VP16 80mg/m2, Carbo AUC 4. Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-01 - etoposide 100mg/m2 135mg NS 500mL 2hr D1-3 + carboplatin AUC 4 300mg NS 250mL 2hr D1 (VP16 80mg/m2, Carbo AUC 4) (CCRT. Xia HeXiong)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-27 - etoposide 100mg/m2 135mg NS 500mL 2hr D1-3 + carboplatin AUC 4 300mg NS 250mL 2hr D1 (VP16 80mg/m2, Carbo AUC 4) (CCRT. Xia HeXiong)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

Small Cell Lung Cancer NCCN Evidence Blocks - Version 1.2024 - 2023-09-05

  • PRIMARY OR ADJUVANT THERAPY FOR LIMITED-STAGE SCLC - SCL-E, 1 OF 6
    • Principles
      • Four cycles of systemic therapy are recommended.
      • Planned cycle length should be every 21–28 days during concurrent RT. During systemic therapy + RT, cisplatin/etoposide is recommended (category 1).
      • The use of myeloid growth factors is not recommended during concurrent systemic therapy plus RT (category 1 for not using GM-CSF).
    • Preferred Regimens
      • Cisplatin 75 mg/m2 day 1 and etoposide 100 mg/m2 days 1, 2, 3
      • Cisplatin 60 mg/m2 day 1 and etoposide 120 mg/m2 days 1, 2, 3
    • Other Recommended Regimens
      • Cisplatin 25 mg/m2 days 1, 2, 3 and etoposide 100 mg/m2 days 1, 2, 3
      • Carboplatin area under the curve (AUC) 5–6 day 1 and etoposide 100 mg/m2 days 1, 2, 3
  • PRIMARY THERAPY FOR EXTENSIVE-STAGE SCLC - SCL-E, 1 OF 6
    • Principles
      • Four cycles of therapy are recommended, but some patients may receive up to 6 cycles based on response and tolerability after 4 cycles.
    • Preferred Regimens
      • Carboplatin AUC 5 day 1 and etoposide 100 mg/m2 days 1, 2, 3 and atezolizumab 1200 mg day 1 every 21 days x 4 cycles followed by maintenance atezolizumab 1200 mg day 1, every 21 days (category 1 for all)
      • Carboplatin AUC 5 day 1 and etoposide 100 mg/m² days 1, 2, 3 and atezolizumab 1200 mg day 1 every 21 days x 4 cycles followed by maintenance atezolizumab 1680 mg day 1, every 28 days
      • Carboplatin AUC 5-6 day 1 and etoposide 80-100 mg/m2 days 1, 2, 3 and durvalumab 1500 mg day 1 every 21 days x 4 cycles followed by maintenance durvalumab 1500 mg day 1 every 28 days (category 1 for all)
      • Cisplatin 75–80 mg/m2 day 1 and etoposide 80–100 mg/m2 days 1, 2, 3 and durvalumab 1500 mg day 1 every 21 days x 4 cycles followed by maintenance durvalumab 1500 mg day 1 every 28 days (category 1 for all)
    • Other Recommended Regimens
      • Carboplatin AUC 5–6 day 1 and etoposide 100 mg/m2 days 1, 2, 3
      • Cisplatin 75 mg/m2 day 1 and etoposide 100 mg/m2 days 1, 2, 3
      • Cisplatin 80 mg/m2 day 1 and etoposide 80 mg/m2 days 1, 2, 3
      • Cisplatin 25 mg/m2 days 1, 2, 3 and etoposide 100 mg/m2 days 1, 2, 3
    • Useful in Certain Circumstances
      • Carboplatin AUC 5 day 1 and irinotecan 50 mg/m2 days 1, 8, 15
      • Cisplatin 60 mg/m2 day 1 and irinotecan 60 mg/m2 days 1, 8, 15
      • Cisplatin 30 mg/m2 days 1, 8 and irinotecan 65 mg/m2 days 1, 8
  • SCLC SUBSEQUENT SYSTEMIC THERAPY (PS 0–2) - SCL-E, 3 OF 6
    • Principles
      • Consider dose reduction or growth factor support for patients with PS 2.
    • CHEMOTHERAPY-FREE INTERVAL (CTFI) >6 MONTHS
      • Preferred Regimens
        • Clinical trial enrollment
        • Re-treatment with platinum-based doublet
      • Other Recommended Regimens
        • Lurbinectedin
        • Topotecan oral (PO) or intravenous (IV)
        • Irinotecan
    • CTFI <=6 MONTHS
      • Preferred Regimens
        • Clinical trial enrollment
        • Lurbinectedin
        • Topotecan oral (PO) or intravenous (IV)
        • Irinotecan
        • Re-treatment with platinum-based doublet may be considered for CTFI 3–6 months
      • Other Recommended Regimens
        • Nivolumab or pembrolizumab (if not previously treated with an ICI)
        • Paclitaxel
        • Temozolomide
        • Cyclophosphamide/doxorubicin/vincristine (CAV)
        • Docetaxel
        • Gemcitabine
        • Oral etoposide
  • Response Assessment - SCL-E - 4 OF 6
    • Limited stage  - For patients receiving adjuvant therapy, response assessment is recommended only after completion of adjuvant therapy; do not repeat scans to assess response during adjuvant treatment.  - Response assessment after adjuvant therapy involves C/A/P CT with contrast and brain MRI (preferred) with contrast or brain CT with contrast (SCL-6).  - For patients receiving systemic therapy + concurrent RT, response assessment is recommended only after completion of initial therapy; do not repeat scans to assess response during initial treatment.  - For patients receiving systemic therapy alone or sequential systemic therapy followed by RT, response assessment by C/A/P CT with contrast is recommended after every 2–3 cycles of systemic therapy and at completion of therapy.
    • Extensive stage -During systemic therapy, response assessment by C/A/P CT with contrast is recommended after every 2–3 cycles of systemic therapy and at completion of therapy.  - For patients with asymptomatic brain metastases receiving systemic therapy before brain RT, it is recommended that brain MRI (preferred) or CT with contrast is repeated after every 2 cycles of systemic therapy and at completion of therapy.
    • Subsequent systemic therapy -Response assessment by C/A/P CT with contrast is recommended after every 2–3 cycles of systemic therapy.
    • Transformed SCLC from NSCLC with an Oncogenic Driver -This is a rare population of patients with very limited data to guide treatment. -Systemic cytotoxic chemotherapy is recommended using the NCCN Guidelines for Small Cell Lung Cancer. -The role of immunotherapy in this setting is unclear based on limited data. -If TKI is continued, ICI should be avoided, due to known toxicity. -Consider referral to a center with experience managing transformed SCLC.

Carboplatin plus etoposide for chemotherapy-naïve extensive-stage small cell lung cancer 2023-06-02 https://www.uptodate.com/contents/image?topicKey=ONC%2F4633&imageKey=ONC%2F75586

  • Cycle length: 21 days, for a maximum of six cycles.

  • Regimen

    • Carboplatin
      • AUC = 5 mg/mL × min IV (AUC is converted to a patient-specific carboplatin dose (in mg) according to renal function by using the Calvert formula. The Calvert formula is total dose (mg) = (target AUC) × (GFR + 25). If using measured serum creatinine, limit the maximal GFR for the calculation to 125 mL/min)
      • Dilute in 250 mL NS and administer over 30 minutes.
      • Day 1
    • Etoposide
      • 100 mg/m2 IV
      • Dilute in 500 mL NS or D5W to final concentration <0.4 mg/mL. Infuse over 30 to 60 minutes; if infused more rapidly, severe hypotension may occur.
      • Days 1, 2, and 3
  • Pretreatment considerations:

    • Emesis risk
      • MODERATE on day 1 and LOW on days 2 and 3.
    • Vesicant/irritant properties
      • Carboplatin and etoposide are irritants.
    • Infection prophylaxis
      • Routine primary prophylaxis with hematopoietic growth factors is not recommended (incidence of febrile neutropenia is about 5%).
    • Dose adjustment for baseline liver or renal dysfunction
      • Each carboplatin dose should be calculated based upon renal function by use of the Calvert formula. A lower starting dose of etoposide may be needed for patients with renal or liver impairment.
  • Monitoring parameters:

    • CBC with differential and platelet count weekly during treatment.
    • Electrolytes and liver and renal function prior to each cycle of chemotherapy.
  • Suggested dose modifications for toxicity:

    • Myelotoxicity
      • Dose adjustment based on myelotoxicity was not reported in the final publication. Per protocol, cycles were delayed for up to 42 days to allow neutrophils to return to >=1500/microL and platelets to >=100,000/microL. However, the United States Prescribing Information recommends that the dose of carboplatin be reduced by 25% if platelets are <50,000/microL and/or ANC is <500/microL.
    • Nonhematologic toxicity
      • Chemotherapy should be held for grade 3 and 4 nonhematologic toxicities (except for neurotoxicity) and is only restarted after the toxicity has resolved to patient’s baseline.
    • Hepatotoxicity
      • No formal etoposide dosing recommendations were reported in this publication. However, accepted dose reductions per product information may be found in the literature.
    • Nephrotoxicity
      • Alterations in renal function during therapy may require a recalculation of the carboplatin dose.
    • If there is a change in body weight of at least 10%, doses should be recalculated.

==========

2024-02-23

[evaluating elevated conjugated bilirubin and potential obstructions]

The level of conjugated bilirubin is elevated, which may indicate obstructions such as gallstones or strictures in the bile ducts, hindering the excretion of bilirubin into the gastrointestinal tract. Abdominal ultrasonography conducted on 2023-07-27 revealed potential chronic liver parenchymal disease and a suspected gallbladder stone. The examination of the liver, particularly the subcostal view, was suboptimal due to a poor echo window.

  • 2024-02-22 Bilirubin direct 0.22 mg/dL
  • 2024-01-31 Bilirubin direct 0.22 mg/dL
  • 2024-01-02 Bilirubin direct 0.16 mg/dL
  • 2023-12-11 Bilirubin direct 0.15 mg/dL

It may be advisable to request a follow-up abdominal ultrasonography and an Alpha-Fetoprotein (AFP) test for further evaluation.

2024-02-01

[monitoring pneumonitis risk: durvalumab/carboplatin for stable patchy consolidation]

Comparing the CXR 2024-01-03, to 2024-01-31, the patchy consolidation in the left middle lung has not become more pronounced. On 2024-01-31, a new session of durvalumab combined with carboplatin was administered. Continuous monitoring of the pulmonary condition is recommended.

Pneumonitis includes acute interstitial pneumonitis, interstitial lung disease, pneumonitis, pulmonary fibrosis is associated with Imfinzi (durvalumab), according to the package insert (https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/761069s035lbl.pdf page 12-13; all grades 34%, grade 3/4 3.4%).

Vital signs and lab results were grossly normal except for elevated AST, ALT and bilirubin levels, no medication discrepancies noted.

2024-01-03

[reconciliation]

The admission note dated 2024-01-02 recorded an ECOG PS of 2. The original regimen was designed as “carboplatin AUC 5-6 on day 1 and etoposide 80-100 mg/m2 on days 1, 2, 3, along with durvalumab 1500 mg on day 1 every 21 days for 4-6 cycles, followed by maintenance durvalumab 1500 mg on day 1 every 28 days.” However, due to the patient’s apparent frailty, since Oct 2023, the regimen was modified to a reduced dose version with carboplatin AUC 2 and etoposide omitted. The CT results from 2023-12-28 still indicate an effective disease control.

Lab data from 2024-01-02 showed slightly elevated ALT (42 U/L) and creatinine (1.32 mg/dL) levels. Current medications do not require dose adjustments based on these readings.

2023-10-12

The patient is currently taking several medications with no discrepancies noted: From our neurologist (as of 2023-08-31) for Syntam (piracetam), Lixiana (edoxaban), and Mesyrel (trazodone); from the chest physician (as of 2023-08-31) for Xanthium (theophylline), Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), and Mecater (procaterol); and from the cardiologist (as of 2023-08-09) for Cartil (diltiazem).

The previously observed spikes in AST and ALT levels in May and July/August of this year have now disappeared. Renal function tests show normal results and no drug dose adjustments are required based on liver and kidney function.

The serum potassium level dropped to 3.1 mmol/L on 2023-10-05, the lowest level recorded in the last three months. This may warrant further monitoring.

2023-09-12

Per the HIS5 records, medications issued as repeat prescriptions by our departments of Neurology, Chest Medicine, and Cardiology on 2023-08-31, 2023-08-31, and 2023-08-09 respectively, are all accounted for in the active medication list. No discrepancies in medication reconciliation have been found.

2023-06-02

  • The patient visited our Psychosomatic Medicine OPD on 2023-05-11 and 2023-05-25, where he was prescribed Zoloft (sertraline), which was duly added to the list of active medications. In addition, the patient has a refillable prescription for Lixiana (edoxaban) from our Neurology OPD dated 2023-04-13, which also appears on the active medication list.

  • It’s advised to note that selective serotonin reuptake inhibitors (SSRIs), such as sertraline, can potentially increase the risk of bleeding, especially when used with antiplatelet and/or anticoagulant medications. There have been several observational studies linking the use of SSRIs to a variety of bleeding complications, ranging from minor problems such as bruising, hematoma, petechiae, and purpura to more serious conditions such as stroke, upper gastrointestinal bleeding, intracranial hemorrhage, postpartum hemorrhage, and perioperative bleeding. In light of this, it is prudent to monitor this patient closely for any signs of bleeding.

  • The liver-associated enzymes ALT and AST, particularly ALT, have both shown an increasing trend in this patient. The patient is currently being treated with Baogan (silymarin) and Baraclude (entecavir), which are appropriate given the patient’s liver status and HBV carrier state.

    • 2023-06-01 S-GPT/ALT 116 U/L
    • 2023-05-04 S-GPT/ALT 140 U/L
    • 2023-04-20 S-GPT/ALT 75 U/L
    • 2023-04-06 S-GPT/ALT 51 U/L
    • 2023-03-27 S-GPT/ALT 20 U/L
    • 2023-03-22 S-GPT/ALT 31 U/L
    • 2023-02-06 S-GPT/ALT 30 U/L
    • 2023-06-01 S-GOT/AST 46 U/L
    • 2023-05-18 S-GOT/AST 64 U/L
    • 2023-05-11 S-GOT/AST 62 U/L
    • 2023-05-04 S-GOT/AST 60 U/L
    • 2023-04-27 S-GOT/AST 49 U/L
    • 2023-04-13 S-GOT/AST 40 U/L
    • 2023-02-06 S-GOT/AST 26 U/L
    • 2023-02-01 S-GOT/AST 22 U/L
  • Etoposide has been associated with hepatotoxicity, but the incidence is low (<= 3%) and therefore it is less likely to be the primary cause of the elevated liver enzymes. On the other hand, carboplatin is reported to be associated with increased serum alkaline phosphatase (24% to 37%) and increased serum aspartate aminotransferase (15% to 19%). This suggests that carboplatin might be a more likely cause of the observed liver enzyme elevation.

  • Given that the patient’s current regimen has already been dose-reduced since initiation (etoposide from 100mg/m2 to 80mg/m2, carboplatin from AUC 5 to AUC 4), it may not be necessary to further reduce the dose immediately unless the liver enzymes rapidly increase.

700370877

240223

[exam findings]

  • 2023-12-01 CT - brain
    • Bony erosion of left mandible. S/P craniotomy. Encephalomalacia at rgiht parietal region. A bony defect at left parietal skull.
  • 2023-11-29 MRI - L-spine
    • Focal T2W hyperintensity lesion in conus medullaris (T11-12 level), suspect spinal cord lesion. Myelitis or tumor? Suggest further evaluation.
    • Degenerative spinal and disc disease.
    • Mild L2-3 retrolisthesis. Grade 1 degenerative spondylolisthesis at L4-5 level.
    • Moderate L2-3, L3-4, severe L4-5 central canal stenosis.
    • Mild spinal cord compression at lower cervical level without myelopathy change.
  • 2023-11-29 L-spine AP + Lat. (including sacrum)
    • Grade 1 degenerative spondylolisthesis at L4-5 level. L5-S1 disc space narrowing. Degenerative change of the spine with marginal spur formation.
  • 2023-08-17 PET scan
    • Glucose hypermetabolism in a focal area in the lower lobe of left lung. Primary lung malignancy may show this picture. However, please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in a focal area in the right posterior upper abdomen just between liver and right kidney and in a focal in the soft tissue of left lower back region. Metastatic lesions may show this picture.
    • Glucose hypermetabolism in some left paraaortic and left common iliac lymph nodes. Metastatic lymph nodes may show this picture.
    • Glucose hypermetabolism in multipe bones as mentioned above, suggesting lmultiple bone metastases.
    • Mild glucose hypermetabolism in a right axillary lymph node and in a focal area in the dome of the liver. The nature is to be determined (early metastatic lesions? other nature?). Please also correlate with other clinical findings for further evaluation.
    • Decreased FDG uptake in the right parietal area of the brain, compatible with post-operative change.
  • 2023-08-16 Tc-99m MDP bone scan
    • A faint hot spot in the posterior aspect of the right 8th rib, and mildly increased activity in the left parietal region of the skull, left aspect of the mandible, left humeral head, and left iliac bone, compatible with the previous PET scan findings of metastatic bone disease.
    • Probably benign lesions in some T- and L-spine, bilateral shoulders, and knees.
  • 2023-08-15 MRI - brain
    • The MRA study shows mild arteriosclerosis of the neck and intracranial vessels with irregular outline but without focal severe stenosis or complete occlusion. Segmental stenoses at left M1-2.
    • Imp: Post resection for right parietal tumor. Left parietal skull tumor still was noted. Small bifrontal and right cerebellar enhancing nodules, c/w metastases.
  • 2023-08-10 Patho - brain/menings (tumor) (Y1)
    • Labeled as “brain”, craniotomy — metastatic carcinoma.
    • Sections of F2023-358FS and S2023-15852 show large round blue cell tumor with marked nucrosis, many mitoses > 10 mitoses/high per field, nuclear molding.
    • IHC stains: CK5/6: (-), p40 (-): dis-favor squamous cell carcinoma, TTF-1 (+), Napsin-A (-), CD56 (+), suggestive of neuroendicrine carcinoma. An addendum report of additional IHC stains will be followed.
    • addtional IHC stains: synaptophysin (+), chromogranin (+), Ki-67: (60-70%).
  • 2023-08-10 Frozen Section
    • Preliminary diagnosis: brain: malignant.
      • The possibility of metastatic carcinoma cannot be excluded.
  • 2023-08-07 CT - chest
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N0(N_value) M:M1c(M_value) STAGE:____(Stage_value)
    • Findings
      • an irregular soft-tissue tumor at paraspinal superior segment of LLL (about 32mm in longest axial dimension), contacting the adjacent descending thoracic aorta and associated small pleural effusion. tiny nodules at both lungs too
      • a large Rt T6-T8 paraspinal tumor with destruction of adjacent vertebrae and rib is found due to metastasis.
      • Mediastinum and hila: no enlarged LN mild calcified plaques of the LAD coronary artery.
      • Thoracic aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: dilated LV.
      • Rt renal cyst measuring 2.2cm (longest axial diameter)
      • marginal spurs of multiple vertebrae due to spondylosis. degenerative spinal canal and lateral recesses stenosis at L5-S1 or L4-5.
    • Impression: LLL cancer T4N0M1c
  • 2023-08-05 MRI - brain
    • Clinical information: general weakness for 2 weeks, unsteady gait 3-4 days.
    • MR of the brain and MRA of the intracranial vessels and neck carotid systems were performed on a 1.5 T superconducting magnet on supine position utilizing head coil with 6 mm slice thickness and 24 cm field of view with intravenous injection of Gadolinium.
    • Findings:
      • One large cystic mass lesion (4.5cm) over right parietal lobe with prominent peritumoral edema, showing irregular rim-enhancement. Another tiny enhancing nodule over left frontal lobe. One bony destructive lesion (2.6cm) over left parietal bone. Favor metastatic lesions.
      • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
      • Short segmental moderate stenosis of left MCA.
  • 2019-04-02 SONO - abdomen
    • Parenchymal liver disease, C/W alcoholic liver disease
    • Fatty liver, mild
    • suspicious, Renal stone, left

[MedRec]

  • 2023-08-07 ~ 2023-08-24 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Small cell lung cancer with brain, bone and lung metastasis, extensive stage, cT4N0M1c stage IVB, s/p right parietal-occipital craniotomy to remove brain tumor on 2023-08-09. C1 chemotherapy with EP on 8/21-8/23
      • Secondary malignant neoplasm of brain, status post right parietal-occipital craniotomy to remove brain tumor on 2023-08-09
      • Essential (primary) hypertension
      • Hypomagnesemia
    • CC
      • General weakness for 2 weeks and unsteady gait 3-4 days.
    • Present illness
      • This 58-year-old male, deniend any medical history. Ths time, he was suffered from general weakness for 2 weeks and unsteady gait for 3-4 days.
      • On 2023-08-02, he visited to our ER, during which he was diagnosed of hypomagnesemia and received treatment with magnesium oxide (MgO) and B complex vitamins.
      • The patient also mentioned that he had chest discomfort. He admitted to regular alcohol consumption, consuming 300-400cc of spirits (shochu) daily. He was sent to our ER by his family.
      • Vita signs(T/P/R): 37.2/113/16, BP: 206/99mmHg, SPO2: 96%. Con’s:E4V5M6. He denied having fever, headaches, nausea, vomiting, or diarrhea. He also denied experiencing symptoms related to upper respiratory tract infections and urinary burning sensation.
      • The Brain MRI (contrast and non contrast) revealed 1. One large cystic mass lesion (4.5cm) over right parietal lobe with prominent peritumoral edema, showing irregular rim-enhancement. Another tiny enhancing nodule over left frontal lobe. One bony destructive lesion (2.6cm) over left parietal bone. Favor metastatic lesions 2. MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels 3. Short segmental moderate stenosis of left MCA.
      • The chest CT for preoperation survey, showed LLL cancer T4N0M1c (E1).
      • NS was consulted, suggested admitted SICU for prepare operation survey and intensive care.
    • Course of inpatient treatment
      • After admission, intravenous Dexamethason and Mannitol and anticonvulsant agent Keppra were prescribed for brain swelling & seizure prevention.
      • Image study with brain MRI (2023-08-05) revealed one large cystic mass lesion (4.5cm) over right parietal lobe with prominent peritumoral edema, showing irregular rim-enhancement. Another tiny enhancing nodule over left frontal lobe. One bony destructive lesion (2.6cm) over left parietal bone. Favor metastatic lesions.
      • Chest CT (with abdominal CT) for tumor survey on 2023/08/07, which showed 1) irregular soft-tissue tumor at paraspinal superior segment of left lower lung (about 32mm in longest axial dimension), contacting the adjacent descending thoracic aorta and associated small pleural effusion; 2) tiny nodules at both lungs too; 3) a large Rt T6-T8 paraspinal tumor with destruction of adjacent vertebrae and rib is found due to metastasis.
      • He underwent operation of right parietal-occipital craniotomy to remove brain tumor on 8/9 23. Labeled as “brain”, craniotomy (8/14 23) proved metastatic carcinoma. IHC stains: CK5/6: (-), p40 (-): dis-favor squamous cell carcinoma, TTF-1 (+), Napsin-A (-), CD56 (+), suggestive of neuroendicrine carcinoma.
      • Repeat brain MRI (8/15 23) showed Post resection for right parietal tumor. Left parietal skull tumor still was noted. Small bifrontal and right cerebellar enhancing nodules, c/w metastases. Bone scan (8/17 23) showed multiple bone mets.
      • Whole PET scan (8/18 23) showed in a focal area in the lower lobe of left lung. Primary lung malignancy may show this picture. However, please correlate with other clinical findings for further evaluation. Glucose hypermetabolism in a focal area in the right posterior upper abdomen just between liver and right kidney and in a focal in the soft tissue of left lower back region. Metastatic lesions may show this picture. Glucose hypermetabolism in some left paraaortic and left common iliac lymph nodes. Metastatic lymph nodes may show this picture.Glucose hypermetabolism in multipe bones as mentioned above, suggesting multiple bone metastases.
      • HBsAg, anti-Hbc and anti-HCV showed negative. The tumor marker showed CA-199:352 U/ml, CEA:1194ng/ml, CA-125:52U/ml, SCC:1.6ng/ml. Port-A was inserted on 8/17 23. We had removed the head surgical stiches on 8/18 23 after the wound healing well with gauze cover. He was transferred to our ward for further evaluation and chemotherapy.
      • Chemotherapy with Etoposide (100mg/m2, D1-D3) plus Cisplatin (75mg/m2, D1) were given on 8/21-8/23 23, smoothly without obvious side effect. He was discharged on 8/24 23 under stable condition and will follow-up at OPD.
    • Discharge prescription
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID 8D
      • Norvasc (amlodipine 5mg) 1# QD 8D
      • Through (sennoside 12mg) 2# HS 8D
      • Keppra (levetiracetam 500mg) 1# BID 8D
      • Promeran (metoclopramide 3.84mg) 1# TIDAC 3D

[consultation]

  • 2023-12-27 Radiation Oncology
    • Q
      • for radiotherapy evaluation due to bone metas
      • This 58-year-old male, a patient of Small cell lung cancer with brain, bone and lung metastasis, extensive stage, cT4N0M1c stage IVB was diagnosed on 8/9 23 and s/p right parietal-occipital craniotomy to remove brain tumor. S/P C1 Chemotherapy with Etoposide (100mg/m2, D1-D3) plus Cisplatin.
      • This time, he was admitted for C5 chemotherapy with EP on 12/22 23. He complaints right ribs pain, followed-up bone scan (2023/12/26) revealed 1. In comparison with the previous study on 2023/08/16, some bone lesions in the right 8th rib, some right costovertebral junctions, left iliac bone and left femur are either more prominent or new, suggesting multiple bone metastases in progression. 2. Two new hot spots in the anterior aspect of left rib cage. The nature is to be determined (new bone metastases? other nature?). So we need your help for radiotherapy evaluation due to bone metas. Thanks a lot!!
    • A
      • The patient’s history was reviewed and patient was examined.
      • S: For radiotherapy due to lung carcinoma with bone metastases and pain.
        • PI: The patient was a case of small cell lung cancer with brain, bone and lung metastasis, extensive stage, cT4N0M1c stage IVB was diagnosed on 8/9 23 and s/p right parietal-occipital craniotomy to remove brain tumor. S/P C1 Chemotherapy with Etoposide (100mg/m2, D1-D3) plus Cisplatin. This time, he was admitted for C5 chemotherapy with EP on 12/22 23. He complaints right ribs pain. For radiotherapy.
        • Family history: (-)
        • Cancer site specific factors: Alcohol (+); Smoking (+); Betel nut (-).
        • Personal Hx: DM (-); HTN (-)
        • Previous RT Hx: (-)
      • O: ECOG: 1
        • PE: neck and bil SCF: neg.; back pain.
        • MRI of brain (2023-08-05): 1. One large cystic mass lesion (4.5cm) over right parietal lobe with prominent peritumoral edema, showing irregular rim-enhancement. Another tiny enhancing nodule over left frontal lobe. One bony destructive lesion (2.6cm) over left parietal bone. Favor metastatic lesions. 2. MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels. 3. Short segmental moderate stenosis of left MCA.
        • CT scan of lung (2023-08-07): LLL cancer T4N0M1c
        • Operation (2023-08-09): right P-O craniotomy to remove brain tumor, navigation assisted, microscope assisted
        • Pathology (S2023-15852, 2023-08-14): ADDENDUM: addtional IHC stains: synaptophysin (+), chromogranin (+), Ki-67: (60-70%). Labeled as “brain”, craniotomy — metastatic carcinoma. IHC stains: CK5/6: (-), p40 (-): dis-favor squamous cell carcinoma, TTF-1 (+), Napsin-A (-), CD56 (+), suggestive of neuroendicrine carcinoma. An addendum report of additional IHC stains will be followed.
        • MRI of brain (2023-08-15): Post resection for right parietal tumor. Left parietal skull tumor still was noted. Small bifrontal and right cerebellar enhancing nodules, c/w metastases.
        • Bone scan (2023-12-27): 1. In comparison with the previous study on 2023/08/16, some bone lesions in the right 8th rib, some right costovertebral junctions, left iliac bone and left femur are either more prominent or new, suggesting multiple bone metastases in progression. 2. Two new hot spots in the anterior aspect of left rib cage. The nature is to be determined (new bone metastases? other nature?).
      • A: Neuroendicrine carcinoma of the lung, LLL, stage cT4N0M1c, with brain, bone, and lung metastases, s/p right P-O craniotomy to remove brain tumor and chemotherapy.
      • P: Radiotherapy is indicated for this patient with the following indicators: bone metastases with pain.
        • Goal: palliation
        • Treatment target and volume: right costovertebral junctional area
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 3000cGy/10 fractions of the right costovertebral junctional area
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-12-28.
  • 2023-11-29 Neurosurgery
    • Q
      • Acute weakness/inability to move; General weakness
      • CC: bil. leg weakness for a long time , but worsen since yesterday
      • PHx:
        • Small cell lung cancer with brain, bone and lung metastasis, extensive stage, cT4N0M1c stage IVB, s/p right parietal-occipital craniotomy to remove brain tumor on 8/9. C1 chemotherapy with EP on 8/21-8/23
        • Secondary malignant neoplasm of brain, status post right parietal-occipital craniotomy to remove brain tumor on 2023-08-09
        • Essential (primary) hypertension
        • Hypomagnesemia
      • Allergy: NKA
    • A
      • 58 y/o male.
      • L-spine MRI:
        • Focal T2W hyperintensity lesion in conus medullaris (T11-12 level), suspected spinal cord lesion. Myelitis or tumor?
        • Degenerative spinal and disc disease.
        • Mild L2-3 retrolisthesis. Grade 1 degenerative spondylolisthesis at L4-5 level.
        • Moderate L2-3-4 and severe L4-5 canal stenosis.
        • Mild spinal cord compression at lower cervical level without myelopathy change.
      • Plan:
        • No neurosurgery is required now. OPD F/U.
  • 2023-08-14 Hemato-Oncology
    • Q
      • This 58 years old male patient who deniend any medical history before. According to the patient’s, he had suffered from general weakness for 2 weeks and unsteady gait for 3-4 days. He visited our ER for help. Initial consciousness remained E4V5M6. He denied having fever, headaches, nausea, vomiting, or diarrhea.
      • Brain MRI with/without contrast revealed 1) one large cystic mass lesion (4.5cm) over right parietal lobe with prominent peritumoral edema, showing irregular rim-enhancement. Another tiny enhancing nodule over left frontal lobe. One bony destructive lesion (2.6cm) over left parietal bone. Favor metastatic lesions.
      • Chest CT (with abdominal CT) showed 1) irregular soft-tissue tumor at paraspinal superior segment of LLL (about 32mm in longest axial dimension), contacting the adjacent descending thoracic aorta and associated small pleural effusion; 2) tiny nodules at both lungs too; 3) a large Rt T6-T8 paraspinal tumor with destruction of adjacent vertebrae and rib is found due to metastasis. LLL cancer T4N0M1c,(E1).
      • Regular alcohol consumption, consuming 300-400cc of spirits (shochu) daily was told. He then underwent right parietal-occipital craniotomy to remove brain tumor on 8/9. Pathology report showed metastatic carcinoma. IHC stains: CK5/6: (-), p40 (-): dis-favor squamous cell carcinoma, TTF-1 (+), Napsin-A (-), CD56 (+), suggestive of neuroendicrine carcinoma.
      • Thus, we need your professional evaluation and recommendation for further management. Thank you very much for your time!
    • A
      • This 58 year old man is a case of newly diagnosis small cell lung cancer with brain, bone and lung metastasis, extensive stage, cT4N0M1c stage IVB, s/p right parietal-occipital craniotomy to remove brain tumor on 8/9. We are consulted for further evaluation.
      • Suggestion:
        • Please arrange PET scan, bone scan, check Anti HBc, AntiHBs, HBsAg, Anti HCV, LDH.
        • We will discuss with patient about further chemotherapy (EP). Please arrange port A insertion. We wil take over this case.
  • 2023-08-09 Anesthesia
    • Q
      • Consult for anesthesia assessment
      • This 58-year-old male, deniend any medical history. Ths time, he was suffered from general weakness for 2 weeks and unsteady gait for 3-4 days. Brain MRI (contrast and non contrast) revealed One large cystic mass lesion (4.5cm) over right parietal lobe with prominent peritumoral edema. We will be arrange operation for brain tumor excision on level B on today.
      • We need your help for anesthesia assessment. Thank you a lot !!!
    • A
      • Dear doctors and nurse practitioners. I have visited the patient and reviewed the history.
      • Patient general condition:
        • GCS: E4V5M6
      • Pre-anesthesia diagnosis:
        • brain tumor
      • Scheduled Operation:
        • brain tumor excision
      • Past history:
        • Denied
      • Lab data:
        • GOT 60
      • CXR:
        • Increased infiltration
      • ECG:
        • NSR, QT prolong
      • Assessment: ASA 2E
      • Plan and recommendation:
        • We will arrange ETGA for anesthesia, and closely monitor during anesthesia.
        • Patient and family have been informed and understood about the risk and plan of aneshtesia for operation, including cardiovascular risks (hypotension, stroke, acute myocardial infarction, shock), pulmonary risks (hypoxia, pulmonary embolism,delay extubation), ICU care and other possible complications.
  • 2023-08-07 Neurosurgery
    • Q
      • Acute weakness/unable to move - general weakness for many days. The patient went to the doctor on 2023/08/02 and was told that the magnesium ions were too low. He admitted because his symptoms did not improve.
      • general weakness for 2 weeks , unsteady gait 3-4 days.
      • Not improved compared to 3 days ago (came to the ED with hypomagnesemia -> MBD with MgO and B complex)
      • chest discomfort+
      • alchohol drinking+, Sorghum liquor 300-400cc everyday.
      • Denied Fever, headache, Nausea, vomiting, diarrhea
      • Denied URI symptoms, Denied urinary burning sensation
      • PmHx Gout
      • NKDA
    • A
      • The patient, a 58-year-old male, presented with a state of overall weakness and fatigue that progressed to an acute inability to walk due to profound weakness. On August 2nd, he sought medical attention and was informed that his magnesium ion levels were abnormally low. However, his symptoms did not show improvement, prompting his current visit.
      • He reported experiencing general weakness for the past two weeks, along with an unsteady gait persisting for 3-4 days. His condition had not improved since his last visit to the Emergency Department, during which he was diagnosed with hypomagnesemia and received treatment with magnesium oxide (MgO) and B complex vitamins. The patient also mentioned feeling chest discomfort. He admitted to regular alcohol consumption, consuming 300-400cc of spirits (shochu) daily.
      • He denied having fever, headaches, nausea, vomiting, or diarrhea. He also denied experiencing symptoms related to upper respiratory tract infections and urinary burning sensation.
      • The patient’s past medical history includes gout. A brain MRI revealed the following findings:
        • A large cystic mass lesion measuring 4.5cm located in the right parietal lobe, accompanied by noticeable peritumoral edema and irregular rim-enhancement. A smaller enhancing nodule was detected in the left frontal lobe. Furthermore, a bony destructive lesion measuring 2.6cm was observed in the left parietal bone. These findings are indicative of potential metastatic lesions.
        • MR angiography of the brain revealed atherosclerotic changes in both intracranial and carotid vessels.
        • A short segmental moderate stenosis of the left middle cerebral artery (MCA) was identified.
      • Considering the clinical and imaging findings, the patient has been advised of the risks and potential outcomes. Surgical intervention has been recommended. Thank you for the consultation.

[chemotherapy]

  • 2024-02-22 - etoposide 100mg/m2 165mg NS 500mL 2hr D1-3 + carboplatin AUC 3 200mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-12-27 - etoposide 100mg/m2 168mg NS 500mL 2hr D1-3 + carboplatin AUC 5 340mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-16 - etoposide 100mg/m2 168mg NS 500mL 2hr D1-3 + NS 1000mL 4hr (before CDDP) + cisplatin 75mg/m2 125mg NS 500mL 3hr D1 + NS 1000mL 4hr (after CDDP) (VP-16 + CDDP, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-18 - etoposide 100mg/m2 168mg NS 500mL 2hr D1-3 + NS 1000mL 4hr (before CDDP) + cisplatin 75mg/m2 125mg NS 500mL 3hr D1 + NS 1000mL 4hr (after CDDP) (VP-16 + CDDP, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-19 - etoposide 100mg/m2 166mg NS 500mL 2hr D1-3 + NS 1000mL 4hr (before CDDP) + cisplatin 75mg/m2 120mg NS 500mL 3hr D1 + NS 1000mL 4hr (after CDDP) (VP-16 + CDDP, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-21 - etoposide 100mg/m2 170mg NS 500mL 2hr D1-3 + NS 1000mL 4hr (before CDDP) + cisplatin 75mg/m2 120mg NS 500mL 3hr D1 + NS 1000mL 4hr (after CDDP) (VP-16 + CDDP, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-02-23

[reconciliation]

The patient’s vital signs remain stable. However, lab results on 2024-02-22 indicate renal insufficiency. Consequently, the dosage of Keppra (levetiracetam) listed in the active medication list should be adjusted to reflect renal function. The current dose of 500mg BID falls within the recommended range for patients with a CrCl of 50 to 80. No medication discrepancies were identified.

2023-12-25

[kidney concerns prompt cisplatin swap: carboplatin steps in]

Despite receiving normal saline hydration 1L before and 1L after each cisplatin dose (reduced to 75mg/m2, standard 100mg/m2), the patient experienced elevations in both serum creatinine and BUN values following initiation of etoposide and cisplatin therapy on 2023-08-21.

  • 2023-12-25 Creatinine 1.70 mg/dL

  • 2023-12-22 Creatinine 2.07 mg/dL

  • 2023-12-01 Creatinine 1.63 mg/dL

  • 2023-11-29 Creatinine 1.91 mg/dL

  • 2023-11-15 Creatinine 1.88 mg/dL

  • 2023-10-31 Creatinine 1.91 mg/dL

  • 2023-10-17 Creatinine 0.88 mg/dL

  • 2023-09-27 Creatinine 1.27 mg/dL

  • 2023-09-18 Creatinine 0.71 mg/dL

  • 2023-08-31 Creatinine 0.78 mg/dL

  • 2023-08-21 Creatinine 0.70 mg/dL

  • 2023-08-14 Creatinine 0.67 mg/dL

  • 2023-08-11 Creatinine 0.62 mg/dL

  • 2023-08-09 Creatinine 0.84 mg/dL

  • 2023-08-08 Creatinine 0.64 mg/dL

  • 2023-08-02 Creatinine 0.80 mg/dL

  • 2023-12-25 BUN 30 mg/dL

  • 2023-12-22 BUN 27 mg/dL

  • 2023-12-01 BUN 37 mg/dL

  • 2023-11-29 BUN 41 mg/dL

  • 2023-11-15 BUN 42 mg/dL

  • 2023-10-31 BUN 46 mg/dL

  • 2023-10-17 BUN 13 mg/dL

  • 2023-09-27 BUN 30 mg/dL

  • 2023-09-18 BUN 14 mg/dL

  • 2023-08-31 BUN 18 mg/dL

  • 2023-08-21 BUN 21 mg/dL

  • 2023-08-14 BUN 17 mg/dL

  • 2023-08-11 BUN 11 mg/dL

  • 2023-08-09 BUN 12 mg/dL

  • 2023-08-08 BUN 12 mg/dL

  • 2023-08-02 BUN 15 mg/dL

To minimize the risk of further kidney damage, considering a switch from cisplatin to carboplatin (AUC 5) in the treatment plan could be beneficial, as carboplatin is known to have less impact on kidney function.

Ref: - Comparison of Carboplatin With Cisplatin in Small Cell Lung Cancer in US Veterans. JAMA Netw Open. 2022 Oct 3;5(10):e2237699. doi: 10.1001/jamanetworkopen.2022.37699. Erratum in: JAMA Netw Open. 2023 Jan 3;6(1):e2246257. PMID: 36264573; PMCID: PMC9585434. - Etoposide phosphate with carboplatin in the treatment of elderly patients with small-cell lung cancer: a phase II study. Ann Oncol. 2001 Jul;12(7):957-62. doi: 10.1023/a:1011171722175. PMID: 11521802.

700769565

240223

[exam findings]

  • 2024-02-16 CT - abdomen
    • 20230808 CC: body weight loss recently.
    • 20230811 CT: Multiple liver metastases are highly suspected.
    • 20230815 CEA: 18ng/mL (<5), CA153: 394U/mL (<35), AFP: 568ng/mL (<9).
    • 20230815 CT-guided biopsy: Adenocarcinoma, moderately differentiated; Either primary cholangiocarcinoma or metastatic adenocarcinoma from upper GI and biliary tract should be considered. Metastatic breast invasive carcinoma is less likely.
    • History: Left breast cancer s/p MRM on 2012/03/28.
    • Findings: Comparison: prior CT dated 2023/11/17.
      • Prior CT identified multiple poor enhancing masses on both hepatic lobes are noted again, increasing in size and number.
        • It is c/w progressive disease.
        • Small size of S4 and S8 portal vein is noted again that is c/w tumor compression.
      • Prior CT identified multiple lung metastases are noted again at the current CT. Part of metastases show mild increasing in size and part of metastases show mild decreasing in size.
        • Lung metastases S/P C/T with stable disease is highly suspected.
      • Prior CT identified few metastatic nodes in the hepatoduodenal ligament are noted again, stable in size.
      • Prior CT identified carcinomatosis and massive ascites is noted again, increasing in size and number that is c/w progressive disease.
      • There is prominence in size of the spleen (long axis: 12.2 cm) that may be portal hypertension.
      • Normal gallbladder is not visualized in the gallbladder fossa.
        • There is mild dilatation of left lobe IHDs that may be tumor compression.
      • There are several renal cysts on both kidney and the largest one measuring 1.2 cm in size at left middle pole.
    • Impression:
      • Multiple liver metastases show progressive disease.
      • Multiple lung metastases show stable disease.
      • Metastatic nodes in the hepatoduodenal ligament show stable disease.
      • Carcinomatosis show progressive disease.
  • 2024-01-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (59 - 14) / 59 = 76.27%
      • M-mode (Teichholz) = 76
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Normal chamber size
      • Mild MR, TR
  • 2024-01-15, 2023-11-17, -08-29 CXR (erect)
    • S/P port-A implantation.
    • S/P Mastectomy, left.
    • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
    • Atherosclerotic change of aortic arch
  • 2024-01-15 ECG
    • Sinus tachycardia
    • Left axis deviation
    • Abnormal ECG
  • 2023-12-26 KUB
    • Ascites is noted after correlate with prior CT.
  • 2023-12-06 Thyroid Ultrasound
    • a thyroid nodule 0.64 x 0.48 x 0.61 cm
  • 2023-11-17 CT - abdomen
    • Findings: Comparison prior CT dated 2023/08/11.
      • Prior CT identified multiple poor enhancing masses on both hepatic lobes are noted again, decreasing in size.
        • The differential diagnosis includes cholangiocarcinoma and hepato-cholangiocarcinoma.
        • Prior CT identified poor visualization of S4 and S8 portal vein is noted again, stationary. The etiology may be tumor compression.
      • Prior CT identified multiple lung metastases are noted again, mild increasing in size.
      • Prior CT identified few metastatic nodes in the hepatoduodenal ligament are noted again, mild decreasing in size.
      • There is massive ascites and soft tissue lesions in the omentum that is c/w carcinomatosis. Please correlate with ascites cytology.
      • There is prominence in size of the spleen (long axis: 12.2 cm) that may be portal hypertension.
      • Normal gallbladder is not visualized in the gallbladder fossa.
        • There is mild dilatation of left lobe IHDs that may be tumor compression.
      • There are several renal cysts on both kidney and the largest one measuring 1.2 cm in size at left middle pole.
    • Impression:
      • Prior CT identified multiple poor enhancing masses on both hepatic lobes are noted again, decreasing in size.
      • Prior CT identified multiple lung metastases are noted again, mild increasing in size.
      • Prior CT identified few metastatic nodes in the hepatoduodenal ligament are noted again, mild decreasing in size.
      • Carcinomatosis is noted. Please correlate with ascites cytology.
  • 2023-08-31 SONO - abdomen
    • Hepatic tumor, huge, right lobe, with suspicious RPV invasion
    • Ascites, small
    • Pleural effusion, right
  • 2023-08-28 CXR (erect)
    • S/P port-A implantation.
    • S/P Mastectomy, left.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
    • Atherosclerotic change of aortic arch
  • 2023-08-18 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (97.3 - 18.9) / 97.3 = 80.58%
      • M-mode (Teichholz) = 80.6
    • Conclusion:
      • Dilated LA
      • Adequate LV,RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Mild AR
  • 2023-08-17 MRA - brain
    • No evidence of brain nodule or metastasis.
  • 2023-08-16 PET scan
    • No previous PET scan for comparison.
    • Several focal or nodular lesions of increased FDG uptake in both lobes of the liver and in the right subphrenic lymph nodes, highly suspected the primary or secondary malignancy.
    • Increased FDG uptake in the left upper and left lower lungs and in the right upper and right lower lungs, highly suspected the secondary malignancy.
    • Left breast cancer s/p treatment, no lesion of increased FDG uptake in bilateral breasts and axillae; highly suspected the primary or secondary malignancy in the liver with right subphrenic lymph nodes involvement, and secondary malignancy in bilateral lungs, by this F-18 FDG PET scan.
  • 2023-08-15 Patho - liver biopsy needle/wedge
    • Liver, CT guide biopsy — Adenocarcinoma, moderately differentiated
    • The specimen submitted consists of two strips of yellow gray soft tissue, labeled liver, measuring up to 1.5 x 0.1 x 0.1 cm. All for section.
    • The sections show a picture of adenocarcinoma, moderately differentiated, composed of low columnar neoplastic cells, arranged in gladular pattern embedded within fibrous stroma. Tumor necrosis is present.
    • IHC, the tumor cells show: CK7(+), CK20(+), GATA3(-), ER(-), PR(-) and HER2/neu(-). Either primary cholangiocarcinoma or metastatic adenocarcinoma from upper GI and biliary tract should be considered. Metastatic breast invasive carcinoma is less likely.
  • 2023-08-11 CT - abdomen
    • Findings:
      • There are multiple poor enhancing masses on both hepatic lobes, the largest one in S4/5/8 measuring 13 cm in size (the largest dimension).
        • There is small size of S4, S8, and S5-6 portal vein that is c/w tumor encasement. Ascites and prominence in size of the spleen (long axis: 12.2 cm) is noted that is c/w portal hypertension.
        • In addition, there are two soft tissue nodules 9 mm and 4 mm at right lower perihepatic space omentum that may be direct tumor seeding.
        • Cholangiocarcinoma (T4) is highly suspected.
        • The differential diagnosis includes multiple liver metastases.
      • There are few enlarged nodes in the hepatoduodenal ligament and adenocarcinoma that are c/w regional metastatic nodes (N1).
      • There are several soft tissue nodules on both lungs that are c/w lung metastases (M1).
      • There are several renal cysts on both kidney and the largest one measuring 1.2 cm in size at left middle pole.
      • Normal gallbladder is not visualized in the gallbladder fossa.
    • Imaging Report Form for Cholangiocarcinoma
      • Impression (Imaging stage) : T:T4(T_value) N:N1(N_value) M:M1(M_value) STAGE:IV(Stage_value)
  • 2021-06-24 Thyroid Ultrasound
    • a thyroid nodule 0.5 x 0.3 x 0.6 cm
  • 2021-01-07 Thyroid Ultrasound
    • a thyroid nodule 0.6 x 0.4 x 0.6 cm

[MedRec]

  • 2023-08-14 ~ 2023-09-07 POMR Hemato-Oncology He JingLiang
    • Discharge note
      • Liver adenocarcinoma with moderately differentiated stage IV. Tumor cells: CK7(+), CK20(+), GATA3(-), ER(-), PR(-) and HER2/neu(-), s/p port-a catheter insertion on 2023/08/23.
      • Left breast cancer, infiltrating ductal carcinoma, pT2N0(0/22)M0, stage I, ER(+, 70%), PR(+, 70%), HER-2 FISH (-) in 2012, s/p left modified radical mastectomy, s/p completion of adjuvant chemotherapy with FEC (Fluorouracil, Epirubicin, Cyclophosphamide) x6 and Tamoxifen, then refill Arimidex, 2023/8/11 CT: multiple liver and lung metastases are highly suspected.
      • Hypercalcaemia
      • Chronic viral hepatitis B without delta-agent
      • Type 2 diabetes mellitus
      • Hyperlipidemia
      • Thyrotoxicosis, unspecified without thyrotoxic crisis or storm
      • Hyponatremia
      • Hypomagnesemia
      • Hypokalemia
    • CC
      • She suffered from fatique, poor appetited and body weight loss 6 kg in half year.
    • Present illness
      • This 66-year-old post menopausal woman has 1) Type 2 diabetes mellitus 2) Hyperlipidemia 3) Hyperthyroidism 4) Hepatitis B carrier. She denied any TOCC histories in recent 3 months.
      • She was diagnosed with left breast cancer pT2N0M0 status post left modified radical mastectomy on 2012/03/28 with completion of adjuvant C/T with FEC x6 and Tamoxifen. IHC revealed ER(+,70%), PR(+,70%), HER-2 FISH (-). She loss follow up for 6 years.
      • However, she suffered from fatique, poor appetited and body weight loss 6 kg in half year. As such, she went to Dr. Li’s OPD for further survey.
      • Abdominal CT revealed multiple liver and lung metastases and two soft tissue nodules 9 mm and 4 mm at right lower perihepatic space omentum on 2023/08/14.
      • After well explain including image and the possible treatment were well explained to the patient. This time, she was admitted to our ward for liver biopsy and PET.
    • Course of inpatient treatment
      • After admission, liver CT-guide biopsy was done that revealed adenocarcinoma, moderately differentiated. The tumor cells show CK7(+), CK20(+), GATA3(-), ER(-), PR(-) and HER2/neu(-). The tumor marker showed CEA: 18.890 ng/ml, CA-153: 394.860 U/ml, AFP: 568.200 ng/ml and CA-125: 187.565 U/ml.
      • Gastroscopy and colonstomy were done that reaveld reflux esophagitis, lower esophagus, LA classification, grade A and Colon polyp at cecum, s/p polypectomy + cliping Colon polyp, sigmoid colon, s/p biopsy. The biopsy revealed Hyperplastic polyp.
      • Brain MRA revealed no evidence of brain nodule or metastasis, Breast sono and Mammography revealed no dominent mass lesion in the breast. As such, consult Oncology for palliative chemotherapy. She underwent of Port-A at right subclavian vein on 8/23 23.
      • She was transfered to Oncology ward for further treatment on 2023/08/24. The lab of electrolyte showed hypercalcaemia (Ca: 2.71mmol/L), so gave hydration with normal saline, Lasix treatmet. She received chemotherapy with C1 Gemzar (800mg/m2)/ Cisplatin (40mg/m2) weekly x 12 on 2023/08/25.
      • Promeran 1tab TIDAC, Imperan 1amp PRNQ6H for vomiting. Vemlidy 1tab QD for Anti-HBC: positive.
      • After treatment, the lab of electrolyte of hypercalcaemia improved (Ca: 2.71 -> 2.72 -> 2.45 -> 2.51mmol/L). Then, she complaints abdomen bolating, and pitting edema 1+ at bilateral lower limbs, the lab of electrolyte showed hyponatremia (Na: 125mmol/L), albumin level 2.8 g/dL, gave Albumin 1bot BID by self-paid x 2 days, Lasix 0.5tab QD, GASLAN 1tab TID,
      • Mint oil and chrysanthemum oil are used for abdominal massage. Dietary education includes adding 2g of salt per day or using salt tablets dissolved in water. A consultation with a dietitian has been arranged to assist with dietary education.
      • Followed-up D-dimer: 8012.80 -> >10000 ng/mL(FEU), so gave Lixiana 1tab QD.
      • KUB: not ileus noted. The symptom of abdomen bolating, pitting edema, and hyponatremia (Na: 125 -> 131 mmol/L), Albumin: 2.8 -> 3.1 g/dL.
      • Followed-up abdomen echo (2023/08/31) relvealed Hepatic tumor, huge, right lobe, with suspicious RPV invasion. Ascites, small. Pleural effusion, right.
      • She received C2 Gemzar (800mg/m2)/ Cisplatin (40mg/m2) weekly x 12 on 2023/09/1, and TS-1 1 tab BID by self-paid since 2023/09/04.
      • After chemotherapy, she deniede having a fever, vomiting, diarrhea, or any complaints. And the lab of CBC/DC showed anemia (Hb: 8.4 g/dL), the lab of electrolyte showed hypomagnesemia (Mg: 1.7mg/dL), hypokalemia (K: 3.3mmol/L), so gave blood transfusion with LPRBC, MgSO4 IVD plus MgO 1tab TID, and Const-K 1tab QD treatmen.
      • She can be discharged on 2023/09/07, the OPD follow-up will be arranged.
    • Discharge prescription
      • Const-K (potassium chloride 750mg/10mEq/tab) 1# QD
      • Lixiana (edoxaban 30mg) 1# QD
      • TS-1 (tegafur, gimeracil, oteracil; 25mg) 1# QD
      • BaoGan (silymarin 150mg) 1# BID
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • MgO 250mg 1# TID
      • Pariet (rabeprazole 20mg) 1# QDAC
      • Vemlidy (tenofovir alafenamide 25mg) 1# QDAC
      • Uretropic (furosemide 40mg) 1# QD
      • Uformin (metformin 500mg) 1# TIDCC
      • methimazole 5mg 1# QOD
      • Tulip (atorvastatin 20mg) 0.5# QD

[consultation]

  • 2024-02-22 Metabolism and Endocrinology
    • Q
      • for Hyperthyroidism for evaluation
      • This 68-year-old woman, who hasing the history of: 1) Type 2 diabetes mellitus under medication control (Uformin 500mg/tab 1tab TIDCC), 2) Hyperlipidemia under medication control (Tulip 0.5tab QD), 3) Hyperthyroidism under medication control since 2012/2~ (Methimazole 5MG/TAB 0.5tab QOD), 4). Letf breast cancer pT2N0M0 status post left modified radical mastectomy on 2012/03/28 with completion of adjuvant C/T with FECx6 and Tamoxifen. IHC revealed ER(+,70%), PR(+,70%), HER-2 FISH (-), 5) Right breast tumor post tumor excision on 2019/11/27.
      • A patient of intrahepatic cholangiocarcinoma with moderately differentiated stage IV. Tumor cells: CK7(+), CK20(+), GATA3(-), ER(-), PR(-) and HER2/neu(-) was diagnosed on 2023-08-17, s/p chemotherapy with Gemzar (800mg/m2) /Cisplatin (40mg/m2) + TS-1 (self-paid) 1# po bid x 12 days. Abdomen CT (2024/02/16) revealed 1. Multiple liver metastases show progressive disease, and massive ascites is noted. 2. Multiple lung metastases show stable disease. 3. Metastatic nodes in the hepatoduodenal ligament show stable disease. 4. Carcinomatosis show progressive disease.
      • The patient request to consult Metabolism Department Dr. Yu for Hyperthyroidism for evaluation, so we need your help, thanks a lot!!
    • A
      • This 67 year old female with DM, dyslipidemia, hyperthyroidism, and left breast cancer was admitted for intrahepatic cholangiocarcinoma. We were consulted for hyperthyrodisim evaluation.
      • S:
        • QOD
      • O:
        • BH 161 cm BW 57 kg
        • HR 80 bpm
        • BT 36.4’C
        • EKG ( 2/15 ) Sinus tachycardia with occasional Premature ventricular complexes
        • WBC/Seg/Band/ANC ( 2/21 ) 1620/60.9/0/972
          • 2024-02-21 WBC 1.62 x10^3/uL
          • 2024-02-19 WBC 4.13 x10^3/uL
          • 2024-02-15 WBC 5.56 x10^3/uL
          • 2024-01-31 WBC 2.66 x10^3/uL
          • 2024-01-22 WBC 3.88 x10^3/uL
          • 2024-01-19 WBC 8.28 x10^3/uL
          • 2024-01-18 WBC 1.65 x10^3/uL
        • ALT/AST/Bilirubin Total/direct ( 2/21 ) 34/59/1.39/0.77
        • TSH/fT4 ( 2/19 ) 2.423/0.92
          • 2024-02-19 TSH 2.423 uIU/mL
          • 2024-01-18 TSH 2.228 uIU/mL
          • 2023-11-20 TSH 3.057 uIU/mL
          • 2023-10-24 TSH 2.432 uIU/mL
          • 2024-02-19 Free-T4 0.92 ng/dL
          • 2024-01-18 Free-T4 1.22 ng/dL
          • 2023-11-20 Free-T4 0.99 ng/dL
          • 2023-10-24 Free-T4 1.02 ng/dL
          • 2024-02-21 TSH receptor Ab 18 %
          • 2023-12-27 TSH receptor Ab 12 %
        • LDL/HDL/TG (2/19) 56/29/78
        • Medication at OPD: methimazole 1# QOD
      • A:
        • Hyperthyroidism, under methimazole
        • Type 2 DM, under metformin
        • Liver adenocarcinoma with moderately differentiated, highly suspected of lung metastasis, stage IV. Tumor cells: CK7(+), CK20(+), GATA3(-), ER(-), PR(-) and HER2/neu(-), s/p Gemzar/ Cisplatin
        • Left breast cancer, infiltrating ductal carcinoma, pT2N0(0/22)M0, stage I, ER(+, 70%), PR(+, 70%), HER-2 FISH (-) in 2012, s/p left modified radical mastectomy, s/p completion of adjuvant chemotherapy with FEC (Fluorouracil, Epirubicin, Cyclophosphamide) x6 and Tamoxifen, then refill Arimidex.last chemotherapy on 2024/2/15
        • Type 2 diabetes mellitus
        • dyslipidemia
      • P:
        • Avoid antithyroid drug (Lica) at this moment for ANC < 1000.
        • Regular follow up liver function, bilirubin, and check WBC/DC.
        • Recheck TSH/FT4 1 week later.
        • We will arrange thyroid echo at OPD later, and please arrange OPD follow up.
  • 2024-02-19 Radiation Oncology
    • Q: for pig-tail insertion, due to ascites.
    • A: According to the clinical condition and imaging findings, drainage is indicated.
  • 2023-08-22 Obstetrics and Gynecology
    • Q: same as for Hemato-Oncology
    • A
      • 66 y/o, P0, married woman (menopaused at 50 y/o) was admitted to our GS ward for suspected liver adenocarcinoma with lung metases.
      • Fatigue, poor appetited and body weight loss 6 kg in half year was mentioned
      • PHx:
        • left breast cancer pT2N0M0 status post left modified radical mastectomy on 2012/3/28 with completion of adjuvant C/T with FEC x6 and Tamoxifen.
        • type 2 diabetes mellitus
        • Hyperlipidemia
        • Hyperthyroidism
        • Hepatitis B carrier
      • Abdominal CT: multiple liver and lung metastases and two soft tissue nodules 9 mm and 4 mm at right lower perihepatic space omentum on 2023/08/14.
      • After admission, certain surveys were done:
        • Tumor marker :CEA 18.890 ; AFP: 568.200, CA-153: 394.860 and CA-125: 187.565.
        • liver biopsy: adenocarcinoma, moderately differentiated, the tumor cells show CK7(+), CK20(+), GATA3(-), ER(-), PR(-) and HER2/neu(-).
        • Gastroscopy and colonstomy: no metastasis evidence.
      • We were consulted for elevated Ca-125: 187.565 U/ml.
      • PV:
        • scanty discharge
        • cervix: grossly normal
      • TVUS:
        • Uterus: AVFL, EM 0.6mm, grossly normal
        • Bilateral adnexa: free, no ovarian mass was noted
        • CDS: massive ascites
      • IMP/Suggestion:
        • No obvious gynecologic lesions
        • elevated serum CA 125 concentration might be related to ascites, liver diseases/cancer etc.
  • 2023-08-22 Hemato-Oncology
    • Q
      • for suspicious chalagiocarcinoma
      • This 66-year-old post menopausal woman has 1) Type 2 diabetes mellitus 2) Hyperlipidemia 3) Hyperthyroidism 4) Hepatitis B carrier. She denied any TOCC histories in recent 3 months. She was diagnosed with left breast cancer pT2N0M0 status post left modified radical mastectomy on 2012/03/28 with completion of adjuvant C/T with FEC x6 and Tamoxifen. IHC revealed ER(+,70%), PR(+,70%), HER-2 FISH (-).
      • She loss follow up for 6 years. However, she suffered from fatique, poor appetited and body weight loss 6 kg in half year. As such, she went to Dr. Li’s OPD for further survey.
      • Abdominal CT revealed multiple liver and lung metastases and two soft tissue nodules 9 mm and 4 mm at right lower perihepatic space omentum on 2023/08/14. After well explain including image and the possible treatment were well explained to the patient. She was admitted to our ward for further suevey on 8/14. After ward, liver biopsy was done that revealed adenocarcinoma, moderately differentiated, the tumor cells show CK7(+), CK20(+), GATA3(-), ER(-), PR(-) and HER2/neu(-).
      • Gastroscopy and colonstomy were done that reaveld aeflux esophagitis, lower esophagus, LA classification, grade A and Colon polyp at cecum, s/p polypectomy + cliping Colon polyp, sigmoid colon, s/p biopsy.
      • The tumor marker revealed CEA 18.890, AFP: 568.200, CA-153: 394.860 and CA-125: 187.565. As such, we need your help for palliative chemotherapy .
    • A
      • Under the impression of cholangiocarcinoma with liver and lung metastasis, we are consulted for palliative chemotherapy.
      • Suggestion:
        • Please check Anti HBc, arrange port A insertion.
        • We had well explaint to patient about palliative chemotherapy (Gem+Cis). We will take over this case if you agree (May transfer to 11A on Dr He’s service) Thanks for your consultation.
  • 2023-08-14 Radiation Oncology
    • Q: This 66 years old woman was giagnosed with left breast cancer then underwent of MRM on 2012/3/28 and completion of adjuvant C/T with FEC x6 and Tamoxifen. However, Abdomial CT showed Multiple liver and lung metastases are highly suspected. As such, we need your help for liver biopsy, thanks.
    • A: According to the clinical condition and imaging findings, biopsy is indicated.

[chemotherapy]

  • 2024-02-23 - oxaliplatin 85mg/m2 100mg D5W 100mg 2hr + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (PLT 48K: 3840 -> 3500mg) (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2024-02-15 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2024-01-19 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2024-01-12 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2023-12-27 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2023-12-19 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2023-11-22 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2023-11-15 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2023-10-24 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2023-10-19 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2023-09-27 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2023-09-21 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2023-09-01 - gemcitabine 800mg/m2 1000mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 50mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2023-08-25 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + NS 500mL 2hr (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 3hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL

TS-1

  • 2023-08-14 ~ 2024-02-15 - TS-1 (tegafur 25mg, gimeracil 7.25mg, oteracil potassium 24.5mg)

==========

2024-02-23

[leukopenia & thrombocytopenia following chemotherapy: monitoring PLT for Transfusion]

Gemcitabine, cisplatin, and TS-1 combination chemotherapy was initiated in 2023-08. The disease remained stable until a CT scan performed on 2024-02-16 revealed multiple liver metastases and carcinomatosis, indicating disease progression. Consequently, the treatment regimen was switched to FOLFOX, which was first administered during this hospitalization.

Leukopenia and thrombocytopenia developed following the last dose of gemcitabine, cisplatin, and TS-1 on 2024-02-15.

  • 2024-02-23 WBC 3.45 x10^3/uL

  • 2024-02-21 WBC 1.62 x10^3/uL

  • 2024-02-19 WBC 4.13 x10^3/uL

  • 2024-02-15 WBC 5.56 x10^3/uL

  • 2024-02-23 PLT 48 *10^3/uL

  • 2024-02-21 PLT 78 *10^3/uL

  • 2024-02-19 PLT 102 *10^3/uL

  • 2024-02-15 PLT 184 *10^3/uL

The WBC count has since recovered to 3.45 K/uL; however, the PLT count remains low at 48 K/uL. If the bleeding risk is assessed as high, leukocyte-reduced packed red blood cell (LRP) transfusion may be necessary.

2024-01-19

[leukopenia]

Granocyte (lenograstim) was administered on 2024-01-11. Subsequently, the WBC nadir, occurred on 2024-01-18. However, by 2024-01-19, this nadir had resolved, indicating a recovery in WBC count.

  • 2024-01-19 WBC 8.28 x10^3/uL
  • 2024-01-18 WBC 1.65 x10^3/uL **
  • 2024-01-15 WBC 2.35 x10^3/uL *
  • 2024-01-11 WBC 2.45 x10^3/uL * Granocyte
  • 2024-01-03 WBC 2.08 x10^3/uL *
  • 2023-12-29 WBC 4.34 x10^3/uL

2024-01-12

[gemcitabine + cisplatin: success might falter as markers surge]

The gemcitabine + cisplatin treatment started on 2023-08-25 and continues, but lab results from 2024-01-09 show record highs for both CEA and CA199 markers. This could potentially indicate developing resistance in the disease.

  • 2024-01-09 CEA (NM) 26.176 ng/ml

  • 2023-12-12 CEA (NM) 18.186 ng/ml

  • 2023-12-05 CEA (NM) 21.272 ng/ml

  • 2023-11-14 CEA (NM) 16.023 ng/ml

  • 2023-11-07 CEA (NM) 19.729 ng/ml

  • 2023-10-24 CEA (NM) 12.994 ng/ml

  • 2023-10-09 CEA (NM) 12.462 ng/ml

  • 2023-09-26 CEA (NM) 7.880 ng/ml

  • 2023-09-19 CEA (NM) 6.288 ng/ml

  • 2023-08-15 CEA (NM) 18.890 ng/ml

  • 2024-01-09 CA-199 (NM) 59.203 U/ml

  • 2023-12-12 CA-199 (NM) 45.760 U/ml

  • 2023-12-05 CA-199 (NM) 51.454 U/ml

  • 2023-11-14 CA-199 (NM) 45.873 U/ml

  • 2023-11-07 CA-199 (NM) 40.871 U/ml

  • 2023-10-24 CA-199 (NM) 42.186 U/ml

  • 2023-10-09 CA-199 (NM) 45.064 U/ml

  • 2023-09-26 CA-199 (NM) 31.407 U/ml

  • 2023-09-19 CA-199 (NM) 33.127 U/ml

  • 2023-08-15 CA-199 (NM) 26.597 U/ml

2023-09-25

This patient’s PharmaCloud is currently inaccessible. After reviewing the HIS5 records, no medication reconciliation issues were identified.

701050910

240223

[exam findings]

  • 2023-07-06 SONO - abdomen
    • Diagnosis:
      • Splenic fossa tumor, enlarged compared to 2022/08 (DDx: lymphoma?, accessory spleen hyperplasia?)
      • Post splenectomy
      • Parenchymal liver disease, mild
      • Pancreatic cystic lesion, body, size similar
      • Renal cysts, both
    • Suggestion:
      • Consider other image studies for the enlaring splenic tumor
  • 2023-07-05 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Hairy cell leukemia, relapsed
    • The sections show hypercellular marrow (60%). Diffuse sheets of monotonous neoplastic cells (80% marrow cells) with oval nuclei surrounded by abundant clear or light pink cytoplasm, and decreased trilineage hematopoiesis are present. Mild marrow fibrosis can be identified.
    • IHC, the neoplastic cells show: CD3(-), CD20(+), DBA 44(+) and Annexin A1(+). The finding is consistent with relapsed hairy cell leukemia.
  • 2023-07-05 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2022-08-24 SONO - abdomen
    • Parenchymal liver disease, mild
    • Suspected Pancreatic cystic lesion, body (stationary)
    • Renal cysts
    • Chronic kidney disease (left)
    • Post splenectomy
    • Probable Accessary spleen (2.91 cm)
  • 2021-03-15 CXR
    • Linear infiltration over right lower lung zone is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
    • Borderline cardiomegaly
  • 2021-03-01 SONO - abdomen
    • Fatty liver, mild
    • s/p splenectomy with small residue spleen
    • Renal cyst, bilateral
  • 2021-03-08 CXR
    • Consolidation in right lower lung zone, r/o pneumonia
  • 2021-03-08 CT - abdomen
    • Partial consolidation at RLL. R/O pneumonia
    • S/P splenectomy with a accessory spleen ?
    • Bil. renal cysts (up to 6.3cm). Left renal stone (3mm).
  • 2020-12-15 Patho - bone marrow biopsy (Y1)
    • Bone marrow, iliac, biopsy — B cell leukemina.
    • Section shows piece(s) of bone marrow with 100% cellularity and M:E ratio of approximately 10:1. There is a predominant small to medium size atypical lymphoid population present.
    • IHC stains: CD3: 2%, CD20: 95%, CD5: 2%, CD19: 95%; CD23: <1%.

[MedRec]

  • 2021-03-25 ~ 2021-04-02 POMR Hemato-Oncology
    • Discharge diagnosis
      • Chronic lymphocytic leukemia of B-cell type not having achieved remission
      • Relapsed HAIR CELL LEUKEMIA s/p Leustatin (cladribine)
      • Carrier of viral hepatitis B
      • Thrombocytopenia, unspecified
    • CC
      • for scheduled chemotherapy
    • Present illness
      • This 65 year-old male patient has the history of 1. HBV carrier 2. s/p splenectomy on 2016-11-16 3.CLL s/p C/T Splenomegaly was told during routine GI OPD f/u. Thrombocytopenia was also noticed. Thus, splenectomy was performed 2016-11-16. However, leukocytosis and anemia were found recent 2 months. He deined any body weight loss, appetite change, fever and abdominal disconfortable. He then visited our OPD and was admiited for bone marrow pucture on 2016/01/03. The pathology result showed Lymphocytic leukemia, B cell type. Flow cytometry at NTUH and TSGH revealed TRAP (+). Hairy cell leukemia was diagnosed. Evaluation of Abdominal echo was arranged for previous history of HBV and the reprot showed suspect retroperitoneal lesion. Furtehr abdominal CT was performed and the result revealed left renal stone & cyst and accesory spleen on 2016-01-30. Bone morrow aspiration and biopsy were done smoothly on 2020/12/15, pathology showed B cell leukemina.
      • Leustatin (cladribine) from 2016/2/20-2/26 6mg in 500ml saline drip for 24 hrs (10ml/vial, 1mg/1ml)
      • This time, he was admitted for scheduled chemotherapy
    • Course of inpatient treatment
      • After admission, chemotherapy with Leustatin 6g QD was administered from 2021/03/25-31. Fever without chills was noted on 3/25, follow up blood culture yielded negative and Acetaminophen prn used. Blood transfusion with LRP or LPRBC if necessary. With the relatively stable condition, he was discharged on 2021/04/02 and will OPD follow up later.
      • take Lenograstim 250mcg on 4/3, 4/4
    • Discharge prescription
      • Granocyte (lenograstim 250mcg) QD SC 2D on 4/6, 4/7
  • 2020-12-13 ~ 2020-12-15 POMR Hemato-Oncology
    • Discharge diagnosis
      • Chronic lymphocytic leukemia of B-cell type not having achieved remission
      • Carrier of viral hepatitis B
      • Chronic viral hepatitis B without delta-agent
      • Neoplasm of unspecified behavior of digestive system
      • Thrombocytopenia, unspecified
    • CC
      • Thrombocytopenia noted for week
    • Present illness
      • This 60 year-old male patient has the history of 1. HBV carrier 2. s/p splenectomy on 2016-11-16 3. CLL s/p C/T Splenomegaly was told during routine GI OPD f/u. Thrombocytopenia was also noticed. Thus, splenectomy was performed 2016-11-16. However, leukocytosis and anemia were found recent 2 months. He deined any body weight loss, appetite change, fever and abdominal disconfortable. He then visited our OPD and was admiited for bone marrow pucture on 2016-01-03. The pathology result showed Lymphocytic leukemia, B cell type. Flow cytometry at NTUH and TSGH revealed TRAP (+). Hairy cell leukemia was diagnosed. Evaluation of Abdominal echo was arranged for previous history of HBV and the reprot showed suspect retroperitoneal lesion. Furtehr abdominal CT was performed and the result revealed left renal stone & cyst and accesory spleen on 2016-01-30. Today, he was admitted for Anemia and thrombocytopenia and further chemotherapy of Leustatin.
    • Course of inpatient treatment
      • After admission, thrombocytopenia was noted. Bone morrow aspiration and biopsy were done smoothly on 12/15. Peripheral blood example was collected for smear. There was no soreness or active bleeding noted. Since relative stable condition, he was discharged on 2020/12/15 and OPD follow up.

[immunochemotherapy]

  • 2024-02-21 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1370mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-COP)
    • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30m D1-2 + palonosetron 250ug D2 + NS 250mL D1-2
  • 2024-01-17 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 650mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-COP, Endoxan 50% off)
    • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30m D1-2 + palonosetron 250ug D2 + NS 250mL D1-2
  • 2023-11-01 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-COP)
    • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30m D1-2 + palonosetron 250ug D2 + NS 250mL D1-2
  • 2023-09-07 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cladribine 6mg NS 500mL 24hr D2-8
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-8 + betamethasone 4mg D2-8
  • 2023-07-07 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cladribine 6mg NS 500mL 24hr D2-8
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-8 + betamethasone 4mg D2-8
  • 2021-03-25 - cladribine 6mg NS 500mL 24hr D1-7
    • [diphenhydramine 30mg + NS 250mL] D1-7

[note]

Hairy Cell Leukemia SUGGESTED TREATMENT REGIMENS - NCCN Evidence Blocks - Version 1.2023 - 2022-10-13 — HCL-A 1 OF 2, p7

  • Initial Therapy
    • Preferred Regimens
      • Purine analogs
        • Cladribine ± rituximab
        • Pentostatin
    • Useful in Certain Circumstances (consider for patients who are unable to tolerate purine analogs including frail patients and those with active infection)
      • Vemurafenib + obinutuzumab
  • Relapsed/Refractory Therapy
    • Less than complete response after initial treatment OR Relapse < 2 years
      • Preferred Regimens
        • Clinical trial
        • Alternative purine analog + rituximab
        • Vemurafenib ± rituximab
      • Other Recommended Regimens
        • Peginterferon-alfa 2a
        • Alternative purine analog
      • Useful in Certain Circumstances
        • Rituximab, if unable to receive purine analog
    • Relapse >= 2 years
      • Preferred Regimens
        • Retreat with initial purine analog + rituximab
        • Alternative purine analog + rituximab
      • Other Recommended Regimens
        • none
      • Useful in Certain Circumstances
        • Rituximab, if unable to receive purine analog
  • Progressive Disease After Relapsed/Refractory Therapy
    • Preferred Regimens
      • Clinical trial
      • Moxetumomab pasudotox
      • Vemurafenib ± rituximab (if not previously given)
    • Other Recommended Regimens
      • Ibrutinib

Cladribine 2023-07-13 https://www.uptodate.com/contents/cladribine-drug-information

  • Adult Dosing - Hairy cell leukemia:
    • IV:
      • 0.14 mg/kg/day over 2 hours for 5 days for 1 cycle or
      • 0.1 mg/kg/day continuous infusion for 7 days for 1 cycle or
      • 0.09 mg/kg/day continuous infusion for 7 days for 1 cycle or
      • 0.15 mg/kg/day over 2 hours on days 1 to 5 as a single course (in combination with concurrent or delayed rituximab) or
      • 5.6 mg/m2 over 2 hours once daily for 5 days as a single course, followed 28 days later by rituximab.
    • SUBQ (off-label route):
      • 0.1 to 0.14 mg/kg/day for 5 days for 1 cycle.

Rituximab 2023-07-13 https://www.uptodate.com/contents/rituximab-intravenous-including-biosimilars-drug-information

  • Adult Dosing - Hairy cell leukemia (off-label use):
    • In combination with cladribine (as initial treatment or after first relapse): IV:
      • 375 mg/m2 once weekly (beginning 28 days ± 4 days after initiation of 5 days of cladribine) for 8 doses or
      • 375 mg/m2 once weekly (beginning concurrently with cladribine) for 8 doses.
    • In combination with vemurafenib (relapsed or refractory disease): IV:
      • 375 mg/m2 on days 1 and 15 every 6 weeks (in combination with vemurafenib) for 2 induction cycles, followed by 375 mg/m2 once every 2 weeks for 4 rituximab monotherapy consolidation doses (total of 8 rituximab doses).

==========

2024-02-23

Anemia with HGB at 7.6 was observed on 2024-02-19, LPRBC transfusion was then carried out.

  • 2024-02-19 HGB 7.6 g/dL
  • 2024-02-15 HGB 8.3 g/dL
  • 2024-02-05 HGB 8.3 g/dL
  • 2024-02-01 HGB 8.7 g/dL
  • 2024-01-29 HGB 9.5 g/dL
  • 2024-01-22 HGB 9.7 g/dL
  • 2024-01-16 HGB 8.7 g/dL
  • 2024-01-15 HGB 9.3 g/dL
  • 2024-01-08 HGB 9.6 g/dL

2023-09-14

[thrombocytopenia]

The patient’s thrombocytopenia was present even before the two most recent rounds of immunochemotherapy (rituximab with cladribine administered on 2023-07-07 and 2023-09-07). The primary treatment has been blood transfusions, which were conducted on the following dates: 2023-07-04, 2023-07-22, 2023-07-27, 2023-07-31, 2023-08-07, 2023-08-28, 2023-09-09, and 2023-09-13.

2023-09-13 PLT 43 10^3/uL 2023-09-11 PLT 34 10^3/uL 2023-09-09 PLT 38 10^3/uL 2023-09-06 PLT 41 10^3/uL 2023-09-05 PLT 43 10^3/uL 2023-08-28 PLT 42 10^3/uL 2023-08-23 PLT 29 10^3/uL 2023-08-22 PLT 26 10^3/uL 2023-08-15 PLT 25 10^3/uL 2023-08-09 PLT 120 10^3/uL 2023-08-07 PLT 26 10^3/uL 2023-08-03 PLT 91 10^3/uL 2023-08-01 PLT 24 10^3/uL 2023-07-31 PLT 31 10^3/uL 2023-07-27 PLT 36 10^3/uL 2023-07-25 PLT 50 10^3/uL 2023-07-21 PLT 25 10^3/uL 2023-07-19 PLT 50 10^3/uL 2023-07-18 PLT 92 10^3/uL 2023-07-16 PLT 120 10^3/uL 2023-07-14 PLT 23 10^3/uL 2023-07-12 PLT 40 10^3/uL 2023-07-10 PLT 75 10^3/uL 2023-07-07 PLT 122 10^3/uL 2023-07-05 PLT 19 10^3/uL 2023-07-04 PLT 23 10^3/uL 2023-06-29 PLT 23 10^3/uL 2023-04-06 PLT 87 10^3/uL 2023-02-09 PLT 132 10^3/uL 2022-11-03 PLT 180 10^3/uL

2023-07-13

[leukopenia]

The recent WBC nadir was noted on 2023-07-10 with a count of 0.88K/uL, and by 2023-07-12, an increase to 1.21K/uL was evident.

  • 2023-07-12 WBC 1.21 x10^3/uL **
  • 2023-07-10 WBC 0.88 x10^3/uL ***
  • 2023-07-07 WBC 3.56 x10^3/uL
  • 2023-07-05 WBC 2.23 x10^3/uL *
  • 2023-07-04 WBC 3.61 x10^3/uL

The patient received the regimen of cladribine plus rituximab on 2023-07-07. It’s well known that cladribine injection often leads to dose-dependent myelosuppression (manifested as neutropenia, anemia, and thrombocytopenia), typically reversible. Additionally, rituximab is associated with an incidence of neutropenia (8% to 14%; grades 3/4: 4% to 49%). As such, the regimen could be the primary cause of the patient’s recent leukopenia.

Given the current trend of increasing WBC count without the administration of G-CSF, it would be advisable to continue monitoring over the next few days to verify if the developed leukopenia is resolved.

[thrombocytopenia]

(this pharmacist note is a continuation of the previous one)

Even as the WBC count gradually recovers, platelet levels continue to decline, noted at 40K/uL on 2023-07-12. If this decrease continues, it is typically recommended to consider transfusion if the platelet count drops to or below a threshold of 10K/uL. If fever, sepsis, or coagulopathy is present, higher thresholds may be needed.

  • 2023-07-12 PLT 40 x10^3/uL
  • 2023-07-10 PLT 75 x10^3/uL
  • 2023-07-07 PLT 122 x10^3/uL

701473497

240223

[exam findings]

  • 2024-02-01 CT - abdomen
    • History and indication: Colon cancer with bladder invasion s/p op; stage III
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Progression of rectal cancer with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion. Some LNs at pelvic cavity. S/P colostomy.
      • Some nodules in bil. lungs. A small calcificaiton at RLL.
      • Some calcifications in bil. scrotum. Mild right hydronephrosis.
      • Atherosclerosis of aorta.
      • S/P left side double J catheter insertion. Some stones (up to 1.5cm) in urinary bladder. Still dilatation of left renal pelvis.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Progression of rectal cancer with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion, LNs and lung metastases.
  • 2023-10-31 CT - abdomen
    • Clinical history: 46 y/o male patient with Sigmoid colon cancer recurrence with bladder wall invasion, T4bN2aM0, stage IIIC, status post T-loop colostomy on 2023/03/08, status post FOLFIRI from 2023/06/10 ~ from pelvis to chest.
    • With and without contrast enhancement CT of abdomen – whole:
      • S/P double J catheter drainage, left side.
      • S/P colostomy in right abdomen.
      • Rectal malignancy with urinary bladder and left distal ureteral invasion
      • Dilatation of left pelvicaliceal system and ureter.
      • Bilateral lung tumors, r/o lung metastasis, progression.
    • Impression:
      • S/P double J catheter drainage, left side. S/P colostomy in right abdomen.
      • Rectal malignancy with urinary bladder and distal ureteral invasion. Progression.
      • Multiple lung metastasis, progression.
  • 2023-05-28 CXR
    • Normal sinus rhythm
    • Right atrial enlargement
    • Rightward axis
    • Pulmonary disease pattern
    • Abnormal ECG
  • 2023-05-25 CT - abdomen
    • History and indication: Colon cancer with bladder invasion s/p op; stage III
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Progression of rectal cancer with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion. Some LNs at pelvic cavity. S/P colostomy.
      • Some nodules in bil. lungs. A small calcificaiton at RLL.
      • Some calcifications in bil. scrotum.
      • Atherosclerosis of aorta.
      • S/P left side double J catheter insertion and the lower end in urethra. Still dilatation of left renal pelvis.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Progression of rectal cancer with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion, LNs and lung metastases. Left hydronephrosis.
  • 2023-04-15 Urology SONO - kidney
    • CC
      • Colon cancer s/p colectomy and partial cystectomy in 2021/05 at Cathay GH
      • Followed by R/T and C/T
      • Fecaluria noted on 2023/02/28
      • Obstructive uropathy s/p URS and DBJ before colostomy
      • Right side colostomy performed in 2023/03
  • 2023-04-15 Bladder sonography
    • PVR 11.55 ml
  • 2023-03-10 Patho - colon biopsy
    • Colon tumor, sigmoid (15 cm from anal verge), biopsy — Compatible with adenocarcinoma, recurrent
    • Microscopically, the sections show a picture of mainly benign mucosa with focal ulcer, necrotic debris and few tumor cells show subtle cribriform pattern, compatible with recurrent adenocarcinoma.
  • 2023-03-09 Signoidoscopy
    • Sigmoid cancer recurrence with lumen narroing at 15 cm from AV, biopsy was done
  • 2023-03-02 CT - abdomen
    • History and indication: Colon cancer with bladder invasion s/p op; stage III
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of rectum with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion. Some LNs at pelvic cavity.
      • Some calcifications in bil. scrotum.
      • Atherosclerosis of aorta.
      • S/P left side double J catheter insertion and the lower end in urethra.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)

[MedRec]

  • 2023-05-04 SOAP Hemato-Oncology
    • P
      • Urologist: C/T goes first and then repair fistula
      • Port-A flush Q3M on 2023-05-04
  • 2023-04-15 SOAP Urology
    • S
      • Colon cancer s/p colectomy and partial cystectomy in 2021/05 at Cathay GH
      • Followed by R/T and C/T
      • Fecaluria noted on 2023/02/28
      • Obstructive uropathy s/p URS and DBJ before colostomy
      • Right side colostomy performed in 2023-03
    • O
      • 2023/04/14 Renal sona: no hydronephrosis, bladder sona: thick bladder wall, small PVR, adviuse hydration and follow-up
    • Diagnosis
      • Dysuria R30.0
    • Prescription
      • Urief (silodosin 8mg) 1# QD
  • 2023-04-13 SOAP Hemato-Oncology
    • S
      • CCRT with CapOx (2- cycles) -> Avstin plus Oxaliplatin x 10 cyces -> shift to Avastin plus irinotecan due to oxaliplatin-induced neuropathy -> Hold avastin for 5-6 months plus irinotecan due to ulcer over anastomic site by avastin -> due to left hydronephrosis, fistula between tumor and posterior wall of bladder was noted. D-J was done and PD was confirmed -> Shift to regorafenib (taken for 2 weeks) since 2023-01. For avoiding infection over fistula, colostomy was conducted on 2023-03-08.
    • P
      • Consider FOLFIRI with or without Anti-EGFR dependent on RAS.
      • Waiting for infection under control and RAS data
  • 2023-03-16 SOAP Hemato-Oncology
    • P: Request to visit Urologist for manage the fistula between bladdner and tumor
  • 2023-03-02 ~ 2023-03-10 POMR Colorectal Surgery
    • Discharge diagnosis
      • Sigmoid colon cancer recurrence with bladder wall invasion, T4bN2aM0, STAGE:IIIC, status post T-loop colostomy on 2023/03/08
      • Enterovesical fistula with urinary tract infection
    • CC
      • Urination with stool content for weeks
    • Present illness
      • This is a 46-year-old male with past history of
          1. Moderate differentiated adenocarcinoma of sigmoid colon with serosa and posterior bladder wal1 invasion, pTLaN2D10, stage 3C
          • s/p anterior reseection with radical lymph node dissection on 2021/05/18
          • s/p radiotherapy with 5400 cGy/30 Fx (2021/06/21 - 2021/08/03, s/p oxaliptin + capecitabine (C1D1 - C2D1 -2022/11/29, 2021/06/22 ~ 07/13)
          • s/p mFOLFOX + Avastin (CIDI ~ C11D1 = 2021/08/10 ~2022/01/12)
          • s/p FOLFIRI (CID1 = 2022/01/25)
          • s/p Strivaga (2023/2/18-3/2)
          1. Right lower lung atypical adenomatous hyperplasia, s/p Video-assisted thoracoscopic wedge resection of RS6 and RS9 + pneumolysis on 2022/02/10
          1. Cystoscopy + left ureteroenoscopy (URS) revealed bladder papillary tumor at posterior wall (S-colon invasion?), left UVI stricture, left middle ureter severe toturous & dilation
          1. HBV carrier, on tenofovir
      • Tracing back to his previous medical history initially he suffered from periumbilical pain then intermittent LLQ abdomen pain for 3 months. The pain sustained more than one hour, described as cramping and severe. He had visited Xindian Cardinal Tien Hospital on 12/07 and then transferred to Taipei Medical University Hospital.
        • Due to above symptoms, he went to Cathay General Hospital GI Dr. Li JiaLong OPD. There was no tenesmus. Body weight lost 7 kg (from 57 to 50)was noted. 2021/05/04 coloscopy was proceeded up to tumor location. It is about 4cm luminal colon tumor mass with nearly total occlusion 40 cm from anal verge s/p biopsy. Pathology report revealed adenocarcinoma. The whole abdomen CT scan performed and finding: Irregular annular thickening of sigmoid colon nearly 6.8 x 3.3cm in size, with perfocal fat stranding.
        • Anterior resection with radical lymph node dissection + partial cystectomy and bladder wall repair was performed on 2021/05/18.
        • After operation , he received CRT of radiotherapy with 5400 cGy/30 fractions during 2021/06/21 - 2021/08/03 and chemotherapy with oxaliptin + capecitabine (CID1 ~ C2D1 = 2021/06/22 ~ 07/13)then mFOLFOx + Avastin (C1D1 ~ C11D1 = 2021/08/10 ~ 2022/01/12). Follow-up Chest CT on 2021/12/31 revealed two new subpleural nodules (5. 5mm and 3mm at RLL of lungs, suspected lung metastasis. so video-assisted thoracoscopic wedge resection of RS6 and RS9 + pneumolysis was performed on 2022/02/10 and the pathology revealed atypical adenomatous hyperplasia.
        • Chemotherapy regimen was shifted to FOLFIRI cycle 1 - cycle 4 on 2022/01/25-2022/04/13.
        • He received FOLFIRI(46) & avastin on 20220413 cycle 4 but nausea, change in bowel habit (stool passage turn less and thin), mild periumbilical pain and tenderness were noted. There were no other symptoms such as fever with chills headache, dizziness, vomiting, diarrhea, constipation, cough with sputum production, dysuria, gross hematuria, diaphoresis (cold sweating) or dyspnea.
      • This time, ever since the AR on 2021/05/18, dirty urine was noted, but recently more stool content has been found. Therefore, he transferred from Cathay General Hospital to our OPD due to recommendation by his father-in-law.
      • Therefore, under the impression of adhesion of bladder and colon he was admitted for further investigation of cancer invasion or possible colonstomy evaluation.
    • Course of inpatient treatment
      • After admission with ward routine and blood examination were done. Operation of T-loop colostomy under general anesthesia were performed on 2023/03/08. NPO and IV fluids support. The wound healing well and no erythema change. Chewing cookies, toast, rice with gum was started at op day. No nausea and no vomiting, flatus passage. On low residual diet was started at post-op day 1. Patient education with colostomy care was done. Normoactive bowel movement and stools passage with diet better tolerated. There wrew no fever and no complication. So he was arranged for discharge for hisstable general condition on 2023/03/10 and will be followed up in ONCOLOGY for further chemotherapy.
    • Discharge prescription
      • Uroprin (phenazopyridine 100mg) 1# TID
      • Morcasin (sulfamethoxazole 400mg, trimethoprim 80mg) 2# BID
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Defram-K (diclofenac 25mg) 1# PRNQ8H
  • 2023-03-02 SOAP Colorectal Surgery
    • S
      • Colon cancer with bladder invasion s/p op; stage III, 2021-05-19
      • post-OP chemotherapy + target therapy ; DJ insertion
      • Stool passage from urine for one week
      • Septicemia 2023-01

[consultation]

  • 2023-06-29 Colorectal Surgery
    • Q
      • This is a 46-year-old male with past history of
          1. Moderate differentiated adenocarcinoma of sigmoid colon with serosa and posterior bladder wal1 invasion, pTLaN2D10, stage 3C
          • s/p anterior reseection with radical lymph node dissection on 2021/05/18
          • s/p radiotherapy with 5400 cGy/30 Fx (2021/06/21 - 2021/08/03, s/p oxaliptin + capecitabine (C1D1 - C2D1 - 2022/11/29, 2021/06/22 ~ 07/13)
          • s/p mFOLFOX + Avastin (CIDI ~ C11D1 = 2021/08/10 ~2022/01/12) - s/p FOLFIRI (CID1 = 2022/01/25)
          • s/p Strivaga (regorafenib) (2023/2/18-3/2),
          1. Right lower lung atypical adenomatous hyperplasia, s/p Video-assisted thoracoscopic wedge resection of RS6 and RS9 + pneumolysis on 2022/02/10,
          1. Cystoscopy + left ureteroenoscopy (URS) revealed bladder papillary tumor at posterior wall (S-colon invasion?), left UVI stricture, left middle ureter severe toturous & dilation,
          1. HBV carrier, on tenofovir.
      • since the AR on 2021/05/18, dirty urine was noted, but recently more stool content has been found, CT showed Progression of rectal cancer with adjacent pelvic wall, ureter, urinary bladder and bowel loop invasion, s/p T-loop colostomy on 2023/03/08.
      • He presented anal pain when sit, we need your further evaluation and management.
    • A
      • this is a 46-year old man with adenocarcinoma of sigmoid colon with serosa and posterior bladder wal1 invasion, pTLaN2D10, stage 3C - s/p anterior reseection with radical lymph node dissection on 2021/05/18
        • and anal pain was told for 8 days
      • DRE: no obvious hemorrhoid but firm mass over ant rectum region about 5cm aav region, possible progress of rectal cancer
      • P:
        • add alcos anal and posuline for supp use
        • warm water sitz bath
  • 2023-06-29 Urology
    • Q
      • He received Left double J catheter replacement on 2023/05/31, he presented with scrotal pain when urination, we need your further evaluation and management.
    • A1
      • After change DBJ last month, urinary incontinence disappeared
      • Drainage effect of stent will be followed (he insist NOT tumor stent for fear of pain )
      • He said he had left scrotal discomfort since last week
      • Physical examination showed no obvious swelling or heating
      • Scrotal ultrasound will be arranged
    • A2 2023-06-30 09:55:48
      • little fluid around testis (malnutriotion may be related)
        • the pain is related to voiding
      • try doxaben HS may be beneficial for voiding
  • 2023-03-06 Gastroenterology
    • Q
      • For HBV medication, tenofovir use
      • This is a 46-year-old male with past history of
          1. Moderate differentiated adenocarcinoma of sigmoid colon with serosa and posterior bladder wal1 invasion, pTLaN2D10, stage 3C
          • s/p anterior reseection with radical lymph node dissection on 2021/05/18
          • s/p radiotherapy with 5400 cGy/30 Fx (2021/06/21 - 2021/08/03),
          • s/p oxaliptin + capecitabine (C1D1 - C2D1 -2022/11/29, 2021/06/22 ~ 07/13)
          • s/p mFOLFOX + Avastin (CIDI ~ C11D1 = 2021/08/10 ~2022/01/12) - s/p FOLFIRI (CID1 = 2022/01/25)
          • s/p Regorafenib (Strivaga, 2/18-3/2)
          1. Right lower lung atypical adenomatous hyperplasia, s/p Video-assisted thoracoscopic wedge resection of RS6 and RS9 + pneumolysis on 2022/02/10
          1. Cystoscopy + left ureteroenoscopy (URS) revealed bladder papillary tumor at posterior wall (S-colon invasion?), left UVI stricture, left middle ureter severe toturous & dilation
          1. HBV carrier , on tenofovir
      • Under the impression of adhesion of bladder and colon he was admitted to our CRS ward for further investigation of cancer invasion or possible colostomy evaluation. During hospitalization, Tenofovir has been used up. We need your expertise for medication use.
    • A
      • 46 years old man has sigmoid cancer, s/p CCRT, chemotherapy, Target therapy, HBV carrier under tenofovir. He has admitted for adhesion of bladder and colon. Therefore, we are consulted for tenofovir.
      • PE
        • conscious: clear
        • chest: smooth breath pattern
        • abdomen: soft and flat
      • Impression
        • Sigmoid cancer, s/p CCRT, target therapy
        • HBV carrirer under Tenofovir
      • Suggestion
        • If the PharmaCloud database indicates that the patient has been prescribed Tenofovir at an outside hospital, the issuing institution should be changed to our hospital (pending confirmation).

[surgical operation]

  • 2023-03-08
    • Surgery: T-loop colostomy        
    • Finding: T-loop colostomy was created at RUQ area        
    • Procedure
      • Patient was put on supine position under ETGA
      • Sterized and drapped as routine
      • RUQ skin incision and muscular layer was splitted, fasia and peritoneum was opened
      • Iluem was identified and externalization, looped with a rubber tube
      • Colostomy was opened and matured by suturing with 3-0 monopril
      • Covered with stoma bag  

[radiotherapy]

[chemotherapy]

  • 2024-02-22 - nivolumab 3mg/kg 100mg NS 100mL 1hr (Opdivo + Stivarga (regorafenib))

  • 2024-02-05 - nivolumab 3mg/kg 100mg NS 100mL 1hr (Opdivo + Stivarga (regorafenib))

  • 2024-01-11 - bevacizumab 5mg/kg 200mg NS 100mL 90min (Avastin + Lonsurf (trifluridine, tipiracil))

  • 2023-12-23 - bevacizumab 5mg/kg 200mg NS 100mL 90min (Avastin + Lonsurf (trifluridine, tipiracil))

  • 2023-11-01 - bevacizumab 5mg/kg 200mg NS 100mL 90min (Avastin + Lonsurf (trifluridine, tipiracil))

  • 2023-10-09 - FOLFIRI

  • 2023-09-12 - FOLFIRI

  • 2023-08-15 - FOLFIRI

  • 2023-07-25 - FOLFIRI

  • 2023-07-05 - irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI Q2W)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL
  • 2023-06-09 - irinotecan 120mg/m2 160mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI Q2W)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2024-02-05 ~ undergoing (2024-02-23) - Stivarga (regorafenib 40mg)

  • 2023-10-30 ~ 2024-02-02 - Lonsurf (trifluridine 15mg, tipiracil 7.065mg) 3# BID

Systemic therapy for nonoperable metastatic colorectal cancer: Approach to later lines of systemic therapy - 2024-02-23 - https://www.uptodate.com/contents/systemic-therapy-for-nonoperable-metastatic-colorectal-cancer-approach-to-later-lines-of-systemic-therapy

  • Microsatellite unstable/deficient mismatch repair tumors - For patients who have high microsatellite instability (MSI-H)/deficient mismatch repair (dMMR) tumors who did not receive an immune checkpoint inhibitor for initial first-line therapy, we suggest immune checkpoint inhibitor immunotherapy rather than another form of systemic therapy. Two options are available:
    • Monotherapy with an immune checkpoint inhibitor that targets the programmed cell death 1 (PD-1) receptor, ie, either nivolumab or pembrolizumab, is one option. In clinical trials, objective response rates (ORRs) with these two PD-1 inhibitors are 30 to 50 percent, and some responses are durable. Both drugs have been approved by the US Food and Drug Administration (FDA) for this indication in the United States, and the choice of one agent over the other is empiric. Patients who experience disease progression on either of these drugs should not be offered the other.
    • Another option is the combination of nivolumab plus ipilimumab, a monoclonal antibody directed against a different immune checkpoint, cytotoxic T lymphocyte antigen 4 (CTLA-4). Although there are no randomized trials directly comparing dual therapy with monotherapy with either nivolumab or pembrolizumab alone, indirect comparisons from the multicohort phase II CheckMate 142 trial suggest that combined immunotherapy provides improved efficacy over anti-PD-1 monotherapy and has a favorable risk-benefit ratio. Updated analyses with long-term follow-up of the two second-line cohorts reported four-year progression-free survival (PFS) of 52 percent in the combination nivolumab-ipilimumab arm and 36 percent with single-agent nivolumab. The combination has received FDA approval in the United States for patients with MSI-H or dMMR mCRC that has progressed despite other treatments. It is currently not known in which patients with MSI-H mCRC to use combined nivolumab plus ipilimumab, or whether this combination is active in patients who relapse or progress on single-agent checkpoint inhibitor immunotherapy.
  • Trifluridine-tipiracil with or without bevacizumab - Trifluridine-tipiracil plus bevacizumab is an option for patients with mCRC who have been previously treated with fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy, an anti-VEGF agent, and an EGFR inhibitor (if RAS wild-type). Trifluridine-tipiracil monotherapy may be offered to patients who are unable to tolerate or have contraindications to bevacizumab.
    • Trifluridine-tipiracil (TAS-102) is an oral cytotoxic agent that consists the nucleoside analog trifluridine (trifluorothymidine, a cytotoxic antimetabolite that, after modification within tumor cells, is incorporated into DNA causing strand breaks) and tipiracil, a potent thymidine phosphorylase inhibitor, which inhibits trifluridine metabolism and has antiangiogenic properties as well.
    • Trifluridine-tipiracil is administered twice daily on days 1 to 5 and 8 to 12 of a 28-day cycle, and bevacizumab is administered at 5 mg/kg on days 1 and 15 of a 28-day cycle. Other studies suggest that an every-two-weeks schedule of administration of trifluridine-tipiracil (twice daily on days 1 to 5 of a 14-day cycle) with bevacizumab (5 mg/kg on day 1 of a 14-day cycle) is associated with less toxicity, especially neutropenia. This schedule is a reasonable alternative for patients who have difficulty tolerating the standard dosing of this combination.

==========

2024-02-23

[regorafenib and nivolumab: evaluating adverse skin reactions]

Stivarga (regorafenib) has been associated with skin rash occurrences in 26% to 30% of cases. Given that this medication has been administered since 2024-02-05 and the onset of skin rash was noted on 2024-02-18, a causal relationship cannot be ruled out.

Dermatologic toxicities, such as immune-mediated rashes including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN, some instances fatal), exfoliative dermatitis, and bullous pemphigoid, may be induced by nivolumab. The mechanism is not dose-related and remains unclear. Typically, dermatologic toxicity presents early in the course of treatment with nivolumab, with a median onset time ranging from 2.8 to 6.1 weeks post-treatment initiation, and can affect patients with any type of tumor. The median onset time for symptoms resembling Sjögren’s disease is approximately 70 days. Therefore, considering the skin rash appeared merely two weeks after starting nivolumab, it is improbable that nivolumab is the cause.

2024-02-01

[strategies for weight management during chemotherapy]

The patient, undergoing treatment with Avastin and Lonsurf, has maintained a body weight of approximately 40kg since Mar 2023, experiencing a decline to 38kg in the last week.

Lonsurf is known to contribute to decreased appetite (reported in 34% to 39% of cases) and diarrhea (reported in 23% to 32% of cases, with grades 3/4 severity in 3%).

Considering these side effects, the introduction of megestrol may be beneficial in addressing the patient’s weight loss.

2023-07-05

[UTI follow-up]

  • Urine culture results from 2023-06-28 identified Escherichia coli > 100K CFU/cc. The patient has been administered Brosym (cefoperazone, sulbactam) 4g IVD Q12H since that day. Lab results of urine analysis showed a decrease in bacteria from 3+ on 2023-06-28 to 1+ on 2023-07-04. Similarly, leukocyte esterase decreased from 2+ on 2023-06-28 to 1+ on 2023-07-04, sediment WBC dropped from > 50/HPF on 2023-06-28 to < 10/HPF on 2023-07-04, and urine color improved from turbid yellow on 2023-06-28 to clear light yellow on 2023-07-04. These results indicate that the antimicrobial agent is effective and the urinary tract infection is improving.
  • Kidney and liver functions appeared normal according to lab data on 2023-07-03, so no drug dose adjustment is required.

700030390

240222

  • 2024-02-21 CXR erect
    • Increase bilateral lung markings.
    • Nodular densities in bilateral lungs, r/o lung metastasis.
    • Tortuous thoracic aorta with intimal calcification.
    • Thoracic spondylosis.
  • 2024-02-21 EGD
    • Diagnosis
      • Esophageal varices, F2CbL1, RCS (-), s/p variceal ligation x 2
      • Gastric varices, cardia
      • Superficial gastritis
      • Duodenal ulcers, bulb
    • Suggestion
      • PPI, terlipressin use
  • 2024-01-16 KUB
    • marginal spurs of multiple vertebral bodies due to spondylosis.
  • 2024-01-12 CXR
    • Multiple nodules in both lungs due to metastases.
    • Rt pleural effusion
    • A poorly defined mass over peripheral of RUL
    • Old fibrocalcified change at Rt apical lung
  • 2024-01-09 SONO - abdomen
    • Diagnosis:
      • Parenchymal liver disease
      • Hepatic tumor, probably hepatoma with bilateral and main trunk portal vein thrombosis
      • GB sludge
      • Ascites
    • Suggestion:
      • Please correlate with other image study and AFP level
  • 2024-01-06 CT - chest
    • Indication: RLL pneumonia
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Several nodular lesions are found at both lungs are found. Metastatic lesion is considered.
        • Consolidation of right upper lobe is found.
        • Bilateral pleural effusion more on right side is found.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • Fibrocalcified lesions are noted at right upper lobe and left upper lobe. Old TB is considered.
      • Visible abdomen:
        • Splenomegaly and ascites formation is found. r/o liver cirrhosis.
        • One soft tissue heterogeneous tumor at S7 of liver measuring 6.05cm in largest dimension. HCC is suspected. Suggest contrast enhanced study.
    • Imp:
      • Hepatic tumor at S7 of liver measuring 6.05cm with bilateral lung meta and bone meta. r/o HCC. Suggest contrast enhanced study.

[MedRec]

  • 2023-12-30 ~ 2024-01-19 POMR Chest Medicine Huang JunYao
    • Discharge diagnosis
      • Pneumonia right middle lobe, sputum culture :Mixed normal flora
      • Hemoptysis
      • Hepatic cell carcinoma,r/o T4NxM1,stage IVB; ECOG2
      • Malignant neoplasm of prostate
      • Chronic obstructive pulmonary disease, unspecified
      • Type 2 diabetes mellitus without complications
      • Major depressive disorder, single episode, unspecified
      • Constipation, unspecified
      • Essential (primary) hypertension
      • Mixed hyperlipidemia
      • Gastro-esophageal reflux disease with esophagitis
      • Suspect UGI bleeding (tarry stool and stool OB 4+)
    • CC
      • dyspnea and productive cough since 2023/12/28, hemoptysis in recently 2 days
    • Present illness
      • This 92 year old male had history of type 2 DM, COPD, old TB. BPH s/p laser TURP with cystostomy (Heish) on 2016/12/06, s/p RT, cT1-2N0M0, stage IIB. He was regular in our CM, Meta and Uro OPD for medication treatment.
      • According to his family statement, he went to our ER due to chest pain when coughing, dyspnea, chillness and dysuria for 2 days ago. This time, he suffered from hemoptysis was noted since yesterday, blood clot was also noted. Therefore he was brought to our ER for help. In ER, vital signs: Temp: 37.3’C, pulse: 96/min, respiration: 18/min and blood pressure: 114/54 mmHg, Spo2:97%. Laboratory data showed no leukocytosis with left shifted (WBC 8450, N.seg 86.8), mild elevated CRP. CXR film showed Increased infiltration over both lower lungs. May be active infection. COVID rapid screening and influenza A+B agents showed negative result. Under the impression of pneumonia and hemoptysis, he was admitted to CM ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission, empiric antibiotic with Brosym IV and Colimycin inhalation were used for pneumonia control. Antitussive, mucolytic agents and other palliative treatment were given for symptomatic relief. Transamin IV used for hemoptysis.
      • Do sputum culture, sputum TB culture and blood culture evalution to identify pathogen.
      • In addition, dysuria occured on admission, highly suspect BPH related adn added Urief 1# QD.
      • Consult GU Dr and non-invasive evaluation such as uroflowmetry and residual urine is recommended.
      • After treatment, no more fever or hemoptysis noted, we tappered IV from Transamin to oral form use.
      • The hemogram, renal function and electrolyte were followed up and showed improvement, and CXR showed r/o right side pleural effusion.
      • Arranged chest echo on 2024/01/05, it revealed 1. Right trivial subpulmonary pleural effusion. 2. Right lower lung consolidation.
      • Follow up chest CT, which chowed Hepatic tumor at S7 of liver measuring 6.05cm with bilateral lung meta and bone meta. r/o HCC. Suggest contrast enhanced study.
      • Arranged abdominal echo for evaluation, Parenchymal liver disease, Hepatic tumor, probably hepatoma with bilateral and main trunk portal vein thrombosis, GB sludge, Ascites was shown and check AFP dislcosed >303000 ng/mL.
      • Due to highly suspect HCC, we consulted G-I doctor, who was impression of suspect HCC, T4NxM1, stage IVB, BCLC C-D: 1. Check HBsAg, anti-Hbs Ab, anti-Hbc Ab, Anti HCV Ab, CEA, CA199; 2. arrange image studies: liver, spleen MRI with/without contrast or triphase liver CT were suggested. Apply HCC Major Illness already.
      • Bedsides, passage tarry stool occured on admission, check stool OB revealed postive 4+. PPI with Pantolac IV was applied for highly suspect UGI bleeding.
      • B-fluid IVF supplement prescribed for poor oral intake.
      • After treatment, no more passage tarry stool, we tappered IV form PPI to oral form Nexium use.
      • Due to his familes further hospice care to HCC termitinal stage, we consulted FMH Dr and combined care at first.
      • Prescried Silymarin for abnormal liver function.
      • The CXR, hemogram, ranal function and electrolyte were followed up and showed improvement.
      • Under stable condition, he was discharged on 2024-01-19. Further Chest OPD followed up was arranged.
    • Discharge prescription
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Urief (silodosin 8mg) 1# QD
      • BaoGan (silymarin 150mg) 1# TID
  • 2023-11-20 SOAP Chest Medicine Huang JunYao
    • Diagnosis
      • Malignant neoplasm of prostate [C61]
      • Chronic airway obstruction(COPD), NEC [J44.9]
      • Mucopurulent chronic bronchitis [J41.1]
      • Reflux esophagitis [K21.0]
      • Arthralgia of temporomandibular joint [M26.62]
      • Dyslipidemia; other and unspecified hyperlipidemia [E78.5]
      • Constipation [K59.00]
      • OA, localized, not specified whether primary or secondary, unspecified site [M19.90]
      • Hypertrophy (benign) of prostate [N40.1]
      • Spondylosis of unspecified site, with mention of myelopathy [M47.10]
      • Atherosclerosis of arteries of the extremities with intermittent claudication [I70.92]
      • Depression [F32.9]
      • Lumbosacral spondylosis without myelopathy [M47.27]
      • Cervical spondylosis without myelopathy [M47.22]
    • Prescription x3
      • Actein Effervescent (acetylcysteine 600mg) 1# BID
      • Xyzal (levocetirizine 5mg) 1# HS
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# BID
      • Spiolto (tiotropium 2.5ug, olodaterol 2.5ug; per puff) 1 puff BID INHL
      • Stilnox (zolpidem 10mg) 1# HS

[consultation]

  • 2024-01-11 Gastroenterology
    • Q
      • Due to HCC termitinal stage and apply HCC Major Illness, we sincerly your special evaluation and help. TKS !!
    • A
      • This 92-year-old male was a case of type 2 DM, COPD, old TB. BPH s/p laser TURP with cystostomy (Heish) on 2016/12/6, s/p RT, cT1-2N0M0, stage IIB. He was regular in our CM, Meta and Uro OPD for medication treatment. This time, he was admitted for hemoptysis. And, abdomen CT revealed suspect HCC with distal meta. We are consulted for further evaluation.
      • O
        • At bedside, stable vital signs
        • Lab
          • 2024-01-09 AFP >303000 ng/mL
          • 2024-01-08 WBC 11.11 x10^3/uL
          • 2024-01-08 HGB 9.9 g/dL
          • 2024-01-08 PLT 268 *10^3/uL
          • 2024-01-05 ALT 40 U/L
          • 2024-01-05 AST 61 U/L
          • 2024-01-05 Creatinine 0.59 mg/dL
          • 2024-01-05 CRP 7.7 mg/dL
          • 2023-12-30 APTT 33.3 sec
          • 2023-12-30 PT 11.7 sec
          • 2023-12-30 INR 1.14
        • CT: Hepatic tumor at S7 of liver measuring 6.05cm with bilateral lung meta and bone meta. r/o HCC.
        • Abdomen echo:
          • Parenchymal liver disease
          • Hepatic tumor, probably hepatoma with bilateral and main trunk portal vein thrombosis
          • GB sludge
          • Ascites
      • A:
        • Suspect HCC, T4NxM1, stage IVB, BCLC C-D
      • P:
        • Check HBsAg, anti-Hbs Ab, anti-Hbc Ab, Anti HCV Ab, CEA, CA199
        • Arrange image studies: liver, spleen MRI with/without contrast or triphase liver CT
        • Please contact us for the survey above complete
  • 2024-01-10 Family Medicine
    • Q
      • Follow up chest CT for evaluation, it revealed hepatic tumor at S7 of liver measuring 6.05cm with bilateral lung meta and bone meta. r/o HCC. Suggest contrast enhanced study. Arranged abdominal echo for evaluation and parenchymal liver disease, Hepatic tumor, probably hepatoma with bilateral and main trunk portal vein thrombosis, GB sludge and Ascites. We checked AFP and result revealed > 303000.
      • We well explined the present condition of HCC, his families asked further hospice care, so we sincerly your special evaluation and help. TKS !!
    • A
      • This is a 92 y/o male has history of COPD, old TB, prostate cancer s/p. He was admitted with a diagnosis of pneumonia and hemoptysis.
      • During this admission, he was incidentally diagnosed with liver cancer with bilateral lung and bone metastases.
        • Cons E4V5M6, ECOG4, DNR(-)
        • Patient dose not know his current status.
      • Hospice team has provided an explanation of hospice care and will coordinate combined care for him.
      • Indication: liver cancer with lung and bone metastasis
      • Plan: Hospice Combined Care

==========

2024-02-22

[variceal bleeding, hepatic encephalopathy & hypokalemia: multifaceted management approach]

Variceal bleeding has resulted in low hemoglobin (7.6 g/dL on 2024-02-22). Symptomatic anemia might necessitate LPRBC transfusion.

Currently, the patient is receiving IV Glypressin (terlipressin acetate), Hemoclot (tranexamic acid), and Panzolec (pantoprazole).

Serum ammonia level reached 92 µmol/L on 2024-02-21, indicating hepatic encephalopathy. Lactul (lactulose) is being administered to reduce ammonia levels.

Serum potassium measured 3.5 mmol/L on 2024-02-22, placing it at the lower end of the reference range. Studies have demonstrated that hypokalemia can increase renal tubular ammonia production, leading to elevated levels in both the tubular lumen and peritubular capillaries. This effect is partially attributed to intracellular acidosis within renal tubular cells, which stimulates ammonia production from glutamine. While appropriate in the context of metabolic acidosis, this mechanism can become clinically significant in patients with advanced cirrhosis, potentially contributing to hepatic encephalopathy.

Therefore, maintaining serum potassium levels within the middle of the reference range may be beneficial in patients with hepatic encephalopathy to minimize this potential complication.

700704015

240221

[exam findings]

  • 2024-02-19 CT - chest
    • Findings
      • massive Lt pleural effusion with nodular thickening and minimal Rt pleural effusion.
      • lungs: partail relaxation atelectasis of LLL. large consolidation with air-bronchogram and extensive ground glass opacity as well as nodules at Lt lung. multiple nodules of variable sizes in Rt lung due to metastasis.
      • liver: multiple tumors of variable sizes (some of which have necrotic part) throughout in both lobes of liver.
      • marked enlarged necrotic tumors in the pancreas especially at tail part. extensive lymphadenopathy in the retroperitoneum with thickening of renal fasciae. moderate abdominal ascites and dilated biliary tree.
      • diffuse subcutaneous edema of abdominal wall and left chest wall.
    • Impression:
      • cholangiocarcinoma with hepatic, pancreas, retroperitoneal LNs, lung, and pleural metastases.
      • partial volume loss and consolidation of left lung and massive Lt pleural effusion.
  • 2023-10-25 SONO - abdomen
    • Multiple liver metastatic tumor, bilateral lobes
    • Hepatic cyst, S4
    • Status post cholecystectomy.
    • Pancreatic tumors, pancreatic body and tail
    • Boderline splenomegaly
    • Suspicious accessory spleen
    • Suspect enlarged lymphnodes, around the aorta
  • 2023-10-18 Patho - stomach biopsy
    • Stomach, remnant, biopsy — chronic gastritis with intestinal metaplasia and Helicobacter infection
    • Microscopically, it shows chronic gastritis with leukocytic and lymphoplasmacytic infiltrate and focal intestinal metaplasia. Helicobacter-like bacilli are seen.
  • 2023-10-12 CT - abdomen
    • Findings
      • S/P Whipple operation.
      • A poor enhancing tumor (2.3x4.3cm) at pancreatic body and tail with splenic vein invasion. Enlarged LNs around pancreas and along aorta.
      • A nodule (0.7cm) at RLL.
      • Some poor enhancing tumors in liver.
      • Left renal cyst (0.8cm).
      • Disc space narrowing at L2/3.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P Whipple operation.
      • A poor enhancing tumor (2.3x4.3cm) at pancreatic body and tail with splenic vein invasion. Enlarged LNs around pancreas and along aorta.
      • Some poor enhancing tumors in liver.
      • A nodule (0.7cm) at RLL.
  • 2023-10-12 CXR erect + L-spine Lat
    • Post-op with metallic materials in LUQ.
    • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation
    • Disc space narrowing at L2-3 level.
    • Gr I spondylolisthesis at L3-4 level.
    • Lumbar spondylosis.
  • 2023-10-04 SONO - abdomen
    • Hepatic tumors, compatible with hepatic metastases
    • Hepatic cyst
    • Post cholecystectomy
    • Pancreatic body-tail region tumor, in favor of retroperitoneal tumor rather than pancreatic origin
    • Para-aortic lymphadenopathy
  • 2023-09-28 Patho - lymphnode biopsy
    • Labeled as “lymph node, retroperitoneum”, CT guided needle biopsy — adenocarcinoma.
    • Section shows lymph node with adenocarcinoma.
    • IHC stains: CK7 (+), CK20 (-), CA19-9 (-), CK19 (+), hepatocyte (+).
    • An adenocarcinoma arising from pancreato-biliary system might be considered. Please correlate with clinical and imaage findings.
  • 2023-09-25 KUB
    • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, L-spine.
    • suture materials over the LUQ region of abdomen
    • increased air in nondistended loops of small bowel over LUQ, RUQ, could be ileus, adhesive?
  • 2023-09-18 CT - abdomen
    • History and indication: Ampulla vater cancer s/p whipple operation on 2011-05-07
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P Whipple operation.
      • A poor enhancing tumor (3.3x5.1cm) at pancreatic body and tail with splenic vein invasion. Enlarged LNs around pancreas and along aorta.
      • Small poor enhancing tumors in liver.
      • Normal appearance of spleen, adrenals and kidneys.
      • Disc space narrowing at L2/3.
    • Addendum Imaging Report Form for Cholangiocarcinoma
      • Impression ( Imaging stage ) : T:T2(T_value) N:N0(N_value) M:M1(M_value) STAGE:IVB(Stage_value)

[MedRec]

  • 2023-09-27 ~ 2023-10-06 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Intrahepatic bile duct carcinoma of adenocarcinoma. IHC stains: CK7 (+), CK20 (-), CA19-9 (-), CK19 (+), hepatocyte (+) with with LNs and liver metastases.
      • History fof Ampulla of Vater Adenocarcnoma, moderately differentiated; pT3N0 cM, pStage IIA S/P operation on 2011/05/07
      • Chronic viral hepatitis B without delta-agent anti-Hbc: positive
      • Unspecified abdominal pain
    • CC
      • fatigue, poor appeitte, body weight loss 7kg, abdominal distension, fullness and pain and back pain for 3-4 months.
    • Present illness
      • This 66-year-old man, had history of ampula of Vater of adenocarcnoma, moderately differentiated; pT3N0 cM, pStage IIA by pathology S/P Whipple`s operation on 2011/05/07 by Dr Lai JieWen without any treatment and follow-up at OPD for 7 years ago. In recent 3-4 month, he suffered from fatigue, poor appeitte, body weight loss 7kg and abdominal distension, fullness and pain and back pain were also noted and he visited to our GS OPD for aid and transferred to our ER on 9/27 23. At arrival to ER, the abdominal CT (9/18 23) showed S/P Whipple operation, In favor of pancreatic body/ tail tumor with LNs and liver metastases. the laboratory showed CRP:19.3mg/dl, WBC: 12890, seg:78, CEA:6.539ng/ml, CA-199:9.775U/ml.
      • Under the impression of suspected pancreatic body/tail tumor with LNs and liver metastases. He was admitted for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, antibiotic with Loforan 2000mg ivd q8h was given for fever and abdominal pain since 9/27 to 9/29 23, owing to fever without chills persistent was noted and antibiotic shifted to Tapimycin 4.5mg ivd q6h since 9/29 23 for infection control. The blood culture x 2 set & urine culture yielded no growth for 5 days aerobically & anaerobically. We will arrange abdominal sono for fever surey. Naproxen 1# po qd was added for rule out tumor fever. The abdominal CT (9/18 23) showed S/P Whipple operation. In favor of pancreatic body/ tail tumor with LNs and liver metastases. (10/3 revised report) showed A poor enhancing tumor (3.3x5.1cm) at pancreatic body and tail with splenic vein invasion. Enlarged LNs around pancreas and along aorta. Small poor enhancing tumors in liver. T:T2(T_value) N:N0(N_value) M:M1(M_value) STAGE:IVB(Stage_value) and radiologist was consulted for CT-guide biopsy evaluation.
      • CT-guide biopsy was done on 9/29 23. The pathology of Labeled as “lymph node, retroperitoneum”, CT guided needle biopsy (10/3 23) adenocarcinoma. IHC stains: CK7 (+), CK20 (-), CA19-9 (-), CK19 (+), hepatocyte (+). Port-A was inserted on 10/3 23.
      • The abdominal sono (10/4 23) revealed hepatic tumors, compatible with hepatic metastases, hepatic cyst, Post cholecystectomy, pancreatic body-tail region tumor, in favor of retroperitoneal tumor rather than pancreatic origin.
      • C1D1 chemotherapy with Gemzar (1000mg/m2) plus Cisplatin (30mg/m2) were given on 10/5 23, smoothly without obvious side effect. He was discharged on 10/6 23 under stable condition and will follow-up at OPD on 10/12 23.
    • Discharge prescription
      • Through (sennoside 12mg) 2# HS
      • Ulstop (famotidine 20mg) 1# BID
      • Acetal (acetaminophen 500mg) 1# PRNQ6H if BT > 38’C
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H if abdominal pain or back pain VAS > 3
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
  • 2023-09-22 SOAP General Surgery Lai JieWen
    • O: 2023/09/18 CT ABD: In favor of pancreatic body/tail tumor with LNs and liver metastases.
  • 2023-09-15 SOAP General Surgery Lai JieWen
    • O: loss forllow up for nearly 3 years. arrange cancer surveillence.
  • 2020-02-07 SOAP General Surgery Lai JieWen
    • O: Left liver cyst (0.50x0.98cm). Right renal stone (0.65cm). S/P cholecystectomy.
  • 2017-05-01 SOAP General Surgery Lai JieWen
    • O: Ampulla vater cancer s/p whipple operation on 2011-05-07
    • Diagnosis
      • Malignant ampulla of Vater neoplasm [C24.1]

[surgical operation]

[chemotherapy]

  • 2024-02-07 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
  • 2024-01-23 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
  • 2024-01-16 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
  • 2024-01-02 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
  • 2023-12-19 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
  • 2023-12-05 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
  • 2023-11-28 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
  • 2023-11-15 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
  • 2023-11-09 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 750mL
  • 2023-11-03 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr + NS 500mL 1hr (postcisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 500mL
  • 2023-10-19 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-10-05 - gemcitabine 1000mg/m2 1700mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL

==========

2024-02-26

[evaluating appetite stimulants in patient care]

Social service staff member Luo YuQuan visited the patient on 2024-02-22 and observed that the patient reported recent feelings of lethargy and fatigue. Additionally, the patient’s wife indicated that he has experienced a loss of appetite.

Considering these symptoms, the addition of the appetite stimulant megestrol could be beneficial for improving the patient’s condition, provided there are no contraindications to its use.

701394185

240221

[exam findings] (not completed)

  • 2024-02-07 CT - abdomen
    • Indication: Adenocarcinoma of sigmoid colon with perforation and left ovarian abscess, pT4bN1bM1c stage IVC, S/P Harman procedure + small bowel segmental resection + partial bilateral salpingo-oophorectomy on 2022/06/09
    • Findings:
      • Prior CT identified liver metastases in both hepatic lobes are noted again, increasing in size and number that is c/w liver metastases with progressive disease.
      • Prior CT identified para-aortic and mesentery lymph nodes are noted again, stationary.
      • S/P LAR with autosuture retention over the rectum.
        • s/p closure of the descending colostomy.
      • There is minimal ascites.
      • The urinary bladder shows diffuse mild wall thickening and S/P Foley’s catheter insertion.
    • Impression:
      • Multiple liver metastases show progressive disease.
  • 2024-02-06 Patho - urinary bladder biopsy
    • Urinary bladder, biopsy — intestinal metaplasia
    • Section shows fragments of mucosa with mildly dysplastic columnar epithelial cells. No definite stromal invasion is found.
    • The immunohistochemical stains reveal CK7(-), CK20(+), and CDX2(-).
    • Please correlate with the clinical presentation. If malignancy is suspected, re-biopsy is suggested.

[MedRec]

  • 2023-11-01, -08-10 SOAP Hemato-Oncology He JingLiang
    • Prescription x3
      • Baraclude (entecavir 0.5mg) 1# QDAC
  • 2023-04-26 SOAP Hemato-Oncology Wan XiangLin
    • Prescription x3
      • Allegra (fexofenadine 60mg) 1# BID
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • ZnO ointment (zinc oxide 200mg/g) BID TOPI
      • Nexium (esomeprazole 40mg) 1# QDAC
  • 2023-02-14, 2022-11-22, -09-05 SOAP Hemato-Oncology Zhang ShouYi
    • Prescription x3
      • Baraclude (entecavir 0.5mg) 1# QDAC
  • 2022-08-08 SOAP Hemato-Oncology Zhang ShouYi
    • S
      • will do HBsAg, anti-HBc, anti-HCV (8/8 22).
      • will consult Dr Wu ChaoQun for Port-A installation (8/8 22).
      • will give #1 palliative C/T wt FOLFIRI / Avastin IV Q2W x 12.
      • will apply Avastin (8/8 22).
      • Adm on 8/15 22 for #1 palliative C/T wt FOLFIRI / Avastin IV Q2W x 12.
    • A
      • Adenocarcinoma of sigmoid colon wt perforation & L ovarian abscess, pT4bN1bM1c stage IVC, s/p Op on 6/9 22
    • Prescription
      • Megejohn (megestrol acetate 160mg) 1# QD
  • 2022-06-09 ~ 2022-07-28 POMR General and Gastrointestinal Surgery Wu ChaoQun
    • Discharge diagnosis
      • Adenocarcinoma of sigmoid colon with perforation and left ovarian abscess, pT4bN1bM1c stage IVC, status post Harman procedure + small bowel segmental resection + partial bilateral salpingo-oophorectomy on 2022/06/09; remove previous artifical fascia and closed the abdominal wall and End colostomy revision on 2022/06/16. ECOG:2
      • Adenocarcinoma of sigmoid colon with perforation with septic shock
      • Intraabdomen leakage with skin fistula with intaabdomen infection (CRPA + Stenotroph. maltophilia + Candida)
      • Intraabdomen abscess status post sono-guide with pig-tail drainage on 2022/07/14
      • Hypokalemia
      • Hypophosphatemia (2022/07/18 P:1.0)
      • Hypoalbuminemia
    • CC
      • abdominal distension for half year, bloody stool for a period of time. She felt general weakness and shortness of breath today.
    • Present illness
      • The 49 years old female patient denied any systemic disease, such as hypertension or diabetes mellitus. This time, she presented to our ER for medical attention due to abdominal distension for half year, bloody stool for a period of time. She felt general weakness and shortness of breath today.
    • Course of inpatient treatment
      • At ER, her initial GCS remained E4V5M6, vital signs TPR: 37.1/140/16, BP: 88/49 mmHg. The physical examination showed cold sweating. Abdomen CT revealed extensive peritonitis with hallow viscus perforation, right ovarian teratoma. We gave IVF challenge 3000 ml for hypotension. She was admitted for received emergent Harman procedure, small bowel segmental resection and partial bilateral BSO due to Sigmoid colon tumor with perforation and left ovarian abscess, colo-ileal fistal, right ovarian tumor on 6/9~6/10. After operation, she was transferred to SICU for post-op inetensive care on 2022/06/10.
      • After operation, Levophed and Dopamin for hemodynamic support and antibiotics with vancomycin and Doripenem, SABS. The intraabdomina abscess culture yield E-coli, group F streptococci and P.a. The wound pus culture yield Bacteroides fragilis and sputum culture showed Candida, so antibiotic with Doripenem, Cravit, and Eraxis.
      • We tried NG feeding since 6/20 smoothly. However, elevation CRP and leukocytosis, fever was noted, add SABS for infection control. Due to right pleural effusion, pigtail was insertion. Smoothly extubation after well weaning profile and on BIPAPuse on 6/20. However, stool leakage from lapa wound on 6/24. Reintubation due to respiratory failure on 6/25. Infection doctor was consultion for antibiotic, he suggest shift to DC SABS and cravit, add Targocid and Finibax use. Because abdomen wound high output dischage, VAC suction was done with drainage turbid bile mix stool dischage, amount 200~250ml/day. Laboratory data improved then start try weaning ventilator and extubation on 7/06. However, shallow of breathing and anxity after extubation, under Bi-PAP support and sedation with Utapine + Xanax use. Abdomen wound shift to ostomy bag cover.
      • This week, the pulmonary condition became improved, try weaning Bi-PAP was done, Pulmonary rehabilitation with Aero-Bika and Triflow training. Unfortunately, Spinking fever (>39.5’C) persist everyday. Fever workup with B/C, S/C TB/C(Nagative) and CVP tip/C and removal Foley (PCT>22) was done. Antibiotic with Vancomycin + Erasix + Doripenem use. Try to oral intake with clear liquid diet on 7/12, Abdominal wound with ostomy bag cover, drainage bile and mix stool 50~100ml/day. We arrange Abdominal CT with/without contrast for abdominal condition evaluation on 7/14, it revealed 1. Some fluid collection in peritoneal cavity. Some LNs (up to 1.2cm) in retroperitoneum. 2. Bil. pleural effusion with adjacent lung collapse. We consulted Radiology for on abdominal pig-tail for drainage abdomen fluid on 7/14~7/17 (Fluid clear). IPPB training for lung collapse. after the fever condiotion subside. After laboratory data revealed improved and hemodynamic condition improved, she was transfer to our GS ward on 7/20.
      • In GS ward, we observed patient recovery and keep empiric antibiotic, stool softener, albumin with lasix therapy, and analgesic agent were administered and the wound management was performed. She try to introduced soft diet with step by step and was tolerate well. However, mild fever was noted and suspected of exposure to COVID-19. Isolated was done since 7/24 and we recheck PCR and fast-screening showed negative both. So we kept triflow training and chest care support for lung physiotherapy. Her generally well beings and relativley stable. Abdomen wound with turbid discharge was decreaing and wound is healing. Final wound culture showed Stenotroph and CRPA, so antibiotic shift to oral Cifipne + Cravit support since 7/27. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. Under improved general condition, she was allowed to discharge today and OPD follow up was arranged.
    • Discharge prescription
      • Cardiolol (propranolol 10mg) 1# TID
      • Ceficin (cefixime 100mg) 2# Q12H
      • Cravit (levofloxacin 500mg) 1.5# QDAC
      • MgO 250mg 1# TID
      • Ulstop (famotidine 20mg) 1# BID
      • Through (sennoside 12mg) 1# HS

[immunochemotherapy]

  • 2024-02-19 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3980mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-14 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4160mg NS 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.25mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-16 - (Avastin + FOLFIRI)
  • 2023-09-06 - (Avastin + FOLFIRI)
  • 2023-08-17 - (Avastin + FOLFIRI)
  • 2023-07-31 - (Avastin + FOLFIRI)
  • 2023-06-27 - (Avastin + FOLFIRI)
  • 2023-06-05 - (Avastin + FOLFIRI)
  • 2023-04-20 - (Avastin + FOLFIRI)
  • 2023-03-29 - (Avastin + FOLFIRI)
  • 2023-03-13 - (Avastin + FOLFIRI)
  • 2023-02-22 - (Avastin + FOLFIRI)
  • 2023-02-02 - (Avastin + FOLFIRI)
  • 2023-01-13 - (Avastin + FOLFIRI)
  • 2022-12-23 - (Avastin + FOLFIRI)
  • 2022-12-09 - (Avastin + FOLFIRI)
  • 2022-11-24 - (Avastin + FOLFIRI)
  • 2022-11-07 - (Avastin + FOLFIRI)
  • 2022-10-21 - (Avastin + FOLFIRI)
  • 2022-08-29 - (FOLFIRI)

==========

2024-02-21

[evaluating liver function in the context of metastatic disease]

A CT scan conducted on 2024-02-07 revealed multiple liver metastases indicative of progressive disease. Consequently, the treatment regimen was transitioned to FOLFOX from Avastin + FOLFIRI, the latter having been administered since the third quarter of 2022.

Abnormal LFT results may reflect the metastatic burden. Both Baraclude and GaoGan are currently being administered, with no discrepancies found in the medication regimen.

  • 2024-02-19 AST 100 U/L
  • 2024-02-19 ALT 42 U/L
  • 2024-02-19 Bilirubin total 1.16 mg/dL
  • 2024-02-19 Bilirubin direct 0.56 mg/dL
  • 2024-02-19 Alkaline phosphatase 432 U/L

701470566

240221

[exam findings]

  • 2023-11-08 Patho - bone marrow biopsy
    • Bone marrow, post iliac crest, biopsy — Marrow hypoplasia. Correlated with clinic features, the histological finding is compatible with aplastic anemia
    • The sections show hypocellular marrow (<5%). All three lineages are markedly decreased. Scattered CD138+ mature plasma cells in interstitium, account for 25% of marrow cells. No increased CD34+ and/or CD117+ blasts. Suggest further bone marrow smear evaluation and clinic correlation.

[MedRec]

  • 2023-12-05 SOAP Hemato-Oncology Gao WeiYao
    • O: 2023/11/08 PATHO - bone marrow biopsy
      • Bone marrow, post iliac crest, biopsy — Marrow hypoplasia
      • Correlated with clinic features, the histological finding is compatible with aplastic anemia
    • A
      • Severe aplastic anemia
      • Gastrointestinal hemorrhage
      • Other pancytopenia
      • Hypokalemia
      • Hypomagnesemia
    • Prescription
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
      • Sandimmun Neoral (ciclosporin 100mg) 1# BID
  • 2023-11-22 ~ 2023-12-02 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Severe aplastic anemia
      • Gastrointestinal hemorrhage
      • Other pancytopenia
      • Hypokalemia
      • Hypomagnesemia
    • CC
      • hemtochezia (red colored) since this morning amd vomited today but no bloody material
    • Present illness
      • This 70-year-old female has a medical history of anemia.
      • She experienced a traumatic SDH along the falx, tentorium, and bilateral cerebral convexity with a mass effect causing midline shift to the right, following which she underwent burr hole drainage on 2023-11-05. She was discharged on 2023/11/16. TOCC(-).
      • She presented with hematuria and bloody stools for several days, prompting her family to bring her to our ED. Upon arrival, her vital signs were recorded as follows: Temperature (T) 36’C, Pulse (P) 94 beats per minute, Respiratory Rate (R) 18 breaths per minute, Blood Pressure (BP) 123/59 mmHg, and SPO2 (oxygen saturation) at 97%. Her Glasgow Coma Scale (GCS) score was clear.
      • Laboratory tests revealed a low platelet count (PLT: 10,000), decreased WBC 1000/uL, anemia (Hb: 3.7g/dL) and PL 1000/uL. Following a blood transfusion, her platelet count increased to 44,000, and her hemoglobin levels rose from 6.9 to 7.4g/dL.
      • After treatment with GCSF, her WBC count increased from 1.41 to 1.64. Lactic acid was measured at 2.4, stool occult blood was 4+, and BUN was 27. She reported an approximate body weight loss of 2kg this month. Chest x-ray revealed patch density at the right upper lobe (RUL). A computed tomography guided biopsy was performed on a mass lesion in the right upper lobe on 2023-11-15, yielding negative findings. Urine analysis showed no abnormalities. She denied any recent travel or specific contact/cluster history.
      • Under the impression of pancytopenia and severe aplastic anemia, so she wsa admitted.
    • Course of inpatient treatment
      • After admission, we administered empirical antibiotics such as cefotaxime to prevent infection.
      • The patient was kept NPO (nothing by mouth) due to GI bleeding and hematuria, and received IV fluid supply.
      • We administered another blood transfusion to address her pancytopenia and low thrombocyte count.
      • There was mild swelling in her eyes following the blood transfusion, but she declined an injection of antihistamine.
      • We consulted with oncology for pancytopenia, so she transfer to 11A care on 2023/11/23.
      • On critical care for severe aplastic anemia and we told family condition. Apply Major Illness and blood transfusion during hospitalization.
      • Under the stable condition, she can be discharged on 2023/12/02. OPD follow up is arranged.
    • Discharge prescription
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
      • Sandimmun Neoral (ciclosporin 100mg) 1# BID
  • 2023-11-05 ~ 2023-11-16 POMR Neurosurgery Xu XianDa
    • Discharge diagnosis
      • Traumatic subdural hemorrhage along falx, tentorium and bilateral cerebral convexity with mass effect causing midline shift to right status post burr hole drainage on 2023-11-05.
      • Pancytopenia
      • Right upper lobe mass lesion post computed tomography guided biopsy on 2023-11-15.
      • Fever
      • Idiopathic aplastic anemia
      • Thrombocytopenia
      • Neutropenia
    • CC
      • Suffered from right side weakness suspect due to fall down.
    • Present illness
      • This is a 70-year-old female with a medical history of anemia. Her current presentation includes right-sided weakness, which is suspected to be a result of a fall, along with signs of potential oral bleeding. She was brought to our Emergency Room (ER) by her family.
      • Upon arrival at the ER, her vital signs were recorded as follows: Temperature (T) 40’C, Pulse (P) 107 beats per minute, Respiratory Rate (R) 18 breaths per minute, Blood Pressure (BP) 176/84 mmHg, and SPO2 (oxygen saturation) at 98%. Her Glasgow Coma Scale (GCS) score was E4V2M5, indicating immobility in her right hand and a recent decline in her level of consciousness.
      • According to her family, she had experienced a recent deterioration in her level of consciousness and reduced function in her right hand. A brain CT scan revealed the presence of a chronic subdural hematoma on the left side with midline displacement.
      • Her serum laboratory data indicated low platelet count (PLT: 19 x10^3/uL), decreased white blood cell count (WBC: 0.70 x10^3/uL), and low hemoglobin levels (HGB: 7.6 g/dL). Neurosurgery (NS) was consulted and recommended immediate admission to the Surgical Intensive Care Unit (SICU) for intensive care.
    • Course of inpatient treatment
      • A woman who required infection control measures, including the use of Tapimycin, received treatment for pancytopenia through G-CSF administration and blood transfusions with FFP, Cryo, and LPR. On 2023-11-05, she underwent Burr hole drainage to remove a chronic subdural hematoma. Successful ventilator weaning and extubation took place on 2023-11-06. Hematology consultation was sought to evaluate her pancytopenia. Her latest assessment revealed a Glasgow Coma Scale (GCS) score of E4V5M6, and she remained stable from a hemodynamic perspective. Consequently, she was transferred to a ward for ongoing care on 2023-11-08, maintaining clear consciousness throughout her stay.
      • The surgical wound on her left scalp was observed to be clean and dry. To prevent seizures, she was prescribed the anticonvulsant medication Keppra. Rheumatology consultation was also sought, and they suggested potential causes for the pancytopenia, including infection, drug reactions, bone marrow diseases (often cancer), and SLE. Pending the bone marrow pathology report, a bone marrow aspiration and biopsy were performed, revealing marrow hypoplasia.
      • In addition to this, she received 2 units of packed red blood cells (PRBC) and 2 units of platelet (PH) transfusions to address anemia and thrombocytopenia. A chest CT scan was conducted to investigate a suspected lung cancer in the right upper lung mass, and a lung biopsy was performed after consultation with a chest specialist. Rehabilitation programs were initiated to address leg weakness. Once her neurological and overall condition stabilized, she was discharged home, with outpatient follow-up appointments scheduled. Suture removal would be performed during one of these outpatient visits.
    • Discharge prescription
      • Allegra (fexofenadine 60mg) 1# BID
      • Norvasc (amlodipine 5mg) 1# QD
      • Through (sennoside 12mg) 2# HS
      • Acetal (acetaminophen 500mg) 1# QID
      • Keppra (levetiracetam 500mg) 1# BID
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
      • Sindine (povidone iodine aq soln) ASORDER EXT
      • Ceficin (cefixime 100mg) 2# Q12H
  • 2023-02-08 SOAP Hemato-Oncology Wan XiangLin
    • S: She was referred on account of anemia told at LMD
    • Assessment:
      • Pancytopenia, suggest bone marrow study
      • refuse transfusion.
    • Plan:
      • Check BCS
      • Check CBC&DC, PT, aPTT, bleeding time and stool OB
      • Check CXR

700024921

240220

[exam findings]

  • 2023-10-31 Cardiac Catheterization
    • SvO2 was also check, it revealed only 45%.
    • Estimated Fick Cardiac index 1.86 L/min/m2 (normal cardiac index range 2.6~4.2 L/min/m2)
    • Estimated Fick cardiac output 2.44 L/min. (nomral cardiac output range 5~6 L/min)
  • 2023-10-12 CXR
    • Tortous aorta with calcification is noted.
    • Pleural effusion over right side is found.
  • 2023-10-10 CXR
    • s/p aortic root valvular replacement
  • 2023-10-06 CT - chest
    • 2023-07-31 CTA showed recurrent tumor as metastatic mediastinal LAP and metastatic tumor in RLL and Rt exudative pleural effusion with metastatic tumor. post op fluid collection over anterior mediastinum r/o abscess. For infection survey
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • s/p anterior chest wall repair with post op. change is found.
        • Lymphadenopathy at paracaval region of the mediastinum measuring 4.36cm is found.
        • Nodular lesions at left lower lobe measuring 0.54cm, right lower lobe measuring 2.17cm, 1.07cm are found. Lung meta is considered.
        • Right moderate pleural effusion is found. Fusiform pleural thickening is found. r/o pleura meta.
      • Visible abdomen:
        • Hepatic tumor at S8 of liver 3.8cm in largest dimension is found. Liver meta is considered.
        • Enlarged prostate up to 4.13cm in largest dimension is found.
        • Cystic change at pancreatic tail measuring 2.67cm in largest dimension.
    • Imp: metastatic mediatsinal lymph nodes and lung meta, liver meta.
  • 2023-10-06 SONO - chest
    • Echo diagnosis: right pleural thickening with trivial amount of organized pleural effusion
  • 2023-10-04 CXR
    • blunting bilateral costophrenic angles
  • 2023-10-04 ECG
    • Sinus tachycardia with occasional Premature ventricular complexes
    • Right bundle branch block
  • 2023-07-31 CTA - chest
    • Indication: 2023-04-03 sternal SCC s/p wedge resection + AsAO replacement. of post-op F/U
    • Comparison was made with CT on 2023/04/20
      • Lungs: septal thickening at anterior RUL and RML. a small rim-enhanced nodule over RLL-S7.
      • Mediastinum and hila:
        • a heterogeneous enhancing mass (28mm) at Rt paracaval region of mediastinum invading adjacent SVC.
        • moderate fluid accumulation in anterior mediastinal compartment.
        • mild pericardial thickening.
      • Vessels:
        • Thoracic aorta: s/p ascending aortic replacement. normal caliber of mild atherosclerotic change of aortic arch and descending thoracic aorta. patency of arch branches and replacement branch to the graft.
        • Central pulmonary arteries: normal caliber and well opacification.
        • Heart: normal size of cardiac chambers. s/p MVR. no filling defects.
      • Pleura:small Rt-sided effusion witha rim-enhanced central low density mass (32mm). associated pleural thickening.
      • Visible abdominal-pelvic contents:
        • several bilateral renal cysts measuring up to 1.6 cm.
        • multiple hepatic cysts measuring up to 1.9cm
        • unremarkable of the GB, spleen, both adrenal glands, pancreas, and no enlarged lymph node. no ascites.
    • Impression:
      • recurrent tumor as metastatic mediastinal LAP and metastatic tumor in RLL and Rt exudative pleural effusion with metastatic tumor.
      • post op fluid collection over anterior mediastinum r/o abscess.
  • 2023-07-28 CXR
    • s/p sternotomy with metalic wire fixation of the sternum.
    • Pleural effusion over right side is found.
  • 2023-07-12 ECG
    • Sinus tachycardia
    • Right bundle branch block
    • Abnormal ECG
  • 2023-07-12 EGD
    • Diagnosis:
      • No bleeder or blood clot during exam
      • Reflux esophagitis LA Classification grade A (minimal)
      • Gastric ulcer, Forrest classification type III, prepyloric antrum
      • Superficial gastritis, antrum
    • Suggestion:
      • No bleeder or blood clot during exam
      • PPI use
  • 2023-07-11 CXR
    • Surgical wires over the sternum.
    • S/P cardiac valve replacement.
    • Blunted bilateral costophrenic angles.
  • 2023-04-20 CT - chest
    • Indication: SOB for days and palpitation
    • Chest CT with and without IV contrast ehnancement shows:
      • Bilateral massive pleural effusion is found.
      • Consolidation over both lungs is found.
      • Minimal air pockets at anterior and superior mediastinum is also noted. r/o residual abscess.
      • s/p chest wall graft at anterior chest is found.
    • Imp:
      • Massive bilateral pleural effusion with consoidation oat both lungs.
      • Minimal air pockets at anterior and superior mediastinum is also noted. r/o residual abscess.
      • Revision on 2023-04-24, minimal fluid collection at left inguia region measuring 4.05cm in largest dimension. Suggest further evaluation.
  • 2023-04-20 CXR
    • Artifacts over the chest.
    • Bilateral pleural effusion, more severe at right side.
    • Cardiomegaly.
  • 2023-04-20 ECG
    • Sinus tachycardia
    • Right bundle branch block
    • Inferior infarct, age undetermined
  • 2023-04-10 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • s/p chest tube placement at left and right hemithorax.
    • Pleural effusion over left side is found.
  • 2023-04-06 Patho - aneurysm
    • DIAGNOSIS:
      • Bone and soft tissue, mediastinum, bilateral clavicle head, upper sternum, bilateral 1st and 2nd ribs, wide excision — Squamous cell carcinoma, moderately differentiated, in favor of thymic origin, if no other primary tumor is found; AJCC 8th edition: pStage IIIB, pT4Nx(if cM0)
      • Lung, RUL, wedge resection — Squamous cell carcinoma, by direct invasion
      • Ascending aorta, excision — Squamous cell carcinoma, by direct invasion
      • Superior vena cava, excision — Squamous cell carcinoma, by direct invasion
      • F2023-00148, Soft tissue, peristernum, biopsy — Negative for malignancy
    • GROSS DESCRIPTION:
      • Specimen submitted in formalin consists of a piece of wide excision of sternal tumor measuring 15.0 x 9.0 x 7.5 cm.
      • The specimen is including, mediastinum, bilateral clavicle head, upper sternum, bilateral 1st and 2nd ribs, overlying skin, measuring 15 x 4 cm, wedge resection of RUL of lung, measuring 10.0 x 3.5 x 2.0 cm, a segment of ascending aorta, measuring 8.7 cm in length, a portion of superior vena cava, measuring 3.2 x 1.4 cm.
      • On cutting, a white, invasive and necrotic tumor measuring 9.0 x 5.5 x 5.0 cm is seen. The tumor has invaded to the sternum, ribs, mediastinum, subcutaneous soft tissue, RUL of lung, ascending aorta, and superior vena cava. The tumor is 0.1 cm, 0.8 cm, 0.15 cm, and 0.1 cm away from the superior, inferior, right, and left resection margins, respectively.
      • The resection margin of RUL of lung is 0.6 cm.
      • Representative sections are taken and labeled as: A1: resection margin of RUL of lung; A2-4: tumor with superior margin (A3: with large vein; the same level); A5-7: tumor with ascending aorta (the same level); A8-9: tumor with ascending aorta; A10-11: tumor with lung; A12: ink right resection margin; A13-14: tumor with inferior resection margins (the same level); A15: tumor with thymus; A16: tumor with left resection margin; A17-A20: tumor with sternum and ribs; X1: tumor with superior vena cava.
      • F2023-00148 - The specimen submitted in fresh consists of 2 pieces of tan, irregular tissue measuring up to 3.5 x 2.6 x 0.5 cm. All for section in 2 cassettes FsA1-2, for frozen examination.
    • MICROSCOPIC DESCRIPTION:
      • Sections show moderately differentiated keratinized squamous cell carcinoma with invasion through the sternal bone to subcutaneous soft tissue, ribs, mediastinal soft tissue, RUL of lung tissue, ascending aorta, and superior vena cava. The resection margins are free of malignancy. Lymphovascular invasion is seen. Peri-neural invasion is not found. If no other primary tumor is found, the morphology is consistent with thymic squamous cell carcinoma. Please correlate with the clinical presentation.
      • F2023-00148 - Sections show fibroadipose tissue and a lymph node without malignancy.
  • 2023-04-03 2D transthoracic echocardiography
    • Conclusion:
      • Adequete LV systolic function, EF 43.3%
      • Moderate AR (Vena contracta width = 5.8 mm), Trivial TR
      • s/p bioprothetic MVR, mild MR, and remaining chordae
      • Minimal pericardial effusion
  • 2023-03-27 Tc-99m MDP bone scan
    • Several hot/faint hot spots in the sternum, highly suspected malignancy with sternum metastasis.
    • Suspected benign lesions in both rib cages, some C-, T- and L-spine, bilateral shoulders, S-I joints, and hips.
  • 2023-03-24 EGD
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
    • Gastric erosions, body, antrum, and cardia
  • 2023-03-22 CT - chest
    • Chest CT with and without IV contrast ehnancement shows:
      • s/p sternotomy with metalic wire fixation of the sternum.
      • Abnormal air pockets at superior and anterior mediastinum is found. Abscess formation cannot be excluded.
    • IMp:
      • Abnormal air pockets at superior and anterior mediastinum is found. Abscess formation cannot be excluded
  • 2023-03-13 Patho - mediastinum mass
    • Mediastinum, superior mass, resection — moderately differentiated squamous cell carcinoma with necrosis
    • Microscopically, sections show moderately differentiated squamous cell carcinoma consisting of nests of squamous tumor cells in infiltrative growth pattern with keratin pearls.The tumor cells have abundant eosinophilic cytoplasm, prominent nucleoli, pleomorphism, nuclear hyperchromasia, and mitiotic activity. The stroma shows focal necrosis and fibrosis.
    • Immunohistochemical stain reveals p63(+), CD117(-), CK(+), S100(-), and Myosin(-).
  • 2023-03-11 CT - chest
    • Indication: sternal wound infection
    • Chest CT with and without IV contrast ehnancement shows:
      • Necrotic mass like lesion at anterior mediastinum encircling ascending aorta is found about 8.4cm is found. Smaller lesion at subcutaneous tissue just anterior to the manubrium is found measuring 2.09cm is found. abscess is favored. Suggest surgical drainage.
      • Cystic change at pancreatic tail measuring 2.52cm is found.
    • Imp:
      • Necrotic mass like lesion at anterior mediastinum encircling ascending aorta is found about 8.4cm is found. Smaller lesion at subcutaneous tissue just anterior to the manubrium is found measuring 2.09cm is found. abscess is favored. Suggest surgical drainage.
  • 2023-03-10 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 26) / 80 = 67.50%
      • M-mode (Teichholz) = 67
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • s/p bioprothetic MVR with adequate function, mild MR, and remaining chordae
      • Grade 1 LV diastolic dysfunction
      • Moderate AR, mild TR
  • 2023-03-09
    • Sinus rhythm with 1st degree A-V block
    • Right bundle branch block
    • Abnormal ECG
  • 2022-06-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (111 - 31.9) / 111 = 71.26%
      • M-mode (Teichholz) = 69.3 - 71.3
      • 2D (M-Simpson) = 56.2
    • Conclusion:
      • Thickened AV with mild AR
      • s/p MV replacement, with bio-prosthesis MV, mild trans-valvular MR, no MS (with remaining cordae)
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, normal IVC size
  • 2021-08-23 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (81.39 - 30.88) / 81.39 = 62.06%
      • LVEF (%) = 50
      • M-mode (Teichholz) = 62.06
    • Conclusion:
      • Thickened AV with mild AR
      • S/p MVR, with bio-prosthesis, with mild trans-valvular MR, no MS, possible remaining chordae connecting to prosthesis strut at anteroseptal side
      • Concentric LVH
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, normal IVC size

[MedRec]

  • 2023-12-16 ~ 2023-12-28 POMR Hemato-Oncology Yang MuJun
    • Discharge diagnosis
      • Thymic moderately differentiated squamous cell carcinoma with lung, liver metastatic, highly suspected malignancy with sternum metastasis, AJCC 8th edition: pStage IIIB, pT4Nx(if cM0), paliactive chemotherapy with cisplatin(30mg/m2) plus docetaxel(25mg/m2) weekly form 2023/12/20~
      • Reflux esophagitis LA Classification grade A (minimal)
      • Chronic viral hepatitis B without delta-agent
      • Anemia in neoplastic disease
      • Acute embolism and thrombosis of deep veins of right upper extremity suspected and D-dimer > 10000
      • Wheezing possibly asthma
    • CC
      • face swelling on 2023/12/11
    • Present illness
      • This 78-year-old male had history of:
        • Anterior mediastinal squamous cell carcinoma status post surgical debridement of sternal sternum sequestrum and abscess drainage on 2023/03/13, s/p radiotherapy (4500cGy/25+15 fractions) on 2023/08/22 ~ 2023/09/08.
        • Infective endocarditits post Mitral valve replacement with 33mm Medtronic Hancock II tissue valve on 2020/08/10.
        • Hypertension.
        • S/P
          • wide excision of sternal SCC + AsAo replacement;
          • Pericardiectomy;
          • wedge resection of RUL;
          • reduction of bilateral clavicles and 1st~4th ribs, and fix the throracic bony cage with titanium mesh and screws;
          • bilateral pectoris major myocutaneous advancement flaps coverage of anterior thorax on 2023/4/3.
      • Patient received radiotherapy (4500cGy/25+15 fractions) on 2023/08/22 ~ 2023/09/08.
      • He sufferred from mild chest wall pain noted for 1 month. Sternal notch area fluid collecting and pain radiation to right shoulder area noted for 3 days.
      • Followed-up Chest CT (2023/03/11) revealed Necrotic mass like lesion at anterior mediastinum encircling ascending aorta about 8.4cm is found. Smaller lesion at subcutaneous tissue just anterior to the manubrium measuring 2.09cm is found, abscess is likely.
      • The surgical of resection of anterior mediastinum tumor on 2023/03/13, the biopsyshowed moderately differentiated squamous cell carcinoma with necrosis, Immunohistochemical stain reveals p63(+), CD117(-), CK(+), S100(-),and Myosin(-) on 2023/03/13.
      • Then, he suffered from Anterior mediastinum squamous cell carcinoma was reported, pus discharge noted from sternum wound was noted for 1 day, so he was admitted on 2023/03/23.
      • Followed-up chest CT (2023/03/22) revealed abnormal air pockets at superior and anterior mediastinum is found. Abscess formation cannot be excluded.
      • Panendoscopy (2023/03/24) disclosed Reflux esophagitis LA Classification grade A-,Superficial gastritis,and Gastric erosions, body, antrum, and cardia.
      • The Tc-99m MDP bone scan (2023/03/27) disclosed several hot/faint hot spots in the sternum, highly suspected malignancy with sternum metastasis.
      • Cancer combine meeting (Hematology Oncology, Plasty, CVS) was done on 2023/03/28, consulted ENT was consulted for evaluation of head and neck tumor who suggested no finding suggestive of tumor in nasal cavity, oral cavity, pharynx, and larynx. Plasty was consulted for flap after tumor excision.
      • After fully explain to patient about surgical indication he and his family agree to received.
      • He underwent
        • wide excision of sternal SCC + AsAo replacement;
        • Pericardiectomy;
        • wedge resection of RUL;
        • reduction of bilateral clavicles and 1st~4th ribs, and fix the throracic bony cage with titanium mesh and screws;
        • bilateral pectoris major myocutaneous advancement flaps coverage of anterior thorax on 2023/04/03.
      • The biopsy showed:
        • Bone and soft tissue, mediastinum, bilateral clavicle head, upper sternum, bilateral 1st and 2nd ribs, wide excision — Squamous cell carcinoma, moderately differentiated, in favor of thymic origin, if no other primary tumor is found; AJCC 8th edition: pStage IIIB, pT4Nx(if cM0)
        • Lung, RUL, wedge resection — Squamous cell carcinoma, by direct invasion
        • Ascending aorta, excision — Squamous cell carcinoma, by direct invasion
        • Superior vena cava, excision — Squamous cell carcinoma, by direct invasion
        • F2023-00148 - Soft tissue, peristernum, biopsy — Negative for malignancy.
      • Followed-up transthoracic echocardiography (2023/04/03) showed LVEF(%) = 43.3%. Adequete LV systolic function, EF 43.3%. Moderate AR (Vena contracta width = 5.8 mm), Trivial TR. s/p bioprothetic MVR, mild MR, and remaining chordae. Minimal pericardial effusion.
      • Chest CT (2023/04/20): Massive bilateral pleural effusion with consoidation oat both lungs. Minimal air pockets at anterior and superior mediastinum is also noted. r/o residual abscess. Revision on 2023-04-24, minimal fluid collection at left inguia region measuring 4.05cm in largest dimension. Suggest further evaluation. Pleural effus cytology: negative.
      • Anti-HBc: POSITIVE on 2023/05/06, s/p Vemlidy 1tab QD since 2023/10/31~.
      • Panendoscopy (2023/07/12): No bleeder or blood clot during exam. Reflux esophagitis LA Classification grade A(minimal). Gastric ulcer, Forrest classification type III, prepyloric antrum. Superficial gastritis, antrum.
      • Chest CTA (2023/07/31) showed: several bilateral renal cysts measuring up to 1.6 cm, multiple hepatic cysts measuring up to 1.9cm, unremarkable of the GB, spleen, both adrenal glands, pancreas, and no enlarged lymph node. no ascites. Impression: recurrent tumor as metastatic mediastinal LAP and metastatic tumor in RLL and Rt exudative pleural effusion with metastatic tumor, post op fluid collection over anterior mediastinum r/o abscess, s/p Right chest tube with drainge bloody pleural effusion 200ml. Chest echo (2023/10/06) revealed right pleural thickening with trivial amount of organized pleural effusion. Consulted 放射腫瘤科 for radiotherapy with 4500cGy/25+15 fractions on 8/22 ~ 9/8/2023.
      • Chest CT (2023/10/06) revealed metastatic mediatsinal lymph nodes and lung meta, liver meta.
      • This time, he complaomed of face swelling on 2023/12/11 then blood transfusion with LPRBC 2U was given on 2023/12/12. Fever without chills was noted post blood transfusion and took Acetal 1# po st then without more fever. Right hand swelling, reddish and right arm circumferencev from 23cm increase to 25cm were found on 2023/12/15 and he came to our ER.
      • At ER, the chest CTA showed S/P PICC. Thrombosis of right subclavian vein and left proximal subclavian vein. A thrombus in SVC. LNs, liver and lung metastases. A poor enhancing lesion (2.4cm) at pancreatic tail.
      • The laboratory revealed D-dimer >10000 ng/mL, CRP = 6.8 mg/dL, HGB = 7.3 g/dL. He was admitted for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, Laboratory shows D-dimer > 10000 and chest CTA showed S/P PICC. Thrombosis of right subclavian vein and left proximal subclavian vein. A thrombus in SVC. LNs. Anticoagulant with Clexance 45mg sc q12h x 7 days (12/16-12/22).
      • The empirical antibiotic with Augmentin 1200mg ivd q8h for right hand erythema & swelling R/O cellulitis due to right hand PICC line.
      • For anemia, HGB 7.3 g/dL and blood transfusion with LPRBC 2U on 2023/12/16. We explained his condition to his family and disscuss treatment on 2023/12/19.
      • Due to cancer in progression, thus shift to paliactive chemotherapy with Cisplatin(30mg/m2) plus docetaxel(25mg/m2) weekly (2 weeks of treatment and 1 week of rest) form 2023/12/20(C1D1), 2023/12/27(C1D8).
      • Steroid with compeslon 5mg/tab 1# bid was give for 2days(12/20~12/21). The Clexance SC shift to lixiana 30mg qd po since 12/23.
      • For DOE intermittent and PFT shows FVC 56%, add MDI with foster 2puff bid.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/12/28 and OPD followed up later.
    • Discharge prescription
      • Antica (orciprenaline, bromhexine, doxylamine) 10mL Q12H
      • Eurodin (estazolam 2mg) 1# PRNHS if insomnia
      • Fudecough (dextromethorphan 15mg) 1# TID
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD
      • Lixiana (edoxaben 30mg) 1# QD
      • MgO 250mg 2# TID
      • Megest (megestrol 40mg/mL) 10mL QD
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
      • Through (sennoside 12mg) 1# HS
      • Ulstop (famotidine 20mg) 1# QD
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
  • 2023-10-05 ~ 2023-10-17 POMR Infectious Disease Hong BoBin
    • Discharge diagnosis
      • Malignant neoplasm of overlapping sites of heart, mediastinum and pleura
      • Pyothorax without fistula
      • Nonrheumatic mitral (valve) insufficiency
    • CC
      • Fever up to 40 degree for one week.
    • Present illness
      • This 78-year-old male had history of:
        • Anterior mediastinal squamous cell carcinoma status post surgical debridement of sternal sternum sequestrum and abscess drainage on 2023/03/13.
        • Infective endocarditits post Mitral valve replacement with 33mm Medtronic Hancock II tissue valve on 2020/08/10.
        • Hypertension.
        • S/P 1.wide excision of sternal SCC + AsAo replacement; 2.Pericardiectomy; 3.wedge resection of RUL; 4. reduction of bilateral clavicles and 1st~4th ribs, and fix the throracic bony cage with titanium mesh and screws; 5.bilateral pectoris major myocutaneous advancement flaps coverage of anterior thorax on 2023/04/03.
        • Patient received radiotherapy since 8/22 ~ 9/8/2023.
        • This time, he suffered from Fever up to 40 degree for one week and productive cough in recent days. He was brought to our emergency department for help.
        • At ED, conscious clear, vital signs showed fever, tachcyadria (BP:117/55; HR:105; BT:38.6’C; RR:18). Laboratory examination revealed leukocytosis (WBC:13660/uL), anemia (Hb:8.6 g/dl), elevated CRP (CRP:16.5 mg/dl).
        • Chest x-ray showed no acute pulmonary lesion.
        • Under the impression of fever cause unknown, he is admitted to the Infection ward for evaluation and management on 2023-10-05.
    • Course of inpatient treatment
      • During the hospital stay, we use parenteral cefuroxime for empirical treatment of lung abscess. The sputum is submitted for sputum culture, TB culture, atypical pneumonia. Chest CT was arrange for lung abscess survey. Chest CT revealed metastatic mediatsinal lymph nodes and lung meta, liver meta. Streptococcus pneumoniae urine Antigen showed Negative. Acid-fast stain showed not found.
      • Sputum culture showed mixed normal flora. Urine culture showed after 48 hours 1000 CFU/mL. We also arrange chest sonography for excluded lung empyema or malignancy. Chest sonography revealed right pleural thickening with trivial amount of organized pleural effusion. Urine culture showed after 48 hours 1000 CFU/mL. No bacterial growth on blood culture is noted. He sudden of fever noted, fever survey was done. Laboratory examination revealed leukocytosis stationary, CRP become better, but anemia is noted. Urinalysis shows no pyuria. No bacterial growth on blood culture is noted.
      • Tumor marker showed elevated SCC, CA125 noted.
      • Naproxen was given for suspect tumor fever.
      • Mucolytics, antitussives and laxatives for relieve symptoms.
      • Blood transfusion with LPRBC one unit for two days.
      • Laxative supp. was given for relieve constipation.
      • Laboratory examination are in improvement. Room air saturation showed 92% without dyspnea. Smooth breath pattern. He is discharged on 2023-10-17.
    • Discharge prescription
      • naproxen 250mg 1# QW14
      • Ulstop (famotidine 20mg) 1# QD
      • Through (sennoside 12mg) 2# HS
      • Cough Mixture (platycodon) 15mL Q12H
      • Actein Effervescent (acetylcysteine 600mg) 1# BID

[consultation]

  • 2024-02-15 Family Medicine
    • Q
      • for combine hospice care.
      • This 78-year-old male had history of:
        • Anterior mediastinal squamous cell carcinoma status post surgical debridement of sternal sternum sequestrum and abscess drainage on 2023/03/13, s/p radiotherapy (4500cGy/25+15 fractions) on 2023/08/22 ~ 09/08.
        • Infective endocarditits post Mitral valve replacement with 33mm Medtronic Hancock II tissue valve on 2020/08/10.
        • Hypertension.
        • S/P 1. wide excision of sternal SCC + AsAo replacement; 2. Pericardiectomy; 3. wedge resection of RUL; 4. reduction of bilateral clavicles and 1st~4th ribs, and fix the throracic bony cage with titanium mesh and screws; 5. bilateral pectoris major myocutaneous advancement flaps coverage of anterior thorax on 2023/04/03.
      • Patient received radiotherapy (4500cGy/25+15 fractions) on 2023/08/22 ~ 09/08.
      • He sufferred from mild chest wall pain noted for 1 month. Sternal notch area fluid collecting and pain radiation to right shoulder area noted for 3 days. Followed-up Chest CT (2023/03/11) revealed Necrotic mass like lesion at anterior mediastinum encircling ascending aorta about 8.4cm is found. Smaller lesion at subcutaneous tissue just anterior to the manubrium measuring 2.09cm is found, abscess is likely. The surgical of resection of anterior mediastinum tumor on 2023/03/13, the biopsyshowed moderately differentiated squamous cell carcinoma with necrosis, Immunohistochemical stain reveals p63(+), CD117(-), CK(+), S100(-),and Myosin(-) on 2023/03/13, s/p paliactive chemotherapy with Cisplatin (30mg/m2) plus docetaxel (25mg/m2) weekly form 2023/12/20~.
      • This time. he suffered from SHORTNESS OF BREATH, DYSPNEA AND GENERALIZED MALAISE FOR 2 DAYS. Chest PA view shows enlargement of cardiac silhouette with suspect right pleura effusion and nodular opacity in RLL. Lab cardiac enzyme elevation (NT-proBNP 2528.3, hs-Troponin I 37.0), CRP 2.7mg/dL, eGFR 73.41mL/min, Hb 10g/dL, vein gas pH7.29 with pCO2 59.4 and HCO3 27.9. EKG sinus tachycardia with RBBB. He was admitted for further management. The patient, and family signs DNR, so we need your help for combine hospice care, thanks a lot!!
    • A
      • When I visited, the patient lied on bed, and his wife stood by him. His consciousness was clear, and he felt better after admission. After discussion, I decided to arrange hospice combine care for this patient. Thanks for your consultation.
      • Indication for hospice combine care: Anterior mediastinal squamous cell carcinoma
      • Plan: hospice combined care
  • 2023-10-31 Cardiology
    • Q
      • for PICC insertion.
      • This 78-year-old male had history of:
        • Anterior mediastinal squamous cell carcinoma status post surgical debridement of sternal sternum sequestrum and abscess drainage on 2023/03/13.
        • Infective endocarditits post Mitral valve replacement with 33mm Medtronic Hancock II tissue valve on 2020/08/10.
        • Hypertension.
        • S/P
          • wide excision of sternal SCC + AsAo replacement;
          • Pericardiectomy;
          • wedge resection of RUL;
          • reduction of bilateral clavicles and 1st~4th ribs, and fix the throracic bony cage with titanium mesh and screws;
          • bilateral pectoris major myocutaneous advancement flaps coverage of anterior thorax on 2023/04/03.
      • This time, he is admitted for chemotherapy, so we need your help for PICC insertion, thanks a lot!!
    • A
      • I’m consulted for PICC.
      • SvO2 was also check, it revealed only 45%.
        • Estimated Fick Cardiac index 1.86 L/min/m2 (normal cardiac index range 2.6~4.2 L/min/m2)
        • Estimated Fick cardiac output 2.44 L/min. (nomral cardiac output range 5~6 L/min)
      • impression
        • Anterior mediastinal squamous cell carcinoma status post surgical debridement of sternal sternum sequestrum and abscess drainage on 2023/03/13
        • Low cardiac output
      • Suggestion
        • We complete PICC smoothly. and low cardiac output was noted.
  • 2023-05-05 Hemato-Oncology
    • Q
      • For anterior mediastinal squamous cell carcinoma chemotherapy survey
      • This 78 year-old male is a care of Anterior mediastinal squamous cell carcinoma
        • s/p surgical debridement of sternal sternum sequestrum and abscess drainage on 2023/03/13.
        • S/P 1.wide excision of sternal SCC + AsAo replacement; 2.Pericardiectomy; 3.wedge resection of RUL; 4. reduction of bilateral clavicles and 1st~4th ribs, and fix the throracic bony cage with titanium mesh and screws; 5.bilateral pectoris major myocutaneous advancement flaps coverage of anterior thorax on 2023/04/03.
      • He was admitted due to right side massive pleural effusion.We need your help for further treatment.
    • A
      • We had discuss with patient about further adjuvant chemotherapy due to pT4Nx and lymphvascular invastion.
      • May consider adjuvant chemotherapy after complete RT (old age).
      • Please check Anti-HBc, Anti-HBs, HBsAg, Anti HCV and 24 urine CCR. Arrange port A insertion.
      • Please arrange our OPD after discharge.
  • 2023-04-28 Radiation Oncology
    • Q
      • for anterior mediastinal squamous cell carcinoma treatment
    • P
      • Radiotherapy is indicated for this patient with the following indicators: stage pT4Nx(cM0).
      • Goal: curative
      • Treatment target and volume: anterior mediastinal tumor bed and peripheral involved area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the anterior mediastinal tumor bed and peripheral involved area.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his family (wife and sister). They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0930, 2023-05-09.
  • 2023-03-24 Plastic and Reconstructive Surgery
    • Q
      • anterior mediastinum SCC for flap after tumor excision
      • He was admitted due to anterior mediastinum SCC.
    • A
      • Methods of flap surgery is considered for this patient.
      • For wound closure of the thorax only, pectoris major myocutaneous flaps can be chosen. If there is a space which needs filling, rectus abdomins muscle flap and split-thickness skin graft on the flap surface can achive the need of spcae filling and wound resurfacing.
  • 2020-08-03 Cardiac Surgery
    • Q
      • This 75 y/o man admitted due to IE. Mitral valve flail. So we need your help for assessment surgery. Thanks!!
    • A
      • This 75 y/o man was a case of IE with Mitral valve flail.
      • If patient’s family agreed to proceed, then I will take over this case and arrange operation.
  • 2020-07-30 Cardiology
    • Q
      • This 75 years old patient is admitted under the diagnosis of Streptococcus gordonii bacteremia.
      • Echocardiography revealed LVEF 66, no vegetation; but degenerative changes of mitral valve with flail posterior mitral leaflet (P3) due to chordae rupture; severe MR (multiple jets). We need youe help for management of chordae rupture. Thank you.
    • A
      • This patient admitted due to sepsis, he had heart murmur since Jun′2018. 2D echo ih 2018 revealed Typical MVP, posterior leaflet with chordal rupture, severe MR.
        • Becaues of 2D echo severe MR, I’m consuled for it
        • Patient denied shortness of breath
      • PE: systolic murmur, Gr III
      • Impression
        • severe MR since 2018
        • sepsis
      • Suggestion:
        • Because of patient without symptoms, CxR no pulmonary edema, familes and patient not favor operation right now
        • If worried about MR related subclinical heart failure, to perform treadmill with Naughton is another choice.

[surgical operation]

  • 2023-04-21
    • Surgery
      • Insertion of Right chest tube
    • Finding
      • bloody pleural effusion 200ml
  • 2023-04-03
    • Surgery
      • reduction of bilateral clavicles and 1st~4th ribs, and fix the throracic bony cage with titanium mesh and screws
      • bilateral pectoris major myocutaneous advancement flaps coverage of anterior thorax
    • Finding
      • about 25cm X 10cm X 3cm skin, whole-layer (bone and soft tissue) defect over sternal region owing to ablasion of cancer
      • missing manubrium, upper-two-thirds-of-body, and xiphoid process of sternum; also mission medial ends of bilateral clavicles; and also missing anterior ends of bilateral 1st~4th ribs; thus only the wired-fixed, lower one-third of sternal body keeping the lower half of the bony thoracic cage fixed
      • exposed heart, artificial aortic segments, and both lungs before my recontruction surgery
      • released structures for flap advancement: origin sites of bilateral pectoris major muscles over medial clavicles, medial ribs, and low part of sternum
      • titanium implants for fixation of clavicles and ribs: BIOPLATE PREFORMED FIXATION SYSTEM - MESH + SCREWS
        • size of mesh before and after trimming: 20cm X 20cm and about 15cm X 15cm
      • distance of cutting ends of bilateral clavicles after reducion and fixation: 8.5cm
  • 2023-04-03
    • Surgery
      • wide excision of sternal SCC + AsAo replacement
      • Pericardiectomy
    • Finding
      • sternal SCC with capsualization involved ascending aorta, brachial-cephalic trunk, SVC. Tumor adhesionof RUL of lung
  • 2023-04-03
    • Surgery
      • Wedge resection of RUL
    • Finding
      • Perioperative consultation
      • A large mediastinal tumor with mediastinal and RUL invasion
      • Wedge resection of RUL was done using endo-GIA
      • No residual tumor or active bleeding noted
  • 2023-03-13
    • Surgery
      • Resection of anterior mediastinum tumor
    • Finding
      • Capsuled mass over upper sternal region extended to anterior mediastinum space with pus accumunation.
  • 2020-08-10
    • Surgery
      • Mitral valve replacement with 33mm Medtronic Hancock II tissue valve.        
    • Finding
      • Ruptured chordae tendineae of P2.
      • Vegetation on anteriior leaflet of mitral valve.    

[radiotherapy]

  • 2023-08-22 ~ 2023-09-11 - 2700cGy/15 fractions of the metastatic tumor in RLL.
  • 2023-05-19 ~ 2023-06-23 - 4500cGy/25 fractions of the anterior mediastinal tumor bed and peripheral involved area.

[chemotherapy]

  • 2024-02-19 - docetaxel 25mg/m2 30mg NS 100mL 1hr + cisplatin 30mg/m2 30mg NS 350mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-02-07 - docetaxel 25mg/m2 30mg NS 100mL 1hr + cisplatin 30mg/m2 30mg NS 350mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-01-31 - docetaxel 25mg/m2 30mg NS 125mL 1hr + cisplatin 30mg/m2 30mg NS 350mL 3hr + NS 250mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-01-17 - docetaxel 25mg/m2 34mg NS 125mL 1hr + cisplatin 30mg/m2 40mg NS 350mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-01-13 - docetaxel 25mg/m2 34mg NS 125mL 1hr + cisplatin 30mg/m2 40mg NS 350mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-27 - docetaxel 25mg/m2 34mg NS 125mL 1hr + cisplatin 30mg/m2 40mg NS 350mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-20 - docetaxel 25mg/m2 34mg NS 125mL 1hr + cisplatin 30mg/m2 40mg NS 350mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-05 - paclitaxel 60mg/m2 80mg NS 250mL 2hr + carboplatin AUC 2 120mg NS 200mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-28 - paclitaxel 60mg/m2 80mg NS 250mL 2hr + carboplatin AUC 2 120mg NS 200mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-14 - paclitaxel 60mg/m2 80mg NS 250mL 2hr + carboplatin AUC 2 120mg NS 200mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-07 - paclitaxel 60mg/m2 80mg NS 250mL 2hr + carboplatin AUC 2 120mg NS 200mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-10-31 - paclitaxel 60mg/m2 80mg NS 250mL 3hr + carboplatin AUC 2 120mg NS 200mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

Clinical presentation and management of thymoma and thymic carcinoma - 2023-11-01 - https://www.uptodate.com/contents/clinical-presentation-and-management-of-thymoma-and-thymic-carcinoma

  • The same regimens are used in the neoadjuvant setting for potentially resectable disease as in the treatment of unresectable disease. Although several regimens are acceptable, cyclophosphamide, doxorubicin, and cisplatin (CAP) and cisplatin and etoposide (PE) have been used successfully for thymomas or thymic carcinomas. The combination of carboplatin and paclitaxel is also used extensively, especially in patients with thymic carcinoma. If chemotherapy is given concurrently with RT, our preferred regimens are PE or carboplatin and paclitaxel.
    • CAP
      • Cyclophosphamide (500 mg/m2 intravenous [IV] day 1), doxorubicin (50 mg/m2 IV day 1), and cisplatin (50 mg/m2 IV day 1), repeated every three weeks. In a United States intergroup study, 29 patients with metastatic or progressive thymoma were treated with CAP. The overall and complete response rates were 50 and 10 percent, respectively, and the median survival was 38 months.
    • PE
      • Cisplatin (60 mg/m2 IV day 1) and etoposide (120 mg/m2 IV days 1 to 3), repeated every three weeks [60]. In a European Organisation for Research and Treatment of Cancer (EORTC) study, 16 patients with advanced thymoma received etoposide plus cisplatin every three weeks. The overall and complete response rates were 56 and 31 percent, respectively, and the median progression-free and overall survival durations were 2.2 and 4.3 years, respectively.
    • CAP with prednisone
      • Cyclophosphamide (500 mg/m2 IV day 1), doxorubicin (20 mg/m2/day as a continuous infusion, days 1 to 3), cisplatin (30 mg/m2 IV days 1 to 3), and prednisone (100 mg/day on days 1 to 5), repeated every three weeks. In a series of 22 patients given induction chemotherapy with the CAP with prednisone regimen, partial responses were observed in 14 cases and complete responses in three cases for an overall 77 percent response rate.
    • Carboplatin (area under the curve [AUC] 6) and paclitaxel (225 mg/m2 IV) every three weeks
      • In a prospective, multicenter study of patients with advanced disease, three complete responses and six partial responses were observed in 21 patients with thymoma (overall response rate, 43 percent). There were five partial responses and no complete responses among the 23 patients with thymic carcinoma (overall response rate, 22 percent).
    • ADOC
      • Cisplatin (50 mg/m2 IV day 1), doxorubicin (40 mg/m2 IV day 1), vincristine (0.6 mg/m2 IV day 3), and cyclophosphamide (700 mg/m2 IV day 4), repeated every three weeks. In another series, 37 patients with advanced disease were treated with ADOC. The overall and complete response rates were 92 and 43 percent, respectively, and the median survival was 15 months.
    • VIP
      • Etoposide (75 mg/m2 IV days 1 to 4), ifosfamide (1.2 g/m2 IV on days 1 to 4), and cisplatin (20 mg/m2 IV days 1 to 4), repeated every three weeks. In an intergroup trial that included 28 patients with advanced thymoma or thymic carcinoma, nine partial responses (32 percent) were observed.

==========

2024-02-20

[chronic anemia worsens with chemo: LPRBC transfusion for the patient]

Lab data on 2024-02-19 showed HGB 7.5 g/dL and an immediate LPRBC transfusion was performed. Vital signs are currently stable.

This patient has a long history of anemia even before the initiation of chemotherapy, but the chemotherapy treatment dose associated with lowered HGB level on a long-term basis.

2024-01-12

[regimen change prompts eGFR decline: further monitoring needed]

Following a switch to docetaxel + cisplatin on 2023-12-20 from the previous paclitaxel + carboplatin regimen, the patient has experienced a preliminary decline in eGFR.

While the current eGFR remains within the acceptable range, further monitoring is necessary to track potential changes.

  • 2024-01-09 eGFR 83.52 ml/min/1.73m^2
  • 2023-12-27 eGFR 114.04 ml/min/1.73m^2
  • 2023-12-25 eGFR 117.87 ml/min/1.73m^2

[observing potential thrombosis after previous event]

A thrombotic event previously occurred in mid-Dec 2023, and a recent slight elevation in D-dimer levels has been observed. Monitoring for any signs of potential thrombosis is recommended.

  • 2024-01-09 D-dimer 2638.00 ng/mL(FEU)
  • 2023-12-25 D-dimer 2152.00 ng/mL(FEU)
  • 2023-12-15 D-dimer >10000 ng/mL(FEU)

2023-11-01

The tumor marker SCC has consistently been elevated throughout the year.

  • 2023-10-12 SCC 122.0 ng/mL
  • 2023-03-24 SCC 125.5 ng/mL

In 2023Q3, radiation therapy of 2700cGy/15 was administered to the metastatic tumor in the right lower lobe (RLL). Additionally, in 2023Q2, a dose of 4500cGy/25 was directed to the anterior mediastinal tumor bed and the surrounding affected area.

The treatment regimen of paclitaxel combined with carboplatin commenced on 2023-10-31.

No discrepancies in medication were identified.

700030422

240220

[exam findings]

  • 2024-02-08 Patho - skin cyst/tag/debridement
    • Skin, back, excision — Epidermal inclusion cyst
    • Sections show piece(s) of skin with one intradermal cyst lined by squamous epithelium. The cystic cavity is full of keratin material.
  • 2024-01-12 CT - abdomen
    • Findings: Comparison prior CT dated 2023/10/16.
      • Prior CT identified segmental asymmetrical wall thickening of the sigmoid colon is noted again, mild decreasing in size and enhancement.
        • Prior CT identified two enlarged nodes in the adjacent mesocolon are not noted again.
      • Prior CT identified several metastases on both hepatic lobes are noted again, increasing in size that are c/w liver metastases S/P C/T with progressive disease.
      • Prior CT identified two ovoid-shaped enlarged nodes in right inguinal area are noted again, stationary.
        • Benign reactive nodes are highly suspected.
      • Diverticulum in right lateral wall of the urinary bladder is noted.
    • Impression:
      • Liver metastases S/P C/T show progressive disease.
  • 2023-10-16 CT - abdomen
    • History and indication: Sigmoid cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Stable of S-colon cancer but mild progression of bil. liver metastases.
      • Left minimal pleural effusion.
      • Some calcifications in prostate.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Stable of S-colon cancer but mild progression of bil. liver metastases.
  • 2023-07-20 MRA - brain
    • Clinical information: r/o brain metastasis or recent stroke
    • Findings:
      • Known a case of sigmoid colon cancer with brain metastasis. NO evidence of brain metastasis.
      • Presence of hydrocephalus with trans-ependymal CSF shift.
      • Moderate periventricular small vessel disease. NO acute ischemic infarct.
      • Suspect one arachnoid cyst over posterior fossa, causing compression of both cerebellar lobes.
      • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
      • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
  • 2023-05-05 CT - abdomen
    • Findings: Comparison: prior CT dated 2022/08/16.
      • Prior CT identified segmental asymmetrical wall thickening of the sigmoid colon is noted again, mild decreasing in size and enhancement.
        • Prior CT identified two enlarged nodes in the adjacent mesocolon are not noted again.
      • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size that are c/w liver metastases S/P C/T with progressive disease.
      • Prior CT identified two ovoid-shaped enlarged nodes in right inguinal area are noted again, stationary.
        • Benign reactive nodes are highly suspected.
      • The urinary bladder shows diffuse wall thickening and small size that may be chronic cystitis.
    • Impression:
      • Liver metastases S/P C/T show progressive disease.
  • 2023-02-11 CT - abdomen
    • Findings
      • Sigmoid colon, s/p operation. No local recurrent tumor.
      • No enlarged lymph nodes in para-aortic and pelvic regions.
      • Several liver metastasis, mild in progression.
      • No ascites, nor extraluminal free air.
      • No bony destructive lesion on these images.
    • Impression
      • Sigmoid colon, s/p operation
      • Liver metastasis, mild in progression
      • Suggest clinical correlation and follow up evaluation
  • 2022-11-09 MRI - brain
    • General brain atrophy. Leukoaraiosis. Mild intracranial artherosclerosis.
  • 2022-08-16 CT - abdomen
    • Findings
      • Mild regression of S-colon cancer and bil. liver metastases (up to 4.0cm).
      • A small nodule (3.6mm) at RLL.
      • Some calcifications in prostate.
      • A nodule (1.9cm) at left buttock.
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • Mild regression of S-colon cancer and bil. liver metastases (up to 4.0cm).
  • 2022-08-03 All-RAS + BRAF
    • There was no variant detected in the KRAS/NRAS gene.
    • There was no variant detected in the BRAF gene.
  • 2022-05-24 CT - abdomen
    • Findings
      • Much regression of S-colon cancer and bil. liver metastases (up to 5.2cm).
      • A bullae (2.8cm) at LUL.
      • Some calcifications in prostate.
      • Some tiny nodules in bil. lungs.
      • A nodule (1.9cm) at left buttock.
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • Much regression of S-colon cancer and bil. liver metastases (up to 5.2cm).
      • A bullae (2.8cm) at LUL.
      • Some tiny nodules in bil. lungs.
  • 2022-03-03 CT - chest
    • Indication: colon cancer with liver meta, favor lung meta
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Pneumatocele at left upper lobe up to 2.48cm in largest dimension is found.
        • Diffuse centrilobular Emphysematous change over both lungs is found.
        • Minimal atelectatic change at right middle lobe and left lingula lobe is found.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
        • No evidence of bilateral pleural effusion.
        • Calcified coronary arteries is found.
      • Visible abdomen:
        • Target like hepatic tumors are found at both lobes of liver up to 9.6cm in largest dimension. Liver meta is considered. In comparison with CT dated on 2022-02-25, the lesion is stationary.
        • The spleen, pancreas, both kidneys and adrenals are intact.
    • Imp:
      • No evidence of pulmonary meta.
      • Diffuse centrilobular Emphysematous change over both lungs.
      • Liver meta. stationary as previous CT on 2022-02-25.
  • 2022-02-25 Patho - colon biopsy (Y1)
    • Colon, sigmoid colon, 30cm from AV, s/p biopsy x6 — Adenocarcinoma.
    • Section shows piece(s) of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2022-02-25 CT - abdomen
    • History: 20220224 sono: Two huge 8.68x7.07cm and 7.68x6.43cm ill-defined hyperechoic lesion with scattered hyperechoic spot at left lobe and S5, Two 2.13cm and 1.5cm hyperechoic lesions with hypoechoic rim was noted at S5 and S6
    • Indication: Suspected HCCs or metastases
    • Findings:
      • There is segmental asymmetrical wall thickening of the sigmoid colon measuring 5 x 2.5 cm in size that may be adenocarcinoma.
        • In addition, there are two enlarged nodes in the adjacent mesocolon that may be metastatic nodes.
      • There are several lobulated well-defined poor enhancing masses on both hepatic lobes, the largest one measuring 9.2 cm in S2-3 of the liver. During dynamic study, all masses show poor enhancement in arterial phase, portal venous phase, and delayed phase images.
        • Metastases are highly suspected.
      • There is a well-defined enlarged node measuring 2.2 x 1.4 cm in hepatoduodenal ligament that may be benign reactive node.
        • The differential diagnosis include metastatic node.
      • There are two ovoid-shaped enlarged nodes in right inguinal area that may be benign reactice nodes.
      • There are two small soft tissue nodule in RML and RLL of the lung at lung window setting, nature? Please correlate with chest CT.
      • The urinary bladder shows diffuse wall thickening and small size that may be chronic cystitis.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N1b (N_value) M:M1 (M_value) STAGE:IVA(Stage_value)

[MedRec]

  • 2022-11-08 SOAP Psychosomatic medicine
    • S
      • Recently found to have increasingly deteriorating memory, depressive symptoms, anxiety symptoms, fear symptoms, delusional symptoms (being stolen, being harmed, jealousy, being intruded, misidentification), hallucinations, behavioral disorders (irritability, aggression, wandering, gluttony, changes in eating, repetitive behavior, bizarre behavior, poor personal hygiene, inappropriate disorganization).
      • Screen dementia positive in the community by (elderly health check, care points, community health centers) with AD-8 test.
      • Past history of hypertension (+, -), DM (+, -), hyperlipidemia (+;-), arrhythmia (+,-), alcohol drink habit (+,-), head injury (+,-).
      • 1st time visiting comes with TZ volunteer, family (couple, son, daughter) due to poor memory, frequently showing forgetfulness for years.
      • Community memory screening AD8 > 2
      • Dementia warning signs assessment > 2
      • In the past few months, have family members mentioned (or have you discovered) that you seem to have the following conditions? Please mark (V) for yes and (X) for no.
        • ( v ) Memory decline affecting life:
        • ( v ) Difficulty planning or solving problems:
        • ( v ) Unable to handle familiar tasks
        • ( v ) Confusion about time and place:
        • ( v ) Difficulty understanding the relationship between visual images and space:
        • ( v ) Difficulty in verbal expression or writing:
        • ( v ) Things are misplaced and lose the ability to retrace steps:
        • ( v ) Poor or weakened judgment:
        • ( v ) Withdrawal from work or social activities:
        • ( v ) Changes in mood and personality:
        • Result: Mark (V) for a total of OO items.
    • O
      • Repeating the same questions, stories, and statements. Difficulty learning how to use tools, equipment, and small appliances. Forgetting the correct month and year. Difficulty remembering appointment times. Persistent problems with thinking and memory.
      • Result explanation:
        • Please check the items below according to the actual scores on the previous page (single choice):
          • AD8 total score >= 2 points
          • GDS total score >= 2 points
      • Patient meets the criteria for Alzheimer’s disorder
        • A: Multiple cognitive developmental impairments combined with the following A-1 and A-2 impairments:
          • A-1: Memory impairment (unable to learn new things or unable to recall previously learned things)
          • A-2: At least one of the following cognitive impairments:
            • Aphasia
            • Apraxia
            • Agnosia
      • Disturbance in executive functioning
        • B: Causing social or occupational difficulties, and a significant decline from the previous level of functioning
        • C: Cognitive decline is gradual and persistent
      • PSP: poor social function, disorientation to time and place, easily lost orientation to home
      • O: Vital sign: relatively stable
        • Physical and neurological examination: no significant abnormal findings were noticed during outpatient visiting
      • Mental Status Examination:
        • JOMAC: poor orientation, memory, and abstract thinking.
        • Insight: partial
        • Impression: Mild Cognitive Impairment
      • Plan to do:
        • Examinations for CBC, VDRL, BUN, Creatinine, GOT, GPT, T4, TSH, B12, and Folic acid.
        • MMSE or CDR cognitive test report.
        • Arrange brain CT or MRI if indicated
    • Diagnosis
      • Mild cognitive impairment of uncertain or unknown etiology G31.84
  • 2022-08-31 SOAP Hemato-Oncology
    • S: 2022-08-03 All-RAS: Wildtype
    • O: 2022/08/16 CT: ABD - Mild regression of S-colon cancer and bil. liver metastases (up to 4.0cm).
  • 2022-08-03 SOAP Hemato-Oncology
    • O: AE: anorexia - staionary
    • P: Avastin 10 - 2 = 8 on 2022-08-03
  • 2022-07-20 SOAP Hemato-Oncology
    • O: AE: anorexia
  • 2022-05-25 SOAP Hemato-Oncology
    • O: AE: Gr 1 constipation -> diarrhea
  • 2022-04-27 SOAP Hemato-Oncology
    • O: AE Gr 1 constipation -> not improved
    • A/P:
      • Avastin 24 - 2 = 22
      • Already explain HTN, proteinuria, hollow organ perforation etc
      • Arrange Abd/Pelvis/Chest CT Q3M, next on 2022-05-24
  • 2022-04-13 SOAP Hemato-Oncology
    • O: AE Gr 1 constipation
    • Prescription
      • Norvasc (amlodipine 5mg) 1# QD
      • Takepron (lansoprazole 30mg) 1# QDAC
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Through (sennoside 12mg) 2# HS
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • MgO 250mg 1# TID
      • Hepac Lock Flush (heparin sodium 100 USP units/mL 10mL) 10# ST IRRI (irrigation)
  • 2022-03-31 SOAP Hemato-Oncology
    • O: Now on FOLFIRI, C1D1 on 2022-03-07
  • 2022-03-17 SOAP Hemato-Oncology
    • S: Hx of sigmoid cancer s/p C/T, T3bN1aM1a, Stage IVA
  • 2022-03-10 ~ 2022-03-10 POMR Hemato-Oncology
    • Discharge diagnosis
      • Sigmoid colon cancer with liver metastases, T3N1bM1a, stage IVA
      • Reflux esophagitis LA grade A
      • Gastric erosions, antrum and low body
      • Chronic viral hepatitis B without delta-agent
      • Constipation, unspecified
    • CC
      • anorexia, epigastric paresthesia, and tea color urine for days
    • Prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Through (sennoside 12mg) 2# HS
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Takepron (lansoprazole 30mg) 1# QDAC
  • 2022-02-23 ~ 2022-03-10 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Sigmoid colon cancer with liver metastases, T3N1bM1a, stage IVA
      • Reflux esophagitis LA grade A
      • Gastric erosions, antrum and low body
      • Chronic viral hepatitis B without delta-agent
      • Constipation, unspecified
    • CC
      • anorexia, epigastric paresthesia, and tea color urine for days
    • Present illness
      • This 74 year-old male patient has the histories of 1) HBV but loss follow-up, 2) inguinal hernia s/p operation, 3) upper GI bleeging s/p micro invasive surgery. He denied any allergey, and family history. He smoke 0.5 PPD for 60 years and no alcholism.
      • He had body weight lost 8 Kgs (60 to 52 Kgs) and severe anorexia in the past 3 months. He visited Postal Hospital for help. Hepatitis markers were checked and HBeAg, Anti-HBs, Anti-HBe, Anti-HBc, Anti-HCV were all negative, and HBsAg 3048.14 IU/mL. Tumor maker was checked and showed AFP 3.9 ng/mL; CEA 1993 ng/mL; CA-199 555 ng/mL. Abdominal sonography was arranged on 2022/02/09 and revealed multiple liver tumors.
      • He transferred to our GI OPD for help. He sufferred from anorexia, epigastric paresthesia, and tea color urine for days. He denied chillness or fever, nausea or vomiting, dizziness, headache, chest tightness or pain, diarrhea or constipation, dysuria or frequency found. No TOCC history was noted. COVID19 rapid test showed Negative. Lab data showed no leukocytosis and normal AST, ALT, bilirubin, r-GT. Elevated ALP 122 U/L.
      • Under the impression of Liver tumor, R/O HCC or metastasis tumor, he was admitted to GI ward for cancer survey and further management.
    • Course of inpatient treatment
      • After admitted, Abdominal echo on 2022/02/24 showed parenchymal liver disease and liver tumors, bilateral lobes, r/o HCC or metastasis tumor.
      • Tumor maker was checked and showed 2022-02-25 AFP 3.6 ng/mL; CA199 592.71 U/mL; CEA 2204.47 ng/mL.
      • Abdominal CT on 2022/02/25 showed colon cancer with liver metastasis, T3 N1b M1a, Stage: IVA.
      • Colonoscopy on 2022/02/25 showed colon polyp, ascending colon, s/p hot snare polypectomy and EZ clip x2. (A), colon polyp, descending colon, s/p biopsy removal. (B), colon polyp, sigmoid colon, colon cancer, Paris classification 0-Isp,12mm, was noted at sigmoid colon, 30cm from AV, s/p biopsy*6. (C) and internal hemorrhoid. Colon, sigmoid colon, 30cm from AV, s/p biopsy showed Adenocarcinoma; IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • Chest CT on 2022/03/03 showed no evidence of pulmonary meta, diffuse centrilobular Emphysematous change over both lungs and liver metastasis.
      • Applying Major Illness on 2022/03/03. Port-A catheter insertion on 2022/03/04.
      • Chemotherapy with FOLFIRI(Campto 90mg/m2, L 400mg/m2, 5FU 400mg/m2 and 2400mg/m2)(C1D1) from 2022/03/07~2022/03/09.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
      • EGD on 2022/02/25 showed reflux esophagitis LA grade A, superficial gastritis, s/p CLO test, gastric erosions, antrum and low body, suspected gastric intestinal metaplasia, antrum, angle, and low body, s/p biopsy and deformed bulb.
      • Reflux esophagitis with Takepron 1# po QDAC.
      • Hepatitis markers were checked and HBeAg, Anti-HBs, Anti-HBe, Anti-HBc, Anti-HCV were all negative, and HBsAg 3048.14 IU/mL.
      • Chronic viral hepatitis B with Baraclude 0.5mg 1# po QDAC.
      • Sennoside 2# po HS for Constipation.
      • Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, he was discharged on 2022/03/10 and OPD followed up later.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Through (sennoside 12mg) 2# HS
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Takepron (lansoprazole 30mg) 1# QDAC
  • 2022-02-23 SOAP Gastroenterology
    • S
      • Loss 8 Kgs (60 to 52 Kgs) and anorexia in the past 3 months.
      • Metastatic lesions were found in the liver with sky high tumor markers at a LMC on 2022-02-08.
      • So, he was referred to our hospital for evaluation.
    • O
      • PE: No icteric sclera, soft abdomen, no leg pitting edema.
      • 2022-02-07 CEA: 1993 (<5).
      • 2022-02-07 Ca19-9: 555. (at a LMC).
      • 2022-02-09 Abdo sono: Multiple liver tumors. (at a LMC).

[consultation]

  • 2024-02-03 Plastic and Reconstructive Surgery
    • Q
      • This 76-year-old man patient is a case of Sgmoid colon cancer with liver metastases, T3N1bM1a, stage IVA under chemotherapy. He was admitted for chemotherapy with Erbitux plus FOLFIRI.
      • This time, he presented back wound with discharge for least 2 days. we need your further evaluation and management.
    • A
      • Excision of the epidermal cyst can be done under local anesthesia in the afternoon of 2024/02/07 (Wed). Thanks.
  • 2023-11-07 Plastic and Reconstructive Surgery
    • Q
      • This 76-year-old man patient is a case of Sgmoid colon cancer with liver metastases, T3N1bM1a, stage IVA s/p chemotherapy with FOLFIRI from 2022/03/07~2023/06/01(15 cycles) and Avastin from 2022/04/27~, progressive disease of liver tumor, palliative chemotherapy with FOLFOX from 2023/06/19~. He was admitted for chemotherapy.
      • This time, he presented with fall down today, left back laceration was noted. we need your further evaluation and management.
    • A
      • I will let the patient get into the OR for wound debridement and suture in the afternoon of 11/8. Thanks.
  • 2023-08-31 Rehabilitation
    • Q
      • This 76-year-old man patient is a case of Sgmoid colon cancer with liver metastases, T3N1bM1a, stage IVA s/p chemotherapy with FOLFIRI from 2022/03/07~2023/06/01(15 cycles) and Avastin from 2022/04/27~, progressive disease of liver tumor, palliative chemotherapy with FOLFOX from 2023/06/19~. He was admitted for prepare chemotherapy.
      • This time, for bilateral lower limbs weakness with action remains unchanged. Now, for evaluate rehabilitation exercises. Thank you.
    • A
      • Due to deconditioning, we were consulted for bedside PT rehabilitation programs.
      • Premorbid status
        • Walk slowly ID; use walker sometimes indoor to walk faster / BADL ID
        • Sedentary lifestyle
      • Physical examination
        • 2023/08/31 14:17 T/P/R: 36.5’C / 85bpm / 18bpm BP:130/78mmHg
        • Body weight: 48.2
        • Consciousness: E4V5M6
        • Cognition: intact
        • Sphincter: urinary and stool continence
        • Muscle power:
          • RUE/RLE 4+/4
          • LUE/LLE 4+/4
        • Functional status: could walk to toilet slowly ID
        • BADL: under supervision
      • Assessment
        • Sgmoid colon cancer with liver metastases, T3N1bM1a, stage IVA s/p chemotherapy with FOLFIRI from 2022/03/07 to 2023/06/01(15 cycles) and Avastin from 2022/04/27, progressive disease of liver tumor, palliative chemotherapy with FOLFOX from 2023/06/19, with deconditioning
        • Chronic viral hepatitis B without delta-agent
        • Anemia due to antineoplastic chemotherapy
        • Hypertension
      • Plan
        • Rehabilitation programs: arrange bedside PT rehabilitation programs.
        • Goal: recondition; improve endurance and muscle strength; improve ambulation.
  • 2023-07-17 Neurology
    • Q
      • for evaluation early dementia
      • This 76-year-old man, a patient of Sigmoid colon cancer with liver metastases, T3N1bM1a, stage IVA s/p chemotherapy with FOLFIRI from 2022/03/07~2023/06/01(15 cycles) and Avastin from 2022/04/27~, progressive disease of liver tumor, palliative chemotherapy with FOLFOX from 2023/06/19~. He was admitted for chemotherapy.
      • Because patients tend to forget things was found at home for days. We need expertise to evaluate his condition thanks!
    • A
      • Assessment
        • Acute short-term memory decline for days, r/o secondary cause of cognitive decline
      • Suggestion
        • Arrange brain MRA with/without contrast to r/o brain metastasis or recent stroke
        • Check TSH, free T4, vitamin B12, folic acid, VDRL, cortisol (8AM), ACTH (8AM), ammonia.
  • 2022-03-02 Hemato-Oncology
    • A
      • Impression:
        • Sigmoid colon cancer with liver metastases, at least cT3N1bM1a, stage IVA, patho: Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • Suggestion:
        • Already make appointment for family meeting in the morning on 2022-03-03
        • arrange chest CT with/without contrast r/o lung meta
        • consult CRS for operation evaluation
        • may add FOLFIRI +/- avastin
        • We wound like to take over this case, thanks for your consultation. If there is any problem, please feel free to let us known.
  • 2022-03-02 Colorectal Surgery
    • A
      • S
        • This 74 year-old male patient was consulted CRS for colon cancer with liver metastases. he has the histories of 1) HBV but loss follow-up, 2) inguinal hernia s/p operation, 3) upper GI bleeging s/p micro invasive surgery. He denied any allergey, and family history.
        • He smoke 0.5 PPD for 60 years and no alcholism. He had body weight lost 8 Kgs (60 to 52 Kgs) and severe anorexia in the past 3 months.
        • He visited Postal Hospital for help. Hepatitis markers were checked and HBeAg, Anti-HBs, Anti-HBe, Anti-HBc, Anti-HCV were all negative, and HBsAg 3048.14 IU/mL. Tumor maker was checked and showed AFP 3.9 ng/mL; CEA 1993 ng/mL ; CA-199 555 ng/mL. Abdominal sonography was arranged on 2022/02/09 and revealed multiple liver tumors. He transferred to our GI OPD for help. He sufferred from anorexia, epigastric paresthesia, and tea color urine for days. He denied chillness or fever, nausea or vomiting, dizziness, headache, chest tightness or pain, diarrhea or constipation, dysuria or frequency found. No TOCC history was noted. COVID19 rapid test showed Negative. Lab data showed no leukocytosis and normal AST, ALT, bilirubin, r-GT. Elevated ALP 122 U/L. Under the impression of Liver tumor, R/O HCC or metastasis tumor, he was admitted to GI ward for cancer survey and further management.
        • After admission, colonscopy was done and the pathlogy showed adenocarcinoma
        • Abdominal CT with contrast was done that showed colon cancer with liver metastasis, T3N1bM1a, stage IVA..
        • Abdomen: soft, no distended, no tenderness
        • pass stool(+)
      • A: S-colon cancer with multiple liver metastases, T3N1bM1a, stage IVA.
      • P:
        • We will discuss with the patient and his son this afternoon
        • Suggest chemotherapy with target therapy first, then re-evaluate for possible colectomy+/-liver surgery
        • Check RAS gene status
        • We would like to follow this patient

[chemoimmunotherapy]

  • 2024-02-19 - cetuximab 500mg/m2 700mg 2hr + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 400mg/m2 560mg NS 100mL 10min + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Erbitux + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + atropine 0.5mg SC + NS 250mL
  • 2024-02-02 - cetuximab 500mg/m2 700mg 2hr + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 400mg/m2 560mg NS 100mL 10min + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Erbitux + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + atropine 0.5mg SC + NS 250mL
  • 2024-01-12 - ………………………… irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 400mg/m2 560mg NS 100mL 10min + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Erbitux + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + atropine 0.5mg SC + NS 250mL
  • 2023-12-26 - ………………………………….. oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-12-07 - ………………………………….. oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-13 - ………………………………….. oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-16 - ………………………………….. oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-22 - ………………………………….. oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-04 - ………………………………….. oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-09 - ………………………………….. oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-24 - ………………………………….. oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-07 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-19 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-01 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-05 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-22 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-01 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-08 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-18 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-04 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-14 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-23 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-02 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-10-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-09-21 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-09-07 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-08-24 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-08-03 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-07-20 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-07-06 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-06-22 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 120mg/m2 175mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-06-08 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-05-25 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-05-11 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-04-27 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-04-13 - ………………………………….. irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-04-01 - ………………………………….. irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-03-18 - ………………………………….. irinotecan 100mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-03-07 - ………………………………….. irinotecan 90mg/m2 135mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-02-20

After initiation of FOLFIRI regimen on 2024-01-12 from prior FOLFOX, both CEA as well as CA199 have dropped dramatically. Lab results other than these tumor markers were unremarkable. No drug discrepancies were noted.

  • 2024-02-20 CEA 1531.85 ng/mL

  • 2024-01-12 CEA 2483.63 ng/mL

  • 2024-02-20 CA199 74.53 U/mL

  • 2024-01-12 CA199 267.11 U/mL

2024-02-05

Given the rising CEA and CA199 levels in recent lab results and liver metastases progression identified on the abdominal CT scan dated 2024-01-12, the treatment was switched back to FOLFIRI from FOLFOX in Jan 2024, with the addition of cetuximab starting Feb 2024.

  • 2024-01-12 CEA 2483.63 ng/mL

  • 2023-12-08 CEA 1122.86 ng/mL

  • 2023-11-08 CEA 703.93 ng/mL

  • 2023-10-04 CEA 400.12 ng/mL

  • 2024-01-12 CA199 267.11 U/mL

  • 2023-12-08 CA199 198.46 U/mL

  • 2023-11-08 CA199 88.48 U/mL

  • 2023-10-04 CA199 34.70 U/mL

Other lab parameters, including blood cell counts, electrolytes, and liver and kidney functions, remained largely normal, presenting no contraindications to the commencement of the new chemotherapy session. The patient’s back wound has been evaluated by our plastic and reconstructive surgeon, recommending an excision of the epidermal cyst under local anesthesia scheduled for the afternoon of 2024-02-07 (Wednesday). No discrepancies in medication were noted.

2023-12-25

[tube feeding]

Potassium Supplementation Options:

  • This hospital currently offers only one oral potassium supplement: Const-K 750mg extended-release tablets, providing 10 mEq of potassium per tablet.
  • For patients requiring oral potassium but struggling to swallow the large Const-K tablets, crushing them into fine particles and mixing with water is permissible.

Dulcolax (bisacodyl 5mg):

  • Since Dulcolax tablets have an enteric coating meant to dissolve in the intestine, splitting or crushing it is not recommended. Fortunately, Bisacodyl suppositories (10mg) offer a similar alternative with the same active ingredient. Additionally, the patient is currently taking Through (sennoside 12mg) twice daily at bedtime.

2023-12-08

[tube feeding]

Const-K 750mg, an extended-release tablet, delivers 10 mEq of potassium per tablet. It is the sole oral potassium supplement available in this hospital. In comparison, a single banana provides more potassium, approximately 2.2 mEq per inch or 0.9 mEq per cm. If injectable potassium supplementation is not preferred, the Const-K tablet can be crushed into fine particles for easier swallowing with water.

Dulcolax, containing bisacodyl 5mg, is an enteric-coated formulation and should not be split or ground. As an alternative, Bisadyl supp pills, which contain bisacodyl 10mg, can be used. Currently, the patient is also taking Through (sennoside 12mg) 2# HS.

2023-11-08

[tube feeding]

Tube feeding is available for all oral medications on the active drug list.

[reconciliation]

Based on the PharmaCloud and HIS5 documentation, there is no evidence of the patient attending any external medical facilities within the last 90 days, and within our institution, the patient’s consultations have been exclusively with the Hemato-Oncology department. A review of the patient’s medication records has not revealed any inconsistencies.

[evaluating A-FOLFIRI to A-FOLFOX switch through temporal CEA changes]

A CT scan dated 2023-10-16 showed stable disease in the sigmoid colon but indicated a mild progression of bilateral liver metastases, which aligns with the trend observed in CEA levels.

  • The peak CEA level within this timeline is on 2023-06-19, at 497.14 ng/mL.

  • After the chemotherapy regimen changed from A-FOLFIRI to A-FOLFOX on the same date (2023-06-19), the CEA levels decreased, reaching a low of 321.79 ng/mL by 2023-09-14, suggesting an initial response to the new treatment.

  • However, there was an increase in the CEA level to 400.12 ng/mL by 2023-10-04, which could potentially indicate a worsening condition or resistance to the current therapy.

CEA lab readings:

  • 2023-10-04 CEA 400.12 ng/mL
  • 2023-09-14 CEA 321.79 ng/mL
  • 2023-08-08 CEA 339.37 ng/mL
  • 2023-07-05 CEA 419.60 ng/mL
  • 2023-06-19 CEA 497.14 ng/mL
  • 2023-05-16 CEA 409.91 ng/mL
  • 2023-05-03 CEA 414.57 ng/mL
  • 2023-04-11 CEA 337.63 ng/mL
  • 2023-03-01 CEA 193.51 ng/mL
  • 2023-02-11 CEA 213.84 ng/mL
  • 2023-02-08 CEA 193.49 ng/mL

2023-10-16

According to PharmaCloud and HIS5 records, the patient has no records of visits to other hospitals in the past three months, nor are there any records from departments other than Hemato-Oncology at our hospital. No medication discrepancy issues were found.

2023-06-20

  • Based on the information retrieved from the PharmaCloud database, the patient visited a local clinic for nausea and vomiting on 2023-06-09. The last chemotherapy treatment took place from 2023-06-01 to 2023-06-03. Delayed nausea and vomiting, a common side effect of chemotherapy, usually begins more than 24 hours after treatment and may continue for several days after completion of therapy. Please monitor to see if the nausea and vomiting resolves.
  • During this hospitalization, the patient started a new regimen of FOLFOX (previously on FOLFIRI). As oxaliplatin is a new component for the patient, a patient education visit was conducted at approximately 15:00 on 2023-06-20. However, at the time of the visit, the patient was resting with his eyes closed. In order not to disturb the patient’s rest, the oxaliplatin medication guide including information on side effects, precautions, and pharmacy contact information was left on the bedside table for the patient to review upon awakening.

2023-06-02

  • The patient had appointments at a local clinic for chronic pharyngitis on 2023-04-03 and 2023-05-02. The medications prescribed during these visits have now expired. No issues were identified during the medication reconciliation process, provided the patient no longer has symptoms of pharyngitis.

2023-05-08

  • On 2023-05-03, lab data showed essentially normal results except for an elevated tumor marker CEA. CEA initially decreased from 2204ng/mL on 2022-02-25 to 50ng/mL on 2022-10-12 after starting bevacizumab plus FOLFIRI treatment on 2022-03-07. However, during the course of treatment, the CEA level has then increased in an apparent trend and has reached 414ng/dL to date. During the same period, another tumor marker, CA199, has also increased, but at a slower rate. This might indicate that the disease has become more heterogeneous with increased resistance and/or that the current regimen may not be as effective as it was initially. Comparing the results of the two most recent CT scans (2023-05-05 and 2023-02-11), it is evident that the liver metastases are showing progressive disease.
    • 2023-05-03 CEA 414.57 ng/mL
    • 2023-04-11 CEA 337.63 ng/mL
    • 2023-03-01 CEA 193.51 ng/mL
    • 2023-02-11 CEA 213.84 ng/mL
    • 2023-02-08 CEA 193.49 ng/mL
    • 2022-11-02 CEA 78.00 ng/mL
    • 2022-10-12 CEA 50.71 ng/mL
    • 2022-09-21 CEA 52.31 ng/mL
    • 2022-08-17 CEA 60.72 ng/mL
    • 2022-07-20 CEA 94.15 ng/mL
    • 2022-06-22 CEA 146.05 ng/mL
    • 2022-06-08 CEA 176.80 ng/mL
    • 2022-05-25 CEA 265.53 ng/mL
    • 2022-05-11 CEA 419.31 ng/mL
    • 2022-04-27 CEA 448.30 ng/mL
    • 2022-04-01 CEA 1395.98 ng/mL
    • 2022-02-25 CEA 2204.47 ng/mL
    • 2023-05-03 CA199 21.68 U/mL
    • 2023-04-11 CA199 18.12 U/mL
    • 2023-03-01 CA199 16.28 U/mL
    • 2023-02-11 CA199 20.05 U/mL
    • 2023-02-08 CA199 14.93 U/mL
    • 2022-11-02 CA199 10.66 U/mL
    • 2022-10-12 CA199 12.81 U/mL
    • 2022-09-21 CA199 10.02 U/mL
    • 2022-08-17 CA199 10.98 U/mL
    • 2022-07-20 CA199 11.93 U/mL
    • 2022-06-22 CA199 12.26 U/mL
    • 2022-06-08 CA199 15.92 U/mL
    • 2022-05-25 CA199 19.70 U/mL
    • 2022-05-11 CA199 33.04 U/mL
    • 2022-04-27 CA199 36.93 U/mL
    • 2022-04-01 CA199 131.87 U/mL
    • 2022-02-25 CA199 592.71 U/mL
  • No medication reconciliation issues have been identified for this patient.

700132281

240220

[exam findings]

  • 2024-01-10 Tc-99m MDP bone scan
    • A hot area at a upper T-spine and faint hot spots in the sternum and right rib cage, the nature is to be determined (early bone mets, post-traumatic change, or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, bilateral shoulders, hips, knees, and tibiae.
  • 2024-01-04 SONO - abdomen
    • Liver tumors, bil. Propable metastases
    • Propable pancreatic tumor, body with enlarged pancreas
    • Propable intra-abdominal lymphadenopathy
  • 2023-12-29 CT - abdomen
    • Findings:
      • There is lobulated wall thickening at the gastric fundus, 5.2 x 2.2 cm in size (base width x wall thickness). Loss of normal fat plane between stomach fundus and pancreatic body is noted.
        • Adenocarcinoma of the stomach fundus with direct pancreatic invasion (T4b) is suspected. Please correlate with gastroscopy.
      • There is an ill-defined poor enhancing mass lesion in the pancreatic body and tail, measuring 6.8 x 2.6 cm in size, with suggestive celiac trunk invasion and splenic vein encasement.
        • Adenocarcinoma of the pancreatic body and tail (T4) is suspected.
        • The differential diagnosis includes adenocarcinoma of the stomach with direct pancreatic invasion.
        • Please correlate with EUS-guided biopsy.
      • There are several enlarged nodes in the gastrohepatic ligament and hepatoduodenal ligament that are c/w regional lymph node metastases.
      • There is a poor enhancing mass 5.4 cm in S8/4 of the liver that is c/w metastasis (M1).
        • In addition, there is one enlarged node 1.87 cm in left para-aortic space that is c/w non-regional lymph node metastasis (M1).
    • Impression:
      • Adenocarcinoma of the stomach fundus with direct pancreatic invasion (T4b) is suspected. Please correlate with gastroscopy.
      • Adenocarcinoma of the pancreatic body and tail (T4) is suspected.
        • The differential diagnosis includes adenocarcinoma of the stomach with direct pancreatic invasion.
        • Please correlate with EUS-guided biopsy.
      • Liver metastasis 5.4 cm in S8/4.
        • CT-guided biopsy is indicated to R/O gastric or pancreatic origin.

[MedRec]

  • 2018-06-07, -03-15, 2017-07-03 SOAP Family Medicine Lin ChunYu
    • Diagnosis
      • IDA, unspecified [D50.9]
      • Other abnormal blood chemistry [R73.9]
    • Prescription x3
      • Foliromin (sodium ferrus citrate 50mg) 1# QD

[immunochemotherapy]

  • 2024-02-19 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 80mg D5W 250mL 2hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2500mg NS 500mL 46hr (Opdivo + 80% FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2024-02-06 - ………………………… oxaliplatin 85mg/m2 80mg D5W 250mL 2hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2000mg NS 500mL 46hr (80% FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2024-01-17 - ………………………… oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-02-20

[monitoring leukopenia in FOLFOX patient, G-CSF not used, dose reduction initiated]

The initial administration of FOLFOX occurred on 2024-01-17. Subsequently, an episode of leukopenia developed in late Jan and early Feb, with a nadir WBC count of 2.67 K/uL. No record of G-CSF administration was found in the HIS5. The patient then recovered, with a WBC count of 12.17 K/uL on 2024-02-18. As of today, no further evidence of leukopenia has been observed.

  • 2024-02-18 WBC 12.17 x10^3/uL
  • 2024-02-05 WBC 2.67 x10^3/uL
  • 2024-01-30 WBC 2.67 x10^3/uL
  • 2024-01-19 WBC 9.53 x10^3/uL
  • 2024-01-09 WBC 10.34 x10^3/uL

Due to the leukopenic episode, the FOLFOX dose has been reduced by approximately 20% since the second administration, which commenced on 2024-02-06.

[long-term Foliromin for iron deficiency: re-check ferritin (MCV trend down) to guide future supplementation]

The patient has a long-standing history of Foliromin (sodium ferrous citrate) prescription by our family medicine specialist for iron deficiency anemia, dating back to at least 2017.

A ferritin level of 12.1 ng/mL was measured on 2023-11-29, which falls within the lower end of the reference range. However, MCV continues to show a slowly downward trend.

  • 2023-11-29 Ferritin 12.1 ng/mL

  • 2024-02-18 MCV 85.4 fL

  • 2024-02-05 MCV 87.0 fL

  • 2024-01-30 MCV 87.9 fL

  • 2024-01-19 MCV 86.1 fL

  • 2024-01-09 MCV 87.5 fL

  • 2023-11-29 MCV 89.0 fL

  • 2023-09-06 MCV 88.6 fL

  • 2023-06-13 MCV 94.9 fL

  • 2022-12-19 MCV 97.7 fL

  • 2022-09-19 MCV 96.8 fL

  • 2022-06-25 MCV 96.9 fL

  • 2022-03-29 MCV 97.7 fL

  • 2022-01-05 MCV 98.1 fL

Given that previous ferritin measurements were performed approximately every 3 months, it is recommended to consider a repeat test to obtain an updated iron storage level. This will inform the decision regarding whether to re-administer iron supplements.

700293834

240220

[exam findings]

  • 2024-02-20 Sigmoidoscopy
    • Findings
      • up to 10cm, lumen narrowing, and radation procitis is seen.
      • check from distal T colstomy and stool obstruction
    • Diagnosis
      • rectum stenosis, can not evaluate primary site
  • 2024-02-08 CT - abdomen
    • Findings
      • S/P operation. Progression of live metastases.
      • Multiple lung metastases.
      • A nodule (2.8cm) in right thyroid gland.
      • A cystic lesion (3.5x4.8cm) in left perineum.
      • Retroversion of uterus. Nodules (up to 2.4cm) in uterus.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P operation. Progression of live metastases.
      • Multiple lung metastases.
  • 2023-11-01 CT - abdomen
    • Prior CT identified liver metastases on both lobes are noted again, mild decreasing in size that are c/w stable disease.
  • 2023-07-31 CT - abdomen
    • Rectal cancer s/p colostomy with liver meta, lung meta. The metastatic lesion regressed slightly. The primary tumor is statinary or minimally regressed.
    • Cystic lesionat left perineum measuring 5.9cm in largest dimension, r/o bartholin cyst.
  • 2023-04-24 All-RAS + BRAF mutation
    • Cellblock No. S2023-05853
    • RESULTS:
      • ALL-RAS: Detected (KRAS codon 12 GGT>GAT, p.G12D)
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-04-22 CT - chest
    • Left lower lobe lung meta. 1.75cm
    • Thyroid metastatic lesion at right lobe. 3.1cm
    • Liver meta at both lobes.
  • 2023-04-10 PET scan
    • Increased FDG uptake in the rectal region, compatible with the primary rectal cancer.
    • Increased FDG uptake in both left and right lobes of the liver, highly suspected rectal cancer with distant metastases.
    • Increased FDG uptake in the left lower lung, highly suspected cancer (rectal or thyroid cancer with distant mets ?), suggesting biopsy for investigation; increased FDG uptake in the left upper lung, the nature is to be determined (inflammation process or cancer with lung mets ?), suggesting follow-up.
    • Increased FDG uptake in both right and left lobes of the thyroid gland, highly suspected another pirmary thyroid cancer, suggesting biopsy (right lobe) for investigation. .
    • Rectal cancer with liver and lung metastasis, cTxNxM1b, stage IVB (AJCC 8th ed.) and highly suspected another primary thyroid cancer, by this F-18 FDG PET scan.
  • 2023-03-29 Patho - colon biopsy
    • Colorectum, upper rectum, biopsy — Adenocarcinoma.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-03-21 Gynecologic Ultrasonography
    • Subserosal myoma 37.3 x 26.2 mm, posterior
    • Bilateral ovarian cysts

[MedRec]

  • 2023-04-18 ~ 2023-04-25 POMR Colorectal Surgery Lv ZongRu
    • Discharge diagnosis
      • Rectal cancer with multiple liver and left lung metastasis, cT4aN2aM1b, stage IVb status post T loop colostomy and port-a insertion, left after left cephalic vein exploration on 2023/04/19. ECOG:0.
      • Secondary malignant neoplasm of unspecified lung
      • Secondary malignant neoplasm of liver and intrahepatic bile duct
    • CC
      • for enterostomy and Consult GS for Port-A implantation.
    • Present illness
      • This is a 54 year old woman with the history of 1) bilateral breast fibroadenomas, 2) rectum adenocaircinam with lumen narrowing was diagnosed in 2023-03.
      • She was just discharged from our CRS ordinary ward on 2023/03/31 under the tentative diagnosis as rectal cancer with multiple liver and lung metastasis.
      • The pathology showed adenocarcinoma. Arrange whole body PET scan showed rectal cancer with liver and lung metastasis, cTxNxM1b, stage IVB and highly suspected another primary thyroid cancer.
      • After discussion, neoadjuvant CCRT was suggested. This time, she is admitted to our ward for enterostomy and Consult GS for Port-A implantation.
    • Course of inpatient treatment
      • After admittion, she was under surgery of T loop colostomy and Port-A insertion on 2023/04/19.
      • NPO with adequate IV fluid supplement and empirical antibiotic treatment with Soonmelt was use after operation.
      • Surgical wound pain was under the medications control. Tolerable oral diet was noted after operation and intravenous fluid supplement was tappered down.
      • Education on care of colostomy was done. Consulted radiation oncology and hematology oncology for neo-adjuvant CCRT. Suggest arrange Chest CT was perfromed on 2023/04/22. The report showed left lower lobe lung meta about 1.75cm; thyroid metastatic lesion at right lobe about 3.1cm; liver meta at both lobes.
      • The post-operative course was relatively smooth without complication. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. She was discharged today and OPD follow-up was arranged.
    • Discharge prescription
      • Deflam-K (diclofenac 25mg) 1# TID
      • Foliromin (ferrous sodium citrate 50mg) 1# QD
      • MgO 250mg 1# TID
  • 2023-03-22 ~ 2023-03-31 POMR Colorectal Surgery Lv ZongRu
    • Discharge diagnosis
      • Rectal cancer with local abscess, and multiple liver with lung metastasis, stage IVb
    • CC
      • Lower abdominal pain for 5 days.
      • Noticed granular bloody stool since 2 months ago
    • Present illness
      • This is a 54 year old woman with the history of bilateral breast fibroadenomas. This time, was admitted due to lower abdominal pain for 5 days.
      • The patient noticed granular bloody stool since 2 months ago. There was no abdominal discomfort then. However, she encountered sudden dull pain at lower abdomen on the following days 5 days ago. It was a suprapubic pain with radiation to right flank with shaking chills for 2 days. She had nausea and vomitted once. Thus, she came to our ER on 2023/03/21 for help.
      • At ER, chills and fever up to 38.2 was noted. PE showed periumbilical tenderness without rebounding pain. Lab data revealed neutrophil predominant leukocytosis WBC 17660/ul with elevated CRP 11.59. Anemia Hb 8.3.
      • ABD CT showed thickening wall of rectosigmoid colon with focal loculated fluid, r/o colon malignancy with rupture and abscess, suspect metastasis to liver. LLL tumor, r/o malignancy. GB stone. and a soft tissue tumor, 6.5cm, r/o uterine myoma.
      • She was referred to CRS OPD next day with blood test showed CEA 186.2ng/mL and highter CRP level to 13.97.
      • Thus, under the impression of abscess of intestine r/o malignancy, she was admitted for further treatment and evaluation.
    • Course of inpatient treatment
      • After admission with ward routine and blood examination were done. NPO and nutrition support by PPN and IV fluids hydration, antibiotic treatment. On full liquid diet was started on 2023/03/27 after abdominal discomfort and general condition subsided. Arrange sigmoidfiberscopy for biopsy was performed on 2023/03/28. No nausea and no vomiting, stools and flatus passage. On semi-liquid diet was started on 2023/03/30. Well bowel movement and stools passage with diet fair tolerant. Now, the patient no fever and no complication. Discharged in general condition stable on 2023/03/31 and will follow up in our out-patient department next week.
    • Discharge prescription
      • MgO 1# TID
      • Through (sennoside 12mg) 1# HS
      • Transamin (tranexamic acid 250mg) 1# BID
      • Curam (amoxicillin 875mg, clavulanic acid 125mg) 1# Q12H

[surgical operation]

[radiotherapy]

[chemotherapy]

  • 2024-02-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL + fluorouracil 2400mg/m2 3820mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2024-01-24 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL + fluorouracil 2400mg/m2 3840mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2024-01-02 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL + fluorouracil 2400mg/m2 3850mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-12-06 - (Avastin + FOLFOX)
  • 2023-11-09 - (Avastin + FOLFOX)
  • 2023-10-20 - (Avastin + FOLFOX)
  • 2023-10-04 - (Avastin + FOLFOX)
  • 2023-09-13 - (Avastin + FOLFOX)
  • 2023-08-21 - (Avastin + FOLFOX)
  • 2023-07-28 - (Avastin + FOLFIRI)
  • 2023-07-12 - (Avastin + FOLFIRI)
  • 2023-06-20 - (Avastin + FOLFIRI)
  • 2023-05-30 - (Avastin + FOLFIRI)
  • 2023-05-08 - (FOLFIRI)

==========

2024-02-20

On 2024-02-19, the patient received Avastin + FOLFOX during her current hospital stay. Lab values obtained on the same date were unremarkable except for an elevated alkaline phosphatase level at 154 U/L.

A subsequent sigmoidoscopy performed on 2024-02-20 revealed luminal narrowing up to 10cm from the anal verge. This finding suggests rectal stenosis and precluded evaluation of the primary tumor site.

No medication discrepancies were identified during the review.

700360174

240220

[lab data]

2023-07-14 Anti-HBc Reactive
2023-07-14 Anti-HBc-Value 7.77 S/CO
2023-07-14 Anti-HBs 437.04 mIU/mL
2023-07-14 HBsAg Nonreactive
2023-07-14 HBsAg (Value) 0.26 S/CO

[exam findings]

  • 2023-12-29 SONO - thyroid gland
    • Enlargement of right thyroid gland with some nodules (up to 2.72cm) and calcification (0.65cm).
  • 2023-12-29 CT - abdomen
    • Findings: Comparison prior CT dated 2023/07/03.
      • Prior CT identified wall thickening of the rectum and regional LAP are noted again, decreasing in size that is c/w rectal cancer S/P CCRT with partial response.
      • Prior CT identified a hypodense lesion in left adrenal gland, 2.5 cm x 1.8 in size and 9 HU at non-enhanced CT, is noted again, stationary.
        • Adenoma of left adrenal gland is highly suspected.
      • There are several gallstones.
      • Bil. renal cysts (up to 3.1cm). Tiny calcifications in both kidneys.
      • Abdominal aorta shows atherosclerosis and ectasia 2.4 cm.
      • Absence of left thyroid gland.
        • Enlargement of right lobe thyroid with poor enhancing nodules (up to 1.7 cm). Please correlate with sonography to R/O nodular goiter.
      • There is aneurysmal dilatation of ascending thoracic aorta, 5 cm in diameter.
      • There are several enlarged LNs at the mediastinum and axillary regions, and some of them show calcification component.
        • Old inflammatory process is highly suspected.
        • In addition, there are several small calcifications in LUL of the lung that are c/w old granulomas.
      • The urinary bladder shows small contracted and diffuse wall thickening. please correlate with clinical condition.
    • Impression:
      • Prior CT identified wall thickening of the rectum and regional LAP are noted again, decreasing in size that is c/w rectal cancer S/P CCRT with partial response. Please correlate with colonoscopy.
  • 2023-11-28 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 26) / 79 = 67.09%
      • M-mode (Teichholz) = 66
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA and aortic root, thickening of LVPW
      • Grade 1 LV diastolic dysfunction
      • Mild AR
  • 2023-11-16 Cardiac Catheterization
    • Finding Summary
      • Left Radio cephalic AVF, draining left innominate vein: 68% stenosis. AV fistula.
    • Intervention Summary
      • Left Radio cephalic AVF, draining left innominate vein, Pre-DS = 68%
        • MLD/RVD=8.8/17.88 mm -> 21.58/26.81 mm, Post-DS = 20%.
        • Guide Wire: Terumo Radifocus 0.035 150cm.
        • Balloon: Bard ATLAS. 16.0 X 40 mm. Pressure: 10 atmospheres.
    • In conclusion :
      • S/P PTA for left radiocephalic AVF, drainig left innominate vein stenosis, successful, from 68% to 20% residual stenosis
    • Recommendation :
      • PTA Intervention
      • treatment: Antegrade
  • 2023-11-16 Peropheral Vascular Test: AV fistula
    • Clinical diagnosis: AVF dysfunction
    • Result:
      • The venous Duplex study revealed a left radiocephalic AVF. Aneuruysmal dilatation at the cannulation sites were detected, with venous diameter at A cannulation site and V cannulation site around 19.1mm and 20.9mm respectively. The draining cephalic vein was small but patent. The draining basilic vein to axillary vein were also patent.
      • The estimated flow volume measured at the feednig radial artery was 3207 ml/min.
      • Subcutaneous tissue edema at left forearm was noticed.
      • The measured MVO/SVC ratio at right arm level was 100%, indicated no significant right central venous stenosis or obstruction.
      • Right side:
        • SVC: 10.2 mmHg ;
        • MVO/SVC: 100 % ;
        • Average MVO/SVC: 100 %
    • Suggestion
      • Left central venous stenosis is highly suspected according the clinical presentation and past history.
      • IV DSA and PTA prn will be arranged.
      • Suggestion: PTA
  • 2023-07-06 PercutaneousTransluminal Angioplasty, PTA
    • Past Medical History
      • The patient has a history of CAD s/p PCI and thoracic aorta aneurysm.
    • Indication
      • The patient was referred with marked swelling of left arm and left forearm. The procedure was explained in detail to the patient and family. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
    • Approach
      • Percutaneous access was performed through the av shunt fistula where a 8F sheath was inserted.
    • Procedure
      • The patient was taken to the cardiac catheterization laboratory in the TZU CHI Taipei Hospital. Heart institute and prepared in the usual sterile fashion. The contrast material used was Omnipaque 350 40cc. The patient was treated with dormicum (Dosage=2.5 mg).
    • Finding Summary
      • Left Radio cephalic AVF, left innominate vein : 81% stenosis. AV fistula.
    • Intervention Summary
      • Left Radio cephalic AVF, draining left innominate vein, Pre-DS = 81%
      • MLD/RVD=4.5/23.5 mm → 20.3/22.6 mm, Post-DS = 10%.
      • Guide Wire: Terumo Radifocus 0.035 150cm.
      • Balloon: Bard ATLAS. 16.0 X 40 mm. Pressure: 10 atmospheres.
    • In conclusion :
      • S/P PTA for left radiocephalic AVF, draining left innominate vein, successful, from 81% to 10% residual stenosis
    • Recommendation :
      • PTA Intervention Treatment: Antegrade
  • 2023-07-04 Patho - colon biopsy
    • Large intestine, lower rectum, 3-5 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2023-07-03 CT - abdomen
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of rectum with adjacent fat stranding and regional LAP.
      • Absence of left thyroid gland. Enlargement of right thyroid gland with nodules (up to 9mm).
      • Some LNs at mediastinum, axillary regions.
      • Left adrenal nodule (2.5cm).
      • Enlargement of prostate.
      • Bil. renal cysts (up to 3.1cm). Tiny calcifications in both kidneys.
      • Normal appearance of liver, spleen, pancreas.
      • Tiny gallbladder stones.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • Some calcifications at bilateral lungs.
    • Addendum Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2023-02-22 CTA - chest
    • Indication: aortic root dilatation hx, acute pul. edema, r/o aortic disseciton
    • With and without contrast enhancement CT of chest shows:
      • No intimal flap, nor intramural hematoma of aorta. Dilatation of aortic root, 5.0cm.
      • No filling defect of pulmonary artery.
      • Suspect stenosis of coronary artery, left anterior descending artery (Srs:8;Img:62).
      • No definite lung consolidation.
      • Small mediastinal lymph nodes.
      • No pleural lesion.
      • Polycystic kidney disease.
      • No bony destructive lesion on these images.
    • Impression
      • No CT-evidence of aortic dissection or pulmonary embolism
      • Aortic root dilatation
      • Suspect coronary artery stenosis, LAD

[MedRec]

  • 2023-07-20 SOAP Radiation Oncology
    • P: Admission for infusional or oral 5-FU (UFUR)
    • Prescription
      • Vemlidy (tenofovir alafenamide 25mg) 1# QW135 (after dialysis on QW1,3,5)
  • 2023-07-14 SOAP Radiation Oncology
    • Plan: CT-simulation will be arranged on 7/18. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 7/20 or 21.
  • 2023-07-13 SOAP Hemato-Oncology
    • O: Will decide what regimen
    • A: Now on HD on W1, 3, 5, Noon time
  • 2023-07-13 SOAP Colorectal Surgery
    • A/P: Conclusion of Cancer Multidisciplinary Team Meeting, Meeting Date: 2023-07-11
      • CCRT (TNT) then OP
  • 2023-07-03 ~ 2023-07-05 POMR Colorectal Surgery
    • Discharge diagnosis
      • Rectal cancer with bleeding, cT4aN2aM0, STAGE:IIIC
      • End stage renal disease
      • Chronic ischemic heart disease, unspecified
      • Chronic systolic (congestive) heart failure
      • Thoracic aortic aneurysm (50 mm)
      • Enlargement of prostate
      • Left adrenal nodule
      • Pure hypercholesterolemia
    • CC
      • Bloody stool for 1 day
    • Present illness
      • This is a 70-year-old male with underlying history of ESRD QW135, CHF, and CAD s/p stent placement. He was admitted this time due to bloody stool for 1 day.
      • He was in his usual status of health until 1 days ago at midnight, when he started to defecate blood clot about 300ml. Then during hemodialysis, another episode of bloody stool was noted, therefore he was sent directly to our ER. After arrival at our ER, no bloody stool was noted. He was currently taking Bokey due to CAD s/p stent status. He denied history of peptic ulcer disease, HBV, HCV infection history,dizziness, abdominal pain, chest tightness or pain.
      • At ER, T/P/R: 36.6/107/18. BP:153/93mmHg. Con’s:E4V5M6. SpO2:95%. PE showed pink conjunctiva, no abdominal tenderness. Lab data showed hyperkalemia, BUN/Cr 107/10.1, WBC 9.34. Sigmoidoscopy showed several 0.2-0.3 cm IIa polyps at sigmoid colon. An ulcerative tumor was noted at lower rectum about 3-5 cm above anal verge, and Internal hemorrhoid. Abdominal CT showed rectal wall thickening r/o tumor. Under the impression of rectal ulcerative tumor bleeding, he was admitted for supportive treatment.
    • Course of inpatient treatment
      • After admission, abdominal CT showed rectal wall thickening r/o tumor. Sigmoidoscopy showed several 0.2-0.3 cm IIa polyps at sigmoid colon. An ulcerative tumor was noted at lower rectum about 3-5 cm above anal verge, and Internal hemorrhoid. The patient had no bloody stool after admission. Due to stable condition, and the patient requested for AV shunt occlusion management, the patient was discharged on 2023/7/5. Regular OPD f/u is arranged. Subsequent chemotherapy may be arranged after definite staging could be done after pathology report.
  • 2023-05-10 SOAP Cardiology
    • A: In stationary condition now, no subjective complaints, asked for drug refill, acceptable BP control, keep on current medications
    • Prescription
      • Atozet (ezetimibe 10mg, atorvastatin 20mg) 1# QD
      • Bokey (aspirin 100mg) 1# QD
      • Coxine (isosorbide-5-mononistrate 20mg) 1# BID
      • Nebilet (nebivolol 5mg) 0.5# BID
  • 2017-09-14 SOAP Cardiology
    • S: A case of chronic GN with ESRD under regular hemodialysis since 2013, QW1,3,5 night
    • Diagnosis
      • Chronic ischemic heart disease, unspecified [I25.9]
      • Chronic systolic (congestive) heart failure [I50.22]
      • End stage renal disease [N18.6]
      • Dependence on renal dialysis [Z99.2]
      • Pure hypercholesterolemia [E78.0]
    • Prescription
      • Vytorin (ezetimibe 10mg, simvastatin 20mg) 0.5 HS
      • Plavix (clopidogrel 75mg) 1# QD
      • Hexal (carvedilol 25mg) 0.5# QD
      • Bokey (aspirin 100mg) 1# QD
  • 2017-01-06 SOAP Nephrology
    • S: ESRD on HD 3
    • O: regular HD 3
    • Diagnosis: Chronic renal failure [N18.6]
  • 2017-01-04 SOAP Nephrology
    • S: ESRD on HD 2
    • O: regular HD 2
    • Diagnosis: Chronic renal failure [N18.6]
  • 2017-01-02 SOAP Nephrology
    • S: ESRD on HD 1
    • O: regular HD 1
    • Diagnosis: Chronic renal failure [N18.6]

[consultation]

  • 2023-12-28, -12-12, -11-10, -10-17, -09-22, -08-24, -07-27, -07-03 Nephrology
    • A: We will arrange hemodialysis QW135 for the patient during the course of hospitalization. Please prescribe EPO 5000 IU QW if Hb < 11.
  • 2023-01-16 Cardiology
    • Q
      • SOB since last night, denied chest pain, denied inadequate H/D recently
      • Allergy: AZ COVID Vaccine
      • PH:
        • CAD, CAG was arranged next month
        • ESRD, H/D QW135
        • Thoracic aneurythm
    • A
      • 69 year-old male had the history of :
        • heart failure
        • CAD, s/p LAD stent
        • ESRD
        • AsAo aneurysm, 48mm noted since 2020 (AsAo grafting had been discussed with the patient)
      • ECG 20230116 sinus, Q wave at inferior wall?
      • Echocardiogram 20230104
        • AO(mm) = 40.7
        • LA(mm) = 34.8
        • IVS(mm) = 13.2
        • LVPW(mm) = 12.5
        • LVEDD(mm) = 55.4
        • M-mode(Teichholz) = 43.7
        • TR: mild; Max pressure gradient = 26 mmHg
        • Conclusion:
          • Dilated LA and LV
          • Concentric LV hypertrophy
          • Global LV hypokinesis with impaired LV systolic function
          • Adequate RV systolic function
          • Possibly impaired LV relaxation
          • Calcified mitral annulus with mild MR, mild AR, TR and PR
      • SPECT 20221229
        • Probably mild myocardial ischemia at the apex, anteroseptal wall and anterolateral wall.
        • Mild reverse redistribution of radioactivity to the inferolateral wall, either normal variant or myocardial ischemia may show this picture.
      • The patient visited emergency department on 2023/01/16 morning due to dyspnea for one night. Elevating NTproBNP level was found. Chest film showed lung infiltration, suspected lung edema.
      • impression
        • Acute lung edema, CRP 0.93
        • heart failure
      • plan
        • as Scheduled hemodialysis
        • repeat TnI and ECG after dialysis
        • oxygen supplement and monitor breath pattern
        • book ICU for respriatory distress
          • If lung edema improves after hemodialysis, may re-evaluate the clinic condition
        • echocardiogram and SPECT done recently

[radiotherapy]

[chemotherapy]

  • 2024-02-19 - oxaliplatin 40mg/m2 50mg D5W 250mL 2hr + leucovorin 100mg/m2 150mg NS 250mL 2hr + fluorouracil 100mg/m2 150mg NS 100mL 10min + fluorouracil 600mg/m2 990mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2024-02-02 - oxaliplatin 40mg/m2 50mg D5W 250mL 2hr + leucovorin 100mg/m2 150mg NS 250mL 2hr + fluorouracil 100mg/m2 150mg NS 100mL 10min + fluorouracil 600mg/m2 990mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2024-01-16 - oxaliplatin 40mg/m2 50mg D5W 250mL 2hr + leucovorin 100mg/m2 150mg NS 250mL 2hr + fluorouracil 100mg/m2 150mg NS 100mL 10min + fluorouracil 600mg/m2 990mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-12-29 - oxaliplatin 40mg/m2 50mg D5W 250mL 2hr + leucovorin 100mg/m2 150mg NS 250mL 2hr + fluorouracil 100mg/m2 150mg NS 100mL 10min + fluorouracil 600mg/m2 990mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-12-12 - oxaliplatin 40mg/m2 50mg D5W 250mL 2hr + leucovorin 100mg/m2 150mg NS 250mL 2hr + fluorouracil 100mg/m2 150mg NS 100mL 10min + fluorouracil 600mg/m2 990mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-10 - oxaliplatin 40mg/m2 50mg D5W 250mL 2hr + leucovorin 100mg/m2 150mg NS 250mL 2hr + fluorouracil 100mg/m2 150mg NS 100mL 10min + fluorouracil 600mg/m2 990mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-18 - oxaliplatin 40mg/m2 50mg D5W 250mL 2hr + leucovorin 100mg/m2 150mg NS 250mL 2hr + fluorouracil 100mg/m2 150mg NS 100mL 10min + fluorouracil 600mg/m2 1090mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-23 - oxaliplatin 40mg/m2 50mg D5W 250mL 2hr + leucovorin 100mg/m2 150mg NS 250mL 2hr + fluorouracil 100mg/m2 150mg NS 100mL 10min + fluorouracil 600mg/m2 1000mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-25 - [fluorouracil 400mg/m2 700mg NS 100mL 10min + leucovorin 20mg/m2 35mg NS 100mL 10min] D1,4,6-7 (CCRT)
  • 2023-08-02 - [fluorouracil 400mg/m2 700mg NS 100mL 10min + leucovorin 20mg/m2 35mg NS 100mL 10min] D1,3-6 (CCRT)

==========

2024-02-20

[uremic pruritus management in hemodialysis: potential safety concerns with levocetirizine, examining ketotifen possibility]

This hemodialysis patient reports insufficient itch relief with Allegra (fexofenadine), potentially indicating uremic pruritus. Consequently, Allegra has been replaced with Xyzal (levocetirizine).

Caution is warranted, as levocetirizine undergoes minimal metabolism (85.8% excreted unchanged). Additionally, it is nondialyzable (<10% removed during a standard 4-hour dialysis session, three times weekly). Therefore, its use is generally contraindicated in hemodialysis patients.

Even in exceptional circumstances where its use is considered, short-term administration is highly recommended to minimize drug accumulation.

One potentially safer alternative therapy to consider is ketotifen. Notably, the manufacturer’s labeling does not include specific dosage adjustments for hemodialysis patients.

Despite the lack of specific guidance, ketotifen offers several potential advantages: it undergoes extensive metabolism in humans, resulting in only three identifiable metabolites detected in urine. Additionally, reported cases of oral ingestion at up to 60 times the recommended dose did not result in fatalities. These factors suggest a potentially favorable safety profile compared to levocetirizine in this patient population.

2024-01-16

The patient’s current medication, as listed in the active medication list, is appropriately adjusted for his hemodialysis schedule of QW135.

2023-09-25

This patient’s PharmaCloud is currently inaccessible. After reviewing the HIS5 records, no medication reconciliation issues were identified.

2023-08-30

Our cardiologist provided a repeat prescription for Atozet (ezetimibe, atorvastatin), Bokey (aspirin), Coxine (isosorbide-5-mononitrate), and Nebilet (nebivolol). All of these drugs are currently listed in the active medication record, and no issues with medication reconciliation have been identified.

2023-08-09

[optimal dosage adjustment of metoclopramide for intermittent hemodialysis patients]

Metoclopramide is not effectively removed during dialysis. Therefore, it is advisable to administer approximately one-third (or less) of the standard total daily dose for patients undergoing intermittent (three times weekly) hemodialysis. ref: Metoclopramide kinetics in patients with impaired renal function and clearance by hemodialysis. Clin Pharmacol Ther. 1985;37(3):284-289. doi:10.1038/clpt.1985.41

700506064

240220

[exam findings]

  • 2021-11-09 Patho
    • Diagnosis
      • Ovary, bilateral, debulking surgery - Residual high grade serous carcinoma
      • Fallopian tube, bilateral, ditto - High grade serous carcinoma
      • Endometrium, uterus, ditto - Free from tumor, endometrial polyp
      • Myometrium, uterus, ditto - Tumor invasion, focal
      • Tumor on bladder, ditto - Tumor present
      • Tumor on rectum, ditto - Tumor present
      • Lymph node, L’t iliac artery, dissection - Tumor metastasis (1/4) without extracapsular extension (0/1)
      • Lymph node, R’t iliac artery, ditto - Tumor metastasis (1/3) without extracapsular extension (0/1)
      • Lymph node, R’t obturator nerve, ditto - Tumor metastasis (1/6) without extracapsular extension (0/1)
      • AJCC Pathologic staging: ypT3cN1a, if cM0; stage IIIC
    • Microscopic Exam
      • Histologic type: high-grade serous carcinoma (refer to S2021-05715)
      • Histologic grade: high grade
      • Contralateral ovary involvement: present
      • Tumor side ovarian surface involvement: present
      • Contralateral ovary involvement: present
      • Right tube involvement: present
      • Left tube involvement: present
      • Right adnexa soft tissue involvement: present
      • Left adnexa soft tissue involvement: present
      • Uterine serosa involvement: present
      • Endometrium involvement: absent, endometrial polyp
      • Myometrium involvement: present, focal
      • Lymph nodes metastasis: tumor metastasis (3/19) without extracapsular extension (0/3) in total number
      • Lymphovascular space invasion: present
      • Tumor on bladder: high grade serous carcinoma with necrosis and microcalcification
      • Tumor on rectum: high grade serous carcinoma with necrosis and microcalcification
    • 2021-04-15 Patho - peritoneum biopsy
      • Peritoneum, debulking -Metastatic serous carcinoma, compatible with fallopian tube or ovarian origin
      • The sections show metastatic serous carcinoma, high grade, compatible with fallopian tube or ovarian origin, composed of nests of pleomorphic neoplastic cells with numerous mitotic figures, arranged in solid and papillary patterns. Scattered psammoma bodies and tumor necrosis are noted.
      • IHC: ER(+), WT1(+), PAX8 (+), p53(+ with aberrant expression).
  • 2021-04-14 Ascites
    • Smears show clusters of pleomorphic tumor cells. Malignancy is favored.
  • 2021-04-14 Frozen Section
    • Peritoneal tumor, frozen section - Malignant, favor serous carcinoma.

[consultation]

  • 2024-01-21 General and Gastrointestinal Surgery
    • Q
      • Abdominal pain > Transferred from another hospital. ABC CT diagnosed ileus
      • abd. pain and vomiting +
      • no fever
      • no chest pain
      • PH: ovarian cancer s/p C/T
      • NKA
    • A
      • impression
        • mechanical ileus, suspect ovarian cancer with peritoneal carcinomatosis related, or adhesion related
        • no signs of bowel strangulation
      • suggest
        • NPO
        • IVF supply
        • NG decompression if necessary

[chemotherapy]

  • 2024-01-16 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr IVF

    • dexamethasone 2mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-12-19

  • 2023-11-16

  • 2023-10-18

  • 2023-09-20

  • 2023-08-23

  • 2023-07-25

  • 2023-07-04

  • 2023-06-21

  • 2023-05-24

  • 2023-05-09

  • 2023-04-25

  • 2023-04-11

  • 2023-03-28

  • 2023-03-15

  • 2023-03-07

  • 2023-02-21

  • 2023-02-27

  • 2023-01-31

  • 2023-01-10

  • ……….

  • 2021-12 ~ 2023-04 - Paclitaxel + Carboplatin

  • 2021-11 ~ 2021-11 - Liposome Doxorubicin + Carboplatin

  • 2021-09 ~ 2021-10 - Paclitaxel

  • 2021-05 ~ 2021-09 - Paclitaxel + Carboplatin

==========

2024-02-20

[tube feeding]

There are 2 oral drugs - Norvasc and Alpraline included in the active medicatin list. Both of them can be tube fed.

2022-01-26

  • Paclitaxel + Carboplatin is preferred as an primary systemic therapy regimen for high-grade serous stage II-IV disease.
  • Albumin-bound paclitaxel could be substituted for patients experiencing a hypersensitivity reaction to paclitaxel.
  • Bevacizumab (or its biosimilar) might be an optional component to the aforementioned regimen.
  • for elderly patients and/or those with comorbidities and/or intolerence, the following adjustment might be considered.
    • paclitaxel 60mg/m2 IV over 1 hour followed by carboplatin AUC 2 IV over 30 minutes
    • days 1, 8, 15; repeat every 21 days
  • no issue found in active medication.

700553809

240220

[lab data]

2023-09-30 Anti-HBc Nonreactive
2023-09-30 Anti-HBc Value 0.08 S/CO
2023-09-30 Anti-HBs 0.17 mIU/mL
2023-09-30 HBsAg Nonreactive
2023-09-30 HBsAg Value 0.39 S/CO
2023-09-30 Anti-HCV Nonreactive
2023-09-30 Anti-HCV Value 0.08 S/CO

2023-07-03 CA125 158.1 U/mL
2023-02-15 CA125 107.4 U/mL

[exam findings]

  • 2023-12-29 Fundus color photo
    • Result: abnomal
    • Clinical diagnosis: retinal break
    • Report: c/d 0.6 ou, pigmented break at 6o’c and dot hemorrhage at 3o’c os
  • 2023-12-29 Microsonography
    • Clinical diagnosis: staphyloma ou
    • Report: RNFL 66/0.67/diffuse thin 70/0.79/falsely detected PPA, staphyloma ou
  • 2023-12-28 Fundus color photo
    • L Eye: nonproliferative diabetic retinopathy, NPDR - moderate
    • R Eye: nonproliferative diabetic retinopathy, NPDR - moderate
  • 2023-09-15 Patho - uterus (with or without SO) neoplastic
    • PATHOLOGIC DIAGNOSIS
      • Endometrium, uterus, staging surgery — Endometrioid carcinoma
      • Myometrium, uterus, ditto — Tumor invasion, more than half thickness
      • Cervix, uterus, ditto — Endocervical stromal invasion
      • Ovary, left, ditto — Free of tumor invasion, cystic follicle
      • Fallopian tube, left, ditto — Free of tumor invasion
      • Ovary, right, ditto — Free of tumor invasion
      • Fallopian tube, right, ditto — Free of tumor invasion
      • Lymph node, right iliac, dissection — Free of tumor metastasis (0/7)
      • Lymph node, right oburator, ditto — Free of tumor metastasis (0/3)
      • Lymph node, left iliac, ditto — Tumor metastasis (2/10)
      • Lymph node, left oburator, ditto — Free of tumor metastasis (0/2)
      • AJCC Pathologic stage — pT2N1a, if cM0, stage IIIC1 / FIGO stage IIIC1
      • 2023 FIGO staging — Stage IIIC1ii
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: staging surgery (TAH, BSO and BPLND)
      • Specimens include: uterus with bilateral adnexa and pelvic LNs
      • Specimen size:
        • uterus: 8.6 x 6.2 x 4.5 cm in size, 147 gm in weight
        • right ovary: 2.3 x 1.2 x 0.9 cm
        • left ovary: 2.3 x 1.6 x 1.5 cm
        • right fallopian tube: 4 cm in length; 0.5 cm in diameter
        • left fallopian tube: 4 cm in length; 0.5 cm in diameter
      • Tumor site: endometrium
      • Tumor size: 3.3 x 2.8 cm
      • The myometrium: tumor invasion greater than 1/2 thickness
      • The cervix : mucus cysts
      • Bilateral adnexa: Not invaded by tumor
      • Lymph nodes: left iliac LNs; left obturator LNs; right iliac LNs and right obturator LNs
      • Representative sections as A: right iliac LNs; B: right obturator LNs; C1-C2: left iliac LNs; D: left obturator LNs, E1: R’t ovary, E2: R’t F-tube, E3: L’t ovary, E4: L’t F-tube, E5-E7: uterus from fundus to cervix, E8-E12: tumor + serosa (ink), E13-E15: low segment of uterus to cervix
    • MICROSCOPIC EXAMINATION
      • Histology type: endometrioid carcinoma
      • Histology grade: grade 1
      • Depth of invasion: greater than half thickness of myometrium
      • Lymphovascular invasion: identified
      • The cervical stroma involvement: involved
      • Resection margins of the cervix: Free, 3 cm away from tumor
      • Additional pathologic findings: squamous metaplasia
      • Lymph nodes: metastatic carcinoma (2/10) in left iliac LNs without extracapsular extension (0/2)
      • Immunohistochemistry: P16(+, patchy), PMS2(+), MSH2(+), MSH6(+) and MLH1(+) for tumor
      • Ascites cytology: positive
  • 2023-09-15 Body fluid cytology - ascites
    • 37 cc orange cloudy ascites — Malignancy
    • The smears show lymphocytes, reactive mesothelial cells and hyperchromatic atypical epithelial clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
  • 2023-07-27 MRI - pelvis
    • Clinical history: 52 y/o female patient with Uterus, endometrium, D&C — endometrioid adenocarcinoma, grade 1. IHC stains: p53 (wild type); Napsin-A (-), ER (+, 50%, strong intensity), PR (+, 50%, strong intensity), vimentin (focal +), p16 (+), CK5/6 (focal +).
    • With and without contrast enhancement MRI: Pelvis
      • Soft tissue tumor in the uterine wall(fundus and body), involvement of more than half of myometrium, r/o endometrial malignancy.
      • More prominent soft tissue in the ovary.
      • There are lymph nodes, up to 0.7cm, in right obturator region. suggest follow up.
      • Cysts in the uterine cervix, suggesting Nabothin cysts.
      • Presence of ascites in the pelvic cavity.
      • Presence of perineural cyst in S1 region.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T:T1b(T_value) N:N0(N_value) M:M0(M_value) STAGE:_ IB___(Stage_value)
    • Impression:
      • Endometrial malignancy, cstage T1bN0M0.
      • Small lymph nodes in right obturator region, suggest follow up.
      • Prominent soft tissue in right ovary, nature?
      • Nabothin cysts.
  • 2023-07-17 Patho - endometrium curretage/biopsy
    • Uterus, endometrium, D&C — endometrioid adenocarcinoma, grade 1.
    • IHC stains: p53 (wild type); Napsin-A (-), ER (+, 50%, strong intensity), PR (+, 50%, strong intensity), vimentin (focal +), p16 (+), CK5/6 (focal +).
  • 2023-07-12 Gynecologic ultrasonography
    • R/O Adenomyosis
    • R/O Endometrial thickening, EM 23.5mm
  • 2023-02-15 Gynecologic ultrasonography
    • Adenomyosis

[MedRec]

  • 2023-12-28 SOAP Metabolism and Endocrinology Yu LiJiao
    • Prescription x3
      • Blopress (candesartan 8mg) 1# HS
      • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID
      • Norvasc (amlodipine 5mg) 1# QD
      • Zulitor (pitavastatin 4mg) 1# Q3D
      • Uformin (metformin 500mg) 0.5# BID
      • Lipanthyl Supra (fenofibrate 160mg) 1# QOD
  • 2023-10-05 SOAP Metabolism and Endocrinology Yu LiJiao
    • Prescription x3
      • Blopress (candesartan 8mg) 1# HS
      • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID
      • Norvasc (amlodipine 5mg) 1# QD
      • Zulitor (pitavastatin 4mg) 1# Q3D
      • Uformin (metformin 500mg) 0.5# BID
  • 2023-09-28 SOAP Radiation Oncology Huang JingMin
    • A: Endometrioid carcinoma of the uterine endometrium, grade 1, AJCC Pathologic stage pT2N1a, cM0, stage IIIC1 / FIGO stage IIIC1. 2023 FIGO stage IIIC1ii, s/p staging surgery (ATH + BSO + BPLND)
    • P: Radiotherapy is indicated for this patient with the following indicators: FIGO stage IIIC1. 2023 FIGO stage IIIC1ii
      • Goal: curative
      • Treatment target and volume: pelvic area
      • Technique: VMAT/IGRT and IVRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions via IVRT to vaginal cuff mucosa surface.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient. She understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-10-11.
  • 2023-08-10 SOAP Metabolism and Endocrinology Yu LiJiao
    • Prescription x2
      • Blopress (candesartan 8mg) 1# HS
      • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID
      • Norvasc (amlodipine 5mg) 1# QD
      • Zulitor (pitavastatin 4mg) 0.5# QN
      • Uformin (metformin 500mg) 0.5# BID
  • 2023-05-11 SOAP Metabolism and Endocrinology Yu LiJiao
    • Prescription x3
      • Blopress (candesartan 8mg) 1# HS
      • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID
      • Norvasc (amlodipine 5mg) 1# QD
      • Zulitor (pitavastatin 4mg) 0.5# QN

[surgical operation]

  • 2023-09-14
    • Surgery
      • Diagnosis: Endometrial cancer
      • Operation: Staging surgery (ATH + BSO + BPLND)   - Finding
      • Uterus: normal size, without invasion to myometrium, cervix was grossly normal.
      • Adnexa:
        • LOV: 2x1x1cm, capsule intact, smooth surface.
        • ROV: 2x1x1cm, capsule intact, smooth surface.
        • Fallopian tube: bilateral grossly normal
      • CDS: free of adhesion, mild clear ascites
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • Bladder and rectum: Normal
      • Omentum: Normal
      • Anti-adhesive agent: Arista
      • Estimated blood loss: 150ml
      • Blood transfusion: nil.
      • Complication: nil.
  • 2023-07-17
    • Surgery
      • Diagnosis: R/O endometrial hyperplasia
      • Surgery: Dilatation and curettage
    • Finding
      • Uterus: Anteversion, 10 cm.
      • Some hyperplastic tissues with blood clots were curetted out.
      • Estimated blood loss: 10 mL, Blood transfusion: nil, complication: nil.   

[radiotherapy]

  • 2023-10-18 ~ 2023-11-30 - 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT. (20231212 SOAP)

[chemotherapy]

  • 2024-02-20 - paclitaxel 175mg/m2 360mg NS 300mL 3hr + cisplatin 75mg/m2 150mg NS 500mL 2hr (Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2024-01-29 - paclitaxel 175mg/m2 355mg NS 300mL 3hr + cisplatin 75mg/m2 150mg NS 500mL 2hr (Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2024-01-05 - paclitaxel 175mg/m2 360mg NS 250mL 3hr + cisplatin 75mg/m2 150mg NS 500mL 2hr (Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-11-15 - cisplatin 40mg/m2 80mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (Gao WeiYao)
    • dexamethasone 4mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) + NS 250mL
  • 2023-11-08 - cisplatin 40mg/m2 80mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (Gao WeiYao)
    • dexamethasone 4mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) + NS 250mL
  • 2023-11-01 - cisplatin 40mg/m2 80mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (Gao WeiYao)
    • dexamethasone 4mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) + NS 250mL
  • 2023-10-23 - cisplatin 40mg/m2 80mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (Xia HeXiong)
    • dexamethasone 4mg + Akynzeo (netupitant 300mg, palonosetron 0.5mg) + NS 250mL

==========

2024-02-20

[low Mg detected, MgSO4 IVD started & high glucose]

Lab on 2024-02-19 showed Mg 1.4 mg/dL, indicating hypomagnesemia, MgSO4 IVD is in use since 2024-02-20 with no discrepancy.

Blood glucose 331 mg/dL on 2024-02-20 05:07, regular insulin could be considered to mitigate the hyperglycemia.

2024-01-29

[hypomagnesemia detected]

The eGFR has improved to 62, and cisplatin continues to be included in the treatment regimen.

  • 2024-01-28 eGFR 62.36 ml/min/1.73m^2
  • 2024-01-12 eGFR 39.52 ml/min/1.73m^2
  • 2024-01-04 eGFR 56.41 ml/min/1.73m^2

On 2024-01-28, serum magnesium was measured at 1.5 mg/dL, prompting the administration of magnesium sulfate injection. Apart from hypomagnesemia, other laboratory findings and vital signs are grossly within normal limits, with no issues detected.

2024-01-05

[declining eGFR: consider carboplatin over cisplatin]

This is the patient’s initial administration of paclitaxel alongside cisplatin. There is a potential for additive myelosuppressive effects, so it’s important to closely monitor the patient’s CBC and WBC DC for at least three weeks following the treatment.

On 2024-01-04, the patient’s eGFR of 56.41 confirmed a decrease in renal function. Given this decline trend and no contraindications, it is recommended to use carboplatin as a substitute for cisplatin.

  • 2024-01-04 eGFR 56.41 ml/min/1.73m^2
  • 2023-12-19 eGFR 76.43 ml/min/1.73m^2
  • 2023-11-28 eGFR 70.52 ml/min/1.73m^2
  • 2023-11-21 eGFR 77.51 ml/min/1.73m^2
  • 2023-11-14 eGFR 75.38 ml/min/1.73m^2
  • 2023-11-07 eGFR 79.75 ml/min/1.73m^2
  • 2023-10-31 eGFR 68.73 ml/min/1.73m^2
  • 2023-10-12 eGFR 79.75 ml/min/1.73m^2
  • 2023-09-27 eGFR 96.20 ml/min/1.73m^2
  • 2023-09-13 eGFR 103.17 ml/min/1.73m^2

700870154

240220

[MedRec]

  • 2023-12-13 ~ 2024-01-10 POMR Hemato-Oncology Yang MuJun
    • Discharge diagnosis
      • Diffuse large B-cell lymphoma, intra-abdominal lymph nodes, stage III, chemotherapy with RCDOP Q3W for 6 cycles (Lipodox by self-payment) (First time only RCOP) from 2024/01/03~
      • Encounter for antineoplastic chemotherapy
      • Acute gastric ulcer without hemorrhage or perforation
      • Heart failure, unspecified
      • Anemia, unspecified
      • Thrombocytopenia, unspecified
      • Unspecified sequelae of cerebral infarction
      • Dyspnea
      • Cerebral infarction, unspecified
    • CC
      • tarry stool for one week
    • Present illness
      • This is a 72 year-old female who has following underlying diseases:
        • CVA
        • Heart failure
      • Patient had upper abdominal discomfort since August, started to feel dyspnea since September, edema since the end of October.
      • She had tarry stool since last week, and it happened everyday.
      • Patient also had left chest stuffy pain but not exacerbated by inspiration.
      • At the ER, patient conscious is clear. Patient had normal skin tugor, clear breathing sounds, and regular heart beat. Lab data: Neutrophil 83%. Lymphocyte 7.7%. HGB 6.6 g/dL. After blood transfusion during ER, HGB had come to 9.4 g/dL.
      • PA/ AP chest film shows: Ground glass opacity in RLL. Upper GI endoscopy: mucosa break<5mm was noted at EC junction. Erythenatous change of gastric mucosa wash found. One 3mm clean-based, Forrest classification III ucler, with surrounding mucosal swelling was noted at the angle. One 2mm sessile polyp was noted at middle body. No bleeding was noted.
      • Under impression of anemia caused by gastric ulcer, she was admitted to our ward for further evaluation.
    • Course of inpatient treatment
      • After adimission we checked her lab dat on 12/14 and showed anemia and thrombocytopenia, with platelets initially low at 24,000 and increased to 50,000 after the transfusion of 4 units of blood.
      • Thus, we consulted Hematologist for her, surgical lymphnode biopsy and further hematology studies were suggested.
      • We also consulted Cardiovascular Specialist and Chest Specialest for her edema to rule out heart failure or pulmonary embolism.
      • 2-D echo showed normal LV systolic function and chest echo showed pleural uffsion but hold fine needle aspiration due to coagulopathy pending corrected.
      • Diurectics and albumin were prescribed for lower limbs edema and pleural effusion.
      • We consulted General Surgeon for her lymphnode excission biopsy and was arranged on 12/21.
      • Pathology report on 12/25 revealed Diffuse-type B cell lymphoma.
      • Thus, the patient was reffered to Oncology ward for further treatment.
      • After Oncology ward, consult surgical for port-a insertion and well done on 12/29.
      • PET scan on 2024/01/02 initially shows Upper and lower mediastinal cavity metastasis.
      • Chemotherapy with First-line for diffuse large B-cell lymphoma, RCDOP Q3W for 6 cycles (Lipodox by self-payment) (First time only RCOP) from 2024/01/03(C1).
      • Additionally, we continued blood transfusion for anemia and thrombocytopenia.
      • PPI iv form for 2024/01/01 stool OB shows 4+. Follow CxR no significantly abnormal on 2024/01/05.
      • For sore throat intermittent, follow rapid test of COVID and influenza A+B were negative.
      • Repeated laboratory data was WBC 4180/uL, HGB 8.5mg/dl, PLT 57000/uL on 2024/01/10.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2024/01/10 and OPD followed up later.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H if pain or fever > 38’C
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Folacin (folic acid 5mg) 1# QD
      • Fudecough (dextromethorphan 15mg) 1# TID
      • Smecta (dioctahedral smectite 3mg) 1# PRNTIDAC if watery stool
      • Uretropic (furosemide 40mg) 0.5# QD
      • Nincort Oral Gel (triamcinolone 1mg/gm) BID TOPI
      • Cravit (levofloxacin 500mg) 1.5# QDAC
      • lysozyme 90mg 1# TID
      • Pariet (rabeprazole 20mg) 1# QDAC
  • 2017-02-23 SOAP Neurology Xiao ZhenLun
    • Diagnosis
      • Unspecified late effect of cerebrovascular disease [I69.30]
      • Fasciitis,unspecified [M72.9]
    • Prescription x3
      • MgO 250mg 1# QD
      • Bokey (aspirin 100mg) 1# QD

[immunochemotherapy]

  • 2024-02-19 - rituximab 375mg/m2 540mg NS 500mL 7hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + vincristine 1.4mg/m2 2mg NS 50mL 15min + prednisolone 60mg/m2 85mg QD PO D1-5 (R-CHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2024-01-29 - rituximab 375mg/m2 540mg NS 500mL 7hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + liposome doxorubicin 30mg/m2 20mg D5W 250mL 2hr + vincristine 1.4mg/m2 2mg NS 50mL 15min + prednisolone 60mg/m2 85mg QD PO D1-5 (R-CHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2024-01-03 - rituximab 375mg/m2 540mg NS 500mL 7hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min …………………………………………. + vincristine 1.4mg/m2 2mg NS 50mL 15min + prednisolone 60mg/m2 85mg QD PO D1-5 (R-CVP or R-COP)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-02-20

[immunochemo with graded doxorubicin addition & electrolyte management]

Liposomal doxorubicin was incorporated into the existing immunochemotherapy regimen on a gradual basis. The initial dose of 20mg was administered on 2024-01-29, followed by an escalation to 40mg on 2024-02-19.

Concomitantly, Const-K and calcium carbonate were used to manage hypokalemia (3.2mmol/L) and hypocalcemia (1.99mmol/L), respectively. No medication discrepancies were identified.

2024-01-26

[managing low platelet counts during cancer treatment]

Since Dec 2023, this patient has exhibited persistent thrombocytopenia, well before starting the R-COP regimen on 2024-01-03. While R-COP may contribute to this condition, it should not be considered the sole cause. Thrombocytopenia could also be a manifestation of the patient’s underlying DLBCL.

  • 2024-01-26 PLT 39 *10^3/uL
  • 2024-01-15 PLT 35 *10^3/uL
  • 2024-01-10 PLT 57 *10^3/uL
  • 2024-01-08 PLT 52 *10^3/uL
  • 2024-01-07 PLT 53 *10^3/uL
  • 2024-01-06 PLT 19 *10^3/uL
  • 2024-01-05 PLT 30 *10^3/uL
  • 2024-01-04 PLT 11 *10^3/uL
  • 2024-01-03 PLT 16 *10^3/uL
  • 2023-12-31 PLT 20 *10^3/uL
  • 2023-12-30 PLT 32 *10^3/uL
  • 2023-12-28 PLT 25 *10^3/uL
  • 2023-12-26 PLT 29 *10^3/uL
  • 2023-12-25 PLT 29 *10^3/uL
  • 2023-12-20 PLT 33 *10^3/uL
  • 2023-12-18 PLT 19 *10^3/uL
  • 2023-12-14 PLT 42 *10^3/uL
  • 2023-12-12 PLT 50 *10^3/uL
  • 2023-12-12 PLT 67 *10^3/uL
  • 2023-12-11 PLT 58 *10^3/uL
  • 2023-12-11 PLT 24 *10^3/uL
  • 2023-11-19 PLT 170 *10^3/uL

Patients being treated with cytotoxic chemotherapy have a suppressed bone marrow that often cannot produce adequate platelets. It is recommended to use prophylactic platelet transfusion in these settings, assuming the patient is hospitalized, afebrile, and without active infection. A threshold platelet count of 10K/uL (transfuse for a platelet count < 10K/uL) is generally used. If fever, sepsis, or coagulopathy is present, or if the patient is not hospitalized and/or cannot be closely monitored, higher thresholds may be needed. (Ref: https://www.uptodate.com/contents/platelet-transfusion-indications-ordering-and-associated-risks)

700953527

240220

[MedRec]

  • 2023-11-21 SOAP Cardiology Liu ZhiRen
    • Diagnosis
      • HCVD, benign without CHF [I11.9]
      • Anxiety state, unspecified [F41.9]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Mixed hyperlipidemia [E78.2]
    • Prescription x3
      • Tulip (atorvastatin 20mg) 1# QW14
      • Diovan (valsartan 160mg) 1# QD
      • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# QD
  • 2022-12-01 SOAP Hemato-Oncology Xia HeXiong
    • Prescription
      • Tagrisso (osimertinib 80mg) 1# QD
  • 2022-11-17 SOAP Hemato-Oncology Xia HeXiong
    • S
      • EGFR: Exon 19 deletion (+)
      • ALK (-)
      • ROS1 (-)
      • 22C3 TPS 2%
      • 28-8 TC < 1%
      • SP142 TC 0%, IC 0%
  • 2022-10-20 SOAP Ear Nose Throat Huang TongCun
    • O
      • 2022/10/14 PATHO - lymphnode biopsy
        • Labeled as “right lower neck”, core needle biopsy — soft tissue with invasive carcinoma.
        • IHC stains: TTF-1 (+), Napsin-A (+), S-100 (-), Dog-1 (-), p63 (-), CK7 (+), Ki-67: 10%.
  • 2022-10-03 SOAP Ear Nose Throat Huang TongCun
    • S: tumor board suggest tumor marker test and sono guided biopsy
    • O:
      • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2022-09-30
        • test tumor marker: CA125, CA153, CA199, CEA, etc.
        • arrange image guided biopsy (neck LN)
  • 2022-01-18 SOAP Ear Nose Throat Huang TongCun
    • O
      • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2021-12-17
        • Please ask the Pathology Department to reconfirm the pathological results. Is it a local in situ carcinoma, or an invasive cancer that has metastasized to the neck from another site?
    • A/P
      • Left lower neck mass (noted since 2016), favor benign nature because stable size (only increase a little) during follow up
      • size increase noted in 2021-10, excision on 2021-11-30 showed compatible with low-grade intraductal carcinoma of salivary gland
  • 2021-12-21 SOAP Radiation Oncology Huang JingMin
    • O
      • Lymphnode aspiration, 2021-11-3: Left lower neck mass — Atypia.
      • MRI: Nasopharynx (2021-11-13): Post operative appearance in and around the area of left parotid gland, seems stationary.
      • Operation (2021-11-30): Excision of left neck mass
      • Pathology (S2021-17525, 2021-12-02): Soft tissue, lower neck, left, excision — Compatible with low-grade intraductal carcinoma of salivary gland. Surgical margins: Free of tumor.
  • 2018-10-30, -08-07, -05-15, -02-20, 2017-11-28, -09-05, -06-13, -03-21 SOAP Cardiology Liu ZhiRen
    • Diagnosis
      • HCVD,benign without CHF [I11.9]
      • Anxiety state, unspecified [F41.9]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Pure hyperglyceridemia [E78.1]
    • Prescription x3
      • Uformin (metformin 500mg) 1# QD
      • Diovan (valsartan 160mg) 1# QD
  • 2017-02-22 SOAP Radiation Oncology Huang JingMin
    • O:
      • Pathology (S2008-09410, 2008-07-22): nasopharynx,biopsy — negative for malignancy – lymphoid hyperplasia.
      • Pathology (S2008-06278, 2008-05-14): salivary gland, parotid, left ,total parotidectomy — acinic cell carcinoma.
        • Surgical margin, parotid, left, total parotidectomy — free (2~3mm away from tumor). The surgical margin is free and 2 to 3 mm away from tumor.
      • A: Acinic cell carcinoma of the Lt parotid gland, stage T4aN0M0 (IVA), s/p Lt total parotidectomy, with facial N adhesion, and s/p radiotherapy.
    • Diagnosis
      • Malignant parotid gland neoplasm [C07]

[consultation]

  • 2024-02-20 Radiation Oncology
    • Q
      • This 72 year old female due to LUL cancer with bony and liver metastasis, she was admitted to our oncology ward for management. This time, she suffered from legs weakness and numbness till difficult walking for one week. She was brought to our ER for help.
      • At ER, blood test showed no leukocytosis nor anemia found, no electrolyte imbalance.
      • T-spine MRI was performed which revealed multiple bone metastasis at the T-spine vertebral body and S1.
      • NS man was consulted and informed poor prognosis of the disease, already discussed with patient and family.
      • Now, we will be keep target therapy with Tagrisso treatment and given pain control.
      • Family talked about they decided do further survey by NS doctor suggested.
      • Monitor U/O for dysuria and considered Foley insertion.
      • For the metastasis of T-spine and S-spine, we sincerely need your expertise for RT. Thanks a lot.
    • A
      • ON CALL
  • 2024-02-16 Neurosurgery
    • Q
      • legs weakness and numbness till difficult walking for 1+ weeks
      • no fever
      • PH:
        • left parotid cancer (acinic cell carcinoma) s/p op by Dr Yen. on 2008-05-14 and post-op RT
        • Left lower neck mass, excision on 2021-11-30 compatible with low-grade intraductal carcinoma of salivary gland
      • 2024-01-30 pain over T spine, Xray: compression, arrange bone scan
      • 2024-02-07 multiple bony mets, add Xegeva x1, continue Tagrisso
      • 2024/02/02 Tc-99m MDP whole body bone scan IMPRESSION:
        • The scintigraphic findings suggest multiple bone metastases. In comparison with the previous study on 2023/01/31, some of the previous bone lesions in the skull, midlde T-spines, adjacent right costovertebral junctions, left acetabulum, sacrum and adjacent right S-I joint are a little more evident
    • A
      • a case of lower limbs weakness and numbness with difficulty in walking for 1+ week
      • back pain
      • lower limbs weakness and numbness
      • MRI multiple heterogeneous enhancing lesions c/w bone metastasis in the T4, T5, T6, T7, T8 and S1, causing epidural extension and moderate indentation on the T7 cord.
      • bone scan suggest multiple bone metastases. In comparison with the previous study on 2023/01/31, some of the previous bone lesions in the skull, midlde T-spines, adjacent right costovertebral junctions, left acetabulum, sacrum and adjacent right S-I joint are a little more evident.
      • CT LUL cancer with bony metastasis, stationary. obstructive airway disease in lungs.
      • Plan: poor prognosis of the disease well discussed with patient and family

[radiotherapy]

  • 2008-06-18 ~ 2008-08-01 - 6600cGy/33 fractions of the Lt parotid to neck area.

[chemotherapy]

  • 2022-12-01 ~ undergoing - Tagrisso (osimertinib 80mg) 1# QD

==========

2024-02-20

[priority issue: bone metastases impacting gait & sensation]

It appears that the bone metastases causing lower limb weakness and numbness with difficulty walking is the most important medical problem for this patient now. Radiation oncologist has been consulted. No medication discrepancy was found.

701450638

240220

[exam findings]

  • 2023-11-10 CT - abdomen
    • Findings: Comparison: prior CT dated 2023/08/18.
      • S/P LAR with autosuture retention over the rectosigmoid junction.
      • S/P colostomy at left upper pelvis and para-stromal hernia.
      • Prior CT identified multiple metastases on both hepatic lobes are noted again, mild increasing in size.
        • It is c/w multiple liver metastases S/P C/T with progressive disease.
      • Prior CT identified metastatic lymph node in hepatoduodenal ligament is noted again, stationary.
      • Prior CT identified few small metastatic nodes in para-aortic space and para-cava space are noted again, stationary that is c/w few metastatic nodes S/P C/T show stable disease.
      • Prior CT identified a lung metastasis in LLL is noted again, stable in size.
    • Impression:
      • Multiple liver metastases S/P C/T show progressive disease.
  • 2023-08-18 CT - abdomen
    • 20220906 CT: Sigmoid colon cancer with micro-perforation and attachment to bladder region and liver, lung with distant lymph nodes metastasis, cT4N2M1b, stage: IVB status post Hartmann’s operation on 2022/09/06
    • History: hepatitis B anti-Hbc: positive
    • Findings: Comparison prior chest CT dated 2023/02/21.
      • S/P LAR with autosuture retention over the rectosigmoid junction.
      • S/P colostomy at left upper pelvis.
      • Prior CT identified multiple metastases on both hepatic lobes are noted again, increasing in size.
        • Multiple liver metastases S/P C/T show progressive disease.
      • Prior CT identified metastatic lymph node in hepatoduodenal ligament is noted again, stationary.
      • Prior CT identified few small metastatic nodes in para-aortic space and para-cava space are noted again, stationary that is c/w few metastatic nodes S/P C/T show stable disease.
      • Prior CT identified a lung metastasis in LLL is noted again, mild decreasing in size.
    • Impression:
      • Multiple liver metastases S/P C/T show progressive disease.
  • 2023-05-30 Tc-99m MDP bone scan
    • Increased activity in the lower C-spine and lower L-spines. Degenerative change is more likely. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone sacn for further evaluation.
    • Increased activity in the right shoulder, right sternoclavicular junction, bilateral hips and knees, compatible with benign joint lesions.
  • 2023-05-19 CT - abdomen
    • 20220906 CT: Sigmoid colon cancer with micro-perforation and attachment to bladder region and liver, lung with distant lymph nodes metastasis, cT4N2M1b, stage: IVB status post Hartmann’s operation on 2022/09/06
    • History: hepatitis B anti-Hbc: positive
    • Findings: Comparison: prior chest CT dated 2023/02/21.
      • S/P LAR with autosuture retention over the rectosigmoid junction.
        • S/P colostomy at left upper pelvis.
      • Prior CT identified several metastases on both hepatic lobes are noted again, mild decreasing in size.
        • However, three liver metastases in S4, S5, and S6/7 are noted again, mild increasing in size.
        • Multiple liver metastases S/P C/T show stable disease.
      • Prior CT identified metastatic lymph node in hepatoduodenal ligament is noted again, stationary.
      • Prior CT identified multiple metastatic nodes in para-aortic space and para-cava space are not noted again that is c/w multiple metastatic nodes S/P C/T show complete response.
      • Prior CT identified a lung metastasis in LLL (Srs:7 Img:5) is noted again, mild decreasing in size.
    • Impression:
      • Multiple liver metastases S/P C/T show stable disease.
  • 2023-05-17 Shoulder Rt
    • AP internal and external rotation views of left shoulder show:
      • Rt osteoarthritis of A-C joint
  • 2023-04-10 SONO - abdomen
    • Liver parenchymal disease
    • liver tumors, favor metastatic tumors
    • fatty infiltration of pancres(incomplete exam of pancreas)
  • 2023-02-21 CT - chest
    • Impression: sigmoid colon cancer with lung, liver, and distant LNs metastases, in regression as compared previous CT on 2022/09/13.
  • 2022-09-13 CT - chest
    • Impression: sigmoid colon cancer with lung, liver, and distant LNs metastases, with pleural effusion.
  • 2022-09-08 All-RAS + BRAF mutation
    • All-RAS: There was no variant detected in the KRAS/NRAS gene
    • BRAF: There was no variant detected in the BRAF gene
  • 2022-09-07 Patho - colon segmental resection for tumor (Y1)
    • Diagnosis:
      • Intestine, large, sigmoid colon, Hartmann procedure - moderately differentiated adenocarcinoma
        • perforation with acute peritonitis
      • Lymph node, regional, dissection
        • metastatic adenocarcinoma (9/13)
      • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
      • AJCC 8th edition pathology stage: pT4aN2b(cM1c); AJCC stage IVC
    • Gross Description:
      • Procedure: Hartmann procedure    - Tumor Site: Sigmoid colon
      • Tumor Size: 6 x 4 cm.
      • Macroscopic Tumor Perforation: Present
      • Macroscopic Intactness of Mesorectum (if applicable): Complete
      • Sections are taken and labeled as: A1: bil cut-ends, A2-4: LNs, A5-10: tumor
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension
        • Tumor invades the visceral peritoneum (including tumor continuous with serosal surface through area of inflammation)
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Involved
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Tumor Budding
        • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2):
        • Intermediate score (5-9)
      • Type of Polyp in Which Invasive Carcinoma Arose: Absent
      • Tumor Deposits: Not identified
        • Specify number of deposits: N/A
      • Regional Lymph Nodes
        • Number of Lymph Nodes Involved/Examined: 9/13
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply)
          • m (multiple primary tumors) r (recurrent) y (posttreatment)
        • Primary Tumor (pT)
          • pT4a: Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
        • Regional Lymph Nodes (pN):
          • pN2b: Seven or more regional lymph nodes are positive
        • Distant Metastasis (pM)
          • N/A
      • Additional Pathologic Findings (select all that apply):
        • perforation with acute peritonitis
      • Ancillary Studies: Pending (IHC stain of MSI will be followed.)
      • Comment(s)
        • NOTE: There is no peritoneal tissue, adjacent organs or structures for proof of tumor invasion or metastasis.
  • 2022-09-06 CT - abdomen
    • Clinical history: 72 y/o male patient with fever for 1 day and abd pain for 1 wk, diarrhea+ for 3 months.
    • With and without contrast enhancement CT of abdomen - whole:
      • Focal thickening wall at the sigmoid colon with ulceration, r/o sigmoid colon cancer.
      • Focal air bubbles around sigmoid colon, proximal to the sigmoid tumor, r/o perforation.
      • There are poor enhancing tumors, up to 6.5cm in S4 liver, r/o liver metastasis.
      • There are multiple enlarged lymph nodes in pericolonic, common iliac and paraaortic regions.
      • Presence of ascites.
      • Left lower lung nodules, r/o lung metastasis.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)
    • Impression:
      • Sigmoid cancer with lymph nodes metastasis, liver and lung metastasis, cstage T4N2M1.
      • Focal air bubbles around sigmoid colon, proximal to the sigmoid tumor, r/o perforation.

[MedRec]

  • 2022-09-23 Gastroenterology
    • S
      • Come for NUC prophylaxis for C/T
      • First C/T scheduled on 20221003
    • O
      • PH:
        • OBI (ChatGPT: In a medical context, OBI stands for “Occult Hepatitis B Infection”. Occult Hepatitis B infection is characterized by the presence of hepatitis B virus (HBV) DNA in the liver (with detectable or undetectable HBV DNA in the serum) of individuals testing hepatitis B surface antigen (HBsAg) negative in routine assays.)
        • S-colon cancer with liver mets, s/p operation, under C/T
      • Start NUC prophylaxis. Check HBV DNA/antiHBs in advance
    • Prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
  • 2022-09-20 SOAP Hemato-Oncology
    • S: explain to pt & his wife & son about the indication & risk / benefit of palliative C/T wt FOLFIRI / Avastin IV Q2W x 12. (9/20 22).
      • 2022/09/14 HBsAg (NM) = Negative;
      • 2022/09/14 Anti-HBc (NM) = Positive;
      • 2022/09/14 Anti-HCV (NM) = Negative;
      • will consult Dr Xiao ZongXian for anti-HBV Tx for C/T (9/20 22).
      • will consult Dr Chen YanZhi for Port-A installation (9/20 22)
      • will do HBsAg, anti-HBc, anti-HCV
      • will give palliative C/T wt FOLFIRI / Avastin IV Q2W x 12. (9/20 22).
      • Adm on 10/3 22 for #1 palliative C/T wt FOLFIRI / Avastin IV Q2W x 12.
  • 2022-09-06 ~ 2022-09-14 POMR Colorectal Surgery
    • Discharge diagnosis
      • Adenocarcinoma of sigmoid colon with microperforation and attachment to bladder region and liver, lung with distant lymph nodes metastasis, cT4N2M1c, stage: IVC status post Hartmann’s operation on 2022/09/06 with lung, liver, and distant LNs metastases, with pleural effusion
      • Malignant neoplasm of sigmoid colon
    • CC
      • abdominal fullness over lower abdomen for a long time this year, assciated requent bowel movement up to 7-8 times per day, acute onset of severe abdominal cramps this morning.
    • Present illness
      • This 72-year-old man denied major systemic disease. This time, he has abdominal fullness over lower abdomen for a long time this year, assciated requent bowel movement up to 7-8 times per day, acute onset of severe abdominal cramps this morning. He was vist our GI OPD for help. Physical Exam show abdomen soft, mass like distention over lower abdomen, tympanic on percussion, dullness on percussion over pelvic region, but marked rebound tenderness over lower abdomen. KUB was performed and revaled stool retention in the bowel. Then,refer to ER for PE signs of peritonitis. At ER, the con’s clear,Vital sign TPR:38.2/110/18 BP:131/79mmHg. Abdomen CT was performed and revealed 1. Sigmoid cancer with lymph nodes metastasis, liver and lung metastasis, cstage T4N2M1, 2. Focal air bubbles around sigmoid colon, proximal to the sigmoid tumor, r/o perforation. CRS was consulted and he underwent oepration of Hartmann’s procedure. Postoperation, he was admission to SICU for further management.
    • Course of inpatient treatment
      • He underwent oepration of Hartmann’s procedure on 2022/09-06. Op finding: 1) micro perforation over sigmoid colon region and attachment to bladder region. 2) much turbid pus intra abdomen. Following the operation, he was transferred to the surgical intensive care unit for further monitoring. At SICU, he was given nothing by mouth with adequate IV fluid supplement and empirical antibiotic treatment with Brosym were prescribed. After well weaning parancter, extubation smoothly on 2022/09/07. She had passed stool with normal bowel movement. Oral intake with clear liquid diet is encouraged. Since the general condition became more stabalized, he was transferrd to ordinary ward for further care on 2022/09/08.
      • We keep antibiotic treatment with Brosym. No fever or chills, leukocytosis improved much. Early activity is encouraged. The wound healing well and no erythema change. He had flatus passage and abdominal wound pain subsided. Drain is clear ascites and removal of JP drain on 2022/09/10. Oral intake program was adjusted and there was no abdominal discomfort after trying oral intake, IV fluid supplement was tapered and discontinued later. Chest CT was done for cancer survey and showed sigmoid colon cancer with lung, liver, and distant LNs metastases, with pleural effusion. His abdominal wound pain had got much better. In stable condition, he was discharged on 2022/09/14 and will receive OPD follow up next week.
    • Prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Curam (amoxicillin 875mg, clavulanic acid 125mg) 1# Q12H
      • Acetal (acetaminophen 500mg) 1# PRNQ6H

[consultation]

  • 2024-01-02 Dermatology
    • Q
      • for acne at face, and skin itchy around whole body evaluation
      • This 73-year-old male, a patient of S-colon cancer, pT4N2M1b, stage: IVB, with microperforation and attachment to bladder region and liver, lung mets with distant LNs mets.
      • Abdomen CT (2023/11/10) revealed Multiple liver metastases S/P C/T show progressive disease. And the tumor marker level is increased, so shift to Cetuximab plus FOLFOX.
      • He complaints acne at face noted since receive targeted therapy with Erbitux, and skin itchy around whole body. So we need your help for acne evaluation, thanks a lot!!
    • A
      • The patient had sufferred from pusutlar lesions on the face and nape (the back of the neck). Besides, xerotic dermatitis was noted on the trunk.
      • Under the impression of acniform eruption and follculitis on the nape, xerotic dermatitis on the trunk.
      • The following sugeetion:
        • for face, Kolincin Gel 1 tube topical bid use over face and Zalaine cream 1 tube topical bid use over nape.
        • for trunk, agree with Mycomb and Sinphraderm use and consider add C.B Strong 2 tube topical PRN use for pruritus control.

[immunochemotherapy]

  • 2024-02-19 - cetuximab 400mg/m2 600mg 2hr + oxaliplatin 85mg/m2 110mg D5W 250mL 4hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (Erbitux + FOLFOX. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2024-01-30 - cetuximab 400mg/m2 600mg 2hr + oxaliplatin 85mg/m2 110mg D5W 250mL 4hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (Erbitux + FOLFOX. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2024-01-02 - cetuximab 400mg/m2 600mg 2hr + oxaliplatin 85mg/m2 110mg D5W 250mL 4hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (Erbitux + FOLFOX. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-12-08 - cetuximab 400mg/m2 600mg 2hr + oxaliplatin 85mg/m2 110mg D5W 250mL 4hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (Erbitux + FOLFOX. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-10 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg 500mL 46hr (Avastin + FOLFOX. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-10-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4030mg 500mL 46hr (Avastin + FOLFOX. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-09-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg 500mL 46hr (Avastin + FOLFOX. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-09-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg 500mL 46hr (Avastin + FOLFOX. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-08-17 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg 500mL 46hr (Avastin + FOLFIRI. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2023-07-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg 500mL 46hr (Avastin + FOLFIRI. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2023-07-13 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg 500mL 46hr (Avastin + FOLFIRI. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2023-06-26 - Avastin + FOLFIRI. He JingLiang
  • 2023-04-14 - Avastin + FOLFIRI. Wan XiongLin
  • 2023-03-27 - Avastin + FOLFIRI. Wan XiongLin
  • 2023-03-10 - Avastin + FOLFIRI. Wan XiongLin
  • 2023-02-21 - Avastin + FOLFIRI. Zhang ShouYi
  • 2023-02-03 - Avastin + FOLFIRI. Zhang ShouYi
  • 2023-01-06 - Avastin + FOLFIRI. Zhang ShouYi
  • 2022-12-19 - Avastin + FOLFIRI. Zhang ShouYi
  • 2022-12-05 - Avastin + FOLFIRI. Zhang ShouYi
  • 2022-11-21 - Avastin + FOLFIRI. Zhang ShouYi
  • 2022-11-07 - Avastin + FOLFIRI. Zhang ShouYi
  • 2022-10-20 - FOLFIRI. Zhang ShouYi
  • 2022-10-03 - FOLFIRI. Zhang ShouYi

==========

2024-02-20

LFTs remained elevated, BaoGan is currently being used. Other labs were largely unremarkable.

  • 2024-02-19 AST 138 U/L
  • 2024-02-19 ALT 174 U/L
  • 2024-02-19 Bilirubin direct 0.39 mg/dL

No medication discrepancy found.

2024-01-31

[high direct-to-total bilirubin ratio]

Lab data:

  • 2024-01-30 DBI/TBI 46.38 %
  • 2024-01-02 DBI/TBI 54.33 %
  • 2023-12-08 DBI/TBI 50.86 %
  • 2023-11-10 DBI/TBI 50.74 %
  • 2023-11-09 DBI/TBI 48.39 %
  • 2023-10-19 DBI/TBI 22.39 %
  • 2023-09-27 DBI/TBI 22.22 %
  • 2023-09-08 DBI/TBI 26.32 %
  • 2023-08-17 DBI/TBI 20.37 %
  • 2023-07-13 DBI/TBI 31.71 %
  • 2023-06-09 DBI/TBI 17.65 %
  • 2023-03-27 DBI/TBI 4.44 %

The ratio of direct bilirubin to total bilirubin showed an upward trend in the serial lab data. Normally, the ratio is less than 20%. A high ratio suggests a problem with the conjugation or excretion of bilirubin. Possible causes of a high ratio:

  • Intrahepatic causes:
    • Liver diseases like hepatitis, cirrhosis, or alcoholic liver disease can affect the conjugation of bilirubin.
    • Liver inflammation or damage can block the bile ducts within the liver, preventing bilirubin excretion.
  • Extrahepatic causes:
    • Gallstones blocking the common bile duct or other biliary ducts.
    • Tumors of the liver, bile ducts, or pancreas.
    • Pancreatitis causing inflammation and blockage of the bile duct.

If primary biliary cholangitis is identified, the addition of Ursodiol (ursodeoxycholic acid) might be a treatment option.

2024-01-03

[cetuximab toxicity: dose adjustment strategies]

Following the CT scan on 2023-11-10, which revealed multiple liver metastases indicating progressive disease, the treatment plan was altered from Avastin + FOLFOX to Erbitux + FOLFOX. The patient was admitted to receive the second session of the Erbitux + FOLFOX regimen.

Due to elevated levels of DBI, TBI, AST, ALT, and alkaline phosphatase, a reduced dose of the regimen was administered. Tumor markers CEA and CA199 continue to be elevated, and a significant downward trend has not been observed.

Our dermatologist has been consulted regarding the management of dermatologic toxicity and infectious sequelae associated with cetuximab, such as acneiform rash and mucocutaneous disease. The recommended approach for managing these side effects is as follows:

  • For the first occurrence of grade 3 or 4 toxicity: Delay cetuximab infusion by 1 to 2 weeks. If there is improvement, resume cetuximab at a dose of 250 mg/m2. If there is no improvement, discontinue cetuximab.
  • For the second occurrence of grade 3 or 4 toxicity: Delay cetuximab infusion by 1 to 2 weeks. If there is improvement, continue cetuximab at 200 mg/m2. If there is no improvement, discontinue cetuximab.
  • For the third occurrence of grade 3 or 4 toxicity: Delay cetuximab infusion by 1 to 2 weeks. If there is improvement, continue cetuximab at 150 mg/m2. If there is no improvement, discontinue cetuximab.
  • For the fourth occurrence of grade 3 or 4 toxicity: Permanently discontinue cetuximab.

2023-09-28

The refill of Baraclude (entecavir) prescribed by our gastroenterologist is included in the list of active medications with no discrepancy found.

2023-08-18

A 28-day supply of Baraclude (entecavir) refilled on 2023-07-25 has been added as a current use item and no medication reconciliation issues found.

2023-07-28

[liver function follow-up]

Observation shows a spike in liver enzymes, which exceeded 200 U/L in early June. Despite a visible decrease, the levels have not yet returned to the normal range. The patient is currently prescribed BaoGan (silymarin). At this time, there does not appear to be a need to change the treatment plan. Please continue to monitor the changes closely.

2023-07-26 S-GPT/ALT 97 U/L
2023-07-13 S-GPT/ALT 155 U/L
2023-07-07 S-GPT/ALT 101 U/L
2023-06-25 S-GPT/ALT 140 U/L
2023-06-21 S-GPT/ALT 156 U/L
2023-06-14 S-GPT/ALT 179 U/L
2023-06-10 S-GPT/ALT 235 U/L
2023-06-09 S-GPT/ALT 217 U/L
2023-04-26 S-GPT/ALT 27 U/L
2023-04-14 S-GPT/ALT 25 U/L

700393370

240219

[lab data]

Examination of Bone Marrow

  • 2023-12-17 clinical diagnosis leukocytosis /blast
  • 2023-12-17 Gross: Marrow +
  • 2023-12-17 Cellularity Hyper-extreme
  • 2023-12-17 Fat componemt +(Normal)
  • 2023-12-17 Megakaryocyte dist absent.
  • 2023-12-17 M/E ↑
  • 2023-12-17 M/E(/) 86/14
  • 2023-12-17 sites lliac. post. R
  • 2023-12-17 type Aspiration
  • 2023-12-17 specimen condition adequate
  • 2023-12-17 smear fair
  • 2023-12-17 Myeloblast 32 %
  • 2023-12-17 N.Myeloblast 0 %
  • 2023-12-17 N.Meta 12 %
  • 2023-12-17 N.Band 0 %
  • 2023-12-17 N.Seg. 2 %
  • 2023-12-17 Eo.Myeloblast 0 %
  • 2023-12-17 Eo.Meta 0 %
  • 2023-12-17 Eo.Band 0 %
  • 2023-12-17 Eo.Seg. 0 %
  • 2023-12-17 Baso 0 %
  • 2023-12-17 Promyelo. 0 %
  • 2023-12-17 Mono. 0 %
  • 2023-12-17 Mo.blast 42 %
  • 2023-12-17 Mo.promono. 0 %
  • 2023-12-17 Mo.mature 0 %
  • 2023-12-17 Lympho 0 %
  • 2023-12-17 Lym.blast 0 %
  • 2023-12-17 Lym.promono. 0 %
  • 2023-12-17 Lym.mature 0 %
  • 2023-12-17 Plasma Cell 0 %
  • 2023-12-17 Pro-eyth. B 0 %
  • 2023-12-17 Normoblast 0 %
  • 2023-12-17 Nor.Baso 0 %
  • 2023-12-17 Nor.polych 6 %
  • 2023-12-17 Nor.ortho. 8 %
  • 2023-12-17 Peroxidase Positive
  • 2023-12-17 LAP NA
  • 2023-12-17 CAE Positive
  • 2023-12-17 ANAE Positive
  • 2023-12-17 Iron stain NA
  • 2023-12-17 PAS NA
  • 2023-12-17 Other stains NA
  • 2023-12-17 Description see comment
  • 2023-12-17 Comments see comment

2023-12-15 FLT3-D835 (bone marrow) Undetectable
2023-12-15 FLT3/ITD (bone marrow) Presence of mutation
2023-12-15 NPM1 (qualitative, BM) Undetectable

2023-12-07 Anti HTLV I/II Nonreactive
2023-12-07 Anti HTLV I/II Value 0.06 S/CO

2023-12-05 Anti-HCV Nonreactive
2023-12-05 Anti-HCV Value 0.30 S/CO
2023-12-05 HBsAg Reactive
2023-12-05 HBsAg (Value) 4397.98 S/CO

[exam findings]

  • 2024-01-23 Microsonography
    • Conclusion: borderline glaucoma
    • Report: disc OCT
    • OD 84um/0.64
    • OS85um/0.58
    • macular OCT
    • OD252
    • OS257um
  • 2024-01-17 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — acute myelogenous leukemia.
    • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 1:2. Three cell lineages are present with left shift of leukocytes.
    • IHC stains: CD117: 10 %; CD34: 25 %; MPO: 35-40 %, CD61: 5 %; CD71: 55-60% (of the nucleated cells).
  • 2024-01-14 CXR
    • S/P nasogastric tube insertion
    • S/P PICC catheter insertion via right forearm.
    • Enlargement of cardiac silhouette.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2024-01-14 KUB
    • S/P nasogastric tube insertion
    • Fecal material store in the distal descending colon, sigmoid colon, and rectum.
    • A calcification projecting at left middle pelvis is noted. Please correlate with CT.
  • 2023-12-21 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A(minimal)
      • Gastric erosions, antrum
      • Pangastritis
      • Duodenal ulcer scar, bulb
    • CLO test: not done
    • Suggestion: PPI use
  • 2023-12-21 ElectroEncephaloGram, EEG
    • Abnormal, continuing generalized slowing with theta waves 5-6 Hz, indicated moderate cortical dysfunction bilaterally, suggest clinical correlation.
  • 2023-12-20 CT - brain
    • Indication: AML
    • Head CT without contrast enhancement shows:
      • brain atrophy with prominent sulci, fissures and dilated ventricles.
      • confluent hypodensity at bilateral periventricular white matter, indicating leukoaraiosis.
      • bilateral paranasal sinusitis change.
    • Impression:
      • Brain atrophy and leukoaraiosis.
      • Bilateral paranasal sinusitis.
  • 2023-12-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (86.8 - 25.1) / 86.8 = 71.08%
      • M-mode (Teichholz) = 71.1
    • Conclusion:
      • Adequate LV systolic function with no regional wall motion abnrmality at resting state
      • Mild MR, TR and PR
      • Mildly thick IVS
      • Sinus tachycardia during the exam, HR 103-109bpm during the exam
  • 2023-12-05 Patho - bone marrow biopsy
    • DIAGNOSIS:
      • Bone marrow, iliac, biopsy — see description.
    • GROSS DESCRIPTION:
      • Specimen submitted in B5 fixative consists of 1 piece(s) of tan, rod shape bone marrow tissue measuring 0.6 x 0.2 x 0.2 cm. All for section in one cassette after decalcification.
    • MICROSCOPIC DESCRIPTION:
      • Section shows piece(s) of bone marrow with 40% cellularity and M:E ratio of approximately 3:1. A predoimant lymphoid subpopulation is present in the marrow
      • IHC stains:
        • CD117: <1 %; CD34: <1 %; MPO: 2 %, CD61: <1 %; CD71: <1 % (of the nucleated cells).
        • The hemogram shows up to 58% blasts. The marrow smear shows many blasts.
        • These findings suggest biopsy specimen might not be representative.
        • Considering the hemogram and smear findings, acute leukemia is considered.

[chemotherapy]

  • 2023-12-07 - daunorubicin 45mg/m2 76mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 170mg NS 500mL 24hr D1-7
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-7

==========

2024-02-19

[tube-feeding]

The 2 drugs in the active medication list - Anxiedin (lorazepam) and Brintellix (vortioxetine) can both be tube-fed.

[AML suppression & transfusion: prophylactic approach at 10K PLT & beyond petechiae]

Patients with AML can have suppressed bone marrow from AML and/or chemotherapy. It is generally recommended to use standard dose prophylactic transfusion of these patients at a threshold platelet count of 10K/uL, and transfusion for any bleeding greater than petechial bleeding.

  • 2024-02-18 PLT 20 *10^3/uL
  • 2024-02-15 PLT 7 *10^3/uL
  • 2024-02-05 PLT 9 *10^3/uL
  • 2024-01-31 PLT 70 *10^3/uL
  • 2024-01-30 PLT 27 *10^3/uL
  • 2024-01-29 PLT 77 *10^3/uL
  • 2024-01-28 PLT 12 *10^3/uL
  • 2024-01-23 PLT 9 *10^3/uL
  • 2024-01-18 PLT 22 *10^3/uL
  • 2024-01-16 PLT 23 *10^3/uL
  • 2024-01-15 PLT 27 *10^3/uL

2024-01-29

[assessing anemia progression after recent LPRBC use]

The anemia observed appears to have intensified, following the administration of Leukocyte-Poor Red Blood Cells (LPRBC) on 2024-01-28. Should this condition persist, further LPRBC transfusions might be necessary.

  • 2024-01-29 HGB 7.8 g/dL
  • 2024-01-28 HGB 8.5 g/dL
  • 2024-01-23 HGB 9.0 g/dL

[considering additional induction for inconsistent blast reduction]

Given that the blast count has not consistently remained below 5% (2024-01-17 bone marrow biopsy pathology IHC MPO 35-40 %) following the initial administration of the standard 7+3 regimen (2023-12-07 started) combined with Rydapt (midostaurin) for FLT3 mutation, it is advisable to proceed with a second cycle of induction therapy promptly, provided the patient’s condition allows for it.

  • 2024-01-29 Blast 5.1 %
  • 2024-01-28 Blast 2.0 %
  • 2024-01-23 Blast 4.0 %
  • 2024-01-18 Blast 4.1 %
  • 2024-01-16 Blast 3.2 %
  • 2024-01-14 Blast 5.3 %
  • 2024-01-09 Blast 10.0 %
  • 2024-01-05 Blast 1.0 %

[implementing simple suspension for esomeprazole tube feeding]

All oral medications listed as active can be administered via tube feeding. However, for Nexium (esomeprazole), it is recommended not to crush the tablets due to manufacturer guidelines. Instead, a simple suspension method (SSM) should be used to prepare the medication for tube administration.

The simple suspension method, also known as the water bath method, is a technique used to disperse solid oral medications into a liquid for administration through a nasogastric (NG) tube. This method is often used for patients who are unable to swallow tablets or capsules, such as those with dysphagia, a feeding tube, or a coma.

To perform the simple suspension method:

  • Place the medication in a small cup or bowl.
  • Add enough warm water to cover the medication.
  • Stir or shake the mixture until the medication is dissolved or dispersed into small enough particles or completely dissolved.
  • Administer the mixture through the NG tube using a syringe or feeding pump.

Tips for using the simple suspension method:

  • Use warm water to help dissolve the medication.
  • Stir or shake the mixture vigorously to ensure that the medication is completely dispersed.
  • If the medication is a capsule, you may need to open it and remove the contents before dissolving it.

2023-12-18

[anemia and neutropenia]

Blood product transfusion is recommended for anemia. For anticipated severe neutropenia (absolute neutrophil count [ANC] < 500 for more than 7 days), prophylactic antibiotics such as ciprofloxacin or levofloxacin may be considered as a preventive measure.

[Rydapt (midostaurin) underdosed]

On 2023-12-05, the patient tested positive for HBsAg, indicating a current infection. Baraclude (entecavir 0.5mg) has been prescribed at a dosage of 1# QDAC.

The FLT3/ITD mutation was detected on 2023-12-15. Rydapt (midostaurin) is recommended at a dosage of 50 mg twice daily from days 8 to 21 of each induction cycle, in combination with daunorubicin and cytarabine. A second induction cycle is advised if there is clear evidence of significant residual leukemia. Presently, Rydapt (midostaurin) is being administered at 25mg BID, which is half the recommended dose. It is therefore suggested to increase the dosage to the recommended 50mg BID.

700737864

240219

[exam findings]

  • 2023-07-18 Long Bones Series
    • An osteolytic lesion in right proximal femur is highly suspected. Please correlate with CT.
  • 2023-07-18 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — myeloma.
    • Specimen submitted in B5 fixative consists of 2 piece(s) of tan, rod shape bone marrow tissue measuring 1.2 x 0.2 x 0.2 cm. All for section in one cassette after decalcification.
    • Section shows piece(s) of bone marrow with 60% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes with many plasmacytoid cells. Megakaryocytes are adequate in number.
    • IHC stains: CD138 70% (of the nucleated cells); Kappa and lambda light chains: a predominant kappa stain (of the CD138 positive cells).
  • 2023-06-20 SONO - nephrology
    • Bilateral parenchymal renal disease with small left kidney
    • Single renal cyst, right kidney
    • Nephrolithiasis, left kidney

[MedRec]

  • 2023-08-11 SOAP Hemato-Oncology Gao WeiYao
    • Prescription
      • Thado (thalidomide 50mg) 2# HS
  • 2023-07-28 SOAP Hemato-Oncology Gao WeiYao
    • O:
      • Lab 2023/07/13 B2-microglobulin (NM) = 3.12 mg/L
      • Lab 2023/07/13 Anti-HBc (NM) = Positive
      • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-07-24
        • multiple myeloma ISS lambda type stage I, use VTd regimen
    • A: Multiple myeloma, kappa, IgG, ISS stage I with anemia and kidney invlvement
  • 2023-07-17 ~ 2023-07-19 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • monoclonal gammopathy
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
      • Chronic kidney disease, unspecified
    • CC
      • for multiple myeloma survey
    • Present illness
      • This 58-year-old man has history of 1) DM, hypertension for 5-6 years and hyperlipidemia under medication treatment, 2) LUS s/p ESWL on 2017/8 and 2022/07; 3) TRUSP biopsy on 2020/12 and pathology showed stromal and glandular hyperplasia; 4)Left ureteral stone s/p left ureterorenoscopic lithotripsy with double-J stenting on 2022-11-18.
      • He has refered to ONC OPD due to presence of paraprotein on 2023/07/03. He complaint of severe low back pain and usually general bone pain bother him. Due to M-peak postive, so he was admitted for bone marrow exam plus cytogenetic and staging, skeletal survey on 2023/07/17.
    • Course of inpatient treatment
      • After admission, he received bone marrow for monoclonal gammopathy survey and pending report. Tramacet 1tab Q12H for lower back pain control. Under the stable condition, he can be discharged on 2023/7/19. OPD follow up is arranged.
    • Discharge prescription
      • Valtrex (valaciclovir 500mg) 2# Q12H
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ12H
  • 2023-07-10 SOAP Hemato-Oncology Gao WeiYao
    • O:
      • Lab 2023/07/04 IgG (blood) = 2542 mg/dL;
      • Lab 2023/06/27 Free Light Chain kappa/lambda
        • FKLC = 60.9 mg/L;
        • FLLC = 17.1 mg/L
    • A: Multiple myeloma should be ruled in; IgG
  • 2023-07-09 SOAP Hemato-Oncology Gao WeiYao
    • O: 2023/06/23 M-peak = Positive;
  • 2022-11-18 ~ 2022-11-19 POMR Urology Xu JunKai
    • Discharge diagnosis
      • Left ureteral stone status post left ureterorenoscopic lithotripsy with double-J stenting on 2022-11-18
      • Acute kidney failure, suspect ureter stone obstruction related
      • Left hydronephrosis
      • Type 2 diabetes mellitus without complications
      • Hyperlipidemia, unspecified
      • Essential (primary) hypertension
    • CC
      • Left flank soreness off and on was found in this month.
      • Voiding difficulty was also noted
    • Present illness
      • This 58-year-old man has history of 1) DM, hypertension and hyperlipidemia under medication treatment; 2) LUS s/p ESWL on 2017-08 and 2022-07; 3) TRUSP biopsy on 2020-12 and pathology showed stromal and glandular hyperplasia.
      • According for this patient statement, left flank soreness off and on was found in this month. Voiding difficulty was also noted. He then visited our OPD for further help where KUB revealed left renal stones. Renal echo revealed left hydronephrosis.
      • Under the impression of left hydronephrosis suspect upper ureteral stone, we advised the patient to receive left URSL. After well explaining, the patient agreed. This time, he was admitted for further evaluation and management.
    • Course of inpatient treatment
      • After admission, the surgery of left ureterorenoscopic lithotripsy with double J stenting was performed on 2022-11-18. Postoperative course was uneventful. With fair urination and stable condition, he was discharged today and would be followed up at urologic clinic.
    • Discharge prescription
      • cephalexin 500mg 1# TID
      • Acetal (acetaminophen 500mg) 1# PRNQID
  • 2017-12-23 SOAP Urology Xu JunKai
    • Diagnosis
      • Nocturia [R35.1]
      • Hypertrophy (benign) of prostate [N40.1]
      • Elevated prostate specific antigen (PSA) [R97.2]
    • Prescription x3
      • Harnalidge (tamsulosin 0.4mg) 1# QDAC
  • 2017-01-06 SOAP Metabolism and Endocrinology Yu LiJiao
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Dyslipidemia ; other and unspecified hyperlipidemia [E78.5]
      • Essential (primary) hypertension [I10]
    • Prescription x3
      • Aprovel (irbesartan 300mg) 1# QD
      • Cardizem Retard (diltiazem 90mg) 1# QN
      • Uformin (metformin 500mg) 1# BID

[surgical operation]

  • 2022-11-18
    • Operation
      • Ureterorenoscopic lithotripsy & double-J stenting, left
    • Finding:
      • One 0.7 x 0.6 cm brownish stone impacted at left middle ureter with polyposis and hydroureter
      • ureter orifice is very near bladder neck

[chemotherapy]

  • 2024-02-06 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2024-01-30 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2024-01-23 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2024-01-16 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2024-01-10 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2023-12-19 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2023-12-12 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2023-12-05 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2023-11-28 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2023-11-21 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2023-11-14 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2023-11-07 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2023-10-31 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2023-10-24 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2023-10-18 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2023-10-11 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2023-10-04 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2023-09-26 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2023-09-19 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2023-09-12 - bortezomib 1.3mg/m2 2.14mg SC 1min
  • 2023-09-05 - bortezomib 1.3mg/m2 2.14mg SC 1min

Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma - 2024-02-19 - https://www.uptodate.com/contents/image?imageKey=ONC%2F101205

  • Cycle length: 28 days.

  • Regimen

    • Bortezomib
      • 1.3 mg/m2 SC
      • Given as a single SC injection.
      • Days 1, 8, 15, and 22
    • Thalidomide
      • 100 mg for first 14 days then 200 mg per day thereafter by mouth
      • Take with water on an empty stomach at least one hour after the evening meal.
      • Daily, days 1 through 21
    • Dexamethasone (“low dose”)
      • 40 mg by mouth
      • Take with food (after meals or with food or milk) in the morning.
      • Days 1, 8, 15, and 22

Multiple Myeloma - VTD (IV-28)-Bortezomib (IV)-Dexamethasone-Thalidomide (28 day) - 2024-02-19 - https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Myeloma/MyelomaVTDBortezomibIVDexamethasoneThalidomideVer1.pdf

  • 28 day cycle for up to 6 cycles

  • Cycle 1

    • Bortezomib
      • 1.3mg/m2
      • 1, 8, 15, 22
      • Intravenous injection over 5 seconds
    • Dexamethasone
      • 20mg once a day in the morning
      • 1, 2, 8, 9, 15, 16, 22, 23
      • Oral
    • Thalidomide
      • 50mg once a day at night
      • 1-28
      • Oral
  • Cycle 2, 3, 4, 5, 6

    • Bortezomib
      • 1.3mg/m2
      • 1, 8, 15, 22
      • Intravenous injection over 5 seconds
    • Dexamethasone
      • 20mg once a day in the morning
      • 1, 2, 8, 9, 15, 16, 22, 23
      • Oral
    • Thalidomide
      • 100mg once a day at night
      • 1-28
      • Oral

VTD - Bortezomib, Thalidomide & Dexamethasone - Multiple Myeloma - 2024-02-19 - https://www.clatterbridgecc.nhs.uk/application/files/3415/9679/5924/VTD__Bortezomib_Thalidomide__Dexamethasone_Multiple_Myeloma_Protocol_V1.0.pdf

  • Dosage
    • Bortezomib
      • 1.3mg/m2
      • S/C
      • Day 1, 4, 8 and 11 of a 28 day cycle
    • Thalidomide
      • 50mg once daily at night. Titrate up to max daily dose of 200mg nocte
      • Oral
      • Days 1 to 28 (continuous)
    • Dexamethasone
      • 40mg
      • Oral
      • Days 1 to 4 and days 8 to 11

==========

2024-02-19

Since Sep 2023, IgG levels have returned to the normal range. The patient admitted this time for peripheral blood stem cell (PBSC) collection. Lab findings from 2024-02-06 were largely within normal limits. Medication not found to be missing.

  • 2024-02-07 IgG (blood) 527 mg/dL
  • 2024-01-23 IgG (blood) 572 mg/dL
  • 2024-01-09 IgG (blood) 564 mg/dL
  • 2023-12-26 IgG (blood) 462 mg/dL
  • 2023-12-12 IgG (blood) 429 mg/dL
  • 2023-11-28 IgG (blood) 427 mg/dL
  • 2023-11-14 IgG (blood) 383 mg/dL
  • 2023-10-31 IgG (blood) 329 mg/dL
  • 2023-10-17 IgG (blood) 338 mg/dL
  • 2023-10-04 IgG (blood) 387 mg/dL
  • 2023-09-19 IgG (blood) 636 mg/dL
  • 2023-08-18 IgG (blood) 2352 mg/dL
  • 2023-07-04 IgG (blood) 2542 mg/dL

700994040

240219

[exam findings]

  • 2023-12-14 Tc-99m MDP bone scan
    • Mildly increased activity in the lower T-spines. Degenerative change is more likely.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Some faint hot spots in the skull and left rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, left hip and bilateral knees, compatible with benign joint lesions.
  • 2023-12-11 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with metastatic pancreatic ductal adenocarcinoma
    • The sections show a picture of adenocarcinoma, moderately differentiated, composed of nests of polygonal neoplastic cells with clear cytoplasm, arranged in glandular and cribriform patterns with focal mucin secretion, embedded in fibrous stroma.
    • IHC shows: CK7(+), CK20(focal +), CA19-9(+), and DPC-4(-). The finding is compatible with metastatic pancreatic ductal adenocarcinoma.
  • 2023-12-08 CT - abdomen
    • CC: diffuse abdominal pain for 10 days, BW loss 6 kg in 1 year.
      • 20231205 US: Hypoechoic nodules (up to 3.20cm) in both hepatic lobes.
    • Findings:
      • There is a lobulated poor enhancing mass in the distal body and tail of the pancreas, measuring 6.5 cm in size (the largest dimension), and highly suggestive direct invasion the stomach fundus.
        • It is c/w adenocarcinoma of the pancreas (T3). Please correlate with CA199.
        • In addition, there is non-visualization of the splenic vein and narrowing of the splenic artery that is c/w tumor direct invasion and encasement.
      • There are four enlarged nodes in the gastrohepatic ligament and peripancreatic tail area that are c/w regional metastatic nodes (N2).
      • There are multiple poor enhancing lesions in both hepatic lobes (up to 2.6 cm in S2) that is c/w metastases (M1).
      • There is a mild heterogeneous poor enhancing mass in left adrenal gland, 2 cm in size. Adenoma is highly suspected.
        • The differential diagnosis includes metastasis.
      • There are several gallstones (up to 1.2 cm).
      • There is mild ascites in the cul-de-sac.
      • S/P hysterectomy. please correlate with clinical history.
      • There is a small soft tissue nodule at RML of the lung, directly attached the pleura (Srs:11 Img:4), 4 mm in size at lung window setting. Please correlate with chest CT.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N2(N_value) M:M1(M_value) STAGE:IV(Stage_value)
  • 2023-12-05 SONO - abdomen
    • Sonography of hepatobiliary system revealed:
      • Hypoechoic nodules (up to 3.20cm) in both hepatic lobes.
      • Gallbladder stone (0.84cm, 0.86cm).
      • Patency of PV, HVs, IVC and aorta in hepatic portion.
      • A cystic lesion (0.64x0.75cm) at pancreatic head. The other portions of pancreas masked by gastric/ bowel gas.
      • Normal appearance of spleen.
      • No evidence of pleural effusion.
      • Left renal stones (0.59cm, 0.63cm).
    • IMP:
      • Hypoechoic nodules (up to 3.20cm) in both hepatic lobes.
      • Gallbladder stone (0.84cm, 0.86cm).
      • A cystic lesion (0.64x0.75cm) at pancreatic head. Left renal stones (0.59cm, 0.63cm).
  • 2023-09-12 BMD
    • L-spines BMD performed by DXA revealed:
      • AP L-spines, BMD of L1-4 0.647 gms/cm2, about 3.9 SD below the peak bone mass (60%) and 0.8 SD below the mean of age-matched people (84%).
    • Impression
      • Osteoporosis

[MedRec]

  • 2023-10-24 SOAP Metabolism and Endocrinology Guo XiWen
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
      • Chronic hepatits,unspecified [K73.9]
      • Other insomnia [G47.09]
    • Prescription x3
      • Kludone (gliclazide 60mg) 1# BID
      • Zulitor (pitavastatin 4mg) 1# QOD
      • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID
      • Eurodin (estazolam 2mg) 1# HS
  • 2017-01-25 SOAP Metabolism and Endocrinology Guo XiWen
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
      • Chronic hepatits,unspecified [K73.9]
    • Prescription x3
      • Silima (silymarin 150mg) 1# QD
      • Januvia (sitagliptin 100mg) 1# QD
      • NovoNorm (repaglinide 1mg) 2# TIDAC
  • 2017-01-13 SOAP Orthopedics Huang MongRen
    • Diagnosis
      • Traumatic arthropathy, site unspecified [M12.50]
      • Osteoporosis, unspecified [M81.0]
      • OA, localized, primary, lower leg [M17.0]
    • Prescription x3
      • Evista (raloxifene 60mg) 1# QD

[consultation]

  • 2024-02-05 Psychosomatic Medicine
    • Q
      • Injury Level: 2, due to overdose with an intent towards self-harm or a well-defined plan. The individual reported ingesting over 30 Eurodin tablets around 40 minutes prior and attempted hanging using a stocking, which was unsuccessful as their feet touched the bathroom steps.
      • Past History:
        • Adenocarcinoma of pancreatic ductal, moderately differentiated, with liver metastasis, stage IV
        • suspected right malignant pleural effusion
      • Drug allergy: ibuprofen, pyrine, skinkenan
    • A
      • Imp: depressive diosrder, NOD, r/o major depressive disorder, single episode.
      • Past history: Pancrease Ca. s/p CT.
      • Long-term Eurodin was used but still failed to have better sleep, attempted suicide by swallowing a large amount of Eurodin.
      • low mood, poor appetite, body weight loss, and insomnia, negative thoughts were all found in recent one months.
      • P:
        • Zyprexa (olanzapine 5mg) 1# PO HS, Lexapro (escitalopram 10mg) 1# PO HS, and Stilnox (zolpidem 10mg) 1# PO HS.
        • OPD follow-up.
  • 2023-12-27 Psychosomatic Medicine
    • Q
      • Cancer inpatients with suicidal thoughts score >= 2.
    • A
      • Psychiatric Impression:
        • Adjustment reaction
      • Clinical course:
        • This is a 67 y/o female, admitted on 2023/12/27 for abdominal pain management. She has underlying disease: Adenocarcinoma of pancreatic ductal, moderately differentiated, with liver metastasis, stage IV.
        • According to the patient, she deny previous psychiatric history. She has been taking Eurodin (estazolam 2mg) 1# HS as sleeping pills for a period of time, and report of good response. Severe intermittent abdominal pain became severe in recent 1 month, depressive mood reaction when suffering pain (report of no remarkable depressive mood if the pain is under control). Poor appetite, low mood, helplessness feeling associated with pain. Experiencing unbearable pain at home without immediate relief led to feelings of helplessness. Due to long waits at the clinic, the individual sought emergency and hospital services, hoping for pain alleviation. She also report constipation which troubles her a lot. She has tolerable night sleep under current Eurodin, and could sleep even better when pain is under control during admission.
        • MSE: kempt, smiley, polite and cooperative attitude, fluent speech, deny suicide thoughts.
      • Suggestion:
        • Adequate pain control as your expertise
        • Provide supportive psychotherapy
        • Agree with keeping current Eurodin (estazolam) 1# HS

[chemotherapy]

  • 2024-02-19 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + Nab-Paclitaxel 125mg/m2 175mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2024-02-07 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + Nab-Paclitaxel 125mg/m2 178mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2024-01-30 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + Nab-Paclitaxel 125mg/m2 183mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2024-01-16 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + Nab-Paclitaxel 125mg/m2 183mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2024-01-09 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + Nab-Paclitaxel 125mg/m2 183mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2024-01-02 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + Nab-Paclitaxel 125mg/m2 186mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-12-21 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + Nab-Paclitaxel 125mg/m2 186mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-02-19

[responding to a glucose surge with insulin regulation]

A significant increase in serum glucose was observed, spiking to 310 mg/dL at 10:38 on 2024-02-19 from 166 mg/dL on 2024-02-18. Regular insulin has been administered since 2024-02-18. It may be necessary to adjust the dosage of regular insulin upward if the elevated glucose levels are not adequately controlled.

2024-02-06

[managing benzodiazepine overdose with flumazenil]

Lab findings from the urine analysis confirmed benzodiazepine toxicity.

  • 2024-02-05 Benzodiazepines (BENZ) Positive
  • 2024-02-05 Benzodiazepines (Value) 497 ng/mL

Flumazenil-hameln (at a concentration of 0.1 mg/ml in a 5 ml ampoule, available now in this hospital) is indicated for the treatment of benzodiazepine overdose. The initial intravenous dose is 0.2 mg administered over 2 minutes; if the desired level of consciousness is not achieved within 1 minute following the initial dose, an additional 0.2 mg may be administered at 1-minute intervals, up to a total of four times. The typical cumulative dosage ranges from 0.6 to 1 mg, with a maximum cumulative dose of 1 mg.

[more pain meds or hospice: addressing patient’s pain-driven death wish]

Based on the psychosomatic medicine consultation, the patient’s desire for death seems to stem from uncontrolled pain. Assuming this is the case, introducing additional analgesics may help alleviate the patient’s suffering. Alternatively, if the pain proves intractable, hospice palliative care may be recommended to both the patient and her family.

Currently, the patient is only being administered oral Tramacet (a combination of tramadol and acetaminophen) for pain management. To enhance analgesic efficacy, consideration could be given to the as-needed (PRN) use of morphine.

2023-12-22

Pathological confirmation of metastatic pancreatic ductal adenocarcinoma was obtained. Lab tests on 2023-12-12 revealed elevated tumor markers CA199 (14408.29 U/mL) and CEA (363.79 ng/mL).

No further results from driver mutation testing are currently available.

Instead of FOLFIRINOX regimen, the patient was initiated on gemcitabine + nab-paclitaxel on 2023-12-21. This combination is considered to have a little more favorable safety profile compared to FOLFIRINOX (NCCN guidelines, version 2023-06-19).

The patient has a long history of type 2 diabetes mellitus. The drugs prescribed by our endocrinologist have been integrated into the active medication list, confirming no discrepancies.

701060745

240219

[MedRec]

  • 2019-08-04 ~ 2019-08-10 POMR Thoracic Surgery Xie MinXiao
    • Discharge diagnosis
      • C34.92 Left lower lung adenocarcinoma, pT1aN0 pStage IA1 status post robotic video-assisted thoracic surgery left lower lobectomy and radical lymph node dissection on 2019/08/07
      • C30.0 Left sinonasal cancer recurrent status post left total maxillectomy, left posterolageral neck dissection, excision of intranasal malignant tumor and Da Vinci surgery on 2018/08/21
      • G47.01 Insomnia due to medical condition
    • CC
      • LUL lung nodule, 1.82cm
    • Present illness
      • This 69-year-old female patient has history of
        • Left sinonasal cancer stage III s/p Da Vinci surgery at Tong general hospital in 2016 s/p L DaVinci ND + L transnal endoscopic (+/-Midfacial excision) + L ora-nasal fistula repair (Ho = R vocal polyp), rpT2N3bMx (NK-SCC) on 2018/08/21
        • Uterine prolapse post Da Vinci robotic hysterectomy and bilateral salpingo-oophorectomy on 2018/04/27
      • She was under regular ENT OPD follow up. Neck CT on 2019/05/20 revealed
        • C/W left sinunasal cancer with post-operation changes and abscess formation as aforementioned. Malignant nodule (19 mm) in LLL.
        • Gall stones.
        • Hepatic cysts, left lobe.
      • No dyspnea, cough or fever was noted. After discussing with the patient and her family on the benefits of surgical treatment as well as subsequent risks and possible complications, she was admitted for RATS LLL wedge, if ca. lobectomy + RLND.
    • Course of inpatient treatment
      • After admission, pre-op assessment was done. Operation of robotic video-assisted thoracic surgery left lower lobectomy and radical lymph node dissection was performed smoothly on 2019/08/07. No complication was noted. Prophylactic antibiotics was prescribed for 1 day. Left chest tube with LPS -18 cmH2O was done. Chest tube was removed on 2019/08/09. She was discharged under stable hemodynamics on 2019/08/10.
    • Discharge prescription
      • Actein (acetylcysteine 200mg) 1# TID
      • MgO 250mg 1# TID
      • Lactam (acetaminophen 500mg) 1# QID
      • Sindine 10% PRN EXT
  • 2018-08-20 ~ 2018-08-27 - POMR Ear Nose Throat Su WanYu
    • Discharge diagnosis
      • C30.0 Left sinonasal cancer recurrent status post left total maxillectomy, left posterolageral neck dissection, excision of intranasal malignant tumor and Da Vinci surgery on 2018-08-21
      • R03.0 Eevated blood pressure reading without diagnosis of hypertension
      • G47.09 Insomnia
    • CC
      • Left sinonasal cancer post Da Vinci surgery in 2016, complicated with left oronasal fistula. Followed MRI showed recurrent.
    • Present illness
      • This 68-year-old female has history of left sinonasal cancer stage III post Da Vinci surgery at Tong general hospital in 2016 and uterine prolapse post Da Vinci robotic hysterectomy and bilateral salpingo-oophorectomy on 2018/04/27.
      • She suffered from complicated with left oronasal fistula since 2016. Easy left nasal obstruction was also noted. She visited our ENT OPD for help. Physical examination revealed a fistula at left hard palate around 0.7x0.3cm. Scope showed left nasal floor focal smooth bulging, a fistula at left nasal floor, left nose post medial maxillectomy, and no tumor found. MRI followed on 2018-08-02 which revealed tumors in left posterior maxillary region extending to pterygoid plates and muscles, and multiple left posterior neck LAPs. After discussion with the patient, we suggest her to receive tumor wide excision. She ask for Da Vinci surgery. Operation details and risks were explained.
      • Under the impression of left sinonasal cancer recurrent, she was admitted to our ward for the operation.
    • Course of inpatient treatment
      • After admission, the surgery of left total maxillectomy, left posterolageral neck dissection, excision of intranasal malignant tumor and Da Vinci robotic - neck malignant tumor resection surgery were performed smoothly on 2018/08/21. Post op condition of no nasal oozing, no headache, E.O.M. were free and full, vision as usual, mild nasal wound pain, left neck wound no oozing with H/V drainage and mild wound pain.
      • After the operation, she was transferred to SICU for post-op intensive care and return to ordinary ward on 8/22. The H/V drainage amount gradually less then removed it on 8/24. Under stable condition, we let her discharged today and arranged OPD follow schedule.
    • Discharge prescription
      • cephalexin 500mg 1# QID
      • Antica Syrup 10mL TID
      • Actein (acetylcysteine 200mg) 1# TID
      • Allegra (fexofenadine 60mg) 1# BID
      • Paran (acetaminophen 500mg) 1# QID
  • 2018-04-26 ~ 2018-04-30 - POMR Obstetrics and Gynecology Chen GuoHu
    • Discharge diagnosis
      • N81.9 Uterine prolapse, cystocele and rectocele
      • N39.3 Stress incontinence
      • R35.0 Urinary frequency
      • Da Vinci robotic hysterectomy and bilateral salpingo-oophorectomy
      • Transvaginal pelvic floor reconstruction on 2018-04-27
    • CC
      • A mass dropping out of vagina for 3 months
    • Present illness
      • This is a 67-year-old female, and she has history of nasopharyngeal carcinoma cancer stage III post Da Vinci surgery at Tong general hospital in 2016. She suffered from a mass dropping out of vagina for 3 months, otherwise she had the symptoms of stress urinary incontinence (SUI) and urinary frequency. She visited our OPD for help, which PV examination revealed uterine prolapse, cystocele and mild rectocele. She was suggested for surgical intervention. Therefore she was admitted for Da Vinci surgery for hysterectomy, BSO and pelvic reconstruction on 2018-04-27.

[surgical operation]

  • 2019-08-07
    • Operation
      • Da Vinci assisted lobectomy
      • Pneumonolysis, intrapleural (extrapleural)
    • Finding
      • One nodular lesion was noted over LB6, size about 2.2cm in diameter.
      • Frozen section: adenocarcinoma
      • One 24 Fr. straight chest tube was inserted via left 9th ICS.
  • 2018-08-21
    • Operation
      • Maxillectomy - total, left
      • posterolageral neck dissection, left
      • Endoscopic-assisted excision of intranasal malignant tumor
      • Da Vinci robotic - neck malignant tumor resection surgery (complexity)
    • Finding
      • MRI = (1) L nasal and maxillary sinus lesion with invasion of pterygoid muscles, (2) cervical LAP over L level II and posterolateral neck.
      • L sinonasal cancer (stage III told) s/p da Vinci op at Tong general hospital in 2016 (Dr. Cai QingShao), complicated with left oronasal fistula (refuse post-op R/T, refuse open op suggested at other hospitals).
      • tumor over L OMC + PE with E-tube invasion, lateral and inferior maxillary sinus wall and nasal floor.
  • 2018-04-27
    • Operation
      • Da Vinci robotic hysterectomy
      • Da Vinci robotic bilateral salpingo-oophorectomy
      • Transvaginal pelvic floor reconstruction
      • Resection of Uterus, Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance
    • Finding
      • Uterus: elongated, 12x5x3cm
      • cervix eroded, prolapsed
      • uterine prolapse, cystocele and rectocele(+) with prolapsed vaginal epithelium
      • bil adnexa: atrophic changes
      • CDS: no fluid
    • Course of inpatient treatment
      • She was arranged to admit for Da Vinci surgery with hysterectomy and bilateral salpingo-oophorectomy & transvaginal pelvic floor reconstruction, which were performed smoothly on 2018-04-27. Her postoperative course was uneventful. Abdominal wound was clear without discharge and healing was well. Her self voiding and eating were OK after adjustiong drugs. So she was discharged and her OPD follow-up appointment is scheduled on next week.

2024-02-19

[tube-feeding]

Tube feeding is available for all oral medications on the active drug list.

701119127

240219

[exam findings] (not completed)

  • 2024-01-19 CT - chest

    • Chest CT with and without IV contrast ehnancement shows:
      • Diffuse tree in bud and Bronchiectatic change over both lungs is found.
      • Confluent lymphadenopathy in the mediastinum is found. In comparison with CT dated on 2023-10-14, the lesion regressed.
      • Calcified coronary arteries is found.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Imp:
      • Bone meta.
      • Mediastinal lymphadenopathy, in regression.
  • 2024-01-12 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (76 - 12.1) / 76 = 84.08%
      • M-mode (Teichholz) = 84
    • Conclusion:
      • Dilated LA
      • Adequate LV, RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Mild MR, TR, AR
  • 2024-01-10, 2023-12-11, -11-16 CXR

    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Linear infiltration over left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2023-10-26 Cell Block

    • 50 cc red cloudy pericardial fluid — Positive for metastatic squamous cell carcinoma - Malignancy
    • The smears and cell block show lymphocytes, PMNs, reactive mesothelial cells and some atypical cells, which immunocytochemistry shows TTF-1(-) and P63(+) for tumor cell. According to clinical information and cytomorphologic findings, it is compatible with metastatic squamous cell carcinoma.
  • 2023-10-25 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (82.6 - 13.6) / 82.6 = 83.54%
      • M-mode (Teichholz) = 83.5
    • Conclusion:
      • Normal chamber size
      • Large pericardial effusion with diastolic RA and RV compression with cardiac tmponade signs
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • AV sclerosis with mild AR , mild TR and PR
      • Calcified mitral annulus with mild MR
      • No regional wall motion abnormalities
  • ……….

  • 2019-09-03 CT - abdomen

    • Clinical history: 71 y/o female patient with rectal cancer post CCRT and C∕T. 108∕8∕27: Persistent elevating CEA. FU CT scan. 2019∕04∕29
      • CEA elevated noted by oncologist; gastric wall thickening suspected by oncologist, abd CT scan: mild rectal wall thickening.
      • Rectal cancer post CCRT and C∕T, Persistent elevating CEA up to 12. => FU CT scan.
    • With and without contrast enhancement CT of abdomen–whole:
      • Thickening wall at the rectum.
      • Presence of gallbladder stone.
      • Cystic lesion, 4.3cm in left adenxa, r/o left ovarian cyst.
      • Right renal cyst, 0.6cm.
      • Generalized low density over liver parenchyma, suggesting fatty liver.
      • Small right lower lung nodules, suggest further study.
    • Impression:
      • Thickening wall at the rectum. Stationary.
      • GB stone.
      • Left ovarian cyst.
      • Right renal cyst.
      • Fatty liver.
      • Small right lower lung nodules, suggest further study.
  • 2019-05-27 EUS

    • No paraesophageal lesion or mural lesion at cardia or lower esophagus
  • 2019-05-27 CT - chest

    • Indication: for f∕u of colon cancer
    • Impression: no lung nodule.
  • 2019-05-03 Surgical pathology Level IV

    • Clinical diagnosis: Abnormal CEA level; suspected colon lesion; Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation; Malignant neoplasm of rectum
    • Pathological DIAGNOSIS:
      • Esophagus, biopsy — Squamous hyperplasia with mild acute inflammation.
  • 2019-04-23 CT - abdomen

    • FINDINGS:
      • There is mild wall thickening in the rectum. Please correlate with colonoscopy.
      • Asymmetrical wall thickening in the gastric fundus (Srs:301, Img:17) is noted that may be adenocarcinoma or normal variation secondary to inadequate distension. Please correlate with gastroscopy.
      • There is fatty density in the pancreatic head and body that is compatible with fatty replacement of the pancreatic parenchyma.
      • Left side ovarian cyst measuring about 3.8 x 3.2 cm is noted. Please correlate with GYN. sonography.
    • Impression:
      • There is mild wall thickening in the rectum. Please correlate with colonoscopy.

[MedRec]

  • 2024-02-01 ~ 2024-02-05 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Recurrent squamous cell carcinoma of anorectum with multiple pelvic, inguinal, paraaortic and mediastinal lymph node metastasis, rcT2N2M1, stage IV s/p concurrent chemoradiotherapy with FOLFOX with progressive disease of mediastinal lymphadenopathy s/p palliative chemotherapy with mDCF (selfpaid of Docetaxel) from 2022/11/29
      • Postive of anti-HBc
      • Paroxysmal atrial fibrillation
      • Right 1st toe paronychia
      • Insomnia
      • Constipation
    • CC
      • for chemotherapy
    • Present illness
      • This 74-year-old female patient has past history of squamous cell carcinoma of rectum cancer, cT2N2M1, stage IV status post concurrent chemoradiotherapy (MMC/5Fu) at KFSYSCC in 2013, C4 PF at TzuChi in 2014. She visited our oncologist OPD for regular follow-up. Followed abdominal CT scan on 2022-03-22 revealed enlarged lymph nodes (up to 3.2cm) at mediastinum. She denied any poor appetite, body weight loss, easy cough, shortness of breath or dyspnea. After discussing with the patient and her family on the benefits of surgical treatment as well as subsequent risks and possible complications.
      • Operation of right video-assisted thoracoscopic surgery lymph node sampling and pneumolysis was performed smoothly on 2022-04-14.pathology showed metastatic squamous cell carcinoma, CD56(-), P40 (+), CK20 (-). PET was performed on 2022/4/23 revealed increased FDG uptake in some right paratracheal and precarinal lymph nodes, an A-P window lymph node, bilateral pulmonary hilar regionsand right lateral chest wall. Besides, there was increased FDG accumulation in the colon, rectum, both kidneys and left ureter.
      • Under the impression of Metastatic squamous cell carcinoma of the mediastinal lymph node from rectum cancer, cT2N2M1, stage IV status post concurrent chemoradiotherapy
      • CCRT with FOLFOX (selfpaid of Oxaliplatin) C1D1 on 2022/05/12, C1D15 on 2022/06/08, C2D1 on 2022/06/23, C2D15 on 2022/07/19.
      • Follow-up abdominal CT on 2022/07/22 showed there is mild wall thickening in the rectum.
      • C3D1 on 2022/07/31. C3D15 on 2022/08/12. C4D1 on 2022/09/02. C4D15 on 2022/09/16. C5D1 on 2022/10/03. C5D15 on 2022/10/20. C6D1 FOLFOX on 2022/11/14.
      • Followed up, CT of chest to abdominal on 2022/11/04 revealed Rectal cancer s/p C/T with mediastinal lymphadenopathy, in progression. Foca recal wall thickening. Stationay. Followed up laboratory test revealed elevated tumor marker (CEA:303ng/ml) on 2022/11/17.
      • Palliative chemotherapy with mDCF (Docetaxel 40mg/m2, self pay, CDDP 40mg/m2, LV 400mg/m2, 5FU 1200mg/m2) C1D1 on 2022/11/29. C1D15 on 2022/12/14.
      • Followed up laboratory test revealed elevated tumor marker (CEA:447.69ng/ml) on 2022/11/29, (CEA:231.89ng/ml) on 2022/12/13.
      • Palliative chemotherapy with mDCF (Docetaxel 40mg/m2, self pay, CDDP 40mg/m2, LV 400mg/m2, 5FU 1200mg/m2) C2D1 on 2023/1/02.   
      • This time, she was admitted due to pericardial effusion seen on CT during regular OPD follow up. According to the patient herself and her family, she had been suffering from progressive exertional dyspnea during the past half year, and had exaggerated in recent 1-2 months. Comparison of CT in July and in October this year revealed increased amount of pericardial effusion and mediastinal lymphadenopathy in progression. Emergency echocardiography showed large pericardial effusion with diastolic RA and RV compression with cardiac tmponade signs. CV was consulted for drainage. During cardiac catheterization, puncture of left chest wall, s/p pericardiocentesis around 170ml. Episode Af was developed on 2023/10/27, so anticoagulant Lixiana and antiarrhythmic agent with Propafenone. Precardial effusion pathology showed positive for metastatic squamous cell carcinoma.
      • C1D1 Cetuximab + FOLFIRI on 2023/11/2-11/4.
      • C1D15 Cetuximab + FOLFIRI on 2023/11/16-18.
      • C2D1 Cetuximab + FOLFIRI on 2023/12/11-12/13.
      • C2D15 Cetuximab + FOLFIRI on 2023/12/25-12/27.
      • C3D1 Cetuximab (self-paid) + FOLFIRI on 2024/01/11-2024/01/13.
      • This time, she has mild chest tightness for 1 day and right toe wound for 1 week. She denied fever, so she was admitted for C3D15 Cetuximab + FOLFIRI on 2024/2/1.
    • Course of inpatient treatment
      • After admission, she received C3D15 FOLFIRI and Cetuximab since 2024/02/02 - 02/04.
      • Mosapin 5mg/tab (Mosapride Citrate) 1# tid for prevent vomit.
      • Baraclude 0.5mg/tab (Entecavir) 1# qdac for anti-HBc postive.
      • Under the stable condition, she can be discharged on 2024/02/05. OPD follow up is arranged.
    • Discharge prescription
      • Actein (acetylcysteine 200mg) 1# TID
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • codeine phosphate 15mg 1# Q6H
      • Dinco Syrup (codeine phosphate) 10mL QID
      • diphenidol 25mg 1# TID
      • Kentamin (Vit B1 50mg, B6 50mg, B12 500ug) 1# TID
      • Lixiana (edoxabam 30mg) 1# QD
      • MgO 250mg 1# TID
      • Mosapin (mosapride citrate 5mg) 1# TID
      • Rytmonorm (propafenone 150mg) 1# BID hold if HR < 60
      • Megejohn (megestrol acetate 160mg) 1# QD
      • Rivotril (clonazepam 0.5mg) 1# HS
      • Through (sennoside 12mg) 2# HS
      • Diclocin (dicloxacillin 250mg) 2# Q6H
  • 2023-08-04, -05-10, -02-08 SOAP Neurology
    • A: r/o CT induced polyneuropathy
    • Prescription x3
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
  • 2017-02-02 SOAP Hemato-Oncology Wan XiangLin
    • S
      • A patient of low rectal cancer (Squamous cell carcinoma) with multiple pelvic, inguinal, paraaortic metastasis, (lung meta?) stage T2N3M1
      • treated at Koo Foundation Sun Yat-Sen Cancer Center s/p CCRT (201311 - 201312)
      • S/P chemotherapy with PF (C4) (201401 - 201404).
      • Skin itching. leg cramping and pain. diarrhea, S/P lab. test.
    • O
      • 20160414 chest CT showed: no lung metastasis.
    • Diagnosis
      • Malignant rectum neoplasm [C20]
      • Peristent disorder of initiating or maintaining sleep [F51.09]
    • Prescription
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Imolex (loperamide 2mg) 1# BID
      • Paran (acetaminophen 500mg) 1# QID
      • Agglutex (heparin 25000U/5mL) 5mL ST
      • NS 20mL ST

[consultation]

  • 2023-10-25 Cardiology
    • Q
      • This 74-year-old female has recurrent squamous cell carcinoma of anorectum with multiple pelvic, inguinal, paraaortic and mediastinal lymph node metastasis, rcT2N2M1, stage IV. Due to large pericardial effusion with diastolic RA and RV compression with cardiac tmponade signs, so we meed your help for drainage.
    • A
      • because of cardiac tamponade, I’m consulted for it
      • I epxlain the indication of emergency drainage for pericardiac effusion and tamponade. It will be arrange right now.
  • 2023-10-24 Cardiology
    • Q
      • This 74-year-old female has recurrent squamous cell carcinoma of anorectum with multiple pelvic, inguinal, paraaortic and mediastinal lymph node metastasis, rcT2N2M1, stage IV s/p concurrent chemoradiotherapy with FOLFOX(selfpaid of Oxaliplatin) from 2022/05/12~2022/11/14 for 11 cycles, progressive disease of mediastinal lymphadenopathy s/p palliative chemotherapy with mDCF(selfpaid of Docetaxel) from 2022/11/29.
      • Due to pericardial effusion, so we need your help for management.
    • A
      • A 74 years old woman with recurrent squamous carcinoma of anorectum and multiple metastasis s/p C/T.
        • Dyspnea on exertion noted for half a year with cardiomegaly seen on CXR, and ECG showed normal sinus rhythm with low voltage QRS in limb leads, and CT scan showed moderate pericardial effusion.
        • Physically, JY flat, BP 136/94 mmHg, HR 92/min and gr 2-3/6 SEM over LSB, leg edema (-). Now she is consulted for further management.
        • also dyspnea (+), chest discomfrot (+)
      • Impression:
        • recurrent squamous carcinoma of anorectum and multiple metastasis s/p C/T
        • pericardial effusion cause to be determined
      • Suggestion:
        • please arrange echocardiography first to evaluate the degree of pericardial effusion and any evidence of cardiac tamponade.
        • contact with us after echocardiography.
  • 2023-01-03 Neurology
    • Q
      • This 74-year-old woman patient is a case of Recurrent squamous cell carcinoma of anorectum with multiple pelvic, inguinal, paraaortic and mediastinal lymph node metastasis, rcT2N2M1, stage IV s/p concurrent chemoradiotherapy with FOLFOX (selfpaid of Oxaliplatin) from 2022/05/12~2022/11/14 for 11 cycles, progressive disease of mediastinal lymphadenopathy s/p palliative chemotherapy with mDCF (selfpaid of Docetaxel) from 2022/11/29.
      • She was admitted for prepare chemotherapy. This time, bilateral lower limbs weakness with trembling developed. Now, for evaluate bilateral lower limbs weakness with trembling examination and therapy. Thank you.
    • A
      • NE:
        • CN: intact
        • MP: full
        • Gait: wide based
        • FNF: No dysmetria
        • Romberg test: positive
      • Imp:
        • r/o sensory ataxia
      • Suggestion:
        • Arrange NCV (upper and lower limbs MNCV + SNCV + H reflex + F wave) and SSEP (upper and lower limbs)
  • 2022-05-10 Radiation Oncology
    • Q
      • This 74-year-old female patient has past history of squamous cell carcinoma of rectum cancer, cT2N2M1, stage IV status post concurrent chemoradiotherapy in 2013-2014 at Koo Foundation Sun Yat-Sen Cancer Center.
      • She visited our oncologist OPD for regular follow-up. Followed abdominal CT scan on 2022-03-22 revealed enlarged lymph nodes (up to 3.2cm) at mediastinum. She denied any poor appetite, body weight loss, easy cough, shortness of breath or dyspnea.
      • After discussing with the patient and her family on the benefits of surgical treatment as well as subsequent risks and possible complications.Operation of right video-assisted thoracoscopic surgery lymph node sampling and pneumolysis was performed smoothly on 2022-04-14.
      • Pathology showed metastatic squamous cell carcinoma, CD56(-), P40 (+),CK20 (-).
      • PET was performed on 2022/04/23 revealed increased FDG uptake in some right paratracheal and precarinal lymph nodes, an A-P window lymph node, bilateral pulmonary hilar regionsand right lateral chest wall. Besides, there was increased FDG accumulation in the colon, rectum, both kidneys and left ureter.
      • Under the impression of 1) Metastatic squamous cell carcinoma of the mediastinal lymph node from rectum cancer, cT2N2M1, stage IV status post concurrent chemoradiotherapy in 2013-2014 at Koo Foundation Sun Yat-Sen Cancer Center.
      • She was admitted for further management. port-A insertion on 2022/05/06
      • We need your experise for radiotherapy evaluation, thanks
    • A
      • The patient’s history was reviewed and patient was examined.
      • S: For radiotherapy due to metastatic squamous cell carcinoma of the mediastinal lymph nodes.
        • PI: The patient has past history of squamous cell carcinoma of anorectum, stage cT2N2M1, stage IV status post concurrent chemoradiotherapy in 2013-2014 at Koo Foundation Sun Yat-Sen Cancer Center. Operation of right video-assisted thoracoscopic surgery lymph node sampling and pneumolysis was performed smoothly on 2022-04-14. Pathology showed metastatic squamous cell carcinoma,CD56(-), P40 (+),CK20 (-). PET (2022-4-28) showed glucose hypermetabolism in some right paratracheal and precarinal lymph nodes and an A-P window lymph node. Metastatic lymph nodes should be considered.
          • Family history: (-)
          • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
          • Personal Hx: DM(-); HTN(-)
          • Allergy(-)
          • Travel Hx(-)
        • Previous RT (2013-11-20 ~ 2014-01-03): 4500cGy/25 fractions of the paraaortic, pelvic, bilateral inguinal, 5040cGy/28 fractions of the LN, and 6000cGy/30 fractions of the anorectal tumor at Koo Foundation Sun Yat-Sen Cancer Center.
      • O:
        • ECOG: 0
        • PE: neck and bil SCF: neg.
        • Pathology (P001325380, 1021101, TSGH): rectum, “5cm”, biopsy - microinvasive squamous cell carcinoma.
        • CT scan of abdomen (2022-03-12): Mild wall thickening of rectum (stable). Enlarged LNs (up to 3.2cm) at mediastinum.
        • CXR (2022-04-13): elongated and tortuosity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta. Clean lung fields based on plain image. Normal shape and size of heart. Normal appearance of both hila. Costophrenic angles are preserved.
        • Operation (2022-04-14): Right VATS lymph node sampling and pneumolysis
        • Pathology (S2022-06359, 2022-04-20): ADDENDUM: IHC stain — CD56(-), P40 (+). ADDENDUM: IHC stain — CK20 (repeat): negative. DIAGNOSIS: (revise) Right paratracheal lymph node, VATS excision — metastatic squamous cell carcinoma.
        • PET (2022-04-28): Glucose hypermetabolism in some right paratracheal and precarinal lymph nodes and an A-P window lymph node. Metastatic lymph nodes should be considered. Please correlate with other clinical findings for further evaluation.
        • 2022/04/29 CA-199 (NM) = 10.120 U/ml;
        • 2022/04/29 CEA (NM) = 4238.1 ng/ml;
      • A: Squamous cell carcinoma of anorectum with multiple pelvic, inguinal, paraaortic and mediastinal lymph node metastasis, stage cT2N2M1, stage IV, s/p CCRT (at Koo Foundation Sun Yat-Sen Cancer Center), with progression of metastatic mediastinal lymph nodes.
      • P: Radiotherapy is indicated for this patient with the following indicators: progression of metastatic mediastinal lymph nodes.
        • Goal: palliation
        • Treatment target and volume: metastatic mediastinal lymph nodes
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5400cGy/27 fractions
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2022-05-12.
  • 2022-04-07 Thoracic Surgery
    • Q
      • The 74 y/o woman has recurren SCC of rectum cancer with enlarged LNs (up to 3.2cm) at mediastinum. We need your help for tissue proof for genetic testing. Thanks!
    • A
      • The patient had Hx of colon cancer. Mediastinal LNs enlargement noted. VATS with biopsy for therapeutic planning is indicated

[radiotherapy]

  • 2022-05-19 ~ 2022-06-28 - 5400cGy/27 fractions of the metastatic mediastinal lymph nodes area.

[chemmotherapy]

  • 2024-01-11- 2023-12-25 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 235mg D5W 250mL 90min + leucovorin 400mg/m2 525mg NS 250mL 2hr + fluorouracil 2800mg/m2 3680mg NS 500mL 46hr (Erbitux + 80% FOLFIRI; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-12-25 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 235mg D5W 250mL 90min + leucovorin 400mg/m2 525mg NS 250mL 2hr + fluorouracil 2800mg/m2 3680mg NS 500mL 46hr (Erbitux + 80% FOLFIRI; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-12-11 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 235mg D5W 250mL 90min + leucovorin 400mg/m2 525mg NS 250mL 2hr + fluorouracil 2800mg/m2 3675mg NS 500mL 46hr (Erbitux + 80% FOLFIRI; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-11-16 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 235mg D5W 250mL 90min + leucovorin 400mg/m2 525mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (Erbitux + 80% FOLFIRI; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-11-02 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 235mg D5W 250mL 90min + leucovorin 400mg/m2 525mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 500mL 46hr (Erbitux + 80% FOLFIRI; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-12-14 - docetaxel 40mg/m2 60mg NS 100mL 1hr + NS 500mL 1hr (before CDDP) + cisplatin 40mg/m2 65mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 1200mg/m2 1800mg NS 500mL 48hr (mDCF)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-11-29 - docetaxel 40mg/m2 60mg NS 100mL 1hr + NS 500mL 1hr (before CDDP) + cisplatin 40mg/m2 65mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 1200mg/m2 1800mg NS 500mL 48hr (mDCF)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-11-14 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2800mg/m2 3850mg NS 500mL (old age 20% off) (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-10-20
  • 2022-10-03
  • 2022-09-15
  • 2022-09-02
  • 2022-08-12
  • 2022-08-01
  • 2022-07-19
  • 2022-06-23
  • 2022-06-08 -
  • 2022-05-12 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (old age 20% off)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-02-19

[proactive potassium supplementation for heart patients on propafenone]

Laboratory findings revealed the development of hypokalemia.

  • 2024-02-16 K(Potassium) 3.1 mmol/L
  • 2024-02-02 K(Potassium) 3.6 mmol/L
  • 2024-01-10 K(Potassium) 3.8 mmol/L

Hypokalemia typically manifests with serum potassium concentrations between 3.0 and 3.4 mEq/L, often remaining asymptomatic. However, individuals with pre-existing cardiac conditions, particularly those receiving digitalis or certain antiarrhythmic medications, may experience symptoms at these potassium levels.

Therefore, potassium supplementation is recommended throughout propafenone therapy to proactively address potential hypokalemia.

2024-01-22

Lab data from 2024-01-22 indicated that the tumor markers CEA and SCC continued their previous upward trend. Other lab parameters, such as blood cell counts, electrolytes, and liver and kidney functions, were within acceptable ranges. No discrepancies in medication were identified.

2024-01-11

[evolving disease activity? CEA & SCC levels raise concerns]

Since mid-Dec 2023, an initial upward trend has been observed in both CEA and SCC levels. This may suggest possible disease progression or decreased effectiveness of the current treatment regimen (Erbitux + FOLFIRI, initialized early Nov 2023).

  • 2024-01-09 CEA (NM) 4604.100 ng/ml

  • 2023-12-26 CEA (NM) 3546.800 ng/ml

  • 2023-12-15 CEA (NM) 3143.700 ng/ml

  • 2023-12-01 CEA (NM) 6128.400 ng/ml

  • 2023-11-17 CEA (NM) 15774.500 ng/ml

  • 2023-10-20 CEA (NM) 20331.000 ng/ml

  • 2023-10-03 CEA (NM) 29059.500 ng/ml

  • 2023-07-11 CEA (NM) 11534.600 ng/ml

  • 2023-06-20 CEA (NM) 5571.400 ng/ml

  • 2023-05-16 CEA (NM) 2113.400 ng/ml

  • 2023-03-21 CEA (NM) 194.380 ng/ml

  • 2023-02-15 CEA (NM) 31.804 ng/ml

  • 2024-01-09 SCC (NM) 2.64 ng/mL

  • 2023-12-15 SCC (NM) 1.76 ng/mL

  • 2023-12-01 SCC (NM) 1.46 ng/mL

  • 2023-11-17 SCC (NM) 2.18 ng/mL

  • 2023-10-20 SCC (NM) 3.31 ng/mL

  • 2023-10-03 SCC (NM) 3.08 ng/mL

2023-11-17

Repeat prescriptions that are still valid currently within the past 3 months are not shown in PharmaCloud.

Slight hyponatremia, hypocalcemia, and hypomagnesemia were observed in the laboratory results from 2023-11-16. Close monitoring is recommended.

An episode of leukopenia occurred on 2023-11-10, approximately 1 week after the patient’s first dose of Erbitux + FOLFIRI (reduced dose). The patient’s WBC before the second administration of the regimen was even lower than before the first administration. Therefore, there is a possibility of developing another episode of leukopenia after the second administration. Careful monitoring is advised.

  • 2023-11-16 WBC 3.14 x10^3/uL
  • 2023-11-10 WBC 2.04 x10^3/uL *
  • 2023-10-31 WBC 6.67 x10^3/uL

700152280

240216

[lab data]

  • 2022-04-08
    • HBsAg negative, value 0.384
    • Anti-HCV negative, value 0.0336
    • Anti-HBc positive, value 0.00706
    • Anti-HBs positive, value 34

[exam findings]

  • 2023-12-12 CXR erect
    • Few metastases in both lungs are noted after correlate with CT.
  • 2023-12-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (88 - 23) / 88 = 73.86%
      • LVEF (%) = 74
      • M-mode (Teichholz) = 76
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • LV posterior wall thickening; normal LV diastolic function.
      • Normal RV systolic function.
      • Mild MR; mild TR; mild aortic valve sclerosis.
  • 2023-12-01 Tc-99m MDP bone scan
    • Mildly increased activity in the lower L-spines. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • A hot spot in the lateral aspect of right rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders and knees, compatible with benign joint lesions.
  • 2023-11-01 CXR erect
    • Multiple randomly distributed pulmonary nodules of varying sizes s/p wedge-resections and areas increased opacity
  • 2023-10-30 Patho - lung wedge biopsy
    • A
      • Lung, right, lower lobe, wedge resection —- Consistent with metastatic endometrioid carcinoma
        • Lymph node, right, group 7, dissection —- Negative for malignancy (0/6)
        • Lymph node, right, group 9, dissection —- Negative for malignancy (0/1)
      • Microscopic Description
        • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobes
        • Histologic Type (select all that apply): Consistent with metastatic endometrioid carcinoma; The immunohistochemical stains reveal CK7(+), CK20(-), PAX8(+), TTF-1(focal +), p40(-), CD56(focal +).
        • Histologic Grade: G3: Poorly differentiated
        • Spread Through Air Spaces (STAS): Present
        • Visceral Pleura Invasion: Present (PL2)
        • Lymphovascular Invasion (select all that apply): Present, Lymphatic
        • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
        • Margins (select all that apply): All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin (centimeters): 0.2 cm
    • B
      • Lung, right, middle lobe, wedge resection —- Consistent with metastatic endometrioid carcinoma
    • C
      • Lung, right, upper lobe, wedge resection —- Consistent with metastatic endometrioid carcinoma
  • 2023-10-30, -10-29 CXR
    • Multiple randomly distributed pulmonary nodules of varying sizes.
  • 2023-10-04 CT - chest
    • Impression: bilateral pulmonary metastatic lesion, in progression as compared with CT on 2023/03/21.
  • 2023-07-29 CT - abdomen
    • S/P hysterectomy.
    • R/O liver cyst, stationary.
    • Progression of bilateral lung metastasis.
  • 2023-03-21 CT - chest
    • Impression: bilateral pulmonary metastatic lesions.
  • 2023-03-11 CT - abdomen
    • S/P hysterectomy.
    • R/O liver cyst.
    • Newly developed RML nodule, r/o lung metastasis.
  • 2022-12-16 Pap Smear
    • Atypical squamous cells (ASC-US)
  • 2022-10-11 CT - abdomen
    • S/P hysterectomy. No evidence of tumor recurrence.
  • 2022-07-01 CT - abdomen
    • Primary lung cancer 7 mm in RUL is suspected.
  • 2022-03-23 Patho - lumph node region resection
    • pathologic diagnosis
      • Endometrium, uterus, frozen and LSC staging surgery — Endometrioid carcinoma, grade 3
      • Myometrium, uterus, ditto — Tumor invasion, greater than half thickness
      • Cervix, uterus, ditto — Free from tumor, atrophy with Nabothian cysts
      • Left ovary, ditto — Free from tumor, corpus albicans
      • Left fallopian tube, ditto — Free from tumor, paratubal cysts
      • Right ovary, ditto — Free from tumor, corpus albicans
      • Right fallopian tube: free from tumor, paratubal cysts
      • Lymph node, left iliac, dissection — Free from tumor metastasis (0/12)
      • Lymph node, left oburator, ditto — Tumor metastasis (1/19)
      • Lymph node, right iliac, ditto — Free from tumor metastasis (0/11)
      • Lymph node, right oburator, ditto — Tumor metastasis (1/16)
      • Parametrium, bilateral — Free from tumor
      • AJCC Pathologic stage — pT1bN1a, if cM0, stage IIIC1 / FIGO stage IIIC1
    • macroscopic examination
      • Operation Procedure: frozen section and LSC staging surgery (TAH, BSO and BPLND)
      • Specimens include: Uterus, bilateral ovaries, fallopian tubes and pelvic LNs
      • Tumor site: endometrium
      • Tumor size: 4.2 x 3.7 cm
      • The myometrium: up to 1.3 cm in thickness
      • The cervix : mucoid cyst
      • Adnexa (bilateral): bilateral ovaries and bilateral tubes are not invaded by tumor
      • Lymph nodes: left iliac LNs; left obturator LNs; right iliac LNs and right obturator LNs
      • Representative sections as follows: [Reference: F2022-00124 FS: endometrial mass, A1: R’t ovary + F-tube, A2: L’t ovary + F-tube, A3-A5: uterus from fundus to cervix, A6-A8: tumor + serosa(ink), A9: tumor + endocervix, A10: cervix, A11: R’t parametrium, A12: L’t parametrium]
        • A1-A2: left iliac LNs;
        • B1-B2: left obturator LNs;
        • C1-C3: right iliac LNs;
        • D1-D2: right obturator LNs.
    • microscopic examination
      • Histology type: Endometrioid carcinoma
      • Histology grade: Grade 3
      • Depth of invasion: greater than half thickness of myometrium, less than 0.1 cm away from serosa
      • Lymphovascular invasion: present
      • The cervical stroma involvement:: absent
      • Resection margins of the cervix: Free, 2.8 cm away from tumor
      • Additional pathologic findings: focal tumor necrosis
      • Lymph nodes:
        • left iliac LNs: free from tumor metastasis (0/12)
        • left oburator LNs: tumor metastasis (1/19) without extracapsular extension (0/1)
        • right iliac LNs: free from tumor metastasis (0/11)
        • right oburator LNs: tumor metastasis (1/16) without extracapsular extension (0/1)
      • Immunohistochemistry: WT-1(-), CK(+), ER(-), PR(-) and vimentin(+. focal) for tumor
  • 2022-03-23 Frozen section
    • Mass, endometrial cavity, frozen section — Adenocarcinoma
  • 2022-03-20 CT - abdomen, pelvis
    • A mass lesion (4.6cm) in uterus.
    • Left liver cyst (6.5mm).
  • 2022-03-20 Gynecologic ultrasonography
    • A 54 x 42 mm mass with flow was noted in endometrial cavity, submucosal myoma with degeneration or endometrial malignancy need to be ruled out
    • Bilateral adnexae: free
  • 2021-11-16 CT - lung/mediastinum/pleura
    • Lungs:
      • areas of patchy expiratory air-trapping in both lower lobes, indicating small airways disease.
      • an ill-defined ground glass nodule at posterobasal segment of LLL (about 7 mm in largest axial dimension) as compared with previous CT study.
    • Impression:
      • LLL-S10 ill-defined GGO 7 mm, suggest f/u LDCT at 12 months later. (GGO: ground glass opacity; LDCT: low dose CT)
      • small airways disease in both lower lobes of lungs.
  • 2021-11-02 SONO - breast
    • Bilateral breasts fibroadenomas. Suggest follow up.
    • BI-RADS category 2, Benign finding.

[MedRec]

  • 2024-01-15 ~ 2024-01-17 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Endometrioid carcinoma of endometrium, grade 3, pT1bN1aM0, stage IIIC1/FIOGO stage IIIC1 with bilateral lung multiple nodules status post three-dimensional video-assisted thoracoscopic surgery right upper, middle and lower lobe lung wedge resection and lymph node dissection on 2023/10/30
      • Chronic viral hepatitis B without delta-agent anti-HBC:positive
    • CC
      • for C3 chemotherapy with Avastin (#2, self-paid) /Taxol/Cisplatin
    • Present illness
      • This is a 71 year-old female had operation history of appendicitis s/p appendectomy.
      • She also had endometrioid carcinoma of endometrium, grade 3, pT1bN1aM0, stage IIIC1/FIOGO stage IIIC1 status post Paclitaxel+Carboplatin since 2022/4-2022/8. It was until March 2023s, she was suspected to have lung metastases but she hesitated to receive tissue proof at that time.
      • CT was done which revealed multiple lung mets in progress on 2023/10/04. Surgical intervention as three-dimensional video-assisted thoracoscopic surgery right upper, middle and lower lobe lung wedge resection and lymph node dissection was performed on 2023/10/30. Pathology showed the findings were consistent with metastatic endometrioid carcinoma. The immunohistochemical stains reveal CK7(+), CK20(-), PAX8(+), TTF-1(focal +), p40(-), CD56(focal +).
      • Anti-HBc: reactive and Baraclude was ordered.
      • Echocardiagraphy (2023/12/04): LVEF(%) = 74. 1. Normal LV systolic function with normal wall motion. 2. LV posterior wall thickening; normal LV diastolic function. 3. Normal RV systolic function. 4. Mild MR; mild TR; mild aortic valve sclerosis.
      • C1 Palliative chemotherapy with Taxol + Cisplain on 2023/12/5, C2 on 2023/12/25 + C1 Avastin (self-paid).
      • Tumor marker showed CA-125: 11.324U/ml on 2023/05/15, 10.87U/ml on 2023/07/11, 15.622U/ml on 2024/01/11.
      • This time, she is admitted for C3 chemotherapy with Taxel + Cisplain + (C2) Avastin self-paid) on 2024/01/15.
    • Course of inpatient treatment
      • After admission, she received pre-medication as Dexamethasone 20mg q6h twice dose and then gave chemotherapy with self paid of Avastin (15mg/kg) + Taxol + Cisplatin on 1/16 24 , smoothly without obvious side effect. She was discharged on 1/17 24 under stable condition and will follow-up at OPD.
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
  • 2023-10-29 ~ 2023-11-02 POMR Thoracic Surgery Xie MinXiao
    • Discharge diagnosis
      • Metastatic endometrical carcinoma over right lung field status post three-dimensional video-assisted thoracoscopic surgery right upper, middle and lower lobe lung wedge resection and lymph node dissection on 2023/10/30.
      • Bilateral lung multiple nodules status post three-dimensional video-assisted thoracoscopic surgery right upper, middle and lower lobe lung wedge resection and lymph node dissection on 2023/10/30
      • Endometrioid carcinoma of endometrium, grade 3, pT1bN1aM0, stage IIIC1/FIOGO stage IIIC1
    • CC
      • Lung metastasis was noted.        
    • Present illness
      • This is a 71 year-old female had operation history of appendicitis s/p appendectomy.
      • She also had endometrioid carcinoma of endometrium, grade 3, pT1bN1aM0, stage IIIC1/FIOGO stage IIIC1 status post chemotherapy. Chemotherapy-related agranulocytosis happened after 3rd chemotherapy. Lung metastasis was noted, and therefore she was transfer to chest surgery for tissue proof of lung tumors. CT was done which revealed multiple lung nodules.
      • After well explaination to the patient and her family of current conditions and treatments, she decided to undergo a surgery. The patient was admitted on 2023/10/29. 3D vedio-assisted thoracic surgery of right upper, middle and lower lobe wedge was arranged on 2023/10/30.
    • Course of inpatient treatment
      • After admission, pre-op assessment was done. Operation of three-dimensional video-assisted thoracoscopic surgery right upper, middle and lower lobe lung wedge resection and lymph node dissection was performed smoothly on 2023/10/30. No complication was noted. Prophylactic antibiotics was prescribed for 1 day. Right chest tube with low pressure suction -18 cmH2O was done. Chest tube was removed on 2023/11/01. She was discharged under stable hemodynamics and chest surgery clinic follow up will be arranged.
    • Discharge prescription
      • Actein (acetylcysteine 200mg) 1# TID
      • MgO 250mg 1# TID
      • Sindine (povidone iodine aq soln) QD EXT
      • Acetal (acetaminophen 500mg) 1# PRNQID
  • 2022-03-22 ~ 2022-03-31 POMR Obstetrics and Gynecology Huang SiCheng
    • Discharge diagnosis
      • Malignant neoplasm of endometrium
      • Malignant neoplasm of endometrium => laparoscopic staging (total hysterectomy + bilateral salpingo-oophorectomy + bilateral Pelvic Lymph nodes Dissection) on 2022/03/23.
      • Female pelvic peritoneal adhesions (postinfective)
      • Abnormal uterine and vaginal bleeding
    • CC
      • Right lower quadrant abdominal dull pain with great mount of vaginal bleeding for 2 days
    • Present illness
      • This is a 70 year-old female, with menstural history G1P1, and menopause when she was 50 y/o. Besides, she also had operation history of appendicitis s/p appendectomy wen she was 13 years ago, and CT image finding of GGO about 0.8cm at LLL. Her ADL is totally independent.
      • According to her statement and medical record, she suffered from Right lower abdominal dull pain for 2 days. There was no relieving nor exaggerate factors. No refer pain, no fever with chillness, no nausea nor vomitus, no recent abdominal trauma history, no constipation, no tarry stool nor bloody stool, no vaginal spotting was noted then. Thus, she visited Dr.祝’s OPD for help at first. At OPD, her vital sign was stable and physcial examination showed no remarkable finding. Transvaginal sonography found a uterine myoma 2.4*2.1cm. Painkiller was prescibed, and no episode of was found in recent half years. However, she was brought to our emergency room on 3/20 due to severe right lower abdominal dull pain with great mount of vaginal bleeding noted.
      • At our triage, her vital sign was stable and physcial examination showed no obvious tenderness, no muscle guarding nor rebounding pain. Laboratory data were all in normal limit, but elevated of tuomr marker CA125(114.7). Abdominal Ct found a A mass lesion (4.6cm) in uterus. Transvaginal sonography showed a 5 x 4 cm poor marginal mass lesion with fluid in uterus with flow(+),suspected submucosal myoma with degeration, but endometrial malignancy need to be ruled out. After we had well explain to the patient and her family of current conditions and treatments, she decided to undergo a surgery.
      • Under the impression of right lower abdominal pain with vaginal bleeding, suspect uterine myoma related, she was admitted to our ward for LAVH+ BSO.
    • Course of inpatient treatment
      • The patient was admitted on 2022/03/22 and underwent Laparoscopic gynecologic oncology staging surgery (LAVH +BSO+ bilateral pelvic lymphectomy) the next day and 2022/03/30 on 1. Port-A, left Fluoroscopy. Her postoperative course was uneventful. her eating and self viding,as well as defecation were both ok. She is to be discharged on 2022/03/31. Her followup appointment is scheduled on 2022/04/07.
    • Discharge prescription
      • cephalexin 500mg 2# QID
      • MgO 250mg 2# QID
      • naproxen 250mg 1# QID
      • Anxiedin (lorazepam 0.5mg) 1# HS for insomnia use

[surgical operation]

  • 2023-10-30 - Op Method:
    • 3D VATS RUL wedge + RML wedge + RLL wedge + LND.
    • Finding:
      • Multiple lung nodules over RML, RUL and RLL, size about 0.8cm.
      • One 20 Fr. stragith chest tube was inserted via right 8th ICS.
    • Procedure:
      • Under DLGA, the patient was put in left lateral decubitus position. The operative field was sterilized and draped as usual. One incision was made over right 8th ICS and entered the pleural cavity carefully. Under the 3D thoracoscope, another incision was made over right 5th ICS in the anterior axillary line. Wedge resection was performed for lesions over RUL, RML and RLL. Lymph node sampling was also performed. After sure the lung can be expanded, massive warm normal saline was irrigated the whole pleural cavity. One chest tube was inserted via camera port. The other wound was closed with 2-0 and 4-0 vicryl layer by layer. After extubated of ETT, she was sent to POR under stable condition.
  • 2022-03-23
    • Diagnosis:
      • Endometrial cancer (Frozen section: Adenocarcinoma)
      • Intra-abdominal adhesions (right site, surgical history: s/p appendectomy)
    • Operation:
      • Laparoscopic gynecologic oncology staging surgery (LAVH + BSO + bilateral pelvic lymphectomy)
    • Finding
      • Uterus: normal size, smooth surface, papillary mass in uterus cavity
      • Bilateral adnexa: grossly normal
      • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
      • CDS: free
      • Adhesion over right abdominal wall
  • 2018-11-06
    • Intracapsular (extracapsular) lens extractionunder microscope + IOL insertion

[chemotherapy]

  • 2024-02-16 - bevacizumab 15mg/kg 700mg NS 100mL 1.5hr + paclitaxel 175mg/m2 258mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 110mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2024-01-16 - bevacizumab 15mg/kg 700mg NS 100mL 1.5hr + paclitaxel 175mg/m2 260mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 110mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-12-25 - bevacizumab 15mg/kg 700mg NS 100mL 1.5hr + paclitaxel 175mg/m2 260mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 110mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-12-05 - …………………………………… paclitaxel 175mg/m2 257mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 110mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-08-23 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 580mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-07-25 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 580mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-07-02 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 580mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-06-08 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 575mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-05-09 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 575mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
  • 2022-04-19 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 575mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL

==========

2024-02-16

As of 2024-02-16, the patient demonstrates stable vital signs and grossly normal laboratory values (2024-02-15). Entecavir (Baraclude) is currently utilized for the management of Anti-HBc positivity. No medication discrepancies were identified.

2022-05-10

  • For this post-operative endometrial cancer patient, the current regimen is preferred, and the patient was able to tolerate the regimen during last hospitalization.
  • Laboratory results on 2022-05-09 indicated that liver and kidney function, CBC and electrolytes were generally normal.
  • Baraclude (entecavir 0.5mg) QDAC is used for the management of heptatitis virus B.

700152752

240216

[lab data]

2023-06-19 RPR/VDRL Nonreactive
2023-06-19 HIV Ab-EIA Nonreactive
2023-06-19 Anti-HIV Value 0.05 S/CO
2023-06-19 Anti-HBs >1000.00 mIU/mL
2023-06-19 HBsAg Nonreactive
2023-06-19 HBsAg (Value) 0.30 S/CO
2023-06-19 Anti-HCV Nonreactive
2023-06-19 Anti-HCV Value 0.07 S/CO
2023-06-06 HBsAg Nonreactive
2023-06-06 HBsAg (Value) 0.27 S/CO
2023-06-06 Anti-HCV Nonreactive
2023-06-06 Anti-HCV Value 0.08 S/CO
2023-06-06 Anti-HBc Reactive
2023-06-06 Anti-HBc-Value 4.98 S/CO
2023-05-30 CEA (NM) 1908.200 ng/ml

[exam findings]

  • 2024-02-07, -01-19, 2023-12-29, -11-16, -10-12, -08-15, -07-21, -06-08, -06-02, -06-01 CXR
    • There are multiple nodular opacities projecting in both lung that are c/w metastases after correlate with CT.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Old fracture of right clavicle S/P long screw fixation shows good alignment and good union.
  • 2024-01-16 L-spine flex. & ext. (including sacrum)
    • Disc space narrowing with marginal osteophyte formation of L4-5.
  • 2024-01-23 Tc-99m MDP bone scan with SPECT
    • Increased activity in the sacrum and lower portion of bilateral S-I joints. The nature is to be determined (bone metastases? degenerative or post-traumatic change? other nature?). Please correlate with other imaging modalities for further evaluation.
    • Some hot spots in the skull. The nature is to be determined. Please also correlate with other imaging modalities for further evaluation.
    • Mildly increased activity in the lower C-spine, lower T-spine and L5 spine, compatible with degenerative change.
    • Some hot spots in bilateral rib cages in linear arrnagement. Post-traumatic change is more likely.
    • Increased activity in the mandible. Dental problem may show this picture. Please also correlate with other clinical findings.
    • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
  • 2024-01-18 MRA - brain
    • Findings
      • An intra-axial enhancing lesion, about 23 mm, with necrotic change and extensive perifocal edema in left temporal lobe, causing effacement of adjacent cortical sulci and mild mass effect. Metastasis is first considered. Abscess is less likely.
      • Well-defined T2-hyperintensities with diffusion elevation in left cerebellar hemisphere, indicating old infarcts.
      • No intracranial hemorrhage, nor acute/subacute infarct.
      • No remarkable finding of skull base and bony structures.
      • No remarkable finding of nasopharynx visible in these images.
      • Segmental narrowing of bilateral MCA segments.
      • Engorged and tortuous VA, indicating dolichoectasia.
    • IMP:
      • Left temporal lobe tumor. Metastasis is considered. Abscess is less likely.
      • Old infarcts in left cerebellum.
  • 2024-01-03 T- L-spine AP + Lat.
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon at right lateral aspect of L4-5.
  • 2023-12-06 CT - abdomen
    • S-colon cancer with regional LAP and lung metastases (mild progression).
  • 2023-11-20 Nasopharyngoscopy
    • Findings: smooth nasopharynx, oropharynx, hypopharynx, sticky post nasal drip, erosion wound over left caudal septum
    • Diagnosis: sticky post nasal drip, erosion wound over left caudal septum
  • 2023-11-01 Bladder Sonography
    • PVR: 14 mL
  • 2023-09-22 ENT Hearing Test
    • PTA
      • R’t : 39 dB HL
      • L’t : 41 dB HL
      • Bil normal to severe SNHL
    • Tymp
      • Bil Type Ad
    • ART
      • Bil absent.
  • 2023-08-28 CT - chest
    • sigmoid colon cancer with stationary of lung metastases and regression regional metastatic LAP compared with CT on 2023/05/19 and 2023/05/26
  • 2023-07-31 T-L spine Lat
    • Increased kyphosis of thoracolumbar spine.
    • Degenerative change of the spine with marginal spur formation.
  • 2023-06-09 All-RAS + BRAF mutation
    • Tissue Block No.: S2023-11068
    • RESULTS:
      • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-06-05 Patho - colon biopsy (Y1)
    • Intestine, large, sigmoid colon, 30 cm AAV, cm from anal verge, biopsy — Adenocarcinoma
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • 2023-06-05 Colonoscopy
    • Mixed hemorrhoid was noted.
    • A tumor lesion is loacted at S-colon (30cm AAV) with nearly lumen obstruction
  • 2023-06-02 Patho - lung transbronchial biopsy
    • Lung, ? side, CT-guide biopsy — consistent with metastatic moderately differentiated adenocarcinoma from colorectal origin
    • Sections show alveolar lung tissue with infiltration of cribriform tumor glands.
    • The immunohistochemical stains reveal CK7(-), CK20(focal +), CDX2(+), and TTF-1(-). The results are consistent with metastatic moderately differentiated adenocarcinoma from colorectal origin.
  • 2023-05-26 CT - chest
    • Indication: multiple lung nodules, nature?
    • Chest CT with and without IV contrast ehnancement shows:
      • Diffuse necrotic nodules are found at both lungs up to 2.4cm at right lower lobe. lung meta is considered.
      • Small lymph nodes are found at mediastinum.
      • Scoliotic alignment of the thoracolumbar spine is noted.
    • Imp: Bilateral lung meta. Colon cancer meta is favored.
  • 2023-05-25 Lower G-I Series (Colon filling study)
    • Administration of contrast medium from anus. Opacification of rectosigmoid colon. Fistula formation with urinary bladder.
    • Impression: Fistula between sigmoid colon and urinary bladder.
  • 2023-05-19 CT - abdomen
    • CC: urine turned sticky with bubbles
      • Urine Culture: Enterococcus faecalis and Escherichia coli: >100000. suspect fistula between intestine and urinary bladder
      • History: menopause, ATH
    • Findings:
      • There is segmental wall thickening of the sigmoid colon, measuring 6 cm in size, with caudal extension into the urinary bladder (diffuse wall thickening and gas content c/w fistula formation).
        • Adenocarcinoma of the sigmoid colon with urinary bladder invasion (T4b) is highly suspected.
        • Please correlate with colonoscopy and cystoscopy.
      • There are seven enlarged nodes in the adjacent mesocolon that are c/w metastatic nodes (N2b).
      • There are multiple variable size soft tissue masses on both lungs, the largest one 2.1 cm at RLL, that are c/w lung metastases (M1a).
        • There are several kissing metastatic nodes in retrocaval space (M1b).
        • In addition, there is a soft tissue nodule 2 cm in the omentum at right upper pelvis that is c/w tumor seeding (M1c).
      • Right renal stones (< 5mm). There are several renal cysts on left kidney and the largest one measuring 2 cm in size at left middle pole para-pelvic area.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M1c(M_value) STAGE:IVC(Stage_value)
  • 2022-11-28 CT - abdomen
    • History and indication: insist on confirm renal stone before go abroad
    • Non-contrast CT of abdomen-pelvis revealed:
      • Some nodules (up to 9mm) at bil. basal lungs.
      • Right renal stones (3-4mm). Nodules (5mm, 7mm) at left kidney.
      • Atherosclerosis of iliac arteries.
    • IMP:
      • Some nodules (up to 9mm) at bil. basal lungs.
      • Right renal stones (3-4mm). Nodules (5mm, 7mm) at left kidney.
  • 2022-09-28 MRA - brain
    • Old insults (ischemic?) in left cerebellum. Nasopharyngeal mucosal thickening. Suggest ENT check-up.
  • 2022-05-23 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (103 - 24) / 103 = 76.70%
      • M-mode (Teichholz) = 76.6
    • Conclusion:
      • Dilated Ao
      • Adequate LV, RV systolic function with normal wall motion
      • LV hypertrophy, Impaired LV relaxation
      • Poor echo window
  • 2022-02-15 Bone densitometry - spine
    • L-spines BMD (AP view) performed by DXA revealed:
      • AP L-spines, BMD of L1-4 0.657 gms/cm2, about 3.3 SD below the peak bone mass (65%) and 0.4 SD below the mean of age-matched people (93%).
    • IMP: osteoporosis
  • 2022-02-15 L spine Ap + Lat. (including sacrum)
    • Maintained bony alignment
    • Disc space narrowing at L4/5
    • Facet degeneration of lumbar spine

[consultation]

  • 2023-06-13 Radiation Oncology
    • Q
      • For evaluation of RT
      • This is a 71 female, had past history of Colon-vesicle fistula; Hypertension; Psoriasis (regular OPD f/u at NTUH)
      • This time was admitted to our ward for cancer survey. CT guide Biopsy and colon scope biopsy had proven maligancy last week.
      • Colon Ca with lung metastasis (Colorectal Carcinoma, Imaging stage T4bN2bM1c, STAGE:IVC)
      • We need your expertise for evaluation of RT, thank you
    • A
      • A: Adenocarcinoma of the sigmoid colon, EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)C, stage T4bN2bM1c (IVC), with colon-vesicle fistula and lung metastases.
      • P: The treatment modality and the possible effects of radiotherapy were well explained. I need to further discuss with the patient and her family.
        • Addendum (2023-06-14): Concern the possible effects of radiotherapy on fistula, after discussed with the patient and her family (younger brother and son), radiotherapy was not planned.
  • 2023-06-12 Urology
    • Q
      • For colon-vesicle fistula before chemotherapy.
      • This is a 71 female, had past history of Colon-vesicle fistula; Hypertension; Psoriasis (regular OPD f/u at NTUH)
      • This time was admitted to our ward for cancer survey. CT guide Biopsy and colon scope biopsy had proven maligancy.
      • Colon Ca with lung metastasis (Colorectal Carcinoma, Imaging stage T4bN2bM1c, STAGE:IVC)
    • A
      • The aim of surgical excision of fistula is to reduce infection rate during chemotherapy
      • There is still large amount of metastatic lymph and lung lesion
      • There is high risk of residual tumor on urinary bladder or urine leakage after fistula resection
      • The more urinary bladder resection will reduce residual cancer but increase risk of urine leakage after bladder repair
      • Colonstomy may reduce fecal contamination to urinary bladder
      • colonstomy may be a feasible alternative
      • The benefit and risk of procedure will explain to her

[surgical operation]

  • 2023-06-15
    • Surgery
      • T loop colostomy
    • Finding
      • dilatation of T colon
      • omentum adhesion to low abdomen.
    • Procedure
      • After GA, abdomen skin is prepare.
      • Incision over RUQ and check bleeding.
      • Lysis of omentum adn free T colon
      • Fix T colon to skin.
      • clean stool in colon and suture.

[radiotherapy]

RT (2024-01-26 ~ 2024-02-08): 3000cGy/10 fractions (6MV photon) of the metastatic brain tumor. RT (2024-02-05 ~ undergoing): 1500cGy/5 fractions (10MV photon) of the metastatic sacrum area.

[chemotherapy]

  • 2024-01-03 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (cetuximab + FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-11-16 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (cetuximab + FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-10-25 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (cetuximab + FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-09-14 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (cetuximab + FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-08-24 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr (cetuximab + FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-08-03 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4650mg NS 500mL 46hr (cetuximab + FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-07-21 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-07-09 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-06-27 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovirin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

==========

2024-02-16

[reconciliation]

Treatment for the patient’s UTI commenced on 2024-02-15 with Flumarin (flumoxef sodium) 1000mg Q8H IVD. Additionally, on 2024-02-05, the patient initiated radiotherapy of the metastatic sacrum area with a total dose of 1500 cGy delivered in 5 fractions using 10MV photons. Baraclude (entecavir) is used to prevent HBV from becoming reactivated. No medication discrepancies were identified.

2023-08-24

After examining both PharmaCloud and HIS5 records, no medication discrepancies were found.

Erbitux (cetuximab) was first administered on 2023-08-03 in conjunction with the 4th dose of the FOLFIRI regimen which began on 2023-06-27 (2023-06-09 no variant detect in the KRAS/NRAS gene). Based on the CEA lab data, the decreasing trend suggests that the regimen has been effective so far.

2023-08-23 CEA (NM) 457.140 ng/ml 2023-08-04 CEA (NM) 962.760 ng/ml 2023-07-14 CEA (NM) 1473.200 ng/ml 2023-07-14 CEA (NM) 1508.900 ng/ml 2023-05-30 CEA (NM) 1908.200 ng/ml

2023-07-24

As of the current date, the patient’s oral Alinamin-F (vitamin B complex) and Bokey (aspirin) prescriptions, which were refilled for 30 days on 2023-07-15, are not listed in the active medication list. To ensure patient appropriate treatment, it is advisable to recheck the necessity of these medications.

2023-06-26

  • According to the PharmaCloud records, the patient received treatment for acute sinusitis from a local ENT clinic on 2023-05-25 and was provided with a 3-day short-term prescription that is no longer valid. This does not pose a medication reconciliation issue.

  • On 2023-05-08, the patient was prescribed Evista (raloxifene 60mg) 1# QD and Celebrex (celecoxib 200mg) 1# QD by our hospital’s orthopedic department, both on a refillable basis. Currently, Evista is included in the patient’s active medication list. Celebrex has been replaced by Deflam-K (diclofenac 25mg) 1# QD, which does not seem to present any medication reconciliation issues. The adjustments are in alignment with the patient’s current health status.

  • A fistula between the sigmoid colon and the bladder was seen on 2023-05-25 in the lower GI series. A urine culture obtained on 2023-06-13 confirmed the presence of both Enterococcus faecalis and Escherichia coli, both greater than 100,000 CFU/cc. After a T-loop colostomy on 2023-06-15, the stool culture on 2023-06-19 showed only the presence of normal flora, with no non-intestinal pathogens identified.

  • The lab results from 2023-06-06 and 2023-06-19 indicated that the patient tested positive for Anti-HBc and Anti-HBs, suggesting a past HBV infection. Given this, if immunosuppressive chemotherapy is planned, prophylactic antiviral therapy with either Baraclude (entecavir 0.5mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25mg) 1# QD is recommended, at least for the duration of the chemotherapy. This measure can help prevent potential reactivation of the HBV infection due to the immunosuppressive effects of chemotherapy.

700165097

240216

[exam findings]

  • 2023-12-04 Patho - breast simple/partial mastectomy
    • Diagnosis:
      • Breast, left, simple mastectomy — invasive lobular carcinoma, grade 1
      • Nipple base — Negative for malignancy
      • Lymph node, left axilla sentinel, excision — Negative for malignancy (0/3)
      • AJCC 8th edition pathology stage: pT2(m)N0(if cM0); anatomic stage IIA; AJCC prognostic stage IA
    • Gross Description
      • Procedure: Simple mastectomy (without nipple and skin)
      • Lymph node sampling (if lymph nodes are present in the specimen): Sentinel lymph node(s)
      • Specimen laterality: Left
      • Sections are taken and labeled as: F2023-548FSA1-2:SLN; F2023-548FSB:nipple base; A1-22:tumor
    • Microscopic Description
      • For Invasive Carcinoma
        • Histologic type: Invasive lobular carcinoma
        • Size of invasive carcinoma (mm): up to 2.5 cm, multiple foci
        • Histologic grade (Nottingham histologic score): Grade I (score 5)
        • Extent of tumor (required only if the structures are present and involved)
        • Skin involvement: not included
        • Chest wall invasion deeper than pectoralis muscle: Absent
      • For Ductal Carcinoma In Situ: not applicable
        • Tumor size (mm):not applicable
        • Nuclear grade: not applicable
        • Architectural pattern: not applicable
        • Tumor necrosis: not applicable
      • Margins:Negative, Closest margin ( 10 mm from deep margin)
      • Nodal status: Negative
        • No. examined: 3
        • No. macrometastases (> 2 mm): 0
        • No. micrometastases (> 0.2 ~ 2 mm and/or > 200 cells): 0
        • No. isolated tumor cells (<= 0.2 mm and <= 200 cells): 0
      • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
        • In the Breast: No applicable
        • In the Lymph nodes: No applicable
      • Immunohistochemical Study
        • CK (for SLN): Negative
      • Reference: S2023-22581
  • 2023-11-27 Tc-99m MDP bone scan
    • Faint hot spots in both rib cages, and increased activity in some upper T-spine, and inferior angle of hte right scapula, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in some T- and L-spine, bilateral shoulders, elbows, S-I joints, and hips.
  • 2023-11-22 CT - chest
    • Findings
      • suspect increased enhancing nodules in Lt breast as compared with Rt side.
      • two Rt renal cysts measuring up to 1cm (longest axial diameter)
    • Impression:
      • Lt breast tumor(s). no lungs abnormaltiy.
  • 2023-11-13 Patho - breast biopsy (no need margin)
    • Breast, left, 11 o’clock, core biopsy — Invasive lobular carcinoma, no special type, NST. IHC stains (using block S2023-22581A): ER (+, 95%, strong intensity), PR (+, 90%, strong intensity), Her2/neu: negative (score=0), Ki-67(8 %), E-cadherin (-).
    • Breast, left, 12 o’clock, core biopsy — Invasive lobular carcinoma, no special type, NST. IHC stains (using block S2023-22581B): ER (+, 95%, strong intensity), PR (+, 90%, strong intensity), Her2/neu: negative (score=0), Ki-67(15 %), E-cadherin (-).
  • 2023-10-27, -08-01 SONO - breast
    • Diagnosis: Bil. fibroadenomas as described
    • BI-RADS: 2. benign finding
  • 2022-07-23 Gynecologic ultrasonography
    • IMP: Uterine myoma
  • 2022-07-23 SONO - nephrology
    • R/O Left parapelvic renal cyst, r/o Dilated renal calyx.

[MedRec]

  • 2024-01-26 SOAP Hemato-Oncology Gao WeiYao
    • Prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Bafen (baclofen 5mg) 1# HS
      • Granocyte (lenograstim 250ug) QD SC on 1/26, 1/27, 1/29

[consultation]

  • 2023-12-25 Plastic and Reconstructive Surgery
    • Q
      • for left breast swelling & pain for days
      • This 49-year-old woman, a patient of left breast Invasive lobular carcinoma, no special type, NST. IHC stains (using block S2023-22581A): ER (+, 95%, strong intensity), PR (+, 90%, strong intensity), Her2/neu: negative (score=0), Ki-67(8%), E-cadherin (-). She was admitted for chemotherapy. We need expertise to evaluate her condition thanks!
    • A
      • I checked patient’s left breast, and I think she does not tolerate the tissue expander as well as I expected. However, there is no obvious sign of infection or severe inflammation. so I explained current situation to the patient. And I will check on her often. Please arrange out-patient appointment for me and her on 12/28. Thanks.
  • 2023-11-30 Plastic and Reconstructive Surgery
    • Q
      • This is a 49 years old woman patient. Due to left breast cancer, she was admitted for surgery of left simple mastectomy + SLNB on 2023/12/01. We need your help for expander. Thank you so much!!
    • A
      • First stage breast reconstruction was planned, and tissue expander will be used. Thanks.

[MedRec]

  • 2024-02-16 - docetaxel 75mg/m2 120mg NS 250mL 1hr + cyclophosphamide 600mg/m2 1000mg NS 250mL 90min
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2024-01-18 - docetaxel 75mg/m2 120mg NS 250mL 1hr + cyclophosphamide 600mg/m2 1000mg NS 250mL 90min
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-12-26 - docetaxel 75mg/m2 120mg NS 250mL 1hr + cyclophosphamide 600mg/m2 1000mg NS 250mL 90min
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-02-16

[repeated leukopenia episodes after chemo, g-csf prophylaxis may be prudent]

Following the first chemotherapy session on 2023-12-26, and the second session on 2024-01-18, the patient experienced episodes of leukopenia with nadir WBC counts of 1.43 K/uL on 2024-01-02 and 2.06 K/uL on 2024-01-26. Given these observations, prophylactic G-CSF administration may be prudent.

700546273

240216

[exam findings]

  • 2024-01-27 CT - abdomen
    • s/p ATH and BSO with post op. change of the pelvis
    • s/p C/T
    • No evidence of abnormal recurrent/residual tumor in the study.
  • 2023-08-28 F-18 Fluorodeoxyglucose (FDG) PET scan
    • No previous study for comparison.
    • Increased FDG uptake in the lower pelvis, compatible with cervical cancer s/p surgical change.
    • Increased FDG uptake in three nodular lesions in bilateral pelvic regions and in the peritonium of LLQ of abdomen, the nature is to be determined (s/p surgical reaction, metastatic lymph nodes or other nature ?), suggesting biopsy (the nodular lesion in the peritonium of LLQ of abdomen) for investigation.
    • Increased FDG accumulation in bilateral pulmonary hilar regions, kidneys, and ureters, probably physiological uptake of FDG.
    • No prominent abnormal focal FDG uptake is noted elsewhere.
  • 2023-08-21 Patho - uterus (with or without SO) neoplastic (Y1)
    • Diagnosis:
      • Cervix, radical hysterectomy — Moderately differentiated squamous cell carcinoma, HPV -associated
      • Endometrium, radical hysterectomy — Negative for malignancy
      • Myometrium, radical hysterectomy — Involved by tumor
      • Parametrium, right, radical hysterectomy — Involved by tumor& margin free
      • Parametrium, left, radical hysterectomy — Negative for malignancy
      • Vaginal cuff, radical hysterectomy — Negative for malignancy; Margin positive for severe dysplasia
      • Ovary, bilateral, radical hysterectomy— Negative for malignancy
      • Fallopian tube, bilateral, radical hysterectomy — Negative for malignancy
      • Lymph node, right iliac, dissection — metastatic carcinoma
      • Lymph node, right obturator, dissection — Negative for malignancy
      • Lymph node, left iliac, dissection — Negative for malignancy
      • Lymph node, left obturator, dissection — Negative for malignancy
      • Lymph node, paraaortic, dissection — Mature fat tissue only
      • AJCC 8th edition pathology stage:pT2bN1(if cM0); AJCC stage IIB
      • AJCC 9th edition Cervix Uteri:pT2bN1a(if cM0); FIGO stage IIIC1; AJCC stage IIIC1
    • Gross description:
      • Procedure (select all that apply)
        • Radical hysterectomy + BSO + BPLND + PALNS
        • Note: For information about lymph node sampling, please refer to the Regional Lymph Node section.
      • Tumor Size:
        • Greatest dimension: 3.5 cm
        • Additional dimensions (centimeters): 3 x 1.4 cm
      • Tumor Site (select all that apply)
        • Left superior (anterior) quadrant (12 to 3 o’clock), left inferior (posterior) quadrant (3 to 6 o’clock), right inferior (posterior) quadrant (6 to 9 o’clock), right superior (anterior) quadrant (9 to 12 o’clock)
      • Sections are taken and labeled as: A1:right iliac LN, A2:right obturator LN, A3:left obturator LN, A4:left iliac LN, A5-6:right adnexae, A7-8:left adnexae, A9-10:right parametrium, A11-12:left parametrium, A13-23:cervical tumor, A24-25:lower segment, A26-27:upper segment, A28:paraaortic LN
    • Microscopic Description:
      • Histologic Type
        • Squamous cell carcinoma, HPV-associated
      • Histologic Grade:
        • G2: Moderately differentiated
      • Stromal invasion:
        • Depth of stromal invasion: 10 mm, entire (The fractions of stromal invasion can be replaced by reporting “depth of stromal invasion in mm / cervical wall thickness in mm” as needed.)
      • Silva Pattern of Invasion (applicable only to invasive endocervical adenocarcinomas): Not applicable
      • Other Tissue/ Organ Involvement (select all that apply):
        • Right parametrium
        • Myometrium, lower segment
      • Margins:
        • Vaginal cuff Margin: Positive for severe dysplasia
        • Parmetrial Margin: Free, 3 mm of closest margin distance at right side
      • Lymphovascular Invasion: Present
      • Regional Lymph Nodes: described as follows
        • Site: (Positive: positive nodes number/total number) (Negative: 0/total number)
        • Pelvic Lymph Nodes:
        • Right iliac: Positive: 2/8
        • Left iliac: Negative: 0/6
        • Right obturator: Negative: 0/9
        • Left obturator: Negative: 0/5
      • Greatest dimension of largest nodal metastatic deposit (required only if macrometastasis or micrometastasis present):4 mm
        • Isolated tumor cells (0.2 mm or less and not more than 200 cells) (required only in the absence of macrometastasis or micrometastasis in other lymph nodes): Absent
      • Para-aortic Lymph Nodes: N/A (fat tissue only)
        • Greatest dimension of largest nodal metastatic deposit (required only if macrometastasis or micrometastasis present): N/A
        • Isolated tumor cells (0.2 mm or less and not more than 200 cells) (required only in the absence of macrometastasis or micrometastasis in other lymph nodes): Absent
      • Distant Metastasis:
        • This excludes metastasis to pelvic or para-aortic lymph nodes, or vagina: Not applicable
      • Additional Pathologic Findings
        • severe dysplasia at vaginal cuff
      • Special Study: immunohistochemistry: p16: Positive (strong, diffuse, >90%), P40(+)
      • Comment(s): None
  • 2023-07-15 CT - pelvis-bone
    • With and without contrast enhancement CT of abdomen–whole:
      • There is enhanced soft tissue tumor, 3.5cm in the uterine cevical region, r/o cervical malignancy.
      • Segmental wall edeman at hepatic flexure of colon.
      • Thickening wall at gastric antrum.
    • Imaging Report Form for Cervical Carcinoma
      • Impression (Imaging stage) : T:T1b2(T_value) N:N0(N_value) M: M0_(M_value) STAGE:IB2(Stage_value)
    • Impression:
      • Cervical tumor, r/o malignancy, cstage T1b2N0M0.
      • Wall edema of hepatic flexure of colon.
      • Wall thickening at gastric antrum, suggest further study.
  • 2023-07-14 Patho - cervix biopsy
    • Uterus, cervix, LEEP conization — Squamous cell carcinoma in situ (CIS), at least, with glandular involvement. Endocervical margin is positive for CIS. NOTE: The possibility of a more advanced lesion cannot be excluded. Please correlate with clinical and image findings.
    • Specimen submitted in formalin consists of one piece of tan, cone-shaped tissue measuring 2.0 x 0.9 x 0.3 cm. The surface is eroded. Entire tissue is serially sectioned in a clockwise fashion from 12 O’clock position and submitted in 1 cassette.
    • Sections show cervical tissue with squamous cell carcinoma in situ (CIS) at least. The dysplastic epithelium shows nuclear hyperchromasia, enlargement and crowding in the entire thickness of the squamous epithelium. The endocervical glands are involved. NOTE: The possibility of a more advanced lesion cannot be excluded. Please correlate with clinical and image findings.
  • 2023-07-14 Patho - cervix biopsy
    • Uterus, endometrium, D&C — squamous cell carcinoma in situ (CIS), at least. NOTE: The possibility of a more advanced lesion cannot be excluded. Please correlate with clinical and image findings.
    • Specimen submitted in formalin consists of blood clots and tissue measuring 0.9 x 0.7 x 0.3 cm. All for section in one cassette.
    • Section shows blood clots and squamous cell carcinoma in situ (CIS), at least. NOTE: The possibility of a more advanced lesion cannot be excluded. Please correlate with clinical and image findings.
  • 2023-07-14 Patho - cervix biopsy (Y1)
    • Uterus, endocervix, ECC — squamous cell carcinoma in situ (CIS), at least. NOTE: The possibility of a more advanced lesion cannot be excluded. Please correlate with clinical and image findings.
    • Specimen submitted in formalin consists of mucin, blood clots, and scanty tissue measuring 1.5 x 0.5 x 0.4 cm. All for section in one cassette.
    • Section shows squamous cell carcinoma in situ (CIS), at least. NOTE: The possibility of a more advanced lesion cannot be excluded. Please correlate with clinical and image findings.
  • 2023-06-27 Patho - endocervix curretage/biopsy
    • Uterus, endocervix, ECC — squamous cell carcinoma is situ (CIS).
    • Specimen submitted in formalin consists of mucin and scanty tissue measuring 0.1 x 0.1 x 0.1 cm. All for section in one cassette.
    • Section shows mucin and scanty squamous cell carcinoma is situ (CIS).
  • 2023-06-27 Patho - cervix biopsy
    • Uterus, endocervix, ECC — squamous cell carcinoma is situ (CIS).
    • Specimen submitted in formalin consists of mucin and scanty tissue measuring 0.1 x 0.1 x 0.1 cm. All for section in one cassette.
    • Section shows mucin and scanty squamous cell carcinoma is situ (CIS).

[MedRec]

  • 2023-08-17 ~ 2023-09-02 POMR Obstetrics and Gynecology Shao ZhiXiuan
    • Discharge diagnosis
      • Malignant neoplasm of cervix uteri, unspecified
      • Malignant neoplasm of cervix uteri (Moderately differentiated squamous cell carcinoma, pT2bN1 (if cM0); AJCC stage IIIC1, FIGO pStage IIIC1, post Radical hysterectomy on 2023/08/18
    • CC
      • Intermittent vaginal spotting since mid June this year
    • Present illness
      • This is a 61y/o woman, G1P1 (C/S), without underlying disease. Her gynecology history as follow: Menopause at 57 y/o, HPV vaccine (-), routine pap smear screen (-). She denied any food or drug allergy, denied anticoagulants or hormone use but taking chinese medicine regularly for 4 years.
      • This time, she noted vaginal spotting for 1 day since 2023/06/19. She denied abdominal pain, purulent vaginal discharge, vaginal irritation/pruritus, nausea or vomiting, tarry/bloody stoool, constipation, unintentional body weight loss or postcoital bleeding. She visited our GYN OPD for evaluation, pelvic examination showed mild hypertrophic cervix deviated to 3’, no active bleeding, R/O mosaic pattern around 11’.
      • Pap smear revealed CIN3. The sonography showed endometrial thickness as 13.8mm, suspected EM polyp (8x6mm) and a cervical mass (35x29mm) with minimal cul-de-sac fluid. Lab data showed elevated tumor marker SCC 2.8 ng/mL.
      • The CT scan reported cervical tumor, r/o malignancy, cstage T1b2N0M0, wall edema of hepatic flexure of colon, wall thickening at gastric antrum. We then arranged LEEP cone + ECC + D&C on 2023/07/14, pathology report revealed at least squamous cell carcinoma in situ (CIS), with glandular involvement and endocervical margin is positive for CIS.
      • After well explanation to the patient and under the impression of cervical squamous cell carcinoma in situ (cT1b2), she was admitted to our ward for radical hysterectomy + BILATERAL SALPINGO-OOOPHORECTOMY + BILATERAL PELVIC LYMPH NODE DISSECTION + PARA-AORTIC LYMPH NODE SAMPLING and further management.
    • Course of inpatient treatment
      • After admission, radical hysterectomy + bilateral salpingo-oophprectomy + bilateral pelvic lymph node dissection + para-aortic lymph node dissection + double-J insertion were proceeded smoothly on 2023/08/18. Post-op condition was stable without complication.
      • Pathology result showed as above on 2023/08/23, with cervical carcinoma FIGO stage IIIC1; AJCC stage IIIC1. Concurrent chemoradiotherapy was suggested by guideline. After discussion with oncology specialist, PET scan was done on 2023/08/28, and report showed FDG uptake in lower pelvis compatible with cervix cancer s/p surgical change and three nodular lesions in bilateral pelvic region and peritonium of LLQ abdomen AND NATURE TO BE DETERMINED. We removed vaccum ball on 08/25, and tried removing foley on 08/25 and 08/30 but failed, voiding difficulty with postvoided residual volume around 600mL thus foley was re-inserted.
      • Under relatively stable condition, the patient was dischraged on 2023/09/02 with OPD follow up and further CCRT treatment discussed with radiologist and oncology specialist.
    • Discharge prescription
      • MgO 250mg 2# QID
      • Wecoli (bethanechol 25mg) 1# TIDAC
      • Eurodin (estazolam 2mg) 1# PRNHS

[surgical operation]

  • 2023-08-18
    • Surgery
      • Diagnosis:
        • R/O cervical SCC, cstage IB2
      • Surgery:
        • Radical hysterectomy + BSO + BPLND + PALNS
        • Bilateral double J insertion by GU Dr
    • Finding
      • Uterus: Avfl, 7*4 cm, cervix mass 3.5x2x2cm with endocervical region involved
      • RAD: grossly normal.
      • LAD: grossly normal.
      • CDS: no ascites, no adhesion bands.
      • Right parametrium: size : 2cm, Induration (-);
      • Left parametrium: size : 2cm, Induration (-);
      • Vagina cuff: 2 cm , gross tumor (-), section margin free
      • Bilateral pelvic lymphnodes: Normal, Induration (-)
      • Right external iliac (-)
      • Right obturatorand and hypogastric (-)
      • Left external iliac(-)
      • Left obturator and hypogastric (-)
      • Paraortic lymphnodes: Normal, induration (-)
      • Estimated blood loss: 350ml
      • Blood transfusion: nil
      • Complication: nil
  • 2023-07-14
    • Surgery
      • Impression:
        • Cervical tumor, squamous cell carcinoma in situ (CIS), cstage T1b2N0M0.     - Procedure:
        • Endocervical curretage   
        • Dilatation and curettage
        • Loop eletrosurgical excision procedure (LEEP).
    • Finding
      • Uterus: Anteversion, 7 cm.
      • Cervix: Hypertrophic cervix with eroded surface. One 1x0.5 cm strip of cervix was electrocauterized.
      • Some endocervical and endometrial tissue, with papillary-like were curetted out.
      • Episiotomy was performed (1cm perineal wound) due to narrow vaginal introitus, s/p suturing repair with 3-0 vicryl material.
      • Estimated blood loss: 10 mL,
      • Blood transfusion: nil,
      • Complication: nil.

[radiotherapy]

[chemotherapy]

  • 2024-02-16 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 50mg/m2 80mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
  • 2024-01-27 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 50mg/m2 80mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
  • 2023-12-30 - paclitaxel 175mg/m2 275mg NS 250mL 3hr + NS 500mL 2hr (before cisplatin) + cisplatin 50mg/m2 75mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
  • 2023-12-04 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + cisplatin 50mg/m2 70mg NS 500mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-19 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited with NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-10-12 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited with NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-10-04 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited with NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-09-27 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited with NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-09-20 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited with NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2024-02-16

[gabapentin and duloxetine in neurotoxicity management]

Grade 2 neurotoxicity has been recorded in the patient’s progress notes. Neurontin (gabapentin) is currently being administered for management. Should the neurological symptoms persist, the use of duloxetine may be considered as a potential therapeutic option.

Ref: Platinum-induced neurotoxicity and preventive strategies: past, present, and future. Oncologist. 2015 Apr;20(4):411-32. doi: 10.1634/theoncologist.2014-0044. Epub 2015 Mar 12. PMID: 25765877; PMCID: PMC4391771.

2023-12-04

[Dipeptiven administration]

To the primary nurse,

Dipeptiven 100 mL (alanyl glutamine 20g) can be diluted with NS 250-1000 mL. After dilution, it can be stored at room temperature for 24 hours.

If the patient is still on port-A, based on her body weight of about 56kg, IV infusion is recommended not less than 3.6 hours (20g / (0.1g/kg/hr x 56kg)), 4 to 6 hours would be even better.

700591359

240216

[chemotherapy]

  • 2024-02-16 - liposome doxorubicin 35mg/m2 51mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 870mg NS 500mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2024-01-26 - liposome doxorubicin 35mg/m2 51mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 872mg NS 500mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2024-01-05 - liposome doxorubicin 35mg/m2 50mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-12-15 - liposome doxorubicin 35mg/m2 50mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-02-16

[leukopenia]

It appears that the patient’s WBC level has been in a downward trend even with G-CSF. G-CSF is still the appropriate agent for this patient’s leukopenia episodes.

  • 2024-02-16 WBC 1.87 x10^3/uL
  • 2024-01-26 WBC 2.49 x10^3/uL
  • 2024-01-05 WBC 2.01 x10^3/uL
  • 2023-12-22 WBC 4.40 x10^3/uL
  • 2023-12-15 WBC 6.01 x10^3/uL

700757783

240216

[exam findings]

  • 2023-11-27 Patho - bone marrow biopsy (Y1)
    • DIAGNOSIS:
      • Bone marrow, iliac, biopsy — myelodysplastic syndrome with excess blast type 2 (10-19%)
      • NOTE: Correlation of bone mrrow smear, peripheral blood data, molecular cytogenetic study, flow cytometery and clinical findings is recommended.
    • Gross description:
      • The specimen submitted consists of 1 bone marrow tissue fragment measuring 2.4x 0.2x 0.2 cm in size, fixed in formalin. Grossly, it is brownish and elastic to hard.
    • MICROSCOPIC DESCRIPTION:
      • Microscopically, section shows hypercellularity marrow (>90%), and myeloid cell proliferation with dysplasia. Blasts (highlighted by CD34 and CD117) are increased in numbers (10-19%). CD61 highlights megakaryocytes (3~4 per HPF) and multinucleation.
      • Immunohisotchemical stain reveals CD68 (+), MPO (+), CD138 (focal+, 1~2%), MPO (+), CD71 (focal+, <=5%), TdT (focal+, <=5%).
  • 2022-11-17 Patho - bone marrow biopsy
    • DIAGNOSIS:
      • Bone marrow, iliac, biopsy — hypercellularity, see description. IHC stains: CD117: 5%; CD34: 5%; MPO: 50%, CD61: 5%; CD71: 30% (of the nucleated cells).
    • GROSS DESCRIPTION:
      • Specimen submitted in B5 fixative consists of 1 piece(s) of tan, rod shape bone marrow tissue measuring 1.9 x 0.2 x 0.2 cm. All for section in one cassette after decalcification.
    • MICROSCOPIC DESCRIPTION:
      • Section shows piece(s) of bone marrow with 90% cellularity and M:E ratio of approximately 2:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number.
      • IHC stains: CD117: 5%; CD34: 5%; MPO: 50%, CD61: 5%; CD71: 30% (of the nucleated cells). The possobility of myelodysplastic syndrome is considered.
  • 2022-07-25 lung perfusion scan4-
    • Multiple sub- or non-segmental perfusion defects in the left upper lung field, the probability of PE is low (5-19%, by modified PIOPED criteria).
    • Cardiomegaly is noted.
  • 2022-06-28 Tl-201 stress myocardial perfusion SPECT
    • Probably mild myocardial ischemia at the anteroapical wall, basal lateral wall and posterior wall.
    • Mild reverse redistribution of radioactivity to the apical lateral wall, either normal variant or myocardial ischemia may show this picture.

[MedRec]

  • 2023-11-26 ~ 2023-11-28 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Refractory anemia, unspecified
      • Myelodysplastic Syndrome suspect leukemic transformation, due to Blast: 13.3%
      • anemia
      • thrombocytopenia
      • hyperuricemia
    • CC
      • for bone marrow examination and further treatment.
    • Present illness
      • This 67 yeasr old female is a case of MDS suspect leukemic transformation. She was regularly follow up and blood transfusion with LPRBC monthly at ONC OPD. However, the laboratory test revealed blast increased on 2023/11/22 consider leukemic transformation.
      • This time, she was admitted for bone marrow examination and further treatment.
    • Course of inpatient treatment
      • After be admitted, she received blood transfusion with LPRBC, LRP for anemia, thrombocytopenia treatment, and the bone marrow was done on 2023/11/27, pending the report. She can be discharged on 2023/11/28, the OPD follow-up will be arranged.
    • Discharge prescription
      • Actein Effervescent (acetylcysteine 600mg) 1# BID
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
      • Feburic (febuxostat 80mg) 1# QD

[chemotherapy]

  • 2024-02-07 - Vidaza (azacitidine) 100mg SC 3min D1-2
  • 2024-01-31 - Vidaza (azacitidine) 100mg SC 3min D1-3
  • 2024-01-17 - Vidaza (azacitidine) 100mg SC 3min D1-3
  • 2024-01-10 - Vidaza (azacitidine) 100mg SC 3min D1-3
  • 2023-12-20 - Vidaza (azacitidine) 100mg SC 3min D1-3
  • 2023-12-13 - Vidaza (azacitidine) 100mg SC 3min D1-3

==========

2024-02-16

[adapting Vidaza (azacitidine) dosing in MDS treatment]

The patient, weighing 59kg with a height of 159cm, has a BMI of 23.3 kg/m2 and a BSA of 1.61 m2.

For MDS, azacitidine administration is typically recommended as follows:

  • Initial treatment cycle involves administering 75 mg/m2/day for 7 consecutive days within a 28-day cycle. In subsequent cycles, the same dosage is continued every 4 weeks. If no improvement is observed after two cycles and the only side effects are nausea and vomiting, the dosage may be escalated to 100 mg/m2/day. A minimum of 4 to 6 cycles is recommended, with the option to extend treatment if the patient derives ongoing benefit.

Alternative dosing schedules include:

  • Administering 75 mg/m2/day for the first 5 days (Monday to Friday), followed by a 2-day break (Saturday and Sunday), and then 75 mg/m^2/day for the next 2 days (Monday and Tuesday), with the cycle repeating every 28 days.
  • Administering 50 mg/m2/day for the first 5 days (Monday to Friday), followed by a 2-day break, and then 50 mg/m^2/day for another 5 days, with the cycle repeating every 28 days.
  • Administering 75 mg/m2/day for 5 days (Monday to Friday), with the cycle repeating every 28 days.

For this patient, Vidaza (azacitidine) was administered at an approximate dosage of 62 mg/m2/day (100mg/day) for 3 or 2 days, with intervals varying from 1 to 3 weeks. This represents a lower dosage (mg/kg/day), shorter duration (reduced from the recommended 7 or 5 days to 3 or 2 days), and a more frequent dosing schedule (shorter cycle intervals). Deviating from the standard recommended regimen could potentially yield different therapeutic outcomes from the original regimen’s design.

[transfusion-dependent patient: elevated ferritin suggests iron overload, deferasirox considered]

Given the patient’s history of receiving multiple blood transfusions monthly for an extended period, lab data from 2023-12-13 revealed a serum ferritin level of 2261.8 ng/mL, suggesting the possibility of iron overload. Jadenu (deferasirox), the sole iron chelator available at this institution, could be considered as a treatment option. As of 2024-02-16, the patient’s ALT level was 14 U/L and the eGFR was 60.88 ml/min/1.73m^2, indicating no contraindications for using this medication. Jadenu treatment may be initiated at a dosage of 14 mg/kg daily, with subsequent dose adjustments every 3 to 6 months, depending on serum ferritin levels.

Jadenu (deferasirox) at a daily dose of 360 mg has been administered since Dec 2023. This dosage is below the suggested level of 14 mg/kg for a 59 kg individual, which would amount to 826 mg daily.

700828939

240216

[exam findings]

  • 2024-02-16 CT - abdomen
    • History: Poorly cohesive carcinoma (signet-ring cell) of gastric with peritoneal seeding, cT4aN3aM1 stage IV, status post gastrojejunostomy with Hyperthermic Intraperitoneal Chemotherapy with Oxalip and Mitomycin on 2023/11/23. ECOG:1
    • Findings: Comparison: prior CT dated 2023/11/08.
      • Prior CT identified focal wall thickening with irregular contour at the gastric antrum is noted again, marked decreasing in wall thickness that is c/w adenocarcinoma of the stomach antrum S/P C/T with partial response or complete response.
        • Please correlate with gastroscopy.
        • In addition, Prior CT identified seven enlarged nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, decreasing in number that are c/w metastatic nodes S/P C/T with partial response.
      • Prior CT identified a soft tissue nodule 0.9 cm in right upper pelvis omentum area is not noted again that may be metastatic node S/P C/T with complete response. Follow up is indicated.
      • Prior CT identified few small lymph nodes in para-aortic space and para-cava space (up to 7 mm) are noted again, decreasing in number that may be non-regional metastatic nodes S/P C/T with partial response.
        • Follow up is indicated.
      • Tiny gallbladder stones.
      • Mild ascites in the pelvis is suspected.
      • S/P port-A implantation at RUQ abdominal wall and the catheter tip located in the upper pelvis midline omentum.
    • Impression:
      • Adenocarcinoma of the stomach antrum S/P C/T with partial response or complete response is highly suspected. Please correlate with gastroscopy.
      • Regional and non-regional metastatic nodes S/P C/T with partial response is highly suspected. Follow up is indicated.
  • 2023-12-18 PD-L1 IHC 28-8
    • Immunostaining Result :28-8
    • Testing assay: pharmDx Assay (Agilent/Dako)
    • Cellblock No. F2023-00526FS
    • RESULTS:
      • Combined Positive Score (CPS) assessment: CPS >= 1 and < 10
      • Combined Positive Score (CPS): 1
  • 2023-11-24 Patho - uterus (with or without SO) neoplastic
    • Stomach, cardia and body, biopsy — poorly differentiated adenocarcinoma with signet-ring cell differentiation, seeding
    • Microscopically, sections show poorly differentiated adenocarcinoma with signet-ring cell diffferentiation and stromal fibrosis.
    • Immunohistochemical stains reveals CK7(+), CK20(+), CDX-2(+), CK(+). The tumor is compatible with gastrointestinal origin.
  • 2023-11-15 Patho - stomach biopsy
    • Stomach, middle body, biopsy — Poorly cohesive carcinoma, signet-ring cell type
    • The sections show a picture of poorly cohesive carcinoma, composed of gastric body mucosal tissue with isolated or small aggregates of tumor cells, pleomorphic eccentric nuclei, abundant clear cytoplasm, and no well-fromed glands.
  • 2023-11-15 Patho - stomach biopsy (Y1)
    • Stomach, angle, biopsy — Poorly cohesive carcinoma, signet-ring cell type
    • The sections show a picture of poorly cohesive carcinoma, composed of isolated and small aggregates of tumor cells with pleomorphic eccentric nuclei and abundant clear cytoplasm, without well-fromed glands.
    • IHC: HER2 — Negative (score = 0)
  • 2023-11-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (53 - 17) / 53 = 67.92%
      • M-mode (Teichholz) = 67
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Mild to moderate MR, mild to moderate TR
      • LV diastolic dysfunction, Gr 1
      • Preserved RV systolic function
  • 2023-11-13 Flow Volume Chart
    • Mild obstructive ventilatory impairment
  • 2023-11-10 ECG
    • Biatrial enlargement
    • Incomplete right bundle branch block pattern
    • Abnormal ECG
  • 2023-11-08 CT - abdomen
    • CC: gastric cancer at antrum by EGD and pathology result at LMC.
    • History: Right ureteral stricture with hydronephrosis, S/P right ureterorenoscopy & internal dilatation of ureter with double-J stenting 
    • Findings:
      • There is focal wall thickening with irregular contour at the gastric antrum, 2.5 cm in wall thickness and 9 cm in size, causing marked dilatation of the proximal stomach.
        • Adenocarcinoma of the stomach antrum (T4a) with gastric outlet obstruction is highly suspected.
        • In addition, there are seven enlarged nodes in the gastrohepatic ligament and hepatoduodenal ligament.
        • Metastatic nodes (N3a) are highly suspected.
      • There is a soft tissue nodule 0.9 cm in right upper pelvis omentum area (Srs:301 Img:48) that may be metastatic node.
      • There are few small lymph nodes in para-aortic space and para-cava space (up to 7 mm). Please correlate with PET scan.
      • There is mild right side hydroureteronephrosis but no delayed contrast excretion of right kidney. However, the transition zone is hard to identify. Please correlate with retrograde pyelography.
      • Tiny gallbladder stones.
      • There is ascites in the pelvis, nature?
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N3a(N_value) M:M0(M_value) STAGE:III(Stage_value)
  • 2023-09-13 ECG
    • Biatrial enlargement
    • Incomplete right bundle branch block
  • 2023-09-07 CT - abdomen
    • History and indication: hydro: r/o radiolucent stone
    • Non-contrast CT of abdomen-pelvis revealed:
      • Right hydronephrosis.
      • Tiny gallbladder stones.
      • Atherosclerosis of aorta, iliac arteries.
      • Partial atelectasis at RML and left lingual lung.
    • IMP:
      • Right hydronephrosis.
      • Tiny gallbladder stones.

[MedRec]

  • 2024-01-31 SOAP Hemato-Oncology He JingLiang
    • Prescription x3
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
  • 2023-12-08 SOAP General and Gastrointestinal Surgery Wu ChaoQun
    • Prescription x3
      • Hepac Lock Flush (heparin sodium) 20mL ST IRRI
      • NS 20mL ST
      • Mosapin (mosapride citrate 5mg) 1# TID
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Amamet (glimepiride 2mg, metformin 500mg) 0.5# QDAC
      • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
  • 2023-11-10 ~ 2023-12-02 POMR General and Gastrointestinal Surgery Wu ChaoQun
    • Discharge diagnosis
      • Poorly cohesive carcinoma (signet-ring cell) of gastric with peritoneal seeding, cT4aN3aM1 stage IV, status post gastrojejunostomy with Hyperthermic Intraperitoneal Chemotherapy with Oxalip and Mytomicin on 2023/11/23. ECOG:1
      • Encounter for adjustment and management of vascular access device with port-A insertion on 2023/11/23.
      • Encounter for antineoplastic immunotherapy with Nivoluamb (100mg) on 2023/12/1.
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
      • Malnutrition
    • CC
      • Intermittent epigastric pain for 4 months, and abdomen fullness accompany vomit was noted since recent 1 month.
    • Present illness
      • This 69-year-old woman has history of
        • Hypertension under medication control for years;
        • Appendectomy;
        • Hysterectomy,
        • Right ureteral stricture with hydronephrosis, post right ureterorenoscopy and internal dilatation of ureter stricture with double-J stenting on 2023-09-14.
      • According for this patient statement, she sufferred from intermittent epigastric pain since 4 months ago. However, abdomen fullness accompany vomit was noted since recent 1 month. She visited to LMD for follow up, then UGI scope showed reddness of mucosa, submucosal infiltration lesion with surrounding mucosal swelling and superfial ulcerations from antrum to angularis biopsy then pathology showed malignancy.
      • Therefore, she came to our GI OPD for help. Further abdomen CT was performed which showed gastric cancer of stomach antrum (T4a) with gastric outlet obstruction is highly suspected. T4aN3aM0; stage: III. As the result, she refferred to our GS OPD for further evaluation.
      • Body weight loss 56kg to 47.5kg in recent 3 months was also noted. Tumor marker of CEA showed 1.55ng/ml. She denied fever, chills dizzness, poor appetite, nausea and tarry stool passage but less of stool passage was noted.
      • This time, she admitted to our ward for nutrition support first and further evaluate and management.
    • Course of inpatient treatment
      • After admitted, nutrtion support with TPN was given due to malnutrition. NG insertion with irrigation was also noted smoothly.
      • UGI scope was performed and showed advanced gastric cancer, Bormann type 4, body and angle, s/p biopsy. Final pathology showed poorly cohesive carcinoma, signet-ring cell type.
      • She received further operation on 2023/11/23 which revealed distal gastric cancer with peritoneal seeding at round ligament and lesser curvature (PCI:5/39), cancer direct invasion to posterior pancreas body.
      • Thus, Open GJ bypass with HIPEC Oxalip 300 mg/M2 (425 mg) + Mytomicin C 15 mg/M2 (21 mg) and port-A insertion was processed successfully on 2023/11/23.
      • Post operaively, we observed patient recovery and keep empiric antibiotic, albumin with lasix therapy, and analgesic agent were administered and the wound management was performed. She try to introduced diet with step by step until well tolerate of semi-liquid diet. Her generally well beings and relativley stable. There were no nosocomial infection and other complications and vital signs were stable after the surgery. We consulted Oncology for further neoadjuvant chemotherapy with IP + IV chemotherapy then will be arrange at OPD. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. Abdomen wound clean and was removal JP tube was done on 2023/11/30.
      • First IV immunotherapy with Nivolumab (100mg) was performed smoothly on 2023/12/01. The medication was applied and no significant discomfort was complained of.
      • Under a relative stable condition, she was allowed to discharge today and OPD follow up was arranged.
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Amamet (glimepiride 2mg, metformin 500mg) 0.5# QDAC
      • Mosapin (mosapride citrate 5mg) 1# TID
      • Takepron (lansoprazole 30mg) 1# QDAC
      • Exforge (amlodipine 5mg, valsatan 160mg) 1# QD
  • 2023-06-27 SOAP Family Medicine Ye JiaQi
    • S
      • HTN, Home SBP 140, Diovan -> Exoforge
      • DM
      • Hematuria
      • skin itchiness and GI discomfort with metformin??
      • Past history HIVD with left S1 radiculpathy
    • Prescription x3
      • Exforge (amlodipine 5mg, valsatan 160mg) 1# QD
      • Uformin (metformin 500mg) 1# QDCC

[surgical operation]

  • 2023-11-23
    • Surgery
      • Open GJ bypass
      • HIPEC
        • Oxalip 300 mg/M2 (425 mg) for 30 mins at 42 C
        • Mytomicin C 15 mg/M2 (21mg) for 60 mins at 42 C
      • Intraabdoiminal Port-A insertion at subhepatic area
    • Finding
      • distal gastric ca with peritoneal seeding at round ligament and lesser curvature
      • PCI 5/39
      • cancer direct invasion to posterior pancreas body

[immunochemotherapy]

  • 2024-02-15 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Opdivo + FOLFOX, Q2W. He JingLiang)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2024-01-18 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Opdivo + FOLFOX, Q2W. He JingLiang)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2024-01-03 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Opdivo + FOLFOX, Q2W. He JingLiang)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-12-18 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Opdivo + FOLFOX, Q2W. He JingLiang)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-12-01 - nivolumab 2mg/kg 100mg NS 100mL 1hr (Wu ChaoQun)

  • 2023-11-23 - [oxaliplatin 300mg/m2 425mg + mitomycin-C 15mg/m2 21mg] IP 1hr (HIPEC. Wu ChaoQun)

==========

2024-02-16

[reconciliation]

An abdominal CT scan performed on 2024-02-16 demonstrated a partial response of the signet-ring cell gastric cancer to the current treatment regimen of nivolumab plus FOLFOX. Vital signs remained stable throughout this hospitalization, and lab findings on 2024-02-15 were generally within normal limits. No medication discrepancies were identified.

2024-01-04

[nivolumab dosing recommendations for gastric cancer: optimization based on clinical research]

Clinical Evidence:

  • The CheckMate 649 trial established nivolumab as a valuable treatment option for patients with advanced or metastatic gastric cancer or gastroesophageal junction cancer. The recommended dosing regimen, when combined with fluoropyrimidine- and platinum-containing chemotherapy (FOLFOX in this patient’s case), is either:
    • 240 mg every 2 weeks
    • 360 mg every 3 weeks
  • This regimen should be continued until disease progression, unacceptable toxicity, or up to a maximum of 2 years.

Optimizing Treatment Efficacy:

  • In this patient’s case, the current nivolumab dose falls below the recommended range. This may lead to a suboptimal treatment effect, meaning the medication might not be exerting its full potential against the cancer.

Ref: - First-line nivolumab plus chemotherapy versus chemotherapy alone for advanced gastric, gastro-oesophageal junction, and oesophageal adenocarcinoma (CheckMate 649): a randomised, open-label, phase 3 trial. Lancet. 2021 Jul 3;398(10294):27-40. doi: 10.1016/S0140-6736(21)00797-2. Epub 2021 Jun 5. PMID: 34102137; PMCID: PMC8436782).

701333841

240216

[lab data]

  • 2022-08-13 Ferritin 694.9 ng/mL
  • 2022-08-13 Folic Acid 9.65 ng/mL
  • 2022-08-13 Vitamin B12 948 pg/mL
  • 2022-08-13 Reticulocyte count 0.360 %
  • 2022-08-13 Fe (Iron-bound) 47 ug/dL
  • 2022-08-13 TIBC 143 ug/dL
  • 2022-08-13 UIBC 96 ug/dL
  • 2022-08-13 DBI/TBI 21.88 %

[exam findings]

  • 2023-05-23 CT - brain
    • No brain infarct or mass
    • Intracranial ICAs and VAs atherosclerosis.
    • Brain atrophy. Chronic Rt mastoiditis and oititiis media.
    • Sagittal plane C-spine images show:
    • Disc space narrowing and marginal spurs of vertebral bodies at C5-C6 and C6-C7 levels due to spondylosis.
    • Mild anterolithesis of C6 vertebra.
    • C2-C3, C3-4, C4-C5, and C5-C6 facets hypertrophy
  • 2023-05-15 SONO - abdomen
    • GB stones and sludge
    • Splenomegaly
  • 2023-03-27, 2022-12-26, -11-25 CXR
    • Atherosclerotic change of aortic arch
  • 2023-03-14 CT - abdomen
    • Clinical history: 71 y/o male patient with RLQ pain for 2 days, constant pain, precipitated by positional change, no related to meal, no bowel movement change, no fever, no nausea
    • PH: Oral cancer s/p OP
    • WITHOUT contrast enhancement CT of abdomen - whole:
      • Presence of gallbladder stones.
      • Presence of splenomegaly.
      • No enlarged lymph node in the paraaortic region.
      • Minimal ascites.
      • Right lower lung nodule, 0.8cm.
      • Tree-in-bud infiltrates in left lower lung.
    • Impression:
      • Gallbladder stones.
      • Splenomegaly.
      • Tree-in-bud infiltrates in left lower lung.
      • Right lower lung nodule, 0.8cm.
  • 2023-03-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (128.9 - 68.9) / 128.9 = 46.55%
      • M-mode (Teichholz) = 46.6
      • 2D (M-simpson) = 50.1
    • Conclusion
      • Borderline LV systolic function with mildly global hypokinesia
      • Mitral valve prolapse (anterior leaflet) with mild mitral regurgitation
      • Trivial tricuspid regurgitation, mild pulmonic regurgitation
      • Impaired LV relaxation
      • Dilated LA and aortic root; thick IVS and LVPW
  • 2022-11-10, -11-04 CXR
    • Enlargement of cardiac silhouette.
    • Atherosclerotic change of aortic arch
    • Peri-bronchial wall thickening of the right and left lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2022-10-31 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Meylodysplasia syndrome (refractory anemia with excess blast-I).
    • Specimen submitted in B5 fixative consists of 1 piece(s) of tan, rod shape bone marrow tissue measuring 2.6 x 0.2 x 0.2 cm. All for section in one cassette after decalcification.
    • Section shows piece(s) of bone marrow with 90% cellularity and M:E ratio of approximately 8:1. Three cell lineages are present with left shift of leukocytes. Megakaryocytes are adequate in number with mild nucleat atypia.
    • IHC stains: CD117: 10%; CD34: 5%; MPO: 80-85%, CD61: 5 %; CD71: 10 % (of the nucleated cells).
  • 2022-10-04 KUB
    • There is splenomegaly.
    • Spondylosis of the L-spine is noted.
  • 2022-09-28 CXR
    • Lung markings: consolidation in the right lower lung field.
  • 2022-09-28 ECG
    • Sinus rhythm with Premature atrial complexes
    • Possible Left atrial enlargement
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2022-09-15, -09-08 CXR
    • Enlargement of cardiac silhouette.
    • Atherosclerotic change of aortic arch.
    • Increased lung markings on both lower lung are noted.
  • 2022-09-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (135 - 66) / 135 = 51.11%
      • M-mode (Teichholz) = 50
    • Dilated LA and LV; mildly abnormal LV systolic function with global hypokinesia
    • Septal hypertrophy; LV diastolic dysfunction, Gr 1
    • Trivial MR, mild AR, mild TR and trivial PR
    • Preserved RV systolic function
    • Rare isolated premature atrial beat (PAC) at the exam
  • 2022-08-29 CXR
    • Increase bilateral lung markings.
    • Mild cardiomegaly.
    • Thoracic spondylosis.
    • Post-op with metallic clips in right neck.
  • 2022-08-15 CXR
    • Crowding of vascular markings over both lungs
    • Thoracic aortic arch calcified atheriosclerotic plaque
    • Normal heart size
    • Rt and Lt subpulmonary effusion
    • Marginal spurs of multiple vertebral bodies
    • Compression fracture of L1 vertebral body
  • 2022-08-11 MRI - kidney, adrenals
    • Splenomegaly with compression on left kidney.
    • Focal T2 hyperintensity in the spleen, suspected splenic infarct.
    • Left pleural effusion.
  • 2022-08-11 SONO - nephrology
    • bilateral chronic change of both kidneys.
  • 2022-08-10 CXR
    • Bilateral parahilar infiltrates, suspected lung edema.
    • No cardiomegaly.
    • Intimal calcification of thoracic aorta.
    • Thoracic spondylosis.
  • 2022-08-09 CT - abdomen
    • Splenomegaly with low attenuations.
    • Compression fracture of L1.
    • Tiny gallbladder stones.
  • 2022-08-08 ECG
    • Normal sinus rhythm
    • Prolonged QT
    • Abnormal ECG
  • 2022-08-03 Transrectal Ultrasound of Prostate, TRUS-P
    • benign prostatic hyperplasia
  • 2022-06-01 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with myelodysplastic syndrom with myelodysplastic/myeloproliferative neoplasm transformation
    • The sections show hypercellular marrow (95%). Marked granulocytic proliferation with left shift in MPO stain. CD61+ megakaryocytes are increased and occasional atypical and small megakaryocytes are present. Decreased in number of CD71+ erythroid precursors. A few CD34+ blasts (2%) and scattered CD117+ immature cells (15%) in paratrabecular and interstitial areas. The finding is compatible with MDS with myelodysplastic/myeloproliferative neoplasm transformation. Suggest bone marrow smear evaluation and clinic correlation.
  • 2022-05-31 CT - abdomen
    • Splenomegaly with low attenuations suspected infarcts.
    • Some LNs (up to 1.5cm) at bil. inguinal regions.
    • Compression fracture of L1.
    • Tiny gallbladder stones.
  • 2022-05-31 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (149 - 49) / 149 = 67.11%
      • M-mode (Teichholz) = 67
    • Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Dilated LV with normal LV and RV systolic function.
    • Aortic valve sclerosis; mild MR; mild PR.
    • Mildly dilated aortic root with mild calcification.
  • 2022-05-30 KUB
    • Increased density of left abdomen.
    • Compression fracture of L1.
  • 2022-04-09 X Ray
    • Rt 7th-9th ribs fracture
  • 2022-03-07 Patho - bone marrow biospy
    • Bone marrow, iliac, biopsy — hypercellular marrow.
    • IHC stains: CD117: <2 %; CD34: <2 %; MPO: 60-70 %, CD61: 5 %; CD71: 15-20 % (of the nucleated cells).
    • Section shows piece(s) of bone marrow with 100 % cellularity and M:E ratio of approximately 4-5:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number with mild nuclear atypia. IHC stains: CD117: <2 %; CD34: <2 %; MPO: 60-70 %, CD61: 5 %; CD71: 15-20 % (of the nucleated cells). The findings are compatible with myelodysplastic syndrome.
  • 2022-03-04 ECG
    • Normal sinus rhythm
    • Prolonged QT
    • Abnormal ECG
  • 2021-12-06 CT - brain
    • Swelling of left parietal scalp.
    • A soft tissue nodule (1.2cm) at right parotid region.
    • Fat tissue at right deep neck.
  • 2021-12-06 CXR
    • Nasogastric tube in place, proper position
    • Consolidation in Rt lung, in regression as compared with the previous image
    • Elevation of both hemidiaphragms
    • Right internal jugular venous catheter with tip in the SVC
  • 2021-11-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (133 - 54) / 133 = 59.34%
      • M-mode (Teichholz) = 58
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA, septal hypertrophy; impaired LV systolic function
    • Trivial MR adn trivial TR
    • Preserved RV systolic function
  • 2021-09-23 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Hypercellular marrow, favor myelodysplastic syndrome
    • The sections show hypercellular marrow (80%). M/E ratio = 5:1 in MPO and CD71 stains. The erythoid precursors are dispersed and scattered. The myeloid cells show left shift with neutrophilia. The CD61+ megakaryocytes are increased in number and occasional abnormal and small megakaryocytes are present. Slightly increased CD34+ and/or CD117+ blasts, accout for 3% of marrow cells. Myelodysplastic syndrom can be considered. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2021-09-23 CT - liver, spleen, biliary duct, pancreas
    • Splenomegaly.

[MedRec]

  • 2023-12-07 SOAP Cardiology Zhan ShiRong
    • Prescription x3
      • Concor (bisoprolol 1.25mg) 1# QD
      • Spiron (spironolactone 25mg) 1# QD
  • 2023-12-06 SOAP Neurology Wang YiChun
    • Prescription x3
      • sodium bicarbonate 300mg 1# QOD
      • Tricozide (trichlomethiazide 2mg) 1# QOD
  • 2023-05-24 ~ 2023-05-31 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Refractory anemia with excess of blasts 1
      • Staphylococcus haemolyticus urinary tract infection
      • Acute kidney failure, unspecified
      • Thrombocytopenia, unspecified
      • Anemia
    • CC
      • For dizziness and fever since 2023/05/23           
    • Present illness
      • This is 71 year-old man with past history of MDS, splenomegaly, antiphospholipid syndrome, malignant neoplasm of upper gum, thrombocytopenia, BPH.
      • Last time, kidney sono and MRI for AKI progression on 2022/08/12, echo showed bilateral chronic change of both kidneys and MRI report showed 1. Splenomegaly with compression on left kidney, 2. Focal T2 hyperintensity in the spleen, r/o splenic infarct and 3. Left pleural effusion. Emergency HD in MICU and suspect HUS.
      • Encocardiography showd LVEF: 50%, Dilated LA and LV; mildly abnormal LV systolic function with global hypokinesia 2. Septal hypertrophy; LV diastolic dysfunction, Gr 1 3. Trivial MR, mild AR, mild TR and trivial PR 4. Preserved RV systolic function 5. Rare isolated premature atrial beat (PAC) at the exam.
      • PCR positive Covid-19 infection on 2022/10/08.
      • He was regularly followed up at ONC OPD. The laboratory test revealed severe anemia and thrombocytopenia, leukocytosis. There were no fever, no chest pain, no abdominal pain nor dysuria. Under the impression of MDS with severe anemia and thrombocytopenia, leukocytosis. He receive targeted therapy with Vidaza from 2022/11/26~2022/12/02(C1), 2022/12/26~2023/01/01(C2). 2023/1/30-2023/2/5(C3). 2023/2/27-3/5(C4). 2023/3/28-4/3(C5). 2023/5/10-5/16(C6). Abdominal echo showed splenomegaly. Scabies was diagnosis last time.
      • This time, he has fall down and hit head at home. He sent to OPD for PL 6000/uL and blood transfusion. After blood transfusion, he had fatigue and fever, so he refered to ED for on 2023/05/23. The lab data showed PL showed 4000/uL, so the LRP transfusion again, but recheck just 7000/uL. He denied vomit, diarrhea or abdominal pain, but malaise and dizziness bother him. His legs more patachiae and ecchymosis noted. Under the impression of MDS in porgression and fever cause unknown, so he was admitted on 2023/05/24.
    • Course of inpatient treatment
      • After admission, he received antibiotic as Rocephin for fever control at first. U/C yield Staphylococcus haemolyticus. Critical care for PLT 4000/uL. Frequency blood transfusion as LPRBC and LRP. Check HLA-ABC low resolusion for LRP choice. Under the stable condition without bleeding sign, so he can be discharged on 2023/05/31. OPD follow up is arranged.
    • Discharge prescription
      • Stogamet (cimetidine 300mg) 1# BID
      • Allegra (fexofenadine 60mg) 1# BID
      • Alpraline (alprazolam 0.5mg) 1# HS
      • calcium carbonate 500mg 1# TID
      • Feburic (febuxostat 80mg) 1# QD
      • Mirtapine Orally Disintegrating (mirtazapine 30mg) 0.5# HS
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q12H
      • Utapine (quetiapine 25mg) 1# HS
      • Sinpharderm Cream (urea) BID TOPI
      • Topsym Cream (fluocinonide 0.05%) BID EXT
      • loperamide 2mg 1# PRNQ8H if diarrhea

[chemotherapy]

  • 2023-05-10 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7
  • 2023-03-28 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7
  • 2023-02-27 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7
  • 2023-01-30 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7
  • 2022-12-26 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7
  • 2022-11-25 - Vidaza (azacitidine) 75mg/m2 100mg QD SC D1-D7

==========

2024-02-16

[navigating anemia treatment for MDS with iron overload]

Azacitidine and decitabine are commonly known as hypomethylating agents (HMA) due to their ability to inhibit DNA methyltransferase. However, it remains uncertain whether this inhibition fully explains their therapeutic action in Myelodysplastic Syndromes (MDS). Comparative studies between azacitidine and decitabine in lower-risk MDS cases have not definitively shown one HMA to be superior to the other. This patient underwent 6 sessions of Vidaza (azacitidine) treatment from Nov 2022 to May 2023, approximately on a monthly basis. For patients who do not sufficiently respond to one HMA, the likelihood of responding to the other is minimal.

Laboratory results on 2024-02-01 revealed a serum ferritin level of 1811 ng/mL, suggesting possible iron overload, likely due to repeated blood transfusions. Should this diagnosis be confirmed, Jadenu (deferasirox), the sole iron chelator available at this hospital, might be considered as a viable treatment option. However, its use is contraindicated in patients with an eGFR < 40. Given the patient’s creatinine level of 6.03 mg/dL, eGFR of 9.82 ml/min/1.73m^2, and BUN of 104 mg/dL on 2024-02-16, it is advisable to minimize the frequency of LPRBC transfusions. Moreover, treatment with erythropoiesis-stimulating agents (ESA) to alleviate anemia associated with MDS is generally more efficacious in patients with serum erythropoietin (EPO) levels below 500 mU/mL. For patients with an adequate response to ESA therapy, it is recommended to continue treatment and adjust administration to minimize transfusions and maintain HGB 10 to 12 g/dL.

2023-05-10

The patient’s reliance on blood transfusions to maintain HGB and PLT levels is a critical aspect of his clinical history and care. The levels of both HGB and PLT have been consistently below the lower limit of normal since 2021, according to available laboratory data in HIS5. Anemia and thrombocytopenia are present prior to the initiation of azacitidine treatment, suggesting that these conditions are unlikely to be due solely to the drug. However, azacitidine may exacerbate these conditions because it can cause myelosuppression. The most update PLT level on 2023-05-09 was 21K/uL. In circumstances where the PLT count dips below 25K/uL, a dose reduction of 50% for the upcoming treatment cycle is typically recommended.

2023-03-28

The patient’s serum creatinine level has remained below 2mg/dl until late March 2023, and there is currently an obvious upward trend in the level.

  • 2023-03-27 Creatinine 2.52 mg/dL
  • 2023-03-24 Creatinine 2.21 mg/dL
  • 2023-03-20 Creatinine 1.95 mg/dL
  • 2023-03-16 Creatinine 1.71 mg/dL

Deferasirox can cause acute renal failure and death, particularly in patients with comorbidities and those who are in the advanced stages of their hematologic disorders. Deferasirox is contraindicated in patients with eGFR less than 40mL/min/1.73m2.

  • 2023-03-27 eGFR 26.95
  • 2023-03-24 eGFR 31.35
  • 2023-03-20 eGFR 36.22
  • 2023-03-16 eGFR 42.15

Other iron chelators are available in the market, but this hospital does not procure deferiprone and deferoxamine is currently out of stock.

To prioritize kidney function over iron overload, an alternative option could be to reduce or hold the dose of deferasirox to prevent the serum creatinine from exceeding 2mg/dL. (eGFR 40 to 60 mL/minute/1.73m2: Reduce initial deferasirox dose by 50%. ref: UpToDate)

2023-03-01

Transfusional iron overload occurs when transfusions are given for anemia not caused by iron deficiency. Despite the administration of Jadenu (deferasirox) since early December 2022, the patient’s ferritin level has been consistently fluctuating at a high level since that time.

  • 2023-02-24 Ferritin (NM) 2013.24 ng/ml
  • 2023-02-21 Ferritin (NM) 1844.19 ng/ml
  • 2023-01-05 Ferritin (NM) 1838.62 ng/ml
  • 2022-12-16 Ferritin (NM) 2051.18 ng/ml
  • 2022-12-01 Ferritin 1554.2 ng/mL
  • 2022-08-13 Ferritin 694.9 ng/mL

Vidaza (azacitidine) to treat MDS: Subsequent cycles 75 mg/m2/day for 7 days every 4 weeks; dose may be increased to 100 mg/m2/day if no benefit is observed after 2 cycles and no toxicity other than nausea and vomiting have occurred. Patients should be treated for a minimum of 4 to 6 cycles; treatment may be continued as long as patient continues to benefit.

Since the patient has been admitted to receive his 4th cycle of azacitidine during this hospitalization, it would be appropriate to evaluate the effectiveness of the treatment in the next few follow-up visits.

2022-12-23

Lab data (2022-12-23) showed low HGB (8.4g/dL, grade 3) and PLT (33K/uL, grade 3). Jadenu (deferasirox) 360mg PO DQAC is applied to lower the excess iron storage in this patient following times of LPRBC transfusion. Since September 20, 2022, Feburic (febuxostat 80mg) has been successful in lowering the patient’s serum uric acid. Rare excess ULN events have been observed since then. The recommended initial dose of febuxostat is 40 mg once daily, as the patient is senior aged, his hyperuricemia has been well-controlled, and his renal function readings are outside the normal limits, it is recommended to adjust the febuxostat dose to 40mg QD. It appears that Allegra (fexofenadine), Feburic (febuxostat), Jadenu (deferasirox), Smecta (dioctahedral smectite), Stogamet (cimetidine), Utapine (quetiapine) have been prescribed twice (one of each drug marked as a self-carried item). Please confirm the need for multiple prescriptions.

2022-11-28

2022-11-25 albumin 3.2g/dL. The patient is receiving azacitidine for the first time. In a study, it was suggested that the use of azacitidine is not recommended when albumin levels are lower than 3 g/dL. (ref: Dose recommendations for anticancer drugs in patients with renal or hepatic impairment. Lancet Oncol. 2019;20(4):e200-e207. doi:10.1016/S1470-2045(19)30145-7). A closer monitor might be necessary.

2022-09-30

Allogeneic hematopoietic cell transplantation (HCT) is the treatment with the highest potential to cure MDS. However, because of advanced age, comorbid conditions, lack of adequately matched donors, and/or patient preferences, only a small subset of patients with MDS are candidates for allogeneic HCT. Ferritin 694.9ng/mL (2022-08-13, normal 23.9~336.2). A high level of iron in the blood might lead to hemochromatosis. The clinical manifestations of iron overload can be influenced by the amount of tissue iron and the presence of other conditions that lead to organ dysfunction. Cardiac iron overload can lead to the following complications: dilated cardiomyopathy, diastolic dysfunction, heart failure, conduction disturbances, sinus node dysfunction. (NT-proBNP 14016 pg/mL 2022-09-28 <- 5491 pg/mL 2022-09-16) There is no further deterioration in kidney function during Sep 2022 as ceatinine remains around 1.5 mg/dL and eGFR remains around 45-50 mg/dL.

2022-03-04

[drug identification]

requesting drug identification for 2 items.

all the 2 items are identified as following…

  • allegra (fexofenadine 60mg) - antiallergic agent, antihistamine, second generation
  • orolisin (orotic acid 30mg + glycyrrhizinate extract 50mg + chlorpheniramine maleate 5mg) - antiallergic agent, antihistamine, second generation

these drugs will be sent back to ward by an in-hospital porter.

701495156

240216

[exam findings]

  • 2023-09-14 Bronchoscopy
    • Clinical diagnosis: Lung tumor, for tissue prove
    • Bronchoscopic diagnosis:
      • Left 2nd carina tumor invasion, extended to LULbronchus and LLL bronchus, s/p biopsy
      • Lower trachea left side submucosal tumor invasion
      • LM bronchus distal superior submucosal tumor invasion
    • Bronchoscopic finding:
      • The nasal mucosa was hypertrophic.
      • The nasal lumen was moderately narrowed.
      • The was copious mucoid nasal discharge retained in the nasal cavity.
      • Mucosa of nasopharynx was hypertrophic .
      • Nasopharynx was moderately narrowed.
      • Mucosa of pharynx cobble-stone in shape .
      • Movement of the both. vocal cord(s) was normal .
      • Bilateral arytenoid proceww was normal .
      • Trachea whole segment. : patent but horse-saddle shape of whole trachea; the mucosa was hypertrophic.
      • Lower third tracheal left side submucosal tumor invaion was noted under EBUS finding but intact mucosa wall by EBUS and fluoroscent scopy.
        • Main carina: sharp and movable on deep breathing.
      • Bilateral endobronchial trees:
        • Left 2nd carina tumor invasion, extended to LULbronchus and LLL bronchus
        • LM bronchus distal superior mucosal and submucosal tumor invasion by EBUS finding and fluorosccent scopy.
    • Special Procedures: Left 2nd carina tumor invasion, extended to LULbronchus and LLL bronchus, s/p biopsy
    • Complication: Nil
    • Notes: Please Watch for the possibilties of hemoptysis, fever
  • 2023-08-30 CT - abdomen
    • CC: easy falling for 2 months. BW loss (more then 10 kg), poor appetite, easy choking and memory impairment.
    • History: alcoholism (one bottle sorghum liqour a day for 5 to 6 years, no drinking these 3 months)
    • Indication: r/o liver cirrhosis or other malignancy
    • Findings:
      • There is a poor enhancing mild heterogeneous soft tissue mass in left hilum, measuring 7.8 cm in size (the largest dimension), causing mild narrowing of left upper lobe bronchus.
        • Small cell lung cancer is highly suspected.
        • The differential diagnosis includes lymphoma.
        • please correlate with PET scan and biopsy.
      • There are several enlarged nodes in paratracheal space and subcarinal space. Metastatic nodes are highly suspected.
      • There is small patchy consolidation with air-bronchogram in LUL of the lung that is c/w Bronchopneumonia.
        • In addition, there is mild left Pleura effusion.
      • There are several hepatic cysts in both lobes and the largest one 3.6 cm in size at S4/5.
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidneys.
      • There is no evidence of ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
      • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Small cell lung cancer at left hilum is highly suspected.
      • The differential diagnosis includes lymphoma.
      • please correlate with PET scan and biopsy.
  • 2023-08-25 MRA - brain
    • Indication: limping gait and bradykinesia r/o PD or other brain lesion
    • Without- and with-contrast multiplanar cerebral MRI and cerebral TOF MRA reveal:
      • General enlargement of ventricles, cistern spaces and cortical sulci, indicating general brain atrophy.
      • A T2- and FLAIR-hyperintensity lesion, about 12 mm x 9 mm without obvious enhancement, nor diffusion change in white matter of right lower cerebellum.
      • A small T2- and FLAIR-hyperintensity lesion in white matter of left inferior frontal gyrus.
      • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
      • No midline shift, nor mass effect.
      • No remarkable finding of skull base and bony structures.
      • No remarkable finding of bilateral orbital contents and optic nerves.
      • No remarkable finding of nasopharynx visible in these images.
      • Diffuse mild luminal irregularity without obvious stenosis of major intracranial arteries in MRA study (including bilateral ICAs, MCAs, ACAs, PCAs and VAs and BA).
    • IMP:
      • General brain atrophy.
      • White matter lesions in right cerebellum and left frontal lobe.
      • Demyelination due to old insults is first considered. Tumor is unlikely.
  • 2023-08-24 ECG
    • Nonspecific ST and T wave abnormality
    • Prolonged QT

[MedRec]

  • 2024-01-31 SOAP Neurology Zhang WanLing
    • Prescription x3
      • Eurodin (estazolam 2mg) 1# HS
      • Norvasc (amlodipine 5mg) 1# PRNQD if SBP > 140mmHg
      • Vit B1 thiamin 100mg 1# QD
  • 2024-01-10 ~ 2024-01-15 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Left lung small cell carcinoma with left pulmonary hilar and bilateral mediastinal lymph nodes metastases, T4N3M0, stage IIIC, s/p chemotherapy with EP from 2023/10/02, s/p radiotherapy with mediastinal tumor and LAPs (66~70 Gy/ 35 fx, from 2023/10/02~).
      • Alcohol use, unspecified with intoxication, unspecified
      • Essential (primary) hypertension
      • Insomnia, unspecified
      • Constipation, unspecified
      • Parkinson’s disease
      • Chronic viral hepatitis B without delta-agent
      • Encounter for antineoplastic chemotherapy
    • CC
      • For chemotherapy with EP (C4)
    • Present illness
      • This 59-year-old man patient suffered from body weight loss 11kg (60 -> 49kg) for 2 months. Progression cough with sputum for 2 months. Poor appetite, easy choking and memory impairment. He was brought to our NM OPD for help. There was no numbness, slurred speech, headache, fever or recent head trauma. Neurological examintation showed liming gait, muscle power RUE/LUE: 5/4+, RLE/LLE: 5/5 and FNF: no dysmetria. No night sweats and fever was noted.
      • Brain MRA on 2023/08/25 showed general brain atrophy, white matter lesions in right cerebellum and left frontal lobe, demyelination due to old insults is first considered and tumor is unlikely.
      • Abdominal CT on 2023/08/30 showed small cell lung cancer at left hilum is highly suspected and the differential diagnosis includes lymphoma.
      • Headache and chest pain in 2023/09. Bronchoscopic for biopsy on 2023/09/14 showed left 2nd carina tumor invasion, extended to LUL bronchus and LLL bronchus, s/p biopsy. Lung, left second carina, bronchoscopic biopsy showed small cell carcinoma, immunohistochemical stains reveal CK(+), TTF-1(+), CD56(+), and Synaptophysin(+). The Ki-67 is > 90%. Port-A catheter insertion on 2023/09/22. Whole body PET scan on 2023/09/20 showed left upper lung, left pulmonary hilar region, and bilateral mediastinal space, highly suspected left lung cancer with regional lymph nodes metastases, left upper lung cancer, cT4N3M0-1. Wholw body bone scan on 2023/09/21 showed no bone metastasis. Diagonsisi was left lung small cell carcinoma with left pulmonary hilar and bilateral mediastinal lymph nodes metastases, T4N3M0, stage IIIC. After discussion plan to received concurrent chemoradiotherapy and explain side effect with patient and his family on 2023/09/25. Consult RTO on 2023/09/25 for evaluate concurrent chemoradiotherapy, - CT-simulation on 2023/09/25. Plan to deliver 50 Gy/ 25 fx to the Rt mediastinal LAPs. The Lt side lung tumor and LAPs: 66~70 Gy/ 35 fx. RT start from 2023/10/02 to 2023/11/20. S/p chemotherapy with EP (etoposide 80mg/m2, cisplatin 20mg/m2, C1D1) on 2023/10/04, EP (etoposide 80mg/m2, cisplatin 20mg/m2, C1D2) on 2023/10/11, EP (etoposide 80mg/m2, cisplatin 25mg/m2, C1D3) on 2023/10/17, EP (Etoposide 80mg/m2 + Cisplatin 25mg/m2 for 3days) on 2023/11/09 (C2D1-3), on 2023/12/11(C3D1-3).
    • Course of inpatient treatment
      • After admission, follow up Chest CT on 2024/01/11 showed left upper lobe lung cancer with mediastinal lymphadenopathy, the lymphadenopathy regressed markedly and the primary tumor regressed also.
      • He received concurrent chemoradiotherapy with EP (Etoposide 80mg/m2 + Cisplatin 25mg/m2 for 3 days)(C4), after CT image on 2024/01/11~2024/01/13.
      • Mopride 1# po TID for abdominal distention. Codeine 1# po HS for cough. Primperan 1# PO TIDAC was given for nausea and vomiting. Codeine 1# po HS for cough.
      • Alcohol use, unspecified with intoxication with Folic Acid 1# po QD and Vit B1 1# po QD.
      • Hypertension subside and discontinues Norvasc 1# po QD and Diovan F.C 160mg 1# po QD.
      • Insomnia with Eurodin 1# po HS. Constipation with Sennoside 2# po HS.
      • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for Anti-HBc reactive.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/12/15 and OPD followed up later.
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • codeine phosphate 15mg 1# HS
      • Mosapin (mosapride citrate 5mg) 1# TID
      • Through (sennoside 12mg) 2# HS
  • 2023-11-15 SOAP Neurology Zhang WanLing
    • Prescription x3
      • Diovan (valsartan 160mg) 1# QD
      • Eurodin (estazolam 2mg) 1# HS
      • Folacin (folic acid 5mg) 1# QD
      • Norvasc (amlodipine 5mg) 1# QD
      • Vit B1 thiamin 100mg 1# QD
  • 2023-08-23 ~ 2023-09-01 POMR Neurology Zhang WanLing
    • Discharge diagnosis
      • Wernicke’s encephalopathy, with cerebellar ataxia and cognitive decline
      • Cerebellar ataxia, alcohol intoxication related
      • Alcohol use, unspecified with intoxication, unspecified
      • Hyponatremia
      • Hypokalemia
      • Soft tissue mass in left hilum, measuring 7.8 cm in size, suspect small cell lung cancer
      • Essential (primary) hypertension
      • Insomnia
    • CC
      • Easy falling for 2 months with complained about BW loss (more then 10 kg), poor appetite, easy choking and memory impairment
    • Present illness
      • This 59 y/o patient with alcoholism (one bottle sorghum liqour a day for 5 to 6 years, no drinking these 3 months) presented with easy falling for 2 months.
      • He also complained about BW loss (more then 10 kg), poor appetite, easy choking and memory impairment. He was brought to our OPD for help.
      • There was no numbness, slurred speech, headache, fever or recent head trauma. Neurological examintation showed liming gait, muscle power: RUE/LUE: 5/4+ RLE/LLE: 5/5 and FNF: no dysmetria.
      • Under the impression of Parkinson’s disease or maligancy, he was admitted for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, we kept closely monitoring his hemodynamic status and vital signs. Adequate hydration with 0.298 KCL in 0.9% N/S was administered for hyponatremia and hypokalemia.
      • We arranged blood rest for cerebellar ataxia and memory decline, including DM, infection, nutritional status, thyroid function, cortisol, and tumor markers. Brain MRA with contrast was arranged and showed white matter lesions in right cerebellum and left frontal lobe, which were suspected demyelination due to old insults.
      • Laboratory data showed pancytopenia, abnormal liver function, low folic acid, and lower albumin. CSF study was performed (open pressure: 13 cm H2O, close pressure: 14 cm H2O; clear, color). CSF analysis revealed normal WBC count and total protein level. Therefore, we sent CSF culture and waiting for its final result. We also sent CSF and serum for PNS (paraneoplastic neurological syndrome) self-paid for body weight loss and jaundice r/o maligamcy. Folic acid and Thiamin supplement were given. His unsteady gait was related to Wernicke encephalopathy.
      • We consulted rehabilitation department for rehabilitation program arranged.
      • The chest and abdominal CT were arranged for suspected lung or liver maligancy. A mass lesion at left hilum was noted, indicating possible small cell lung cancer or lymphoma. We explained lung tumor and hepatic cysts in chest and abdominal CT to the patient and his elder sister.
      • The patient wants to be discharged after completing exam for ataxia, and then received further exam in the chest medicine OPD. Under stable condition, he was discharged on 2023/09/01. We suggested OPD follow up at neurology and oncology.
    • Discharge diagnosis
      • Diovan (valsartan 160mg) 1# QD
      • Actein Effervescent (acetaylcysteine 600mg) 1# BID
      • Eurodin (estazolam 2mg) 1# HS
      • Folacin (folic acid 5mg) 1# QD
      • Vit B1 (thiamine 100mg) 1# QD
      • Through (sennoside 12mg) 2# HS (if no stool passage)

[consultation]

  • 2023-09-26 Radiation Oncology
    • Q
      • This 59-year-old man patient is a case of Left lung small cell carcinoma with left pulmonary hilar and bilateral mediastinal lymph nodes metastases, T4N3M0, stage IIIC. He was admitted for prepare therapy. Now, for evaluate concurrent radiotherapy to lung tumor. Thank you.
    • A
      • CCRT is indicated. CT-simulation will be arranged today. Plan to deliver 50 Gy/ 25 fx to the Rt mediastinal LAPs. The Lt side lung tumor and LAPs: 66~70 Gy/ 33~35 fx. RT will start around 10/2. Thank you very much.
  • 2023-09-18 Nephrology
    • Q
      • This 59-year-old man patient is a case of Mediastinal mass, R/O lung cancer or lymphoma. He was admitted for lung tumor biopsy. This time, Alcohol use, unspecified with intoxication with hyponatremia (Na:113mmol/L) and hypomagnesemia (mg:1.7mg/dL) with weakness. Hyponatremia with 3% NS IVF supplementation and hypomagnesemia with MgSO4 1pc iv QD therapy, but, hyponatremia without improving. Now, for evaluate hyponatremia examine and therapy. Thank you.
    • A
      • We visited the patient at the bedside and evaluated his condition. His consciousness was clear, speech was coherent showed no signs of distress. Bilateral lower limb were slightly edematous 2+.
      • Blood test showed refractory hyponatremia
        • 2023-09-18 Na (Sodium) 113 mmol/L
        • 2023-09-17 Na (Sodium) 114 mmol/L
        • 2023-09-16 Na (Sodium) 116 mmol/L
        • 2023-09-15 Na (Sodium) 113 mmol/L
        • 2023-09-14 Na (Sodium) 106 mmol/L
        • 2023-09-14 Na (Sodium) 105 mmol/L
        • 2023-09-13 Na (Sodium) 101 mmol/L
        • 2023-08-31 Na (Sodium) 122 mmol/L
        • 2023-08-27 Na (Sodium) 126 mmol/L
        • 2023-08-24 Na (Sodium) 111 mmol/L
      • Our impressions are as follows:
        • Hyper/euvolemic hypotonic hyponatremia (but no evidence of cirrhosis, heart failure, CKD or nephrotic syndrome)
        • r/o pseudohyponatremia due to serum high protein or lipid content (e.g hyperlipidemia, plasma cell dyscrasia)
        • r/o SIADH, perhaps secondary to lung tumor (especially SCLC)
      • Our advices are as follows:
        • Record daily I/O and BW
        • Check urine Na, Cre, Osm
        • Check serum Osm, glucose, T Protein, TG, LDL, HDL (fasting)
        • Restrict FREE WATER intake to < 1000mL/day, soup or beverages are reasonable fluid alternatives
        • Infuse IV 3% saline 15-30mL/h until serum Na > 120mEq/L
        • May consider IV Furosemide 20mg QD-BID in conjunction with IV 3% saline if 3% saline alone is ineffective
        • Monitor serum Na levels at least Q12H to QD, change in Na levels should not exceed 6-8mEq/L within any 24-hour period
      • Please be assured that we will continue to follow up on this patient. Feel free to contact us should you require further assistance.

[chemotherapy]

  • 2024-02-15 - [etoposide 80mg/m2 125mg NS 500mL 2hr + cisplatin 25mg/m2 35mg NS 200mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP)] D1-3 (VP-16 + CDDP)
    • [dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL] D1-3
  • 2024-01-11 - [etoposide 80mg/m2 125mg NS 500mL 2hr + cisplatin 25mg/m2 35mg NS 200mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP)] D1-3 (VP-16 + CDDP)
    • [dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL] D1-3
  • 2023-12-11 - [etoposide 80mg/m2 125mg NS 500mL 2hr + cisplatin 25mg/m2 35mg NS 200mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP)] D1-3 (VP-16 + CDDP)
    • [dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL] D1-3
  • 2023-11-10 - [etoposide 80mg/m2 125mg NS 500mL 2hr + cisplatin 25mg/m2 35mg NS 200mL 24hr + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP)] D1-3 (VP-16 + CDDP)
    • [dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL] D1-3
  • 2023-10-18 - etoposide 80mg/m2 125mg NS 500mL 2hr + cisplatin 25mg/m2 35mg NS 200mL 24hr + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (VP-16 + CDDP)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-10-11 - etoposide 80mg/m2 125mg NS 500mL 2hr + cisplatin 25mg/m2 30mg NS 200mL 24hr + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (VP-16 + CDDP)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-10-04 - [etoposide 80mg/m2 125mg NS 500mL 2hr + cisplatin 25mg/m2 30mg NS 200mL 24hr + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP)] D1-3 (VP-16 + CDDP)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

==========

2024-02-16

No instances of hyponatremia have been observed since Oct 2023. During the current hospitalization, vital signs have remained stable and lab findings on 2024-02-15 were unremarkable. No medication discrepancies were identified.

2023-09-18

Hyponatremia is noted. The serum sodium levels in this patient over the past three months have been documented as follows:

2023-09-18 Na (Sodium) 113 mmol/L 2023-09-17 Na (Sodium) 114 mmol/L 2023-09-16 Na (Sodium) 116 mmol/L 2023-09-15 Na (Sodium) 113 mmol/L 2023-09-14 Na (Sodium) 106 mmol/L 2023-09-14 Na (Sodium) 105 mmol/L 2023-09-13 Na (Sodium) 101 mmol/L 2023-08-31 Na (Sodium) 122 mmol/L 2023-08-27 Na (Sodium) 126 mmol/L 2023-08-24 Na (Sodium) 111 mmol/L

Hyponatremia, with some cases being severe (sodium <120 mmol/L), has been associated with tramadol use. Although it is less likely that the current case of hyponatremia is due to Tramacet 0.5# Q6H, which was initiated on 2023-09-13, well after the onset of hyponatremia, it would be prudent to hold tramadol-containing medications and monitor the patient’s sodium levels for several days.

701509127

240216

[exam findings]

  • 2024-01-04 MRI - pancreas
    • Abdominal MRI with and without IV contrast enhancement shows:
      • Heterogeneous soft tissue mass at pancreatic body measuring 3.9cm in largest dimension is found. The lesion attached to celiac trunk. Pancreatic cancer is favored.
      • MRCP shows obliteration of the pancreatic duct at distal part is found.
      • Small lymph nodes are found inferior to the main pancreatic mass.
    • Imp:
      • Pancreatic cancer with celiac trunk invasion and regional lymph nodes
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T4(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2024-01-04 Patho - pancreas biopsy
    • Pancreas, endoscopic biopsy — Ductal adenocarcinoma, poorly differentiated
    • The specimen submitted consists of multiple small strips of yellow gray soft tissue, labeled pancreas, measuring up to 0.3 x 0.1 x 0.1 cm. All for section.
    • The sections show a picture of ductal adenocarcinoma, composed of nests, cords, and single large pleomorphic neoplastic cells in fibrous stroma. Focal glandular differentiation and mucin secretion are present.
  • 2023-12-22 CT - abdomen
    • 20231218 CC: abdominal pain for 2-3 months.
    • History: She ever visited MacKay Memorial Hospital for aid.
    • EGD and sono at Cathay General Hospital was performed 2 months ago showed gastritis. Some drugs were given. But treatment was not effective.
    • Indication: chronic abdominal pain
    • Findings:
      • There is a poor enhancing mass 3.2 cm in the pancreatic body (Srs:301 Img:26) with posterior extension and direct invasion the Celiac trunk (up to 2.2 cm) (Srs:301 Img:21-25).
        • Adenocarcinoma of the pancreatic body with Celiac trunk invasion (T4) is highly suspected. Please correlate with CA199 and EUS-guided biopsy.
      • There are four enlarged nodes in the gastrohepatic ligament and the mesentery root that are c/w metastatic nodes (N2).
      • There is an ill-defined mild poor enhancing area in S8 of the liver (Srs:301 Img:11) that may be pseudo-lesion (flow artifact).
        • The differential diagnosis includes tumor. Please correlate with MRI.
      • There are several hepatic cysts in both lobes (up to 0.7 cm in S4).
      • There is a poor enhancing mass 5 cm in the uterus with multiple calcification component that is c/w myoma with fibroid.
    • Impression:
      • Adenocarcinoma of the pancreatic body with Celiac trunk invasion (T4) is suspected. Please correlate with CA199 and EUS-guided biopsy.
        • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for pancreatic cancer: T4N2M0; stage: III.
  • 2023-12-19 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A (minimal)
      • Superficial gastritis
      • Gastric subepithelial lesion, antrum, PW.
      • Suspect external compression , upper body, PW.
    • CLO test: not done
    • Suggestion:
      • Further evaluation for gastric subepithelial lesion and external compression

[MedRec]

  • 2024-01-21 ~ 2024-01-25 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • pancreatic cancer, ductal adenocarcinoma, poorly differentiated, T4N2M0,stage: III, s/p FOLFIRINOX
      • Chronic viral hepatitis B without delta-agent
      • constipation
    • CC
      • for chemotherapy with FOLFIRINOX Q2W
    • Present illness
      • [omitted] And she complainted lower back pain, so gave OxyNorm for pain control. Anti-Hbc: reactive on 2024/01/11, s/p Vemlidy. The port-a catheter was insertion on 2024/01/18.
      • Under the impression of pancreatic cancer, ductal adenocarcinoma, poorly differentiated, T4N2M0,stage: III, s/p chemotherapy with FOLFIRINOX.
      • This time, she is admitted for C1D1 chemotherapy with FOLFIRINOX on 2024/01/21.
    • Course of inpatient treatment
      • After admission, she received C1D1 chemotherapy with FOLFIRINOX (Irino by self-paid, and the dose decreased 20% due to first chemotherapy) on 1/22-1/24, Vemlidy for Anti-HBc: reactive, Imperam for vomiting. After chemotherapy, smoothly without obvious side effect. She was discharged on 1/25 24 under stable condition, and the OPD will be arranged.
    • Discharge prescription
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Gasmin (dimethylpolysiloxane 40mg) 1# TID
      • Through (sennoside 12mg) 2# HS
      • Bisadyl supp (bisacolyl 10mg) 2# PRNQD RECT
      • OxyNorm (oxycodone 5mg) 1# Q8H
      • Alpraline (alprazolam 0.5mg) 1# PRNHS
      • Mosapin (mosapride citrate 5mg) 1# TID
  • 2024-01-01 ~ 2024-01-05 POMR Gastroenterology Li ZhongXian
    • Discharge diagnosis
      • Malignant neoplasm of body of pancreas
      • Gastro-esophageal reflux disease with esophagitis
      • Functional dyspepsia
    • CC
      • Admitted for pancreatic tumor survey
    • Present illness
      • This 72-year-old woman’s medical history was unremarkable. Since 3 months ago, she has developed abdominal pain that radiates to the back. She went to Cathay General Hospital and MacKay Memorial Hospital to hava examinations and gastritis was diagnosed. Some medications were prescribed but did not releive her symptoms. On 2023/12/18, she came to our OPD. Abdominal CT was performed and revealed suspected adenocarcinoma of the pancreatic body with Celiac trunk invasion (T4N2M0). Her CA199 level was also found to be elevated (1367.28).
      • Under the impression of pancreatic adenocarcinoma, she is admitted for further evaluation and management.
    • Course of inpatient treatment
      • After admission, the patient had a EUS-guide biopsy on 2024/01/03, and MRI of pancreas on 2024/01/04. The MRI results suggested pancreatic cancer with celiac trunk invasion and regional lymph nodes. Pathology results of the biospy revealed ductal adenocarcinoma, poorly differentiated. Adequate pain control was prescribed. She will be discharged today, and will be informed with the further treatment plan at the OPD next week.
    • Discharge prescription
      • none

[chemotherapy]

  • 2024-02-15 - oxaliplatin 85mg/m2 85mg D5W 250mL 2hr + irinotecan 180mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2400mg NS 500mL 46hr (FOLFIRINOX 75%)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2024-01-22 - oxaliplatin 85mg/m2 85mg D5W 250mL 2hr + irinotecan 180mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2400mg NS 500mL 46hr (FOLFIRINOX 75%)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

Chemotherapy regimens for metastatic pancreatic cancer: FOLFIRINOX - 2024-02-16 - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571

  • Cycle length: 14 days.

  • Regimen

    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 180 mg/m2 IV
      • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 400 mg/m2 IV bolus
      • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
      • Day 1
    • FU
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

Modified FOLFIRINOX chemotherapy for pancreatic cancer - 2024-02-16 - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546

  • Cycle length: 14 days.

  • Regimen

    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 150 mg/m2 IV
      • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

==========

2024-02-16

[rising CA-199 in newly-started FOLFIRINOX Regimen, further investigation needed. unremarkable labs & no med discrepancies]

This patient initiated FOLFIRINOX treatment in late January 2024 and the current hospitalization pertains to the second cycle. While other lab findings on 2024-02-15 were unremarkable and no medication discrepancies were identified, ongoing elevation of the tumor marker CA-199 warrants further investigation.

  • 2024-02-06 CA-199 (NM) 3521.000 U/ml
  • 2024-01-16 CA-199 (NM) 2048.960 U/ml
  • 2023-12-26 CA-199 1367.280 U/mL

701515147

240216

[exam findings]

  • 2024-02-14 CXR
    • S/P NG tube indwelling.
    • S/P Port-A infusion catheter insertion.
    • Left pleural effusion.
    • Ground glass opacities in bil. lungs.

[MedRec]

  • 2024-02-15 Multi-disciplinary Team Recommendations - Palliative Care
    • Referral Date: 2024-02-15
    • Response Content:
      • The patient was diagnosed with gastric cancer at a Taipei Hospital in December last year and sought a second opinion at Taipei Veterans General Hospital. Due to respiratory distress, jaundice, and acute renal failure, chemotherapy was not feasible, and palliative care was recommended.
      • The eldest brother still wished to pursue aggressive treatment, hence the transfer to our hospital. During the combined hospice caregiver’s visit, the patient’s wife mentioned the difficulty of seeing the patient with intubation and ECMO, with many tubes inserted, causing much distress.
      • The family (patient’s wife, daughter, mother, sister, and second brother) reached a consensus on opting for palliative care, except for the eldest brother. Now, disregarding the eldest brother’s opinion, the family wishes to spare the patient further suffering, consenting to palliative ward transfer without the use of vasopressors and minimal morphine for breath control. The patient, fully conscious, expressed a desire not to be resuscitated and agreed to the palliative ward transfer.
      • Assistance was provided to complete the Advance Palliative Care Directive (missing one witness, to be filled by the patient’s daughter in the evening). The combined hospice caregiver informed the patient’s wife that the thoughts would be conveyed to Dr. Shen from family medicine, awaiting the palliative consent form from Dr. Shen and also reminded of preparations for eventualities, providing a supportive handbook.
    • Conclusion and Recommendations: Palliative co-care and follow-up on the Advance Palliative Care Directive.
    • Responder: Chen Hui
    • Response Date: 2024-02-15 17:22
    • Doctor’s Response: 02/15 18:29 He Jingliang Response: Acknowledged
  • 2024-02-14 SOAP Medical Emergency Chen YuLong
    • S: Injury Severity Level: 3, Referral > Acute Peripheral Severe Pain (8-10).
      • The patient’s family transferred him from Taipei Veterans General Hospital to our hospital on their own. In early January, the patient was diagnosed with gastric cancer at MOHW Taipei Hospital.
      • The family took the patient to the outpatient clinic of Taipei Veterans General Hospital for a transfer to inpatient care, stating that Taipei Veterans General Hospital only administered antibiotics and bile drainage without any other treatment and even suggested hospice care.
      • Therefore, the family decided to transfer the patient to our hospital for a reevaluation and treatment.
      • 2023/12 diagnosed stage IV gastric cancer
      • pulmonary embolism s/p ECMO
      • AKI s/p H/D
      • NKA
      • PH denied
    • P: preliminary impression C16.9 Malignant neoplasm of stomach, unspecified
      • (DNR, Critical) stage IV gastric cancer, oa Onco. Septic shock, mutiple organ failure.
      • Levophed, Sintrix, CRP11.8 BUN116 Cr5.6 GFR11 GPT71 GGT65 dBI 14 Ti 40 CKMB 1.6

==========

2024-02-16

[tube feeding]

There are currently no oral drugs on the active medication list.

700472307

240210

[lab data]

  • 2023-02-10 HBsAg Nonreactive
  • 2023-02-10 HBsAg (Value) 0.36 S/CO
  • 2023-02-10 Anti-HBc Nonreactive
  • 2023-02-10 Anti-HBc-Value 0.05 S/CO
  • 2023-02-10 Anti-HCV Nonreactive
  • 2023-02-10 Anti-HCV Value 0.06 S/CO

[exam findings]

  • 2024-01-31 ECG
    • Sinus tachycardia
    • Poor wave progression v1~3
    • Abnormal ECG
  • 2024-01-31 SONO - chest
    • Echo diagnosis
      • Pleural effusion, minimal, left
      • Consolidation, LLL
  • 2024-01-30 Ascites Tapping
    • 2000 ml yellowish color ascites were drained.
  • 2024-01-30 SONO - abdomen
    • Findings
      • Liver: Fine echotexture. Several hypoechoic lesions at both lobes, the biggest one measured 12 cm at left lobe
      • Bile: Echogenic substance in GB
      • Pancreas: Part of head and part of tail masked
      • Spleen: Measured 8.3 x 4 cm
    • Diagnosis:
      • Hepatic tumor, mulitple, probably metastatic tumor
      • GB sludge
      • Ascites, massive
      • Splenomegaly
  • 2024-01-17 SONO - chest
    • Echo diagnosis
      • Pleural effusion, moderate, right
      • Atelectasis, LLL, RLL
  • 2024-01-15 SONO - chest
    • Echo diagnosis
      • left side small amount of pleural effusion over dependent portion, 430cc serosangious flujd was aspirated for analysis.
  • 2024-01-11 EGD
    • Suboptimal study of the gastric body and fundus due to much residual food
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
    • Gastric ulcerative tumor, body
    • Status post ND tube placement
  • 2024-01-05 MRA - T-aorta
    • Indication: D-dimer 7894, NT-proBNP 27988 R/O pulmonary embolism
    • Chest MRI without IV contrast enhancement shows:
      • Moderate left pleural effusion is found.
      • Left hilar lymphadenopathy is noted.
      • No significant pulmonary embolism is found. However, the non-contrast study is limited in the sensitivity of detecting pulmonary embolism.
      • Huge Soft tissue mass at mid-abdomen measuring 14.8cm in largest dimension. In comparison with CT dated on 2023-10-06, the lesion enlarged markedly.
      • Diffuse gastric wall thickening is found.
      • Lymphadenopathy at paraaortic region is found.
      • Mild ascites formation is found.
      • There is no evidence of destructive bone lesion.
    • Imp:
      • Diffuse lymphadenopathy at abdominal cavity and probably left pulmonary hilar region. Recurrent/residual lymphoma is considered.
      • No significant pulmonary embolism is found. However, the non-contrast study is limited in the sensitivity of detecting pulmonary embolism.
  • 2024-01-05 ECG
    • Normal sinus rhythm
    • Septal infarct, age undetermined
    • Prolonged QT
    • Abnormal ECG
  • 2024-01-05 CXR
    • S/P port-A implantation.
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2024-01-02 SONO - nephrology
    • Interpretation:
      • Parenchymal change of bilateral kidneys, cause to be determied
      • Presence of ascites
      • Splenomegaly
  • 2023-12-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (95.9 - 37.6) / 95.9 = 60.79%
      • 2D (M-Simpson) = 60.8
    • Conclusion:
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Mild AR, MR and TR
      • Dilated LA, thick IVS and LVPW
      • Tachycardia during the exam, around 120bpm
  • 2023-12-27 ECG
    • Sinus tachycardia with Premature atrial complexes
    • Septal infarct, age undetermined
    • Abnormal ECG
  • 2023-12-25 KUB
    • Splenomegaly.
    • Ascites is highly suspected. Please correlate with sonography.
  • 2023-12-20 ECG
    • Sinus tachycardia
    • Poor wave progression V1~4
    • Abnormal ECG
  • 2023-12-07 CXR
    • S/P Port-A infusion catheter insertion.
    • Bilateral pleural effusion.
  • 2023-12-06 ECG
    • Normal sinus rhythm
    • poor R wave progression
  • 2023-12-06 EGD
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
    • Gastric ulcerative tumor, middle body to cardia, AW and GC site with easily touch bleeding.
    • Gastric ulcer scar, antrum, GC
  • 2023-11-17 ENT Hearing Test
    • Reliabilty Fair
    • PTA
      • R’t : 20 dB HL, WNL except 6k-8k Hz
      • L’t : 23 dB HL, normal to moderate SNHL
    • Tymp
      • Bil Type A
    • ART
      • Bil Ipsi 4k Hz absent, contra absent.
  • 2023-11-07 MRA - brain
    • No evidence of brain metastasis.
  • 2023-10-06 CT - abdomen
    • Findings: Comparison: prior CT dated 2023/08/23.
      • Prior CT identified diffuse wall thickening of the stomach is noted again, stationary. It is c/w stable disease.
        • Prior CT identified regional LAP are not noted again.
        • Please correlate with contrast enhanced CT with oral water to full distension the stomach.
      • There is splenomegaly (the greatest anterior-posterior dimension: 14.8 cm).
    • Impression:
      • Gastric lymphoma S/P C/T show stable disease. Please correlate with contrast enhanced CT with oral water to full distension the stomach.
  • 2023-08-29 Patho - stomach biopsy
    • Stomach, body, biopsy — Gastric ulcer with residual diffuse large B-cell lymphoma
    • The specimen submitted consists of two small pieces of gray-white soft tissue, labeled body, AW and GC site, measuring up to 0.2 x 0.2 x 0.1 cm. All for section.
    • The sections show mucosal tissue with necrosis, fibrinous exudate, granulation tissue, and moderate acute and chronic inflammatory cells infiltration. Clusters of large to medium-sized atypical lymphoid cells in the lamina propria with crush artifact can be found.
    • IHC, the atypical lymphoid cells reveals: CD79a(+), PAX5(+), CD20(-) and CD3(-). the finding is compatible with residual diffuse large B-cell lymphoma.
  • 2023-08-28 Patho - bone marrow biopsy
    • Bone marrow, iliac, clinical history of lymphoma, R-CHOP from 2023/2/17~2023/06/20 (6th dose), biopsy — Negative for malignancy.
    • IHC stains: CD3: <1%; CD20: <1 %; bcl-2: <1%, bcl-6: <1 % (of the nucleated cells).
    • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • 2023-08-23 CT - abdomen
    • Gastric wall thickening, c/w gastric lymphoma
    • Splenomegaly
  • 2023-07-14 PET scan
    • In comparison with the previous study on 2023/02/13, the previous glucose hypermetabolism in the gastric region and lymph nodes in bilateral thigh regions are less evident, suggesting partial response to the therapy.
    • The glucose hypermetabolism in the the bone marrow of the skeleton is also less evident.
  • 2023-06-10 KUB
    • Degeneration of bony structures.
  • 2023-06-10 CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2023-06-02 CT - abdomen
    • CC: nausea and poor appetite for 1 month. Persist poor intake due to pain after intake. BW loss 7-8 kgs since 2023-01
      • 20230129 CT: Wall thickening of stomach & regional LAP r/o malignancy.
      • 20230130 gastroscopy: Diffuse ulcerative lesions with blood clot on surface were noted at antrum, body, fundus and cardia, s/p biopsy.
        • Pathology: Gastric lymphoma.
    • Findings: Comparison prior CT dated 2023/01/29.
      • Prior CT identified diffuse wall thickening of the stomach and regional LAP is noted again, mild decreasing in wall thickness and lymph nodes size that is c/w gastric lymphoma S/P C/T with partial response.
      • There is splenomegaly and the greatest anterior-posterior dimension measuring about 14.8 cm.
    • Impression:
      • Gastric lymphoma S/P C/T show partial response.
  • 2023-04-03, -03-06 CXR
    • Increased lung markings on both lower lung are noted.
  • 2023-02-28 CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2023-02-15 CXR
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2023-02-14 CT - chest
    • Indication: Large B cell lymphoma, non-geminal center type, Bcl-2 (diffuse +), B-cl-6 (equivocal to focal +). C-myc (-), Ki-67 (95%), CD23 (-), CD10 (-).
    • MDCT (128-detector rows, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Comparison was made with previous abdomimal CT dated on 2023/01/29
      • Lungs:
        • Linear band subsegmental atelectasis at both lower lobes,
          • inferior lingular segment, and RML.
          • mosaic attenuation changes in both lower lobes too.
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal-pelvic contents:
        • large region infiltrative lesion and wall thickening of the stomach, with ulceration at antral, body, and fundal regions. small LNs at perigastric region.
        • normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
        • enlarged prostate.
      • Visualized bones:marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • no LAP or mass in the chest and visible lower neck.
      • gastric lypmhoma with perigastric LAP.
  • 2023-02-13 Whole body PET scan
    • There was increased FDG uptake in the gastric region (SUVmax early: 33.94, delay: 41.31), and lymph nodes in bilateral thigh regions (SUVmax early: 4.37). In addition, diffusely increased FDG uptake was also noted in bone marrow including sternum, both rib cags, scapulae, spines, sacrum, pelvic bones, humeri and femurs.
    • IMPRESSION:
      • Glucose-hypermetabolism in the gastric region (Deauville score 5), compatible with large B-cell lymphoma.
      • Glucose-hypermetabolism in lymph nodes in bilateral thigh regions (Deauville score 4), highly suspected lymphoma with involvement of lymph node regions.
      • Diffusely increased FDG uptake in bone marrow including sternum, both rib cags, scapulae, spines, sacrum, pelvic bones, humeri and femurs, probably severe anemia. However, lymphoma with involvement of bone marrow may be excluded, suggesting follow-up.
      • Large B-cell lymphoma with involvement of stomach and lymph nodes in bilateral thigh regions, by this F-18 FDG PET scan.
  • 2023-02-10 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 24) / 104 = 76.92%
      • M-mode (Teichholz) = 77.2
    • Dilated LA
    • Adequate LV, RV systolic function with normal wall motion
    • LV hypertrophy, Impaired LV relaxation
    • Mild AR (aortic regurgitation is the diastolic flow of blood from the aorta into the left ventricle)
  • 2023-01-31 Patho - stomach biopsy
    • Stomach, body, biopsy — Lymphoma, B cell type, diffuse pattern. High grade.
    • IHC stains: CK (-), CD3 and CD20: a predominant CD20 B cell sub-population. Bcl-2 (diffuse +), B-cl-6 (equivocal to focal +).
    • Addtional IHC stains: C-myc (-), Ki-67 (95%), CD23 (-), CD10 (-). Diffuse large B cell lymphoma, non-geminal center type is considered.
    • Section shows gastric glandular mucosal tissue with diffuse infiltration by round blue neoplastic cells.
  • 2023-01-30 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Diffuse ulcerative lesions, antrum, body, fundus and cardia, highly suspected malignancy, suspected lymphoma, s/p biopsy
      • Reflux esophagitis LA Classification grade A
  • 2023-01-29 CT - abdomen
    • History and indication: abdominal pain
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of stomach with regional LAP r/o malignancy.
      • Normal appearance of liver, spleen, pancreas, adrenals and kidneys.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • No abnormal density at bilateral basal lungs.
    • IMP:
      • Wall thickening of stomach with regional LAP suspected malignancy.
  • 2023-01-08 CT - abdomen
    • Normal appearance of the appendix.
    • The both kidneys show normal contrast excretion, size, and contour without evidence of renal stone or tumors.
    • The liver parenchyma reveals no evidence of focal lesion.
    • The gallbladder is normal in size and wall thickness.
    • The pancreas & spleen appears normal in size and contour.
    • No evidence of ascites or intra-abdominal fluid collection.
    • No evidence of paraaortic or pericaval lymphadenopathy in this study.

[MedRec]

  • 2023-12-20 ~ 2024-02-10 POMR Chest Medicine Wu ZhiWei
    • Admission diagnosis
      • Gastro-esophageal reflux disease with esophagitis with Gastric ulcerative tumor, middle body to cardia, AW and GC site with easily touch bleeding by 2023/12/06 EGD report
      • Double hit, Gastric lymphoma with large B cell lymphoma, stage IV, non-geminal center type CK (-), CD3 and CD20: a predominant CD20 B cell sub-population. Bcl-2 (diffuse +), B-cl-6 (equivocal to focal +). C-myc (-), Ki-67 (95%), CD23 (-), CD10 (-), R-CHOP from 2023/02/17~2023/06/20 (6th dose)
      • Essential (primary) hypertension
    • Discharge diagnosis
      • Severe sepsis with septic shock
      • Acute respiratory failure s/p intubation and mechanical ventilator support.
      • Bilateral bacterial pneumonia (sputum culture: stenotrophomonas maltophilia)
      • Acute kidney failure
      • Double hit, Gastric lymphoma with large B cell lymphoma, stage IV with liver and intra-abdominal lymph node metastasis, non-geminal center type CK (-), CD3 and CD20: a predominant CD20 B cell sub-population. Bcl-2 (diffuse +), B-cl-6 (equivocal to focal +). C-myc (-), Ki-67 (95%), CD23 (-), CD10 (-), R-CHOP from 2023/2/17~2023/06/20 (6th dose)
      • Neutropenia ANC:249
    • CC
      • Tarry stool passage since 2023/12/17
    • Present illness
      • This 59-year-old male patient has the history of 1) HTN for 30 years under medical treatment just 2 years and 2) gout for years.
      • According to himself and his wife, he sufferred nausea and poor appetite for about 1 month. BW loss 7-8 kg in 1+ months and poor intake. Upper GI endoscopy was performed on 2023/01/30 and pathology showed Lymphoma, B cell type, diffuse pattern. High grade. IHC stains: CK (-), CD3 and CD20: a predominant CD20 B cell sub-population. Bcl-2 (diffuse +), B-cl-6 (equivocal to focal +), C-myc (-), Ki-67 (95%), CD23 (-), CD10 (-). Diffuse large B cell lymphoma, non-geminal center type is considered.
      • Abd CT on 2023/01/29, report showed wall thickening of stomach with regional LAP r/o malignancy. EGD showed 1. Diffuse ulcerative lesions, antrum, body, fundus and cardia, highly suspected malignancy, r/o lymphoma, s/p biopsy and 2. Reflux esophagitis LA Classification grade A, PPI used.
      • Heart echo was done showed LVEF 70%. Follow up abd CT showed no LAP or mass in the chest and visible lower neck and gastric lypmhoma with perigastric LAP.
      • The PET for staging, report showed large B-cell lymphoma with involvement of stomach and lymph nodes in bilateral thigh regions on 2023/02/14.
      • 2023/02/13 Bone marrow showed negative for malignancy.
      • He received chemotherapy with R-CHOP 6th since on 2023/02/17-2023/06/20 (by Dr Hsia).
      • 2023/07/14 PET showed in comparison with the previous study on 2023/02/13, the previous glucose hypermetabolism in the gastric region and lymph nodes in bilateral thigh regions are less evident, suggesting partial response to the therapy, The glucose hypermetabolism in the the bone marrow of the skeleton is also less evident.
      • 2023/07/18 PES showed reflux esophagitis LA Classification grade A (minimal), gastric ulcer, lower body, GC, s/p biopsy (A), gastric polyps, antrum, PW, gastric polypoid lesion with ulceration, fundus, upper body, AW, s/p biopsy (B), and pathology showed Ulcer, H pylori NOT present. IHC stain of cytokeratin (CK) highlights preserved glands.
      • 2023/08/23 Abd CT: Gastric wall thickening, c/w gastric lymphoma and splenomegaly
      • 2023/08/28 BM: Negative for malignancy. IHC stains: CD3: <1%; CD20: <1 %; bcl-2: <1%, bcl-6: <1 % (of the nucleated cells).
      • 2023/08/29 EGD showed Esophageal lesion, lower esophagus, s/p biopsy (C), Superficial gastritis, Gastric ulcerative tumor, body, AW and GC, s/p biopsy (B) and Gastric scar, antrum, GC, s/p biopsy (A).
      • 2023/08/29 Esophagus, lower, 38 cm biopsy — Compatible with large B-cell lymphoma with esophageal involvement.
      • 2023/08/29 Stomach, body, biopsy — Gastric ulcer with residual diffuse large B-cell lymphoma.
      • Under the impression of Gastric Diffuse large B cell lymphoma, non-geminal center type stage IV post R-CHOPx6 with residual lymphoma, so he was referred and admitted to Dr Kao for future treatment.
      • He received C1 R-DHAP since 9/26-9/29, C2 on 12/7-12/9 23 for his refractory lymphoma.
      • Follow-up abdominal CT (2023/10/6)showed Gastric lymphoma S/P C/T show stable disease. Tarry stool passage and stool OB 4+ were noted, R/O GI bleeding or tumor bleeding. Intravenous PPI was added and EGD showed Reflux esophagitis LA Classification grade A, Superficial gastritis, Gastric ulcerative tumor, middle body to cardia, AW and GC site with easily touch bleeding. He complained of tachycardia and EKG showed possible anterior infract coronary artery disease suspected.
      • This time, he suffered from tarry stool passage on 12/17 23 and epigastric pain was also noted. Owing to tarry stool passage, watery diarrhea, epigastric discomfort and poor appetite were also noted in recent 2 days and visited to OPD on 12/19 23 and blood transfusion with LPRBC2U & LRP 2PH was given. Epigastric pain progression and tarry stool passage remain and vomiting were developed and came to our ER on 12/20 23. At ER, the laboratory showed WBC:760, Hb:8.3, seg:32.8, ANC:249, PL:22K, PCT:11.71, CRP:34.4, TBI:2.19, Cr:2.03. Under the impression of neutropenia and GI bleeding or tumor bleeding suspected and he was admitted for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, NPO except drugs/hydration and antibiotic with Cefim, primperan and PPI therapy were given for nausea with vomiting, stool OB 4+ R/O GI bleeding or tumor progression related and infection control. The blood culture x 2 set showed negative.
      • Owing to poor appetite and nausea with vomiting and general weakness, fatigue were also noted and PPN support was added.
      • Tramtor 100mg ivd prnq6h was given for pain control.
      • Tachycardia was found on 12/26 and EKG showed sinus tachycardia with premature atrial complexes septal infarct, age undetermined.
      • Owing to poor appetite was noted and PPN was added for cachexia.
      • Tramtor was given for pain control.
      • The heart echo showed LVEF 60.8%. 1. Adequate LV systolic function with no regional wall motion abnormality at resting state. 2. Mild AR, MR and TR. 3. Dilated LA, thick IVS and LVPW. 4. Tachycardia during the exam, around 120bpm.
      • Concor and Norvasc were given for tachycardia and hypertension control.
      • General weakness & fatigue and high CRP:19.4 were found R/O severe sepsis without septic shock.
      • Septic work-up was performed and antibiotic with Tapimycin was given.
      • Acute kindey injury (cr:3.13) was noted on 1/2 and renal sono showed parenchymal change of bilateral kidneys, cause to be determied.
      • Presence of ascites and splenomegaly. Hydration were given for cachexia and AKI.
      • Antibiotic with Brosym was administered for infection control, correct hypomagnesaemia & hypokalemia.
      • Antibiotic shifted to Imipenem since 2024/01/05 for infection control.
      • NG tube was inserted on 2024/01/08 but the patient self-removal of nasogastric tube on 2024/01/09.
      • Owing to elevation D-dimern and NT-proBNP was found R/O pulmonary embolism and MRA: T-aorta showed diffuse lymphadenopathy at abdominal cavity and probably left pulmonary hilar region.
      • Recurrent/residual lymphoma is considered. No significant pulmonary embolism is found. However, the non-contrast study is limited in the sensitivity of detecting pulmonary embolism. We explained his poor condition to his family and on critical.
      • Intravenous PPI was added due to stool OB 4+ and tarry stool passage R/O GI bleeding or tumor bleeding.
      • Dyspnea was noted and CXR showed bilateral pleural effusion and chest tapping about 430cc yellowish fluid was done on 2024/01/15 and report showed transudate.
      • The cytology & cell block report lymphoma. Dyspnea progression was noted on 2024/01/17, ABG shwoed metabolic acidosis.
      • Jusonin 60mg ivd was given. Follow-up CXR revealed bilateral pleural effusion progression and pig-tail drainage was inserted on 2024/01/17 (removed on 2024/01/26).
      • Owing to disease progression noted and we explained his poor condition to his family (son, daughter, wife and sister). The patient’s condition was explained to the family, and the possibility of intubation and resuscitation in case of deterioration was discussed. However, the patient had already expressed a wish not to be resuscitated and had signed an advance medical directive to this effect.
      • Cytology & cell block of pleural effusion showed negative for malignancy. Target therapy with Gazvay on 2024/01/18, smoothly with dyspnea improved. Intravenous PPI, Transamin and blood transfusion for tarry stool passage and symptom relief. EGD shwoed suboptimal study of the gastric body and fundus due to much residual food, reflux esophagitis LA Classification grade A, gastric ulcerative tumor, body, status post ND tube placement on 2024/01/11. Follow-up CXR showed massive pleural effusion and pig-tail drainage was inserted on 2024/01/17.
      • Immunotherapy with Columiv 2.5mg in N/S 100ml IVF 4hrs was administered on 2024/01/25, smoothly without CRS symptoms. Albumin and Lasix to keep I/O balance.
      • Abdominal dullness was noted and 2000 ml yellowish color ascites were drained.
      • Abdominal sono showed Hepatic tumor, mulitple, probably, metastatic tumor, Ascites, massive, splenomegaly on 2024/01/30.
      • Septic work-up was performed and antibiotic with Cefim was added for sepsis.
      • Owing to dyspnea progression and metabolic acidosis were noted and we explained his poor condition to his family and endotracheal tube was inserted on 2024/02/01. Jusonin was given to correct acidosis. Midatin pump titration. He was transferred to MICU on 2024/02/01.
      • After transferred to MICU, the patient received ventilator support and dormicum pump infusion. Antibiotic with meropenem (2/1-2/9), Cravit (2/9-) and Targocid (2/3-) were used for infection control. We added anti-fungal with Eraxis (2/5-) for sputum culture yield candida troicalis.
      • We consulted the nephrologist for CKD and AKI with metabolic acidosis ==> the suggestions: keep I/O and electrolyte balance, follow kidney function. Aggressive fluid hydration with H/S infusion.
      • Vasopressin and albumin injection were given for shock status.
      • We well explained with family about poor prognosis (gastric diffuse large B cell lymhpoma with liver and abdominal lymph node metastasis), and they understood and decided refuse cardiac massage and defibrillation.
      • Persistent oliguria and hypotension were noted. The nephrologist suggestion: not recommended hemodialysis due to terminal stage.
      • Family physician was consulted for hospice combine care.
      • The family requested hospice extubation on 2024/02/10.
      • After withdrawl endotracheal tube and ventilator machine support, few minutes later, bradycardia and EKG showed standstill. So, announced expired at 10:46, 2024/02/10.

[consultation]

  • 2024-01-24 Rheumatology and Immunology
    • Q
      • for Glofitamab infusion with CRS happened will given Tocilizumab used to CRS
      • This 59-year-old man, a patient of Double hit, Gastric lymphoma with large B cell lymphoma, stage IV, non-geminal center type CK (-), CD3 and CD20: a predominant CD20 B cell sub-population. Bcl-2 (diffuse +), B-cl-6 (equivocal to focal +). C-myc (-), Ki-67 (95%), CD23 (-), CD10 (-).
      • R-CHOP from 2023/2/17~2023/06/20 (6th dose) and R-DHAP x 2 time. He was admitted due to tarry stool passage and neutropenia.
      • Target therapy with Gazyva was given on 2024-01-18. We will given Glofitamab infusion on 2024-01-24. We need expertise to evaluate his condition thanks!
    • A
      • History review was performed. Patient was admitted due to gastric lymphoma & received R-CHOP from 2023/2/17~2023/06/20 (6th dose) and R-DHAP x 2 time. He began to receive Gazyva since 2024-01-18. Glofitamab will be scheduled infusion on 2024-01-24. I was consulted for CRS.
      • Suggestion:
        • Grading for CRS.
        • If CRS happen, corticosteroid may be use first (low dose to pulse dosage dependent on it’s severity).
        • If not effective, please consider tocilizumab (4-8mg/kg).
  • 2024-01-04 Neurology
    • Q
      • for acute kindey injury evaluation
      • This 59-year-old man, a patient of Double hit, Gastric lymphoma with large B cell lymphoma, stage IV, non-geminal center type CK (-), CD3 and CD20: a predominant CD20 B cell sub-population. Bcl-2 (diffuse +), B-cl-6 (equivocal to focal +). C-myc (-), Ki-67 (95%), CD23 (-), CD10 (-), R-CHOP from 2023/2/17~2023/06/20 (6th dose) and R-DHAP x 2 time. He was admitted due to tarry stool passage and neutropenia.
      • Owing to elevated Cr index from 3.13 -> 3.75 on 2024-01-04. The renal sono showed Parenchymal change of bilateral kidneys, cause to be determied. Presence of ascites. Splenomegaly. We need expertise to evaluate his condition thanks!
    • A
      • We are consulted for AKI
      • 59/M. Double hit, Gastric lymphoma with large B cell lymphoma, stage IV, non-geminal center type.
      • Info:
        • Cre: 1.7 -> 3.1 -> 3.7
        • BUN: 23 -> 40 -> 46, within 1 week
        • Na/K: 134/2.9
        • PCT 5.97, CRP 19.4
        • Urinalysis: RTE cell 10-19/HPF, PRO 1+
        • U/B Culture: NIL
        • Renal echo: Parenchymal change of bilateral kidneys, cause to be determied. Presence of ascites. Splenomegaly
        • Abx: Tapimycin 4.5gm Q8H x 7 days
        • No obvious renal toxic medication usage, except cisplatin
        • BW: 66.9 kg
        • U/O: ~ 2300-2600/day, non-oliguric
        • Poor oral intake recently, on TPN
        • Increased skin turgor, frequent diarrhea recently
        • C. difficile in 2023-10
      • Impression:
        • AKI on CKD KDIGO stage 2, non-oliguric, suspect acute tubular necrosis, r/i dehydration and infection related (prerenal AKI due to diarrhea and poor oral intake is more favored).
        • Our recommendation as below:
          • Please treat infection as your expertise, may keep antibiotic as brosym (Tazocin may exacerbate diarrhea) escalate if necessary
          • Please titrate fluid hydration to around 2000-2500mL/day (slight I/O positive) to keep adequate renal perfusion, prevent diarrhea and dehydration.
          • Please check FENA (Serum and urine sodium/Serum and urine creatinine) and FEUric acid (Serum and urine uric acid)
          • Please follow BUN/CRE, electrolytes, VBG, CBC/DC regularly.
          • Please record I/O on a daily basis and BW at least BIW or TIW
      • We will follow-up this case.
  • 2023-12-28 Cardiology
    • Q
      • He complained of tachycardia and chest discomfort for days and EKG (2023/12/20) shwoed sinus tachycardia, poor wave progression V1-V4. EHG (2023/12/27) revealed sinus tachycardia with premature atrial complexes septal infarct. We need expertise to evaluate his condition thanks!
    • A
      • I was consulted for sinus tachycardia. The patient was admitted due to stage IV lymphoma.
      • O
        • EKG showed new PRWP since this December.
        • CXR: cardiomegaly?
        • TTE 2023/02: no structural heart disease
        • Lab: anemia
      • Impression: sinus tachycardia, r/o cancer therapy related, r/o underlying diseases related
      • Suggestion:
        • Follow an echocardiography.
        • Treat underlying diseases as your expertise.
    • A 2023-12-29 16:18:38
      • An echocardiography showed no overt structural heart disease or pulmonary hypertension.
      • Please survey and treat underlying diseases, since sinus tachycardia is usually secondary to noncardiac diseases.
      • If the patient was still symptomatic, may consider beta blocker or non-DHP CCB for symptom relief.

[surgical operation]

  • 2022-01-04
    • Surgery
      • Hemorrhoidectomy        
    • Finding
      • Prolasped hemorrhoids at 3,7,11 o’clock        
    • Procedure
      • Under IVGA, Patient was placed on modified Jack-Knife position
      • Tap anus apart
      • Disinfected perianal area with aqueous Beta-Iodine and draped perianal area as usual
      • Local anesthesia applied with mixture of 20ml Marcaine 0.5% and 1% Xylocaine 20ml + E
      • Expose anal canal retractor and identified of hemorrhoid
      • Skin incision was made longitudinally the sites as figure to just above the level of internal sphincter
      • Elevate all tissue above sphincter plant. Turn it over and trimmed away hemorrhoid plexuses
      • Check bleeders and suture mucosa and skin back to sphincter with 4-0 Vicryl
      • Identical procedures were done as figure below
      • Wash anal canal and apply Neomycine ointment
      • Pack wound with gauze 

[chemoimmunotherapy]

  • 2024-01-25 - glofitamab 2.5mg NS 100mL 4hr (Columvi)

    • methylprednisolone 80mg + diphenhydramine 50mg + acetaminophen 1000mg PO + NS 250mL
  • 2024-01-18 - obinutuzumab 1000mg NS 500mL 5hr (Gazyva)

    • dexamethasone 20mg + diphenhydramine 50mg + acetaminophen 1000mg PO + NS 250mL
  • 2023-12-07 - rituximab 375mg/m2 650mg NS 500mL 8hr D1 + carboplatin AUC 5 300mg 24hr D2 + dexamethasone 40mg/m2 20mg BID PO D2-5 + cytarabine 2000mg/m2 3500mg NS 500mL 3hr Q12H D3 (R-DHAP Q3W. Gao WeiYao)

    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2
  • 2023-09-26 - rituximab 375mg/m2 679mg NS 500mL 8hr D1 + cisplatin 100mg/m2 180mg NS 500mL 24hr D2 + dexamethasone 40mg/m2 20mg BID PO D2-5 + cytarabine 2000mg/m2 3600mg NS 500mL 3hr Q12H D3 (R-DHAP Q3W. Gao WeiYao)

    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + NS 250mL D1-3 + acetaminophen 500mg PO D1 + palonosetron 250ug D2-3
  • 2023-06-20 (R-CHOP Q3W. Xia HeXiong)

  • 2023-05-30 - rituximab 375mg/m2 680mg NS 500mL 10hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)

    • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2
  • 2023-04-03 - rituximab 375mg/m2 680mg NS 500mL 10hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)

    • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2
  • 2023-03-09 - rituximab 375mg/m2 680mg NS 500mL 10hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)

    • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2
  • 2023-02-17 - rituximab 375mg/m2 680mg NS 500mL 10hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + doxorubicin 50mg/m2 90mg NS 50mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)

    • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + acetaminophen 500mg PO D1 + palonosetron 250ug D2

(R)DHAP - Cisplatin, Cytarabine and Dexamethasone +/- Rituximab - 2024-01-08 - https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2018/11/RDHAP.pdf

  • Indication
    • Salvage chemotherapy for relapsed/refractory Hodgkin’s or Non-Hodgkin’s Lymphoma
    • First line therapy in combination with alternating R-CHOP in patients with Mantle Cell Lymphoma with stage III/IV disease up to 65 years of age.
  • ICD-10 codes
    • Code with prefix C81-86
  • Regimen details
    • dexamethasone
      • 40mg
      • IV or PO
      • D1-4
    • rituximab
      • 375mg/m2
      • IV infusion
      • D1
      • for B cell Non Hodgkin’s lymphoma patients only
    • cisplatin
      • 100mg/m2
      • IV infusion
      • D1
    • cytarabine
      • 2g/m2 BD (12 hours apart)
      • IV infusion
      • D2
    • Consider starting GCSF (according to local policy, dose based on weight) either to shorten the duration of neutropenia (days 3-9) or to facilitate peripheral bloods stem cell collection (days 6-12).
  • Cycle frequency
    • Repeated every 21-28 days - as soon as blood counts recovered i.e. neutrophils > 1.0 x 10^9/L and platelets (unsupported) > 100 x 10^9/L (unless cytopenias related to disease).
  • Number of cycles
    • Relapse setting: 2 cycles - then reassess disease for suitability for consolidation with stem cell transplant.
    • Non-transplant eligible: up to 6 cycles (total).
    • Mantle cell lymphoma: 3 cycles alternating with R-CHOP followed by consolidation with autograft.
  • Administration
    • Day 1
      • Rituximab is administered in 500mL sodium chloride 0.9%.
        • The first infusion should be initiated at 50mg/hour and if tolerated the rate can be increased at 50mg/hour every 30 minutes to a maximum of 400mg/hour.
        • Subsequent infusions should be initiated at 100 mg/hour and if tolerated increased at 100mg/hour increments every 30 minutes to a maximum of 400 mg/hour.
      • Cisplatin is administered in 1000mL sodium chloride 0.9% over 2 hours following the pre and post hydration as per protocol below:
        • Infusion Fluid & Additives - Volume - Infusion Time
          • [Sodium Chloride 0.9% - 1000mL - 1 hour]
          • [Mannitol 20% - 200mL - 30 minutes] or [Mannitol 10% - 400mL - 30 minutes]
        • Ensure urine output > 100mL / hour prior to giving cisplatin. Give a single dose of furosemide 20mg IV if necessary.
          • [Cisplatin in Sodium Chloride 0.9% - 1000mL - 2 hours]
          • [Sodium Chloride 0.9% + 2g MgSO4 + 20mmol KCl - 1000mL - 2 hours]
        • Total - 3200mL or 3400mL - 5 hours 30 minutes
        • Note:
          • Additional pre hydration may be given as per local policy or required for individual patients.
          • Patients with low magnesium levels (< 0.7 mmol/L) should have an additional 2g magnesium sulphate added to the pre-hydration bag.
          • An accurate fluid balance record must be kept.
          • All patients must be advised to drink at least 2 litres of fluid over the following 24 hours
    • Day2
      • Cytarabine is administered in 1000mL sodium chloride 0.9% over 3 hours.
        • Start time of each infusion must be 12 hours apart.
        • A total of 2 doses are given.
  • Pre-medication
    • Rituximab premedication:
      • Paracetamol 500mg-1g PO 30-60 minutes prior to rituximab infusion
      • Chlorphenamine 10mg IV bolus 15-30 minutes prior to rituximab infusion
      • Dexamethasone 8mg IV bolus or hydrocortisone 100mg IV bolus 15 minutes prior to rituximab infusion (may be omitted if day 1 dexamethasone has been taken at least 30 minutes prior to the start of the rituximab infusion)
  • Emetogenicity
    • This regimen has high emetic potential.
  • Additional supportive medication
    • Allopurinol 300mg OD (100mg OD if CrCl < 20mL/min) for the first 2 weeks.
    • Antiemetics as per local policy
    • Antiviral prophylaxis as per local policy.
    • Prophylactic antibiotics may be required e.g. ciprofloxacin (or as per local policy) when neutrophil count < 0.5 x 10^9/L.
    • Consider antifungal and PCP prophylaxis as per local policy.
    • Mouthwashes as per local policy.
    • H2 antagonist or proton-pump inhibitor if required.
    • Prednisolone 0.5% eye drops 1 drop QDS to both eyes (to avoid chemical conjunctivitis from high dose cytarabine) to start on day 2 for 5-7 days.
    • If magnesium/potassium levels < normal reference range, replace as per local policy.
  • Extravasation
    • Rituximab and cytarabine are neutral (Group 1)
    • Cisplatin is an exfoliant (Group 4)
  • Investigations - pre first cycle
    • Investigation - Validity period
      • FBC - 14 days
      • U&Es - 14 days
      • LFTs - 14 days
      • Magnesium - 14 days
      • Calcium - 14 days
    • Other pre-treatment investigations:
      • Hepatitis B sAg & core antibody
      • Hepatitis C antibody
      • HIV antibody
      • Immunoglobulin levels (IgG, A, M)
      • HbA1c
      • LDH
  • Investigations - pre subsequent cycles
    • Investigation - Validity period
      • FBC - 72 hours
      • U&Es - 72 hours
      • LFTs - 72 hours
      • Magnesium - 72 hours
      • LDH - If clinically indicated
  • Standard limits for administration to go ahead
    • If blood results not within range, authorisation to administer must be given by prescriber/consultant - Unless cytopenias are disease related.
    • Investigation - Limit
      • Neutrophils ≥ 1.0 x 10^9/L
      • Platelets ≥ 100 x 10^9/L
      • Creatinine Clearance (CrCl) ≥ 60 mL/min
      • Bilirubin < 1.5 x ULN
  • Dose modifications
    • Haematological toxicity
      • There is no dose adjustment for haematological toxicity.
      • If neutrophils < 1.0 x 10^9/L and/or platelets (unsupported) < 100 x 10^9/L delay treatment until recovery (unless cytopenias are disease-related).
    • Renal impairment
      • Cisplatin CrCl (mL/min) - Cisplatin dose
        • ≥ 60 - 100%
        • 45-59 - 75%
        • <45 - Consider substitution with carboplatin
        • note: Consider omission of platinum at lesser renal impairment / ototoxicity in mantle cell lymphoma, as the most important component of the regimen is cytarabine.
      • Cytarabine CrCl (mL/min) - Cytarabine dose
        • 60 - 100%

        • 46-60 - 60%
        • 31-45 - 50%
        • < 30 - Omit/Contraindicated
    • Hepatic impairment
      • Cytarabine dose should be reduced to 50% if bilirubin > 1.5 x ULN. Doses may be escalated in subsequent cycles in the absence of toxicity (consultant decision).
    • Other toxicities
      • Cisplatin
        • Neurotoxicity including ototoxicity
          • Grade 1 - 100%
          • Grade 2 - 50%
          • Grade 3 - Omit
          • Grade 4 - Discontinue
        • Stomatitis/Mucositis
          • Grade 1 - 100%
          • Grade 2 - Omit until <= grade 1 then 75% dose
          • Grade 3 - Omit until <= grade 1 then 50% dose
          • Grade 4 - Discontinue or omit until <= grade 1 then 50% dose
      • Other toxicities (except alopecia or nausea and vomiting)
        • Grade 3
          • Cisplatin - Interrupt treatment until resolved then consider dose reduction
          • Cytarabine - Interrupt treatment until resolved then consider dose reduction
        • Grade 4
          • Cisplatin - Interrupt treatment until resolved
          • Cytarabine - 75% dose
  • Adverse effects
    • Serious side effects
      • Myelosuppression
      • Infertility
      • Secondary malignancy
      • Anaphylactoid reaction
      • Nephrotoxicity
      • CNS toxicity (cytarabine)
      • Neurotoxicity including ototoxicity
      • Nephrotoxicity including electrolyte disturbance
      • Hepatotoxicity
    • Frequently occurring side effects
      • Myelosuppression
      • Gastrointestinal toxicity
      • Rash
      • Conjunctivitis (cytarabine)
      • Arrhythmia
    • Other side effects
      • Cytarabine syndrome (fever, myalgia, rash)

==========

2024-02-08

[kidney decline and fluid concern: edema check recommended]

Kidney function is deteriorating.

  • 2024-02-08 Creatinine 5.73 mg/dL
  • 2024-02-05 Creatinine 5.36 mg/dL
  • 2024-02-02 Creatinine 4.04 mg/dL

The patient’s body weight increased from 70.4kg on 2024-02-02 to 75.1kg on 2024-02-08. It is advisable to assess for any indicators of fluid accumulation or edema.

When furosemide is used, higher doses may be required to achieve the desired diuretic response due to decreased secretion into the tubular fluid.

Additionally, the absence of acidosis is confirmed by blood gas analysis on 2024-02-08. If the underlying causes of the acidosis have been resolved, then it would be appropriate to consider discontinuing sodium bicarbonate therapy at an opportune moment.

2024-02-02

[strategic Jadenu administration: addressing high ferritin level]

On 2024-02-01, a ferritin level of 10238 ng/mL was observed, potentially indicative of iron overload, possibly from multiple blood transfusions. Confirmation of this could lead to the consideration of Jadenu (deferasirox) as a treatment option, the only iron chelator available in this hospital. Its use is contraindicated for patients with eGFR < 40. (2024-02-01 eGFR 19.94 ml/min/1.73m^2)

Upon recovery of kidney function to eGFR > 40, an initial 50% dose reduction is recommended. No dosage adjustment is needed for eGFR > 60.

For patients with moderate liver impairment (Child-Pugh class B), a 50% dose reduction is advised initially, with vigilant monitoring for efficacy and adverse reactions that might necessitate further dosage adjustments. Jadenu use is not recommended for severe liver impairment (Child-Pugh class C).

In cases with no liver or kidney impairments, Jadenu may be started at 14 mg/kg daily, with dose adjustments every 3 to 6 months based on serum ferritin levels, and tailored to individual responses and treatment goals. If control is insufficient at 21 mg/kg/day, doses may be increased up to 28 mg/kg/day for persistently high serum ferritin levels above 2500 ng/mL. Doses above 28 mg/kg/day are not advised. A reduction in dose is considered if serum ferritin levels drop below 1000 ng/mL on two consecutive assessments, especially for doses above 17.5 mg/kg/day. Therapy should be paused if levels fall below 500 ng/mL, with monthly monitoring thereafter.

2024-01-26

[monitoring for CRS during these 2 or 3 days]

The last R-DHAP treatment was administered on 2023-12-07, with an expectation that the bone marrow suppression effect would almost diminish by the end of the year. However, since the beginning of 2024, the patient’s HGB levels have continued to remain low, ranging from just over 6 to 8 g/dL, indicating persistent anemia.

  • 2024-01-26 HGB 7.8 g/dL
  • 2024-01-24 HGB 7.9 g/dL
  • 2024-01-22 HGB 7.1 g/dL
  • 2024-01-20 HGB 8.2 g/dL
  • 2024-01-19 HGB 7.1 g/dL
  • 2024-01-18 HGB 8.9 g/dL
  • 2024-01-17 HGB 7.4 g/dL
  • 2024-01-16 HGB 6.7 g/dL
  • 2024-01-15 HGB 6.1 g/dL
  • 2024-01-13 HGB 7.3 g/dL
  • 2024-01-12 HGB 8.8 g/dL
  • 2024-01-11 HGB 7.0 g/dL
  • 2024-01-10 HGB 6.3 g/dL
  • 2024-01-08 HGB 7.7 g/dL
  • 2024-01-05 HGB 8.8 g/dL
  • 2024-01-04 HGB 8.4 g/dL
  • 2024-01-02 HGB 7.6 g/dL

Gazyva (obinutuzumab) was administered on 2024-01-18, and 8 days later today 2024-01-26, the patient’s HGB had dropped by approximately 1 g/dL, necessitating a transfusion today. While the incidence of anemia with Gazyva is 12% to 39% (grades 3/4: 5% to 10%), it was administered only once as per the regimen schedule. Attention should now be directed towards the potential impact of Columvi (glofitamab) administered on 2024-01-25, as it has a higher incidence of decreased hemoglobin (72%; grades 3/4: 8%).

Close monitoring for cytokine release syndrome (CRS) is advised during these 2 or 3 days while Columvi (glofitamab) is being initiated.

For continuing the Columvi (glofitamab) regimen, the next 10mg dose should be scheduled for 2024-02-01 (C1D15).

[grading and managing CRS in glofitamab therapy]

Cytokine release syndrome (CRS) - 2024-01-26 - https://www.uptodate.com/contents/cytokine-release-syndrome-crs

In the event of cytokine release syndrome (CRS) caused by glofitamab, grading can be aligned with the NCI CTCAE v5.0 criteria.

  • Grade 1 - Fever, with or without constitutional symptoms.
  • Grade 2 - Hypotension responding to fluids. Hypoxia responding to <40 percent FiO2.
  • Grade 3 - Hypotension managed with one pressor. Hypoxia requiring ≥40 percent FiO2.
  • Grade 4 - Life-threatening consequences; urgent intervention needed.

Regardless of the underlying cause of mild CRS, it is suggested symptomatic treatment with antihistamines, antipyretics, intravenous fluids, and close monitoring. For patients with mild CRS, the balance of benefit and toxicity with symptomatic treatment is more favorable than with high dose glucocorticoids, tocilizumab, or interruption of the infusion. The goal of management is to prevent life-threatening toxicity from CRS while sustaining the antitumor effects of the immunotherapy.

For grade 3/4 CRS caused by glofitamab, administer dexamethasone 8 mg (or 5 mg/m2 if <45 kg; maximum: 8 mg) IV or PO Q8H for up to 3 days, then taper over 4 days. In addition, for patients with an inadequate response, tocilizumab (8 mg/kg IV) can be given.

2024-01-15

[Bestnem 500mg Q6H too high for eGFR 18.47, consider 200mg Q6H or 500mg Q12H]

The eGFR level of 18.47 measured on 2024-01-15 falls within the 15-30 range for which the Sanford Guide recommends Imipenem/Cilastatin dosing of 200mg Q6H or 500mg Q12H. As the current regimen of Bestnem 500mg IVD Q6H exceeds the recommended Sanford Guide guidance, a dose adjustment to either 200mg Q6H or 500mg Q12H is recommended to potentially reduce the risk of adverse effects.

2024-01-09

[Feburic dose modification for lower eGFR]

As of 2024-01-08, the patient’s uric acid level was 6.0mg/dL and eGFR was 19.54mL/min/1.73m².

While currently taking Feburic (febuxostat 80mg) 1# QD, this dosage exceeds the recommended limit of 40mg daily for patients with CrCl below 30mL/minute.

Therefore, a dose reduction to 0.5# QD is advisable to ensure safe and effective management.

2024-01-08

[prioritizing kidney recovery: temporary hold on R-DHAP]

The patient’s eGFR has significantly declined over the past six months, dropping from over 80 to below 20 (as of 2024-01-08). This concerning decline occurred despite receiving only three immunochemotherapy sessions during this period:

  • 2023-06-20: R-CHOP
  • 2023-09-26: R-DHAP
  • 2023-12-07: R-DHAP (with carboplatin replacing cisplatin)

Lab results for eGFR

  • 2024-01-08 eGFR 19.54
  • 2024-01-05 eGFR 17.36
  • 2024-01-04 eGFR 17.62
  • 2024-01-02 eGFR 21.79
  • 2023-12-29 eGFR 44.06
  • 2023-12-25 eGFR 52.94
  • 2023-12-21 eGFR 40.22
  • 2023-12-20 eGFR 35.91
  • 2023-12-19 eGFR 40.22
  • 2023-12-14 eGFR 41.79
  • 2023-12-04 eGFR 35.11
  • 2023-12-03 eGFR 35.30
  • 2023-12-01 eGFR 29.74
  • 2023-11-24 eGFR 26.63
  • 2023-11-06 eGFR 44.37
  • 2023-11-02 eGFR 37.61
  • 2023-10-17 eGFR 46.26
  • 2023-10-09 eGFR 43.47
  • 2023-10-06 eGFR 31.72
  • 2023-10-02 eGFR 39.48
  • 2023-09-25 eGFR 61.69
  • 2023-09-13 eGFR 61.69
  • 2023-08-28 eGFR 59.52
  • 2023-08-20 eGFR 58.49
  • 2023-07-12 eGFR 67.82
  • 2023-07-05 eGFR 81.29
  • 2023-06-19 eGFR 70.60
  • 2023-06-16 eGFR 84.20

It is important to note that the R-DHAP regimen is not recommended for patients with creatinine clearance (CrCl) below 30mL/min.

[tube feeding]

Concor 5mg - Utilize the Simple Suspension Method (SSM) for administration. This method requires dissolving the tablet in warm drinking water for 5-10 minutes, occasionally stirring or gently shaking the container until complete dissolution. Once dissolved, it is suitable for administration via a feeding tube. The SSM is effective for dissolving tablets and capsules in warm water, preparing them for suspension and tube feeding.

2023-06-12

  • The patient has been regularly visiting a local healthcare provider primarily for the management of his hypertension. The most recent consultation was on 2023-06-06, during which the patient was prescribed bisoprolol, valsartan, atorvastatin, and febuxostat. The current active medication list includes Concor (bisoprolol), Feburic (febuxostat), Atozet (ezetimibe + atorvastatin), and Exforge (amlodipine + valsartan). So far during this hospitalization, there have been no observations of elevated blood pressure readings. No discrepancies have been identified in the medication reconciliation process.

  • Leukopenia was detected with the lowest WBC count dropping to 420/uL on 2023-06-10, 11 days after the last R-CHOP regimen was initiated on 2023-05-30. To address this, G-CSF (filgrastim 150ug) was administered for 3 consecutive days beginning on 2023-06-10, which led to a noticeable increase in WBC count by 2023-06-12.

    • 2023-06-12 WBC 0.69 x10^3/uL
    • 2023-06-10 WBC 0.42 x10^3/uL
    • 2023-06-06 WBC 6.74 x10^3/uL
    • 2023-05-30 WBC 3.68 x10^3/uL
    • 2023-05-16 WBC 8.06 x10^3/uL
  • Possible leukopenia-related bilateral ground-glass opacity in the lower lungs was revealed in the CXR performed on 2023-06-10, potentially indicating respiratory infections. This might also be substantiated by an elevated CRP level of 8.9mg/dL and a fever of 39.2°C recorded on the same day. Following the initiation of Cefim (cefepime 2000mg every 8 hours), the patient’s fever seems to have been managed effectively.

  • Recent lab results have shown that the patient’s hs-Troponin I, total bilirubin, and BUN levels have exceeded the upper limit of normal. The root causes of these elevated levels might require further investigation.

    • 2023-06-10 hs-Troponin I 17.7 pg/mL
    • 2023-06-10 Bilirubin total 1.24 mg/dL
    • 2023-06-06 Bilirubin total 0.67 mg/dL
    • 2023-06-06 BUN 34 mg/dL
    • 2023-05-30 BUN 22 mg/dL

2023-03-06

  • Since 2023-02-28, the patient has been receiving consecutive doses of Granocyte (lenograstim 250ug) for several days and no leukopenia is observed now.
    • 2023-03-06 WBC 10.64 x10^3/uL
    • 2023-03-04 WBC 15.66 x10^3/uL
    • 2023-03-02 WBC 1.44 x10^3/uL
    • 2023-02-28 WBC 0.51 x10^3/uL
    • 2023-02-22 WBC 5.49 x10^3/uL
    • 2023-02-20 WBC 7.31 x10^3/uL
    • 2023-02-19 WBC 9.48 x10^3/uL
    • 2023-02-17 WBC 9.66 x10^3/uL
    • 2023-02-16 WBC 11.02 x10^3/uL
  • The patient received blood transfusions on 2023-02-16 ~ 19 and 2023-03-02 ~ 03, and the latest record shows that the hemoglobin level is close to normal.
    • 2023-03-06 HGB 10.5 g/dL
    • 2023-03-04 HGB 11.8 g/dL
    • 2023-03-02 HGB 7.8 g/dL
    • 2023-02-28 HGB 9.9 g/dL
    • 2023-02-22 HGB 9.4 g/dL
    • 2023-02-20 HGB 9.7 g/dL
    • 2023-02-19 HGB 8.6 g/dL
    • 2023-02-17 HGB 7.8 g/dL
    • 2023-02-16 HGB 5.9 g/dL
  • Currently, the platelet count is within the normal range.
    • 2023-03-06 PLT 212 x10^3/uL
    • 2023-03-04 PLT 216 x10^3/uL
    • 2023-03-02 PLT 112 x10^3/uL
    • 2023-02-28 PLT 114 x10^3/uL
    • 2023-02-22 PLT 239 x10^3/uL
    • 2023-02-20 PLT 248 x10^3/uL
    • 2023-02-19 PLT 267 x10^3/uL
    • 2023-02-17 PLT 265 x10^3/uL
    • 2023-02-16 PLT 320 x10^3/uL
  • The patient seems to be prone to developing pancytopenia after the first R-CHOP treatment from 2023-02-17. The lowest blood counts were observed one to two weeks after treatment according to the data. Therefore, measures such as G-CSF might be prepared ahead of the next chemotherapy.

2023-03-02

  • Lab data
    • 2023-03-02 Procalcitonin(PCT) 3.75 ng/mL
    • 2023-03-02 WBC 1.44 x10^3/uL
    • 2023-02-28 WBC 0.51 x10^3/uL
    • 2023-02-22 WBC 5.49 x10^3/uL
    • 2023-02-19 WBC 9.48 x10^3/uL
    • 2023-02-16 WBC 11.02 x10^3/uL
  • The patient’s temperature has not exceeded 37.3 degrees Celsius since 2023-03-02, following the administration of piperacillin and tazobactam and Granocyte (lenograstim), indicating initial control of febrile neutropenia.
  • According to the current National Health Insurance drug reimbursement regulations, short-acting injection of granulocyte-colony stimulating factor (G-CSF) such as filgrastim and lenograstim can be used for patients with hematological malignancies after receiving intravenous chemotherapy.
  • The patient has B cell lymphoma and started his first cycle of R-CHOP on 2023-02-17. Leukopenia was observed on 2023-02-28, and the aforementioned national health insurance drug reimbursement regulations could be applied.

2023-02-13

  • The patient was unable to take in a sufficient amount of food due to pain after intake. As a result of the poor response to acetaminophen and the development of anorexia following use of Nexium, Pariet has been prescribed. In the event that poor intake persists in this patient, Tramacet 2 hrs before prandial might be considered.
  • As a PPI, Panzolec (pantoprazole) is duplicated by self-carried Pariet (rabeprazole). If two PPIs are necessary, please confirm.

701320703

240208

[exam findings]

[MedRec]

  • 2021-08-04 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • S
      • Lt breast locally advanced ca (TNBC)
      • neoadjuvant C/T with TC -> EC since 2021-07-31
    • Diagnosis
      • Malignant neoplasm of unspecified site of left female breast [C50.912]
    • Prescription
      • Silverzine (silver sulfadiazine 10mg/g) BID EXT
  • 2021-07-29 ~ 2021-07-31 POMR General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Left breast cancer with lymph node metastasis cT4N1M0 stage IIIB status post left breast biopsy and port-A implacement
      • ECOG performance score: 0
      • Encounter for antineoplastic chemotherapy
    • CC
      • palpable a mass at left breast and associated with ulceration and serous discharge
    • Present illness
      • This 60-year-old female patient denied any past history including DM, HBV or hypertension. She denied any TOCC histories in recent 3 months. She palpable a mass at left breast last June but she ignored it. Until, the mass grew larger quickly and associated with ulceration and serous discharge since this April. She received Traditional Chineses medicine first but the symptom didn’t improved. She went to Dr. Chang OPD for further survey. After physical examination, palpable a 12x9x5 cm protruding mass with skin ulceration at left breast and left axillar lymph node up to 4 cm in size. Breast sono revealed left breast malignancy with axillary lymph nodes metastasis; #5Location: Left 12/0.2 cm, Size: 4.76x5.58 cm; #6 Location: Left 3/2.19 cm, Size: 1.58x1.62 cm. Tc-99m MDP whole body bone scan showed a hot spot in the sternum, bone metastasis should be watched out.
      • Under the impression of left breast invasive carcinoma with lymph node metastasis cT4N1M0 stage IIIB. After well explain the possible treatment modality were well explained to the patient. She was admitted to our ward for implantation port-a catheteriplatation and arrange neo-adjuvant chemotherapy with 1st TC (Taxotere 75mg/m2 + Carboplatin 450mg) for every three weeks.
    • Course of inpatient treatment
      • After admittion, she underwent of left breast tumor biopsy + Port-A catheter implatation on the right side on 2021/07/30. The post-operative course was relatively smooth without complication. The wound is clean and dry.
      • Taxotere 101mg in NS 250/ml IV 1hr and Carboplatin 450mg were performed on 2021/07/31, there was no special complain.
      • Under the stable condition, she was discharged today and will be arrange next neo-adjuvent chemotherapy treatment.
    • Discharge prescription
      • Silverzine (silver sulfadiazine 10mg/g) BID EXT
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Limeson (dexamethasone 4mg) 1# BID
      • Acetal (acetaminophen 500mg) 1# PRNTID
  • 2021-07-26 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • S
      • Lt breast protruding mass with axillar LN
      • noted for 1+ yr
      • at least locally advanced breast cancer
    • O
      • postmenopausal 45 y/o
      • menarche 13 y/o
      • G0P0
      • FH of breast ca (+) grandmother and aunt
      • HRT (+) 3M
      • A 12x9x5 cm protruding mass with skin ulceration at left breast
      • Lt axillar LN up to 4 cm in size
    • Diagnosis
      • Unspecified lump in breast [N63]
    • Prescription
      • Silverzine (silver sulfadiazine 10mg/g) BID EXT

[immunochemotherapy]

  • 2024-02-08 - vinorelbine 25mg/m2 48mg NS 50mL 10min + carboplatin AUC 5 450mg NS 250mL 2hr

    • Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO + betamethasone 8mg + diphenhydramine 30mg + NS 250mL + acetaminophen 500mg PO
  • 2024-01-19 - vinorelbine 30mg/m2 55mg NS 250mL 10min + carboplatin AUC 5 450mg NS 250mL 2hr

    • Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO + betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2023-11-27 - Trodelvy (sacituzumab govitecan) 10mg/kg 180mg NS 100mL 3hr

    • Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO + betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2023-11-08 - Trodelvy (sacituzumab govitecan) 10mg/kg 180mg NS 100mL 3hr

    • Akynzeo (netupitant 300mg, palonosetron 0.5mg) PO + betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2023-03-24 - Enhertu (trastuzumab deruxtecan) 100mg D5W 100mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-02-24 - Enhertu (trastuzumab deruxtecan) 100mg D5W 100mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-02-10 - Enhertu (trastuzumab deruxtecan) 100mg D5W 100mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-01-27 - Enhertu (trastuzumab deruxtecan) 100mg D5W 100mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-01-09 - Enhertu (trastuzumab deruxtecan) 100mg D5W 100mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2022-12-26 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-12-12 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 693mg NS 250mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-11-28 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-11-14 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-26 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-12 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-09-21 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-09-08 - Halaven (eribulin mesylate) 1.4mg/m2 2.3mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 678mg NS 250mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-08-23 - Halaven (eribulin mesylate) 1.4mg/m2 2.3mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 665mg NS 250mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-07-20 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-07-06 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-06-22 - Halaven (eribulin mesylate) 1.4mg/m2 2.4mg NS 50mL 10min + Avastin (bevacizumab) 10mg/kg 700mg NS 250mL 90min

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-05-23 - Keytruda (pembrolizumab) 200mg NS 100mL 30min

  • 2022-04-27 - Keytruda (pembrolizumab) 200mg NS 100mL 30min

  • 2022-04-07 - Keytruda (pembrolizumab) 200mg NS 100mL 30min

  • 2022-03-17 - Keytruda (pembrolizumab) 200mg NS 100mL 30min

  • 2022-02-23 - Keytruda (pembrolizumab) 200mg NS 100mL 30min

  • 2022-01-04 - pembrolizumab 200mg NS 100mL 30min + epirubicin 90mg/m2 154mg NS 100mL 30min + cyclophosphamide 600mg/m2 1030mg NS 500mL 1hr (Keytruda + EC(90) Q3W)

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO
  • 2021-12-07 - pembrolizumab 200mg NS 100mL 30min + epirubicin 90mg/m2 157mg NS 100mL 30min + cyclophosphamide 600mg/m2 1047mg NS 500mL 1hr (Keytruda + EC(90) Q3W)

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO
  • 2021-11-16 - pembrolizumab 200mg NS 100mL 30min + epirubicin 90mg/m2 160mg NS 100mL 30min + cyclophosphamide 600mg/m2 1060mg NS 500mL 1hr (Keytruda + EC(90) Q3W)

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO
  • 2021-10-26 - pembrolizumab 200mg NS 100mL 30min + epirubicin 90mg/m2 160mg NS 100mL 30min + cyclophosphamide 600mg/m2 1066mg NS 500mL 1hr (Keytruda + EC(90) Q3W)

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-10-05 - pembrolizumab 200mg NS 100mL 30min + docetaxel 75mg/m2 135mg NS 250mL 60min + carboplatin AUC 2 450mg NS 250mL 2hr

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-09-14 - docetaxel 75mg/m2 134mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-08-24 - docetaxel 75mg/m2 135mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-07-30 - docetaxel 75mg/m2 135mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

Treatment protocols for breast cancer - 2024-02-08 - https://www.uptodate.com/contents/treatment-protocols-for-breast-cancer

==========

2024-02-08

[precautions for chemotherapy during holidays]

The final two treatments of the vinorelbine plus carboplatin regimen occurred on 2024-01-19 and 2024-02-08, with the nadir of leukopenia and thrombocytopenia recorded on 2024-01-26, roughly one week after the initial treatment.

  • 2024-02-07 WBC 9.93 x10^3/uL

  • 2024-02-01 WBC 12.25 x10^3/uL

  • 2024-01-29 WBC 1.11 x10^3/uL **

  • 2024-01-26 WBC 0.68 x10^3/uL ***

  • 2024-01-22 WBC 11.94 x10^3/uL

  • 2024-01-17 WBC 13.18 x10^3/uL

  • 2024-02-07 PLT 56 *10^3/uL **

  • 2024-02-01 PLT 41 10^3/uL **

  • 2024-01-29 PLT 74 *10^3/uL **

  • 2024-01-26 PLT 12 10^3/uL **

  • 2024-01-22 PLT 38 10^3/uL **

  • 2024-01-17 PLT 114 10^3/uL

Following the administration of Granocyte (lenograstim), leukopenia has ceased. However, there was slight thrombocytopenia present even before the first treatment, which worsened post-medication.

On 2024-02-08, the second treatment day coinciding with the Lunar New Year holiday, the vinorelbine dose was reduced by approximately 15% compared to the first session. Despite this reduction, the risk of leukopenia and thrombocytopenia cannot be entirely dismissed, suggesting the preemptive preparation of G-CSF and platelet transfusions might be prudent.

[declining liver function: considering GaoGan (silymarin) in absence of contraindications]

Lab results showed that the patient’s liver function deteriorated in these 7 days, it might be beneficial to add BaoGan (silymarin) as a hepatoprotective agent if there is no contraindication.

  • 2024-02-07 ALT 56 U/L

  • 2024-02-01 ALT 31 U/L

  • 2024-02-07 AST 87 U/L

  • 2024-02-01 AST 44 U/L

  • 2024-02-07 Bilirubin total 3.62 mg/dL

  • 2024-02-01 Bilirubin total 2.33 mg/dL

  • 2024-02-07 Bilirubin direct 2.30 mg/dL

  • 2024-02-01 Bilirubin direct 1.36 mg/dL

700027657

240207

[exam findings]

[MedRec]

  • 2023-07-05 SOAP Hemato-Oncology Xia HeXiong

    • A/P
      • C-spine MRI will be done on 2023-07-15, RTC on 2023-07-19 for the decision of further treatment.
      • Paitent can’t afford A+B (atezolizumab + bevacizumab). May apply ramucirumab plus self pay FOLFOX.
  • 2023-06-14 SOAP Dermatology Zhou WeiTing

    • Prescription
      • Royalsense (clindamycin 10mg/g) BID TOPI
      • doxycycline 100mg 1# BID
      • fusidic acid 20mg/g BID EXT
      • doxycycline 100mg 1# BID (self-paid)
  • 2023-06-14 SOAP Hemato-Oncology Xia HeXiong

    • A/P
      • Although the CT showed stable, the AFP level is still increasing.
      • Will arrange C-spine MRI and shift sorafenib (TKI, VEGF inh) to regorafenib (TKI, VEGF inh) or ramucirumab (VEGF inh, VEGFR2 inh) by NHI (or 1. Atezolizumab (anti-PD-L1) + Bevacizumab (VEGF inh); 2. FOLFOX)
  • 2023-06-02 SOAP Hemato-Oncology Wan XiangLin

    • Prescription
      • Nexavar (sorafenib 200mg) 2# BIDAC 28D
      • loperamide 2mg 1# BID
  • 2023-05-05, -04-07, -03-08 SOAP Hemato-Oncology Wan XiangLin

    • Prescription
      • Nexavar (sorafenib 200mg) 2# BIDAC 28D
  • 2023-04-06 SOAP Dermatology Zhou WeiTing

    • S
      • hand-foot syndrome.
      • seocndary infection was noted.
    • Prescription
      • Sinpharderm Cream (urea) QN TOPI
      • cephalexin 500mg 1# TID
      • Transamin (tranexamic acid 250mg) 1# TID
      • tetracycline ointment TID EXT
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
  • 2023-03-22, -03-08 SOAP Dermatology Zhou WeiTing

    • O
      • tapper down oral medication frequency.
    • Prescription
      • doxycycline 100mg 1# BID
      • Ulstop (famotidine 20mg) 1# BID
      • Broen-C (bromelain 20000units, L-cysteine 20mg) 1# BID
      • Biomycin Ointment (neomycin, tyrothricin) BID TOPI
      • Sinpharderm Cream (urea) QN TOPI
      • Mycomb Cream (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
  • 2023-02-07, -01-10, 2022-12-13 SOAP Hemato-Oncology Zhang ShouYi

    • Prescription
      • Nexavar (sorafenib 200mg) 2# BIDAC 28D
  • 2023-02-01 SOAP Dermatology Zhou WeiTing

    • S: improved and dry out.
    • Prescription
      • doxycycline 100mg 1# BID
      • Ulstop (famotidine 20mg) 1# BID
      • Biomycin Ointment (neomycin, tyrothricin) BID TOPI
      • Sinpharderm Cream (urea) BID TOPI
      • Allegra (fexofenadine 60mg) 1# BID
  • 2023-01-18 SOAP Dermatology Zhou WeiTing

    • S
      • severe bullae papules and plaques erupition over hands and feet after medication
    • O
      • drug induced.
      • hand-foot skin erpution.
      • Suspect related medication: sorafenib
    • Plan:
      • education about drug side effec and explain
      • Strongly suggested OPD f/u
    • Prescription
      • Silverzine (silver sulfadiazine 10mg/g) BID EXT
      • Acetal (acetaminophen 500mg) 1# PRNQID
      • Compesolon (prednisolone 5mg) 1# BID
      • doxycycline 100mg 1# BID
      • Topsym Cream (fluocinonide 0.05%) BID EXT
      • Ulstop (famotidine 20mg) 1# BID
  • 2022-11-22 SOAP Radiation Oncology Huang JingMin

    • S
      • For radiotherapy due to HCC with C spine metastases.
      • PI: 72 y/o male, a pt of HCC s/p TACE x 6 from 2020.04 to 2021.06 & s/p Op x 2 in 2021.03 & 2022.09 by Dr Wu ChaoQun & recurrence wt bone mets Dx in Nov 2022.
      • Family history: (father: HCC)
      • Cancer site specific factors: Alcohol (quit); Smoking (+); Betel nut (quit).
      • Personal Hx: DM(-); HTN(-)
      • Allergy(-)
      • Previous RT Hx: (-)
    • O:
      • ECOG: 0
      • PE: neck and bil SCF: neg; but paitn of the low neck area.
      • TAE (2022-06-10): HCC at RIGHT hepatic lobe s/p TACE.
      • CT scan of abdomen (2022-07-08): 1. Viable HCC 0.8 cm in S4 liver is highly suspected. 2. Detailed findings, please see description.
      • Operation (2022-08-11): Laparoscope S4b partial reection
      • pathology (S2022-13192, 2022-08-12): 1. Liver, S4b, partial resection — Hepatocellular carcinoma. 2. Pathologic Staging: ypT1aNx; Stage IA if cM0.
      • CT scan of lung (2022-10-21): Fibrocalcified lesions are noted at right upper lobe and left upper lobe, old TB is considered. NO evidence of recurrent/residual HCC in the study.
      • CT scan of C spine (2022-11-11): Probably multiple bone metastases, cervical spine, with C5 pathological fracture.
      • Bonne scan (2022-11-18): 1. Increased activity in the upper and lower C-spines. Either bone metastases or degenerative spine disease may show this picture. 2. Mildly increased activity in the L4-5 spines. Degenerative change may show this picture. 3. Some hot spots in the sternum and right rib cage and increased activity in the left iliac bone. The nature is to be determined (post-traumatic change? bone metastases?).
      • C-spine AP+ Lat (2022-11-19): 1. mild retrolisthesis at C4-5. 2. Unremarkable change in the width of the bony spinal canal. 3. compression fracture at C5 vertebrla body with blurred vertebral cortical margins.
    • A:
      • Hepatocellular carcinoma, s/p TAE and laparoscope S4b partial reection, Pathologic Staging: ypT1aNx(cM1), with multiple bone metastases and C5 pathological fracture.
    • P:
      • Radiotherapy is indicated for this patient with the following indicators: C spine metastases with C5 pathological fracture
      • Goal: palliation
      • Treatment target and volume: C5 and peripheral involved spine area
      • Technique: IMRT
      • Preliminary planning dose: 3000cGy/15 ractions
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2022-11-28.
      • Suggest the patient visit ortho or NS for evaluation of surgery first. The patient and his wife would like to visit ortho (Dr. Zen) first and then make a decision.
  • 2021-08-10 ~ 2021-08-16 POMR General and Gastrointestinal Surgery Wu ChaoQun

  • 2021-06-09 ~ 2021-06-11 POMR General and Gastrointestinal Surgery Wu ChaoQun

  • 2021-03-30 ~ 2021-04-03 POMR General and Gastrointestinal Surgery Wu ChaoQun

    • Discharge diagnosis
      • Hepatocellular carcinoma, ypT1bN0M0, Stage:IB , Barcelona Clinc Liver Cancer stage A, ECOG: 1, status post laparoscopic S5 resection and laparoscopic cholecystectomy on 2021/03/31
      • Alcoholic liver cirrhosis, Child A
      • Liver cell carcinoma
    • CC
      • Liver tumor was noted by MRI.
    • Present illness
      • This 71 years old male has history of
          1. Hepatocellular carcinoma, initial cT2N0M0, stage II, Barcelona Clinc Liver Cancer stage A, status post transarterial chemoembolization *5 on 2020/04/20, 07/01, 09/14, 12/01 and 2021/03/03.
          1. Alcoholic liver cirrhosis, Child A
          1. Gout
          1. non HBV or HCV
      • He was regularly followed up at our GI OPD. The follow up abdomen CT was done on 2021/02/25 which revealed (1) Right HCCs s/p TACE with viable tumors (up to 3.9cm). (2) Liver and renal cysts (5.0cm). (3) A LN (1.1cm) at hepatic hilar region. (4) Liver cirrhosis. Tumor marker showed incerease of AFP:749.2ng/mL. He reffered to GS Dr. Wu’s OPD for help. Arrange Liver MRI was performed which revealed HCC 4 x 3.3 cm in S5 of the liver, no evidence of ascites or lymphadenopathy on 03/24. ICG test showed 12.4%. He denied fever, nausea, dyspnea, abdominal pain, frequent urinary, and tarry stool. Physical examination showed abdomen soft and ovoid, no palpable mass, no tenderness. Under impressed of HCC, he was admitted to our ward for surgical intervention.
    • Course of inpatient treatment
      • After admission, he received laparoscopic cholecystectomy and S5 hepectectomy was processed successfully on 2021/03/31. Post operaively, we observed patient recovery and keep empiric antibiotic, stool softener, albumin with lasix therapy, and analgesic agent were administered and the wound management was performed. He try to introduced soft diet and can tolerate well. His generally well beings and relativley stable without other complications and vital signs were stable after the surgery. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. Abdomen wound clean and was removal JP tube was done on 2021/04/02. Under improved general condition, he was allowed to discharge today and OPD follow up was arranged.
    • Discharged prescription
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
      • Through (sennoside 12mg) 2# HS
      • MgO 250mg 1# TID
  • 2021-03-03 ~ 2021-03-05 POMR Gastroenterology Chen JianHua

    • CC: for scheduled 5th TACE.
  • 2020-11-30 ~ 2020-12-03 POMR Gastroenterology Chen JianHua

    • CC: HCC s/p embolization with recurrence admitted for the 4th TACE
  • 2020-09-14 ~ 2020-09-16 POMR Gastroenterology Chen JianHua

    • CC: Hepatoma s/p embolization with recurrence admitted for the 3rd TACE    
  • 2020-07-01 ~ 2020-07-03 POMR Gastroenterology Chen JianHua

    • Discharge diagnosis
      • Hepatocellular carcinoma, cT2N0M0, stage II, Barcelona Clinc Liver Cancer stage A, status post 2nd transarterial chemoembolization
      • Alcoholic liver cirrhosis, Child A
      • Gout
      • Liver cell carcinoma
    • CC
      • for 2nd TACE
    • Present illness
      • This 70 years old male had history of 1) Alcoholic liver cirrhosis, Child A; 2) Gout; 3) Hepatocellular carcinoma, cT2N0M0, stage II, Barcelona Clinc Liver Cancer stage A, status post 1st transarterial chemoembolization.
      • He was regular followed up at our GI OPD. Abdominal CT was perfromed on 2020/06/18 and revealed 1) Right HCCs s/p TACE with viable tumors (up to 2.9cm); 2) A LN (1.1cm) at hepatic hilar region; 3) Liver cirrhosis.
      • Alpha-feto-protein (AFP) was 268.5ng/dl on 2020/06/18. There was no fever, chills, nausea, vomiting, poor appetite, abdomen pain, bloody or tarry stool passage, tea color urine. He was admitted to GI ward for 2nd TACE.
    • Course of inpatient treatment
      • After admission, the 2nd transarterial chemoembolization for hepatocelluar carcinomas was performed smoothly on 2020/07/01. There was no fever episode, no abdominal pain after procedure. Follow-up liver function tests revealed mild elevation of ALT (59 U/L) and no hyperbilirubinemia were found.
      • Under stable condition, he was discharged on 2020/07/03 and GI OPD follow up was arranged later.
    • Discharge prescription
      • Lactam (acetaminophen 500mg) 1# PRNQ6H if BT > 38.2 or chills post TACE
  • 2020-04-20 ~ 2020-04-22 POMR Gastroenterology Chen JianHua

    • Discharge diagnosis
      • Hepatocellular carcinoma T2N0M0 stage II status post transarterial chemoembolization
      • Alcoholic liver cirrhosis, Child A
      • Gout
    • CC
      • for first TACE
    • Present illness
      • This 70 years old male had history of alcoholic hepatitis and gout for years which were regular follow up at our OPD.
      • Serum alphafeto protein on 2020/03/16 was 64.523 ng/ml. Follow-up abdominal echography on 2020/04/02 showed liver tumor, S5, 3.3 cm. Computed tomography of the abdomen revealed liver cell tumor, T2N0M0, Stage:II and liver cirrhosis. Informed the benefit and risk of TACE.
      • The patient was arranged admitted for first TACE on 2020-04-20. He denied fever, cough, loss appetite, chest pain, tarry stool passage, oliguria, nor limbs edema.
    • Course of inpatient treatment
      • At ward, the liver reserve was Child A. We informed the risk and benefit of TACE to the patient and the family. They understood and signed the permit.
      • TACE was done on 2020-04-20 and there was no complication. Puncture wound was clear and no bleeding. Pain control and IV fluid were given. Follow up ALT/Total bil/CBC/DC were checked on 2020/04/22 which showed stationary.
      • Under the stable vital sign, the patient was discharged on 2020-04-22. OPD follow up was arranged.

[surgical operation]

[radiotherapy]

[immunochemotherapy]

  • 2024-02-05 - ramucirumab 8mg/kg 600mg NS 250mL 60min + oxaliplatin 65mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 500mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL (Cyramza + FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2024-01-11 - ramucirumab 8mg/kg 600mg NS 250mL 60min + oxaliplatin 65mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 500mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL (Cyramza + FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-12-18 - ramucirumab 8mg/kg 600mg NS 250mL 60min + oxaliplatin 65mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 500mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL (Cyramza + FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-11-21 - ramucirumab 8mg/kg 600mg NS 250mL 60min + oxaliplatin 65mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 500mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL (Cyramza + FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-01 - ramucirumab 8mg/kg 600mg NS 250mL 90min + oxaliplatin 65mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 500mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL (Cyramza + FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

2024-02-07

[marked AFP suppression following current chemotherapy initiation]

Lab data on 2024-02-02 were generally within normal limits, with the exception of a notably elevated AFP level, which significantly deviated from the reference range.

Since initiating ramucirumab plus FOLFOX on 2023-11-01, the previously increasing trend in AFP levels has been markedly suppressed, even showing a slight decrease, indicating the continued efficacy of this treatment regimen.

  • 2024-01-11 AFP 1890.8 ng/mL
  • 2023-12-19 AFP 2110.6 ng/mL
  • 2023-11-30 AFP 1855.1 ng/mL
  • 2023-11-02 AFP 2331.8 ng/mL
  • 2023-08-16 AFP 2310.7 ng/mL
  • 2023-07-01 AFP 1096.1 ng/mL
  • 2023-06-09 AFP 610.7 ng/mL
  • 2023-05-29 AFP 405.1 ng/mL
  • 2023-05-02 AFP 120.1 ng/mL
  • 2023-04-07 AFP 133.9 ng/mL

Medication not found to be missing.

700556472

240207

[MedRec]

  • 2024-02-05 ~ 2024-02-07 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Recurrence pancreatic head adenocarcinoma, pT2N1 with small intestine and CBD invasion, complicated with obstructive jaundice - s/p classical Whipple procedure with SMV-portal reconstruction on 20210629, with peritoneal carcinomatosis (2021/08/30), s/p 1L FOLFIRINOX*12 (80%) 2021/09/03-2022/02/24
      • Anemia
      • Type 2 diabetes mellitus
    • CC
      • Lower limbs edema for months and bilateral redness and tenderness for 5 days
    • Present illness
      • The is a 65-year-old female, with ADL-partially dependent. Past history of
        • Type 2 diabetes mellitus
        • Pancreatic head adenocarcinoma, pT2N1 with small intestine and CBD invasion, complicated with obstructive jaundice - s/p classical Whipple procedure with SMV-portal reconstruction on 20210629 - Recurrence with peritoneal carcinomatosis (2021/08/30), s/p 1L FOLFIRINOX x12 (80%) 2021/09/03-2022/02/24 at CGMH hospital follow up.
      • According to the patient’s sister and medical record, she complained lower limbs edema for months and bilateral redness and tenderness for 5 days, so she was brought to our ED for help on 2023/02/05. At ED, the lab data showed WBC 5720, Hb 6.1, PCT 0.55, CRP 1.2, Alb 2.1, normal liver and renal function. Initial antibiotic for suspect cellulitis over both leg and albumine supplement. She has few BW loss, but intake more (4 cans of nutritional supplements and powdered milk per day). She denied fever, conscious disturbance, dyspnea, dysuria or tarry stool in 1 month.
      • Under the impression of hypoalbuminemia with lower legs edema and anemia, so she was admitted on 2024/02/05.
    • Course of inpatient treatment
      • After admission, she received antibiotic as Augmentin for prevent infection.
      • Self paid of albumin for hypoalbuminemia.
      • LPRBC 2u for anemia correct and Lasix 10mg IVD after BT on 2/6.
      • We check stool ob for anemia survey.
      • (CGMH prescribed but not used yet) Novomix 10u bidac for sugar control during hospitalization.
      • Family denied ONC OPD for supportive care.
      • Under the stable condition, she can be discharged on 2024/2/7 and FM OPD follow up is arranged.
    • Discharge prescription
      • Curam (amoxicillin 500mg, clavulanic acid 125mg) 1# Q8H

700826143

240207

[lab data]

2024-01-03 BM chromosome analyz

  • Chromosome Analysis:
    • Tissue Examined:Bone marrow
    • Staining Method:G-Banding
    • Colony number:NA
    • Bands level:350
    • Chromosome Counts:
      • 45-()、46-(19)、47-()、Other-(1) Total-(20)
    • Karyotype:46,XX[19]
  • Interpretation:
    • Analysis of this bone marrow sample shows a female having 46,XX[19] karyotype. There was no significant clonal chromosomal abnormality detected. Additionally, one cell with 44,XX,-8,-19 was observed. No clinical significance can be ascribed to this single finding at the present time.
  • Note: ROUTINE BANDED LEVEL DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF RESOLUTIONS.

[exam findings]

  • 2024-02-06 CXR (supine)
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • moderate enlarged cardiac silhoutte due to dilated cardiac chambers (LAD,RAD) and prominent cardiophrenic angle mediastinal fat pad /supine position
    • Crowding of vascular markings over Rt lower lung zone
    • Severe OA change at Lt glenohumeral joint
    • old fracture of Rt M/3 clavicle
  • 2023-12-08 MR Cholangiography, MRCP
    • Indication: 20231206 US - pancreatic lesion 0.41 cm at the body.
    • Findings:
      • A cystic lesion 6 x 3 mm at the pancreatic body (Srs:103 Img:2) in MRCP is suspected but it is not identified on T2WI.
        • IPMN (side-branch type) is highly suspected.
        • Please correlate with contrast enhanced dynamic CT.
      • The liver shows marked hypointensity on both T1WI and T2WI that is c/w iron deposition (primary hemochromatosis). please correlate with clinical condition.
      • There are several renal cysts on both kidney (up to 1.2 cm).
    • IMP:
      • IPMN (side-branch type) is highly suspected. Please correlate with contrast enhanced dynamic CT.
      • Iron deposition (primary hemochromatosis) in the liver is suspected. please correlate with clinical condition.
  • 2023-12-06 SONO - abdomen
    • Diagnosis:
      • Pancreatic cyst, body
      • Splenomegaly, borderline
      • Renal cyst, left kidney
      • Pleural effusion, right
    • Suggestion:
      • MRCP/MRI for pancreatic lesion
  • 2023-12-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (154 - 74) / 154 = 51.95%
      • 2D (M-Simpson) = 52
    • Conclusion:
      • Mild global hypokinesia of LV with borderline LV systolic function.
      • Preserved RV systolic function.
      • Septal hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; severely dilated LA and mildly dilated RA.
      • Mild to moderate MR; mild TR; mild PR; mild aortic valve sclerosis.
      • Dilated aortic root and proximal ascending aorta ( 36 mm) with mild calcification.
      • Minimal amount pericardial effusion ( < 50ml).
  • 2023-12-05 Patho - bone marrow biopsy
    • PATHOLOGIC DIAGNOSIS
      • Bone marrow, biopsy — Compatible with myelodysplastic syndrome
      • Immunohistochemical stains:
        • MPO: positive for myeloid series
        • CD71: positive for erythroid series
        • CD61: positive for megakaryocytes
        • CD117: positive for blast
        • CD34: positive for blast
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consisted of one strip of bone marrow tissue measuring 2.2 x 0.3 x 0.3 cm in size, fixed in B-5 solution. Grossly, it was tan in color and bony hard in consistence. All embedded for section after short decalcification.
    • MICROSCOPIC EXAMINATION
      • Microscopically, the sections show pictures as follows:
        • Hypercellularity for her age, 90%
        • M/E ratio about 2~3/1, hyperplasia of both myeloid and erythroid series
        • Megakaryocyte proliferation, 20% with nuclear atypia and interstitial distribution. No obviously myelofibrosis
        • No obvious increase of blast (3-5%)
      • According to all above histopathologic findings and past history, it is compatible with myelodysplastic syndrome. Please correlate with clinical and bone marrow smear findings for final diagnosis.
  • 2022-07-22 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, s/p CLO test
      • Gastric ulcer, Forrest classification type III, antrum, PW, s/p biopsy
      • Gastric erosion, antrum, AW/LC site
      • Duodenal ulcer, Forrest classification type III, bulb, AW
    • CLO test: Positive
    • Suggestion:
      • Pursue CLO test and biopsy result
      • PPI use
  • 2022-07-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (154 - 48) / 154 = 68.83%
      • M-mode (Teichholz) = 68
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, grade 2 LV diastolic dysfunction
      • Mild AR, TR and mild to moderate MR

[MedRec]

  • 2024-01-23 SOAP Hemato-Oncology Gao WeiYao
    • A: a female having 46,XX[19] karyotype
    • Order
      • LPRBC 2U
    • Prescription
      • diphenhydramine 30mg ST IVD
      • NS 500mL IVD
      • Jadenu (deferasirox 360mg) 1# QDAC 7D
  • 2023-12-26 SOAP Hemato-Oncology Gao WeiYao
    • Order
      • LPRBC 2U
    • Prescription
      • diphenhydramine 30mg ST IVD
      • NS 500mL IVD
      • Jadenu (deferasirox 360mg) 1# QDAC 7D
  • 2023-12-19 SOAP Hemato-Oncology Gao WeiYao
    • O: 2023/12/05 PATHO - bone marrow biopsy
      • Compatible with myelodysplastic syndrome with no obvious increase of blast (3-5%)
    • A: Preliminary impression
      • D46.9 Myelodysplastic syndrome, unspecified
      • Transfusion-related hyperferritinemia
    • Prescription
      • Jadenu (deferasirox 360mg) 1# QDAC 7D
  • 2023-12-02 ~ 2023-12-09 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Myelodysplastic syndrome, unspecified
      • Dizziness and giddiness
      • Anemia, unspecified
    • CC
      • general fatigue and weakness for days
    • Present illness
      • The is a 78-year-old female with the history of myelodysplastic syndrome with single linear dysplasia, ringed sideroblast (MDS-RS-SLD) which was diagnosed in 2022 at CGMH, APP s/p op for many years, bilateral TKR (total knee replacement) for many years at MacKay Hospital.
      • For MDS, she was under regular follow up at out hema OPD. Oral Danazol 1# QD was tried since 2023/10/20, no response to oral danazol and severe anemia was found on 2023/12/01 (Hb 4.4, Coomb test: negative). She was then referred to ER for blood transfusion and await admission for complete survey. Associated symptoms included dizziness for days, generalized chest discomfort, and general weakness.
      • At ER her conscious level was E4V5M6, vital sign: BT:35.9, PR:89, RR:18, BP:119/56mmHg. Physical examination showed conjunctiva pale, no abdominal pain, no acute bleeding sign, bilateral pitting edema 1-2+, and bilateral knee old OP scar. Lab data showed anemia (Hb 4.4 g/dL, after BT with LPRBC 4 units to 7.1 g/dL), high ferritin 2418.4 ng/mL. Chest x-ray showed cardiomegaly. Under the tentative diagnosis of myelodysplastic syndrome with severe anemia, she was admitted to our ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission, blood transfusion was done with LPRBC 4u on 12/1, 2u on 12/4, 2u on 12/6, 2u on 12/8 due to anemia, Hb 4.4 -> 7.1 -> 6.1 -> 7.9 -> 7.7 g/dL.
      • We added Jadenu 1# QDAC for high ferritin.
      • She underwent bone marrow puncture on 2023/12/05, and the result showed compatible with myelodysplastic syndrome.
      • Heart echo was arranged due to cardiomegaly and old age, which showed LVEF (%) = 52, mild global hypokinesia of LV with borderline LV systolic function, preserved RV systolic function, septal hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; severely dilated LA and mildly dilated RA, mild to moderate MR; mild TR; mild PR; mild aortic valve sclerosis, dilated aortic root and proximal ascending aorta (36mm) with mild calcification, minimal amount pericardial effusion (<50ml).
      • Due to abnormal liver function and RUQ mild tenderness, we followed lab datas and arranged abdominal echo. HBV, HCV were negative. Elevated GOT 50 -> 48 -> 47 U/L, GPT 53 -> 47 -> 48 U/L, total bilirubin 1.99 -> 2.25 mg/dL, direct bilirubin 0.98 mg/dL, GGT 301 U/L, ALK-P 165 U/L were found.
      • Abdominal echo revealed pancreatic cyst (body), borderline splenomegaly, left renal cyst, right pleural effusion. Lipase and amylase were normal.
      • MRCP was arranged and the report was still pending. During the admission, she had well appetite and no abdominal pain, no tarry stool.
      • Under stable condition, discharged on 12/9 and HEMA, GI OPD follow up was arranged.
    • Discharge prescription
      • Jadenu (deferasirox 360mg) 1# QDAC 11D
  • 2023-12-01 SOAP Hemato-Oncology Li QiCheng
    • S: No response to oral danazol, Hb 4.4, Coomb test (-)
      • Plan: refer to ER for blood transfusion and await admission for complete survey
  • 2023-11-17 SOAP Hemato-Oncology Li QiCheng
    • S: Hb 3.7, to arrange blood transfusion for 2 weeks
    • Order
      • LPRBC 4 unit
      • ferritin
      • direct Coombs’ test
      • indirect Coombs’ test
    • Prescription
      • NS 500mL IVD QD 2D
      • Danol (danazol 200mg) 1# QD 14D
  • 2023-11-03 SOAP Hemato-Oncology Li QiCheng
    • S: 2023-11-03 Hb 4.9
    • Order
      • LPRBC 2 unit
    • Prescription
      • Benamine (diphenhydramine 30mg) ST IVD
      • NS 500mL IVD
      • Danol (danazol 200mg) 1# QD 14D
  • 2023-10-20 SOAP Hemato-Oncology Li QiCheng
    • S:
      • 78 y female
        • 2022: Dx: MDS at CGMH, intermittent blood transfusion
        • 2023-10-11: Hb 4.6, s/p PRBC 2 units
        • 2023-10-20: No hepatosplenomegaly, try Danazol 1# QD
      • CC: dizzniess for days and need blood transfusion
        • last blood tranfusion was 3wks ago
        • generalized chest discomfort
      • no fever, no abdominal pain, no dysuria, no headachea, no vomiting, no diarrhea
      • Allergy: none
      • PHx: Myelodysplastic syndrome with single linear dysplasia, ringed sideroblast (MDS-RS-SLD) - f/u at CGMH
        • Gastric ulcer
    • A/P
      • Preliminary impression: D46.9 Myelodysplastic syndrome, unspecified
        • Dizziness, Chest tightness, MDS, Hb (8.6) 4.6 - BT 4U -> 6.7
        • GUs
      • Lab
        • 2023/10/11 12:27
          • WBC = 2.90 x10^3/uL;
          • HGB = 4.6 g/dL;
    • Prescription
      • Danol (danazol 200mg) 1# QD 14D
  • 2022-07-27 SOAP Hemato-Oncology Wan XiangLin
    • S: Referred because of macrocytic anemia. constipation in recent 3 months, weight loss.
      • Vegeterian for more than 30 years
    • Preliminary impression
      • R06.00 Dyspnea, unspecified
      • Macrocytic anemia
  • 2017-01-12 SOAP Cardiology Duan DeMin
    • S: no chest tightness after inderal use; Recheck BP: 142/71, 84bpm
    • Diagnosis
      • CHF [I50.9]
      • Chest pain, unspecified [R07.9]
      • GERD [K21.9]
      • HCVD [I11.9]
    • Prescription x3
      • Concor (bisoprolol 5mg) 1# QD
  • 2017-01-05 SOAP Hemato-Oncology Wan XiangLin
    • S
      • Referred because of leukopenia, anemia.
      • Vegeterian for more than 10 years.
    • O
      • A: Bicytopenia.
      • P: anemia workups.
    • Diagnosis
      • Osteoarthrosis, localized,not specified whether primary or secondary, lower leg [M17.9]
      • Anemia, unspecified [D64.9]
      • IDA, unspecified [D50.9]

==========

2024-02-07

[NCCN guidelines on serum erythropoietin testing]

Revised international prognostic scoring system (IPSS-R) in myelodysplastic syndrome: score = 3.5 => risk grouop = intermediate

  • Cytogenetics - Good — 1.0 (analysis of bone marrow sample shows a female having 46,XX[19] karyotype, no significant clonal chromosomal abnormality detected)
  • Bone marrow blast >2 to <5 — 1.0
  • HGB <8 — 1.5
  • PLT >= 100 — 0
  • ANC >= 0.8 — 0

The NCCN guidelines recommend evaluating serum erythropoietin (EPO) levels to determine the necessity of recombinant human (rHu) EPO therapy.

While luspatercept is approved for anemia associated with MDS, it is currently not available at this hospital.

701242135

240207

[MedRec]

  • 2023-06-20 SOAP Hemato-Oncology Xia HeXiong
    • S: HBs Ag (+), Anti-HBc (+), AntiHBs (-), Anti-HCV (-)
    • P: Consider TNT: CCRT with 5-FU -> FOLFOX x 12-16 weeks (propose to be 8 cycles) -> evaluating OP
    • Prescription
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
  • 2023-06-09 SOAP Radiation Oncology Wang YuNong
    • S: for neoadjuvant CCRT evaluation
    • Plan: He and his family will seek 2nd opinion at NTUH next W2. CT-simulation will be arragned on 2023/06/19. Plan to deliver 45 Gy/ 25 fx to the anus, rectum, lymphatic draiange area (including inguinal). Then boost the anal tumor and LAPs to 50.4~54 Gy/ 28~30 fx.
  • 2023-06-08 SOAP Hemato-Oncology Xia HeXiong
    • S: Complicated anal fistula s/p op , chronic inflammation, Malignant change. patho: Anal canal, biopsy — Signet-ring cell carcinoma
    • A: RAS is done or not?
  • 2023-05-28 ~ 2023-06-03 POMR Colorectal Surgery Xiao GuangHong
    • Discharge diagnosis
      • Anorectal fibrosis with partial obstruction
      • Anal canal signet ring cell carcinoma, AJCC9th: cT2N1CM0, stage IIB     
      • Hypokalemia, K 2.5 mmol/L
      • Bilateral renal stones
    • CC
      • progressed abdominal distention for four days
    • Present illness
      • This 59-year-old male who has operation history of (1) Spinal angioma s/p surgery 4 years ago (2) 7 times fistulotomy history (3) Anal fistula s/p multiple fistulotomy and seton drainage enterostomy on 2021/08/23. (4) buttock and anal abscess, multiple anal fistulas and cutaneous fistulas; status post excision of all fistulas on 2021/09/02, status post closure of colostomy on 2023/03/15.
      • This time, he came to our ER due to progressing abdominal distention and constipation. The symptoms had exacerbated for 4 days and accompanied with nausea and vomitting, sever abdominal cramping, no defecation, poor appetite. However, no fever, jaudice, chest pain or tightness were reported.
      • At ER, vital signs were BP:160/103; HR:92bpm ; BT:37.2’C; RR:18; Con’s:E4V5M6, SpO2:95%. Lab showed CRP 7.5mg/dl without leukocytosis. Abdominal CT revealed fecal materials impaction in the course of colons and segmental asymmetrical wall thickening of the rectum. Complicated with gas-filled distended bowel loops of the abdomen. Under the impression of ileus, after initial managment at ER, the patient was admitted to our ward for further evaluation and manantment.
    • Course of inpatient treatment
      • After admission, NPO with fluid hydration and NG decompression were administered. EVAC Q6H and lactulose were prescribed for promoting bowel movement. However, there was no flatus yet. Thus, colostomy was suggested but the patient refused. He started defecating and flatus since 2023/05/29 morning.
      • Sigmoidscopy on 2023/05/30 and 2023/06/01 which had drainage of stool (>1000ml and >1500ml respectively) and large amount of air.
      • Rectal tube was inserted on 2023/06/01 for decompression. With improving abdominal distention, he was discharged on 2023/06/03 and would be followed up at CRS clinic.
    • Discharge prescription
      • Const-K (KCl 750mg 10mEq) 1# QD
      • Lactul (lactulose 666mg/mL) 10mL TID
      • MgO 250mg 2# BID

[radiotherapy]

  • 2023-06-27 ~ 2023-08-04 - completed RT to the pelvis (including Rt buttock and bil. inguinal region): 45 Gy/ 25 fx. The anal tumor and LAPs: 50.4 Gy/ 28 fx.

[chemotherapy]

  • 2024-02-05 - oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2000mg/m2 3700mg NS 500mL 46hr + hydroxocobalamin 1mg IM (post oxalip) (FOLFOX)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2024-01-11 - oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2000mg/m2 3700mg NS 500mL 46hr + hydroxocobalamin 1mg IM (post oxalip) (FOLFOX)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-12-22 - oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2000mg/m2 3700mg NS 500mL 46hr + hydroxocobalamin 1mg IM D2 (post oxalip) (FOLFOX)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-28 - oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2000mg/m2 3700mg NS 500mL 46hr + hydroxocobalamin 1mg IM D2 (post oxalip) (FOLFOX)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-06 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr + hydroxocobalamin 1mg IM D2 (post oxalip) (FOLFOX)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • ……….

  • 2023-09-05 - oxaliplatin 85mg/m2 160mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr + hydroxocobalamin 1mg IM (post oxalip) (FOLFOX)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-25 - [fluorouracil 400mg/m2 750mg NS 50mL 10min + leucovorin 20mg/m2 40mg NS 100mL 10min] D1-4

    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-06-27 - [fluorouracil 400mg/m2 750mg NS 50mL 10min + leucovorin 20mg/m2 40mg NS 100mL 10min] D1-4,7

701251769

240207

[MedRec]

  • 2021-10-29, -08-06, -05-14, -02-19 SOAP Cardiology Duan DeMin
    • S: come for BP control; mostly < 140/90mmHg with Concor and Exforge; formerly followed up at TMUH
    • Prescription x3
      • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
      • Concor (bisoprolol 5mg) 1# QD
  • 2020-12-24 SOAP Chest Medicine Yang MeiZhen
    • S: bronchoscopy with electrocautery for RB10 endobronchial tumors with finally patent. Much purulent secretion runned out from RB10. give prophylactic anti for possible fever and transient bacteremia.
    • A/P: Bronchoscopy with/without electrocautery 2 months later.
    • Prescription
      • Transamin (tranexamic acid 250mg) 1# BID
      • Acetal (acetaminophen 500mg) 1# TID
      • Curam (amoxicillin 500mg, clavulanic acid 125mg) 1# TID
      • Compesolon (prednisolone 5mg) 1# QD
  • 2020-11-26 SOAP Chest Medicine Yang MeiZhen
    • S: bronchoscopy with electrocautery for RB10 endobronchial tumors, give prophylactic anti for possible fever.
    • Prescription
      • Transamin (tranexamic acid 250mg) 1# BID
      • Acetal (acetaminophen 500mg) 1# TID
      • Curam (amoxicillin 500mg, clavulanic acid 125mg) 1# TID
      • Compesolon (prednisolone 5mg) 2# QD
      • Adrenalin (epinephrine 1mg) ST TOPI for bronchoscopy
  • 2020-10-28 Hemato-Oncology Xia HeXiong
    • A/P:
      • Admission on 2020-10-28 for previous regimen of chemotherapy (2016-02-04 to 2019-01-12) with Docetaxel/Gemcitabine if data is adequate.
  • 2020-10-21 Hemato-Oncology Xia HeXiong
    • A/P:
      • After discussion with Chest Expert Dr. Yang, the regimen will be shifted back docetaxel plus gemcitabine which is effective before.
      • Once the tumor over LLL is shrinked. Brochoscope will be arranged again.
    • Prescription
      • G-CSF (filgrastim 150ug) SC 3D
  • 2020-10-13 SOAP Chest Medicine Yang MeiZhen
    • S: bronchoscopy for LLL endobronchial lesion enaluate and manage.
    • Prescription
      • Transamin (tranexamic acid 250mg) 1# BID
      • Curam (amoxicillin 500mg, clavulanic acid 125mg) 1# TID
      • Acetal (acetaminophen 500mg) 1# TID
  • 2020-09-18 ~ 2020-09-19 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Malignant neoplasm of overlapping sites of corpus uteri
      • Essential (primary) hypertension
      • Idiopathic gout, unspecified site
    • CC
      • For further management of her disease
    • Present illness
      • The 57 y/o woman has past history of hypertension for 20+ years under medicine control. Cancer history of Endometrial stromal sarcoma, Stage I, high grade post surgcal intervention on 2015/04; Recurrently Ctage IV with lung and brain metastases on 2016/01. She start chemotherapy as doetaxel/gemcitabine from 2016-02-04 to 2019-01-12, best response: CR, but progression in brain, s/p craniotomy and s/p SBRT s/p IA, C1D1 on 2019-01-25, best response PD over brain (Brain MRI) 2019-04-26 vs 2019-01-14) and new lesion over LLL of lung (Chest CT 2019-04-25 vs 2019-01-14). Then the chemothrapy was shifted to temzolomide and irinotecan (TEMIRI: T: 150 mg/m2 on D1-5 and Irinotecan 100 mg/m2 on D1/D15 Q4W), C1D1 on 2019-05-16. Due to Gr 4 myelosuppression, the dose was adjusted to irinotecan 80 mg/m2 and temozolomide 140 mg/Day.
      • This time, she is admitted for further management with next dose of chemotherapy on 2020/09/18.
    • Course of inpatient treatment
      • After admission, she received C17D1 self paid of Temodol 140mg D1-D5 (Q1M) + Irinotecan (80mg/m2) (Q2W) on 2020/09/18. She can be toleranced chemotherapy during hospitalization. Under the stable condition, she can be discharged on 2020/09/19. OPD follow up is arranged on 2020/09/24 and re-admission for alone C17D15 Irinotecan on 2020/10/02.
    • Discharge prescription
      • Temodal (temozolomide 100mg) 1# QDAC 3D (for 9/20-9/22 use)
      • Temodal (temozolomide 20mg) 2# QDAC 3D (for 9/20-9/22 use)
      • Emend (aprepitant 125mg) 1# QD 2D (for 9/20-9/21 use)
      • Granocyte (lenograstim 250ug) SC 3D (for 9/24-9/26 use)
  • 2020-09-08 SOAP Hemato-Oncology Xia HeXiong
    • S
      • NRS: 2
      • s/p TAH + BSO on 2015-03-19, Endometrial stromal sarcoma, Stage I, high grade; currently Ctage IV with lung and brain metastases
      • For follow up the disease condition
      • Dry couigh for days
    • O
      • s/p doetaxel/Gemcitabine from 2016-02-04 to 2019-01-12, best response: CR, but progression in brain, s/p craniotomy and s/p SBRT
      • s/p IA, C1D1 on 2019-01-25, best response PD over brain (Brain MRI) 2019-04-26 vs 01-14) and new lesion over LLL of lung (Chest CT 2019-04-25 vs 01-14)
      • CxR on 2020-09-08: Brochitis
      • Now temzolomide and irinotecan (TEMIRI: T: 150 mg/m2 on D1-5 and Irinotecan 100 mg/m2 on D1/D15 Q4W), C1D1 on 2019-05-16.
      • Due to Gr 4 myelosuppression, Irino 80 mg/m2, temozolomide 140 mg/Day
    • A/P
      • Check hemogram and biochemistry
      • May consider G-CSF if neutropenia
      • Admission for next dose of chemotherapy with TEMIRI if data is adequate

[consultation]

  • 2024-02-05 Urology
    • Q
      • for Right adrenal mass, metastasis or original?
      • The 61-year-old woman has past history of hypertension for 20 more years under medicine control. Cancer history of Endometrial stromal sarcoma s/p TAH + BSO, Stage I, high grade s/p chemotherapy with Docetaxel/Gemcitabine (2016-02-04 to 2019-01-12), CR, with brain metastasis s/p craniotomy and s/p SBRT, with lung metastasis, cT0N0M1, Stage IV s/p chemotherapy with Docetaxel/Gemcitabine. This time, admission for suspect disease progression and for later line Chemotherapy.
      • We sincerely need your professional assistance!!
    • A
      • This 61-year-old female patient has history of endometrial sarcoma with brain and lung metastasis. Recent CT revealed a 4.5cm right adrenal mass which gradually enlarged from 1.5cm in 2022. The appearance of the mass suggest its metastatic origin. However, functional survey of adrenal tumor can still be arranged. Please treat her underlying malignancy as your expertise and arrange adrenal survey as follow:
        • Blood aldosterone, renin activity, ACTH, cortisol, and DHEA-S
        • Urine catecholamine and VMA
      • Thank you for your consultation !!!

[chemotherapy]

  • 2023-12-21 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min

    • dexamethasone 4mg + NS 250mL
  • 2023-12-07 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 90mg D5W 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-11-30 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min

    • dexamethasone 4mg + NS 250mL
  • 2023-10-18 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-10-11 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min

    • dexamethasone 4mg + NS 250mL
  • 2023-09-26 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-09-19 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min

    • dexamethasone 4mg + NS 250mL
  • 2023-09-05 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-08-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min

    • dexamethasone 4mg + NS 250mL
  • 2023-08-15 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 90mg D5W 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-08-08 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min

    • dexamethasone 4mg + NS 250mL
  • 2023-07-11 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-06-27 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-06-20 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min

    • dexamethasone 4mg + NS 250mL
  • 2023-06-06 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-30 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min

    • dexamethasone 4mg + NS 250mL
  • 2023-05-16 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • ……….

  • 2020-12-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-12-15 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-12-02 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-11-20 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 30mg/m2 50mg D5W 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-10-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 30mg/m2 50mg D5W 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-10-07 - irinotecan 80mg/m2 125mg NS 500mL 1.5hr

    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 3mg + atropine 0.5mg SC + aprepitant 125mg PO + NS 250mL + NS 1000mL (Y-sited C/T 24hr)
  • 2020-09-18 - irinotecan 80mg/m2 125mg NS 500mL 1.5hr + temozolomide 140mg PO D1-2

    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 3mg + atropine 0.5mg SC + aprepitant 125mg PO + NS 250mL + NS 1000mL (Y-sited C/T 24hr)

==========

700952699

240206

[MedRec]

  • 2024-01-24 SOAP Gastroenterology Xu RongYuan
    • Diagnosis
      • Cirrhosis of liver without mention of alcohol [K74.69]
      • Pancytopenia [D61.818]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Anemia, unspecified [D64.9]
      • Esophageal varices without mention of bleeding [I85.00]
      • Hypoalbuminemia [E88.09]
      • Alcoholic fibrosis and sclerosis of liver [K70.2]
    • Prescription x3
      • Gasmin (dimethylpolysiloxane 40mg) 1# TID
      • Uretropic (furosemide 40mg) 1# BID
      • Pronolol (propranolol 10mg) 1# QD
      • Emetrol (domperidone 10mg) 1# BIDAC
      • Lactul Syrup (lactulose 666mg/mL) 10mL QD
      • BaoGAn (silymarin 150mg) 1# QD
      • Nexium (esomeprazole 40mg) 1# QDAC
  • 2024-01-23 SOAP Rheumatology and Immunology Chen ZhengHong
    • A
      • Allergic urticaria & chronic dermaitits
      • Cirrhosis of liver
    • Prescription x3
      • Allegra (fexofenadine 60mg) 1# BID
      • Ichderm Cream (doxepin 50mg/gm) QID TOPI
  • 2024-01-17 SOAP Metabolism and Endocrinology Guo XiWen
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
      • Goiter, specified as simple [E04.0]
      • Alcoholic fibrosis and sclerosis of liver [K70.2]
      • Obesity, unspecified [E66.9]
    • Prescription x3
      • Zulitor (pitavastatin 4mg) 1# QOD
      • Soliqua (insulin glargine 100unit/mL, lixesenatide 50ug/mL) 26unit QD SC
      • Kludone (gliclazide 60mg) 1# BID
  • 2024-01-10 SOAP Neurology Liu ZhiYang
    • S: right wrist numb in recent days
    • Prescription x3
      • Neurontin (gabapentin 100mg) 1# PRNQD
      • TieShrShuPap (flurbiprofen 40mg/patch) 1# QD EXT
      • Kentamin (Vit B1 50mg, B6 50mg, B12 500ug) 1# QD
      • Gingonin (ginkgo biloba 40mg) 1# QD
      • Acetal (acetaminophen 500mg) 0.5# PRNQD
  • 2023-07-31 ~ 2023-08-04 POMR Gastroenterology Wang JiaQi
    • Discharge diagnosis
      • Chronic hepatic failure with coma
      • Unspecified cirrhosis of liver, CAUSE ?, CHILD B WITH ASCITES
      • Esophageal varices without bleeding
      • Type 2 diabetes mellitus without complications
      • anemias
    • CC
      • Conscious disturbance with abdomen fullness and left leg edema in recent 10 days.
    • Present illness
      • This 72 year-old female with underlying of 1. Type 2 DM, 2. liver cirrhosis, EV bleeding s/p ligation. This time, she suffered from fatigue and didn’t sleep well for 2 months. However, the symptoms of fatigue and weakness got worse since last month. She had walked hard and slept more than 18 hours/day.
      • According to her family, she suffered from conscious disturbance with abdomen fullness and left leg edema in recently 10 days. There was no fever, chillness or nausea/vomiting. She came to our ER for help on 2023/07/31. At ER, vital signs: BP:162/100mmHg, PR:67 bpm, BT:37’C, RR:18/min, Con’s:E3V5M6, SpO2: 96%. PE showed Abdomen: abdnominal bloating and tightness. Laboratory data revealed pancytopenia, elevated total bilirubin (1.65 mg/dL) and ammonia:82 umol/L. Paracentesis 250ml at ER. Denied TOCC history. Under the impression of hepatic encephalopathy, the patient was admitted to our GI ward for further evaluation and treatment on 2023/07/31.
    • Course of inpatient treatment
      • After admission, she received diuretic with lasix and spironolactone and lactulose for hepatic encephlopathy and liver cirrohosis with ascites treatment. The abdomen echo and panendoscopy were performed, which showed liver cirrhosis with severe ascites and splenomegaly, middle to lower esophagus esophageal varices and gastric varices. The abdomen CT revealed liver cirrhosis with portal hypertension. Follow-up laboratory data revealed improved ammonia level. We well explained the need and risk of esophageal varices ligation, but family is hesitated.
      • Under stable condition with clear consciousness, she was discharge on 2023/08/04, GI OPD follow up was arranged later.
    • Discharge prescription
      • BaoGan (silymarin 150mg) 1# QD
      • Lactul (lactulose 666mg/mL) 20mL BID
      • Nexium (esomeprazole 40mg) 1# QDAC
  • 2017-09-01 SOAP Hemato-Oncology Gao WeiYao
    • Diagnosis
      • Pancytopenia [D61.818]
      • Anemia, unspecified [D64.9]
      • Cirrhosis of liver without mention of alcohol [K74.69]
      • Esophageal varices without mention of bleeding [I85.00]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Reflux esophagitis [K21.0]
      • Ulcer of esophagus [K22.10]
      • Ascites, moderate [R18.8]
      • Hypoalbuminemia [E88.09]
    • Prescription
      • Benamine (diphenhydramine 30mg) ST IVD
      • NS 500mL ST IVD
  • 2017-01-04 SOAP Gastroenterology Xu RongYuan
    • Diagnosis
      • Cirrhosis of liver without mention of alcohol [K74.69]
      • Esophageal varices without mention of bleeding [I85.00]
      • Reflux esophagitis [K21.0]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Ulcer of esophagus [K22.10]
    • Prescription x3
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Mosad (mosapride citrate 5mg) 1# TID
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • propranolol 10mg 1# QD

==========

2024-02-06

[optimizing basal insulin in hyperglycemia management]

Throughout this hospitalization, serum glucose levels in the TPR panel were consistently observed between 200mg/dL and 290mg/dL. It is recommended to increase the daily basal insulin dosage by 2 units to assess potential improvements in glucose management.

700142890

240205

[exam findings]

  • 2024-02-02 CT - brain
    • Findings:
      • There are newly developed multiple poor enhancing masses in the liver and one poor enhancing mass in the spleen.
        • Metastases in the liver and spleen is highly suspected.
      • There are several soft tissue lesions in the mesentery and uterine fossa that are c/w local recurrent tumors.
      • There are several enlarged nodes in para-aortic space and para-cava space that are c/w metastatic nodes.
      • S/P colostomy at the sigmoid colon.
      • S/P double J catheter insertion, bilateral urinary tract.
        • However, mild bilateral hydroureteronephrosis are still noted.
    • Impression:
      • Multiple Metastases in the liver and spleen are highly suspected.
      • There are several soft tissue lesions in the mesentery and uterine fossa that are c/w local recurrent tumors.
      • There are several enlarged nodes in para-aortic space and para-cava space that are c/w metastatic nodes.
  • 2024-02-02 CXR erect
    • S/p port-A placement with its tip at Superior vena cava
    • Increased pulmonary vasculature is found.
    • Osteopenia of the bony structure is noted.
  • 2024-01-12 SONO - nephrology
    • Normal bilateral kidney size
    • Bilateral hydronephrosis, mild degree, s/p double J cathter placement
  • 2024-01-01 CT - brain
    • Findings
      • Swelling of left parietal scalp.
      • No midline shift.
      • Lacunar infarcts at bil. basal ganglia.
      • No evidence of intracranial hemorrhage.
      • Intact bony structures.
      • Widening of cortical sulci and dilatation of ventricles.
    • IMP:
      • Swelling of left parietal scalp.
      • Brain atrophy and lacunar infarcts.
  • 2023-12-31 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
    • Increased lung markings on both lower lungs are noted. Please correlate with clinical condition.
  • 2023-12-12 PET scan
    • Glucose hypermetabolism in the periphery of some focal areas in the left pelvic cavity and midline lower pelvic cavity. Residual malignancy should be watched out. Please correlate with other clinical findings for further evaluation.
    • Multiple glucose hypermetabolic lesions in both lobes of the liver, suggesting multiple liver metastases.
    • Glucose hypermetabolism in some focal areas in the right paraaortic region. Metastatic lymph nodes may show this picture.
    • Glucose hypermetabolism in a foal area in the right anterior pelvic wall. The nature is to be determined (a metastatic lesion? inflammation/infection? other nature?). Please also correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
  • 2023-11-20 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Ovary, oophorectomy site unspecified, exploratory laparotomy with debulking tumor surgery (GYN)/ “Oopherectomy, side unspecified (F2023-519)” —- carcinosarcoma, see microscopic description. IHC stain: CK (+, on few minute foci of epithelium-like neoplastic cells), vimentin (diffuse strong + on neoplastic spindle cells and pleomorphic neplastic cells), SMA (-), CD34 (-), CD117 (-), NSE (-). Also present, benign mucinous cyst.
      • Sigmoid colon, exploratory laparotomy segmental resection of S-colon (end-colostomy) (S2023-13174A) — No residual tumor involvement. Two benign peri-clonic lymph nodes
      • Plevic tumor, excision (S2023-13174B) — Tumor invlovement.
      • pT2b, at least; pNX (if cM0); FIGO Stage: IIB, at least.
    • MACROSCOPIC EXAMINATION:
      • Procedure (select all that apply) exploratory laparotomy with debulking tumor surgery (GYN)/ “Oopherectomy, side unspecified(F2023-519)” + exploratory laparotomy segmental resection of S-colon (end-colostomy) (S2023-13174A) + pelvic tumor excision (S2023-13174B).
        • Pleurocentesis (pleural fluid)
      • Specimen size
        • Labled as “ovary site unspcified”: 1550 gms; 16 x 10 x 10 cm. Partially encapsulated.
      • Specimen Integrity
        • Specimen Integrity of unspcified Ovary (if applicable)
        • Specimen Integrity of Fallopian Tubes (if applicable)- not identified.
      • Tumor Site: (Note: Please select the primary tumor site only)
        • unspecified ovary (F2023-519FS)
        • pelvic tumor (S2023-23174B)
      • Ovarian Surface Involvement - Present
      • Fallopian Tube Surface Involvement (required only if applicable) - not applicable
      • Tumor Size : 16 x 10 x 10 cm. (Note: For bilateral tumors, please report maximum dimension for each primary tumor, specifying by laterality.)
        • Greatest dimension (centimeters): 16 cm
      • Additional dimensions (centimeters): 10 x 10 cm
      • Pelvic tumor (S2023-23174B): 2 pieces, 2.5 x 2.0 x 0.5 cm.
      • Sections are taken and labeled as: Tissue for frozen section: F2023-00519FSA1-3: ovarian tumor. Tissue for formalin fixation: F2023-519A1-5: ovarian tumor; A6: non-malignant ovary. S2023-23174A sigmoid colon; A1: bilateral cut ends; A2-4: sigmoid colon; A5-7: pericolonic tissue; B: “pelvic tumor”.
    • MICROSCOPIC EXAMINATION:
      • Histologic type: carcinosarcoma
      • Histologic grade: high grade
      • Contralateral ovary involvement: no tissue received
      • Tumor side ovarian surface involvement: present
      • Contralateral ovary surface involvement: no tissue received
      • Right tube involvement: no tissue received
      • Left tube involvement: no tissue received
      • In situ adenocarcinoma in right and/or left fallopian tube: no tissue received
      • Right adnexa soft tissue involvement: no tissue received
      • Left adnexa soft tissue involvement: no tissue received
      • Pelvic soft tissue involvement: present (sigmoid colon)
      • Uterine serosa involvement: non-applicable (if no uterus received)
      • Omentum involvement: not received
      • Uterine Cervix involvement: not received
      • Endometrium involvement: not received
      • Myometrium involvement: not received
      • Appendix involvement: not received
      • Largest Extrapelvic Peritoneal Focus (required only if applicable)
        • pelvic tumor (S2023-23174B): 2.5 x 2.0 x 0.5 cm
      • Regional Lymph Nodes: no tissue received
      • Other organs or specimens involvement: S2023-20163 Colorectum, recto-sigmoid junction, (clinically: huge pelvic mass), biopsy — carcinoma, poorly differentiated.
        • IHC stains: CK7 (+); CK20 (-): dis-favor colorectal or gastric primary adenocarcinoma, PAX-8 (-): dis-favor endometrial or ovarian adenocarcinoma; CD3 and CD20: no predomkinant sub-population, dis-favor lymphoma.
        • Additional IHC stains: CK7 (+), Napsin-A (-) and TTF-1 (-) (for pulmonary adenocarcinoma), GATA-3 (-) (for breast carcinoma), CD56 (-) (for neuroendocrine carcinoma), calretinin (-) (for mesothelioma), CK5/6 (-) and p40 (-) (for squamous cell carcinoma).
  • 2023-11-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (63 - 25) / 63 = 60.32%
      • M-mode (Teichholz) = 60
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Mild MR and trivial TR
      • Borderline pulmonary hypertension
      • LV diastolic dysfunction. Gr 1
      • Preserved RV systolic function
      • Sinus tachycardia with HR 111 at the exam
  • 2023-11-09 CT - abdomen
    • A large mass (14.5 x 14.5 x 16.9 cm) at lower abdomen with solid/ cystic parts and colon invasion. Another tumors (2.9cm, 4.3cm) at left pelvic cavity.
      • DDX: GYN tumor with colon invasion, colon cancer with uterus invasion.
    • Mild right hydronephrosis.
  • 2023-11-01 Patho - colon biopsy
    • Colorectum, recto-sigmoid junction, (clinically: huge pelvic mass), biopsy — carcinoma, poorly differentiated.
    • IHC stains: CK7 (+); CK20 (-): dis-favor colorectal or gastric primary adenocarcinoma, PAX-8 (-): dis-favor endometrial or ovarian adenocarcinoma; CD3 and CD20: no predomkinant sub-population, dis-favor lymphoma.
      • An addendum report of additional IHC stains: Napsin-A and TTF-1 (for pulmonary adenocarcinoma), GATA-3 (for breast carcinoma), CD56 (for neuroendocrine carcinoma), calretinin (for mesothelioma) will be followed.
  • 2023-10-31 Gynecologic ultrasonography
    • R/O Huge plevis mass: 170 x 129 mm (papillary: 95 x 75 mm) , no blood flow , Asites(-)
  • 2023-10-31 SONO - abdomen
    • Findings
      • An at least 15.7 cm cystic lesion with an adjucent 8 cm heterechoic lesion at lower abdomen
    • Diagnosis:
      • Rule out abdominal cystic tumor with solid part, lower abdomen, rule out distended urinary bladder
  • 2023-10-31 EGD
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis
    • Gastric erosion, antrum
  • 2023-10-30 MRI - L-spine
    • Presence of spondylolisthesis at L4/5, grade I.
    • There shows no evidence of significant spinal canal stenosis.
    • Bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression.
    • Abnormal multiple enlarged left paraaortic and iliac chain LAPs?
    • Abnormal distension of urinary bladder or a large ovarian cyst/CA? Suggest check low abdomen/pelvic CT.
  • 2023-10-16 KUB
    • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.

[MedRec]

  • 2023-11-19 ~ 2023-11-29 POMR Colorectal Surgery Chen ZhuangWei
    • Discharge diagnosis
      • Huge tumor lesion at low abdomen and pelvic involving rectosigmoid colon, ovary, urinary bladder and right hydronephrosis status post debulking tumor surgery and segmental resection of sigmoid colon (end-colostomy) on 2023/11/20.
      • diabetes mellitus
      • hyperlipidemia
      • Essential (primary) hypertension
    • CC
      • Abdominal distention with one palpable mass over lower abdomen area noted one month ago       
    • Present illness
      • This 69-year-old, G3P2AA1 woman had medical history of 1. Hypertension 2. DM 3. Dyslipidemia. She received hysterectomy 30 years ago due to huge myoma.
      • She had abdominal distention with one palpable mass over lower abdomen area noted one month ago. Body weight loss as 8 kg in the recent few months and decreased appetite was noted. She also mentioned frequent passage of little stool, blood streak in stool. Bilateral legs pitting edema 3-4+ was also noted. There was no fever, dyspnea, vaginal bleeding or other specific discomfort. Hence the patient visited GI OPD for further evaluation and management.
      • PES showed gastritis and GERD. Colonoscopy showed colon tumor, suspcious metastasis in rectosigmoid junction, biopsy was done and pathology showed carcinoma, poorly differentiated. She was then transferred to GYN OPD.
      • TVUS showed R/O Huge plevis mass, 170 x 129 mm (papillary: 95x75mm).
      • CT showed a large mass (14.5 x 14.5 x 16.9 cm) at lower abdomen with solid/ cystic parts and colon invasion. Another tumors (2.9cm, 4.3cm) at left pelvic cavity. DDX: GYN tumor with colon invasion, colon cancer with uterus invasion. Mild right hydronephrosis was also found.
      • After well explained and discussion with patient, she decided to accepted operation and admitted to our ward on 2023/11/19. On arrival, the vital signs were stable, Blood test showed Hgb level as 9.1 g/dL (ANEMIA), WBC level as 18290 and albumin level as 3.1 g/dL. We arranged preoperative evaluation and preparation. The CA125 level was 36.1, the CEA level was 4.23 and the CA153 level was 18.4.        
    • Course of inpatient treatment
      • After admission with ward routine and blood examination were done. Operation of DJ insertion, debulking tumor surgery, and segmental resection of sigmoid colon (end-colostomy) werer performed on 2023/11/20. NPO and IV fluids support. The wound healing well and no erythema change. The colonstomy was inatct and no infectino sign. Chewing cookies, toast, rice with gum was started at op day. No nausea and no vomiting, flatus passage thorough colostomy. On low residual diet was started at post-op day 1.
      • We treated her hypokalemia with intravenous KCl then taper to oral const K QID with spirolactone. Well bowel movement and stools passage with diet well tolerated. No fever and no complication. Removal of JP drain at post-op day 7 and 8. Removal of central venous catheter on post-op day 8. Discharged in general condition stable on 2023/11/29 and will follow up in our out-patient department next week.
    • Discharge prescription
      • Spiron (spironolactone 25mg) 1# QN
      • MgO 250mg 1# TID
      • Const-K (KCl 750mg/10mEq) 1# QID
      • Ceficin (cefixime 100mg) 2# BID
      • carvedilol 6.25mg 1# BID hold if HR < 60
      • Nincort Oral Gel (triamcinolone 1mg/gm) BID TOPI
      • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
      • OxyNorm (oxycodone 5mg) 1# PRNQ6H if pain couldn’t tolerate with tramacet.
  • 2023-11-01 SOAP Gastroenterology Li ZhongXian
    • Prescription x3
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Pariet (rabeprazole 20mg) 1# QDAC
      • Uretropic (furosemide 40mg) 1# PRNQD
      • Through (sennoside 12mg) 1# HS

[surgical operation]

  • 2023-10-20
    • Surgery
      • Exp. Lap with debulking tumor surgery (GYN) and segmental resection of S-colon (end-colostomy) on 2023-11-20     
    • Finding
      • Huge tumor lesion at low abdomen and pelvis with irregular ulcerative tumor massess involving whole pelvic wall, RS-colon, ovary, posterior urinary bladder and left common iliac vessels, causing tumor unresectable!
      • A big perforated hole(3cm in size was found at upper rectum after GYN Dr removal of the relatively cystic part of the huge tumor. Some liquid stool seepage from the hole was noted. Much normal saline irrigation and rectal wash was done.
      • The perforated hole can not be repaired due to a locally cancer invasion. Segmental resection of S-colon with end S-colostomy was done smoothly (Hartmann)
      • Two drains in pelvic floor and rectum.
  • 2023-11-20
    • Surgery
      • Diagnosis: Pelvic mass, r/o malignancy
      • Operation: Oopherectomy, side unspecified   - Finding
      • Subumbilical midline vertical skin incision
      • Uterus: status post hysterectomy, invisible
      • Adnexa: a huge pelvic mass with solid part, about 25 X 15 cm in size, tense adhesion with the bladder, bowel and pelvic wall
      • CDS & pelvic wall: occupied with tumor cells
      • Ascites: scanty
      • Bilateral pelvic lymph nodes: not examined
      • Bowel: rectum rupture noted during surgery; status post colonostomy
      • Many residual tumors (+)
      • Estimated blood loss: 250 mL
      • Blood transfusion: nil
      • Complication: nil  

[chemotherapy]

  • 2023-12-29 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 1000mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2024-02-05

[hyperglycemia and leukocytosis: a cortisol connection?]

Lab results:

  • 2024-02-05 Cortisol 41.21 ug/dL
  • 2024-02-05 Neutrophil 99.1 %
  • 2024-02-05 WBC 49.03 x10^3/uL
  • 2024-02-05 HGB 8.7 g/dL
  • 2024-02-05 PLT 464 *10^3/uL
  • 2024-02-05 ALT 46 U/L
  • 2024-02-05 Bilirubin direct 0.47 mg/dL
  • 2024-02-05 Alkaline phosphatase 1193 U/L
  • 2024-02-05 CRP 37.7 mg/dL
  • 2024-02-05 Procalcitonin (PCT) 2.15 ng/mL

Since 2024-02-04, hyperglycemia was noted in the TPR panel, accompanied by a right-shifted leukocytosis with a predominance of neutrophils, as confirmed by lab results on 2024-02-05. These findings could be secondary to hypercortisolism, recorded at 41 ug/dL, necessitating further investigation to determine the underlying cause, which could include adrenocortical carcinoma or Cushing’s syndrome. Evaluation of ACTH levels could provide more information to form insights.

2024-01-08

[hypokalemia]

The patient has had persistent hypokalemia since 2024-01-01. A single dose of 4 units of regular insulin was administered on 2023-12-31. No further insulin injections have been given since then. She has been receiving “0.298% KCl in 0.9% NaCl 500mL IVD BID” for a week. This delivers 40mEq of potassium daily, equivalent to 4 tablets of Const-K (750mg, 10mEq). Despite this, the serum potassium level remains low. Therefore, a gradual increase in the daily potassium supplementation may be necessary.

  • 2024-01-08 K(Potassium) 2.1 mmol/L
  • 2024-01-05 K(Potassium) 2.3 mmol/L
  • 2024-01-04 K(Potassium) 2.1 mmol/L
  • 2024-01-03 K(Potassium) 1.9 mmol/L
  • 2024-01-02 K(Potassium) 2.4 mmol/L
  • 2024-01-02 K(Potassium) 2.0 mmol/L
  • 2024-01-02 K(Potassium) 1.8 mmol/L
  • 2024-01-02 K(Potassium) 2.1 mmol/L
  • 2024-01-01 K(Potassium) 2.1 mmol/L
  • 2023-12-30 K(Potassium) 4.1 mmol/L

Low magnesium (1.7mg/dL on 2024-01-05) can independently cause the kidneys to waste potassium through the urine. This likely involves an increase in potassium channels that allow potassium to exit the body. Providing appropriate magnesium supplements could be helpful.

700540670

240205

[MedRec]

  • 2018-10-04 ~ 2018-10-08 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • L03.116 - Cellulitis of left lower limb
      • C56.9- Ovarian cancer adenocarcinoma pT3bN1M0 stage IIIb
    • CC
      • Left thigh swelling, redness with pain
    • Present illness
      • The 64 year old woman past historyv had has (1) Thyroid tumor, multinodular goiter status post total thyroidectomy on 2011/12/12 (2) Hypothyroidism under medication (Thyroxine) control (3) DM (4) hyperlipidemia under medication (Vytorin) control (5) ovarian cancer adenocarcinoma pT3bN1M0 stage IIIb, status post debulking surgery (ATH + BSO + Cytoreduction surgery + infracolic omentectomy) on 2015/08/26.
      • She was diagnosed cellulitis of left thigh since from 2018/02/08. In infection outpatient department Dr Peng given Penicillin G 2.4MU/4mL/syringe IM (2018/04/25, 05/23, 06/20, 07/18, 08/15, 09/02). Pelvis CT showed status post operation, no evidence of tumor recurrence on 2018/06/06. we reviewed laboratory finded CRP (0.52mg/dL -> 0.13mg/dL -> 0.87mg/dL) on 2018/10/04.
      • This time, she was complained left thigh swelling, redness with pain (VAS 2/10) on 2018/10/04, she came to our Emergency room for help, she was denied fever and sweating, Laboratory showed CRP:0.87 mg/dL elevation, they given her Oxacillin 2g IVD Q6H then left thigh redness rapid improved. Now she was admitted for further evalaution and managment.
    • Course of inpatient treatment
      • After admission, she accept antibiotics treatment oxacillin 2gm IVD Q6H, during antibiotics treatment, she’s left thigh redness with pain improve. Under the stable condition, discharge the patient and OPD follow.
    • Discharge prescription
      • Diclocin (dicloxacillin 250mg) 2# Q6H
      • Allegra (fexofenadine 60mg) 1# BID
      • Through (sennosides 12mg) 1# HS

701338812

240205

[lab data]

2023-08-29 Anti-HBc Reactive
2023-08-29 Anti-HBc-Value 6.12 S/CO
2023-08-29 Anti-HBs 85.60 mIU/mL
2023-08-29 HBsAg Nonreactive
2023-08-29 HBsAg (Value) 0.35 S/CO

2023-08-29 Anti-HCV Nonreactive
2023-08-29 Anti-HCV Value 0.10 S/CO

[exam findings]

  • 2024-02-01 MRI - upper adbomen
    • Indication: epigastric pain for recent one months.
    • Abdominal MRI with and without IV contrast enhancement shows:
      • status post gastrojejunostomy bypass
      • Gastric wall thickneing at antrum is found. In comparison with CT dated on 2023-12-15, the lesion is stationary.
      • Small lymph nodes are found at periantral region. However, the lesions are non-specific
      • Tiny hepatic cyst measuring 0.8cm in largest dimension is found at S7/8 (Se13 Im10).
  • 2024-01-16 Tc-99m MDP bone scan
    • Increased activity in the middle and lower T-spines and L4-5 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2024-01-15 MRI - brain
    • Indication: Adenocarcinoma of right upper lobe lung post operation 3 dimensions video-assisted thoracoscopic surgery right upper lobe wedge resection and radical lymph node dissection 2023/12/29.
    • Findings:
      • Mild degree of general enlargement of ventricles, cistern spaces and cortical sulci, indicating general brain atrophy.
      • Ossification of posterior longitudinal ligament causing spinal canal stenosis at visible C1-2 levels.
    • IMP:
      • Mild general brain atrophy. OPLL at C-spine. No evidence of brain metastasis.
  • 2024-01-12 PET scan
    • Mild glucose hypermetabolism in the stomach around the previous operative area and in two focal areas in the peripyloric area. The nature is to be determined (residual or recurrent malignancy? inflammation?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the upper lobe of right lung and in the right lateral chest wall. Post-operative inflammation may show this picture.
    • Mild glucose hypermetabolism in bilateral pulmonary regions. Inflammatory process may show this picture.
  • 2024-01-01 CXR erect
    • s/p right chest tube in place, its tip directed superomedially, projecting over 3rd rib
    • Port-A catheter inserted into SVC via left subclavian vein.
    • s/p RUL wedge resection
    • Rt pneumothorax in regression
    • Subcutaneous emphysema in the right neck and chest wall.
  • 2023-12-29 Patho - lung wedge biopsy
    • Diagnosis
      • Lung, right, upper lobe, VATS wedge resection (S2023-26261A) and biopsy with frozen section (F2023-583FS) —- adenocarcinoma.
        • IHC stains: Napsin-A (+), TTF-1 (+), CK5/6 (-), p40 (-), CD56 (-).
      • Lymph node, ipsilateral (group No. 2+4), lymphadenectomy (S2023-26261B) —– free
      • pT1b pN0 (if cM 0); Pathology stage: IA2, at least
    • Gross Description
      • Specimen received:
        • Lung, size:_biopsy specimen: 0.6 x 0.3 x 0.2 cm; wedge resection specimen: 10 x 5 x 4 cm
        • Lymph nodes, 1bottle, maximal size: 1.0 x 0.4 x 0.3 cm
      • Tumor Site: Peribronchial
      • Gross Tumor Size:
        • Solitary : 1.1 x 1.0 x 1.0 cm
      • Gross tumor patterns: Well defined
        • Representative sections are taken and labeled as:
          • Tissue for frozen section: F2023-583FS: RUL biopsy.
          • Tissue for formalin fixation: S2023-26261A RUL wedge resection specimen: A1-3: tumor; A4-8: non-tumor; B: LN2+4.
    • Microscopic Description
      • Tumor Size - 1.1 x 1.0 x 1.0 cm.
      • Tumor Focality - Single tumor
        • Note: Required elements that differ among the tumor nodules (eg, tumor size, histologic type) should be reported for each tumor nodule.
      • Histologic Type (select all that apply) - Invasive adenocarcinoma, acinar predominant (100 %)
      • Histologic Grade (according to the main histological type) - G1: Well differentiated
      • Spread Through Air Spaces (STAS) - Not identified
      • Visceral Pleura Invasion - Not identified
      • Lymphovascular Invasion (select all that apply) - Not identified
      • Direct Invasion of Adjacent Structures (select all that apply) - No adjacent structures present
      • Margins (select all that apply) - All margins are uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margin (centimeters): 2.5 cm
      • Specify closest margin: resection stapled margin.
      • Treatment Effect - No known presurgical therapy
      • Lymph Node Examination (required only if the lymph nodes present in the specimen) - free (right group 2+4: 0/10
      • Extranodal Extension - Not identified
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition) – IA2, at least
        • Note: Reporting of pT, pN, and (when applicable) pM categories is based on information available to the pathologist at the time the report is issued. Only the applicable T, N, or M category is required for reporting; their definitions need not be included in the report. The categories (with modifiers when applicable) can be listed on 1 line or more than 1 line.
      • TNM Descriptors (required only if applicable) (select all that apply) - N/A.
        • Primary Tumor (pT) - pT1b: Tumor >1 cm, but <=2 cm in greatest dimension
          • Note: Tumors with these features are classified as T2a if <=4 cm or if the size cannot be determined and T2b if >4 cm but <=5 cm.
        • Regional Lymph Nodes (pN) - pN0: No regional lymph node metastasis
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case) - if cM0
      • Additional Pathologic Findings (select all that apply) - None identified
      • Ancillary Studies - IHC stains: Napsin-A (+), TTF-1 (+), CK5/6 (-), p40 (-), CD56 (-).
        • Note: For reporting cancer biomarker testing results, the CAP Lung Biomarker Template should be used. Pending biomarker studies should be listed in the Comments section of this report.
  • 2023-12-28 ECG
    • Normal sinus rhythm
    • Possible Septal infarct, age undetermined
    • Abnormal ECG
  • 2023-12-28 CXR
    • Subtle nodular increased opacity over peripheral of RUL
    • Marginal spurs of multiple vertebral bodies of T-spine due to spondylosis.
    • Port-A catheter inserted into SVC via left subclavian vein.
  • 2023-12-15 CT - abdomen
    • History: Gastric cancer of antrum with pancreatic neck invasion, cT4bN2M0 stage IVA status post gastrojejunostomy bypass on 2023/08/28
    • Findings:
      • There is a newly developed small ground-glass opacity 1 cm at RUL of the lung (Srs:301 Img:10). Primary lung cancer is highly suspected.
        • In addition, there are few lymph nodes in para-tracheal space.
        • Follow up is indicated.
      • Prior CT identified wall thickening at gastric antrum is noted again, marked decreasing in wall thickness. Please correlate with gastroscopy.
      • Prior CT identified peri-gastric lymph nodes are noted again, decreasing in size.
      • A liver cyst 0.6cm in S8.
      • status post gastrojejunostomy bypass
    • Impression:
      • Primary lung cancer 1 cm in RUL is highly suspected.
      • Prior CT identified wall thickening at gastric antrum is noted again, marked decreasing in wall thickness. Please correlate with gastroscopy.
      • Prior CT identified peri-gastric lymph nodes are noted again, decreasing in size.
  • 2023-11-21 ECG
    • Marked sinus bradycardia
  • 2023-08-29 Body fluid cytology - ascites
    • Negative
  • 2023-08-22 CT - abdomen
    • Clinical history: 72 y/o male patient with gastric ulcer r/o cancer.
    • Findings
      • Wall thickening at gastric antrum with ulceration, r/o gastric malignancy.
      • Presence of perigastric lymph nodes.
      • R/O liver cyst, 0.6cm in S8 liver.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M0(M_value) STAGE:IVA__(Stage_value)
    • Impression:
      • Gastric antrum tumor with ulceration with perigastric lymph nodes, r/o gastric malignancy, if proven malignancy, cstage T4bN2M.
      • R/O liver cyst.
  • 2023-08-22 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (120 - 30.6) / 120 = 74.5%
      • M-mode (Teichholz) = 74.5
      • 2D (M-Simpson) = 53.9
    • Conclusion:
      • Thickened AV with moderate AR
      • Normal MV with mild MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, normal IVC size
  • 2023-08-10 Patho - stomach biopsy
    • Stomach, antrum, biopsy — Ulcer with high-grade gastric dysplasia, and H.pylori present
      • note: If clinical suspicion of malignant tumor persists, re-biopsy is recommended.
    • Microscopically, it shows ulcer with necrotic debris, hemorrhage, leukocytic infiltrate and high-grade dysplasia of gastric mcuosa with nuclear hyperchromasia and plemorphism. Helicobacter-like bacilli are seen.
    • Immunohistochemical stain of CK is negative for invasive lesion.
  • 2023-08-10 EGD
    • Reflux esophagitis, lower esophagus, LA classification, grade A
    • Gastric ulcerative lesion, rule out advanced gastric cancer type III, antrum, s/p biopsy
    • Rule out gastric outlet obstruction related to the antral lesion
    • Incomplete study, food in stomach and failed to enter duodenum

[MedRec]

  • 2023-09-20 ~ 2023-09-25 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Gastric cancer of antrum with pancreatic neck invasion, cT4bN2M0 stage IVA status post gastrojejunostomy bypass on 2023/08/28 s/p chemotherapy with biweekly FLOT (Docetaxel 50mg/m2, Oxalip 85mg/m2, LV 200mg/m2, 5FU 2600mg/m2) plus Nivolumab (3mg/kg, 200mg, self pay) on 2023/09/22~
      • Chronic viral hepatitis B without delta-agent
      • Essential (primary) hypertension
    • CC
      • For perioperative chemotherapy with FLOT plus Nivolumab (C1D1).
    • Present illness
      • This 72 year old man patient sufferred from poor intake with postprandial fullness and poor appetite with body weight loss 10kg in recent half years. Then he came to LMD for help. UGI scope showed gastric ulcer with moderate dysplasia. Then he referred to our hospital for further management. Repeat PES on 2023/08/10 showed reflux esophagitis, lower esophagus, LA classification, grade A, gastric ulcerative lesion, rule out advanced gastric cancer type III, antrum, s/p biopsy, rule out gastric outlet obstruction related to the antral lesion and incomplete study, food in stomach and failed to enter duodenum. Stomach, antrum, biopsy pathology showed ulcer with high-grade gastric dysplasia, and H.pylori present. Tumor marker on 2023/07/18 of CEA:2.25ng/ml CA199:385.56 U/ml. 2D echo on 2023/08/22 showed M-mode(Teichholz) = 74.5, 1. Thickened AV with moderate AR 2. Normal MV with mild MR 3. Normal LV chamber size and wall thickness 4. Preserved LV and RV systolic function 5. Mild PR, mild TR, normal IVC size. - Abdominal CT on 2023/08/22 showed 1. Gastric antrum tumor with ulceration with perigastric lymph nodes, r/o gastric malignancy, if proven malignancy, cstage T4bN2M, stage IVA. 2. R/O liver cyst. GJ bypass and Port-A catheter insertion on 2023/08/28. Now, he was admitted to ward for perioperative chemotherapy with biweekly FLOT (Docetaxel 50mg/m2, Oxalip 85mg/m2, LV 200mg/m2, 5FU 2600mg/m2) plus Nivolumab (3mg/kg, 200mg, self pay) (C1D1) on 2023/09/22.
    • Course of inpatient treatment
      • After admitted, Dorison 1# po BID and Famotidine 1# po BID D1~D3 from 2023/09/21~2023/09/23.
      • Perioperative chemotherapy with biweekly FLOT (Docetaxel 50mg/m2, Oxalip 85mg/m2, LV 200mg/m2, 5FU 2600mg/m2) plus Nivolumab (3mg/kg, 200mg, self pay, buy 5 and get 1 free) (C1D1) on 2023/09/22~2023/09/23.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
      • Chronic viral hepatitis B without delta-agent(Anti-HBc(+)) with Vemlidy 1# po QD.
      • Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, he was discharged on 2023/09/25 and OPD followed up later.       
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
  • 2023-09-12 SOAP Hemato-Oncology Xia HeXiong
    • P: Admission for Perioperative C/T with FLOT or FOLFOX plus Nivolumab
  • 2023-08-21 POMR General and Gastrointestinal Surgery Wu ChaoQun
    • Discharge diagnosis
      • Gastric cancer of antrum with pancreatic neck invasion, cT4bN2M0 stage IVA status post gastrojejunostomy bypass on 2023/08/28. ECOG:1
      • Essential (primary) hypertension
    • CC
      • Poor intake with postprandial fullness and poor appetite with body weight loss 10kg in recent half years.
    • Present illness
      • This 72 year old male with past history of hypertension without regular follow up. This time, he sufferred from poor intake with postprandial fullness and poor appetite with body weight loss 10kg in recent half years. Then he came to LMD for help. UGI scope showed gastric ulcer with moderate dysplasia. Then he referred to our hospital for further management.
      • Repeat UGI scope also revealed gastric ulcerative lesion, rule out advanced gastric cancer type III, antrum, status post biopsy. Pathology showed ulcer with high-grade gastric dysplasia, and H.pylori present. Tumor marker of CEA:2.25ng/ml CA199:385.56 U/ml. He denied of fever, chills, dizzness, vomiting or tarry stool.
      • Under impressed of gastric ulcer with high grade dysplasia and suspect of malignancy, he was admitted for nutrition support first and further surgical intervention.
    • Course of inpatient treatment
      • After admission, pre-operation survey was done and no abnormality. TPN was also given for pre-operation nutrition support. He received operation on 8/28 then operation finging showed distal pylroic tumor with direct invasion to posterior pancreas neck and multiple LN at peripyloric area were noted.
      • Due to above of the finding and poor nutrtion with this case, GJ bypass was performed first. Post operaively, we observed patient recovery and keep empiric antibiotic, albumin with lasix therapy, and analgesic agent were administered and the wound management was performed. He try to introduced liquid diet with step by step and until to semi-liquid diet was tolerate well. His generally well beings and relativley stable.
      • We consulted Oncology for further chemotherapy with immunotherapy, then the regimen will be arrange at OPD. There were no nosocomial infection and other complications and vital signs were stable after the surgery. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. Abdomen wound clean and removal JP tube was done smoothly on 9/2.
      • Under improved general condition, he was allowed to discharge today and GS and Oncology OPD follow up was arranged.
    • Discharge prescription
      • Olmetec (olmesartan medoxomil 20mg) 1# QD
      • Acetal (acetaminophen 500mg) 1# QID
      • Rich (lansoprazole 30mg) 1# QDAC
      • Mopride (mosapride citrate 5mg) 1# TID

[consultation]

  • 2023-08-31 Hemato-Oncology
    • Q
      • for neoadjuvant chemotherapy with immunotherapy, we will planning for further operation after 3 months later
      • This 72 y/o male with past history hypertension without regular follow up. This time, he diagnosis for gastric ulcerative with high grade dysplasia and suspect of malignancy then was admitted on 8/21. He received operation on 8/28 then operation finging showed distal pylroic tumor with direct invasion to posterior pancreas neck and multiple LN at peripyloric area were noted. Due to above of the finding and poor nutrtion with this case, GJ bypass was performed first. After operation, we need your help for neoadjuvant systemic chemotherapy + immunotherapy for 3 months first, then we will planning for further tumor resection procedure after 3 moths later.
    • A
      • Patient examined and Chart reviewed. A case of locally far advanced gastric cancer is ntoed. I am consulted for the further management with neoadjuvant treament.
      • My suggestiolns:
        • Already discuss with patient and family regarding chemotehrapy (FOLFOX or FLOT) plus immune checkpoint inhibitor
        • Please arrange my OPD if discharge
      • Thanks for your consultation. Any problem, please let me know.
  • 2023-08-22 Gastroenterology
    • Q
      • nutrition support with TPN
      • This 72 y/o male with past history of hypertension without regular follow up. This time, he sufferred from poor intake with postprandial fullness and poor appetite with BW loss 10kg in recent half years. Then he came to LMD for help. UGI scope showed gastric ulcer with moderate dysplasia. Then he referred to our hospital for further management. Repeat UGI scope also revealed gastric ulcerative lesion, rule out advanced gastric cancer type III, antrum, s/p biopsy. Pathology showed ulcer with high-grade gastric dysplasia,and H.pylori present. Under impressed of gastric ulcer with high grade dysplasia and suspect of malignancy, he was admitted on 8/21, then further operation with subtotal gastrectomy will be arrange. Pre-operative nutrition support with TPN is planning. Thanks for your time!!
    • A
      • A case of suspect gastric cancer who request pre-op nutrition support.
        • General appearance: ill looking
        • GI tract: Dysphagia (-), Abd pain (-), Abd distension (-), Nausea (-), Vomiting (-), Diarrhea (-), Poor appetite (-), Poor digestion (+), BW loss (+, 10kg/6M) , stool (+), Bowel sound (-)
        • Feeding: Full liquid diet as tolerance
        • Allergy: NKA
      • Nutrition assessment:
        • BH 164cm BW 51.5kg
        • IBW 59kg 87%IBW BMI 19.2
        • BEE (calculated based on IBW) 1211kcal TEE 1890kcal
      • Lab data: Alb 4.0 TP 6.8 Na 138 K 3.5 BS 100
      • According to the patient`s present conditions, parenteral nutrition plus enteral feeding (as tolerance) will be suitable for nutrition supply. We will follow this case for adjustment of optimal nutrition support.
      • PN use recommendation:
        • DC SMOFkabiven peri 1440ml QD
        • SMOFkabiven central 1477ml QD, 61.5ml/hr
        • Lyo-Povigent 4ml/QD (add in TPN) (if not availabe, then swift to B-complex 1ml/QD and Vitacicol 2ml/QD in TPN)
        • Addaven 10ml/QD (add in TPN)
      • Items to be monitored when PN use
        • TPN is for single route, do not mix with other drugs except TPN drugs.
        • Check BW QW5 and record I/O Q8H
        • Check one touch Q6H x 2 days, if stable QD check
        • Please control BS <200 mg/dl with RI sliding scale
        • QW1 check CBC/DC
        • QW1 check BUN. Cr. AST. ALT. T/D Bil. TG. ALP. rGT. Na. K. Cl. Ca. P. Mg. Zinc. Alb. Prealbumin or Transferrin
        • When TPN is insufficient, replace with YF5 or D10W.

[surgical operation]

  • 2023-12-29
    • Surgery
      • 3D VATS RUL wedge resection + LND.
    • Finding
      • One GGO lesion was noted over RUL, size about 1.0cm in diameter.
      • Frozen section: adenocarcinoma.
      • One 20 Fr. straight chest tube was inserted via right 4th ICS.
  • 2023-08-28
    • Surgery
      • GJ bypass
      • port A insertion
    • Finding
      • distal pylroic tumor with direct invasion to posterior pancreas neck
      • multiple LN at peripyloric area
      • no ascite
      • no liver mets
      • no peritoneal seeding
      • patient’s daugther decide GJ bypass and Port-A insertion

[immunochemotherapy]

  • 2024-02-05 - nivolumab 3mg/kg 200mg NS 100mL 1hr + docetaxel 50mg/m2 65mg D5W 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr (Y-sited with Lv) + leucovorin 200mg/m2 300mg NS 250mL 2hr (Y-sited with Oxa) + fluorouracil 2600mg/m2 3500mg NS 500mL 24hr (Opdivo + FLOT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2024-01-18 - nivolumab 3mg/kg 200mg NS 100mL 1hr + docetaxel 50mg/m2 65mg D5W 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr (Y-sited with Lv) + leucovorin 200mg/m2 300mg NS 250mL 2hr (Y-sited with Oxa) + fluorouracil 2600mg/m2 3500mg NS 500mL 24hr (Opdivo + FLOT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-12-14 - nivolumab 3mg/kg 200mg NS 100mL 1hr + docetaxel 50mg/m2 65mg D5W 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr (Y-sited with Lv) + leucovorin 200mg/m2 300mg NS 250mL 2hr (Y-sited with Oxa) + fluorouracil 2600mg/m2 3500mg NS 500mL 24hr (Opdivo + FLOT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-11-17 - nivolumab 3mg/kg 200mg NS 100mL 1hr + docetaxel 50mg/m2 60mg D5W 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr (Y-sited with Lv) + leucovorin 200mg/m2 240mg NS 250mL 2hr (Y-sited with Oxa) + fluorouracil 2600mg/m2 3500mg NS 500mL 24hr (Opdivo + FLOT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-03 - nivolumab 3mg/kg 200mg NS 100mL 1hr + docetaxel 50mg/m2 60mg D5W 100mL 1hr + oxaliplatin 85mg/m2 100mg D5W 250mL 2hr (Y-sited with Lv) + leucovorin 200mg/m2 350mg NS 250mL 2hr (Y-sited with Oxa) + fluorouracil 2600mg/m2 3000mg NS 500mL 24hr (Opdivo + FLOT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-17 - nivolumab 3mg/kg 200mg NS 100mL 1hr + docetaxel 50mg/m2 60mg D5W 100mL 1hr + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr (Y-sited with Lv) + leucovorin 200mg/m2 300mg NS 250mL 2hr (Y-sited with Oxa) + fluorouracil 2600mg/m2 4000mg NS 500mL 24hr (Opdivo + FLOT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-21 - nivolumab 3mg/kg 200mg NS 100mL 1hr + docetaxel 50mg/m2 60mg D5W 100mL 1hr + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr (Y-sited with Lv) + leucovorin 200mg/m2 300mg NS 250mL 2hr (Y-sited with Oxa) + fluorouracil 2600mg/m2 4000mg NS 500mL 24hr (Opdivo + FLOT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-02-05

[no more leukopenia now, checking WBC left shifts]

A leukopenia episode was observed with a notably low WBC count of 1.82K/uL on 2024-02-02, following approximately two weeks after the last Opdivo + FLOT treatment on 2024-01-18. The timely administration of Granocyte (lenograstim) has effectively resolved the leukopenia as of the current date.

  • 2024-02-05 Metamyelocyte 1.9 %

  • 2024-02-05 Promyelocyte 1.0 %

  • 2024-02-05 WBC 13.12 x10^3/uL 2024-02-05 Opdivo + FLOT

  • 2024-02-02 WBC 1.82 x10^3/uL ***

  • 2024-01-23 WBC 4.40 x10^3/uL

  • 2024-01-17 WBC 3.72 x10^3/uL 2024-01-18 Opdivo + FLOT

  • 2024-01-10 WBC 6.61 x10^3/uL

  • 2023-12-28 WBC 15.72 x10^3/uL

  • 2023-12-26 WBC 2.01 x10^3/uL **

  • 2023-12-14 WBC 6.16 x10^3/uL 2023-12-14 Opdivo + FLOT

  • 2023-11-28 WBC 2.84 x10^3/uL *

  • 2023-11-21 WBC 4.20 x10^3/uL

  • 2023-11-17 WBC 2.54 x10^3/uL * 2023-11-17 Opdivo + FLOT

  • 2023-11-03 WBC 2.26 x10^3/uL ** 2023-11-03 Opdivo + FLOT

  • 2023-11-01 WBC 2.17 x10^3/uL **

  • 2023-10-11 WBC 3.22 x10^3/uL 2023-10-17 Opdivo + FLOT

  • 2023-10-04 WBC 2.82 x10^3/uL *

  • 2023-09-21 WBC 4.21 x10^3/uL 2023-09-21 Opdivo + FLOT

  • 2023-09-01 WBC 5.35 x10^3/uL

The differential WBC count continues to exhibit a left shift, warranting an investigation to exclude the presence of an infection.

2023-12-15

The lab data from 2023-12-14, as well as TPR readings, appear generally normal. After reviewing the PharmaCloud and HIS5 records, no discrepancies were found in the active medication list.

2023-10-17

No discrepancy in the medication is found after a review of the PharmaCloud and HIS5 records.

700371314

240202

[Lab data]

2023-10-05 BM Cytogenetics Lab Report

  • Chromosome Analysis
    • Tissue Examined: Bone marrow
    • Staining Method: G-Banding
    • Colony number: NA
    • Bands level: 400
    • Chromosome Counts: 45-(5)、46-(15)、47-()、Other-() Total-(20)
    • Karyotype: 46,XY[15]
  • Interpretation:
    • Analysis of this bone marrow sample shows a male having 46,XY[15] karyotype. There was no significant clonal chromosomal abnormality detected. However, from 20 cells analyzed, five cells with abnormal karyotypes [45,X,-Y; 45,XY,-7; 45,XY,-8; 45,XY,-13 and 45,XY,-18, respectively] were observed. No clinical significance can be ascribed to these non-clonal findings at the present time.
  • Note
    • ROUTINE BANDED LEVEL DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF RESOLUTIONS.

2023-08-30 Anti-HBc Nonreactive
2023-08-30 Anti-HBc-Value 0.36 S/CO
2023-08-30 Anti-HBs 14.93 mIU/mL
2023-08-30 HBsAg Nonreactive
2023-08-30 HBsAg (Value) 0.39 S/CO
2023-08-30 Anti-HCV Nonreactive
2023-08-30 Anti-HCV Value 0.10 S/CO

[exam findings]

  • 2023-12-26 CT - chest
    • Clinical diffuse large B-cell lymphoma.
    • Small right lower lung nodule, stastionary.
    • Post-op at lumbar spine.
  • 2023-12-26 CT - neck
    • Negative result.
  • 2023-12-25 SONO - neck (lymph node)
    • Prominent musular density in left neck. Suggest clinical correlation.
  • 2023-11-13 Nasopharyngoscopy
    • crust over max opening, R otalgia, “mass over R acromion”
  • 2023-09-11 Patho - bone marrow biopsy
    • Bone marrow, biopsy — No evidence of large B-cell lymphoma with bone marrow involvement
    • The sections show normocellular marrow (20%). M/E ratio = 4:1. The myeloid cells show good maturation. The megakaryocytes are normal in number and morphology. IHC, scattered small CD3+ T-cells and CD20+ B-cells in interstitium without lymphoid aggregates.There is no evidence of large B-cell lymphoma with bone marrow involvement can be identified in the sections examined.
  • 2023-09-07 MRI - larynx
    • Indication: Right maxillary Diffuse large B-cell lymphoma, Immunohistochemistry shows Bcl-2(+),Bcl-6(+), c-myc(weakly +, 10%) and MUM-1(+)
    • Findings
      • Severe mucosal thickening and air-fluid level in right maxillary sinus, indicating sinusitis.
      • A cyst-like lesion, about 35 mm x 30 mm x 7 mm, with air-fluid level inside and rim enhancement at right posterior cervical space, associating with diffuse faint enhancement in surrounding soft tissue. C/W abscess formation.
      • Multiple lymph nodes at both sides of the neck, with larger ones at right retropharyngeal region (20 mm) and left level II (15 mm).
      • No abnormality at nasopharynx, oropharynx, hypopharynx and larynx.
      • No abnormality at parotid, submandibular and sublingual glands.
    • IMP:
      • Right maxillary sinusitis. Abscess formation at right posterior cervical space. Enlarged lymph nodes at right retropharyngeal region and left level II.
  • 2023-09-07 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (108 - 27) / 108 = 75.00%
      • M-mode (Teichholz) = 75
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Concentric LVH; LV diastolic dysfunction, Gr 1
      • Mild MR and trivial TR
      • Preserved RV systolic function
  • 2023-09-07 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 60 dB HL, LE 40 dB HL
      • R’t normal to severe SNHL
      • L’t normal to moderately severe SNHL
  • 2023-08-30 CT - abdomen
    • History: Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck s/p Neck LND
    • Prior CT identified hemangioma 1.58 cm in S5 of the liver is noted again, decreasing in size to 1.28 cm and blurring of the tumor border. Follow up is indicated.
  • 2023-08-21 Patho - lymph node region resection
    • PATHOLOGIC DIAGNOSIS
      • Right paranasal sinuses, multiple sinusectomy — Chronic rhinosinusitis
      • Tumor, R’t maxillary sinus, excision — Diffuse large B-cell lymphoma
      • Nasopharynx, R’t, biopsy — Chronic inflammation
      • R’t neck level 3 LNs, dissection — Negative for malignancy (0/2)
      • R’t neck level IIa, IIb, Va and tumor, wide excision — Diffuse large B-cell lymphoma
        • Vessel, IJV, ditto — Free of tumor invasion
        • SCM Muscle, ditto — Free of tumor invasion
      • R’t neck level Ib LN, dissection — Fat only
      • R’t retropharyngeal lymph node, ditto — Nerve ganglia and one tiny lymph node
    • MACROSCOPIC DESCRIPTION
      • Operation procedure: neck dissection + multiple sinusectomy + wide excision + biopsy
      • Main location: (A) R’t neck and (B) R’t maxillary sinus
      • Specimen Size: (A) R’t neck level IIa, IIb, Va and tumor: 6.3 x 5.2 x 4.5 cm and SCM muscle 5.3 x 3.7 x 3.3 cm (B) R’t maxillary sinus: 2 x 1.5 x 0.7 cm
      • Tumor Site: (A) R’t neck and (B) R’t maxillary sinus
      • Tumor Size: (A) R’t neck: multiple, up to 4.7 cm and (B) R’t maxillary sinus: one piece, 2 x 1.5 x 0.7 cm
      • Right paranasal sinus: multiple small pieces, up to 1.3 x 0.7 x 0.6 cm
      • Nasopharynx: 2 small pieces, up to 0.4 x 0.3 x 0.2 cm
      • R’t retropharyngeal lymph node: 1.9 x 0.9 cm
      • Representative sections as A: R’t paranasal sinuses, B: R’t maxillary tumor, C: nasopharynx, D: R’t neck level III LNs, E1-E3: IJV, E4-E13: main tumor, E14-E18: SCM muscle, F: R’t neck level Ib LN and G: R’t retropharyngeal lymph node
    • MICROSCOPIC EXAMINATION
      • R’t neck level IIa, IIb, Va and tumor: diffuse large B-cell lymphoma shows diffusely large atypical lymphoid cells with prominent nucleoli. Immunohistochemistry shows CD3(-), CD20(+), Bcl-2(+), CD30(-), CD10(-), Bcl-6(+), c-myc(weakly +, 10%), Ki-67(80-90%), CK(-) and MUM-1(+) for tumor, indicates a case of diffuse large B-cell lymphoma, non-germinal center B cell subtype. Besides, IJV and SCM muscle are free of tumor invasion as well as 18 reactive lymph nodes
      • Right paranasal sinuses: chronic rhinosinusitis and bone
      • Tumor at R’t maxillary sinus: diffuse large B-cell lymphoma
      • R’t nasopharynx: chronic inflammation
      • R’t neck level 3 LNs: negative for malignancy (0/2)
      • R’t neck level Ib LN: fat only
      • R’t retropharyngeal lymph node: nerve ganglia and one tiny benign lymph node at peripheral fat tissue
  • 2023-08-08 PET
    • A prominent glucose hypermetabolic lesion in the right maxillary sinus. Primary malignancy in this region should be watched out. Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in a right retropharyngeal lymph node and in some right neck level II lymph nodes. Metastatic lymph nodes may show this picture.
    • Glucose hypermetabolism in the left pulmonary hilar lymph nodes. Inflammatory process is more likely. Howver, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Mild hypermetabolism in some mediastinal and right pulmonary hilar lymph nodes. Inflammation may show this picture.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiologcal FDG accumulation may show this picture.
  • 2023-07-31 CT - neck
    • Multiple enlarged right posterior neck LAPs, up to 4.7 cm.
    • No obvious nasopharynx, hypopharynx or larynx mass.
    • Relative prominent right tonsil?
    • Suggest clinical correlation.
  • 2022-05-02 CT - abdomen
    • History: 20220414 Sono abd: Moderate fatty liver with fat sparing area; Hepatic lesion, r/o hemangioma, S5/6; Renal stone, right
    • Findings
      • Abdominal CT with and without enhancement revealed:
      • Hypervascular hepatic tumor at S5 of liver about 1.58cm in largest dimension is found.
      • Two subpleural nodules are found at right lower lobe about 0.3cm and right middle lobe about 0.28cm in largest dimension is found.
    • Imp:
      • Hepatic hemangiomas.
      • Subpleural nodules at right lung. Suggest follow up.
  • 2022-04-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 29) / 89 = 67.42%
      • M-mode (Teichholz) = 67.1
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Grade 1 LV diastolic dysfunction
      • Trivial TR
  • 2021-12-03 Neck soft tissue
    • Osteoporosis. Loss of nature lordotic curve. Spondylosis, esp C4-5-6.

[MedRec]

  • 2023-09-06 ~ 2023-09-28 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Right maxillary Diffuse large B-cell lymphoma, Immunohistochemistry shows Bcl-2(+), Bcl-6(+), c-myc(weakly +, 10%) and MUM-1(+) s/p chemotherapy with R-DA-EPOCH (Rituximab 375mg, D1, Etoposide 50mg/m2 + Doxorubicin 10mg/m2 + Vincristine 0.4mg/m2 D2~D5, Prednisone 60mg/m2 po D1~D5, Cyclophosphamide 750mg/m2 D6) from 2023/09/18~
      • Essential (primary) hypertension
      • Insomnia, unspecified
      • Herpes Zoster at the L3~L4
      • Constipation, unspecified
    • CC
      • For diffuse large B-cell lymphoma study and chemotherapy with R-DA-EPOCH (C1).
    • Present illness
      • This 64-year-old man patient suffered from hoarseness in 2022/09. He had been to our ENT OPD for check up, where vocal atrophy was told. Right neck palpable mass noted in 2023/07, he came to our ENT OPD foe help. At our Ent OPD, fiberscope revealed bulggin of right lateral pharyngeal wall, right tonsillar asymmetric hypertrophy with granular surface, biopsy was done; right neck level II a 4cm mass without tenderness.
      • The pathology revealed suspicious malignancy, we arrange a series of image survey. No chills with fever, night sweat and body weight loss was noted. Neck CT on 2023/07/31 which revealed multiple enlarged right posterior neck LAPs, up to 4.7 cm. Whole body PET scan on 2023/08/08 revealed right maxillary sinus of primary malignancy with right retropharyngeal lymph node and in some right neck level II lymph nodes metastatic.
      • Modified Radical neck dissection, right, type II, excision of maxillary sinus tumor, right, multiple sinusectomy, right, navigation-guided endoscopic sinus surgery, nasopharyngeal biopsy, right and sinoscopy on 2023/08/18 and right maxillary sinus excision patholoy showed Diffuse large B-cell lymphoma, Immunohistochemistry shows CD3(-), CD20(+), Bcl-2(+), CD30(-), CD10(-), Bcl-6(+), c-myc(weakly +, 10%), Ki-67(80-90%), CK(-) and MUM-1(+) for tumor, indicates a case of diffuse large B-cell lymphoma, non-germinal center B cell subtype. Besides, IJV and SCM muscle are free of tumor invasion as well as 18 reactive lymph nodes.
      • Abdominal CT on 2023/08/30 showed prior CT identified hemangioma 1.58 cm in S5 of the liver is noted again, decreasing in size to 1.28 cm and blurring of the tumor border. Body weight loss 3kg(80 -> 77kg) for 1 month from 2023/08~2023/09.
      • Now, he was admitted to ward for diffuse large B-cell lymphoma study and prepare chemotherapy with R-DA-EPOCH (C1).
    • Course of inpatient treatment
      • After admitted, Port-A catheter insertion on 2023/09/06. Larynx MRI on 2023/09/07 showed right maxillary sinusitis. Abscess formation at right posterior cervical space, enlarged lymph nodes at right retropharyngeal region and left level II.
      • PTA on 2023/09/07 showed R’t normal to severe SNHL and L’t normal to moderately severe SNHL.
      • 2D echo on 2023/09/07 showed M-mode(Teichholz) = 75, 1. Adequate LV systolic function with normal resting wall motion 2. Concentric LVH; LV diastolic dysfunction, Gr 1 3. Mild MR and trivial TR 4. Preserved RV systolic function.
      • Check 24hrs CCr. on 2023/09/07 showed 103.5 mL/min.
      • Ultracet 0.5# po Q6H for pain control.
      • Allegra 1# po BID and Mycomb cream BID use for neck skin redness rash.
      • Bone marrow study on 2023/09/11 showed no evidence of large B-cell lymphoma with bone marrow involvement.
      • Chemotherapy with R-DA-EPOCH (Rituximab 375mg, D1, Etoposide 50mg/m2 + Doxorubicin 10mg/m2 + Vincristine 0.4mg/m2 D2~D5, Prednisone 60mg/m2 po D1~D5, Cyclophosphamide 750mg/m2 D6)(C1) from 2023/09/18~2023/09/23.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
      • Lenograstim 250mcg SC QD from D7 2023/09/24~2023/09/28, 2023/09/29, 2023/10/01.
      • Insomnia with Eurodin 0.5# po HS.
      • Herpes Zoster at the L3~L4 (rigth lower back skin redness rash 6cm–improving) with Valaciclovir 500mg 2# po TID from 2023/09/07~2023/09/18 and Acyclovir cream(self pay) TID TOPI use from 2023/09/07~2023/09/28.
      • Constipation with Sennoside 2# po HS, MgO 2# po Q6H and Bisadyl supp 1pill RECT PRNQD.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/09/28 and OPD followed up later.
    • Discharge prescription
      • Eurodin (estazolam 2mg) 0.5# HS
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# PRNQ6H
      • Bisadyl supp (bisacodyl 10mg) 1# PRNQD
      • Ulstop (famotidine 20mg) 1# BID
      • Through (sennoside 12mg) 2# HS
      • MgO 250mg 2# Q6H
      • Acetal (acetaminophen 500mg) 1# Q6H
      • Granocyte (lenograstim 250ug) SC on 2023-09-29 and 2023-10-01
  • 2023-08-29 SOAP Hemato-Oncology Xia HeXiong
    • P
      • Regimen, R-DA-EPOCH
      • Admission for Chest/Abd/Pelvis CT and H&N MRI, BM study (A+B+C), Heart Echo, 24 hours CCr and Audiometry
      • Port-A insertion by CS Chief Hsieh
  • 2023-08-18 ~ 2023-08-23 POMR Ear Nose Throat Su WanYu
    • Discharge diagnosis
      • Right neck mass status post right neck dissection on 2023-08-18.
      • Right maxillary sinus benign tumor status post navigation guide endoscopic sinus surgery on 2023-08-18.(8/24 patho: Diffuse large B-cell lymphoma)
      • Enlarged prostate without lower urinary tract symptoms
      • Localized enlarged lymph nodes
    • CC
      • Hoarseness over 6 months, right neck palpable mass noted for 3 weeks.
    • Present illness
      • This 64-year-old man denied of having chronic disease before. The patient suffered from hoarseness for over 6 months. He had been to our ENT OPD for check up, where vocal atrophy was told. Due to right neck palpable mass noted for 3 weeks, he came to our ENT OPD foe help. At our Ent OPD, fiberscope revealed bulggin of right lateral pharyngeal wall, right tonsillar asymmetric hypertrophy with granular surface, biopsy was done; right neck level II a 4cm mass without tenderness.
      • The pathology revealed suspicious malignancy, we arrange a series of image survey. The neck CT on 2023-07-31 which revealed multiple enlarged right posterior neck LAPs, up to 4.7 cm.
      • The whole body PET scan revealed: 1. A prominent glucose hypermetabolic lesion in the right maxillary sinus. Primary malignancy in this region should be watched out. 2. Glucose hypermetabolism in a right retropharyngeal lymph node and in some right neck level II lymph nodes. Metastatic lymph nodes may show this picture.
      • Under the impression of right nasal lesion, right neck mass and right oropharyngeal lesion suspect malignancy, surgery of right neck dissection, nasopharyngeal lesion biopsy and right tonsillectomy for tissue prof were suggested. After well explanation about the surgical details, he was admitted for the operation.
    • Course of inpatient treatment
      • After admission, pre-op evaluation was done. The patient underwent the operation of right neck dissection, right maxillary sinus tumor excision, right multiple sinusectomy and right nasopharyngeal biopsy. The whole procedure prformed smoothly, and the patient tolerated the whole procedure well. Post the operation, a hemo-vac drain tube was placed. Neck wound covered with steri-stip.
      • Prophylatic antibiotic with cephalexin 1# po q6h, pain control with Acetal 1# po q6h, anti-cough with Medicon-A 1# po tid. Under daily wound care and medication treatment, the hemo-vac drainage amount decrease day by day. The hemo-vac drainage tube was removed on post op day-5.
      • There was no wound infection or wound active bleeding noted.The surgical pathology was pending. Under relative stable condition, he was discharge today with OPD follow up.
    • Discharge prescription
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# QID
      • cephalexin 500mg 1# QID
      • Allegra (fexofenadine 60mg) 1# BID
      • Acetal (acetaminophen 500mg) 1# QID
  • 2022-04-28 SOAP Gastroenterology Li ZhongXian
    • Prescription x3
      • Dexilant (dexlansoprazole 60mg) 1# QD
  • 2022-04-26 SOAP Cardiology Liu GuanLiang
    • Prescription x3
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 0.5# QD

[consultation]

  • 2023-12-28 Orthopedics
    • Q
      • For mass behind right shoulder, nature??
      • This 64-year-old man patient suffered from hoarseness in 2022/09. He had been to our ENT OPD for check up, where vocal atrophy was told. Right neck palpable mass noted in 2023/07, he came to our ENT OPD foe help. At our Ent OPD, fiberscope revealed bulggin of right lateral pharyngeal wall, right tonsillar asymmetric hypertrophy with granular surface, biopsy was done; right neck level II a 4cm mass without tenderness.
      • The pathology revealed suspicious malignancy, we arrange a series of image survey. No chills with fever, night sweat and body weight loss was noted.
      • Neck CT on 2023/07/31 which revealed multiple enlarged right posterior neck LAPs, up to 4.7 cm. Whole body PET scan on 2023/08/08 revealed right maxillary sinus of primary malignancy with right retropharyngeal lymph node and in some right neck level II lymph nodes metastatic.
      • Modified Radical neck dissection, right, type II, excision of maxillary sinus tumor, right, multiple sinusectomy, right, navigation-guided endoscopic sinus surgery, nasopharyngeal biopsy, right and sinoscopy on 2023/08/18 and right maxillary sinus excision patholoy showed Diffuse large B-cell lymphoma, Immunohistochemistry shows CD3(-), CD20(+), Bcl-2(+), CD30(-), CD10(-), Bcl-6(+), c-myc(weakly +, 10%), Ki-67(80-90%), CK(-) and MUM-1(+) for tumor, indicates a case of diffuse large B-cell lymphoma, non-germinal center B cell subtype. Besides, IJV and SCM muscle are free of tumor invasion as well as 18 reactive lymph nodes.
      • Abdominal CT on 2023/08/30 showed prior CT identified hemangioma 1.58 cm in S5 of the liver is noted again, decreasing in size to 1.28 cm and blurring of the tumor border. Body weight loss 3kg (80 -> 77kg) for 1 month from 2023/08~2023/09.
      • Port-A catheter insertion on 2023/09/06. Larynx MRI on 2023/09/07 showed right maxillary sinusitis. Abscess formation at right posterior cervical space, enlarged lymph nodes at right retropharyngeal region and left level II.
      • PTA on 2023/09/07 showed R’t normal to severe SNHL and L’t normal to moderately severe SNHL.
      • 2D echo on 2023/09/07 showed M-mode(Teichholz) = 75, 1. Adequate LV systolic function with normal resting wall motion 2. Concentric LVH; LV diastolic dysfunction, Gr 1 3. Mild MR and trivial TR 4. Preserved RV systolic function.
      • Check 24hrs CCr. on 2023/09/07 showed 103.5 mL/min.
      • Hold chemotherapy with Herpes Zoster at the L3~L4 (rigth lower back skin redness rash 6cm - improving) with Valaciclovir 500mg 2# po TID from 2023/09/07~2023/09/18 and Acyclovir cream (self pay) TID TOPI use from 2023/09/07~2023/09/28.
      • Bone marrow study on 2023/09/11 showed no evidence of large B-cell lymphoma with bone marrow involvement.
      • Chemotherapy with R-DA-EPOCH (Rituximab 375mg, D1, Etoposide 50mg/m2 + Doxorubicin 10mg/m2 + Vincristine 0.4mg/m2 D2~D5, Prednisone 60mg/m2 po D1~D5, Cyclophosphamide 750mg/m2 D6) (C1 from 2023/09/18~2023/09/23, C2 on 2023/11/1, C3 on 2023/11/23). Now, he was admitted for chemotherapy with R-DA-EPOCH (C4).
      • We sincerely need your professional assistance!!
    • A
      • Dx: Diffuse large B-cell lymphoma
      • PE:
        • right shoulder bony prominence over the right superior border of scapular, nontender (discovered soon after the surgery)
        • ROM: intact
        • No skin lesions
      • CXR: No bony lesion over the scapular or clavile
      • CT: no visible bony lesion, osteolytic lesion over the CT
      • Plan:
        • Arrange OPD f/u at ORTH OPD
        • Active survillance, may arrange imaging again if persisited symptoms or enlargement
        • Conservative treatment with symptomatic treatment

[surgical operation]

  • 2023-08-18
    • Surgery
      • Modified Radical neck dissection, right, type II
      • Excision of maxillary sinus tumor, right
      • Multiple sinusectomy, right
      • Navigation-guided endoscopic sinus surgery
      • Nasopharyngeal biopsy, right
      • Sinoscopy
    • Finding
      • tumor over Right maxillary sinus
      • NP biopsy, right
      • huge neck mass with adheion to internal jugular vein and SCM muscle (unkown primary neck cancer? Occult metastasis from NPC? primary malignancy was from right maxillary sinus?)
      • Will check EBV and HPV status in the pathological specimen
  • 2021-10-12
    • Surgery
      • Arthroscopic rotator cuff repair, acromioplasty + biceps tenodesis        
    • Finding
      • left rotator cuff tear, 3x2 cm, over supraspinatus tendon
      • type II acromion with subacromial spur
      • significant synovitis and bursitis        
      • biceps tendon subluxation with partial tear

[immunochemotherapy]

  • 2024-02-01 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 40mg/m2 75mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2
  • 2024-01-12 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 40mg/m2 75mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2
  • 2023-12-22 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 40mg/m2 75mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2
  • 2023-11-23 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 40mg/m2 75mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2
  • 2023-11-01 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 50mg/m2 90mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2
  • 2023-09-18 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 50mg/m2 90mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2

Dose-adjusted R-EPOCH – (da)-R-EPOCH: Infusional etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R) for non-Hodgkin lymphoma - 20231006 - https://www.uptodate.com/contents/image?imageKey=ONC%2F88411

  • Cycle length: 21 days.
  • Regimen
    • Rituximab
      • 375 mg/m2 IV
      • Dilute in NS or D5W to a final concentration of 1 to 4 mg/mL. Initial infusion: Start at 50 mg/hour; escalate in 50 mg/hour increments every 30 minutes to a maximum of 400 mg/hour, as tolerated. In the absence of an initial infusion reaction, for subsequent infusions, administer 20% of the total dose over the first 30 minutes and the remaining 80% over 60 minutes, as tolerated. The 90-minute infusion schedule should NOT be used in patients who have clinically significant cardiovascular disease or have a circulating lymphocyte count ≥5000/microL.
      • Day 0 or 1
    • Etoposide
      • 50 mg/m2 per day IV
      • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
      • Days 1 to 4 (96 hours)
    • Doxorubicin
      • 10 mg/m2 per day IV
      • (together with etoposide)
    • Vincristine
      • 0.4 mg/m2 per day IV (dose not capped)
      • (together with etoposide)
    • Cyclophosphamide
      • 750 mg/m2 IV
      • Dilute with 250 mL NS or D5W and administer over 30 minutes.
      • Day 5
    • Prednisone
      • 60 mg/m2 orally twice daily
      • Administer first dose 30 minutes prior to chemotherapy on day 1.
      • Days 1 to 5
    • Granulocyte colony stimulating factor (G-CSF)
      • Start day 6
  • Pretreatment considerations:
    • Hydration
      • Patients receiving cyclophosphamide should maintain adequate oral hydration (2 to 3 L/day) and void frequently to reduce risk of hemorrhagic cystitis.
    • Emesis risk
      • MODERATE.
    • Prophylaxis for infusion reactions
      • Premedicate with acetaminophen and diphenhydramine, with or without an H2 receptor blocker, 30 minutes prior to at least the first and second infusions of rituximab.
    • Vesicant/irritant properties
      • Doxorubicin and vincristine are vesicants; avoid extravasation. Etoposide is an irritant.
    • Infection prophylaxis
      • Primary prophylaxis with hematopoietic growth factors is an essential component of this regimen. Regular or pegylated G-CSF may be used according to center policy. In addition, due to the risk of developing Pneumocystis jiroveci pneumonia and other opportunistic infections, consider the use of antimicrobial prophylaxis.
    • Dose adjustment for baseline liver or renal dysfunction
      • Adjustment of initial cyclophosphamide, doxorubicin, etoposide, and vincristine doses may be needed for preexisting liver dysfunction. In addition, dose adjustment of etoposide and cyclophosphamide may be required for renal dysfunction.
    • Hepatitis screening
      • Patients should be screened for hepatitis B and C prior to starting rituximab, and, if positive, considered for antiviral prophylaxis.
    • Cardiac screening
      • Doxorubicin is associated with cardiomyopathy, the incidence of which is related to cumulative dose. Assess baseline LVEF prior to initiation of therapy. Dose alterations should be considered for LVEF <50%, and doxorubicin therapy is contraindicated in patients with LVEF <30% at initiation, those with recent myocardial infarction, severe myocardial dysfunction, severe arrhythmia, or previous therapy with high cumulative doses of doxorubicin or any other anthracyclines.
    • CNS prophylaxis
      • The need for CNS prophylaxis is determined based upon the aggressiveness of the tumor reflected in the histology, organ involvement, and presence or absence of high risk features.
    • HIV screening
      • Patients should be screened for HIV prior to starting therapy. Consider reducing the initial dose of cyclophosphamide to 187 mg/m2 if CD4 <100/microL at diagnosis.
    • Neurotoxicity
      • Vincristine may cause constipation, and in severe cases, paralytic ileus. A routine prophylactic regimen against constipation is recommended in all patients receiving vincristine.
  • Monitoring parameters:
    • CBC with differential and platelet count twice weekly during treatment.
    • Assess basic metabolic panel (creatinine and electrolytes) and liver function prior to each subsequent treatment cycle.
    • Monitor cumulative doxorubicin dose. Reassess LVEF periodically during dose-adjusted EPOCH-R therapy, as clinically indicated.
    • Carriers of hepatitis B or C should be monitored for clinical and laboratory signs of active infection during and following completion of therapy. Rituximab should be discontinued if reactivation occurs.
  • Suggested dose modifications for toxicity:
    • Myelosuppression
      • Each new cycle should be delayed until ANC is >1000/microL and platelet count is >100,000/microL. Doses of etoposide, doxorubicin, and cyclophosphamide are adjusted based upon the nadir ANC and platelet counts:
        • If nadir ANC ≥500/microL, increase doses by 20% over preceding cycle.
        • If ANC <500/microL on one or two measurements, doses remain the same as preceding cycle.
        • If ANC <500 on ≥3 measurements or platelets <25,000/microL on one measurement, doses reduced by 20% from preceding cycle. Doxorubicin and etoposide doses are not reduced below starting dose.
    • Neuropathy
      • Dose adjustment of vincristine may be necessary if the severity of neuropathy persists or worsens. No specific guidelines are available for dose adjustments.
    • Hepatic dysfunction
      • Dose adjustments of vincristine may be necessary in the setting of liver toxicity.

==========

2024-02-02

Lab results from 2024-01-29 and 2024-02-01, along with vital signs readings in the TPR panel during the current hospital admission, remained predominantly normal. Examination of the HIS5 and PharmaCloud databases disclosed no medication discrepancies.

2024-01-15

[etoposide dose increase back to standard recommended]

If no other issues or reasons for caution are identified, increasing the etoposide dose back to the standard level of 50mg/m2 (from the current 40mg/m2) is recommended.

2023-12-25

[etoposide back to standard? clear coast, time to increase dose]

Recent lab tests (2023-12-22) show no obviously abnormalities.

While the etoposide dose has been reduced since 2023-11-23 (40mg/m2 75mg instead of the standard 50mg/m2 90mg), no adverse reactions of grade 2 or higher have been documented in the latest progress notes (2023-12-06 and current admission). In the event that absence of other concerns or contraindications, it is recommended to increase the etoposide dose back to the standard level.

2023-11-02

The R-DA-EPOCH regimen was initiated on 2023-09-18 (cycle 1) and continued on 2023-11-01 (cycle 2). Lab values for LDH and B2 microglobulin were not particularly elevated at the time of diagnosis with DLBCL and have remained relatively stable, showing no significant changes after administration of one cycle of R-DA-EPOCH.

  • 2023-10-27 B2-Microglobulin 2119 ng/mL

  • 2023-08-31 B2-Microglobulin 1899 ng/mL

  • 2023-10-26 LDH 179 U/L

  • 2023-10-03 LDH 299 U/L

  • 2023-09-06 LDH 200 U/L

During this hospitalization, the patient received the 2nd cycle of treatment. To date, there are no updated PET/CT imaging results following the initiation of therapy. The WBC DC in early Oct after the first cycle had shown single digit percentages of metamyelocytes, myelocytes, promyelocytes and atypical lymphocytes. However, in the most recent data from 2023-10-26, these numbers have dropped to zero.

WBC DC 2023-09-06 2023-09-18 2023-09-24 2023-09-26 2023-09-28 2023-10-03 2023-10-04 2023-10-09
Band 0.0 0.0 0.0 4.1 0.0 4.5 0.0 2.0
Neutrophil 73.5 54.5 57.2 92.9 80.4 53.9 66.7 59.4
Lymphocyte 16.7 34.6 38.3 2.0 15.7 22.5 18.2 24.7
Monocyte 8.1 7.7 1.0 1.0 1.9 6.7 10.1 9.9
Eosinophil 1.4 3.0 3.5 0.0 0.0 1.1 1.0 0.0
Basophil 0.3 0.2 0.0 0.0 1.0 0.0 0.0 0.0
Metamyelocyte 0.0 0.0 0.0 0.0 1.0 2.2 1.0 2.0
Myelocyte 0.0 0.0 0.0 0.0 0.0 4.5 3.0 2.0
Promyelocyte 0.0 0.0 0.0 0.0 0.0 2.3 0.0 0.0
Atypical Lymphocyte 0.0 0.0 0.0 0.0 0.0 2.3 0.0 0.0

No drug discrepancy is detected.

2023-10-06

No medication inconsistencies were identified in the review of both PharmaCloud and HIS5 records. Prophylactic G-CSF was prescribed after the patient’s first R-DA-EPOCH treatment on 2023-09-18, and only a brief period of leukopenia was observed.

700578300

240202

[diagnosis] - 2023-03-21 admission note

  • Descending colon adenocarcinoma obstruction with peritoneal seeding, lung and liver metastases, cT4aN2bM1c, stage IVC, s/p T-loop colostomy excisional biopsy of omental seeding on 2022/11/21 and palliative chemotherapy with FOLFIRI from 2022/12/02 and Target therapy with Avastin from 2022/12/16
  • Unspecified viral hepatitis B without hepatic coma
  • Essential (primary) hypertension

[past history]

  • The patient had hypertension for 10 years ago under regular medical control, and hyperlipidemia
  • History of operation:
  • Myoma, s/p total hysterectomy for 20 years ago in FuYou Hospital
  • T-loop colostomy excisional biopsy of omental seeding on 2022/11/21

[allergy]

  • NKDA             

[family history]

  • Her mother had hypertension and DM, while her father had hemorrhagic stroke
  • There is no family history of cancer, mental diseases or asthma.

[exam findings]

  • 2023-11-11 CT - abdomen
    • History and indication: D-colon adenocarcinoma obstruction with peritoneal seeding, lung and liver meta, cT4aN2bM1c, stage IVC
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Stable condition of D-colon cancer, peritoneal seeding, LNs, lung and liver metastases. Small bowel ileus. Partial consoliation at RLL.
      • Invisible uterus.
      • Liver and renal cysts (up to 9.0cm).
      • Gallbladder stones (up to 1.9cm).
    • IMP:
      • Stable condition of D-colon cancer, peritoneal seeding, LNs, lung and liver metastases. Small bowel ileus. Partial consoliation at RLL.
  • 2023-11-08 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, descending colon, s/p chemotherapy, left hemicolectomy and closure of T-colostomy —- adenocarcinoma, moderately differentiated.
        • others: Transverse colon, left hemicolectomy and closure of T-colostomy — colostomy confirmed and free of tumor.
      • Resection margins: free
      • Lymph node, mesocolic, s/p chemotherapy, dissection —- metastatic adenocarcinoma (1/15), no extranodal extension.
      • Lymph node, IMA / SMA, dissection —– N/A.
      • ypT4a ypN1a (if cM1c) yPathology stage: IVC.
    • Gross Description:
      • Procedure - left hemicolectomy: 10 x 3.0 x 3.0 cm and closure of T-colostomy + lymph node dissection
      • Tumor Site - Descending colon, grossly 3.0 cm from cut end.
      • Tumor Size: 3 x 2 x 2 cm.
      • Macroscopic Tumor Perforation: Not identified
      • Macroscopic Intactness of Mesorectum- Incomplete
      • Sections are taken and labeled as: A1-4: tumor; A5: bilateral margins; A6-16: lymph nodes; B: Transverse colon colostomy.
    • Microscopic Description:
      • Histologic Type - Adenocarcinoma
      • Histologic Grade - G2: Moderately differentiated
      • Tumor Extension - Tumor invades the visceral peritoneum (including tumor continuous with serosal surface through area of inflammation)
      • Margins -
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Involved
      • Lymphovascular Invasion: Not identified
      • Perineural Invasion: Not identified
      • Tumor Budding
        • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2) - Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: none.
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes
        • Number of Lymph Nodes Involved/Examined: s/p chemotherapy, 1/15, no extranodal extension.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition): ypStage: IVC.
        • TNM Descriptors - y (posttreatment)
        • Primary Tumor (pT) - ypT4a: Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
        • Regional Lymph Nodes (pN) - ypN1a: One regional lymph node is positive
        • Distant Metastasis (pM) - if cM1c.
      • Additional Pathologic Findings - None identified
      • Ancillary Studies - IHC MMR- S2022-20638
  • 2023-09-22 CT - abdomen
    • Findings:
      • Prior CT identified wall thickening of the D-colon is noted again, mild decreasing in size that is c/w descending colon cancer S/P C/T with stable disease.
      • Prior CT identified a metastasis 1 cm in LLL of the lung is noted again, stable in size.
      • Prior CT identified a metastasis in S6 of the liver 1.2 cm is noted again, decreasing in size to 0.6 cm and no enhancement that is c/w liver metastasis S/P C/T with near complete response.
      • Prior CT identified omentum seeding are not noted again that also c/w carcinomatosis S/P C/T with complete response.
      • S/P right transverse colostomy and para-stromal hernia,
      • S/P hysterectomy
      • Liver cysts and left renal cyst (upt o 9.0 cm).
      • Gallbladder stones (up to 1.9 cm).
    • Impression:
      • Distal descending colon cancer with lung metastasis S/P C/T show stable disease.
      • Liver metastasis S/P C/T show near complete response.
      • Omentum tumor seeing S/P C/T show complete response.
  • 2023-06-23 CT - abdomen
    • Findings:
      • Prior CT identified wall thickening of the D-colon is noted again, mild decreasing in size that is c/w descending colon cancer S/P C/T with partial response.
      • Prior CT identified a metastasis 1 cm in LLL of the lung is noted again, mild decreasing in size to 0.9 cm.
      • Prior CT identified a metastasis in S6 of the liver 2.8 cm is noted again, decreasing in size to 1.2 cm and no enhancement that is c/w liver metastasis S/P C/T with near complete response.
      • Prior CT identified omentum seeding are not noted again that also c/w carcinomatosis S/P C/T with complete response.
      • S/P right transverse colostomy and para-stromal hernia,
      • S/P hysterectomy
      • Liver cysts and left renal cyst (upt o 9.0cm).
      • Gallbladder stones (up to 1.9cm).
    • Impression:
      • Distal descending colon cancer with lung metastasis S/P C/T show partial response.
      • Liver metastasis and omentum tumor seeing S/P C/T show complete response.
  • 2023-03-23 CT - abdomen
    • History and indication:
      • D-colon adenocarcinoma obstruction with peritoneal seeding, lung and liver meta, cT4aN2bM1c, stage IVC
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Much regression of D-colon cancer, peritoneal seeding, LNs, lung and liver metastases.
      • Liver and renal cysts (upt o 9.0cm).
      • Gallbladder stones (up to 1.9cm).
    • IMP:
      • Much regression of D-colon cancer, peritoneal seeding, LNs, lung and liver metastases.
  • 2023-01-30 KUB
    • There are three gallstones.
    • S/P colostomy at right lower abdomen?
    • Spondylosis of the L-spine is noted.
  • 2022-11-22 All-RAS + BRAF
    • Cell Block: S2022-20638 A1
    • RESULTS:
      • There was no variant detect in the KRAS/NRAS gene.
      • There was no variant detect in the BRAF gene.
  • 2022-11-22 Patho - omentum biopsy
    • Omentum, excisional biopsy — metastatic adenocarcinoma, colorectal origin
    • Microscopically, it shows adenocarcinoma composed of invasive neoplastic glands with tumor necrosis and stromal fibrosis. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • Immunohistochemical stain reveals CK7(-), CK20(+), EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • 2022-11-18 ECG
    • Sinus bradycardia
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2022-11-18 Flow Volumn Loop
    • Normal ventilation
  • 2022-11-18 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (83 - 14) / 83 = 83.13%
      • M-mode (Teichholz) = 83
    • Conclusion:
      • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis; trivial MR; mild TR.
      • Multiple liver cysts with variable sizes (the largest one up 8.8 cm).
  • 2022-11-17 CT - abdomen
    • History and indication: Advanced D-colon cancer with obstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of D-colon with adjacent fat stranding and regional LAP.
      • Some soft tissues (up to 2.9cm) in peritoneal cavity.
      • Right thyroid nodule (0.8cm).
      • A nodule (0.9cm) at LUL.
      • Invisible uterus.
      • Liver and renal cysts (upt o 8.8cm). A poor enhancing tumor (2.4cm) in right hepatic lobe.
      • Gallbladder stones (up to 1.9cm).
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2b(N_value) M:M1c(M_value) STAGE:IVC(Stage_value)

[surgical operation]

  • 2022-11-21
    • Surgery
      • T-loop colostomy        
      • Excisional biopsy of omental seeding     
    • Finding
      • Carcinomatosis, omental seeding     
      • T-loop colostomy was created at RUQ area 

[immunochemotherapy]

  • 2024-02-01 - (Avastin + FOLFIRI)
  • 2024-01-16 - (Avastin + FOLFIRI)
  • 2023-10-19 - (Avastin + FOLFIRI)
  • 2023-09-22 - (Avastin + FOLFIRI)
  • 2023-08-31 - (Avastin + FOLFIRI)
  • 2023-08-10 - (Avastin + FOLFIRI)
  • 2023-07-27 - (FOLFIRI)
  • 2023-07-13 - (Avastin + FOLFIRI)
  • 2023-06-30 - (Avastin + FOLFIRI)
  • 2023-06-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI without bolus 5FU)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL Q12H D1-2 + aprepitant 125mg PO D1-3 + lorazepam 1mg Q12H D1-3
  • 2023-05-29 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI without bolus 5FU)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-04 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-13 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-21 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-03 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-16 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-30 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-28 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-16 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-02 - + irinotecan 120mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-02-02

[reconciliation]

No inconsistencies in medication management were found during a detailed review of both the HIS5 and PharmaCloud databases.

2023-06-20

The patient visited a local clinic on 2023-06-13 for her primary hypertension. She was prescribed Norvasc (amlodipine 5mg) to be taken once daily. This medication is now on the patient’s active medication list as a self-carried item with no reconciliation issues identified.

2023-05-05

During this hospital stay, the patient has experienced vomiting 3 to 4 times while on metoclopramide. If the symptom persists, it may be worth considering prescribing prochlorperazine upon discharge.

2023-04-14

On 2023-04-06, the patient’s lab data showed normal readings except for an elevated CEA of 6.38ng/mL. It seems that the patient is tolerating the treatment well.

2023-03-23

On 2023-03-07, the patient was observed to have neutropenia. However, there was no administration of G-CSF and no reduction of the regimen dosage. Despite this, there have been no new episodes of neutropenia observed as of the present time.

  • 2023-03-16 WBC 6.12 x10^3/uL

  • 2023-03-07 WBC 2.92 x10^3/uL

  • 2023-03-02 WBC 6.36 x10^3/uL

  • 2023-02-14 WBC 4.11 x10^3/uL

  • 2023-03-16 Neutrophil 66.7 %

  • 2023-03-07 Neutrophil 39.1 %

  • 2023-03-02 Neutrophil 67.7 %

  • 2023-02-14 Neutrophil 63.0 %

According to today’s (2023-03-23) CT results, there is a significant regression of D-colon cancer, peritoneal seeding, lymph nodes, lung, and liver metastases. These findings suggest that the Avastin + FOLFIRI regimen is still effective.

The patient’s medical history indicates that her mother had DM. However, there is no record of the patient’s HbA1c test result in HIS 5, which is a recommended test to monitor and manage diabetes.

700862958

240202

[lab data]

2023-09-26 HBsAg (NM) Negative
2023-09-26 HBsAg Value (NM) 0.510
2023-09-26 Anti-HBc (NM) Negative
2023-09-26 Anti-HBc Value (NM) 2.500
2023-09-26 Anti-HCV (NM) Negative
2023-09-26 Anti-HCV Value (NM) 0.044
2023-09-26 Anti-HBs (NM) Negative
2023-09-26 Anti-HBs value (NM) <2.000 mIU/mL

[exam findings]

  • 2024-01-04 Sigmoidoscopy
    • Rectal cancer s/p CCRT with significant tumor regression at 10 cm from AV
  • 2023-11-06 Bladder Sonography
    • PVR: 7.38ml
  • 2023-11-06 Uroflowmetry
    • Q max: fair
    • flow pattern: obstructive
  • 2023-11-02 Anoscopy
    • Prolapsed mixed hemorrhoids
  • 2023-09-27 MRI - pelvis
    • Findings:
      • There is circumferential mild asymmetrical wall thickening at the rectosigmoid junction, measuring 5 cm in size, that is c/w adenocarcinoma (T3).
      • There are four enlarged nodes in the peri-rectal space and sigmoid mesocolon (N2a) (Srs:8 Img:7,8,10).
    • IMP:
      • Adenocarcinoma of the rectosigmoid junction is noted.
      • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T3 N2a M0, stage: IIIB
  • 2023-09-22 CT - abdomen
    • Findings:
      • There is circumferential mild asymmetrical wall thickening at the rectum, measuring 5 cm in size, that is c/w adenocarcinoma (T3).
      • There is no enlarged node in the peri-rectal space (N0). Please correlate with MRI.
      • There is no focal lesion in both lungs.
      • There are few small lymph nodes in the paratracheal space that may be benign reactive nodes.
  • 2023-09-14 Patho - colon biopsy
    • Rectal tumor, biopsy — Adenocarcinoma
    • The specimen submitted consisted of multiple small pieces of colonic tissue measuring up to 0.3 x 0.2 x 0.2 cm in size, fixed in formalin. Grossly, they were grey in color and soft in consistence. All embedded for section.
    • Microscopically, the section shows a picture of adenocarcinoma characterized by cribriform or glandular tumor cell infiltrate with desmoplasia.
    • Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor cells.
  • 2023-09-14 Colonoscopy
    • Findings
      • The scope had been inserted up to cecum. A tumor was noted at about 10 cm above anal verge. Biopsy was done
      • Internal hemorrhoid was noted
    • Diagnosis
      • Rectal cancer s/p biopsy
      • Internal hemorrhoid

[MedRec]

  • 2023-12-04 SOAP Urology Cai YaoZhou
    • Prescription x3
      • Uropin (phenazopyridine 100mg) 1# TID
      • Urief (silodosin 8mg) 1# QD
  • 2023-09-28 SOAP Radiation Oncology Huang JingMin
    • S:
      • For pre-op CCRT (TNT) due to rectal adenocarcinoma.
      • PI: The patient suffered from bowel habite change with mucus coating. His diagnosis is adenocarcinoma of the rectum, CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+), stage cT3N0M0 (IIA).
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM (-); HTN (-)
      • Previous RT Hx: (-)
    • O:
      • ECOG: 0
      • PE: left ear hearing loss; neck and bil SCF: neg.
      • Colonoscopy (2023-9-14): A tumor was noted at about 10 cm above anal verge. Biopsy was done. Diagnosis: Rectal cancer s/p biopsy. Internal hemorrhoid.
      • Pathology (S2023-18420, 2023-9-18): Rectal tumor, biopsy — Adenocarcinoma. CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor cells.
      • CXR (2023-9-21): Essential negative findings
      • CT scan of abdomen (2023-9-22): 1. There is circumferential mild asymmetrical wall thickening at the rectum, measuring 5 cm in size, that is c/w adenocarcinoma (T3). 2. There is no enlarged node in the peri-rectal space (N0). Please correlate with MRI. 3. There is no focal lesion in both lungs. There are few small lymph nodes in the paratracheal space that may be benign reactive nodes. Stage T3N0M0 (IIA).
    • A:
      • Adenocarcinoma of the rectum, CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+), stage cT3N0M0 (IIA)
    • P:
      • TNT is indicated for this patient with the following indicators: rectal cancer, stage cT3N0M0
      • Goal: curative
      • Treatment target and volume: pelvic area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fracions of the rectal tumor bed.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient ad his family. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2023-10-9 (in accordance with chemotherapy).
  • 2023-09-28 SOAP Hemato-Oncology Xia HeXiong
    • P
      • Tx Plan: CCRT with infusional 5-FU -> FOLFOX for 12-16 weeks (favor 8 doses) -> OP
      • Arrange Port-A insertion
      • May consider admission for infusional FL
  • 2023-09-28 SOAP Colorectal Surgery Xiao GuangHong
    • A: cT3N0M0, stage IIA
      • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-09-26
        • Suggest Pre-op CCRT (TNT) then follow up CT/MRI
    • P: F/U sigmoidoscopy 3 months later for evaluation of reponse
  • 2023-09-21 SOAP Colorectal Surgery Xiao GuangHong
    • O
      • 2023/09/14 Colonoscopy: A tumor was noted at about 10 cm above anal verge
      • 2023/09/14 PATHO - Colon biopsy: Rectal tumor, biopsy — Adenocarcinoma
  • 2019-03-14 SOAP Neurosurgery
    • S: low back pain off and on for a long time, which has worsened recently
    • O:
      • E4V5M6
      • cranial nerves: intact
      • mp: full
    • P: check L spine => L4-5 Gr.1 listhesis
    • Diagnosis
      • Other spondylosis with myelopathy, site unspecified [M47.10]
      • Spondylolysis, site unspecified [M43.00]

[radiotherapy]

  • 2023-10-17 ~ 2023-11-23 - 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed area.

[chemotherapy]

  • 2004-02-01 - oxaliplatin 60mg/m2 95mg D5W 250mL 2hr + leucovorin 300mg/m2 475mg NS 250mL 2hr + fluorouracil 300mg/m2 475mg NS 250mL 2hr + fluorouracil 2400mg/m2 3810mg NS 500mL 46hr (FOLFOX Q2W. Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2004-01-17 - oxaliplatin 60mg/m2 95mg D5W 250mL 2hr + leucovorin 300mg/m2 475mg NS 250mL 2hr + fluorouracil 300mg/m2 475mg NS 250mL 2hr + fluorouracil 2400mg/m2 3810mg NS 500mL 46hr (FOLFOX Q2W. Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2024-01-03 - oxaliplatin 60mg/m2 95mg D5W 250mL 2hr + leucovorin 300mg/m2 475mg NS 250mL 2hr + fluorouracil 300mg/m2 475mg NS 250mL 2hr + fluorouracil 2400mg/m2 3810mg NS 500mL 46hr (FOLFOX Q2W. Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-12-19 - oxaliplatin 60mg/m2 95mg D5W 250mL 2hr + leucovorin 300mg/m2 475mg NS 250mL 2hr + fluorouracil 300mg/m2 475mg NS 250mL 2hr + fluorouracil 2400mg/m2 3810mg NS 500mL 46hr (FOLFOX Q2W. Yang MuJun)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-20 - [leucovorin 20mg/m2 30mg NS 250mL 10min + fluorouracil 400mg/m2 600mg NS 250mL 10min] D1-4 (CCRT. Xia HeXiong)
    • [dexamethasone 4mg + NS 250mL] D1-4
  • 2023-10-17 - [leucovorin 20mg/m2 30mg NS 250mL 10min + fluorouracil 400mg/m2 600mg NS 250mL 10min] D1-4 (CCRT. Xia HeXiong)
    • [dexamethasone 4mg + NS 250mL] D1-4

==========

2024-02-02

[reconciliation]

Lab findings dated 2024-02-01 and vital sign measurements from the TPR panel during this hospitalization were generally within normal parameters. A detailed review of both the HIS5 and PharmaCloud databases revealed no inconsistencies in medication management.

2024-01-18

[rectal cancer treatment: ongoing efficacy]

Lab results from 2024-01-17 indicated broadly normal values in blood cell counts, electrolytes, and liver and kidney functions, presenting no contraindications for proceeding with the third FOLFOX session during the current hospitalization.

Additionally, a sigmoidoscopy performed on 2024-01-04 revealed significant tumor regression in the rectal cancer post-chemoradiotherapy, suggesting that the overall treatment remains effective to date.

2024-01-03

[reconciliation]

The patient recently received a 28-day supply of Gaslan, glimepiride, aspirin, and dipyridamole from JingMei Hospital on 2023-12-27 to manage his blood glucose and cardiovascular conditions. Apart from Gaslan, all other medications prescribed by JingMei Hospital and our urology department on 2023-12-25 have been included in the active medication list. It is recommended to verify if the patient’s gastrointestinal symptoms have improved, to determine if there is still a need for Gaslan.

Lab results on 2024-01-02 showed no contraindication for the patient to receive another session of chemotherapy in this hospital stay.

2023-12-20

Lab data from 2023-12-19 and TPR readings, appear generally normal. After reviewing the PharmaCloud and HIS5 records, no discrepancies were found in the active medication list.

700531243

240201

[exam findings] (not completed)

  • 2024-01-15

    • LVEF = (LVEDV - LVESV) / LVEDV = (37 - 13) / 37 = 64.86%
      • LVEF (%) = 64
      • M-mode (Teichholz) = 64
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Normal LV diastolic function.
      • Normal RV systolic function.
      • Mild AR; mild MR; moderate TR.
      • Sinus tachycardia during exam.
  • 2024-01-10 MRA - brain

    • Indication: Just receive C/T and discharged on 2024-01-09
      • General weakness, dizziness, vomiting, and left hand weakness started from 2024-01-09
    • Findings
      • mild dilated intraventricular and extraventricular CSF spaces
      • foci with high SI on DWI and low SI on ADC in the bilateral frontal lobes, left temporal lobe and left cerebellar hemisphere
      • some white matter gliosis in the bilateral frontal lobes; old lacunar infarction in the right basal ganglion; mild bilateral periventricular leukoaraiosis.
    • IMP:
      • recent ischemic infarction in the bilateral frontal lobes, left temporal lobe and left cerebellar hemisphere without evidence of acute hemorrhagic transformation.
  • 2024-01-10 CT - brain

    • Findings
      • mild dilated intraventricular and extraventricular CSF spaces
      • mild bilateral periventricular leukoaraiosis.
    • IMP
      • no acute intracranial hemorrhage
  • 2024-01-03 Ascites tapping

    • Course: 18G needle was inserted at RLQ under echo guided insertion.
    • Findings: 1400ml of yellow ascited were aspirated.
  • 2023-12-19 Ascites tapping

    • Course: 18G needle was inserted at RLQ under echo guided insertion.
    • Findings: 600ml of yellow ascites was aspirated.
  • 2023-12-05 Ascites tapping

    • Course: 18G needle was inserted at RLQ under echo guided insertion.
    • Findings: 3000ml of yellow ascites were aspirated
  • 2023-11-27 Body fluid cytology - asictes

    • 20 cc orange turbid ascites — Positive for malignancy
  • 2023-11-27 Ascites tapping

    • Course: 18G needle was inserted at RLQ under echo guided insertion.
    • Findings: 3000 ml light orange color ascites was drained.
  • ……….

  • 2023-11-01 Patho - peritoneum biopsy

    • Peritoneum, biopsy — Consistent with metastatic ovarian serous adenocarcinoma
    • Specimen submitted in formalin consists of a piece of tan, irregular tissue measuring 1.5 x 1.5 x 0.6 cm. All for section in one cassette.
    • Sections show metastatic adenocarcinoma in fibrous tissue.
      • The immunohistochemical stain reveals PAX8(+). The result is consistent with metastatic ovarian serous adenocarcinoma.
  • ……….

  • 2023-09-14 Patho - ovary

    • Diagnosis:
      • Ovary, left, salpingo-oophorectomy —- high grade serous adenocarcinoma.
        • IHC stains: p53 (aberrant type), Napsin-A (-), WT-1 (focal +), ER (+, 5%, strong intensity), PMS2 (+), MSH6 (+), MSH2 (+), MLH1 (+).
      • Fallopian tube, left, salpingo-oophorectomy — free
      • if capsule intact during surgery pT1a pNx (if cM0), FIGO stage: IA, at least
      • if capsule ruptured during surgery pT1c1 pNx (if cM0), FIGO stage: IC1, at least
      • if capsule ruptured before surgery pT1c2 pNx (if cM0), FIGO stage: IC2, at least
    • Gross description:
      • Procedure - Left salpingo-oophorectomy: ovary: 11 x 9 x 2.3 cm opened. Tube: 5 x 0.3 x 0.3 cm intact.
      • Specimen Integrity-
        • Specimen Integrity of Right Ovary- no right ovary submitted.
        • Specimen Integrity of Left Ovary -Capsule opened. See comment.
        • Specimen Integrity of Right Fallopian Tube- no right fallopian tube submitted.
        • Specimen Integrity of Left Fallopian Tube- left tube intact
      • Tumor Site: Left ovary
      • Ovarian Surface Involvement- Absent
      • Fallopian Tube Surface Involvement - Absent
      • Tumor Size - Greatest dimension (centimeters): 11 cm
        • Additional dimensions (centimeters): 9 x 3 cm
      • Sections are taken and labeled as: A1: tube; A2: ovarian wall; A3-6: solid part of left ovarian tumor.
    • Microscopic Description:
      • Histologic Type: Serous carcinoma
      • Histologic Grade - High grade
      • Implants (required for advanced stage serous/seromucinous borderline tumors only) - Not applicable
      • Other Tissue/ Organ Involvement (select all that apply): Not applicable
      • Largest Extrapelvic Peritoneal Focus (required only if applicable) - no tissue submitted
      • Peritoneal/Ascitic Fluid - Not submitted
      • Regional Lymph Nodes: No lymph nodes submitted
      • Additional Pathologic Findings - None identified
      • Comment(s) - Please correlate with operation note.
  • ……….

[MedRec]

  • 2024-01-11 ~ 2024-01-17 POMR Neurology Xu BoRen
    • Discharge diagnosis
      • Multifocal cerebral infarcts involved cerebellum and bilateral cerebral hemisphere, TOAST:4. Specific etiology, suspect cancer type
      • Modified ranking scale 1
      • left ovarian high-grade serous adenocarcinoma with peritoneal carcinomatosis and liver metastases, pTxNxM1, Stage IV, status post Left salpingo-oophorectomy on 2023/09/13 + Diagnostic Exploratory Laparoscopy, peritoneal biopsy and ascites drainage on 2023/11/01, immunohistochemical stain reveals PAX8(+)
      • Postprocedural pelvic peritoneal adhesions
      • Reflux esophagitis LA Classification grade A
      • Urinary tract infection (U/C no grew)
    • CC
      • generalized weakness, vertigo, nausea and vomiting with left limbs clumsiness noted since yesterday.
    • Present illness
      • This 68 y/o woman has a history of
        • left ovarian high-grade serous adenocarcinoma with peritoneal carcinomatosis and liver metastases, pTxNxM1, Stage IV, status post Left salpingo-oophorectomy on 2023/09/13 + Diagnostic Exploratory Laparoscopy, peritoneal biopsy and ascites drainage on 2023/11/01, immunohistochemical stain reveals PAX8(+)
        • Postprocedural pelvic peritoneal adhesions
        • Reflux esophagitis LA Classification grade
        • Hypokalemia
        • Toxicoderma
        • Acute embolism and thrombosis of unspecified deep veins of right lower extremity under Eliquis 5 mg 1 tab BID.
        • massive ascites S/P abdominal tapping on 2023/11/27, 2023/12/5, 2023/12/19,
        • Cachexia.
      • She had received chemotherapy and was discharged on yesterday. However generalized weakness, vertigo, nausea and vomiting with left limbs clumsiness noted since yesterday. Hence she came to our for help 2024/01/10 afternoon.
      • Conscious remain clear, GCS E4V5M6, CNs: intact, MP: upper 5/4 lower 5/5, mild left dysmetria. NIHSS 000 000 1000 10000 (2).
      • Lab showed hyponatremia (Na 131), elevated D dimer 9414, CA-125 392.8 on 2023/12.
      • Brain CT showed no ICH.
      • Brain MRI showed multifocal cerebral infarcts involved cerebellum and bilateral cerebral hemisphere.
      • Thus she was admitted to our ward for further eveluation.
    • Course of inpatient treatment
      • After admisison, adequate hydration and continuted previous NOAC with Eliquis for DVT history.
      • Empirinic antibiotic with Flumarin day 7 for urinary tract infection, culture no grew.
      • PPI with Nexium for GERD, Hemoptysis since before, n’t progressive, high risk for ulcer.
      • Stroke risk factor survey showed No HTN, DM or Hyperlipidemia.
      • TCD/CCCD showed Increased PI in bilateral MCA, indicating distal stenosis.
      • Adequate total VA flow volume (280 ml/min).
      • 2D echo showed LVEF 64%, Mild AR; mild MR; moderate TR.
      • Sinus tachycardia during exam. Pending 24 hours holter.
      • We also maintenance rehab. program and well tolerance.
      • Only mild left hand clumsiness with weakness.
      • Regular schedule the chemotherapy also done during this admission on 2024/01/16.
      • Under the general condition stable, she is discharge on 2024/01/17 and will be followed up at OPD.
    • Discharge prescription
      • Alpraline (alprazolam 0.5mg) 1# HS
      • Eliquis (apixaban 5mg) 1# BID
      • Eurodin (estazolam 2mg) 0.5# PRNHS if insomnia
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Through (sennoside 12mg) 2# HS
      • Uroprin (phenazopyridine 100mg) 1# TID
      • Durogesic (fentanyl 12ug/h, 2.1mg/patch) 1# Q3D EXT
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • diphenidol 25mg 1# TID
      • morphine 15mg 1# PRNQ6H if pain
  • 2023-09-21, -06-15, -03-23, 2022-12-29, -10-06, -07-05, -04-12 SOAP Psychosomatic Medicine Li JiaFu
    • Diagnosis
      • Insomnia, unspecified [G47.00]
      • Anxiety disorder, unspecified [F41.9]
    • Prescription x3
      • Valdoxan (agomelatine 25mg) 1# QN
      • Rivotril (clonazepam 0.5mg) 1# QN
  • 2023-09-13 ~ 2023-09-17 POMR Obstetrics and Gynecology Zen LunNa
    • Discharge diagnosis
      • Left ovarain tumor post Left salpingo-oophorectomy on 2023/09/13
      • Abdominal pain
    • CC
      • Lower abdominal pain since two months ago   - Present illness
      • This is a 68 y/o female paitent with the past histories of:
        • Anxiety disorder, unspecified
        • Insomnia, unspecified
        • Senile cataract s/p Intraocular lens on 2022/03/28 amd 2022/06/13
        • Age-related osteoporosis
        • Bilateral primary osteoarthritis of knee
        • Derangement of posterior horn of lateral meniscus due to old tear or injury, right knee
        • Benign neoplasm of liver
      • She has felt lower abdominal pain since the middle of July. She first seeked for help at TuCheng Hospital and she was informed there was a uterine cyst that caused the pain. Under conservative treatments, she was in relatively stable conditions. Hereafter, on 09/11 she seeked for second help at TuCheng hospital due to the intermittent abdominal pain and the CT was done and revealed as the followings:
        • Uterine mass lesion ~11 cm in diameter with compression forward and causing bladder compression
        • Mild R’t hydroureter, RUQ surgical clip retension
      • This time, she sufferred from acute lower abdominal pain this morning and she was sent to our ER for help. At that time PE performed and showed without nauseau, vomitting, diarrhea, constipation, and fever.
      • Additionally, GYN Dr. Tseng was consulted with the first impression: pelvic mass 126*93mm, r/o teratoma or endometrioma with torsion. Hence, the patient is now under urgent surgical interventions to control her pain.
      • Menstrual histories:
        • G2P2A0 (NSD*2)
        • menopause at age of 48 years old.
    • Course of inpatient treatment
      • The patient was admitted on 2023/09/13 from ER with the symptom acute lower abdominal pain. After the consultation with Dr. Saing, a pelvic mass with 126x93mm was observed under the sonography and left salpingo-oophorectomy was scheduled on the same day under the impression of teratoma or endometrioma with torsion.
      • She underwent left salpingo-oophorectomy on 2023/09/13 and her postoperative course was uneventful. Her appetite was fine and she can void well.
      • The patient complained of intermittent abdominal wound pain and constipation. The analgesic medications and stool softener were given accordingly.
      • The vital sign was stable after surgery. She is discharged on 2023/09/17 and she will have her OPD follow-up next week.
    • Discharge prescription
      • cephalexin 500mg 1# QID
      • Keto (ketorolac 10mg) 1# QID
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • Through (sennoside 12mg) 2# HS
      • Rivotril (clonazepam 0.5mg) 1# QN
      • Valdoxan (agomelatine 25mg) 1# QN

[consultation]

  • 2024-01-12 Rehabilitation

    • A
      • Assessment
        • Recent ischemic infarction in the bilateral frontal lobes, left temporal lobe and left cerebellar hemisphere on 2024/01/10 with left hemiparesis
        • Left ovarian high-grade serous adenocarcinoma with peritoneal carcinomatosis and liver metastases, pTxNxM1, Stage IV, status post Left salpingo-oophorectomy on 2023/09/13 + Diagnostic Exploratory Laparoscopy, peritoneal biopsy and ascites drainage on 2023/11/01, immunohistochemical stain reveals PAX8(+)
      • Plan
        • Rehabilitation programs: arrange bedside PT and OT rehabilitation programs.
        • Goal: Ambulation without device smoothly indoor; BADL ID.
        • Suggest tracking the food and water intake for 2-3 days. If there are issues with inadequate food or water intake or frequent choking, please notify CR 羅元廷(69028). Swallowing therapy would be arranged to increase swallowing ability and NG tube insertion is recommended.
        • The patient was educated about oral hygiene and safe eating, including proper positioning (must be seated upright), consuming small amounts at a time and ensuring no wet voice before taking the next bite.
  • 2024-01-10 Neurology

    • Q
      • General weakness, dizziness, vomiting , and left hand weakness started from 2024-01-09
    • A
      • O
        • Brain CT: no ICH
        • Brain MRI: multifocal cerebral infarcts involved cerebellum and bilateral cerebral hemisphere.
      • impression: multifocal cerebral infarcts, favor embolic stroke or Trousseau syndrome
      • suggestion:
        • give IV NS 40ml/hr, keep current medication including eliquis ( give eliquis 1# stat for evening dose)
        • give symptomatic treatment including promeran and cephadol
        • arrange neurology ward admission (Dr. Xu BoRen)
        • monitor vital signs/GCS/MP at least Q4H
        • tight control SBP < 220 or DBP < 120, tight control BS < 180
  • 2023-11-10 Dermatology

    • Q
      • for skin rash & icthing (2023/11/08 C/T with Abraxance/Carboplatin)
      • This 68-year-old woman, a patient of ovary cancer with peritonal seeding and liver mets S/P C/T on 2023/11/08. intermittent skin rash, icthing over whole body for days. anti-histamin was given but did not improve. We need expertise to evaluate her condition thanks!
    • A
      • This patient suffered from generalized erytematous papules on trunk and 4 limbs for days
      • Imp: Toxicoderma
      • Suggestion:
        • Zaditen (ketotifen) 1 / Bid
        • Xyzal (levocetirizine) 1 / Hs
        • Mycomb (triacinolone, neomycin, nystatin) 2 tubes / bid
  • 2023-11-02 Hemato-Oncology

    • A
      • This 68 year old woman is a case of newly diagnosis Ovarian high-grade serous adenocarcinoma with peritoneal carcinomatosis and liver metastases, pTxNxM1, Stage IV s/p Left salpingo-oophorectomy on 2023/09/13 and Diagnostic Exploratory Laparoscopy, peritoneal biopsy and ascites drainage on 2023/11/01. We are consulted for further treatment (neoadjuvant therapy).
      • Suggestion:
        • Consult GS for port A insertion if patient agree further treatment
        • Check HBsAg, Anti HBc, Anti HBs, Anti HCV before chemotherapy.
        • Consider commercial gene test for HRD, BRCA (self pay) for further study
        • Carboplatin + Paclitaxel +/- avastin is indicated for this patient
        • We had well explaint to patient and her husband this afternoon. Patient also said she and her children will discuss with Dr Gao tomorrow morning.
  • 2023-10-26 Obstetrics and Gynecology

  • 2023-09-13 Obstetrics and Gynecology

[surgical operation]

  • 2023-09-13 - Op Method: Diagnosis: Left ovarian mass
    • Surgery: Left salpingo-oophorectomy
    • Finding:
      • Uterus: Avfl, normal size, grossly normal.
      • RAD: grossly normal.
      • LAD: one 1086 cm cystic lesion in the LOV with mucinous content, mild adhesion to left pelvic wall.
      • CDS: free of adhesion. No ascites.
      • Estimated blood loss: 50cc.
      • Blood transfusion: nil
      • Complication: nil

[chemotherapy]

  • 2024-01-16 - nab-paclitaxel 100mg/m2 137mg 30min
    • dexamethasone 4mg + NS 250mL
  • 2024-01-09 - nab-paclitaxel 100mg/m2 137mg 30min
    • dexamethasone 4mg + NS 250mL
  • 2024-01-02 - bevacizumab 15mg/kg 700mg NS 100mL 1.5hr + nab-paclitaxel 100mg/m2 140mg 30min + carboplatin AUC 5 550mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-20 - nab-paclitaxel 100mg/m2 150mg 30min
    • dexamethasone 4mg + NS 250mL
  • 2023-12-13 - nab-paclitaxel 100mg/m2 150mg 30min
    • dexamethasone 4mg + NS 250mL
  • 2023-12-06 - bevacizumab 15mg/kg 800mg NS 100mL 1.5hr + nab-paclitaxel 100mg/m2 150mg 30min + carboplatin AUC 5 750mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-22 - nab-paclitaxel 100mg/m2 150mg 30min
    • dexamethasone 4mg + NS 250mL
  • 2023-11-15 - nab-paclitaxel 100mg/m2 150mg 30min
    • dexamethasone 4mg + NS 250mL
  • 2023-11-08 - nab-paclitaxel 100mg/m2 150mg 30min
    • dexamethasone 4mg + NS 250mL
  • 2023-11-07 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 800mg NS 250mL (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-02-01

[evaluating Avastin’s risks: cerebral infarcts and bleeding concerns]

Avastin (bevacizumab) has been linked to venous thromboembolism (grades 3/4: 5% to 11%; 2024-01-31 D-dimer 7060 ng/mL FEU) and hemorrhage (grades >=3: <=7%; including major hemorrhage). Given that this patient recently experienced multifocal cerebral infarcts affecting the cerebellum and bilateral cerebral hemispheres in early to mid-January 2024, it is crucial to exclude the possibility that these infarcts may have been induced by the medication prior to next administration.

Additionally, recent lab data indicated rising CA125 and CA199 levels, warranting close observation and subsequent follow-up.

  • 2024-01-30 CA125 (NM) 719.6 U/ml

  • 2024-01-02 CA125 392.8 U/mL

  • 2023-12-13 CA125 159.2 U/mL

  • 2024-01-30 CA199 (NM) 1468.90 U/ml

  • 2023-12-13 CA199 333.96 U/mL

  • 2023-11-27 CA199 161.03 U/mL

700971684

240201

[lab data]

2024-01-31 CMV IgM Nonreactive
2024-01-31 CMV IgM Value 0.10 Index
2024-01-31 Mycoplasma IgM Negative Index
2024-01-31 Mycoplasma IgM Value 0.5 Index
2024-01-31 BM chromosome analyz see attachment

  • CYTOGENETICS LABORATORY REPORT
    • Chromosome Analysis
      • Tissue Examined: Bone marrow
      • Staining Method: G-Banding
      • Colony number: NA
      • Bands level: 350
      • Chromosome Counts: 45-(3), 46-(12), 47-(), Other-(), Total-(15)
      • Karyotype: 46,XY[12]
    • Interpretation:
      • Analysis of this bone marrow sample shows a male having 46,XY[12] karyotype. There was no significant clonal chromosomal abnormality detected. Additionally, out of 15 cells analyzed, three cells with abnormal karyotypes [45,X,-Y; 45,XY,-13 and 45,XY,-15, respectively] were observed. No clinical significance can be ascribed to these non-clonal findings at the present time.
    • Note:
      • ROUTINE BANDED LEVEL DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF RESOLUTIONS.

2024-01-25 FLT3-D835 mutation (BM) Undetectable
2024-01-24 CMV viral load assay Target not detecetedIU/mL
2024-01-23 Aspergillus Ag Negative
2024-01-23 Aspergillus Ag Value 0.1 Ratio
2024-01-23 FLT3/ITD mutation (BM) Presence of mutation
2024-01-23 NPM1 mutation (qualit BM) Undetectable

2024-01-12 Anti-HCV Nonreactive
2024-01-12 Anti-HCV Value 0.12 S/CO
2024-01-12 Anti-HBc Reactive
2024-01-12 Anti-HBc-Value 6.70 S/CO
2024-01-12 Anti-HBs 463.82 mIU/mL
2024-01-12 HBsAg Nonreactive
2024-01-12 HBsAg (Value) 0.46 S/CO

[exam findings]

  • 2024-01-16, -01-15 CXR
    • S/P PICC catheter insertion via left forearm.
    • Enlargement of cardiac silhouette.
    • Linear infiltration over right middle lung and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Patchy consolidation of both lung is noted. Please correlate with clinical condition to rule out Bronchopneumonia.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2024-01-15 Peripherally Inserted Central Catheter
    • Indication of PICC: acute leukemia for further chemotherapy
    • We perform PICC at cath room. Under the peripheral echo guiding, We successful pucnture left basilic vein. Under the fluroscopy revealed the wire in true lumin. Micro-sheath was advanced. PICC catheter tip advanced in high right atrial under the fluroscopy smoothly.
    • SvO2 was also check, it revealed 69 %.
      • Estimated Fick Cardiac index 3.89 L/min/m2 (normal cardiac index range 2.6~4.2 L/min/m2)
      • Estimated Fick cardiac output 6.7 L/min. (nomral cardiac output range 5~6 L/min)
  • 2024-01-15 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Acute myeloid leukemia and see descripton
    • The specimen submitted consists of a strip of gray-brown and hard bony tissue, measuring 2.2 x 0.3 x 0.3 cm. All for section after decalcification.
    • The sections show hypercellular marrow (90%). The marrow space is near totally replaced by a population of medium to large-sized immature cells with round to oval nucleus and moderate amount cytoplasm. The CD71+ erythroid precursors are markedly decrease (3%).
    • IHC, the immature cells shows CD34+ (80%), CD117+ (90%) MPO+ (30%) and CD163+ (30%). The finding is compatible with acute myelomonocytic leukemia. Suggest bone marrow smear evaluation and clinic correlation.
  • 2024-01-15 SONO - abdomen
    • Diagnosis:
      • Parenchymal liver disease, with Splenomegaly, r/o early liver cirrhosis
      • Liver cysts
      • Renal stones, RK
      • Chronic kidney disease
      • Renal cyst, LK
      • Bilateral pleural effusion
  • 2024-01-11 CXR
    • Cardiomegaly
    • Increased infiltration over both lower lungs. May be active infection.
    • R/O right pleural effusion.
    • Degenerative joint disease of T-spine with marginal osteophytes.

[MedRec]

  • 2024-01-11 Medical Emergency Yang YaZhi
    • S
      • Acute leukemia was diagnosed in Cardinal Tien Hospital, bone marrow biopsy result pending.
      • Pancytopenia noted, BT with LPRBC 2U on 1/10, PLT 1PH on 1/11
      • no fever, no cough, no sputum, no SOB, no chest pain, no abd pain, no back pain, no dysuria
      • Past history: HTN
      • Surgical history: nil
      • Allergy: NKA
      • Exposure (TOCC): denied
      • Discharge medication:
        • Amlodipine 1# QD
        • Telmisartan 1# QN
        • Esomeprazole 1# QDAC
        • Tramol 1# BID
    • A
      • Preliminary impression: C95.90 Leukemia, unspecified not having achieved remission

[chemotherapy]

  • 2024-01-16 - daunorubicin 45mg/m2 60mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 140mg NS 500mL 24hr D1-7 (20% off)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL

Chemotherapy induction regimens for acute myeloid leukemia - 2024-01-22 - https://www.uptodate.com/contents/image?imageKey=HEME%2F78251

  • Cytarabine plus daunorubicin
    • Dosing
      • Cytarabine: 100 to 200 mg/m2 daily as a continuous infusion for 7 days;
      • Daunorubicin: 60 to 90 mg/m2 intravenous push on each of the first 3 days of treatment
    • “Standard 7+3” induction regimen resulting in approximately 60 to 80% remission rate and acceptable toxicity in patients under 60 years old
  • Cytarabine (HiDAC) plus daunorubicin
    • Dosing
      • Cytarabine: 1 to 3 g/m2 twice daily for a total of 12 doses;
      • Daunorubicin: 45 mg/m2 intravenous push for 3 days following cytarabine
    • Yields a 90% remission rate; however, substantial toxicity precludes post-remission therapy in a high proportion of patients
  • Cytarabine plus idarubicin
    • Dosing
      • Cytarabine: 100 to 200 mg/m2 daily as a continuous infusion for 7 days;
      • Idarubicin: 12 to 13 mg/m2 IV push on each of first 3 days of treatment
    • Has produced a greater remission rate (88 versus 70%) than cytarabine/daunorubicin in younger patients; appears superior to daunorubicin in patients with hyperleukocytosis; overall survival not clearly superior to “standard” regimen
  • CPX-351: Liposomal daunorubicin plus cytarabine in a fixed 5:1 molar ratio
    • Dosing
      • Daunorubicin (44 mg/m2) and cytarabine (100 mg/m2) intravenously over 90 minutes on days 1, 3, and 5
    • CPX-351 achieved superior rates of remission and survival with comparable toxicity, when compared with 7+3 in older patients with AML

==========

2024-02-01 (not posted)

FLT3-ITD mutations are found in 1/3 of AML cases, while FLT3-TKD mutations are found in approximately 10%. Laboratory results on 2024-01-23 showed FLT3-ITD (+), FLT3-TKD (-) and NPM1 (-). Wild-type NPM1 with FLT3-ITD (no adverse genetic lesion) is stratified as intermediate risk in the European LeukemiaNet stratification scheme. Rydapt (midostaurin) 50 mg BID is initiated on day 8 of the standard 7 + 3 schedule for 2 weeks, it follows the schedule without discrepancies.

2024-01-22

[progress in AML following chemotherapy]

On 2024-01-15, the patient’s peripheral blood blast percentage was nearly 100%, and a bone marrow biopsy revealed AML, indicated by CD34+ (80%), CD117+ (90%), MPO+ (30%), and CD163+ (30%). No FLT3 mutation was found in the recent HIS5 records.

A reduced dose of the standard 7+3 regimen (cytarabine + daunorubicin) commenced on 2024-01-16. One week later, the peripheral blood blast percentage decreased to 72%, indicating an ongoing response.

  • 2024-01-22 Blast 72.9 %
  • 2024-01-21 Blast 83.0 %
  • 2024-01-20 Blast 90.4 %
  • 2024-01-19 Blast 97.0 %
  • 2024-01-18 Blast 91.3 %
  • 2024-01-17 Blast 91.6 %
  • 2024-01-16 Blast 99.0 %
  • 2024-01-15 Blast 98.0 %
  • 2024-01-14 Blast 95.0 %
  • 2024-01-13 Blast 95.0 %
  • 2024-01-11 Blast 94.0 %

A follow-up bone marrow examination is recommended between day 14 to 22 for further response assessment.

701352408

240201

[exam findings] (not completed)

  • 2024-01-11 Sigmoidoscopy
    • Findings
      • Rectal cancer s/p chemotherapy; a long fibrotic segment from dentate line up to 8 cm AAv
      • Np obvious tumor was noted, no tumor obstruction was noted
    • Diagnosis:
      • Rectal cancer s/p chemotherapy
  • 2024-01-02 CT - abdomen
    • History and indication: Mucinous adenocarcinoma of rectal, cT3N2bM1a, stage IVA, s/p concurrent chemoradiotherapy with 5-Fu
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Progression of rectal cancer with regional LAP.
      • Liver cysts (up to 1.3cm).
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Progression of rectal cancer with regional LAP.
  • 2023-10-03 PET scan
    • Glucose hypermetabolism in the lower portion of the rectum, compatible with primary malignancy of the rectum.
    • Mild glucose hypermetabolism in four regional lymph nodes. The nature is to be determined (inflammatory process? metastatic lymph nodes of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation may show this picture.
    • No prominent abnormal FDG uptake was noted in the right inguinal lymph node and elsewhere.
  • 2023-09-22 MRI - pelvis
    • Findings:
      • There is a soft tissue mass in the right lateral posterior wall of the low rectum, measuring 2 cm in size.
        • Adenocarcinoma (T3) of the rectum is highly suspected.
      • There are eight enlarged nodes in the peri-rectal space, left internal iliac chain, and sigmoid mesocolon that are c/w metastatic nodes (N2b).
      • There is one enlarged node 1 cm in right inguinal area that may be non-regional metastatic node (M1a).
        • Please correlate with PET scan. Otherwise, follow up is indicated.
      • There are several hepatic cysts in both lobes and the largest one 1.5 cm in size at S4.
      • A renal cyst 1.3 cm in right lower pole is noted.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2b(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
  • 2023-09-19 Patho - colorectal polyp
    • Labeled as “An circumferential ulcer at low rectum, 5cm from AV”, biopsy (A) — granulation tissue and ulcer debris only. No epithelial component present for evaluation. IHC stain CK (-).
    • Labeled as “Low rectal whitish mucosa around the ulcer, cause ?”, biopsy (B) — benign squamous epithelium with parakeratosis.

[MedRec]

  • 2024-01-18 SOAP Dermatology Zhou WeiTing
    • Prescription
      • doxycycline 100mg 1# BID
      • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI for forehead
      • Zalain External Gel (sertaconazole 2%) Q3D EXT
      • fusidic acid 20mg/gm BID EXT
  • 2024-01-11 SOAP Dermatology Wu RuoWei
    • S
      • Improving but oily scalp and severe dandruff
      • Forehead lesion improving
    • O
      • Hair less patch with erythema, scaling and pus formation over vertex scalp
      • Erythematous plaques with scaling and excoriation over right side forehead
      • Oily scalp with severe scaling -> probably due to poor hygiene
    • A
      • Scalp: seborrheic dermatitis with secondary bacterial infection, tinea capitis should also ruled out
      • Forehead: seborrheic dermatitis
    • Plan:
      • Oral doxycyline
      • Oral orolisin
      • Topical mycomb, zalain, OTM
    • Prescription
      • doxycycline 100mg 1# BID
      • Orolisin (chlorpheniramine maleate 5mg, orotic acid 30mg, glycyrrhizic acid 50mg) 1# TID
      • tetracycline eye ointment BID EXT for scalp wound
      • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI for forehead
  • 2023-12-14 SOAP Dermatology Wu RuoWei
    • S: Lesion over scalp
    • O: Scalp erythema with scaling and wound over scalp
    • A:
      • Wound with secondary infection
      • Seborrheic dermatitis
    • P:
      • oral doxycycline, orolisin
      • topical zalain, OTM
    • Prescription
      • doxycycline 100mg 1# BID
      • Orolisin (chlorpheniramine maleate 5mg, orotic acid 30mg, glycyrrhizic acid 50mg) 1# BID
      • tetracycline eye ointment BID EXT for scalp wound
      • Zalain External Gel (sertaconazole 2%) Q3D EXT wash hair
  • 2023-09-21 SOAP Radiation Oncology Huang JingMin
    • S: For preoperative TNT due to rectla cancer.
    • A: Adenocarcinoma of the rectum, stage cT1-2N1Mx.
    • P: Radiotherapy is indicated for this patient with the following indicators: stage cT2N1
      • Goal: curative
      • Treatment target and volume: pelvic area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed area.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her father. She understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be s1030, 2023-09-25.
  • 2023-09-21 SOAP Hemato-Oncology Xia HeXiong
    • P: Propose TNT
      • CCRT with infusional FU -> FOLFOX for 12-18 weeks (favor 8 cycles) -> Evaluate OP
  • 2023-09-18 SOAP Colorectal Surgery Xiao GuangHong
    • S: First visit patient, rectal cancer diagnosed at Taipei City Hospital
    • P: Arrange sigmoidoscopy for R/O colonic lesion

[consultation]

  • 2024-01-04 Dermatology
    • Q
      • Patient was 55 years old women diagnosis was Rectal adenocarcinoma with mucinous features in 2023-09, cT1-2N1Mx, Schizophrenia irregular medication control.
      • 2023/12/14
        • Wound with secondary infection
        • Seborrheic dermatitis
      • Plan:
        • oral doxycycline, orolisin
        • Topical zalain, OTM
      • for skin lesions, we need your further evaluation and management.
    • A
      • CC: Scalp and forehead lesions
      • Cutaneous findings:
        • Hair less patch with erythema, scaling and pus formation over vertex scalp
        • Erythematous plaques with scaling and excoriation over right side forehead
        • Oily scalp with severe scaling -> probably due to poor hygiene
      • PH:
        • Rectal adenocarcinoma with mucinous features
        • Schizophrenia, poor self-care and poor Hygiene
      • Imp:
        • Scalp: seborrheic dermatitis with secondary bacterial infection, tinea capitis should also ruled out
        • Forehead: seborrheic dermatitis
      • Plan:
        • Oral doxycycline 1#BID
        • Oral orolisin 1#TID
        • Topical Zalain gel TIW for scalp wash
        • Topical Mycomb BID for scalp and forehead lesions
        • Had education of scalp washing
        • Arrange dermatology OPD follow up after discharge
  • 2024-01-03 Colorectal Surgery
    • Q
      • Due to disease progression,we need your further evaluation and management. (OP? or keep TNT treatment?) Thanks a lot!!!
    • A
      • I’ve visited this case. The patient is a case of rectal cancer s/p CCRT with tumor progression. She also complained frequent abdominal cramping pain.
      • PE: abd: soft; mild distension; no tendernss
      • Imp : Rectal cancer s/p CCRT with tumor progression, suspect tumor partial obstruction
      • Please arrange OPD after discharge and surgery will be arranged
  • 2023-12-30 Psychosomatic Medicine
    • Q:
      • Cancer inpatients with suicidal thoughts score >= 2.
    • A:
      • Psychiatric impression:
        • schizophrenia
        • insomnia
      • Current chief problem: suffered form rectal pain related anxiety and poor sleep.
      • MSE: conscious alert and oriented, mostly incoherent and irrelevent speech, mild talktiveness, paralogical thinking pattern, less persecutory ideation, residual AH, tangential thoughts.
      • Suggestion:
        • keep abilify 15mg 1# HS, and Depakine 200mg HS,
        • may add anxiedin 1~2# HS for anxiety and insomnia
        • arrange PSY OPD follow up
  • 2023-10-03 Radiation Oncology
    • Q
      • The patient is an 55 year-old female with a history of Schizophrenia, Adenocarcinoma of the rectum, stage cT1-2N1Mx, diagnosed at MOHW Taipei Hospital.
      • VS Huang: Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed area.
      • PET on 2023/10/03, Port-A will arrange on 2023/10/04.
      • Positioning mark was washed by the patient, we need your further evaluation and management.
    • A
      • The patient is an 55 year-old female with a history of Schizophrenia, Adenocarcinoma of the rectum, stage cT1-2N1Mx, diagnosed at MOHW Taipei Hospital
      • 2023-10-03 PET:
        • Glucose hypermetabolism in the lower portion of the rectum, compatible with primary malignancy of the rectum.
        • Mild glucose hypermetabolism in four regional lymph nodes. The nature is to be determined (inflammatory process? metastatic lymph nodes of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
      • 2023-09-22 MRI:
        • There is a soft tissue mass in the right lateral posterior wall of the low rectum, measuring 2 cm in size. Adenocarcinoma (T3) of the rectum is highly suspected.
        • There are eight enlarged nodes in the peri-rectal space, left internal iliac chain, and sigmoid mesocolon that are c/w metastatic nodes (N2b).
        • There is one enlarged node 1 cm in right inguinal area that may be non-regional metastatic node (M1a).
        • T3 N2b M1a. stage: IVA
      • Under the impression of rectal cancer, cT3 N2b M1a. stage: IVA, neoadjuvant CCRT is indicated. CT-simulation will be arranged today. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx. RT might start around 10/11 or later. Thank you very much.
  • 2023-09-28 Psychosomatic Medicine
    • Q
      • Patient was 55 years old women diagnosis was Rectal adenocarcinoma with mucinous features in 2023-09, cT1-2N1Mx , Schizophrenia with irregular medication control.
      • This time, she was admitted for cancer survey and chemotherapy, We need your consultation for evaluation. Thanks a lot!!!
    • A
      • This 55 y/o single woman was admitted for scheduled chemotherapy. She now lives with his parents, and not employed.
        • According to the patient and her father, her highest education: high school and worked as a office worker, until her 30s, she developed referential and persecutory delusion, auditory hallucination, disorganized speech, isolated behaviors for over 1 months and was brought to MOHW Bali Psychiatric Center and stayed for 1 year.
        • She could help housechore at home but can’t never return to work, regular follow up at RenJi Hospital, and been to RenJi Day Ward in recent 1 year, taking abilify 15mg/d, risperidal 1mg/d, quetiapine 100mg/d, depakine 200mg/d, akinfree. She ever received 1 monthly depot last year for few months.
        • In recent 2 months, she discharged from RenJi Day Ward, not taking medications nor return to OPD for 2 months, stated residure AH and referential ideation: throat is sore and needs to be cleared, always worried that someone is watching her, auditory hallucination, and multiple somatic complaints and preoccupation: spots on the arm, pimples on the head that are bleeding. limited insight: don’t want to go to day classes or take medication anymore, want to do many things, Japanese and English studies were interrupted and not learned, want to learn.
      • MSE: thin, spots on the arm, social smile, mild euphoric mood, talkative, stooped posture and mild restlessness, residure AH, referential ideation, somatic preoccupation, tangential thoughts.
      • IMP: Schizophrenia, chronic
      • Suggestion:
        • Add back antipsychotics: abilify 15mg 1# HS, adjunctive with Depakine 200mg HS, inderal 1# HS.
        • Arrange PSY OPD follow up.

[radiotherapy]

[chemotherapy]

  • 2023-12-29 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-12-11 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-11-13 - leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 400mg/m2 580mg NS 100mL 10min (CCRT)
    • dexamethasone 4mg + NS 250mL
  • 2023-10-16 - leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 400mg/m2 580mg NS 100mL 10min (CCRT)
    • dexamethasone 4mg + NS 250mL
  • 2023-10-11 - leucovorin 20mg/m2 30mg NS 100mL 10min D1-3 + fluorouracil 400mg/m2 580mg NS 100mL 10min D1-3 (CCRT)
    • dexamethasone 4mg D1-3 + NS 250mL D1-3

==========

2024-02-01

[check to see if the tachycardia is transient]

Lab results from 2024-01-31 were largely within normal ranges, and vital signs from the TPR panel remained within normal limits, with the exception of tachycardia, noted as HR 113 this morning. Should the tachycardia prove to be transient, proceeding with chemotherapy administration should not be deemed contraindicated.

2024-01-02

[reconciliation]

This patient’s PhamaCloud record shows receipt of Epine (quetiapine 200mg) on 2023-12-15 from MOHW Bali Psychiatric Center. It has now been replaced with Otzuka (aripiprazole 15mg). Notably, both medications carry boxed warnings regarding increased mortality in elderly patients with dementia-related psychosis and potential suicidal thoughts or behavior. HIS5 records showed the patient’s 2 past consultations for suicidal thoughts scores of 2 or higher in the Psychosomatic Medicine department, close monitoring of potential suicidal ideation and behavior is strongly advised.

Additionally, our Psychosomatic Medicine specialist suggested lorazepam on 2023-12-30, yet it isn’t listed in the active medication list. It is recommended a check of the need for lorazepam.

701493510

240201

[exam findings]

  • 2024-01-11 CT - abdomen
    • History and indication: Colon cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P colostomy. R-S colon cancer with adjacent structures invasion (uterus, left lower ureter, adjacent bowel loop, posterior pelvic wall), LNs, liver, spleen and lung metastases (progression).
      • Left hydronephrosis.
      • Gallbladder stones (up to 5mm).
      • Atherosclerosis of aorta, iliac arteries.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • R-S colon cancer with adjacent structures invasion (uterus, left lower ureter, adjacent bowel loop, posterior pelvic wall), LNs, liver, spleen and lung metastases (progression).
  • 2023-10-21 MRI - brain
    • Indication: colon cancer with lung mets; dizziness, nausea with vomiting and unsteady gait
    • Findings:
      • Two heterogeneously enhancing tumors (35 mm and 20 mm) associating with perifocal edema in left cerebellar hemisphere, causing mass effect on brain parenchyma and CSF spaces. Resultant hydrocephalus also noted.
      • An enhancing nodule (5 mm) in posterior part of right mesial temporal lobe.
    • IMP:
      • C/W Brain metastases.
  • 2023-09-15 All-RAS + BRAF gene mutation analysis
    • Cell block no. S2023-015925
    • RESULTS:
      • ALL-RAS: Detected (KRAS codon 12 GGT>TGT, p.G12C)
      • BRAF: There was no variant detect in the BRAF gene
  • 2023-09-15 CXR (erect)
    • S/P port-A implantation.
    • Lung metastases.
    • Atherosclerotic change of aortic arch
  • 2023-08-22 CT - abdomen
    • PHx: Rectosigmoid junction cancer near total obstruction with lung metastases stage IV
    • Without contrast enhancement CT of abdomen shows:
      • Rectosigmoid colon CA with adjacent structure invasion.
      • s/p T-loop colostomy. Fecal material in proximal colon.
      • Left hydronephrosis.
      • Peritoneal stranding and minimal ascites.
      • Nodular lesions in both lung fields.
      • No bony destructive lesion on these images.
    • Impression
      • Rectosigmoid colon CA with lung metastasis
      • s/p T-loop colostomy.
      • r/o obstruction or stool impaction.
      • Left hydronephrosis.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N1(N_value) M:M1(M_value) STAGE:____(Stage_value)
  • 2023-08-22 KUB
    • s/p Rorximal T-loop colostomy with soft-tissue mass like structure, colonic segment bulging from the colostomy
    • fecal material filled nondilated D-colon and cecum
    • Atherosclerosis of abdominal aorta and bilateral common and external iliac arteries.
  • 2023-08-18 CXR (erect)
    • Presence of ileus.
    • S/P Port-A infusion catheter insertion.
    • Multiple nodules at bil. lungs.
  • 2023-08-11 Patho - colon biopsy
    • Rectum, biopsy — Adenocarcinoma, well differentiated
    • The sections show a picture of adenocarcinoma, well differentiated, composed of columnar neoplastic cells arranged in glandular pattern with desmoplastic stromal reaction.
    • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
  • 2023-08-09 CT scan (patient carried)
    • CC: Difficult defecation for 1-2 years. Poor appetite, nausea with vomiting after meal, and general weakness for weeks.
      • No passage flatus and stool about 10 days.
      • Colonoscopy showed an ulcerative mass at sigmoid about 30 cm from AV, partial obstructed. Biopsy and pathology proved adenocarcinoma.
      • 20230810 sigmoidoscopy: One mass was noted in the rectum (6 cm AAV)
    • Indication: rectal cancer with obstruction
    • Findings:
      • There is segmental wall thickening at the rectosigmoid junction, measuring 7.5 cm in size, with suggestive tumor necrosis and left L3 ureter invasion (moderate left hydroureteronephrosis and delayed contrast excretion of left kidney) that is c/w adenocarcinoma (mucinous type?) of the rectosigmoid junction (T4b).
      • There are seven enlarged nodes in the sigmoid mesocolon that are c/w metastatic nodes (N2b).
      • There are multiple variable sized soft tissue lesions in both lung and the largest one in RUL, measuring 4.1 cm that are c/w multiple lung metastases (M1a).
      • The differential diagnosis includes primary lung cancer at RUL with lung-to-lung metastases. CT-guided biopsy of RUL lesion is indicated.
      • In addition, there are several enlarged nodes in the paratracheal space that may be metastatic nodes.
      • There is ascites and suggestive fatty stranding in the omentum that may be normal variation secondary to ascites and carcinomatosis M1C). Please correlate with ascites cytology.
      • There are few gallstones.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)

[MedRec]

  • 2023-09-15 ~ 2023-09-18 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Rectosigmoid junction cancer near total obstruction with lung metastases stage IV
      • Chronic viral hepatitis B without delta-agentanti-Hbc positive
    • CC
      • for C1D1 palliative chemotherapy with FOLFIRI
    • Present illness
      • This 66-year-old woman, a patient of rectosigmoid junction cancer near total obstruction with lung metastases stage IV status post T-loop colostomy was diagnosed on 2023/08/09, had dysuria with fever and then went to Wan Fang Hospital emergent room for help last month on 2023/07/14. Abdominal CT (2023/7/14) revealed colorectal cancer with multiple lung metastasis. However she suffered from no passage flatus and stool about 10 days since 2023/08/07, poor appetite, nausea with vomiting after meal, and general weakness for 2 weeks.
      • Image study with sigmoidscopy (2023/8/10) showed Rectal cancer with obstruction s/p biopsy and rectum, biopsy (2023/8/11) proved adenocarcinoma, well differentiated, IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+). Repeat abdominal CT (2023/8/22) revealed rectosigmoid colon CA with lung metastasis, s/p T-loop colostomy. r/o obstruction or stool impaction. Left hydronephrosis.
      • The tumor marker showed CA-199 = 912.700, CEA = 256.480 on 2023/8/15. Hepatitis marker revealed HBsAg:negative, Anti-Hbc: positive and anti-HCV:negative. Port-A was inserted on 2023/8/18.
      • Today, she was admitted for C1D1 palliative chemotherapy with FOLFIRI on 2023/9/15.
    • Course of inpatient treatment
      • After admission, chemotherapy with Campto (180mg/m2) plus Leucovorin (400mg/m2)and 5-FU (2800mg/m2) were given on 9/15-9/17 23, smoothly without obvious side effect.
      • All-RAS + BRAF was checked on 9/15 23.
      • Entecavir was added for anti-Hbc positive.
      • She was discharged on 9/18 23 under stable condition and will follow-up at OPD.
    • Discharge diagnosis
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Baraclude (entecavir 0.5mg) 1# QDAC
  • 2023-08-23 ~ 2023-08-30 POMR Colorectal Surgery Chen ZhuangWei
    • Discharge diagnosis
      • Rectosigmoid junction cancer near total obstruction with lung metastases stage IV status post T-loop colostomy on 2023/08/09, complicated with marked prolaspe of distal limb of loop-T colostomy
    • CC
      • No stool from T-loop colostomy for two days
    • Present illness
      • This 66 years old female patient had a history of Rectosigmoid junction cancer near total obstruction with lung metastases stage IV status post T-loop colostomy on 2023/08/09.
      • According to patient and her families statement, had dysuria with fever and then went to Wan Fang Hospital emergent room for help last month (2023/07/14). Abdominal CT revealed colorectal cancer with multiple lung metastasis, and admission for further management was suggested, but patient refused.
      • However she suffered from no passage flatus and stool about 10 days since 2023/08/07, poor appetite, nausea with vomiting after meal, and general weakness for 2 weeks. She was sent to our hospital for further evaluation on 2023/08/07, physical examination showed abdomen distension, hyperactive bowel sound. KUB revealed ileus, and CXR revealed multiple nodules at bilateral lungs. Consult CRS was performed and operation of T-loop colostomy under general anesthesia was performed on 2023/08/09.
      • This time, the patient was suffered from colon became bulging from the colostomy for two days. Constipation with poor apeptite was noted. The patient dnied nause or vomiting. Due to above symptom, the patient came to our ER for help. At ER, PE showed fair respiratory patterm, no abdominal pain; Lab data showed no infection sign. Under the impression of suspect T-loop obstruction, the patient was admitted.
    • Course of inpatient treatment
      • After admission, Lifoxitin as empirical antibiotic was used. Antibiotic change to Brosym due to fever onset and lab data on 08/25 revealed persistent infection sign.
      • Fever relief after medicine used and fair appetite after Megest was used. Fiar T-loop colon bag function was noted during hospitation. After fair respiratory patterm and appetite, stable T-loop bag function, the patient was discharged on 08/30 and OPD follow-up was suggested.
    • Discharge prescription
      • MgO 250mg 1# TID
      • Ceficin (cefixime 100mg) 2# BID
  • 2023-08-07 ~ 2023-08-11 POMR Colorectal Surgery Xiao GuangHong
    • Discharge diagnosis
      • Rectosigmoid junction cancer near total obstruction with lung metastases stage IV status post T-loop colostomy on 2023/08/09
      • Cachexia
    • CC
      • Difficult defecation for 1-2 years.
      • Poor appetite, nausea with vomiting after meal, and general weakness for weeks.
      • No passage flatus and stool about 10 days.
    • Present illness
      • This 66 years old female patient denied any history of systemic disease.
      • According to patient and her families statement, has dysuria with fever and then came to Wan Fang Hospital emergent room for help last month (2023/07/14). Abdominal CT revealed colorectal cancer with multiple lung metastasis, and admission for further management was suggested, but patient refused.
      • However she suffered from no passage flatus and stool about 10 days, poor appetite, nausea with vomiting after meal, and general weakness for 2 weeks. She was sent to our hospital for further evaluation on 2023/08/07, physical examination showed abdomen distension, hyperactive bowel sound. KUB revealed ileus, and CXR revealed multiple nodules at bilateral lungs. Consult our CRS and then she was admitted for further treatment and management.
    • Course of inpatient treatment
      • After admission with ward routine and blood examination were done. Operation of T-loop colostomy under general anesthesia was performed on 2023/08/09. NPO and IV fluids support. The colostomy wound healing well and no erythema change. Chewing cookies, toast, rice with gum was started at post-op day 1. No nausea and no vomiting, flatus passage. On low residual diet was started at post-op day 2. Well bowel movement and stools passage (+) with diet well tolerated. No fever and no complication. Discharged in general condition stable on 2023/08/11 and will follow up in our out-patient department next week.
    • Prescription
      • none

[consultation]

  • 2023-12-05 Radiation Oncology
    • Q
      • for pelvic cavity tumor compression and radiotherapy evaluation
      • This 66-year-old woman, a patient of rectosigmoid junction cancer near total obstruction with lung & brain metastases stage IV status post T-loop colostomy by Dr Xiao GuangHong was diagnosed on 2023/08/09 S/P C/T with FOLFIRI one time on 9/15 23. She complained of severe anal pain for days. Dr. Xiao GuangHong, a colorectal surgeon, diagnosed the pain as being caused by a tumor pressing on the pelvic cavity. We need expertise to evaluate her condition thanks!
    • A
      • O
        • RT (2023-10-27 ~ 2023-11-23): 1250cGy/5 fractions (6MV photon) of the whole brain, and 3000cGy/12 frcations (6MV photon) of the metastatic brain tumors.
      • A:
        • Adenocarcinoma of the RS colon, stage cT4bN2bM1a, stage IVA, s/p chemotherapy, with brain metastases, s/p radiotherapy.
      • P:
        • Radiotherapy is indicated for this patient with the following indicators: Pain of the pelvic to sacral area.
        • Goal: palliation
        • Treatment target and volume: pelvic area
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her husband. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0930, 2023-12-11.
  • 2023-10-24 Radiation Oncology
    • Q
      • The 66 y/o woman has RS colon with lung and brain mets, we need your help for RT assessment. Thanks!
    • A
      • The patient’s history was reviewed and patient was examined.
      • S: For radiotherapy due to adenocarcinoma of the rectum with multiple including brain metastases.
        • PI: The patient suffered from unstable gait and dizziness, MRI of brain showed metastases. Referred for radiotherapy of the brain.
        • Family history: (father: adenocarcinoma of the prostate)
        • Cancer site specific factors: Alcohol (-); Smoking (quit); Betel nut (-).
        • Personal Hx: DM (-); HTN (-)
        • Previous RT Hx: (-)
      • O: ECOG: 2
        • PE: neck and bil SCF: neg; left hand showed abnormal cerebellar test.
        • Operation (2023-08-09): T-loop colostomy.
        • CT scan (2023-08-09):
          • There is segmental wall thickening at the rectosigmoid junction, measuring 7.5 cm in size, with suggestive tumor necrosis and left L3 ureter invasion (moderate left hydroureteronephrosis and delayed contrast excretion of left kidney) that is c/w adenocarcinoma (mucinous type?) of the rectosigmoid junction (T4b).
          • There are seven enlarged nodes in the sigmoid mesocolon that are c/w metastatic nodes (N2b).
          • There are multiple variable sized soft tissue lesions in both lung and the largest one in RUL, measuring 4.1 cm that are c/w multiple lung metastases (M1a).
          • The differential diagnosis includes primary lung cancer at RUL with lung-to-lung metastases. CT-guided biopsy of RUL lesion is indicated.
          • In addition, there are several enlarged nodes in the paratracheal space that may be metastatic nodes.
          • There is ascites and suggestive fatty stranding in the omentum that may be normal variation secondary to ascites and carcinomatosis (M1c). Please correlate with ascites cytology.
          • There are few gallstones. Stage cT4bN2bM1a, stage IVA.
        • Sigmoidscopy (2023-08-10): One mass was noted in the rectum (6 cm from anal verge). Diagnosis: Rectal cancer with obstruction s/p biopsy.
        • Pathology (S2023-15925, 2023-08-15): Rectum, biopsy — Adenocarcinoma, well differentiated
        • MRI of brain (2023-10-21):
          • Two heterogeneously enhancing tumors (35 mm and 20 mm) associating with perifocal edema in left cerebellar hemisphere, causing mass effect on brain parenchyma and CSF spaces. Resultant hydrocephalus also noted.
          • An enhancing nodule (5 mm) in posterior part of right mesial temporal lobe. Imp: C/W Brain metastases.
      • A:
        • Adenocarcinoma of the RS colon, stage cT4bN2bM1a, stage IVA, status during chemotherapy, with brain metastases.
      • P:
        • Radiotherapy is indicated for this patient with the following indicators: brain metastases
        • Goal: palliation
        • Treatment target and volume: brain
        • Technique: VMAT/IGRT and 2D
        • Preliminary planning dose: 1250cGy/5 fractions of the whole brain, and 3000cGy/12 fractions of the metastatic brain tumors.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her family. She understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2023-10-26.

[surgical operation]

  • 2023-08-09
    • Surgery
      • T-loop colostomy        
    • Finding
      • T-loop colostomy was created at RUQ area        
    • Procedure
      • Patient was put on supine position under ETGA
      • Sterized and drapped as routine
      • RUQ skin incision and muscular layer was splitted, fasia and peritoneum was opened
      • Iluem was identified and externalization, looped with a rubber tube
      • Colostomy was opened and matured by suturing with 3-0 monopril
      • Covered with stoma bag   

[radiotherapy]

[chemotherapy]

  • 2024-01-11 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-19 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-01 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-09-15 - irinotecan 180mg/m2 265mg D5W 250mL 90min + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4120mg NS 500mL 46hr (FOLFIRI)
    • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

==========

2024-02-01

[reconciliation]

Lab results showed hypokalemia (2.8 mmol/L), hypomagnesemia (1.5 mg/dL), injectable KCl + NaCl, injectable MgSO4 were applied. Smecta (dioctahedral smectite) and loperamide were prescribed for diarrhea. No drug discrepancy identified

2023-12-15

Elevated levels of CRP and PCT were detected.

  • 2023-12-14 Procalcitonin (PCT) 26.95 ng/mL
  • 2023-12-13 CRP 7.6 mg/dL
  • 2023-12-13 CRP 7.0 mg/dL

Cefepime 2g Q8H started on 2023-12-14. The patient’s body temperature has shown a preliminary downward trend since its peak of 37.8’C on the morning of 2023-12-15.

700941015

240131

[MedRec]

  • 2024-01-30 SOAP Medical Emergency Li XuanQing
    • O
      • Abdomen: soft, RLQ tenderness, hyperactive bowel sounds
    • A
      • Preliminary impression: K35.80 Unspecified acute appendicitis
    • Prescription
      • Laston (ketorolac) 30mg ST IVP
      • Flumarin (flomoxef sodium) 1000mg ST IVD
      • Laston (ketorolac) 30mg ST IVD slow drip > 10 min
      • Despas (hyoscine-N-butylbromide) 20mg ST IVD slow drip > 10min
      • NS 500mL ST IVD
  • 2023-10-27 SOAP Metabolism and Endocrinology Qiu QuanTai
    • S: T2DM since about 35 Y/O
    • Prescription x3
      • Jardiance (empagliflozin 10mg) 1# QD
      • Uformin (metformin 500mg) 2# BIDAC
      • Atozet (ezetimibe 10mg, atorvastatin 20mg) 1# QDAC
      • Blopress (candesartan 8mg) 1# QD
  • 2019-12-26 SOAP Metabolism and Endocrinology Zhang YaLi
    • Diagnosis
      • Type 2 diabetes mellitus without complications [E11.9]
      • Hyperlipidemia, unspecified [E78.5]
    • Prescription x3
      • Jardiance (empagliflozin 25mg) 1# QD
      • Crestor (rosuvastatin 10mg) 1# QD
      • Amepiride (glimepiride 2mg) 0.5# QDAC
      • Uformin (metformin 500mg) 1# BID

[surgical operation]

  • 2024-01-30
    • Surgery
      • laparoscopic appendectomy        
    • Finding
      • diated appendix
      • pus ccumulation in appendix
      • rupture (-)
      • fecalith (-)
      • ascites (-)

==========

2024-01-31

[reconciliation]

No medication discrepancy identified in Stazolin (cefazolin) 1000mg Q8H IVD and metronidazole 500mg Q6H IVD after appendectomy.

701008526

240131

[diagnosis]

  • recurrent rectal cancer with liver metastasis status post transanal minimally invasive surgery (TAMIS) on 2020-07-02, RFA on 2020-12-11, rcTxN0M1a, stage IVA

[exam findings]

  • 2023-12-15 Nasopharyngoscopy
    • foregn body stuck at throat, mild pain, intentional cough to expectorate in vain, no vocal palsy
  • 2023-11-07 CT - abdomen
    • History and indication: Recurrent rectal cancer with liver metastasis
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Rectal cancer s/p operation without interval change.
      • Liver tumor s/p RFA.
      • Bil. renal cysts (up to 3.4cm).
      • No ascites. Some small lymph nodes at mediastinum. Bronchiectasis at RML. A nodule (1.1cm) at RUL.
      • S/P posterior longitudinal transpedicular screws and rods fixation.
    • IMP:
      • Rectal cancer s/p operation without interval change.
      • Liver tumor s/p RFA without viable tumor.
  • 2023-09-26 EGD
    • Reflux esophagitis LA Classification grade A
  • 2023-09-20, -09-11 ECG
    • Sinus rhythm with 1st degree A-V block
  • 2023-08-30 SONO - abdomen
    • Diagnosis:
      • Post cholecystectomy
      • Hepatic tumor C/W single metastasis s/p RFA
      • Liver cyst
      • Hepatic tumor R/O hemangioma
      • Renal cyst, left
  • 2023-07-03 Swallowing video fluoroscopy
    • Mild hocking during swallowing.
  • 2023-06-30 CT - abdomen
    • History: Recurrent rectal cancer with liver metastasis
    • Findings:
      • S/P LAR with autosuture retention over the rectum.
        • There is no evidence of tumor recurrence.
      • There is a non-enhancing lesion 2.1 x 1.5 cm in S5 of the liver that is c/w metastasis s/p RFA with complete response.
        • In addition, Prior CT identified a poor enhancing lesion 8 mm in S8 of the liver is noted again, stationary. Follow up is indicated.
        • Prior CT identified few hepatic cysts on left lobe liver, the largest one 1 cm in S4, are noted again, stationary.
      • Bil. renal cysts (up to 2.9cm).
      • S/P posterior instrumentation fixation from L4 To L5.
    • Impression:
      • S/P LAR with autosuture retention over the rectum.
      • There is no evidence of tumor recurrence.
  • 2023-06-23 Anoscopy
    • Stool color : normal
    • Rectal mucosa : normal
    • Anal canal : abnormal
    • Impression : DRE/anoscopy: no palpable mass, no blood, mild hemorrhoids
  • 2023-06-21 Nasopharyngoscopy
    • Findings
      • vocal cords movement well and symmetric.
      • much whitish sputum in hypopharynx and larynx.
    • Diagnosis/conclusion
      • Swallowing disorder
  • 2023-04-28 Nasopharyngoscopy
    • Findings
      • No tumor noted in nasopharynx, oropharynx, hypopharynx and larynx.
      • Injected arytneoids.
    • Diagnosis/conclusion
      • Reflux laryngitis
  • 2023-04-27 Tc-99m MDP bone scan
    • In comparison with the previous study on 2021/04/20, the lesions in the L-spines are a little more evident. Degenerative change in a little more severe status may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • No prominent change is noted in other bone lesions.
  • 2023-04-07 Anoscopy
    • Stool color : normal
    • Rectal mucosa : normal
    • Anal canal : abnormal
    • Impression : 2022-01-18: DRE: mild blood in finger, no tumor obstruction, mild hemorrhoids
  • 2023-03-31 Bladder sonography
    • Report: PVR: 67 ml
  • 2023-03-31 Uroflowmetry
    • Q max : low
    • flow pattern : obstructive
  • 2023-03-27 CT - abdomen
    • History and indication: Recurrent rectal cancer with liver metastasis
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Rectal cancer s/p operation without interval change.
      • Liver tumor s/p RFA.
      • Bil. renal cysts (up to 2.9cm).
      • S/P posterior longitudinal transpedicular screws and rods fixation.
    • IMP:
      • Rectal cancer s/p operation without interval change.
      • Liver tumor s/p RFA without viable tumor.
  • 2023-02-19 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-02-16 CT - brain
    • Clinical history: 86 y/o male patient with contusion of scalp, initial encounter: Malignant neoplasm of rectum, Essential (primary) hypertension
      • preliminary impression: Contusion of scalp, initial encounter.
    • Without enhancement CT of brain:
      • Low density lesions in bilateral basal ganglia regions, could be due to infarcts.
      • Widening cerebral sulci, fissure and cisterns due to cerebral atrophy.
      • No intracranial hemorrhage.
      • No midline structure deviation.
      • Normal pneumotization of paranasal sinuses and bilateral mastoid air cells.
      • Calcification of bilateral supraclinoid ICAs and VAs.
    • Impression:
      • Suspected infarcts in bilateral basal ganglia region.
      • Brain atrophy.
  • 2022-12-05 CT - abdomen
    • Indication: Recurrent rectal cancer with liver metastasis status post transanal minimally invasive surgery (TAMIS) on 2020/07/02, RFA on 2020/12/11, (kras 12/13mutated), rcTxN0M1a, stage IVA
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness) Abdominal CT with and without enhancement revealed:
      • s/p RFA at right lobe liver. Several hepatic cysts at both lobes of liver is found. Simple cysts are favored.
      • s/p LAR. Minimal infiltration at presacral space is found. In comparison with CT dated on 2022-08-25, the lesion is stationary.
      • Swelling of the cecum is found. In comparison with CT dated on 2022-08-25, the change is stationary. Suggest correlate with tumor marker.
    • Imp:
      • s/p LAR with residual infiltration at presacral space. Statinary.
      • s/p RFA at right lobe liver. No recurrent/residual tumor in the liver is found.
      • Swelling of cecum. Suggest correlate with tumor marker and follow up.
  • 2022-10-18 KUB
    • S/P posterior longitudinal transpedicular screws and rods fixation.
    • Presence of ileus.
    • S/P operation.
    • Compression fracture of L1-3.
  • 2022-09-30 Nasopharyngoscopy
    • no obvious bleeder or erosion wound noticed over bilateral nasal cavity, Npx
  • 2022-09-06 CT - brain
    • Brain atrophy with bilateral periventricular ischemic/aging white matter change. Atherosclerosis.
  • 2022-08-25 CT - abdomen
    • Rectal cancer s/p operation without interval change.
    • Liver tumor s/p RFA without viable tumor.
  • 2022-05-20 Colonoscopy
    • Local recurrent cancer at low rectum
    • Colon polyps, A-colon and S-colon
  • 2022-05-17 CT - abdomen, pelvis
    • Post-op at the colon, with prominent soft tissue around anastomosis, suggest colonoscopy study.
    • S/P RFA for liver tumor.
    • Duodenal diverticulum.
    • Stationary of right upper pole kidney low density lesion, 1.4cm, suggest follow up.
    • Fibrotic infiltrate in bilateral upper lungs.
  • 2022-02-16 Chest PA erect view
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-02-14 Chest PA erect view
    • Ground glass opacity in bilateral lower lungs.
  • 2022-01-04 CT - whole abdomen, pelvis
    • S/P RFA for liver tumor.
    • Duodenal diverticulum.
    • Stationary of right upper pole kidney low density lesion, 1.4cm, suggest follow up.
    • Fibrotic infiltrate in bilateral upper lungs.
  • 2021-10-01 Sigmoidoscopy
    • Diagnosis: local recurrent cancer at low rectum
    • Suggestion: possible R/T or transanal debulking excision
  • 2021-09-23 CT - whole abdomen, pelvis
    • Rectal cancer s/p operation without interval change.
    • Liver tumor s/p RFA without viable tumor.
  • 2021-04-20 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20190725, the lesions in the upper L-spines are a little less evident. Compression fracture or severe degenerative change with some resolution may show this picture.
    • The previous hot spots in some right costovertebral junctions are also a litlte less evident. However, please correlate with other imaging modalities for further evaluation.
    • No prominent change is noted in the lesions in the lower L-spines. Post-operative change may show this picture.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and wrists, compatible with benign joint lesions.
  • 2021-04-06 CT - whole abdomen, pelvis
    • Post-op at the colon with preirectal fatty infiltrates, stationary.
    • S/P RFA for liver tumor.
    • Suspected complicated right renal cyst.
    • Fibrotic infiltrates in bilateral lung apex and RML.
    • Osteoblastic lesions in the ribs, spine and pelvis, suspected bone metastasis.
  • 2021-02-26 Colonoscopy
    • Recurrent rectal tumor found 6cm AAV.
  • 2021-01-07 CT - liver, spleen, biliary duct, pancreas
    • Rectal cancer s/p operation without interval change.
    • Liver tumor s/p RFA without viable tumor.
  • 2020-11-10 PET scan
    • In comparison with the previous study on 20200622, the previous glucose hypermetabolic lesion in the segment 5 of the liver is less evident. However, the previous glucose hypermetabolic lesion on the rectal wall disappeared and no prominent FDG uptake was noted in the previous glucose hypermetabolic lesion in the segment 4 of the liver.
    • Two mild and small glucose hypermetabolic lesions in the right lower lung field. The nature is to be determined (inflammation? early metastases? other nature?).
    • Glucose hypermetabolism in bilateral pulmonary hilar regions and some mediastinal lymph nodes. Inflammation may show this picture.
    • Increased FDG accumulation in the colon. Physiological FDG accumulation is more likely.
  • 2020-10-30 Sigmoidoscopy
    • Previous anastomosis site was no evidence disease (NED).
  • 2020-10-07 CT - abdomen, pelvis
    • Metastasis 1.6 x 1.1 cm in S5 of the liver is suspected and it shows stable in size. Please correlate with MRI.
    • Renal cyst with hemorrhage 2 cm at right upper pole shows stable in size.
  • 2020-07-03 Patho - colorectal polyp
    • Rectum, transanal excision - Adenocarcinoma, recurrent
  • 2020-06-22 PET scan
    • A glucose-hypermetabolic lesion on rectal wall, compatible with the lesion of recurrent rectal cancer as diagnosed histopathologically.
    • Glucose hypermetabolism in the lesion in segment 5 of liver revealed in the previous CT scan, hepatic metastasis may show such a picture.
    • Another glucose-hypermetabolic lesion in segment 4 of liver, nature to be determined (inflammatory lesion, malignancy, or other nature).
    • Mild glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, reactive change resulting from locoregional inflammation may show such a picture.
    • Rectal cancer with recurrence, rcTxN0M1a, stage IVA (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2020-06-17 CT - abdomen, pelvis
    • Metastasis 1.6 x 1.1 cm in S5 of the liver is suspected.
    • Renal cyst with old hemorrhage 2 cm at right upper pole is suspected.
  • 2020-06-15 Patho - colon biopsy
    • Large intestine, rectum, biopsy - Adenocarcinoma, moderately differentiated
  • 2020-06-12 Sigmoidoscopy
    • one 2.5cm tumor mass was noted in the low rectum (previous anastomosis, posterior site)
  • 2020-01-03 Patho - colon segmental resction for tumor
    • Recto-Sigmoid colon, LAR - Adenocarcinoma
    • Bilateral cutting ends, ditto - Free of tumor invasion
    • Lymph node, dissection - Positive for tumor metastasis (2/12) without extracapsular extension (0/2)
    • AJCC pathologic stage - ypT3N1b(if cM0), stage IIIB
    • IHC: CDX-2(+), MLH1(+), PMS2(+), MSH2(+) and MSH6(+)
  • 2019-07-01 CT - liver, spleen, biliary duct
    • Rectal cancer s/p CCRT with regional LAP (T3N2Mx).
    • Segmental wall edema of terminal ileum with adjacent fat stranding and ascites. A poor enhancing lesion (2.4cm) in right kidney.
  • 2019-06-08 CT - abdomen
    • Imaging Report Form for Colorectal Carcinoma: T3N2Mx

[MedRec]

  • 2023-12-30 SOAP Gastroenterology Wang JiaQi
    • Prescription x3
      • Ulstop (famotidine 20mg) 1# BID
      • Gasmin (dimethylpolysiloxane 40mg) 1# BID
      • Mosapin (mosapride citrate 5mg) 1# BID
  • 2023-12-28 SOAP Cardiology Xie JianAn
    • Prescription x3
      • Januvia (sitagliptin 100mg) 0.5# QD
      • Eliquis (apixaban 5mg) 0.5# BID
      • Zandip (lercanidipine 10mg) 1# QD
  • 2023-12-15 SOAP Neurology Xu BoRen
    • A: chemotherapy related polyneuropathy + L spine radiculopathy
    • Prescription x3
      • Muaction (tramadol 100mg) 1# PRNBID
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
      • Trynol (amitriptyline 25mg) 1# HS
      • Neurontin (gabapentin 100mg) 1# BID
      • calcium carbonate 500mg 1# QD
      • U-Ca (calcitriol 0.25mg) 1# QD
  • 2023-12-15 SOAP Urology Luo QiWen
    • Prescription x3
      • Urief (silodosin 8mg) 1# QN
      • Betmiga (mirabegron 50mg) 1# QN
  • 2023-11-15 SOAP Psychosomatic Medicine Chen YiQian
    • A/P
      • Dx:
        • Insomnia
        • R/O MCI
      • Tx:
        • Psychoeducation
        • Family counseling
        • Provide emotional support
    • Prescription x3
      • Alpraline (alprazolam 0.5mg) 1# HS

[consultation]

  • 2022-05-19 Colorectal Surgery
    • Q
      • The 85y/o male recurrent rectal cancer with liver metastasis status post transanal minimally invasive surgery (TAMIS) on 2020/07/02, RFA on 2020/12/11, rcTxN0M1a, stage IVA
      • 2022/05/17 f/u CT Impression: Post-op at the colon, with prominent soft tissue around anastomosis, suggest colonoscopy study, so we need ypor help. Thank you.
    • A
      • The 85y/o male recurrent rectal cancer with liver metastasis status post transanal minimally invasive surgery (TAMIS) on 2020/07/02, RFA on 2020/12/11, rcTxN0M1a, stage IVA, with C/T + target therapy.
      • Impression:
        • Post-op at the colon, with prominent soft tissue around anastomosis, suggest colonoscopy study.
        • S/P RFA for liver tumor.
        • Duodenal diverticulum.
        • Stationary of right upper pole kidney low density lesion, 1.4cm, suggest follow up.
        • Fibrotic infiltrate in bilateral upper lungs.
      • A: Recurrent rectal cancer with liver metastases s/p CCRT and RFA, with disease progression
      • P:
        • Colonoscopy will be performed on this Friday afternoon
        • We would like to follow this patient
  • 2022-01-08 Infectious Disease
    • Q
      • The 85 y/o man has recurrent rectum cancer under chemotherapy. Due to fever with chills, we gave Cefepime for infection control at first. The Sphingomonas paucimobilis bacteremia from port-a was noted, but Port-a was removed in 20220106. We need your help for antibiotic assassment. Thanks!
    • A
      • Infections of Sphingomonas paucimobilis include bacteraemia/septicaemia caused by contaminated solutions, e.g. distilled water, and sterile drug solutions.
      • Infections due to S. paucimobilis have not been associated with mortality.
      • The drug of choice may be a fluoroquinolone because of the susceptibility patterns and ease of administration.
      • Levofloxacin in a dose of 500 mg per day, or Finibax in the dose of 500 mg every 8 hours may be used.
  • 2021-11-08 Urology
    • Q
      • The 82 y/o man has recurrent rectum cancer stage IV with urinary incontinence, so we need your help for management. Thanks!
    • A
      • This 84yo male has underlying diseases of recurrent rectal cancer with liver metastasis status post transanal minimally invasive surgery (TAMIS) on 2020/07/02, RFA on 2020/12/11, (kras 12/13mutated), rcTxN0M1a, stage IVA.
      • CC: urinary incontinence was noted for 3 months
      • PI: urgency+, frequency+, IPSS: 22
      • Suggestion:
        • acquire U/A, PSA fisrt
        • arrange UFM, PVR and TURSP
        • may add solifenacin if PVR < 100 ml
  • 2021-09-28 Colorectal Surgery
    • Q
      • The 84 y/o man has adenocarcinoma of rectum, cT3N2bM0, IIIC, s/p CCRT with partial response, s/p laparoscopic- LAR and protective ileostomy (2020-01-02), pT3N1bM0(2/12), LVI(+), PNI(-), stage IIIB. Due to few bloody after stool passage for 1-2 weeks, no hemorrhoid or fistula noted, so we need your help for management. Thanks!
    • A
      • The patient was consulted for bloody stool passage in recent 1-2 weeks.
      • 2021-09-23 CT:
        • Rectal cancer s/p operation without interval change.
        • Liver tumor s/p RFA without viable tumor.
      • A:
        • Local recurrent rectal adenocarcinoma with S5 liver metastasis, stage IVa s/p transanal local excision (2020-07-02) and s/p palliative R/T + chemotherapy + target therapy and RFA for liver metastasis
        • Adenocarcinoma of rectum, cT3N2bM0, IIIC, s/p CCRT with partial response, s/p laparoscopic- LAR and protective ileostomy(109-01-02), pT3N1bM0(2/12), LVI(+), PNI(-), stage IIIB, s/p close ileostomy (2020-04-20)
      • P
        • Suggest sigmoidoscopy this Friday afternoon
        • We would like to follow this case
  • 2021-08-10 Psychosomatic Medicine, Mental Health
    • Q
      • The 84 y/o man has recurrent rectal cancer stage IVA, is admitted for deep drowsy. In hospital, we hold his sedation as Eurodin, Revotril and Imipramine. Due to delirium at night for days, so we need your help for management.
    • A
      • Psychiatirc impression:
        • acute delirium
      • Psychiatric history:
        • This 84 year-old male patient with history of rectal cancer stage IVA under chemotherapy. He suffered form diarrhea after chemotherapy since last discharge (20210629~20210716). He present weakness, bedridden and persistent diarrhea during late July 2021. This time we was brought to this ER on 20210801 due to general weakness and drowsiness.
        • According to his son, he display consciousness flactuation and disorientation since late July and progressed after this admission. Sleep cycle disturbance. Sundowning syndrome. Self talking and suspect visual hallucination. Upon visit, sleepiness, poor attention lasting, hearing impairment, incoherent and irrelevent speech, disoriented to time and place.
        • 20210809 Given 0.5# Rivotril due to poor sleep, still cannot fall asleep; given 0.5# again, can fall asleep, but becomes drowsy during the day
        • currently hold eurodin, rivotril and imipramine
      • Suggesting:
        • please correct his underlying condition
        • encorage daily activities and prevnet daytime sleep, reorientation to time, person and place
        • DC rivotril and neurontin and avoid BZD use
        • give risperidol 0.5# hs
        • please contact us if any psychiatric problem
  • 2021-08-09 Urology
    • Q
      • The 84 y/o man has Adenocarcinoma of rectum, cT3N2bM0, stage IIIC, post operation with CCRT and chemotherapy. Due to frequency urine noted, we gave Harnalige for control since 20210805, but his son complainted of condition without control. The patient urinates every 2-3 hours during the day and every 1-2 hours at night, so we need your help for management. Thanks!
    • A
      • S/O
        • The 84 y/o man
        • Adenocarcinoma of rectum, cT3N2bM0, stage IIIC, post operation with CCRT and chemotherapy
        • Admitted for weakness
        • Due to frequency urine noted,
        • Harnalige for control since 20210805, but his son complainted of condition without control
        • UA: clear
      • P
        • arrange random PVR, if PVR <300 ml, administer Vesicare 1 tab QD
  • 2020-11-13 Gastroenterology
    • A
      • 83M
      • PH:
        • Adenocarcinoma of rectum, cT3N2bM0, stage IIIC status post laparoscopic low anterior resection and protective loop-ileostomy on Jan. 02, 2020 status post CCRT, rcTxN0M1a, stage IVA
        • DVT with left IVC filter status post removal IVC filter on Apr. 7, 2020
        • Gallbladder stones with acute cholecystitis post cholecystectomy on Jan. 19, 2020
        • Hypertension for 10+ years under medical treatment
        • Type 2 diabetes mellituss for 10+ years under medical treatment
        • HIVD s/p L3-L5 spine surgery on 2017-12 at Cathay General Hospital
      • CC:
        • Followed up CT on 2020/06/17 and 10/07 revealed “metastasis 1.6 x 1.1 cm in S5 of the liver is suspected” –> adm for solitary liver lesion
      • Due to liver tumor, we are consulted for RFA.
      • S+O
        • No disconfort
        • Conscious: E4V5M6
        • Abdomen: Soft and flat, no tenderness, no rebound tenderness
        • Lab
          • 2020-11-09 AST:17, ALT:37, BUN:24, Cr:0397, T-bil:0.56
          • WBC:4.97, Hb:11.8, PLT:248
      • Impression
        • Liver tumor, S5
      • Suggestion
        • arrange abdominal echo
        • arrnage GI OPD after discharge. We will discuss with the patient about RFA in GI OPD
  • 2020-11-12 General and Gastrointestinal Surgery
    • Q
      • This time,he was admitted for clarifying the nature of solitary liver lesion. PET done on 20201110 which revealed In comparison with the previous study on 20200622, the previous glucose hypermetabolic lesion in the segment 5 of the liver is less evident. However, the previous glucose hypermetabolic lesion on the rectal wall disappeared and no prominent FDG uptake was noted in the previous glucose hypermetabolic lesion in the segment 4 of the liver.
      • We need your expertise for op evaluation, thanks
    • A
      • S: a case of rectal cancer with recurrence, rcTxN0M1a, stage IVA. PET found suspected liver METs over S4 & S5, further evaluation is consulted.
      • O: vital signs: stable, no fever
        • abdomen: soft, ovoid, decrease bowel sound, no tenderness, no rebounding pain
        • lab data: see chart
        • CT & PET: suspected liver & lung METS
      • A: rectal cancer with recurrence, rcTxN0M1a, stage IVA.
      • P: Please arrange biopsy of suspected liver tumors for tissue prove
        • If rectal Ca with liver METS diagnosed, surgical intervention is not suitable for him due to high surgical risk (old age, previous DVT, and terminal stage).
        • RFA and RT, or target and immunotherapy is better and suggested.
  • 2020-01-18 General and Gastrointestinal Surgery
    • Q
      • PH: adenocarcinoma of rectum, cT3N2bM0, III s/p L-LAR with protective ileostomy (2020-01-02), decreased appetite, abdomen fullness and discomfort and feels weakness
    • A
      • A case of acute RUQ pain for days
      • PE
        • soft abdomen, no muscle guarding
        • positive murphy signs and knocking pain, right
      • lab disclosed neutrophilia over 80%, CRP over 28
      • CT: gall stones with acute cholecystitis
      • Emergency op or drainage is indicated
  • 2020-01-18 Colorectal Surgery
    • Q
      • PH: adenocarcinoma of rectum, cT3N2bM0, III s/p L-LAR with protective ileostomy (2020-01-02), decreased appetite, abdomen fullness and discomfort and feels weakness
    • A
      • This 83-year-old with a known history of adenocarcinoma of rectum, cT3N2bM0, III s/p L-LAR with protective ileostomy (2020-01-02) This time, he had decreased appetite, abdomen fullness and discomfort and feels weakness. His laboratory data showed leucocytosis and elevated CRP level. After evaluation, please arrange abdominal CT.
      • PE:
        • Rebounding pain (+) especial right side and RUQ.
        • knocking tederness (-)
        • ileostomy: gas + watery yellowish diarrhea
      • Suggest:
        • please check abdominal CT
        • please consult GS

[surgical operation]

  • 2020-12-11 Colon cancer with single liver metastasis s/p RFA (2 sessions) using RVS

  • 2020-01-19

    • Surgery: Exp lap with cholecystectomy and drainage
    • Finding
      • black stones with GB wall thickening and pericholecystal abscesses and adhesions
      • one impaction over orifice of cystic duct
      • no liver tumor or cirrhotic change
  • 2019-10-22

    • Diagnosis: L3-S1 spondylosis, radiculopathy
    • PCS code: 96005C
    • Finding
      • bilateral L3-4 HIVD, ASD, spinal stenosis, radiculopathy
      • L5-S1 HIVD
      • intraoperative fluoroscopy confirmed needle localization

[radiotherapy]

  • 2019-04-18 ~ 2019-05-31: 4500cGy/25fx of the pelvic and 5040cGy/28fx of the rectal tumor area

[chemotherapy]

  • 2024-01-30 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 3660mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-21 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 3660mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-07 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 3580mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-10-09 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 3580mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-09-11 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 3610mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-14 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 3610mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-07-17 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 3630mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-06-13
  • 2023-05-22
  • 2023-04-24
  • 2023-03-28
  • 2023-02-20 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 3770mg NS 500mL 46hr (FOLFOX Q2W, ox and 5fu 20% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-01-09 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-12-02 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-11-16 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-10-27 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-10-14 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-08-22 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-08-01 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-07-18 - oxaliplatin 85mg/m2 115mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3770mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-06-16 - oxaliplatin 85mg/m2 115mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3790mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-05-23 - oxaliplatin 85mg/m2 115mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3790mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-03-09 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 3750mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2021-12-15 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 3615mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2021-11-24 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 3615mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2021-11-04 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 3690mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2021-10-19 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2800mg/m2 3625mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2021-09-24 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2800mg/m2 3675mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
  • 2021-06-29 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 560mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
  • 2021-06-02 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 560mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
  • 2021-04-21 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 250mg 90min + leucovorin 400mg/m2 560mg 2hr + fluorouracil 2800mg/m2 3900mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
  • 2021-04-07 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
  • 2021-03-22 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 235mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2800mg/m2 3650mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
  • 2021-03-08 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 235mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2800mg/m2 3650mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
  • 2020-10-06 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 235mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2800mg/m2 3650mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
  • 2020-09-21 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3720mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
  • 2020-09-07 - irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3720mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
  • 2020-08-18 - irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3730mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
  • 2020-08-03 - irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 535mg 2hr + fluorouracil 2800mg/m2 3750mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD
  • 2020-07-20 - irinotecan 180mg/m2 240mg 90min + leucovorin 400mg/m2 535mg 2hr + fluorouracil 2800mg/m2 3750mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD

==========

2024-01-31

Lab results from 2024-01-30 did not reveal any significant findings that would contraindicate proceeding with a new session of the FOLFOX regimen.

The active medication list has been updated to include repeat prescriptions from our gastroenterologist (2023-12-30), cardiologist (2023-12-28), neurologist, urologist (2023-12-15), and psychosomatic physician (2023-11-15), with no discrepancies noted.

2023-12-22

Lab results obtained on 2023-12-21 were largely unremarkable with the exception of mild anemia (HGB 9.5 g/dL). Due to this finding, the new session FOLFOX regimen has been continued on 2023-12-21.

Medications from repeat prescriptions issued by our neurologist, urologist (2023-12-15), and psychosomatic physician (2023-11-15) have been successfully integrated into the active medication list. No discrepancies were identified.

2023-11-06

After checking the PharmaCloud database and the patient’s current medication list, it is confirmed that all medications from the refill order have been taken. No discrepancies are found.

2023-10-09

[reconciliation]

The patient has attended multiple departments in our hospital and has been issued several repeat prescriptions that remain valid to date:

  • 2023-09-19 Gastroenterology: Ulstop (famotidine), Gaslan (dimethylpolysiloxane), Mopride (mosapride citrate)

  • 2023-09-15 Cardiology: Januvia (sitagliptin), Eliquis (apixaban), Zandip (lercanidipine)

  • 2023-09-08 Urology: Urief (silodosin), Betmiga (mirabegron)

  • 2023-09-01 Neurology: Muaction (tramadol), Kentamin (Vit B1, B6, B12), Trynol (amitriptyline), Neurontin (gabapentin), CaCO3, U-Ca (calcitriol)

  • 2023-08-30 Psychosomatic Medicine: Alpraline (alprazolam)

All these medications are actively being used by the patient, and no inconsistencies have been identified.

[tumor markers]

The most recent CT scan of the abdomen dated 2023-06-30 shows no evidence of tumor recurrence in the rectum following LAR surgery. While a lesion in S5 of the liver post-RFA indicates complete recovery, a previously detected lesion in S8 and some liver cysts in the left lobe remain stable, suggesting the need for continued surveillance. However, given the increasing trend of the tumor markers CEA and CA199 in recent months, further imaging or testing may be required to obtain an updated status of the disease.

2023-09-28 CEA (NM) 41.773 ng/ml 2023-08-29 CEA (NM) 41.022 ng/ml 2023-08-01 CEA (NM) 28.657 ng/ml 2023-06-27 CEA (NM) 32.370 ng/ml 2023-06-06 CEA (NM) 38.089 ng/ml 2023-05-09 CEA (NM) 29.020 ng/ml 2023-04-11 CEA (NM) 29.090 ng/ml 2023-03-07 CEA (NM) 30.892 ng/ml 2023-02-22 CEA (NM) 22.304 ng/ml 2023-01-20 CEA (NM) 29.331 ng/ml

2023-09-28 CA-199 (NM) 128.119 U/ml 2023-08-29 CA-199 (NM) 124.920 U/ml 2023-08-01 CA-199 (NM) 100.17 U/ml 2023-06-27 CA-199 (NM) 102.499 U/ml 2023-06-06 CA-199 (NM) 108.696 U/ml 2023-05-09 CA-199 (NM) 99.780 U/ml 2023-04-11 CA-199 (NM) 94.910 U/ml 2023-03-07 CA-199 (NM) 91.315 U/ml 2023-02-22 CA-199 (NM) 66.824 U/ml 2023-01-20 CA-199 (NM) 70.223 U/ml

2023-08-14

On 2023-06-23, our cardiologist prescribed Januvia (sitagliptin), Eliquis (apixaban), and Zandip (lercanidipine) for the patient, while on 2023-07-01, our gastroenterologist prescribed Ulstop (famotidine), Gaslan (dimethylpolysiloxane), and Mopride (mosapride citrate). All medications, with the exception of Mopride, are currently on the active medication list. Please determine if the use of Mopride is still necessary.

2023-07-17

This patient just refilled his prescription for Januvia (sitagliptin), Eliquis (apixaban), Zanidip (lercanidipine), Betmiga (mirabegron), Urief (silodosin) on 2023-07-11 at a local pharmacy and these drugs are now added to the active medication list with no reconciliation issues found.

2023-06-12

  • According to the PharmaCloud database, the patient has solely been using our hospital for both outpatient and inpatient services over the past three months.
  • The patient visited our Neurology and Psychosomatic Medicine OPD on 2023-06-09 for chemotherapy-related polyneuropathy, L spine radiculopathy, suspected mild cognitive impairment, and insomnia. Refillable prescriptions were given for Muaction (tramadol), Kentamin (B1, B6, B12), Trynol (amitriptyline), Neurontin (gabapentin), calcium carbonate, U-Ca (calcitriol), and Alpraline (alprazolam). These drugs are appropriately reflected on the current active medication list. No issues were identified in the medication reconciliation process.

2023-05-22

  • A review of PharmaCloud records did not identify any medication reconciliation issues.

  • This patient’s chemotherapy-induced polyneuropathy may be more likely due to the oxaliplatin component of the FOLFOX regimen, which was started in Oct 2021. Appropriate measures have been taken, including the addition of Kentamin (B1, B6, B12) and Neurontin (gabapentin) to the patient’s active medication regimen as prescribed by our neurologist.

  • The patient’s CEA and CA199 levels have shown similar upward trends in recent months, which may indicate that the disease is becoming more resistant to current treatment. This may require further evaluation and possible adjustments to the future treatment plan.

    • 2023-05-09 CEA (NM) 29.020 ng/ml
    • 2023-04-11 CEA (NM) 29.090 ng/ml
    • 2023-03-07 CEA (NM) 30.892 ng/ml
    • 2023-02-22 CEA (NM) 22.304 ng/ml
    • 2023-05-09 CA-199 (NM) 99.780 U/ml
    • 2023-04-11 CA-199 (NM) 94.910 U/ml
    • 2023-03-07 CA-199 (NM) 91.315 U/ml
    • 2023-02-22 CA-199 (NM) 66.824 U/ml

2023-03-27

  • CEA and CA199 levels have been consistently above the normal range since Oct 2022.
  • The patient is being treated for bilateral L5 and bilateral below wrist numbness caused by chemotherapy-related polyneuropathy and L spine radiculopathy. The treatment plan, including the use of Kentamine (B1 50mg + B6 50mg + B12 500ug), Neurontin (gabapentin), Trynol (amitriptyline), and Muaction (tramadol), has been properly prescribed by our neurologist on 2023-03-24.
  • As of now, the patient has had one bowel movement on 2023-03-26 and there are no signs of constipation. Loperamide 2mg PRNQ4H has been prepared in advance if needed.
  • Based on the TPR panel, the patient’s underlying conditions of hypertension and diabetes are well controlled.
  • There were no medication reconciliation issues identified and there are no issues with the current active prescription.

2023-02-20

  • As of now, the patient’s TPR, blood pressure, and blood sugar level remain stable. The lab data 2023-02-19 showed grossly normal readings, except for slightly high BUN and slightly low levels of albumin and calcium.
  • The recently prescribed drugs that were disclosed in the NHI PharmaCloud System have been appropriately prescribed during this hospital stay. No medication reconciliation issues have been found in the patient.

2023-01-09

  • 2020 ASCO guidelines suggest that clinicians may offer duloxetine to patients with chemotherapy-induced peripheral neuropathy, and 2020 joint ESMO/EONS/EANO guidelines recommend duloxetine for treatment of neuropathic pain in this setting. ref: Loprinzi CL, Lacchetti C, Bleeker J, et al. Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325.
  • Duloxetine for adult patients with chemotherapy-induced peripheral neuropathy: Oral initial 30 mg once daily for 1 week, then 60 mg once daily. Ref: Smith EM, Pang H, Cirrincione C, et al; Alliance for Clinical Trials in Oncology. Effect of duloxetine on pain, function, and quality of life among patients with chemotherapy-induced painful peripheral neuropathy: a randomized clinical trial. JAMA. 2013;309(13):1359-67. doi:10.1001/jama.2013.2813
  • There is Cymbalta (duloxetine 30mg/cap) available in the stock.

2022-12-02

  • In this case, the patient had chemotherapy related polyneuropathy and L spine radiculopathy, which was evaluated by our neurologist on 2022-11-14. Neurontin (gabapentin 100mg/cap) 1# BID has been prescribed.
  • At this time, vital signs appear to be stable. According to the lab data on 2022-12-01, there was a slight pancytopenia, but overall the results were normal.
  • There is no issue with the active prescription.

2022-10-14

  • Duloxetine is recommended for the mitigation of chemotherapy-related sensorimotor polyneuropathy (Type of recommendation: evidence based, benefits equal harms; Evidence quality: intermediate; Strength of recommendation: moderate. Ref: Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. Journal of Clinical Oncology 2020 38:28, 3325-3348)
  • Duloxetine for chemotherapy-induced peripheral neuropathy (off-label use): Oral initial: 30 mg once daily for 1 week, then 60 mg once daily.

2022-07-18

  • Colonoscopy (2022-05-20) showed local recurrent cancer at low rectum.
  • CEA levels continue to rise in recent months:
    • 2022-06-24 23.795 ng/mL
    • 2022-06-10 17.995 ng/mL
    • 2022-05-17 14.022 ng/mL
    • 2022-03-18 13.494 ng/mL
    • 2022-01-20 8.210 ng/mL
    • 2021-12-14 6.908 ng/mL
  • CA199 exhibits a similar trend to CEA
  • Lab data on 2022-07-18 showed generally normal readings except for slight anemia.

2022-05-17

  • Lab data on 2022-05-16 showed that liver and kidney function, electrolytes and CBC were generally normal.
  • Biomarkers
    • CEA 2022-03-18 13.494 ng/ml <- 2022-01-20 8.210 ng/ml <- 2021-12-14 6.908 ng/ml, increasing
    • CA199 2022-03-18 73.781 U/ml <- 2022-01-20 49.528 U/ml <- 2021-12-14 40.779 U/ml, increasing
  • The last CT scan was performed on 2022-01-04, so the image may need to be updated.

2022-01-04

  • according to in-hospital database, the patient had mild drug allergy with: Sketa, Warfarin, Dipyridamole, Valaciclovir, Solaxin (chlorzoxazone).

2021-04-28

  • O
    • stool Clostridium difficile GDH positive reported on 4/27
  • A
    • Clostridioides difficile infection (CDI) is one of the most common nosocomial infections and is an increasingly frequent cause of morbidity and mortality among older adult hospitalized patients.
    • vancomycin, fidaxomicin, metronidazole might work on CDI.
    • according to lab data reported on 4/19, the patient has normal liver and kidney functions, no need to adjust dose for the above antimicrobials.
  • Suggestion
    • discontinuation of the inciting antibiotic agent as soon as possible at least in the patient’s room.
    • vancomycin 125mg PO QID for 10 days or fidaxomicin 200mg PO BID for 10 days could be considered.
    • if vancomycin is prescribed, therapeutic drug monitoring for its trough level at 30 minites just before the 5th dose administration is highly recommended.
    • monitor clinical signs for CDI and recheck stool GDH after having administrating of the above antimicrobials for 5 days to evaluate the effect.

701139535

240131

[exam findings]

  • 2023-11-17 CT - abdomen
    • History and indication: Adenocarcinoma of rectum with multiple lung metastasis, stage IVA
    • Findings:
      • S/P LAR with autosuture retention over the rectum.
      • Prior CT identified soft tissue nodule with calcification component at LUL and RUL of the lung are noted again, stationary.
      • Prior CT identified multiple cysts in the liver and kidney is noted again, stationary. It is c/w adult type polycystic liver and kidney disease.
      • Prior CT identified atherosclerosis of aorta, iliac, coronary and visceral arteries is noted again, stationary.
    • Impression:
      • Prior CT identified soft tissue nodule with calcification component at LUL and RUL of the lung are noted again, stationary.
      • Lung metastases show stable disease.
  • 2023-11-07 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (112 - 56) / 112 = 50.00%
      • M-mode (Teichholz) = 61.3
    • Conclusion
      • Normal LV systolic function with normal wall motion.
      • Hypertrophic cardiomyopathy without outflow tract obstruction, dilated LA; LV diastolic dysfunction Gr 1.
      • Normal RV systolic function.
      • Aortic valve sclerosis with mild AR; posterior mitral valve calcification with no MS, mild MR; trivial TR; mild PR.
      • An atheroma (5.7mm of thickness) at aortic root.
  • 2023-09-13 CT - brain
    • Brain atrophy.
    • Intracranial arterhiosclerosis.
  • 2023-08-04 ECG
    • Normal sinus rhythm
    • Inferior infarct, age undetermined
    • Abnormal ECG
  • 2023-08-03 CT - abdomen
    • History and indication: Adenocarcinoma of rectum with multiple lung metastasis, stage IV
    • Non-contrast CT of abdomen-pelvis revealed:
      • S/P colon operation.
      • A nodule (1.2cm) at LUL. Regression of right lung nodules.
      • Polycystic liver and kidneys.
      • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
      • Surgical wires over the sternum.
    • IMP:
      • S/P colon operation.
      • A nodule (1.2cm) at LUL. Regression of right lung nodules.
  • 2023-08-02 07:07 ECG
    • Sinus rhythm with 1st degree A-V block
    • Possible Left atrial enlargement
    • Inferior infarct old
    • right side EKG showing no RV infarct
  • 2023-08-02 06:25 ECG
    • Sinus rhythm with 1st degree A-V block
    • Nonspecific ST abnormality
    • old inferior MI
    • Left atrial enlargement
  • 2023-08-01, -05-23 CXR
    • S/P port-A implantation.
    • S/P median sternotomy with metalic wires fixation. Please correlate with clinical history.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • S/P metalic autosuture at right lung.
  • 2023-05-18 CXR
    • Tortous aorta with calcification is noted.
    • s/p sternotomy with metalic wire fixation of the sternum.
    • s/p op. over right lung.
  • 2023-05-04 ECG
    • Possible Left atrial enlargement
    • Inferior infarct, age undetermined
    • Nonspecific T wave abnormality
  • 2023-04-24, -04-21 CXR
    • s/p right chest tube in place, its tip directed superiorly projecting over 3rd intercostal space
    • multifocal consolidation in Rt lung s/p wedge-resection at RUL and RLL
  • 2023-04-24 Patho - lung wedge biopsy
    • PATHOLOGIC DIAGNOSIS:
      • Lung, right, upper lobe, wedge resection — Adenocarcinoma x 2, metastatic, consistent with colorectal origin
      • Lymph node, right, group No.11, lymphadenectomy — Negative for malignancy (0/2)
    • MACROSCOPIC EXAMINATION:
      • Specimen: Lung, 2 pieces of wedge resection; specimen A1: size: 6.0 x 3.0 x 3.0 cm, 22 g; specimen A2: 5.5 x 4.5 x 3.0 cm, 19 g.
        • Lymph nodes, a bottle, group 11; maximal size: 1.3 x 0.7 cm
      • Tumor Site: Periphery
      • Tumor Size: specimen A1: Solitary: 1.7 x 1.5 x 1.5 cm; specimen A2: 1.8 x 1.6 x 1.5 cm
      • Gross tumor patterns: poorly defined
      • Tissue for sections:
        • A1: resection margin, specimen A1; A2: lung, non-tumor, specimen A1; A3-4: tumor, specimen A1; A5: resection margin, specimen A2; A6: lung, non-tumor, specimen A2; A7-8: tumor, specimen A2; B: lymph node, group 11.
    • Microscopic Description
      • Tumor Focality: Separate tumor nodules of same histopathologic type in same lobe
      • Histologic Type (select all that apply) : Metastatic adenocarcinoma with abundant extravasated mucin, mucinous adenocarcinoma is favored; The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), TTF-1(-), and Napsin A(-), The results are consistent with colorectal origin
      • Histologic Grade: G2: Moderately differentiated
      • Spread Through Air Spaces (STAS): Not identified
      • Visceral Pleura Invasion: Not identified
      • Lymphovascular Invasion (select all that apply): Present, Lymphatic
      • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
      • Margins (select all that apply): All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin (centimeters): specimen A1: 0.3 cm; specimen A2: 0.3 cm
        • Specify closest margin: wedge resection margin
      • Regional Lymph Nodes: group 11: 0/2
      • Extranodal Extension: Not identified
      • Additional Pathologic Findings (select all that apply): None identified
  • 2023-04-21 ECG
    • Sinus rhythm with occasional Premature ventricular complexes or aberrant conduction
    • Possible Left atrial enlargement
    • Inferior infarct , age undetermined
    • Abnormal ECG
  • 2023-04-21 CXR
    • two nodular opacities (up to 20mm, lobular borders) over RUL
    • a tiny granuloma at lateral RLL
    • s/p prior median sternotomy with wires fixation s/p CABG
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • mild enlarged cardiac silhoutte due to dilated cardiac chamber (LVD) and prominent cardiophrenic angle mediastinal fat pad
    • Coronary arterial calcification (left circumflex artery, left anterior descending artery) indicating CAD
    • s/p prior median sternotomy with wires fixation
  • 2023-03-23 CT - chest
    • Indication: for R’t lung nodules and sternum f/u
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Nodular lesions with central calcification scattered at both lungs up to 1.6cm is found at right upper lobe. Lung meta is considered first but other possibiity cannot be excluded.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
        • s/p sternotomy with metalic wire fixation of the sternum.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Polycystic change at both lobes of liver are found.
        • There is no ascites accumulation at abdominal cavity.
        • There is no evidence of destructive bone lesion.
    • Imp: Nodular lesions with central calcification at both lungs. Lung meta is favored. Suggest check tumor marker such as CEA or others.
  • 2023-02-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (136 - 40.3) / 136 = 70.37%
      • M-mode (Teichholz) = 70.4
      • 2D (M-simpson) = 56.1
    • Conclusion:
      • Thickened AV with trivial AR
      • Calcification of posterior MV leaflet, mild MR
      • Concentric LVH, mildly dilated LV
      • Preserved LV and RV systolic function
      • Hypokinesia of basal to mid inferior wall
      • Mild PR, mild TR, normal IVC size
      • Dilated LA
  • 2022-12-29 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • s/p sternotomy with metalic wire fixation of the sternum.
    • Nodular lesion at right upper lobe and right central lung field is found.
    • Clear bilateral costophrenic angle is noticed.
  • 2022-12-29 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Inferior infarct, age undetermined
    • Abnormal ECG
  • 2022-04-28 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (186 - 76) / 186 = 59.14%
      • 2D (M-simpson) = 59
    • Conclusion:
      • Dilated LA, LV
      • Adequate LV, RV systolic function with normal wall motion
      • Concentric LV hypertrophy, Impaired LV relaxation
      • Mild AR
      • Calcified aortic valve and mitral annulus, No significant AS, MS
  • 2021-10-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (144 - 42) / 144 = 70.83%
      • M-mode (Teichholz) = 71
    • Conclusion:
      • Dilated LV with hypokinesia of inferior wall, posterior wall; preserved LV and RV systolic function.
      • Septal and RV hypertrophy with indeterminated LV filling pressure and impaired RV relaxation.
      • Aortic valve sclerosis with trivial AR; marked mitral annulus calcification with mild MR; mild PR.
      • Dilated aortic root and proximal ascending aorta (39mm) with prominent calcification.
      • Minimal pericardial effusion (< 50ml); some R’t pleural effusion.
  • 2021-09-24 CT - chest
    • Indication: CAD 3VD for CABG preoperative evaluation
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Calcified coronary arteries is found.
        • Mild pericardial effusion is found.
        • Tiny nodualr lesion at right upper lobe up to 0.3cm, and 0.17cm, left upper lobe about 0.24cm is found.
        • Several calcified dots at both lungs is found.
        • Minimal atelectatic change over left lower lung is found.
      • Visible abdomen:
        • s/p LAR.
        • Diffuse cystic change at liver and both kidneys are found. Polycystic kidney is considered.
        • The spleen, pancreas, both adrenals are intact.
    • Imp:
      • Nodular lesions at right upper lobe and left upper lobe, please exclude the possiblity of lung meta.
      • Polycystic liver and kidneys.
      • Calcified coronary arteries is found.
  • 2021-09-23 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (142 - 88) / 142 = 38.03%
      • M-mode (Teichholz) = 37
      • 2D (M-simpson) = 30
    • Conclusion:
      • Dilated LA and LV; moderate to severely abnormal LV systolic function with inferoposterior wall hypokinesia
      • Septal hypertrophy
      • Mild MR, mild AR and trivial TR
      • Moderate pericardiac effusion without cardiac tamponade sign
      • Preserved RV systolic function
  • 2021-09-22 Cardiac Catheterization
    • Exam: CATH
    • Diagnosis: MI, CAD with TVD
    • Past Medical History
      • The patient has a history of ESRD under H/D and Hypertension.
    • Indication
      • The patient was referred with NSTEMI. The procedure was explained in detail to the patient and family. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
    • Approach
      • Percutaneous access was performed through the right radial artery where a 6F sheath was inserted.
    • Catheters
      • Left coronary angiography was performed using 6Fr JL3.5 catheter and right coronary angiography was performed using 6Fr JR4 catheter.
    • Procedure
      • Percutaneous 18020A-Cath one side
      • Percutaneous 18022A-CAG
      • Percutaneous 33076A-PTCA 1 Vessel
      • The patient was taken to the cardiac catheterization laboratory. Heart institute and prepared in the usual sterile fashion. The contrast material used was Omnipaque 350 120cc. The patient was treated with Heparin (Dosage=7000) and NTG (Dosage=200).
    • Activated Clotting Time and BP
      • The measurement data of ACT was 257 S (ACT 1).
    • Finding Summary
      • LAD-D2 : 90-99 % stenosis, Type: C, TIMI: (1)
      • Syntax Score = 32.5
      • Suggest OP : Wait discussion stage PCI or CABG
      • Euro Score = 9.52%
      • In conclusion : CAD with TVD
      • Recommendation : PCI for DB2 for possible thombotic occlusion
      • Left Main :
        • Calcification
      • Left Anterior Descending :
        • Calcification, proximal part 70-80% stenosis, distal part 60-70% stenosis; DB1 90-99% stenosis, DB2 haziness with TIMI 1 flow (thrombus?)
      • Left Circumflex :
        • Calcification, middle part CTO with collaterals from bridging collaterals
      • Right Coronary :
        • Calcification, middle part 70-80% stenosis, distal part 80-90% stenosis with collaterals from LCA
    • Intervention Summary
      • LAD-D1
      • MLD/RVD=0/2.5 mm
      • Guiding catheter: Medtronic Luncher 6F EBU3.5.
      • Guide Wire: Asahi Fielder FC wire.
      • Balloon: OrbusNeich Sapphine. 1.0 X 10 mm. Pressure: 10-16 atmospheres. Note: ruptured at 16 atm.
      • A workhorse soft-tip wire could not cross the DB2 lesion, which suggested it as a chronic obstruction. A 1.0mm SC balloon was tried to dilate the proximal part of DB2 but failed.
      • In conclusion : CAD with TVD
      • Recommendation : CABG first, or PCI/medical therapy if the patient refused the surgery.
  • 2018-08-06 SONO - hepatobiliary
    • Sonography of hepatobiliary system revealed:
      • Diffuse anechoic nodules in the liver and bilateral kidneys, r/o polycystic renal and liver disease.
      • Normal appearance of gall bladder without stone.
      • Patency of PV, HVs, IVC and aorta in hepatic portion.
    • Impression:
      • Diffuse anechoic nodules in the liver and both kidneys, r/o polycystic renal and liver disease.

[MedRec]

  • 2024-01-25 SOAP Cardiac Surgery Xu ZhanYang
    • Prescription x3
      • Doxaben (doxazosin 4mg) 2# QD
      • Bokey (aspirin 100mg) 1# QD
      • Caduet (amlodipine 5mg, atorvastatin 20mg) 1# QD
      • Plavix (clopidogrel 75mg) 1# QD
      • Ulstop (famotidine 20mg) 0.5# QD
      • Syntrend (carvedilol 25mg) 0.5# BID
  • 2023-05-16 SOAP Hemato-Oncology
    • S
      • Metaastatic adenocarcinoma over right upper lobe, status post video-assisted thoracoscopic surgery right upper lobe and right lower lobe lung wedge resection and lymph node dissection on 2023-04-21.
      • Multiple lung nodules status post video-assisted thoracoscopic surgery right upper lobe and right lower lobe lung wedge resection and lymph node dissection on 2023-04-21
      • End stage renal disease
      • 2023-05-16 adenocarcinoma of rectum with multiple lung mets
      • explain the clinical utcome to patient and her daugther. suggest C/T with FOLFIRI. apply Avastin
  • 2021-09-22 ~ 2021-10-08 POMR Cardiac Surgery Xu ZhanYang
    • Discharge diagnosis
      • Non-ST elevation myocardial infarction, 3-vessel disease, post coronary artery bypass graft 110/10/29
      • End stage renal disease
      • Essential (primary) hypertension
      • Pure hypercholesterolemia
    • CC
      • sudden onset severe chest pain around 2:00AM since this morning.
    • Present illness
      • This 65-year-old male has the past history of 1. Polycystic kidney under HD QW135, Hypertension for 6 years ago, LMD further 2. Colon cancer s/p operation for 1 year at NTUH. Denied diabetes mellitus, hyperlipidemia.
      • According to the description of the patient and medical record, he ever experienced pain of neck for 2 weeks ago, he visit LMD and medication used for pain control. This time, he suffered from anterior pain, onset around 2:00AM since this morning. The character was compressive sensation. No cold sweating or radiation to bilateral shoulders, jaw. The severity of chest pain was scoring 9 by pain score. So the patient was sent to ER for help. At ED, vital signs included HR:81/min; BP:142/69mmHg. Complete EKG: sinus, Q wave in III/aVF, STD in I/aVL. Emergent anti-platelet agents loading and heparin were given.
      • Cardiologist was consulted for arranging primary PCI. The intervention was performed and dignosis CAD with TVD. And consider CABG first, or PCI/medical therapy if the patient refused the surgery. The patient was admitted to ICU for further care.
    • Course of inpatient treatment
      • He received cardiac cath which showed CAD with TVD. And consider CABG first, or PCI/medical therapy if the patient refused the surgery. The patient was admitted to ICU for further care on 2021/09/22.
      • After admission to the MICU, nephrologist was consulted for arranging hemodialysis.
      • Dual antiplatelet therapy, Beta blocker, Statin, and H2 blocker was given.
      • The 2D transthoracic echocardiography was performed, which report as conclusion:
        • Dilated LA and LV; moderate to severely abnormal LV systolic function with inferoposterior wall hypokinesia.
        • Septal hypertrophy.
        • Mild MR, mild AR and trivial TR.
        • Moderate pericardiac effusion without cardiac tamponade sign.
        • Preserved RV systolic function.
      • Cardiovascular Surgeon was consulted for surgical intervention evaluation. After surgical risk and procedure well explained, he and his family was agreed surgical intervention. He was transferred to Cardiac Surgical Ward on 9/24 under stable condition.
      • After transferring to general ward, neck pain was complaining WHICH WAS SUSPECTED ONGOING ANGINA. Angidil infusion was prescribed. Brilinta was stopped, shift to Clexane FOR PRE-OP.
      • Cardiac enzyme was closely monitored, until 9/24 night, enzyme reaches the peak. Inform family shall be considered earlier CABG. Thus, he received CABG X4 and transferred to the SICU for postoperative intensive care on 9/29.
      • Postoperation, ABX WITH Vancomycin and Brosym use. Under CVVH since 9/29-10/01 then change to H/D.
      • Try weaning ventilator AND HE WAS extubated on 9/30. Under hemodynamic stable and he was transferred to ward.
      • At ward, general appearance was fair and no severe wound pain with well wound condition. Left chest tube was in place with well function. We encouraged him to PERFORM TRIFLOW TRAINING AND AMBULATION on bed for exercise and started to try ambulation.
      • Chest tube was removed on 2021/10/05. Respiratory pattern smoothly after chest tube removal. Cardiac echo was done on 10/8 with normal LVEF 59%.
      • With uneventful postoperative condition, he was discharged on 2021-10-08 and would be followed up at CVS clinic.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Bokey (aspirin 100mg) 1# QD
      • Caduet (amlodipine 5mg, atorvastatin 20mg) 1# QD
      • calcium carbonate 500mg 1# TIDCC
      • carvedilol 6.25mg 1# BID hold if HR < 60
      • Coxine (isosorbide-5-mononitrate 20mg) 1# BID
      • Doxaben (doxazosin 4mg) 1# QD
      • Folacin (folic acid 5mg) 1# QD
      • Kentamin (Vit B1 50mg, B6 50mg, B12 500ug) 1# QD
      • Plavix (clopidogrel 75mg) 1# QD
      • Ulstop (famotidine 20mg) 0.5# QD
      • Sindine (povidone iodine 10% aq soln) ASORDER EXT

[consultation]

  • 2024-01-30, 2023-12-29, -12-12, -11-16, -10-24, -09-21, -08-24, -08-01, -07-10, -05-23, -04-21 Nephrology
    • Q
      • The patient is a 68 y/o male with the history of Polycystic kidney under HD QW135 for 9+ years, Hypertension for 9 years ago, Colon cancer s/p operation for 4 year at NTUH. Hyperlipidemia, Non-ST elevation myocardial infarction, 3-vessel disease, post coronary artery bypass graft s/p CABG x 4 in 2021/10/29, Metastatic adenocarcinoma over right upper lobe, status post video-assisted thoracoscopic surgery right upper lobe and right lower lobe lung wedge resection and lymph node dissection on 2023-04-21 and Multiple lung nodules status post video-assisted thoracoscopic surgery right upper lobe and right lower lobe lung wedge resection and lymph node dissection on 2023-04-21. The RUL lung wedge resection pathology showed adenocarcinoma x 2, metastatic, consistent with colorectal origin. The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), TTF-1(-), and Napsin A(-).
      • This time, he was admitted to our ward for chemotherapy. We need your expertise to arrange hemodialysis. Thanks a lot!
    • A
      • We will arrange hemodialysis QW135 for the patient during the course of hospitalization.
      • Please prescribe EPO 5000 IU QW if Hb < 11.
  • 2023-08-02 Cardiology
    • Q
      • for suspect AMI
      • The patient is a 68 y/o male with the history of Polycystic kidney under HD QW135 for 9+ years, Hypertension for 9 years ago, Colon cancer s/p operation for 4 year at NTUH. Hyperlipidemia, Non-ST elevation myocardial infarction, 3-vessel disease, post coronary artery bypass graft s/p CABG x 4 in 2021/10/29, Metaastatic adenocarcinoma over right upper lobe, status post video-assisted thoracoscopic surgery right upper lobe and right lower lobe lung wedge resection and lymph node dissection on 2023-04-21 and Multiple lung nodules status post video-assisted thoracoscopic surgery right upper lobe and right lower lobe lung wedge resection and lymph node dissection on 2023-04-21. The RUL lung wedge resection pathology showed adenocarcinoma x 2, metastatic, consistent with colorectal origin. The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), TTF-1(-), and Napsin A(-).
      • This time, he was admitted to our ward for chemotherapy with C2D15 FOLFIRI/#4 Avastin.
      • During chemotherapy, he complaints headache, and chest tightness, the SBP 198mmHg, follow-up cardiac enzymes: CK-MB 3.2ng/mL, CPK 47U/L, Troponin-I 34.2pg/mL, 12-lead EKG suspect AMI, and gave Angidil 20mg in N/S 80ml with pump run 3ml/hr. We need your expertise to arrange hemodialysis. Thanks a lot!
    • A
      • This 68 y/o male patient is a case of HTN, polycystic kidney diseaes anbd ESRD under regular hemodialysis. He also had past history of old non-ST elevation MI and 3-V CAD s/p CABG (LIMA insitu to LAD; SVG sequentially to D2-OMx-PDA) with additional vein interposed between AsAo and SVG conduit. on 2021-10-29. He was diagnosed rectal cancer with lung metastasis and was admitted for C/T. However, sudden onset of chest pain over right chest wall developed in this morning. The chest pain was not associated withg dyspnea or diaphoresis. The duration of chest pain lasted for 1~2 hours. The folow-up EKG showed ST depression at lateral leads, and mild elevation of hsTroponin-I was detected. Now we are consulted. The patient denied chest pain at present.
        • 20230802 EKG: old inferior wall MI, ST depression with T wave inversion at V5~6, lead I and aVL
        • 20230214 Echo: LVEF: 56.1%, LV:53/32, IVS/PW;23/16, LA:44, AO:35, thickened AV with trivial AR, calcification of posterior MV leaflet, mild MR, concentric LVH, mildly dilated LV, preserved LV and RV systolic function, hypokinesia of basal to mid inferior wall, mild PR, mild TR, normal IVC size, dilated LA
      • Lab:
        • CKMB 2023-08-02 3.2
        • CK 2023-08-02 47
        • hs-Troponin I 2023-08-02 31.2
      • Impression:
        • Atypical chest pain
      • Suggestion:
        • The clinical presentation for right chest pain is atypical for angina pectoris. However, ST depression at lateral leads during chest pain was recorded from the EKG study.
        • Please follow cardiac markers (CK, CKMB and hsTroponin-I) and EKG again to clarify the diagnosis of acute NSTEMI.
        • If evolutional elevation of hsTroponin-I is detected, type II MI will be prefered.
        • Please keep on DAPT use.
        • Please repeated echocardiograpphy study to evaluate the LV wall motion asynergy and LV systolic function.

[immunochemotherapy]

  • 2024-01-30 - irinotecan 170mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 395mg NS 250mL 2hr + fluorouracil 2400mg/m2 2990mg NS 500mL 46hr (FOLFIRI 70%)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
  • 2023-12-29 - irinotecan 170mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 390mg NS 250mL 2hr + fluorouracil 2400mg/m2 2970mg NS 500mL 46hr (FOLFIRI 70%)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
  • 2023-12-12 - irinotecan 170mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 390mg NS 250mL 2hr + fluorouracil 2400mg/m2 2970mg NS 500mL 46hr (FOLFIRI 70%)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
  • 2023-11-16 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 170mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 390mg NS 250mL 2hr + fluorouracil 2400mg/m2 2970mg NS 500mL 46hr (FOLFIRI 70%)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
  • 2023-10-24 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 170mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 390mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFIRI 70%)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
  • 2023-09-21 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 170mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 390mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFIRI 70%)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
  • 2023-08-24 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 170mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 390mg NS 250mL 2hr + fluorouracil 2400mg/m2 2300mg NS 500mL 46hr (FOLFIRI 70% x 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
  • 2023-08-01 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 390mg NS 250mL 2hr + fluorouracil 2400mg/m2 2300mg NS 500mL 46hr (FOLFIRI 70% x 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
  • 2023-07-11 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2300mg NS 500mL 46hr (FOLFIRI 70% x 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
  • 2023-06-23 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2500mg NS 500mL 46hr (FOLFIRI 30% off)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg IV + NS 250mL
  • 2023-05-25 - bevacizumab 5mg/kg 200mg NS 100mL 90min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-05-24 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 2500mg NS 500mL 46hr (FOLFIRI 30% off)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + atropine 0.5mg SC + NS 250mL

==========

2024-01-31

[adjusting chemotherapy for hemodialysis patients: fluorouracil and irinotecan]

Fluorouracil itself is not significantly removed by dialysis, but its metabolite, FBAL, can be, making no dosage adjustment necessary for patients on intermittent hemodialysis. Administration should occur post-dialysis on treatment days.

Irinotecan, with partial dialyzability and its active metabolite SN38 not dialyzable, is advised against in hemodialysis due to potential toxicity, especially in end-stage kidney disease. If used, initializing a reduced dose of 50% to 66% of the standard, is recommended, considering individual patient response.

2023-10-25

No medication discrepancies were noted. As of 2023-09-21, the doses of irinotecan and fluorouracil in the FOLFIRI regimen have been increased to 70% of the standard dose, and it appears that the patient is still able to tolerate them.

2023-08-02

  • The patient recently obtained a 28-day supply of hydralazine on 2023-07-31. In stead of hydralazine, the active medication list includes carvedilol and Caduet (amlodipine, atorvastatin), no reconciliation issues found with these medications.

[hemodialysis]

  • Hemodialysis QW135 is arranged for the patient during the course of hospitalization on 2023-08-01 by our nephrologist and EPO 5000 IU QW is suggested if Hb < 11.

  • It is advisable to administer Vemlidy (tenofovir alafenamide) and famotidine after the dialysis session has been completed.

[hypertension]

Despite the patient’s current medication regimen of beta-blocker carvedilol and calcium channel blocker amlodipine, the hypertension readings remain elevated. Therefore, it may be worth considering the addition of an angiotensin-receptor blocker, such as valsartan, to better manage the patient’s hypertension.

2023-06-26

  • Given that the patient is regularly receiving recombinant epoetin beta 2000IU every two or three days at a local clinic, it is likely that these treatments align with the dialysis schedule for his ESRD. Therefore, if the duration of hospital stay is anticipated to exceed the usual interval between dialysis sessions, there might be a need to arrange for in-hospital dialysis. Additionally, the administration of recombinant epoetin beta would need to be organized in accordance with this plan.
  • If Vemlidy (tenofovir alafenamide) is to be given on the same day as dialysis, it should be given after the dialysis is completed.

2023-05-25

  • The patient is currently taking Vemlidy (tenofovir alafenamide 25mg) once daily for his HBV condition. For patients undergoing intermittent hemodialysis (thrice weekly), Vemlidy does not require dosage adjustment. If the dose is scheduled on a dialysis day, it should be administered after the dialysis.

  • If the treatment is switched to Baraclude (entecavir), dosage adjustments are needed for patients on intermittent hemodialysis (thrice weekly). Although entecavir is not significantly dialyzed (13%), it is recommended to administer 10% of the usual indication-specific dose daily. Alternatively, the usual indication-specific dose can be administered every 7 days. Similar to Vemlidy, if the dose falls on a dialysis day, it should be administered after hemodialysis.

  • There appears to be no issue with the current anti-HBV medication listed in the active prescription for the patient.

  • For patients on intermittent hemodialysis (thrice weekly), the dosage adjustments for famotidine are as follows: If the usual dose is 10 mg twice daily, use 10 mg every other day; if the usual dose is 20 mg once daily, use 10 mg every other day; and if the usual dose is 20 mg twice daily, use 10 mg once daily or 20 mg every other day. No supplemental dose is necessary, and it should be administered after hemodialysis on dialysis days.

  • The current prescription of Ulstop (famotidine) at 10mg QD appears to be appropriate and doesn’t pose any issues.

2023-05-24

  • According to the PharmaCloud database, it appears that the patient regularly visits a local physician (LMD) to refill his prescription for epoetin beta for anemia associated with end-stage renal disease (ESRD). However, this medication is not currently on the patient’s active medication list in our records. Therefore, it would be prudent to verify the patient’s continued use of epoetin beta and consider adding it to the active medication list to ensure proper medication reconciliation.

  • It is about to apply the FOLFIRI plus Avastin to the patient on hemodialysis.

    • In patients with renal impairment and a glomerular filtration rate (GFR) less than 10 mL/minute, it is recommended to start irinotecan therapy at 50% to 66% of the initial dose and increase the dose if well tolerated. However, caution should be exercised in patients with impaired renal function.
    • In patients on hemodialysis, irinotecan may be started at 50% to 66% of the initial dose and increased if tolerated, although this is not usually recommended by the manufacturer. Alternatively, the weekly dose could be reduced from 125 mg/m2 to 50 mg/m2 and administered either after hemodialysis or on nondialysis days. This approach allows for better control of potential accumulation of the drug in the body due to impaired renal function.
  • Fluorouracil is typically administered at a standard dose to patients undergoing hemodialysis without the need for dose adjustment. However, it is generally given after the hemodialysis session on dialysis days to prevent potential drug removal during the procedure.

  • This patient also has coronary artery disease 3-vessel disease status post coronary artery bypass graft on 2021-10-29. Fluorouracil has been associated with cardiotoxicity, as reported in postmarketing studies. Manifestations of cardiotoxicity may include angina, myocardial infarction/ischemia, arrhythmia, and heart failure. The risk factors for this toxicity include continuous infusion administration (as opposed to intravenous bolus) and pre-existing coronary artery disease. The American Heart Association recognizes fluorouracil as an agent that may cause reversible direct myocardial toxicity or exacerbate underlying myocardial dysfunction. Therefore, if a patient has previously experienced cardiotoxicity related to fluorouracil, the risks of resuming treatment with this drug have not been well established and must be carefully weighed against the potential benefits. Given these risks, it is recommended to monitor the patient’s cardiovascular status closely during the course of treatment with fluorouracil.

  • As with bevacizumab, no dose adjustment is required for any degree of renal impairment. However, cardiovascular toxicity, GI toxicity (perforation or fistula), thromboembolic events should be observed.

701340072

240131

[exam findings]

  • 2024-01-29 CT - abdomen
    • Abdominal CT with and without enhancement revealed:
      • Splenomegaly and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
      • Modereate ascites is found.
      • Several low density lesions are found at both lobes of liver with marginal enhancement and loss of surface integrity at S5. Multiple metastatic tumor with probably previous tumor rupture is found.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • The portal vein and IVC are patent.
      • The stomach, colon and pancreas are intact.
    • Imp:
      • Multiple hepatic tumors with bone meta, the origin should be further investigated. HCC is less likely.
  • 2024-01-29 KUB
    • Compression fracture of L1 vertebral body
    • marginal spurs of multiple vertebral bodies due to spondylosis.
    • increased air in nondistended loops of small bowel over RUQ, could be paralytic ileus

[MedRec]

  • 2024-01-29 SOAP Medical Emergency Li XuanQing
    • S
      • Abdominal distension and pain 1 week
      • constipation in the first 2-3 days then few stools noticed
      • no fever, no chest pain, no back pain
      • no N/V, no diarrhea, no tarry stool, no dysuria
      • Past History: HBV carrier
      • Surgical history: denied abd OP
      • Drug allergy: NKDA
    • O
      • Vital signs: BP:134/80; HR:106; BT:35.7’C; RR:18;
      • Con’s:E4V5M6
      • SpO2:99%
      • Conscious: clear and oriented
      • HEENT: pink conjunc, anicteric sclera
      • BS: bil. symmetric expansion
      • Heart: RHB
      • Abdomen: distended, diffuse tenderness, no rebound tenderness, no muscle guarding
      • Ext: freely movable, no pitting edema
    • A/P
      • Preliminary impression: R10.9 Unspecified abdominal pain
      • 2024/01/29 09:04 WBC = 10.38 x10^3/uL;
      • 2024/01/29 09:16 Bilirubin total = 2.11 mg/dL;
      • 2024/01/29 09:16 CRP = 11.3 mg/dL;
      • 2024/01/29 09:16 Creatinine = 0.62 mg/dL;
      • 2024/01/29 09:16 ALT = 54 U/L;
      • 2024/01/29 10:43 Bilirubin direct = 1.11 mg/dL;
      • 2024/01/29 10:43 r-GT = 1054 U/L;
      • 2024/01/29 10:43 Alkaline phosphatase = 402 U/L;
      • 2024/01/29 10:43 AST = 56 U/L;
      • 2024/01/29 CT: ABD — whole abdomen, Pelvis (with and without contrast)
        • Imp: Multiple hepatic tumors with bone meta, the origin should be further investigated. HCC is less likely.
    • Prescription
      • TaiTa No.5 Inj (electrolyte solution) 1000mL ST IVD
      • Flumarin (flomoxef sodium) 1000mg ST & Q8H IVD
      • NS 1000mL ST IVD
      • Tramtor (tramadol) 100mg ST IVD
      • Imperan (metoclopramide) 10mg ST IVD

==========

2024-01-31

[reconciliation]

The patient presented to our emergency department with a week-long history of abdominal distension and pain. CT imaging revealed multiple hepatic tumors and bone mets, necessitating further investigation to determine the primary source. Lab tests highlighted abnormalities in liver function.

  • 2024-01-29 Bilirubin direct 1.11 mg/dL
  • 2024-01-29 r-GT 1054 U/L
  • 2024-01-29 Alkaline phosphatase 402 U/L
  • 2024-01-29 AST 56 U/L
  • 2024-01-29 Bilirubin total 2.11 mg/dL
  • 2024-01-29 CRP 11.3 mg/dL
  • 2024-01-29 ALT 54 U/L

Ongoing management includes hydration, analgesics, electrolyte supplementation, diuretics, and gastrointestinal motility-enhancing agents. A review of the PharmaCloud database found no discrepancies in medication administration.

701020753

240130

[exam findings]

  • 2024-01-18 CT - abdomen

    • History and indication: Malignant neoplasm of descending colon
    • With and without contrast CT of abdomen-pelvis revealed:
      • S/P operaiton and internal stenting. Enlarged LNs (up to 1.0cm) at mesentery and retroperitoneum.
      • Multiple liver metastases.
      • Right abdominal wall herniation.
      • Left renal stone (5mm).
      • Interstitial pattern at bilateral basal lungs. A nodule (1.5cm) at RLL.
    • IMP:
      • S/P operaiton. Liver and lung metastases.
  • 2023-11-03 All-RAS + BRAF mutation

    • Cellblock No. F2022-00282 FsA4
    • RESULTS:
      • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-10-04 CT - abdomen

    • History: D-colon CA wt obstruction, pT3N1c cM0, pStage IIIB, s/p Op on 2/17 21 by Dr Lv ZongRu
      • 20220520 CT: two kissing lesions with soft tissue and cystic component in right adnexa, measuring 4.8 cm and 2.8 cm in size. The differential diagnosis includes cystic adenocarcinoma of right ovary or tumor seeding of the colon cancer.
      • 20220617 Rt, oophorectomy: adenocarcinoma, metastatic, colon origin.
      • 20230531 CT: Recurrent adenocarcinoma of the sigmoid colon.
      • 20230627 sigmoidoscopy: sigmoid colon cancer with obstruction S/P stent implantation.
    • Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There are three newly developed poor enhancing lesions 1.6 cm in S7 and S2, and 1.1 cm in S6 of the liver that are c/w metastases.
      • There is a newly developed soft tissue nodule in RLL of the lung, 1 cm in size, that is c/w lung metastasis.
      • Prior CT identified multiple lymph nodes in the celiac trunk, hepatoduodenal ligament, para-aortic space, para-cava space, mesentery, and bilateral inguinal area are noted again, stable in size.
        • Metastatic nodes S/P C/T show stable disease.
      • S/P metalic stent implantation at the sigmoid colon cancer area.
      • Prior CT identified segmental circumferential wall thickening at the sigmoid colon is noted again, stationary.
      • S/P left hemicolectomy.
      • Right middle abdominal wall herniation.
      • A renal stone 5 mm in left upper pole.
    • Impression:
      • Three newly developed metastases in S7, S2, and S6 of the liver.
      • One newly developed metastasis 1 cm at RLL of the lung.
      • Multiple metastatic nodes S/P C/T show stable disease.
  • 2023-06-26 CT - abdomen

    • Findings
      • Enhanced, thickening mucosa at sigmoid colon is found. In comparison with CT dated on 2023-05-31, thelesion is stationray.
      • Severe dilated intestines is found. There is right abdominal wall herniation. No strangulation at the herniated sac is found but narrowing of the intestinal lumen at sigmoid colon wall thickning region is found.
    • Imp
      • Wall thickneing at sigmoid colon with proximal intestinal dilatation. r/o recurrent/residual tumor with intestinal obstruction.
  • 2023-06-26 CXR

    • Cardiomegaly is noted.
    • S/p port-A placement with its tip at left brachiocephalic vein.
    • Faint aveolar opacity over right lower lobe and ll is found.
    • Osteopenia of the bony structure is noted.
    • Increased intestinal gas is found.
  • 2023-06-26 ECG

    • Sinus tachycardia
    • ST & T wave abnormality, consider anterior ischemia
  • 2023-05-31 CT - abdomen

    • History: D-colon CA wt obstruction, pT3N1c cM0, pStage IIIB, s/p Op on 2021/02/17
      • 20220520 CT: two kissing lesions with soft tissue and cystic component in right adnexa, measuring 4.8 cm and 2.8 cm in size.
        • The differential diagnosis includes cystic adenocarcinoma of right ovary or tumor seeding of the colon cancer.
      • 20220617 Rt, oophorectomy: adenocarcinoma, metastatic, colon origin.
    • Findings:
      • There is segmental circumferential wall thickening at the sigmoid colon, 5 cm in size, causing marked dilatation of the proximal colon.
        • Recurrent adenocarcinoma of the sigmoid colon is highly suspected.
        • Please correlate with colonoscopy and CEA.
      • S/P left hemicolectomy
      • Prior CT identified multiple lymph nodes in the celiac trunk, hepatoduodenal ligament, para-aortic space, para-cava space, mesentery, and right supra-diaphragm cardiac-phrenic space are noted again.
        • Some of them show enlarged in size.
        • Metastatic nodes are highly suspected.
      • Right middle abdominal wall herniation.
      • Mild fatty liver.
      • A renal stone 5 mm in left upper pole.
      • Prior CT identified multiple small poor enhancing lesions in the spleen are noted again, stationary.
    • Impression:
      • Recurrent adenocarcinoma of the sigmoid colon is highly suspected.
        • Please correlate with colonoscopy and CEA.
      • Metastatic nodes in para-aortic space and para-cava space.
  • 2023-05-24 Peripheral Echography

    • Report:
      • Right side:
        • SVC: 14.1 mmHg ; 15.7 mmHg ;
        • MVO/SVC: 89 % ; 87 % ;
        • Average MVO/SVC: 88 %
      • Left side:
        • SVC: 11.9 mmHg ; 14.4 mmHg ;
        • MVO/SVC: 84 % ; 80 % ;
        • Average MVO/SVC: 82 %
      • Thrombus : None
      • Varicose vein : None
    • Conclusion
      • No evidence of DVT, bilateral lower legs
      • Right CFV trivial reflux
      • Left CFV trivial reflux
  • 2023-05-24 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (123 - 31) / 123 = 74.80%
      • M-mode (Teichholz) = 75
  • 2023-04-07, -02-23 CXR

    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-02-23 CT - abdomen

    • History and indication:
      • Malignant neoplasm of descending colon
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P operaiton. Enlarged LNs (up to 2.0cm) at mesentery and retroperitoneum.
      • Right abdominal wall herniation.
      • Left ovary cyst (2.0cm).
      • Left renal stone (5mm).
      • Grade 4 fatty liver.
      • Interstitial pattern at bilateral basal lungs.
    • Imp
      • S/P operaiton. Enlarged LNs (up to 2.0cm) at mesentery and retroperitoneum.
  • 2023-01-27 Colonoscopy

    • The scope only reach the D-colon (40cm AAV, previous anastomosis) under good colon preparation. No mucosal lesion was found. The scope can not be advanced more.
  • 2023-01-27 Esophagogastroduodenoscopy, EGD

    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
    • Gastric polyp, fundus, favor fundic gland polyp
    • Suspect gastric subepithelial lesion, fundus
  • 2022-11-14 CT - abdomen

    • Abdominal CT with and without enhancement revealed:
      • Left renal tiny stone about 0.2cm is found.
      • The spleen, liver, pancreas and adrenals are intact.
      • The GB is well distended without soft tissue lesion
      • Abdominal wall herniation is found at RLQ.
      • s/p LAR.
      • Mininmal interstitial change at bilateral basal lungs. previous viral infection is favored.
    • Imp:
      • s/p LAR.
      • No evidence of recurrent/residual tumor in the study.
      • Left renal stone.
  • 2022-10-12 Carotid angiography bilat. Vertebral angiography

    • Diagnostic intraarterial angiography of brain vasculature by way of bilateral internal carotid and left vertebral arteries was performed. The related benefit and risk of this procedure was explained to patient and patient family member with written consent being obtained in advance.
    • Imaging findings:
      • Fenetration of V-B junction. Suggest follow up by MRA annually.
      • The whole procedure was smoothly done without apparent immediate complication and the patient stood it well under local anesthesia.
  • 2022-10-12 Aortography - thoracic

    • Diagnostic aortography was performed. The related benefit and risk of this procedure was explained to patient and patient family member with written consent being obtained in advance.
    • Imaging findings:
      • Type I aortic arch.
      • No critical stenosis of bilateral proximal carotid and vertebral arteries.
      • The whole procedure was smoothly done without apparent immediate complication and the patient stood it well under local anesthesia.
  • 2022-10-11 ECG

    • Normal sinus rhythm
    • T wave abnormality, consider anterior ischemia
  • 2022-09-20 MRA - brain

    • Findings:
      • Known a case of colon cancer. No abnormal signal lesion within brain parenchyma.
      • Mild periventricular small vessel disease. NO acute ischemic infarct.
      • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
      • MR angiography of the brain shows possible one fusiform aneurysm (8.5mm in length) over V-B junction. Suggest check CTA or refer to my OPD (W3/No.209).
    • Impression:
      • Possible one fusiform aneurysm (8.5mm in length) over V-B junction. Suggest check CTA or refer to my OPD (W3/No.209).
  • 2022-07-25 CT - chest

    • Indication: submassive PE s/p EKOS throbmolysis post-op f/u
    • Findings:
      • pulmonary arteries: complete resolution of filling defects at Rt distal pulmonaty artery and RUL pulmonary artery compared with CTPA on 2022/6/21. well opacification of other pulmonary arteries. dilated right main artery (2.5cm).
      • Pleura: trace bilateral effusions.
      • Lungs: multiple small solid nodules in both lungs, with minimal centrilobular nodular and branching opacities at RUL.
        • mosaic attenuation at RLL and LLL.
      • Visible abdomen:
        • right middle abdominal wall herniation and a 4mm left renal stone.
    • Impression:
      • resolution of pulmonary embolism as compared with CTPA on 2022/06/21.
      • multiple small solid nodules in both lungs due to metastases, with minimal inflammatory bronchiolitis at RUL.
  • 2022-06-27 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (106 - 27) / 106 = 74.53%
      • LVEF(%) = 74
      • M-mode (Teichholz) = 74
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated LA; LV diastolic dysfunction Gr 1.
      • Normal RV systolic function.
      • Mild MR; mild TR; mild PR.
      • Possible mild pulmonary hypertension, estimated PASP: 38 mmHg.
      • No RA/RV dilatation; no RV pressure overload sign.
  • 2022-06-21 CTA - chest

    • Findings
      • Vessels:
        • pulmonary arteries: filling defects at Rt distal pulmonaty artery and RUL pulmonary artery consistent with acute pulmonary embolism. dilated trunk (3.5cm in caliber) and left and right main arteries.
          • well opacified proximal and middle segments of the LAD, and LCX, and right coronary arteries.
        • Aorta: normal appearance of thoracic aorta.
        • Heart: dilated LA.
      • Pleura: small bilateral effusions.
      • Lungs: dependent partial atelectasis of both lower lobes. mosaic attenuation at LUL.
      • Visible abdomen: right middle abdominal wall herniation and mild ascites. increased air in nondistended loops of small bowel and colonic segments. a tiny left renal stone 5mm.
    • Impression:
      • Rt pulmonary artery and RUL pulmonary artery acute pulmonary embolism.
      • pulmonary hypertension and small pleural effusion.
      • dependent atelectasis of both lower lobes of lungs and suspect LUL small airways disease.
  • 2022-06-21 Vein Sonography

    • Conclusion:
      • No venous thrombosis at bilateral deep and superficial venous system
      • No varicose veins at both GSV/SSV area
      • delay venous return at both popliteal and PTV due to prolonged bed rest
      • The MVO/SVC ratio didnot favor the proximal iliac vein or IVC obstruction
  • 2022-06-21 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (137 - 54) / 137 = 60.58%
      • M-mode (Teichholz) = 60
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA and LV, grade 1 LV diastolic dysfunction
      • Mild MR, TR and PHTN
  • 2022-06-17 Patho - soft tissue tumor, extensive resection

    • PATHOLOGIC DIAGNOSIS
      • Ovary, right, salpingo-oophorectomy with frozen section (F2022-283) —- adenocarcinoma, metastatic. IHC stains: CK7 (-), CK20 (+), CDX-2 (+), PAX-8 (-), WT(-): a pattern of colon origin.
      • Ovary, left, salpingo-oophorectomy —- Free
      • Fallopian tube, left, salpingo-oophorectomy —- free.
      • Fallopian tube, right, salpingo-oophorectomy —-adenocatcinoma, metastatic
      • Uterus, corpus, total hysterectomy (S2022-9791A) — free; Endometrium: benign atrophic
      • Uterus, cervix, total hysterectomy — free
      • Abdominal tumor, excision (S2022-9791B) — one tumor nodule and one of two lymph node with tumor metastasis (½).
      • Abdominal tumor, excision (S2022-9791C) — calcified fibrotic nodes and one benign lymph node (0/1)
      • Lymph node, Bilateral pelvic iliac and obturator, dissection (S2022-9791D-G) — Free.
    • MACROSCOPIC EXAMINATION
      • Procedure
        • Debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymphnode dissection + abdominal tumor excision) + enterolysis
        • Peritoneal washing
      • Specimen size:
        • right ovary: 8 x 6 x 4 cm (opened by surgeon) with multiple solid component inside and on the serosal surface of the ovary, the largest tumor focus 3 x 2.2 x 2.2 cm.
        • left ovary: 2 x 1.5 x 1 cm;
        • right tube: 4.5 x 0.5 x 0.5 cm;
        • left tube: 4 x 0.5 x 0.5 cm;
        • uterus: 8 x 5 x 3 cm
          1. abdominal tumor: 3 pieces, up to 0.8 x 0.4 x 0.4 cm.
          1. abdominal tumor”: 3 pieces, up to 1.2 x 0.8 x 0.8 cm.
      • Specimen Integrity
        • Specimen Integrity of Right Ovary
          • Capsule – opened by the surgeon
        • Specimen Integrity of Left Ovary
          • Capsule intact
        • Specimen Integrity of Right Fallopian Tube – tumor seeding
        • Specimen Integrity of Left Fallopian Tube-Serosa intact
      • Tumor Site: Right ovary
      • Ovarian Surface Involvement- Present (Right)
      • Fallopian Tube Surface Involvement -Present (Right)
      • Tumor Size -multiple solid component inside and on the serosal surface of the ovary, the largest tumor focus 3 x 2.2 x 2.2 cm.
        • Greatest dimension (centimeters): 3 cm
        • Additional dimensions (centimeters): 2.2 x 2.2 cm
      • Sections are taken and labeled as:
        • Tissue for frozen section: F2022-282FSA1-4: right ovarian tumor.
        • Tissue for formalin fixation: F2022-282X1: right Fallopian tube; X1-8: additional sampling of tumor in and on the right ovary.
        • S20229791A1: left Fallopian tube; A2: left ovary; A3-4: endometrium and uterine corpus; A5-6: uterine cervix; B: “02. abdominal tumor”; C: “03. abdominal tumor”; D: “04 right iliac lymph nodes”; E: “05. right obturator lymph nodes”; F: “ 06. left iliac lymph nodes”; G: “07. left obturator lymph nodes”.
    • MICROSCOPIC EXAMINATION:
      • Histologic type: adenocarcinoma.
      • Contralateral ovary involvement: absent
      • Tumor side ovarian surface involvement: present
      • Contralateral ovary surface involvement: absent
      • Right tube involvement: absent
      • Left tube involvement: present
      • In situ adenocarcinoma in right &/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: present
      • Left adnexa soft tissue involvement: absent
      • Pelvic soft tissue involvement: present (tissue labeled as “02. abdominal tumor”)
      • Uterine serosa involvement: absent
      • Omentum involvement: no tissue submitted.
      • Uterine Cervix involvement: absent
      • Endometrium involvement: absent
      • Myometrium involvement: absent
      • Appendix involvement: not received
      • Peritoneal/Ascitic Fluid- Negative for malignancy (normal/benign)
      • Regional Lymph Nodes: Negative for metastasis: describe locations - 0/29= D: “04 right iliac lymph nodes” 0/9; E: “05. right obturator lymph nodes” 0/7; F: “06. left iliac lymph nodes” 0/7; G: “07. left obturator lymph nodes” 0/6.
      • Other organs or specimens involvement: absent.
  • ……

  • 2021-02-18 Patho - colon segmental resection for tumor

    • PATHOLOGIC DIAGNOSIS
      • Large intestine, descending colon, extensive left hemicolectomy
        • Adenocarcinoma, moderately differentiated
        • A tumor deposit is seen
        • A colostomy is present
      • Small intestine, ileum, extensive left hemicolectomy —- Negative for malignancy
      • Omentum, extensive left hemicolectomy —- Negative for malignancy
      • Resection margins: free
      • Lymph node, mesocolic, dissection —- Negative for malignancy (0/70)
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: pStage IIIB, pT3N1c(if cM0)
    • MACROSCOPIC EXAMINATION
      • Operation procedure: extensive left hemicolectomy
      • Specimen site: descending colon
      • Specimen size: colon: 57 cm in length, ileum: 7 cm, omentum: 28 x 6 x 2 cm, appendix is not found; with a colostomy
      • Tumor size: 3.5 x 3.0 cm, annularly ulcerated
      • Tumor location: 3.0 cm and 55 cm away from the two resection margins, respectively
      • Depth of invasion grossly: mesocolic soft tissue
      • Mucosa elsewhere: congestion
      • Representative sections are taken and labeled as: A1-2: bilateral resection margins; A3: colon, non-tumor; A4: colostomy; A5:omentum; A6-9: tumor; A10-15: lymph node, mesocolic.
    • MICROSCOPIC EXAMINATION
      • Histology: adenocarcinoma
      • Histology Grade: moderately differentiated
      • Depth of invasion: mesocolic soft tissue
      • Angiolymphatic invasion: Present.
      • Perineural invasion: Present.
      • Discontinuous extramural tumor extension: Not identified.
      • Serosal margin status of colon: Uninvolved, 2 mm in distance.
      • Lymph node metastasis, mesocolic: 0/70
      • Lymph node metastasis, IMA / SMA: Not received
      • Extranodal involvement: Not identified.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN): pN1c: No regional lymph nodes are positive, but there are tumor deposits in the subserosa, mesentery, or nonperitonealized pericolic, or perirectal/mesorectal tissues.
        • Distant Metastasis (pM): if cM0
      • Type of polyp in which invasive carcinoma arose: Tubular adenoma.
      • Additional pathologic findings:
        • A tumor deposit is seen.
        • A colostomy is present.
        • The immunohistochemical stains reveal EGFR(-), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
        • Tumor Budding: Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2): Low score (0-4)
        1. TNM descriptors: unknown
      • Tumor regression grading S/P CCRT: patient not received

[consultation]

  • 2023-06-26 Colorectal Surgery
    • Q
      • Abdominal pain > Acute moderate central pain (4-7), self-reported abdominal pain for 4-5 days and feeling like vomiting
      • fever, no diarrhea, no bloody stool, deny URI S/S
      • PH: colon cancer s/p op and C/T; s/p appendectomy; Rt ovary tumor; Arrhythmia
      • KNA
    • A
      • this is a 66- year old woman with intestinal obstruction
      • CT : R/I sidmoid colon cancer with obstruction
      • A/P: admission and suggest NPO and NG free drainage
      • suggest exp lap or stent decompression
  • 2022-06-23 Anesthesia
    • Q
      • We have current evidence for acute submassive Pulmonary embolism at RPA.
      • She will be received surgical intervention (EKOS) on 6/23.
      • We need your help for pre-op (surgical intervention (EKOS)) anesthesia evaluation. Thanks a lot.
    • A
      • Dx: Acute submassive Pulmonary embolism at RPA
      • Op: EKOS
      • Hx: 6/17 ATH
      • Condition: Cons. clear, previous walking ok, no dyspnea, chest tightness or leg edema
      • CXR: Cardiomegaly, Tortous aorta with calcification, Osteopenia, Senile fibrotic change
      • EKG: Left atrial enlargement
      • AS A4 due to Acute submassive Pulmonary embolism at RPA (ASA 4: A patient with a severe systemic disease that is a constant threat to life.)
      • Airway: Mouth open ok, previous ETT ok
      • Plan:
        • High risk of stroke, shock, MI, AKI…
        • Anes. plan and risk was told to her at bedside at 0830 and son at door of SICU at 0850
        • Resucitation will be procedured if emergence condition.
        • We will arrange ETGA
        • Correct underly dx as your expertise.
        • Follow one-touch q6h when nil per os if DM or high risk of hypoglycemia
  • 2022-06-21 Cardiac Surgery
    • Q
      • for surgical intervension
      • The 65 years old female patient, a case of pelvic tumor, right ovarian cancer s/p debulking surgery on 20220617, Hx of colon cancer s/p OP and arrhythmia
      • She sufferred from sudden onset of dyspnea and elvated D-dimer
      • Chest CT showed right pulmonary embolism
      • We need expertise to evaluate her condition thanks
    • A
      • I have had the pleasure of involving with the patient’s care. In brief, She is a 65 year old female seen in consultation for opinion regarding treatment options for acute submassive Pulmonary embolism at RPA
      • Her underlying dz was noted for:
        • right ovarian adenocarcinoma -> debulking surgery on 2022-06-17
        • Right pulmonary artery and RUL pulmonary artery embolism was noted by CT
        • 2D echo and lower extremities ultrasound done and reviewed. no DVT, no RV strain.
      • upon my visit, her con’s clear. O2: mask. HR 76 NSR. hemodynamics stable.
      • SUGGESTION & PLAN:
        • We have current evidence for acute submassive Pulmonary embolism at RPA
        • I think we have reached a point where there is prudence in considering surgical intervention (EKOS)
        • Explain to family. The patient and family are agreeable with my surgical consultation.
  • 2022-06-21 Cardiology
    • Q
      • Chest CTA -> Right pulmonary embolism
      • Shortness of breath (SOB) was noted at 01:59 this day on 2022/06/21. She had shortness of breath before but SOB could relived by its own. This time, her SOB persisted with respiratory rate up to 36/min.
      • Portable Chest X ray was done and no hemothorax, pleural effusion, or pneumonia match was noted. Breathing sound showed negative wheezing or rhonchi.
      • Blood gas was done and mild respiratory alkalosis was noted with PH:7.403, HCO3:20.5mmol/L, PCO2:33.7mmHg, PO2:101.6mmHg. D-dimer was 9434.35 and NT-proBNP was 166pg/ml.
      • Foster was given as empirical medicine for SOB. Mask oxygenation was used to replace O2 cannula.
      • Her SOB subsided in the morning, and further differential diagnosis was suggested. We need your expertise to evaluate this patient. Thank you very much.
    • A
      • The 65 years old female patient, a case of pelvic tumor, right ovarian cancer s/p debulking surgery on 20220617, Hx of colon cancer s/p OP and Hx of arrhythmia.
      • She sufferred from sudden onset of dyspnea and elvated D-dimer.
        • Chest CT showed right pulmonary embolism
        • O2 sat 95 %, BP 135/63 mmHg, HR 87 BPM
        • CXR showed normal heart size, left platelet lesion
      • Impression
        • acute pulmonary embolism
        • Pelvic tumor and right ovarin cancer s/p debulking surgery
      • Suggest
        • monitor hemodynamics and O2 saturation
        • to arrange echocardiography and venous duplex of lower extremity
        • to check protein C and S, antithrombin III, ANA, lupus anticoagulant
        • clexane 60 mg H q12h if no bleeding tendency or contraindication
        • Blood transfusion to correct anemia
  • 2021-01-17 Colerectal Surgery
    • Q
      • Abdominal pain > Acute central moderate pain (4-7), self-reported abdominal distension and abdominal pain. Vomiting this morning. This patient has been diagnosed with irritable bowel syndrome, she still has abdominal pain after taking medication. TOCC-
      • abdominal fullness and intermittent cramping pain for three days, no radiation to back
      • nausea and vomiting for three times
      • no diarrhea
      • denied fever
      • bilateral pelvic pain for long time, took Ibuprofen rencently
      • PH: arrythmias under Inderal, bil. renal stones s/p ESWL; s/p appendectomy
      • Allergy: nil
    • A
      • suspect D colon lesion with obstruction
      • please NPO with hydration 2500ml QD + antibiotics treatment
      • T loop colostomy if still obstruction
      • NG tube free drain is suggested

[surgical operation]

  • 2022-06-23
    • Surgery
      • Right pulmonary artery EKOS (EkoSonic endovascular system) catheter implantation (12cm) under fluoroscopy
    • Finding
      • Intra-op fluoroscopy confirmed submassive emboli at RPA superior trunk and inter-lobar branch
      • EKOS catheters were inserted at desired target positions.
  • 2022-06-17
    • Surgery
      • Debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymphnode dissection + abdominal tumor excision) + enterolysis
    • Finding
      • Uterus: 8x5x3 cm, normal looking
      • cervix – seemed free of cancer invasion
      • right ovary and tube: ROV 8x8cm solid, necrotic mass, spontaneous ruptured with bloody ascites 600c.c (whole part cut, for frozen pathology)
        • origin? may be primary ovarian cancer or metastitic colon cancer (previous colon cancer stage III, s/p subtotal colectomy + colostomy)
        • frozen pathology of right ovary – adenocarcinoma, origin to be deterimined
      • left ovary and tube: normal-looking
      • bowels and liver – seemed free of cancer invasion
      • omentum and appendix – not found due to previous resection?
      • abdominal tumor (located on bladder surface) – cancer invasion?
      • abdominal tumor (located on right pelvis) – cancer invasion?
      • Bilateral pelvic iliac and obturator LNs was removed
      • CDS: bloody ascites 600c.c (cytology was sent), amnd severe bowel adhesion (due to previous s/p subtotal colectomy + colostomy and appendectomy?) was noted between ant peritoneum, bladder, bil pelvis and bowels s/p enterolysis
      • After the operation, optimal debulking surgery was achieved; no residue tumor
      • A 7mm JP drain was placed in CDS
  • 2021-02-17
    • Surgery
      • Subtotal colectomy + Closure of loop colostomy      
    • Finding
      • Anastomosis : Functional end-to-end anastomosis by GIA * 2    
      • One JV at pelvic area  
  • 2021-01-18
    • Surgery
      • T loop colostomy        
    • Finding
      • Dilation of T colon    

[chemotherapy]

  • 2024-01-29 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
  • 2024-01-05 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
  • 2023-12-06 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
  • 2023-11-15 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
  • 2023-11-02 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.25mg
  • 2023-10-11 - irinotecan 160mg/m2 240mg D5W 250mL 90min (FOLFIRI. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 0.25mg
  • 2023-09-20 - irinotecan 160mg/m2 240mg D5W 250mL 90min (FOLFIRI. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 0.25mg
  • 2023-08-30 - irinotecan 160mg/m2 240mg D5W 250mL 90min (FOLFIRI. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 0.25mg
  • 2023-08-09 - irinotecan 160mg/m2 240mg D5W 250mL 90min (FOLFIRI. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 0.5mg
  • 2023-07-19 - irinotecan 160mg/m2 260mg D5W 250mL 90min (FOLFIRI. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 0.5mg
  • 2023-06-20 - irinotecan 160mg/m2 260mg D5W 250mL 90min (FOLFIRI. He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg SC
  • 2023-05-12 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr (FOLFOX. Wan XiangLin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-07 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr (FOLFOX. Wan XiangLin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-17 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr (FOLFOX. Wan XiangLin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-21 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr (FOLFOX. Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-31 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-13 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-22 - oxaliplatin 90mg/m2 150mg D5W 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-01 - oxaliplatin 80mg/m2 130mg D5W 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-04 - oxaliplatin 80mg/m2 130mg D5W 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-09-13 - bevacizumab 5mg/kg 300mg NS 150mL 90min + oxaliplatin 80mg/m2 130mg D5W 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-08-23 - oxaliplatin 70mg/m2 110mg D5W 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-08-08 - irinotecan 160mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
  • 2022-07-22 - irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4590mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
  • 2021-05-14 - oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4530mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-04-30 - oxaliplatin 85mg/m2 137mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-04-16 - oxaliplatin 60mg/m2 90mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-08-23 ~ undergoing - Xeloda (capecitabine 500mg) 3# BID
  • 2021-06-25 ~ 2021-11-29 - Xeloda (capecitabine 500mg) 2# BID

==========

2024-01-30

[propranolol dosage consideration following new BP data]

Lab data from 2024-01-29 and vital signs from the TPR panel appear largely within normal limits. However, the BP reading on the morning of 2024-01-30 was 98/51 mmHg, which is not considered high. Based on the clinical context, it might be feasible to slightly reduce the dosage of Propranolol (Propranolol) if deemed appropriate.

2023-07-05

[leukopenia]

  • The temporal changes in the WBC count are summarized in the following table, where records marked with an asterisk represent WBC counts < 3K/uL.

    • 2023-07-03 WBC 2.81 x10^3/uL *
    • 2023-07-01 WBC 3.68 x10^3/uL
    • 2023-06-29 WBC 4.66 x10^3/uL
    • 2023-06-28 WBC 3.10 x10^3/uL
    • 2023-06-27 WBC 2.23 x10^3/uL * filgrastim
    • 2023-06-26 WBC 2.48 x10^3/uL *
    • 2023-06-20 WBC 9.57 x10^3/uL irinotecan - can be associated with leukopenia (63% to 96%, grades 3/4: 14% to 28%)
    • 2023-06-14 WBC 5.16 x10^3/uL
    • 2023-06-07 WBC 5.72 x10^3/uL
    • 2023-05-12 WBC 5.62 x10^3/uL oxaliplatin
    • 2023-04-28 WBC 4.95 x10^3/uL
    • 2023-04-07 WBC 6.58 x10^3/uL oxaliplatin
    • 2023-03-17 WBC 7.04 x10^3/uL oxaliplatin
  • The dosage of irinotecan used on 2023-06-20 was adjusted down from the standard 180mg/m2 to 160mg/m2.

  • On 2023-07-03, the ANC was 2.81K/uL x 41.9% = 1177/uL, which is a grade 2 neutropenia (1000~1499/uL). If this value occurs during a therapy cycle, a further decrease of 20mg/m2 to 140mg/m2 could be considered.

701505090

240130

[exam findings]

  • 2024-01-18 CT - abdomen
    • History and indication: Rectal adenocarcinoma
    • With and without contrast CT of abdomen-pelvis revealed:
      • Mild regression of rectal cancer and liver metastases. Stable condition of LUL lesion.
      • Liver and renal cysts.
      • Gallbladder polyp (2.9mm).
    • IMP:
      • Mild regression of rectal cancer and liver metastases. Stable condition of LUL lesion.
  • 2023-12-21 MRI - brain
    • No evidence of intracranial lesion.
  • 2023-11-21 All-RAS + BRAF mutation
    • Cellblock No. S2023-23092
    • RESULTS:
      • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-11-20 PET scan
    • Increased FDG uptake in a focal area from the R-S junction to rectal region, compatible with the primary rectal cancer.
    • Increased FDG uptake in both lobes of the liver, highly suspected rectal cancer with liver metastases.
    • Mildly increased FDG uptake in a small nodular lesion in the left upper lung, the nature is to be determined (favor inflammation process due to lower uptake of FDG).
    • Increased FDG uptake in several lymph nodes of bilateral neck regions, probably benign in nature, suggesting follow-up.
    • Increased FDG uptake in the left 7th rib, the nature is to be determined also (post-traumatic change, cancer with bone mets, or other nature ?), suggesting follow-up.
    • Rectal cancer, cTxNxM1a, stage IVA (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-11-20 Patho - colon biopsy (Y1)
    • Colorectum, low- middle rectum, 6 cm from anal verge, biopsy — Adenocarcinoma.
    • Section shows piece(s) of colonic tissue with invasive irregular neoplastic glands. An addendum report of the result of IHC stains of EGFR, PMS2, MSH6, MSH2, and MLH1 will be followed.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-11-17 Sigmoidoscopy
    • Diagnosis:
      • One ulcerative tumor mass was found at low-middle rectum (6cm AAV) with lumen narrowing and impending obstruction
    • Suggestion:
      • F/U pathology report
  • 2023-11-15 CT - abdomen
    • CC: BW loss 13kg, altered bowel habit for 8 months, anal bleeding (+).
      • 20231114 CC: colorectal cancer Dx at the MaioLi HongDa Hospital.
      • 20231117 colonoscopy: One ulcerative tumor at low-middle rectum (6cm AAV) with lumen narrowing and scope cannot be passed through.
    • Findings:
      • There is circumferential mild asymmetrical wall thickening at the rectosigmoid junction (5 cm in size) and wall thickening at right lateral aspect of the rectum (2.3 cm in size).
        • Adenocarcinoma of the rectum (T3) is highly suspected.
        • Please correlate with colonoscopy and MRI.
      • There are seven enlarged nodes in the perirectal space and sigmoid mesocolon that may be metastatic nodes (N2b).
      • There are several lobulated poor enhancing masses on both hepatic lobes (up to 6.6 cm in S5/7/8) that are c/w liver metastases (M1a).
      • There is a small ground-glass opacity 6 mm at LUL of the lung (Srs:601 Img:30).
        • Primary lung cancer is suspected.
        • The differential diagnosis includes metastasis and intrapulmonary node.
      • There are several hepatic cysts in both lobes (up to 3.1 cm in S7).
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2b(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)

[MedRec]

  • 2023-12-03 ~ 2023-12-07 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Rectal adenocarcinoma with impending obstruction and liver metastases, T3N2bM1a; stage: IVA
    • CC
      • For schedualed chemotherapy with FOLFIRI
    • Present illness
      • This is a 49 year-old female, with history of rectal adenocarcinoma with impending obstruction and liver metastases, T3N2bM1a; stage: IVA, left lung 0.6cm nodule., admitted for schedualed chemotherapy with FOLFIRI plus Erbutux.
      • Tracing back to her history, she suffered from body weight loss 13kg, bowel habit change for 8 months accompanied with anal bleeding without tarry stool. She visited MiaoLi HongDa Hospital for help and colorectal cancer was proven via colonoscopy by pathology, therefore, she was reffered to our GI OPD for survey.
      • Further abdominal CT revealed rectal cancer with liver metastases, and left lung nodule. Port-a insertion was done on 2023/11/30.
      • This time, she was admitted for Chemotherapy with FOLFIRI plus Erbitux C1.
    • Course of inpatient treatment
      • After admission, we prescribed C1 chemotherapy with 5-FU and Irinotecan
      • (this section should not be correct after reviewing the records) After she admitted, she received hydration. the stool softener drugs, Imperan for vomiting treatment. After treatment, the symptom of nausea, vomiting improved. He received C3 chemotherapy with cisplatin 40mg/m2 weekly on 2023/11/28. Then, he suffered from hematemesis once (64.2ml bloody) on 2023/11/29, and after radiotherapy, he suffered from hematemesis noted (174 ml blood clot) on 2023/11/30, so gave Transamine 500mg IVD, Transamine 500mg INHL, hold Bokey for bleeding control. Due to the tumor is bleeding, so continue radiotherapy. After treatment, the symptom of hematemesis improved, and hold C4 chemotherapy this moment. He can be discharged on 2023/12/05, the OPD follow-up will be arranged.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Vemlidy (tenofovir alafenamdie 25mg) 1# QD

[consultation]

  • 2024-01-02 Dermatology
    • Q
      • for acne evaluation
      • This is a 49 year-old female, with history of rectal adenocarcinoma with impending obstruction and liver metastases, T3N2bM1a; stage: IVA, left lung 0.6cm nodule., admitted for schedualed chemotherapy with FOLFIRI plus Erbitux.
      • She complaints acne at face noted since targeted therapy with Erbitux, so we need your help for acne evaluation, thanks a lot!!
    • A
      • The patient had sufferred from anceiform eruption with fine pusutles formaiton over face with mild pruritus.
      • Under the impression of acne vulgaris favor target therapy related.
      • The following sugeetion:
        • allegra 1# bid po and Kolincin Gel 1 tube topical bid use over facial lesions.
        • If still progressive, consider add Doxycycline 1# bid po use for 5-7 days.

[immunochemotherapy]

  • 2024-01-29 - cetuximab 400mg/m2 400mg 2hr + irinotecan 180mg/m2 255mg D5W 250mL 90min + leucovorin 400mg/m2 565mg NS 250mL 2hr + fluorouracil 2400mg/m2 3410mg NS 500mL 46hr (Erbitux + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.5mg SC
  • 2024-01-15 - cetuximab 400mg/m2 400mg 2hr + oxaliplatin 85mg/m2 120mg D5W 250mL 4hr + leucovorin 400mg/m2 575mg NS 250mL 2hr + fluorouracil 2400mg/m2 3450mg NS 500mL 46hr (Erbitux + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2024-01-02 - cetuximab 400mg/m2 400mg 2hr + irinotecan 180mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 575mg NS 250mL 2hr + fluorouracil 2400mg/m2 3470mg NS 500mL 46hr (Erbitux + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.5mg SC
  • 2023-12-18 - cetuximab 400mg/m2 400mg 2hr + irinotecan 180mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Erbitux + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.5mg SC
  • 2023-12-04 - irinotecan 180mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL + atropine 0.5mg SC

701507492

240130

[lab data]

2024-01-22 HBV DNA PCR (Quantitative) 246 IU/mL

2024-01-20 HBeAg Nonreactive 2024-01-20 HBeAg Value 0.361 S/CO

2024-01-11 HBsAg (NM) Positive 2024-01-11 HBsAg Value (NM) 1660.000 2024-01-11 Anti-HCV (NM) Positive 2024-01-11 Anti-HCV Value (NM) 57.800 2024-01-11 Anti-HBc (NM) Positive 2024-01-11 Anti-HBc Value (NM) 0.007 2024-01-11 Anti-HBs (NM) Negative 2024-01-11 Anti-HBs value (NM) <2.000 mIU/mL

[exam findings]

  • 2024-01-04 MRI - nasopharynx
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2024-01-04 SONO - abdomen
    • Indication: Cancer evaluation
    • Symptoms:
      • Liver
        • Coarse liver parenchyma with uneven surface.
      • Pancreas
        • Some parts of pancreas blocked by bowel gas, especially head and tail
      • Spleen
        • Splenomegaly
    • Diagnosis:
      • Liver cirrhosis
      • Status post cholecystectomy
      • Splenomegaly
    • Suggestion:
      • Check HBsAg, anti-HBc, anti-HCV, a-fetoprotein
      • Regular GI OPD follow up after discharge
  • 2024-01-03 Tc-99m MDP bone scan
    • Faint hot spots in both rib cages, and increased activity in the right femoral shaft, U/3, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the lower L- spine, bilaterla shoulders, S-I joints, hips, and knees.
  • 2023-12-25 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopharynx, left, biopsy — Non-keratinizing squamous cell carcinoma, undifferentiated type
    • The sections show a picture of non-keratinizing squamous cell carcinoma, undifferentiated subtype, composed of nests of large neoplastic cells with oval vesicular nuclei and syncytial growth pattern. Keratin formation is absent. Tumor necrosis and inflammatory exudate are present.
  • 2023-12-22 CT - temporal bone HRCT (without contrast)
    • Indication: left otorrhea on and off for one year
    • Without-contrast high-resolution CT scan of temporal bones with 1-mm axial and coronal images reveals:
      • Soft tissue opacification in left mastoid air cells and right middle ear cavity, indicating mastoiditis and COM.
      • Diffuse soft tissue density associating bony destruction involving left nasopharynx, clivus, sphenoid sinuses, pterygopalatine fossa, inferior orbital fissure, foramen ovale and foramen lacerum. R/O advance NPC.
      • Tubular calcification along bilateral intracranial ICAs.
    • IMP:
      • Suspected advanced NPC. Suggest further evaluation.
      • Left COM and mastoiditis.
  • 2023-12-22 Nasopharyngoscopy
    • Findings
      • left facial tender
      • HRCT showed left NP swelling
    • Diagnosis/Conclusion
      • Npscope: left NP swelling tumor, s/p biopsy
  • 2023-12-11 Ear Nose Throat Hearing Test
    • Tymp:
      • RE type Ad; LE perforation?
    • ART:
      • RE ipsi absent, contra CNT.
      • LE ispi CNT, contra absent.
    • PTA:
      • Reliability FAIR
      • Average RE 45 dB HL; LE 85 dB HL.
      • RE normal to profound HL.(1k,4k Hz masking dilemma)
      • LE severe mixed type HL.

[MedRec]

  • 2024-01-10 SOAP Oral and Maxillofacial Surgery He ChengHan
    • S
      • pre-RT dental extraction
    • O: the patient came for dental evaluation before RT of NPC.
      • O: Tooth 11,14,15,32: retained root, food deposition with local inflammation, poor prognosis
      • A: Tooth 11,14,15,32: retained root
      • P: Suggest extraction of tooth 11,14,15,31,32 and 41 before RT.
    • A
      • Nasopharyngeal squamous cell carcinoma, stage cT4N1M0, undifferentiated type.
    • Plan:
      • Explain the risk/benefit of the treatment to the patient
      • Sign informed consent.
      • Block anesthesia of anterior mandible.
      • Complicated extraction of tooth 31,32 and 41
      • Suture the gingiva with Vicryl 4-0.
      • Prescribe Acetal and Amoxicillin.
      • Teach the patient how to do home care and OPD follow-up.
      • Next visit for stitches removal.
    • Prescription
      • Acetal (acetaminophen 500mg) 1# PRNTID
      • Actein (acetylcysteine 200mg) 1# TID
      • amoxicillin 250mg 2# Q8H
  • 2024-01-02 ~ 2024-01-05 POMR Ear Nose Throat Huang YunCheng
    • Discharge diagnosis
      • Nasopharyngeal squamous cell carcinoma, stage cT4N1M0, undifferentiated type.
    • CC
      • Intermittent left otorrhea for 1 year.
    • Present illness
      • This is a 68-year-old man with underlying hypertension, coronary artery disease and diabetes mellitus. he had noticed left otorrhea on and off for about one year. The patient visited local clinic, but the symptom didn’t subside despite medical treatment. The patient then visited our OPD where initial local finding showed right intact eardrum left tympanic membrane perforation with acute infection.
      • Antibiotic of Curam and Earflo were given with mild improvement.
      • Also, audiometry revealed left side mixed type hearing loss.
      • Microscope revealed left chronic otitis media with middle ear polyp.
      • Hence HRCT was arranged to evaluate the middle ear condition. However, the report showed not only left COM with mastoiditis but also diffuse soft tissue at left nasopharynx and density associating multiple bony subsite destruction.
      • Subsequent nasopharynoscope revealed left nasopharynx swelling tumor of which the biopsy report showed nasopharyngeal carcinoma.
      • Admission for further examination was suggested, and the patient agreed after thorough consideration. Therefore, under the impression of nasopharyngeal cancer, the patient was admitted for cancer work-up. 
    • Course of inpatient treatment
      • After admission, serial tests were arranged for tumor staging work up.
      • Nasopharynx MRI showed cT4N1MX.
      • Abdominal sonography showed no prominent metastasis.
      • Whole body bone scan showed faint hot spots in both rib cages, and increased activity in the right femoral shaft which suggested further follow-up.
      • OS, radio-oncologist, hematologist were consulted for evaluation.
      • Under relative stable condition, the patient was dishcarged with OPD follow up.

[consultation]

  • 2024-01-05 Hemato-Oncology
    • Q: same content in the consultation to Radiation Oncology
    • A
      • Dear doctor: This 68 year old man is a case of Non-keratinizing squamous cell carcinoma, undifferentiated type, of the nasopharynx, stage cT4N1M0 (stage IVA). We are consulted for CCRT.
      • Please arrange port A insertion. And check HBsAg, Anti HBc, Anti HBs, Anti HCV. Thanks for your consultation.
      • Arrange our OPD after discharge.
  • 2024-01-05 Radiation Oncology
    • Q
      • Dear doctor, this patient was a newly-diagnosed case of nasopharyngeal carcinoma.
      • He had undergone several study for tumor staging.
        • Bone scan survey report was currently pending. (Initial interpretation seemed to be fair.)
        • MRI showed cT4N1Mx disease with intra-cranial invasion.
        • Abdominal echo showed no evidence of liver metastasis.
      • For the above impression, we would like to ask your expertise to guide our CCRT treatment plan. Thx!!
    • A
      • The patient’s history was reviewed and patient was examined.
      • S: For radiotherapy due to nasopharyngeal carcinoma.
        • PI: According to the patient’s statement, he suffered fro diplopia, left facial focal numbness, occasional stuffy nose, or epistaxis, and hearing impairment for an uncertain period.
        • Family history: (-)
        • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
        • Personal Hx: DM (-); HTN (+)
        • Previous RT Hx: (-)
      • O: ECOG: 0
        • PE: neck and bil SCF: neg; left lateral eye fixation; left facial focal numbness, left side hearing impairment.
        • NP scopy (2023-12-22): left NP swelling tumor , s/p biopsy
        • CT scan of temporal bone (2023-12-22): 1. Soft tissue opacification in left mastoid air cells and right middle ear cavity, indicating mastoiditis and COM. 2. Diffuse soft tissue density associating bony destruction involving left nasopharynx, clivus, sphenoid sinuses, pterygopalatine fossa, inferior orbital fissure, foramen ovale and foramen lacerum. R/O advance NPC. 3. Tubular calcification along bilateral intracranial ICAs. Imp: (1)Suspected advanced NPC. Suggest further evaluation. (2)Left COM and mastoiditis.
        • Pathology (S2023-25765, 2023-12-26): Nasopharynx, left, biopsy – Non-keratinizing squamous cell carcinoma, undifferentiated type.
        • CXR (2024-01-02): No cardiomegaly. No active lung lesion. Tortuosity of the aorta. Degenerative joint disease of T-spine with marginal osteophytes.
        • Bone scan (2024-01-03): Faint hot spots in both rib cages, and increased activity in the right femoral shaft, U/3, the nature is to be determined (post-traumatic change or other nature ?),
        • Abd sono (2024-01-04): Liver cirrhosis. Status post cholecystectomy. Splenomegaly.
        • MRI of nasopharynx (2024-01-04): T4 (intracranial, cranial nerves involvement; N1M0, stage IVA
      • A: Non-keratinizing squamous cell carcinoma, undifferentiated type, of the nasopharynx, stage cT4N1M0 (stage IVA)
      • P: Radiotherapy is indicated for this patient with the following indicators: stage cT4N1M0 (stage IVA)
        • Goal: curative
        • Treatment target and volume: nasopharyngeal tumor, peripheral involved, and bilateral neck
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5000cGy/25 fractions of the nasopharyngeal tumor, peripheral involved, to bilateral neck, and 7000cGy/35 fractions of the nasopharyngeal tumor and involved nodal lesions. The treatment modality and the possible effects of radiotherapy were well explained to the patient and his sister. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started after completion of pre-RT dental evaluation and management.
  • 2024-01-04 Oral and Maxillofacial Surgery
    • Q
      • Dear doctor, this patient was a newly-diagnosed case of nasopharyngeal carcinoma, he was admitted for tumor staging and would receive examination schedule as following: Bone scan: 1/3 1200, Abd sono: 1/4 1030, MRI: 1/4 1240.
      • Since the patient would receive radiation therapy as primary treatment modality, we would like to sincerely ask for your expertise to evaluated the patient’s dental condition and perfomed tooth extraction if needed. Thx!!
    • A
      • Dear doctor, the patient came for dental evaluation before RT of NPC.
      • O: Tooth 11,14,15,32: retained root, food deposition with local inflammation, poor prognosis
      • A: Tooth 11,14,15,32: retained root
      • P: Suggest extraction of tooth 11,14,15,32 before RT.

[radiotherapy]

[chemotherapy]

==========

2024-01-30

[prophylactic nucleoside analogues prescribed for this HBV carrier, silymarin may also be considered.]

The presence of detectable HBV DNA PCR, positive HBsAg, and anti-HBc positivity in recent lab results warrants consideration of pre-emptive antiviral nucleoside analog therapy before commencing chemotherapy to mitigate the risk of HBV reactivation. Self-carried Vemlidy (tenofovir alafenamide) has been prescribed with no discrepancy identified.

Since elevated AST, ALT and direct bilirubin were also noted, the addition of BaoGan (silimarin) could be considered optionally if no contraindication exists.

701509592

240130

[lab data]

2024-01-02 Anti-HBc (NM) Positive
2024-01-02 Anti-HBc Value (NM) 0.012
2024-01-02 Anti-HBs (NM) Positive
2024-01-02 Anti-HBs Value (NM) 12.6 mIU/mL
2024-01-02 HBsAg (NM) Negative
2024-01-02 HBsAg Value (NM) 0.477
2024-01-02 Anti-HCV (NM) Negative
2024-01-02 Anti-HCV Value (NM) 0.035

2023-12-27 Fe (Iron-bound) 36 ug/dL
2023-12-27 TIBC 276 ug/dL
2023-12-27 UIBC 240 ug/dL

[MedRec]

  • 2024-01-14 ~ 2024-01-18 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Adenocarcinoma of D-colon, pT3N1bM0. stage IIIb post left hemicolectomy on 2023/11/28
      • Postive of anti-HBc
    • CC
      • for adjuvent chemotherapy
    • Present illness
      • The 68 y/o woman has Adenocarcinoma of D-colon, pT3N1bM0. stage IIIb post left hemicolectomy on 2023/11/28 in Cardinal Tien hospital nad HBV under treatment of Baraclude since 2024/01/12. She visited our gastroenterology due to colon cancer treatment, then was transferred to Oncology for arrange treatment. She received Port-A insertion on 2024/01/11.
      • This time, she is admitted for first course of first adjuvent chemotherapy, so she was asdmitted on 2024/01/14.
    • Course of inpatient treatment
      • After admission, she received adjuvent as C1D1 FOLFOX on 2024/01/15-01/17.
      • Keep baraclude 1# qdac for postive of anti-HBc.
      • NS hydration during chemotherapy.
      • Under the stable condition, she can be discharged on 2024/01/18. OPD follow up and re-admission is arranged.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
  • 2024-01-12 SOAP Gastroenterology Xiao ZongXian
    • A
      • Resolved HBV
      • Adenocarcinoma of D-colon, pT3M1bM0, stage IIIb
      • post Lt hemicolectomy on 2023-11-28
    • P
      • On HBV prophylaxis for chemotherapy: ETV on 2024/01/12
    • Prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
  • 2023-12-27 SOAP Gastroenterology Zhao YouCheng
    • S
      • Marked hypoalbuminemia has been found prior to undergoing partial colectomy for colon cancer.
    • O
      • P.E.: No icteric sclera, soft abdomen, no leg pitting edema.
      • 2023-10-31: alb 1.83 (at Cardinal Tien hospital)

[chemotherapy]

  • 2024-01-29 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3750mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-01-15 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3750mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

701511954

240130

{donor}

[MedRec]

  • 2024-01-29 ~ 2024-01-30 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Other blood donor, stem cells
    • CC
      • for Peripheral blood stem cell collection
    • Present illness
      • This is a 37-year-old female without any past medical history. She had been selcected for HSCT donor at almost one year ago.
      • This time, she was admitted for Peripheral blood stem cell, and DLI to the recipient.
    • Course of inpatient treatment
      • After being admitted, consult Anesthesia Department for A-line catheter inserting at left radial artery, Vitacal kept injection for prevention Hypocalcemia first. And she received the peripheral blood was circulated and collected the stem cells. After 16+6 liters of peripheral blood was circulated and collected the stem cells, adequate number of CD34+ cell were collected according to the recipient weight (Total CD34+ cell: 152.419*10^6). She was discharged at today with no specific condtion.
  • 2024-01-16 SOAP Hemato-Oncology He JingLiang
    • S
      • BMT/HSCT donor for pre-donation evaluation.
      • Review the referring sheet and system review.
      • Past history: Nothing in particular.
      • Family history: No systemic disease in the family members.
      • Personal history: Smoking (no), alcohol consumption (no), betel nut chowing (no)
      • Allergy: no medicine allergy history.
      • Travel history: no recent travel history.
    • O
      • Skin: unremarkable.
      • HEENT: no deformity, no icteric sclera, no anemic conjunctiva, no visual or auditory deficit
      • Neck: soft and supple, no jugular vein engorgement
      • Chest: symmetrical, no deformity, clear breathing sound, bilaterally
      • Heart: regular heart beat, no murmur
      • Abdomen: soft and flat, no palpable liver and spleen, no inguinal LN enlargement
      • Back and spine: no deformity, no knocking pain at both CV angles
      • Extremity: free movable, no deformity, warm and pink in color
      • Digital examination: not done
    • Diagnosis
      • Bone marrow donor [Z52.3]

701513098

240130

{bone marrow donor}

[MedRec]

  • 2024-01-30

  • 2024-01-23 SOAP Hemato-Oncology He JingLiang

    • S
      • BMT/HSCT donor for pre-donation evaluation.
      • Review the referring sheet and system review.
      • Past history: Nothing in particular.
      • Family history: No systemic disease in the family members.
      • Personal history: Smoking (no), alcohol consumption (no), betel nut chowing (no)
      • Allergy: no medicine allergy history.
      • Travel history: no recent travel history.
    • O
      • Skin: unremarkable.
      • HEENT: no deformity, no icteric sclera, no anemic conjunctiva, no visual or auditory deficit
      • Neck: soft and supple, no jugular vein engorgement
      • Chest: symmetrical, no deformity, clear breathing sound, bilaterally
      • Heart: regular heart beat, no murmur
      • Abdomen: soft and flat, no palpable liver and spleen, no inguinal LN enlargement
      • Back and spine: no deformity, no knocking pain at both CV angles
      • Extremity: free movable, no deformity, warm and pink in color
      • Digital examination: not done
    • Plan
      • arrange admission
    • Diagnosis
      • Bone marrow donor [Z52.3]

700146860

240129

[exam findings] (not completed)

  • 2023-12-14, -10-25, -04-06 EGD
    • Findings
      • Esophagus
        • Minimal mucosa break < 5mm was noted at EC junction.
      • Stomach
        • A huge ulcerative, fungating tumor with necrotic tissue and ozzing at distal stomach, almost occupied whole antrum, s/p hemostasis with Argon plasma coagulation.
        • Coffee ground content was noted at stomach.
    • Diagnosis:
      • Gastric adenocarcinoma, Borrmann type III, tumor bleeding, s/p hemostasis with APC.
      • Reflux esophagitis LA Classification grade A (minimal)
    • Suggestion:
      • PPI usage
  • 2023-05-17 SONO - abdomen
    • Findings
      • Liver
        • Homogeneous echotexture of liver parenchyma. A 0.8 cm hyperechoic mass at rt ant seg.
        • A 0.45cm anechoic lesion was noted at S2.
      • Pancreas
        • Some parts of pancreas blocked by bowel gas, especially head and tail
      • Spleen
        • No splenomegaly
    • Diagnosis:
      • Liver cyst
      • Hepatic tumor R/O hemangioma
  • 2022-11-21 PD-L1 IHC
    • Cellblock No. S2022-19870
    • RESULTS:
      • Combined Positive Score (CPS) assessment: CPS >= 1 and < 10
      • Combined Positive Score (CPS): 5%
  • 2022-11-21 PD-L1 (22C3)
    • Cellblock No. S2022-19870
    • RESULTS:
      • Combined Positive Score (CPS) assessment: CPS >= 1 and < 10
      • Combined Positive Score (CPS): 5%
  • 2022-11-21 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
    • Tumor type: adenocarcinoma
    • Tumor location: stomach
    • Testing assay: SP142 Assay (Ventana)
    • Testing platform: BenchMark ULTRA
    • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
    • Control slide result: [V]Pass, [ ]Fail
    • Adequate tumor cells present (>= 50 viable tumor cells): [V] Yes, [ ] No
    • Result:
      • Tumor cell (TC) staining assessment:
        • TC category: TC >= 5% and < 50%
        • Percentage of PD-L1 expressing tumor cells (%TC): 5%
      • Tumor-infiltrating immune cell (IC) staining assessment:
        • IC category: IC >= 1% and < 5%
        • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): 1%
      • Note:
        • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
        • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2022-11-11 Patho - stomach biopsy
    • Stomach, low body and antrum, biopsy — Adenocarcinoma
    • Microscopically, the sections show a picture of tubular adenocarcinoma of the gastric tissue characterized by tumor cells arranged in tubular, fused glandular or subtle cribriform pattern with enlarged and hyperchromatic nuclei infiltrating in ulcerative stroma.
  • 2022-11-11 EGD
    • Indication: UGI bleeding
    • Findings
      • Esophagus
        • Mucosa break < 5mm was noted at EC junction.
      • Stomach
        • One large semi-annular ulcerative tumor with elevated and nodular margin was noted at low body and antrum. One hemoclip was in-place. One exposed vessel was noted on the ulcer base, s/p hemostasis with argon coagulation plasma, s/p biopsy*8.
    • Diagnosis:
      • Highly suspected gastric malinancy, Borrmann type III, Forrest classification type IIa, s/p hemostasis with APC and biopsy*7
      • Reflux esophagitis LA Classification grade A
    • Suggestion:
      • High dose PPI*3 days
  • 2022-11-10 CT - abdomen
    • History and indication: suspect gastric cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of gastri antrum and lower gastric body with a big ulcer, adjacent fat stranding and regional LAP.
      • Liver and renal cysts (up to 1.4cm). Left liver hemangiomas (6mm, 7mm). Accessory spleen at LUQ.
      • Hyperplasia of left adrenal gland.
      • A nodule (2.5mm) at LUL.
      • Atherosclerosis of aorta, iliac arteries.
      • S/P NG tube indwelling.
      • Degeneration and spondylosis of L-S spine.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N3a(N_value) M:M1(M_value) STAGE:IVB(Stage_value)
  • 2022-11-10 SONO - abdomen
    • Findings
      • Liver
        • Homogeneous echotexture of liver parenchyma.
        • A 0.45cm anechoic lesion was noted at S2.
      • Kidney
        • A 1.91cm anechoic lesion was noted at right kidney.
        • A 0.86cm anechoic lesion was noted at left kidney.
      • Pancreas
        • Some parts of pancreas blocked by bowel gas, especially head and tail
    • Diagnosis:
      • Liver cyst, S2
      • Renal cyst, both kidney
  • 2022-11-08 EGD
    • Diagnosis:
      • Highly suspected gastric malinancy, Borrmann type III, Forrest classification type IIa, s/p hemostasis with hemoclips and biopsy*3
      • Reflux esophagitis LA Classification grade A
      • Incomplete study
    • Suggestion:
      • High dose PPI*3 days
      • NG tube for decompression
      • Admission for UGI care and malinancy work-up

[MedRec]

  • 2023-12-13 ~ 2023-12-18 POMR Gastroenterology Chen JiangHua

    • CC
      • tarry stool passage for days
    • Course of inpatient treatment
      • After admission, NPO with adequate IV fluid supplement, IV form PPI agent and IV transamin were administered.
      • Blood was transfused for the management of anemia.
      • Upper G-I panendoscopy was performed and revealed Gastric adenocarcinoma, Borrmann type III, tumor bleeding, s/p hemostasis with APC; Reflux esophagitis LA Classification grade A (minimal).
      • There was no more tarry stool passage after treatment, oral intake trying was administered. PPI agent and Transamin was shifted to oral form. Under stable condition, she was discharged on 2023/12/18 and GI OPD Follow-up would was arranged later.    
    • Discharge prescription
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Trand (tranexamic acid 250mg) 1# BID
  • 2023-10-20 ~ 2023-10-26 POMR Gastroenterology Chen JiangHua

    • CC
      • tarry stool passage for days
    • Present illness
      • This time, she suffered from tarry stool passage for days. General malaise was noted. She denied chest tightness/pain, diarrhea/constipation, dysuria/frequency found. No TOCC history was noted. She was brought to our GI OPD for help. At GI OPD, the laboratory data showed anemia (Hb: 5.8 g/dL -> 6.4g/dL post LPRBC 2 Units), no leukocytosis. PE showed pale conjunctiva, no icteric sclera, soft abdomen, no leg pitting edema.
      • Under the impression of favor gastric cancer with bleeding. She was admitted to our GI ward for management and further survey.
    • Course of inpatient treatment
      • After admission, NPO with adequate IV fluid supplement, IV form PPI agent and IV transamin were administered.
      • Blood was transfused for the management of anemia.
      • Upper G-I panendoscopy was performed and revealed Reflux esophagitis LA Classification grade A (minimal); Gastric adenocarcinoma, Borrmann type III, tumor bleeding, s/p hemostasis with APC.
      • There was no more tarry stool passage after treatment, oral intake trying was administered. PPI agent and Transamin was shifted to oral form. Under stable condition, she was discharged on 2023/10/26 and GI OPD Follow-up would was arranged later.    
    • Discharge prescription
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Transamin (tranexamic acid 250mg) 1# BID
  • 2023-05-15 ~ 2023-05-17 POMR Gastroenterology Chen JiangHua

    • Discharge diagnosis
      • Gastric adenocarcinoma T4aN3aM1, stage IVB
      • post bleeding Anemia
    • CC
      • Tarry stool passage 7 times since yesterday
    • Present illness
      • This is a 92-year-old male with underlying disease of:
        • Gastric adenocarcinoma T4aN3aM1,stage IVB, with bleeding, with Chinese herbal decoction management.
        • Chronic anemia
        • Old CVA
        • CKD stage III
        • HTN
        • DM
        • HLD
      • This time, he suffered from tarry stool passage 7 times since yesterday. He was brought to our GI OPD for help. He denied fever, URI sympyoms, chest tightness, epigastric pain, abdominal pain found.
      • At GI OPD, blood test showed mild anemia (Hb:10 g/dL). PE showed no icteric sclera, soft abdomen, no leg pitting edema. Under the impression of favor gastric cancer with bleeding. He was admitted to our GI ward for management and further survey.
    • Course of inpatient treatment
      • After admission, we gaved IV PPI for suspect UGIB control. LPRBC was transfusioned for anemia. Since there was no tarry or bloody stool passage, she started oral diet as toleravle. Under relative stable condition, she was discharged on 2024/05/17.  
  • 2023-04-05 ~ 2023-04-08 POMR Gastroenterology Chen JiangHua

    • Discharge diagnosis
      • Malignant neoplasm of stomach with bleeding
      • Acute posthemorrhagic anemia
    • CC
      • tarry stool for 3 times for a day.
    • Present illness
      • This is a 92-year-old male with underlying disease of:
        • Gastric adenocarcinoma T4aN3aM1,stage IVB, with bleeding
        • Chronic anemia
        • Old CVA
        • CKD stage III
        • HTN
        • DM
        • HLD
      • He was admitted on 2022/11/08 for GIB. PES revealed:
        • Highly suspected gastric malinancy, Borrmann type III, Forrest classification type IIa, s/p hemostasis with hemoclips and biopsy*3
        • Reflux esophagitis LA Classification grade A
      • Abdomonal CT reported gastric carcinoma T4aN3aM1, stage:IVB. Further biopsy showed adenocarcinoma. The patient and his family preferred to palliative care.
      • Recurrent tarry stool and anemia was noticed after admission. This time, the patient was found tarry stool for 3 times since 2023/04/05 morning. Accompanied symptoms included productive cough with whitish sputum for 2 days and chronic bilateral legs pitting edema for 5-6 years. There was no fever, chillness, nausea, vomiting, abdominal pain, dyspena, orthopnea, PND or chocking history recently.Due to the above problem, he was sent to our ER.
      • At ER, his consciousness was E4V5M6, vital signs were BP:143/63; HR:78; BT:36.5’C; RR:20; SpO2:97%. PE showed chronic weak ill-looking, moderate anemia conjunctiva, pitting edema(+).
      • Lab data revealed severe normocytic anemia (Hb 6.2, 4/3 Hb: 8.1) and impaired renal function (Cr: 1.31).
      • CXR showed Ground glass opacity in RLL.
      • Pantoprazole was given.
      • Under the impression of UGI bleeding, he was admitted for further care and management.
    • Course of inpatient treatment
      • After admission, we gaved use PPI pump for UGIB control. Also, we arranged PES to survey the lesion. LPRBC was transfusioned for anemia.
      • As times went by, the patient regained fair spirit, Lab data follow up showed health status improved. Under stable status of health, we discharged the patient on 2023/04/08.
  • 2022-12-21 SOAP Psychosomatic Medicine Chen YiQian

    • Diagnosis
      • Unspecified dementia, unspecified severity, with behavioral disturbance [F03.91]
    • Prescription x3
      • Risperdal (risperidone 1mg) 1# HS
      • Exelon Patch (rivastigmine 4.6mg/24h, 9mg/patch) 1# QD EXT
      • Anxiedin (lorazepam 0.5mg) 1# PRNHS
  • 2022-11-08 ~ 2022-11-21 POMR Gastroenterology Chen JiangHua

    • Discharge diagnosis
      • Gastric adenocarcinoma T4aN3aM1, stage IVB
      • Gastric cancer with one exposed vessel bleeding status post hemostasis with submucosal epinephrine injection and hemoclips on 2022/11/08
      • Reflux esophagitis Los Angeles grade Classification grade A
      • Osteoarthritis of right knee with acute inflammation
      • Type 2 diabetes mellitus
      • Hypertension
      • Chronic kidney disease, stage 3
      • Chronic obstructive pulmonary disease
    • CC
      • tarry stool for a period of time (Family doesn’t know the exact duration)
    • Present illness
      • This 92-year-old female has histories of hypertension, diabetes mellitus, hyperlipidemia, coronary arteriosclerosis under plavix control, dementia, old CVA and COPD for years under regular medication control. She COVID-19 was confirmed on 2022/09/23.
      • This time, she suffered from tarry stool for a period of time (Family doesn’t know the exact duration). She visited ER for help.
      • At ER, vital sign BT 36.4C, HR 96/min, RR 18/min, BP 125/61 mmHg, SpO2 94% under room air, consciousness was clear (GCS:E4V5M6).
      • Blood test showed leukocytosis (11.11*10^3/uL), but no left shift, anemia (Hb:7.1 mg/dL), renal dysfunction (BUN/Cr:46/1.38mg/dl), no electrolyte imbalance.
      • EGD was performed and revealed
        • Highly suspected gastric malinancy, Borrmann type III, Forrest classification type IIa, s/p hemostasis with hemoclips and biopsy*3.
        • Reflux esophagitis LA Classification grade A.
      • Medical treatment with Hemoclot 500mg IVD, blood transfusion with LPRBC, pantoloc 80mg IVD and 200mg in NS 500ml IVD 21ml/hr.
      • There was no fever, no dizziness, no URI symptoms, no chest tightness, no epigastric pain.
      • Under impression of gastrointestinal bleeding with anemia,she was admitted to GI ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission to GI ward, NPO with adequate IV fluid supply, NG with decompression and high dose PPI for Gastrointestinal bleeding.
      • Anemia was corrected using blood trnasfusion with LPRBC.
      • EGD on 2022/11/08 was reported 1.Highly suspected gastric malinancy, Borrmann type III, Forrest classification type IIa, s/p hemostasis with hemoclips and biopsy*3. 2.Reflux esophagitis LA Classification grade A.
      • The pathology was showed ulcer with intestinal metaplasia and atypical glands.
      • Abdominal sonography was reported 1.Liver cyst,S2. 2.Renal cyst, both kidney.
      • Abdomonal CT was reported gastric Carcinoma T4aN3aM1, STAGE:IVB.
      • Second look EFD was performed on 2022/11/11 for gastric biopsy.
      • The pathology was showed adenocarcinoma.
      • Family meeting on 2022/11/11 with her family talk about operation and palliative care, that her family need discuss.
      • Oncologist was consulted and who suggested 1. Well discussion with patient and family. 2. Please check HBV and HCV status. 3. Please check the biopsy with MMR (Mismatch Repair), Her2, PD-L1. 4. May consider NGS.
      • Family meeting with oncologist Dr. Xia on 2022/11/18 with her family talk about chemotheraphy, that her family need discuss.
      • Oral intake trying was administered since 2022/11/10 and there was no tarry stool nor coffee ground.
      • IV PPI shifted to oral form with Nexium.
      • Right knee swelling with local heat was found on 2022/11/15. Orthologist was consulted and who suggested 1. Conservative treatment with activity restriction and avoid excessive knee flexion. 2. May consider joint aspiration if progressive painful swelling noted, but carries risk of infection. But still complaint right knee swelling, we contact Orthologist and who suggested if worse may need right knee aspiration and steroid injection. The right knee swelling with local heat was improved.
      • Under the stable condition,she was discharge on 2022/11/21 and GI OPD was arranged leater.
    • Discharge prescription
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Bisacodyl supp 10mg 1# PRNQOD RECT if constipation
      • Ultibro Breezhaler (indacaterol 100mug, glycopyrronium 50ug) 1# QD INHL
      • Atanaal (nefedipine 5mg) 1# PRNQ6H if SBP > 170
  • 2022-09-23 ~ 2022-09-27 POMR Integrative Medicine Chen HengXiang

  • 2021-08-27 ~ 2021-08-28 POMR Nephrology Hong SiQun

  • 2020-11-02 ~ 2020-11-10 POMR Ear Nose Throat Su WanYu

  • 2019-06-05 SOAP Urology Xie ZhengXing

    • Diagnosis
      • Unspecified urinary incontinence [R32]
      • Neuromuscular dysfunction of bladder, unspecified [N31.9]
    • Prescription
      • Wecoli (bethanechol chloride 25mg) 1# BID
  • 2017-08-14 SOAP Cardiology Zhang HengJia

    • Diagnosis
      • Cerebral artery occlusion, with cerebral infarction [I63.50]
      • Acute cystitis [N30.01]
      • Cardiac dysrhythmia, unspecified [I49.9]
      • Chest pain,unspecified [R07.9]
      • HCVD, unspecified, without CHF [I11.9]
    • Prescription x3
      • Norvasc (amlodipine besylate 5mg) 1# BID
      • Uretropic (furosemide 40mg) 0.5# QD
      • Plavix (clopidogrel 75mg) 1# QD
      • Olmetec (olmesartan medoxomil 20mg) 1# BID
  • 2017-07-27 SOAP Chest Medicine Huang JunYao

    • Diagnosis
      • Chronic airway obstruction (COPD), NEC [J44.9]
      • GERD [K21.9]
      • Allergic rhinitis [J30.0]
      • bilateral lung nodules [R91.1]
    • Prescription x3
      • Pulmicort (budesonide 64ug/dose) 1 puff QD perNA
      • Ultibro (indacaterol 110ug, glycopyrronium 50ug) 1# QD INHL
      • Allegra (fexofenadine 60mg) 1# BID
      • Welizen (famotidine 20mg) 1# BID
      • Shitan (bromhexine 8mg) 1# BID
      • Fucou (dextromethorphan, cresolsufonate, lysozyme) 1# BID
  • 2017-06-12 SOAP Metabolism and Endocrinology Yu LiJiao

    • Diagnosis
      • Right pons infarction on 2016/11/30 with left hemiparesis [I63.8]
      • Hypertension [I10]
      • Type 2 diabetes mellitus with hyperglycemia [E11.65]
      • Pure hypercholesterolemia [E78.0]
    • Prescription x3
      • Tulip (atorvastatin 20mg) 0.5# QD
      • Plavix (clopidogrel 75mg) 1# QD
      • Grumed (glimepiride 2mg) 0.5# QDAC
      • Trajenta (linagliptin 5mg) 1# QD
      • Uformin (metformin 500mg) 1# QD

[surgical operation]

  • 2020-11-03 - Op Method:
    • Emergent incision and drainage of deep neck infection, right
    • Finding:
      • abscess over right submental deep neck
      • pus culture done
      • DM, HT, HCVD, angina, COPD, hyperlipidemia, senile = thus LA operation was advised by the superintendent

==========

2024-01-29

[addressing continuous high glucose readings]

During this hospital stay, 4 serum glucose measurements consistently showed values around 300 mg/dL despite the administration of regular insulin and oral antihyperglycemic agents. If hyperglycemia persists, consideration may be given to adding basal insulin to the regimen.

700185693

240129

[exam findings]

  • 2023-11-29 Patho - soft tissue tumor, extensive resection
    • Diagnosis:
      • Ovary, left, laparoscopic debulking surgery — clear cell carcinoma, and endometrioma
      • Ovary, right, laparoscopic debulking surgery — negative for malignancy
      • Fallopian tube, bilateral, laparoscopic debulking surgery — negative for malignancy
      • Cervix, laparoscopic debulking surgery — severe dysplasia (CIN3) with glandular involvement
      • Myometrium, laparoscopic debulking surgery — adenomyosis
      • Endometrium, laparoscopic debulking surgery — negative for malignancy
      • Lymph node, left iliac, dissection — negative for malignancy
      • Lymph node, left obturator, dissection — negative for malignancy
      • Lymph node, right iliac, dissection — negative for malignancy
      • Lymph node, right obturator, dissection — negative for malignancy
      • Omentum, laparoscopic debulking surgery — negative for malignancy
      • AJCC 8th edition pathology stage: pTIc1N0(if cM0); FIGO stage: IC1
    • Gross description:
      • Procedure (select all that apply)
        • laparoscopic debulking surgery (total hysterectomy + bilateral salpingo-oophorectomy + BPLND + omentectomy) and laparoscopic fulguration of pelvic endometriosis
      • Specimen size:
        • Uterus: 8x 6x 6X 5 cm, 63-g
        • Ovary, left: 8x 8 cm
        • Ovary, right: 3x 2x 1 cm
        • Fallopian tube, right: 5 cm in length and 0.4 cm in diameter
        • Fallopian tube, left: 5 cm in length and 0.4 cm in diameter
        • Omentum: 10x 3x 1 cm
        • Note: For information about lymph node sampling, please refer to the Regional Lymph Node section.
      • Specimen Integrity
        • NOTE: For primary ovarian tumors, if the ovary containing primary tumor is removed intact into a laparoscopy bag and ruptured in the bag by the surgeon without spillage into the peritoneal cavity (to allow for removal via laparoscopy port site or small incision), the specimen integrity should be listed as “capsule intact” with a comment explaining this in the report.
        • Specimen Integrity of Left Ovary (if applicable): Capsule ruptured
        • Specimen Integrity of Right Ovary (if applicable): Capsule intact
        • Specimen Integrity of Right Fallopian Tube (if applicable): Serosa intact
        • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
      • Tumor Site:
        • Note: Please select the primary tumor site only
        • Left ovary
      • Ovarian Surface Involvement (required only if applicable):
        • Absent
      • Fallopian Tube Surface Involvement (required only if applicable):
        • Absent
      • Tumor Size
        • Note: For bilateral tumors, please report maximum dimension for each primary tumor, specifying by laterality.
        • Greatest dimension (centimeters): 5 cm
        • Additional dimensions (centimeters): 3 x 2 cm
      • Sections are taken and labeled as: F2023-536FSA1-2 and A1-6:left ovarian tumor, F2023-527A5: left tube, A1-2:right adnexae, A3:cervix, A4-5:coprus, A6:omentum, A7:left iliac LN, A8:left obturator LN, A9: right iliac LN, A10:right obturator LN
    • Microscopic Description:
      • Histologic Type:
        • Clear cell carcinoma
      • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors)
        • Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.)
        • WHO Grading System
        • Not applicable
      • Implants (required for advanced stage serous/seromucinous borderline tumors only)
        • Note: Serous tumor implants that were formerly classified as “invasive implants” are now classified as low-grade serous carcinoma of the peritoneum.
        • Not applicable
      • Other Tissue/ Organ Involvement (select all that apply):
        • Not identified
      • Largest Extrapelvic Peritoneal Focus (required only if applicable)
        • Not applicable
      • Peritoneal/Ascitic Fluid
        • Negative for malignancy
      • Regional Lymph Nodes:
        • Left iliac — negative for malignancy (0/3)
        • Left obturato — negative for malignancy (0/13)
        • Right iliac — negative for malignancy (0/3)
        • Right obturator — negative for malignancy (0/10)
      • Additional Pathologic Findings
        • Cervix: severe dysplasia (CIN3) with glandular involvement
        • Myometrium: adenomyosis
      • Immunohistocehncial stains — Napsin A (+), p16: negative( weak, < 5%), p53: wild type (weak to moderate, 50%).
  • 2023-11-10 SONO - thyroid
    • Autoimmune thyroid disease
  • 2023-10-11 CT - abdomen
    • Indication: p0, SEX (-). r/o chocolate cyst and adenomyosis
    • Findings:
      • There is a cystic mass in left adnexa with mild wall thickening and enhancing mural nodule, measuring 7.8 cm in size (the largest dimension).
        • Cystic adenocarcinoma of left ovary is highly suspected.
        • The differential diagnosis includes cystic adenoma.
    • Impression:
      • Cystic adenocarcinoma of left ovary 7.8 cm is highly suspected.
      • The differential diagnosis includes cystic adenoma.
  • 2023-10-09 Gynecologic ultrasonography
    • IMP: R/O LT Ovarian cystic mass: 75mmx73mm, papillary: (37mmX27mm), no blood flow
  • 2023-10-09 ENT Hearing Test
    • Tymp bil type A
    • ART RE contra 2000-4000 Hz and LE contra 500 ,4000 Hz absent
    • PTA:
      • Reliability FAIR
      • Average RE 11 dB HL; LE 16 dB HL
      • bil WNL except LE 4000 Hz absent
  • 2023-08-07 ENT Hearing Test
    • Reliabilty Fair
    • PTA
      • R’t : 8 dB HL, WNL
      • L’t : 16 dB HL, normal to mild SNHL
    • Tymp
      • R’t : Type As
      • L’t : Type A
    • ART
      • Bil contra absent.
  • 2021-09-24 Neurosonograpy
    • Adequate total VA flow volume (154 ml/min).
    • Normal extracranial carotid, vertebral arterial flows.
  • 2021-09-24 ENT Hearing Test
    • Tymp:
      • Bil type A
    • ART:
      • Bil WNL.
    • PTA
      • Reliability FAIR
      • Average RE 9 dB HL; LE 20 dB HL.
      • R’t WNL.
      • L’t normal to mild SNHL.
  • 2021-09-24 OVEMP
    • cVEMP: Interaural Amplitude Asymmetry ratio : 11.17%, <35%, WNL.
    • oVEMP: Bil show no response.

[MedRec]

  • 2024-01-26 SOAP Gastroenterology Xiao ZongXian
    • S: Bowel irritability after meal.
    • A: Possible chemotherapy-induced GI sx
    • Prescription x3
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Dicetel (pinaverium bromide 100mg) 1# BID
      • Ulstop (famotidine 20mg) 1# BID
  • 2024-01-16 SOAP Infectious Disease Yang QinHui
    • S: referred from Onco for URI
      • sorethroat, running nose, sneezing and ocugh for days
      • hx of ovary cancer under C/T
    • Prescription
      • Xyzal (levocetirizine 5mg) 1# QD
      • Actein Effervescent (acetylcisteine 600mg) 1# BID
      • ZCough (benzonatate 100mg) 1# TID
      • Acetal (acetaminophen 500mg) 1# PRNQ6H if fever BT > 38’C
  • 2024-01-16 SOAP Cardiology Liu ZhiRen
    • S
      • Cystic adenocarcinoma of left ovary s/p first chemotherapy, palpitation off andon for 2 days just after C/T
      • improved now
      • Hx of MVP, COVID-19(+) 2023-03
      • occasionally cough
      • exertional dyspnea, mild, no chest pain
      • insmonia and anxiety
    • O
      • BP: 145/72; HR: 89;
      • 2024-01 ECG: Normal
      • 2023-12 CXR: Normal
      • 2023-11 Normal thyroid function
      • DM-
      • HTN-
      • asthma-
      • smoking-
      • NKA
      • RHB, no mur
      • BSclear
      • no leg edema
    • Prescription
      • Pronolol (propranolol 10mg) 1# PRNTID
  • 2024-01-16 SOAP Psychosomatic Medicine Li JiaFu
    • Diagnosis
      • Unspecified Anxiety Disorder [F41.9]
      • Major Depressive Disorder, Single Episode, Moderate [F32.1]
    • Prescription
      • Lexapro (escitalopram 10mg) 0.5mg QN
      • Anxiedin (lorazepam 0.5mg) 1# QN
      • Alpraline (alprazolam 0.5mg) 1# PRNBID
      • Eurodin (estazolam 2mg) 1# PRNHS
  • 2023-12-29 SOAP Gastroenterology Xiao ZongXian
    • S
      • For HBV prophylaxis
      • Dyspeisia recently
    • A: Resolved HBV - On prophylaxis of antiviral therapy for chemotherapy since 2023/12/29
    • Prescription
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
  • 2023-11-27 ~ 2023-12-03 POMR Obstetrics and Gynecology Chen GuoHu
    • Discharge diagnosis
      • Malignant neoplasm of left ovary
      • Left ovarian cancer, post laparoscopic debulking surgery (laparoscopic total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + omentectomy) and laparoscopic fulguration of pelvic endometriosis on 2023/11/28
      • Endometriosis of pelvic peritoneum
      • Pelvic peritoneal adhesions
    • CC
      • Progressive LY ENLARGINHG left ovarian cystic mass for six months.
    • Present illness
      • This is a 60 years old female, G0P0, sex(-), menopause at 52 years old, with A past history of breast cancer stage II status post left partial mastectomy with chemotherapy and radiation therapy 20+ years ago at Cardinal Tien Hospital, and hyperthyroidism 20+ years ago with regular follow-up without medication. She denied food or drug allergy, and denied hormone and illicit drug usage.
      • According to the patient, she had regular follow-up of breast cancer at Cardinal Tien Hospital, where sonography showed ovarian mass and the doctor suggested follow-up after 3 months. She then came to our OPD for consultation. She denied abdominal pain, increased vaginal discharged, urinary incontinence, dyuria, diarrhea or constipation. GYN Sonography on 2023/10/09 showed uterus size 49x26mm, endometrium thickness 5.5mm, but progression in size of the left ovarian cystic mass: 75x73mm, and papillary content 37x27mm without blood flow, and no ascites. Abdominal CT showed that cystic adenocarcinoma of left ovary 7.8 cm is highly suspected with the differential diagnosis including cystic adenoma. Tumor markers were within normal range (CA125 5.1 U/mL, CEA 1.42 ng/mL).
      • After discussing with the doctor, she asked for surgical intervention. The operation and complication had been fully explained to the patient and her family.
      • She was then admitted to the ward on 2023/11/27 for preparation of Laparoscopic Left salpingo-oophorectomy + frozen section or debulking depending on the frozen pathology report, and further management.
    • Course of inpatient treatment
      • The patient was admitted on 2023/11/27. She underwent laparoscopic Left salpingo-oophorectomy during the operation, and frozen section pathology of the left ovary showed malignant tumor. The debulking surgery (laparoscopic total hysterectomy and bilateral salpingo-oophorectomy + omentectomy + bilateral pelvic lymph node dissection) + laparoscopic fulguration of pelvic endometriosis + enterolysis were then done on 2023/11/28.
      • We gave her Cefazolin and Gentamycin IV form for 3 day and then shifted her antibiotics to Cephalexin oral form.
      • Post-operation wound was dry and clean without dehiscence, discharge, or oozing. Her lab data on 2023/11/28 also showed elevated WBC without fever. Her condition was stable without fever and special complaints since 3 days after the debulking surgery. After flatus, her eating, self voiding and defecation were all ok. The JP drain was removed on 2023/12/2 smoothly. Since all her general conditions were all improved and relatively stable, we arranged discharge on 2023/12/03 for her for further OPD follow up of her recovery status and surgical wound conditions.
    • Discharge presciption
      • Acetal (acetaminophen 500mg) 1# QID
      • Alpraline (alprazolam 0.5mg) 1# TID
      • cephalexin 500mg 1# QID
      • diphenidol 25mg 1# TID
      • Eurodin (estazolam 2mg) 1# PRNHS
      • MgO 250mg 1# QID
      • Through (sennoside 12mg) 2# HS
  • 2021-11-22, -09-20 SOAP Metabolism and Endocrinology Guo XiWen
    • Diagnosis
      • Nontoxic goiter, unspecified [E04.9]
      • Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm [E05.00]
    • Prescription x3
      • Cardiolol (propranolol 10mg) 1# QD
      • methimazole 5mg 2# QD
  • 2020-04-17 SOAP Metabolism and Endocrinology Zhang YaLi
    • Diagnosis
      • Nontoxic goiter, unspecified [E04.9]
    • Prescription x3
      • Polupi (propylthiouracil 50mg) 1# QW14
      • propranolol 10mg 1# PRNQD

[surgical operation]

  • 2023-11-28
    • Op Method:
      • laparoscopic debulking surgery (total hysterectomy + bilateral salpingo-oophorectomy + BPLND + omentectomy) and laparoscopic fulguration of pelvic endometriosis
    • Finding:
      • Uterus: 7x6x5cm, normal-looking
      • LOV and tube
      • tumor rupture due to severe adhesion
      • LOV: 8x8cm cystic tumor with septums, mural part and chocolate fluid inside, suspected ovarian endometrioma
        • Frozen section pathology of left ovary: malignancy
        • left fallopian tube – grossly normal
      • ROV: 2x2cm, grossly normal
        • right fallopian tube – grossly normal
      • omentum, peritoneum, liver and bowels – seemed free of cancer invasion
      • CDS: no fluid but severe pelvic endometriosis (AFS score > 40) and pelvic adhesion were noted between post uterus, left adnexum, left pelvic wall, US ligament, sigmoid colon and rectum and s/p laparoscopic fulguration of pelvic endometriosis and lysis
      • After the surgery, optimal debulking was achieved
      • A 7 mm JP drain was placed in CDS

[chemotherapy]

  • 2024-01-29 - paclitaxel 175mg/m2 257mg NS 250mL 3hr + carboplatin AUC 5 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2024-01-08 - paclitaxel 175mg/m2 258mg NS 250mL 3hr + carboplatin AUC 5 825mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2024-01-29

[reconciliation]

Medications prescribed by specialists in family medicine and gastroenterology on 2024-01-26, and by cardiologists and psychosomatic medicine experts on 2024-01-16, are generally listed in the current active medication roster without issues noted.

700214839

240129

[exam findings]

[MedRec]

  • 2023-10-05 SOAP Hemato-Oncology Xia HeXiong
    • S
      • Treatment course:
        • s/p partial mastectomy and axillary lymph nodes dissection
        • Adjuvant chemotherapy (since 2018/02/22 AC follow by TH)
        • Adjuvant R/T (2018-09-18 ~ 2018-10-31: 5000cGy/25 fractions of the left breast to left SCF, and 6000cGy/30 fractions of the left breast tumor bed (scar) area.)
        • Adjuvant Herceptin (until 2019/05)
        • Adjuvant endocrine therapy (tamoxifen since 2018/09- (? or 2019-06-12) to 2023-06-14)
      • Recurrence over C3, C6 and T1 and L (MRI an Bone scan) vertebral bodies, favor
        • s/p C6 corpectomy to remove cervical spine metastasis
        • reconstruction with VDRS artificial bone+ C5-7 plating
        • R/T 30 Gy/ 10 fx to the multiple mets region, C-spine and sternoclavicular region
    • P
      • Arrange Chest/Abd/Pelvis CT in 2023-10
      • Breast sono Q1Y, next in 2024-01
      • Mammo Q1Y, net in 2024-03
      • Apply CDK4/6 + letrozole
  • 2023-10-03 SOAP Radiation Oncology Wang YuNong
    • O
      • 2023/09/27 Tc-99m MDP whole body bone scan
        • Highly suspected multiple bone metastases in some C-, T- and L-spine, sternum, left sternoclavicular junction, left pelvic bones, left S-I joint, left acetabulum, and right femoral trochanters.
      • 2023/09/25 MRI: L-spine
        • Multiple bone destructions at thoraco-lumbar spine and bil. pelvic bones, especially at T12, L1, L3.
      • 2023/09/21 PATHO - bone resection
        • C6 vertebrae and C56/C67 disc, C6 corpectomy — Metastatic invasive carcinoma, consistent with breast primary
      • 2023/09/16 MRI: C-spine
        • Acute compression fracture of C6 vertebra. R/O pathologic fracture.
        • Enhancing lesions over C3, C6 and T1 vertebral bodies, favor metastases.
    • P:
      • CT-simulation for L-spine mets and pelvic and femoral mets will be done today.
      • Plan to deliver 30 Gy/ 10 fx to the multiple mets region. RT will start aorund 2023/10/09.
      • RT for the C-spine and sternoclavicular region will be arranged the the current Tx completes.
  • 2023-09-15 ~ 2023-09-28 POMR Neurosurgery Hong LiWei
    • Discharge diagnosis
      • Acute compression fracture of cervical 6 vertebra, metastatic invasive carcinoma status post C6 corpectomy to remove cervical spine metastasis and reconstruction with VDRS artificial bone + C5-7 plating on 2023-09-20
      • Secondary malignant neoplasm of bone
      • Cervicalgia
      • Radiculopathy, cervical region
      • Malignant neoplasm of unspecified site of left female breast
    • CC
      • Neck soreness about 5 months, severe recurrent trapezius region pain brachialgia has been persistent for months, more sever of right side, associated with numbness in right hand a weeks.
    • Present illness
      • This 56 years old female patient had left breast cancer s/p left partial mastectomy + axillary lymph node dissection on 2018-01-31. Adjuvant chemotherapy with Epirubicin 90mg/m2 + Endoxan 600mg/m2 + Fluorouracil 500mg/m2 x4 course erery three weeks since since 2018/02/22 to 2018/04/27, then tyrosine hydroxylase (Nolbaxol 75mg/m2+ Herceptin 6mg/m2) since 2018/05/19-2018/07/02.
      • She was suffered from neck soreness about 5 months, severe recurrent trapezius region pain brachialgia has been persistent for months, more sever of right side, associated with numbness in right hand a weeks. Pain got worse at early morning and just awakened from sleep. She also complained itchy throat and frequent coughing, she visited to Orthopedics clinic first, but owing to ineffective conservative treatment and frequent recurrences. She visited our clinic, X-ray showed C5-6 vertebrae osteolytic picture, r/o metastasis. Then, she was admitted to neuro ward for further survey and treatment.
      • No trauma history
    • Course of inpatient treatment
      • Upon admission, C-spine MRI with contrast showed:
        • Acute compression fracture of C6 vertebra. R/O pathologic fracture;
        • Enhancing lesions over C3, C6 and T1 vertebral bodies, favor metastases.
        • Retrolisthesis of C5 on C6, grade I.
      • We also consulted Radiology and Oncology for further evaluation, who suggestion:
        • Please check CEA, CA-153, LDH, serum EP, albumin/globulin, ALK-P;
        • C-spine surgery biopsy for tissue proof.
      • After well explained to the patient about MRI findings. We informed that operation is a treatment option for cervical spine metastasis with cord compression and unstable spine. But the patient hesitated. Finally she decided operation.
      • Postoperative course was uneventful. Analgesic agents were used for wound pain control. One JP drain was inserted and record amount Q8H. Her neck and right shoulder pain got improved. C-spine X-rays showed good positions of implants.
      • She complained of right thigh sorness. L-spine MRI with contrast was performed on 2023/09/25 and revealed multiple bone metastases/destructions at thoraco-lumbar spine and bil. pelvic bones, especially at T12, L1, L3. JP drain was removed on 2023/09/25.
      • Dentistry was consulted for dental evaluation prior to Xgeva use.
      • The wounds were clean and dry. She was discharged and outpatient follow-up was mandatory. Sutures would be removed at outpatient.
    • Discharge prescription
      • Celebrex (celecoxib 200mg) 1# BID
      • Kentamin (Vit B1 50mg, B6 50mg, B12 500ug) 1# TID
      • Through (sennoside 12mg) 2# HS
      • Sindine (povidone iodine aq soln) ASORDER EXT
  • 2023-09-14 SOAP Neurosurgery Hong LiWei
    • S
      • neck pain, radiate to bil. shoulder pain (R>L) and right upper arm, for 1 month
      • s/p left partial mastectomy and axillary LN dissection on 2018/01/31, pT2N1aM0, stage IB, ER: (+, 75%); PR (+, 25%); Her2/neu: Positive (score=3+), 95%; Ki-67: 40%; p53: 75%
      • menopausal after chemotherapy
      • phx: breast ca.
    • O
      • E4V5M6
      • pupil: 3+/3+
      • MP R L
      • UE 5 5
      • LE 5 5
      • paresthesia
      • SLRT
      • patrick test
      • tineal test
      • x ray showed C56 vertebrae osteolytic picture, r/o metastasis
    • A
      • neck pain, radiate to bil. shoulder pain (R>L) and right upper arm, x ray showed C56 vertebrae osteolytic picture, r/o metastasisneed MRI c+-
      • 9/15 admission, arrange MRI C+- of C-spine
      • h/s hydration+acetylcysteine 1pc bid for renal protection

[consultation]

[surgical operation]

  • 2023-09-21
    • Surgery
      • C6 corpectomy to remove cervical spine metastasis
      • reconstruction with VDRS artificial bone+ C5-7 plating
      • C-arm and microscope assisted
    • Finding
      • under c-arm localization
      • split platysma muscle
      • split to pre-vertebral space via medial side of carotid sheath
      • dissect bilateral longus coli muscle
      • set retraction screws on C5 and C7 body
      • do C56, C67 discectomy first
      • do C6 corpectomy to remove spinal metastasis, send pathology
      • insert VDRS artificial bone, length: 2.15cm
      • do C5-7 plating with screws fixation
      • plate: 4.2cm, screws: 1.4cm*4
      • well hemostasis
      • set vacuum ball*1
      • close wound layer by layer

[immunochemotherapy]

  • 2024-01-27 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 1min + pertuzumab 420mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-30 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 1min + pertuzumab 420mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-04 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

not posted yet

[Bard]

Missing the loading dose of Pertuzumab (840mg) and instead using a 420mg dose requires careful consideration, as its impact on treatment efficacy and potential risks depends on several factors:

  1. Timing of missed dose:

Early in the treatment course: Missing the loading dose early on can significantly impact initial drug exposure and potentially weaken treatment efficacy. In this case, resuming with the recommended maintenance dose (420mg every 3 weeks) might not be sufficient to compensate. Later in the treatment course: If several loading doses have already been administered, the impact of missing one dose might be less significant, offering more leeway for resuming with the maintenance dose.

  1. Reason for missing the dose:

Accidental: If the omission was accidental and unlikely to occur again, resuming with the maintenance dose may be acceptable after discussing it with your doctor.

[cGPT]

Missing the full loading dose of 840 mg and instead using a 420 mg dose could have implications for the effectiveness of the treatment, especially in the initial stages. Here are some potential considerations and impacts:

Reduced Initial Drug Levels:

The purpose of the loading dose is to quickly achieve effective drug levels in the body. Using only half of the intended loading dose may result in lower drug concentrations initially, which might reduce the effectiveness of the treatment during the early phase. Delayed Therapeutic Effect:

It might take longer to reach the therapeutic levels of pertuzumab in the bloodstream, potentially delaying the onset of the drug’s therapeutic effects. Adjustment of Subsequent Doses:

If the loading dose is missed or reduced, healthcare providers might need to adjust subsequent doses to achieve the desired drug levels. This could involve administering an additional dose or modifying the maintenance doses, though such adjustments should be based on clinical judgment and the specific circumstances of the treatment.

Clinical Decision and Monitoring:

In cases where the loading dose is not administered as recommended, it’s important for healthcare providers to closely monitor the patient’s response to treatment and adjust the dosing regimen as necessary. This might include more frequent assessments of tumor response and monitoring for side effects.

700551138

240129

{serous carcinoma of right fallopian tube with peritoneal and pleural invastion with tumor recurrent, pT3cN1aM1a, stage IVA}

[diagnosis] - 2023-03-30 discharge note

  • Right fallopian tube carcinoma, pT3N1aM1a, FIGO stge IVA s/p Debulking surgery + CRS HIPES s/p IP C/T with Taxol/CDDP and Peripheral C/T with Taxol and Carboplatin with pseudomyxoma peritonei with liver and spleen metastases s/p C/T with Avastin/Taxotere/Carboplatin and IO therapy with Keytruda s/p mild progressive disease of pseudomyxoma peritonei with liver and spleen metastases with IO therapy with Q3W Keytruda and C/T with Avastin/Lipo-Dox/Carboplatin
  • Essential (primary) hypertension
  • Insomnia
  • Chronic viral hepatitis B without delta-agent

[past history]

  • Hypertension more than 10years with regular medical at our CV OPD
  • Goiter post subtotal thyroidectomy at VGH-Taipei 10years ago.

                                                        

[allergy]

  • Drug adverse event: never occurred
  • Food allergy: never occurred
  • Transfusion adverse event: never received transfusion                                                         

[family history]

  • Non contributory to the psychiatric disorders.
  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-10-27 CT - abdomen
    • FINDINGS: Comparison prior CT dated 2023/08/17.
      • The small intestine shows mild dilatation that is c/w obstruction.
      • Prior CT identified two focal fluid collection in the mesentery of the pelvis are noted again, mild increasing in size.
      • Prior CT identified lobulated cystic lesion in Rt subphrenic space with S8 liver invasion, Rt lower medial perihepatic space with S6 invasion, gastrohepatic ligament, lesser sac, and the medial perisplenic space with spleen invasion are noted again, mild increasing in size.
        • Pseudomyxoma peritonei with liver and spleen metastases S/P C/T show mild progressive disease.
      • S/P hysterectomy
        • S/P LAR with autosuture retention over the rectosigmoid junction.
        • S/P water bag breast implantation, bilateral.
      • There is no focal lesion in both lung and mediastinum.
        • There is mild pericardial effusion.
    • IMP:
      • The small intestine shows mild dilatation that is c/w obstruction.
      • Prior CT identified two focal fluid collection in the mesentery of the pelvis are noted again, mild increasing in size.
      • Pseudomyxoma peritonei with liver and spleen metastases S/P C/T show mild progressive disease. please correlate with clinical condition.
  • 2023-10-27 CXR
    • Cardiomegaly is noted.
    • S/p port-A placement with its tip at Superior vena cava
    • Scoliotic alignment of the thoracolumbar spine is noted.
    • Pleural effusion over right side is found.
  • 2023-08-02, -07-26 KUB
    • Fecal material store in the colon.
    • S/P metalic autosuture at the rectosigmoid junction
  • 2023-07-18 KUB
    • Radiopaque spots at pelvic region.
    • Presence of ileus.
  • 2023-07-18 CXR (erect)
    • Blunted bilateral costophrenic angles.
    • Presence of ileus.
  • 2023-06-07 All-RAS + BRAF mutation
    • Tissue Block No: S2019-12133 Fs
    • RESULTS:
      • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-05-08 CT - abdomen
    • History and indication: Right fallopian tube cancer s/p OP and C/T
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy and colon operation.
      • Some low attenuations at liver and spleen (up to 1.8cm). Focal thickening of peritoneum.
      • S/P mammoplasty.
      • Absence left thyroid gland. A nodule (7mm) at right thyroid gland.
    • IMP:
      • S/P hysterectomy and colon operation.
      • Some low attenuations at liver and spleen (up to 1.8cm) r/o metastases.
      • Focal thickening of peritoneum r/o tumor seeding.
  • 2023-04-17 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (90.5 - 35.0) / 90.5 = 61.33%
      • M-mode (Teichholz) = 61.3
    • Conclusion
      • Normal AV with mild AR
      • Normal MV with mild MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, normal IVC size
  • 2023-03-29 Foot Lt
    • Fracture of 5th MT base of left foot is highly suspected. please correlate with clinical condition.
    • Osteoporotic change
  • 2022-12-02 ECG
    • Sinus bradycardia
    • Moderate voltage criteria for LVH, may be normal variant
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2022-12-02 PET scan
    • Glucose hypermetabolism in multiple focal areas in the right lobe of the liver, in a small focal area in the left lobe of the liver, in two focal areas in the spleen and in a focal area in the anterior aspect of the upper midline abdominal cavity, compatible with multiple metastatic lesions.
    • A glucose hypermetabolic lesion in the posterior aspect of the left upper thigh. The nature is to be determined (a metastatic lesion? inflammation or infection?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the right shoulder and in the esophagus. Inflammation may show this picture.
    • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.
  • 2022-12-01 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (66 - 20) / 66 = 69.70%
      • M-mode (Teichholz) = 70
    • Concentric LVH with normal LV systolic function.
    • Mild RV hypertrophy with normal RV systolic function.
    • Mild aortic valve sclerosis; mild MR; mild PR.
    • Minimal amount pericardial effusion (<50ml).
    • poor apical echo window
  • 2022-11-18 CT - abdomen
    • History: Serous carcinoma of Rt fallopian tube with peritoneal and pleural invasion with tumor recurrent, pT3cN1aM1a; Stage IVA
      • 20220128 CT: Pseudomyxoma peritonei is highly suspected.
      • 20220224 CT guided biopsy: liver metastasis
    • FINDINGS:
      • Prior CT identified lobulatd cystic lesion in Rt subhphrenic space, S8 liver invasion, Rt lower medial perihepatic space with indentation the liver capsule, gastrohepatic ligament, lesser sac, and the medial perisplenic space with indentation the splenic capsule are noted again.
        • Pseudomyxoma peritonei with liver and spleen metastases S/P C/T show mild progressive disease.
      • S/P hysterectomy
      • S/P LAR with autosuture retention over the rectosigmoid junction.
      • S/P water bag breast implantation, bilateral.
      • There is no focal lesion in both lung and mediastinum.
      • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
      • There is no ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
      • There is no focal lesion in the mesentery.
    • IMP:
      • Pseudomyxoma peritonei with liver and spleen metastases S/P C/T show mild progressive disease. please correlate with clinical condition.
  • 2022-11-18 CXR
    • Scoliosis of the T-spine with convex to right side.
    • Enlargement of cardiac silhouette.
  • 2022-10-19 Sonography - right shoulder
    • Findings
      • Thickening and inhomogeneous echogenesity of right supraspinatus tendon. No definite discontinuity.
      • Prominent fluid in subacromial-subdeltoid bursa.
    • Impression
      • Supraspinatus tendinosis and subacromial-subdeltoid bursitis
      • suspected subacromial impingement. Suggest radiography correlation.
  • 2022-08-27 CT - abdomen
    • Focal low attenuation at right kidney r/o nephritis.
    • S/P mammoplasty.
  • 2022-08-27 CXR
    • Blunted bilateral costophrenic angles.
    • Presence of scoliosis of the T-spine.
  • 2022-07-22 CT - abdomen
    • History: Serous carcinoma of Rt fallopian tube with peritoneal and pleural invasion with tumor recurrent, pT3cN1aM1a; Stage IVA
      • 20220128 CT: Pseudomyxoma peritonei is highly suspected.
      • 20220224 CT guided biopsy: liver metastasis
    • FINDINGS:
      • Prior CT identified lobulatd cystic lesion in Rt subhphrenic space, S8 liver invasion, Rt lower medial perihepatic space with indentation the liver capsule, gastrohepatic ligament, lesser sac, and the medial perisplenic space with indentation the splenic capsule are not noted again, except a small cystic lesion in the spleen.
        • Pseudomyxoma peritonei with liver and spleen metastases S/P C/T with near complete response are suspected.
      • S/P hysterectomy
      • S/P LAR with autosuture retention over the rectosigmoid junction.
      • S/P water bag breast implantation, bilateral.
    • IMP:
      • Pseudomyxoma peritonei with liver and spleen metastases S/P C/T with near complete response are suspected. please correlate with clinical condition.
  • 2022-04-13 Panendoscopy
    • Reflux esophagitis LA grade A
    • Superficial gastritis
    • Gastric erosions, antrum
  • 2022-04-12 CT - abdomen
    • Clinical history: 64 y/o female patient with Serous carcinoma of right fallopian tube with peritoneal and pleural invasion with tumor recurrent, pT3cN1aM1a; Stage IVAFor tumor f/u.
    • Findings
      • Post-op at the colon. S/P hysterectomy.
      • There are subphrenic and subhepatic soft tissue tumors, regression as compare with CT study on 2022-03-02.
      • Wall edema of the cecum.
      • Spleen tumor, 0.97cm.
    • Impression:
      • Post-op at the colon. S/P hysterectomy.
      • Pseudomyxoma peritoneum with liver and spleen involvement, regression as compare with CT study on 2022-03-02.
      • Wall edema of the cecum.
  • 2022-04-11 Patho - colon biopsy
    • Transverse colon, biopsy — Nonspecific active colitis
  • 2022-04-07 KUB
    • S/P metalic autosuture at the the rectosigmoid junction
  • 2022-03-02 CT - abdomen, pelvis
    • Pseudomyxoma peritonei with liver and spleen metastases show stationary.
  • 2022-02-24 Needle aspiration cytology - liver
    • Smears show histiocytes and clusters of atypical hyperchromatic papillary tumor. Malignancy is favored.
  • 2022-02-23 CT - lung/mediastinum/pleura
    • no lung metastasis. pseudomyxoma peritonei and splenic lesion.
  • 2022-01-28 CT - abdomen, pelvis
    • Pseudomyxoma peritonei is highly suspected. Please correlate with aspiration cytology.
  • 2021-11-04 SONO - abdomen
    • Right liver cyst (1.75x2.10cm).
  • 2021-08-10 CT - abdomen, pelvis
    • s/p LAR and autosuture. No evidence of recurrent/residual tumor in the current study.
  • 2021-05-11 SONO - abdomen
    • A hepatic cyst measuring 1.81 cm in S6 is noted.
  • 2021-02-09 CT - abdomen, pelvis
    • Post-op at the colon. S/P hysterectomy and oophorectomy.
  • 2020-11-19 Whole body PET scan
    • Mild glucose hypermetabolism in a right axillary lymph node. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in bilateral shoulders and in the soft tissues around bilateral hips. Inflammatory process may show this picture.
    • Mildly increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.
  • 2020-11-13 CT - abdomen, pelvis
    • No Abscess or lymphocele in right pelvic sidewall is noted.
  • 2020-09-18 CT - abdomen, pelvis
    • Abscess 3.5 x 2.8 cm in right pelvic sidewall is suspected.
    • The differential diagnosis include lymphocele.
  • 2020-09-08 CT - abdomen, pelvis
    • Post op. change of the rectum.
    • Cystic change at right pelvic side wall, stable.
  • 2020-05-25 CT - abdomen, pelvis
    • S/P hysterectomy.
    • Some LNs (up to 1.1cm) at bil. inguinal regions.
    • A cystic lesion (3.8cm) at right pelvic cavity.
  • 2019-12-24 CT - abdomen, pelvis
    • S/P pigtail catheter drainage, right lower abdomen.
    • S/P CAPD catheter in the pelvic cavity, with focal loculated fulid in pericatheter region.
    • Cystic lesion, 3.8cm in right pelvic cavity, r/o lymphocele.
    • Post-op at the colon.
    • Bilateral pleural effusion with basal atelectasis.
  • 2019-07-25 Patho Level VI - sigmoid colon
    • pathologic diagnosis
      • Sigmoid colon, radical proctectomy? — Serous carcinoma, metastatic
      • Faciform ligament, excision — Serous carcinoma, metastatic
      • Soft tissue over rectum, excision — Serous carcinoma, metastatic
      • Lymph nodes, mesocolic, dissection — Metastatic serous carcinoma (4/4)
    • microscopic examination
      • Histology: Serous carcinoma, metastatic
      • Histology Grade: High grade
      • Depth of invasion: Subserosal tumor with muscularis propria invasion
      • Angiolymphatic invasion: Present
      • Perineural invasion: Not identified
      • Lymph node metastasis, mesocolic: Positive (4/4)
      • Faciform ligament: Serous carcinoma, metastatic
      • Soft tissue over rectum: Serous carcinoma, metastatic
  • 2019-07-25 Patho Level VI - BSO, hysterectomy
    • pathologic diagnosis
      • Fallopian tube, right, BSO — Serous tubal intraepithelial carcinoma and serous carcinoma, consistent with right fallopian tube is primary site
      • Ovaries, bilateral, BSO — Involved by serous carcinoma
      • Fallopian tube, left, BSO — Involved by serous carcinoma
      • Uterus, corpus, total hysterectomy — Involved by serous carcinoma
      • Uterus, cervix, total hysterectomy — Free of carcinoma
      • Omentume, omentectomy — Involved by serous carcinoma
      • Peritoneum, right, excision — Involved by serous carcinoma
      • Bladder, biopsy — Involved by serous carcinoma
      • Lymph nodes, external iliac, left, PLND — Metastatic serous carcinoma
      • Pathologic Stage: pT3cN1aM1a; Stage IVA at least
    • microscopic examination
      • Histologic type: Serous carcinoma
      • Histologic grade: High grade
      • Bilateral ovaries involvement: Present
      • Bilateral ovarian surface involvement: Present
      • Right tube involvement: Present
      • Left tube involvement: Present
      • Serous tubal intraepithelial carcinoma in right fallopian tube: Present
      • Uterine serosa involvement: Present
      • Omentum involvement: Present
      • Uterine Cervix: Chronic cervicitis, Nabothain cyst and squamous metaplasia
      • Endometrium involvement: Atrophy
      • Myometrium: Leiomyoma and adenomyopsis
      • Largest Extrapelvic Peritoneal Focus: 5.0 x 3.5 x 2.0 cm
      • Peritoneal/Ascitic Fluid: Malignant (positive for malignancy)
      • Pleural Fluid: Malignant (positive for malignancy)
      • Regional Lymph Nodes: Positive for metastasis
      • Other organs or specimens involvement: Present, specify: Bladder and sigmoid colon (S2019-12175)
      • Additional Pathologic Findings: Brenner tumor in right ovary
      • IHC for tumor cells (S2019-12133FS): WT1(+), PAX8(+), p53(+ aberrant expression), calretinin(-)

[MedRec]

  • 2023-10-27 ~ 2023-11-02 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Right fallopian tube carcinoma, pT3N1aM1a, FIGO stge IVA s/p Debulking surgery + CRS HIPES s/p IP C/T with Taxol/CDDP and Peripheral C/T with Taxol and Carbplatin with pseudomyxoma peritonei with liver and spleen meta s/p C/T with Avastin/Taxotere/Carboplatin and IO therapy with Keytruda s/p mild PD of pseudomyxoma peritonei with liver and spleen meta with IO therapy with Q3W Keytruda and C/T with Avastin/Lipo-Dox/Carboplatin with liver and spleen meta and peritoneum seeding
      • Ileus, suspect partial obstruction or paralytic ileus
      • Secondary malignant neoplasm of retroperitoneum and peritoneum
      • Secondary malignant neoplasm of liver and intrahepatic bile duct
      • Essential (primary) hypertension
      • Insomnia
      • Chronic viral hepatitis B without delta-agent
      • Constipation, unspecified
      • Anemia due to antineoplastic chemotherapy
      • Cachexia
    • CC
      • For lower abdominal pain and nausea with vomiting since three days ago
    • Present illness
      • The 65-years-old female has had past histories of 1. Hypertension more than 10 years with regular medical at our CV OPD, 2. Goiter post subtotal thyroidectomy at VGH-Taipei 10 years ago.
      • According to the statement by herself, she suffered from on and off dry cough and progresstion SOB for 20 days. She ever visited LMD for help. But there was no obvious improvement. CXR revealed Bilateral pleural effusions. Chest echo was done, right side 1100 ml serosangunous and left side 600 ml.
      • 2D echo on 2019/07/15 showed 1. Septal hypertrophy with normal LV amnd RV systolic function. 2. Mild AV sclerosis; mild aortic root calcification. 3. Some left pleural effusion.
      • Chest cheo tapping on 2019/07/15 and 2019/7/17. Pleural effusion pathology showed positive for adenocarcinoma. Pleural effusion pathology showed suspicious for malignancy IHC satin: TTF-1(-), Napsin-A(-), CK7(+), CK5/6(+), CK(+), Calretinin (+), CK20(-), P40(focal+).
      • Lung CT on 2019/07/16 showed bilateral pleural effusion and ascites formation. Tumor mark CA-125:1902.5 U/ml. Removed right pig-tail on 2019/07/22
      • GYN echo on 2019/07/18 showed 1. Uterine myoma 2. RT adnexa mass. Abdominal CT on 2019/07/19 showed 1. Cystic adenocarcinoma of the ovary with carcinomatosis is highly suspected. Please correlate with ascites cytology and CA-125. 2. Detailed findings, please see description.
      • Abdominal echo on 2019/07/19 showed mild ascites, mild pleural effusion, left, suspected fatty infiltration of pancreas and suboptimal examination of liver due to poor echo window. Ascites pathology showed poistive for malignancy.
      • Under the impression of ovarian cancer with peritoneal and invasion. She underwent operation of Debulking surgery (ATH + BSO + Cytoreduction surgery + infracolic omentectomy + Appendectomy) + CRS HIPES on 2019-07-19.
      • #1 IP chemotherapy with Intaxel 60mg + Cisplatin 60mg and Peripheral chemotherapy with Intaxel 200mg and CARBOPLATIN 300 mg with Cisplatin and Intaxel were prescribed on 8/20 19, #2 on 9/11 19, #3 on 10/15 19, #4 on 11/11 19, #5 chemotherapy with Taxol/Carboplatin on 12/9 19. #6 on 2/3 20.
      • Follow-up abdominal CT (9/20 19) showed local recurrent cystic adenocarcinoma of the fallopian tube is highly suspected. Moderate right side hydroureteronephrosis is noted.
      • Abdomianl CT on (10/16 19) showed minimal right hydronephrosis, s/p LAP, ATH and BSO and bilateral pleural effusion.
      • Abd CT (5/25 20) showed s/p hysterectomy. Some LNs (up to 1.1cm) at bil. inguinal regions. A cystic lesion (3.8cm) at right pelvic cavity. CXR (5/26 20) revealed two nodular opacity projecting in R upper lung. Chest CT (6/4 20) revealed no evidence of pulmonary mass in the study.
      • The tumor marker showed CEA / CA-125: 0.5 / 23.9.CEA / CA-125: 0.2 / 19.3. Abd sono & CXR (9/1 20): negative.
      • Chect CT was performed and showed no lung metastasis. pseudomyxoma peritonei and splenic lesion was noted. CT guided biopsy for liver tumor tissue proof then final pathology showed atypical hyperchromatic papillary tumor.
      • Abdominal CT (3/2 22) showed Pseudomyxoma peritonei with liver and spleen metastases show stationary.
      • #1 Chemotherapy with Taxol (160mg/m2)  plus CArboplatin (AUC:5, 450mg) was given on 2/3 22.
      • #1 chemotherapy with Taxotere/Carboplatin on 3/2 22. #2 chemotherapy with Taxotere/Carboplatin & (#1) Avastin (self-paid) on 3/28 22. #3 chemotherapy with Carboplatin & (#2) Avastin (self-paid)/(#1) Keytruda (self-paid) on 4/26 22, #4 chemotherapy with Carboplatin & (#3) Avastin (self-paid)/(#2) Keytruda (self-paid) on 5/17 22, #5 chemotherapy with Carboplatin & (#4) Avastin (self-paid)/(#3) Keytruda (self-paid) on 6/8 22, #6 chemotherapy with Carboplatin & (#5) Avastin (self-paid)/(#4) Keytruda (self-paid) on 6/30 22, #7 chemotherapy with Carboplatin & (#6) Avastin (self-paid)/(#5) Keytruda (self-paid) on 7/21 22, #8 chemotherapy with Carboplatin & (#7) Avastin (self-paid)/(#6) Keytruda (self-paid) on 8/23 22.
      • Abd CT (8/27 22) showed focal low attenuation at R kidney r/o nephritis. S/P mammoplasty. Abd CT (11/18 22) revealed pseudomyxoma peritonei with liver and spleen metastases S/P C/T show mild progressive disease.
      • We explain to pt & her daughter-in-law & son about resumption of palliative C/T.
      • Will give palliiative Tx with Keytruda 100mg (self-paid) / & Avastin ( #2 ) (self-paid) / Carboplatin IV Q3W x 4~6. will consider to add Gem ( non-hair loss agent )
      • PET scan (12/2 22): Lesions at in R liver, in a small one in L liver, in two lesion at spleen & a focal lesion at anterior upper midline abdominal cavity, c/w mets lesions. Lesion in the posterior aspect of the L upper thigh. nature ? (a metastatic lesion? inflammation or infection?).
      • #1 palliiative Tx wt Keytruda 100mg (self-paid) / & Avastin (self-paid) / Lipo-Dox (self-paid)/ Carboplatin IV Q3W x 6 on 12/1 22, #2 palliiative Tx wt Keytruda 100mg (self-paid) / & Avastin (self-paid) / Lipo-Dox (self-paid)/ Carboplatin IV Q3W x 6 on 01/05 23, #3 palliiative Tx wt Keytruda 100mg (self-paid) / & Avastin (贈品, 打2送1) / Lipo-Dox (self-paid)/ Carboplatin IV Q3W x 6 on 2/8 23, #4 palliiative Tx with Keytruda 100mg (self-paid) / & Avastin (self pay) / Lipo-Dox (self-paid)/ Carboplatin IV Q3W x 6 on 3/6 23, #5 palliiative Tx with Keytruda 100mg (self-paid) / & Avastin (self pay) / Lipo-Dox (self-paid)/ Carboplatin IV Q3W x 6 on 3/29 23.
      • 2D echo on 2023/04/17 showed M-mode(Teichholz) = 61.3, 1. Normal AV with mild AR 2. Normal MV with mild MR 3. Normal LV chamber size and wall thickness 4. Preserved LV and RV systolic function 5. Mild PR, mild TR, normal IVC size. Abdominal CT on 2023/05/08 showed S/P hysterectomy and colon operation, some low attenuations at liver and spleen (up to 1.8cm) r/o metastases and focal thickening of peritoneum r/o tumor seeding. Tumor mark on 2023/05/16 showed (CA-125:83.3 U/mL, CA-199:22.29 U/mL, CEA:1.02 ng/mL).
      • Palliative chemotherapy with weekly Topotecan(3.75mg/m2)(self pay) was given on 2023/05/22(C1D1), 2023/06/07(C1D8), 2023/06/20(C1D15), 2023/07/13(C2D1), 2023/08/02(C2D8). Leukocytopenia with dely chemotherapy. Tumor mark on 2023/05/30 showed increased (CA-125:145.7 U/mL, CA-199:28.82 U/mL, CEA:1.05 ng/mL). Palliative chemotherayp with weekly Gemzar(800mg/m2)(self pay) on 2023/06/26(C1D1), 2023/07/13(C1D8), 2023/08/02(C1D15). Now, she was admitted to ward for follow-up, Abdominal CT and palliative chemotherayp with weekly Gemzar(800mg/m2)(self pay)(C2D1)/Topotecan(3.75mg/m2)(self pay)(C2D15).
      • According to the patient’s statement and medical record, She suffered from lower abdominal pain and nausea with vomiting since three days ago, and she had stool passage in these days, and complained poor appetite for 3 days. She denied fever, chillness, headache,conscious disturbance, dyspnea, cough, sputum, chest pain or chest tightness, dysuria, burning sensation, diarrhea, constipation, tarry stool, bloody stool, coffee ground emesis, or change of bowel habits recently. She also denied general weakness, cold sweating, recent weight loss. She didnot had recent travelling history and history of contact to sick people. According to the above, the patient came to our ER for help.
      • The blood test and images/examination of abdominal CT was performed. Lab data showed CKD, mild hypokalemia, no leukocytosis, elevated CRP level. The abdominal CT showed small intestine shows mild dilatation that is c/w obstruction. Physical examination was done at ward and revealed normal to hyperactive bowel sound and no obvious tenderness.
      • Under the impression of Ileus, suspect partial obstruction or paralytic ileus , and intraabdominal infection, the patient was admitted to our ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission, suspect partial obstruction or paralytic ileus, IAI infection, empirical antibiotic with Loforan 2gm/vial 2000mg IVD Q8H for IAI from 2023/10/27~2023/10/31.
      • IVF for poor appetite supportive.
      • Imperan 10mg/2mL/amp 1amp Q8H for nausea and vomiting.
      • Through 12mg/tab 2# PO HS, MgO 250mg/tab 1# PO TID.
      • Bisadyl supp 10mg/pill 2pill RECT for no stool passage.
      • Limadol 100mg/2mL/amp 50mg IVD PRNQ6H for pain control.
      • Explain to patient and family for disease condition on 2023/10/30.
      • Hypertension with Carvedilol HEXAL 6.25mg/tab 1# PO QD, Exforge F.C. 5mg & 160mg/tab 0.5# PO QD.
      • Insomnia with Alpraline 0.5mg/tab 1# PO PRNQN if insomnia, Lexapro 10mg/tab 1# PO QN.
      • Cachexia with Megejohn 160mg/tab 1# PO QD.
      • Chronic viral hepatitis B with (Anti-HBc reactive) with Baraclude 0.5mg/tab 1# po QDAC.
      • Anemia was noted, BT LRBC 2 unit for 2 days on 2023/11/01 and 2023/11/02.
      • Due to she feels her symptoms get improved, want to discharge. With the stable condition, she was discharged on 2023/11/02 and OPD followed up later.
    • Discharge prescription
      • Through (sennoside 12mg) 2# HS
  • 2023-09-27 SOAP Cardiology Zhang HengJia
    • Prescription x3
      • Exforge (amlodipine, valsartan) 0.5# QD
      • carvedilol 6.25mg 1# QD
  • 2023-09-27 SOAP Psychosomatic Medicine Li JiaFu
    • Prescription x3
      • Lexapro (escitalopram 10mg) 1# QN
      • Alpraline (alprazolam 0.5mg) 1# PRNQN
  • 2023-07-05 SOAP Psychosomatic Medicine
    • Diagnosis
      • Generalized anxiety disorder [F41.1]
      • Major depressive disorder single episode,unspecified [F32.9]
      • Nonorganic sleep disorder,unspecified [F51.9]
      • Malignant neoplasm of right fallopian tube [C57.01]
    • Prescription x3
      • Anxiedin (lorazepam 0.5mg) 1# QN
      • Lexapro (escitalopram 10mg) 1# QN
      • Stilnox (zolpidem 10mg) 1# HS
      • Alpraline (alprazolam 0.5mg) 1# PRNQN
  • 2023-07-05 SOAP Cardiology Zhang HengJia
    • P: change CCB to Exforge, F/U blood biochemistry.
    • Prescription x3
      • Exforge (amlodipine, valsartan) 0.5# QD
      • carvedilol 6.25mg 1# QD
  • 2023-05-16 SOAP Hemato-Oncology Xia HeXiong
    • P: Already mention the slow progression of liver and peritoneum comparing 2023-05 vs 2023-02 vs 2022-11 and 2022-08. -> RTC 4 weeks
  • 2023-04-18 SOAP Hemato-Oncology Xia HeXiong
    • P: Admission on 2023-04-18 for heart echo then decide the next 6th Lipo-Dox / Carboplatin -> Becasue patient can not tolerate the C/T AE and LVEF drop from 70 to 61, she would not like to take the 6th dose of Lipo-Dox / Carboplatin.
      • Abd/Pelvis plus Chest CT will be arranged two weeks later (on 2023-05-02).
  • 2023-04-17 SOAP Cardiology
    • A/P: Malignant neoplasm of right fallopian tube; Bilateral pleural effusion; HCVD, HLD, B hepatitis
      • A: need to R/O pericardioal effusion w/u for right pleural effusion
      • P: need to keep BB and CCB, 2D and CT of chest are indicated, watch for pancytopenia
  • 2023-04-12 SOAP Hemato-Oncology
    • P: Admission on 2023-04-18 for heart echo then decide the next 6th Lipo-Dox / Carboplatin
  • 2019-10-24 SOAP Psychosomatic Medicine
    • S
      • 1st time visiting come to my clinical due to insomia, dysphoric mood, anxiety, depression, cannot control emotion and ……..
      • 1st time visiting come alone. She claimed she cannot sleep well for a while.
    • O
      • Psychiatric impression:
        • Neurotic depression
        • Insomnia
      • Present illness:
        • This 61 y/o female suffered from serous carcinoma of right fallopian tube with peritoneal and pleural invasion, pT3cN1aM1a and was admitted to our hospital for chemotherapy. Severe insomnia was told and we were consulted for drug adjustment. Upon visit, the patient was coherent and relevant, cooperative attitude and mild anxiousness. According to herself, she started to have sleep disturbance with middle type insomnia ever since she was informed that she had cancer in 2019-07.
        • However, she didn’t seek psychiatric help due to she believed that the cancer treatment also caused insomnia. She received Alpraline 0.5mg/tab 1# HS, Eurodin 2mg/tab 1# HS, rivotril 0.5mg/tab 1# HS but in vain, and would switch to isolated ward due to she felt sensitivity to the environment at night. She claimed that she had low mood but denied suicidal thoughts or hopelessness sensation, decreased appetite was told. She is hesitate to adjust psychotropics in fear that the medications may cause renal impairment. There were no previous psychiatric history, no substance use history.
      • Suggestion:
        • D/C Eurodin 1# and Alpraline 1# HS
        • Add Mirtapine 1# HS for depressed mood
        • May titrate Rivotril dosage if the patient agrees
        • Arrange OPD follow-up
    • Diagnosis
      • Generalized anxiety disorder [F41.1]
      • Major depressive disorder single episode,unspecified [F32.9]
      • Nonorganic sleep disorder,unspecified [F51.9]
      • Malignant neoplasm of right fallopian tube [C57.01]
    • Prescription
      • Lexapro (escitalopram 10mg) 0.5# QN
      • Rivotril (clonazepam 0.5mg) 0.5# QN
      • Alpraline (alprazolam 0.5mg) 1# PRNQN
      • Eurodin (estazolam 2mg) 1# HS
  • 2019-09-19 SOAP Hemato-Oncology
    • O:
      • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2019-08-01
        • Diagnosis: Tubal cancer
        • Staging: pT3cN1aM1a; at least Stage IVA
        • Treatment: Post-operative chemotherapy is recommended.
      • AE: Hair loss: Grade 2: Total hair loss.
      • 20190910 prescription: Taxol/Carboplatin IP with Taxol/Carboplatin C/T
  • 2017-01-03 SOAP Cardiology
    • Diagnosis
      • Other and unspecified angina pectoris [I20.9]
      • HCVD, unspecified, without CHF [I11.9]
      • Mixed hyperlipidemia [E78.2]
      • Cardiac dysrhythmia, unspecified [I49.9]
      • Chest pain, other [R07.89]
      • Generalized anxiety disorder [F41.1]
    • Prescription
      • Algitab (alginic acid, MgCO3, Al(OH)3, 200mg) 1# TID
      • Alpraline (alprazolam 0.5mg) 0.5# HS
      • Pitator (pitavastatin 2mg) 1# QD
      • Syntrend (carvedilol 6.25mg) 1# QD
      • Bokey (aspirin 100mg) 1# QOD

[surgical operation]

  • 2019-07-19
    • Debulking surgery (ATH + BSO + cytoreduction + infracolic omentectomy + appendectomy)
    • CRS HIPES

[chemoimmunotherapy]

  • 2024-01-03 - gemcitabine 800mg/m2 1200mg NS 100mL 30min (He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-12-20 - gemcitabine 800mg/m2 1200mg NS 100mL 30min (He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-12-11 - gemcitabine 800mg/m2 1200mg NS 100mL 30min (He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-08-18 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-08-02 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-07-13 - gemcitabine 800mg/m2 1200mg NS 100mL 30min + topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-26 - gemcitabine 800mg/m2 1200mg NS 100mL 30min (Xia HeXiong)
    • dexamethasone 4mg + NS 250mL
  • 2023-06-20 - topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-07 - topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-05-23 - topotecan 3.75mg/m2 4mg NS 100mL 30min (Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-03-29 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + liposome doxorubicin 25mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr (2023-04-12 WBC 1.46K/uL) (Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-06 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + liposome doxorubicin 25mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr (Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-10 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + liposome doxorubicin 25mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr (Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-05 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + liposome doxorubicin 25mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr (Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-02 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + liposome doxorubicin 25mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 3 150mg NS 250mL 2hr (Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1
  • 2022-08-23 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 150mg NS 250mL 2hr (Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-07-21 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 150mg NS 250mL 2hr (Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-06-30 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 150mg NS 250mL 2hr (Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-06-08 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 150mg NS 250mL 2hr (Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-05-17 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 400mg NS 250mL 2hr (Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-04-26 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + carboplatin AUC 4 400mg NS 250mL 2hr (Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-03-28 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr (Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-03-02 - + docetaxel 60mg/m2 90mg NS 250mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr (Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1
  • 2020-02-03
  • 2019-12-09
  • 2019-11-11
  • 2019-10-15
  • 2019-09-11
  • 2019-08-20 - paclitaxel 160mg/m2 240mg 3hr + carboplatin AUC 5 300mg 2hr + [paclitaxel 60mg + cisplatin 60mg] IP

Primary Systemic Therapy Regimens - Primary Therapy for Stage II–IV Disease - Epithelial Ovarian/Fallopian Tube/Primary Peritoneal (Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer, NCCN guidelines version 5.2022 20220916, OV-C 6 OF 11, p43)

  • High-grade serous, Endometrioid (grade 2/3), Clear cell carcinoma, Carcinosarcoma
    • Preferred Regimens
      • Paclitaxel/carboplatin q3weeks
      • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7 & GOG-218)
    • Other Recommended Regimens
      • Paclitaxel weekly/carboplatin weekly
      • Docetaxel/carboplatin
      • Carboplatin/liposomal doxorubicin
      • Paclitaxel weekly/carboplatin q3weeks
    • Useful in Certain Circumstances
      • IP/IV paclitaxel/cisplatin (for optimally debulked stage II–III disease)
      • For carcinosarcoma:
        • Carboplatin/ifosfamide
        • Cisplatin/ifosfamide
        • Paclitaxel/ifosfamide (category 2B)

Acceptable Recurrence Therapies for Epithelial Ovarian (including LCOC)/Fallopian Tube/Primary Peritoneal Cancer (Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer, NCCN guidelines version 5.2022 20220916, OV-C 9 OF 11, p51)

  • Recurrence Therapy for Platinum-Resistant Disease (alphabetical order)
    • Preferred Regimens
      • Cytotoxic Therapy
        • Cyclophosphamide (oral)/bevacizumab
        • Docetaxel
        • Etoposide, oral
        • Gemcitabine
        • Liposomal doxorubicin
        • Liposomal doxorubicin/bevacizumab
        • Paclitaxel (weekly)
        • Paclitaxel (weekly)/bevacizumab
        • Topotecan
        • Topotecan/bevacizumab
      • Targeted Therapy (single agents)
        • Bevacizumab
    • Other Recommended Regimens
      • Cytotoxic Therapy
        • Capecitabine
        • Cyclophosphamide
        • Doxorubicin
        • Ifosfamide
        • Irinotecan
        • Melphalan
        • Oxaliplatin
        • Paclitaxel
        • Paclitaxel, albumin bound
        • Pemetrexed
        • Sorafenib/topotecan
        • Vinorelbine
      • Targeted Therapy (single agents)
        • Niraparib (category 3)
        • Olaparib (category 3)
        • Pazopanib (category 2B)
        • Rucaparib (category 3)
      • Hormone Therapy
        • Aromatase inhibitors (anastrozole, exemestane, letrozole)
        • Leuprolide acetate
        • Megestrol acetate
        • Tamoxifen
    • Useful in Certain Circumstances
      • Immunotherapy
        • Dostarlimab-gxly (for dMMR/MSI-H recurrent or advanced tumors)
        • Pembrolizumab (for patients with MSI-H or dMMR solid tumors, or TMB-H tumors >=10 mutations/megabase)
      • Hormone Therapy
        • Fulvestrant (for low-grade serous carcinoma)
      • Targeted Therapy
        • Entrectinib or larotrectinib (for NTRK gene fusion-positive tumors)
        • Dabrafenib + trametinib (for BRAF V600Epositive tumors)
        • For low-grade serous carcinoma:
          • Trametinib
          • Binimetinib (category 2B)

==========

2024-01-29

[reconciliation]

Baraclude (entecavir), Stilnox (zolpidem), and Alpraline (alprazolam) were prescribed on 2024-01-17, while Norvasc (amlodipine), Exforge (amlodipine, valsartan), and Carvedilol were prescribed on 2023-12-20 by our OPD. These medications are currently being used without any noted issues.

2023-12-11

The patient obtained repeat prescriptions for Exforge (amlodipine, valsartan) and Hexal (carvedilol) from our cardiologist, and Lexapro (escitalopram) and Alpraline (alprazolam) from our psychiatrist on 2023-09-27. These medications are accurately listed as the patient’s active medication, and no issues with medication reconciliation have been detected.

2023-08-17

This patient received repeat prescriptions from our cardiologist (for Exforge (amlodipine, valsartan) and Hexal (carvedilol)) and our psychiatrist (for Anxiedin (lorazepam), Lexapro (escitalopram), Stilnox (zolpidem), and Alpraline (alprazolam)) on 2023-07-05. These drugs are well included in the active formulary and no reconciliation issues were identified.

2023-07-14

On 2023-07-08, the patient refilled her prescription for Baraclude (entecavir) at a local pharmacy. In addition, on 2023-07-05, our cardiologist wrote a prescription for Exforge (amlodipine, valsartan) and Carvedilol. On the same day, our psychosomatic medicine specialist also prescribed Anxiedin (lorazepam), Lexapro (escitalopram), Stilnox (zolpidem), and Alpraline (alprazolam) for the patient. These medications were appropriately added to the patient’s active medication list with no reconciliation issues identified.

2023-05-23

  • According to the PharmaCloud database, it seems that the patient has only received medical care at our hospital for the past three months. No discrepancies or issues have been identified during the medication reconciliation process for this patient upon her current admission.
  • The patient has been unable to tolerate the adverse events associated with chemotherapy and her LVEF has decreased from 70% to 61%. Therefore, she decided not to receive the 6th dose of the Lipo-Dox and Carboplatin chemotherapy regimen.
  • The patient is currently receiving topotecan, a medication which is reimbursable by the National Health Insurance (NHI) for use as a second-line chemotherapy treatment for ovarian cancer and small cell lung cancer. The eligibility for this is conditional on the first-line treatment including platinum compounds.
  • The patient’s body surface area (BSA) is 1.56 m2, based on a height of 157 cm and weight of 56 kg. The administered dose of topotecan is 4mg, which is approximately 2.5mg/m2. The recommended dose of topotecan for ovarian cancer and small cell lung cancer is 1.5 mg/m2/day for five consecutive days every 21 days. Our current regimen administers a more concentrated dose in a single day. This warrants monitoring for potential myelosuppression and other adverse reactions.
  • The patient experienced an episode of leukopenia on 2023-04-12, with a WBC count of 1.46K/uL, after the previous regimen of lipo-dox and carboplatin administered on 2023-03-29. However, the patient’s WBC count has since recovered to 3.56K/uL on 2023-05-22, making topotecan administration not contraindicated.
  • The patient’s SBP exceeds 200mmHg several times and remains around 190mmHg 2023-05-23 08:33 this morning even she is taking Norvasc (amlodipine 5mg 0.5# QD) and Hexal (carvedilol 6.25mg 1# QD), it might be beneficial to double Norvasc to 1# QD first and monitor if the high SBP being mitigated.

2023-03-30

  • Consecutive 3 days of granocyte (lenograstim) is scheduled approximately 1 week after the patient received chemotherapy to prevent them from leukopenia without an issue.

2022-12-02

  • Several SBP data points exceeded 200mmHg in this patient while taking the self-care medications Norvasc (amlodipine) and Carvedilol (carvedilol) these two days. In order to mitigate her hypertension, the addition of an ARB, such as valsartan, losartan, might be beneficial.

2022-04-06

  • This patient was diagnosed with serous carcinoma of the right fallopian tube with peritoneal and pleural invasion with recurrent tumors, received [paclitaxel + carboplatin] 6 times in the period from 2019-08-20 to 2020-02-03 following debulking surgery on 2019-07-19, now she is on [docetaxel + carboplatin] since 2022-03-02 (plus bevacizumab since 2022-03-28).

701494845

240129

[exam findings]

  • 2023-12-07 CT - chest
    • Indication: Peripheral T-cell lymphoma, stage IV, CD3 (+, diffuse), CD20 (focal+ at background B cells), CK(-), CD4(+, diffuse), CD8(+), CD56(focal+, 1%), Ki-67 index: 50%, EBV (+)
    • Chest CT with and without IV contrast ehnancement shows:
      • Tiny nodule at url measuring 0.26cm in largest dimension. (Se202 IM37).
      • One ground glass nodule at right middle lobe measuring 0.2cm is also found. (Se202 Im99). Suggest follow up
      • Very small lymph nodes are found at paraaortic region. The findning in non-specific
    • Imp:
      • No evidence of lymphadenopathy in the study
      • Tiny lung nodules at right lung. Suggest regular follow up.
  • 2023-09-12 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (88.6 - 21.9) / 88.6 = 75.28%
      • M-mode (Teichholz) = 63.1
      • 2D (M-Simpson) = 62.8
    • Conclusion:
      • Normal AV/MV, no AR, No MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • No PR, no TR, normal IVC size
  • 2023-09-11 PET
    • Glucose hypermetabolism lesions in bilateral neck regions, SCF, left axilla, mediastinum, celiac lymph nodes, bilateral para-aortic space, and pelvis, highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
    • Glucose hypermetabolism lesions in the spleen and in skeleton including scapulae, left rib, pelvic bones, and femurs, highly suspected lymphoma with involvement of spleen and bone marrow.
    • Highly suspected lymphoma, c-stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-08-31 Patho - lymph node region resection
    • Lymph node, neck, left, excision — Malignant lymphoma — Peripheral T cell lymphoma, NOS (addendum)
    • Operation procedure: Excision; Topology: left neck; Specimen size and number: 1 piece, 5.2x 4.4x 3.6 cm in size
    • Immunohistochemical stain profiles: CD3 (+, diffuse), CD20 (focal+ at background B cells), CK(-), CD4(+, diffuse), CD8(+), CD56(focal+, 1%), Ki-67 index: 50%, EBV (+), ALK1(-), CD10(-), TdT(-), Granzyme B(-), CD15 & CD30 ( focal+), EBER(+).
    • Special stain: Acid-fast stain: Negative for TB bacilli, PAS stain: negative for microorganism.
  • 2023-08-26 CT - abdomen
    • History and indication: fever unknown and neck lymphma
    • Non-contrast CT of abdomen-pelvis revealed:
      • Hepato-splenomegaly. Enlarged LNs at retroperitoneum and bil. inguinal regions.
      • Some calcifications at pelvic cavity.
      • Collapse of gallbladder.
    • IMP:
      • Hepato-splenomegaly. Enlarged LNs at retroperitoneum and bil. inguinal regions.
  • 2023-08-25 Nasopharyngoscopy
    • Findings: Smooth nasopharynx, oropharynx and hypopharynx; fair vocal cord movement.
    • Dx/Conclusion: No finding of mucosal lesion in the study.
  • 2023-08-22 CT - neck
    • Diffuse multiple enlarged left neck LNs, mainly in the posterior cervical space.
    • Multiple LAPs also were noted in left supraclavicular space.
    • After IV contrast administration shows well or heterogenous enhancement of those LNs.
    • Suggest clinical correlation.

[MedRec]

  • 2023-08-25 ~ 2023-09-18 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites, Lugano stage IV
      • Acute lymphadenitis of face, head and neck
      • Hepatomegaly with splenomegaly, not elsewhere classified
      • Nonspecific mesenteric lymphadenitis
      • Acute lymphadenitis of other sites
      • Unspecified adrenocortical insufficiency
    • CC
      • fever off and on for 6 months and left neck palpable lymph nodes for 4 months.
    • Present illness
      • The 23-year-old male patient has history of Covid-19 infection and influenza A infection. He has suffered from fever off and on for 6 months and left neck palpable lymph nodes for 4 months, since this April. He went to ShuangHe Hospital for with suspect malignancy by needle aspiration at ShuangHe Hospital on 2023-08-08. CT was scheduled on Aug 29, so he came to our Oncology OPD for help on 8/18 and Neck CT was done on Aug 22. CT report showed diffuse multiple enlarged left neck LNs, mainly in the posterior cervical space. Multiple LAPs also were noted in left supraclavicular space. After IV contrast administration shows well or heterogenous enhancement of those LNs.
      • He came to our ER yesterday due to fever again and skin rashes after contrast medium injection. At ER, fever noted with BT 39.7’C. Lab data showed normal white count WBC:8160, and elevated CRP level 17.5. Urinalysis showed no UTI and CxR film showed no pneumonia. Empirical antibiotic Augmentin was given for infection control at ER. Under the impression of Fever and left neck lymphadenopathy, cause unknown, he is admitted to our Infection ward for further evaluation and management on 2023-08-25.     
    • Course of inpatient treatment
      • After admission, patient received antibiotic with Cravit iv for infection control and cover possible atypical infection, fever off and on after admission under antibiotic treatment, check laboratory data with virus infection EMB, CMV, HIV all showed negative result, the abdominal CT scan showed Hepato-splenomegaly. Enlarged LNs at retroperitoneum and bil. inguinal regions and mass lestion over nack, the ENT was consulted and Impression of suspect lymphoma. the excisional biopsy for the patient was done on 8/30 and pending phathology.
      • The TB qauntiferon was check and report showed indeterminate, we will keept follow phathology report. Due to persisted fever the antibiotic Gentamicin was added since Aug 29 and check coartisol level showed 0.48 only, added Hydrocortisal 50mg Q8H and the Meta was consulted due to possbile medical effect, or possible related with stress caused adrenal insufficiency, and if the patient performs less adrenal insufficiency symptoms, suggested downgrade steroid dose gradually and check ACTH and corstisol level for evaluation.
      • No more fever and more stable condition, follow up laboratory data on Sep 05, with noraml WBC and CRP 1.7 mg/dL. Pending phathology report if negative finding, he can be discahrge in this week. However, the phathology report showed T- cell Lymphoma, so he was trasfer to Hematologist for continue care and treatment.    
      • After transferred to Hemalogy ward, we arranged heart echo, PET/CT scan, and bone marrow biopsy for the patient. Port-A insertion was arranged and done on 2023-09-11.
      • Lab data was then followed up, and as PET/CT reported Highly suspected lymphoma, c-stage IV (AJCC 8th ed.), the patient has started his chemotherapy on 9/12 with CHOEP.
      • After chemotherapy started, we followed up the patient’s blood data every day, and there was no more fever noted. We added Feburic, Promeran and Famotidine for symptom prevention, and the patient had no elevation of uric acid and LDH noted. The patient’s first session of chemotherapy was finished on 2023-09-15, and we followed up his lab data on renal function, electrolyte, uric acid and LDH every day.
      • There was no abnormal lab data noted in each follow up, and there was no discomfort or fever noted. Under stable condition, the patient was discharged on 2023-09-18, with OPD follow up arranged on 2023-09-22.
  • 2023-08-18 SOAP Hemato-Oncology Gao WeiYao
    • S
      • He received needle aspiration over neck and lymphoma was suspected at ShuangHe Hospital.
      • Fever for 6 months and Neck tumor were noted since April, 2023.
      • Nonsmoker

[chemotherapy]

  • 2024-01-26 - cyclophosphamide 750mg/m2 1430mg NS 500mL 30min D1 + doxorubicin 50mg/m2 95mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 190mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
  • 2023-12-27 - cyclophosphamide 750mg/m2 1420mg NS 500mL 30min D1 + doxorubicin 50mg/m2 94mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 189mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
  • 2023-12-09 - cyclophosphamide 750mg/m2 1410mg NS 500mL 30min D1 + doxorubicin 50mg/m2 94mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 188mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
  • 2023-11-13 - cyclophosphamide 750mg/m2 1390mg NS 500mL 30min D1 + doxorubicin 50mg/m2 90mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 180mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
  • 2023-10-23 - cyclophosphamide 750mg/m2 1350mg NS 500mL 30min D1 + doxorubicin 50mg/m2 90mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 180mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
  • 2023-10-02 - cyclophosphamide 750mg/m2 1350mg NS 500mL 30min D1 + doxorubicin 50mg/m2 90mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 180mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
  • 2023-09-12 - cyclophosphamide 750mg/m2 1330mg NS 500mL 30min D1 + doxorubicin 50mg/m2 88mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 177mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3

Initial treatment of peripheral T cell lymphoma - INDUCTION THERAPY - 2023-11-24 - https://www.uptodate.com/contents/initial-treatment-of-peripheral-t-cell-lymphoma

  • Fit, younger patients
    • For medically fit, younger patients with CD30-negative PTCL, we suggest CHOEP rather than CHOP or more intensive regimens. Compared with CHOP, CHOEP is associated with better clinical outcomes and moderately increased toxicity; other intensive regimens are associated with similar outcomes but substantially greater toxicity.
    • CHOEP administration - Many experts limit use of CHOEP to medically fit patients <=60 or 65 years because of toxicity.
    • In CHOEP, intravenous etoposide 100 mg/m2 on days 1 through 3 of each 21-day cycle is added to the CHOP regimen. An alternate version of CHOEP administers intravenous etoposide 100 mg/m2 on day 1 of CHOP, followed by oral etoposide 200 mg/m2 on days 2 and 3 of each 21-day cycle. The higher oral dose of etoposide is necessary due to poor bioavailability with oral administration.
    • PET3 is performed after the first three cycles of CHOEP in order to decide whether to give three additional cycles of induction or treat for refractory PTCL (as described above for BV+CHP).
  • Older or less-fit patients
    • For older or less medically fit individuals of any age with CD30-negative PTCL, we favor CHOP induction therapy to avoid the increased toxicity associated with CHOEP.
    • CHOP administration - CHOP is given every three weeks for three cycles, followed by PET3 to guide completion of six total cycles of CHOP (for patients with CR or PR) versus management for refractory disease.

==========

2024-01-29

[reconciliation]

Lab results on 2024-01-25 indicated normal liver and kidney function tests, with serum uric acid levels at 9.0 mg/dL, suggesting hyperuricemia. This condition is being managed with Feburic (febuxostat), and there are no discrepancies in medication.

700052492

240126

[exam findings]

  • 2024-01-22 Fine Needle Aspiration Cytology - lymph node
    • Indication: Squamous cell carcinoma of the postcricoid area, p16 (-), stage cT2N0M0, s/p CCRT, with right neck level III~IV neck node metastasis, status post right modified radical neck dissection and CCRT, with lung metastases, status post VATS RUL and RML wedge + LN sampling, with tumor recurrence at right lower neck and progression.
    • Result: 2 alcohol fixed slides and 1 cc red, cloudy — Malignancy
    • MICROSCOPIC DESCRIPTION: Smears show necrotic debris, neutrophils, histiocytes, and atypical hyperchromatic cells with focal keratinization. Metastatic squmaous cell carcinoma is favored. Please correlate with the clinical presentation and further examination is suggested.
  • 2024-01-19 SONO - head and neck soft tissue
    • Clinical Impression/Intent: right level 4 neck mass
    • Sonographic Impression: right level 4 neck mass, size: 3.55*1.96, heterogenous, suspect metastatic LN
  • 2024-01-18 CT - neck
    • Indication:
      • hypopharyngeal cancer, cT2N0M0, stage II (diagnosed on 2020/08/04), with neck recurrence s/p CCRT and C/T.
      • right neck mass lesion with reddish and icthing about 6x3cm for 10-12 days. R/O disease progression
    • Head and Neck CT with and without IV contrast administration shows: comparison 2023/12/22 CT
      • LAPs at right neck, level III-IV, up to 5.6 cm, central necrotic change was noted, with intervally enlarged size.
      • No evident nodule or mass in the post-cricoid region.
      • No nodule was seen in the bil. visible apical lungs.
      • Correlation with previous imaging study for comparison is suggested.
  • 2024-01-18 Nasopharyngoscopy
    • Findings
      • smooth nasopharynx, oropharynx and hypopharynx; right vocal cord paralysis.
    • Conclusion
      • History of hypopharyngeal cancer s/p CCRT
  • 2023-12-22 CT - chest
    • Indication: Squamous cell carcinoma of the postcricoid area, p16 (-), stage cT2N0M0, s/p CCRT, with right neck level III~IV neck node metastasis, status post right modified radical neck dissection and CCRT
    • Chest CT with and without IV contrast ehnancement shows:
      • Necrotic lymphadenopathy at right lower neck measuring 3.8cm in largest dimension. (SE304 IM3).
      • s/p right upper lobe op.
      • No evidence of bilateral pleural effusion.
      • S/p port-A placement with its tip at Superior vena cava
    • Imp:
      • Right lower neck lymphadenopathy. The lesion is new as compared with previous CT on 2023-02-21.
      • NO evidence of lung meta in the study.
  • 2023-11-15 CXR erect
    • Atherosclerotic change of aortic arch
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2023-10-13 Nerve Conduction Velocity, NCV
    • Findings
      • prolonged DLs, lower CMAP amplitudes and normal NCVs of bil. ulnar and right peroneal n.
      • prolonged sensory DLs, lower SNAP amplitudes on bil. median, ulnar and sural n. with marked slowing of NCVs
      • the F-wave latencies of bil. median, ulnar, peroneal and tibial n. were normal.
      • the H-reflex study of bil. tibial n. were prolonged
    • Conclusion:
      • sensory predominant polyneuropathies
  • 2023-10-03 Neurosonography
    • wall thickening on bil. common carotid arteries
    • damped peak systolic velocities on right ICA and ECA, may suggest post-stenotic or increased resistance distally, smaller diameter (0.24cm) and lower flow (26cc/min) on right VA
  • 2023-09-30 CT - brain
    • No brain nodule or mass.
  • 2023-09-12 SONO - abdomen
    • Chronic liver parenchymal disease
  • 2023-08-23 MRI - brachial plexus
    • Findings
      • normal bone alignment of the spine; post-OP change at the middle adn lower C-spine.
      • heterogeneous enhancing soft tissue at the right lower neck, involving right carotid space, paravertebral space at the lower C-spine with extention to the right brachial pelxus. As compared with previous MRI on 20230512, the sizes were mildly decreased
      • an enlarged lymph node in the right middle carotid space
    • IMP:
      • tumors in the right lower neck, mild decrease in size
      • an enlarged lymph node in the right carotid space
  • 2023-07-11 Nasopharyngoscopy
    • much saliva over right pyriform sinus. invisible vocal cord
  • 2023-05-12 MRI - brachial plexus
    • Indication: right upper limb weakness
    • Without- and with-contrast MRI of brachial plexuses, focusing on right side, with axial, sagittal and coronal T1WI and T2WI using 3 mm - 5 mm thickness reveal:
      • Severe progressive enlargement of the enhancing soft tissue mass at right lower neck, involving carotid space, paravertebral space (C4-T1 levels), and extending along brachial plexus, as compared with MRI on 20221214. Progressive recurrence is considered.
      • S/P disc prosthesis at C3-4-5-6-7.
      • No enlarged lymph node.
      • Scoliosis of C-spine.
    • IMP: C/W Tumor recurrence at right lower neck, involving carotid and paravertebral space and brachial plexus. Severe progression as compared with MRI on 20221214.
  • 2023-03-29 Tc-99m MDP bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in bilateral rib cages, lower C-spine, lower L-spine, bilateral shoulders, right femoral shaft, D/3, and left knee.
  • 2023-03-14 Patho - lung wedge biopsy
    • PATHOLOGIC DIAGNOSIS:
      • Lung, right, middle lobe, wedge resection —- Metastatic squamous cell carcinoma
      • Lymph node, right, group No.7, lymphadenectomy —- Negative for malignancy (0/16)
      • Pleura, right, excision —- Metastatic squamous cell carcinoma
    • MACROSCOPIC EXAMINATION:
      • Specimen: Lung, size: 6.0 x 3.2 x 2.4 cm, 14 g
        • Lymph nodes, a bottle, group 7, maximal size: 1.3 x 0.7 cm
      • Tumor Site: Periphery
      • Tumor Size: Solitary: 3.0 x 2.7 x 1.8 cm
      • Gross tumor patterns: poorly defined, Pleural retraction
      • A piece of pleural nodule, measuring 1.0 x 1.0 x 0.5 cm, is received
      • Tissue for sections: A1: resection margin; A2: lung; A3-5: tumor; B: lymph node, group 7; C: pleural nodule.
    • Microscopic Description
      • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobes
      • Histologic Type (select all that apply): Consistent with metastatic squamous cell carcinoma, keratinizing
      • Histologic Grade: G2: Moderately differentiated
      • Spread Through Air Spaces (STAS): Not identified
      • Visceral Pleura Invasion: Present (PL1)
      • Lymphovascular Invasion (select all that apply): Present, Lymphatic, Arterial, Venous
      • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
      • Margins (select all that apply): All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin (centimeters): 0.3 cm
        • Specify closest margin: resection margin
      • Treatment Effect: No known presurgical therapy
      • Regional Lymph Nodes: group 7: 0/16
      • Extranodal Extension: Not identified
      • Additional Pathologic Findings: The pleural nodule reveals metastatic squamous cell carcinoma.
  • 2023-03-14 Patho - lung wedge biopsy
    • PATHOLOGIC DIAGNOSIS:
      • Lung, right, upper lobe, wedge resection — Metastatic squamous cell carcinoma,
    • MACROSCOPIC EXAMINATION:
      • Specimen: Lung, size: 6.0 x 5.8 x 3.0 cm, 38 g
      • Tumor Site: Periphery
      • Tumor Size: Solitary: 2.2 x 2.0 x 1.5 cm
      • Gross tumor patterns: poorly defined
      • Several pleural fibrotic nodules, measuring up to 0.5 x 0.4 x 0.2 cm, are seen.
      • Tissue for sections: A1: resection margin; A2: lung; A3: bronchus; A4-6: tumor; A7: pleural fibrosis.
    • Microscopic Description
      • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobes
      • Histologic Type (select all that apply): Consistent with metastatic squamous cell carcinoma, keratinizing
      • Histologic Grade: G2: Moderately differentiated
      • Spread Through Air Spaces (STAS): Not identified
      • Visceral Pleura Invasion: Not identified
      • Lymphovascular Invasion (select all that apply): Not identified
      • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
      • Margins (select all that apply): All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin (centimeters): 0.3 cm
        • Specify closest margin: resection margin
      • Treatment Effect: No known presurgical therapy
      • Additional Pathologic Findings: Several pleural fibrotic nodules are seen.
  • 2022-07-19 MRI - larynx
    • The current study was compared to the prior one obtained on 2021/08/23.
    • Progressive effacement of right pyriform sinus with mucosal thickening. Suggest clinical correlation and tissue proof.
    • Diffuse softt issue swelling at AE folds and retropharyngeal wall.
    • Paranasal sinusitis.
  • 2022-05-17 Tc-99m MDP bone scan
    • In comparison with the previous study on 2020/7/31, the lesions in the lower C-spine and L4-5 spines are a little more evident. The nature is to be determined (degenerative change in a little more severe status? other nature?). Please correlate with other imaging modalities for further evaluation.
    • Some new faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders and left knee. Benign joint lesions such as arthritis are more likely.
  • 2022-02-22 Patho - lymph node region resection
    • PATHOLOGIC DIAGNOSIS
      • Lymph nodes, level III-IV, right, neck LN dissection — Metastatic squamous cell carcinoma (1/7)
      • Lymph nodes, level II, right, neck LN dissection — Negative for malignancy (0/4)
      • Soft tissue, level IV, biopsy for frozen section — Metastatic squamous cell carcinoma
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure(s): Right neck LN dissection
      • Specimen Type: Right neck lymph node dissection, including level II and level III-IV
        • Representative parts ae taken for section as: S2022-02835A= level II lymph nodes, B1-B2= level III-IV lymph nodes.
      • Specimen received for frozen section: two pieces of pink gray soft tissue, labeled level IV, measuring up to 0.9 x 0.5 x 0.3 cm. All for section as: F2022-00064.
    • MICROSCOPIC EXAMINATION
      • Number of lymph nodes involved: 1 (level III-IV)
      • Number of lymph nodes examined: 4 (level II), 7 (level III-IV)
      • Size of largest metastatic deposit: 2.2 cm
      • Extranodal extension: Present
      • The sections of frozen section specimen also show metastatic squamous cell carcinoma (not identified in frozen section slide), composed a few neoplastic cells in fibrous stroma. No lymphoid tissue can be found.
      • IHC, the neoplastic cells reveal: CK(+) and P40(+).
  • 2021-03-09 MRI - larynx
    • Intervally increased soft tissue in the supraglottic, post-cricoid region, combined with edema likely
    • Severe narrowed supaglottic airway.
  • 2020-07-31 Patho - larynx biopsy
    • Labeled as “postcricoid tumor”, biopsy — squamous cell carcinoma.
    • IHC stains: p16 (-), p40 (+).

[MedRec]

  • 2024-01-10 SOAP Neurology Liu ZhiYang
    • Prescription x3
      • Pentop (pentoxifylline 400mg) 0.5# BID
      • Toppamax (topiramate 25mg) 1# BID
  • 2023-12-13 SOAP Neurology Liu ZhiYang
    • Prescription x3
      • Cymbalta (duloxetine 30mg) 1# BID
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
      • Pentop (pentoxifylline 400mg) 0.5# BID
  • 2023-12-13 SOAP Gastroenterology
    • Diagnosis
      • Chronic viral hepatitis B without delta-agent [B18.1]
    • Prescription x3
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
  • 2023-09-28 SOAP Neurology Liu ZhiYang
    • S:
      • left arm and bil. leg numb, also right shoulder pain under medication
      • Phx: Squamous cell carcinoma of the postcricoid area
    • A:
      • C-spine MRI: Cervical spondylosis s/p oepration with diffuse spinal canal stenosis. compressive myelopathy and neuroforaminal narrowings at C3-4-5-6-7.
  • 2023-09-12 SOAP Gastroenterology
    • Diagnosis
      • Chronic viral hepatitis B without delta-agent [B18.1]
    • Prescription x3
      • Baraclude (entecavir 0.5mg) 1# QOD
  • 2020-07-29 ~ 2020-07-31 POMR Ear Nose Throat
    • Discharge diagnosis
      • C13.0 Post-cricoid tumor, suspect malignant status post laryngomicrosurgery and esophagoscopy on 2020-07-31
      • Gastro-esophageal reflux disease with esophagitis, LA Classification grade A
      • Essential (primary) hypertension
      • Carrier of viral hepatitis B
    • CC
      • Sorethroat and cough for 1 year
    • Present illness
      • This 48-year-old man is a hepatitis B carrier who has history of GERD and hypertension without medication control. He has smoking for 30 years with alcohol drinking. He suffered from sorethroat and cough for 1 year. Regurgitation was also complained. He treated at local clinic but in vain. He then visited our ENT OPD for help. At OPD, fiberscope found post-cricoid tumor. Under the suspect of malignancy, we suggest him admission for tumor survey and LMS biopsy.
    • Course of inpatient treatment
      • After admission, tumor survey were arranged. MRI was done on 7/29 which revealed submucosal tumor at posterior hypopharyneal wall. D/D: inflammatory/infectious mass, malignancy. UGI/PES was done on 7/30 which revealed erosive esophagitis LA Classification grade A. The patient underwent larygomicrosurgery and esophagoscopy on 2020/7/31. Post-operation, there was no active oral bleeding but throat pain with cough were noted. Clindamycin and paran were added for symptoms relief. Bone scan was done on 7/31 which revealed no strong evidence of bone metastasis. Under relatviely stable condition, the patient was discharged with medication and OPD follow-up. 
    • Discharge prescription
      • Lindacin (clindamycin 150mg) 2# QID
      • Lactam (acetaminophen 500mg) 1# QID
      • Nexium (esomeprazole 40mg) 1# QDAC
  • 2023-03-12 ~ 2023-03-15 POMR Thoracic Surgery Xie MinXiao
    • Discharge diagnosis
      • Right upper and right middle lobe lung nodules, suspect metastatic status post three-dimensional video-assisted thoracoscopic surgery right upper and right middle lobe wedge resection and lymph node sampling on 2023-03-13
      • Hypopharyngeal cancer (squamous cell carcinoma) cT2N0M0 stage II status post concurrent chemoradiotherapy
      • Viral hepatitis B without hepatic coma
      • Gastro-esophageal reflux disease
      • Essential (primary) hypertension
    • CC
      • lung nodules was told by chest CT and PET while ENT OPD follow up        
    • Present illness
      • This is a 50 y/o male patient with history of hypopharyngeal cancer with neck recurrence s/p CCRT, HTN, HBV carrier, psoriasis vulgaris. Abnormal finding of lung was noted on CT and PET while ENT OPD follow up. He was then referred to our CS OPD due to lung nodules over RUL, RML. He denied poor appetite, dyspnea, dysphagia, chest discomfort, abdominal discomfort, nor dysuria. Dry cough was noted for many years.
      • He suffered from right shoulder pain and soreness in the recent one month. He took painkillers but in vain. Body weight loss 2 kg in the rescent three months was also mentioned.
      • Whole body PET scan done on 2023/01/17 showed two glucose hypermetabolic lesions in the upper lobe of right lung and a glucose hypermetabolic lesion in the middle lobe of right lung, lung metastases should be watched out.
      • Chest CT revealed many ill-defined nodular lesions of variable sizes in RUL and RML mesuaring up to 24mm, due to metastases.
      • After discussing with the patient and his family on the benefits of surgical treatment as well as subsequent risks and possible complications, the patient was admitted for 3D VATS RML, RUL metastectomy on 2023/03/13 under the impression of lung nodules over RUL, RML, suspect lung metastasis.
    • Course of inpatient treatment
      • After admission, pre-op assessment was done. Operation of three-dimensional video-assisted thoracoscopic surgery right upper and right middle lobe wedge resection and lymph node sampling was performed smoothly on 2023-03-13. No complication was noted. Prophylactic antibiotics was prescribed for 1 day. Right chest tube with LPS 18 cm H2O was done. Chest tube was removed on 2023-03-15. He was discharged under stable hemodynamics and OPD follow up will be arranged.
    • Discharge prescription
      • Actein (acetylcysteine 200mg) 1# TID
      • Ripam (clonazepam 0.5mg) 1# BID
      • Celebrex (celecoxib 200mg) 1# BID
      • Sindine (povidone iodine Aq soln) QD EXT

[consultation]

  • 2023-05-08 Neurology
    • Q
      • The 50 y/o man has recurrent hypopharynx with right upper and right middle lobe lung nodules, suspect metastatic status post three-dimensional video-assisted thoracoscopic surgery right upper and right middle lobe wedge resection and lymph node sampling on 2023-03-13. Due to he has right upper limb numbness with painful sensation, MP 3 to weak 4, we need your help for management. Thanks!
    • A
      • CC: Rt upper limb weakness and numbness for more then 2 months
      • O
        • CN: intact
        • MP: RU:4 RL:5 LU:5 LL:5
        • Pinprick: allodynia over right upper limb.
      • Imp: r/o brachial plexopathy due to mets.
      • Suggestion:
        • arrange NCV (Motor sensory nerve conduction of upper and lower limbs, H reflex, F wave, QST)
        • You may try lyrica #1 BID for neuralgia
  • 2023-05-08 Neurosurgery
    • Q
      • The 50 y/o man has recurrent hypopharynx with right upper and right middle lobe lung nodules, suspect metastatic status post three-dimensional video-assisted thoracoscopic surgery right upper and right middle lobe wedge resection and lymph node sampling on 2023-03-13. Due to he has right upper limb numbness with painful sensation, MP 3 to weak 4, we need your help for management. Thanks!
    • A
      • A case of recurrent hypopharyngeal cacner with distal metastasis;
      • NS is consulted for right UE numbness/ weakness for months.
      • O
        • Current status: MP: RT UE 2-3; sensation: Rt UE hypothesia
        • DTR: 0-+; Sphincter: continence
      • A: metastastic tumor, involving right neck?
      • P: Please arrange right brachial plexus MRI with and without Gd;

[surgical operation]

  • 2023-03-13
    • Surgery
      • VATS RUL and RML wedge + LN sampling.
    • Finding
      • One tumor was noted over the apex of RUL, another nodular lesion was noted over RML, size about 2.0cm in diameter.
      • One 24 Fr. straight chest tube was inserted via right 8th ICS.

[radiotherapy]

[chemotherapy]

  • 2024-01-26 - docetaxel 75mg/m2 115mg NS 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-12-25 - cetuximab 500mg/m2 700mg 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-11-16 - cetuximab 500mg/m2 700mg 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-10-23 - cetuximab 500mg/m2 700mg 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-10-06 - cetuximab 500mg/m2 700mg 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-09-04 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-07-31 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-07-03 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-06-05 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-05-08 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-04-03 - NS 500mL 2hr D1 (before cisplatin) + cisplatin 100mg/m2 160mg NS 500mL 4hr D1 + NS 500mL 2hr D1 (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 21hr D1-4 (PF, Q4W)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-04-26 - (cisplatin, QW)

  • 2022-04-19

  • 2022-04-12

  • 2022-04-08

  • 2022-03-29

  • 2022-03-22

  • 2020-10-20 - (cisplatin, QW)

  • 2020-10-13

  • 2020-10-06

  • 2020-09-29

  • 2020-09-22

  • 2020-09-15

==========

2024-01-26

[neurological follow-up in this cisplatin-treated patient]

This is a patient who has a long history of underlying neurological conditions. Cervical polyradiculopathy was found on 2010-06-30. On 2010-07-23, the patient was diagnosed with herniated intervertebral discs (HIVD) at the C3, C4, C5, C6, and C7 levels, along with canal stenosis. He subsequently underwent Anterior Cervical Discectomy and Fusion (ACDF) and right Trans-Ulnar Synovectomy (TUS) / Carpal Tunnel Syndrome (CTS) neurolysis on 2010-07-07. On 2016-02-06, the patient presented with a mass on the left dorsal ear and was undergoing follow-up after cervical surgery. He also exhibited muscular atrophy in his limbs. On 2016-03-04, the patient reported soreness, especially in cold weather conditions. Later, on 2023-03-07, the patient experienced pain in the back of the neck and radiating numbness and weakness in the right upper extremity, persisting for three months. The pain was not relieved by painkillers.

The patient had used cisplatin in Sep and Oct in 2020, Mar and Apr in 2022, 2nd and 3rd quarters in 2023. Cisplatin is known associated with peripheral neuropathy.

While the patient’s neurological issues cannot be solely attributed to cisplatin, its potential role in causing neuropathy cannot be excluded. The patient has been more frequently visiting neurology since Sep 2023, with the most recent appointment on 2024-01-10. Monitoring the effectiveness of symptom control proposed by our neurologist is suggested.

Additionally, docetaxel, started during this hospitalization, is also associated with neurological adverse reactions. These include central nervous system toxicity (20% to 58%; dysesthesia and paresthesia both ≤6%), neuromuscular and skeletal issues like asthenia (53% to 66%; severe weakness 13% to 18%), myalgia (3% to 23%; severe myalgia 2%), and neuromuscular reactions (16%), as well as peripheral motor neuropathy (4%; mainly distal extremity weakness) and arthralgia (3% to 9%).

Given that chemotherapy-induced peripheral neuropathy remains a challenging medical issue to fully overcome, continued follow-up in neurology outpatient clinics is recommended.

2023-07-31

The patient just refilled Ultracet (tramadol, acetaminophen) and Lyrica (pregabalin) for his aalignant neoplasm of hypopharynx at a local pharmacy on 2023-07-27. In current active medication list, there were Tramacet, Lyrica and Durogesic (fentanyl) prescribed, no reconciliation issues identified.

700374777

240126

[exam findings] (not completed)

  • 2023-05-10 PET
    • Increased FDG uptake in the middle third of esophagus, compatible with the primary esophageal cancer.
    • Increased FDG uptake in lymph nodes in bilateral upper mediastinum and in the left supraclavicular fossa, highly suspected cancer with regional lymph nodes metastases.
    • Increased FDG uptake in bilateral pulmonary hilar and right lower mediastinal lymph nodes, probably reactive nodes.
    • Increased FDG uptake at the left shoulder, probably benign in nature.
    • Increased FDG accumulation in bilateral kidneys and colon, physiological uptak of FDG is more likely.
    • Esophageal cancer, cTxN2M0, stage III at least (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-05-09 Patho - esophageal biopsy
    • Esophagus, 20 cm below incisor, biopsy — No significant pathologic change
    • Esophagus, 21-24 cm below incisor, biopsy — severe squamous dysplasia
    • Microscopically, section A shows bland squamous mucosal epithelium and no significant pathologic change. Section B shows severe squamous dysplasia with high grade nuclear atypia of the squamous cells and loss of polarity.
  • 2023-05-09 MRI - brain
    • No evidence of brain metastasis.
  • 2023-05-08 Miniprobe Endoscopic Ultrasound
    • Advanced esophageal SCC, middle esophagus, EUS staging T3Nx
    • Suspected esophageal dysplasia, 20 cm below incisors, s/p biopsy (A)
    • Suspected early esophageal SCC, 21-24 cm below incisors, uT1a, s/p biopsy (B)
    • Esophageal inlet patch, c/w heterotopic gastric mucosa
  • 2023-05-08 SONO - abdomen
    • Renal stones, both
  • 2023-05-05 ECG
    • Normal sinus rhythm
    • Minimal voltage criteria for LVH, may be normal variant
    • Borderline ECG
  • 2023-05-05 CXR
    • Rt-sided convexity of the azygoesophageal recess interface, due to esophageal tumor
  • 2023-04-28 CT - chest
    • Indication: 20230418 EGD: Esophageal mass like lesion, 25cm to 30cm below incisors, s/p biopsy, R/O malignancy; Stenosis at 30cm below
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lymphadenopathy at left lower neck and bilateral paratracheal is found.
        • Long segmental wall thickening at esophagus up to 6.7cm is found. Esophageal cancer is considered.
      • Visible abdomen:
        • Bilateral renal stones are found.
        • The spleen, liver, pancreas and adrenals are intact.
    • Imp: Esophageal cancer with mediastinal lymph nodes and left lower neck.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression ( Imaging stage ): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-04-27 Tc-99m MDP bone scan
    • Increased activity in the L3 spine. Severe degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Mildly increased activity in the lower T-spines, L4-5 spines and bilateral S-I joints. Degenerative change is more likely.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, left wrist, right knee, bilateral ankles and feet, compatible with benign joint lesions.
  • 2023-04-19 Patho - esophageal biopsy (Y2)
    • Esophagus, 25 cm to 30 cm below incisor, biopsy — moderate differentiated squamous cell carcinoma
    • Microscopically, section shows moderate differentiated squamous cell carcinoma consisting of invasive irregular squamous epithelial tumor nests arranged in solid architecture. The tumor cells display nuclear pleomorphis, hyperchromasia, high N/C ratio and prominent nucleoli.
  • 2023-04-18 Esophagogastroduodenoscopy, EGD
    • Esophageal mass-like lesion, 25cm to 30cm below incisors, s/p biopsy, R/O malignancy
    • Stenosis at 30cm below incisors

[chemotherapy]

  • 2024-01-26 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-06-30 - NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 137mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1800mg NS 500mL 24hr D1-4
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-05-30 - NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 137mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1800mg NS 500mL 24hr D1-4
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-07-03

  • According to the PharmaCloud database, our hospital was the sole provider for this patient’s healthcare needs. In addition to the hemato-oncology department, the patient had an appointment with our gastroenterologist on 2023-04-24 who prescribed a 28-day course of a PPI Pariet (rabeprazole) for his gastroesophageal reflux disease with esophagitis. This prescription is currently invalid and the symptoms are no longer listed on the active medical problem list. As a result, no problems were identified during the medication reconciliation process.

701507856

240126

[lab data]

2023-12-22 HBV-DNA-PCR Target Not Detected IU/mL
2023-12-21 Anti-HCV Nonreactive
2023-12-21 Anti-HCV Value 0.15 S/CO
2023-12-21 HBsAg Nonreactive
2023-12-21 HBsAg (Value) 0.49 S/CO
2023-12-21 Anti-HBs 267.16 mIU/mL
2023-12-21 Anti-HBc IgM Nonreactive
2023-12-21 Anti-HBc IgM Value 0.09 S/CO
2023-12-21 Anti-HBc Reactive
2023-12-21 Anti-HBc-Value 6.93 S/CO

[exam findings]

  • 2024-01-22 CT - brain
    • Imp: Brain atrophy. Multiple bil. brain and right cerebellar metastases with hemorrhages.
  • 2023-12-26, -12-21 CXR erect
    • A mass opacity projecting in left middle lung is noted that is c/w primary lung cancer after correlate with CT.
  • 2023-12-25 ALK IHC (EGFR positive should be self-paid)
    • Cellblock No. S2023-24780
    • RESULT: Positive
  • 2023-12-21 ECG
    • Sinus bradycardia
    • Nonspecific ST abnormality
  • 2023-12-18 Peripheral Vascular Test - Artery, upper limbs
    • Findings
      • Atherosclerosis: Mild
      • Doppler: Decreased flow velocity at L’t Subclavian A., Axillary A., Brachial A., Radial A., Ulnar A.
    • Conclusions:
      • Decreased flow spectrum from left subclavian artery, consider severe left subclavian stenosis. Patent left axillary, brachial, antebrachial, raidal and ulnar artery.
      • Patent right upper limbs arteries.
  • 2023-12-15 Tc-99m MDP bone scan
    • Increased activity in the middle C-spine, L2-3 spines and bilateral S-I joints. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Some faint hot spots in the skull. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, elbows, hips and knees, compatible with benign joint lesions.
  • 2023-12-14 ROS1 IHC
    • Cellblock No.: S2023-24780
    • RESULTS: Negative
  • 2023-12-14 PD-L1 IHC
    • Cellblock No.: S2023-24780
    • RESULTS:
      • Tumor cell (TC) staining assessment: TC: >= 5% and <10%
      • Percentage of PD-L1 expressing tumor cells (%TC): 5%
  • 2023-12-14 PD-L1 (22C3)
    • Cellblock No.: S2023-24780
    • RESULTS:
      • Tumor Proportion Score (TPS) assessment: TPS <1%
      • Tumor Proportion Score (TPS): 0%
  • 2023-12-14 EGFR
    • Cellblock No.: S2023-24780
    • No mutation was detected at exons 18,19, 20, 21 of EGFR gene in this specimen
  • 2023-12-14 PET scan
    • A glucose hypermetabolic lesion in the upper lobe of the left lung near left pulmonary hilum. Primary lung malignancy may show this picture.
    • Glucose hypermetabolism in some left mediastinal lymph nodes. Metastatic lymph nodes should be watched out.
    • Multiple glucose hypermetabolic lesions in bilateral cerebral and cerebellar hemispheres, suggesting multiple cerebral and cerebellar metastases.
    • Glucose hypermetabolism in the stomach. Inflammation may show this picture. please correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation is more likely. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2023-12-11 Patho - brain biopsy
    • Brain tumor, frozen + biopsy — Metastatic pulmonary mucinous adenocarcinoma
    • The specimen submitted consists of some small pieces of sticky brain tumor tissue measuring 1.5 x 1.0 x 0.2 cm in aggregate, fixed in formalin. Grossly, they are gray in color and sticky mucus in consistency. All mbedded for section. Reference: frozen section, F2023-00562 some sticky mucoid tumor tissue, all embedded.
    • Microscopically, the section shows a picture of metastatic pulmonary adenocarcinoma characterized by atypical tumor cells arranged in papillary or tubular patterns with intracytoplasmic mucin.
    • Immunohistochemistry shows TTF-1(+), CK7(+), Napsin-A(+), PAX-8(-) and CK20(-) for tumor.
  • 2023-12-11 Frozen Section
    • Brain tumor, frozen — Mucinous adenocarcinoma, metastatic
  • 2023-12-09 CT - brain
    • Indication: brain meta, for navigator
    • With and without-contrast CT of brain shows:
      • Multiple mass lesions, up to 32mm, in bilateral cerebral and right cerebellar hemispheres. Enhancement after contrast administration.
      • Minimal midline shift to left, 4mm.
    • Impression
      • Multiple brain metastasis
  • 2023-12-08 CT - chest
    • Indication: brain metastasis for tumor survey
    • Chest CT with and without IV contrast ehnancement shows:
      • One ground glass nodule at left upper lobe measuring 0.6cm in largest dimension is found. (Se202 Im24).
      • Soft tissue mass at left upper lobe measuring 2.73cm in largest dimension is found. The lesion attached to left hilar region
      • Some lymph nodes are found at bilateral paratracheal region.
      • Cystic change at left ovary up to 2.86cm is found.
    • Imp:
      • left upper lobe lung cancer with brain meta. and mediastinal lymphadenopathy.
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)
  • 2023-12-07 MRI - brain
    • Indication: Brain metastasis for survey
    • Without- and with-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) reveal:
      • Numerous intra-axial tumors with heterogeneous enhancement and perifocal edema involving bilateral cerebral and cerebellar hemispheres, and pons, with the largest one about 33 mm at right anterior frontal lobe. Midline shift to left side for 8 mm also noted.
      • Mild degree of general enlargement of ventricles, cistern spaces and cortical sulci, indicating general brain atrophy.
    • IMP:
      • Multiple brain metastases (with the largest one about 33 mm at right anterior frontal lobe causing mass effect).
  • 2023-12-07 ECG
    • Prolonged QT
    • Nonspecific T wave abnormality
  • 2023-12-06 CXR erect
    • A lobulated left parahilar lung tumor mass.

[MedRec]

  • 2024-01-17 SOAP Hemato-Oncology He JingLiang
    • S: CDDP + Gemzar C1D8, ALK positive, apply Alectinib
    • O: Cancer multidisciplinary team meeting conclusion, Meeting date: 2023-12-26
      • RT to brain lesions
      • pending ALK, ROS1, PD-L1.
    • Prescription
      • Hepac Lock Flush (heparin sodium) ST IRRI
      • Norvasc (amlodipine 5mg) 1# QD
      • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC if nausea or vomiting
      • Through (sennoside 12mg) 2# HS
      • Ulstop (famotidine 20mg) 1# BID
      • Bokey (aspirin 100mg) 1# QD
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Crestor (rosuvastatin 10mg) 1# QD
  • 2024-01-04 ProgressNote Gao ZhenYi
    • Problem #2: Left upper lobe lung cancer with brain metastasis and mediastinal lymphadenopathy, cT3N2M1c, stage IVB
      • Assessment:
        • Chest CT:
          • LUL nodule, 0.6cm
          • Soft tissue mass at LUL 2.73cm
          • Some lymph nodes are found at bilateral paratracheal region.
      • Plan:
        • Carefully monitor vital signs and closely track the neurological status.
        • Administer Keppra at a dose of 500mg twice daily for anticonvulsant therapy.
        • Anti-brain swelling Mannitol 75ml QD then taper off
        • Prescribe an H2 blocker to prevent stress ulcers.
        • Administer pain relief as necessary (using Paran).
        • Administer dexamethasone 1 tablet twice daily, to alleviate brain swelling.
        • 8th RT on 1/3 for brain tumor for 3960cGy/12 fx for tumor control with hippocampal sparring. Much improved consciousness & verbal response. Impaired recent memory noted by her son.
        • Follow up lab data on 1/1 showed mild leukocytosis with WBC:12K, nuu:94%, CRP:0.1 and hypocalcemia with Ca:1.93.
        • Plan to start chemotherapy
  • 2024-01-03 ProgressNote Zhang YouKang
    • Subjective
      • 8th RT fraction to metastatic brain tumors today.
      • Much improved consciousness & verbal response.
      • Impaired recent memory noted by her son.
      • Acceptable appetite and oral intake.
      • On wheel chair use.
    • Objective
      • RT dose: 2640cGy/8 fractions (6 MV photon) to metastatic brain tumors (sparring bilateral hippocampi), 2023/12/22 to 2024/01/03.
      • Date of evaluation, 2024/01/03: Radiation dermatitis, grade 0; N/V, grade 0; IICP, grade 1.
      • EGFR mutation: wild type; PD-L1: 5 % (IHC); 1% (22C3).
      • Radiotherapy Adverse Reactions (2024-01-03)
    • Problem #2: Left upper lobe lung cancer with brain metastasis and mediastinal lymphadenopathy, cT3N2M1c, stage IVB
      • Assessment:
        • Lung cancer, LUL, mucinous adenocarcinoma, with multiple brain metastasis s/p stereotactic brain tumor biopsy on 2023/12/11; ECOG = 2.
        • RT response: partial response.
      • Plan:
        • Local RT (planning dose: 3960cGy/12 fx, sparring bilateral hippocampi); 4 more fx to finish.
    • Attending doctor comments
      • Keep dexamethasone 4mg 1# QD.
      • Walking slowly as rehabilitation.
  • 2023-12-06 ~ 2024-01-11 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Left upper lobe lung cancer with brain metastasis and mediastinal lymphadenopathy, cT3N2M1, stage IVA
      • Brain metastasis status post stereotactic Brain tumor biopsy on 2023-12-11
      • Severe left subclavian artery stenosis
    • CC
      • intermmitent dizziness in recent one year, and worsened since this 2023 May.
    • Present illness
      • This is a 72-year-old female patient with no significant medical history. Over the past year, she has experienced intermittent episodes of dizziness, which worsened notably since May 2023. Additionally, she has reported disorientation, forgetfulness, and a tendency to become easily lost. Seeking medical attention, she initially visited Yonghe Cardinal Tien Hospital, where a brain CT scan revealed multiple intracranial lesions, raising suspicion of brain metastasis. Subsequently, she sought a second opinion at our neurosurgery clinic. During her outpatient visit, the patient presented with clear and responsive consciousness, with intact cranial nerve function, muscle strength, and deep tendon reflexes. Nevertheless, the brain CT scan again indicated the presence of multiple intracranial lesions, further heightening the suspicion of brain metastasis. Consequently, the patient was admitted to undergo additional evaluations, including brain MRI, chest and abdominal CT scans, and tumor marker testing.
    • Course of inpatient treatment
      • Upon admission, the anticonvulsant medication Keppra was prescribed. Elevated levels of tumor markers CEA and CA199 were detected, prompting preoperative examinations.
      • A lobulated left parahilar lung tumor mass was identified through a chest X-ray, and brain MRI revealed multiple brain metastases, with the largest one measuring about 33 mm, causing mass effect in the right anterior frontal lobe.
      • A whole-body CT scan indicated the presence of left upper lobe lung cancer with brain metastasis and mediastinal lymphadenopathy.
      • A brain CT scan for navigation purposes was performed on 2023-12-09.
      • After thoroughly explaining the imaging findings to the patient and family, a brain biopsy was scheduled for 2023-12-11. The patient underwent a stereotactic brain tumor biopsy, which resulted in a frozen report indicating mucinous adenocarcinoma with metastatic properties. The post-operative course proceeded without complications, and analgesic agents were utilized to manage wound pain.
      • During the hospitalization, elevated blood pressure (systolic BP > 20 mmHg) was observed in both arms. The patient reported mild dizziness while ambulating after surgery, and a cardiovascular specialist was consulted. The assessment revealed a weak left radial pulse (1+) with no accompanying symptoms. Recommendations included:
        • Scheduling an upper extremity Duplex study.
        • Checking the lipid profile, including total cholesterol, LDL, HDL, and triglycerides, and prescribing rosuvastatin if LDL levels exceed 100.
        • Considering the addition of aspirin (100mg daily) if there are no contraindications.
      • A consultation with a hematologist-oncologist was also sought regarding the left upper lobe lung cancer, which involved brain metastasis and mediastinal lymphadenopathy, categorized as T3N2M1.
      • Further evaluation was requested, including:
        • Coordinating a bronchoscopy to obtain tissue proof of the left upper lobe lung cancer.
        • If the bronchoscopy results are inconclusive, considering a CT-guided biopsy.
        • Arranging a bone scan and PET/CT scan for a comprehensive assessment.
        • Pending the pathology results of the brain tumor, considering a colonoscopy if mucinous adenocarcinoma with an origin from the colon is identified.
        • As of the current status, the patient remains conscious with an E4V4M6 score. Head wounds are clean and dry, and continuous monitoring of the clinical condition is being conducted.
      • On 2023/12/20, Anticonvulsant Keppra was maintained.
      • Anti-swelling Mannitol was prescribed and tapper off.
      • Steroid prednisolone 2# TID was prescribed.
      • The final pathology reported metastatic pulmonary mucinous adenocarcinoma. EGFR. PD-L1, PD-L1 IHC and ROS1 IHC were conducted.
      • Oncology radiologist was consulted. RT to brain tumor for 3960cGy/12 fx for tumor control with hippocampal sparring if feasible.
      • CT simulation on 2023/12/20 13:30 will be arranged. RT will be initiated 2-3 days later.
      • Steroid dexamethasone 4mg oral BID was switched at least during brain RT.
      • Peripheral Vascular Test : Artery. upper limbs duplex was performed on 2023/12/20, which revealed 1. Decreased flow spectrum from left subclavian artery, consider severe left subclavian stenosis. Patent left axillary, brachial, antebrachial, raidal and ulnar artery; 2. Patent right upper limbs arteries.
      • We added aspirin 100mg qd for severe left subclavian stenosis.
      • We checked lipid profile and was within normal limit. As of the current status, she remains conscious with an E4V4M6 score. Head wound with stitches were clean and dry.
      • After trasnfered to Oncology ward, we consulted GS for port-A implantation for further chemotherapy.
      • Radiotherapy started on 2023/12/25 for brain metastasis. 12 times RT was done from 2023/12/22 to 2024/01/09 for metastatic brain tumors with hippocampal sparring. Much improved consciousness and verbal response were noted after RT.
      • Follow up lab data on 2024/01/01 showed mild leukocytosis with WBC 12K, nuu 94%, CRP 0.1 and hypocalcemia with Ca 1.93.
      • Follow up lab data on 2024/01/09 showed no leukocytosis and normal PCT. Chest xray showed no pneumonia patch.
      • We start chemothrapy of Gemcitabine 1000mg + cisplatin 35mg on 1/10. Vena, decan, and aloxi were given for vomitting prevent.
      • There were no nausea, vomitting, diarrhea after chemotherapy.
      • Under stable condition of no fever, no dyspnea, no nausea, no diarrhea, she was discharged and turned to OPD follow-up.
    • Discharge prescription
      • Norvasc (amlodipine 5mg) 1# QD
      • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC if nausea or vomiting
      • Through (sennoside 12mg) 2# HS
      • Keppra (levetiracetam 500mg) 1# BID
      • Ulstop (famotidine 20mg) 1# BID
      • Bokey (aspirin 100mg) 1# QD
      • Bisadyl supp (bisacodyl 10mg/pill) 2# PRNQD RECT
      • Acetal (acetaminophen 500mg) 1# PRNQID if pain
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Limeson (dexamethasone 4mg) 1# QD
      • Crestor (rosuvastatin 10mg) 1# QD
  • 2023-12-06 SOAP Neurosurgery Xu XianDa
    • S
      • Female patient with recurring dizziness since the previous year.
      • Dizziness worsened significantly in May and reached a peak in November.
      • Symptoms include disorientation, forgetfulness, and a tendency to become lost.
      • No history of hypertension (H/T) or diabetes mellitus (DM).
      • Patient has a 30-year history of smoking one pack of cigarettes per day.
    • O
      • BP:148/73; HR:94;
      • Female patient with clear and responsive consciousness.
      • Normal cranial nerve function.
      • Muscle power (MP) rated at 5 in all limbs with no spasticity.
      • Brisk deep tendon reflexes (DTR) observed in limbs.
      • No signs of dysmetria in finger-nose-finger (FNF) testing.
      • Brain CT reveals multiple intracranial lesions.
      • Impression: Brain metastasis.
    • Plan:
      • Admit the patient for a comprehensive assessment, which will include brain MRI, chest and abdominal CT scans, as well as tumor marker testing.

[chemotherapy]

  • 2024-01-17 - gemcitabine 800mg/m2 1000mg NS 100mL 30min + cisplatin 25mg/m2 35mg NS 350mL 3hr + NS 250mL 60min (after cisplatin) (Gemzar applied twice and omitted once)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-01-10 - gemcitabine 800mg/m2 1000mg NS 100mL 30min + NS 250mL 2hr (before cisplatin) + cisplatin 25mg/m2 35mg NS 350mL 3hr + NS 250mL 60min (after cisplatin) (Gemzar applied twice and omitted once)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-01-26

[alectinib administration via tube feeding]

The administration of Alecensa (alectinib) typically involves swallowing the capsule whole, as indicated in the Taiwan package insert, which advises against opening the capsule or dissolving its contents.

Despite this, there have been clinical cases where Alecensa was administered via tube feeding in patients with NSCLC, leading to positive outcomes. For instances:

  • A Stage IV NSCLC patient reliant on ventilator support showed tumor shrinkage and improved respiratory status after receiving dissolved Alecensa through a nasogastric tube (NGT). [1]
  • A patient with NSCLC and leptomeningeal carcinomatosis, experiencing drowsiness and difficulty swallowing, also benefited from NGT-administered Alecensa. [2]
  • A Stage IV NSCLC patient with disease progression on crizotinib and tracheostomy for tumor-related airway obstruction responded well to Alecensa dissolved in an olive oil-based solution, administered via a percutaneous endoscopic gastrostomy (PEG) tube. [3]
  • A Stage IV NSCLC patient showed improvement after Alecensa treatment but developed a Grade 3 maculopapular rash after three weeks. The medication was temporarily stopped for steroid treatment. Two weeks later, treatment resumed with Alecensa dissolved in olive oil, starting at 37.5 mg/day and gradually increasing to 300 mg BID. The patient’s rash did not recur, and no other significant adverse reactions were observed. After three weeks, the disease did not worsen. Once the patient’s appetite improved and weight increased, the PEG tube was removed, and they continued on Alecensa 300 mg BID. [4]

Pharmacologically, alectinib hydrochloride is a white to off-white powder containing insoluble particles, formulated into immediate-release capsules. Opening the capsules may lead to dispersion and inhalation of the contents, potentially altering the active ingredient’s concentration. Laboratory tests have shown that Alecensa capsules can dissolve in 40’C warm water within 10 minutes utilizing Simple Suspension Method (SSM), although the resulting suspension may appear cloudy, making it difficult to ascertain complete dissolution. This suspension remains stable for up to 6 hours at 25’C but may turn gel-like after 24 hours. [5]

A Phase I clinical trial assessed the relative bioavailability and pharmacokinetics of an oral suspension of Alecensa compared to its capsule formulation in healthy participants. The study found higher individual peak levels and overall systemic exposure to Alecensa and its metabolite M4 in the oral suspension group, both under fed and fasting conditions, compared to the capsule group. The bioavailability of Alecensa and M4 significantly increased post-administration in the oral suspension group, but there was no significant difference in the incidence or severity of treatment-emergent adverse events (TEAEs) between the two formulations. [6]

Ref: 1. Watanabe Y et al., Ann. Cancer Res. Ther. 2016; 24:47-51. https://www.jstage.jst.go.jp/article/acrt/24/2/24_47/_article 2. Kanai O et al., Clin. Case Rep. 2017; 26:927-930. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5458002/ 3. Bejarano MT et al., J Oncol Pharm Pract 2019;25:1722-1725. https://pubmed.ncbi.nlm.nih.gov/30124125/ 4. Anderson BE et al., J Oncol Pharm Pract 2020. https://journals.sagepub.com/doi/abs/10.1177/1078155220918644 5. Manufacturer inhouse data 6. Liu S et al., Clin Transl Sci 2023;16:1085-1096. https://pubmed.ncbi.nlm.nih.gov/36978270/

2024-01-25

[analyzing post-granocyte WBC recovery and left-shifted distribution]

Following the administration of Granocyte (lenograstim), the episode of leukopenia observed on 2024-01-22 resolved.

  • 2024-01-25 Band 21.5 %
  • 2024-01-25 Neutrophil 58.0 %
  • 2024-01-25 Metamyelocyte 10.3 %
  • 2024-01-25 WBC 12.91 x10^3/uL
  • 2024-01-22 WBC 1.37 x10^3/uL **
  • 2024-01-17 WBC 3.76 x10^3/uL
  • 2024-01-09 WBC 8.74 x10^3/uL
  • 2024-01-01 WBC 12.18 x10^3/uL

Subsequent lab results showed no further evidence of leukopenia and indicated a left-shifted distribution, consistent with ongoing G-CSF effect. The blood cell differential on 2024-01-25 revealed increased band cells, neutrophils, and metamyelocytes, alongside mild elevated WBC counts.

This left shift, often linked to rapid blood cell production in response to infections or inflammation, coincides with the CXR on 2024-01-22 showing patchy density in the left pulmonary hilar region. The current empirical use of Brosym (cefoperazone, sulbactam) aligns with these indications.

2024-01-23

[ALK rearrangement discovered: targeted therapy options]

For this patient, who tested positive for ALK on immunohistochemistry IHC on 2023-12-25, consideration might be given to using alectinib, brigatinib, or lorlatinib. If alectinib is the chosen medication, the recommended dosage is 600mg taken twice daily with food.

[hypokalemia - serial serum potassium monitoring and intervention]

The serial data of serum potassium levels indicate a continuing development of hypokalemia. Consequently, Const-K 10mEq TID has been recently initiated to address this condition.

  • 2024-01-22 K(Potassium) 2.8 mmol/L
  • 2024-01-17 K(Potassium) 3.3 mmol/L
  • 2024-01-09 K(Potassium) 3.8 mmol/L
  • 2024-01-01 K(Potassium) 4.2 mmol/L
  • 2023-12-29 K(Potassium) 4.5 mmol/L

When increased sympathetic tone is thought to play a major role, the administration of a nonspecific beta blocker, such as propranolol, might be considered.

2024-01-05

[carboplatin, pemetrexed, pembrolizumab as NSCLC treatment]

For this patient, tests have not detected EGFR or ROS1 mutations, and the PD-L1 22C3 Tumor Proportion Score (TPS) is less than 1%, with Immunohistochemistry (IHC) Tumor Cells (TC) at 5%.

If the patient recovers to ECOG PS 0-1, a potential treatment regimen could include a combination of either carboplatin or cisplatin, along with pemetrexed and pembrolizumab.

700161986

240125

[exam findings]

[MedRec]

  • 2024-01-24 SOAP Psychosomatic Medicine Li JiaFu
    • Diagnosis
      • Generalized anxiety disorder [F41.1]
      • Panic disorder [episodic paroxysmal anxiety] without agoraphobia [F41.0]
      • Malignant neoplasm of unspecified site of left female breast [C50.912]
    • Prescription x3
      • Anxiedin (lorazepam 0.5mg) 1# QN
      • Zoloft (sertraline 50mg) 1# QN
  • 2024-01-08 SOAP Hemato-Oncology Gao WeiYao
    • Prescription
      • Femara (letrozole 2.5mg) 1# QD
  • 2023-12-29 ~ 2024-01-01 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Infiltrating ductal carcinoma of the left breast, stage pT1N3(31/34)M0, ER(-), PR(+, 60%), Her-2/neu (-, 1+), s/p partial mastectomy and axillary lymph nodes dissection, with bone metastases
      • Mixed hyperlipidemia
      • Generalized anxiety disorder
    • CC
      • for Anti-estrogens with Q1M Faslodex (500mg, self pay) and follow up CT.            
    • Present illness
      • The 66-year-old woman has had infiltrating ductal carcinoma of the left breast, ER(-), PR(60%), Her-2/Neu(1+), s/p partial mastectomy and axillary lymph nodes dissection, pT1N3(31/34)M0 in 2005/12. However, recurrence progression with bony mets s/p RT to right low lateral chest wall area (30Gy/15fx) on 2017, under hormonal therapy with Letrozole and Hormonal therapy with Famera and self-paid of Faslodex (500mg) QM was given from 2018/06/07. Then she started kisqali CDK4/6 inhibitor 2 tab QD from 2019/07/22 (3 weeks plus rest 1 week). Follow up chest CT on 2021/9/18 which revealed no evidence of recurrent/residual tumor in the current study.
      • The bone-densitometry showed normal also noted on 2021/12/6. RT OPD follow up and who assassment the area can’t RT again and suggest to orthopedics for vertebroplasty, but patient refused for probable side effect. Xgeva was given Q4W since 2021/12/9. Anti-estrogens with Q1M Faslodex (500mg, self pay) from 2021/12/19~.
      • Bone scan was arranged on 2022/11/24 showed in comparison with the previous study on 2021/11/18, the bone lesion in the L3 spine is less evident. Mildly increased activity in some middle and lower T-spines. Degenerative change may show this picture.
      • Follwed CT was perfromed on 2023/07/18 revealed mild fibrosis at lower lobes of lungs, stable. no locoregional recurrent breast tumor based this exam.
      • Due to low back pain in progress, she sent to NS OPD for help. Spinal-MRI showed recent compression fractur at L3 and L4 vertebral bodies. Lumbar spondylosis with spinal canal stenosis and neuroforaminal narrowing, esp L3-4. Lumbar vertebra, L3 compression fracture status post L3 kyphoplasty on 2023/10/05.
      • This time, she denied vomit, bone pain or diarrhea, so she was admitted for follow up chest CT and Anti-estrogens with Q1M Faslodex (500mg, self pay) on 2023/12/29.
    • Course of inpatient treatment
      • After admission, she received Faslodex 500mg by self pay on 2023/12/30. Chest CT follow up on 2023/12/30 and report showed left adrenal nodule (1.0cm) and stable condition of bil. lung fibrosis. Under the stable condition, she can be discharged on 2024/01/01. OPD follow up is arranged.
    • Discharge prescription
      • Kisqali (ribociclib 200mg) 1# QD
      • BioThree (bacillus mesentericus, streptococcus faecalis, clostridium butyricum; 22mg) 1# TID
      • BioCal Chewable Tablets (tribasic calcium phosphate 1203mg, cholecalciferol 330IU) 1# TID
  • 2023-08-21 SOAP Hemato-Oncology Gao WeiYao
    • P: Refer to NS Lee for prior history of L compression fracture, but recent bone scan showed more prominent with back pain.
  • 2018-02-07 SOAP Psychosomatic Medicine Chen YiQian
    • Diagnosis
      • Panic disorder [episodic paroxysmal anxiety] without agoraphobia [F41.0]
    • Prescription x3
      • Zoloft (sertraline 50mg) 1# HS
  • 2018-01-15 SOAP Chest Medicine Su WenLin
    • Diagnosis
      • Asthma [J45.991]
      • Allergic rhinitis, unspecified [J30.9]
      • Malignant female breast neoplasm, NOS [C50.912]
      • Comnon migraine without mention of intractable migraine [G43.009]
      • Mixed hyperlipidemia [E78.2]
    • Prescription x3
      • Foster BID INHL
      • Xyzal (levocetirizine 5mg) 1# HS
  • 2017-01-23 SOAP Hemato-Oncology Gao WeiYao
    • S
      • For follow up
      • History of infiltratig ductal carcinoma of Lt breast, Lt, T1N3Mx post operation (2025-12-xx) at TSGH followed by taxotere and pharmorubicin
      • HEAVILY LN METASTASES - S-node (2/2), level I (14/14), level II (3/3), level III (3/3), unlabelled lymphoid tissue (9/12), ER (-), PR (+), Her-2 (-)
    • O
      • She had nolvadex for 5 years and femara for almost 5 yrx and she requested to discontinue the femara today (20161226)
      • She was informed to have autonomic dysfunction (20160905) She claimed it was relieved by Rivotril 0.5 tab 0.5 mg/tab plus lepax10 mg hs (ativan 0.5 mg/tab).
      • Radiologist Dr Kuo suggest to repeat mammo and breast sono 3 months later based on April 21 suspected mammo findings by Dr Kuo. (20140516)
      • Questionable nodule over LLL (20140516)
      • s/P mastectomy
      • migraine relieved by sibelium (suzin)
      • Under femara treatment
    • Diagnosis
      • Malignant female breast neoplasm, NOS [C50.912]
      • Comnon migraine without mention of intractable migraine [G43.009]
      • Mixed hyperlipidemia [E78.2]

==========

2024-01-25

[stable vitals amidst possible treatment-related hematologic effects]

The patient, currently treated with fulvestrant, letrozole, and ribociclib for her infiltrating ductal carcinoma, exhibited largely normal lab values on 2024-01-25, except for leukopenia (2.1K/uL) and anemia (HGB 10g/dL). These conditions might be associated with her treatment, particularly ribociclib (anemia: 17% to 19%; leukopenia: 27% to 33%) and/or fulvestrant (anemia: 4% to 40%; lymphocytopenia: 35%).

Throughout this hospitalization, the patient’s vital signs have remained stable, and no discrepancies in medication have been identified.

700349893

240125

[exam findings]

  • 2024-01-23 CXR erect
    • Increase bilateral lung markings.
    • Plerual calcification in right upper.
    • No cardiomegaly.
    • Tortuous thoracic aorta with intimal calcification.
    • Thoracic spondylosis and compression fractures.

[MedRec]

  • 2024-01-25 Progress Note
    • Problem List
      • Problem #1: Thrombocythemia cause unknown
        • Assessment:
          • worsen for PLT higher
        • Plan:
          • bone marrow, BCRABL, Jak-c and chromosome is arranged
          • IVF hydration 1000ml qd
          • monitor PLT level
    • Problem #2: Urinary tract infection
      • Assessment:
        • no fever is stable condition
      • Plan:
        • antibiotic as Rocephine 2g qd
        • pending U/C
    • Attending physician ward round records and comments
      • Myeloproliferative disease should be ruled in.
  • 2024-01-24 Vs Note on Admission Day Gao WeiYao
    • A 90-yr-old man with stroke history with ECOG 4 was sent to ER on account of poor intake for 3 days and malaise for 1+ weeks. Care-giver denied he has fever, chills, choking, diarrhea or falls. At ED, his vital sign showed BP:89/60mmHg, HR:109/bpm, BT:35.5’C, RR 20/bpm, conscious E3V2M5. Lab data showed WBC 28470/uL, PL 1649000/uL (his platelet count was 900,000 in Mar 2023), Reticulocyte 2.810, Lactate 2.5, Na 154, BUN/Cr 86/1.88.
  • 2024-01-23 SOAP Medical Emergency Chen ZuYi
    • A/P
      • preliminary impression: other malaise
      • 2024/01/23 23:08 WBC = 28.47 x10^3/uL;
      • 2023/03/30 20:02 WBC = 14.50 x10^3/uL;
      • 2022/10/18 07:02 WBC = 17.70 x10^3/uL;
      • 2022/10/16 14:51 WBC = 17.47 x10^3/uL;
      • 2024/01/23 23:08 PLT = 1649 x10^3/uL;
      • 2023/03/30 20:02 PLT = 921 x10^3/uL;
      • 2022/10/18 07:02 PLT = 956 x10^3/uL;
      • 2022/10/16 14:51 PLT = 925 x10^3/uL;
  • 2023-12-07 SOAP Orthopedics Huang ZhenWen
    • O
      • bilateral knee OA, knee flexion contracture.
      • creatine: 1.24
    • Prescription x3
      • Celebrex (celecoxib 200mg) 1# QD
  • 2023-07-22 SOAP Orthopedics Zhu ChongHua
    • S
      • bilateral knee pain for days
      • surgical hx: left ITC fracture s/p ORIF
    • O
      • 2nd Prolia
    • A
      • left ITC fracture s/p ORIF
      • osteoporosis, T score: -4
      • bilateral OA knee
    • p:
      • prolia: 20221103, 20230722
      • Ca+ vit D supplemenet
    • Prescription x3
      • Mobic (meloxicam 15mg) ST IM
      • Celebrex (celecoxib 200mg) 1# QD
      • BioCal Chewable Tablets (tribasic calcium phosphate 1203mg, cholecalciferol 330IU) 1# TID
      • Prolia (denosumab 60mg) ST SC
  • 2017-03-22 SOAP Neurology Xiao ZhenLun
    • Diagnosis
      • Cerebral artery occlusion, with cerebral infarction [I63.9]
      • Essential hypertention, unspecified [I10]
      • Dyslipidemia; other and unspecified hyperlipidemia [E78.4]
      • Gout, unspecified [M10.9]
      • OA, localized, not specified whether primary or secondary, unspecified site [M19.90]
    • Prescription x3
      • Arcoxia (etoricoxib 60mg) 1# QD
      • Dulcolax (bisacodyl 5mg) 1# QN
      • Syntam (piracetam 1200mg) 1# BID
      • Rivotril (clonazepam 0.5mg) 1# BID
      • Through (sennosides 12mg) 2# HS
      • Robestar (rosuvastatin 10mg) 0.5# QD
      • Bokey (aspirin 100mg) 1# QD

==========

700654288

240125

[lab data]

2024-01-25 HBsAg Nonreactive
2024-01-25 HBsAg (Value) 0.44 S/CO
2024-01-25 Anti-HBc Nonreactive
2024-01-25 Anti-HBc-Value 0.17 S/CO
2024-01-25 Anti-HCV Nonreactive
2024-01-25 Anti-HCV Value 0.09 S/CO

[exam findings]

  • 2024-01-25 Flow Volume Chart
    • Moderate restrictive ventilatory impairment
  • 2024-01-24 CXR erect
    • Chest PA view shows: Normal heart size.
      • Placement of right subclavian port-A catheter.
      • Medial mass with bulging contour.
      • Left pleural effusion.
  • 2024-01-24 Chest lateral Lt
    • Medial mass. Left pleural effusion, with blunted posterior costophrenic angle.

[MedRec]

  • 2024-01-24 SOAP Medical Emergency Chen ZuYi
    • S
      • Transferred from XinDian Cardinal Tien Hospital by Dr Ou WeiRen. The patient unexpectedly found that her white blood cells were too high after giving birth late last year, and she was suspected of having lymphoma after examination.
      • 2023/12/20 at Cardinal Tien Hospital: Vaginal delivery in normal pregnancy.
      • 2023/12/25 at Cardinal Tien Hospital: CT of the chest without/with intravenous contrast.
        • FINDINGS:
          • Pleura: small bilateral pleural effusion.
          • Mediastinum: a huge heterogeneous mass in superior mediastinum, with internal hemorrhagic part, about 183mm in greatest dimension.
          • Heart/great vessel: cardiomegaly.
          • Pericardial effusion.
          • Other: splenomegaly.
        • Impression:
          • Suspect thymic tumor, suggest further evaluation.
          • Splenomegaly.
      • 2024/01/10 at Cardinal Tien Hospital:
        • CHEST MRI
          • MRI of the chest without and with contrast enhancement shows:
            • A 18.5129cm lobular heterogeneously enhanced mass in the anterior upper mediastinum. Some cystic component in the mass.
            • No definite nodules at bilateral hilar, supraclavicular area and upper abdominal cavity.
            • Presence of small amount of pericardial effusion and bilateral pleural effusion.
            • Splenomegaly.
          • Imp:
            • Anterior upper mediastinal mass, suspect thymoma or lymphoma pericardial effusion and bilateral pleural effusion
            • Splenomegaly
        • BRAIN MRI
          • MRI of the brain without and with contrast enhancement shows:
            • No abnormal signal intensity lesion in the brain parenchyma.
            • Normal size of the ventricles and cerebral sulci.
            • No mass effect. No abnormal contrast enhancement.
          • Imp:
            • No abnormal findings
    • A/P
      • Preliminary impression: C81.99 Hodgkin lymphoma, unspecified, extranodal and solid organ sites
      • Susp lymphoma, Rt, susp mediastinitis, WBC 30K, Hb 9.9, CRP 5.2, Loforan, OA ONC

==========

2024-01-25

[vaccine recommendations for hepatitis B susceptible individuals with cancer]

Lab results on 2024-01-25 show both HBsAg and anti-HBc as nonreactive. This could indicate either susceptibility to future hepatitis B infection (if anti-HBs is nonreactive) or immunity from hepatitis B vaccination (if anti-HBs is also nonreactive).

For susceptible individuals, it is recommended all unvaccinated patients with cancer aged 19 or older should receive the hepatitis B vaccine. (Ref: Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2024. MMWR Morb Mortal Wkly Rep. 2024 Jan 11;73(1):11-15. doi: 10.15585/mmwr.mm7301a3.) Additionally, coadministration of hepatitis B and hepatitis A vaccines is an option.

Inactivated vaccines are generally advised to be administered at least two weeks prior to starting chemotherapy or other immunosuppressive therapies to enhance the immune response. (Ref: Practical review of immunizations in adult patients with cancer. Hum Vaccin Immunother. 2015;11(11):2606-14. doi: 10.1080/21645515.2015.1062189.) A recombinant hepatitis B vaccine is available at this hospital.

700766819

240125

[exam findings]

  • 2024-01-24 CXR
    • S/P port-A implantation.
    • Enlargement of cardiac silhouette.
    • Increased lung markings on both lower lungs are noted. Please correlate with clinical condition.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2024-01-24 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 18 dB HL; LE 13 dB HL.
    • RE normal to mild SNHL but have A-B gap at 1k Hz.
    • LE WNL.
  • 2024-01-16 Patho - ovary (tumor)
    • Diagnosis:
      • Ovary, right, oophorectomy —- Clear cell carcinoma, AJCC 8th edition: pStage IA, pT1aN0(if cM0) , FIGO Stage IA, at least
      • Ovary, left, oophorectomy —- Negative for malignancy
      • Fallopian tube, right, salpingectomy —- Negative for malignancy
      • Fallopian tube, left, salpingectomy —- Negative for malignancy       - —- Hydrosalpinx       - —- Endometriosis
      • Uterus, corpus, abdominal total hysterectomy —- Negative for malignancy       - —- Leiomyoma
      • Uterus, cervix, abdominal total hysterectomy —- Negative for malignancy
      • Uterus, endometrium, abdominal total hysterectomy —- Negative for malignancy       - —- Endometrial polyp
      • Omentum, omentectomy —- Negative for malignancy
      • Lymph node, right pelvic, dissection —- Negative for malignancy (0/14)
      • Lymph node, left pelvic, dissection —- Negative for malignancy (0/12)
      • Lymph node, para-aortic, dissection —- Negative for malignancy (0/6)
    • Gross description:
      • Procedure (select all that apply): Debulking surgery (ATH + BSO + BPLND + para-arotic lymph node dissection + omentectomy)
      • Specimen size:
        • F2024-00015:
          • right ovary: 16.5 x 7.5 x 4.3 cm, 310 g;
          • right tube: 6.0 cm in length and 0.3 cm in diameter;
        • S2024-00966:
          • left ovary:  3.0 x 2.2 x 0.7 cm;  
          • left tube: 7.0 cm in length and 1.0 cm in diameter;
          • uterus: 16.5 x 9.5 x 8.0 cm, 547 g;
          • Cervix: 4.1 x 3.8 x 3.5 cm;
          • Endometrial cavity: 5.7 x 4.0 x 0.5 cm with a polyp, measuring 2.0 x 1.4 x 0.4 cm;
          • Several leiomyomas, measuring up to 4.2 x 3.8 x 3.5 cm  
      • Specimen Integrity
        • Specimen Integrity of Right Ovary (if applicable): Capsule intact, intra-operation rupture (-)
        • Specimen Integrity of Left Ovary (if applicable): Capsule intact
        • Specimen Integrity of Right Fallopian Tube (if applicable):Serosa intact
        • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
      • Tumor Site: Right ovary
      • Ovarian Surface Involvement (required only if applicable): Absent
      • Fallopian Tube Surface Involvement (required only if applicable): Absent
      • Tumor Size: Greatest dimension (centimeters): 16.5 cm
      • Additional dimensions (centimeters): 7.5 x 4.3 cm
      • Sections are taken and labeled as:
        • F2024-00015: Representative sections are taken and labeled as: FsA1-2, for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: fallopian tube; X2: adnexa; X3-8: tumor.
        • S2024-00966: Representative sections are taken and labeled as: A1-3: lymph node, right pelvic; B1-3: lymph node, left pelvic; C: lymph node, para-aortic; D1: cervix; D2: endometrium; D3: endometrial polyp; D4-5: leiomyoma; D6: corpus; D7: posterior wall; E1-2: left ovary and fallopian tube; F1-2: oemntum.  
    • Microscopic Description:
      • Histologic Type: Clear cell carcinoma; The immunohistochemical stains reveal CK(+), PAX8(+), Napsin A(+), p53(wild type), PR(-), WT-1(-), SALL4(-), and alpha-inhibin(-).  
      • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors): not applicable
        • Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.
      • Implants (required for advanced stage serous/seromucinous borderline tumors only): not applicable
      • Other Tissue/ Organ Involvement (select all that apply): Not identified
      • Largest Extrapelvic Peritoneal Focus (required only if applicable): Not identified  
      • Peritoneal/Ascitic Fluid: N2024-188
      • Regional Lymph Nodes: Negative for metastasis: right pelvic: 0/14; left pelvic: 0/12; para-aortic: 0/6
      • Additional Pathologic Findings: Endometrial polyp, leiomyomas, and left hydrosalpinx and endometriosis are seen.
  • 2024-01-12 ECG
    • Normal sinus rhythm
    • Low voltage QRS
    • Borderline ECG
  • 2024-01-12 CT - abdomen
    • History and indication: abdominal pain
    • IMP:
      • A cystic lesion (13cm) at right abdomen with some solid parts r/o ovary tumor.
      • Some tumors (up to 5.6cm) at uterus r/o myomas.
      • Right liver hemangioma (2.6cm) and cyst (4mm).
  • 2024-01-12 Gynecologic Ultrasonography
    • IMP:
      • R/O RT adnexa mass
      • Multiple myomas

[MedRec]

  • 2024-01-23 SOAP Obstetrics and Gynecology Shao ZhiXuan
    • P: Multidisciplinary Cancer Conference Conclusion, Meeting Date: 2023-01-18
      • Treatment Plan: Postoperative adjuvant chemotherapy is recommended for clear cell carcinoma.
    • Prescription
      • Meififen (diclofenac Na 75mg) 1# QD
      • MgO 250mg 1# TID
  • 2024-01-12 ~ 2024-01-19 POMR Obstetrics and Gynecology Shao ZhiXuan
    • Discharge diagnosis
      • Right ovarian clear cell carcinoma with torsion, pT1aN0M0, FIGO stage IA, s/p debulking surgery on 2024/01/12
      • Abdominal pain
      • Anemia
    • CC
      • abdominal pain with cold sweating since yesterday
      • heavy bleeding noted a palpable mass above the umbilicus for 2 years.        
    • Present illness
      • This 50 years old female without underlying systemic disease, G0P0, SEX(+), had received open myomectomy 20+ years ago. According to the patient, she had gradually irregular menstral cycle. Hypermenorrhea and dyesmenorrhea also complained for years. Her last menstrual period was 2024/01/05.
      • This time she complained progress IVE abdominal pain since yesterday and shifted to right lower abdomen in this afternoon. Cold sweating also noted. She denied fever, chills, nausea. vomiting, dysuria or constipation. She came to our ER for help.
      • At ER, her vital signs were stable and lab datas showed anemia with Hb 8.0. The abdominal CT was arranged and showed a cystic lesion (13cm) at right abdomen with some solid parts r/o ovarian tumor. The GYN doctor was consulted for further evaluation. The echogram showed a huge right adnexa mass, r/o torsion or malignancy.
      • Under impression of huge right adnexa mass, r/o torsion, she was admitted for emergent laparotomy right salping-oophrectomy. If consider malignancy, the right adnexa mass would send frozen section and change to debulking surgery when proved malignancy. The pRBC was transfused. The laparotomy right salping-oophrectomy was done on 2024/01/12 and the MALIGNANCY was told by frozen section. The debulking surgery was done and she was admitted for post-operation care and further treatment plan.
    • Course of inpatient treatment
      • The patient was admitted from ER on 01/13/2024 due to abdominal pain suspected right ovarian tumor with torsion. She underwent debulking surgery (abdominal total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + para aortic lymph note sampling + infracolic omentectomy). The frozen section initial diagnosis revealed malignant tumor (carcinoma) and pending immunohistochemical stains for final diagnosis. Postoperative recovery was smooth. Final pathology report showed right ovarian clear cell carcinoma, AJCC 8th edition: pStage IA, pT1aN0 (if cM0) , FIGO Stage IA.
      • The GYN tumor board conference on 2024/01/18 suggested the patient to receive chemotherapy. Her postoperative course was uneventful. Self voiding was smooth. JP drain with serosaguinous fluid and removed smoothly. She was discharged on 2024/01/19. Her follow up appointment is scheduled on 2024/01/24.
    • Discharge prescription
      • Meififen (diclofenac Na 75mg) 1# QD
      • MgO 250mg 1# QID
      • Through (sennoside 12mg) 1# HS
      • Miyarisan BM (clostridium butyricum miyairi 40mg) 1# TID

[surgical operation]

  • 2024-01-12 - Op Method:
    • Diagnosis:
      • Right huge ovarian mass with torsion, frozen section: malignancy
    • Operation:
      • Debulking surgery (ATH + BSO + BPLND + para-arotic lymph node dissection + omentectomy)   - Finding:
    • Supraumbilical midline vertical skin incision
    • Uterus: hypertrophic and disfigured by multiple myomas, tense adhesion with bladder
    • Adnexa:
      • LOV: 322cm, grossly normal, capsule intact, smooth surface.
      • ROV: 141310cm, with fallopian tube torsion, capsule intact, some necrotic and soft tissue mass and 700cc bloody jelly like fluid noted inside the tumor, intra-operation rupture (-)
      • Frozen section: malignancy
    • CDS: free from adhesion and ascites
    • Ascites: minimal, wash with diswater 20cc and sent cytology analysis
    • Bilateralpelvic lymph nodes and para-arotic LNs: normal (+), enlarged (-), indurated (-)
    • Omentum: grossly normal.
    • Liver: grossly normal & smooth
    • Subdiaphragmatic surface: grossly normal
    • Appendix: grossly normal
    • Estimated blood loss: 600ml
    • Blood transfusion: pRBC 2U
    • Complication: nil

[chemotherapy]

==========

700927977

240125

[MedRec]

  • 2023-10-13 SOAP Cardiology Huang XuanLi
    • Prescription x3
      • Coralan (ivabradine 5mg) 1# BID
      • Entresto (sacubitril 97mg, valsartan 103mg; 200mg) 0.25# QD skip once if SBP < 100mmHg
      • Feburic (febuxostat 80mg) 0.5# QOD
      • Harnalidge (tamsulosin 0.4mg) 1# QDAC
      • Pentop (pentoxifylline 400mg) 1# QD
      • Through (sennoside 12mg) 2# HS
      • Budema (bumetanide 1mg) 0.5# QD
  • 2017-01-04 SOAP Cardiology Huang XuanLi
    • Diagnosis
      • CHF; Congestive heart failure [I50.22]
      • Essential hypertention, unspecified [I10]
      • Femoral hernia unilateral or unspecified, recurrent without mention of obstruction or gangrene [K41.91]
      • Other insomnia [G47.09]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Neuralgia,neuritis, and radiculitis,unspecified [M79.2]
    • Prescription x3
      • Adalat Oros (nifedipine 30mg) 1# PRN
      • Urief (silodosin 4mg) 1# BID
      • Coxine (isosorbide-5-mononitrate 20mg) 0.5# HS
      • Busix (bumetanide 1mg) 1# QD
      • Concor (bisoprolol 5mg) 0.5# QD
  • 2017-01-03 SOAP Neurosurgery Li DingZhou
    • Diagnosis
      • Spondylosis of unspecified site, with mention of myelopathy [M47.10]
      • Discitis, unspecified, lumbar region [M46.46]
      • Other spondylosis, cervical region [M47.892]
      • Unspecified systolic (congestive) heart failure [I50.20]
      • Spinal stenosis, site unspecified [M48.00]
      • Acute and subacute endocarditis, unspecified [I33.9]
      • Overflow incontinence [N39.490]
      • Cervical root disorders, not elsewhere classified [G54.2]
      • Close fracture of lumbar without mention of spinal cord injury [S32.000A]
      • Localized osteoporosis [Lequesne] [M81.6]
    • Prescription x3
      • Celebrex (celecoxib 200mg) 1# PRNQD
      • Neurontin (gabapentin 100mg) 1# QD
      • Aelocon (Vit B1 50mg, B2 5mg) 1# QD

[consultation]

==========

2024-01-25

[ongoing renal deterioration and bumetanide dosage considerations]

Recent test results indicate a mild increase in hs-Troponin I at 164.1 pg/mL, CKMB at 17.6 ng/mL, CK at 405 U/L, and ECG showing T wave depression in lateral leads, therefore a consultation with our cardiologist is just initialized.

This patient has experienced a gradual deterioration in kidney function in recent months. Consequently, all medication dosages on the active list have been adjusted to accommodate the patient’s current renal status.

  • 2024-01-25 Cre 4.24 mg/dL
  • 2024-01-25 BUN 57 mg/dL
  • 2024-01-25 eGFR 14.36 ml/min/1.73m^2
  • 2024-01-23 eGFR 16.14 ml/min/1.73m^2
  • 2024-01-05 eGFR 21.73 ml/min/1.73m^2
  • 2023-10-13 eGFR 27.16 ml/min/1.73m^2
  • 2023-09-15 eGFR 37.38 ml/min/1.73m^2

Additionally, for the patient’s eGFR <30, increased doses of bumetanide may be necessary for an effective diuretic response (2024-01-24 input 1710 output 230 + loss).

Given the absence of serological hepatitis virus data in the patient’s history in HIS5, the elevated liver enzyme levels (AST at 170 U/L and ALT at 95 U/L on 2024-01-25) might be further investigated once the patient’s cardiological conditions have stabilized.

701512638

240125

[exam findingns]

2024-01-25 HBsAg Nonreactive
2024-01-25 HBsAg (Value) 0.42 S/CO
2024-01-25 Anti-HCV Nonreactive
2024-01-25 Anti-HCV Value 0.14 S/CO
2024-01-25 Anti-HBc Reactive
2024-01-25 Anti-HBc-Value 3.19 S/CO
2024-01-25 Anti-HBc IgM Nonreactive
2024-01-25 Anti-HBc IgM Value 0.08 S/CO
2024-01-25 Anti-HBs 184.65 mIU/mL

[MedRec]

  • 2024-01-23 SOAP Hemato-Oncology Gao WeiYao
    • S
      • Hualian TzuChi Dr Hseu WL friend
      • Adenocarcinoma of stomach, diffuse type, Her-2 (-), pT4aN3aMb post total gastrectomy on 2024-01-02 (presenting with gastric outlet obstruction).
    • O
      • BP 125/76; BH 168 cm; BW 55 kg; BMI 19.5

==========

2024-01-25

[reactive anti-HBc and prophylactic antiviral strategy]

Lab results on 2024-01-25 indicated a reactive anti-HBc status. In light of this finding, it is advisable to consider prophylactic antiviral nucleoside analog therapy before commencing chemotherapy treatment.

700504699

240124

[lab data]

2023-10-04 HBsAg Nonreactive
2023-10-04 HBsAg (Value) 0.39 S/CO
2023-10-04 Anti-HBc Reactive
2023-10-04 Anti-HBc-Value 5.48 S/CO
2023-10-04 Anti-HCV Nonreactive
2023-10-04 Anti-HCV Value 0.05 S/CO

[exam findings]

  • 2023-10-10 Knee bilat.
    • Osteoarthritis of the bilateral knee with osteophytes formation and joint space narrowing of the lateral femorotibial joint.
    • There is osteolytic lesion right distal femur.
  • 2023-10-02 CXR (erect)
    • Patchy opacity projecting at left upper lateral lung or pleura area is noted. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Linear infiltration over left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2023-07-18 Shoulder Rt and Humerus Rt
    • Osteoporotic or osteolytic change of right humerus, right clavicle and right scapular is noted that may be multiple myeloma? please correlate with clinical condition or CT.
  • 2023-05-09 Humerus Bilat
    • Osteoporotic or osteolytic change of left clavicle and left humerus are noted that may be multiple myeloma? please correlate with clinical condition or CT.
    • Fracture of left humeral neck is noted.
  • 2023-04-24 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — myeloma.
    • Section shows piece(s) of bone marrow with 50 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes and increased plasmacytoid subpopulation. Megakaryocytes are adequate in number.
    • IHC stains: CD117: <2%; MPO: 25-30%, CD138: 25-30 %; (of the nucleated cells). Kappa and Lambda light chains show a predominant kappa sub-population.
  • 2023-01-08 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Linear infiltration over left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2023-01-06 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Inferior infarct, age undetermined
    • Abnormal ECG
  • 2023-01-06 ECG
    • Normal sinus rhythm
    • Right superior axis deviation
    • Pulmonary disease pattern
    • Cannot rule out Inferior infarct, age undetermined
    • Abnormal ECG
  • 2022-10-24 CXR
    • Normal sinus rhythm
    • Left axis deviation
    • Incomplete right bundle branch block
  • 2022-10-24 CXR
    • Tortuosity of the aorta with atherosclerotic change.
    • Increased lung markings over both lungs.
    • Degenerative joint disease of T-spine with marginal osteophytes.
    • Osteopenic change.
  • 2022-07-13 Mini-mental state examination, MMSE
    • Score 10
      • Score Level of impairment
      • = 27 None

      • 21-26 Mild
      • 11-20 Moderate
      • <= 10 Severe
  • 2022-07-13 Clinical Dementia Rating, CDR
    • Score 2
      • Composite Rating Symptoms
      • 0 none
      • 0.5 very mild
      • 1 mild
      • 2 moderate
      • 3 severe
  • 2022-07-01 CT - brain
    • Brain atrophy and leukoaraiosis.
    • Diffuse osteolytic bone change with some area of cortical destruction. Suggest further workup.
  • 2021-11-12 ENT Hearing Test
    • PTA
    • Reliability FAIR
    • Average R’t 89 dB HL; L’t 70 dB HL
    • R’t moderately severe to profound mixed type HL
    • L’t moderate to profound mixed type HL.
    • (masking dilemma)
  • 2021-11-12 Auditory brainstem evoked response, ABR
    • ABR show response at 60 dB nHL in both ears.
  • 2021-10-15 ENT Hearing Test
    • PTA:
      • Reliability FAIR
      • Average R’t 85 dB HL; L’t 73 dB HL
      • R’t moderately severe to profound mixed type HL
      • L’t moderate to profound mixed type HL.
      • (masking dilemma)
    • Tymp: R’t type C; L’t type A.
    • ART: Bil absent.
  • 2021-04-02 ENT Hearing Test
    • PTA:
    • Reliability FAIR
    • Average RE 89 dB HL; LE 60 dB HL
    • RE severe to profound MHL (mixed hearing loss)
    • LE moderate to profound SNHL (sensory neural hearing loss)
  • 2021-02-19 ENT Hearing Test
    • Reliabilty Fair
    • PTA
      • R’t : 85 dB HL, severe to profound mixed type HL
      • L’t : 61 dB HL, moderate to severe SNHL
    • Tymp
      • R’t : Type C
      • L’t : Type A
    • ART
      • Bil absent.
  • 2021-01-19 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2020/03/31, the previous bone lesions in the left humeral head, right pubic bone and bilateral knees are a little less evident.
    • The lesions in the upper portions of bilateral S-I joints and greater trochanter of left femur are new. The nature is to be determined (post-traumatic change? other nature?). Please correlate with other clinical findings for further evaluation.
    • Other bone lesions are either stationary or a little less evident.
  • 2021-01-18 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Plasma cell myeloma
    • The sections show normocellular marrow (30%). The M/E ratio about 3:1. The myeloid cells show good maturation. The megakaryocytes are unremarkable. Sheets and isolated CD138+ mature and immature plasma cells in interstitium, constitue 50% of marrow cells are noted. The plasma cells also reveal kappa light chain restriction and negative for lambda light chain.
  • 2020-03-31 Tc-99m MDP bone scan with SPECT
    • Prominently increased activity in the left humeral head, right pubic bone and bilateral knees. Multiple myeloma involving these bones should be watched out. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Increased activity in the middle and lower C-spines, some middle to lower T-spines, some L-spines and sacrum. Either degenerative change or multiple myeloma may show this picture.
    • Some faint hot spots in bilateral rib cages and increased activity in the sternum. The nature is to be determined (post-traumatic change? other nature?). Please also correlate with other clinical findings for further evaluation.
    • Mildly iuncreased activity in the right shoulder. Arthritis may show this picture.
  • 2019-05-30 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (57.8 - 11.6) / 57.8 = 79.93%
      • M-mode (Teichholz) = 79
    • Normal chamber size
    • Adequate LV and RV performance
    • Possibly impaired LV relaxation
    • AV sclerosis with trivial AR ; mild MR, TR and PR
    • No regional wall motion abnormalities
  • 2019-05-14 Myocardial perfusion SPECT with persanti
    • Probably mild to moderate myocardial ischemia with possible a small portion of severe ischemia at the apical lateral wall and mild myocardial ischemia at the apical anteroseptal wall.
    • Mild reverse redistribution of radioactivity to the inferolateral wall and posterior wall, either normal variant or myocardial ischemia may show this picture.
  • 2017-07-10 Nerve Conduction Velocity, NCV
    • The NCV study showed
      • Prolonged distal motor latency and slowing of motor and sensory nerve conduction velocity in bilateral median nerves.
      • Decreased CMAP and SAP amplitude in left median nerve.
      • Decreased CMAP amplitude in bilateral peroneal nerves.
      • Decreased SAP amplitude in right ulnar and left sural nerves.
      • The F wave and H reflex were normal.
      • The above findings suggest entrapment neuropathy of bilateral median nerves at the wrist(left side was severer) with superimposed bilateral peroneal neuropathy.
      • Advise careful clinical correlation.
  • 2019-05-30 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (120 - 32) / 120 = 73.33%
      • M-mode (Teichholz) = 73
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA, septal hypertrophy, LV diastolic dysfunction, Gr 1
    • Trivial MR and trivial TR
    • Preserved RV systolic function
  • 2017-01-23 Pulmonary Tc-99m perfusion and ventilation scan
    • The Tc-99m MAA perfusion lung scan was obtained 5-10 minutes after injection of Tc-99m MAA 5 mCi. The scintigraphy revealed several smalll subsegmental or nonsegmental defects in perfusion in the upper lobe and the superior segment of the lower lobe of both the right lung and the left lung.
    • The Tc-99m DTPA aerosol lung ventilation lung scan, which was obtained immediaely after inhalation of the radioagent 30 mCi, revealed that there were deficient ventilation in the upper lobe of the superior segment of the lower lobe of both the right lung and left lung, in an extent much larger than were the defects shown on perfusion scan.
    • The scintigraphy revealed several small subsegmental or non-segmental ventilation-perfusion matched defects in the upper lobe and the superior segment of the lower lobe of both the right and left lung, indicating that the probability of pulmonary embolism was low (reported risk of lower than 20%, by revised PIOPED Criteria for Pulmonary Embolus Diagnosis). Please correlate with clinical findings for further evaluation.
  • 2017-01-19 ECG
    • Sinus rhythm with Premature atrial complexes
    • Left axis deviation
    • S1-S2-S3 pattern, consider pulmonary disease, RVH, or normal variant
    • Abnormal ECG
  • 2017-01-12 CXR
    • Thoracic aortic arch calcified atheriosclerotic plaque
    • Mild cardiomegaly
    • Osteoporotic compression fracture of multiple vertebral bodies
    • osteolytic change in visible bones.

[MedRec]

  • 2023-10-02 ~ 2023-10-05 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Multiple myeloma, IgA type, ISS stage 3, bone marrow (2023-04-26) showed myeloma. IHC stains: CD117: <2%; MPO: 25-30%, CD138: 25-30 %; (of the nucleated cells). Kappa and Lambda light chains show a predominant kappa sub-population.
      • Essential (primary) hypertension
      • Chronic viral hepatitis B without delta-agent anti-Hbc positive
    • CC
      • for elevated IgA index progression & first daratuzumab/Velcade/Dexa treatment
    • Present illness
      • This 82 year-old woman had medical history of (1) HTN (2) Hyperlipidemia (3) Osteoarthritis knee (5) multiple myeloma, IgA type, ISS stage 3 under Velcade on 2016/5-2017/1 (total 21 times) and Thalidomide since 2019/1-2019/12. She was regular followed up at our OPD with normal IgA level in Mar 2020. According to her and son, right shoulder soreness with pain were noted for one week. She denied fall down, traumatic recently; there was no local heating nor inflammation situation. She comes to our Oncology OPD for help, the x-ray showed no fracture lesion. Under the impression of osteolysis of right shoulder, she was admitted for further management on March 2020. Orthopedist was consulted and they suggested to arrange bone scan or MRI.
      • Bone scan was performed on 2020/03/31 which revealed some faint hot spots in bilateral rib cages and increased activity in the middle and lower C-spines, some middle to lower T-spines, some L-spines, sacrum, sternum, left humeral head, right pubic bone, right shoulder and bilateral knees in whole body survey.
      • Then she was regularly followed up at ONC OPD for Xegeva. Bone marrow on 2020/10/06 showed Hypocellularity, hypocellular marrow (<10%) with almost hemorrhage. Some plasma cells show about 10-20% of hematopoietic cells. Immunohistochemistry of CD34 and CD117 show no increase of blast, CD138 highlights plasma cell, Kappa/lambda light chain: no convincing kappa restriction.
      • Her bone morrow aspiration and biopsy were done and report showed bone marrow with fat and blood only, but MM FISH studies with CD138 selection resulted 1q21 (CKS1B) amplification at ChangHua Christian Hospital (outsourced) on 2020/12/30. Bone marrow showed plasma cell myeloma and IgA level 3373 on 2021/01/18. Bone scan was done on 2021/01/19 showed no evidence of bone lesions. Apply ixazomib on 2021/01/19, under IRd treatment started 2021/01/29 {Ninlaro 3 mg d1, d8, d18 q28d、lenalido 25mg d1-d21 and dexa 40 mg d1, d8, d15, d22} at ONC OPD.
      • The bone marrow, iliac, biopsy (2023/04/26) proved myeloma. IHC stains: CD117: <2%; MPO: 25-30%, CD138: 25-30 %; (of the nucleated cells). Kappa and Lambda light chains show a predominant kappa sub-population.
      • She received Revlimid 1# po qod & Ninlaro 1# po QWAC was given since 2021/05/25 to 2023/04/07. Limeson 5# po QW was given since 2023/05/09 to 2023/09/26. Xgeva 120mg sc was given on 2023/05/02 & 2023/06/06.
      • The elevate IgA showed 527 mg/dL on 2022/12/23, 1020 mg/dL on 2023/1/20, 968 mg/dL on 2023/2/24, 1213 mg/dL on 2023/3/24, 1683 mg/dL on 2023/4/21, 2477 mg/dL on 2023/5/23, 2817 mg/dL on 2023/6/6, 3161 mg/dL on 2023/6/20, 3443 mg/dL on 2023/7/18, 4893 mg/dL on 2023/8/15, 5331 mg/dL on 2023/9/12, 4568 mg/dL on 2023/9/26.
      • She complained of bilateral shoulder for days and Humerus Bilat/Shoulder RT (2023/05/09 & 2023/07/18) showed osteoporotic or osteolytic change of right humerus, right clavicle and right scapular is noted that may be multiple myeloma?
      • This time, owing to elevate IgA idex progression was noted and will given first daratuzumab/Velcade/Dexa treatment on 2023/10/02.
    • Course of inpatient treatment
      • After admission, cehmotherapy with Darzalex (16mg/kg, total 876mg) plus Velcade (1.3mg/m2, total 1.9mg) and Limeson 4mg total 20mg D1-D2 were given on 10/4 23, smoothly without obvious side effect. Anti-Hbc showed positive and Entecavir was added. She was discharged on 10/5 23 under stable condition and will next admission on 10/10 23.
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# HS
      • MgO 250mg 1# TID
      • Through (sennoside 12mg) 2# HS
      • Xyzal (levocetirizine 5mg) 1# QD
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# Q6H
  • 2023-08-18 SOAP Cardiology Xie JianAn
    • Prescription x3
      • Licodin (ticlopidine 100mg) 1# QD
      • Urosin (atenolol 100mg) 0.25# QD
      • Zulitor (pitavastatin 4mg) 0.5# QN
      • Diovan (valsartan 160mg) 0.5# QD
      • Ulstop (famotidine 20mg) 1# QD
  • 2023-07-26 SOAP Neurology Xiao ZhenLun
    • Prescription x3
      • Syntam (piracetam 1200mg) 1# BID

[consultation]

  • 2023-12-13 Psychosomatic Medicine
    • Q
      • Cancer inpatient suicide ideation score >= 2.
    • A
      • This 80 y/o woman was admitted for multiple myeloma. She has suffered from cognitive impairment (taking Syntam in NEU OPD), hearing loss (eardrum rupture), and partially dependent ADL. At home, she can walk slowly with a cane and go out for walks. She mostly can bathe and dress herself but needs her son to watch over her. Dependent IADL, often confused about time and space, and also unclear about her illness and treatment. 2022/7 MMSE 10, CDR 2; She has a fine drive and sleep, but often complained of weakness and pain, with negative thinking and rumination, sometimes expressed death thought (getting old, better to leave early). Denied concrete suicide plan.
      • Brain CT: 2022/7
        • Brain atrophy and leukoaraiosis.
        • Diffuse osteolytic bone change with some areas of cortical destruction.
      • IMP:
        • Depressive disorder
        • Senile dementia, moderate
        • r/o mood and neurocognitive problem related to multiple myeloma
      • Suggestion:
        • zoloft 50mg 0.5# HS.
        • Check TSH, fT4, Folic acid, Vit B12.
        • Arrange PSY OPD follow up.
  • 2020-03-28 Orthopedics
    • Q
      • This 82 year-old woman had medical history of 1) Hypertensive heart disease without heart failure 2) Cardiac arrhythmia 3) Hyperlipidemia 4) Osteoarthritis knee 5) multiple myeloma, IgA type, ISS stage 3 under Thado control. she was regular OPD follow up since Jun. 2006.
      • According to her and son, she had right shoulder soreness with pain since few weeks ago. She denied fall down, traumatic recently; there was no local heating nor inflammation situation. She comes to our Oncology OPD for help, the x-ray showed no fracture lesion. We need your expertise for further management, thanks
    • A
      • This 82-year-old woman suffered from right shoulder soreness and pain weeks ago.
      • local findings:
        • no local heat
        • near full ROM of shoulder
        • supraspinatus test: -
      • X-ray:
        • OA change of right shoulder joint, supscious osteolytic lesion in right humerus
      • Suggestion:
        • the pain in right shoulder may caused by Multiple myeloma, further evaluation (MRI, bone scan)
        • OA of the joint also resulted in shoulder pain
        • Please prescribe NSAID (Arcoxia or Celebrex) for symptom relieve.

[chemotherapy]

  • 2024-01-24 - daratumumab 16mg/m2 840mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C6D1)
    • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
  • 2024-01-16 - bortezomib 1.3mg/m2 1.9mg SC 1min (DVd C5D14)
  • 2024-01-09 - bortezomib 1.3mg/m2 1.9mg SC 1min (DVd C5D7)
  • 2024-01-03 - daratumumab 16mg/m2 849mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C5D1)
    • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
  • 2023-12-13 - daratumumab 16mg/m2 843mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C4D1)
    • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
  • 2023-12-06 - daratumumab 16mg/m2 854mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C3D15)
    • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
  • 2023-11-29 - daratumumab 16mg/m2 860mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C3D8)
    • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
  • 2023-11-22 - daratumumab 16mg/m2 864mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C3D1)
    • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
  • 2023-11-15 - daratumumab 16mg/m2 856mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C2D15)
    • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
  • 2023-11-01 - daratumumab 16mg/m2 880mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C2D8)
    • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
  • 2023-10-25 - daratumumab 16mg/m2 880mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C2D1)
    • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
  • 2023-10-17 - daratumumab 16mg/m2 880mg NS 500mL 4hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C1D15)
    • dexamethasone 4mg 2.5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
  • 2023-10-11 - daratumumab 16mg/m2 867mg NS 500mL 6hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C1D8)
    • dexamethasone 4mg 5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL
  • 2023-10-04 - daratumumab 16mg/m2 876mg NS 1000mL 8hr + bortezomib 1.3mg/m2 1.9mg SC 10min (DVd C1D1)
    • dexamethasone 4mg 5# PO + diphenhydramine 30mg + acetaminophen 500mg 2# PO + nontelukast 10mg 1# PO + NS 250mL

Treatment Name: DVd (Daratumumab + Velcade® (bortezomib) + dexamethasone) - 2023-10-18 - https://www.chemoexperts.com/dvd-daratumumab-velcade-bortezomib-dexamethasone.html

  • DVd (Daratumumab + Velcade® (bortezomib) + dexametha­sone) is a Chemotherapy Regimen for Multiple Myeloma (MM)
    • D - Daratumumab (Darzalex®)
    • V - Velcade® (bortezomib)
    • d - dexamethasone (dex)
  • Goals of therapy:
    • DVd is not given to cure multiple myeloma, but rather to slow the progression of the disease and to decrease symptoms.
  • Schedule
    • Daratumumab intravenous (I.V.) infusion or subcutaneous (SubQ) injection (Darzalex Faspro®) on Days 1, 8, and 15 of Cycles 1, 2, and 3; then Day 1 only of Cycles 4, 5, 6, 7, and 8, then once monthly (every 28 days) thereafter. The time of infusion varies depending upon the tolerability and number of previous infusions
    • Bortezomib subcutaneous (S.Q.) injection on Days 1, 4, 8 and 11 of Cycles 1, 2, 3, 4, 5, 6, 7, and 8
    • Dexamethasone 20 mg (five 4 mg tablets) by mouth on Days 1, 2, then Days 4, 5, then Days 8, 9, then Days 11, 12 of Cycles 1 through 8.
    • Cycles 1 through 8 are repeated every 21 days.
  • Estimated total infusion time for this treatment:
    • For daratumumab, Cycle 1 Day 1 may take up to 8 hours because of the possibility of experiencing infusion reactions. If you do not experience any with the first infusion, Cycle 1 Day 8 may be reduced to 6 hours. If you do not experience any infusion reactions during the first two daratumumab doses, it may only take up to 4 hours after that. There is also a 90-minute rapid infusion option if it is well tolerated
    • If daratumumab is given by subcutaneous injection (Darzalex Faspro®), there may be an observation time of up to 6 hours after the first dose to observe for reactions. If no reactions are seen, the observation times for future doses may be much shorter or not needed at all
    • On days that only bortezomib and dexamethasone are given, infusion time may be as little as 1 hour
    • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time
    • DVd is usually given in an outpatient infusion center, allowing the person to go home afterwards. It is repeated every 21 days. This is known as one Cycle. Each cycle may be repeated up to eight times and then ONLY daratumumab is given (no Velcade or dexamethasone) until daratumumab no longer works or until unacceptable side effects occur.
  • Common DVd Starting Doses
    • Daratumumab 16 mg/kg intravenous (I.V.) infusion on Days 1, 8, and 15 of Cycles 1, 2, and 3; then Day 1 only of Cycles 4 through 8, then once monthly (every 28 days) thereafter
    • Bortezomib 1.3 mg/m2 subcutaneous (S.Q.) injection on Days 1, 4, 8 and 11 of Cycles 1 through 8
    • Dexamethasone 20 mg (five 4 mg tablets) by mouth on Days 1, 2, then Days 4, 5, then Days 8, 9, then Days 11, 12 of Cycles 1 through 8
    • Cycles 1 through 8 are 21 days in duration.

Major toxicities of selected treatment regimens used for relapsed multiple myeloma - 2024-01-24 - https://www.uptodate.com/contents/image?imageKey=HEME%2F108257

  • Options for initial relapse
    • Daratumumab, lenalidomide, dexamethasone (DRd)
      • Major toxicities: Acute or delayed hypersensitivity reaction, opportunistic infections, diarrhea, fatigue.
      • Adjunctives: Prophylaxis for infusion reactions; antiviral prophylaxis; thromboprophylaxis.
      • Clinical use: Preferred for patients relapsing off therapy or while on small doses of single agent lenalidomide or on bortezomib maintenance.
      • Other: Can interfere with cross-matching and red blood cell antibody screening.
    • Daratumumab, bortezomib, dexamethasone (DVd)
      • Major toxicities: Peripheral neuropathy, transient cytopenias, acute or delayed hypersensitivity reaction, fatigue, nausea.
      • Adjunctives: Prophylaxis for infusion reactions; antiviral prophylaxis.
      • Clinical use: Preferred if refractory to full doses of lenalidomide or refractory to a lenalidomide containing triplet.
      • Other: Can interfere with cross-matching and red blood cell antibody screening.
    • Daratumumab, carfilzomib, dexamethasone (DKd)
      • Major toxicities: Hypersensitivity reaction, transient cytopenias, fatigue, diarrhea, hypokalemia, hypertension, dyspnea, serious cardiac dysfunction (approximately 5%).
      • Adjunctives: Prophylaxis for infusion reactions; antiviral prophylaxis; thromboprophylaxis.
      • Clinical use: Option for patients refractory to both bortezomib and lenalidomide.
      • Other: Can interfere with cross-matching and red blood cell antibody screening.
    • Isatuximab, carfilzomib, dexamethasone
      • Major toxicities: Hypersensitivity reaction, transient cytopenias, respiratory infections, fatigue, diarrhea, hypertension, serious cardiac dysfunction.
      • Adjunctives: Prophylaxis for infusion reactions; antiviral prophylaxis.
      • Clinical use: Option for patients refractory to both bortezomib and lenalidomide.
      • Other: Can interfere with cross-matching and red blood cell antibody screening.
    • Bortezomib, lenalidomide, dexamethasone (VRd)
      • Major toxicities: Peripheral neuropathy, transient cytopenias, fatigue, gastrointestinal distress.
      • Adjunctives: Thromboprophylaxis; antiviral prophylaxis.
      • Clinical use: May be preferred for patients relapsing off therapy or on lenalidomide maintenance.
      • Other: Subcutaneous, once-weekly dosing of bortezomib decreases toxicity.
    • Bortezomib, cyclophosphamide, dexamethasone (VCD)
      • Major toxicities: Peripheral neuropathy, transient cytopenias.
      • Adjunctives: Antiviral prophylaxis; PCP prophylaxis.
      • Clinical use: May be preferred for patients relapsing while off therapy or on lenalidomide maintenance.
      • Other: Subcutaneous, once-weekly dosing of bortezomib decreases toxicity.
    • Carfilzomib, lenalidomide, dexamethasone (KRd)
      • Major toxicities: Gastrointestinal distress, transient cytopenias, fatigue, hypokalemia, hypertension, dyspnea, serious cardiac dysfunction (approximately 5%).
      • Adjunctives: Thromboprophylaxis; antiviral prophylaxis.
      • Clinical use: May be preferred for more aggressive relapse in fit patients.
      • Other: More cumbersome than weekly schedule of bortezomib- or ixazomib-based regimens.
    • Carfilzomib, pomalidomide, dexamethasone (off-label)
      • Major toxicities: Transient cytopenias, fatigue, hypokalemia, hypertension, dyspnea, potentially severe diarrhea, serious cardiac dysfunction (approximately 5%).
      • Adjunctives: Thromboprophylaxis; antiviral prophylaxis.
      • Clinical use: May be preferred for patients with aggressive disease relapsing on standard dose lenalidomide.
    • Bortezomib, pomalidomide, dexamethasone (off-label)
      • Major toxicities: Peripheral neuropathy, thrombocytopenia, lymphopenia, potentially severe diarrhea, asthenia/fatigue, peripheral neuropathy.
      • Adjunctives: Thromboprophylaxis; antiviral prophylaxis.
      • Clinical use: May be preferred for patients relapsing on standard dose lenalidomide.
    • Ixazomib, lenalidomide, dexamethasone (IRd)
      • Major toxicities: Diarrhea, constipation, nausea, vomiting, thrombocytopenia, peripheral neuropathy, peripheral edema, and back pain.
      • Adjunctives: Thromboprophylaxis; antiviral prophylaxis.
      • Clinical use: May be preferred for frail patients or those with a clinically indolent relapse.
      • Other: Oral regimen.
    • Elotuzumab, lenalidomide, dexamethasone
      • Major toxicities: Acute or delayed hypersensitivity reaction, opportunistic infections, hepatic dysfunction, fatigue.
      • Adjunctives: Prophylaxis for infusion reactions; antiviral prophylaxis; thromboprophylaxis.
      • Clinical use: May be preferred for frail patients or those with a clinically indolent relapse.
  • Options for multiply relapsed disease: Includes regimens above that have not yet been used
    • Daratumumab, pomalidomide, dexamethasone
      • Major toxicities: Hypersensitivity reaction, thrombocytopenia, lymphopenia, potentially severe diarrhea, asthenia/fatigue, peripheral neuropathy.
      • Adjunctives: Prophylaxis for infusion reactions; antiviral prophylaxis; thromboprophylaxis.
      • Clinical use: Reserved for patients who have had at least two prior regimens, including lenalidomide and a proteasome inhibitor.
      • Other: Can interfere with cross-matching and red blood cell antibody screening.
    • Isatuximab, pomalidomide, dexamethasone
      • Major toxicities: Hypersensitivity reaction, thrombocytopenia, lymphopenia, potentially severe diarrhea, asthenia/fatigue, peripheral neuropathy.
      • Adjunctives: Prophylaxis for infusion reactions; antiviral prophylaxis; thromboprophylaxis.
      • Clinical use: Reserved for patients who have had at least two prior regimens, including lenalidomide and a proteasome inhibitor.
      • Other: Can interfere with cross-matching and red blood cell antibody screening.
    • Elotuzumab, pomalidomide, dexamethasone
      • Major toxicities: Acute or delayed hypersensitivity reaction, opportunistic infections, hepatic dysfunction, thrombocytopenia, lymphopenia, potentially severe diarrhea, asthenia/fatigue.
      • Adjunctives: Prophylaxis for infusion reactions; thromboprophylaxis.
      • Clinical use: Reserved for patients who have had at least two prior regimens, including lenalidomide and a proteasome inhibitor.
    • Selinexor, bortezomib, dexamethasone
      • Major toxicities: Thrombocytopenia, neutropenia, and hyponatremia. Neurologic toxicity (eg, dizziness, confusion).
      • Adjunctives: Antiviral prophylaxis; antiemetic prophylaxis.
      • Clinical use: Reserved for patients with disease refractory to a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody.
      • Other: Must monitor sodium.
    • Selinexor plus dexamethasone
      • Major toxicities: Thrombocytopenia, neutropenia, and hyponatremia. Neurologic toxicity (eg, peripheral neuropathy, dizziness, confusion).
      • Adjunctives: Antiemetic prophylaxis.
      • Clinical use: Reserved for patients who have had at least four prior regimens, including at least two proteasome inhibitors, at least two immunomodulatory agents, and an anti-CD38 monoclonal antibody.
      • Other: Oral regimen. Must monitor sodium.

[medication]

  • Ninlaro (ixazomib) KNINL01, KNINL01A
    • 2021-01-29 ~ 2023-04-21 3mg/cap QWAC
  • Revlimid (lenalidomide) KREVL01
    • 2022-02-04 ~ 2023-03-31 25mg QD PO
    • 2021-01-29 ~ 2022-02-01 25mg QOD PO
  • Thado (thalidomide) KTHAD01
    • 2019-01-18 ~ 2020-01-02 50mg HS PO
    • 2017-01-05 ~ 2017-11-16 100mg HS PO
  • Velcade (bortezomib) CVELC01
    • 2017-01-26 1.9mg ST SC
    • 2017-01-05 1.9mg ST SC
  • Licodin (ticlopidine) KLICO01
    • 2019-05-30 ~ 2024-01-24 ongoing 100mg BID PO
  • Xgeva (denosumab) CXGEV01
    • 2022-01-18 120mg Q1M SC
    • 2021-12-07 120mg Q1M SC
    • 2021-11-09 120mg Q1M SC
    • 2021-10-12 120mg Q1M SC
    • 2021-01-14 120mg Q1M SC
    • 2020-12-10 120mg Q1M SC
    • 2020-11-13 120mg Q1M SC
    • 2020-10-16 120mg Q1M SC
    • 2020-09-08 120mg Q1M SC
    • 2020-08-11 120mg Q1M SC
    • 2020-07-14 120mg Q1M SC

==========

2024-01-24

[evaluating osteoporotic changes after Xgeva discontinuation]

Bortezomib was administered on 2024-01-03, 2024-01-09, and 2024-01-16 (days 1, 7, and 14), deviating from the typical days 1, 4, 8, and 11 schedule in cycle 5 of the DVd regimen. The patient was admitted for Cycle 6 Day 1 treatment. Lab results on 2024-01-23 showed pancytopenia, a decreased eGFR of 53 mL/min/1.73m2, low serum albumin at 2.8 g/dL, and elevated total bilirubin at 0.73 mg/dL. However, these findings should not contraindicate treatment continuation.

The patient had previously been treated with several doses of Xgeva in the first half of 2023. Following this, multiple bone X-rays indicated osteoporotic or osteolytic changes. Therefore, reintroducing Xgeva to address the bone condition could be considered.

2024-01-03

[macrocytic anemia]

The lab results indicate the presence of macrocytic anemia, which could be attributed to deficiencies in vitamin B12, folate, or copper. To alleviate the anemia, it may be advantageous to consider supplementation with vitamin B12 and/or folate.

  • 2024-01-02 HGB 8.6 g/dL
  • 2024-01-02 MCV 103.6 fL

Additionally, daratumumab and bortezomib in DVd regimen are associated with anemia.

2023-12-13

[DVd Regimen: deviation from original schedule]

The patient was admitted for C4D1 of her daratumumab treatment, which is part of the DVd regimen in combination with bortezomib. The administration schedule for this regimen involves daratumumab on Days 1, 8, and 15 for Cycles 1, 2, and 3; then only on Day 1 for Cycles 4 through 8, followed by a monthly administration (every 28 days) thereafter.

This hospitalization marks the beginning of Cycle 4, and according to the regimen design, daratumumab should only be administered on Day 1 up to Cycle 8. Additionally, as per the regimen’s design, bortezomib is scheduled on Days 1, 4, 8, and 11 for Cycles 1 to 8, and in practice, it is administered concurrently with daratumumab.

Ref: https://www.darzalexhcp.com/pdfs/cp-142382v4-darzalex-maia-cassio-apollo-dosing-admin-guide.pdf

[to reassess bone health]

It is common practice to administer a single dose of a potent bisphosphonate (ie, zoledronic acid at 4 or 5 mg for a single dose) after stopping denosumab therapy to prevent rebound bone loss and fractures. Markers of bone resorption rebound and increase rapidly after denosumab discontinuation, and this can lead to increased loss of bone mineral density and the development of vertebral fractures, particularly in patients with baseline osteoporosis, with a history of prior fracture, or on continued aromatase inhibitor therapy.

The last 3 doses of Xgeva (denosumab 120mg) were administered on 2023-03-24, 2023-05-02, and 2023-06-06. Since it has been over 6 months since the last dose, and there are no hospital records of bisphosphonate use since then, it is recommended to reassess the patient’s bone health.

2023-12-06

[reconciliation]

Currently, access to the PharmaCloud database is unavailable.

There has been a downward trend in eGFR readings over the past 2-3 weeks. Despite this, the patient’s current renal function does not necessitate any dose adjustments at this time.

  • 2023-12-05 eGFR 62.30 ml/min/1.73m^2
  • 2023-11-28 eGFR 73.34 ml/min/1.73m^2
  • 2023-11-21 eGFR 81.63 ml/min/1.73m^2

No discrepancies have been identified in the active medication list.

2023-11-29

The DVd regimen, which began on 2023-10-04, might have led to a decrease in IgA levels, yet they remain elevated along with FKLC and B2-Microglobulin.

  • 2023-11-27 FKLC 139.0 mg/L

  • 2023-11-27 FLLC 5.9 mg/L

  • 2023-11-27 FK/FL ratio 23.56 ratio

  • 2023-11-23 B2-Microglobulin 5746 ng/mL

  • 2023-11-22 IgA 3460 mg/dL

  • 2023-09-26 IgA 4568 mg/dL

  • 2023-09-12 IgA 5331 mg/dL

Based on the lab results from 2023-11-28, the patient’s liver and kidney functions are grossly normal, indicating no need for dosage adjustments due to liver or renal concerns for now.

2023-11-01

[pancytopenia after 2023-10-25 C2D1 DVd]

On 2023-10-25, DVd (C2D1) was administered, which resulted in the onset of pancytopenia. Appropriate measures, including the administration of G-CSF and blood transfusion, were promptly undertaken.

  • 2023-11-01 WBC 2.70 x10^3/uL

  • 2023-10-31 WBC 2.55 x10^3/uL

  • 2023-10-25 WBC 2.57 x10^3/uL

  • 2023-11-01 HGB 7.6 g/dL

  • 2023-10-31 HGB 8.6 g/dL

  • 2023-10-25 HGB 8.6 g/dL

  • 2023-11-01 PLT 128 *10^3/uL

  • 2023-10-31 PLT 42 *10^3/uL

  • 2023-10-25 PLT 170 *10^3/uL

[withhold Diovan temporarily]

The latest blood pressure measurement, taken on 2023-11-01 at 12:59, was 100/52. Given the absence of current hypertension, it is advisable to temporarily withhold Diovan (valsartan) to reduce the potential for hypotension.

2023-10-18

[DVd regimen]

This patient received lenalidomide from 2021 to 2023Q1 (and thalidomide prior to that). The DVd regimen is preferred for patients who are refractory to full doses of lenalidomide or to a lenalidomide-containing triplet regimen.

The patient started the DVd regimen in early Oct 2023, with the first dose (C1D1) administered on 2023-10-04, the second dose (C1D8) administered on 2023-10-11, and the third dose (C1D15) administered on 2023-11-17. This hospitalization is for the end of cycle 1.

These three daratumumab infusions were administered over 8 hours, 6 hours, and 4 hours, respectively, which effectively reduced the risk of infusion reactions.

The major toxicities of the DVd regimen include peripheral neuropathy, transient cytopenias, acute or delayed hypersensitivity reaction, fatigue, and nausea. Please continue to monitor the patient for these toxicities.

2023-10-11

This patient received repeat prescriptions from our cardiology department for Licodin (ticlopidine), Urosin (atenolol), Zulitor (pitavastatin), Diovan (valsartan), and Ulstop (famotidine) on 2023-08-18, and from our neurology department for Syntam (piracetam) on 2023-07-26. There are no discrepancies, and all these medications are currently being used as prescribed.

[rising IgA levels in 2023]

Since the beginning of this year (2023), IgA levels have risen from the triple digits to the mid-four digits by August, suggesting that the disease may still be progressing.

  • 2023-09-26 IgA 4568 mg/dL
  • 2023-09-12 IgA 5331 mg/dL
  • 2023-08-15 IgA 4893 mg/dL
  • 2023-07-18 IgA 3443 mg/dL
  • 2023-06-20 IgA 3161 mg/dL
  • 2023-06-06 IgA 2817 mg/dL
  • 2023-05-23 IgA 2477 mg/dL
  • 2023-05-09 IgA 2054 mg/dL
  • 2023-05-02 IgA 1923 mg/dL
  • 2023-04-21 IgA 1683 mg/dL
  • 2023-04-07 IgA 1475 mg/dL
  • 2023-03-24 IgA 1213 mg/dL
  • 2023-03-10 IgA 1058 mg/dL
  • 2023-02-24 IgA 968 mg/dL
  • 2023-02-10 IgA 1016 mg/dL
  • 2023-01-27 IgA 1063 mg/dL
  • 2023-01-20 IgA 1020 mg/dL
  • 2023-01-06 IgA 515 mg/dL

2023-01-09

  • Neutropenia has be mitigated with filgrastim (G-CSF)

    • 2023-01-09 WBC 2.94 *10^3/uL
    • 2023-01-07 WBC 0.96 *10^3/uL
    • 2023-01-06 WBC 0.94 *10^3/uL
    • 2022-12-23 WBC 4.61 *10^3/uL
  • Over the past three months, the IgA levels have been around 500 +- 50 mg/dL, relatively stable, but showing a slowly upward trend.

    • 2023-01-06 IgA515 mg/dL
    • 2022-12-23 IgA527 mg/dL
    • 2022-12-09 IgA473 mg/dL
    • 2022-11-25 IgA534 mg/dL
    • 2022-11-11 IgA460 mg/dL
    • 2022-10-28 IgA451 mg/dL
    • 2022-10-14 IgA410 mg/dL
    • 2022-09-30 IgA390 mg/dL
  • Revlimid (lenalidomide) has demonstrated a significantly increased risk of deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as risk of myocardial infarction and stroke in patients with multiple myeloma who were treated with lenalidomide and dexamethasone therapy. Please monitor for and advise patients about the signs and symptoms of thromboembolism as always.

  • Ninlaro (ixazomib) has been prescribed as a self-paid item and is not listed on PharmaCloud nor in the active prescriptions. Please make sure that the patient’s ANC be greater than 1000/mm3, platelets be greater than 75,000/mm3, and nonhematologic toxicities be at baseline or less than grade 1 (per prescriber discretion) prior to initiating a new cycle of therapy. It is recommended that patients who are seropositive for Varicella zoster virus (VZV) and herpes simplex virus (HSV) receive an antiviral prophylaxis with acyclovir or valacyclovir prior to receiving a proteasome inhibitor (bortezomib, carfilzomib, ixazomib), as there is an increased risk of reactivation if the proteasome inhibitor is used.

700715400

240124

[lab data]

  • 2022-02-18
    • All-RAS mutation not detected (wild type)
    • BRAF mutation not detected (wild type)
    • EGFR G719X mutation not detected
    • EGFR Exon19 deletion not detected
    • EGFR S768I not detected
    • EGFR T790M not detected
    • EGFR Exon20 insertion not detected
    • EGFR L858R not detected
    • EGFR L861Q not detected

[exam findings]

  • 2023-11-24 CT - abdomen
    • History: S-colon cancer with liver metastasis S/P OP and C/T.
    • Findings: Comparison prior CT dated 2023/07/12 and MRI dated 2023/07/26.
      • Prior MRI identified seven metastases in left lobe liver are noted again, decreasing in size.
        • Liver metastases S/P C/T with partial response is highly suspected.
        • Follow up MRI 3 months later is indicated.
      • S/P LAR with autosuture retention over the sigmoid colon.
        • In addition, Prior CT identified a cystic lesion 1.9 cm in the right lateral aspect of the anastomosis area is noted again, decreasing in size to 1.7 cm.
      • S/P near total resection of S5/6/7.
        • S/P partial resection of S8 of the liver with biloma 4 cm.
        • S/P partial resection of left lateral aspect of S2-3 of the liver.
      • Prior CT identified some LNs at mediastinum, mesentery and retroperitoneum are noted again, decreasing in size.
      • A renal cyst 0.9 cm in left middle pole is noted.
      • There is no focal lesion in both lung and mediastinum.
      • S/P right lobectomy of the thyroid?
        • please correlate with clinical history.
    • Impression:
      • Liver metastases S/P C/T with partial response is highly suspected.
      • Follow up MRI 3 months later is indicated.
  • 2023-08-07 PET
    • Increased FDG uptake in the S- and R-colon, probably feces accumulation.
    • At least six nodular lesions of increased FDG uptake in the right lobe of the liver, highly suspected colon cancer with liver metastases.
    • Increased FDG uptake in several celiac lymph nodes, highly suspected colon cancer with distant lymph nodes metastases.
    • Increased FDG uptake in the left rib cage, highly suspected bone metastases.
    • Sigmoid colon cancer s/p treatment with celiac lymph nodes, liver and left ribs metastases, ycTxNxM1b, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-07-26 MRI - liver, spleen
    • History: S-colon cancer with liver metastasis S/P OP and C/T.
    • Findings:
      • There are seven newly developed masses on S2-3-4 of the liver, showing hypointensity on T1WI, mild hyperintensity on both T2WI and DWI, and poor enhancement in dynamic study. The largest one 1.7 cm in S4.
        • Seven metastases are noted.
      • S/P near total resection of S5/6/7.
      • S/P partial resection of S8 of the liver with biloma 4 cm.
      • S/P partial resection of left lateral aspect of S2-3 of the liver.
      • A renal cyst 0.9 cm in left middle pole is noted.
    • Impression:
      • Seven metastases on S2-3-4 of the liver are noted.
  • 2023-07-12 CT - abdomen, pelvis
    • Findings:
      • There is an ill-defined poor enhancing lesion 1.9 cm in S6 of the liver that may be metastasis and flow artifact. Please correlate with sonography and MRI.
      • S/P LAR with autosuture retention over the sigmoid colon.
        • In addition, Prior CT identified a cystic lesion 1.9 cm in the right lateral aspect of the anastomosis area is noted again, stationary.
      • S/P near total resection of S5/6/7.
      • S/P partial resection of S8 of the liver with biloma 4 cm.
      • S/P partial resection of left lateral aspect of S2-3 of the liver.
      • Prior CT identified some LNs at mediastinum, mesentery and retroperitoneum are noted again, stationary.
      • A renal cyst 0.9 cm in left middle pole is noted.
      • S/P right lobectomy of the thyroid? please correlate with clinical history.
    • Impression:
      • There is an ill-defined poor enhancing lesion 1.9 cm in S6 of the liver that may be metastasis and flow artifact. Please correlate with sonography and MRI.
  • 2023-04-19 CT - abdomen, pelvis
    • Findings:
      • S/P LAR with autosuture retention over the sigmoid colon.
        • In addition, Prior CT identified a cystic lesion 1.9 cm in the right lateral aspect of the anastomosis area is noted again, stationary.
      • S/P near total resection of S5/6/7.
      • S/P partial resection of S8 of the liver with biloma 4.6 cm.
      • S/P partial resection of left lateral aspect of S2-3 of the liver.
      • There is an ill-defined poor enhancing lesion 1.2 cm in the residual S2 of the liver. Follow up is indicated.
      • Prior CT identified some LNs at mediastinum, mesentery and retroperitoneum are noted again, stationary.
      • Hyperplasia of left adrenal gland.
      • A renal cyst 0.9 cm in left middle pole is noted.
      • S/P right lobectomy of the thyroid? please correlate with clinical history.
    • Impression:
      • S/P LAR with autosuture retention over the sigmoid colon. There is no evidence of tumor recurrence.
  • 2023-01-17 CT - abdomen, pelvis
    • History and indication: S-colon cancer s/p c/T OP for liver and primary lesion
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P colon operation.
      • S/P liver operation with biloma formation (up to 4.6cm). Some hypodense lesions in liver.
      • Some LNs at mediastinum, mesentery and retroperitoneum.
      • Minimal ascites. Hyperplasia of left adrenal gland.
      • Tiny renal cysts.
      • Absence of right thyroid gland.
      • Atherosclerosis of aorta, iliac arteries.
      • Right minimal pleural effusion.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P colon operation.
      • S/P liver operation with biloma formation (up to 4.6cm).
      • Some LNs at mediastinum, mesentery and retroperitoneum.
  • 2022-10-20 CT - abdomen, pelvis
    • History and indication: Sigmoid colon cancer with liver mets, s/p neoadjuvant C/T with P-FOLFIRI, s/p over sigmoid and liver, s/p adjuvant C/T with P-FOLFIRI
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P colon operation.
      • S/P liver operation with biloma formation (up to 6.1cm). Some hypodense lesions in liver.
      • Some LNs at mediastinum, mesentery and retroperitoneum.
      • Minimal ascites. Hyperplasia of left adrenal gland.
      • Collapse of gallbladder.
      • Atherosclerosis of aorta, iliac arteries.
      • Right minimal pleural effusion.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P colon operation.
      • S/P liver operation with biloma formation (up to 6.1cm). Some hypodense lesions in liver.
      • Some LNs at mediastinum, mesentery and retroperitoneum.
  • 2022-08-16 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS
      • Liver, S2, S2 resection — Metastatic colonic adenocarcinoma
      • Liver, S8 and S3, partial hepatectomy — Metastatic colonic adenocarcinoma
      • Liver, S6-7, S6-7 resection — Metastatic colonic adenocarcinoma
      • Tumor regression grade: Grade 3 (fibrosis > cancer cells)
    • MACROSCOPIC EXAMINATION
      • Procedures: S2 and S6-7 resection, and S8 and S3 partial hepatectomy
      • Specimen Size: 16 x 10 x 5.0 cm & 190 gm (S2), 2.0 x 2.0 x 1.5 cm & 10 gm (S3), 9.0 x 7.0 x 5.0 cm & 110 gm S8), 20 x 11 x 6.0 cm and 420 gm (S6-7)
      • Tumor Focality: Multiple (number: 4)
      • Tumor Site: S2, S8, S3, and S6-7
      • Tumor Size: 6.0 x 5.0 x 5.0 cm (S2), 1.2 x 0.9 x 0.8 cm (S3), 6.5 x 5.5 x 5.0 cm (S8), and 11.5 x 7.9 x 6.5 cm (S6-7) respectively
      • Large vessel involvement: Not identified
      • Non-tumorous part: Not cirrhotic
      • Sections are taken and labeled as: A1-A4= S2 tumor, B= S3 tumor, C1-C4= S8 tumor, D1-D4= S6-7 tumor
    • MICROSCOPIC EXAMINATION
      • Diagnosis: Metastatic colonic adenoarcinoma
      • Histologic grade: Moderately differentiated
      • Tumor growth pattern: Infiltrative
      • Tumor pseudocapsule: Absent
      • Percentage of necrosis:10%; Percentage of fibrosis: 50%
      • Parenchymal margin: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margins: 0.1 cm (S2, S8, S6-7)
      • Vascular invasion: Not identified
      • Perineural invasion: Not identified
      • Tumor regression grade: Grade 3 (fibrosis > residual cancer cells)
      • Non-neoplastic liver parenchyma: Perivenular congestion, regeneration of hepatocytes, and mild lymphocytic portal inflammation, compatible with chemotherapy-associated liver injury
      • Fatty Change: Absent
  • 2022-08-16 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Sigmoid colon, sigmoid colectomy — Adenocarcinoma, moderately differentiated
      • Resection margins, sigmoid colectomy – Free
      • Lymph nodes, mesocolic, sigmoid colectomy — Negative for malignancy (0/19)
      • Pathology stage: ypT3N0M1a; Stage IVA
    • MACROSCOPIC EXAMINATION
      • Operation procedure: Sigmoid colectomy
      • Specimen site: Sigmoid colon
      • Specimen size: 18.0 cm in length
      • Tumor size: 3.8 x 3.0 cm
      • Tumor location: 6.0 cm and 9.0 cm away from the two resection margins, respectively .
      • Depth of invasion grossly: Pericolic soft tissue
      • Mucosa elsewhere: Unremarkable
      • Representative parts are taken for section and labeled: A1= tumor + pelvic wall, A2-A4= tumor, A5-A8= regional LNs, B= anastomosis site, proximal, C= anastomosis site, distal.
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: Moderately differentiated
      • Depth of invasion: Pericolic soft tissue
      • Angiolymphatic invasion: Not identified
      • Perineural invasion: Not identified
      • Tumor cell budding: Low
      • Margins
        • Proximal and distal anastomosis sites: Free
        • Circumferential (radial) margin: Uninvolved, 5 mm from the margin
        • Pelvic wall: Fibrous adhesion without cancer cells
      • Lymph node metastasis, mesocolic: Negative for malignancy (0/19) (No. Positive / No. Total)
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): ypT3 (Tumor invades pericolic tissue)
        • Regional Lymph Nodes (pN): ypN0 (No regional lymph node metastasis)
        • Distant Metastasis (pM): M1a (Metastasis to liver (see S2022-13475))
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: None identified
      • Treatment effect: Partial response; Residual cancer with evident tumor regression (partial response, score 2)
      • IHC(S2022-01236): EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • 2022-08-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 30) / 116 = 74.14%
      • M-mode (Teichholz) = 74
    • Conclusion:
      • Normal LV filling pressure.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis.
  • 2022-07-29, -07-23 KUB
    • S/P sigmoid colon stenting.
  • 2022-07-23 KUB
    • S/P sigmoid colon stenting with marked distension of the proximal colon. stenting obstruction is highly suspected.
  • 2022-07-21 CT - abdomen, pelvis
    • Mild regression of S-colon cancer and liver metastases. S/P S-colon stenting. Dilatation of colon.
  • 2022-05-05 CT - abdomen, pelvis
    • Much regression of S-colon cancer and liver metastases.
  • 2022-01-22 CT
    • Findings
      • Huge heterogeneous soft tissue mass at both lobes of liver up to 12.5cm is found.
      • s/p sigmoid colon stent placement. The sigmoid colon wall is thick. Some lymph nodes (n = 4) is found.
    • Imp:
      • Sigmoid colon cancer s/p stent placement and liver mets.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T3N2M1
  • 2022-01-20 Patho - colon biopsy
    • Colon, sigmoid, biopsy - Adenocarcinoma, moderately differentiated
    • IHC: EGFR(+), PMS2(focal +), MLH1(+), MSH2(+), and MSH6(+).
    • Section shows pieces of colonic tissue with tumor necrosis, tubulovillous glands and scant invasive irregular neoplastic glands.
  • 2022-01-19 Colonoscopy
    • Colon cancer, sigmoid colon, with acute obstruction s/p self expandable metal stent placement and biopsy
    • Mixed hemorrhoid

[MedRec]

  • 2024-01-02 ~ 2024-01-05 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • S-colon cancer with liver metastases, T3N2M1a, stage IVA s/p S-colon stenting on 2022/01/19 and chemotherapy with FOLFIRI from 2022/01/24~2022/07/13 (for 12 cycles), Vectibix (panitumumab) from 2022/03/23~2022/07/13 (for 8 cycles) s/p Sigmoid colectomy and open S6-7, S2 and S8 partial and S3 partial hepatectomy on 2022/08/15 s/p chemotherapy with FOLFIRI/Vectibix from 2022/09/13~2023/04/07, with liver metastasis, ypT3N2M1b, stabe IVB, s/p chemotherapy with FOLFIRI/Vectibix from 2023/08/29~
      • Chronic viral hepatitis B without delta-agent
      • Type 2 diabetes mellitus with hyperglycemia
      • Essential (primary) hypertension
      • Hyperlipidemia, unspecified
      • Dermatitis, due to Panitumumab related
    • CC
      • For palliative chemotherapy with FOLFIRI/Vectibix(self-paid)(C4D1).            
    • Present illness
      • This 60-year-old woman patient referred from Cardinal Tien Hospital due to abdominal discomfort 2022/01. According to patient and family statement, she had sufferred from of chronic constipation for 1 year and involuntary weight loss about 5kg in one month. She visited Cardinal Tien Hospital and low GI series was arranged. After examination, abdmonial fullness, watery diarrhea was noted, however laxatives had no effect. Due to persisted symptoms, she visited Cardinal Tien Hospital ER for help.
      • Abdominal CT on 2022/01/18 revealed dilated colon, a transition zone at sigmoid colon and multiple liver neoplasm, sigmoid cancer with multiple liver metastasis was highly suspected.
      • Sigmoidoscopy on 2022/01/19 showed colon cancer, sigmoid colon, with acute obstruction s/p self expandable metal stent placement and biopsy, mixed hemorrhoid. Sigmoid biopsy showed adenocarcinoma, moderately differentiated. Port-A catheter insertion on 2022/01/21. Chest CT on 2022/01/22 showed sigmoid colon cancer s/p stent placement and liver meta.
      • Palliative chemotherapy with biweekly FOLFIRI (Campto 180mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) was given on 2022/01/24~2022/07/13 for 12 cycles. Target therapy with Panitumumab (Vectibix) (6mg/kg) 400mg on 2022/03/23~2022/07/13 for 8 cycles. Abdominal CT on 2022/05/05 showed much regression of S-colon cancer and liver metastases.
      • Lower abdominal fullness with severe pain on 2022/07. Abdominal CT on 2022/07/21 showed mild regression of S-colon cancer and liver metastases, S/P S-colon stenting and dilatation of colon. KUB on 2022/07/21 showed ileus. Sigmoidoscopy on 2022/07/21 showed sigmoid colon cancer post SEMS with stent dysfunction (obstruction), s/p placement of a new metal stent, proctocolitis distal to the tumor, anal prolapse and incomplete study of colon.
      • 2D echo on 2022/08/09 showed M-mode(Teichholz) = 74, 1.Normal LV filling pressure. 2.Normal LV and RV systolic function. 3.Mild aortic valve sclerosis.
      • Sigmoid colectomy and open S6-7, S2 and S8 partial and S3 partial hepatectomy on 2022/08/15.
      • Sigmoid colon pathology showed adenocarcinoma, moderately differentiated without lymph node metastasis(0/19), ypT3N0M1a; Stage IVA.
      • Liver pathology showed metastatic colonic adenocarcinoma.
      • Post-OP chemotherapy with biweekly FOLFIRI (Campto 180mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) /Vectibx (6mg/kg, given 400mg) was given on 2022/09/13(C1D1), 2022/09/27(C1D15), 2022/10/11(C2D1), 2022/10/28(C2D15), 2022/11/08(C3D1), 2022/11/22(C3D15), 2022/12/06(C4D1), 2022/12/20(C4D15), 2023/01/03(C5D1), 2023/01/17(C5D15), 2023/02/08(C6D1), 2023/02/27(C6D15), 2023/03/17(C7D1).
      • Abdominal CT on 2022/10/22 showed S/P colon operation, S/P liver operation with biloma formation (up to 6.1cm). Some hypodense lesions in liver and some lymph nodes at mediastinum, mesentery and retroperitoneum. Follow-up, Abdominal CT on 2023/01/17 showed S/P colon operation, S/P liver operation with biloma formation (up to 4.6cm) and some lymph nodes at mediastinum, mesentery and retroperitoneum. Follow-up, Abdominal CT on 2023/04/22 showed S/P LAR with autosuture retention over the sigmoid colon, no evidence of tumor recurrence.
      • Follow-up, Abdominal CT on 2023/07/12 showed an ill-defined poor enhancing lesion 1.9 cm in S6 of the liver that may be metastasis and flow artifact. suggest correlate with sonography and MRI.
      • Abdominal MRI was done on 2023/07/26 showed seven metastases on S2-3-4 of the liver are noted.
      • Whole body PET scan on 2023/08/11 showed 1. Increased FDG uptake in the S- and R-colon, probably feces accumulation, 2. At least six nodular lesions of increased FDG uptake in the right lobe of the liver, highly suspected colon cancer with liver metastases, 3. Increased FDG uptake in several celiac lymph nodes, highly suspected colon cancer with distant lymph nodes metastases, 4. Increased FDG uptake in the left rib cage, highly suspected bone metastases, 5. Sigmoid colon cancer s/p treatment with celiac lymph nodes, liver and left ribs metastases, ycTxNxM1b, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
      • Palliative chemotherapy with biweekly FOLFIRI (Campto 180mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) /Vectibx (6mg/kg, self pay, given 400mg) on 2023/08/29(C1D1), 2023/09/18(C1D15), 2023/10/09(C2D1), 2023/11/01(C2D15), 2023/11/21(C3D1), 2023/12/11(C3D15).
      • Follow up bdominal CT for survey on 2023/11/24 showed Liver metastases S/P C/T with partial response is highly suspected.
      • Now, she was admitted to ward for chemotherapy with biweekly FOLFIRI (Campto 180mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) /Vectibx (6mg/kg, self pay, given 400mg) on 2024/01/03(C4D1).
    • Course of inpatient treatment
      • After admitted, palliative chemotherapy with biweekly FOLFIRI (Campto 180mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) /Vectibx (6mg/kg, self pay, given 400mg) from 2024/01/03~2023/01/05(C4D1).
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting and Olanzpine 1# po HS for severe vomiting.
      • ULSTOP F.C 20mg/tab 1# PO BID for GERD.
      • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for Anti HBc(+).
      • Type 2 diabetes mellitus with Diet control and check finger sugar and Meftormin 500mg 2# po BID, Canaglu 100mg 1# PO QD and Glitis 30mg 1# PO QD.
      • Hypertension with Irbesartan 300mg 0.5# PO QD, Zanidip F.C 10mg 1# PO QD and Concor 5mg 1# PO QD.
      • Hyperlipidemia with Crestor 10mg 1# PO QN.
      • Dermatitis, due to Panitumumab related, Allegra 60mg/tab 1# PO BID and Topsym cream 0.05%, 10gm/tube 1qs for skin rash and itchy.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2024/01/05 and OPD followed up later.
    • Discharge diagnosis
      • Allegra (fexofenadine 60mg) 1# BID
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Limeson (dexamethasone 4mg) 1# QD
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Ulstop (famotidine 20mg) 1# QD
      • Zyprexa Zydis (olanzapine 5mg) 1# HS
      • Topsym Cream (fluocinonide 0.05%) QD EXT

[surgical operation]

  • 2022-08-15
    • Surgery: Sigmoid colectomy        
    • Finding: Sigmoid cancer with pelvic wall direct invasion
  • 2022-08-15
    • Surgery: open S6-7, S2 and S8 partial and S3 partial hepatectomy
    • Finding: multiple liver tumor 0.5 to 7 cm bilat lobe

[consultation]

  • 2022-07-21 colon and rectal surgery
    • Q
      • Lower abdomen pain VAS 10 for 2 days
      • Hx of sigmoid cancer with multiple liver metastasis
      • Deny abd op hx
    • A
      • S/O
        • S colon cancer with obstruction and multiple liver s/p stent by GI
        • low abdomen pain and no solid stool for 1~2 days
        • CT: favored solid stool stuck in stent
      • A/P:
        • suggested medical treatment + maybe st enema
        • T loop colostomy if no improving
  • 2022-01-21 hematology and oncology
    • please check AntiHbc for chemotherapy HBV evaluation
    • if proven colon cancer, for advanced metastasis colon cancer, systemic therapy is indicated. Ex: FOLFOX+/-avastin or FOLFIRI+/-avastin, +ceftuximab if KRAS wide type, consider IO if dMMR/MSI-H
    • pending pathology result and we wound like to follow up this case
  • 2022-01-19 colon and rectal surgery
    • This is a case of sigmoid cancer with obstruction, multiple liver metastasis. I’ve discussed with the patient and her families, palliative stent is indicated. After colonic stent, palliative chemotherapy and target therapy will be arranged.

[chemotherapy]

  • 2024-01-23 - panitumumab 6mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL
  • 2024-01-03 - panitumumab 6mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-12-11 - (FOLFIRI plus panitumumab)

  • 2023-11-21 - (FOLFIRI plus panitumumab)

  • 2023-10-31 - (FOLFIRI plus panitumumab)

  • 2023-10-09 - (FOLFIRI plus panitumumab)

  • 2023-09-18 - (FOLFIRI plus panitumumab)

  • 2023-08-29 - (FOLFIRI plus panitumumab)

  • 2023-04-07 - (FOLFIRI plus panitumumab)

  • 2023-03-17 - (FOLFIRI plus panitumumab)

  • 2023-02-27 - (FOLFIRI plus panitumumab)

  • 2023-02-08 - (FOLFIRI plus panitumumab)

  • 2023-01-17 - (FOLFIRI plus panitumumab)

  • 2023-01-03 - (FOLFIRI plus panitumumab)

  • 2022-12-20 - (FOLFIRI plus panitumumab)

  • 2022-12-06 - (FOLFIRI plus panitumumab)

  • 2022-11-22 - (FOLFIRI plus panitumumab)

  • 2022-11-08 - (FOLFIRI plus panitumumab)

  • 2022-10-25 - (FOLFIRI plus panitumumab)

  • 2022-10-11 - (FOLFIRI plus panitumumab)

  • 2022-09-27 - (FOLFIRI plus panitumumab)

  • 2022-09-13 - (FOLFIRI plus panitumumab)

  • 2022-07-13 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr (FOLFIRI plus panitumumab)

  • 2022-06-29 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr

  • 2022-06-15 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr

  • 2022-06-01 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr

  • 2022-04-27 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr

  • 2022-04-13 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr

  • 2022-04-01 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr

  • 2022-03-23 - panitumumab 6mg/kg 90min

  • 2022-03-18 - irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr

  • 2022-02-24 - irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr

  • 2022-02-11 - irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr

  • 2022-01-24 - irinotecan 120mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr

==========

2024-01-24

[reconciliation]

The PharmaCloud database indicates that on 2024-01-22, the patient refilled prescriptions for Concor (bisoprolol), Zanidip (lercanidipine), Aprovel (irbesartan), and Xanax (alprazolam) at Cardinal Tien Hospital. These medications are currently being used, and no discrepancies in medication have been identified.

2023-11-01

[sharp rise and subsequent decline of CEA and CA199]

Both tumor markers, CEA and CA199, showed a sharp increase starting in 2023Q3 and have recently shown a decrease (although not yet in the normal range). Given that the primary treatment, P-FOLFIRI, has been used for over a year and a half without adjustments, the reasons for the decline in tumor markers may warrant further investigation.

  • 2023-10-25 CEA 55.55 ng/mL

  • 2023-09-06 CEA 484.09 ng/mL

  • 2023-08-29 CEA 581.20 ng/mL

  • 2023-07-17 CEA 172.08 ng/mL

  • 2023-06-17 CEA 30.15 ng/mL

  • 2023-05-25 CEA 7.86 ng/mL

  • 2023-03-30 CEA 2.33 ng/mL

  • 2023-03-09 CEA 2.64 ng/mL

  • 2023-01-31 CEA 2.44 ng/mL

  • 2023-01-17 CEA 2.46 ng/mL

  • 2023-01-03 CEA 2.54 ng/mL

  • 2023-10-25 CA199 52.99 U/mL

  • 2023-09-06 CA199 183.01 U/mL

  • 2023-08-29 CA199 268.44 U/mL

  • 2023-07-17 CA199 76.81 U/mL

  • 2023-06-17 CA199 16.80 U/mL

  • 2023-05-25 CA199 8.73 U/mL

  • 2023-03-30 CA199 5.91 U/mL

  • 2023-03-09 CA199 6.00 U/mL

  • 2023-01-31 CA199 6.64 U/mL

  • 2023-01-17 CA199 6.84 U/mL

  • 2023-01-03 CA199 7.19 U/mL

2023-08-30

The patient primarily receives medical care at Cardinal Tien Hospital. On 2023-08-28, refills were obtained for medications including metformin, pioglitazone, canagliflozin, bisoprolol, lercanidipine, irbesartan, rosuvastatin, and alprazolam. These drugs are mainly for the treatment of Type 2 Diabetes Mellitus and hypertension. As of now, these medications are accounted for in the active medication list and no discrepancies have been identified.

2022-07-22

  • Irinotecan has been titrated up from an initial 2/3 recommended dose to its current recommended dose with normal liver function lab results as of 2022-07-21.
  • It has been found that patients taking canagliflozin are more likely to develop genitourinary fungal infections (females: 11% to 12%; males: 4%), and those who do develop such infections are more likely to suffer recurrences. Additionally, pioglitazone has been associated with upper respiratory tract infections. Infection signs should be monitored as usual.

2022-04-01

  • a patient diagnosed with sigmoid colon cancer s/p stent placement and liver mets transferred from Cardinal Tien Hospital on 2022-01-19 and start receiving FOLFIRI since 2021-01-24 (plus panitumumab since 2022-03-23).
  • lab data reported on 2022-02-18 revealed that RAS and BRAF were both wild type and that no EGFR mutations were found. pathology results on 2022-01-20 indicated pMMR and EGFR(+). the patient is receiving appropriate treatment with no issues currently.

700852752

240124

[exam findings]

  • 2023-12-25 CXR
    • multifocal areas of consolidation and ground-glass opacities
    • in both lungs, upper lung predominance
  • 2023-11-28 SONO - abdomen
    • right neck tumor, r/o lymphadenitis
    • local cellulitis
  • 2023-10-02 Patho - esophageal biopsy
    • Labeled as “middle esophagus”, biopsy — benign squamous mucosa.
    • PAS stain highlights abundant colonies of candida species.
  • 2023-10-02 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A
      • R/O Esophageal candidiasis, s/p biopsy
      • Superficial gastritis with erosions, s/p CLO
      • Gastric fundic gland polyps
      • Duodenitis
    • CLO test: Negative
    • Suggestion:
      • PPI therapy
      • Pursue CLO and pathology result
  • 2023-09-08 CXR erect
    • Faint aveolar opacity over RIGHT MIDDLE LOBE is found.
    • Aonther opacity over left central lung is found.
  • 2023-08-24 CT - chest
    • Impression
      • bilateral lung infection, most severe in RML with areas of necrosis and parapneumonic effusion.
      • extensive 3V-CAD. Calcified AV with stenosis and LVD.
  • 2023-08-24 SONO - chest
    • Echo diagnosis: pleural effusion
    • Chest echography was performed first. The suitable intercostal space was selected and located. Catheter was inserted with negative pressure smoothly. Right side pleural effusion was drawn smoothly. Watch out BP after tapping.
    • Suggestion:
      • check BP and taking rest after tapping.
      • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
  • 2023-08-18 SONO - chest
    • Echo diagnosis: right side minimal amount of pleural effusion, 450cc serosangious fluid was aspirated for analysis.
  • 2023-06-21 Nasopharyngoscopy
    • Findings: smooth np, larynx and hp
    • Diagnosis: lt deep neck infection s/p IV ABX
  • 2023-06-14 CT - neck
    • Indication: r/o deep neck infection
    • Without-contrast Ct scan of head and neck region with 3-mm axial, sagittal and coronal images reveals:
      • Enlargement of left palatine tonsil and thickening of left oropharyngeal and hypopharyngeal wall.
      • Multiple lymph nodes at both side of the neck, more prominent on left side with the largest one about 18 mm at left level II.
      • Extensive severe beam-hardening artifacts over oral cavity.
    • IMP:
      • Enlargement of left palatine tonsil and thickening of left oropharyngeal and hypopharyngeal wall, associating with enlarged lymph nodes at left neck.
      • D/D: tonsilitis, malignancy.
  • 2023-06-12 Nasopharyngoscopy
    • Scope: smooth NPx, larynx, hypopharynx
    • adequate airway curently
    • left tongue base, lateral pharyngeal wall, post. pharyngeal wall bulging with pus coating
  • 2023-05-09 CT - brain
    • No brain lesion.
    • Intracranial ICAs atherosclerosis.
    • Age-appropriate cerebral atrophy.
  • 2023-04-13 CT - abdomen
    • History and indication: Pancytopenia
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy.
      • Bil. minimal pleural effusions.
      • Tiny liver and renal cysts.
      • Mild hyperplasia of left adrenal gland.
      • Wall edema of gallbladder.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • S/P hysterectomy.
      • Bil. minimal pleural effusions.
  • 2023-04-12 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with myelodysplastic syndrome with excess blasts-1
    • The sections show hypercellular marrow (70%). M/E ratio = 1:2 in CD71 and MPO stains. The erythoid precursors are marked increased, dispersed and scattered. The megakaryocytes are normal in number, and few micromegakaryocytes are present. Increased CD34+ and/or CD117+ immature cells, account for 5-10% of nucleated cells. No metastatic carcinoma can be identified in CK stain. The finding is compatible with myelodysplastic syndrome with excess blasts-1. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2023-04-11 EGD
    • Diagnosis:
      • Reflux esophagitis, Gr A
      • Superficial gastritis, antrum
    • CLO test: not done
    • Suggestion:
      • Medication and OPD f/u
      • Colon scope may be planned for GI bleeding and anemia survey
      • EGD was suggested annually for GERD f/u
  • 2023-01-02 SONO - abdomen
    • Impression:
      • Fatty liver.
      • Right renal stone.

[MedRec]

  • 2023-07-23 ~ 2023-08-02 POMR Hemato-Oncology Gao WeiYao
    • Present illness
      • This time, she has dizziness without SOB or dyspnea for 3 days. She was admitted for chemotherapy and blood transfusion on 2023/07/23.
    • Course of inpatient treatment
      • After admission, she received blood transfusion for anemia and thrombocytopenia correct. Chemo as C2 Dacogen since 7/24-7/28.
      • Fever was noted under neutropenic stage, antibiotic treatment for infection control, but no evidence of bacteremia. U/C mix growth without dysuria.
      • Under the stable condition, she can be discharged on 2023/08/02. OPD follow up is arranged.
    • Discharge prescription
      • Allegra (fexofenadine 60mg) 1# BID
      • Ceficin (cefixime 100mg) 2# Q12H
  • 2023-06-24 ~ 2023-07-05 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Acute tonsillitis, unspecified
      • myelodysplastic syndrome with excess blasts-1
      • Oral mucositis (ulcerative), unspecified
      • Periapical abscess without sinus
    • CC
      • fever, sore throat and cough for 2~3 days
    • Present illness
      • She received target chemotherapy with cycle 1 Decitabine since 2023/05/16 to 05/20.
      • Last hospitalization during 2023/06/11 to 2023/06/19 because of sore throat under the diagnosis of acute pharyngitis/tonsillitis, suspected deep neck infection, she received antibiotics treatment.
      • This time, she presented fever, sore throat and cough for 2~3 days. She visited to ENT for follow up with nasopharyngoscopy showed left deep neck infection.
      • Poor intake and generalized malaise developed, she visited to our ER. The laboratory disclosed pancytopenia and elevated CRP. CxR revealed clear bilateral costophrenic angles. Physical examination showed left tonsil, mild enlarged and redness and left upper neck swelling. Empirical antibiotics with Tapimycin was prescribed.
      • Under the tentative diagnosis of myelodysplastic syndrome with excess blasts-1 and left deep neck infection, she was admitted on 2023-06-24.
    • Course of inpatient treatment
      • After admission, tapimycin 4.5gm Q6H for tonsilitis.
      • Panadol was given for fever control.
      • On 2023/06/26, her fever subsided and sore throat was improved.
      • On 2023/06/27, we consult oral surgeon for further evaluation and 1. Oral ulcer of tooth 24 palatal side due to low immunity and 2. Apical abcess of tooth 26 noted.
      • Mycostatin 5cc QID + nincort were given.
      • Now, we keep complete IV tapimycin and will follow lab data later.
      • In addition, due to MDS with anemia and thrombocytopenia, we give blood transfusion for sdupportive care.
      • Under relative stable condition, she was discharge with OPD follow up.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
      • Mycostatin oral suspension (nystatin 0.1MU/mL) 5mL QID
      • Through (sennoside 12mg) 2# HS
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# Q12H
      • Bisadyl supp (bisacodyl 10mg/pill) 2# PRNHS RECT for constipation
      • Nincord Oral Gel (triamcinolone 1mg/gm) BID TOPI
      • Ceficin (cefixime 100mg) 2# Q12H
  • 2023-06-11 ~ 2023-06-19 POMR Hemato-Oncology Gao WeiYao
    • CC
      • for planned target therapy schedule.
    • Present illness
      • She received target therapy with cycle 1 Decitabine since 2023/05/16 to 05/20. After the last chemotherapy, she complained sore throat, poor appetite, weakness, and weigh two kilograms less, no fever or chills, no cough or sputum, no dyspnea, no nausea or vomit, no diarrhea.
      • This time, she is admiited to our Hematology Oncology ward for planned target therapy schedule.
    • Course of inpatient treatment
      • After admission, she complained sore throat. Comfflam was prescribed for her sore throat.
      • ENT was consulted. Acute pharyngitis/tonsillitis, deep neck infection can’t be ruled out. Neck CT was arranged on 06/14.
      • Infx was also consulted. tapimycin 4.5g Q6H was used for her acute pharyngitis/tonsillitis.
      • She had no fever. Neck CT (2023/06/14): Enlargement of left palatine tonsil and thickening of left oropharyngeal and hypopharyngeal wall, associating with enlarged lymph nodes at left neck. D/D: tonsilitis, malignancy. Nasopharyngoscopy showed left tongue base, lateral pharyngeal wall, post. pharyngeal wall bulging with pus coating.    
      • On 2023/06/15, her sore throat improved.
      • On 2023/06/19, skin rash on her left elbow improved.
      • Under stable condtion, she was discharged with Oncology and ENT OPD follow up.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# Q6H
      • Mycostatin oral suspension (nystatin 0.1MU/mL) 5mL QID
      • Through (sennoside 12mg) 2# HS
      • Bisadyl supp (bisacodyl 10mg/pill) 2# PRNHS RECT if no stool passage for 3 days
      • Ceficin (cefixime 100mg) 2# Q12H
      • Rivotril (clonazepam 0.5mg) 1# QD
      • Rivotril (clonazepam 0.5mg) 0.5# HS
      • Seroxat (paroxetine 20mg) 0.5# QD
      • Seroxat (paroxetine 20mg) 1# HS
  • 2023-05-12 ~ 2023-05-20 POMR Hemato-Oncology Gao WeiYao
    • discharge diagnosis
      • myelodysplastic syndrome with excess blasts-1
      • Abnormal weight loss
    • CC
      • for first decitabine
    • Present illness
      • Under the impression of Compatible with myelodysplastic syndrome with excess blasts-1, so she was admitted for first decitabine on 2023/05/12.
    • Course of inpatient treatment
      • After admission, she received Target therapy as Decitibine 20mg/m2 IVD 1hr since 5/16-5/20.
      • Promeran 3.84mg/tab 1# tidac and monitor GI tract problem.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Through (sennoside 12mg) 2# HS
  • 2023-04-10 ~ 2023-04-13 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • myelodysplastic syndrome with excess blasts-1
    • CC
      • Tarry stool for 1 week
    • Present illness
      • This is a 73-year-old female with past history of
        • hyperlipidemia
        • gastric ulcer s/p treatment on 2018/12
        • right invasive ductal carcinoma, grade I, ER+, PR-, Her2-, p53-, Ki67 5%, pT1bN0M0; pStage: IA, s/p partial mastectomy
        • uterine myoma s/p ATH.
      • This time, she suffered from tarry stool for 1 week.
      • She has suffered from chronic constipation for 6 months, 2-3 days of no stool passage would be followed by abdominal cramping pain and yellow-brownish diarrhea. The symptoms exacerabated since 2023/02, accompanied with decrease of appetite and general malaise. She went to Taipei city hospital HePing Branch for help on 2023/03 and colonoscopy was done and showed negative finding. According to the patient, diffuse abdominal pain especially at RLQ became more frequently since colonoscopy.
      • Last week she suffered from watery diarrhea for 3-6 times/day for 3 days. Thus, she went to a clinic for help. On 2023/04/09. she started to have watery tarry stool. There were 5 times of watery tarry stool passage in this 2 days. She also noticed body weight decrease for 4kg in 2 months. Thus, she went to the same clinic for help. Blood test was done and Hb 5.8mg/dL was found. Thus, she was refered to our hospital for help.
      • She went to Dr Gao’s OPD and was refered to ER for transfusion and arranged admission. At ER, vital signs was stable, with BP: 148/65mmHg, HR: 91bpm, BT: 36.6’C, RR:18bpm, Con’s:E4V5M6, SpO2:100%. Lab showed Hb 5.7mg/dL. 2 U of pRBC was tranfused and pantoprazole 40mg were first given. Afterwards, she was admitted to hemotology ward for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, 2U LPRBC was tranfused on 2023/04/11. EGD done on 2023/04/11 showed Reflux esophagitis, Gr A. Superficial gastritis, antrum. Therefore, we will try soft diet from 2023/04/12.
      • Due to CBC showed blast 13.9%., bone marrow biopsy (with chromosome) with peripheral smear was done on 2023/04/12. Peripheral smear showed hypercellular bone marrow with marked increase of erythroid lineage, and decreased M/E ratio. Furthermore, plasma cell markedly increased under microscopic high power field. Therefore, multiple myeloma lab profile was drawn, with results pending.
      • Due to blood-tinged stool noted on 2023/04/12 midnight, abdominal CT with contrast was done on 2023/04/13 which showed no structural lesion at small or large intestine.
      • Due to stable condition, the patient was discharged on 2023/04/13. Regular OPd f/u was arranged on 2023/04/18.
    • Discharge prescription
      • Nincort Oral Gel (triamcinolone 1mg/gm) BID TOPI
      • Through (sennoside 12mg) 1# PRNHS if no stool
      • Transamin (tranexamic acid 250mg) 1# PRNBID if bolldy stool

[consultation]

  • 2024-01-19 Chest Medicine
    • Q
      • The 73 y/o woman has myelodysplastic syndrome with excess blasts-1. Due to frequency pneumonia over upper both lung, so we need your help for management. Thanks!
    • A
      • HX, PE, CXR review, pt is a case of myelodprofierative disorder, preleukemia stage with excess blasts-1, with frequency pneumonia
      • Suggest
        • sputum TB work up
        • check cryptococcus and aspergillus ag when next blood test
        • RX underlying condtion myelodprofierative disorder, preleukemia stage
        • best supportive carenutrtion, nutrition, I/O, electrolyte balance
        • add on amikin inhale
        • follow up lab, image and bacteria days later after work up and adjust antibiotics regimen
  • 2023-11-09 Dermatology
    • Q
      • The 73 y/o woman has MDS under chemotherapy and blood transfusion. Her general skin rashes and itchy, so we need your help for management. Thanks!
    • A
      • Under the impression of blood tranfusion-related gernalized allergy reaciton. notice antibiotics ie Tapimycin association.
      • The following sugestion:
        • consider Vena 1 Amp and Deca 1 Amp Ivdrip before the following blood transfusion (prevention)
          • shift another type of antibiotic use as your experists.
        • adequent systemic medication use now.
        • If lesions progressive, consider elevate Vena dosage to 1 Amp Q8H use and regular sytemic steroid ie compresolone 2# QD to Bid po use.
        • Topysm cream (fluocinonide) 2 tube topical bid use over reddish lesions.
  • 2023-09-01 Dermatology
    • Q
      • The 73 y/o woman has MDS with pancytopenia. This time, she has pneumonia over right lower lung. Due to oral candiads, we gave Flu-D for treatment, but skin rash is noted since 8/31 night. We hold it and gave antihistamin since 8/31 night, but in vain. We need your help for management. Thanks!
    • A
      • This patient suffered from generalized erytehamtous papules-plaques on trunk for days.
      • Imp: Subacute dermatitis
      • Suggestion:
        • dexamethasone *1 / Qd
        • Zaditen (ketotifen) 1 /Bid
        • Mycomb (nystatin, triamcinolone, neomycin, gramicidin) *10 tubes/bid
  • 2023-08-24 Chest Medicine
    • Q
      • The 73 y/o woman has MDS under aggessive care. Due to fever and right lung pneumonia, so she was admitted. Her fever without control, chest CT was done this morning. We need your help for bilateral pneumonia management.
    • A
      • O
        • 20230823 CT of chest
          • RML lobar consolidation with air-bronchograms with areas of poor enhancement. dependent band subsegmental atelectasis at both lower lobe.
          • extensive consolidation with surrounding ground glass opacity over superior lingular and apicoposterior segment of LUL.
          • patchy consolidation and ground glass opacities at RUL.
          • airspace nodular opacities in LLL and LUL too.
        • Lab
          • 2023-08-22 WBC 1.28 x10^3/uL
          • 2023-08-22 HGB 9.3 g/dL
          • 2023-08-22 PLT 77 *10^3/uL
          • 2023-08-22 Neutrophil 1.3 %
          • 2023-08-22 Lymphocyte 80.3 %
          • 2023-08-22 Monocyte 0.6 %
        • 20230820 sputum culture: MNF.
      • Impression:
        • Lobar Pneumonia, RML.
        • Pneumonia, LUL (apicopost. segment), left lingula. RUL.
      • Suggestion:
        • AFB and TB/C of sputum: 3 sets in the morning (risk of pulmonary tuberculosis), possible TB PCR of sputum if positive
          • Suggest chest tapping again for culture, right side pleural effusion. (20230824 afternoon: safty completed)
        • Sputum culture, mycoplasma and chlamydia IgM of blood, Streptococcus pneumonia and legionella Ag in urine.
        • PJP PCR of sputum, CMV DNA (NHI)and IgM in blood, Cryptococcus Ag in blood, Aspergillus Ag in blood.
        • Empiric antibiotics first and guided by subsequent culture results.
  • 2023-08-15 Infectious Disease
    • A
      • Consultation for Mepem antibiotic
        • 73-year-old MDS with leukemic transformation female patient suffers from neutropenic fever and right lung pneumonia.
        • White count only 1020, with ANC only 35.
        • Tapimycin is replaced by Mepem this afternoon.
      • Suggestion:
        • Continue Mepem for one week first
        • Add Targocid for possible MRSA coverage, Targocid 600mg iv q12h for 3 doses till 9AM, 2023/08/16, then 500mg iv qd since 2023/08/17.
        • Check blood and sputum culture report.
  • 2023-06-27 Oral and Maxillofacial Surgery
    • Q
      • For gum pain
      • This 73 years old woman is a patient of myelodysplastic syndrome with excess blasts-1 s/p Target therapy as Decitibine 20mg/m2 IVD 1hr since 5/16-5/20, past history of
        • ptosis of eyelid,
        • hyperlipidemia,
        • gastric ulcer,
        • right invasive ductal carcinoma s/p right partial mastectomy (grade I, ER+, PR-, Her2-, p53-, Ki67 5%, pT1bN0M0; pStage: IA)
        • uterine myoma s/p abdominal total hysterectom
      • this time was admitted to our ward for acute-tonsilitis.
      • Now her tonsilitis improved with no fever.
      • She complainted about pain in the upper left gums for about 6 days.
      • We need your expertise for evaluation of gum pain, thank you!
    • A
      • This is a 73-year-old woman with pain over her upper left gingiva for 6 days.
      • O:
        • A white patch with ulcerative surface over upper right gingiva near the palatal side of tooth 24, palpation pain was noted.
        • Mild swelling over her upper left posterior gingiva near the buccal side of tooth 26, percussion pain of tooth 26 was noted.
      • A:
        • Oral ulcer of tooth 24 palatal side due to low immunity
        • Apical abcess of tooth 26
      • P:
        • Physical exam
        • Keep observation of the oral ulcer, please contact us after her ANC raise to normal level.
  • 2023-06-13 Infectious Disease
    • Q
      • For antiobiotics of acute pharyngitis/tonsillitis, ENT suggested consulting for ABX
      • This 73 years old woman is a patient of compatible with myelodysplastic syndrome with excess blasts-1, and past history of ptosis of eyelid, hyperlipidemia, gastric ulcer, right invasive ductal carcinoma s/p right partial mastectomy (grade I, ER+, PR-, Her2-, p53-, Ki67 5%, pT1bN0M0; pStage: IA), and uterine myoma s/p abdominal total hysterectomy.
      • She received target therapy with cycle 1 Decitabine since 2023/05/16 to 05/20.
      • This time, she is admiited to our Hematology Oncology ward for planned target therapy schedule.  
      • sore throat with dysphagia for since 5/16 after target therapy, left more severe
      • odynophagia+, fever-, WBC:2l, CRP:2.1
      • We consulted ENT for acute pharyngitis/tonsillitis, Abx was suggested.
      • We need your expertise for antiobiotics of acute pharyngitis/tonsillitis, thank you!
    • A
      • The patient’s conditin as your description.
      • Tapimycin 4.5g iv q8h is suggested for the acute pharyngitis/tonsillitis.
      • Please arrange neck CT to exclude deep neck infection.
      • Please collect adequte culture.
  • 2023-06-12 Ear Nose Throat
    • Q
      • For evaluation of dysphagia after first dose of target therapy, cycle 1 Decitabine since 2023/05/16 to 05/20
      • This 73 years old woman is a patient of compatible with myelodysplastic syndrome with excess blasts-1, and past history of ptosis of eyelid, hyperlipidemia, gastric ulcer, right invasive ductal carcinoma s/p right partial mastectomy (grade I, ER+, PR-, Her2-, p53-, Ki67 5%, pT1bN0M0; pStage: IA), and uterine myoma s/p abdominal total hysterectomy.
      • She received target therapy with cycle 1 Decitabine since 2023/05/16 to 05/20.
      • After last chemotherapy, she complained dysphagia, sore throat and cough. No fever.
      • This time, she is admiited to our Hematology Oncology ward for planned target therapy schedule.  
      • We need your expertise for evaluation of dysphagia before second target therapy, thank you!
    • A
      • S:
        • sore throat with dysphagia for since 5/16 after target therapy, left more severe
        • odynophagia+, fever-, dyspnea-
        • Allergy: denied
      • O:
        • Oral cavity and oropharynx: left post. pharyngeal wall bulging
        • no uvula deviation
        • Scope: smooth NPx, larynx, hypopharynx
          • adequate airway curently
          • left tongue base, lateral pharyngeal wall, post. pharyngeal wall bulging with pus coating
        • left upper neck tenderness
      • A: acute pharyngitis/tonsillitis, deep neck infection can’t be ruled out
      • Plan:
        • After discussing with Dr. Lan
          • Consult infection for IV antibiotic suggestion (stronger is favored)
          • suggest hold target/chemo therapy, infection control first
          • Pain control
          • self-paid Difflam spray and parmason for oral hygiene if the patient agreed
          • Instruct the patient to rinse her mouth after meals and avoid eating hot and spicy foods.
          • Monitor airway, well educated about airway issue
          • check infection profile
          • if s/s still progressed after antibiotic Tx, consider CT with/without contrast exam if no contraindication to rule out deep neck infection/mediastinitis
          • ENT OPD f/u
        • neck CT (without contrast CT): no obvious abscess formation, left pharyngeal wall swelling with enlarged LNs
        • leading Dx: infection with reactive LN
        • DDx: malignancy can’t be ruled out, lymphoma……..
        • please keep IV anti for 2 weeks
        • if s/s no improvement, suggest left tonsillectomy to rule out malignancy

[chemotherapy]

  • 2023-11-02 - decitabine 20mg/m2 21mg NS 100mL 1hr D1-5
  • 2023-07-24 - decitabine 20mg/m2 31mg NS 100mL 1hr D1-5
  • 2023-05-16 - decitabine 20mg/m2 32mg NS 100mL 1hr D1-5

==========

2024-01-24

[addressing hemoptysis with inhaled tranexamic acid]

Today’s progress note indicated that the patient experienced a mild episode of coughing up blood last night. Should the hemoptysis persist, the use of inhaled tranexamic acid (500mg/5mL, up to five days) has been reported to effectively reduce the volume of hemoptysis, expedite its resolution, and potentially shorten the duration of hospitalization.

Ref: - Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018;154(6):1379. - Nebulized tranexamic acid for recurring hemoptysis in critically ill patients: case series. Int J Emerg Med. 2020;13(1):45.

2023-07-05

  • I visited the patient around 11:15 on 2023-07-05 carrying the decitabine medication usage information. The patient was lying in bed and her awake husband was sitting in the bench by the window.

  • I first asked the patient’s husband how the patient’s recent condition was and whether the discomfort in the mouth had worsened or improved? The husband said that the patient is currently using the oral paste prescribed by the doctor, and the condition is manageable. He also asked if the infection was caused by the use of decitabine. I responded that since April, the patient’s white blood cell count has consistently remained around 2000 +- 500, and there was no significant fluctuation due to the administration of decitabine in mid-May. Although the effect of decitabine on white blood cells can’t be entirely ruled out, it does not seem to be the primary cause based on the observations.

701007202

240124

[exam findings]

2024-01-23 lab data showed both DGH and Toxin A/B positive.

==========

2024-01-24

[TDM scheduling for optimized vancomycin treatment in CDI]

Lab data from 2024-01-23 confirmed positivity for both DGH and Toxin A/B.

For patients with severe or fulminant C. difficile infection, an initial oral dose of vancomycin can be 10 mg/kg, administered four times daily for 10 days, with a maximum dose of 500 mg per administration. In critically ill patients, the addition of intravenous metronidazole may be considered.

This patient exhibits impaired renal function as evidenced with an eGFR of 21 mL/min/1.73m², an elevated serum creatinine (2.94 mg/dL) and blood urea nitrogen (BUN) (31 mg/dL) on 2024-01-24. While the vancomycin manufacturer’s labeling lacks specific dosage adjustments for this degree of renal impairment, the low systemic absorption of vancomycin suggests dose modification may not be necessary.

Oral vancomycin 500mg QID has just been prescribed from 2024-01-23 for a duration of seven days, adhering to standard usage. Therapeutic drug monitoring (TDM) is recommended to be scheduled on day 3, specifically on 2024-01-26, with a blood sample to be drawn within 30 min before the next dose.

Ref: Does oral vancomycin use necessitate therapeutic drug monitoring? Infection. 2020 Apr;48(2):173-182. doi: 10.1007/s15010-019-01374-7.

701492978

240124

[exam findings]

  • 2023-12-15 SONO - breast
    • Diagnosis
      • Bil. fibroadenomas as described
      • Right breast cancer (#2)
    • Treatment
      • explain the finding
    • Suggestion and Plan
      • further treatment
    • BI-RADS: 6. known biopsy-proven malignancy
  • 2023-12-01 CT - chest
    • Indication: Malignant neoplasm of unspecified site of right female breast
    • Chest CT with and without IV contrast ehnancement shows:
      • Residual soft tissue lesion at right outer breast with minimal enhancement is found. In comparison with CT dated on 2023-08-16, the lesion regressed. However, one nodular lesion at left breast just below nipple is found. Suggest correlate with breast echo. (Se401 Im29).
    • Imp:
      • Right breast cancer s/p C/T with regression of main mass and shringkage of right axillary lymphadenopathy.
      • Left breast nodule. Suggest correlate with breast echo.
  • 2023-09-08 Doppler color flow mapping
    • LVEF = (LVEDV - LVESV) / LVEDV = (92.0 - 27.5) / 92.0 = 70.11%
      • M-mode (Teichholz) = 75.4-70.1
      • 2D (M-Simpson) = 73
    • Conclusion:
      • Normal AV/MV with no AR/<R
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • No PR, no TR, normal IVC size
  • 2023-08-17 Tc-99m MDP bone scan
    • Increased activity in the lower T-spine and L5 spine. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Some faint hot spots in the sternum and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips, knees and feet, compatible with benign joint lesions.
  • 2023-08-16 CT - chest
    • Indication: breast cancer
    • Findings:
      • Chest wall and visible lower neck:
        • multiple discrete enlarged LNs at Rt deep axilla.
        • ill-defined enhancing tumor at Rt breast upper outer quadrant.
      • Visible abdominal contents:
        • several small gall bladder stones.
        • several hepatic cysts measuring up to 21mm. suspect minimal retrouterine space ascites.
      • Visualized bones:
        • marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • Rt breast cancer T1or T3?N1Mx.
  • 2023-08-07 Patho - breast biopsy (no need margin)
    • Breast, right, core needle biopsy — Invasive carcinoma of no special type
    • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in solid to ductal architecture and stromal fibrosis with lymphocytic infiltrate. The neoplastic cells have hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic activity.
    • Immunohistochemical study demonstrates:
      • ER: negative
      • PR: negative
      • Her2/neu: positive (3+)
      • Ki-67 inedex: 40%
      • E-cadherin: positive
      • p63: negative
  • 2023-08-07 Patho - lymphnode biopsy
    • Lymph node, right axillary, CT guide buiosy — Inasive carcinoma, metastatic
    • Microscopically, it shows presence of nests of invasive carcinoma with syromal fibrosis and lymphocytic infiltrate.
  • 2023-08-04 SONO - breast
    • CC and Indication
      • Breast lumps
    • History
      • No specific risk factors
    • Findings
      • Parenchymal pattem: Loosely (inhomogeneously) sonodense
      • Focal sonographic lesion: Yes
        • Location: Right 9.5 o’clock / 5 cm
        • Size: 2.35 x 2.20 x 2.52 cm
        • Margins : Sharp, jagged
        • Shape: Irregular
        • Orientation: Not parallel
        • Axillary lymph node: Yes
        • Vascularity: Present immediately adjacent to lesion
        • Echogenicity: hypoechoic
        • Internal echo pattern: nonhomogeneous
    • Diagnosis
      • Highly suspicious of malignancy,with sonographic positive axillary LAP
    • Treatment
      • Core-needle biopsy
    • Suggestion
      • Regular OPD follow-up
    • BI-RADS:
      • 4C-moderate concern, but not classic for malignancy Biopsy Should Be Considered

[MedRec]

  • 2023-09-07 ~ 2023-09-13 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Right breast cancer, ER(-), PR(-), HER-2 type, cT1N1M0, stage IB s/p Adjuvant chemotherapy with TCHP from 2023/09/12~
      • Hypokalemia
      • Insomnia, unspecified
    • CC
      • For prepare adjuvant chemotherapy with TCHP (C1).
    • Present illness
      • This 47-year-old woman patient suffered from right breast lump was noted without nipple discharge in 2023/07.
      • Breast sono on 2023/08/04 showed right 9.5/5 irregular shape tumor, 2.35x2.20x2.52cm, LAP(+). Right axillary lymph node SONO guide biosy on 2023/08/07 showed inasive carcinoma, metastatic.
      • Right breast core needle SONO guide biopsy on 2023/08/07 showed invasive carcinoma of no special type, Immunohistochemical study demonstrates: (1) ER: negative (2) PR: negative (3) Her2/neu: positive(3+) (4) Ki-67 inedex: 40% (5) E-cadherin: positive (6) p63: negative.
      • Chest CT on 2023/08/16 showed right breast cancer, T1 or T3?N1Mx.
      • Whole body bone scan on 2023/08/17 showed no bone metastasis. Port-A catheter implantation on 2023/08/23.
      • Explain her condition and chemotherapy with TCHP * 6 or AC * 4 -> TPH to patient and her family on 2023/08/29 with TCHP * 6 -> favored by patient.
      • Now, she was admitted to ward for adjuvant chemotherapy with TCHP (Taxotere 60mg/m2, Carboplatin AUC:4, Herceptin (self pay) 600mg SC, Pertuzumab (self pay) 840mg -> hereafter 420mg) (C1).
    • Course of inpatient treatment
      • After admitted, 2D echo on 2023/09/08 showed M-mode (Teichholz) = 75.4-70.1; 1. Normal AV/MV with no AR/<R; 2. Normal LV chamber size and wall thickness; 3. Preserved LV and RV systolic function; 4. No PR, no TR, normal IVC size.
      • Applying Major Illness on 2023/09/12.
      • Dorsion 1# po BID and Cimetidine 1# po BID on D1~D3 from 2023/09/11~2023/09/13.
      • Adjuvant chemotherapy with TCHP (Taxotere 60mg/m2, Carboplatin AUC:4, Herceptin (self pay) 600mg SC, Pertuzuman (self pay) 840mg -> hereafter 420mg) (C1) on 2023/09/12.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
      • Hypokalemia (K:3.0mmol/L) with 0.298% KCl in NS 500ml IVF BID from 2023/09/08~2023/09/11.
      • Insomnia with Xanax 1# po PRNHS.
      • Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, she was discharged on 2023/09/13 and OPD followed up later.        
    • Discharge prescription
      • Limeson (dexamethasone 4mg) 1# BID
      • Alpraline (alprazolam 0.5mg) 1# PRNHS
      • Stogamet (cimetidine 300mg) 1# BID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
  • 2023-08-29 SOAP Hemato-Oncology Xia HeXiong
    • A: right breast cancer, HER-2 type, cT1N1M0
    • P: Already suggeset
      • TCHP * 6 -> favored by patient
      • AC * 4 -> TPH

[immunochemotherapy]

  • 2024-01-24 - docetaxel 60mg/m2 100mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 100mL 1hr (TCHP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-30 - docetaxel 60mg/m2 100mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 100mL 1hr (TCHP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-01 - docetaxel 60mg/m2 100mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 100mL 1hr (TCHP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-02 - docetaxel 60mg/m2 100mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 100mL 1hr (TCHP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-10-12 - docetaxel 60mg/m2 100mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 100mL 1hr (TCHP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-09-12 - docetaxel 60mg/m2 100mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr + trastuzumab 600mg SC 2min + pertuzumab 840mg NS 100mL 1hr (TCHP, pertuzumab loading)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-01-24

Apart from a mild case of hypokalemia (3.3mmol/L), the lab results from 2024-01-23 were largely normal. The decision to use oral potassium supplements can be based on clinical assessment and necessity.

The planned 6 cycles of TCHP therapy will be completed during this hospitalization. Subsequent treatment plans and follow-up schedules might be discussed with the patient to achieve a consensus through shared decision making. (The CT scan on 2023-12-01 revealed regression of the lesion in the right breast and the emergence of a new nodular lesion in the left breast.)

2023-11-02

Lab results from 2023-11-01 showed normal values for CBC, WBC-DC, electrolytes, and liver and kidney function tests.

No moderate or severe treatment related adverse events have been documented. As a result, the 3rd cycle of the docetaxel, carboplatin, trastuzumab and pertuzumab chemotherapy regimen was administered on 2023-11-02 without any complications to date.

2023-10-12

Review of PharmaCloud and HIS5 records revealed no medication reconciliation issues.

701497658

240124

[exam findings] (not completed)

  • 2023-10-07 CT - brain
    • Brain metastasis
    • Ventriculomegaly
    • Minimal midline shift
  • 2023-09-27 EGFR mutation
    • Cellblock No. S2023-19306
    • RESULTS
      • No mutation was detected at exons 18,19,20,21 of EGFR gene in this specimen.
  • 2023-09-27 PD-L1 (22C3)
    • Cellblock No. S2023-19306
    • RESULTS
      • Tumor Proportion Score (TPS) assessment: TPS >= 1% and <50%
      • Tumor Proportion Score (TPS): 2%
  • 2023-09-26 Patho - lung transbronchial biopsy
    • Lung, RUL, CT-guide biopsy—adenocarcinoma, moderately differentiated
    • Sections show acinar glandular cells and solid tumor nests infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal CK7(+), CK20(-), TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.
  • 2023-09-26 ECG
    • This is an abnormal EEG suggesting right central focal moderate to severe epileptogenic activities.
    • Background: theta 7-8 Hz
    • continuous focal sharp and spiky waves over right central area
    • Advise AEDs used
    • Please correlate clinically.
  • 2023-09-26 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (96 - 24) / 96 = 75.00%
      • LVEF (%) = 75
      • M-mode (Teichholz) = 75
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH; LV diastolic dysfunction Gr 3 (restrictive pattern).
      • Normal RV systolic function.
      • Mild MR; mild TR; mild PR; aortic valve sclerosis.
      • Possible mild pulmonary hypertension, estimated PASP: 41 mmHg.
  • 2023-09-18 EEG
    • This EEG featured nearly continuous periodic spikes or spike-and-wave complexes in right hemisphere with phase reversals at P4 and T6, and with occasional spreading to the left side. The background activity were composed by rare alpha rhythm at 8-9 Hz, 20-40 uV in left posterior head area and beta rhythm at 13-15 Hz,10-20 uV in left anterior head area.
    • This EEG suggests periodic lateralized epileptiform discharges in right hemisphere. Advise clinical correlation and adjustment of anti-epileptic drugs.
    • Conclusion: Abnormal EEG.
  • 2023-09-15 CT - brain for navigator
    • Findings
      • Several intra-axial enhancing tumors associating with extensive perifocal edema involving right frontal lobe, bilateral temporal lobes, right basal ganglion and vermis, with the largest one about 32 mm in right temporal lobe, Metastases are first considered.
      • No bony abnormality.
    • IMP:
      • Multiple brain metastases.
  • 2023-09-15 CT - brain
    • Findings
      • decreased Intraventricular and extraventricular CSF spaces, more on the right side; 7.5mm midline shift to the left side
      • multiple brain tumors in the bilateral supratentorial brain and the verebellar vermis, more on the right side with severe perifocal edema in the right basal ganglion, right thalamus, right temporal lobe and right parietal lobe.
      • unremarkable change in the skull base
      • low density change in the right pons. r/o recent infarction.
    • IMP:
      • multiple brain metastais with 7.5mm midlins shift to the left side.
      • low density change in the right pons. r/o recent infarction.
  • 2023-09-13 CT - chest
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:M1c(M_value) STAGE:____(Stage_value)
    • Findings
      • lungs: a spiculated tumor with pleural tails over RUL (24mm) consistent with a primary lung cancer.
        • additional small nodules in both lungs.
        • moderate, bilateral, upper lobes predominant, centrilobular emphysema, in lungs.
        • substantial subpleural paraseptal emphysema in upper lobes.
      • Mediastinum and hila: metastatic lymphadenopathy in both sides of the visceral space.
      • Thoracic aorta: normal caliber, mild atherosclerotic change.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal size of cardiac chambers.
      • Pleura: minimal Rt-sided effusion.
      • Chest wall and visible lower neck: small LN at Rt supraclavicular fossa.
      • Visible abdominal-pelvic contents:
        • multiple small bilateral renal cysts.
        • numerous hepatic cysts measuring up to 11.2cm.
        • unremarkable of the GB, spleen, both adrenal glands, pancreas
      • Visualized bones: unremarkable.
    • Impression:
      • RUL cancer T4N3M1c(E1)
  • 2023-09-12 MRA - brain
    • Findings:
      • Several enhancing mass lesions over both temporal lobes, left thalamus, the cerebellar vermis and right corona radiata. The largest one (3.4cm) at right temporal lobe with prominent peritumoral edema. Favor metastatic lesions.
      • Compressed right lateral ventricle.
      • MR angiography of the brain shows normal intracranial vessel including circle of willis.
      • Suspect one acute ischemic lacuna infarct or tiny metastasis over right cerebellar lobe.
  • 2023-09-12 CT - brain
    • Focal hyperdense mass-like lesion over right temporal lobe. Prominent subcortical edema over right fronto-temporal lobes. Suggest check enhanced MRI to rule out occult tumor.
    • Compressed right lateral ventricle.
    • R/O minimal acute SAH over right pre-central sulcus.
  • 2023-09-12 CXR
    • a spiculated tumor at Rt apical lung consistent with primary lung cancer
  • 2023-09-12 ECG
    • Sinus rhythm with Premature atrial complexes

[MedRec]

  • 2023-09-12 ~ 2023-11-07 POMR Integrative Medicine Duan WeiLun
    • Discharge diagnosis
      • Right upper lung adenocarcinoma, cT4N3M1c, stage IVB, with multiple cerebral and cerebellar meta, with increasing intracranial pressure, s/p operation and insertion port-A on 10/18.
      • Essential (primary) hypertension, poorly controlled
      • hypernatremia and hypokalemia
      • Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus
      • Pneumonia due to Klebsiella pneumoniae (2023.09.25)
      • Pneumonia due to Pseudomonas (2023.09.25)
      • Chronic viral hepatitis B without delta-agent
      • Pulmonary candidiasis (2023.09.21)
      • Dependence on respirator [ventilator] status s/p tracheostomy on 10/18
      • Pneumonia due to 10/16 sputum/c:CR-Acinetobacter, CRPA (P.aeruginosa)
    • CC
      • Left side limb weakness for 3 days
    • Present illness
      • This individual is a 71-year-old man with a pre-existing condition of hypertension, which is currently being managed with medication. Recently, he experienced a three-day episode of weakness in his left limbs.
      • As reported by the patient’s family, this weakness, accompanied by a headache, began three days ago. There is no history of trauma or prior stroke episodes in the patient’s medical records.
      • Due to the worsening nature of his symptoms, the patient was brought to our Emergency Room for medical assistance.
      • Upon arrival at the Emergency Room, the patient displayed stable vital signs and was fully conscious (E4V5M6). A neurological examination revealed central facial palsy on the left side and reduced muscle strength on the left side (muscle power 4).
      • A brain CT scan was conducted, revealing a hyperdense mass-like lesion in the right temporal lobe, as well as significant subcortical edema in the right fronto-temporal lobe.
      • Subsequently, an MRA (Magnetic Resonance Angiography) was performed, which detected several enhancing mass lesions in both temporal lobes, the left thalamus, the cerebellar vermis, and the right corona radiata.
      • Upon consultation with a neurosurgeon, it was strongly recommended that the patient be admitted for further treatment. Given the clinical impression of a brain tumor with associated brain edema, the patient was admitted to our ward for further evaluation and management.
    • Course of inpatient treatment
      • This individual, a 71-year-old man, has a preexisting medical condition of hypertension that is currently managed with medication. Recently, he experienced a three-day episode of left limb weakness accompanied by a headache. These symptoms began three days ago, and there is no history of trauma or prior strokes in his medical records. Due to the worsening nature of his symptoms, the patient was brought to our Emergency Room for medical assistance.
      • Upon arrival at the Emergency Room, the patient had stable vital signs and was fully conscious (E4V5M6). A neurological examination revealed central facial palsy on the left side and reduced muscle strength on the left side (muscle power 4).
      • A brain CT scan revealed a hyperdense mass-like lesion in the right temporal lobe, along with significant subcortical edema in the right fronto-temporal lobe.
      • Subsequently, an MRA (Magnetic Resonance Angiography) detected several enhancing mass lesions in both temporal lobes, the left thalamus, the cerebellar vermis, and the right corona radiata.
      • Following consultation with a neurosurgeon, admission for further treatment was strongly recommended.
      • Given the clinical impression of a brain tumor with associated brain edema, the patient was admitted for further evaluation and management. Monitoring of the neurological condition will continue during the ward stay.
        • Treatment includes Mannitol 75ml every 8 hours and Medason 40mg every 8 hours for brain edema control.
        • The anticonvulsant agent Keppra 500mg every 12 hours has been prescribed for seizure prevention.
      • A whole-body CT scan revealed right upper lung cancer, staged as T4N3M1c(E1). However, a seizure occurred on the morning of 9/15, around 3 am, characterized by bilateral eye deviation and right leg twitching.
        • Anxicam 2mg was administered twice, after which the patient’s level of consciousness dropped to E1V1M4.
      • A brain CT scan revealed multiple brain metastases with a 7.5mm midline shift to the left side.
        • Consequently, the Keppra dosage was adjusted to 1000mg every 12 hours for seizure control.
      • The patient exhibited breathing sounds with rales and poor cough ability.
      • Chest x-rays showed increased infiltration, leading to chest percussion and suction as needed, with the addition of tapimycin for suspected aspiration pneumonia.
      • Oxygen support was provided with a 10L/min mask to maintain oxygen saturation at 100%.
      • The patient underwent nasogastric tube feeding and had a Foley catheter in place due to the brain tumor diagnosis.
      • The patient’s son and family were fully informed of the situation.
      • On 2023/09/16, the patient underwent a left temporal craniotomy and removal of a metastatic tumor and sent biopsy (9/20 Brain boipsy showed: left temporal craniotomy and removal of tumor; No metastatic carcinoma can be identified in cytokeratin immunostain), after which he was transferred to the Surgical Intensive Care Unit (SICU) for post-operative care.
      • During SICU, the patient received oxygenation with ventilator assistance and H2 blockers for preventing stress ulcers.
        • Steroids, particularly Solu-medure, continued to be administered.
        • An anti-brain swelling agent, mannitol, was used.
        • Empirical antibiotic treatment with tapimycin initiated on 2023/09/15 continued.
        • Hypernatremia was noted, leading to a gradual shift in intravenous fluids to half saline and the provision of free water with meals.
      • Arrange EEG on 9/18 showd periodic lateralized epileptiform discharges in right hemisphere.
      • On 2023/09/20, a right-side eyelid seizure attack occurred. A neurologist was consulted, suggesting the addition of Vimpat and Topamax for epilepsy management.
      • The patient’s current conscious state is E3M5-6VE, and efforts are being made to wean him off the ventilator using the psv mode. Neurologic monitoring is ongoing and closely followed.
      • On 2023/09/25, consult chest men and hematology and oncology for lung cancer. He will be take over to chest men for interventional treatment.
      • After transfer to ICU, ventialtor supply and tapper to off sedation titration. steroid with solu-medrol iv injection and bronchodialtor inhalation.
      • Precribed Ciprofloxacine(09/26-09/30) and Fluconazole(09/26-10/01) for infection control.
      • AED as Depakine, Keppra, Vimpat and Topamax were given for epilepsy agent.
      • Adjust Mannital dose and anti-hypertension agent for BP control.
      • Echocardiography was arranged for heart function survey, and which showed EF 75%, aortic valve sclerosis.
      • Conscult chest surgiest for considor prot-A placement for further invassive chemotherapy.
      • Collect cortisol/thyroid, HbA1C, HIV and HBV.
      • Considor CT quide biopsy for evaluation lung cancer survey and disclosed adenocarcinoma, moderately differentiated “stage IVB,T4N3M1c”.
      • Arrange EEG on 2023/09/26 showed continuous focal sharp and spiky waves over right central area.
      • Arrange family meeting and Well explain to his son and little sister about the critical condition, side effect for cancer treatment, they understood that.
        • Decan 1amp Q8H and mannitol for brain metastasis.
        • PPI wtih self-carried Lansoprazole to prevent Cushing’s ulcers.
      • 2023/09/28 positioning for radiotherapy.
      • Sent Genetic Test/ PD-L1, EGFR(2023/09/27) for lung cancer.
      • Adjust Deparkin to max dose (2023/09/28 valproic acid 48) for intermittent ssizure.
      • However, septic shock and AKI with oliguria, and metabolic acidosis were noticed on 2023/10/01. Mannitol and anti-hypertensive agents were stopped. IV fluid challenge with N/S, Plasbumin infusion, Blood transfusion with FFP 4unit for 3 days (10/01-10/03), and Vasopressor with Norepinephrine titration were administered to correct shock status. Rolikan was given to correct metabolic acidosis. Culture samples inculding sputum and blood were repeated. Foley catheter was changed and urine routine was obtained, suspecision of UTI. We stopped antibiotic with Ciprofloxacin and changed to Brosym (10/1-10/5) + Targocid (10/1-10/14) for infection control. Besides, antifungal with Fluconazole was stopped and changed to Mycamine (10/01-10/14) for infection control. The patient was relieved from shock status and renal function improving soon after treatments.
      • As a result of sepsis, we canceled port-A insertion and chemotherapy was hold due to poor conditions. We well explained to the patient’s family (son) about his critical conditions and he could understand.
      • Self-payment target therapy with Tagrisso 1# PO QD was prescribed (10/2-10/6) as his family’s wish and we kept tracing for the report of Genetic Test/ PD-L1, EGFR. On 10/2, IICP signs were noticed and we resumed Mannitol regularly used. However, polyuria (6300ml/day) was noticed after Mannitol given, suspecision of central DI.
      • Radiation to metastatic brain tumors since 10/3 x 12fx. Another blood transfusion with FFP 4unit for 3 days (10/4-10/6) and adequate IV fluid with 0.298% N/S were prescribed for polyuria and hydration.
      • We consulted Nephrologist for polyuria, who replied 1) Check urine Na, K, Osm (random urine), 2) Follow up on serum electrolyte to avoid severe urinary loss during diuresis, 3) Reduce the solute in IV fluid and try NG enteral fluid replacement for polyuria if possible, 4) Consider decreasing the dose of Mannitol if osmotic diuresis does not resolve.
      • The brain radiotherapy QD was arranged since 2023/10/03. On 2023/10/05, we discontinued Brosym (10/01-10/05) and changed to Sintum (10/05-10/14) due to sputum culture yielded Pseudomonas.
      • On 10/06, the EGFR gene mutation test showed no mutation was detected at exons 18,19,20,21 of EGFR gene in this specimen. We well explained the report of EGFR gene mutation test to his family (son) by telephone and he can understand.
      • Self-payment target therapy with Tagrisso was discontinued for EGFR negative.
      • BT with LRP for thrombocytopenia. Taper Rivotril and lorazepam dose.
      • DC mannitol for large amount urine output.
      • Adjust dexamathasone dosage.
      • Control infection change Targocid (teicoplanin 10/17~), Mepem (meropenem 10/17~), Mycamine (micafungin 10/18~) and Baktar po (sulphamethoxazole + trimethoprim, 10/17~) treatment.
      • Correct thrombocytopenia and anemia given transfusion. Consult surgy perpare insertion port-A and Tracheostomy on 10/18.
      • Bilatory pleural effusion try given FFP with Lasix annx insertion pig-tail daring.
      • Arranged C/T with carboplatin 70% + alimta full (D1) on 10/20. FFP 4U QD x 3 days (10/23-10/25) for volume restored and IV fluid hydration for polyuria and hyponatremia.
      • Discontinued Morcasin po (10/17~10/25) due to negative of PjP, Ganciclovior was prescribed for CMV infection (viral load assay: 10000 IU/mL), also consult INF for CMV infection and persist fever, and consulted Ophthamology for exclude CMV retinitis.
      • We changed antibiotic with Amikacin/INHL (10/19-10/27) to Colimycin/INHL (10/27-) due to sputun culture yielded CRPA.
      • precribed G-CSF (10/30-11/3) for neutropenia. Adeqaute fluid supply for dehydration.
      • Go on weaning and try T-mask overnight since 11/2 as tolerance. Arrange bedside rehabillation.
      • DC Ganciclovir, taper to Valcyte for CMV viral load 2950 on 11/6.
      • Precribed antibiotic with Ceficin (11/7-) for infection control. He will transfer to ward for further care.
      • Under improve condition, he was transfer to gemeral ward for further care. His consciousness clear to confused under Tr mask supply. After his family discuss with Dr Yang MeiZhen. He is prepare discharge today then transfer to nursing home for further care and management on 2023/11/07. Remove CVP on 2023/11/07. And OPD follow up is arranged.
    • Discharge prescription
      • Ceficin (cefixime 100mg) 2# BID since 2023-11-07
      • Cordaraone (amiodarone 200mg) 1# BID hold if HR < 70bpm
      • Folacin (folic acid 5mg) 1# QD
      • Keppra Oral Soln (levetiracetam 100mg/mL) 5mL BID
      • Rivotril (clonazepam 0.5mg) 1# PRNHS if insomnia
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# HS
      • Valcyte (valganciclovir 450mg) 2# QD since 2023-11-07
      • Biomycin Ointment (neomycin, tyrothricin) BID TOPI for posterior buttock wound
      • Acetal (acetaminophen 500mg) 1# Q6H
      • Depakine Oral Soln (valproate Na 200mg/mL) 400mg Q12H
      • hydralazine 50mg 1# Q8H hold if BP < 130/90mmHg
      • Norvasc (amlodipine 5mg) 1# Q12H hold if BP < 120/70mmHg
      • Cortisone (cortisone acetate 25mg) 1# QD
      • Ulstop (famotidine 20mg) 1# BID
      • Bisadyl Supp (bisacodyl 10mg) 2# PRNQOD if constipation
      • Foster Evohaler (beclomethasone 100ug, formoterol 6ug; per dose; 120 doses/bot) 2# BID INHL
      • Spiriva Respimat (tiotropium 2.5ug/puff) 2# HS INHL
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Const-K (KCl 10mEq) 1# QD
      • Nexium (esomeprazole 40mg) 1# QDAC

[chemotherapy]

  • 2023-12-28 - pemetrexed 500mg/m2 800mg NS 100mL 10min + NS 250mL (before carboplatin) + carboplatin AUC 6 400mg NS 250mL 2hr + NS 250mL (after carboplatin) (Li Zhong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 100mL
  • 2023-11-29 - pemetrexed 500mg/m2 800mg NS 100mL 10min + carboplatin AUC 5 400mg NS 250mL 2hr (Li Zhong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 100mL
  • 2023-10-20 - pemetrexed 500mg/m2 800mg NS 100mL 10min + carboplatin AUC 5 300mg NS 250mL 2hr (Yang MeiZhen)
    • dexamethasone 4mg + hydroxocobalamin 1mg IM + NS 100mL 10min + KCl inj 15% 5mL NS 500mL 2hr + KCl inj 15% 5mL D5W 500mL 2hr + mannitol 20% 150mL (before carboplatin) + lorazepam 0.5mg PO (before carboplatin) + granisetron 3mg NS 100mL 30min (before carboplatin) + KCl inj 15% 5mL NS 500mL 2hr (after carboplatin) + KCl inj 15% 5mL D5W 500mL 2hr (after carboplatin)

==========

2024-01-24

[recovery patterns of WBC and PLT after chemotherapy]

The last administration of pemetrexed plus carboplatin for this patient occurred on 2023-12-28.

The nadir for both WBC and PLT counts was observed on 2024-01-08, which aligns with the expected timeline for these side effects.

According to UpToDate, carboplatin tends to have a higher incidence of leukopenia and thrombocytopenia compared to pemetrexed.

Currently, both WBC and PLT levels are in the process of recovery.

  • 2024-01-23 WBC 5.38 x10^3/uL

  • 2024-01-19 WBC 4.21 x10^3/uL

  • 2024-01-15 WBC 20.07 x10^3/uL

  • 2024-01-11 WBC 1.54 x10^3/uL **

  • 2024-01-08 WBC 1.01 x10^3/uL ***

  • 2024-01-02 WBC 4.65 x10^3/uL

  • 2023-12-27 WBC 5.20 x10^3/uL

  • 2024-01-23 PLT 174 *10^3/uL

  • 2024-01-19 PLT 97 10^3/uL

  • 2024-01-15 PLT 42 *10^3/uL **

  • 2024-01-11 PLT 137 *10^3/uL

  • 2024-01-08 PLT 17 10^3/uL **

  • 2024-01-02 PLT 108 *10^3/uL

  • 2023-12-27 PLT 110 *10^3/uL

700561999

240123

[lab data]

2023-12-28 Anti-HCV Nonreactive
2023-12-28 Anti-HCV Value 0.33 S/CO

2023-12-27 Anti-HBc IgM Nonreactive
2023-12-27 Anti-HBc IgM Value 0.09 S/CO
2023-12-27 HBsAg Nonreactive
2023-12-27 HBsAg (Value) 0.57 S/CO
2023-12-27 Anti-HBc Nonreactive
2023-12-27 Anti-HBc-Value 0.21 S/CO

[MedRec]

  • 2023-12-27 ~ 2023-12-29 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Recurrent endometrioid adenocarcinoma s/p operation (LTH+BSO+BPLND) and radiotherapy with pleural metastasis, stage IV
      • Invasive lobular carcinoma of the left breast, pT1bN0(cM0). Prognostic stage: IA, s/p BCT+ALND, radiotherapy,
      • Constipation
      • Essential (primary) hypertension
    • CC
      • SOB without control and left lateral chest pain also noted for 2 weeks
    • Present illness
      • This 57-year-old female patient has past history of hypertensive over 5 years with regular medicine control, Endometrioid adenocarcinoma, Grade 2, of the uterus, stage pT1bN0(cM0), s/p operation (LTH + BSO + BPLND) and radiotherapy and Invasive lobular carcinoma of the left breast, , pT1bN0(cM0). Prognostic stage: IA, s/p BCT + ALND, radiotherapy, and status during endocrine therapy. Bone scan was done on 2023/05, but no evidence of bone metastasis.
      • Last time, she had cough with SOB and left chest wall pain, so she was admitted to Integrative (hospital) Medicine department for treatment. Pleural effusion drainage and pathology showed metastatic carcinoma, consistent with endometrioid carcinoma on 2023/11/24.
      • The chest CT was done on 2023/12/02, report showed severe pleural thickening and pleural thickening at left hemithorax is found.
      • This time, she also has SOB on exrcise and chest wall pain for 2 weeks, so she was brought to our ED for help on 2023/12/25.
      • The CXR showed left pleural effusion. Rib filme showed no fracture. The lab data showed elevated CRP 12.0g/dL and hypercalcemia 2.83 mmol/L. Initial antibiotic as Brosym for infection control and pain control with Tramadol iv form.
      • Under the impression of Endometrioid adenocarcinoma with pleural metastasis and SOB, so she was admitted for treatment on 2023/12/27.
    • Course of inpatient treatment
      • After admission, we check HBV and HCV for survey. Empiric antibiotic as Brosym 4g q12h for prevent pneumonia.
      • She received pre-medication as oral steroid and C1 chemo as Taxel + Cisplatin on 2023/12/28.
      • Under the stable condition, she can be discharged on 2023/12/29. OPD follow up is arranged.
    • Discharge prescription
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
      • Through (sennoside 12mg) 2# HS
  • 2023-12-09 SOAP Obstetrics and Gynecology Hong ZhengXiu
    • A: Conclusions of Cancer Multidisciplinary Team Meeting, Meeting date: 2023-12-07
      • Treatment plan: Notify the hemato-oncology department for systemic chemotherapy (lung metastasis).
  • 2023-11-22 ~ 2023-12-05 POMR Chest Medicine Rao LunYu
    • Discharge diagnosis
      • Secondary malignant neoplasm of pleura
      • Left side massive pleural effusion due to endometrial CA with pleural metastasis
      • Malignant neoplasm of endometrium
      • Malignant neoplasm of unspecified site of left female breast
      • Left invasive lobular carcinoma, cT1N0M0, stage IIA status post left breast conserving therapy and axillary lymph node dissection on May 25, 2022.
    • CC
      • Severe dry cough and SOB for 2-3 weeks, left lateral chest pain was noted at OPD.
    • Present illness
      • This 57-year-old female patient has past history of hypertensive over 5 years with regular medicine control. She denied any TOCC histories in recent 3 months.
      • This time, she suffered from severe dry cough and SOB for 2-3 weeks, left lateral chest pain was noted today. Therefore she was brought to our ER for help. In ER, vital signs: Temp: 36.9’C, pulse: 98/min, respiration: 18/min and blood pressure: 118/78 mmHg, SpO2:96%. Laboratory data showed no leukocytosis with left shifted (WBC 8280/N.seg 76.1). CXR film showed massive left pleural effusion. After bed side chest echo tapping 1100ml of left chest in ER. Under the impression of massive pleural effusion, she was admitted to CM ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission, antitussive, mucolytic agents and other palliative treatment were given for symptomatic relief. The chest echo arrange on 2023/11/23, which showed left side massive pleural effusion, and the pig-tail drinage was performed and serosangious fluid was drained out. Pleural biopsy, fluid culture and cytology was done. The pleural efffusion analysis dislcosed exaduate, added empiric antibiotic with Rocephine IV (2023/11/24~) for infection control. Further CXR will follow up on 2023/12/01.
      • The pleural effusion cytology disclosed atypia and plueral biopsy pathogy disclosed metastatic carcinoma, consistent with endometrioid carcinoma. Thus, GYN Dr as consulted on 2023/11/30 suggest arrange Abdominal CT to pelvis. However impove of laboratroy and Chest Film. We remove pigtail drainage on 2023/12/04 smoothly. Currently, stable vital sign and respiratory condition. She was discharge on 2023-12-05 then GYN and CM OPD for further management.
    • Discharge prescription
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
      • Through (sennoside 12mg) 2# HS
      • codeine phosphate 15mg) 1# HS
  • 2022-05-24 ~ 2022-05-26 POMR General and Gastrointestinal Surgery Li ChaoShu
    • Discharge diagnosis
      • Left breast cancer, invasive lobular carcinoma, cT1N0M0, clinical stage IA status post left breast conserving therapy and axillary lymph node dissection on 2022-05-25; ECOG 0
      • Malignant neoplasm of unspecified site of left female breast
      • Malignant neoplasm of endometrium
      • ECOG performance: 0
      • Endometrial cancer, pT1bN0M0, stage IB status post abdominal total hysterectomy and bilateral salpingo-oophorectomy
      • Insomnia
    • CC
      • She was diagnosed with abnormal under mammography by health examination.
    • Present illness
      • This 55-year-old female patient has past history of 1) hypertensive over 5 years with regular medicine control 2) insomnia 3) endometrial cancer s/p ATH + BSO on 2017/04/25 at Taipei TzuChi Hospital. She denied any TOCC histories in recent 3 months.
      • She was regular follow up by health examination. However, Mammography showed focal architectural distortion noted in outer portion of right breast (anterior third portion) and a benign calcification in left breast on 2022/04/27. So she visited to our OPD for help. She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, no body weight loss. Breast sono showed benign neoplasm of breast, infavor of benign fibrocystic disease (FCD)left breast tumor, 3 o’clock location, r/o malignancy, location: left 3 o’clock / 3 cm, size: 0.5 x 1cm; suggest biopsy. Core needle biopsy revealed invasive lobular carcinoma, because the tumor is too small, ER, PR, HER2 and Ki-67 are not recommended for this specimen.
      • After fully explaination the treatment options with general surgery. This time, she was admitted to our ward for partial mastectomy + SLNB on 2022/05/25.
    • Course of inpatient treatment
      • After admittion, arragne abdominal sono was done that revealed no obvious lesion for metastasis. She underwent of left breast conserving therapy and axillary lymph node dissection on 2022-05-25. The post-operative course was relatively smooth without complication. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. The final pathology and Tc-99m MDP whole body bone scan report is pending. She was discharged on May 25, 2022 and OPD follow-up was arranged on 2022-06-02.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ8H
      • MgO 250mg 1# TID
  • 2017-04-10 ~ 2017-04-17 POMR Obstetrics and Gynecology Hong ZhengXiu
    • Discharge diagnosis
      • C54.1 Endometrial endometrioid adenocarcinoma clinical stage Ib
      • N80.0 Adenomyosis
      • N80.3 Endometriosis of pelvic peritoneum
      • 2017/04/12 Cystoscopy and retrograded Ureteral catheterization
    • CC
      • vaginal spotting since November of 2016
    • Present illness
      • Miss Lu, a 50 y/o woman, G3P2AA1, presented to our OPD for vaginal spotting since November of 2016.
      • This patient was disturbed by prolonged mense duration and viginal spotting since last year, but lower abdominal pain, lower limbs edema, and fresh blood were denied. It was recognized as menopausal syndrome by herself, but the viginal spotting showed progressively when moving since March, 2017. GYN doctor of Cardinal Tien Hospital was visited and D&C revealed endometrial cancer. She visited Dr. Hung for second opinion on 2017/04/10. Repeated pap smear was done and she was admitted to our ward for laparoscopic staging operation with Thunderbeat arranged on 2017-04-12.
    • Course of inpatient treatment
      • After admission, pelvic CT revealed endometrial endometrioid adenocarcinoma clinical stage Ib on 2017-04-11. Patient underwent cystoscopy and bilateral ureteral catheter were inserted smoothly by GU doctor and laproscopic debulking operation (LTH + BSO + BPLND) and adhesionolysis by GYN doctor on 2017-04-12. Her postop course was uneventful. She remained afebrile and stable and was discharged on POD #5. She was discharged on 2017-04-17. Her followup appointment is scheduled on next week.

[surgical operation]

  • 2022-05-25
    • Operation
      • BCT + ALND        
      • IOUS
    • Finding:
      • IOUS: left breast cancer, 3 o’clock/3cm location, was encountered.
      • Clinical tumor status:
        • Tumor size: <2cm (cT1)
        • Gross skin invasion: No
        • Gross pectoral fascia invasion: No
        • Tumor location: left side, lateral upper quadrum (3/3cm)
        • Clinical T stage: cT1 (<2cm)
      • Clinical nodal status:
        • Axillary dissection: SLND using isotope, but failed detection => converted ALND
        • Gross LNs: negative LAPs
        • Clinical N stage: cN0
      • OP status:
        • Procedures: BCT + ALND
        • Pre-OP tissue prove: CNB
        • Nerve preservation: long thoracic nerve and thoracodorsal nerve
        • Drainage: Blake x 1 (15Fr), in axillary space   - PostOP elastic bandage: Yes   - PostOP skin flap: No   - Closure of wound: two-layer, 3-0 Vicryl and 5-0 Nylon
      • Path of frozen section: free margins   - Procedure:   - Under ETGA, set the patient in supine position and prepared the OP field as usual. Made IOUS to defined margins. Made partial mastectomy and sent the specimen for frozen exam. The report disclosed malignancy. Commenced axillary LN dissection. Closed the wound as two layer sutures with 3-0 Vicryl and 5-0 Nylon. Finally, covered the wound with elastic bandage.
  • 2017/04/12 13:00 doctor Hung ZhengXiu
    • Operation
      • debulking operation (LTH + BSO + BPLND) by LSC
      • Laparoscopic adhesionolysis
    • Finding
      • The uterus was enlarged as three months pregnancy in size.
      • The anterior and posterior cul-de-sac were denesly adhered due to previous twice Cesarean sections.
      • With the use of thunderbeat, at the beginning of the operation, the uterus was removed by dissecting bilateral uterine arteries down to the isthmus and paracervical stump.
      • And bilateral adnexae were also removed through vagina.
      • Bilateral pelvic lymph nodes were dissected with the aids of suction tip and monopolar coagulators.
      • No indurated pelvic lymph node were palpabled.
      • Bilateral obturator bleeders were checked and Surgicele were placed.
      • The vaginal cuff was repaired with continuous sutures with number one Vicryl.
      • At the end of vaginal suture repair, at central portion interrupted sutures were added.
      • Total blood loss was 150 cc.
  • 2017/04/12 12:25 doctor Lin JiaDa
    • Operation
      • Cystoscopy + retrograded Ureteral catheterization
    • Finding
      • Bilateral ureteral catheter were inserted smoothly

[radiotherapy]

  • 2022-06-29 ~ 2022-08-09 - 5000cGy/25 fractions of the left breast, and 6000cGy/30 fractions of the left breast tumor bed (scar) area.
  • 2017-05-12 ~ 2017-06-30 - 4500cGy/25 fractions of the pelvic, and another 900cGy/3 fractions via IVRT to vaginal cuff mucosa surface.

[chemotherapy]

  • 2024-01-22 - paclitaxel 175mg/m2 297mg NS 250mL 3hr + cisplatin 75mg/m2 127mg NS 500mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-12-28 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + cisplatin 75mg/m2 128mg NS 500mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2024-01-23 (not posted)

anemia episode was observed on 2024-01-21

  • 2024-01-21 HGB 8.8 g/dL
  • 2023-12-25 HGB 10.1 g/dL
  • 2023-11-24 HGB 11.1 g/dL
  • 2023-11-21 HGB 12.7 g/dL

700752671

240123

[lab data]

2022-10-24 Anti-HBc Reactive
2022-10-24 Anti-HBc-Value 6.32 S/CO
2022-10-24 HBsAg Nonreactive
2022-10-24 HBsAg (Value) 0.35 S/CO
2022-10-24 Anti-HCV Nonreactive
2022-10-24 Anti-HCV Value 0.13 S/CO

[exam findings]

  • 2023-10-24, -10-02 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Tortuosity of thoracic aorta
    • Borderline cardiomegaly
    • Spondylosis with scoliosis of the T-spine with convex to right side
  • 2023-10-23 CT - abdomen
    • History and indication: duodenum cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Malignancy in GB and duodenum with adjacent structures invasion. Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with ascites.
      • Splenomegaly.
      • Tiny renal cysts.
      • Degeneration and spondylosis of L-S spine.
    • IMP:
      • Malignancy in GB and duodenum with adjacent structures invasion (stable). Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with ascites c/w tumor seeding. Splenomegaly.
  • 2023-08-30 Joint soft tissue sonography
    • Findings: Hypoechoic disruption of the right supraspinatus tendon fibers extending from the bursal surface to the articular surface
    • Impression: Right supraspinatus tendon full-thickness tear
  • 2023-08-02 Antegrade Venography
    • Venography via left port-A catheter administration revealed some blood clot around distal end of the catheter without occlusion. Patency of SVC.
  • 2023-07-31 Abdomen - standing (diaphragm)
    • Spondylosis with scoliosis of the L-spine with convex to left side.
    • Ileus projecting at LMQ abdomen is suspected.
    • Pneumobilia on both hepatic lobes are noted.
  • 2023-07-18 CT - abdomen
    • Clinical history: 81 y/o female patient with abdominal pain, suspect IAI.
    • With and without contrast enhancement CT of abdomen - whole:
      • Infiltrative soft tissue tumors in the GB, IHDs and along CHD region, hepatic hilar regions and around duodenum.
      • Dilatation of IHDs with pneumobilia, dilatation of P-duct.
      • Soft tissue tumors in the peritoneum and subphrenic region, could be due to carcinomatosis.
      • Mucosal enhancement at ascending colon.
      • Portal venous thrombosis.
      • Presence of ascites.
    • Impression:
      • Malignancy in GB, IHDs and CHD regions, hepatic hilar and around duodenum. Stationary.
      • Peritoneal tumors with ascites, r/o carcinomatosis.
      • More prominent mucosal enhancement at ascending colon. Suggest clinical correlation.
  • 2023-07-16 KUB
    • Presence of scoliosis of the lumbar spine.
    • Presence of ileus.
  • 2023-07-16 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
    • Left axis deviation
    • Abnormal ECG
  • 2023-06-27 ECG
    • Sinus bradycardia
    • Left axis deviation
  • 2023-05-19 Myocardial perfusion SPECT with persantin
    • Probably mild myocardial ischemia at the basal inferolateral wall.
    • Reverse redistribution of radioactivity to the apical lateral wall, either normal variant or myocardial ischemia may show this picture.
  • 2023-05-02 Angegrade venography
    • Venography via left port-A catheter administration revealed some blood clot around distal end of the catheter without occlusion.
  • 2023-04-20 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (72.1 - 21.0) / 72.1 = 70.87%
      • M-mode (Teichholz) = 70.6
    • Conclusion:
      • Dilated LA
      • Adequate LV, RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Mild MR, TR
  • 2023-04-19 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
  • 2023-04-17 CT - abdomen
    • History and indication: duodenum with S4 liver invasion, multiple metastatic nodes
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Malignancy in GB and duodenum with adjacent structures invasion. Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with small amount ascites.
      • Splenomegaly.
      • Enlargement of left thyroid gland.
      • Tiny renal cysts.
      • Partial atelectasis at LLL.
      • Degeneration and spondylosis of L-S spine.
    • IMP:
      • Malignancy in GB and duodenum with adjacent structures invasion (stable). Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with small amount ascites. Splenomegaly.
  • 2023-03-02 SONO - abdomen
    • Liver tumor, S4, suspect metastasis
    • GB lesion, suspicious tumor, and cholecystopathy
    • Intra-IHD lesion, B8, unknown etology and IHD dilatation
    • CBD wall asymmetric thickness, suspicous infiltrative cause
    • Marked MPD dilatation
    • Splenomegaly
  • 2023-01-12 CT - abdomen
    • History and indication: Adenocarcinoma of gallbladder cancer with S4 liver invasion
    • With and without-contrast CT of abdomen-pelvis revealed:
      • GB cancer (2.7cm) with liver invasion. Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with small amount ascites.
      • Splenomegaly.
      • Enlargement of left thyroid gland.
      • Tiny renal cysts.
      • S/P Port-A infusion catheter insertion. Degeneration and spondylosis of L-S spine.
    • IMP:
      • GB cancer (2.7cm) with liver invasion. Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with small amount ascites r/o tumor seeding.
  • 2022-11-09 Patho - liver biopsy needle/wedge
    • Liver, EUS-FNB — Adenocarcinoma, moderately differentiated
    • The sections show a picture of adenocarcinoma, composed of nests of columnar neoplastic cells with glandular formation and mucin secretion, embedded in fibrous stroma.
    • IHC shows: CK7(+), CK20(-), and CDX2(+).
    • Comment: The histological pattern and immunophenotype are similar to duodenal biopsy specimen (S2022-9593). Adenocarcinoma of duodenum origin can not be completely excluded. Suggest clinic correlation.
  • 2022-11-09 Patho - duodenum biopsy
    • Duodenum, 2nd portion PW, biopsy — Adenocarcinoma, moderately differentiated, upper GI type
    • The secvtions show a picture of adenocarcinoma, upper gastrointestinal type, composed of columnar neoplastic cells, arranged in glandular and papillary patterns with desmoplastic stromal reaction.
    • IHC, tumor cells reveal: CK7(+), CK20(-), and CDX2(+).
  • 2022-11-08 EUS
    • Diagnosis:
      • GB tumor prob. cancer s/p EUSFNB (A)
      • Hepatic tumor Prob. GB cancer with liver involvement s/p FNB (B)
      • duodenal tumor s/p Bx (C)
      • Ascites, moderate
      • MPD dilatation
      • Lymphadenopathy
    • Suggestion:
      • pursue pathological result
  • 2022-11-04 MRI - MR Chloangiography, MRCP
    • Findings:
      • There is an ill-defined, mild heterogeneous mass measuring 7.3 x 4 cm in the gallbladder fossa and S4 of the liver, showing hypointensity on T1WI and mild hyperintensity on both T2WI and DWI. During dynamic study, this tumor shows poor contrast enhancement in arterial phase, portal-venous phase and delayed phase images.
        • Gallbladder cancer is highly suspected.
        • The differential diagnosis include cholangiocarcinoma and poorly differentiated HCC.
      • There are enlarged nodes in gastrohepatic ligament, celiac trunk, hepatoduodenal ligament, aortocaval space, and para-aortic space that are c/w metastatic nodes.
      • There is ascites and soft tissue lesions in the parietal peritoneum in right perihepatic space and omentum that may be carcinomatosis? Please correlate with ascites cytology.
      • There is marked dilatation and pneumobilia on both lobes IHDS. please correlate with clinical history.
      • There is irregular liver contour, hypertrophy of S1, atrophy of S2-3, non-visualization of left portal vein.
        • Chronic cholangitis induce biliary cirrhosis is highly suspected.
      • There is spleen size prominence (long axis: 11 cm) and ascites that may be portal hypertension.
      • The pancreatic duct shows dilatation the may be IPMN, main duct type.
      • There are several renal cysts on both kidney and the largest one measuring 0.5 cm in size at left upper pole.
    • IMP:
      • Gallbladder cancer with S4 liver invasion is highly suspected.
        • The differential diagnosis include cholangiocarcinoma and poorly differentiated HCC at S4 liver with gallbladder invasion.
      • Multiple Metastatic nodes in gastrohepatic ligament, celiac trunk, hepatoduodenal ligament, aortocaval space, and para-aortic space.
      • Carcinomatosis is suspected. Please correlate with ascites cytology.
      • IHDs dilatation and pneumobilia.
      • Chronic cholangitis induce biliary cirrhosis is suspected.
      • IPMN of the pancreas is highly suspected.
  • 2022-10-25 Patho - gall bladder (malignancy)
    • Labeled as “gallbladder”, core needle biopsy — high grade dysplasia. See description.
    • Section shows high grade dysplasia lined tissue with focal inner muscular layer and outer muscular layer.
    • IHC stains: CK 19 (+), Ki-67: 5%. Also present is one piece of benign liver tissue and benign bile canaliculi tissue.
  • 2022-10-24 SONO - abdomen
    • Diagnosis:
      • Liver parenchymal disease
      • liver tumors: cause to be determined
      • dilatation of bilateral IHD, pneumobilia
      • GB sac could not be identified
      • dilatation of main pancreatic duct: body portion(some parts of pancreas obscured)
      • ascites: small amount
    • Suggestion:
      • 4 phase CT or dynamic MRI study

[MedRec]

  • 2022-10-23 ~ 2022-10-26 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Upper abdominal pain, unspecified
      • Malignant neoplasm of gallbladder suspected S/P CT guide biopsy on 2022-10-25 and pathology report was pending .
    • CC
      • upper abdominal pain since Sep 2022
    • Present illness
      • This 81-year-old woman, a patient suspected gallbladder cancer by whole abdominal CT exam at CGMH hospital. She suffered form upper abdominal pain, distension, poor appetite and body weight loss (2-3kg) since Sep 2022 and she visited to CGMH for medical attention where abdominal CT showed decreased and heterogenous enhancement at biliary tract and mild dilated pancreatic duct, mild ascites noted, no GB stone nor CBD stone was found. She was referred to oncologist Dr. Kao’s OPD for second opinion.
      • Upon admission, she noted persisted intermittent epigastralgia and mild panic, no fever, no chillness, no bowel habit change, no jaundice. the laboratory data showed no significance, no abnormal liver chemistry, pending for tumor biomarker. Owing to above, she was aditted for further evaluation and management.
    • Course of inpatient treatment
      • After admission, image study with abdominal sono (2022/10/24) showed Liver parenchymal disease, liver tumors: cause to be determined, dilatation of bilateral IHD, pneumobilia, (GB sac could not be identified), dilatation of main pancreatic duct: body portion(some parts of pancreas obscured), ascites: small amount. Radiologist was consulted for CT guide biopsy evaluation.
      • CT guide biopsy was performed on 2022/10/25, smoothly without active bleeding or abdominal pain. The pathology report was pending. She was discharged on 2022/10/26 under stable condition and will follow-up at OPD.
  • 2022-10-20 SOAP Hemato-Oncology Gao WeiYao
    • S
      • for 2nd opinion, referred by sister Lin
      • Being informed to have hepatobiliary tract neoplasm
      • Epigastric pain for one month but it resolved by itself and CT done at Linkou CGMH
      • History of biliary tract infection before
    • O
      • BP 145/85; HR 78
    • A
      • BH 152, BW 66.7

[consultation]

[chemotherapy]

  • 2024-01-22 - oxaliplatin 85mg/m2 127mg D5W 250mL 6hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4200mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-27 - (FOLFOX)
  • 2023-11-14 - (FOLFOX)
  • 2023-10-02 - (FOLFOX)
  • 2023-09-13 - (FOLFOX)
  • 2023-08-30 - (FOLFOX)
  • 2023-08-14 - (FOLFOX)
  • 2023-06-27 - (FOLFOX)
  • 2023-06-02 - (FOLFOX)
  • 2023-05-02 - (FOLFOX)
  • 2023-04-18 - (FOLFOX)
  • 2023-03-29 - (FOLFOX)
  • 2023-02-13 - (FOLFOX)
  • 2023-01-30 - (FOLFOX)
  • 2023-01-09 - (FOLFOX)
  • 2022-12-26 - (FOLFOX)
  • 2022-12-13 - (FOLFOX)
  • 2022-12-01 - oxaliplatin 85mg/m2 137mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-11-17 - leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 48hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

==========

2024-01-23

[CEA marker trends and imaging updates]

The patient has been undergoing FOLFOX treatment since Dec 2022, for over a year, and has generally tolerated it well.

She is also receiving Baraclude (entecavir) for reactive Anti-HBc and Megejohn (megestrol acetate) for cachexia, with no discrepancies in medication identified.

The CEA marker showed a recent high in November 2023. There has been no updated imaging study since Oct 2023, which may warrant renewal.

701227488

240123

[MedRec]

  • 2024-01-21 ~ 2024-01-22 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Other pancytopenia
      • Thrombocytopenia, unspecified
      • Anemia, unspecified
    • CC
      • shortness of breath for months
    • Present illness
      • This is a 89-year-old female with anemia for over ten years. She had family history of thalassemia. This time, she came to our HEMA OPD due to severe anemia, shortness of breath noted for months. She also complaint about low back pain for years. At OPD, blood test revealed pancytopenia, blood transfusion with LPRBC 2u was arranged. There was no fever, no chills, no chest pain, no nausea or vomiting, no tarry stool. The patient was admitted for clarifying the nature of severe anemia and pancytopenia.
    • Course of inpatient treatment
      • After admission, blood test was arranged which showed Hb 4.9 g/dL, blood transfusion with LPRBC 2u was ordered. She underwent bone marrow puncture and biopsy on 2024/01/22. Under stable condition, she discharged on 2024/01/22 and OPD follow up was arranged.
  • 2024-01-18 SOAP Hemato-Oncology Gao WeiYao
    • S
      • Gyn Prof. Dr Hwang’s relative
      • History of anemia post transfusion 7 yrs ago
      • History of severe anemia as low as 3.9.
      • back pain, lower back nature?
      • family history of thalassemia
    • O
      • WBC = 1.94 x10^3/uL;
      • HGB = 4.2 g/dL;
      • MCV = 92.6 fL;
      • PLT = 47 x10^3/uL;
      • BP:116/47; HR:78/min;
    • A
      • BW 40
      • pancytopenia nature to be determined

701484337

240123

[exam findings]

  • 2024-01-20 CT - abdomen
    • With and without contrast enhancement CT of abdomen–whole:
      • Clinical sigmoid ccancer s/p treatment.
      • Small left renal stone without obstruction.
      • Right renal cyst, 1.1cm.
      • Stationary paraaortic lymph nodes.
      • Soft tissue tumor, 2cm in right pelvic cavity (lymph node or ovary?) stationary.
      • There are multiple liver tumors, up to 6.1cm in S4-8 liver, with peripheral nodular enhancement, r/o liver hemangiomas.
      • Dilatation of CBD.
      • Outpouching lesions in ascending colon, suggesting colon diverticula.
    • Impression:
      • Clinical sigmoid ccancer s/p treatment.
      • Stationary paraaortic lymph nodes.
      • Right pelvic cavity soft tissue, lymph node or ovary? stationary.
      • Multiple liver tumors, r/o hemangiomas.
      • Dilatation of CBD.
      • Ascending colon diverticula.
  • 2023-12-19 CXR erect
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Tortuosity of thoracic aorta
    • Borderline cardiomegaly
  • 2023-11-28 Gynecologic Ultrasonography
    • R/O Endometrial polyp
    • Uterine myoma
  • 2023-10-27 CT - abdomen
    • Findings: Comparison: prior CT from NTUCC dated 2023/05/11.
      • There is no focal wall thickening at the rectum.
        • Please correlate with colonoscopy.
      • Prior CT identified one enlarged node 1.3 cm in right external iliac chain and three enlarged nodes in left para-aortic space and aortocaval space are noted again, stationary.
        • Please correlate with PET scan.
      • Prior CT identified ten hemangiomas on both hepatic lobes (the largest one 6 cm in S6/7) are noted again, stationary.
        • In addition, few cysts on both hepatic lobes are also noted.
      • S/P cholecystectomy.
        • There is mild dilatation of IHDs and CHD.
        • Please correlate with serum alk-p and bilirubin level.
      • A renal cyst 1.2 cm in right middle pole is noted.
    • Impression:
      • There is no focal wall thickening the rectum.
        • Please correlate with colonoscopy.
      • Prior CT identified one enlarged node 1.3 cm in right external iliac chain and three enlarged nodes in left para-aortic space and aortocaval space are noted again, stationary.
        • Please correlate with PET scan.
  • 2023-07-10 All-RAS + BRAF mutation
    • Cellblock No. F2023-00289 A2
    • RESULTS:
      • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-06-23 Patho - breast mastectomy with regional lymph nodes
    • PATHOLOGIC DIAGNOSIS
      • Breast tumor, left, BCT + frozen —- Solid papillary carcinoma with invasion
      • Resection margins, ditto — Free of tumor invasion
      • Lymph node, left axillary sentinel area, frozen (F2023-00289) — Free of tumor metastasis (0/4)
      • AJCC Pathologic Anatomic Stage — pT1cN0, if cM0, stage IA; Prognostic Stage — Stage IA
    • MACROSCOPIC EXAMINATION
      • Breast: 8.5 x 6 x 2.2 cm
      • Skin: 3.5 x 0.7 cm
      • Nipple: Not received
      • Tumor: 1.1 x 1.1 cm
      • Resection margins: Free, 0.2 cm away from closest 3 o’clock margin, 0.9 cm from base and at least 1.3 cm away from peripheral margins
      • Lymph node: left axillary sentinel LNs, sent for frozen section (F2023-00289)
      • Representative sections as F2023-00289 FSA: L’t axillary sentinel LNs, FSB: 3 o’clock margin and base, A1-A3: tumor and A4: skin
    • MICROSCOPIC EXAMINATION
      • Histologic type: solid papillary carcinoma with invasion
      • Size of invasive carcinoma: 1.1 x 1.1 cm
      • Histologic grade (Nottingham histologic score): Grade II (score 6) including (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1
      • Margins: Free of tumor invasion
      • Nodal status: Free of tumor metastasis (0/4)
      • Treatment Effect: N/A
      • Lymphovascular space invasion: Not identified
      • Perienural invasion: Not identified
    • IMMUNOHISTOCHEMISTRY
      • F2023-00289A2: synaptophysin(+, diffuse), chromogranin-A(+, scatter) for tumor, CK5/6(-) and P63(-) for myoepithelial cell
      • Please refer to S2023-11754 for ER, PR, Her2/neu and Ki67 status
  • 2023-06-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (84 - 34) / 84 = 59.52%
      • M-mode (Teichholz) = 59
    • Conclusion:
      • Mild septal hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; severely dilated LA.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis with mild AR; mild MR; mild TR; mild PR.
      • Mild aortic root calcification; mildly dilated proximal ascending aorta (32 mm).
  • 2023-06-13 Patho - breast biopsy (no need margin)
    • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
    • IHC stains: ER (+, 100%, strong intensity), PR (+, 75%, strong intensity), Her2/neu: negative (score=0), Ki-67 (10 %), p63 (-), CK5/6 (-), E-cadherin (+).
  • 2023-06-13 SONO - breast
    • Imp
      • Left breast tumor, r/o malignancy, suggest biopsy.
      • Left breast cyst.
    • BI-RADS: Category 4c: highly suspicious abnormality-biopsy should be considered.
  • 2023-06-13 Mammography
    • Impression: Hyperdense tumor, 1.47cm in UOQ of left breast (posterior third portion), suggest sonographic correlation.
    • BI-RADS: Category 0 (incomplete. Need additional imaging evaluation.)
  • 2023-06-07 MRI - pelvis
    • Findings:
      • There is soft tissue lesion in the left lateral wall of the upper rectum, measuring 1.2 cm in size, with submucosa involvement that is c/w adenocarcinoma (T2).
        • In addition, there are three enlarged node 0.4 cm in left perirectal space, 1.6 cm in right internal iliac chain, and 0.6 cm in left sigmoid mesocolon that are c/w regional metastatic node (N1b).
      • There is one enlarged node 1.3 cm in right external iliac chain and three enlarged nodes in left para-aortic space and aortocaval space. Non-regional metastatic node (M1a) is highly suspected.
        • Please correlate with PET scan.
      • There are ten hemangiomas on both hepatic lobes and the largest one measuring 6 cm in S6/7.
        • In addition, few cysts on both hepatic lobes are also noted.
      • S/P cholecystectomy.
      • A renal cyst measuring 1.2 cm in right middle pole is noted.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T2(T_value) N:N1b(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
  • 2023-06-05 PET
    • A glucose hypermetabolic lesion at the R-S junction, compatible with the primary rectal cancer.
    • Increased FDG uptake in the left para-aortic lymph nodes, at the L2-3 spine level, metastatic lymph nodes should be considered.
    • Increased FDG uptake in the left breast, the other primary breast cancer should be considered, suggesting biopsy for investigation.
    • Increased FDG uptake at the upper pole of the right kidney, the nature is to be determined also (urine retention, tumor, or other nature ?). Please correlate with other clinical findings for further evaluation.
    • Low-dose CT showed focal or nodular lesions of faint FDG uptake in the liver and in the left upper lung, suggesting follow-up.

[MedRec]

  • 2023-12-07 SOAP Urology Wu ShuYu
    • S: frequency for long, urgency, improving on Oxbu
    • O: ask for refill only
    • A: OAB (overactive bladder)
    • Prescription x3
      • Oxbu (oxybutynin 5mg) 1# QD
  • 2023-10-19 Hemato-Oncology Xia HeXiong
    • S: Celebrex (celecoxib) and Solaxin (chlorzoxazone) prescribed on 2023-10-02 in NTUH BeiHu Branch, for soreness over body
  • 2023-07-04 SOAP Hemato-Oncology Xia HeXiong
    • O
      • 2023/06/23 PATHO - breast mastectomy with regionl lymph nodes
        • Breast tumor, left, BCT + frozen —- Solid papillary carcinoma with invasion
        • Resection margins, ditto — Free of tumor invasion
        • Lymph node, left axillary sentinel area, frozen (F2023-00289) — Free of tumor metastasis (0/4)
        • AJCC Pathologic Anatomic Stage — pT1cN0, if cM0, stage IA; Prognostic Stage — Stage IA
        • Histologic grade (Nottingham histologic score): Grade II (score 6) including (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1
        • Margins: Free of tumor invasion
        • F2023-00289A2: synaptophysin (+, diffuse), chromogranin-A (+, scatter) for tumor, CK5/6 (-) and P63 (-) for myoepithelial cell
        • Please refer to S2023-11754 for ER, PR, Her2/neu and Ki67 status
    • A/P
      • bevcizumab (bevacizumab will be given)
      • Admission for 1st cycle of FOLFOX
  • 2023-06-19 ~ 2023-06-24 POMR General and Gastrointestinal Surgery Chen YenZhi
    • Discharge diagnosis
      • Invasive carcinoma of left of breast, no special type, cT1bN0M0, stage IA, status post left partial mastectomy and sentinel lymph node biopsy and right port-A implantation on 2023/03/21, ECOG:0, ER (+), PR(+), Her2(-), Ki-67(10 %)
      • Malignant neoplasm of sigmoid colon
      • Essential (primary) hypertension
    • CC
      • Left breast tumor was incidentally noted during sigmoid cnacer survey.
    • Present illness
      • This 74 years old female has history of 1) Hypertension under medicaiton control, 2) Sigmoid cancer cT2N1bM1a, stage IV.
      • According to her statement, sigmoid cancer was diagnosis on April, 2023 at NTUH. She went to our hospital for second opinion. However, left breast tumor was incidentally noted during sigmoid cnacer survey.
      • On 06/05 PET was performed which revealed primary rectal-sigmoid cancer with lymph node metastasis and suspecious primary breast cancer. She was referred to GS OPD for breast tumor survey.
      • On 06/13 mammography showed a hyperdense tumor, 1.47cm in UOQ of left breast. Breast sono revealed left 3o’clock/2.23cm, size 0.8x0.48cm irregular shape hypoechoic tumor, suspect malignancy, BI-RADS: Category 4c.
      • Therefore, arrange left breast sono-guide biopsy was done, pethology revealed invasive carcinoma, no special type, IHC stains: ER (+, 100%, strong intensity), PR(+, 75%, strong intensity), Her2/neu: negative(score=0), Ki-67(10 %), p63 (-), CK5/6 (-), Ecadherin (+). Physical examination showed no palpable mass at bilateral breast without tenderness, no nipple retraction and without disacharge nor bleeding, no palpable axillary lymph node.
      • Under impression of left breast cancer, she admitted for surgery management.
    • Course of inpatient treatment
      • After admitted, we arrange cardiopulmonary function test for preoperation survey. She received left breast partial mastectomy, sentinel lymph node biopsy and right port-A implantation was performed on 2023/06/21.
      • The post-operative course was relatively smooth without complication. During the hospitalization analgesic agent were administered and the wound management was performed. There were no nosocomial infection and other complications. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. The wound is clean and without hematoma. Under improved general condition, she was allowed to discharge today, take one JP drain to home and OPD follow up was arranged. 
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
  • 2023-06-15 SOAP General and Gastrointestinal Surgery Chen YenZhi
    • S
      • left breast tumor was incidently noted
    • O
      • 2023/06/13 PATHO - breast biopsy (no need margin)
        • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
        • IHC stains: ER (+, 100%, strong intensity), PR (+, 75%, strong intensity), Her2/neu: negative (score=0), Ki-67 (10 %), p63 (-), CK5/6 (-), E-cadherin (+).
    • A/P
      • left breast BCT and right chest port-A implantation
  • 2023-06-13 SOAP Hemato-Oncology Xia HeXiong
    • S
      • Newly diagnosed sigmoid cancer
      • PH: HTN, lipoma, LC, ERCP
      • For further management of the disease
    • O
      • 2023/06/05 Whole body PET scan:
        • A glucose hypermetabolic lesion at the R-S junction, compatible with the primary rectal cancer.
        • Increased FDG uptake in the left para-aortic lymph nodes, at the L2-3 spine level, metastatic lymph nodes should be considered.
        • Increased FDG uptake in the left breast, the other primary breast cancer should be considered, suggesting biopsy for investigation.
        • Increased FDG uptake at the upper pole of the right kidney, the nature is to be determined also (urine retention, tumor, or other nature ?). Please correlate with other clinical findings for further evaluation.
        • Low-dose CT showed focal or nodular lesions of faint FDG uptake in the liver and in the left upper lung, suggesting follow-up.
      • 2023/05/11 CT (at NTUH) 0401180014
        • History of S-colon cancer – CEA = 1.73 ng/ml; CA19-9 = 16.8 U/ml (2023/05/8).
        • CT without and with contrast enhancement Indication: for evaluation Findings:
          • colon – the S-colon cancer should be correlated with clinical findings. – no regional LNs; – there is no evidence of paraaortic LAPs in abdomen; there is no evidence of LAPs in pelvic cavity and bilateral inguinal areas. – there is no ascites
          • liver – a large hemangioma 65.0mm at the S4a/8 area; – a large hemangioma 60.7mm at the S6 of right lobe of liver; – other multiple smaller hemangiomas are noted in both lobes of liver (arrow key images) – several small cysts in both lobes of liver; – hepatic veins and portal veins are patent
          • operative change of the GB; slightly dilated common bile duct
          • a duodenal diverticulum is noted at the second portion of duodenum
          • tiny cysts in the right kidney; there are no focal lesions in the spleen pancreas both adrenal and kidneys
          • no definite focal lesions in the pelvic cavity
          • atherosclerosis of the aorta;
          • spondylosis of the lumbar spine is noted; The alignment is intact.
          • A vertebral body hemangioma at the L2;
      • Impression
        • S-colon cancer cTxN0M0
        • multiple liver hemangiomas
      • 2023/06/07 MRI Pelvis
        • Findings
          • There is soft tissue lesion in the left lateral wall of the upper rectum, measuring 1.2 cm in size, with submucosa involvement that is c/w adenocarcinoma (T2).
            • In addition, there are three enlarged node 0.4 cm in left perirectal space, 1.6 cm in right internal iliac chain, and 0.6 cm in left sigmoid mesocolon that are c/w regional metastatic node (N1b).
        • There is one enlarged node 1.3 cm in right external iliac chain and three enlarged nodes in left para-aortic space and aortocaval space. Non-regional metastatic node (M1a) is highly suspected.
          • Please correlate with PET scan.
        • There are ten hemangiomas on both hepatic lobes and the largest one measuring 6 cm in S6/7.
          • In addition, few cysts on both hepatic lobes are also noted.
        • S/P cholecystectomy.
        • A renal cyst measuring 1.2 cm in right middle pole is noted.
        • T2N1bM1a, STAGE: IVA
    • P
      • Suggest admission for C/T with FOLFIRI with or without bevcizumab

[surgical operation]

  • 2023-06-21
    • Surgery
      • left partial mastectomy and SLNB
      • port-A implantation
    • Finding
      • left 3/3 tumor
      • SLNB: negative of malignancy, 0/4
      • right chest port-A implantation via right cephalic vein with cut-down method and 7fr Kabi set fixed at 14cm

[chemotherapy]

  • 2024-01-22 - bevacizumab 5mg/kg 260mg NS 100mL 90min + oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-12-29 - bevacizumab 5mg/kg 260mg NS 100mL 90min + oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-11-28 - bevacizumab 5mg/kg 260mg NS 100mL 90min + oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-10-27 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-09-27 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-09-08 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-08-23 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-08-04 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-07-21 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-07-07 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

==========

2024-01-23

[Vit B and CIPN: no clear recommendation, potential benefits remain]

B-Red (hydroxocobalamin) 1mg IM was administered on 2024-01-23 after chemotherapy to prevent oxaliplatin-induced neurotoxicity.

The year 2020 ASCO and joint ESMO/EONS/EANO guidelines concluded that clinicians should not offer vitamin B as a neuroprotectant agent to individuals receiving potentially neurotoxic chemotherapy.

Schloss et al. reported that vitamin B complex supplementation was statistically ineffective at preventing CIPN as compared to the placebo, although as indicated by the results of the Patient Neurotoxicity Questionnaire (PNQ), patients taking the vitamin B complex perceived a reduction in sensory peripheral neuropathy. Importantly, in cases of CIPN coexisting with vitamin B12 deficiency, patients did benefit from the oral supplementation of this medication. Lastly, Abe et al. reported that oral vitamin B12 supplementation did not help in the prevention of the CIPN onset. Their study did not include the control group and they compared the efficacy of B12 supplementation versus goshajinkigan—observed incidence of neuropathy was 88.9% and 39.3%, respectively.

Vitamin B complex supplementation cannot be recommended as the main way of CIPN prevention. Nevertheless, since such therapy does not impact the effectiveness of chemotherapy (with the exception of high doses of pyridoxine), and in some particular cases could potentially have an ameliorative effect, treatment with the vitamin B complex could be a safe and cheap solution.

Ref: Nutrients 2022, 14(3), 625; https://doi.org/10.3390/nu14030625

700857014

240122

[exam findings]

  • 2024-01-17 SONO - abdomen
    • Mild GB wall thickening, possibly secondary to acute hepatitis
    • Minimal right perirenal fluid, focal
  • 2024-01-15 Peripherally Inserted Central Catheter
    • Indication of PICC: plastic anemia with severe thrombocytopenia and anemia, for further chemotherapy
    • We perform PICC at cath room. Under the peripheral echo guiding, We successful pucnture left basilic vein. Under the fluroscopy revealed the wire in true lumin. Micro-sheath was advanced. PICC catheter tip advanced in high right atrial under the fluroscopy smoothly.
    • SvO2 was also check, it revealed 68 %.
      • Estimated Fick Cardiac index 2.28 L/min/m2 (normal cardiac index range 2.6~4.2 L/min/m2)
      • Estimated Fick cardiac output 3.58 L/min. (nomral cardiac output range 5~6 L/min)
  • 2024-01-02 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — marked hypocellularity.
    • Section shows piece(s) of bone marrow with 1% cellularity and M:E ratio of approximately 1:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are markedly reduced in number. There is no malignancy present.
    • IHC stains: CD117: <1%; CD34: <1 %; MPO: 50%, CD61: <1 %; CD71: 50 % (of the nucleated cells). Feature suggestive of severe aplastic anemia. Please correlate with clinical, hemogram, and other laboratoy findings.

[MedRec]

  • 2024-01-12 SOAP Hemato-Oncology Gao WeiYao
    • A: Aplastic anemia with severe thrombocytopenia and anemia
  • 2023-12-29 ~ 2024-01-02 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Severe Thrombocytopenia, unspecified
      • Severe anemia, unspecified
      • Other pancytopenia
    • CC
      • gum bleeding for three months
    • Present illness
      • This is a 58-year-old female with the past history of brain surgery 40 years ago due to intracranial hemorrhage caused by traffic accident.
      • This time, she visited our hema OPD due to purpura over extremiteis for years and gum bleeding for three months. Accompanied with mild dyspnea. There was no fever, no chills, no chest pain, no nausea or vomiting, no tarry stool. Blood test was arranged which revealed pancytopenia. She was then referred to ER for emergent blood transfusion and admission for further studies.
      • At our ER, her vital signs were BP 150/64; HR 114; BT 37’C; RR 18; Con’s:E4V5M6, SpO2 100%. Blood transfusion with LPRBC 4u was arranged. Chest x-ray revealed negative findings.
      • Under the impression of pancytopenia, she was admitted for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, blood transfusion with LPRBC 4u on 12/29, 2u on 12/30, LRP 2u on 12/29 were ordered. We followed up blood test which revealed Hb 4.3 -> 6.5 -> 8.5 g/dL, WBC 2920->1590->1670 uL, PLT 9000->106000->74000 uL. Bone marrow puncture and biopsy was arranged on 2024/01/02 which showed relative dry tapping, yellowish bone marrow biopst, suspect myelofibrosis.
      • She had no significant discomfort during her stay. Under under stable condition, she discharged on 2024-01-02 and OPD follow up was arranged.

[chemotherapy]

  • 2024-01-16 Thymoglobuline (rabbit anti-human thymocyte immunoglobulin) 3.5mg/kg 194mg NS 500mL 12hr D1-5
    • [methylprednisolone 40mg + diphenhydramine 30mg + acetaminophen 1000mg PO + NS 250mL] D1-5

Triple IST (hATG, CsA, EPAG) — Triple immunosuppressive therapy (IST) for severe AA (SAA) comprises eltrombopag (EPAG; a bone marrow stimulating agent) plus two immunosuppressive agents (horse antithymocyte globulin [hATG] and cyclosporine [CsA]). As discussed above, triple IST is generally preferred over treatment with hATG plus CsA alone (no eltrombopag). Ref: 2024-01-22 https://www.uptodate.com/contents/treatment-of-aplastic-anemia-in-adults

==========

2024-01-22

[managing leukopenia and thrombocytopenia in aplastic anemia]

A 58-year-old female, newly diagnosed with aplastic anemia, began treatment with antithymocyte globulin at a dosage of 3.5mg/kg daily for five days starting on 2024-01-16. Additionally, ciclosporin at 300mg daily, divided into two doses (approximately 6mg/kg), was initiated on 2024-01-22. To manage severe leukopenia, G-CSF (filgrastim) has been administered since 2024-01-20. Due to observed thrombocytopenia episodes with platelet counts below 20K/uL, the concurrent initiation of eltrombopag with standard immunosuppressive therapy (antithymocyte globulin and cyclosporine) can also be considered.

Given the patient’s relatively young age, it might be advisable to assess eligibility and seek a match for allogeneic hematopoietic cell transplantation in advance.

700887256

240122

[MedRec]

  • 2023-10-18 ~ 2023-10-22 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Pancreatic cancer under chemotherapy in VGHTPE, last chemotherapy with FOLFIRINOX on 2023/10/04
      • Agranulocytosis secondary to cancer chemotherapy
      • Fever, culture pending
      • Chronic ischemic heart disease, unspecified
      • Paroxysmal atrial fibrillation
      • Other hyperlipidemia
      • Hypomagnesemia
      • Hypokalemia
    • CC
      • He was found lying on the ground by his family members.
    • Present illness
      • The 77 year-old male with history of
        • Pancreatic cancer under chemotherapy in TPEVGH, last chemotherapy with FOLFIRINOX on 2023/10/04,
        • heart disease for least 10 years, CAD s/p stents,
        • spondylolisthesis s/p,
        • Retinal vascular occlusion left eye,
        • Prostatectomy for 10 years.
      • According to the statement of the family, he was found lying on the ground by his family members, so he was brought to our ER for help. Associated symptoms included poor appetite, weakness, fatigue and fever.
      • At ER he conscious level is E4V4M6, vital sign: BT: 38.5’C; PR: 61 time/min; RR: 18 time/min; BP: 124/59mmHg, physical examination showed not under distress, conjunctiva: pale, bilateral clear breathing sounds, no tenderness, no muscle guarding, no rebounding pain, no knocking pain. Denied TOCC history in recent three months.
      • Lab data showed leuokopenia, neutropenia, anemia were noted. CXR was showed no active lung lesion.
      • Follow Brain CT(-C) showed Brain atrophy. Under the tentative diagnosis of neutropenia fever due to cancer chemotherapy. So, he was admitted to our ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission, last time chemotherapy with FOLFIRINOX on 2023/10/04 to 2023/10/06, neutropenia fever was noted, Granocyte 250mcg/vial 1vial SC QD from 2023/10/18~2023/10/20.
      • Empirical antibiotic with Tapimycin 4.5g/vial 4.5g IVD Q6H for infection control from 2023/10/17~2023/10/22.
      • Electrolyte imbalance and anemia were noted, after correction, get improved.
      • With the stable condition, he was discharged on 2023/10/22 and went to TPEVGH OPD followed up later.    

700972958

240122

[lab data]

2024-01-20 Anti-HCV Nonreactive
2024-01-20 Anti-HCV Value 0.16 S/CO
2024-01-20 HBsAg Nonreactive
2024-01-20 HBsAg (Value) 0.35 S/CO
2024-01-20 Anti-HBc Reactive
2024-01-20 Anti-HBc-Value 3.34 S/CO

==========

2024-01-22

[acute pancreatitis: supportive care on track, hepatic markers soar (ABD SONO reveals gallbladder sludge)]

This patient’s current primary medical concern is acute pancreatitis. Supportive therapy with fluid replacement and pain control (using normal saline and tramadol) is being effectively implemented.

Although vital signs, urine output, electrolytes, and serum glucose grossly remain within acceptable ranges, significant elevations were observed in hepatobiliary-related markers (AST, ALT, alkaline phosphatase, gamma-GT, and bilirubin) on 2024-01-20.

Abdominal sonography performed on 2024-01-22 revealed the presence of gallbladder sludge, which may represent a potential contributing factor requiring further management. Is this patient a candidate for cholecystectomy?

701123478

240122

[MedRec]

  • 2024-01-11 SOAP Hemato-Oncology Yang MuJun
    • S: arrange admission for TNT, CCRT with 5FL and then FOLFOX 8 doses, refer to GS for port A insertion and radio-oncologist for RT
  • 2024-01-11 SOAP Radiation Oncology Huang JingMin
    • A:
      • Adenocarcinoma of the rectum, stage cT3N2aM0(IIIB).
    • P:
      • TNT then operation is indicated for this patient with the following indicators: stage cT3N2aM0(IIIB).
        • Goal: curative
        • Treatment target and volume: the pelvic area
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the recta tumor bed.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2024-01-18.
  • 2024-01-11 SOAP Colorectal Surgery Xiao GuangHong
    • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2024-01-09
      • Complete colonoscopy.
      • TNT then OP.

701157014

240122

[MedRec]

  • 2023-10-14, -07-22, -04-29, -03-04, 2022-11-12 SOAP Orthopedics Liu JiYuan
    • Prescription x3 (2023-03-04 x2)
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
      • Celebrex (celecoxib 200mg) 1# QD
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# BID
  • 2022-06-19 ~ 2022-06-24 POMR Orthopedics Liu JiYuan
    • Discharge diagnosis
      • Left femoral head avascular necrosis post Bipolar hemiarthroplasty on 2022/06/20
    • CC
      • Left hip pain for three months
    • Present illness
      • The 54 y/o male has hypertension under medication control. He has smoking and alcohol history. He received right bipolar hemiarthroplasty 3-4 ago. This time, he noticed left hip pain while climbing stairs and came to local clinic for treatment.
      • Due to failure to conservative treatment, he was referred to our OPD for evaluation. The PE showed limping gait and painful ROM. The xray showed left femoral AVN r/o septic arthritis. The bipolar hemiarthroplasty was suggested.
      • He was admitted for preoperative survey and further management.
    • Course of inpatient treatment
      • After admission, preoperative survey revealed no contraindication. The left bipolar arthroplasty was done on 2022/06/20 smoothly. The patient tolerated the procedure well. The postoperative care initiated and the Hb was rechecked on the second days which showed acceptable level. The wound showed mild oozing without loose stitch. The hemovac showed serous discharge and it was removed under low drain amount. The Foley was removed after the patient could walk with assistance to toilet. The patient was taught to place pillow between legs after operation. The rehabilitation started with stable clinical condition. Initially, The strengthening exercise of lower limb was taught and the patient could walk with walker for short distance. The general condition was improved after postoperative care and the wound was kept dry and clean. Due to stable condition, the patient was discharged on 2022/06/24 with some painkiller and the OPD follow-up was arranged one week later.   
    • Discharge prescription
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# BID
      • Sindine (povidone iodine aq soln) ASORDER EXT

[surgical operation]

  • 2022-06-20 - Op Method: Left hip bipolar hemiarthroplasty         
    • Finding:
      • Left femoral head avascular necrosis
      • Prosthesis :
      • Brand : Stryker
      • Cup : 48mm
      • Head : 28mm, metal
      • Stem : #7         
    • Procedure:
      • Under spinal anesthesia, the patient was placed in right decubitus position with side post support in the back and the lower abdomen. Left hip and the whole left leg was disinfected and draped as usual.
      • Posterolateral approach with a curvilinear incision 12 cm in length centered over the greater trochanter was made. The wound was deepened. the fascia lata was split in the same direction along the wound. The short external rotators of the hip and the upper half of the gluteus maximus tendon were detached from their insertion to expose the joint capsule. One T capsulotomy was made and the hip was dislocated with internal rotation. The fractured femoral head was removed with a cork screw driver and the diameter of the head was measured. The remnant of the ligamentum teres was excised. The surface of the acetabulum was checked for smoothness.
      • The hip was flexed, adducted, and internally rotated again. The length of the neck was trimmed with one finger breath left. The femoral canal was prepared with reamer and rasp till appropriate size.
      • Then the femoral stem of desired size was inserted into the femoral canal. the femoral head and cup components of the prostheses were assembled and reduced into the joint cavity after profuse irrigation. The stability of the prostheses was checked.
      • Then the capsule was repaired. One #1/8 hemovac drain was placed. The gluteus maximus and the short external rotators were reattached. The fascia lata was repaired and the wound was closed in layers with compressive dressing to finish the procedure.         

701481589

240122

[lab data]

2023-05-30 Anti-HBc Reactive
2023-05-30 Anti-HBc-Value 3.37 S/CO
2023-05-30 Anti-HBs 80.54 mIU/mL

[exam findings]

  • 2024-01-18 Nasopharyngoscopy
    • Scope: much crust at bi nasopharynx, removed; bi nasopharynx posterior wall and roof soft tissue necrosis and whitish change
    • Conclusion
      • NPC s/p CCRT
      • Post-irradiation nasopharyngeal necrosis
  • 2023-12-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (88 - 21) / 88 = 76.14%
      • M-mode (Teichholz) = 75
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Normal chamber size
      • Trivial MR, TR
  • 2023-12-04 MRI - nasopharynx
    • Findings comparison 2023/05/30 MRI
      • Remarkable tumor regression in the nasopharynx, skull base and intracranial parts. Still abnormal signal intensity of the skull base bones.
      • Total regression, No neck LAP.
      • Decreased pneumontization of the bilateral mastoid air cells indicating chronic mastoiditis.
      • Presence of thick fluid accumulation and thickened mucoperiosteum in the paranasal sinuses, bilateral.
    • IMP:
      • Remarkable tumor regression. Total regression, No neck LAP. Bilateral mastoiditis. Bil. CPS.
  • 2023-11-16 Nasopharyngoscopy
    • Findings
      • much crust at bi nasopharynx (R>L) and right choana, removed; bi nasopharynx posterior wall and roof soft tissue necrosis and whitish change
    • Conclusion
      • NPC s/p CCRT
      • Post-irradiation nasopharyngeal necrosis
  • 2023-10-19 Nasopharyngoscopy
    • Findings
      • much crust at bi posterior nasal cavity and bi nasopharynx (R>L), removed partially; residual crust at right nasopharynx
    • Conclusion
      • NPC s/p CCRT
      • suspect post-irradiation nasopharyngeal necrosis
  • 2023-09-21 Nasopharyngoscopy
    • Findings
      • much crust at bi posterior nasal cavity and bi nasopharynx (R>L), removed partially; mucosa detail of the nasohparynx not clearly seen
    • Conclusion
      • NPC s/p CCRT
      • bi sinusitis, suggest nasal douch
  • 2023-09-11 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 48 dB HL; LE 31 dB HL.
    • RE mild to severe mixed type HL.
    • LE normal to moderately severe HL.(0.5k,1k Hz masking dilemma)
  • 2023-08-24 Nasopharyngoscopy
    • Findings
      • much crust at bi posterior nasal cavity and bi nasopharynx (R>L), removed partially; mucosa detail of the nasohparynx not clearly seen ; hypopharynx and larynx np; suspected right posterior nasal cavity synechiae
    • Conclusion
      • NPC s/p CCRT
  • 2023-07-27 Nasopharyngoscopy
    • Findings
      • bi anterior nasal cavity erosions, crust/mucus coating on bi nasohparynx (right>left) and right middle meatus and bi choana, no gross tumor found
    • Conclusion
      • NPC with right nasal cavity invasion under CCRT
  • 2023-06-29 Nasopharyngoscopy
    • Findings
      • mucus coating on bi nasohparynx and right middle meatus, pulsatile at right sphenoid ostium; tumor size decreased significantly
    • Conclusion
      • NPC with right nasal cavity invasion under CCRT
  • 2023-06-01 PET
    • A large glucose hypermetabolic lesion involving the right posterior nasal cavity, right maxillary sinus, nasopharynx, skull base, sphenoid sinus and right medial temporal fossa of the brain, compatible with a primary malignant tumor.
    • Glucose hypermetabolism in some bilateral retropharyngeal lymph nodes and in some bilateral neck level II lymph nodes. Metastatic lymph nodes may show this picture.
  • 2023-05-30 MRI - nasopharynx
    • Findings
      • Bilateral nasopharynx tumor, with nasal cavity invasion, invsion to the skull base bones and medial right temporal fossa and cavernous sinus.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Enlarged bilateral neck LNs, all above the level of cricoid cartilage.
    • IMP:
      • NPC with skull base and right intracranial extension T4N2M0 stage IVA
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:4(T_value) N:2(N_value) M:0(M_value) STAGE:IVA (Stage_value)
  • 2023-05-24 Patho - nasopharyngeal/oropharyngeal biopsy (Y2)
    • Nasopharynx, right, biopsy — Squamous cell carcinoma, non-keratinizing and undifferentiated
    • The specimen submitted consists of 3 tissue fragments measuring up to 1 x 0.5 x 0.5 cm in size, fixed in formalin. Grossly, they are grayish and solid. All for section.
    • Microscopically, section shows undifferentiated, non-keratinizing squamous cell carcinoma composed of syncytial growth with oval or round vesicular nuclei and prominent nucleoli. There is inflammatory response with necrosis in the adjacent stroma.
    • IHC stain — EBER (+), CK (+), p16 (-)
  • 2023-05-23 Nasopharyngoscopy
    • Findings
      • granular tumor with touch bleeding at bi nasopharynx posterior wall, right NP roof, right choana, bi septum posterior part, right inferior T posterior part and right middle meatus
      • biopsy from right nasopharynx done
    • Conclusion
      • right nasopharyngeal and right nasal tumor
  • 2023-05-23 ENT Hearing Test
    • Tymp type C
    • ART bil absent
    • PTA:
      • Reliability FAIR
      • Average RE 60 dB HL; LE 25 dB HL
      • RE mild to profound MHL
      • LE normal to moderate SNHL
  • 2023-05-19 CT - sinuses for navigator
    • Indication: right sinonasal tumor s/p biopsy. nasopharyngeal tumor
    • CT of sinus without/with contrast enhancement shows:
      • lobulated enhancing tumor centered at nasopharynx and posterior nasal cavity, maximal diameter about 4.5cm, with involvement of posterior ethmoid sinus, posterior and medial right maxillary sinus, right pterygopalatine fossa, sphenoid sinus, paired longus colli muscles, and possible also skull base bone involvement. Suspect nasopharyngeal carcinoma (NPC) or nasal cancer. Suggest tissue proof, and MRI evaluation for more accurate and complete staging.
      • enlarged lymph nodes at bilateral level II, probably lymphadenopathy.
      • right maxillary sinusitis change with increased effusion.
    • Impression:
      • Suspect NPC or nasal cancer. Suggest tissue proof, and MRI evaluation for more accurate and complete staging.
  • 2023-05-19 Patho - paranasal biopsy
    • Nasal cavity, right, biopsy — Squamous cell carcinoma, non-keratinizing and poorly differentiated
    • Microscopically, section shows poorly differentiated squamous cell carcinoma characterized by diffuse sheets of non-keratinizing tumor with invsive growth pattern. The tumor shows nuclar hyperchromasia, pleomorphism, prominent nculeoli, high N/C ratio and mitotic activity.

[MedRec]

  • 2023-07-27 SOAP Hemato-Oncology Xia HeXiong
    • P: Arrange weekly CDDP for CCRT “then followed by PF x 3”
  • 2023-06-08 SOAP Hemato-Oncology Xia HeXiong
    • A: NPC with right nasal cavity invasion; cT4N2M0; stage:IVA
    • P:
      • prepare for CCRT
      • Port-A on 2023-06-13
      • Simulation on 2023-06-05
      • Arrange weekly CDDP for CCRT
  • 2023-06-05 SOAP Radiation Oncology Chang YouKang
    • Diagnosis: Nasopharyngeal cancer, NK & undiffentiated carcinoma, cT4N2M0; stage IVA; ECOG = 1.
    • Plan: CCRT followed by adjuvant C/T or induction C/T followed by CCRT may be considered.
      • RT to NPX tumor and LAPs for 7140cGy/34 fx is suggested for locoregional control. Possible radiation toxicity (radiation mucositis, pharyngitis, esophagitis, dermatitis) is told to her.
      • CT simulation will be arranged on 2023-06-05, 09:30. Diet education & psychological support is given.
  • 2023-05-29 POMR Ear Nose Throat Huang TongCun
    • Discharge diagnosis
      • Malignant neoplasm of nasopharynx, T4N2M0; stage:IVA
    • CC
      • Tinnitus and aural stuffiness (R>L) since 3 years ago, aggravated for half year
    • Present illness
      • This 62 year-old female patient denied any underlying disease. She suffered from tinnitus and aural stuffiness (R>L) since 3 years ago, aggravated and body weight loss 3kg for half year. Epistaxis off and on and intermittent nasal rhinorrhea for years was noted. Denied smoking, drinking and betel nut. She visited local clinic, but the symptom didn’t subside despite medical treatment. Therefore, the patient came to our ENT OPD for help. Physical exam showed polypoid mass at right nasal cavity upper part and right middle meatus with involvement of bilateral posterior septum and right choana. Bilateral nasopharynx posterior wall mass with smooth surface and mucus coating was also noted.
      • Biopsy of right nasal tumor was done on 2023/05/18 and pathology revealed squamous cell carcinoma, non-keratinizing and poorly differentiated.
      • Biopsy of right nasopharynx on 2023/5/23 also revealed Squamous cell carcinoma, non-keratinizing and undifferentiated.
      • Under the impression of nasopharyngenl carcinoma with nasal cavity involvement, admission for further examination was suggested, and the patient agreed after thorough consideration. Therefore, the patient was admitted for cancer work-up.           - Course of inpatient treatment
      • After admission, serial tests were arranged for tumor staging work up. Nasopharynx MRI showed nasopharynx carcinoma T4N2M0, stage:IVA. Abdominal sonography showed negative. PET was done on 2023/06/01 and the result was pending.
      • OS was consulted for pre-RT tooth evaluation. Radio-oncologist was consulted for radiation therapy. Under relative stable condition, the patient was dishcarged with OPD follow up
    • Discharge prescription
      • Allegra (fexofenadine 60mg) 1# BID

[consultation]

  • 2023-05-30 Oral and Maxillofacial Surgery
    • Q
      • For tooth evaluation
      • This 62 year-old female patient denied any underlying disease. She suffered from tinnitus and aural stuffiness (R>L) since 3 years ago, aggravated for half year and epistaxis off and on. She went to our ENT OPD for help. In OPD, polypoid mass at right nasal cavity upper part and right middle meatus with involvement of bilateral posterior septum and right choana. Biopsy was done on 2023/05/18 and pathology revealed squamous cell carcinoma, non-keratinizing and poorly differentiated. Under the impression of nasopharyngenl Carcinoma. The patient was admitted for cancer work-up on 2023/05/29. After admitted, arragne MRI on 5/30; Abd sonography on 5/31; PET on 6/1. We will arrange CCRT for this patient. We need your help for tooth evaluation. Thank`s a lot
    • A
      • We are consulted for dental evaluation prior to CCRT.
      • panoramic film:
        • Prosthodontics: 27,36
        • no large decayed tooth or severe periodontitis of teeth
      • Plan:
        • intraoral physical eaxmination
        • take a panoramic film
        • teach her how to do home care (The patient’s current dental condition does not require extraction treatment.)
        • full mouth scaling and oral hygiene instruction

[radiotherapy]

  • 2023-06-14 ~ 2023-08-01 - 7140cGy/34 fractions (6 MV photon) to NPX tumor and LAPs.

[chemotherapy]

  • 2024-01-19 - cisplatin 60mg/m2 90mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 + fluorouracil 1000mg/m2 1500mg NS 500mL (Y-sited cisplatin D1) D1-4 (PF Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-12-18 - cisplatin 60mg/m2 90mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 + fluorouracil 1000mg/m2 1500mg NS 500mL (Y-sited cisplatin D1) D1-4 (PF Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-11 - cisplatin 60mg/m2 90mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 + fluorouracil 1000mg/m2 1500mg NS 500mL (Y-sited cisplatin D1) D1-4 (PF Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-28 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-21 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-14 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-07 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-30 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-23 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-16 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-01-22

[reconciliation]

Lab data from 2024-01-19 indicated generally normal levels across blood cell counts, electrolytes, and liver and kidney functions. Additionally, a review of the medication records revealed no discrepancies.

2023-10-30

[Achrimobacter xylosoxidans bacteremia]

For treating Achromobacter xylosoxidans infections in patients without cystic fibrosis:

  • Ceftazidime 1-2 gm IV q8-12 h
  • Imipenem-cilastatin 500 mg IV q6h or Meropenem 1-2 gm IV q8h or Doripenem 500 mg IV q8h (not for pneumonia)
  • Ciprofloxacin 400 mg IV q12h

701491453

240122

  • 2023-07-21 ~ 2023-07-25 POMR Obstetrics and Gynecology Huang SiCheng
    • Discharge diagnosis
      • Malignant neoplasm of endometrium
      • Endometrial hyperplasia
      • Postmenopausal bleeding
      • Anemia due to abnormal vaginal bleeding
    • CC
      • Vaginal bleeding for 1 week
    • Present illness
      • This is a 54 year-old female, G1P1, without systemic disease, admitted because of large amount of vaginal bleeding for 1 week.
      • Tracing back to her history, her menstrual cycle was irregular with unknown last mestrual period and intermittend vaginal spoting for years. There was also a palpable mass below the umbilicus noted for years. She also lost weight about 3kg in 2 weeks. This time, she had large amount vaginal bleeding one week ago and needed to change pad 5-6 times a night, with blood clots found sometimes, accompanied with dizziness. Therefore, she came to our GYN OPD for help. At OPD, her lab data revealed anemia (Hb 6.2g/dL). Sonography was done and revealed endometrium 5.74mm and left ovarian cyst 8.1*4.8cm.
      • Under the impression of endometrial cancer, she was admitted for further survey and management.
    • Course of inpatient treatment
      • Under the impression of endometrial hyperplasia with polyp suspected endometrial cancer. She was admission for further survey and management on 2023/07/22.
      • Due to anemia (Hb = 6.0) and blood transfusion with LP-RBC 4U/2U were given on 2023/07/22 and 2023/07/24.
      • The pelvic MRI was done and revealed diffuse soft tissue tumor in the uterine cavity and cervical region with parametrial involvement and hydrometra, pelvic lymph nodes, r/o endometrial malignancy, cstage T3bN1aM0. We was consult GU for cystoscopic because of suspected cervical cancer on 2023/07/22. The cervix biopsy was performed on 2023/07/23 and showed Adenocarcinoma.
      • The Upper G-I panendoscopy and Colon fiberoscopy were arranged for work up and tumor survey. We arranged discharge for her for further OPD follow up on 2023/07/27.  
    • Discharge prescription
      • Anxiedin (lorazepam 0.5mg) 1# HS

[radiotherapy]

[chemotherapy]

  • 2024-01-23 - paclitaxel 175mg/m2 238mg NS 250mL 4hr + carboplatin AUC 5 675mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-12-20 - paclitaxel 175mg/m2 240mg NS 250mL 4hr + carboplatin AUC 5 825mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-11-15 - cisplatin 35mg/m2 50mg NS 500mL 90min + NS 500mL 1hr (post cisplatin) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 1000mL
  • 2023-11-08 - cisplatin 35mg/m2 50mg NS 500mL 90min + NS 500mL 1hr (post cisplatin) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 1000mL
  • 2023-11-01 - cisplatin 35mg/m2 50mg NS 500mL 90min + NS 500mL 1hr (post cisplatin) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 1000mL
  • 2023-10-25 - cisplatin 35mg/m2 50mg NS 500mL 90min + NS 500mL 1hr (post cisplatin) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 1000mL
  • 2023-09-12 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 1000mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-08-22 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 960mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

700206320

240119

[exam findings] (not completed)

  • 2023-12-19 Patho - ureter biopsy
    • Labeled as “right renal pelvis tumor”, URS biopsy — carcinoma, high grade.
    • Specimen submitted in formalin consists of 3 piece(s) of tan, irregular tissue measuring 0.4 x 0.2 x 0.1 cm. All tissue for section(s) in one cassette(s).
    • Section shows pieces of high grade carcinoma.
    • IHC stains: CK7 (+), GATA-3 (equivocal), CD10 (-), CAIX (-), vientin (-), RCC (-). The tumor location and the IHC pattern are in favor of urothelial carcinoma.

[MedRec]

  • 2023-12-19 ~ 2024-01-04 POMR Urology Cai YaoZhou
    • Discharge diagnosis
      • Right renal pelvis urothelial carcinoma, cT3N2M0, stage IV status post 1) Rightr ureterorenoscopic exam & double-J stenting on 2023-12-19; 2) Port-A insertion on 2023-12-25; 3) Immunotherapy with Nivolumab (#1) on 12/27, Chemotherapy with Carboplatin + Gemcitabine (#1 D1) on 12/27, Chemotherapy with Gemcitabine (D8) on 2024-01-03
      • Benign neoplasm of right kidney
      • Right hydronephrosis
    • CC
      • Presented with hematuria and right flank soreness for the past two weeks
    • Present illness
      • This 47-year-old female with no surgical or chronic medical history. Previously sought emergency care for urinary tract infection and migraines. On 2016-11-05, elevated Cr of 1.3 mg/dL was detected. Regular follow-ups have been conducted since then. Presented with hematuria and right flank soreness for the past two weeks. Sought consultation at the Nephrology Department, where lab data revealed elevated Cr of 2.9 mg/dL. Renal ultrasound showed right renal pelvic mass lesion and hydronephrosis, r/o urothelial carcinoma. Subsequently, referred to the Urology Department for further investigation.
      • Under the impression of right renal tumor, we advised the patient to receive right fURS exam biopsy. After well explaining, the patient agreed. This time, she was admitted for further evaluation and manageme.
    • Course of inpatient treatment
      • After admission, the surgery of 1) Rightr ureterorenoscopic exam & double-J stenting on 2023-12-19; 2) Port-A insertion was performed on 2023-12-25. Post operation, MRI revealed right renal pelvis urothelial carcinoma, cT3N2M0, stage IV. Pathrology showed carcinoma, high grade.
      • PET showed metastatic lymph node. She received Immunotherapy with Nivolumab (#1) on 12/27 and chemotherapy with Carboplatin + Gemcitabine (#1 D1) on 12/27.
      • After treatment, severe nausea and poor oral intake was noted. IVF support and symptom treatment. Stable condition she receive chemotherapy with Gemcitabine (D8) on 2024-01-03.
      • With fair urination, he was discharged today and would be followed up at urologic clinic for further treatment.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQID
      • Roumin (prochlorperazine maleate 5mg) 1# PRNQ12H
  • 2021-02-26, 2020-11-20, -08-14, -05-22, -02-04, 2019-11-12, -08-13 SOAP Nephrology Hong SiQun
    • Prescription x3
      • Foliromin (ferrous sodium citrate 50mg) 1# QD
      • Atozet (ezetimibe 10mg, atorvastatin 20mg) 1# QD
      • Compesolon (prednisolone 5mg) 2# QOD
      • Pentop (pentoxifylline 400mg) 1# QD
  • 2019-05-21 SOAP Nephrology Hong SiQun
    • S
      • AIMHI study V1
    • O
      • Cr 1.6 -> 1.8 -> 1.8 -> 1.8 -> Cr 1.9, LDL 136
    • Diagnosis
      • Abnormal renal function test [R94.4]
      • Dyslipidemia [E78.4]
    • Prescription x3
      • Vytorin (ezetimibe 10mg, simvastatin 20mg) 1# HS
      • Compesolon (prednisolone 5mg) 2# QOD
      • Pentop (pentoxifylline 400mg) 1# QD
  • 2019-01-11 SOAP Nephrology Hong SiQun
    • S
      • elevated CRE and came for F/U
      • add prednislone 2# qod and follow up
    • Diagnosis
      • Abnormal renal function test [R94.4]
    • Prescription x3
      • Compesolon (prednisolone 5mg) 2# QOD
      • Pentop (pentoxifylline 400mg) 1# QD
  • 2018-09-21 SOAP Nephrology Hong SiQun
    • S
      • CKD for follow up
      • add trental and follow up
      • elevated CRE and came for F/U
      • acute on chronic CKD, cause?
    • O
      • arrange further study
      • consider renal biopsy if progression
    • Diagnosis
      • Abnormal renal function test [R94.4]
    • Prescription x3
      • Pentop (pentoxifylline 400mg) 1# QD
  • 2018-08-23 SOAP Metabolism and Endocrinology Zen YiQian
    • S
      • PH: migraine, CKD
      • CC: frequently attacked recently, painkiller can’t improve, photophobia
    • O
      • E4V5M6
      • CNs: intact
      • MP: full
      • sensaiton: intact
      • FNF: no dysmetria
      • gait: steady
      • impression: migraine
      • plan: imigran and try suzin
      • 2017/12/26 BUN 26 mg/dL, CRE 1.6 mg/dL
      • 2018/05/04 BUN 25 mg/dL, CRE 1.6 mg/dL
      • 2018/05/04 CA 125 53.7 IU/mL
    • Diagnosis
      • Comnon migraine with intractable migraine, so stated [G43.019]
      • Chronic renal insufficiency [N18.9]
    • Prescription x3
      • Imigran (sumatriptan 50mg) 3# QW
  • 2017-07-13 SOAP Metabolism and Endocrinology Zen YiQian
    • S
      • migrane attacked and lasted over 24 hrs
      • not subsided after panadol and NSAID tx
      • PH: eczema
    • O
      • palpule with severe itching and excoriation over back
      • 2016/11/23 GLU 136 mg/dL, CRE 1.3 mg/dL
    • Diagnosis
      • Eczema [L30.8]
      • Renal function impairment [N18.9]
      • Mixed hyperlipidemia [E78.2]
    • Prescription x3
      • Allegra (fexofenadine 60mg) 1# BID

[consultation]

[immunochemotherapy]

  • 2024-01-19 - carboplatin 260mg NS 100mL 1hr + gemcitabine 1000mg/m2 1400mg NS 100mL 1hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 500mL
  • 2024-01-03 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL
  • 2023-12-27 - nivolumab 300mg NS 100mL 1hr + carboplatin 260mg NS 100mL 1hr + gemcitabine 1000mg/m2 1400mg NS 100mL 1hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 500mL
  • 2023-12-20 mitomycin-C 30mg/m2 30mg BI 1hr

==========

2024-01-19

[transfusion in chemotherapy-induced anemia]

Given the patient’s renal impairment, a modified treatment regimen of nivolumab combined with gemcitabine and carboplatin was administered instead of the standard nivolumab, gemcitabine, and cisplatin therapy.

The patient’s hemoglobin levels have shown a consistent decline, indicating anemia:

  • 2024-01-19 HGB 6.9 g/dL
  • 2024-01-03 HGB 8.1 g/dL
  • 2023-12-19 HGB 9.5 g/dL
  • 2023-12-12 HGB 10.2 g/dL

Anemia is associated with gemcitabine (68%; grade 3: 7%; grade 4: 1%), carboplatin (21% to 90%), and nivolumab (26% to 41%; grades 3/4: <=3%). The downward trend in HGB might suggest insufficient red blood cell production to match the treatment schedule. A transfusion was performed on 2024-01-19, which is considered an appropriate action. If adverse reactions increase, modifying the administration interval or dose reduction could be further decided.

700930423

240119

[diagnosis] - 2023-04-10 admission note

  • Adenocarcinoma of descending-sigmoid colon with liver metastasis cT3N1M1, stage IVB

[past history] - 2023-01-12 admission note

  • Chronic hepatitis C for 40 years
  • Diabetes mellitus for 5 years with insulin control.
  • Hypertension since 2009 without drug control.
  • Panic disorder with medical treatment since 1990

[allergy]

  • Omnipaque (iohexol) - skin rash

[family history]

  • Father: pancreatic cancer
  • Two younger brother: coronary artery disease post PTCA with stenting
  • Mother: heart disease
  • Elder sister: breast cancer

[lab data]

  • 2022-12-13 Anti-HBc Reactive
  • 2022-12-13 Anti-HBc-Value 6.08 S/CO
  • 2022-12-13 HBsAg Nonreactive
  • 2022-12-13 HBsAg (Value) 0.33 S/CO
  • 2022-12-13 Anti-HCV Reactive
  • 2022-12-13 Anti-HCV Value 12.14 S/CO

[exam findings]

  • 2023-11-29 All-RAS + BRAF mutation
    • Cellblock No. S2018-12982A4
    • RESULTS:
      • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-11-29 KUB
    • Spondylosis of the L-spine is noted.
  • 2023-11-15 CT - abdomen
    • History: synchronous D-colon cancer (pT3N0M0) and Sigmoid cancer (pT2N0M0) s/p Lt hemicolectomy on 2018-08-14 by Dr Xiao GuangHong
      • 2019/09/12 MRI: two metastases in S8 dome and S7 s/p Op by Dr Wu ChaoQun,
      • 2020/04/07 MRI: A poor enhancing nodule (2.9cm) in Rt liver dome
      • 2020/09/15 MRI: A poor enhancing nodule (1.2cm) in Rt liver dome
      • 2022/01/07 MRI: No focal lesion in the right liver dome
      • 2022/12/02 MRI: Two metastases 4 cm in S2 and 1 cm in S4.
      • 2023/03/17 MRI: Two metastases 2.6 cm in S2 and 1 cm in S4.
    • Findings: Comparison prior MRI dated 2023/03/17.
      • There is a poor enhancing lesion 4.4 x 2.5 cm in S2 of the liver dome. Please correlate with MRI to R/O metastasis S/P treatment?
      • There is a rim enhancing lesion 2 cm in S4 of the liver that is c/w metastasis.
      • S/P partial resection of S8 dome and S6/7 of the liver.
        • There is mild irregular liver contour that may be cirrhosis.
        • There is splenomegaly (long axis: 12 cm) that may be portal hypertension.
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, & both kidneys.
        • There is no evidence of ascites or lymphadenopathy.
        • The abdominal aorta and IVC are grossly unremarkable.
    • IMP:
      • There is a poor enhancing lesion 4.4 x 2.5 cm in S2 of the liver dome. Please correlate with MRI to R/O metastasis S/P treatment?
      • Metastasis 2 cm in S4 of the liver.
  • 2023-11-08 EGD
    • Reflux esophagitis LA Classification grade A
    • Esophageal varices F1CbLi.; S/P EVL
    • Superficial gastritis; antrum
  • 2023-10-13 PET
    • Two glucose hypermetabolic lesions in the segment 2 and segment 4 of the liver respectively, compatible with liver metastases.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar and some mediastinal lymph nodes. Inflammation is more likely.
    • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulaiton may show this picture.
  • 2023-10-03 ECG
    • Sinus rhythm with 1st degree A-V block with frequent Premature ventricular complexes
  • 2023-10-03 ECG
    • Sinus bradycardia with 1st degree A-V block
  • 2023-08-16 SONO - abdomen
    • Diagnosis:
      • poor echo window due to much bowel gas and unable to detect two lesions, S2 and S4, noted at liver MRI (2023/07/18).
      • Suspcious liver calcified, right posterior segment
      • Liver cirrhosis, mild splenomegaly
      • fatty infiltration of pancreas
    • Suggestion:
      • arrange other image for complete liver survey
  • 2023-07-21 Myocardial perfusion SPECT with persantin
    • Probably moderate myocardial ischemia at the inferoposterior wall and mild myocardial ischemia at the anteroapical wall, anteroseptal wall and basal lateral wall.
  • 2023-07-18 MRI - upper abdomen
    • History and indication: Liver metastases
    • With and without contrast MRI of liver revealed:
      • Stable size (1.0cm) of S4 lesion. Decreased size (2.2cm) of S2 lesion.
      • Tiny cysts in liver and spleen.
    • IMP:
      • Stable size (1.0cm) of S4 lesion. Decreased size (2.2cm) of S2 lesion.
  • 2023-07-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (82 - 38) / 82 = 53.66%
      • 2D (M-Simpson) = 54
    • Conclusion:
      • Hypokinesia of LV inferior wall, posterior wall with preserved LV systolic function.
      • Normal RV systolic function.
      • Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Mild aortic valve sclerosis with mild AR; mild PR; mild posterior mitral annulus calcification.
      • Dilated aortic root and proximal ascending aorta (40 mm) with mild calcification.
  • 2023-06-29 ECG
    • Sinus rhythm with 1st degree A-V block with frequent Premature ventricular complexes
    • Abnormal ECG
  • 2023-06-29 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2023-06-29 Abdomen - standing (diaphragm)
    • Spondylosis of the L-spine is noted.
    • Splenomegaly.
  • 2023-05-18 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Suboptimal study, due to food residuals
      • Reflux esophagitis LA Classification grade A
      • Esophageal varices, F1CbLi. RCS(-) White nipple sign(-). From 32cm to 40cm below incisors.
      • Gastric shallow ulcers, antrum
    • Suggestion
      • Suboptimal study, due to food residuals
      • PPI use
      • Regular follou up
  • 2023-03-17 MRI - upper abdomen
    • History and Indication:
      • synchronous D-colon cancer (pT3N0M0) and Sigmoid cancer(pT2N0M0) s/p Lt hemicolectomy on 20180814
      • 2019/09/12 MRI: two metas in S8 dome and S7 s/p Op
      • 2020/04/07 MRI: A poor enhancing nodule (2.9cm) in Rt liver dome
      • 2020/09/15 MRI: A poor enhancing nodule (1.2cm) in Rt liver dome
      • 2022/01/07 MRI: No focal lesion in the right liver dome
      • 2022/12/02 MRI: Two metastases 2.5 cm in S2 and 1 cm in S4.
    • MR Imaging of the abdomen was performed on a 1.5 T superconducting magnet and phase arrayed body coil. Patient kept in supine position with field of view 38 cm, slice thickness 6 mm and gap 1 mm.
    • Non-contrast MRI has limitation in diagnosis of solid organ pathology, bowel loop lesion, and vascular system abnormality. We recommend contrast enhanced MRI if patient’s renal function can tolerate Gd-DTPA injection.
      • Prior MRI identified a metastasis 4 cm in S2 of the liver is noted again, decreasing in size to 2.6 cm that is c/w metastasis S/P C/T with partial response.
        • In addition, Prior MRI identified a metastasis 1 cm in S4 of the liver is noted again, stable in size that is c/w metastasis S/P C/T with stable disease.
      • S/P partial resection of S8 dome and S6/7 of the liver.
        • There is mild irregular liver contour that may be cirrhosis.
      • There is splenomegaly (long axis: 12 cm) and small recanalization of paraumbilical vein that is compatible with portal hypertension.
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, & both kidneys.
      • There is no evidence of ascites or lymphadenopathy.
      • The abdominal aorta and IVC are grossly unremarkable.
    • IMP:
      • One metastasis in S2 liver S/P C/T shows partial response.
      • One metastasis in S4 liver S/P C/T shows stable disease.
  • 2022-12-02 MRI - upper abdomen
    • History and Indication: synchronous D-colon cancer (pT3N0M0) and Sigmoid cancer(pT2N0M0) s/p Lt hemicolectomy on 20180814.
      • 2019/09/12 MRI:two metas in S8 dome and S7 s/p Op
      • 2020/04/07 MRI: A poor enhancing nodule (2.9cm) in Rt liver dome
      • 2020/09/15 MRI: A poor enhancing nodule (1.2cm) in Rt liver dome
      • 2022/01/07 MRI: No focal lesion in the right liver dome
    • Findings
      • There are two mass lesions measuring 4 cm in S2 and 1 cm in S4 of the liver, showing hypointensity on T1WI and mild hyperintensity on both T2WI and DWI.
        • Two metastases 4 cm in S2 and 1 cm in S4 of the liver are suspected.
      • S/P partial resection of S8 dome and S6/7 of the liver.
        • There is mild irregular liver contour that may be cirrhosis.
      • There is splenomegaly (long axis: 12 cm) and small recanalization of paraumbilical vein that is compatible with portal hypertension.
    • IMP:
      • Two metastases 4 cm in S2 and 1 cm in S4 of the liver are suspected.
  • 2022-09-15 SONO - abdomen
    • S/P right liver operation. Mild splenomegaly.
  • 2022-06-27 MRI - upper abdomen
    • S/P liver operation. Liver cirrhosis with splenomegaly.
  • 2022-06-21 Patho - colorectal polyp
    • Colon, descending colon (40 cm from anal verge), Biopsy removal Specimen: A — Hyperplastic polyp
      • Section shows fragment(s) of polypoid colonic mucosal tissue with crowded benign hyperplastic mucinous glands.
    • Colon, sigmoid colon (25 cm from anal verge), Polypectomy (cold snaring) Specimen: B — Tubular adenoma with low grade dysplasia
      • Section shows fragment(s) of polypoid colonic mucosal tissue with proliferative tubular mucinous glands lined by cells containing hyperchromatic, elongated nuclei with low grade dysplasia.
  • 2022-06-21 Colonoscopy
    • Colon cancer s/p op
    • No evidence of recurrence
  • 2022-06-06 SONO - abdomen
    • poor echo window
    • Liver cirrhosis (incomplete exam of liver), mild splenomegaly
    • fatty infiltration of pancreas
  • 2022-03-31 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2022-03-04 SONO - abdomen
    • Liver cirrhosis
    • Splenomegaly
    • Suboptimal examination of liver due to poor echo window
  • 2022-01-07 MRI - upper abdomen
    • History and Indication:
      • synchronous D-colon cancer (pT3N0M0) and Sigmoid cancer (pT2N0M0) s/p Lt hemicolectomy on 20180814
      • 2019/09/12 MRI: two metas in S8 dome and S7 s/p Op,
      • 2020/04/07 MRI: A poor enhancing nodule (2.9cm) in Rt liver dome
      • 2020/09/15 MRI: A poor enhancing nodule (1.2cm) in Rt liver dome
      • 2021/07/09 MRI: No focal lesion in the right liver dome
    • Findings:
      • S/P partial resection of S8 dome and S6/7 of the liver. There is no abnormal signal nodule in the residual liver on both T1WI, T2WI, and DWI.
      • There is mild irregular liver contour that may be cirrhosis.
      • There is splenomegaly (long axis: 12 cm) and small recanalization of paraumbilical vein that is compatible with portal hypertension.
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, & both kidney.
      • There is no evidence of ascites or lymphadenopathy.
      • The abdominal aorta and IVC are grossly unremarkable.
    • IMP:
      • No focal lesion in the residual liver.
      • Cirrhosis of the liver and portal hypertension.
  • 2021-12-03 SONO - abdomen
    • Suspected cirrhosis with splenomegaly, mild
    • Pancreas not shown
    • Suboptimal examination of liver due to poor echo window
  • 2021-09-30 SONO - abdomen
    • S/P right liver operation.
  • 2021-07-16 Bladder sonography
    • PVR 5.12mL
  • 2021-07-16 Uroflowmetry
    • Q max: good
    • flow pattern: obstructive
  • 2021-07-09 MRI - upper abdomen
    • No focal lesion in the residual liver.
    • Cirrhosis of the liver and portal hypertension.
  • 2021-05-12 Patho - stomach biopsy
    • Stomach, mid body, PW side, s/p biopsy — Chronic gastritis, H pylori NOT present
  • 2021-03-02 SONO - abdomen
    • S/P partial resection of right lobe liver.
    • Early cirrhosis of the liver and Splenomegaly.
  • 2020-12-07 MRI - upper abdomen
    • S/P liver operation. A small hemangioma (0.8cm) at S7 of liver. Tiny liver cysts. Liver cirrhosis with splenomegaly.
  • 2020-10-20 Patho - colorectal polyp
    • Colon polyp, splenic flexure, polypectomy — Tubular adenoma with low grade dysplasia
  • 2020-10-20 Colonoscopy
    • Colon cancer s/p op
    • No evidence of recurrence
    • Splenic flexure polyp s/p polypectomy
  • 2020-09-16 Neurosonology
    • Mild to moderate atheromatous lesions in L middle CCA; mild atheromatous lesions in bilateral CCA bifurcations.
    • Smaller caliber with decreased flow in L cervical VA, possible L VA hypoplasia.
    • Normal extracranial carotid and R vertebral arterial flows.
  • 2020-09-15 MRI - upper abdomen
    • Colon cancer s/p operation.
    • Much regression of right liver nodules (up to 1.2cm).
    • Splenomegaly.
  • 2020-08-15 MRA - brain
    • Indication: brain concussion with unsteady gait
    • IMP
      • No definite intracranial hemorrhage
      • Brain atrophy
  • 2020-08-15 CT - brain
    • Indication: suspected concussion
    • IMP:
      • No definite intracranial hemorrhage
      • Brain atrophy and intracranial arteriosclerosis
  • 2020-05-06 Nerve Conduction Velocity, NCV
    • Findings
      • MNCV: decrease amplitude in left peroneal nerve and right tibial nerve acrros popliteal fossa.
      • SNCV: decrease amplitude in bilateral median, ulnar and sural nerves. slow NCV in bilateral median and left ulnar nerves.
      • F-wave: prolonged latencies in bilateral median, left ulnar, bilateral peroneal+ tibial nerves.
      • H-reflex: prolonged latencies bilaterally.
    • Conclusion
      • This NCV study suggests axonal sensory polyneuropathy, may superimposed polyradiaculopathy.
  • 2020-05-06 Quantitative Sensory Threshold, QST
    • Findings: Abnormal warm threshold and normal cold threshold in left extremities.
    • Conclusion: This QST study suggests small fiber neuropathy in left extremities.
  • 2020-04-14 PET
    • No prominent FDG uptake was noted in the liver dome tumor delineated in the MRI imaging. However, a metastatic lesion of low FDG uptake can not be ruled out. Please correlate with other imaging modalities for further evaluation.
    • A glucose hypermetabolic lesion in the left supraclavicular fossa. The nature is to be determined (a metastatic lesion? other nature?). Please correlate with other clinical findings for further evaluation.
    • A mild glucose hypermetabolic lesion in the left anterior upper chest region near the Port-A implantation. The nature is to be determined. (inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
    • No prominent glucose hypermetabolism in the lesion in the middle lobe of right lung. Please also correlate with other imaging modalities for further evaluation.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammatory process may show this picture.
  • 2020-04-07 MRI - liver, spleen
    • History and indication: colon colon cancer with liver & lung mets
    • IMP: Right liver metastases s/p resection. A poor enhancing nodule (2.9cm) in right liver dome suspected metastases.
  • 2020-04-07 CT - chest
    • no interval change of a RML perifissural solid nodule as compared with previous CT study on 2019/11/22, more in favor odfan intrapulmonary LN rather metastatic nodule.
    • substantial centrilobular emphysema and subpleural paraseptal emphysema in RUL and LUL.
  • 2019-11-22 CT - chest
    • Indication: colon cancer with liver mets
    • Imp: Very tiny nodule at right upper lobe about 0.6cm in largest dimension is found. Nature to be determined.
  • 2019-10-02 Surgical pathology Level V
    • Clinical diagnosis: Malignant sigmoid colon neoplasm
    • Pathologic diagnosis
      • Liver, S7, segmental hepatectomy — Metastatic colonic adenocarcinoma
      • Liver, S8, partial hepatectomy — Metastatic colonic adenocarcinoma
      • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
    • Macroscopic examination
      • Procedures: Segmental hepatectomy of S7 and partial hepatectomy of S8
      • Specimen Size: 8.4 x 6.8 x 3.0 cm, 178 gm (S7), 5.5 x 4.7 x 2.1 cm and 24 gm (S8)
      • Tumor Focality: Multiple (number: 2)
      • Tumor Site: S7 and S8
      • Tumor Size: 2.5 x 2.3 x 2.2 cm with satellite nodule, 0.3 cm (S7); and 2.0 x 1.8 x 1.5 cm (S8)
      • Large vessel involvement: Not identified
      • Non-tumorous part: Cirrhotic
      • Sections are taken and labeled as: A1-A2= S7 tumor, A3= S7 satellite nodule + margin, B1-B2= S8 tumor
    • Microscopic examination
      • Diagnosis: Metastatic colonic adenoarcinoma
      • Histologic grade: Moderately differentiated
      • Tumor growth pattern: Infiltrative
      • Tumor pseudocapsule: Absent
      • Tumor necrosis: Mild (10%)
      • Parenchymal margin: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margins: 1.1 cm (S7) and 1.1 cm (S8), respectively
      • Vascular invasion: Not identified
      • Perineural invasion: Not identified
      • Tumor regression grade: Grade 4 (residual cancer cells predominate over fibrosis)
      • Non-neoplastic liver parenchyma: Chronic hepatitis C with cirrhosis
      • Fatty Change: Present (5%)
  • 2019-09-12 MRI - liver, spleen
    • A case of synchronous D-colon cancer (pT3N0M0) and Sigmoid cancer (pT2N0M0) s/p Laparoscopic left hemicolectomy on 2018-08-14.
      • Hard stool passage
      • liver metastasis
      • obvious tumor at right lobe at least two tumor at S8 and S6-7
    • Findings
      • Hypervascular hepatic tumor at S7 of liver up to 2.7cm, and another less enhanced tumor at dome up to 1.6cm is found. Metastasis is considered.
      • Very tiny nodule at right middle lobe up to 0.2cm is found. lung meta is considered.
    • Impression:
      • Compatible with liver and lung meta.
  • 2019-09-10 SONO - abdomen
    • Diagnosis
      • Parenchymal liver disease
      • Hepatic tumor, nature to be determinated
    • Suggestion
      • Post tumor biopsy, please pursue pathology report
  • 2019-09-09 Surgical pathology level V
    • Indication: Malignant sigmoid colon neoplasm
    • Diagnosis: Liver, clinical history of colorectal carcinoma, CT guided biopsy — Adenocarcinoma.
      • IHC stain CK20 (+), compatible with colorectal adenocarcinoma.
  • 2019-08-26 PET
    • Multiple mildly to moderately glucose hypermetabolic lesions in right lobe of liver, hepatic metastases from tumors of lower FDG avidity (e.g., better differentiated tumors) should be considered. Please correlate with other work-up studies for further evaluation.
    • A nodule-like lesion in the middle lobe of right lung without prominent glucose hypermetabolism, the nature is to be determined (pulmonary metastasis, inflammatory lesion, or else). Please correlate with other work-up studies and keep follow-up for further evaluation.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, reactive change in response to locoregional inflammation may show such a picture.
  • 2019-08-19 CT - abdomen
    • Colon cancer s/p operaiton. In favor of lung and liver metastases.
  • 2019-02-14 SONO - abdomen
    • Suspected chronic liver parenchyma disease (Please correlate with liver function)
    • Poor assessment of biliary tract and PV
    • Pancreas not shown
    • Suboptimal examination of liver due to poor echo window
  • 2018-11-16 Brainstem auditory evoked potential, BAEP
    • The BAEP study showed no response of left wave I. The above finding suggest left side lesion distal to auditory nerve. Advise clinical correlation.
  • 2018-11-06 Colon fiberoscopy
    • Colon cancer s/p op
    • No evidence of cancer recurrence
  • 2018-10-13 MRI - L-spine
    • Grade I spondylolisthesis at L4/5 with moderate spinal canal stenosis.
  • 2018-08-02 Surgical pathology Level VI
    • pathologic diagnosis
      • Large intestine, descending-sigmoid colon (and sigmoid?), laparoscopic left hemicolectomy?/ Laparoscopic anterior resection and anastomosis-malignant? — Adenocarcinoma, moderately differentiated x2
      • Resection margins: free
      • Lymph node, mesocolic, dissection — Free (0/16)
      • Lymph node, IMA / SMA, dissection — N/A.
      • AJCC 8th edition Pathology stage:
        • Larger one: pT3N0 (if cM0); pStage: IIA.
        • Smaller one: pT2N0 (if cM0); pStage: I.
        • NOTE: cM might be the same or might be upgraded when more clinical and image data are available for evaluation.
    • macroscopic examination
      • Operation procedure: laparoscopic left hemicolectomy?/ Laparoscopic anterior resection and anastomosis-malignant?
      • Specimen site: descending sigmoid colon
      • Specimen size: 11 cm in length
      • Tumor size: the larger one 3.5 x 3 x 3 cm at 1.8 cm away from one end and another smaller one 1 x 0.5 x 0.5 cm at 2.0 cm from the other end.
      • Tumor location: 1.8 cm and 2.0 cm away from the two resection margins, respectively.
      • Depth of invasion grossly: the smaller one: muscularis propria; the larger one: mesocolic soft tissue.
      • Mucosa elsewhere: Free.
      • Tissue for sections: A1-2: bilateral margins; A3-5: the larger tumor; A6: the smaller tumor; A7-9: lymph nodes.
    • microscopic examination
      • Histology: Adenocarcinoma,
      • Histology Grade: moderately differentiated
      • Depth of invasion: the smaller one: muscularis propria; the larger one: mesocolic soft tissue.
      • Angiolymphatic invasion: Not identified.
      • Perineural invasion: Not identified.
      • Discontinuous extramural tumor extension: Not identified.
      • Serosal margin status of colon: Uninvolved, 2 mm in distance.
      • Lymph node metastasis, mesocolic: Free (0/16)
      • Lymph node metastasis,, IMA / SMA: N/A.
      • Extranodal involvement: N/A.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT)
          • Larger one: pT3N0 (if cM0); pStage: IIA.
          • Smaller one: pT2N0 (if cM0); pStage: I.
        • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
        • Distant Metastasis (pM): if cM0
        • NOTE: cM might be the same or might be upgraded when more clinical and image data are available for evaluation.
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: None identified.
      • TNM descriptors: N/A.
      • Tumor regression grading S/P CCRT: N/A.
    • REFERENCE:
      • S2018-11971: Colon, splenic flexure 60 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • S2018-11972: Colon, descending 45 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2018-07-17 Surgical pathology Level IV
    • Colon, descending 45 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • Colon, splenic flexure 60 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2018-07-17 Colon fiberoscopy
    • Splenic flexure cancer with partial obstruction s/p biopsy, tattooed and clipped
    • Suspected synchnous D-colon cancer s/p biopsy tattooed and clipped
    • Colon polyp s/p polypectomy
  • 2018-04-30 24hrs Holtor’s scan
    • Baseline was sinus rhythm with 1st degree AV block
    • A few isolated APCs
    • A few isolated VPCs (mono-form, burden <1%)
  • 2018-04-23 EKG
    • Sinus rhythm with 1st degree A-V block

[MedRec]

  • 2024-01-10 SOAP Hemato-Oncology He JingLiang
    • Prescription x3
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Alpraline (alprazolam 0.5mg) 1# QN
  • 2023-12-05 SOAP Gastroenterology Xu RongYuan
    • Prescription x3
      • Pariet (rabeprazole 20mg) 1# QDAC
  • 2023-11-08 SOAP Neurology Xiao ZhenLun
    • Prescription x3
      • Rivotril (clonazepam 0.5mg) 2# HS
      • Saline (nicametate citrate 50mg) 1# TID
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
      • Syntam Granules (piracetam 1200mg) 1# QD
      • Secorin (oxazolam 10mg) 1# HS
  • 2023-11-08 SOAP Metabolism and Endocrinology Guo XiWen
    • Prescription x3
      • Zulitor (pitavastatin 4mg) 1# QD
      • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID
      • Relinide (repaglinide 1mg) 1# TIDAC
      • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD

[consultation]

  • 2023-02-06 Psychosomatic Medicine
    • Q
      • Cancer inpatient has suicidal ideation score of >=2.
    • A
      • “I am getting more and more worried as I think about it.”, “It has made my temper very bad and hurt the people closest to me.”, “The relapse is so recurrent that it has made me like this. Living is not just helpless, it’s already meaningless.”
      • The patient has long-term generalized disorder and panic disorder, loss of gollow-up in 2019 after the diagnsois of maliganacy. Long-term floating anxiety to apprehensive rumination adverselty influence his quality of life and quality of mood as easy anger and easy dysphoria. Currently, he mainfests depression as low self-esteem, feeling of helplessness and worthlessness, although he recognises the clinical reality. He worries about bad effect of antidepressant on his physical problems; reassurnace.
      • Please reinstate escitalopram 5mg QN, titrate it up to 10mg a couple days later. Alprazolam 0.5mg hs. Psychiatry outpatient follow up, please. Thanks.

[multiteam]

  • 2023-02-07 Psycho-Oncology
    • Reason for consultation: Other: Cancer inpatient has suicidal ideation score of >=2
    • Conclusion:
        1. 2/7 visit, the patient reported that a psychiatrist had also visited the day before. He has been taking anti-anxiety medication for 6-7 years but has not stopped, only taking it when feeling uncomfortable. He has gone to see a psychiatrist before but did not continue after undergoing liver tumor radiofrequency ablation. He is expected to undergo six rounds of chemotherapy this time, but as there is a liver tumor close to a blood vessel, there is a greater risk. After the chemotherapy, even if he get better, the cancer will likely recur in 1-2 years. This is why he marked the suicide ideation score in the middle - “it’s better to just go, but I don’t have the courage.” After treatment, he will probably feel tired for three days. When anxiety comes on, he cannot control it and have to go to the hospital. He experienced a sudden onset during the Chinese New Year when his child invited them to Hualien. His son went to the pharmacy to buy medication, and after taking it, he felt better. He has been seeing an otolaryngologist for medication, but he does not know why he experience anxiety. He has Arab ancestry and is physically strong.
        1. 2018/08 rectosigmoid colon cancer, postoperative concurrent chemoradiotherapy (CCRT), 108/10 recurrence, postoperative liver metastasis, previously visited for suicidal ideation (moderate). 111/12 recurrence, admitted for the fourth round of chemotherapy on 2/6, BSRS = 8 (mild), suicidal ideation score of 2 (moderate).
        1. Reviewed their treatment history and anxiety experiences, encouraged them to complete cancer treatment, follow up with the psychiatrist for medication adjustment, and contact the Love Life Adjustment Association (an anxiety support group).
      • (AP) The patient can express themselves through conversation, is willing to cooperate with cancer treatment, and is hesitant to follow up with the psychiatrist. They have been encouraged to take the initiative to make an appointment and will be cared for again during the next chemotherapy session.
  • 2023-02-07 Social Services
    • Referral Date: 2023-02-06
    • Reason for Referral: Other: Patient has suicidal ideation with a score of >=2
    • Handling Status: Not opening a case
    • Reason for Not Opening a Case: Meeting with the patient on 2023-02-07:
      • Family Situation: The patient is 75 years old, married with a daughter and a son. The patient lives with his wife and children.
      • Evaluation and Treatment:
        • The patient just finished meeting with the psychologist and the psychiatrist visited the patient yesterday. The patient reported a history of diagnosed panic disorder and currently feels hopeless and depressed due to long-term illness, but he has no actual suicidal thoughts or plans at present due to family and ethical beliefs. During the meeting, the patient’s mood was still stable. The social worker was concerned about the patient’s sleep and the patient reported that his sleep is sometimes good and sometimes bad, and it can be affected by his mood swings. However, the recent birth of his grandchild at home is something that has made him happy recently.
        • The evaluation meeting determined that the patient’s mood is mainly affected by his illness, but he is currently able to cooperate with related medical treatments. The family has a good level of economic support and there are no current issues. Therefore, the social worker will provide emotional support and counseling to the patient.

[chemoimmunotherapy]

  • 2024-01-18 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 80mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Avastin + FOLFOX. Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-12-28 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 80mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Avastin + FOLFOX. Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-27 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 80mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Avastin + FOLFOX. Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-17 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI, dose reduced)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + atropine 0.5mg IVD
  • 2023-06-28 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI, dose reduced)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + atropine 1mg IVD
  • 2023-06-01 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 790mg NS 250mL 2hr + fluorouracil 2800mg/m2 5560mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + atropine 1mg IVD
  • 2023-05-04 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 795mg NS 250mL 2hr + fluorouracil 2800mg/m2 5580mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
  • 2023-04-10 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5630mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
  • 2023-03-15 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5650mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
  • 2023-02-22 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
  • 2023-02-06 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
  • 2023-01-12 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
  • 2022-12-26 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
  • 2022-12-12 - irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5500mg NS 500mL 46hr (FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + atropine 1mg IVD
  • 2020-07-17 - oxaliplatin 85mg/m2 170mg D5W 250mL 2hr + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2800mg/m2 5700mg NS 500mL 46hr (FOLFOX, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • …. .. ..

==========

2024-01-19

Medications prescribed by other departments are incorporated into the current medication list, and no discrepancies have been identified.

2023-07-18

In addition to visiting our hemato-oncology department, the patient also consulted our urologist on 2023-07-07 and our cardiologist on 2023-07-14. The urologist prescribed Urief (silodosin) and the cardiologist prescribed Concor (bisoprolol). These medications were accurately added to the active formulary and no discrepancies were found during reconciliation.

2023-06-29

According to the current PharmaCloud database, the patient refiled his prescription at Taipei City Hospital on 2023-06-21 for Algitab Chewable Tablets (alginic acid), Avamys Nasal Spray (fluticasone furoate), and Engene Eye Drops Patron (flavineadenine dinucleotide), all of which are valid for 28 days and are currently still valid. However, these medications are not yet on the patient’s active formulary at our hospital. This could lead to potential medication reconciliation discrepancies. It’s advisable for the primary care team to confirm whether these medications are still needed for the patient’s current clinical condition. If these medications are needed, they should be added to the patient’s active formulary accordingly.

2023-06-02

Per the PharmaCloud database, this patient recently had an outpatient visit at Taipei City Hospital on 2023-05-24. He was prescribed Algitab, Broen-C, acetaminophen for oral use, and sulfamethoxazole eye drops for a 28-day duration. Most of these medications are intended to manage GI symptoms. Upon examination of the current medication list, equivalent therapeutic drugs have already been prescribed. Consequently, no issues were identified during the medication reconciliation process.

2023-04-11

Based on the serum glucose level range of 288 mg/dL to 230 mg/dL, it appears that the patient’s underlying condition of type 2 DM is not well-controlled despite taking Galvus Met (vildagliptin + metformin) and Relinide (repaglinide). However, since there is no evidence of renal insufficiency (as of 2023-04-10 with Cre at 1.02mg/dL, eGFR at 75.67, and BUN at 21), the addition of Dibose (acarbose 100mg) 0.5# TIDAC is recommended if the high glucose level persists.

2023-02-23

  • The recurrence of cancer has left the patient feeling helpless, and he has been visited by a psychiatrist, a counseling psychologist, and a social worker in early Feb 2023. He is currently still taking alprazolam, but his emotional state is stable.

  • The patient’s HbA1c has shown a slow decline trend, blood sugar readings were 145 to 164 mg/dL on 2/22 and 2/23, there is still room for improvement.

    • 2023-02-13 HbA1c 6.1 %
    • 2022-09-15 HbA1c 6.6 %
    • 2022-06-06 HbA1c 6.4 %
    • 2022-03-01 HbA1c 6.1 %
    • 2021-12-22 HbA1c 6.2 %
    • 2021-09-30 HbA1c 6.8 %
    • 2021-06-18 HbA1c 6.6 %
    • 2021-02-22 HbA1c 6.4 %
    • 2020-11-30 HbA1c 6.5 %
    • 2020-09-08 HbA1c 6.8 %
    • 2020-06-15 HbA1c 7.0 %
    • 2020-03-23 HbA1c 7.2 %
    • 2019-09-20 HbA1C 6.7 %
    • 2018-04-12 HbA1C 7.1 %

700959021

240119

{Triple cancer - endometrium ca, rectal ca, RCC}

[exam findings]

  • 2024-01-18 SONO - chest
    • Symptom: dyspnea
    • Indication: r/o pleural effusion
    • Clinical diagnosis:
      • Triple cancer (endometrium, rectal ca, kidney RCC )
      • ESRD under maintenance H/D TIW
    • The patient was in sitting upright posture while th chest echography was performed using: 3.75-mHz convex probe.
    • Findings
      • Left-side of thorax:
        • moderate loculated effusion, septum and fibrin
      • Pleural thickening
        • LLL atelectasis
      • Right-side of thorax:
        • no effusion
        • no active lung lesion
      • Special Procedure
        • A 16# long catheter was inserted into left 5th ICS along mid-posterior scapular line. 750ml yellow fluid was drained and sent for routine, BCS, bacteria/TB/fungus cultures and cell block, TB-PCR.
    • Echo diagnosis
      • Pleural effusion, moderate, left, complicated
      • Atelectasis, LLL
  • 2024-01-17 CT - neck
    • Indication: Left clavicle region swelling for 3 days, pain(+). History of endometrial cancer, colon cancer
    • Neck CT without/with contrast enhancement shows:
      • bilateral symmetric pharyngeal mucosa.
      • no definite enlarged cervical lymphadenopathy.
      • suspect left proximal humerus greater tubercle fracture.
      • no definite destructive bone lesion at bilateral clavicle or other visible bones.
      • left pleural effusion, status post pigtail insertion.
      • left perihilar lung collapse with calcification, occult lung lesion cannot be excluded. Suggest further evaluation.
    • Impression:
      • Suspect left proximal humerus greater tubercle fracture.
      • No destructive bone lesion.
      • Left pleural effusion.
      • Left perihilar lung collapse with calcification, occult lung lesion cannot be excluded. Suggest further evaluation.
  • 2024-01-17 Clavicle LT
    • Left clavicle X-rays show: Left proximal humerus fracture, greater tubercle. Calcification near greater humeral tubercle, calcified tendinosis of distal supraspinatus tendon is suspected.
  • 2024-01-10 Peropheral Vascular Test - AV fistula
    • Clinical diagnosis: AVF dysfunction
    • Report:
      • Access type: graft
      • Site: left upper arm
      • Clinical problem: left arm swelling
      • Age of vascular access:
      • Result:
        • Left brachio-graft axillary shunt, feeding volume 1489 ml/min, graft degeneration improved after POBA
        • There is no obvious hematoma over elbow area.
      • Suggestion: Clinical follow up
  • 2024-01-09 Cardiac Catheterization
    • Past Medical History
      • The patient has a history of ESRD under H/D.
    • Indication
      • The patient was referred with left arm swelling. The procedure was explained in detail to the patient and family. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
    • Approach
      • Percutaneous access was performed through the graft graft where a 6F sheath was inserted. Percutaneous access was performed through the graft graft where a 6F sheath was inserted.
    • Procedure
      • The patient was taken to the cardiac catheterization laboratory in the TZU CHI Taipei Hospital. Heart institute and prepared in the usual sterile fashion. The contrast material used was Omnipaque 350 50cc. The patient was treated with Dormicum (dosage 2.5mg).
    • Finding Summary
      • Left Brachio graft axillary shunt, A to V puncture site with 50% stenosis(graft degeneratoin) GV junction with 55% stenosis with colalterals and left central vein with 90% stenosis.
    • Recommendation
      • PTA
    • Intervention Summary
      • Left Brachio graft axillary shunt, A and V puncture site degeneration, Pre-DS = 50%
        • MLD/RVD=3.5/7 mm → 5.6/7 mm, Post-DS = 20%.
        • Balloon: Bard Conquest. 7.0 X 40 mm. Pressure: 10 atmospheres.
      • Left Brachio graft axillary shunt, GV junction, Pre-DS = 55%
        • MLD/RVD=3.36/7.45 mm → 5.52/6.83 mm, Post-DS = 19%.
        • Balloon: Bard Conquest. 7.0 X 40 mm. Pressure: 20 atmospheres.
      • Left Brachio graft axillary shunt, left central vein, Pre-DS = 90%
        • MLD/RVD=1.2/12 mm → 4.48/10.22 mm, Post-DS = 62%.
        • Balloon: Boston Mustang. 10.0 X 40 mm. Pressure: 14 atmospheres.
        • Balloon2: Abbott Armada 35. 12.0 X 40 mm. Pressure: 10 atmospheres. but still suboptimal result,
    • In conclusion:
      • Left brachio graft-axillary shunt, A and V puncture site (graft) degeneration, GV junction and left central vein stenosis s/p POBA successful bur left central vein suboptimal result.
    • Recommendation:
      • close monitor venous pressure
  • 2024-01-09 Peripheral Vascular Test - AV fistula
    • Clinical diagnosis: AVF dysfunction
    • Report:
      • Access type: graft
      • Site: left upper arm
      • Clinical problem: arm swelling
      • Age of vascular access:
      • Result: Left brachio-graft-axillary shunt, feeding volume 413 ml/min, AV junction 0.38 cm, near AV junction graft degeneration 0.15 cm, A puncture site 0.64 cm, V puncture site 0.42 cm, GV junction no obvious stenosis
    • Suggestion:
      • Because of arm swelling, and prior PTA history, arrange IVDSA and PTA PRN.
      • Suggestion: PTA
  • 2024-01-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (174 - 128) / 174 = 26.44%
      • M-mode (Teichholz) = 26.4
      • 2D (M-Simpson) = 31.8
    • Conclusion:
      • Sclerosis of AV with severe AS, mild AR (AVA 0.86, Vmax 3.64)
      • Thickened and calcified MV, mild MR
      • Concentric LVH, dilated LV
      • Poor LV systolic function, global hypokinesia and apical akinesia
      • Mild PR, mild TR, normal IVC size
      • Dilated LA, pleural effusion noted
  • 2024-01-07 CT - chest
    • Left pleural effusion with left lung collapse and clacifications.
    • Nodules (up to 5.6mm) at right lung.
    • Liver cirrhosis with a cyst (1.6cm).
    • Cardiomegaly.
  • 2024-01-07 ECG
    • Sinus tachycardia with frequent Premature ventricular complexes in a pattern of bigeminy
    • Left ventricular hypertrophy with repolarization abnormality
  • 2023-12-12 Parathyoid scan with SPECT
    • Two focal areas of mildly increased radiotracer uptake in the middle portion of the right thyroid bed and lower portion of the left thyroid bed respectively. The nature is to be determined (hyperplastic parathyroid glands or parathyroid adenomas? some kind of thyroid lesions?). Please correlate with clinical findings for further evaluation.
  • 2023-09-05 CT - abdomen
    • S/P left nephrectomy.
    • Liver cirrhosis.
    • Left pleural effusion.
    • GB stones.
    • R/O liver cyst, 1.5cm in right lobe liver.
    • Coronary artery calcifications.
  • 2023-07-06 CXR erect
    • S/P port-A implantation.
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • A nodular opacity projecting in the right lower medial lung, retrocardiac area, is suspected. Please correlate with CT.
  • 2022-12-08 ENT Hearing Test
    • Tymp RE type As, LE type A
    • ART bil absent
    • PTA:
      • Reliability FAIR
      • Average RE 18 dB HL, LE 23 dB HL
      • bil normal to mild SNHL
  • 2022-11-11 CT - chest
    • Calcified coronary arteries is found.
    • Faint aveolar opacity over Right upper lobe, right lower lobe and left lower lobe
    • Bilateral pleural effusion.
    • Liver cirrhosis with splenomegaly
  • 2022-10-20 EEG
    • Conclusion: Abnormal EEG.
    • The background activities were composed by alpha rhythm at 8-9 Hz, 20-60 uV in bilateral posterior head areas and beta rhythm at 13-15 Hz, 10-20 uV in bilateral anterior head areas. There were occasional diffuse slow waves at 4-6 Hz, 20-50 uV in bilateral hemispheres. No obvious photic driving response was noted. This EEG suggests mild diffuse cortical dysfunction. Advise clinical correlation.
  • 2022-09-09 Patho - kidney partial/total resection
    • PATHOLOGIC DIAGNOSIS
      • Tumor, left kidney, laparoscopic radical nephrectomy — Clear cell renal cell carcinoma
      • Resection margin, ditto — Free of tumor invasion
      • Ureter, ditto — Free of tumor invasion
      • Perirenal fat, ditto — Free from tumor invasion
      • AJCC Pathologic staging — pT1a, if cN0 and cM0, stage I
    • Gross Description:
      • Procedure: laparoscopic radical nephrectomy
      • Laterality: Left
      • Specimen size: 19.2 x 12.3 x 3.8 cm, 468 gm in weight
        • kidney: 6.7 x 3.3 cm
        • ureter: 7.1 cm in length, 0.3 cm in diameter
      • Tumor size: 2.3 x 1.8 cm
      • Tumor site: hilar region
      • Tumor focalty: solitary
      • Tumor extent: The tumor is grossly confined in the kidney
      • Representatively embedded for sections as A1-A2: renal pelvis, A3-A7: tumor, A8: renal hilum, A9: perirenal fat and A10: ureter
    • Microscopic Description
      • Histological type: clear cell renal cell carcinoma
      • Histological grade: grade 2
      • Pathological staging: pT1a, if cN0 and cM0, stage I
      • Resection margins: Free
      • Lymphovascular invasion: Not identified
      • Tumor necrosis: absent
      • Additional pathologic findings: cystic change
      • Immunohistochemistry: CK7(-), vimentin(+), PAX8(+, focal), CD10(+, focal) and CA IX(+) for tumor
      • Non-tumor kidney: chronic pyelonephritis with thyroidization, diffuse global glomerulosclerosis, microcalcification and subintimal hyperplasia of arteries with microcalcification of arterial wall
  • 2022-02-11 Patho - lung total/lobe/segmental
    • PATHOLOGIC DIAGNOSIS:
      • Lung, left, upper lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor
    • MACROSCOPIC EXAMINATION:
      • Specimen: Lung, size: 6.5 x 6.0 x 2.5 cm
      • Tumor Site: Periphery
      • Tumor Size: 2.8 x 2.6 x 1.8 cm
      • Gross tumor patterns: poorly defined,
      • Tissue for sections: A1: resection margin; A2: lung, non-tumor; A3-5: tumor.
    • Microscopic Description
      • Tumor Focality: Single tumor
      • Histologic Type (select all that apply): Adenocarcinoma; The immunohistochemical stains reveal CDX2(+) and TTF-1(-). The results are consistent with metastatic colonic tumor.
      • Histologic Grade: G2: Moderately differentiated
      • Spread Through Air Spaces (STAS):Present
      • Visceral Pleura Invasion: Not identified
      • Lymphovascular Invasion (select all that apply): present
      • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
      • Margins (select all that apply): All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin (centimeters): 0.3 cm;
        • Specify closest margin: resection margin
      • Treatment Effect: No known presurgical therapy
  • 2019-03-20 SONO - nephrology
    • Interpretation:
      • Bilateral parenchymal renal disease with samll-sized kidney.
      • Right renal cyst.
      • Right moderate hydronephrosis.
      • Right peri-renal fluid acculumation.
  • 2018-01-22 Surgical pathology Level VI
    • PATHOLOGIC DIAGNOSIS:
      • Lung, LLL, lobectomy —– Adenocarcinoma, moderately differentiated, consistent with metastatic colonic origin
      • Lymph node, lobar, lymphadenectomy —– Negative for malignancy (0/5)
      • Lymph node, area 5, lymphadenectomy —– Negative for malignancy (0/2)
      • Soft tissue, area 7, lymphadenectomy —– Negative for malignancy (0/0)
      • Lymph node, area 10, lymphadenectomy —– Negative for malignancy (0/1)
    • MACROSCOPIC EXAMINATION:
      • Topography: LLL
      • Procedure: lobectomy
      • Size of lung received: 14.8 x 8.0 x 4.5 cm
      • Weight of lung received: 120 gm
      • Tumor location: peripheral
      • Tumor size: 2.5 x 2.0 x 1.5 cm
      • Tumor description: gray, solid, and necrosis
      • Satellite tumor nodules: absent
      • Mainstem bronchus: not involved
      • Bronchial margin: free, 1.2 cm from margin
      • Visceral pleural margin: free, 0.9 cm
      • Pleura: smooth
      • Non-neoplastic lung: congestion
      • Lymph node: area 5, 7, and 10
      • Representative sections are taken and labeled as: A1: resection margin; A2: lymph node, lobar; A3: lung, non-tumor; A4-8: tumor; B: lymph node, area 5; C: lymph node, area 7; D: lymph node, area 10.
    • MICROSCOPIC EXAMINATION:
      • Histology type: adenocarcinoma; The immunohistochemical stains reveal CDX2(+) and TTF-1(-). The results are in favor of metastatic colonic adenocarcinoma.
      • Histology grade: moderately differentiated (G2).
      • Tumor necrosis: moderate (40%)
      • mitotic activity: marked (> 20/10hpf)
      • peritumor infiltrates: mild
      • in situ carcinoma: absent
      • angiolymphatic invasion: present
      • perineural invasion: absent
      • mainstem bronchus: no involvement
      • bronchial margin: free
      • visceral pleural involvement: The tumor does not invade the visceral pleura (P0).
      • Tumor cells in the subpleural lymphatics: no
      • non-neoplastic lung: congestion
      • Lymph node metastasis
        • group as specified
        • lobar: 0/5
        • area 5: 0/2
        • area 7: 0/0
        • area 10: 0/1
        • over all: 0/8
      • perinodal (extracapsular) tumor extension: absent

[MedRec]

  • 2022-08-04 ~ 2022-08-06 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Malignant neoplasm of rectum
      • K-ras wild type, recurrent adenocarcinoma of rectum with lung metastasis, pT3N1bM1 pStage: IV
      • pathology (S2013-17848, 2013-11-19): Uterus, corpus, laparoscopic assisted vaginal hysterectomy (s/p RT) — endometrioid adenocarcinoma, Grade 2 — TNM: ypT1a, FIGO stage: ypIA.
      • Chronic kidney disease, unspecified
      • Type 2 diabetes mellitus without complications
    • CC
      • arrange chest CT exam for survey
    • Present illness
      • The 56-year-old woman has past history of old right brainstem hemorhagic stroke was noted on 2009, and then could not walk independently since 2016, hypertension for over 20 years, COPD for over 20 years without regular medications control currently, type II DM for around 10 years, and end-staged renal disease status post regular H/D since 2019/03 (QW135 currently).
      • She also had previous histories of endometrial cancer, adeno of rectal cancer stage IIIB on 2015/6, and left lower lung metastatic cancer (colonic related) status post surgical treatment (Please see the details at the past histories).
      • Left arteriovenous graft occlusion post Percutaneous Transluminal Angioplasty + thrombectomy on 2021/06/22. She was then referred back to our Chest surgery Dr. Xie’s OPD back for the further survey.
      • Further chest CT showed lobulated mass at left lower lobe, favored metastatic lesion related. After fully explanation and discussion to the patient and her families, she received video-assisted thoracic surgery (Left upper lobe tumor wedge resection) on 2022/02/10. Pathology showed Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor, CDX2(+) and TTF-1(-).
      • The chemotherapy regimen started as C1D1 HDFL on 2022/03/03 was complicated of related hepatic encephalopathy treated.
      • Under the impression of lung metastasis from colonic cancer, so she was admitted for reduced dose chemotherapy for recent history of HDFL related hepatic encephalopathy on 2022/03/29.
      • FOLFIRI was discontinued on 2022/03/31, because of the patient had improvement of numbness and weakness after the chemotherapy injection.
      • Sigmoidscopy was done, report showed internal hemorrhoid and no bleeding later.
      • The EEG on 2022/03/15 showed No obvious photic driving response was noted.
      • The tumor marker showed CEA:<0.3, CA-199:9.271.
      • She started took Xeloda 1# po bid since 2022-04-28 then shifted to 2# po bid since 2022-05-05.
      • Today, she was admitted arrange chest CT exam for Xeloda treatment response evaluation on 2022/08/04.
    • Course of inpatient treatment
      • After admission, Xleoda 2# po bid was given. The chest CT (2022-08-05) showed chest:s/p op. over left lower lobe with regional soft tissue is found. Suggest closely follow up. Small lymph nodes are found in the mediastinum. There is no evidence of mediastinal LAP. Patent airway is found. Left pleural effusion is found. Abdomen: Soft tissue mass with strong enhancement at left kidney up to 2.6cm is found. There is stone at dependent portion of GB. GB stone(s) are noted. Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis. The renal vein and INFERIOR VENA CAVA are patent.
      • QW 1.3.5 H/D was given. She was discharged on 2022-08-06 under stable condition and will follow-up at OPD.
    • Discharge prescription
      • none
  • 2017-06-13 SOAP Metabolism Guo XiWen
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
      • Obesity, unspecified [E66.9]
    • Prescription
      • Kludone (gliclazide 60mg) 1# QDAC
      • Victoza (liraglutide) 1.2mg QDAC SC
      • Blopress (candesartan 8mg) 1# QD
      • Glucobay (acarbose 100mg) 1# TIDAC
  • 2017-02-07 SOAP Hemato-Oncology Gao WeiYao
    • Diagnosis
      • Malignant rectum neoplasm [C20]
      • Maliganat uterus neoplasm, corpus uteri, except isthmus [C54.1]
      • Arterial embolism and thrombosis of lower extremity [I74.3]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
  • 2017-01-10 SOAP Neurology Su YuQin
    • Diagnosis
      • Unspecified late effect of cerebrovascular disease [I69.80]
      • Malignant rectum neoplasm [C20]
      • Arterial embolism and thrombosis of lower extremity [I74.3]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertention, unspecified [I10]
      • Dyslipidemia; other and unspecified hyperlipidemia [E78.5]
    • Prescription
      • Urinol (allopurinol 100mg) 1# QD
      • NovoNorm (repaglinide 1mg) 2# BID
      • Imolex (loperamide 2mg) 1# PRN
      • Grumed (glimepiride 2mg) 1.5# BID
      • Trajenta (linagliptin 5mg) 1# QD
      • Hyzaar (losartan 100mg, hydrochlorothiazide 12.5mg) 0.5# QD
      • Lipanthyl Supra (fenofibrate 160mg) 0.5# QD

==========

2024-01-19

[myocardial injury indicators: rising hs-Troponin I]

Lab results indicate low CK levels, normal CK-MB, and a consistent increase in hs-Troponin I, suggesting myocardial injury.

  • 2024-01-17 CKMB 4.4 ng/mL
  • 2024-01-17 CK 26 U/L
  • 2024-01-17 hs-Troponin I 1095.8 pg/mL
  • 2024-01-17 hs-Troponin I 983.3 pg/mL
  • 2024-01-07 hs-Troponin I 589.8 pg/mL
  • 2020-09-15 hs-Troponin I 69.6 pg/mL

The pattern of these biomarkers might point to several potential causes:

  • Microinfarctions: These could occur without significant CK elevation due to their small scale.
  • Unstable Angina: Persistent reduced blood flow may not trigger a pronounced CK rise but can still cause elevated hs-Troponin I levels.
  • Myocarditis: This condition, marked by inflammation of the heart muscle, could elevate hs-Troponin I without substantially increasing CK.

Given these findings, consulting a cardiologist may be beneficial for further evaluation and management.

[optimizing midodrine dosage for this hemodialysis patient]

Midodrine, dosed at 7.5mg, commenced pre-hemodialysis treatment QW135 from 2024-01-18, aiming to prevent post-dialysis hypotension, with current blood pressure around 90/50 mmHg. The dosage, confirmed via telephone with the nurse practitioner, aligns with the patient’s customary regimen.

(the following text is wrong and not posted)

Midodrine, at a dose of 7.5mg, has been initiated for post-hemodialysis treatment as of 2024-01-18, with current blood pressure readings around 90/50 mmHg.

Midodrine’s effectiveness is attributed to its major metabolite, desglymidodrine, generated through the deglycination process. The peak plasma concentration of midodrine occurs about 30 minutes post-administration, with a half-life of approximately 25 minutes. Desglymidodrine reaches peak levels in the blood between 1 to 2 hours after midodrine administration and has a half-life of 3 to 4 hours.

For patients undergoing thrice-weekly intermittent hemodialysis, initiating midodrine at a low dose, such as 2.5 mg once or twice daily, is advisable. Dosage can be adjusted based on individual response and tolerability, with careful monitoring.

701505232

240119

[MedRec]

  • 2024-01-10 SOAP Plastic and Reconstructive Surgery Zhang MengZong
    • S: Chronic ulcer with necrotizing fasciitis is found about 4 * 6 cm in size over the left medial ankle s/p Dermacell implantation for 30 days.
    • O: Chronic ulcer with necrotizing fasciitis is found over the left medial ankle s/p Dermacell implantation about 3 * 5 cm in size –> superficial debridement –> wound CD with Allevyn Ag q2d
  • 2024-01-03 SOAP Plastic and Reconstructive Surgery Zhang MengZong
    • S: Chronic ulcer with necrotizing fasciitis is found about 4 * 6 cm in size over the left medial ankle s/p Dermacell implantation for 23 days.
    • O: Chronic ulcer with necrotizing fasciitis is found about 4 * 6 cm in size over the left medial ankle s/p Dermacell implantation –> removal of skin staples –> wound CD with Allevyn Ag q3d
  • 2023-11-23 ~ 2023-12-27 POMR Rheumatology and Immunology Chen ZhengHong
    • Discharge diagnosis
      • Systemic lupus erythematosus
      • Chronic ulcer with necrotizing fasciitis over the left medial ankle; statsus post deep debridement + fasciectomy + negative pressure wound therapy on 2023/11/27, deep debridement + negative pressure wound therapy on 2023/12/04, deep debridement + Dermacell artificial dermis implantation + negative pressure wound therapy on 2023/12/11
      • Glomerular disease in systemic lupus erythematosus
      • Acute kidney failure
      • Antiphospholipid syndrome
      • Tiny duodenal ulcer, superior duodenal angle
      • Hypomagnesemia
      • Hemolytic anemia post spleenectomy
      • Hyperkalemia
      • Abnormality of albumin
      • Reflux esophagitis, grade A(minimal)
    • CC
      • Chronic ulcer with necrosis is found over the left medial ankle for about 6 weeks
    • Present illness
      • This 41-year-old famale had histories of
        • Sytemic lupus erythematous with diffuse proliferatine lupus nephritis and membranous nephritis, ISN/RPS class IV+V,modified NIH AI:19& CI:4;2;with autoimmune hemolytic anema (post spleenectomy in 2018), with aPL psitive, seizure with lupus PRES,with lupus angitis, with suspect lupus pneumonitis, and plerual efffusion/ ascities status post.
        • Lupus nephritis,
        • Left medial ankle bulla, suspect lupus related —> calciphylaxis ulcer
        • Gall bladder stone with acute on chronic cholecystitis, refused surgery
      • Chronic ulcer with necrosis is found over the left medial ankle for about 6 weeks.
      • She visited our OPD of plastic surgery. Physical examination showed chronic ulcer with necrosis is found about 4 * 6 cm in size over the left medial ankle,mild redness around wound, local heat, no discharge, VAS 5.
      • Surgical tangenital debridement were recommended. Then, she was admitted for surgical intervention.
    • Course of inpatient treatment
      • Belimumab (self-paid) course (Belimumab is an IgG1-lambda monoclonal antibody that prevents the survival of B lymphocytes by blocking the binding of soluble human B lymphocyte stimulator protein (BLyS) to receptors on B lymphocytes. This reduces the activity of B-cell mediated immunity and the autoimmune response.)
        • 1st Belimumab 640mg on 2023/09/13
        • 2nd Belimumab 640mg on 2023/09/27
        • 3rd Belimumab 640mg on 2023/10/13
        • 4th Belimumab 400mg on 2023/10/24
      • Chronic ulcer with necrosis is found over the left medial ankle for about 6 weeks. She visited our OPD of plastic surgery. Physical examination showed chronic ulcer with necrosis is found about 4 * 6 cm in size over the left medial ankle, mild redness around wound, local heat, no discharge, VAS#5. Surgical tangenital debridement were recommended. Then, she was admitted for surgical intervention.
      • After admission, hyperkalemia (6.6) with metabolic acidosis, bicarbonate = 15 and hemolytic anemia were noted, We consulted Nephrology and DC Exforge, add Sodium bicarbonate 2# TID, NESP 20 ug IV st and QW3 for anemia, add Lasix, Kalimate, RI + Vitagen 50% for potassium control, follow up K showed improved potassium level: (5.8 -> 6.0 -> 5.1 -> 5.4 -> 4.7 -> 4.9 -> 4.8).
      • CVC was inserted on 2023/11/24 because of difficulty in placing peripheral intravenous catheters. We consulted Rheuma under the impression of SLE, lupus nephritis with uncontrolled lupus disease activiety and autoimmune hemolytic anemia.
      • Debridement for chronic ulcer with necrosis over the left medial ankle was performed on 2023/11/27. Due to uncontrolled lupus disease activity, she was transfered to Rheuma ward on 2023/11/27.
      • After transferral to rheumatology ward, we checked APS profile, SSA/SSB, anti-ICS, anti-BMZ, ESR, CRP, thyroid function & electrolytes which disclosed APS with Anti-Cardiolopin IgG 2023-11-28 51 GPL-U/mL, Anti-ENA SS-A(Ro) 224 EliA U/ml, and Anti-ENA SS-B(La) 24 EliA U/ml. We kept DMARDs treatment (CellCept250 mg/cap 4 cap BID, Plaquenil 200mg/tab 1 tab BID) and Prednisolone 1 tab BID for SLE with lupus nephritis control, Warfarin 1mg/tab 1 tab BID for APS control, Revatio 20mg/tab (Sildenafil) 1 tab TID for pulmonary hypertension control according to discharge summary of TMUH. We rechecked risk management plan before Belimumab infusion which disclosed Anti-HBc Reactive, Anti-HCV and HBsAg nonreactive.
      • Immunotherapy of Belimumab (self-paid) was administered on 2023/11/30. The 2023/11/28 cardiac echo revealed EF 75% with concentric LV hypertrophy with indeterminated LV filling pressure; mildly dilated LA, marked calcification of mitral papillary muscles with trivial MR; mild aortic valve with trivial AR, minimal amount pericardial effusion ( < 50ml), and sinus tachycardia.
      • Albumin 1 bot IVD x 3 days (11/28~30) was administered for hypoalbuminemia (Albumin 2.4 g/dL). The following thyroid function revealed Free-T4 1.10 ng/dL, TSH 1.754 uIU/mL.
      • For persistent nausea and intermittent vomiting since 2023/10, we arranged gastroscopy on 2023/11/29 - Reflux esophagitis LA Classification grade A (minimal), superficial gastritis, antrum, tiny duodenal ulcers, superior duodenal angle and PPI with Nexium was added for duodenal ulcers and GERD grade A.
      • We taper off Kalimate for hyperkalemia resolved and MgSO4 IVD stat + MgO 1# TID was added for hypomagnesemia (Mg 2023-11-29 1.1 mg/dL).
      • Deep debridement + negative pressure wound therapy (small size) was performed on 2023/12/04 and we kept wound care by negative pressure wound therapy.
      • We rechecked D-dimer, PT/APTT, lipid profile, Albumin which disclosed HGB 8.7 g/dL, D-dimer 4181.00 ng/mL, Albumin 2.7 g/dL, Cr 1.25 mg/dL, eGFR 50.20 ml/min. DVT of left foot was suspected and Clexane 60mg/0.6mL/syringe 60 mg SC QD was prescribed since 2023/12/09 and the follolwing D-dimer: 2284 ng/mL on 2023/12/11, D-dimer 1701.00 ng/mL on 2023/12/14. We consulted CV for pulmonary hypertension evaluation and recommendation for Revatio indication and suspect DVT who suggest to arrange venous duplex evaluation, check NTproBNP level, according to pulmonary hypertension history at TMUH, may keep revatio use, if still renal function and potassium, consider Angiotensin receptor blockade QD and carvedilol bid and spironolactone 1#QD for better BP control, and then discontinue clonidine under the impression of hypertensive heart disease, pulmonary hypertension? (may trace right heart catheterization and echocardiogram report at TMUH).
      • She received deep debridement + Dermacell artificial dermis implantation (4*4 cm) + negative pressure wound therapy (small size) on 2023/12/11 smoothly.
      • The following laboratory data revealed Cr 1.31 mg/dL, NT-proBNP 7291.8 pg/mL. We changed anti-hypertensive agents and monitored BP variation to protect renal function and adjusted to Carvedilol 25mg QD. 2023/12/15 Vein sonography showed no evidence of deep vein thrombosis at bilateral lower limbs, bilateral long saphneous vein engorgement at thigh level, left side more severe; with soft tissue edema at medial side of bilateral thighs. For foaming urine sometimes, we rechecked C3, C4, ESR, CRP, D-dimer, NT-proBNP and 24 hrs urine protein which disclosed low C3, mild improved creatinine, D-dimer and NT-proBNP.
      • She received immunotherapy of Belimumab (self-paid) 400 mg on 2023/12/26 smoothly. We tried to off VAC negative pressure and her Dermacell artificial dermis implantation attachment well, then was shiftted to self-paid Allevyn Ag covered. The whole therapeutic process was smooth & patient tolerated it well without severe side effect or complaints. With relatively stable condition, she was discharged on 2023/12/27 and AIR + PS OPD follow-up was arranged on 2024/01/03.
    • Discharge prescription
      • Atotin (atorvastatin 20mg) 1# QOD
      • Blopress (candesartan 8mg) 1# BID
      • CellCept (mycophenolate mofetil 250mg) 4# BID
      • Cofarin (warfarin 1mg) 1# BID
      • Compesolon (prednisolone 5mg) 1# BID
      • Eltroxin (levothyroxine 50ug) 1# QDAC
      • hydralazine 50mg 1# TID
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
      • MgO 250mg 1# TID
      • Nexium (esomeprazole 40mg) 1# QDAC 2023/11/29 gastroscopy: GERD grade A
      • Plaquenil (Hydroxychloroquine 200mg) 1# BID
      • Revatio (sildenafil 20mg) 1# TID if SBP <90/50 mmHg hold
      • Rivotril (clonazepam 0.5mg) 1# BID
      • Spiron (spironolactone 25mg) 1# QD
      • Strocain (oxethazaine polymigel 5mg) 1# TIDAC for stomach ache
      • Syntrend (carvedilol 25mg) 1# BID
      • Zinga (zinc gluconatte 78mg) 1# QD
  • 2023-11-17 SOAP Plastic and Reconstructive Surgery Zhang MengZong
    • P
      • Admission for debridement + NPWT (small), HBOT, IV antibiotic, Dopplar sonography
      • Consult Rheu, Nephro
  • 2023-11-14 SOAP Plastic and Reconstructive Surgery Zhang MengZong
    • S
      • Chronic ulcer with necrosis is found over the left medial ankle for about 6 weeks.
      • Hx. of SLE, Lupus nephritis, seizure attack
    • O
      • Height 160, Weight 47, BMI 18.4
      • Chronic ulcer with necrosis is found about 4 * 6 cm in size over the left medial ankle. –> superficial debridement (wound culture) –> wound CD with prontosan gel bid
    • P
      • education
      • HBOT is suggested.

==========

2024-01-19

[SLE management]

Based on the PharmaCloud database, this patient had multiple admissions to TMUH before seeking treatment at our hospital around late 2023. Given that immunosuppressive agents were used prior to her current treatment, vigilant monitoring for signs of infection is recommended. Typically, immunizations should precede immunosuppressive therapy.

Exposure to UV light can trigger or worsen systemic lupus erythematosus (SLE) symptoms, though this varies among patients. About one-third may react to sun exposure, another third with prolonged exposure, and the rest may not react at all. Most SLE patients are advised to avoid direct or reflected sunlight and UV light sources, using sunscreens with a minimum SPF of 55 that block both UV-A and UV-B rays.

A recent study in the Annals of the Rheumatic Diseases has confirmed the renal protective effects of sodium glucose cotransporter 2 (SGLT2) inhibitors in lupus nephritis, both in mouse models and patients, suggesting significant clinical benefits of this treatment approach. (Reference: Onuora S., “SGLT2 inhibitors protect podocytes in lupus nephritis”, Nat Rev Rheumatol, 2023 Oct, 19(10): 605, DOI: 10.1038/s41584-023-01024-1, PMID: 37666997).

701511827

240119

[lab data]

2024-01-18 Anti-HBc Nonreactive
2024-01-18 Anti-HBc-Value 0.42 S/CO
2024-01-18 HBsAg Nonreactive
2024-01-18 HBsAg (Value) 0.40 S/CO
2024-01-18 Anti-HCV Nonreactive
2024-01-18 Anti-HCV Value 0.15 S/CO

[MedRec]

  • 2024-01-17 SOAP Medical Emergency Lin QinXiang
    • Preliminary Impression: N39.0 Urinary tract infection, site not specified
    • 20231222 33072AB_Abdomen C-/C+ N Imaging findings:
      • CT scan of the abdomen and pelvis without/with IV contrast enhancement shows:
      • suboptimal study due to some respiratory motion artifacts.
      • pericardial effusion(s) with calcifications of the tortuous aorta; bronchiectasis and bronchial wall thickening with ill-defined consolidation and air bronchogram at the left lingular, right middle and bil. lower lobes; moderate pleural effusion(s) on both sides; r/o funnel chest (pectus excavatum); presence of the interventricular septum sign, r/o anemia.
      • r/o parenchymal liver disease with hepatic cysts, both lobes.
      • gallbladder sludge, r/o cholecystitis, with pericholecystic fluid collection(s).
      • left renal cyst.
      • no evidence of focal lesion at the spleen, pancreas, bil. adrenals, and right kidney.
      • reflexed and enlarged uterus, r/o uterine fibroid(s), with simple fluid in the uterine cavity, and pelvic edema; enlargement and edema of the uterine cervi x with endocervical enhancement; s/p urinary catheterization in position with chronic cystitis.
      • s/p nasogastric (NG) intubation in position, r/o reflux esophagitis; r/o antral gastritis.
      • mild ascites with dirty mesenteric and omental fat; no evidence of enlarged lymphadenopathy.
      • mild degenerative scoliosis of the lumbar spine; chronic to old benign compression fracture(s) and wedge deformity or decrease in height of the T12 and L5 vertebrae with intravertebral vacuum phenomenon(a), suggestive of osteonecrosis, at the L5 level; varying-sized osteolytic lesions scattered at the bil. iliac bones.
      • extensive subcutaneous edema at the trunk.
      • Impression:
        • pericardial effusion(s);
        • bronchiectasis with secondary infections, left lingular, right middle and bil. lower lobes; bil. pleural effusion(s);
        • r/o funnel chest (pectus excavatum);
        • r/o anemia.
        • r/o parenchymal liver disease with hepatic cysts, both lobes.
        • GB sludge, r/o cholecystitis.
        • left ren al cyst.
        • reflexed and enlarged uterus, r/o uterine fibroid(s);
        • r/o pelvic inflammatory disease (PID) with possible cervicitis; chronic cystitis.
        • r/o reflux esophagitis;
        • r/o antral gastritis.
        • mild ascites, r/o peritonitis.
        • mild degenerative scoliosis, lumbar spine;
        • chronic to old benign compression fracture(s), T12 and L5 vertebrae, with osteonecrosis, L5 level;
        • r/o multiple bony metastases?, bil. iliac bones.
        • extensive subcutaneous edema, trunk.
  • 2024-01-12 SOAP Psychosomatic Medicine Zen YuLun
    • S
      • C.C. & P.I.: The first time visit, the patient is abscent, her daughter come.
      • Background and current position: .
      • Hx of Suicide/Self-injury/Violence: .
      • Hx of Substance abuse: .
      • Hx of psychi/medical disease and treatment: .
      • Current medications: .
      • Family Hx: .
      • Premorbid personality: .
      • Key person and social support: .
    • O
      • Height:150 cm; Weight:38 kg; BMI: 16.9
      • [PPFE] Mental status examination:
        • Consciousness: clear
        • Appearance:
        • Attitude:
        • Affect:
        • Speech:
        • Behavior:
        • Thought:
        • Perception:
        • JOMAC:
    • A/P
        • Establish therapeutic alliance
        • Confirm a diagnosis:
        • Psychoeducation on the disease course
        • Examinations
        • Pharmacotherapy
        • instill hope.

[consultation]

  • 2024-01-17 Urology
    • Q
      • C.C. suspect papillary urothelial malignancy, poor intake since 2023 September, BW loss 59 -> 38 kg, dysuria and hypogastric pain for 2 months
      • Allergy: NKDA
      • PHx: major depression disorder
        • no cough, no dyspnea, no cold sweating
        • no fever, no chills
        • (+) hypogastric pain, no chest/back pain
        • no nausea, no vomiting, no diarrhea
        • no tarry stool
        • (+) dysuria
    • A
      • This 69-year-old female patient was transferred from the oncology ward at other hospital. We were consulted for suspected GU tract cancer.
      • PH:
        • Major depression
        • Chronic bed ridden status due to anorexia
      • Lab:
        • Urine
          • 2024-01-17 Color Yellow
          • 2024-01-17 App Turbid
          • 2024-01-17 SG 1.010
          • 2024-01-17 PH 5.5
          • 2024-01-17 Leucocyte Ester 3+
          • 2024-01-17 NIT 1+
          • 2024-01-17 Sediment-RBC 10-19 /HPF
          • 2024-01-17 Sediment-WBC >=100 /HPF
          • 2024-01-17 Bacteria 1+ /HPF
        • Blood
          • 2024-01-17 Creatinine 0.35 mg/dL
      • Image:
        • No image was available
        • The report of prior CT exam showed no evidence of bladder tumor, hydronephrosis or upper GU tract tumor
      • Impression:
        • Unknown cause of body weight loss
      • Suggestion:
        • There is no evidence of GU tract tumor currently.
        • Further examination can be arranged at OPD.
        • Suggest OPD follow up.

701343853

240118

[MedRec]

  • 2024-01-17 DutyNote Li YuZhong
    • Problem List
      • Problem 1: gastric ulcer, Forrest classification III, prepyloric antrum, AW/LC, s/p CLO test and biopsy
    • Course of disease or treatment
      • This is a 72 year old female with underlying of HTN, CAD s/p PCI under bokey, uterine prolapse status post Robotic assisted sacrocolpopexy 2022/07/20
      • She complaint of general weakness, dizziness, nausea, vomiting and epigastric dullness on 2024/01/15 night. Tarry stool passage was seen on 2024/01/16 for 3 times. She was brought to our ER on 2024/01/16 morning. Vital sign was as following: BP:112/67; HR:109; BT:36.4’C; RR:18; Con’s:E4V5M6. Serum data reported normocytic anemia (Hb8.7 g/dL), mild leukocytosis and high BUN (55mg/dL). Blood transfusion 3 unit and PPI were given.
      • Under the impression of upper GI tract bleeding, EGD was done and reported: gastric ulcer, Forrest classification III, prepyloric antrum, AW/LC, s/p CLO test and biopsy.
      • Follow up serum data showed some recovery of anemia (9.4 g/dL). After her condition was relative stable, she was admitted to ward for further evaluation and management.
    • Treatment recommendations
      • Monitor vital sign
      • Recheck CBC, DC, renal function and electrolyte tomorrow
      • NPO with glucose one touch monitoring
      • Taita no5 500ml BID
      • Pantoprazole 40mg Q12H
      • Transamine 500mg Q12H
      • Hold bokey and xanthium
      • Keep other OPD medications
      • May try soft diet if serum data no abnormal tomorrow
  • 2024-01-17 VsNoteOnAdmissionDay Li ZhongXian
    • Attending progress Note on admission
    • A:
      • Response to treatment: pending
      • GU with recent bleeding
    • P:
      • Diagnostic plan:
        • Check B/R, BUN/Cr, Na, K, ALP, GGT, GOT, GPT, TB, Amylase, lipase, CRP, Alb, LDH, UA, Free T4, TSH, HbA1c, HBsAg, Anti-HCV, IgM anti-HAV, AFP, Lactate, BNP, CRP, PCT, Urine/R, Stool/R, Stool/C, Blood/C, Urine/C, Sputum/C, iFOBT, EKG, CxR, KUB
        • Sono abdomen, colon scope and EGD may be planned
        • CT of abdomen/ liver, biliary tract and pancreas may be planned
      • Treatment plan:
        • NPO/Try water/diet
        • Empiric antibiotics with
        • PPI Tx + GI medication + Symptomatic treatment
        • Adequate volume resuscitation and Keep I/O & E balance
        • Keep Pt’s OPD medication
        • Consult GS/RAD specialist for
      • Education plan:
        • Explained the patient’s serious condition and all plans,infection related complications to the family and the patient
        • Avoid alcohol drinking, hepatoxicity agent, Nsaids, anticoagulants, spicy and fatty foods
  • 2022-07-18 ~ 2022-07-23 POMR Urology Luo QiWen
    • Discharge diagnosis
      • Uterine prolapse status post Robotic assisted sacrocolpopexy 2022/07/20
      • Urge incontinence
      • Nocturia
    • CC
      • Urinary frequency (Q1H) for over six months
    • Present illness
      • This is a 71 year-old female with systemic underlying disease of Hypertension and history of angina s/p catheterization but without stenting, and were all under medications control with Norvasc, bokey, and theophylline. Her ADL is totally independent.
      • According to her statement and medical records, she suffered from severe urinary frequency (Q1H) and nocturia (4 times) for over six months. Besides, a protruding mass was also noted at her vigina, but spontaneously subscided. No pain, no abnormal discharge, no operation history, no incarceration nor other remarkable discomfort was told. She was referred from GI Dr. Chao to GU Dr. Yang’s OPD due to the clinical problem mentioned above. Urinalysis found no sign of urinary tract infection. However, uroflometry found urinary frequency. Thus, symptomatic treatment with detrusitol was prescibed and she can hold urine than before. Due to her clinical problem still persisted, surgical intervention was then suggested.
      • Under the impression of over active bladder with pelvic organ prolapse, she was admitted to our ward for robotic assisted uterine suspension and further care.
    • Course of inpatient treatment
      • After admission, she recieved Robotic assisted sacrocolpopexy on 2022/07/20. The operation went smooth without immediate complications. She had keep bed rest for two days. No fever, no wound oozing nor pus discharge, but gastric discomfort was noted. We had removed foley on 2022/07/22 and no urine retension was found. Now, her clinical condition is relatively stable and may discharge and follow up at OPD.
    • Discharge prescription
      • Through (sennoside 12mg) 2# HS
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
      • Cardizem Retard (diltiazem 90mg) 1# QD
      • Sindine (povidone iodine aq soln 10%) ASORDER EXT

[surgical operation]

  • 2022-07-20 - Op Method: Robotic assisted sacrocolpopexy         
    • Finding:
      • pevic organ prolapse, stage III; cervix 2 cm outside of introitus
      • console time 3 hr 35 cm

==========

2024-01-18

Pre-meal blood glucose levels were recorded at 132, 157, and 108 mg/dL on 2024-01-16, 2024-01-17, and 2024-01-18, respectively, indicating consistently elevated values. It is recommended that the patient continues with follow-up monitoring.

Upon review of the HIS5 records, no discrepancies in medication were identified.

701358512

240117

[MedRec]

  • 2023-12-22 ~ 2023-12-25 POMR Urology Cai YaoZhou
    • Discharge diagnosis
      • Left renal cell carcinoma, T3aN1M1, Stage IV
      • Anemia (Hb:6.6g/dl)
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
    • CC
      • Weakness, dizziness, poor appetite, and persistent nausea for several days.
    • Present illness
      • This is a 53-year-old woman with history of:
        • Hypertension
        • Type II DM
        • Left renal cell carcinoma, T3aN1M1, Stage IV
          • Axitinib + Pembrolizumab for 4 times, shift to Atezolizumab on 2021/07/15-2023/01/06 (19th) due to heart failure  
          • target tx with cabozantinib approved (2022/03/07-2023/11/26) and Afinitor (2023/10/23-11/21).
          • Immunotherapy with Nivolumab on 2023/02/10-2023/10/17, due to regioal lymphadenopathy and bilateral lung meta.
        • Sepsis, heart failure, left distal common femoral artery pseudoaneurysm in 2023/07.
      • She had been under the Cabozantinib and Nivolumab treatment.
        • CT on 2023/05/31 showed partial response to Nivo + cabo.
        • CT on 2023/10/18 revealed mild increased tumor size, disease progression.
      • Thus, shift to afinitor and cabozantinib had been made. After starting Afinitor treatment on 10/23, she experienced severe diarrhea and feelings of nausea and vomiting. Additionally, she had a noticeable weight loss. She was hospitalized twice to manage these symptoms and stopped taking Afinitor on 2023/11/21.
      • This time, She has suffered from weakness, dizziness, poor appetite, and persistent nausea for several days. Thus, she was admitted for further evaluation and management.
    • Course of inpatient treatment
      • After admission, she accepted blood transfusion therapy, due to anemia. During treatment, she still has weakness, dizziness, poor appetite, and mild nausea. After the blood transfusion, the hemoglobin level increased from 6.6 g/dL to 9.8 g/dL.
      • Because symptoms relieved after treatment, she was discharged today and would be followed up at urologic clinic.
  • 2022-02-15 ~ 2022-02-19 POMR Urology Cai YaoZhou
    • Discharge diagnosis
      • Left renal cell carcinoma, cT3aN1M1, stage 4 status post immunotherapy with Atezozulimab (#8)
    • CC
      • Admission for immunotherapy with Atezozulimab (#8)
    • Present illness
      • This 51-year-old women had histories of
        • Hypertension and DM under medication control;
        • Left RCC, cT3aN1M1, stage 4 start Axitinib + Pembrolizumab for 4 times, shift Atezozumab since 2021/07/15 due to heart failure.
      • This time, she admission for immunotherapy with Atezozulimab (#8).
    • Course of inpatient treatment
      • At admission, 8th immonotherapy with Atezozulimab was gave. She was discharged with stable condition on 2022/02/19 and would be followed up at urologic clinic.

[immunochemotherapy]

  • 2023-10-17 - nivolumab 200mg NS 100mL 1hr
    • diphenhydramine 30mg + NS 250mL
  • 2023-09-28
  • ……….
  • 2022-02-15 - atezolizumab 1200mg NS 250mL 1hr
    • diphenhydramine 30mg + NS 250mL

  • 2023-11-21 ~ 2024-01-17 going - sunitinib
  • 2023-02-09 ~ 2023-11-26 - cabozantinib

==========

2024-01-17

[stage IV RCC on sunitinib: historical anemia, emergency event & HGB low]

This 53-year-old female patient with stage IV renal cell carcinoma (RCC) was started on sunitinib in late Nov 2023 after progression on cabozantinib. The patient had a history of anemia prior to starting sunitinib, with no hemoglobin (HGB) values within the normal range in 2023.

On 2024-01-16, the patient presented to the emergency department with suspected coffee-ground emesis. This was likely the primary cause of the recent anemia episode. However, sunitinib is known to be associated with an incidence of decreased HGB (26% to 79%; grades 3/4: 3% to 8%; grade 4: 2%) and hemorrhage (22% to 37%; grades 3/4: <=4%). Therefore, the historic low HGB value on 2024-01-16 cannot be definitively excluded as a side effect of sunitinib. The patient underwent a blood transfusion on the same day, which was a reasonable course of action. In addition, this patient also underwent multiple blood transfusions in 2023.

  • 2024-01-16 HGB 6.3 g/dL
  • 2023-12-25 HGB 9.8 g/dL
  • 2023-12-22 HGB 6.6 g/dL
  • 2023-11-23 HGB 8.9 g/dL
  • 2023-11-21 HGB 9.7 g/dL
  • 2023-11-03 HGB 9.1 g/dL
  • 2023-10-16 HGB 8.7 g/dL
  • 2023-09-28 HGB 8.1 g/dL
  • 2023-09-05 HGB 9.5 g/dL
  • 2023-08-18 HGB 9.9 g/dL
  • 2023-07-25 HGB 10.7 g/dL
  • 2023-07-24 HGB 10.5 g/dL
  • 2023-07-21 HGB 9.8 g/dL
  • 2023-07-20 HGB 7.9 g/dL
  • 2023-07-18 HGB 9.2 g/dL
  • 2023-06-25 HGB 10.0 g/dL
  • 2023-06-07 HGB 10.3 g/dL
  • 2023-05-21 HGB 10.6 g/dL
  • 2023-05-02 HGB 11.0 g/dL
  • 2023-04-14 HGB 10.4 g/dL
  • 2023-03-29 HGB 11.2 g/dL
  • 2023-03-10 HGB 10.4 g/dL
  • 2023-02-23 HGB 9.8 g/dL
  • 2023-02-10 HGB 8.5 g/dL
  • 2023-01-05 HGB 10.1 g/dL

In the event of grade 3 or 4 hemorrhage, it is recommended to withhold sunitinib until resolution to <= grade 1 or baseline, then resume at a reduced dose or discontinue (depending on severity and persistence). Discontinue sunitinib if grade 3 or 4 hemorrhagic events do not resolve.

The standard dosage of sunitinib for advanced RCC is 50mg daily, but the patient is currently taking 12.5mg daily. This is a significant underdose, and there seems no room to further reduce the dose.

700888080

240116

[exam findings]

  • 2024-01-15, 2023-12-25, -12-18, -12-15, - 12-10 CXR erect
    • Atherosclerotic change of aortic arch
    • Lung metastases are suspected after correlate with CT.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-12-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (63.1 - 20.2) / 63.1 = 67.99%
      • M-mode (Teichholz) = 68.0
      • 2D (M-Simpson) = 65.1
    • Conclusion:
      • Thickened AV with trivial AR
      • Normal MV with no MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, normal IVC size
  • 2023-12-25 Bronchodilator Test
    • Severe restrictive and moderate obstructive pulmonary function impairment.
    • Negative bronchodilator test.
    • Suggested COPD
  • 2023-11-23, -11-10 CXR
    • Multiple nodules at bil. lungs.
    • Atherosclerosis of the aorta.
  • 2023-11-23 KUB
    • Lumbar spondylosis and scolisis.
  • 2023-11-13 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with intrahepatic cholangiocarcinoma
    • The specimen submitted consists of two strips of yellow gray soft tissue, labeled liver, measuring up to 1.5 x 0.1 x 0.1 cm. All for section.
    • The sections show a picture of adenocarcinoma, moderately differentiated, composed of nests and cords of polygonal neoplastic cells with moderate amount cytoplasm in fibrous stroma. Focal glandular differentiation and tumor necrosis are present.
    • IHC shows: CK7(+), CK19(+), CK20(-), Arginase-1(-), and Hepatocyte(-). The finding is compatible with intrahepatic cholangiocarcinoma.
  • 2023-11-11 EGD
    • Diagnosis:
      • Reflux esophagitis,Gr A
      • Superficial gastritis, antrum
      • Gastric erosion, GCS of lower body
    • CLO test: not done
    • Suggestion:
      • Medication and OPD f/u
      • EGD was suggested for erosion f/u 3 months later
      • EGD was suggested annually for GERD f/u
  • 2023-11-11 SONO - abdomen
    • Diagnosis:
      • Liver tumors, suspected metastatic tumors
      • liver parenchymal disease
      • mild gallbladder wall thickening
      • ascites: small amount
    • Suggestion:
      • correlate with other image study result such as CT scan/MRI
  • 2023-11-04 CT - abdomen
    • History and indication: hepatic tumors R/O mets.
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Poor enhancing tumors (up to 11.5cm) in both hepatic lobes.
      • Multiple lung nodules.
      • Increased soft tissues in peritoneal cavity with ascites.
      • Hyperplasia of left adrenal gland.
      • Mild splenomegaly.
      • Small caliber of left portal vein.
      • Some LNs at hepatic hilar region and retroperitoneum.
      • Atherosclerosis of aorta, iliac arteries.
    • Addendum Imaging Report Form for Cholangiocarcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N1(N_value) M:M1(M_value) STAGE:IV(Stage_value)

[MedRec]

  • 2023-11-10 ~ 2023-11-14 POMR Gastroenterology Wang JiaQi
    • Discharge diagnosis
      • Hepatic tumors, favor cholangiocarcinoma with peritoneal, lymph nodes, lung metastasis and small amount ascites status post CT quiding liver biopsy on 2023/11/13.
      • Reflux esophagitis, grade A
      • Essential (primary) hypertension
      • Chronic obstructive pulmonary disease
    • CC
      • epigastric pain and BW loss 6 KG in 1 mo
    • Present illness
      • This 71 year-old male has the histories of 1) Hypertension, 2) DM, 3) COPD.
      • This time, he suffered from epigastric pain for days. Poor appetite and body weight loss 4 kg in 1 month were noted. He visited local medical clinic for help. Abdominal sonography showed liver tumor. So he transfer to our GI OPD for help.
      • Abdominal CT was performed on 2023/11/04 and revealed In favor of liver cholangiocarcinomas with peritoneal seeding, LNs and lung metastases.
      • There was no headache or dizziness, no sorethroat or rhinorrhea, cough or dyspnea, no chest tightness or pain, no myalgia/arthralgia found.
      • Physical exam showed pink conjunctiva, breath sound: coarse, Heart soudn: RHB w/o murmur, abdomen: soft, epigastric tenderness, normoactive bowel sound without metallic sound, no flank knocking pain, no lower leg pitting edema, no wound or skin rash found.
      • Under the impression of 1) Suspect liver cholangiocarcinomas with peritoneal seeding, LNs and lung metastases, he was admitted to ordinary ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission, hepaptitis markers (HBsAg, Anti HCV) and tumor markers (CEA, CA19-9) were all checked.
      • Upper GI endoscopy and abdominal sonography were all performed which revealed liver tumors, suspected metastatic tumors and minimal ascites on Echo.
      • EGD showed Reflux esophagitis, Gr A. In addition, oral form PPI with Nexium 1# po QDAC was given.
      • Because he still complained about intermittent Lelt epigastric pain, painkiller with scanol 1# po TID was used for symptoms relief.
      • We explained this condition to himself and his family, they understood. Informed the needs and the risks of CT quiding liver biopsy, they understood and agreed. CT quiding biopsy was done on 11/13 without complications.
      • Another hepatitis markers with Anti-HBc, Anti-HBs and LDH were checked.
      • Oncologist was consulted for management of favor CCC with intra-hepatic, peritoneal, LN and lung mets s/p biopsy who suggested OPD follow up and pending pathology.
      • There was no more epigastric pain nor fever after treatment. Under a stable condition, he was discharged on 11/14 and further GI/Oncology OPD follow up was arranged.
    • Discharge prescription
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Acetal (acetaminophen 500mg) 1# TID

[chemotherapy]

  • 2024-01-10 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 50mg/m2 50mg NS 500mL 2hr + NS 500mL 2hr (after CDDP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-12-27 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 50mg/m2 50mg NS 500mL 2hr + NS 500mL 2hr (after CDDP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-12-20 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 50mg/m2 50mg NS 500mL 2hr + NS 500mL 2hr (after CDDP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-12-05 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 50mg/m2 50mg NS 500mL 2hr + NS 500mL 2hr (after CDDP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-11-29 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + cisplatin 50mg/m2 50mg NS 500mL 1hr (gemcitabine + cisplatin; Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-01-16

[combining immunotherapy with chemotherapy in biliary tract tumors] - Ref: 2024-01-16 - https://www.uptodate.com/contents/systemic-therapy-for-advanced-cholangiocarcinoma

The current treatment regimen for advanced or metastatic biliary tract tumors for this patient is gemcitabine plus cisplatin.

Adding durvalumab to this regimen, as seen in the TOPAZ-1 trial, can enhances OS and response, without notably increasing toxicity. Similarly, pembrolizumab combined with gemcitabine and cisplatin, as demonstrated in the KEYNOTE-966 trial, also improves OS and is well-tolerated.

However, due to non-coverage by NHI and potential reimbursement issues, the addition of durvalumab or pembrolizumab may be more suitable for patients who can financially manage the costs.

2023-11-30

[hyperuricemia, hyperkalemia, hypercalcemia]

Hyperuricemia, hyperkalemia, hypercalcemia were observed.

  • 2023-11-30 K(Potassium) 5.1 mmol/L
  • 2023-11-30 Ca (Calcium) 3.51 mmol/L
  • 2023-11-30 Uric Acid 12.2 mg/dL
  • 2023-11-30 BUN 50 mg/dL
  • 2023-11-30 Creatinine 1.64 mg/dL
  • 2023-11-30 Na (Sodium) 134 mmol/L
  • 2023-11-29 Ca (Calcium) 3.68 mmol/L
  • 2023-11-29 Uric Acid 11.4 mg/dL
  • 2023-11-29 K(Potassium) 5.2 mmol/L

Hyperuricemia is treated with Fasturtec (rasburicase), Februic (febuxostat) and Rolikan (sodium bicarbonate).

Hyperkalemia is treated wtih Kalimate (calcium polystyrene sulfonate).

Hyperuricemia and hyperkalemia are frequent symptoms of tumor lysis syndrome. Another typical symptom is hyperphosphatemia, so it’s recommended to also monitor serum phosphate levels.

Hypercalcemia is treated with Miacalcic (calcitonin).

For severe hypercalcemia, the maintenance dose of calcitonin can be up to 8 units/kg (2023-11-29 70kg => 560 units) Q6H to Q12H, starting with an initial dose of 4 units/kg (280 units) Q12H. Since the current administration of 100 IU Q6H is below the recommended dosage, this might extend the duration of therapy. It’s advisable to limit calcitonin therapy to a period of 24 to 48 hours to avoid tachyphylaxis.

Given that the serum calcium level has exceeded 3.5 mmol/L (14 mg/dL) and if the reading does not obviously trend downwards, the combined use of calcitonin with bisphosphonates for a longer effect might be an option.

701187248

240116

[exam findings]

  • 2023-11-08 Tc-99m MDP bone scan
    • Faint hot spots in both rib cages, cancer with early bone mets may be considered, suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, mandible, sternum, some C-, T- and L-spine, sacrum, bilateral shoulders, elbows, S-I joints, and hips.
  • 2023-11-06 CXR (erect)
    • Atherosclerotic change of aortic arch
  • 2023-10-02, -09-29 KUB
    • Degeneration and spondylosis of L-S spine.
  • 2023-09-14 Patho - stomach subtotal/total (tumor)
    • Diagnosis
      • Stomach, antrum, radical D2 subtotal gastrectomy — Adenocarcinoma, moderately differentiated, pStage IIIA, pT3N2 (if cM0)
      • Duodenum, radical D2 subtotal gastrectomy — Negative for malignancy
      • Omentum, radical D2 subtotal gastrectomy — Negative for malignancy
      • Gallbladder, cholecystectomy — Negative for malignancy
      • Lymph node, No 1, dissection — Negative for malignancy (0/2)
      • Lymph node, No 3, dissection — Metastatic adenocarcinoma (1/ 4)
      • Lymph node, No 4, dissection — Metastatic adenocarcinoma (2/ 5)
      • Lymph node, No 5, dissection — Negative for malignancy (0/ 0)
      • Lymph node, No 6, dissection — Metastatic adenocarcinoma (2/ 4)
      • Lymph node, No 7, 8, 9, 11p, dissection — Metastatic adenocarcinoma (1/ 15)
      • Lymph node, No 12a, dissection — Negative for malignancy (0/1)
      • Lymph node, No 14v, dissection — Negative for malignancy (0/1)
    • Gross Description:
      • Procedure:
        • radical D2 subtotal gastrectomy
        • cholecystectomy
      • Specimen size:
        • specimen 1: Greater curvature: 15.0 cm, Lesser curvature: 9.2 cm,
        • specimen 2: Omentum: 37.5 x 23.0 x 1.3 cm
        • speicmen: 11 Gallbladder: 1.7 x 1.2 x 0.5 cm (all submitted)
      • Tumor Site: Antrum, posterior wall
      • Tumor Size: 6.3 x 5.0 x 1.0 cm
      • Gross configuration: For advanced carcinoma (Borrmann classification): Type II: Fungating, ulcerated with sharp raised margins
      • Sections are taken and labeled as: A1: proximal resection margin; A2: distal resection margin; A3: stomach, non-tumor; A4-8: tumor (A4-5: the same level); B1-2: omentum; C: lymph node, No 1; D: lymph node, No 3; E : lymph node, No 4; F: lymph node, No 5; G: lymph node, No 6; H1-3: lymph node, No 7, 8, 9, 11p; I: lymph node, No 12a; J: lymph node, No 14v; K1-2: gallbladder.
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma: Lauren classification of adenocarcinoma: Intestinal type; WHO: Tubular, moderately differentiated
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor penetrates the subserosal connective tissue without invasion of the visceral peritoneum or adjacent structures
      • Margins
        • Proximal margin: uninvolved by invasive carcinoma: 5.0 cm
        • Distal margin: uninvolved by invasive carcinoma: 1.2 cm
        • Radial margin: very close, < 0.1 cm
      • Lymphovascular Invasion: present
      • Perineural Invasion: present
      • Regional Lymph Nodes: please see diagnosis
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): not applicable
          • Primary Tumor (pT): pT3: Tumor penetrates the subserosal connective tissue without invasion of the visceral peritoneum or adjacent structures
          • Regional Lymph Nodes (pN): pN2: Metastasis in three to six regional lymph node
          • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
      • Additional Pathologic Findings:
        • Intestinal metaplasia: present
        • Low-grade dysplasia: absent
        • High-grade dysplasia: present
        • Helicobacter pylori-type gastritis: absent
        • Autoimmune atrophic chronic gastritis: absent
        • Polyp(s) : absent
  • 2023-09-01 CT - abdomen
    • CC: Epigastralgia, R/O PUD; 20230830 gastroscopy: A 3-5cm mass with deep ulcer was noted at PW of antrum, s/p biopsy 6 (A). Suspected advanced gastric cancer, Bormann 2.
    • Indication: Gastric cancer staging
    • Findings:
      • There is segmental wall thickening in the gastric antrum, measuring 5 cm in size, that is c/w adenocarcinoma (T3).
      • There are two enlarged nodes in the peri-gastric antrum area that may be metastatic nodes (N1).
      • There is no focal lesion in both lungs.
        • There are two enlarged nodes in right paratracheal space and paraaortic space. Follow up is indicated.
      • A renal cyst 1 cm in right upper pole is noted.
      • The gallbladder shows small contracted.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N1(N_value) M:M0(M_value) STAGE:III(Stage_value)
  • 2023-08-30 Patho - stomach biopsy (Y1)
    • Stomach, PW of antrum, biopsy — poorly differentiated adenocarcinoma
    • Microscopically, it shows poorly differentiated adenocarcinoma composed of proliferation of atypical tumor cells arranged in solid to glandular architecture and invasive growth pattern.
      • Tumor cells show nuclear hyperchromasia, pleomorphism and prominent nucleoi.
      • Both H.pylori and fungal hyphae are seen at the superficial mucosa.
    • IHC stain — CK: positive and Her2/neu: neagtive at tumor
  • 2023-08-30 EGD
    • Reflux esophagitis, LA A
    • Esophageal lesion, upper esophagus, s/p biopsy (B)
    • Suspected advanced gastric cancer, Bormann 2, PW of antrum, s/p biopsy (A)
    • Superficial gastritis, antrum, s/p CLO test

[MedRec]

  • 2023-11-06 ~ 2023-11-11 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Adenocarcinoma of gastric antrum, pT3N2M0 stage IIIA, status post radical D2 subtotal gastrectomy and cholecystectomy and Braun’s anastomosis on 2023/09/14. ECOG:1
      • Chronic superficial gastritis without bleeding
      • Cachexia
    • CC
      • for bone scan (for right low rib pain) and C1 FOLFOX
    • Present illness
      • This 73-year-old male with past history of type 2 diabetes with medications control. He also sufferred from presented with progressive constipation lasting 1-2 years, experiencing stool every third day. He has no history of bloody or tarry stools, no small caliber stool, but reported a sensation of tenesmus. No significant weight loss was noted, and there is no family history of gastrointestinal (GI) cancer.
      • According for his statement, his national health insurance fecal immunochemical test (NHI FIT) in 2023 was negative. On examination in July, the decision was made to arrange for an IVG CFS in late A colonoscopy in 202308 showed the presence of several polyps, which were removed. One was in the ascending colon, two in the hepatic flexure, and one in the transverse colon. By late 202308, the patient had added complaints of occasional epigastric pain and acid reflux for months. An EGD was ordered. The gastroscopy showed possible reflux esophagitis, a lesion in the upper esophagus, a suspected gastric cancer in the antrum of the stomach, and superficial gastritis. A biopsy was taken from the gastric lesion. The clostridium-like organism (CLO) test was negative, implying the absence of Helicobacter pylori infection. The biopsy results from the stomach confirmed a poorly differentiated adenocarcinoma.
      • A subsequent CT scan for staging of the gastric cancer in September showed that the cancer is at stage T3N1M0, which corresponds to stage III disease. The cancer involves the gastric antrum wall but does not penetrate the serosa or adjacent structures. There are metastases to one to two regional lymph nodes, but no evidence of distant metastasis. Therefore, laparosocpe D2 subtotal gastrectomy was suggested. However, status post radical D2 subtotal gastrectomy and cholecystectomy and Braun’s anastomosis on 2023/09/14. ECOG:1. Port A inserted thro’ left cephalic vein on 2023/10/18.
      • This time, admission for bone scan (for right low rib pain) and C1 FOLFOX.
    • Course of inpatient treatment
      • After admitted, bone scan was done on 11/08 and shows 1. Faint hot spots in both rib cages, cancer with early bone mets may be considered, suggesting follow-up with bone scan in 3 months for further evaluation. 2. Suspected benign lesions in the maxilla, mandible, sternum, some C-, T- and L-spine, sacrum, bilateral shoulders, elbows, S-I joints, and hips.
      • Adjuvent chemotherapy with FOLFOX (Oxalip 85mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) from 2023/11/09~2023/11/11.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/11/11 and admission was arrange later.
    • Discharge prescription
      • Alpraline (alprazolam 0.5mg) 1# HS
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Kludone (gliclazide 60mg) 0.5# QD
      • MgO 250mg 1# QID
      • Stilnox (zolpidem 10mg) 1# HS
      • Stogamet (cimetidine 300mg) 1# TID
      • Through (sennoside 12mg) 2# HS
      • Tulip (atorvastatin 20mg) 1# HS
      • Uformin (metformin 500mg) 1# BIDCC
      • Bisadyl supp (bisacodyl 10mg/pill) 1# Q3D RECT
  • 2023-10-19 SOAP Hemato-Oncology Xia HeXiong
    • P
      • Admission for bone scan (for right low rib pain) and FOLFOX
      • Plan: FOLFOX x 6 -> CCRT -> FOLFOX x 6
    • Prescription
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Megest (megestrol 40mg/mL) 10mL QD
      • Bisadyl supp (bisacodyl 10mg/pill) 1# Q3D RECT
  • 2023-09-11 ~ 2023-10-05 POMR General and Gastrointestinal Surgery Chen YenZhi
    • Discharge diagnosis
      • Adenocarcinoma of gastric antrum, pT3N2M0 stage IIIA, status post radical D2 subtotal gastrectomy and cholecystectomy and Braun’s anastomosis on 2023/09/14. ECOG:1
    • CC
      • Epigastralgia or acid reflux sensation for months.
    • Present illness
      • This 73-year-old male with past history of type 2 diabetes with medications control. He also sufferred from presented with progressive constipation lasting 1-2 years, experiencing stool every third day. He has no history of bloody or tarry stools, no small caliber stool, but reported a sensation of tenesmus. No significant weight loss was noted, and there is no family history of gastrointestinal (GI) cancer.
      • According for his statement, his national health insurance fecal immunochemical test (NHI FIT) in 2023 was negative. On examination in July 2023, the decision was made to arrange for an IVG CFS in late A colonoscopy in 202308 showed the presence of several polyps, which were removed. One was in the ascending colon, two in the hepatic flexure, and one in the transverse colon.
      • By late 202308, the patient had added complaints of occasional epigastric pain and acid reflux for months. An EGD was ordered. The gastroscopy showed possible reflux esophagitis, a lesion in the upper esophagus, a suspected gastric cancer in the antrum of the stomach, and superficial gastritis. A biopsy was taken from the gastric lesion. The clostridium-like organism (CLO) test was negative, implying the absence of Helicobacter pylori infection. The biopsy results from the stomach confirmed a poorly differentiated adenocarcinoma.
      • A subsequent CT scan for staging of the gastric cancer in September 2023 showed that the cancer is at stage T3N1M0, which corresponds to stage III disease. The cancer involves the gastric antrum wall but does not penetrate the serosa or adjacent structures. There are metastases to one to two regional lymph nodes, but no evidence of distant metastasis. Therefore, laparosocpe D2 subtotal gastrectomy was suggested and scheduled. Due to the above reasons, the patient was admitted for scheduled surgery and further management.
    • Course of inpatient treatment
      • On admission, the patient underwent a thorough pre-operative survey which showed no abnormalities. Subsequently, he successfully underwent a radical D2 subtotal gastrectomy with Braun’s anastomosis and cholecystectomy on 2023-09-14.
      • After the surgery, we closely monitored the patient’s recovery and administered empiric antibiotics, nutrition support via partial parenteral nutrition (PPN), and analgesic agents. We also observed poor bowel movement with minimal flatus and substantial gastric juice drainage via NG tube. To promote bowel movement, we administered Zirocin and Promeran from 2023-09-19 and supported nutrition via total parenteral nutrition (TPN) from 2023-09-22.
      • A small bowel series conducted on 20th September showed no abnormal bowel loop displacement or ileus pattern. Despite initial struggles with the NG tube, the patient later tolerated it well with intermittent clamping. We continued the current treatment, maintaining close monitoring of vital signs.
      • As of today’s date (2023-10-01), some metrics show slight fluctuations from their initial results at admission, but none are cause for concern. This includes liver function tests, renal function tests, a slight decrease in albumin levels, and a slight increase in Creatinine values, reducing the eGFR. However, the blood picture remained stable with CBC values within normal range. White blood cells count increased to 10.26 on 2023-09-25 likely due to the surgical procedure and has returned to 3.71 as of 2023-10-02.
      • The patient remains on a comprehensive medication management plan including pain management (Acetaminophen asneeded), GI care (Rabeprazole), nutrition support (SmofKabiven),electrolytes and trace elements replenishment, and hydration (Saline 0.9%).
      • In this weeks started from 2023/10/01. His had fair acitivity and he started soft diet on 2023/10/03. He denied nausea/vomiting, abdominal pain. And we removed two JP drain on 2023/10/02 and 2023/10/04. Under relative stable condition, he was discharged on 2023/10/05 and will follow up at our OPD next week.
    • Discharge prescription
      • Zirocin (azithromycin 250mg) 1# QD
      • Through (sennoside 12mg) 2# HS
      • Stilnox (zolpidem 10mg) 1# HS
      • Pariet (rabeprazole 20mg) 1# QDAC
      • Harnaldge (tamsulosin 0.4mg) 1# QDAC
      • Mopride (mosapride citrate 5mg) 1# TID
      • Acetal (acetaminophen 500mg) 1# PRNQ6H

[surgical operation]

  • 2023-09-14
    • Surgery
      • radical D2 subtotal gastrectomy
      • cholecystectomy
      • Braun’s anastomosis
    • Finding
      • cT4aN2M0
      • distal gastric tumor with serosa involve
      • no peritoneal seeding
      • LN enlarge at station 4 and 6

[chemotherapy]

  • 2024-01-15 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3 + hydroxocobalamin 1mg IM (Vit B12, post oxa)
  • 2023-12-25 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3 + hydroxocobalamin 1mg IM (Vit B12, post oxa)
  • 2023-12-04 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-09 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-01-16

Lab testing demonstrated a blood ferritin level of 18.9 ng/mL (2024-01-15), which falls below the normal range. Therefore, initiating oral iron supplementation may be beneficial to maintain adequate iron stores in this patient.

2023-12-26

[reconciliation]

Leukopenia was identified in lab results on 2023-12-25. Consequently, the 5-FU bolus was omitted, and the Oxaliplatin dose was adjusted to 75mg/m2 from the originally planned 85mg/m2 for this chemotherapy session.

  • 2023-12-25 WBC 2.36 x10^3/uL
  • 2023-12-04 WBC 3.01 x10^3/uL
  • 2023-11-06 WBC 3.54 x10^3/uL
  • 2023-10-05 WBC 3.10 x10^3/uL
  • 2023-10-02 WBC 3.71 x10^3/uL
  • 2023-09-28 WBC 5.49 x10^3/uL

Despite vitamin B12 supplementation during this chemotherapy session, the patient’s mean corpuscular volume (MCV) on 2023-12-25 (79fL) remained below the lower limit of normal. This suggests mild microcytic anemia, potentially due to iron deficiency. Iron supplementation could therefore be helpful to raise the iron content of RBC, addressing this issue.

2023-12-05

2023-12-04 HGB 11.5 g/dL < 13.5 and MCV 77.8 fL < 80. It is suggested to consider some vitamin and mineral supplements:

  • Vitamin B12: Absorption of vitamin B12 can be significantly affected after gastrectomy because the stomach produces intrinsic factor, which is essential for its absorption. Vitamin B12 injections or high-dose oral supplements might be necessary.
  • Iron: Iron deficiency is common, particularly if the duodenum is bypassed. Iron supplements might be needed, and it’s important to monitor iron levels regularly.

701393041

240116

[lab data]

2023-12-20 CMV viral load assay 1040 IU/mL

2023-12-19 STR DNA fingerprint FINISH %

2023-12-18 CMV viral load assay 396 IU/mL

2023-12-12 CMV IgM Nonreactive
2023-12-12 CMV IgM Value 0.10 Index

2023-12-11 CMV viral load assay 74 IU/mL

2023-12-08 Anti-HBc Reactive
2023-12-08 Anti-HBc-Value 3.10 S/CO

2023-12-06 CMV viral load assay <35 IU/mL

2023-11-18 STR DNA fingerprint FINISH %

2023-11-13 EB VCA IgG Positive Ratio
2023-11-13 EB VCA IgG Value 3.6 Ratio

2023-11-10 HBsAg (NM) Negative
2023-11-10 HBsAg Value (NM) 0.539
2023-11-10 Anti-HBs (NM) Positive
2023-11-10 Anti-HBs value (NM) 59.1 mIU/mL
2023-11-10 Anti-HCV (NM) Negative
2023-11-10 Anti-HCV Value (NM) 0.047
2023-11-10 Anti-HBc (NM) Positive
2023-11-10 Anti-HBc Value (NM) 0.008

2023-11-09 VZV IgG Positive Index
2023-11-09 VZV-G Value 5.9 Index

2023-11-09 Mycoplasma IgM Negative Index
2023-11-09 Mycoplasma IgM Value 0.1 Index

2023-11-08 RPR Nonreactive

2023-11-08 EB VCA IgM Negative Index
2023-11-08 EB VCA IgM Value 0.1 Index

2023-11-08 CMV IgG Reactive
2023-11-08 CMV IgG Value 92.1 AU/mL
2023-11-08 CMV IgM Nonreactive
2023-11-08 CMV IgM Value 0.27 Index

2023-11-08 HIV Ab-EIA Nonreactive
2023-11-08 Anti-HIV Value 0.05 S/CO

2023-11-08 Anti HTLV I/II Nonreactive
2023-11-08 Anti HTLV I/II Value 0.08 S/CO

2023-10-20 IgE 14.5 IU/mL
2023-10-19 IgG 1831 mg/dL
2023-10-19 IgM 51.0 mg/dL
2023-10-19 IgA 421 mg/dL

2023-07-20 Ferritin (NM) 1548.71 ng/ml
2023-06-23 Ferritin (NM) 1258.84 ng/ml

2023-06-23 HLA DQ-high 02:01
2023-06-23 HLA DQ-high 04:02

2023-04-10 HLA A-high 24:02
2023-04-10 HLA A-high 33:03
2023-04-10 HLA B-high 40:01
2023-04-10 HLA B-high 58:01
2023-04-10 HLA C-high 03:02
2023-04-10 HLA C-high 07:02

2023-04-10 HLA DR-high 03:01
2023-04-10 HLA DR-high 08:09

[exam findings]

  • 2023-12-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (106 - 38) / 106 = 64.15%
      • M-mode (Teichholz) = 63
    • Conclusion
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, LVH, grade 1 LV diastolic dysfunction
      • Mild AS, AR, and PR
  • 2023-12-16, -12-14 Abdomen - Standing (Diaphragm)
    • Spondylosis of the L-spine is noted.
  • 2023-12-14 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2023-07-14 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with myelodysplastic syndrome
    • The specimen submitted consists of two cores of gray-brown and hard bony tissue, measuring up to 2.7 x 0.3 x 0.3 cm. All for section after decalcification.
    • The sections show normocellular marrow (25%). M/E ratio = 2:1 in CD71 and MPO stains. The erythoid precursors are dispersed and scattered. The CD61+ megakaryocytes are moderately increased, and occasional micromegakaryocytes are present. Mild perivascular and paratrabecular fibrosis can be found. Slightly increased increased CD34+ and/or CD117+ immature cells, account for 3% of nucleated cells. The finding is compatible with myelodysplastic syndrome. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2023-01-04 SONO - Spleen
    • Homogeneous echogenicity of the spleen.
    • Soft tissue nodule, 2.06 in the lower pole of the spleen, accessary spleen? Suggest follow up study.
  • 2022-06-20 SONO - Spleen
    • Homogeneous echogenicity of the spleen.
    • Mild splenomegaly (12.73 x 5.32 cm).
    • Soft tissue nodule, 1.7 x 1.51 cm in splenic hilar region, accessary spleen? Suggest follow up study.

[MedRec]

  • 2023-11-05 ~ 2023-12-08 POMR Hemato-Oncology Gao WeiYao

    • Discharge diagnosis
      • Acute myeloblastic leukemia, post allo-PBSCT on 2023/11/17
      • Refractory anemia with excess of blasts
      • GVHD with mucositis and liver function
      • Anemia
      • Electrolyte imbalance
      • Hickman insertion
    • CC
      • for allo-PBSCT
    • Present illness
      • The 59 years old male was diagnosed of myelodysplastic syndrome (MDS) with Refractory Anemia with excess of blast (RAEB) since April 2022 at FuRen Univ Hosp. According to the patient, the initial presentation was dizziness. After diagnosing, he was then regularly taking Hydroxyurea 1# QOD since April 2022 at FuRen Univ Hosp.
      • He came to our hemato-oncologic clinic (Dr Zhang ShouYi) on 2022/06/18 and we have arranged JAK2 mutation test (2022/06/20) which was revealed undetectable.
      • We applied Azacitidine 75mg/m2 SC D1~D7 Q4W x 4 on 2022/06/27. We suggest to check HLA high resolution for stem cell collection.
      • He was then started Azacitidine at our OPD since 2022/07/04 and regular follow up at our clinic. Azacitidine 75mg/m2 SC D1~D7 Q4W x 4 on 2022/07/04-2023/9/18.
      • Family conference was done for allo-PBSCT on 2023/09/25.
      • This time, he sufferes from dry cough also noted at night. He denied fever, oral ulcer, sore-throat or anal pain. He was admitted for allo-PBSCT on 2023/11/05.
    • Course of inpatient treatment
      • After admission, he received hickmen insertion from CVS on 2023/11/09. During hospitalization, he received GCSF 150mcg qd for neutropenia.
      • ID/NST/OS were consulted for assessment.
      • Chemo are arranged as FluMel140-ATG since 2023/11/11-11/15 and ATG since 11/15-11/16.
      • Ciclosporin 1.5mg/kg q12h since 11/16.
      • Hydration and sent to BMT room on 11/16 night.
      • Allo-PBSCT on 11/17.
      • Chemo as MTX 15mg/m2 on 11/18 and 11/22.
      • GCSF 300mcg since 11/18.
      • Lasix 20mg bid for keep I/O balance.
      • MUD allogeneic PBSCT with donor blood type O and recepitent blood type A.
      • Day 0 in 2023/11/17 (CD34+/kg x 10^6 = 11.6/kg x 10^6).
      • Fortunately, his WBC up 960 in Day 10 on 11/27.
      • Blood transfusion during hospitalization.
      • Antibiotics as Cefepime and Targocid for fever control and add steroid for suspect engraftment symdrom.
      • Spiking fever was noted, so we shift Cefepime to Mepem treatment.
      • Follow up Cyslosporin level and adjust dose to 275mg daily.
      • GVHD with liver function impairement and lip mucositis grade II.
      • Hickman catheter was removed on 12/04 and wound healing well.
      • Under the stable condition, he can be discharged and take oral prednisolon 2# bid going back home. MBD on 2023/12/08. OPD follow up is arranged.       
    • Discharge prescription
      • MgO 250mg 1# TID
      • Rivotril (clonazepam 0.5mg) 1# PRNHS
      • Sandimmun Neoral (ciclosporin 100mg) 1# Q12H
      • Sandimmun Neoral (ciclosporin 25mg) 1# TID
      • Through (sennoside 12mg) 2# HS
      • Compesolon (prednisolone 5mg) 2# BID
      • Ulstop (famotidine 20mg) 1# BID
  • 2023-08-19 ~ 2023-09-04 POMR Hemato-Oncology Gao WeiYao

  • 2023-07-26 ~ 2023-08-01 POMR Hemato-Oncology Gao WeiYao

    • Discharge diagnosis
      • Refractory anemia with excess of blasts, unspecified
      • Acute myeloblastic leukemia, not having achieved remission
      • Anemia, unspecified
    • CC
      • mild gum bleeding
    • Present illness
      • The 59 years old male was diagnosed of myelodysplastic syndrome (MDS) with Refractory Anemia with excess of blast (RAEB) since April 2022 at FuRen Univ Hosp.
      • According to the patient, the initial presentation was dizziness. After diagnosing, he was then regularly taking Hydroxyurea 1# QOD since April 2022 at FuRen Univ Hosp.
      • He came to our hemato-oncologic clinic on 2022/06/18 and we have arranged JAK2 mutation test (2022/06/20) which was revealed undetectable.
      • We applied Azacitidine 75mg/m2 SC D1~D7 Q4W x 4 on 2022/06/27. We suggest to check HLA high resolution for stem cell collection.
      • He was then started Azacitidine at our OPD since 2022/07/04 and regular follow up at our clinic.
      • According to the OPD medical record, therapy with Azacitidine was launched on C1 azacitidine 75mg/m2 SC D1~D7 Q4W x 4 on 2022/07/04. C1b azacitidine x 2 on 2022/07/11, C2 azacitidine on 2022/08/01. C2b on 2022/08/08. C3 on 2022/08/29. C4 on 2022/09/05, C4b on 2022/09/26, C5 azacitidine 75mg/m2 SC D1~D7 Q4W x 7 on 2022/11/08, C6 on 2022/12/05, C7 on 2023/01/23, C8 on 2023/02/13, C9 2023/03/15, C10 2023/04/12, C11 2023/05/24 at our OPD.
      • He could tolerate with the therapy as well. This time, he has suffered from mild gum bleeding for days since 2023/07/23 as experienced before. Thus, he visited our OPD and revelaed leukopenia (WBC:1870, PLT:32K, MCV:95.2, Hb:6.8) was noted, then he was refered to ER for advanced evaluation. Under the impression of MDS with RAEB, he was admitted for further care.
    • Course of inpatient treatment
      • After admission, we have applied azacitidine 146mg SC D1~D7 x 7 since 2023/07/26 for him and explained about the stem cell collection for him. Family meeting was suggested in future. Patient could understand it as well. Under the stable condition, he was arranged discharge on 2023/08/01 and OPD follow up as planned.
  • 2022-10-04 SOAP Dermatology Zhou WeiTing

    • S: dry skin over expose area.
    • O: xerotic dermaitits due to target therapy.
    • Prescription
      • Topsym Cream (fluocinonide 0.05%) QN EXT
      • Xyzal (levocetirizine 5mg) 1# QN
      • Sinpharderm Cream (urea) BID TOPI
      • Asthan (ketofifen 1mg) 1# QD
  • 2022-09-01 SOAP Dermatology Zhou WeiTing

    • S: severe itchy papules and plaques erupition over trunk after medication
    • Prescription
      • Topsym Cream (fluocinonide 0.05%) BID EXT
      • Compesolon (prednisolone 5mg) 1# QD
      • Xyzal (levocetirizine 5mg) 1# QN
      • Orolisin (chlorpheniramine maleate 5mg, orotic acid 30mg, glycyrrhizic acid 50mg) 1# PRNTID
      • C.B. Ointment (chlorpheniramine, lidocaine, methyl salicylate, menthol, camphor) PRNBID TOPI
  • 2022-06-20 SOAP Hemato-Oncology Zhang ShouYi

    • Order
      • LRP 1U
      • LPRBC 2U
    • Prescription
      • Transamin (tranexamic acid 250mg) 1# BID
      • Benamine (diphenhydramine 30mg) ST IVD
      • Decan (dexamethasone 4mg) ST IVD
      • NS 500mL ST IVD
  • 2022-06-18 SOAP Hemato-Oncology Zhang ShouYi

    • S
      • 58 y/o male, a pt of myelofibrosis (?) or MDS wt RAEB (?), Dx in April 2022 at FuRen Univ Hosp, suffered from dizziness in April 2022.
      • Bone marrow biospy (4/29 22): Blast: 5.6%.
      • MDS wt excess blast & fibrosis.
      • Hb (3/29 22):7.1, MCV:89.4, MCHC:36.4, plt:61K, WBC:2610, blast:5%.
      • under Hydroxyurea 1# QOD since April 2022 by at FuRen Univ Hosp.
      • no exertional dyspnea, no easy fatigue, no easy dizziness, no lethargy, no palpitation
      • no tarry nor bloody stool passage
      • gum bleeding (+) epistaxis, no easy bruising.
      • no particular drugs in use (eg Aspirin or NASID or anonymous drugs)
      • came to our hemato-oncologic clinic on 6/18 22
      • R/I myelofibrosis
      • R/I MDS wt RAEB (?),
      • will do JAK2 mutation test (6/18 22).
      • will do abd sono (6/18 22).
      • will do CBC & DC, reticulocyte,
      • will do PT, APTT, fibrinogen.
      • s/p educate pt about preventing from trauma & avoiding NSAID (6/18 22).
      • RTC 1 wk later on 6/28 22 for JAK2 report.
    • Diagnosis
      • Anemia, unspecified [D64.9]
      • IDA, unspecified [D50.8]

[chemotherapy]

  • 2023-11-28 - methotrexate 10mg/m2 19mg NS 50mL
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-11-23 - methotrexate 10mg/m2 18mg NS 50mL
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-11-20 - methotrexate 10mg/m2 19mg NS 50mL
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-11-18 - methotrexate 15mg/m2 28mg NS 50mL
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-11-11 - fludarabine 30mg/m2 50mg NS 250mL 1hr D1-5 + melphalan 70mg/m2 120mg NS 500mL 1hr D4-5
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-09-18 - azacitidine 75mg/m2 143mg SC D1-7
  • 2023-07-26 - azacitidine 75mg/m2 146mg SC D1-7
  • 2023-05-24 - azacitidine 75mg/m2 142mg SC D1-7
  • 2023-04-12 - azacitidine 75mg/m2 145mg SC D1-7
  • 2023-03-15 - azacitidine 75mg/m2 145mg SC D1-7
  • 2023-02-13 - azacitidine 75mg/m2 130mg SC D1-7
  • 2023-01-03 - azacitidine 75mg/m2 130mg SC D1-7
  • 2022-12-05 - azacitidine 75mg/m2 130mg SC D1-7
  • 2022-11-08 - azacitidine 75mg/m2 130mg SC D1-7
  • 2022-09-26 - azacitidine 75mg/m2 130mg SC D1-7
  • 2022-09-29 - azacitidine 75mg/m2 130mg SC D1-7
  • 2022-08-01 - azacitidine 75mg/m2 130mg SC D1-7
  • 2022-07-04 - azacitidine 75mg/m2 130mg SC D1-7

==========

2024-01-16

[Ciclosporin dose optimization]

Following the adjustment of the daily dose to 220mg, observed serum trough levels have shown a gradual decline. To maintain the desired concentration range of 200-300 ng/mL, an increase in the daily dose to 240mg is recommended.

  • 2024-01-15 Cyclosporine-A 242.5 ng/mL
  • 2024-01-12 Cyclosporine-A 295.5 ng/mL
  • 2024-01-08 Cyclosporine-A 344.1 ng/mL

The administration of Grancicure (ganciclovir) 500mg Q12H IVD has effectively reduced the CMV viral load. Starting from 2024-01-17, Grancicure will be replaced with Valcyte (valganciclovir) 900mg QD PO.

  • 2024-01-15 CMV viral load assay 786 IU/mL
  • 2024-01-08 CMV viral load assay 64300 IU/mL
  • 2023-12-30 CMV viral load assay 12200 IU/mL
  • 2023-12-20 CMV viral load assay 1040 IU/mL
  • 2023-12-18 CMV viral load assay 396 IU/mL
  • 2023-12-11 CMV viral load assay 74 IU/mL
  • 2023-12-06 CMV viral load assay <35 IU/mL

Also note that the patient’s WBC count and HGB level are gradually decreasing.

  • 2024-01-15 WBC 2.30 x10^3/uL

  • 2024-01-12 WBC 2.24 x10^3/uL

  • 2024-01-08 WBC 3.89 x10^3/uL

  • 2024-01-06 WBC 3.59 x10^3/uL

  • 2024-01-04 WBC 4.30 x10^3/uL

  • 2024-01-02 WBC 4.96 x10^3/uL

  • 2024-01-15 HGB 7.3 g/dL

  • 2024-01-12 HGB 8.6 g/dL

  • 2024-01-08 HGB 9.3 g/dL

  • 2024-01-06 HGB 9.3 g/dL

  • 2024-01-04 HGB 7.4 g/dL

  • 2024-01-02 HGB 10.2 g/dL

2024-01-03

[Sandimmun injection (Ciclosporin) TDM]

Following the recent ciclosporin trough level of 416.5 ng/mL on 2024-01-02, the Sandimmun injection dosage has been adjusted from 250mg to 220mg daily. To monitor the effectiveness of this adjustment, it is kindly requested a new blood sample four days after the adjustment, to be drawn prior to the scheduled administration, for another trough level test.

2023-12-26

[steady rise, time to tune down: ciclosporin level management - Sandimmun injection (Ciclosporin) TDM]

This patient has been taking ciclosporin 275mg QD since 2023-12-12. Lab results for ciclosporin trough levels on 2023-12-15, 2023-12-18, 2023-12-21, and 2023-12-25 showed values of 152, 222, 292, and 318 ng/mL, respectively. Based on this monotonic trend, if the current dose is continued, the trough level could exceed the recommended upper limit of 400 ng/mL by the end of 2023 or early 2024. Therefore, it is recommended to reduce the dose to 250mg QD and recheck the trough concentration 4 days after the change.

2023-09-25

The attending physician Dr. Gao held an interprofessional practice and patient family meeting in the ward conference room at 15:00 on 2023-09-25, to introduce the patient to the importance, possible risks, and prognosis of allogeneic peripheral blood stem cell transplantation in the treatment plan, and to answer questions from patients and their families. The patient did not ask the pharmacist any specific questions during the meeting. In a chat with the patient after the meeting, I emphasized the importance of controlling potential post-transplant infections.

700570266

240115

  • diagnosis
    • 2022-08-15 discharge
      • Malignant neoplasm of cervix uteri, unspecified
      • cervical cancer (adenocarcinoma), stage IVa post CCRT, suspected cancer recurrence (C53.9)
      • urinary tract infection, urine culture: mixed growth 7000
      • constipation
  • past history
    • Septoplasty, 20 years ago
    • Adenocarcinoma of the uterine cervix, FIGO stage IVA, with bladder invasion, start radiotherapy and chemotherpy since 2021/04
    • Large gallstone 2021/03
    • Left side moderate hydronephrosis and hydroureter 2021/03
    • C/S surgery (Cesarean Section), by patient personal choose  

[family history]

  • Mother: Colon cancer
  • Father: HCC
  • Sister: Breast cancer   

[exam findings]

  • 2023-12-07 CT - abdomen
    • History and indication: Cervical cancer s/p OP and C/T
    • Non-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. Some small LNs at mediastinum, retroperitoneum and bil. inguinal regions. Focal sclerotic change of L3.
      • S/P bilateral double J catheters insertion. Bil. renal cysts (up to 1.2cm). Tiny liver cysts.
      • Swelling of left lower extremity.
      • S/P Port-A infusion catheter insertion. S/P foley catheter indwelling.
      • A nodule (4.5mm) at RLL.
    • IMP:
      • S/P hysterectomy. A nodule (4.5mm) at RLL r/o metastases. Some small LNs at mediastinum, retroperitoneum and bil. inguinal regions. Focal sclerotic change of L3 r/o metastases.
  • 2023-11-03 SONO - nephrology
    • Interpretation:
      • Bilateral chronic change with right small sized kidney.
      • Left mild hydronephrosis with D-J.
      • Bladder hyperechoic lesion, cause?
  • 2023-09-22 All-RAS + BRAF
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene
  • 2023-09-07 MRI - pelvis
    • Clinical history: 61 y/o female patient with Cervical cancer s/p OP and CCRT and C/T
    • Findings:
      • S/P hysterectomy. Irregular soft tissue tumor (2cm) between urinary bladder and vaginal stump, right, r/o recurrent tumor.
      • Enlarged lymph nodes in left inguinal region.
      • Diffuse swelling of left lower extremity.
      • S/P double J catheter insertion.
      • Non-enhancing nodule, 0.4cm in right lobe liver, r/o liver cyst.
      • There are lymph nodes in paraaortic and aortocaval regions.
    • Impression:
      • S/P hysterectomy. S/P double J catheter insertion, bilateral.
      • R/O recurrent tumor in posterior urinary bladder, between right posterior urinary bladder and vaginal stump region.
      • Left inguinal lymph nodes, paraaortic and aortocaval lymph nodes, r/o metastasis.
      • Diffuse swelling of left lower extremity.
  • 2023-06-29 CT - abdomen
    • History and indication: Cervical cancer s/p OP and C/T
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. Some small LNs at retroperitoneum and bil. inguinal regions.
      • S/P bilateral double J catheters insertion. Bil. renal cysts (up to 1.2cm). Tiny liver cysts.
    • IMP:
      • S/P hysterectomy. No evidence of tumor recurrence.
      • S/P bilateral double J catheters insertion.
  • 2023-04-07 CT - abdomen
    • Findings
      • S/P hysterectomy
      • S/P double J catheter insertion, bilateral.
      • Prior CT identified a hepatic cyst 5 mm at S5/8 of the liver is noted again, stationary.
        • In addition, Left renal cyst, 1.2cm, also shows stationary.
    • Impression:
      • S/P hysterectomy.
      • There is no evidence of tumor recurrence.
  • 2023-01-06 MRI - pelvis
    • Findings
      • S/P hysterectomy.
      • Segmental wall edema/thickening at rectosigmoid colon.
      • S/P double J catheter insertion, bilateral.
      • Non-enhancing nodule in left kidney, r/o left renal cyst (1.4cm).
    • Impression:
      • Clinical cervical cancer s/p hysterectomy.
      • Segmental wall edema/thickening at rectosigmoid colon. Suggest clinical correlation.
      • R/O left renal cyst.
  • 2022-11-10 CT - abdomen
    • S/P hysterectomy. No evidence of tumor recurrence.
    • S/P bilateral double J catheters insertion.
  • 2022-10-12 CXR
    • S/P Port-A infusion catheter insertion.
    • S/P bilateral double J catheters insertion.
    • Solitary pulmonary nodule at RLL.
    • Normal appearance of trachea and bil. main bronchus.
  • 2022-10-04 SONO - breast
    • Diagnosis
      • Benign neoplasm of breast, infavor of benign fibrocystic disease (FCD), Uncertain breast tumor, in favor of benign fibroadenoma (FA)
    • Treatment
      • biopsy is not necessary
    • Suggestion and Plan
      • Regular OPD follow-up, Follow up breast sonography in next OPD visit
      • BI-RADS 3 - Probably Benign Finding (<2% malignant) Initial Short-Interval Follow-Up Suggested
  • 2022-08-11 Pure Tone Audiometry, PTA
    • Reliabilty Fair
    • PTA
      • R’t : 30 dB HL, normal to mild SNHL
      • L’t : 33 dB HL, normal to severe SNHL.
  • 2022-07-13 Patho - uterus with or without SO non-neoplastic/prolapse
    • Cervix uteri cancer checklist:
    • pathologic diagnosis
      • Tumor, uterine cervix, laparoscopic total hysterectomy — Adenocarcinoma
      • Endometrium, uterus, ditto — Free of tumor
      • Myometrium, uterus, ditto — Tumor invasion, leiomyoma
      • Lymph nodes, dissection — Not received
      • AJCC pathological stage (post CCRT) — ypT2a1, if cN0 and cM0, stage IIA1 / FIGO stage IIA1
    • microscopic examination
      • Tumor location:
        • Cervix
        • Vagina involvement: N/A
        • Corpus involvement: involved and one leiomyoma measured 3 cm
      • Tumor size: 2.5 x 2.0 cm
      • Tumor type: Adenocarcinoma
      • Histologic grade: moderately differentiated
      • Depth of invasion: about 0.6 cm, >1/2 cervical wall
      • Parametrial involvement: N/A
      • Parametrial cut end: N/A
      • Vaginal cut end: N/A
      • Lymphovascular invasion: NOT identified
      • Perineural invasion: Present
      • Lymph nodes: NOT received
    • IHC
      • P16(-), CEA(+), ER(-), PR(-), vimentin(-), P53(focal +, wild type), compatible with endocervical origin
  • 2022-05-31 Patho - cervix biopsy, endocervix curretage/biopsy
    • Uterus, cervix, biopsy (S2022-8981) — adenocarcinoma, well differentiated.
      • IHC stains: p16 (-), vimentin (-), p53 (diffuse +), Napsin-A (-), PAX-8 (+).
    • Uterus, endocervix, ECC (S2022-8982) — adenocarcinoma, well differentiated.
      • IHC stains: p16 (-), vimentin (-), p53 (diffuse +), Napsin-A (-), PAX-8 (equivocal).
  • 2022-05-18 MRI - pelvis
    • Findings
      • Soft tissue tumor(2.5cm) in cerivcal region, suspected cervical malignancy.
      • Relative thickening posterior wall of urinary bladder.
      • Soft tissue tumor, 3cm in posterior wall of uterine body, suspected uterine myoma.
      • Presence of gallbladder stones.
    • Impression
      • Cervical tumor, suspected malignancy.
      • Suspected uterine myoma.
      • Relative thickening posterior wall of urinary bladder.
      • GB stones.
  • 2022-02-24 Gynecologic ultrasonography
    • suspect degeneration myoma
    • adenomyosis
  • 2022-02-18 CT - abdomen
    • Findings
      • There is mild enhancing lesion 1.5 cm in left side uterine cervix area. Please correlate with physical examination or hysteroscope.
      • There is no enlarged node in left common iliac chain.
      • Soft tissue tumor 2.6 cm in posterior aspect of uterine body myometrium is noted that may be myoma.
      • S/P double J catheter insertion, bilateral.
      • Left renal cyst, 1.2cm.
    • Impression
      • Mild enhancing lesion 1.5 cm in left side uterine cervix araa. Please correlate with physical examination or hysteroscope.
  • 2021-12-06 Gynecologic ultrasonography
    • EM: 7.5mm with fluid
    • Uterine myoma
  • 2021-11-24 MRI - pelvis
    • Cervical cancer s/p RT.
    • Relative thickening posterior wall of urinary bladder with adhesion with anterior uterine cervix. Residual tumor? Suggest cystoscopy follow up.
    • Suspected uterine myoma.
    • GB stones.
  • 2021-08-17 CT - abdomen, pelvis
    • Cervical cancer with lymph node in left common iliac region s/p, regression as compare with old CT study.
    • S/P double J catheter insertion, bilateral.
    • Suspected uterine myoma.
    • Left renal cyst.
  • 2021-05-02 Gynecologic ultrasonography
    • Uterine myoma
    • Clinical: cervical cancer VIIA under CCRT with massive vaginal bleeding
  • 2021-04-19 Pure Tone Audiometry, PTA
    • PTA: Reliability FAIR
    • Average RE 31 dB HL // LE 31 dB HL
    • RE normal to mild SNHL
    • LE normal to moderately severe SNHL
  • 2021-03-31 Pathology (Cardinal Tien Hospital)
    • Uterus, exocervix, biopsy — Adenocarcinoma.
  • 2021-03-30 Patho - endocervix curretage/biopsy
    • Uterus, endocervix, ECC — severe glandular dysplasia
    • Immunohistochemical stain reveals CK(-), VIMENTIN (-), p16(-) and CEA(+).
  • 2021-03-30 Patho - cervix biopsy
    • Cervix, biopsy— adenocarcinoma
    • Immunohistochemical stain reveals CK(+), p16(-), CEA(+), vimentin(-). CK20(-), GATA3(-)
  • 2021-03-23 CT (Cardinal Tien Hospital)
    • Findings
      • A 7 x 3.5cm mass in the uterine cavity and extension to the cervix and, to the posterior urinary bladder wall.
      • A 3.5cm cyst at the left adnexa. No definite iliac or paraaortic lymphadenopathy.
      • No abdominal fluid collection.
    • Imp:
      • Uterine tumor involving endometrial cavity and cervix with posterior, urinary bladder wall extension, suspect endometrial ca or cervical ca.
      • Small hepatic cysts in the right lobe, Left ovarian cyst, stage cT4N1M0.
  • 2021-03-22 IntraVenous Pyelography, IVP (Cardinal Tien Hospital)
    • suspect left bladder tumor with left side obstructive uropathy.
  • 2021-03-20 SONO - abdomen (Cardinal Tien Hospital)
    • Moderate fatty liver and fat infiltration the pancreas
    • Large gallstone
    • Left side moderate hydronephrosis and hydroureter

[consultation]

  • 2023-11-15 Rehabilitation
    • Q: for Lymphedema of left lower limb
    • A: The patient had undergone lymphedema treatment at Dr. Qiu JiaYi’s outpatient clinic. Please schedule a follow-up appointment with Dr. Qiu after discharge.
  • 2023-11-06 Dermatology
    • Q
      • for multiple lesion of left femoral biopsy
    • A
      • This patient suffered from multiple nodules on abd area for months.
      • Imp: R/O Malignat, skin meta
      • Suggestion: Arrange skin biopsy
  • 2023-11-03 Nephrology
    • Q
      • for BUN/Cr elevated, decrease of urine output step by step
      • This 61-year-old woman patient is a case of Cervical cancer (adenocarcinoma), cT4N0M0, stage IVa post concurrent chemoradiotherapy with tumor recurrence s/p chemotherapy with Avastin(15mg/kg)/Taxol(175mg/m2)/Carboplatin(AUC:5) from 2022/08/12~2023/02/04(6 cycles), recurrence s/p chemotherapy with Taxol(175mg/m2)/Topotecan(0.75mg/m2) from 2023/09/28~ admitted for palliative chemotherapy.
      • We sincerely need your professional assistance!!
    • A
      • 61-year-old woman
      • Dx: Cervical cancer (adenocarcinoma), cT4N0M0, stage IVa post concurrent chemoradiotherapy with tumor recurrence s/p chemotherapy with Avastin(15mg/kg)/Taxol(175mg/m2)/Carboplatin(AUC:5) from 2022/08/12~2023/02/04(6 cycles), recurrence s/p chemotherapy with Taxol(175mg/m2)/Topotecan(0.75mg/m2) from 2023/09/28~ admitted for palliative chemotherapy.
      • O
        • BW 81-82.4
        • Urine output: ~580+loss
        • BUN: 23-24-39-43-53
        • CRE: 1.52 -> 2.30 -> 3.61 -> 5.26 within 1 mo
        • U-CRE: 112.09, U/O 350 cc(09/27)
        • Na/K: 138/3.5
        • HCO3: 32.4
        • Hgb: 8.1-8.6
        • Urinalysis -> NIL
        • Renal echo/Abd CT: bil. DBJ insertion
        • Pelvis MRI 09/07: R/O recurrent tumor in posterior urinary bladder, between right posterior urinary bladder and vaginal stump region.
        • Bil. DBJ in situ, inerted in 2023-07
        • Unable to obtain renal image
        • Medication history:
          • Diuretics: lasix #1 BID 40 mg/day + Budema #1 TID , aldactone -> U/O 580 + loss
          • DM: NIL
          • HTN:
          • Abx: Rocephin
          • Fluid: For drug
          • Other: Ketosteril, pentop
        • Accompanied by husband
        • Consciousness: E4V5M6, depressed
        • Bilateral lower limbs severe edema
        • Vital signs: 144/91 HR 102, SpO2 95% under N/C 2L
      • Impression AKI on CKD, progression in one month
      • Recommendation:
        • Please arrange renal echo first to r/o obstructive uropathy, consult GU for DBJ revision if hydronephrosis/hydroureter
        • Consider dialysis for fluid extraction if necessary by Dr. Wang but patien hesitated
        • Keep current medication use and correct infection status, keep recording I/O, avoid any nephrotoxic medications
        • f/u hemograms, electrolyte, BUN/CRE, blood gas routinely
        • Please feel free to contact us if any inquiries.
  • 2021-05-02 Obstetrics and Gynecology
    • Q
      • S: Abnormal viginal bleeding since yesterday
        • No TOCC
        • She just discharged from OBGYN ward 2 days ago due to 2nd course C/T of cervical cancer.
    • A
      • S
        • P1NSD1, 25 years ago. Adenocarcinoma of the uterine cervix, FIGO stage IVA under CCRT.
        • Denied TOCC
        • She just discharged from hematology ward 2 days ago due to 2nd course C/T of cervical cancer.
          • Family history: (mother: colon cancer, elder sister: breast cancer)
          • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
          • Personal Hx: DM(-); HTN(-)
      • O
        • Endocervical adenocarcinoma; S/P radiotherapy due to cervical cancer.
        • PI: The patietn suffered from urinary frequence and post menopausal bleeding (uncertain duration).
          • GU cystoscopy – suspected meta adenocarcinoma in Cardinal Tien hospital. cervical biopsy as done in Cardinal Tien hospital, cervical cancer.
        • Previous RT Hx: (-)
        • Lab data: Hb=8.9 g/dL; CRP=1.7
        • Vaginal bleeding was noted in our ER.
        • Echo:
          • Uterus: 11.9x8.36 cm, EM: 1.3 cm with blood clot.
          • Uterine myoma 2.4x3.0 cm
      • A: Adenocarcinoma of the uterine cervix, FIGO stage IVA, with bladder invasion.
      • P: CCRT is indicated for this patient with the following indicators: FIGO stage IVA.
        • Plan:
          • Blood transfusion for anemia
          • Transamin and Ergometrine for hemostasis
          • OPD follow up
  • 2021-04-20 Obstetrics and Gynecology
    • Q
      • For vaginal bleeding
      • This 58 y/o woman was Adenocarcinoma of the uterine cervix, FIGO stage IVA, with bladder invasion.
      • She was admitted for per-chemotherapy examination and CCRT with weekly CDDP on 2021/04/15.
      • Vaginal bleeding was noted last night, we need your help for further mamagement, thanks a lot.
    • A
      • Blood clot was noted in vagina. No active bleeding right now.
      • Bosmin gauze was inserted for compression.
      • Conservative treatment, CCRT and Transamin IV were suggested.

[radiotherapy]

  • 2021-04-20 ~ 2021-06-17
    • 4500cGy/25 fractions (15MV photon) of the pelvic
    • 5400cGy/30 fractions (15MV photon) of the cervical tumor
    • 7020cGy/39 fractions (15MV photon) of the cervical tumor bed.

[immunochemotherapy]

  • 2023-12-12 - paclitaxel 80mg/m2 120mg NS 400mL 3hr + topotecan 0.75mg/m2 1.2mg NS 40mL 30min D1-3 (He JingLiang)

    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-11-20 - bevacizumab 15mg/kg 900mg NS 100mL 90min + paclitaxel 80mg/m2 120mg NS 500mL 3hr + topotecan 0.75mg/m2 1.2mg NS 40mL 30min D1-3 (Xia HeXiong)

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-09-28 - topotecan 0.75mg/m2 1.4mg NS 40mL 30min D1-3 (Xia HeXiong)

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-02-03 - bevacizumab 15mg/kg 900mg NS 100mL 90min + paclitaxel 175mg/m2 295mg NS 500mL 3hr + carboplatin AUC 5 350mg NS 250mL 2hr (Xia HeXiong)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-12-01 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)

  • 2022-11-10 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)

  • 2022-10-21 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)

  • 2022-09-01 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)

  • 2022-08-12 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)

  • 2021-06-10 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

  • 2021-05-28 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

  • 2021-05-21 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

  • 2021-05-13 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

  • 2021-05-07 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

  • 2021-04-28 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

  • 2021-04-20 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

==========

2024-01-15

[levofloxacin dose adjust needed! eGFR 12 recommend 500mg QOD per Sanford Guide]

The Cravit (levofloxacin) dosage for this patient with an eGFR of 12.03 (2024-01-15) requires adjustment based on the Sanford Guide recommendations. While the current regimen uses 750mg QOD, the recommended regimen for this eGFR range is 750mg once followed by 500mg Q48H. Therefore, it is recommended to reduce the dose to 500mg QOD to align with the Sanford Guide for optimal safety and efficacy.

2024-01-03

Imaging and Disease Status: MRI (2023-09-07) and CT (2023-12-07) both indicate disease progression, aligning with the rising CEA levels over the past year.

  • 2024-01-03 CEA 69.11 ng/mL
  • 2023-10-11 CEA 69.94 ng/mL
  • 2023-09-20 CEA 51.92 ng/mL
  • 2023-08-30 CEA 48.75 ng/mL
  • 2023-08-01 CEA 39.69 ng/mL
  • 2023-07-05 CEA 24.40 ng/mL
  • 2023-06-07 CEA 25.70 ng/mL
  • 2023-05-10 CEA 13.94 ng/mL
  • 2023-04-12 CEA 7.26 ng/mL
  • 2022-11-22 CEA 2.85 ng/mL
  • 2022-11-02 CEA 4.12 ng/mL
  • 2022-10-19 CEA 2.82 ng/mL
  • 2022-10-04 CEA 2.11 ng/mL

Renal Function: Deteriorated in late Oct to early Nov 2023, with partial improvement but still not meet normal levels. Latest eGFR value was below 30 mL/min/1.73m2.

  • 2024-01-02 Creatinine 1.84 mg/dL (eGFR 29)
  • 2023-12-19 Creatinine 1.37 mg/dL
  • 2023-12-15 Creatinine 1.51 mg/dL
  • 2023-12-07 Creatinine 2.52 mg/dL
  • 2023-11-29 Creatinine 1.65 mg/dL
  • 2023-11-22 Creatinine 1.86 mg/dL
  • 2023-11-17 Creatinine 2.34 mg/dL
  • 2023-11-15 Creatinine 2.54 mg/dL
  • 2023-11-13 Creatinine 2.23 mg/dL
  • 2023-11-07 Creatinine 2.29 mg/dL
  • 2023-11-02 Creatinine 5.26 mg/dL

Medication Recommendations:

  • Continue Pentop (pentoxifylline) 400mg QD, as it’s already at the recommended maximum daily dose.
  • Consider reducing Promeran (metoclopramide) tab from TIDAC to BIDAC.
  • Closely monitor potassium levels due to ongoing potassium supplementation to avoid over-supplementation.

2023-11-16

[renal function follow-up]

On 2023-11-02, the patient’s serum creatinine reached a recent peak of 5.29 mg/dL and has since stabilized around the 2.2 - 2.5 mg/dL range. The patient, 61F, 62.9 kg, has a calcuated CrCl of 23 mL/min.

The current prescription of Tapimycin (piperacillin and tazobactam) at a dosage of 2.25g IVD Q6H is appropriate.

  • 2023-11-15 Creatinine 2.54 mg/dL
  • 2023-11-13 Creatinine 2.23 mg/dL
  • 2023-11-07 Creatinine 2.29 mg/dL
  • 2023-11-02 Creatinine 5.26 mg/dL (recent peak)
  • 2023-10-30 Creatinine 3.61 mg/dL
  • 2023-10-18 Creatinine 2.30 mg/dL
  • 2023-10-11 Creatinine 1.52 mg/dL
  • 2023-10-02 Creatinine 0.99 mg/dL

[rapid weight loss]

The patient experienced a rapid weight loss of over 20 kg within two weeks, dropping from 83.2 kg on 2023-11-01 to 62.9 kg by 2023-11-15.

Currently, the patient is being treated with furosemide and bumetanide, both of which are potent diuretics. Excessive use of these medications can result in significant diuresis, leading to water and electrolyte depletion. Consequently, close medical monitoring is essential, and the dosage and administration schedule should be tailored to the specific needs of the patient.

2023-10-31

[renal function]

2023-10-30 BUN 43 mg/dL, eGFR 13.62 mL/min/1.73m2, Cre 3.61 mg/dL -> CrCl 21 mL/min (Cockcroft-Gault).

For patients with a CrCl of 20 to 39 mL/minute, the recommended dose of topotecan is reduced to 0.75 mg/m2 - this was the dose administered on 2023-09-28.

While the manufacturer’s labeling does not provide dosage adjustments for CrCl <20 mL/minute, it can be inferred that the dosage restrictions for this range would be even more stringent. Given the patient’s consistent decline in renal function over time, it is crucial to exercise caution when using this medication and to closely monitor for any adverse reactions.

[rapid weight gain]

According to the HIS5 records, the patient’s body weight was 67.5kg on 2023-09-20 and increased to 83kg by 2023-10-30. This significant weight gain could suggest the presence of edema or potential heart failure. Further evaluation is recommended.

2022-12-02

  • There is no LVEF test result available in HIS5 currently. Since bevacizumab has been determined to be an agent that may either cause reversible direct myocardial toxicity or exacerbate underlying myocardial dysfunction (magnitude: moderate/major) (AHA [Page 2016]), It is recommended that a 2D cardiac sonography be ordered.
  • Other than a slightly elevated SBP, the vital signs are stable. Readings from the lab on 2022-12-01 were generally normal.

2022-11-11

  • Exforge (amlodipine 5mg + valsartan 160mg) QD has been prescribed by our cardiologist on 2022-10-01 for 28 days as a treatment for the patient’s primary hypertension.
  • Since the patient’s blood pressure remains elevated during this hospitalization, Exforge might be considered for reinstatement to replace current Diovan (valsartan).

2022-10-24

  • In the last 3 weeks, the serum creatinine level has increased (1.24 2022-10-19 <- 1.18 2022-10-04 <- 0.80 2022-09-26). Please monitor the renal function if it continues to decline.

2022-09-21

  • The patient’s SBP appeared to be between 146 and 197 when she arrived on the ward. The use of Sevikar (amlodipine + olmesartan) 1# QD or Exforge (amlodipine + valsartan) 1# QD might be considered to replace current Norvasc if hypertension (SBP > 150mmHg) for consecutive days is observed.

700823818

240115

[exam findings]

  • 2023-11-29 CT - abdomen
    • History: Adenocarcinoma of the pancreas with liver and left adrenal gland metastases, pT3N1M1, stage IV.
    • Findings: Comparison: prior CT dated 2023/07/14.
      • Prior CT identified lobulated cystic lesion 7 cm in the pancreatic body and tail is noted again, increasing in size to 10 cm.
        • It is c/w progressive disease.
      • Prior CT identified several metastases on both hepatic lobes are noted again, marked increasing in size and number that is c/w multiple liver metastases with progressive disease.
      • There are two newly developed soft tissue masses in the cranial and right lateral aspect of the upper described cystic pancreatic mass that are c/w metastatic nodes.
      • There is a soft tissue nodule 8 mm at RLL of the lung.
        • Follow up is indicated.
      • Ascites in the pelvis is highly suspected. Please correlate with sonography.
      • The entire colon shows mild distension and fecal material that is c/w chronic constipation.
      • Partial atelectasis in RML of the lung is suspected.
        • Please correlate with chest CT.
    • Impression:
      • Mucinous cystic adenocarcinoma of the pancreas with multiple liver metastases shows progressive disease. please correlate with clinical condition.
  • 2023-10-03 Uroflowmetry
    • Q max : poor
    • flow pattern : obstructive
  • 2023-09-26 Bladder sonography
    • PVR: 164 ml
  • 2023-09-04 KUB
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
    • Fecal material store in the colon.

[MedRec]

  • 2023-10-31 SOAP Rheumatology and Immunology Chen JunXiong
    • S: told has RA under ShuangHe Hosp. plaquenil
    • Prescription x3
      • Plaquenil (hydroxychloroquine 200mg) 1# QDCC 28D
  • 2023-08-25 ~ 2023-09-14 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Adenocarcinoma of panceras with liver and left adrenal gland metastases, pT3N1M1, stage IV
      • Oxacillin Resistant Staphylococcus aureus urinary tract infection
      • Cachexia
      • Hypokalemia
      • Hypertension
      • Constipation
      • Port-a insertion on 2023/09/07
    • CC
      • for pain control and future treatment
    • Present illness
      • The 74 y/o woman has adeno of panceras with liver and left adrenal gland metastases, pT3N1M1, stage 4 under Gemicitabin on 2023/06/10 and 2023/06/21 at TSGH. Port-a was removed due to infection.
      • Due to abdominal pain, she has Fentanyl 75mcg + Noxycodone 1# prnq6h + Painkyl 1 patch prnq4h.
      • Her BW loss 6kg in 3 months and poor intake bother her.
      • Under the impression of adenocarcinoma of panceras with liver and left adrenal gland metastases, pT3N1M1, stable 4 with cachexia, so she was admitted on 2023/08/25.
    • Course of inpatient treatment
      • After admission, we taper nacrotic for con’s confuse and severe weakness.
      • Foley catheter insertion for ICP > 500ml.
      • PPN supplement by selfpay for cachexia and poor intale.
      • Antibiotic as Rocephin for UTI treatment.
      • We gave Promeran, Through, Lactulose and Dulcolax for severe constipation.
      • IVF with NAKO NO.5 500 mL qd supplement.
      • Adjust narcotic with Fentanyl 62.5mcg + morphine 1# prnq4h.
      • Fortunately, her performance improvement and ADL well during hospitalization.
      • Her antibiotic shifted to Avelox for ORSA UTI on 2023/08/30. Foley was removed on 2023/09/01.
      • Sudden onset, fever without chills on 2023/08/31, check lab data showed PCT 0.05, but no bacteremia.
      • GS was consulted for port-a insertion on 2023/09/07.
      • C1D1 Gemzar + Abraxane on 2023/09/12.
      • She can be tolerance without side effect, MBD is arranged on 2023/09/14.
    • Discharge prescription
      • morphine 15mg 1# PRNQ4H 7D if pain
      • Alpraline (alprazolam 0.5mg) 1# HS 7D
      • Baraclude (entecavir 0.5mg) 1# QDAC 7D
      • Lactul (lactulose 666mg/mL) 20mL TID 7D
      • Neurontin (gabapentin 100mg) 1# TID 7D
      • Oxbu ER (oxybutynin 5mg) 1# QD 7D
      • Norvasc (amlodipine 5mg) 1# QD 7D
      • Through (sennoside 12mg) 2# HS 7D
      • Wecoli (bethanechol 25mg) 1# TIDAC 7D
      • bisacodyl supp 10mg/pill2# QOD RECT 7D
      • Durogesic (fentanyl 12ug/h 2.1mg/patch) 1# Q3D EXT 7D
      • fentanyl Transdermal Patch 50ug/h 5mg/patch 1# Q3D EXT 7D
      • Const-K ER (potassium chloride 750mg/10mEq/tab) 1# BID 3D
  • 2023-08-24 SOAP Hemato-Oncology Gao WeiYao
    • S: She was diagnosed to have pancreatic adenocarcinoma with liver metastase in May 2023 and diagnosed at TSGH. She experienced sepsis after 1 dose of chemotherapy. Port-A was removed.
    • A: BW 34 (originally 50 kg; admission 38.8 kg in May 2023), Under fentanyl

[chemotherapy]

  • 2024-01-12 - irinotecan liposome 70mg/m2 87mg D5W 250mL 1.5hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3515mg NS 500mL 46hr (Onivyde + 5-FU. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-12-29 - irinotecan liposome 70mg/m2 84mg D5W 250mL 1.5hr + leucovorin 400mg/m2 450mg NS 250mL 2hr + fluorouracil 2800mg/m2 3300mg NS 500mL 46hr (Onivyde + 5-FU. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-11-14 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-10-31 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-10-17 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-10-03 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-09-19 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 153mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-09-12 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 153mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

Liposomal Irinotecan drug information - 2024-01-15 - https://www.uptodate.com/contents/liposomal-irinotecan-drug-information

  • Dosing - Adult - Pancreatic adenocarcinoma, metastatic:
    • IV: 70 mg/m2 once every 2 weeks (in combination with fluorouracil and leucovorin); continue until disease progression or unacceptable toxicity (Wang-Gillam 2016).
      • Note: Reduce initial starting dose to 50 mg/m2 in patients known to be homozygous for the UGT1A1*28 allele; the dose may be increased to 70 mg/m2 as tolerated in subsequent cycles.

Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) for advanced pancreatic and biliary cancer - 2023-12-25 - https://www.uptodate.com/contents/image?imageKey=ONC%2F89668

  • Cycle length: 4 weeks.

  • Regimen

    • Nabpaclitaxel
      • 125 mg/m2 IV
      • Administer undiluted over 30 minutes.
      • Days 1, 8, and 15
    • Gemcitabine
      • 1000 mg/m2 IV
      • Dilute in 250 mL NS (concentration no greater than 40 mg/mL) and administer over 30 to 60 minutes, after nabpaclitaxel.
      • Days 1, 8, and 15
  • Pretreatment considerations:

    • Emesis risk
      • MODERATE.
    • Vesicant/irritant properties
      • Nabpaclitaxel can cause significant tissue damage; avoid extravasation.
    • Prophylaxis for infusion reactions
      • Premedication to prevent hypersensitivity reactions is generally not needed. Premedication may be needed in patients who have had a prior hypersensitivity reaction to nabpaclitaxel.
    • Infection prophylaxis
      • The incidence of febrile neutropenia with this regimen is 3%. Primary prophylaxis with G-CSF is not indicated.
    • Dose adjustment for baseline liver or renal dysfunction
      • A lower starting dose for gemcitabine and nabpaclitaxel may be needed for patients with liver impairment. Do not administer nabpaclitaxel to patients with pancreatic cancer and moderate to severe liver impairment (AST <10 times the ULN and total bilirubin >1.5 times the ULN OR AST >10 times the ULN OR bilirubin >5 times the ULN).
  • Monitoring parameters:

    • CBC with differential and platelets weekly during treatment.
    • Assess comprehensive metabolic panel prior to each cycle or when clinically indicated during treatment.
    • Monitor for infusion reactions.
    • Monitor for extravasation.
    • Sensory neuropathy occurs frequently with nabpaclitaxel; assess for changes in neurologic function prior to each treatment cycle.
    • Monitor for signs and symptoms of pneumonitis.
  • Suggested dose modifications for toxicity:

    • Myelotoxicity
      • Do not administer nabpaclitaxel and gemcitabine on day 1 of each new cycle unless ANC is >1500/microL and platelet count is >100,000/microL. For patients who develop neutropenic fever OR ANC <500/microL for >7 days or delay of next cycle by >7 days or thrombocytopenia, withhold treatment until counts recover to an ANC of at least 1500/microL and platelet count of at least 100,000/microL on day 1, or to an ANC of at least 500/microL and platelet count of at least 50,000/microL on days 8 or 15 of the cycle. Upon resumption of therapy, reduce both drugs by 20 to 25% upon the first occurrence, an additional 20 to 25% on the second recurrence, and discontinue treatment for a third occurrence.
    • Sepsis
      • Sepsis has occurred in patients with or without neutropenia (risk factors are biliary obstruction or presence of a biliary stent). Initiate broad-spectrum antibiotics in the presence of fever, even if not neutropenic. Interrupt nabpaclitaxel and gemcitabine until sepsis resolves and, if neutropenic, until neutrophils are at least 1500/microL, then resume at lower doses.
    • Thrombotic microangiopathy
      • Thrombotic microangiopathy (TMA; also sometimes called thrombotic thrombocytopenic purpura [TTP] or hemolytic uremic syndrome [HUS]) has been associated with gemcitabine in individuals who have received a large or small cumulative dose. Consider the possibility of TMA if the patient develops Coombs-negative hemolysis, thrombocytopenia, renal failure, and/or neurologic findings. Management consists of drug discontinuation and supportive care, without plasma exchange, as long as there is high confidence in a drug-induced etiology rather than TTP.
    • Peripheral neuropathy
      • For days 1,8, and 15: withhold nabpaclitaxel for grade 3 or 4 neuropathy. Resume nabpaclitaxel at 20 to 25 percent reduced doses when peripheral neuropathy improves to grade ≤2 or completely resolves. Upon resumption of therapy, reduce nabpaclitaxel by 20 to 25% for the first occurrence of grade 3 or 4 peripheral neuropathy, and an additional 20 to 25% for the second occurrence. Discontinue treatment for a third occurrence. For grade 2 peripheral neuropathy, decrease nabpaclitaxel dose by 20 to 25%.
    • Hepatotoxicity
      • Gemcitabine is commonly associated with a transient rise in serum transaminases, but these are seldom of clinical significance. There is insufficient information from clinical studies to allow clear gemcitabine dose recommendations in these patients.
      • Reduced starting doses of nabpaclitaxel are recommended for individuals with pre-existing moderate to severe hepatic impairment; the need for further dose adjustments in subsequent courses based upon ongoing hepatotoxicity should be based on individual tolerance and clinician judgment.
      • One protocol recommends the following: on days 1, 8, and 15, for serum bilirubin elevations ≥grade 2, withhold both drugs until toxicity resolves to grade ≤1; resume treatment at the same dose as before. If not resolved, discontinue therapy.
    • Pulmonary toxicity
      • A variety of manifestations of pulmonary toxicity have been reported with gemcitabine. Pneumonitis has occurred with the use of nabpaclitaxel in combination with gemcitabine. Permanently discontinue treatment with both agents.
    • Other toxicity
      • On days 1, 8, and 15: for grade 3 cutaneous toxicity, hold both drugs until recovered to <= grade 2, and reduce nabpaclitaxel dose by 20 to 25% and gemcitabine dose by 20%. For grade 3 mucositis or diarrhea, withhold therapy until it improves to ≤grade 1, then resume with reduction of nabpaclitaxel dose by 20 to 25% and gemcitabine dose by 20%.

Treatment protocols for pancreatic cancer - 2023-12-25 - https://www.uptodate.com/contents/treatment-protocols-for-pancreatic-cancer

==========

2024-01-15

[reconciliation]

This patient was admitted for her second dose of the liposomal irinotecan + leucovorin + fluorouracil regimen on 2024-01-14. She tolerated the treatment.

Her hypokalemia, which was low at 2.5 mmol/L on 2024-01-12, improved to 3.6 mmol/L by 2024-01-15. No medication discrepancies were identified.

2023-12-25

[revise nab-paclitaxel sequence to ensure treatment efficacy]

Concerns have arisen regarding a deviation from the established administration sequence for the gemcitabine plus nab-paclitaxel regimen. The protocol explicitly mandates administering nab-paclitaxel first, followed by gemcitabine. However, recent administrations reversed this sequence, potentially compromising treatment efficacy. To ensure optimal outcomes, it is recommended to revert to the original protocol’s sequence.

Ref: Increased survival in pancreatic cancer with nab-paclitaxel plus gemcitabine. N Engl J Med. 2013 Oct 31;369(18):1691-703. doi: 10.1056/NEJMoa1304369. Epub 2013 Oct 16. PMID: 24131140; PMCID: PMC4631139.

[disease progress: comfort first, intensive chemo might not fly]

A recent CT scan on 2023-11-29 unfortunately indicated disease progression.

There is an article reporting a comparative effectiveness cohort study, FOLFIRINOX was associated with improved survival of approximately 2 months compared with gemcitabine plus nab-paclitaxel and was also associated with fewer posttreatment complications. A randomized clinical trial comparing these first-line treatments is warranted to test the survival and posttreatment hospitalization (or complications) benefit of FOLFIRINOX compared with gemcitabine plus nab-paclitaxel. Ref: Comparison of FOLFIRINOX vs Gemcitabine Plus Nab-Paclitaxel as First-Line Chemotherapy for Metastatic Pancreatic Ductal Adenocarcinoma. JAMA Netw Open. 2022 Jun 1;5(6):e2216199. doi: 10.1001/jamanetworkopen.2022.16199. PMID: 35675073; PMCID: PMC9178436.

Given the patient’s currently compromised performance status (ECOG PS 4 as of 2023-12-25 progress note), intensive chemotherapy might not be the most suitable option. Therefore, best supportive care or a less intensive regimen like mFOLFOX6 might be more appropriate at this time.

2023-08-30

According to PharmaCloud, this patient has only received medical treatment at TSGH in the last three months. However, the last date of treatment was on 2023-06-21, and there are currently no active prescriptions from TSGH. Therefore, no medication reconciliation issues have been found.

701361664

240115

[exam findings]

  • 2024-01-02 EGD
    • Diagnosis:
      • Esophageal varices, F1-2CbLi. RCS(+) White nipple sign(-), s/p EVLx4 with super 7.
      • Reflux esophagitis LA Classification grade A (minimal)
      • Portal hypertensive gastropathy
      • Gastric ulcers, antrum and angle
      • Gastric varix, cardia
      • Duodenal shallow ulcers, bulb and SDA
    • CLO test: not done
    • Suggestion:
      • Cold and liquid diet for 1-2 days
      • Monitor the signs of GI bleeding
  • 2023-12-29 CT - abdomen
    • Findings: Comparison prior CT dated 2023/10/20.
      • Prior CT identified wall thickening at the gastric antrum is noted again, mild increasing size. Please correlate with gastroscopy.
      • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size.
      • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stable in size.
      • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size.
        • There is splenomegaly (the greatest cranial-caudal dimension: 17.7 cm).
      • Left renal cyst, 0.9cm
      • There is mild ascites in the pelvis.
    • Impression:
      • Prior CT identified wall thickening at the gastric antrum is noted again, mild increasing size. Please correlate with gastroscopy.
      • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size.
  • 2023-12-29 ECG
    • Normal sinus rhythm
    • Incomplete right bundle branch block
    • Borderline ECG
  • 2023-10-20 CT - abdomen
    • Findings: Comparison prior CT dated 2023/09/04.
      • Prior CT identified wall thickening at the gastric antrum is noted again, stable in size. Please correlate with gastroscopy.
      • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size.
      • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stable in size.
      • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size.
        • There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
      • Left renal cyst, 0.9cm
  • 2023-09-04 CT - abdomen
    • Findings
      • Stable condition of gastric cancer, LNs and liver metastases.
      • Liver cirrhosis with portal vein and splenomegaly. Mild small bowel ileus.
      • Left renal cyst (8mm). Minimal ascites.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Stable condition of gastric cancer, LNs and liver metastases.
      • Liver cirrhosis with portal vein and splenomegaly. Mild small bowel ileus.
  • 2023-06-05 CT - abdomen
    • Indication: Gastric cancer with liver mets
    • Abdominal CT with and without enhancement revealed:
      • Lobulated low density lesion at S5/6/7/8 of liver measuring 9.8cm in largest dimension is found. Liver meta is considered. In comparison with CT dated on 2023-02-24, the lesion progressed slightly.
      • Chains of lymphadenopathy at gastrohepatic ligment and perigastric region is found. In enlargement.
      • The GB is well distended without soft tissue lesion
      • Wall thikening at gastric antrum is found. Compatible with gastric cancer.
      • Splenomegaly is found.
      • The GB is well distended without soft tissue lesion
    • Imp:
      • Gastric cancer with regional lymphadenopathy and liver meta. In progression.
  • 2023-06-01 All-RAS + BRAF mutation
    • Cellblock No. S2023-03168
    • RESULTS:
      • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-05-04 EGD
    • Diagnosis:
      • Gastric cancer, Borrmann type III, antrum, AW
      • Reflux esophagitis LA grade A
      • Esophageal varices, F1CbLi. RCS(-)
      • Superficial gastritis
      • Duodenal ulcer, Forrest type IIc, bulb and pylorus
      • Deformed antrum
    • CLO test: not done
    • Suggestion:
      • Oral PPI use
      • If bleeding continued, suggest ER visit.
  • 2023-02-24 CT - abdomen
    • History: gastric cancer.
    • Indication: for clinical trail
    • Findings: Comparison prior CT dated 2023/01/13.
      • Prior CT identified wall thickening at the gastric antrum is noted again, mild increasing in size. Please correlate with gastroscopy.
      • Prior CT identified several metastases on both hepatic lobes are noted again, increasing in size.
      • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, increasing in size.
      • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size.
        • There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
      • Left renal cyst, 0.9cm
    • Impression:
      • Metastases on both hepatic lobes and metastatic lymph nodes in the gastrohepatic ligament and hepatoduodenal ligament show increasing in size that is c/w progressive disease. please correlate with clinical condition.
  • 2023-01-13 CT - abdomen
    • Findings: Comparison: prior CT dated 2022/12/09.
      • Prior CT identified wall thickening at the gastric antrum is noted again, stationary. Please correlate with gastroscopy.
      • Prior CT identified several metastases on both hepatic lobes are noted again, increasing in size.
      • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stable in size.
      • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size.
        • There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
      • Left renal cyst, 0.9cm
    • Impression:
      • Liver metastases on both lobes show increasing in size, please correlate with clinical condition.
  • 2022-12-09 CT - abdomen
    • Findings: Comparison: prior CT dated 2022/10/28.
      • Prior CT identified wall thickening at the gastric antrum is noted again, stationary. Please correlate with gastroscopy.
      • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size.
      • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stable in size.
      • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size. There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
      • Left renal cyst, 0.7cm
    • Impression:
      • Gastric cancer with lymph nodes and liver metastases (mild increasing in size), and portal venous thrombosis S/P C/T show stable disease. Follow up is indicated.
  • 2022-10-28 CT - abdomen
    • Findings: Comparison: prior CT dated 2022/09/14.
      • Prior CT identified wall thickening at the gastric antrum is noted again, stationary. Please correlate with gastroscopy.
      • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stable in size.
      • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size.
        • There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
      • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size.
      • Left renal cyst, 0.7cm
    • Impression:
      • Gastric cancer with lymph nodes and liver metastases(mild increasing in size), and portal venous thrombosis S/P C/T show stable disease. Follow up is indicated.
  • 2022-09-14, -08-03, -06-22 CT - abdomen
    • Gastric cancer with lymph nodes and liver metastases, and portal venous thrombosis S/P C/T show stable disease.
    • Follow up is indicated.
  • 2022-05-20 CT - abdomen
    • Findings:
      • Prior CT identified wall thickening at the gastric antrum is noted again, stationary that is c/w gastric cancer.
      • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, mild decreasing in size.
      • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, marked decreasing in size.
        • There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
      • Prior CT identified several metastases on both hepatic lobes are noted again, decreasing in size.
      • Left renal cyst, 0.7cm
      • Minimal ascites in the lower pelvis is suspected.
    • Impression:
      • Gastric cancer with lymph nodes and liver metastases, and portal venous tumor thrombosis S/P C/T show partial response.
  • 2022-03-18 CT - abdomen
    • Findings:
      • Prior CT identified wall thickening at the gastric antrum is noted again, stationary that is c/w gastric cancer.
      • Prior CT identified multiple metastatic nodes nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stationary.
      • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, increasing in size.
        • There is splenomegaly and the greatest cranial-caudal dimension measuring about 14.8 cm in length.
      • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size. However, the tumor margin is hard to define. Please correlate with MRI.
      • Left renal cyst, 0.7cm
      • Minimal ascites in the lower pelvis is suspected.
    • Impression:
      • Gastric cancer with lymph nodes and liver metastases, and portal venous tumor thrombosis. cT3N2M1. cstage:IVb.
  • 2022-03-16 MRI - brain
    • No intracranial metastasis.
  • 2022-03-11 Tc-99m MDP bone scan
    • Increased activity in the lower C-spines and L5 spine. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • A hot spot in the posterolateral aspect of left rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, hips and right knee, compatible with benign joint lesions.
  • 2022-03-01 CT - abdomen gastric filling with water
    • Clinical history: 42 y/o male patient with gastric cancer was suspected.
    • With and without contrast enhancement CT of abdomen - whole:
      • Thickening wall at the gastric antrum, r/o gastric malignancy.
      • There are multiple enlarged perigastric lymph nodes, could be due to lymph nodes metastasis.
      • Presence of thrombosis at main portal vein.
      • Left renal cyst, 0.7cm.
      • There are multifocal poor enhancing lesions in both lobes of liver, R/O liver metastasis.
      • Presence of some ascites in the pelvic cavity.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)
    • Impression:
      • R/O gastric malignancy with lymph nodes metastasis, portal venous invasion/thrombosis.
      • Suspicious liver metastasis. if proven metastasis, cstage T3N2M1. IVb.
  • 2022-02-25 Patho - stomach biopsy (Y1)
    • Stomach, antrum, AW side, biopsy — moderately differentiated adenocarcinoma
    • Microscopically, it shows moderately differentiated adenocarcinoma composed of a proliferation of irregular neoplastic glands and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei, pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • Immunohistochemical study reveals CK(+), CD56(-), SOX10(-), S100(-) and Ki-67 50%.
    • IHC stain — Her2/neu: negative (0/1+)

[chemotherapy] (not completed)

  • 2023-12-26 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-11-29 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-11-14 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-10-31 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-10-17 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-09-26 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-09-12 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-08-22 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-08-08 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 170mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-07-25 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 170mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-11 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 170mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-20 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 170mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-31 - oxaliplatin 130mg/m2 240mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2023-05-10 - oxaliplatin 130mg/m2 240mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2023-04-20 - oxaliplatin 130mg/m2 240mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2023-03-29 - oxaliplatin 130mg/m2 240mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2023-03-09 - oxaliplatin 130mg/m2 240mg D5W 500mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2023-02-22 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
  • 2023-02-01 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • 2023-01-04 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • 2022-12-14 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • 2022-11-23 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
  • 2022-11-02 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • 2022-10-12 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • 2022-09-21 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
  • 2022-08-31 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • 2022-08-10 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
  • 2022-08-03 - oxaliplatin 130mg/m2 239mg D5W 500mL 2hr + capecitabine 500mg PO 2# QD 3# QN D1-14
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2022-07-27 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
  • 2022-06-29 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + oxaliplatin 130mg/m2 239mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2022-06-02 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + oxaliplatin 130mg/m2 236mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2022-04-28 - oxaliplatin 130mg/m2 230mg D5W 500mL 2hr + capecitabine 500mg PO 2# QD 3# QN D1-14
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2022-04-22 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
  • 2022-03-31 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + oxaliplatin 130mg/m2 230mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14

==========

701492350

240115

[exam findings]

  • 2023-09-01 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 25) / 80 = 68.75%
      • M-mode (Teichholz) = 68
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Normal chamber size
      • Mild MR, TR
  • 2023-08-14 Tc-99m MDP bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, maxilla, mandible, some T- and L-spine, left sternoclavicular junction, bilateral shoulders, S-I joints, hips, and knees.
  • 2023-08-14 CT - chest
    • Indication: right breast cancer, diagnosed at Feng Rong Hospital, CNB: invasive ductal carcinoma, ER(+), PR(+), HER-2(-), Ki-67<5%
    • Findings:
      • Lungs:a subleural bulla or lung cyst at RML 16mm.
        • a reticular opacity over RLL may represents atelectasis or r/o fibrosis. normal appearance of Lt lung.
      • Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
      • Chest wall and visible lower neck: a Rt axillary enlarged LN (25mm in longest axial dimension). two enhancing nodules at UOQ of Rt breast measuring up to 14mm.
      • Mild atherosclerotic change of the abdominal aorta and bilateral common iliac arteries. small and large bowels grossly unremarkable.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • Rt breast cancer T1c or T2 N1
  • 2023-07-31 Patho - lymphnode biopsy
    • Lymph node, right axilla, core needle biopsy — Metastatic carcinoma, consistent with breast origin
    • Section shows cores of lymphoid tissue with metasatic irregular neoplastic glands. The immunohistochemical stain of GATA3 is positive.
    • IMMUNOHISTOCHEMICAL STUDY
        1. ER (Ab): Positive (>90%, strong)
        1. PR (Ab): Positive (10%, moderate)
        1. Her-2/neu (Ab): Equivocal (2+)
        1. Ki-67: 15%
  • 2023-07-31 Her-2/neu - DISH
    • HER-2 (by in situ hybridization) — Negative (NOT amplified)
    • METHOD AND DETAILS:
      • Number of observers: 1
      • Number of invasive tumor cells counted: 20
      • Average number of HER2 signals per cell: 2.9
      • Average number of CEP17 signals per cell: 2.6
      • HER2/CEP17 ratio: 1.12
      • Heterogeneous signals: Absent
      • Origin slide and block number: S2023-15086
      • Specimen: Formalin-fixed paraffin embedded tissue
      • Adequacy of sample for evaluation: Yes
      • Method of in situ hybridization: CISH (Ventana INFORM HER2 Dual ISH DNA Probe Cocktail Assay, Roche company)
    • APPENDIX:
      • ASCO/CAP scoring criteria (2018):
        • Group 1 = HER2/CEP17 ratio >=2.0; >=4.0 HER2 signals/cell
        • Group 2 = HER2/CEP17 ratio >=2.0; <4.0 HER2 signals/cell
        • Group 3 = HER2/CEP17 ratio <2.0; >=6.0 HER2 signals/cell
        • Group 4 = HER2/CEP17 ratio <2.0; >=4.0 and <6.0 HER2 signals/cell
        • Group 5 = HER2/CEP17 ratio <2.0; <4.0 HER2 signals/cell
      • Negative:
        • Group 5
        • Group 2 and concurrent IHC 0-1+ or 2+
        • Group 3 and concurrent IHC 0-1+
        • Group 4 and concurrent IHC 0-1+ or 2+
      • Positive:
        • Group 2 and concurrent IHC 3+
        • Group 3 and concurrent IHC 2+ or 3+
        • Group 4 and concurrent IHC 3+
        • Group 1

[MedRec]

  • 2023-09-01 ~ 2023-09-07 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Right breast invasive ductal carcinoma, ER(+), PR(+), HER-2(-), T1N1M0, stage IIA s/p chemotherapy with EC by T from 2023/09/06~
    • CC
      • For prepare chemotherapy.
    • Present illness
      • This 60-year-old woman patient suffered from right breast tumor in 2022/05. Sono by myself: two hypoechoi lesions over right 10’ region, 1.41x0.76x1.08 and 0.79x0.60x0.72 respectively, LAP(+) over right axilla. MMG at LMD showed heterogenous dense breast tissue with a small hyperdense lobular mass at right UOQ retroglandular area. Right breast cancer, diagnosed at Feng Rong Hospital. CNB at Feng Rong Hospital showed invasive ductal carcinoma, ER(+), PR(+), HER-2(-), Ki-67: <5%, refer for further management.
      • Right axilla lymph node core needle biopsy on 2023/07/31 pathology showed metastatic carcinoma, consistent with breast origin, ER: Positive(> 90%, strong), PR: Positive(10%, moderate), Her-2/neu: Equivocal(2+), Ki-67: 15%. Chest CT on 2023/08/14 showed right breast cancer T1c or T2 N1. Whole body bone scan on 2023/08/14 showed no strong evidence of bone metastasis. Colonoscopy on 2023/08/22 showed colon polyp and mixed hemorrhoid. Breast sona on 2023/09/01 showed right 10 o’clock / 4 cm, size: 1.44 x 0.90 x 1.42cm, right 10 o’clock / 3 cm, size: 0.72 x 0.71 x 0.81cm, highly suspicious of malignancy, with sonographic positive axillary LAP. Now, she was admitted to ward for prepare chemotherapy with EC * 4 followed by docetaxel * 4 followed by OP.
    • Course of inpatient treatment
      • After admitted, 2D echo on 2023/09/01 showed M-mode (Teichholz) = 68, 1. Preserved LV and RV systolic function with normal wall motion; 2. Normal chamber size; 3. Mild MR, TR. Consult GS for Port-A catheter insertion on 2023/09/05.
      • Chemotherapy with EC by T(Epirubicin 90mg/m2, Cyclophamide 600mg/m2)(C1) on 2023/09/06.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2023/09/07 and OPD followed up later.     
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
  • 2023-08-22 SOAP Hemato-Oncology Xia HeXiong
    • O
      • 2023/07/31 Her-2/neu - DISH
        • HER-2 (by in situ hybridization) — Negative (NOT amplified)
    • P
      • EC * 4 followed by docetaxel * 4 followed by OP
      • Admission for Port-A (if not done), Heart echo and then C/T
  • 2023-08-19 SOAP General and Gastrointestinal Surgery Chen YenZhi
    • O
      • 20230819 CT: no liver metastasis, no bone metastasis
      • bone scan: no bone metastasis
    • A/P
      • right breast cancer, multifocal, luminal A, cT1N1, stage 2
      • suggest: neoadjuvant chemotehrapy with following operation
      • arrange port-A implantation on 9/7
      • refer to oncologist for neoadjuvant chemotherapy
  • 2023-08-08 SOAP General and Gastrointestinal Surgery Chen YenZhi
    • S:
      • right breast cacner, diagnosied at Feng Rong Hospital, refer for further management
    • O:
      • no palpable breast tumor, no large movable LAP over right axilla
      • CNB at Feng Rong Hospital: invasive ductal carcinoma, ER(+), PR(+), HER-2(-), Ki-67<5%
      • MMG at LMD: heterogenous dense breast tissue with a small hyperdense lobular mass at right UOQ retroglandular area
      • sono by myself: two hypoechoi lesions over right 10’ region, 1.41x0.76x1.08 and 0.79x0.60x0.72 respectively, LAP(+) over right axilla
      • 2023/07/31 PATHO-lymphnode biopsy
        • Lymph node, right axilla, core needle biopsy — Metastatic carcinoma, consistent with breast origin
          1. ER (Ab): Positive (> 90%, strong)
          1. PR (Ab): Positive (10%, moderate)
          1. Her-2/neu (Ab): Equivocal (2+), FISH (-)
          1. Ki-67: 15%
      • no neurological sign
      • no bone pain
    • A
      • right breast cancer, multifocal, luminal A, cT1N1
  • 2023-07-29 SOAP General and Gastrointestinal Surgery Chen YenZhi
    • S:
      • right breast cacner, diagnosied at Feng Rong Hospital, refer for further management
    • O:
      • no palpable breast tumor, no large movable LAP over right axilla
      • CNB at Feng Rong Hospital: invasive ductal carcinoma, ER(+), PR(+), HER-2(-), Ki-67<5%
      • MMG at LMD: heterogenous dense breast tissue with a small hyperdense lobular mass at right UOQ retroglandular area
      • sono by myself: two hypoechoi lesions over right 10’ region, 1.41x0.76x1.08 and 0.79x0.60x0.72 respectively, LAP(+) over right axilla

[chemotherapy]

  • 2024-01-13 - docetaxel 60mg/m2 90mg NS 250mL 2hr
    • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-12-22 - docetaxel 60mg/m2 90mg NS 250mL 1hr
    • dexamethasone 4mg PO + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-24 - epirubicin 90mg/m2 130mg NS 100mL 30min + cyclophosphamide 600mg/m2 850mg NS 500mL 1hr
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-30 - epirubicin 90mg/m2 130mg NS 100mL 30min + cyclophosphamide 600mg/m2 850mg NS 500mL 1hr
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-27 - epirubicin 90mg/m2 130mg NS 100mL 30min + cyclophosphamide 600mg/m2 850mg NS 500mL 1hr
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-06 - epirubicin 90mg/m2 130mg NS 100mL 30min + cyclophosphamide 600mg/m2 850mg NS 500mL 1hr
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-01-15

Lab results on 2024-01-12 were grossly normal with no evidence of a contraindication to docetaxel administration.

700556004

240114

[lab data]

2023-06-13 Anti-HBs 0.00 mIU/mL
2023-06-13 HBsAg Reactive
2023-06-13 HBsAg (Value) 6203.60 S/CO
2023-06-13 Anti-HCV Nonreactive
2023-06-13 Anti-HCV Value 0.17 S/CO
2023-05-23 HBeAg Nonreactive
2023-05-23 HBeAg (Value) 0.949 S/CO
2023-05-23 HBsAg Reactive
2023-05-23 HBsAg (Value) 5353.06 S/CO

2023-05-02 P.jiroveci DNA-Sp Undetectable
2023-05-02 CMV viral load assay <35 IU/mL
2023-05-02 EBV DNA PCR Not deteceted copies/mL

2023-04-29 Gamma 25.9 %
2023-04-28 B2-Microglobulin 6183 ng/mL

2023-04-27 HIV Ab-EIA Nonreactive
2023-04-27 Anti-HIV Value 0.04 S/CO

2023-04-27 LDH 344 U/L

[exam findings]

  • 2024-01-02 ECG
    • Sinus tachycardia
  • 2023-12-22 CXR
    • S/P port-A implantation.
    • Multiple lung metastases.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-12-07 Patho - breast simple/partial mastectomy
    • Diagnosis
      • Breast, left, simple mastectomy — invasive carcinoma, NST, no special type.
      • Margin: free
      • Lymph node, no tissue submitted
      • ypT4a pNx (if cM1); anatomic stage: IV , pathology prgnostic stage group: IV
    • Gross Description
      • Procedure - simple mastectomy: breast: 11 x 8 x 5.5 cm with skin grossly invaded by tumor. Skin: 10 x 8 cm.
      • Lymph node sampling (if lymph nodes are present in the specimen)- no tissue submitted
      • Specimen laterality - Left
        • Sections are taken and labeled as: Tissue for formalin fixation: S2023- 24591: A1-2: peripheral margin; a3: deep margin; A4-8: tumor
    • Microscopic Description
      • For Invasive Carcinoma
        • Histologic type: Invasive carcinoma
        • Size of invasive carcinoma (mm): 70 x 70 x 40 mm.
        • Histologic grade (Nottingham histologic score): grade II (score 6,7)
        • Extent of tumor (required only if the structures are present and involved)
          • Skin involvement: Present (with ulceration )
          • Chest wall invasion deeper than pectoralis muscle: Absent
      • For Ductal Carcinoma In Situ- multiple folci
        • Tumor size (mm): 3 x 2 x 2 mm
        • Nuclear grade: 2
        • Architectural pattern: Comedo
        • Tumor necrosis: Present
      • Margins: Negative, Closest margin (2 mm from deep margin)
      • Nodal status: no tissue submitted
      • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
        • In the Breast - Probable or definite response to presurgical therapy in the invasive carcinoma
        • In the Lymph nodes - no tissue submitted
      • Immunohistochemical Study - S2023-24591A3
        • ER (Ab): Positive (5%, strong); PR (Ab): Negative (0%); Her-2/neu : Positive (3+); Ki-67: 40-50%; p53: 95%
  • 2023-11-10 CT - abdomen
    • History: left breast cancer with multiple lung metastases.
      • 20231106 US: a faint heterogenous hypoechoic lesion at S5 near surface: size about 1.6cm(?)
      • HBV related cirrhosis, child A with splenomegaly
    • Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
    • Findings:
      • Prior CT identified left breast cancer (4.0cm) is noted again, increasing in size to 6.1 cm that is c/w progressive disease.
        • In addition, prior CT identified multiple metastases on bilateral lungs are noted again, marked increasing in size and number that is c/w multiple lung metastases with progressive disease.
      • There are two poor enhancing lesion 0.7 cm in S5 sub-capsule area. and 0.8 cm in S4 of the liver. Follow up is indicated. Otherwise, please correlate with MRI.
      • Prior CT identified Cirrhosis of the liver with portal hypertension (splenomegaly) is noted again, stationary.
      • Prior CT identified some calcifications in the uterus are noted again, stationary that is c/w fibroids.
    • Impression:
      • Left breast cancer with multiple lung metastases show progressive disease.
      • There are two poor enhancing lesion 0.7 cm in S5 sub-capsule area. and 0.8 cm in S4 of the liver. Follow up is indicated. Otherwise, please correlate with MRI.
  • 2023-11-09 PET scan
    • In comparison with the previous study on 2023/02/15, the glucose-hypermetabolism in the left breast is a little less evident and the previous glucose hypermetabolic lesions in the left axillary region and left 1st rib disappeared. However, more new bilateral lung lesions are noted, suggesting multiple lung metastases in progression.
    • Glucose hypermetabolism in the right shoulder joint and in the right hip joint. Inflammtion may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Increased FDG accumulation in bilateral kidneys and colon, probably physiological accumulation of FDG.
  • 2023-11-06 SONO - abdomen
    • Findings:
      • Coarse liver parenchyma with uneven surface, increased brightness of liver parenchyma with far attenuation was noted. some parts of liver obscured by bowel gas: incomplete exam of liver.
        • a faint heterogenous hypoechoic lesion was noted at S5 near surface: size about 1.6cm.
      • a high echoic lesion was noted in the gallbladder, size about 0.4cm; diffuse gallbladder wall thickening was noted.
      • mild splenomegaly
    • Diagnosis:
      • Liver cirrhosis (incomplete exam of liver: please see description), fatty liver (moderate)
      • liver hypoechoic lesion: suspected liver tumor
      • mild splenomegaly
      • gallbladder stone
      • gallbladder wall thickening
    • Suggestion:
      • suggest further image study: such as CT scan
  • 2023-10-31 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (88 - 14) / 88 = 84.09%
      • M-mode (Teichholz) = 84
    • Conclusion:
      • Mild septal and RV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis; mild PR.
      • Dilated proximal ascending aorta (35 mm).
  • 2023-08-14 SONO - abdomen
    • Findings
      • Coarse liver parenchyma with uneven surface, increased brightness of liver parenchyma.
        • some parts of liver obscured by bowel gas: incomplete exam of liver.
        • Lesion could be masked due to cirrhosis background.
      • a high echoic lesion was noted in the gallbladder, size about 0.5cm; diffuse gallbladder wall thickening was noted.
      • mild splenomegaly
    • Diagnosis:
      • Liver cirrhosis (incomplete exam of liver: please see description), fatty liver
      • mild splenomegaly
      • gallbladder stone
      • gallbladder wall thickening
  • 2023-07-12 ENT Hearing Test
    • Tymp bil type B
    • ART bil ansent
    • PTA:
      • Reliability FAIR
      • Average RE 39 dB HL; LE 41 dB HL
      • RE mild to moderate SNHL
      • LE midl to moderately severe SNHL
  • 2023-06-30 CT - brain
    • no evidence of brain metastasis.
  • 2023-06-13, -05-17, -05-11 CXR
    • Multiple nodules at bil. lungs.
  • 2023-05-08, -05-05, -05-02, -04-27, -04-24, -04-20 CXR
    • Multiple nodules in both lungs due to metastases.
  • 2023-04-25 Esophagogastroduodenoscopy, EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A
      • Mild oozing lesion, antrum, GC, s/p hemostasis with argon plasma coagulation
    • Suggestion:
      • High dose PPI use
      • Coagulopathy correction
      • 2nd look maybe indicated, if active bleeding present
  • 2023-04-24 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Hypercellularity
    • Immunohistochemical stains:
      • MPO: positive for myeloid series
      • CD71: positive for erythroid series
      • CD61: positive for megakaryocytes
      • CD34 & CD117: positive for blast
      • CD138: positive for plasma cells
      • Kappa & lambda light chain: polyclonality
      • CK: negative for carcinoma cell
    • Microscopically, the section shows pictures as follows:
      • Hypercellularity for her age, 70%
      • M/E ratio > 10, hyperplasia of myeloid series and marked hypoplasia of erythroid series
      • Adequate megakaryocytes with focal mononucleation and hyposegmentation
      • No increase of blast
      • Increase of plasma cells (about 10%) with polyclonality of kappa and lambda light chains
    • According to above histopathologic findings, it maybe either therapeutic effect or myelodysplastic syndrome. Please correlate with clinical finding and bone marrow smear for conclusive diagnosis.
  • 2023-04-17 CXR
    • Multiple nodules of variable sizes in both hypoinflated lungs due to metastases.
  • 2023-04-17 SONO - chest
    • Findings
      • Left-side of thorax:
        • There was no pleural effusion in the left hemithorax. The pleural gliding and diaphragm excursion were adequate.
      • Right-side of thorax:
        • There was no pleural effusion in the right hemithorax. The pleural gliding and diaphragm excursion were adequate. Large amount of ascites was also noted in the abdominal cavity. We tried echo-assisted ascites tapping first but failed because of too thick of skin and soft tissue to approach ascites. We then performed echo-assisted pig-tail insertion from RLQ for ascites tapping under her son’s agreement. After local anaesthesia, Fr 10 pig-tail was inserted smoothly and total 1000cc yellowish turbid fluid was drained immediately. The specimen was submitted for routine, biochemistry, TB, bacterial culture and cell block. The whole procedure was smoothly.
    • Special Procedure
      • Insertion of pig-tail catheter fr.10 through the RLQ abdomen
    • Echo diagnosis
      • No pleural effusion.
      • Massive ascites post pig-tail insertion for ascites drainage.
  • 2023-04-15 Gynecologic ultrasonography
    • Findings
      • Uterus Position : AVF
        • Myoma: Myoma: 11 x 8 mm,
      • Endometrium:
        • Thickness: 15.7 mm
      • CUL-DE-SAC: with fluid
      • Other: Asites >1000ml
    • IMP:
      • EM: 15.7mm, blood clot
      • Ascites
  • 2023-04-06 CT - abdomen
    • History and indication: Sepsis
    • Non-contrast CT of abdomen-pelvis revealed:
      • Left breast cancer (4.0cm) with calcification.
      • Multiple nodules at bilateral basal lungs.
      • Liver cirrhosis with splenomegaly.
      • Some calcifications in uterus.
      • S/P foley catheter indwelling. S/P Port-A infusion catheter insertion.
    • IMP: Left breast cancer with lung metastases. Liver cirrhosis with splenomegaly.
  • 2023-04-05 CT - brain
    • Brain atrophy.
  • 2023-04-05 ECG
    • Sinus tachycardia
    • Poor wave progression
    • Abnormal ECG
  • 2023-02-17 SONO - abdomen
    • Liver cirrhosis with suspected muliple regeneration noules
  • 2023-02-15 PET
    • Glucose-hypermetabolism in the left breast and several left axillary lymph nodes, compatible with the primary left breast cancer with regional lymph nodes metastases.
    • Glucose-hypermetabolism in bilateral lung fields and the left 1st rib, highly suspected cancer with distant metastases.
    • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    • Left breast cancer with regional lymph nodes, bilateral lungs and left 1st rib metastases, cTxN2M1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-02-14 ECG
    • Normal sinus rhythm
    • Low voltage QRS
    • Inferior infarct, age undetermined
  • 2023-02-14 Spirometry
    • mild restrictive impairment
  • 2023-02-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (68 - 17) / 68 = 75%
      • M-mode (Teichholz) = 75
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Normal chamber size
      • Trivial TR
  • 2023-02-06 CT - chest
    • Indication: Left breast palpable tumor noted for several days. Left breast heterogenous hypoechoic lesion under the nipple, size: 5.0x5.0cm
    • MDCT (256-detector rows, GE Revolution, was performed with 0.625 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Lungs: multiple randomly distributed pulmonary nodules of varying sizes due to metastases. mosaic attenuation changes in both lower lobes may be due to obstructive airway disease
      • Mediastinum and hila: no enlarged LN or mass.
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: no effusion or nodule.
      • Chest wall and visible lower neck: an ill-defined large soft-tissue tumor (52mm in longest dimension) with areas of cystic or necrotic change, and thickening of overlying skin, and with multiple metastaic LAP at left axilla.
      • Visible abdominal contents: appearance of liver cirrhosis and moderate splenomegaly. normal appearance of gall bladder. unremarkable of the, both adrenal glands, pancreas, and both kidneys. no enlarged lympode.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression: Lt breast cancer T3N2M1
  • 2023-02-03 Patho - breast biopsy
    • Breast tumor, left, core needle biopsy — Invasive carcinoma of no special type
    • Microscopically, the sections show a picture of invasive carcinoma of no special type characterized by tumor nests infiltrating in the sclerotic stroma with tumor necrosis.
    • Immunohistochemistry shows P63(-), ER(80%, 2~3+), PR(50%, 2+), Her2/neu(+, Dako score 3+) and Ki-67: 70% for tumor.
  • 2023-02-02 Mammography
    • Impression:
      • R/O left breast malignancy with axillary lymph nodes metastasis.
      • Group hetergeneous calcifications in UIQ of right breast (posterior third portion). Malignancy?
    • BI-RADS: Category 5: highly suggestive of malignancy-appropriate action should be taken.
  • 2021-04-16 Nerve Conduction Velocity, NCV
    • Findings
      • The results of NCV study showed (1) prolonged distal motor latency and decreased sensory nerve conduction velocity in bilateral median nerves, (2) decreased motor nerve conduction velocity in left median nerve, (3) reduced CMAP amplitude in left peroneal nerve.
      • The results of F-wave and H-reflex studies were within normal limits.
      • The thermal QST study showed normal cold and warm threshold in upper and lower limbs.
    • Conclusion
      • The above findings suggest (1) bilateral median distal neuropathy, more severe in the left side, (2) left peroneal neuropathy. Advise clinical correlation.

[immunochemmotherapy]

  • 2024-01-23 - trastuzumab 600mg SC 3min + docetaxel 75mg/m2 110mg NS 250mL 2hr (Gao WeiYao)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-12-26 - trastuzumab 600mg SC 3min + docetaxel 75mg/m2 116mg NS 250mL 2hr (Gao WeiYao)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-12-19 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)

    • SOAP: The patient reported vomiting and nausea, so she refused to take Perjecta. Only Herceptin administered today.
  • 2023-11-28 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)

  • 2023-10-31 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)

  • 2023-10-12 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)

  • 2023-09-21 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)

  • 2023-09-07 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)

  • 2023-07-04 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr (Wang ShengLin)

  • 2023-06-13 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 1hr (Wang ShengLin)

  • 2023-03-29 - epirubicin 90mg/m2 157mg NS 100mL 30min + cyclophosphamide 600mg/m2 1044mg NS 500mL 1hr (EC(90) Q3W)

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL + Granocyte (lenograstim 250ug) SC
  • 2023-02-17 - epirubicin 90mg/m2 155mg NS 100mL 30min + cyclophosphamide 600mg/m2 1033mg NS 500mL 1hr (EC(90) Q3W)

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-05-23 ~ Femara (letrozole)

  • 2023-05-19 ~ 2023-05-24 - Cytotec (misoprostol)

Pertuzumab - Adult Dosing - 2024-01-03 - https://www.uptodate.com/contents/pertuzumab-drug-information

  • Breast cancer, metastatic, HER2+
    • IV: 840 mg over 60 minutes followed by a maintenance dose of 420 mg over 30 to 60 minutes every 3 weeks until disease progression or unacceptable toxicity (in combination with trastuzumab [or trastuzumab/hyaluronidase] and docetaxel).
  • Breast cancer, early HER2+, adjuvant treatment
    • IV: 840 mg over 60 minutes followed by a maintenance dose of 420 mg over 30 to 60 minutes every 3 weeks for a total of 1 year (up to 18 cycles) or until disease progression or unacceptable toxicity (whichever occurs first); as part of a combination regimen containing trastuzumab (or trastuzumab/hyaluronidase) and including standard anthracycline- and/or taxane-based therapy; pertuzumab and trastuzumab (or trastuzumab/hyaluronidase) should begin on day 1 of the first taxane-containing cycle.
  • Breast cancer, early HER2+, neoadjuvant treatment
    • IV: 840 mg over 60 minutes followed by a maintenance dose of 420 mg over 30 to 60 minutes every 3 weeks for 3 to 6 cycles; may be administered as one of the regimens below. Postoperatively, continue pertuzumab and trastuzumab (or trastuzumab/hyaluronidase) to complete 1 year of treatment (up to 18 cycles); refer to specific protocol for details.
      • Four preoperative cycles of pertuzumab, trastuzumab (or trastuzumab/hyaluronidase), and docetaxel, followed by 3 postoperative cycles of fluorouracil, epirubicin, and cyclophosphamide (FEC) or
      • Three or four preoperative cycles of FEC (alone) followed by 3 or 4 preoperative cycles of pertuzumab, trastuzumab (or trastuzumab/hyaluronidase), and docetaxel or
      • Six preoperative cycles of pertuzumab, trastuzumab (or trastuzumab/hyaluronidase), docetaxel, and carboplatin
      • Four preoperative cycles of dose-dense doxorubicin and cyclophosphamide alone, followed by 4 preoperative cycles of pertuzumab, trastuzumab (or trastuzumab/hyaluronidase), and paclitaxel.
  • Missed doses or delays: If <6 weeks has elapsed, administer pertuzumab 420 mg (maintenance dose) as soon as possible; do not wait until the next planned dose. If >= 6 weeks has elapsed, readminister pertuzumab 840 mg (loading dose) over 60 minutes, and then follow with a maintenance dose of pertuzumab 420 mg (over 30 to 60 minutes) every 3 weeks thereafter.
  • Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

==========

not posted

  • 2023-12-26 CA-153 (NM) 118.131 U/ml

  • 2023-12-12 CA-153 (NM) 110.748 U/ml

  • 2023-06-20 CA-153 (NM) 44.155 U/ml

  • 2023-04-03 CA-153 (NM) 64.922 U/ml

  • 2023-02-06 CA-153 50.7 U/mL

  • 2023-12-26 CEA (NM) 12.156 ng/ml

  • 2023-12-12 CEA (NM) 17.145 ng/ml

  • 2023-06-20 CEA (NM) 27.607 ng/ml

  • 2023-04-03 CEA (NM) 35.020 ng/ml

  • 2023-02-06 CEA 24.89 ng/mL

2024-01-22

[prophylactic G-CSF for post-chemotherapy leukopenia]

This patient is scheduled to receive her second session of trastuzumab + docetaxel on 2024-01-23. Following her first session on 2023-12-26, she experienced a nadir WBC count of 0.48K/uL on 2024-01-02, one week later. G-CSF (filgrastim) 300mg daily from 2024-01-03 to 2024-01-05 successfully mitigated the leukopenia. However, due to a recent downward trend in WBC counts across the past three data points, prophylactic G-CSF is recommended for potential standby use.

  • 2024-01-20 WBC 3.42 x10^3/uL *
  • 2024-01-18 WBC 4.02 x10^3/uL
  • 2024-01-08 WBC 5.07 x10^3/uL
  • 2024-01-06 WBC 17.95 x10^3/uL
  • 2024-01-04 WBC 1.19 x10^3/uL ** 1/3-1/5 G-CSF
  • 2024-01-02 WBC 0.48 x10^3/uL *** nadir
  • 2023-12-26 WBC 6.86 x10^3/uL trastuzumab + docetaxel
  • 2023-12-25 WBC 1.94 x10^3/uL **
  • 2023-12-21 WBC 6.00 x10^3/uL 12/19 G-CSF
  • 2023-12-06 WBC 3.56 x10^3/uL *

2024-01-03

[Neutropenia and Febrile Episode]

The patient recently experienced an episode of grade 4 neutropenia (severely low white blood cell count) on 2024-01-02. This is likely due to the combined effects of the chemotherapy medications trastuzumab and docetaxel, with docetaxel likely playing a stronger role.

  • 2024-01-02 WBC 0.48 x10^3/uL

  • 2023-12-26 WBC 6.86 x10^3/uL

  • 2024-01-02 Neutrophil 0.0 %

  • 2023-12-26 Neutrophil 82.2 %

To address the neutropenia, the patient received:

  • A single dose of Granocyte (lenograstim 250ug) on 2024-01-02.
  • G-CSF (filgrastim) 600mg daily starting on 2024-01-03.

Additionally, the patient experienced a fever with a peak temperature of 39°C in the night of 2023-01-02. This fever has been successfully controlled with the administration of Cefim (cefepime 2g Q8H).

No identification of medication reconciliation issues.

2023-06-16

  • The chronological data for the patient’s WBC levels is organized in the following table, with asterisks (*) denoting instances when the WBC count fell below 3K/uL. According to the available HIS5 data, there were three episodes of leukopenia, where the WBC count fell below 3K/uL. These instances occurred in late Feb to early Mar, early Apr, and late Apr. The first two episodes could potentially be attributed to the chemotherapy regimen of epirubicin and cyclophosphamide. However, the cause of the third episode is less certain as there was a full recovery between the second and third episode, and no chemotherapy treatment was administered during this period.
    • 2023-06-13 WBC 4.68 x10^3/uL 2023-06-13 trastuzumab + pertuzumab
    • 2023-05-17 WBC 3.88 x10^3/uL
    • 2023-05-12 WBC 4.74 x10^3/uL
    • 2023-05-11 WBC 3.52 x10^3/uL
    • 2023-05-10 WBC 3.95 x10^3/uL
    • 2023-05-08 WBC 5.11 x10^3/uL
    • 2023-05-05 WBC 7.37 x10^3/uL
    • 2023-05-02 WBC 8.82 x10^3/uL
    • 2023-04-29 WBC 5.39 x10^3/uL
    • 2023-04-27 WBC 4.56 x10^3/uL
    • 2023-04-26 WBC 4.85 x10^3/uL
    • 2023-04-25 WBC 6.28 x10^3/uL
    • 2023-04-24 WBC 1.81 x10^3/uL * cause unknown
    • 2023-04-20 WBC 1.51 x10^3/uL * cause unknown
    • 2023-04-17 WBC 3.36 x10^3/uL
    • 2023-04-13 WBC 7.86 x10^3/uL
    • 2023-04-10 WBC 1.37 x10^3/uL *
    • 2023-04-08 WBC 0.13 x10^3/uL *
    • 2023-04-05 WBC 0.06 x10^3/uL *
    • 2023-03-29 WBC 7.28 x10^3/uL 2023-03-29 chemo
    • 2023-03-16 WBC 5.07 x10^3/uL
    • 2023-03-09 WBC 6.67 x10^3/uL
    • 2023-03-05 WBC 13.05 x10^3/uL
    • 2023-03-03 WBC 1.87 x10^3/uL *
    • 2023-03-02 WBC 0.48 x10^3/uL *
    • 2023-02-23 WBC 2.32 x10^3/uL *
    • 2023-02-16 WBC 3.66 x10^3/uL 2023-02-17 chemo
    • 2023-02-14 WBC 3.86 x10^3/uL

In continuation of the previous pharmacist note.

  • According to Taiwan’s NHI reimbursement guidelines, the administration of G-CSF is approved for patients with non-hematologic malignancies who have a WBC count of less than 1000/uL or an ANC of less than 500/uL after chemotherapy. In this specific case of the patient, these criteria have been met, suggesting that if the use of G-CSF is deemed beneficial, it will be covered by the NHI.
  • Granocyte (lenograstim) was administered concurrently with the chemotherapy regimen on 2023-03-29. It’s recommended for primary and secondary prophylaxis that G-CSF administration typically starts 24 to 72 hours after the end of chemotherapy treatment (https://www.uptodate.com/contents/use-of-granulocyte-colony-stimulating-factors-in-adult-patients-with-chemotherapy-induced-neutropenia-and-conditions-other-than-acute-leukemia-myelodysplastic-syndrome-and-hematopoietic-cell-transplantation). ref(1): Delayed Granulocyte Colony-Stimulating Factor (G-CSF) Administration after Chemotherapy Reduces Total G-CSF Doses without Affecting Neutrophil Recovery in a Randomized Clinical Study in Children with Solid Tumors. Pediatr Hematol Oncol. 2020;37(8):665-675. ref(2): Efficacy of delayed administration of post-chemotherapy granulocyte colony-stimulating factor: evidence from murine studies of bone marrow cell kinetics. Exp Hematol. 2008;36(1):9-16.

700396247

240112

{head and neck… not completed}

[exam findings]

  • 2023-12-15 CT - chest
    • Indication: Nasopharyngeal non-keratinizing carcinoma with neck lymph node, liver and bone metastases, stage IVB
    • Chest CT with and without IV contrast ehnancement shows:
      • Consolidation of right lower lobe is found.
      • Paraseptal Emphysematous change over both upper lobes is also noted.
      • S/p port-A placement with its tip at Superior vena cava.
      • Small lymph nodes are found at both sides of the mediastinum and bilatearal lower neck. In comparison with CT dated on 2023-05-10, the lesions are stationary.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Some lymph nodes are found at hepatic hilum.
      • Low density lesions are found at S4 and S8 of liver up to 2.3cm in largest dimension. Liver meta is considered. The lesions are more necrotic but the size is stationary.
    • IMp:
      • NPC with bone, thoracic and abdominal lymph nodes meta and liver meta. Stationary.
  • 2023-12-13 Pelvis-THR & Bilat. Hip Lat
    • Multiple bony metastases.
  • 2023-12-13, -08-04, -07-31 CXR erect
    • S/P port-A implantation.
    • Multiple bony metastases.
    • Atherosclerotic change of aortic arch
  • 2023-07-31 Abdomen - Standing (Diaphragm)
    • Multiple bony metastases.
  • 2023-07-17 Tc-99m MDP bone scan
    • Several new lesions of increased radioactivity in some upper T-spine, bilateral rib cages, left scapula, and left femur compared with the previous study on 2023-01-10, indicating metastatic bone disease in progression.
  • 2023-05-10 CT - chest
    • Indication: Malignant neoplasm of superior wall of nasopharynxL - MRI: multiple bone metastasis with pathological compression fracture at L2 vertebral body; r/o liver metastasis and LUNG METASTASES
    • Comparison was made with previous CT dated on 2023/01/07
      • Lungs: several plate atelectases at bilateral lower lobes.
        • substantial subpleural paraseptal emphysema/bullae and mild centrilobular emphysema at both upper lobes.
        • no abnormal nodule in the lungs.
        • as compared with previous CT study on.
      • Mediastinum and hila: significant decrease in size of enlarged LNs in the visceral space and both hila compared with previous CT dated on 2023/01/07
        • mild calcified plaques of the LAD coronary artery.
      • Chest wall and visible lower neck: significant decrease in size of enlarged LNs compared with previous CT dated on 2023/01/07
      • Visible abdominal-pelvic contents: significant decrease in size of the hepatic tumors compared with previous CT dated on 2023/01/07
      • Visualized bones: diffuse destructive mixed lytic and blastic change in all visible bones.
    • Impression:
      • nasopharyngeal tumor with bones, distant LNs, and liver metastases, significant regression in liver and LNs metastases, but progression of bony metastassis as compared with previous CT dated on 2023/01/07
  • 2023-04-19 SONO - abdomen
    • Hepatic tumors R/O metastasis
    • Postcholecystectomy
  • 2023-02-02 MRI - nasopharynx
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:T1(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-01-19 Patho - nasopharyngeal/oropharyngeal biopsy
    • PATHOLOGIC DIAGNOSIS
      • Nasopahrynx, right, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B).
        • IHC stains: CK (+).
      • Nasopahrynx, left, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B).
        • IHC stains: CK (+).
    • MACROSCOPIC EXAMINATION
      • Number of tissue fragments: 01: right: 1 piece; 02 left: 4 pieces
      • Specimen size: 01 right: 0.2 x 0.1 x 0.1 cm; 02: left: 0.5 x 0.4 x 0.1 cm.
    • MICROSCOPIC EXAMINATION
      • Histologic Type - Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B)
      • Treatment Effect - no previous treatment
      • Additional Pathologic Findings - None identified
      • Ancillary Studies - IHC stains: CK (+).
      • Clinical History (select all that apply) - left neck tumor metastasis
  • 2023-01-18 PET scan
    • No significant glucose hypermetabolism lesions in bilateral lungs is noted, suggesting further investigation and follow-up.
    • Glucose hypermetabolism in the left nasopharyngeal region, in lymph node regions on both sides of the diaphragm, right lobe of the liver and multiple bone marrows, highly suspected malignancy with distant metastases, suggesting biopsy (lesions in the right lobe of the liver) for investigation.
    • Malignancy (lung, lymphoma or others ?) with multiple bone metastases, c-stage IV, by this F-18 FDG PET scan.
  • 2023-01-17 EGD
    • Diagnosis:
      • Suspect duodenal tumor, bulb, AW, s/p biopsy (A)
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, s/p CLO test
      • R/o gastric intestinal metaplasia, prepyloric antrum, s/p biopsy(B)
      • Duodenal shallow ulcers, bulb to 2nd portion
      • Duodenitis, bulb
      • Duodenal subepithelial lesions, 2nd portion, suspect lymphatic cyst
  • 2023-01-12 Patho - lymph node region resection
    • Lymph node, left neck, excision — Metastatic squamous cell carcinoma, non-keratinized
    • The specimen submitted consisted of one lymph node tissue measuring 1.2 x 1.1 x 0.6 cm in size, fixed in formalin. All embedded for sections.
    • Microscopically, the sections show a picture of metastatic squamous cell carcinoma characterized by solid tumor cells infiltrated in lymphoid parenchyma.
    • Immunohistochemistry of CK(+), P40(+), TTF-1(-), Napsin-A(-) and CD56(-) for tumor, compatible with metastatic squamous cell carcinoma, non-keratinized. Clinical correlation is advised.
  • 2023-01-10 Tc-99m MDP bone scan
    • The scintigraphic findings are compatible with multiple bone metastases.
  • 2023-01-10 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 29.6) / 116 = 74.48%
      • M-mode (Teichholz) = 74.5
    • Conclusion:
      • Borderline aortic root size, normal AV with no AR
      • Thickened and prolapse of MV, no MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • Mild PR, no TR, normal IVC size
  • 2023-01-07 CT - chest
    • Indication: R/O lung cacner with neck lymph node and bone metastases
      • Chest CT with and without IV contrast ehnancement shows:
        • Several atelectatic change at bilateral lower lobes is found.
        • Bilateral subclavicular lymphadenopathy is also noted.
        • Enlarged lymph nodes are found at both sides of the mediastinum.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • Paraseptal Emphysematous change over bialteral upper lobes is found.
        • Calcified coronary arteries is found.
        • Low density lesions are found at both lobes of liver measuring 3.7cm in largest dimension. Liver meta is considered.
        • Relatively prominent sulci, fissue and dilated ventricles indicate brain atrophy.
    • Imp:
      • Diffuse bone meta, liver meta and bilateral lung atelectasis, mediastinal and subclavicular lymphadenopathy, r/o lung cancer with extensive meta. Suggest tissue proof from subpraclavicular lymph nodes
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T: Tx(T_value) N: N3(N_value) M: M1(M_value) STAGE: ____(Stage_value)
  • 2023-01-04 MRI - L-spine
    • multiple bone metastasis with pathological compression fracture at L2 vertebral body
    • r/o liver metastasis

[chemotherapy]

  • 2024-01-12 - docetaxel 75mg/m2 160mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-12-14 - docetaxel 75mg/m2 160mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-11-10 - docetaxel 75mg/m2 160mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-10-14 - docetaxel 75mg/m2 160mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-09-08 - docetaxel 75mg/m2 160mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-08-09 - docetaxel 75mg/m2 160mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-07-04 - carboplatin AUC 5 485mg NS 250mL 2hr + fluorouracil 1000mg/m2 2100mg NS 500mL 22hr D1-2 (PF Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-06-01 - cisplatin …… (not completed)
  • 2023-04-17
  • 2023-03-13
  • 2023-02-17
  • 2023-01-20

==========

2024-01-12

[episodic hyperuricemia: inconsistent Feburic use impedes control]

The patient exhibited episodic hyperuricemia throughout the past year, suggesting inadequate control of his uric acid levels.

  • 2024-01-11 Uric Acid 9.6 mg/dL ++
  • 2023-12-18 Uric Acid 3.7 mg/dL
  • 2023-12-14 Uric Acid 8.5 mg/dL +
  • 2023-11-13 Uric Acid 6.5 mg/dL
  • 2023-11-09 Uric Acid 8.2 mg/dL +
  • 2023-09-07 Uric Acid 7.8 mg/dL +
  • 2023-08-21 Uric Acid 6.9 mg/dL
  • 2023-08-07 Uric Acid 3.5 mg/dL
  • 2023-07-31 Uric Acid 9.1 mg/dL ++
  • 2023-07-03 Uric Acid 8.6 mg/dL +
  • 2023-06-05 Uric Acid 11.0 mg/dL ++++
  • 2023-05-31 Uric Acid 9.0 mg/dL ++
  • 2023-03-12 Uric Acid 6.5 mg/dL
  • 2023-02-16 Uric Acid 5.8 mg/dL
  • 2023-01-23 Uric Acid 8.2 mg/dL +
  • 2023-01-06 Uric Acid 5.2 mg/dL

In response to these hyperuricemic episodes, Feburic therapy was administered during several hospitalizations. However, outpatient visits did not consistently prescribe this medication, potentially contributing to the elevated serum uric acid levels.

Therefore, it is recommended to consider either extending Feburic therapy or exploring alternative options such as benzbromarone (on prescription at the OPD visits) for improved management of serum urate levels.

701174678

240112

[exam findings]

  • 2023-10-31 ECG portable 7 days
    • Findings
      • Baseline was persistent AFIB with SVR
        • MAX HR: 82 bpm
        • Avg HR: 54 bpm
        • MIN HR: 32 bpm
      • Ventricular Ectopy: 359
      • 1 episode of short-run VT (7 beats, 109bpm)
      • 1 episode of long pause, max 2.00 sec, related to AFIB SVR
      • 1 test events at begining, ECG showed persistent AFIB
    • Conclusion
      • Baseline was persistent AFIB with SVR
      • Rare isolated VPC
      • 1 episode of short-run VT (7 beats, 109bpm)
      • 1 episode of long pause, max 2.00 sec (related to AFIB SVR)
  • 2023-10-24 MRA - brain
    • Focal old ischemic cortical infarct over right medial occipital lobe.
    • Mild periventricular small vessel disease. NO acute ischemic infarct.
    • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
    • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
    • Short segmental severe stenosis of left distal ICA (ophthalmic segment) with post-stenotic dilatation.
    • Paranasal sinusitis.
  • 2023-10-24 CXR
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • patchy opacity at medial RUL
  • 2023-10-23 ECG portable 24hr
    • Baseline was incessant AFIB with SVR (Average HR: 57bpm, range between: 51-70 bpm)
    • A few isolated VPCs / VPC couplets
    • 1 episode of non-sustained VT (5 beats, 120 bpm)
    • No long pause
  • 2023-10-20 ECG
    • Atrial fibrillation
    • Abnormal ECG
  • 2023-09-25 Neurosonography
    • Moderate atheromatous lesion in R CCA bifurcation with ulcerated plaqaue; mild to moderate atheromatous lesions in R ICA; L middle CCA and L CCA bifurcation; mild atheromatous lesions in R subclavian artery; irregular bradycardia with heart rate between 31 and 53 BPM.
    • Elevated flow velocities in bilateral MCAs (PS/ED: R = 207/49, L = 295/59 cm/s), suggesting bialteral MCA stenosis.
    • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows. 4) Normal bilateral ophthalmic arterial flows.
    • Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
  • 2023-09-11 C-spine AP + Lat
    • mild anterior and posterior spur formation at the lower C-spine.
    • mild decreased disc space in the C6/7 disc.
  • 2023-06-16 MRI - prostate
    • Clinical history: 75 y/o male patient with 112/05/02, high PSA 41.5, he prefer TRUS-P biopsy after discussion (2023/05/11)
      • 2023/05/11, DRE: no hard nodule, TRUS-P biopsy 12 cores, educate further care, 2023/05/18, pathology showed
        • Histologic Type: Prostatic acinar adenocarcinoma
        • Histologic Grade: Gleason score = 7 (4 + 3).
      • arrange MRI and bone scan for staging
    • Imaging Report Form for Prostate Carcinoma
      • Impression (Imaging stage): T:T3b(T_value) N:N0(N_value) M:Mo(M_value) STAGE: IIIB (Stage_value)
    • Impression
      • Prostate cancer (in body, base and apex, mainly in left lobe with abutting left seminal vesicle base), r/o seminal vesicle involvement. cstage T3bN0M0.
  • 2023-05-24 Tc-99m MDP bone scan
    • Faint hot spots in the sternum and both rib cages, respectively, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, mandible, some C-, T- and L-spine, sacrum, bilateral sternoclavicular junctions, shoulders, S-I joints, hips, and knees.
  • 2023-05-11 Patho - prostate needle biopsy
    • PATHOLOGIC DIAGNOSIS
      • Prostate, right, needle biopsy — Prostatic acinar adenocarcinoma (Gleason score 7 = 4 + 3) involving 5 of 6 strips of prostatic tissue by the number of involved strips or 70 % by the involved volume of the specimen. The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
      • Prostate, left, needle biopsy — Prostatic acinar adenocarcinoma (Gleason score 7 = 4 + 3) involving 6 of 6 strips of prostatic tissue by the number of involved strips or 80 % by the involved volume of the specimen. The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Prostatic acinar adenocarcinoma
      • Histologic Grade: Gleason score = 7 (= 4 + 3 ).
  • 2023-05-02 Low dose CT, LDCT - chest
    • Mild subpleural fibrosis both lower and upper lobes.
    • extensive 3V-CAD, suggest further test for evaluation any hemodynamically significant stenosis of coronary arteries
  • 2023-05-02 ECG 8C
    • Atrial fibrillation with slow ventricular response with premature ventricular or aberrantly conducted complexes
    • Incomplete left bundle branch block
  • 2023-05-02 SONO - abdomen
    • GB polyp, tiny
    • Pancreas not shown
  • 2022-11-30 EGD
    • Reflux esophagitis LA Classification grade A-
    • R/o intestinal metaplasia, antrum to body
    • Superficial gastritis
    • Post clipping, LC of low body
  • 2022-10-03 Patho - colorectal polyp
    • Diagnosis
      • Intestine, large, rectum, polypectomy — tubular adenoma
      • Intestine, large, transverse colon, polypectomy — tubular adenoma
      • Intestine, large, ascending colon, 100 cm from anal verge, polypectomy — tubular adenoma
  • 2022-08-12 SONO - nephrology
    • Chronic parenchymal renal disease
  • 2022-07-18 CT - chest
    • Findings
      • Lungs:
        • with areas of patchy expiratory air-trapping in both lower lobes and posterior both upper lobes.
        • patchy ground glass opacities with septal thickening in bilateral lungs RUL most prominent..
      • Mediastinum and hila: the trachea and main bronchi are normallly identified without endobronchial lesion.
      • Vessels: moderate calcified plaques of the LAD, and LCX, and right coronary arteries.
      • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: dilated LA and RA, and LVH.
      • Pleura: trace effusion.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal contents: a tiny calcification over pancreatic tail.
        • Atherosclerotic change of the abdominal aorta.
      • Visualized bones: multiple marginal spurs of vertebrae.
    • Impression:
      • interstitial lung process or infection.
      • obstructive small airways disease.
      • moderate 3V-CAD.
  • 2022-07-13 CXR erect
    • hazy areas of increased opacity (ground-glass opacities) over and Lt perihilar midlung zone
    • reticular opacities over RUL
    • mild enlarged cardiac silhoutte
    • Costophrenic angles are preserved
  • 2022-05-31 Myocardial perfusion SPECT with persantin
    • Probably mild to moderate myocardial ischemia with possible a portion of severe ischemia at the inferolateral wall and posterior wall and mild myocardial ischemia at the anteroseptal wall.
  • 2022-05-30 ECG portable 24hr
    • Baseline was sinus bradycardiawith 1st degree AVB (average HR: 44-59 bpm)
    • Occasional junctional esacape beats noted (13:20)
    • Paroxysmal AFIB noted
    • A few isolated VPCs
    • Frequent isolated APCs / APC couplets (burden 2%)
    • 22 episodes of long pause, max 2.304 sec, related to blocked APC +/- junctional escape beats
  • 2022-05-25 Neurosonography
    • Mild to moderate atheromatous lesions in bilateral distal CCAs and bilateral CCA bifurcations; mild atheromatous lesions in bilateral middle CCA and R ICA.
    • Normal extracranial carotid and vertebral arterial flows.
  • 2022-05-24 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 19) / 104 = 70.49%
      • LVEF (%) = 82
      • M-mode (Teichholz) = 82
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated LA; LV diastolic dysfunction Gr 3 (restrictive pattern).
      • Normal RV systolic function.
      • Mild to moderate MR; moderate to severe TR; mild PR; mild aortic valve sclerosis (NCC).
      • Possible severe pulmonary hypertension, estimated PASP 78 mmHg.
  • 2022-04-18 ECG
    • Sinus rhythm with 1st degree A-V block with Premature atrial complexes
  • 2022-01-14 SONO - nephrology
    • Chronic parenchymal renal disease
  • 2021-03-26 EGD
    • Diagnosis:
      • Extensive intestinal metaplasia, antrum to body
      • Atrophic gastritis, antrum, s/p CLO test
      • Gastric polyp, 0-Is, LC of lower body, favor adenomatous or inflammatory polyp, s/p cold-snaring polypectomy(A), s/p hemoclipping
      • Gastric ulcer, H2, LC of lower body, s/p biopsy(B)
      • duodenal ulcer scar, GC of bulb
    • CLO test: Positive
    • Suggestion:
      • Please monitor bleeding and pursue pathology report, CLO test results.
      • Consider EGD FU for extensive IM change
  • 2021-01-08 EGD
    • Diagnosis
      • Hypertrophic fold, body, s/p biopsy (A)
      • Gastric polyp, prob. adenoma, angularis, s/p biopsy (B)
      • Atrophic gastritis, body
      • Reflux esophagitis LA Classification grade A
      • gastritis, antrum s/p CLO test negative
  • 2020-12-25 SONO - abdomen
    • Suspected liver hemangioma, right
    • Pancreas not shown
  • 2019-07-22 MRA - brain
    • Mild general brain atrophy.
    • Mild intracranial arteriosclerosis.
  • 2019-06-27 Color Transcranial Sonography
    • Moderate to severe atherosclerosis in Rt ICA (with diameter stenosis of 33.1%), Rt CCA (with diameter stenosis of 38.8%), Rt Bifurcation (with diameter stenosis of 50.3%), Rt Subclavian Artery, & Lt CCA (with diameter stenosis of 52.7%), Lt Bifurcation (with diameter stenosis of 51%).
    • Normal RI in bilateral ICA.
    • Elevated PI in Rt ACA, Rt MCA, Rt PCA, & Lt ACA, Lt MCA, indicating distal stenosis.
    • Increased PSV in bilateral MCA, suggesting focal stenosis.
    • Adequate total VA flow volume (199 ml/min), indicating absence of Vertebrobasilar insufficiency.
    • Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
    • Advise clinical correlation.
  • 2019-04-09 Transrectal Ultrasound of Prostate, TRUS-P
    • CC: nocturia, right inguinal mass, weak stream.
    • Prostate   - Size of prostate: 4.71(T)cm x1.99(L)cm x4.46(AP)cm=21.8cc   - Size of adenoma: 2.87(T)cm x1.37(L)cm x2.55(AP)cm=5.2cc   - Calculi: No   - Cyst:(Max) No   - Intravesical growth: No
    • Seminal vesicles   - Size: L’t 1.95x0.685cm   - Cyst: No
      • Abscess: No    - Tumor: No
          - Size: R’t 1.36x0.698cm
      • Cyst: No    - Abscess: No
      • Tumor:No
    • Diagnosis   - Benign prostatic hyperplasia

[medication]

  • 2023-10-21 - CELIG - Eligard (leuprorelin acetate 22.5mg) Q3M SC
  • 2023-07-27 - CELIG - Eligard (leuprorelin acetate 22.5mg) Q3M SC

700910204

240111

[exam findings]

  • 2023-11-14 Ocular Fundus Photography
    • Left - NPDR, moderate
    • Right - NDR
  • 2023-11-07 CT - chest
    • Findings: Comparison was made with CT on 2023/07/29
      • Lungs: interval increase number and size of nodules of variable sizes in both upper lobes (up to 10mm at RUL) due to metastases as compared with previous chest CT on 2023-07-29
      • Mediastinum and hila: a well-defined soft-tissue nodule at left prevascular space, at the level of thoracic inlet 9srs/img11/8.
        • extensive coronary arterial calcification
      • Thoracic aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Pleura: trace Lt-sided effusion .
      • Visible abdominal contents: Hyperplasia of bilateral adrenal glands.
        • marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • endometrial ca of uterus with lung metastasis.
      • enlarged left thyroid lobe or metastatic LAP in thoracic inlet of upper mediastinum.
      • extensive 3V-CAD.
  • 2023-10-11 CT - abdomen
    • 2023/07/24 Endometroid adenocarcinoma, pT3aN0(if cM0); stage IIIA
      • vaginal bleeding. she did not have R/T or C/T
    • Findings:
      • There are three kissing soft tissue masses in the uterine fossa, the largest one measuring 4.7 cm in size (the largest dimension), that may be recurrent adenocarcinomas.
      • There are two kissing small soft tissue nodules in left adnexa that may be metastatic nodes.
      • There is a cystic-like lesion 3.4 cm in the cul-de-sac that also may be recurrent tumor.
      • There is a cystic lesion in right adnexa, 4.3 cm in size (the largest dimension), that may be lymphocele.
        • The differential diagnosis includes recurrent tumor.
      • Hyperplasia of bilateral adrenal gland are noted.
    • Impression:
      • There are three kissing soft tissue masses in the uterine fossa, the largest one measuring 4.7 cm in size (the largest dimension), that may be recurrent adenocarcinomas.
  • 2023-08-02 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (122 - 34) / 122 = 72.13%
      • M-mode (Teichholz) = 72
    • Conclusion:
      • Concentric LV hypertrophy and mild RV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis.
      • Prominent epicardial and pericardial fat.
  • 2023-08-02 SONO - vein
    • No evidence of DVT, bilateral lower legs
    • Right CFV trivial reflux
    • Right LSV trivial reflux, involved right sphenofemoral junction (SFJ) with proximal GSV 0.8 cm,
    • Right low leg soft tissue mild edema.
  • 2023-07-29 CTA - chest
    • Right upper lobe tiny nodule. 0.3cm
    • Pulmonary embolism is found at branching pulmonary artery over left side. (Se305 IM24).
    • Cardiomegaly and Calcified coronary arteries is found.
  • 2023-07-24 Patho - uterus (with or without SO) neoplastic
    • Diagnosis:
      • Uterus, endometrium, staging surgery — Endometroid adenocarcinoma, FIGO grade 2
      • Uterus, myometrium, staging surgery — Tumor involving srosa and > 1/2 myometrial thickness. Intramural leiomyoma
      • Cervix, staging surgery — Tumor involving cervical stromal connective tissue
      • Ovary, bilateral, staging surgery — Negative for malignancy
      • Fallopain tube, bilateral, staging surgery — Negative for malignancy
      • Omentum, staging surgery — Negative for malignancy
      • Lymph node, left iliac, dissection — Negative for malignancy
      • Lymph node, left obturator, dissection — Negative for malignancy
      • Lymph node, right iliac, dissection — Negative for malignancy
      • Lymph node, right obturator, dissection — Negative for malignancy
      • AJCC 8th edition pathology stage:pT3aN0 (if cM0); FIGO stage IIIA
    • Gross description:
      • Procedure (select all that apply)
        • laparotomy gynecologic oncology staging surgery (ATH + BSO + infracolic omentectomy + BPLND)    
        • Note: For information about lymph node sampling, please refer to the Regional Lymph Nod section.
      • Tumor Site (select all that apply)
        • Endometrium
      • Tumor Size:
        • Greatest dimension: 6 cm
        • Additional dimensions (centimeters): 5 x 1.5 cm
      • Sections are taken and labeled as:A1-2: left ilia LN, B1-2:left obturator LN, C1-2: right iliac LN,D1-2:right obturator LN, E1-2:right adnexae, E3-4:left adnexae, E5:cervix and margin, E6-9:tumor, E10:myoma, F:omentum
    • Microscopic Description:
      • Histologic Type:Endometrioid carcinoma with focal squamous differentiation
      • Histologic Grade: (required only if applicable) FIGO grade 2 (low-grade)
      • Myometrial Invasion: present (>= 1/2 whole thickness)
      • Uterine Serosa Involvement: Present
      • Cervical Stromal Involvement: Present
      • Other Tissue/ Organ Involvement (select all that apply): Not identified
      • Margins (required only if cervix and/or parametrium/paracervix is involved by carcinoma)
        • Ectocervical/Vaginal Cuff Margin: Free ( 8 mm of closest margin distance)
        • Parametrial/Paracervical Margin: Free
      • Lymphovascular Invasion: Present
      • Regional Lymph Nodes:
        • Right Pelvic Node: 0 / 9
        • Left Pelvic Node: 0 / 6
        • Para-aortic Node: Not included
      • Greatest dimension of largest nodal metastatic deposit (required only if macrometastasis or micrometastasis present): Not applicable
      • Isolated tumor cells (0.2 mm or less and not more than 200 cells) (required only in the absence of macrometastasis or micrometastasis in other lymph nodes): Absent
        • Note: Number of lymph nodes with macrometastasis, lymph nodes with micrometastasis, and lymph nodes with isolated tumor cells may be reported separately but this is not mandatory.
      • Additional Pathologic Findings: None identified
      • Immunostain — p16 (focal patchy+, 30%), p53: wild-type, Napsian A (-).
  • 2023-07-12 MRI - pelvis
    • Clinical history: 62 y/o female patient with Uterus, endometrium, endometrial aspiration — Endometroid adenocarcinoma, well differentiated.
    • With and without contrast enhancement MRI: Pelvis
      • Diffuse soft tissue tumors in the uterine cavity (from fundus and lower body), c/w endometrial malignancy. With extension to right parametrium.
      • Small lymph nodes in bilateral obturator regions.
      • Non-enhancing nodules, up to 1.8cm in left kidney, r/o bilateral renal cyst.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T:T3a(T_value) N:N0(N_value) M:M0(M_value) STAGE:_IIIA__(Stage_value)
    • Impression:
      • Endometrial malignancy, cstage T3aN0M0.
      • Bilateral renal cysts.
  • 2023-06-30 Patho - endometrium curretage/biopsy
    • Uterus, endometrium, endometrial aspiration — Endometroid adenocarcinoma, well differentiated
    • The specimen submitted consists of multiple small pieces of gray-brown soft tissue, measuring up to 0.3 x 0.3 x 0.2 cm and totally weighing 2 gm. All for section in one cassette.
    • The sections show endometroid adenocarcinoma, well differentiated, composed of endometrial tissue with densely packed glands, confluent glands, cribrifrom glands, and focal papillary architecture. Nuclear atypia is mild to moderate. Prominent squamous differentiation is present.
  • 2023-06-23 Gynecologic ultrasonography
    • Endometrial thickening, EM 14.3mm
    • R/O Uterine myoma
  • 2023-04-13 SONO - neck (lymph node)
    • Sonography of neck revealed some LNs in bil. neck.
    • R/O a lipoma (0.49x1.65cm) at submental region.
  • 2022-12-06 SONO - nephrology
    • Bilateral parenchymal renal disease, c/w diabetic kidney disease
    • Single renal cyst, left kidney

[MedRec]

  • 2023-07-23 ~ 2023-08-03 POMR Obstetrics and Gynecology Huang SiCheng
    • Discharge diagnosis
      • Malignant neoplasm of endometrium post laparotomy gynecologic oncology staging surgery on 2023/07/24
      • Endometroid adenocarcinoma, pathology stage:pT3aN0(if cM0); FIGO stage IIIA,FIGO grade 2
      • Postmenopausal bleeding
      • Endometrial hyperplasia
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
      • Pulmonary embolism is found at branching pulmonary artery over left side.
    • CC
      • Abnormal vaginal bleeding for one month
    • Present illness
      • This 63 y/o woman with menopause, P2 (C/S, NSD), with past history of HTN, DM, dyslipidemia. She came to our hospital this time due to abnormal vaginal bleeding for one month.
      • According to the patient, she had regular menstral cycle with duration/interval of 5-6/28-30 days, with menorrhagia, no dysmenorria. She had menopause 13 years ago, at the age of 50 y/o. However, heavy bleeding was noted by patient one month ago. She must wear diapers whole day long, and needs to change per hour. She also noted decreased body weight (88kg-83kg), abdominal distension, malaise and exertional dyspnea. She denied abdominal pain, no nausea or vomiting, no tarry/bloody stoool, no constipation, no urinary freqency.
      • Due to above symptoms, she turned to our GYN OPD for help. The transvaginal sono on 2023.06.23 revealed uterine myoma in size of 45 x 32mm, endometrium: 1.43cm, otherwise normal. Endometrial aspiration showed endometriod adenocarcinoma, well differentiated. Tumor marker showed CA125 = 11.7 U/mL; CA199 = 15.73 U/mL; CEA = 1.86 ng/mL, Hb: 10.2 g/dL. Abdominal MRI was also done on 2023.07.17 and revealed diffuse soft tissue tumors in the uterine cavity (from fundus and lower body), c/w endometrial malignancy, with extension to right parametrium, cT3aN0M0. And the Hb showed 8.0 g/dL.
      • Under the impression of endometriod adenocarcinoma, cT3aN0M0, she was admitted on 2023.07.23 for laparoscopic staging surgery and post operative care.
    • Course of inpatient treatment
      • This is a 62 y/o woman with HTN, DM and dyslipidemia under medical control. She received laparoscopic staging surgery for endometrial cancer on 2023/07/24. Her postoperative status has been stable; however, elevated D-dimer > 10000 ng/mL was noted on 07/28 and 07/29. Chest CTA on 07/29 revealed pulmonary embolism (filling defect) over the left pulmonary branch.
      • The cardiologist was consulted. Clexane 60mg SC QD was administered since 07/28, titrated to 80mg Q12H on 07/29. Component therapy was given to keep Hb > 10 g/dL.
      • Under the impression of pulmonary embolism, she was transferred to MICU on 07/29.
      • After admission to MICU, CV suggest check protein C, protein S, anti-thrombin III, lupus anticogulant and clexane 80mg q12h s, then blood transfusion LPRBC 1u st to keep Hb > 10mg/dL.
      • Hypoglycemia, hold OHA for hypoglycemia.
      • Precirbed Lixana 30mg QD since 7/31. Due to relative codition, she will transfer to ward for further care on 2023/07/31, Eating and urination by self voiding, as well as defecation were smooth. The vital sign was stable after surgery.
      • The surgical pathology revealed endometrioid adenocarcinoma stage:pT3aN0(if cM0); FIGO stage IIIA,FIGO grade 2. The Gyn tumor conference suggest further radiotherapy and chemotherapy. chest CTA show right upper lobe tiny nodule 0.3cm.
      • She is discharged on 08/03/2023 afternoon and her followup appointment is scheduled on next week.
    • Discharge prescription
      • Pradaxa (dabigatran 110mg) 1# BID
      • Biomycin (neomycin, tyrothricin) BID TOPI for hip lesion
      • cephalexin 500mg 1# QID
      • MgO 250mg QID
      • naproxen 250mg 1# TID

[consultation]

  • 2023-07-31 Psychosomatic Medicine
    • Q
      • Cancer inpatient with suicidal thoughts scoring >= 2 points.
    • A
      • Psychiatric impression:
        • adjustment reaction
        • r/o depressive disorder
      • Psychiatric history:
        • This 62-year-old woman without any psychiatric history.
        • She was admitted to OBGYN for endometriod adenocarcinoma, cT3aN0M0, for laparoscopic staging surgery.
        • She expected to go home after the operation, but a pulmonary embolism occurred after the operation and she needed to be treated in the intensive care unit.
        • This change of the condition had a great impact on her mood. She felt depression and negative thinking during admission in MICU.
        • However, her depression much improved today because of she could transfer to general ward under stable condition.
      • MSE:
        • consious alert, fair attention, coherent and relevnet speech, fair spontaneious speech, residual low mood, but no lack of intrest for pleasure; poor appetite and sleep at night in ICU.
        • there was no psyhomotor agitation or retardation, less fatigue, less negative thinking and denied current suicide ideation, denied anxiuos dissdtress
      • Suggestion:
        • psychoeducation
        • discussed psychiatric treatment about the patient, she refused psychotropic medication
        • arrange psychiatric OPD follow up
  • 2023-07-29 Cardiology
    • Q
      • This is a 62 y/o woman with HTN, DM and dyslipidemia. She received laparoscopic staging surgery for endometrial cancer on 2023/07/24. Her postoperative status has been stable; however, elevated D-dimer > 10000 ng/mL was noted on 07/28 and 07/29. Clexane 60mg SC QD was administered, titrated to 90mg Q12H on 07/29. Chest CTA on 07/29 revealed pulmonary embolism (filling defect) over the left pulmonary branch. We will arrange ICU transfer a.s.a.p. and we hope you could help evaluate the patient as your expertise. Thank you.
    • A
      • I was consulted for acute pulmonary embolism
      • Endometrial cancer status post laparoscopic staging surgery on 2023/07/24
      • No dyspnea under Nasal cannula
      • Lab
        • 2023-07-29 D-dimer > 10000.00 ng/mL(FEU)
        • 2023-07-28 CRP 2.6 mg/dL
        • 2023-07-28 D-dimer > 10000.00 ng/mL(FEU)
        • 2023-07-25 WBC 8.17 x10^3/uL
        • 2023-07-25 HGB 8.9 g/dL
        • 2023-07-25 PLT 227 x10^3/uL
        • 2023-07-23 BUN 21 mg/dL
        • 2023-07-23 Creatinine 0.87 mg/dL
      • Chest CTA: Right upper lobe tiny nodule. 0.3cm
        • Pulmonary embolism is found at branching pulmonary artery over left side.
        • Cardiomegaly and Calcified coronary arteries is found.
      • EKG: NSR
      • Impression:
        • Acute pulmonary embolismi, left, non-massive type
        • Endometrial cancer status post laparoscopic staging surgery on 2023/07/24
        • Anemia
      • Suggestion:
        • Please give Enoxaparin 80mg Q12H SC. (BW: 83kg)
        • PRBC transfusion, keep Hb > 10g/dl.
        • Admit to CV ICU
        • The family was well explained about the treatment strategy, including catheter-directed thrombectomy if failure to medical treatment.
        • Please check protein C, protein S, anti-thrombin III, lupus anticogulant.
      • Thanks for your consultation and F/U on call.
    • A 2023-08-01 08:54:54
      • Suggest Dabigatran 110mg BID PO (full dose) despite Edxoaban (30mg) 1# QD (lose dose strategy) according to obesity status and consideration of antidote availablity.
      • Arrange cardiac echo and vein echo for further study.
      • Thanks for your consultation and F/U on call.

[surgical operation]

  • 2023-07-24
    • Surgery
      • Diagnosis: Endometrial cancer
      • Operation: Laparascopy -> shift to laparotomy gynecologic oncology staging surgery (ATH + BSO + infracolic omentectomy + BPLND)       
    • Finding
      • Supraumbilical midline vertical skin incision
      • Uterus:
        • disfigured due to tumor mass occupying, papillary mass in uterus cavity with extention to the cervix, intraoperative rupture (+)
        • severe adhesion to the bowel and cul de sac
        • Adnexa: grossly normal
        • CDS: ascites (-), adhesion (+)
        • Bilateralpelvic lymph nodes: normal(+), enlarged(-), indurated(-)
        • Omentum: grossly normal, infracolic omentectomy was done
        • Estimated blood loss: 550 mL
        • Blood transfusion: nil
        • Complication: nil

[radiotherapy]

  • 2023-10-24 ~ 2023-12-13 - 4500cGy/25 fraction sof the pelvic, and 5940cGy/33 fractions of the vaginal stump recurrent tumor area.

[chemotherapy]

  • 2023-12-12 - cisplatin 40mg/m2 70mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-05 - cisplatin 40mg/m2 70mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-28 - cisplatin 40mg/m2 70mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-20 - cisplatin 40mg/m2 70mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-01-11

[hyperuricemia]

During this hospitalization, the patient experienced a significant increase in serum uric acid levels. Feburic (febuxostat) 80mg QD was initiated to address this.

  • 2024-01-10 Uric Acid 8.2 mg/dL
  • 2023-11-17 Uric Acid 6.8 mg/dL
  • 2023-07-31 Uric Acid 6.8 mg/dL
  • 2022-04-19 Uric Acid 6.9 mg/dL

If the elevated uric acid levels persist despite Feburic therapy, the addition of benzbromarone may be considered for further urate reduction.

700268312

240110

[exam findings]

  • 2023-12-29 Nasopharyngoscopy
    • Findings
      • Nose: no tumor lesion, bil meatus purulency
      • Nasopharynx: smooth purulent PND
      • Oropharynx: no tumor lesion
      • Larynx: no tumor lesion, bilateral vocal movement: symmetric
      • Hypopharynx: no tumor lesion
    • Diagnosis/conclusion
      • sinusitis
  • 2023-12-21 CT - abdomen
    • History and indication: Adenocarcinoma of ascending colon cT4bN2M0 IIIC
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A-colon cancer s/p operation.
      • Colonic diverticula.
      • Liver cysts (up to 6.7cm).
      • S/P right THR.
      • Atherosclerosis of aorta, iliac and visceral arteries.
      • Increased density at bilateral basal lungs.
    • IMP:
      • A-colon cancer s/p operation. No evidence of tumor recurrence.
  • 2023-10-23 All-RAS + BRAF mutation
    • Cellblock No. S2023-18526 A5
    • RESULTS:
      • ALL-RAS: Detected (KRAS codon 12 GGT>TGT, p.G12C)
      • BRAF: Detected (BRAF codon 600 GTG>GAG, p.V600E)
  • 2023-09-15 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, ascending colon, right hemicolectomy —- Adenocarcinoma, poorly differentiated
      • Small intestine, terminal ileum, right hemicolectomy —- Negative for malignancy
      • Omentum, right hemicolectomy —- Adenocarcinoma, metastatic
      • Resection margins: free
      • Lymph node, mesocolic, dissection —- Metastatic adenocarcinoma (1/22)
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: pStage IVA, pT3N1aM1a or pStage IVC, pT3N1aM1c, Please discussion the tumor stage in tumor board.
    • Gross Description:
      • Operation procedure: right hemicolectomy;
      • Specimen site: ascending colon
      • Specimen size: Colon: 9.3 cm in length; Terminal ileum: 4.0 cm in length; Omentum: 6.2 x 5.3 x 2.3 cm with a metastatic tumor, measuring 3.5 x 3.0 x 2.3 cm; Appendix: not found
      • Tumor size: 8.0 x 4.5 x 1.7 cm
      • Tumor location: 5.5 cm and 5.0 cm away from the two resection margins, respectively.
      • Depth of invasion grossly: mesocolic soft tissue
      • Mucosa elsewhere: Several diverticula are found in ascending colon.
      • Macroscopic Tumor Perforation: Not identified
      • Sections are taken and labeled as: A1: proximal resection margin; A2: distal resection margin; A3: ileocecal valve; A4: diverticula; A5-9: tumor; A10: colon; A11-13: lymph node, mesocolic; A14: metastatic tumor in omentum.
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G3: Poorly differentiated
      • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: very close, <0.1 cm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Tumor Budding: Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: not applicable
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes: Number of Lymph Nodes Involved/Examined: 1/22
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply) :not applicable
        • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN): pN1a: One regional lymph node is positive
        • Distant Metastasis (pM):
          • pM1a: Metastasis to one site or organ is identified without peritoneal metastasis or
          • pM1c: Metastasis to the peritoneal surface is identified alone or with other site or organ metastases
      • Additional Pathologic Findings (select all that apply): Diverticula are found.
  • 2023-09-12 Flow Volume Loop Chart
    • Mild restrictive ventilatory impairment
  • 2023-09-12 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (61 - 18) / 61 = 70.49%
      • 2D (M-Simpson) = 70
    • Conclusion:
      • Indeterminated LV filling pressure and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis with trivial AR; mild MR; mild PR.
      • Mild aortic root calcification with small protruding atheroma (3.4 mm of thickness).
  • 2023-08-29 CT - abdomen
    • With and without contrast enhancement CT of abdomen - whole:
      • Segmental wall thickening at ascending colon with abutting to adjacent liver and regional peritoneal mass. R/O asending colon malignancy.
      • Liver cysts, up to 6.6cm in right lobe.
      • Unremarkable change of the spleen, pancreas and both kidneys.
      • Enlarged lymph nodes in pericolnic region.
      • No ascites.
      • Outpouching lesions in sigmoid colon, suggesting sigmoid colon diverticula.
      • Post-op at right hip.
      • T11 compression fracture.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIc__(Stage_value)
    • Impression:
      • Ascending colon cancer with regional lymph nodes, cstage T4bN2bM0.
      • Sigmoid colon diverticula.
      • Liver cysts.
  • 2023-08-28 Patho - colon biopsy
    • Colon, ascending, 67-70 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    • Specimen submitted in formalin consists of 5 pieces of tan, irregular tissue measuring up to 0.3 x 0.1 x 0.1 cm. All for section in one cassette.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands and extravasated mucin.
    • The immunohistochemical stains reveal EGFR(+), PMS2(-), MLH1(-), MSH2(+), and MSH6(+).
  • 2023-08-28 EGD
    • Reflux esophagitis LA Classification grade A (minimal)
    • Duodenal ulcer scar, bulb
  • 2023-08-24 MRA - brain
    • Short segmental severe stenosis of left distal VA. Suggest PTA and stenting.
    • Short segmental moderate stenosis of left distal ICA (cavernous segment).
    • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
    • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
  • 2023-08-18 Neurosonology
    • moderate atheroma on right carotid bifurcation and left CCA, ICA with diameter reduction of 33-47%, severe atheroma on left carotid bifurcation with diameter reduction of 64%,
    • higher peak systolic velocities (166/23 cm/s) on left carotid bifurcation, (185/37 cm/s) on left ICA, may suggest focal severe stenosis (50-69%)
    • antegrade of bil. ophthalmic a. flows

[MedRec]

  • 2023-09-12 ~ 2023-09-19 POMR Colorectal Surgery Chen ZhuangWei
    • Discharge diagnosis
      • Adenocarcinoma of ascending colon, cT4bN2bM0, IIIC status post single-incision laparoscopic right hemicolectomy on 2023/09/14, pT3N1aM1a(1/22), G3, LVI(+), PNI(+), CRM(-), stage IVa (metastastic tumor on omentum), stage IVa
    • CC
      • tarry stool for around one month
    • Present illness
      • This is a 82 y/o female with underlying disease of anemia, syncope episode and insomnia. This time she was admitted due to tarry stool for around one month.
      • According to the patient statement, she suffered from tarry stool for around one month with iFOB positive and HGB = 8.2 g/dL. She denied nausea/vomiting, fever, abdominal pain, constipation, diarrhea, dyspnea or dysuria. Due to above symptoms, she went to our GI OPD on 8/22.
      • Upper GI endoscopy showed Reflux esophagitis LA Classification grade A (minimal) and Duodenal ulcer scar, bulb.
      • And colonoscopy showed suspected ascending colon cancer. Pathology showed adenocarcinoma.
      • Abdominal CT on 8/29 showed 1. Ascending colon cancer with regional lymph nodes, cstage T4bN2bM0, IIIc. 2. Sigmoid colon diverticula. 3. Liver cysts.
      • Under impression of Adenocarcinoma of A-colon, she was admitted for further evaluation and surgical intervention.
    • Course of inpatient treatment
      • This 82 years old female patient was a case of Adenocarcinoma of A-colon. She underwent single-incision laparoscopic right hemicolectomy on 2023/09/14. The post-operative course was relatively smooth without complication. The bowel function, urinary function were normal and the wound pain was tolerable. She started semi liquid diet on 9/17 and JP drain was removed on 9/19. She was discharged on 112/9/19 and will follow up in our out-patient department next week.
    • Discharge prescription
      • MgO 250mg 2# BID
      • Through (sennoside 12mg) 1# HS

[surgical operation]

  • 2023-09-14
    • Surgery
      • Laparoscopic right hemicolectomy (Glove port use)      
    • Finding
      • A locally advanced 5-6cm tumor is located at proximal A-colon with suspected a 2cm tumor deposit (seeding) on nearly omentum    
      • Right hemicolectomy was achieved smoothly. Blood loss was about 30ml.    
      • Anastomosis was performed using endo-GIA for both ends and side-to-side sutures with 4/0 PDS+ seromuscular retention    
      • A drain in Morrison’s pouch    

[chemotherapy]

  • 2024-01-09 - irinotecan 180mg/m2 195mg D5W 250mL 90min + leucovorin 400mg/m2 435mg NS 250mL 2hr + fluorouracil 2800mg/m2 3050mg NS 500mL 46hr (FOLFIRI, Iri 80%, Covorin 80%, 5FU 80%; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-12-19 - irinotecan 180mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 430mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (FOLFIRI, Iri 80%, Covorin 80%, 5FU 80%; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-12-01 - irinotecan 180mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 425mg NS 250mL 2hr + fluorouracil 2800mg/m2 2000mg NS 500mL 46hr (FOLFIRI, Iri 80%, Covorin 80%, 5FU <70%; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-11-10 - irinotecan 180mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 425mg NS 250mL 2hr + fluorouracil 2800mg/m2 2000mg NS 500mL 46hr (FOLFIRI, Iri 80%, Covorin 80%, 5FU <70%; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-10-23 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 425mg NS 250mL 2hr + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI, Iri 80%, Covorin 80%, 5FU 80%; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

==========

2024-01-10

[reconciliation]

The patient received repeat prescriptions for Rivotril (clonazepam) and Mirtapine (mirtazapine) at NTUH on 2023-11-13, followed by refills on 2023-12-07 and 2024-01-01. However, these medications are currently not listed as active in her medication record. Here are some possible explanations:

  • The patient may no longer require these medications. To confirm this, it would be helpful to review the reason for their initial prescription and any recent clinical assessments.
  • There may be an error in the medication record. Please double-check the patient’s active medication list and compare it to available PharmaCloud records.
  • The patient may not be taking the medications as prescribed. This could be due to various reasons, such as side effects, lack of perceived benefit, or forgetting to take them.

Therefore, it is recommended to understand the reason for the non-use of the prescribed medications will help determine the most appropriate course of action.

2023-12-04

Currently, PharmaCloud access is unavailable.

Following the initiation of a dose-reduced FOLFIRI regimen, with the 3rd session starting on 2023-12-01, the patient has not experienced vomiting or nausea and reports good sleep and appetite.

No discrepancies in medication have been identified in the HIS5 records.

700274792

240110

[MedRec]

  • 2024-01-05 SOAP Hemato-Oncology Gao WeiYao
    • A: CML
      • 2024/01/05 BCR/abl Philadelphia chromosome (qualitative) - Presence of mutation
    • Diagnosis
      • C92.10 - Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission
      • D47.1 - Chronic myeloproliferative disease
      • D72.829 - Elevated white blood cell count, unspecified
    • Prescription
      • Tasigna (nilotinib 150mg) 2# Q12H 14D

[chemotherapy]

Comparison of tyrosine kinase inhibitors used for chronic myeloid leukemia - 2024-01-10 - https://www.uptodate.com/contents/image?imageKey=HEME%2F89930

Agent Dosing frequency and timing in relation to food Dose adjustments for baseline kidney/liver dysfunction Major toxicities Other
Imatinib Daily (or twice daily) with food Yes (kidney, liver) Bone marrow suppression; fluid retention/edema; gastrointestinal effects; heart failure; hepatotoxicity. Longest record of safety data
Nilotinib Twice daily without food Yes (liver) Bone marrow suppression; cardiovascular events; electrolyte imbalance; hepatotoxicity. Black box warning: QT prolongation (screening required). _
Dasatinib Daily with or without food No Bone marrow suppression; pleural/pericardial effusions; pulmonary arterial hypertension; QT prolongation; aspirin-like effect. _
Bosutinib Daily with food Yes (kidney, liver) Bone marrow suppression; fluid retention/edema; gastrointestinal effects. _
Ponatinib Daily with or without food Yes (liver) Bone marrow suppression; fluid retention/edema; gastrointestinal effects; heart failure; hypertension; pancreatitis; aspirin-like effect; arterial thrombosis. Black box warning: cardiovascular events; hepatic toxicity. Active against BCR::ABL1 T315I mutation; limited long-term safety data
Asciminib Daily or twice daily without food No Upper respiratory tract infections; musculoskeletal pain; fatigue; nausea; rash; and diarrhea. Hypertriglyceridemia; cytopenias; elevated creatine kinase; hepatotoxicity; pancreatitis. Active against BCR::ABL1 T315I mutation; limited long-term safety data

==========

2024-01-10

[nilotinib]

This patient is newly diagnosed with CML.

Lab data: 2024/01/05 - BCR/abl Philadelphia chromosome (qualitative) - Presence of mutation.

  • 2024-01-10 WBC 41.60 x10^3/uL
  • 2024-01-05 WBC 72.21 x10^3/uL
  • 2023-12-25 WBC 73.26 x10^3/uL
  • 2023-12-08 WBC 94.03 x10^3/uL

Absence of blasts in recent WBC DC makes the diagnosis of advanced CML (accelerated phase or blast phase) highly improbable. Chronic phase CML is therefore the most likely diagnosis.

BCR-ABL1 tyrosine kinase inhibitors (TKIs) are the first-line therapy for all CML phases, except for specific contraindications like pregnancy.

Initial CML treatment typically employs either imatinib or a second-generation TKI (dasatinib, nilotinib, bosutinib). Other TKIs (ponatinib, asciminib) are reserved for refractory patients or those with specific mutations (e.g., T315I). Notably, nilotinib is currently the patient’s TKI of choice.

Nilotinib is known to prolong the QT interval. Monitoring for and correcting hypokalemia, hypomagnesemia, and pre-existing QTc prolongation are crucial before and during nilotinib treatment. Regular ECGs (baseline, 7 days after initiation, periodic) are essential to track QTc, especially after dose adjustments.

Sudden deaths have been reported with nilotinib. Contraindications include hypokalemia, hypomagnesemia, and long QT syndrome. Concomitant medications that prolong the QT interval or strongly inhibit CYP3A4 should be avoided. Nilotinib intake should be separated from food by at least 2 hours (before) and 1 hour (after).

[reconciliation]

This patient’s primary hospital is New Taipei City Hospital according to PharmaCloud database. On 2024-01-09, refills were prescribed for several medications: Gaslan, Periscon (mosapride), Vesicare (solifenacin), Harnalidge (tamsulosin), Eurodin (estazolam), Meptin-Mini (procaterol hydrochloride hemilydrate), Colin Soln (chlorpheniramine maleate), and Allevo (levocetirizine dihydrochloride).

However, these refilled medications are not currently listed as active in the patient’s record. Please verify with the patient whether he still require these medications and, if clinically necessary, ask him or his family member to bring them to the hospital.

Note that Tasigna (nilotinib 150mg) 2# Q12H prescribed on 2024-01-05 in the outpatient clinic is currently being used without any identified issues.

700402171

240110

[MedRec]

  • 2017-10-16 ~ 2017-10-28 POMR Colorectal Surgery Xiao GuangHong
    • Discharge diagnosis
      • C18.7 Sigmoid colon cancer with obstruction, cT3N0M0 s/p exploratory laparotomy with sigmoid colectomy, pT3N2aM0, (4/16), G2, LV (+); pStage IIIB
      • S/P Port-A catheter implatation
    • CC
      • Constipation off and on for 2 months.
      • Intermittent low abdominal pain and passage of loose stool more than 10 times/day in recent 2 days.
      • Cold sweating with nausea, without fever were noted for one day.
    • Present illness
      • This 40 years old male patient denied any history of systemic disease. He suffered from constipation off and on for 2 months, without medical treatment. This time, he complained of intermittent low abdominal pain and passage of loose stool more than 10 times/day in recent 2 days. Cold sweating with nausea, without fever were noted for one day. He came to our emergency department for help on 106-10-15 night. Physical examination showed tenderness of low abdominal region, hypo-active bowel sounds. Leukocytosis with WBC 17.43 x10^3/uL, N.band 1.0 %, N.seg. 92.0 %. No elveated CRP 0.22 mg/dL. Abdomen-Standing (Diaphragm) X-ray showed presence of ileus.
      • Abdominal CT revealed in favor of S-colon cancer with obstruction, suggest colonscopy study, cstage T3N0Mx. At ER, EVAC enema and empirical antibiotics treatment by Ceftriaxone Sandoz. CRS was consult and NG decompression first was suggest. After fully explaination, he is admitted to our ward for further evalation and management.
    • Course of inpatient treatment
      • After admission, NPO and NG decompression. Nutrition support by Clinimix N9 and IV fluids support.
      • Antibiotics treatment by Ceftriaxone Sandoz (2017/10/16~10/17).
      • Fever with BT: 38.2~38.8 C and leukocytosis with WBC 15.94 x10^3/uL, N.band 16.0 %, N.seg. 59.0 %, CRP 18.32 mg/dL on 10/17, we consult infectious doctor and antibiotics change to Brosym (10/17~10/25).
      • Leukocytosis and abdominal pain were improved, operation of Exp Lap AR under general anesthesia were performed on 2017/10/20.
      • Foley was removal at post op day 1, voiding smoothly by patient himself.
      • The wound healing well and no erythema change. No nausea and no vomiting, flatus passage. On low residual diet was started at post-op day 3. Bowel movement normal and stools passage (+) with diet well tolerated.
      • Leukocytosis was improved with WBC 6.53 x10^3/uL, N.seg. 55.0 %, CRP 1.26 mg/dL on 10/23. DC Brosym and shift to oral antibiotics by CURAM on 10/25 by infectious doctor suggested.
      • The surgical pathology proved adenocarcinoma of sigmoid colon (4/16), G2, LV (+), pT3N2aM0; pStage: IIIB.
      • Adjuvant chemotherapy was suggested, GS was consulted and Port-A implantation was performed on 10/26.
      • CVP was removal on 10/26. No fever and no complication.
      • Discharged in general condition stable on 106/10/28 and will follow up in our out-patient department next week.
    • Discharge prescription
      • Curan 1# Q12H 3D
      • Meitifen 75mg 1# PRNQ12H 7D

[radiotherapy]

[chemotherapy]

  • 2024-01-08 - oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 300mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-12-25 - oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 300mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-12-11 - oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO

==========

2024-01-10

The lab results on 2024-01-07 were grossly normal and ECOG PS 1, no obvious contraindication to the administration of FOLFOX.

701337994

240110

[exam findings]

  • 2023-12-12 CT - chest
    • Adenocarcinoma of lung (ROS: mutation) with LNs mets & disease progression
    • Comparison was made with CT dated on 2023/08/25
      • Lungs: no interval change in size of LUL spiculated tumor (2.1 cm srs/img302/51), associated interlobular septal thickening, and with regression of radiation pneumonitis in upper and midlung zonesas compared with CT on 2023/08/25
      • Mediastinum and hila: stationary of metastaic LAP at Lt hilum
      • Pleura: minimal Lt-sided effusion..
      • segmental OPLL at T2-T4 levels.
    • Impression:
      • LUL cancer with hilar LAP, post treatment, stationary with regression of radiation penumonitis as compared with CT on 2023/08/25
  • 2023-08-25 CT - chest
    • Malignant neoplasm of upper lobe, left bronchus or lung
      • MRA: Brain (2023-07-19): multiple brain met.
      • RT (2023-7-27 ~ 2023-8-10) Completion of radiotherapy on 2023-8-10.
    • Comparison was made with previous CT dated on 2023/5/6
      • Lungs: no interval change size of LUL spiculated tumor (2 cm srs/img202/28), associated interlobular septal thickening, and with extensisve radiation pneumonitis in upper and midlung zones as compared with CT on 2023/05/06
      • Mediastinum and hila: stationary of metastaic LAP at Lt hilum
      • Pleura: minimal Lt-sided effusion..
    • Impression:
      • LUL cancer stationary with radiation penumonitis as compared with CT on 2023/05/06
  • 2023-07-19 MRA - brain
    • Findings
      • mild dilated intraventricular and extraventricular CSF spaces
      • punctate white matter gliosis in the supratentorial brain; nodular lesions in the left posterior frontal lobe, left superior parietal lobe, left occipital lobe and left pons. r/o metastasis. PLeaes correlate with contrast-enhanced study.
    • IMP:
      • r/o brain metastasis. Please correlate with contrast-enhanced study.
  • 2023-05-06 CT - chest
    • Progression of left lung lesions.
    • Stable of right lung lesions.
  • 2023-01-30 CT - chest
    • Progression from adenocarcinoma of lung with left supraclavicular lymph node metastases post Iressa (since 2011 to 2022), stage T4N3M0, stage III on MK 2009/10/01 Poar LIUMR c6D1 on MK 2010/02/09AFU6, local recurrent
    • Comparison was made with previous CT dated on 2022/8/18
      • Lungs: interval significant decreased LUL spiculated tumor (3.9 cm srs/img302/25) and decreased numbe and size of small nodules in both lungs as compared with CT on 2022/08/18.
      • Mediastinum and hila: signficant regresion of metastaic LAP as compared with previous CT son 2022/0/18
      • Pleura: trace Lt-sided effusion.
    • Impression:
      • LUL cancer T4N3M1a, signficant in regression as compared with previous CT study on 2022/08/18
  • 2022-11-03 Tc-99m MDP bone scan
    • Some hot spots in the skull and right rib cage and increased activity in the distal portion of left humeral shaft. The nature is to be determined (post-traumatic change? bone metastases? other nature?). Please correlate with other clinical findings and follow up bone scan for further evaluation.
    • Mildly increased activity in some T- and L-spines and sacrum. Degenerative change is more likely.
    • Increased activity in bilateral shoulers, hips, knees and feet. Benign joint lesions may show this picture.
  • 2022-08-18 CT - chest
    • Indication: follow up progessive Rt lung adenocaricnoma with ALK-positive under TKI. Evaluate tumor response to TKI
    • Chest CT with and without IV contrast ehnancement shows:
      • Huge soft tissue mass at left upper lobe with regional consolidation is found. The left upper lobe bronchus is partially obstructed by the mass. Lung cancer is considered. In comparison with CT dated on 2022-02-22, the lesion enlarged with broader extension.
      • Lymphadenopathy at mediastinum is found.
      • Left mild pleural effusion is found.
      • Minimal pericardial effusion is also found.
      • Mild pericardial effusion is found.
    • Imp:
      • Left upper lobe lung cancer with mediastinal lymphadenopathy and consolidation over left upper lobe, in progression.
  • 2022-05-16 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana) S2022-6896
      • Tumor type: adenocarcinoma
      • Tumor location: lung
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark XT
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: Pass,
      • Adequate tumor cells present (>=50 viable tumor cells): Yes
    • Result:
      • Tumor cell (TC) staining assessment: TC category: TC < 1%
      • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2022-04-21 Patho - lung transbronchial biopsy
    • Lung, ? side, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show acinar glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for the diagnosis.
  • 2022-02-22 CT - chest
    • History of adenocarcinoma of lung with Lt supraclavicular LN metastases post Iressa
      • Initial stage T4N3M0, stage III on MK 2009/10/01
      • Poar LIUMR X6D1 on MK follow up ca of lung status under Iressa
    • Comparison made with previous CT dated on 2021/11/19
      • Lungs:
        • the LUL spiculated tumor with pleural tails is 2.84 cm in longest axial dimension (srs/img10/22).
        • small nodule in anterior LUL (srs/img10/23 and a tiny centrilobular nodule in LLL (srs/img10/73)
      • Mediastinum and hila: heterogeneous enhancing left hilar lymphadenopathy (24 mm) and several small LNs in both sides of visceral space, increase in size as compared with previous CT study on 2021/11/19.
    • Impression:
      • LUL cancer T4N3, seems slightlt in progression as compared with previous CT study on 2021/11/19.
  • 2021-11-19 CT - chest
    • History of lung Ca under Iressa TKI treatment, evaluate tumor status
    • Chest CT with and without IV contrast ehnancement shows:
      • Spicualted mass at left upper lobe up to 2.61cm in largest dimension is found.
      • Enlarged lymph nodes are found at left hilar region. Non-specific lymph nodes are found at paratracheal region is found.
    • Imp:
      • Left upper lobe lung mass with left hilar lymphadenopathy, T2N1-2Mx.

[consultation]

  • 2023-09-19 Ear Nose Throat
    • Q
      • The 67 years old woman has adenocarcinoma of lung cancer with brain mets. Due to vertigo frequency in 1+ months, so we need your help for management. Thanks!
    • A
      • Hx of adenocarcinoma of lung cancer with brain mets
      • Vertigo (unsteadiness, exacerbated when sitting up and standing up, lasted for hours) for a month.
        • Ear drum: bil intact
        • EAC: clean
        • FNF: ok
        • HINTS: normal VOR, no nstagmus, normal test of skew
      • Imp: Vertigo, nature?
      • Plan:
        • May try Diphenidol (patient mentioned s/s improved under Diphenidol, and she claimed she had drugs)
        • ENT OPD f/u for inner ear battery test

[radiotherapy]

[chemotherapy]

  • 2024-01-09 - vinorelbine 20mg 1# PO + carboplatin AUC 5 400mg NS 250mL (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-13 - vinorelbine 20mg 1# PO + carboplatin AUC 5 300mg NS 250mL (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-14 - vinorelbine 20mg 1# PO + carboplatin AUC 5 300mg NS 250mL (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-10-17 - vinorelbine 20mg 1# PO + carboplatin AUC 5 300mg NS 250mL (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-09-21 - vinorelbine 20mg 1# PO + carboplatin AUC 5 300mg NS 250mL (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-07-06 - docetaxel 75mg/m2 110mg NS 150mL 1hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-06-16 - docetaxel 75mg/m2 110mg NS 150mL 1hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-26 - docetaxel 75mg/m2 110mg NS 150mL 1hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-21 - pemetrexed 500mg/m2 745mg NS 100mL 10min + carboplatin AUC 5 365mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-23 - pemetrexed 500mg/m2 727mg NS 100mL 10min + carboplatin AUC 5 280mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-24 - pemetrexed 500mg/m2 727mg NS 100mL 10min + carboplatin AUC 5 280mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-31 - pemetrexed 500mg/m2 727mg NS 100mL 10min + carboplatin AUC 5 275mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-05 - pemetrexed 500mg/m2 730mg NS 100mL 10min + [NS 500mL 2hr + diphenhydramine 30mg + NS 250mL] (before CDDP) + cisplatin 75mg/m2 110mg NS 350mL + NS 500mL 2hr (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-13 - pemetrexed 500mg/m2 730mg NS 100mL 10min + NS 500mL 2hr (before CDDP) + cisplatin 75mg/m2 110mg NS 350mL + NS 500mL 2hr (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-22 - pemetrexed 500mg/m2 730mg NS 100mL 10min + NS 500mL 2hr (before CDDP) + cisplatin 75mg/m2 110mg NS 350mL + NS 500mL 2hr (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

Vinorelbine - 2024-01-10 - https://www.uptodate.com/contents/vinorelbine-drug-information

  • Dosing - Adult
    • Non–small cell lung cancer:
      • Metastatic (single-agent therapy): IV: 30 mg/m2 once a week.
      • Locally advanced or metastatic (in combination with cisplatin): IV: 25 mg/m2 on days 1, 8, 15, and 22 of a 28-day cycle or 30 mg/m2 once a week.
      • Advanced disease (off-label dosing): IV: 25 to 30 mg/m2 days 1, 8, and 15 every 28 days (in combination with gemcitabine) for 6 cycles or until disease progression or unacceptable toxicity.
    • Small cell lung cancer, refractory (off-label use):
      • IV: 25 or 30 mg/m2 every 7 days until disease progression or unacceptable toxicity.

==========

not posted

dosage not correct?

701342169

240110

[lab data]

2023-05-23 Anti-HBc Reactive
2023-05-23 Anti-HBc-Value 9.12 S/CO
2023-05-23 Anti-HCV Nonreactive
2023-05-23 Anti-HCV Value 0.16 S/CO
2023-05-23 HBsAg Reactive
2023-05-23 HBsAg (Value) 3336.74 S/CO
2023-05-23 Anti-HBs 0.53 mIU/mL

[exam findings]

  • 2023-12-25 CT - abdomen
    • S/P colon operation.
    • Grade 4 fatty liver. A hypodense lesion (1.6cm) at left hepatic lobe. S/P right liver operation..
  • 2023-09-07 CT - abdomen
    • S/P colon operation.
    • Grade 4 fatty liver. A hypodense lesion (1.6cm) at left hepatic lobe r/o metastases. S/P right liver operation.
  • 2023-06-16 PET scan
    • Increased FDG uptake in the left anterior upper abdominal cavity. The nature is to be determined (post-operative infecton/inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
    • Two glucose hypermetabolic lesions in the segment 8/4 and segment 7 of the liver respectively. Liver metastases may show this picture.
    • A small and mild glucose hypermetabolic lesion in the segment 8 of the liver. An early liver metastasis can not be ruled out.
    • A focal area of decreased FDG uptake in the segment 5 of the liver, compatible with post-operative change.
    • Mild glucose hypermetabolism in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammatory process is more likely.
  • 2023-05-06 ECG
    • Sinus tachycardia with frequent Premature ventricular complexes
    • Possible Inferior infarct , age undetermined
    • Abnormal ECG
  • 2023-05-06 CT - abdomen
    • S/P colon operation. Fat stranding at upper abdomen. Some fluid collection at upper abdomen and abdominal wound.
    • Left pleural effusion. Partial atelectasis at bil. basal lungs.
    • Grade 4 fatty liver. A hypodense lesion (2.8cm) at right hepatic lobe, metastases ?

[MedRec]

  • 2023-05-06 ~ 2023-05-23 POMR Colorectal Surgery Chen ZhuangWei
    • Discharge diagnosis
      • Transverse colon cancer with liver metastasis status post right hemicolectomy and hepatectomy at S5 on 2023/03/22 (Taichung ChengChing Hospital), pT3N1bM1a stage IVa, complicating with deep wound infection and intra-abdomen abscess status post limited laparotomy with debridement and drainage of intra-abdomen abscess on 2023/05/06
      • Coronary artery disease with stent
      • Type 2 diabetes mellitus without complications
      • Hypertensive heart disease
      • Hyperlipidemia
    • CC
      • surgical wound swelling and arrythemia and fever was noted
    • Present illness
      • This is 69-year-old female patient had past history of colon cancer stage III with liver metastasis. She received colon cancer on 2023/03/23 at Taichung ChengChing Hospital.
      • This time, she suffered from surgical wound swelling and arrythemia and fever was noted. She was brough to our emergency room for help. PE no muscle guarding or peritoneal signs. Arrange abdominal CT revealed 1. S/P colon operation. Fat stranding at upper abdomen. Some fluid collection at upper abdomen and abdominal wound. 2. Left pleural effusion. Partial atelectasis at bil. basal lungs. 3. Grade 4 fatty liver. A hypodense lesion (2.8cm) at right hepatic lobe, metastases ? CRS. was consultion, after well explain for surgery is indication, she received surgery of limited laparotomy with drainage of deep wound and intra-abdomen abscess on 2023-05-06, post operative she was admitted to SICU for intensive care.
    • Course of inpatient treatment
      • She received surgery of limited laparotomy with drainage of deep wound and intra-abdomen abscess on 2023/05/06. After operation, she was transferred to SICU for intensive care.   
      • At SICU, antibiotics with Vancomycin and Doripenem administered. Extubated of endotracheal tube smoothly after pass weaning parameter on 5/8. We started try clear liquid diet since 5/9. After gemeral condition being stabilized, she will be transferred to ordinary ward for further care on 5/10.
      • After transferred to ward, we have kept wound wet dressing with normal saline and emperical antibiotics with vancomycin+ doripenem. The wound culture found Proteus spp. infection., which is only resistance to first generation antibiotics. We have also followed up laboratory data, and has also showed improvement. Her vital sign was relatively stable and conscious, appetite were also good. We have shifted emperical antibiotics to cefoxitin on 2023/05/13. Laboratory was followed up on 05/15, and has showed improvement. Furthermore, surgical wound was dressing with green guard gel due to no more pus like discharge nor bad oder. Now, her clinical condition is relatively stable, and she may discharge and keep follow up at OPD.
    • Discharge prescription
      • Ceficin (cefixime 100mg) 2# Q12H 7D

[consultation]

  • 2023-05-22 Hemato-Oncology
    • A
      • This 69 year old woman is a case of T-colon cancer with liver metastasis, s/p right hemicolectomy + liver S5 segment resection on 2023/03/22, pT3N1bM1a, stage IVA, RAS wide type, no BRAf mutation, proficient mismatch repair.
      • She had underline disease of CAD s/p stent. She was admiited due to deep wound infection with necrotizing fasciitis s/p limited laparotomy with drainage of deep wound and intra-abdomen abscess on 2023/05/06 - Wound culture with Proteus species.
      • We are consulted for further palliative chemotherapy after infection control.
      • Palliative chemotherapy + target therapy is indicated (FOLFIRI+Avastin). We will discuss with patient.
      • Please check HbsAg, Anti HBc,Anti HBs, Anti HCV, CEA, CA199, LDH. Arrange our OPD after discharge.
  • 2023-05-08 Infectious Disease
    • Q
      • Peritonitis with intra-abdomen and deep wound infection s/p emergent debridement and drain on 5/6
      • r/o septic shock
    • A
      • Agree with your current antibiotcs us of finibax and vancomycin.
      • Please adjust antibiotic according to culture results and clinical conditions.

[surgical operation]

  • 2023-05-06
    • Surgery
      • Limited laparotomy with drainage of deep wound and intra-abdomen abscess
    • Finding
      • After limited laparotomy, much pus was drained from a deep and poor healing wound, and underlying bowel like organ can be seen. however, severe adhesions over intraabdominal cavity was found and thorough exploration is difficult and impossible.
      • Debridement of the deep wound and much normal saline irrigation was done.
      • Wound was left open for wet dressing.

[immunochemotherapy]

  • 2024-01-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 325mg D5W 250mL 90min + leucovorin 400mg/m2 725mg NS 250mL 2hr + fluorouracil 2800mg/m2 5050mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-12-14 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 320mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-11-22 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 320mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-11-02 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 319mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4970mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-10-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 319mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4970mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-09-25 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 315mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4930mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-09-04 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 315mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4925mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-08-17 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 310mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4930mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-07-28 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 310mg D5W 250mL 90min + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2800mg/m2 4840mg NS 500mL 46hr (Avastin + FOLFIRI. Q2W. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-07-10 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr (FOLFIRI Q2W. Gao WeiYao)

==========

2024-01-10

[labs confirm HBV: Vemlidy maintained, medication compliance assured]

Lab results (2023-05-23) showed HBsAg and anti-HBc reactive and Vemlidy (tenofovir alafenamide) is currently in use, no medication discrepany found.

701510940

240110

==========

2024-01-10

After 5 days of hydroxyurea treatment (500mg BID from 2024-01-04 to 2024-01-08), the blast percentage in peripheral blood significantly reduced from nearly 20% to below 10%.

  • 2024-01-08 Blast 6.1 %
  • 2024-01-05 Blast 2.5 %
  • 2024-01-04 Blast 17.5 %
  • 2024-01-03 Blast 19.1 %

Hydroxyurea can be used off-label for cytoreduction in AML, effectively normalized the WBC count to 4.1K/uL by 2024-01-08. Consequently, further administration of hydroxyurea is currently unnecessary.

700043422

240109

[exam findings]

  • 2023-09-01 All-RAS + BRAF gene mutation analysis
    • Cell Block No. S2023-12334
    • RESULTS:
      • ALL-RAS: Detected (KRAS codon 12 GGT>GTT, p.G12V)
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-08-27 ECG
    • Normal sinus rhythm
    • Low voltage QRS
    • Prolonged QT
    • Abnormal ECG
  • 2023-08-26 CT - abdomen
    • Non-contrast CT of abdomen-pelvis revealed:
      • S/P ileostomy with incisional hernia. Progression of A-colon cancer (10.3x11.6x15.4cm) with right lateral abdominal wall and psoas muscle invasion.
      • Small stones in left kidney.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • GGO at right basal lung.
    • IMP:
      • S/P ileostomy with incisional hernia.
      • Progression of A-colon cancer (10.3x11.6x15.4cm) with right lateral abdominal wall and psoas muscle invasion.
      • Some lymph nodes at RLQ.
      • GGO at right basal lung.
  • 2023-08-26 CT - brain
    • Non-contrast brain CT revealed:
      • Widening of cortical sulci and dilatation of ventricles.
    • IMP:
      • Brain atrophy.
  • 2023-06-26 ECG
    • Sinus rhythm with occasional atrial-paced complexes and Fusion complexes
    • Low voltage QRS
    • Prolonged QT
  • 2023-06-21 Patho - colon biopsy
    • Colorectum, ascending colon, biopsy — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-06-16 CT - abdomen
    • CC: general weakness, poor appetite,
    • PHx: COPD, HTN, DM, colon cancer diagnosed by Cardinal Tien Hospital
    • Findings:
      • There is a well-defined heterogeneous enhancing mass in the ascending colon, measuring 15 cm (the largest dimension), and direct invasion right psoas muscle and duodenum 2nd-3rd junction that is c/w adenocarcinoma of the ascending colon (T4b).
        • The differential diagnosis includes adenocarcinoma associated with tumor necrosis and abscess formation.
        • please correlate with clinical condition.
        • In addition, there are four enlarged nodes in the right side mesocolon that are c/w metastatic nodes (N2a).
      • S/P ileostomy at right upper pelvis.
      • Hyperplasia of left adrenal gland is noted.
    • Imaging Report Form for Colorectal Carcinoma
  • 2023-06-16 ECG
    • Sinus tachycardia
    • Low voltage QRS
    • Borderline ECG
  • 2023-06-16 CXR
    • Tortous aorta with calcification is noted.
    • S/p port-A placement with its tip at Superior vena cava.

[MedRec]

  • 2023-06-16 ~ 2023-06-20 POMR Colorectal Surgery Lv ZongRu
    • Discharge diagnosis
      • Advance ascending colon cancer with psoas muscle invasion post loop ileostomy, cT4bN2aM0, stage IIIC. ECOG:1.
      • Hypertension
      • Diabetes mellitus
      • Hyperlipidemia
      • Chronic obstructive pulmonary disease
    • CC
      • complaint of no hospital bed for chemotherapy in Cardinal Tien Hospital
    • Present illness
      • This is a 58 year-old men had history of
        • hypertension with medicin control over 10 years;
        • diabetes mellitus with medicin control over 10 years;
        • hyperlipidemia with medicin control over 10 years;
        • Chronic Obstructive Pulmonary Disease with medicin control for many years;
        • Gastroesophageal reflux disease with medicine control for many years.
        • Diangosised of Malignant tumor in ascending colon with right psoas muscle invasion on 2023/05 by Cardinal Tien Hopital.
        • port-A insertion on 2023/05/15 at Cardinal Tien Hospital.
        • ileostomy post operation on 2023/05/15 at Cardinal Tien Hospital.
      • He denied any TOCC histories in recent 3 months.
      • According the patient statement, discharge on 2023/05/18 at Cardinal Tien Hospital. Due to he had watery diarrhea off and on for about month,and intermittent right back pain over 1 years. Poor intake about 1 month and body weight loss over 20 kg. During hospitalization, diangosised of Malignant tumor in ascending colon with right psoas muscle invasion. Port-A insertion and ileostomy post operation on 2023/05/15 at Cardinal Tien Hospital.
      • PET 2023/05/23 showed 1). Malignant tumor in ascending colon with right psoas muscle, invasion; cT4bN0M0, c-stage IIC., 2). Bilateral pleural effusion., 3). Post colostomy in RUQ.
      • Brain MRI showed no organic brain lesion and no evidence of metastasis on 2013/05/27.
      • Due to the complaint of no hospital bed for chemotherapy in Cardinal Tien Hospital, the patient visited our emergency room for his disease.
      • At emergency room, Abdominal CT showed There is a well-defined heterogeneous enhancing mass in the ascending colon, measuring 15 cm (the largest dimension), and direct invasion right psoas muscle and duodenum 2nd-3rd junction that is c/w adenocarcinoma of the ascending colon (T4b). In addition, there are four enlarged nodes in the right side mesocolon that are c/w metastatic nodes (N2a). no distant metastasis. Laboratory data showed WBC: 12.80 x10^3/uL, CRP: 12.5 mg/dL.
      • After consultation to proctologist and initial management, the patient was admitted to our ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission, highly suspect ascending colon cancer with local advanced invasion. Paliative chemotherapy + radiotherapy first, but insufficient information of pathology report in other hospital. Thus, colonscopy biopsy was performed on 2023/06/20. Under the stable condition, he was discharged today and the final report will be follow up in OPD.
    • Discharge prescription
      • Curam (amoxicillin 875mg, clavuanic acid 125mg) 1# Q12H
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQID
  • 2023-08-27 Colorectal Surgery
    • Q
      • Family members said that when the patient wanted to get up to change his stoma, he collapsed and fell to the ground, not sure where he hit.
      • denied fever, tarry stool, chocking recently.
      • Hx
        • Advance ascending colon cancer with psoas muscle invasion post loop ileostomy, cT4bN2aM0, stage IIIC. ECOG:1.
        • Hypertension
        • Diabetes mellitus
        • Hyperlipidemia
        • Chronic obstructive pulmonary disease
    • A
      • This is a Advance ascending colon cancer with psoas muscle invasion post loop ileostomy, cT4bN2aM0, stage IIIC. ECOG:1. with conscious change this morning
      • GCS: E3M5V2
      • A/P: admission for antibioitc drugs treatment
      • please check BZD drug overdose problem
      • thanks for your consultation

[immunochemotherapy]

  • 2024-01-08 - bevacizumab 5mg/kg 150mg NS 100mL 60min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3875mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. dose reduced) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-12-25 - bevacizumab 5mg/kg 150mg NS 100mL 60min + irinotecan 180mg/m2 198mg D5W 250mL 90min + leucovorin 400mg/m2 440mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. dose reduced) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-12-11 - bevacizumab 5mg/kg 150mg NS 71mL 60min + irinotecan 180mg/m2 235mg D5W 250mL 90min + leucovorin 400mg/m2 524mg NS 250mL 2hr + fluorouracil 2800mg/m2 3670mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. dose reduced) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-11-27 - bevacizumab 5mg/kg 100mg NS 71mL 60min + irinotecan 180mg/m2 235mg D5W 250mL 90min + leucovorin 400mg/m2 524mg NS 250mL 2hr + fluorouracil 2800mg/m2 3670mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. doce reduced) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-11-14 - bevacizumab 5mg/kg 100mg NS 71mL 60min + irinotecan 180mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 422mg NS 250mL 2hr + fluorouracil 2800mg/m2 2960mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. dose reduced) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-10-31 - bevacizumab 5mg/kg 100mg NS 71mL 60min + irinotecan 180mg/m2 257mg D5W 250mL 90min + leucovorin 400mg/m2 572mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. doce reduced) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-10-16 - irinotecan 180mg/m2 276mg D5W 250mL 90min + leucovorin 400mg/m2 615mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 1000mL 46hr (FOLFIRI Q2W. doce reduced) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-10-02 - irinotecan 180mg/m2 294mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 1000mL 46hr (FOLFIRI Q2W. doce increased) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-09-18 - irinotecan 180mg/m2 268mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4172mg NS 1000mL 46hr (FOLFIRI Q2W) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-08-14 - oxaliplatin 85mg/m2 112mg D5W 250mL 2hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 1000mL 46hr (FOLFOX Q2W) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-02 - (FOLFOX Q2W) (Lv ZongRu)
  • 2023-07-17 - (FOLFOX Q2W) (Lv ZongRu)
  • 2023-07-03 - (FOLFOX Q2W) (Lv ZongRu)

==========

2024-01-09

[anemia]

Compared to the previous session on 2023-12-25, the dosage of Irinotecan and fluorouracil administered during this session on 2024-01-08 was increased.

The patient’s HGB level remains low at 7.8g/dL as of 2024-01-08. Available lab data indicates persistent anemia since at least June 2023, with no recovery to normal levels. If the anemia becomes symptomatic, RBC transfusion may be necessary.

The patient has already received several blood transfusions throughout the previous months, specifically on 2023-08-30, 2023-11-13, and 2023-12-11.

2023-12-27

[anemia]

Hemoglobin has been around 7 to 8 g/dL for the past two months. The FOLFIRI dose has been reduced during this hospitalization. If anemia is symptomatic, please perform RBC product transfusion as clinically indicated.

  • 2023-12-25 HGB 7.3 g/dL
  • 2023-12-11 HGB 7.1 g/dL
  • 2023-11-27 HGB 8.3 g/dL
  • 2023-11-13 HGB 7.2 g/dL
  • 2023-10-30 HGB 8.9 g/dL

2023-12-13

[anemia]

In the pharmacist note dated 2023-11-16, the following assessment was made: Considering the already reduced dose of the FOLFIRI regimen, further alleviation of anemia severity might necessitate lengthening the treatment intervals, potentially impacting the expected therapeutic effectiveness. In the recent two administrations (irinotecan on 2023-11-27 and 2023-12-11: 235mg; 5-FU on 2023-11-27 and 2023-12-11: 3670mg), both irinotecan and 5-FU doses were increased compared to the previous administration (irinotecan on 2023-11-14: 190mg; 5-FU on 2023-12-11: 2690mg), while maintaining a biweekly interval. Recent data may indicate that the rate of hemoglobin supplementation is not keeping pace with the anemia caused by the treatment. Consequently, in subsequent therapy sessions, blood transfusions may become a necessary adjunct to the treatment regimen.

  • 2023-12-11 HGB 7.1 g/dL BT
  • 2023-11-27 HGB 8.3 g/dL
  • 2023-11-13 HGB 7.2 g/dL BT
  • 2023-10-30 HGB 8.9 g/dL
  • 2023-10-16 HGB 10.6 g/dL

2023-11-16

[anemia]

Laboratory data indicated episodes of anemia. Blood transfusions were appropriately administered to the patient on 2023-08-30 and 2023-11-13.

  • 2023-11-13 HGB 7.2 g/dL BT
  • 2023-10-30 HGB 8.9 g/dL
  • 2023-10-16 HGB 10.6 g/dL
  • 2023-10-02 HGB 10.1 g/dL
  • 2023-09-18 HGB 10.1 g/dL
  • 2023-09-04 HGB 9.7 g/dL
  • 2023-08-30 HGB 8.1 g/dL BT
  • 2023-08-27 HGB 9.5 g/dL
  • 2023-08-26 HGB 10.6 g/dL
  • 2023-08-14 HGB 9.3 g/dL
  • 2023-08-01 HGB 10.5 g/dL
  • 2023-07-17 HGB 8.8 g/dL
  • 2023-07-03 HGB 9.4 g/dL
  • 2023-06-19 HGB 8.8 g/dL
  • 2023-06-16 HGB 9.3 g/dL
  • 2021-09-03 HGB 13.7 g/dL

The patient is currently being treated with Avastin and a reduced dose of the FOLFIRI regimen. Bevacizumab is less commonly associated with anemia. Given that the dose of the FOLFIRI regimen has already been reduced, further mitigation of the severity of anemia might require extending the treatment intervals, which could potentially affect the anticipated therapeutic efficacy.

700359263

240109

==========

2024-01-09

Lab results:

  • 2024-01-08 NT-proBNP > 35000.0 pg/mL

  • 2024-01-08 CKMB 5.5 ng/mL

  • 2024-01-08 hs-Troponin I 62.9 pg/mL

  • 2024-01-08 CK 86 U/L

  • 2024-01-08 ECG

    • Sinus rhythm with 1st degree A-V block
    • Non-specific intra-ventricular conduction block
    • T wave abnormality, consider inferolateral ischemia
  • 2024-01-08 CXR

    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • moderate enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad /supine position
    • Rt and Lt subpulmonary effusion
    • Linear band subsegmental atelectasis at lung bases
    • marginal spurs of multiple vertebral bodies

Potential causes:

  • Heart failure remains a likely cause, strongly supported by the significantly elevated NT-proBNP and the enlarged cardiac silhouette on CXR.
  • Myocardial infarction (heart attack) is still a possibility, given the elevated hs-Troponin I and T wave abnormality on ECG. Further investigations like a repeat ECG and echocardiography would be crucial to confirm or rule out this diagnosis.
  • Acute coronary syndrome (ACS) is also a possibility due to the potential for ischemia suggested by the ECG findings.
  • Other potential contributing factors:
    • Atherosclerosis, as evidenced by the calcified changes in the aorta on CXR.
    • Possible pulmonary congestion or effusions, as indicated by the subpulmonary effusions on CXR.

It might be beneficial to consult a cardiologist.

700817160

240109

[lab data]

2023-12-04 FKLC 135.0 mg/L
2023-12-04 FLLC 178.0 mg/L

2023-11-28 Protein, total 5.9 g/dL
2023-11-28 Albumin 35.2 %
2023-11-28 Alpha-1 2.3 %
2023-11-28 Alpha-2 14.6 %
2023-11-28 Beta 21.9 %
2023-11-28 Gamma 26.0 %
2023-11-28 M-peak Positive
2023-11-28 A/G Ratio 0.50

[MedRec]

  • 2023-12-09 ~ 2023-12-12 POMR Nephrology Lin DingYun
    • Discharge diagnosis
      • Nephrotic syndrome with other morphologic changes
      • Type 2 diabetes mellitus with diabetic chronic kidney disease
      • Essential (primary) hypertension
      • Idiopathic gout, unspecified site
      • Pure hypercholesterolemia
      • Anemia, unspecified
      • Cyst of kidney, acquired
    • CC
      • Lower limbs edema for 2 months
    • Present illness
      • This is a 65 years old male with underlying disease of type 2 DM, hypertension, gouty arthritis, CKD stage 4, was admitted for lower limbs edema for 2 months.
      • The patient was in his usual health status, until the end of Sep 2023, when he was infected with COVID-19 infection. He noted that lower limbs edema developed gradually thereafter. His general appetite and spirit also became worsen. He denied use of NSAIDs recently. There was no fever, chills, dyspnea, decreasing urine output.
      • He visted the nephrologist OPD on 2023-10-28, and low serum albumin was noted, 2.9 to 2.1 mg/dL. Urine protein was also increased, UACR 1.98 to UPCR 9.3. Renal function was relative stable, around 2.67~3.3mg/dL.
      • Relevant studies for proteinuria showed presence of M-protein on protein EP and IFE, suspected to be IgG + Kappa. Under the impression of nephrotic syndrome with unclear cause, he was admitted for kidney biopsy.
    • Course of inpatient treatment
      • After admission, we have checked the CBC, coaggulation and bleeding time, and we also adjusted anti-hypertensive agents for blood pressure control.
      • Due to anemia (HB 8.5g/dL), blood transfustion with LPRBC 2U was done on 12/09 and 12/10.
      • Desmopressin was given for preventing bleeding before kidney biopsy on 12/11.
      • The patient stood well during the whole procedure, and follow-up renal echo showed minimal hematoma and stable hemogram level.
      • Due to stable condition, he was discharge on 2023/12/12.
    • Discharge prescription
      • Budema (bumetanide 1mg) 1# QD
      • Feburic (febuxostat 80mg) 0.5# QD
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
      • colchicine 0.5mg 0.5# QD
      • Foliromin (ferrous sodium citrate 50mg) 1# BID

700867511

240109

[exam findings]

  • 2024-01-07 ECG
    • Normal sinus rhythm
    • Septal infarct, age undetermined
  • 2023-12-08 ECG
    • Normal sinus rhythm
    • Anterolateral infarct, age undetermined
    • Abnormal ECG
  • 2023-11-22 Peipheral Vascular Test - AV fistula
    • Result: Adequate size of RIJV
  • 2023-11-17 PET scan
    • Glucose hypermetabolism in multipe bones as mentioned above, suggesting multiple bone metastases.
    • Glucose hypermetabolism in some left supraclavicular lymph nodes, bilateral pulmonary lymph nodes and multiple bilateral mediastinal lymph nodes. Metastatic lymph nodes should be watched out. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the lower portion of the esophagus. Inflammation is more likely. Please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-11-10 Tc-99m MDP bone scan
    • The scintigraphic findings suggest multiple bone metastases.
  • 2023-10-26 T-spine AP + Lat.
    • Post percutaneous vertebroplasty of the visible lumbar or thoracic spine at T8.
  • 2023-10-16 Patho - bone fragment/pathologic fracture
    • T8 vertabrae, biopsy — Metastatic adenocarcinoma and see description
    • The specimen submitted consists of three strips of brown-gray bony tissue, labeled T8 vertebrae, measuring up to 1.2 x 0.2 x 0.2 cm. All for section.
    • The sections show a picture of metastatic adenocarcinoma, composed of nests and cords of columnar to cuboidal neoplastic cells, arragned in glandular and cribrifrom patterns with muicin secretion.
    • IHC shows: CK7(+), CK20(-), CDX2(-), TTF1(-) and PSA(-). Suggest check respiratory tract and pancreaticobiliary tract.
  • 2023-10-14 ECG
    • Anteroseptal infarct, age undetermined
  • 2023-10-14 CXR
    • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture at T8, mets or multiple myeloma?
  • 2023-09-15 Nasopharyngoscopy
    • Findings: smooth nasopharynx, oropharynx, hypopharynx
    • Diagnosis: multiple bone metastasis
  • 2023-09-01 MRI - T-spine
    • Diffuse bony metastases involving vertebral column, including T1-4, T6-9, T11-12, L1-3, L5 and S2 vertebral body.
  • 2023-08-24 CT - abdomen
    • R/O vascular thrombosis of bil. lower lungs.
    • Enlargement of prostate.
  • 2023-08-24 T spine AP + Lat
    • T8 compression fracture
    • General osteoporosis
    • Concave vertebrae of T-L spine
  • 2023-08-16 CT - chest
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T0(T_value) N:N0(N_value) M:M1c(M_value) STAGE:IVB(Stage_value)
    • Findings
      • Lungs:
        • extensive, bilateral, upper lobes predominant, centrilobular emphysema, in the lungs.
        • minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine.
        • areas of septal thickening at S6 and S10 of LLL and central bronchial
        • wall thickening at both lower lobes.
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels: mild coronary arterial calcification
      • Thoracic aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal size of cardiac chambers.
      • Pleura: no effusion
      • Visible abdominal contents: no abnormal density in visible portion of the the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys.
      • Visualized bones: lytic or blastic change with compression fracture of T8 vertebral body.
    • Impression:
      • extensive emphysema with lower lobes bronchitis, LLL interstitial infiltration r/o edema, and pathological compression fracture of T18.
      • no obvious solid lung tumor.
  • 2023-05-31 Bronchodilator Test
    • severe obstructive impairment after bronchodilator; non-significant bronchodilator response; compatible with GOLD stage III.
  • 2022-11-03 CXR erect
    • Increased lung volume and areas of hyperlucency/decreased vascular markings due to emphysematous change
  • 2022-11-03 Bronchodilator Test
    • moderate obstructive impairment; non-significant bronchodilator response; compatible with GOLD stage II
  • 2022-10-24 Myocardial perfusion SPECT with persantin
    • Probably mild myocardial ischemia at the apex, middle to basal inferior wall, and inferoseptal wall (LAD and RCA territories) of LV.
    • Mild dilatation of LV is noted on post-stress images.
  • 2022-08-11 ECG
    • Anteroseptal infarct, age undetermined
  • 2022-05-19 Bronchodilator Test
    • compatible with GOLD stage II
  • 2022-05-04 Bruce ECG
    • Findings
      • The patient exercised according to the BRUCE for 07:05 min:s, achieving a work level of max METS: 8.6.
      • The resting heart rate of 91 bpm rose to a maximal heart rate of 144 bpm.
      • This value represents 92 % of the maximal, age-predicted heart rate.
      • The resting blood pressure of 113/76 mmHg, rose to a maximum blood pressure of 208/95 mmHg.
      • The exercise test was stopped due to Target heart rate [85-99% MHR], Dyspnea, Fatigue.
    • Conclusion
      • Probably negative for myocardial ischemia (baseline Q wave at V1-3)
  • 2022-04-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (67 - 27) / 67 = 59.70%
      • M-mode (Teichholz) = 58
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Septal hypertrophy; LV diastolic dsyfunction, Gr 1
      • Trivial MR and trivial TR
      • Preserved RV systolic function

[MedRec]

  • 2023-12-08 ~ 2023-12-12 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Adenocarcinoma of lung cancer with multiple bone metastasis, stage IV
      • Chronic obstructive pulmonary disease
      • Anterolateral infarct
      • Chronic ischemic heart disease
      • Essential (primary) hypertension
      • Mixed hyperlipidemia
    • CC
      • for chemotherapy and pain control
    • Present illness
      • The 67 y/o man has BPH, COPD (smoking 1.5 PPD for 50 years and Lung function: severe obstructive impairment after bronchodilator; non-significant bronchodilator response; compatible with GOLD stage III on 2023/05/31), HTN, Hyperlipidemia and CAD under ASA and Coxine since 2022/11-2023/12/7.
      • Due to he has dyspnea on exercise, the chest CT was done from CM OPD on 2023/08/16, report showed extensive emphysema with lower lobes bronchitis, LLL interstitial infiltration r/o edema, and pathological compression fracture of T18. no obvious solid lung tumor.
      • He was refered to ONC OPD for T8 pathologic fracture, so he did the MM survey and the T-spine MRI was done on 2023/09/01, report showed diffuse bony metastases involving vertebral column, including T1-4, T6-9, T11-12, L1-3, L5 and S2 vertebral body.
      • ENT OPD for suspect unknown primary and multiple bone mets survey, but no evidence of NPC.
      • The EGD also was done for primary unknown on 2023/09/26, report showed Reflux esophagitis LA Classification grade A(minimal), Gastric erosions, antrum, s/p biopsy(B) and Gastric shallow ulcers, bulb, s/p biopsy(A), but all of pathology showed not cancer.
      • On 2023/10/16, the bone pathology showed metastatic adenocarcinoma, IHC shows: CK7(+), CK20(-), CDX2(-), TTF1(-) and PSA(-).
      • The bone scan and self paid of PET were showed multiple bone metastases on 2023/11.
      • ONC OPD gave pain killers as Fentanyl 12 mcg, Ultracet 1# q6h and Cataflam 75mg qd, but in vain.
      • Under the impression of metastatic adenocarcinoma, primary origin suspect lung, so he was admitted for chemotherapy and pain control on 2023/12/08.
    • Course of inpatient treatment
    • After admission, he received pain control with Durogesic 12mcg/h, 2.1mg/patch 2 patch q3d. B12 IM and MultiVit on 2023/12/11. First chemo as Alimta + Cisplatin on 2023/12/12. Under the stable condition, he can be discharged on 2023/12/12. OPD follow up is arranged.
    • Discharge prescription
      • Limeson (dexamethasone 4mg) 1# BID
      • Cough Mixture (platycodon ) 8mL PRNQ8H
      • Neurontin (gabapentin 100mg) 1# TID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Through (sennoside 12mg) 2# HS
      • Ulstop (famotidine 20mg) 1# BID
      • Durogesic (fentanyl 12ug/h, 2.1mg/patch) 2# Q3D EXT
  • 2023-11-15 SAOP Chest Medicine Wu ZhiWei
    • A/P
      • Plan:
        • refer to ortho/oncology fot spine T8 pathologic fracture (adenoCA with unknown origin)
        • quit smoking
      • smoking: 2 PPD x 50 years, current
      • PHx: COPD s/p anoro [chest Dr. Huang & Wu]; CAD under aspirin
    • Prescription x3
      • Anoro Ellipta (umeclidinium 55ug/dose, vilanterol 22ug/dose; 30 doses/bot) 1# QD INHL

[chemotherapy]

  • 2024-01-02 - pemetrexed 500mg/m2 726mg NS 100mL 10min + cisplatin 75mg/m2 100mg NS 350mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-12 - pemetrexed 500mg/m2 726mg NS 100mL 10min + cisplatin 75mg/m2 100mg NS 350mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-01-09

[reconciliation]

A repeat prescription for Anoro Ellipta for the patient’s COPD, issued on 2023-11-15 by our pulmonologist, has been added to the active medication list.

[reduced CEA growth after pemetrexed-cisplatin initiation]

The patient’s CEA level doubled within a month, from 2023-11-14 to 2023-12-15. Notably, this rapid increase seems to have slowed down in the following 21 days (2023-12-15 to 2024-01-05), with only a 12% increase observed. The initiation of pemetrexed + cisplatin therapy on 2023-12-12 may be contributing to this slowdown.

  • 2024-01-05 CEA (NM) 383.080 ng/ml
  • 2023-12-15 CEA (NM) 341.960 ng/ml
  • 2023-11-14 CEA (NM) 176.550 ng/ml
  • 2023-09-15 CEA 49.34 ng/mL
  • 2023-08-23 CEA 20.17 ng/mL

700289323

240108

[MedRec]

==========

2024-01-08

[reconciliation]

The medications prescribed by both your cardiologist and psychosomatic medicine specialist on 2023-10-19 are currently in use without any discrepancies. These repeat prescriptions will expire soon. Please remind the patient to consider scheduling follow-up appointments with both specialists before the prescriptions expire, if clinically necessary.

701111632

240108

[MedRec]

  • 2024-01-04 ~ 2024-01-08 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Invasive carcinoma (NST, no special type) of the left breast, stage pT2N1a (2/21)(cM0); pStage: IIB, ER (+, 90 %), PR (+, 70 %), HER-2/Neu (-, score=1+); HER2 Dual ISH: (-, non-amplified), s/p MRM and axillary lymph nodes dissection, chemotherapy, radiotherapy, and status during endocrine therapy, with multiple bone metastases, stage IV
      • Right lower lung pneumonia, sputum culture: Mixed normal flora Growth:4+
      • Hypokalemia
      • Oral candidas
    • CC
      • for fever without comtrol for 10 days
    • Present illness
      • This 54 year-old woman has invasive carcinoma (NST, no special type) of the left breast, stage pT2N1a (2/21)(cM0); pStage: IIB, ER (+, 90 %), PR (+, 70 %), HER-2/Neu (-, score=1+); HER2 Dual ISH: (-, non-amplified), s/p MRM and axillary lymph nodes dissection on 2016-08-04, Chemotherapy was started on 2016-09-02 and completed on 2017-03-27.
      • Nolvadex since 2017-04-14. Completion of radiotherapy on 2017-06-16.
      • Regular followed up and abdominal echo showed Hepatic tumor, rule out metastatic tumor on 2021/01/19.
      • Followed up ABD CT showed the largest one measuring 1.5 x 0.7 cm at S2, are noted again, stable in size and feature and a hemangioma 0.7 cm in the spleen is suspected on 2021/01/29.
      • Bone scan also was done on 2021/03/16, image showed in comparison with the previous study on 2016/07/21, the lesions in the sternum and lower T-spine are new. Bone metastases should be considerd.
      • 2021/04/20 E2 <15.0 pg/mL, FSH 31.14 mIU/mL. Whole body PET scan on 2021/04/13 showed glucose hypermetabolism in the sternum and T11 spine, compatible with bone metastases.
      • Under the impression of Invasive carcinoma (NST, no special type) of the left breast, stage pT2N1a (2/21)(cM0); pStage: IIB, ER (+, 90 %), PR (+, 70 %), HER-2/Neu (-, score=1+); HER2 Dual ISH: (-, non-amplified), s/p MRM and axillary lymph nodes dissection, chemotherapy, radiotherapy, and status during endocrine therapy, with newly identified recurrence with multiple bone metastases, stage IV, /p RT and Kisqualis permitted in May 2021. but declined in April 2023, /p Aromasin since 2023/11.
      • Follow up chest CT on 2023/08/19 showed left upper lobe tiny nodule, right middle lobe ground glass nodule stationary and bone meta is found.
      • Follow up bone scan on 2023/10/9 showed increased tracer uptake in the sternum and T11 spine come to more evident, indicating metastatic bone disease in progression.
      • She was diagnosed with influenza B on 2023/12/25 and took antiviral drugs at my own expense. But, she still have a fever up to 39.1C at LMD and Tamiflu for 5 days productive cough (yellowish sputum) with sore throat for 7 days, so she was brought to our ED for help on 2024/01/03.
      • CXR showed pneumonia over RLL. Lab data showed WBC 3400/uL, CRP 3.6mg/dL, ALT 71U/L and AST 79U/L, normal renal function.
      • Initial antibiotic as Cravit for infection control. Under the impression of RLL pneumonia, so she was admitted on 2024/01/04.
    • Course of inpatient treatment
      • After admission, she received Cravit for pneumonia control. Throat swab was done for oral candidas and we gave Nystatin treatment. After treatment, her cough with sputum decrease and no fever, so she can be discharged and take oral antibiotic going back home on 2024/01/08. OPD follow up is arranged.
    • Discharge prescription
      • Actein Effervescent (acetylcysteine 600mg) 1# BID
      • Z-cough (benzonatate 100mg) 1# TID
      • Cravit (levofloxacin 500mg) 1.5# QDAC

701488075

240108

[exam findings]

  • 2024-01-05 SONO - thyroid gland
    • Enlargement of right thyroid gland.
    • A cystic lesion with mural nodule (1.35x2.32cm) in right thyroid gland.
  • 2024-01-03 CT - chest
    • Indication: right lower gum malignancy, s/p surgery and adjuvant CCRT
    • without & with contrast enhancement, coronal and sagittal reconstructed images and axial slab MIP images shows:
      • lungs: multiple nodules of variable sizes at both lower lobes and lingula measuring up to 27mm at RLL.
        • centrilobular nodules and opacification of bronchi at RLL.
        • centrilobular emphysema at both upper lungs.
      • Mediastinum and hila: extensive lymphadenopathy with low attenuation in the Rt visceral space and Rt hilum, that narrowing distal intermediate bronchus and inferior pulmonary artery.
      • Thoracic aorta: normal caliber,Heart:
      • Pleura: minimal Rt-sided effusion.
      • Chest wall and visible lower neck: Rt thyroid low attenuated nodule (29mm)
      • Visible abdominal contents: several poor ehancing tumors in the liver up to 55mm.
        • a large soft-tissue mass at hepatic hilum, likely metastatic LAP, 34mm. a suspect tumor at left kidney (22mm).
        • marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • oral cancer with lung, mediastinal-hilar-abdominal LNs, hepatic and renal metastases.
      • obstructive RLL bronchopneumonia.
      • Rt thyroid mass, metastatic?
  • 2023-12-14 CT - abdomen
    • History and indication: PDSCC of hard palate, s/p wide excision
    • Non-contrast CT of abdomen-pelvis revealed:
      • Some nodules in bil. visible lungs.
      • A hypodense nodule (3.3cm) at left hepatic lobe.
      • Some calcifications at prostate.
    • IMP:
      • Lung and liver metastases.
  • 2023-12-12 SONO - abdomen
    • Suspect liver metastasis, S4
  • 2023-12-11 Nasopharyngoscopy
    • NER
    • bil stiff free flap
    • trismus
  • 2023-11-22 MRI - nasopharynx
    • Findings
      • post-OP change with flap reconstruction in the bilateral head and soft palate without evidence of local recurrence.
      • selling of the left massetor muscles and left pterygoid muscles with a small part, about 12.7mm, in the medial aspect of the left mandible (srs9, img 12 and srs750, img 1).
      • low SI change on T1WI in the bome marrow of the left mandible with heterogeneous enhancement.
      • a nodular lesion, about 34mm in the right thyroid gland.
      • mucosal thickening in the left nasopharynx.
      • soft tissue swelling in the oropharyngeal, oral cavity and hypopharyngeal mucosa.
    • IMP:
      • focal abnormal ADC lesion in the left masticator space. r/o tumor. Please f/u.
      • mucosal thickening in the left nasopharyngeal mucosa
      • abnormal SI change in the left mandibular bone marrow. PLease correlate with previous study.
  • 2023-10-02 ENT Hearing Test
    • Tymp RE type C, LE type B
    • ART bil absent
    • PTA:
      • Reliability FAIR
      • Average RE 54 dB HL, LE 56 dB HL
      • RE mild to profound HL
      • LE moderate to profound HL
  • 2023-07-12 Patho - lip biopsy/wedge resection
    • Diagnosis:
      • neck level III lymph node, right, selective neck dissection — Negative for malignancy
      • neck level IIa lymph node, right, selective neck dissection — Negative for malignancy
      • neck level Ib lymph node, right, selective neck dissection — Negative for malignancy
      • Submandibular gland, right, selective neck dissection — Negative for malignancy
      • neck level III lymph node, left, selective neck dissection — Negative for malignancy
      • neck level IIa lymph node, left, selective neck dissection — Negative for malignancy
      • neck level Ib lymph node, left, selective neck dissection — Negative for malignancy
      • Submandibular gland, left, selective neck dissection — Negative for malignancy
      • neck level Ia lymph node, median, selective neck dissection — Negative for malignancy
      • neck level Ib lymph node, left, selective neck dissection — Negative for malignancy
      • infratemporal fossa, left, wide excision — Negative for malignancy
      • lateral pterygoid muscle and palate, left, wide excision — Negative for malignancy
      • tooth, bilateral (#33, #36, #38, #47), extraction — Confirmed
      • hard paltate, bilateral, wide excision — Negative for malignancy
      • medial pterygoid muscle and palate, left, wide excision — Negative for malignancy
      • anterior hard palate, median (14-24), left, wide excision — Negative for malignancy
      • hard palate tumor with bone erosion, median — Squamous cell carcinoma, moderate to poorly differentiated
      • Bone, maxilla, bilateral, Maxillectomy — Involved by squamous cell carcinoma
    • Microscopic examination
      • Histologic Type — Squamous cell carcinoma
      • Histologic Grade — G3: Poorly differentiated
      • Microscopic Tumor Extension: Maxilla
      • Margins (obtained from the main resection specimen):
        • Margins uninvolved by invasive carcinoma
        • Distance from closest margin: 5 mm
      • Lymph-Vascular Invasion: present
      • Perineural Invasion: not identified
  • 2023-07-06 PET scan
    • Glucose hypermetabolism involving bilateral soft palate and hard palate, compatible with primary malignancy involving these regions.
    • Mild glucose hypermetabolism in multiple bilateral neck level II and Ib lymph nodes. Either metastatic lymph nodes or inflammation may show this picture. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammatory process may show this picture.
  • 2023-06-27 CT - neck
    • Oralcavity - Impression (Imaging stage) : T:T4a N:N0 M:M0 STAGE:____
  • 2023-06-26 Patho - tongue biopsy
    • Tumor, left soft palate, punch biopsy — Squamous cell carcinoma and candidiasis
    • The specimen submitted consisted of multiple fragments of tumor tissue measuring up to 0.5 x 0.4 x 0.2 cm in size, fixed in formalin. Grossly, they were gray in color and soft in consistence. All embedded for sections.
    • Microscopically, the sections show a picture of squamous cell carcinoma, poorly differentiated characterized by solid tumor nests infiltration with focal keratin formation. Besides, ulcer, bacterial colonies and fungal hyphae and spores, morphology consistent with candidiasis are also included.
    • Immunohistochemistry shows CK(+), P16(-) and P63(+) for tumor, special stain of PAS highlights fungal infection.
  • 2023-06-26 Nasopharyngoscopy
    • bil soft palate/hard palate granular tumor
    • recurrent, operated in 2018
    • suspect malignancy
  • 2023-06-26 ENT Hearing Test
    • Tymp RE type C, LE type As
    • ART absent
    • PTA:
      • Reliability FAIR
      • Average RE 43 dB HL; LE 51 dB HL
      • RE mild to severe HL, masking dilemma
      • LE moderate to severe MHL

[surgical operation]

  • 2023-07-11
    • Surgery
      • free left anterolateral thigh flap and titanium-plate reconstruction of palate
      • reduction and fixation of fractured mandible
    • Finding
      • missing lower parts of bilateral maxilla, the upper teeth, and the palate owing to ablasion of cancer
      • also missing mucosa of bilateral walls of pharynx, but it was not resurfaced since the wounds can heal gradually by itself
      • free flap: left anterolateral thigh flap
        • dimension of flap: 12cm X 8cm
        • pedicle of flap: descending branches of lateral circumflex artery and veins from left profundus femoris system, 1A2V
        • numbers and type of perforators: 2, inta-muscular
        • recepient vessels: right superior thyroid artery and vein
        • design of flap: an ovale skim paddle, folded posteriorly as 7cm X 8cm and 5cm X 8cm parts, the previous is for resurfacing the oral side of palate, and the later is for the nasal side
        • ischemic time: 1H40M
        • fair prefusion and color of the flap at the end of the operation
        • primary closure of the flap donor wound
      • the bony part of the palate was reconstructed with a titanium plate
      • fractured mandible from its synphysis for fascilitating the cancer ablasion surgery
      • one 10F JP drain over left supra-clavicular region for post-operative drainage   
  • 2023-07-11
    • Surgery
      • Wide excision of oral cancer
      • selective neck dissection, bilateral
      • Tracheotomy
      • Maxillectomy, bilateral
      • Bilateral partial glossectomy
      • Extraction of caries (#12, #13#, #15, #21, #22, #24, #33, #36, #38, #47)
    • Finding
      • cT4aN2cM0
      • tumor over bilateral hard palate, soft palate, lateral tongue, with invading of left infratemporal fossa
      • L lateral pterygoid plate and muscle excised, margin may not be adqeuate although grossly free (skull base exposed, pterygoid plexus oozing= hemostasis with bipolar electrocautery)
      • L CN 11 explsed and preserved
      • all upper gum, gingiva, and hard palate excised
      • trismus after prior op (R lower gum fibrosis), 2fB=> mandibulectomy for access of cancer

[radiotherapy]

  • 2023-08-10 ~ 2023-09-20 - completed RT to the bil. neck lymphatic drainage area: 50 Gy/ 25 fx. The preOP hard palate tumor bed: 60 Gy/ 30 fx.

[chemotherapy]

  • 2023-09-14 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (CCRT. Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3 + metoclopramide 10mg
  • 2023-09-07 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (CCRT. Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-31 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (CCRT. Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-24 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (CCRT. Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-17 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (CCRT. Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-10 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (CCRT. Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

701502293

240108

[exam findings]

[MedRec]

  • 2023-12-09 ~ 2023-12-27 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Severe sepsis with septic shock
      • Adenocarcinoma of pancreatic ductal with retroperitoneal and superior mesenteric artery involvement stage IV
      • Obstructive jaundice related to tumor status post percutaneous trannshepatic gallbladder drainage on December 14, 2023
      • Hypocalcemia
      • Hypertension
      • Constipation
      • Type 2 diabetes mellitus
      • Port-a insertion on 2023/12/14
    • CC
      • abdominal pain for two weeks, fever and dysuria were noted today
    • Present illness
      • This 49 y/o female patient has past history of 1) Hypertension 2) Diabetes mellitus 3) mesenteric tumors s/p operation and radiotherapy x7 (last date 2023/12/08) at Cardinal Tien Hospital.
      • The patient stated that she began seeing a doctor at Cardinal Tien Hospital six months ago due to abdominal pain. After six months of tests, she was diagnosed with a tumor. She underwent surgery and radiation therapy. She felt that she did not have a good connection with the doctors at Cardinal Tien Hospital and did not want to return. The patient’s family member stated that Cardinal Tien Hospital had informed them that the patient had only one month to live. The patient hopes that coming to TzuChi Hospital may give her a better chance. She hopes to continue her treatment here in the future.
      • According to the description of the patient record. This time, she was presented to our ER with abdominal pain for two weeks, fever and dysuria were noted today. At ER, GCS:E4V5M6, HR:140/min, RR: 20/min, BP:74/39mmHg, SpO2:95%. A chest film disclosed the lung fields are clear. Laboratory studies disclosed WBC:2920u/L, hypokalemia(K:3.3mmol/L), hyponatremia(Na:127mmol/L), PCT:48.94ng/mL and hyperbilirubinemia(TBI:5.12mg/dl, DBI:3.14mg/dl). On vasopressor with levophed titration for septic shock.
      • Abdomen CT showed soft tissue mass at 3rd portion of doudenum measuring 5.5cm in largest dimension is found. The lesion obliterate CBD and IHDs with dilatation of the biliary trees. Some lymph nodes are found at mesenterric region. Therefore, GS was consulted and suggested transfer to ICU.
      • Under the impression of 1) Septic shock 2) Retroperitoneal tumor with SMA involvement, unknown stage, she was admitted to ICU for further treatment on 2023-12-09.
    • Course of inpatient treatment
      • She sent to MICU at first due to shock and she received fluid hydration and vasopressin agent titration. Empiric antiboltic with Brosym (since 12/9) was prescribed for infection control. Pain control for abdominal discomfort.
      • After stable of hemodyanemic, she was transferred to ward.
      • EUS-biopsy was done and showed one 50 x 46 mm heterogeneous hypoechoic lesion with calcification component arising from the uncinate process of pancreas, indicating a pancreatic uncinate process tumor and pathology showed pancreatic ductal adenocarcinoma on 2023/12/18.
      • Due to jaundice and tumor obstruction, PTGBD was placed on 2023/12/13. Port-A was implanted on 2023/12/13.
      • Radiology was consulted for radiotherapy and the treatment planning was done on 2023/12/18.
      • Currently, Cravit 750mg QD was given for infection control, imperan 10mg TID for nausea and vomiting since admission.
      • Panzolec 40mg for ulcer prevention. RI 25U in PPN, forxiga 1tab QD, Pioglit 1tab QD for surgar control.
      • Concor 1tab QD, Exforge 1tab QD for BP control. Acetal 1tab QID, tramator 100mg IVD PRNQ12H, Fentanyl patch Q3D for pain control.
      • Semiliquid diet 1200kcal and PPN for nutrition support.
      • Due to Hb dropped from 10.3 to 7.0, blood transfusion with LPRBC 3U was done on 12/15-16.
      • Hypokalemia correct during hospitalization. PTGBD revision revealed due to dislocation of the catheter on 12/21.
      • At ONC ward, she received Mycostatin (Nystatin) 3ml qd qid for oral candidas.
      • Chemo as Gemzar/Abraxance on 2023/12/25.
      • We taper Fentanyl 50mcg to 12 mcg with Morphine 3mg sc prnq4h. Thus, her painful condition got well after chemotherapy.
      • Standing abdomen film was done for abdominal distention and vomit, the image showed stool impaction.
      • Under the stable condition, she can be discharged on 2023/12/27. OPD follow up is arranged.
    • Discharge prescription
      • Lactul Syrup (lactulose 666mg/mL) 10mL TID
      • Durogesic (fentanyl 12ug/h, 2.1mg/patch) 1# Q3D EXT for 2023-12-30
      • Bisadyl supp (bisacodyl 10mg) 2# QD RECT
      • Through (sennoside 12mg) 2# HS
      • Morphine 15mg 1# PRNQ6H

[consultation]

[chemotherapy]

  • 2023-12-25 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + Nab-paclitaxel 125mg/m2 200mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

700179585

240105

[History]

  • Left iavasive ductal carcinoma of breast (2023/09/21): Femara and Palbociclib
  • Infiltrating tubulolobular carcinoma (2006): chemotherapy, radiotherapy (21 times) and tamoxifen

[exam findings]

  • 2023-12-30 CXR supine
    • S/P PICC catheter insertion via right forearm.
    • Pleura effusion of right and left costal-phrenic angle
    • S/P pigtail catheter implantation at bilateral CP angle.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2023-12-29 SONO - chest
    • Right massive pleural effusion post pig-tail insertion.
  • 2023-12-22 MRI - brain
    • No evidence of brain metastasis. Cerebral white matter T2-hyperintensities, stationary as compared with scan MRIs.
  • 2023-12-20 SONO - chest
    • Pleural effusion, moderate, left
    • Pleural effusion, moderate, oragnized, right
    • Atelectasis, LLL, RLL
    • Pleural thickening, diffuse
  • 2023-12-15 Tc-99m MDP bone scan
    • Increased activity in the middle and lower T-spines, L3-5 spines and bilateral S-I joints. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2023-12-14 CXR
    • S/P PICC catheter insertion via right forearm.
    • Pleura effusion of right and left costal-phrenic angle
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Otherwise, there is no significant abnormality of the chest. (Note that ground-glass lesion, small nodule or retrocardiac lesion might be missed on plain chest radiography.)
  • 2023-12-14 Cardiac Catheter
    • SvO2 was also check, it revealed 76 %.
    • Estimated Fick Cardiac index 2.44 L/min/m2 (normal cardiac index range 2.6~4.2 L/min/m2)
    • Estimated Fick cardiac output 3.88 L/min. (nomral cardiac output range 5~6 L/min)
  • 2023-12-14 SONO - chest
    • Pleural effusion, moderate and organized, right
    • Pleural effusion, moderate, left
    • Atelectasis, RML, RLL and LLL
    • Lung nodule, left
    • Pleural thickening, bilateral
  • 2023-12-12 CXR erect
    • Rt greater than Lt, large volume of bilateral pleural effusions
    • Regression of Rt pleural effusion s/p thoracocentesis
    • Consolidation and volume reduce over lower lung zones dependent lung parenchyma.
  • 2023-12-12 CT - chest
    • without contrast enhancement, coronal and sagittal reconstructed images shows:
      • large volume of bilateral pleural effusions.
      • lungs: partial posterior atelectasis of both lower lobes.
        • mild interstitial and alveolar lung edema at nondependent LUL, RML, and RUL r/o lymphangitic infiltration.
      • Mediastinum and hila: no enlarged LN or mass.
      • Thoracic aorta: normal caliber,
      • Central pulmonary arteries: normal caliber.
      • Heart: normal size of cardiac chambers.
      • Chest wall and visible lower neck: absence of Rt breast,
        • skin thickening over left breast, anterior chest wall.
      • Visible abdominal-pelvic contents: Rt renal stone measuring 0.4cm.
      • Visualized bones: small blastic change in multiple vertebrae, may be bony metastasis
  • 2023-12-12 ECG
    • Sinus tachycardia
    • Cannot rule out Inferior infarct, age undetermined
    • Possible Anterior infarct, age undetermined
  • 2023-12-12 CXR erect
    • Rt greater than Lt, moderate bilateral pleural effusions
    • Consolidation and volume reduce over lower lung zones dependent lung parenchyma.
    • elongated and tortuosity of thoracic aorta
  • 2023-12-12 SONO - chest
    • Right thorax: large amount, septated pleural effusion s/p drainage twice; total 250cc yellowish fluid was drained.

[chemotherapy]

  • 2024-01-04 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min (Gemzar weekly)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-12-21 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min (Gemzar weekly)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-12-15 - gemcitabine 800mg/m2 1200mg NS 250mL 30min (Gemzar weekly)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

700204503

240105

[exam findings]

  • 2023-12-20 Gynecologic ultrasonography
    • ATH + BSO
    • IMP:
      • R/O Pelvis mass (67 x 33mm, 37 x 25mm)
      • R/O LT cyst (17mm x 14mm)
  • 2023-12-06 Gynecologic ultrasonography
    • ATH + BSO
    • IMP: R/O Pelvis mass (97 x 40mm, 63 x 31mm)
  • 2023-11-22 Pure Tone Audiometry, PTA
    • Reliabilty Fair
    • R’t : 15 dB HL, normal to mild SNHL
    • L’t : 6 dB HL, WNL.
  • 2023-11-07 Patho - uterus (with or without SO) neoplastic
    • PATHOLOGIC DIAGNOSIS
      • Ovary, left, salpingo-oophorectomy —- high grade serous adenocarcinoma.
      • Ovary, right, salpingo-oophorectomy —- high grade serous adenocarcinoma. P53 (aberrant type), Napsin-A (-), PMS2 (+), MSH6 (+), MSH2 (+), MLH1 (+), ER (+, 40%, intermediate intensity), PR (+, 50%, stron gintensity).
      • Fallopian tube, left, salpingo-oophorectomy —- free
      • Fallopian tube, right, salpingo-oophorectomy —- tumor seeding.
      • Uterus, corpus, total hysterectomy — benign proliferative phase; myomas; adenomyosis.
      • Uterus, cervix, total hysterectomy — free
      • Omentume, omentectomy —- free
      • Lymph node, bilateral pelvic, dissection — free.
      • AJCC cancer staging 8 th edition: pT1c1 pN0 (if cM0); pStage: IC1, at least.
    • MACROSCOPIC EXAMINATION
      • Procedure (select all that apply) - Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy)  
      • Specimen size:
        • right ovary: 158 gms; 10 x 6 x 6 cm;
        • left ovary: 540 gms; 18 x 11 x 7 cm; operative findings: “intraoperative rupture due to severe adhesion”
        • right tube: 6 x 0.4 x 0.4 cm. Tumor seeding: 2.1 x 0.6 cm;
        • left tube: 6 x 0.4 x 0.4 cm, free;
        • uterus: 125 gms; 12 x 6 x 6 cm; 2 myomas: up to 3 x 3 x 3 cm. Adenomyosis present. Endometrium free.
        • Omentum: 28 x 5 x 1.5 cm: free.
      • Specimen Integrity
        • Specimen Integrity of Right Ovary: Capsule intact
        • Specimen Integrity of Left Ovary: ruptured
        • Specimen Integrity of Right Fallopian Tube: tumor seeding
        • Specimen Integrity of Left Fallopian Tube- free
      • Tumor Site: Bilateral ovaries
        • Right fallopian tube seeding
      • Ovarian Surface Involvement - Present ( Left)
      • Fallopian Tube Surface Involvement- Present ( Right)
      • Tumor Size: left ovarian tumor (the larger one)
      • Greatest dimension (centimeters): 18 cm
      • Additional dimensions (centimeters): 11 x 7 cm
      • Sections are taken and labeled as: A1: cervix; A2: uterine corpus; A3: myomas; A4: left tube; A5-8: left ovary; A9: right tube; A10-12: right ovary; A13: omentum; A14-15: left common iliac lymph nodes; A16: left obturator lymph nodes; A17: right common iliac lymph nodes; A18-19: right obturator lymph nodes.
    • MICROSCOPIC EXAMINATION:
      • Histologic type: serous adenocarcinoma
      • Histologic grade: high grade
      • Contralateral ovary involvement: present
      • Tumor side ovarian surface involvement: present
      • Contralateral ovary surface involvement: absent
      • Right tube involvement: present
      • Left tube involvement: absent
      • In situ adenocarcinoma in right &/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: present
      • Left adnexa soft tissue involvement: present
      • Pelvic soft tissue involvement: absent
      • Uterine serosa involvement: absent
      • Omentum involvement: absent
      • Uterine Cervix involvement: absent
      • Endometrium involvement: absent
      • Myometrium involvement: absent
      • Appendix involvement: not received
      • Largest Extrapelvic Peritoneal Focus (required only if applicable)- not applicable.
      • Peritoneal/Ascitic Fluid- Negative for malignancy (normal/benign)
      • Regional Lymph Nodes: free: A14-15: left common iliac lymph nodes (0/16); A16: left obturator lymph nodes (0/2); A17: right common iliac lymph nodes (0/4); A18-19: right obturator lymph nodes (0/12).
        • Negative for metastasis: (0/ total No. of nodes: 0/34)
      • Other organs or specimens involvement: absent.
  • 2023-10-30 Gynecologic ultrasonography
    • R/O Huge Pelvis mass (202 mm x 79 mm) , RI : 0.47

[MedRec]

  • 2023-11-05 ~ 2023-11-12 POMR Obstetrics and Gynecology Zen LunNa
    • Discharge diagnosis
      • Malignant neoplasm of left ovary, Debulking surgery on 2023-11-06
      • Malignant neoplasm of right ovary
      • Female pelvic peritoneal adhesions (postinfective)
    • CC
      • Abdominal fullness for 2 months (since September 2023).
    • Present illness
      • This 47-year-old, G0P0, sex(+), married woman without systemic disease. Her last menstrual period was on 10/27/2023, duration lasted for 4 days. Hypermenorrhea with blood clots occasionally was mentioned.
      • She was in her usual health status until she experienced abdominal fullness with palpable abdominal mass since September 2023. She had been visited Hualien Tzu Chi Hospital GI OPD where irritable bowel syndrome was told and medications were given but in vain. Upper endoscopy and coloscopy were arranged that showed no specific abnormality.
      • Abdominal CT scan was done and revaled Ovarian Carcinoma T1bN0M0 and uterine myoma (2.7 cm). Blood test showed tumor markers: CA 125 level was 4076 and CA 199 level was 56.3. She came to our GYN OPD for further management on 10/30/2023. Physical examination showed a palpable mass noted below the umbilicus.
      • Transvaginal sonography showed a huge pelvic mass(202x79mm) and no ascites. After well explaination and discussion with patient and family, debulking surgery for ovarian cancer was decided and she was scheduled on 11/06/2023. She was admitted to our ward on 11/05/2023 for scheduled operation and further management. Urologist was consulted for ureter catheter insertion.
    • Course of inpatient treatment
      • The patient was admitted on 11/5/2023 due to ovarian cancer. She underwent Debulking surgery (abdominal total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + para aortic lymph note sampling + infracolic omentectomy) on 11/06/2023.
      • The pathology report:
        • Ovary, left, salpingo-oophorectomy —- high grade serous adenocarcinoma.
        • Ovary, right, salpingo-oophorectomy —- high grade serous adenocarcinoma.
      • Bilateral ovarian cancer AJCC cancer staging 8 th edition: pT1c1 pN0 (if cM0); pStage: IC1, at least.
      • Her post operative condition was stable and so she discharged on 11/12/2023 and she will have her OPD follow up next week.
    • Discharge prescription
      • Keto (ketorolac 10mg) 1# QID
      • Gasmin (dimethylpolysiloxane 40mg) 1# QID
      • MgO 250mg 2# QID
      • Through (sennoside 12mg) 2# HS
      • tetracycline HCl TID EXT
      • cephalexin 500mg 1# QID
      • Anxiedin (lorazepam 0.5mg) 1# HS

[surgical operation]

  • 2023-11-06
    • Surgery
      • Diagnosis:
        • Bilateral huge ovarian mass, r/o ovarian cancer
      • Surgery:
        • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy + para aortic lymph note sampling)
          • ATH = abdominal total hysterectomy
          • BSO = bilateral salpingo-oophorectomy
          • BPLND = bilateral pelvic lymph node dissection
    • Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, severe dense adhesion to the ovaries, bowel and cul de sac due to the tumor mass.
      • Adnexa:
        • LOV: huge ovarian mass, about 18 X 10 X 10 cm-sized; multiple septums with solid content, fluid content and mucoid content; with severe dense adhesion to the uterus and bowel; intraoperative rupture due to severe adhesion
        • ROV: 10 X 8 X 6 cm-sized solid ovarian mass; with severe dense adhesion to the uterus and bowel
        • Fallopian tube: bilateral grossly normal
      • CDS: adhesion (+)
      • Ascites: bloody, about 50 ml
      • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
      • Omentum: grossly normal without palpable tumor mass; infracolic omentectomy was done.
      • Liver: grossly normal & smooth
      • Appendix: grossly normal
      • After the operation, optimal debulking surgery was achieved without visible residual tumor.
      • Estimated blood loss: 1300 mL
      • Blood transfusion: pRBC 2U
      • Complication: nil       

[chemotherapy]

  • 2024-01-05 - paclitaxel 175mg/m2 290mg NS 500mL 3hr + carboplatin AUC 5 700mg NS 250mL 2hr (Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-12-15 - paclitaxel 175mg/m2 290mg NS 500mL 3hr + carboplatin AUC 5 700mg NS 250mL 2hr (He JingLiang)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-22 - paclitaxel 175mg/m2 290mg NS 500mL 3hr + carboplatin AUC 5 700mg NS 250mL 2hr (He JingLiang)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-01-05

[tumors have decreased in size]

On 2023-10-30, a gynecologic ultrasound revealed a large pelvic mass measuring 202 mm x 79 mm. A debulking surgery performed on 2023-11-06 confirmed the tumor to be high-grade serous adenocarcinoma. Following this, a regimen of paclitaxel and carboplatin was initiated on 2023-11-22, with the third cycle administered during this hospitalization on 2024-01-05. Subsequent gynecologic ultrasounds on 2023-12-06 and 2023-12-20 showed a reduction in the size of the pelvic mass to 97 x 40 mm and 63 x 31 mm, and then to 67 x 33 mm and 37 x 25 mm, respectively, indicating a decrease in size.

The patient, with an ECOG Performance Status of 0, had lab results that were generally normal as of 2024-01-01. Currently, access to the patient’s PharmaCloud records is unavailable. However, a review of HIS5 records revealed no discrepancies in medication.

700712591

240105

[lab data]

2023-12-05 EBV DNA quantative PCR <35 IU/mL
2023-12-04 HCV RNA-PCR quantative Target Not Detected IU/mL

2023-11-28 HBsAg Nonreactive
2023-11-28 HBsAg (Value) 0.35 S/CO
2023-11-28 Anti-HCV Reactive
2023-11-28 Anti-HCV Value 14.16 S/CO
2023-11-28 Anti-HBc Nonreactive
2023-11-28 Anti-HBc-Value 0.21 S/CO
2023-11-28 Anti-HBs 1.51 mIU/mL

[exam findings]

  • 2024-01-03 Pap Smear
    • Moderate dysplasia (CIN2)
  • 2024-01-03 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 39 dB HL; LE 38 dB HL.
    • RE normal to moderate mixed type HL.
    • LE normal to moderately severe mixed type HL.
  • 2023-11-30 PET scan
    • Glucose hypermetabolism involving the nasopharynx, more prominent at the right side. Primary nasopharyngeal malignancy may show this picture.
    • Glucose hypermetabolism in a left retropharyngeal lymph node. Metastatic lymph node may show this picture.
    • Mild Glucose hypermetabolism in some bilateral neck level II and right neck evel Ib lymph nodes. The nature is to be determined (inflammation? metastatic lymph nodes of low FDG uptake?). Please correlate with other imaging modalities for further evaluation.
    • Glucose hypermetabolism in some focal areas in the maxilla and mandible. Dental problem may show this picture. Please correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG uptake may show this picture.
  • 2023-11-29 MRI - nasopharynx
    • Indication: NPC
    • Neck MRI without/with Gadolinium-based contrast enhancement shows:
      • abnormal thickening of bilateral nasopharyngeal mucosa, especially on right side, compatible with nasopharyngeal carcinoma (NPC). There is no involvement to parapharngeal space, nor pterygoid and prevertebral muscles. T1 disease is favored.
      • enlarged lymph nodes at bilateral retropharyngeal spaces, bilateral level Ib and II, compatible with N2 disease.
    • Impression:
      • NPC, T1N2.
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:T1(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)
  • 2023-11-17 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopahrynx, right, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B).
    • IHC stain: CK (+).
  • 2023-11-17 Nasopharyngoscopy
    • Findings
      • Some clear mucus content at nasopharynx, right nasopharyngeal Rosenmullar fossa
      • smooth oropharynx, hypopharynx and patent airway.
    • Dx, Conclusion
      • Postnasal dripping.
      • right nasopharyngeal lesion, r/o cyst or tumor

[MedRec]

  • 2023-11-28 ~ 2023-11-30 POMR Ear Nose Throat Huang TongCun
    • Discharge diagnosis
      • Malignant neoplasm of nasopharynx, cT1N2M0, stage III
    • CC
      • Lumping throat, dry cough, easy choking for 2 months
    • Present illness
      • This 72-year-old woman was a HCV carrier for more than 10 years. Lumping throat, dry cough, and easy choking were noted for 2 months and worsened recently. Hoarseness was noted too. She denied alcohol drinking, smoking and betel nut chewing. Neigher body weight loss nor poor appetite were noted. She went to our ENT OPD for help. Physical exam showed right nasopharyngeal smooth bulging tumor at Rosenmuller fossa and no neck mass. Fiberscopic exam showed smooth oropharynx and hypopharynx.
      • Biopsy of the tumor was done, and the pathology report revealed non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B). Admission for further examination was suggested, and the patient agreed after thorough consideration. Therefore, under the impression of nasopharyngeal cancer, the patient was admitted for cancer work-up.        
    • Course of inpatient treatment
      • After admission, serial tests were arranged for tumor staging work up.
      • Nasopharyngeal MRI showed nasopharyngeal carcinoma T1N2M0, stage:III.
      • Abdominal sonography showed gall stones and GB slugde.
      • PET was done and the result was pending.
      • GI man was consulted for HCV, and check a-Fetoprotein and HCV RNA PCR quantative was suggested.
      • Under relative stable condition, the patient was dishcarged with OS/ Dental/ ENT OPD follow up.     

[radiotherapy]

  • 2023-12-07 SOAP Radiation Oncology Huang JingMin
    • S: For CCRT due to nasopharyngeal carcinoma.
      • PI: Incidental finding nasopharyngeal tumor at TuCheng Hospital. nasopharyngeal carcinoma was proved at our hospital. Due to old age, CCRT then C/T was suggested by medical oncologist.
      • Family history: (mother: nasopharyngeal carcinoma)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM (-); HTN (-)
      • Previous RT Hx: (-)
    • A:
      • Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B) of the nasopharynx, stage cT1N2M0.
    • P: CCRT then adjuvant chemotherapy is indicated for this patient with the following indicators: NPC, stage cT1N2M0. The medical oncologist opinion: Due to old age, suggest CCRT then C/T.
      • Goal: curative
      • Treatment target and volume: nasopharyngeal tumor to bilateral neck
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5000cGy/25 fractions of the nasopharyngeal to bilateral neck, and 7000cGy/35 fractions of the nasopharyngeal tumor to involed neck nodal lesions.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her family. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2023-12-13.
      • According to the patient and her family statement, the pre-RT dental evaluation: no dental extraction.
  • 2023-11-30 SOAP Oral and Maxillofacial Surgery He ChengHan
    • S
      • Ask for oral examination
      • pre-CCRT dental evaluation
    • O
      • Panoramic findings:
        • Missing: 16,17,2427,3537,46,47
        • Impaction: nil
        • Crown and Bridge: 13,14,42X31-32,43X45
        • Caries: nil
        • retained root:23
        • Periodontal condition: chronic periodontitis
      • multiple questionable teeth were present
    • A/P
      • Take panoramic film for evaluation
      • Explain the findings and treatment plan to the patient (multiple teeth might be extracted for prevention).
      • patient understands but chose to receive CCRT first.

[chemotherapy]

  • 2024-01-05 - cisplatin 40mg/m2 64mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited with cisplatin) (CCRT. Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

700039857

240104

[exam findings]

  • 2023-11-03 MRI - nasopharynx
    • Imaging Report Form for Hypopharynx Carcinoma
      • Impression (Imaging stage) : T: 1(T_value) N: 0(N_value) M: 0(M_value) STAGE: I(Stage_value)
  • 2023-10-30 Patho - larynx biopsy
    • Labeled as “Arytenoid and aryepiglottic fold uneven mucosal surface, left”, LMS biopsy — squamous cell carcinoma in situ (CIS)
    • Section shows squamous cell carcinoma in situ (CIS).
  • 2023-10-27 Bronchodilator Test
    • poor done, difficult interpretation
    • Mild restrictive ventilatory impairment
    • with response to bronchodilator, AHR or learning effect?
  • 2023-10-26 Miniprobe Endoscopic Ultrasound
    • Diagnosis:
      • Esophageal cancer, cT3NxMx, upper to lower esophagus
      • Rule out left dysplastic arytenoid cartilage mucosal lesion
      • Gastric mucosal lesions, rule out gastric cancer, upper body, GC, s/p biopsy
      • Superficial gastritis and atrophic gastritis
    • Suggestion:
      • Consider to consult ENT for left arytenoid cartilage mucosal lesion biopsy
      • Pursue the pathology report
  • 2023-10-25 Tc-99m MDP bone scan
    • Faint hot spots in the sternum and both rib cages, respectively, the nature is to be determined (post-traumatic change, bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, mandible, some T- and L-spine, bilateral shoulders, S-I joints, and hips.
  • 2023-10-24 PET
    • Glucose hypermetabolism in the middle portion of the esophagus, compatible with primary esophageal malignancy.
    • Mild glucose hypermetabolism in three adjacent lymph nodes. Metastatic lymph nodes of low FDG uptake can not be ruled out. Please correlate with other imaging modalities for further evaluation.
    • Glucose hypermetabolism in a right supraclavicular lymph node. A metastatic lymph node may show this picture.
    • Glucose hypermetabolism in the region about the left posterior aspect of the cricoid cartilage. The nature is to be determined. Please correlate with other clinical findings for further evaluation.
    • Increased FDG accumultion in both kidneys. Physiological FDG accumulation may show this picture.
  • 2023-10-23 MRI - brain
    • Old lacunes in bilateral basal ganglia. Cerebral small vessel disease. General brain atrophy. Venous angioma in left cerebellum.
  • 2023-10-21 CT - chest
    • Indication: Esophageal cancer survey
    • Chest CT with and without IV contrast ehnancement shows:
      • Wall thickening at middle third esophagus measuring 5.5cm in largest dimension. Regional lymph nodes (n=4) is found.
      • Some reticulation at right lower lobe is found. Previous aspiration is considered.
      • Bilateral renal cysts are found. Polycystic disease is considered.
    • Imp:
      • Compatible with esophageal cancer with regional lymph nodes. No evidence of distant meta.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T2(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-10-16 Patho - stomach biopsy
    • Esophagus, 30 cm to 33 cm below incisor, biopsy — Squamous cell carcinoma, moderately differentiated
    • Section shows pieces of squamous mucosa with infiltration of nests of neoplastic squamous cells.
  • 2023-10-16 EGD
    • Diagnosis:
      • Esophageal polypoid lesion, 30cm to 33cm below incisors, s/p biopsy (B)
      • Gastric mucosal lesion, upper body, GC, s/p biopsy (A)
      • Mucosal lesion, left arytenoid cartilage.
      • Reflux esophagitis LA Classification grade A (minimal)
      • Superficial gastritis and atrophic gastritis
    • Suggestion:
      • ENT OPD for mucosal lesion, left arytenoid cartilage.
      • Pursue pathology report
  • 2023-10-16 SONO - abdomen
    • R/o polycystic kidney disease

[MedRec]

  • 2023-12-15 SOAP Radiation Oncology Wang YuNong
    • S
      • Diagnosis:
        • Esophageal ca, cT3N2M0
        • Hypopharygneal ca, cT1N0M0.
      • However, the Rt SCF LAP could be counted as from hypopharynx, and the staging won’t be the same.
      • CC: can’t swallow saliva.
    • O
      • Since 2023-12-08 RT to the hypophayrnx and bil. neck: 12 Gy/ 6 fx. The esophagus and adjacent lymphatic drainage area: 10.8 Gy/ 6 fx.
      • Chest CT showed esophageal cancer, middle third, cT2N2M0
      • 2023-10-26) EUS showed:
        • Esophageal cancer, cT3NxMx, upper to lower esophagus
        • Rule out left dysplastic arytenoid cartilage mucosal lesion
        • Gastric mucosal lesions, rule out gastric cancer, upper body, GC, s/p biopsy
    • Plan:
      • RT to the hypopharynx and bil. neck: 50 Gy/ 25 fx.
      • The hypopharyngeal tumor and Rt SCF LAPs: 70 Gy/ 35 fx.
      • The esophagus and adjacent lymphatic drainage area: 45 Gy/ 25 fx.
      • The esophageal tumor: 50.4 Gy/ 28 fx.
  • 2018-01-12 SOAP Orthopedics Lin KunHui
    • diagnosis
      • Synovitis and tenosynovitis, unspecified [M65.9]
      • Olecranon bursitis [M70.22]

[consultation]

  • 2023-11-02 Oral and Maxillofacial Surgery
    • Q
      • for perpare CCRT evaluation
      • This 68 year old man is a case of Squamous cell carcinoma of esophageal cancer, middle third, moderately differentiated, cT2N2M0, stage IIIB & hypophargenal cancer (SCC). We need expertise to evaluate his condition thanks!
    • A
      • This is a 68-year-old male patient recently diagnosed with esophageal cancer and laryngeal cancer and is scheduled for concurrent chemoradiotherapy, and we were consulted for pre-CCRT dental evaluation.
      • O:
        • Full mouth multiple residual roots and severe periodontitis was noted.
        • Poor oral hygiene was noted.
        • Multiple caries was revealed by radiographic examination.
      • P:
        • Explained the findings and treatment plan to the patient and his family.
        • Suggest extraction of tooth 16, 24, 26, 34, 42, 43
        • Patient wanted to consider.
  • 2023-10-26 Radiation Oncology
    • Q
      • This 68-year-old man, had past history of hypertension and a smoker.
      • He had suffered from dysphagia for solid material with sorethorat for 1~2 months, associated with body weight loss 13~14 kg in 2-3 month.
      • He came to GI OPD and done PES and biopsy showed esophageal cancer, SCC.
      • This time, he admission for esophageal cacner staging.
      • Chest CT show esophageal cancer, middle third, cT2N2M0
      • Arrange on port A and jejunostomy on 10/30.
      • We would like to consult for CCRT further treatment. Thank you.
      • Sincerely request your help to evaluate and manage this patient.
    • A
      • 2023-10-26 EUS showed:
        • Esophageal cancer, cT3NxMx, upper to lower esophagus
        • Rule out left dysplastic arytenoid cartilage mucosal lesion
        • Gastric mucosal lesions, rule out gastric cancer, upper body, GC, s/p biopsy
      • In consideration of the possiblity of hypopharyngeal ca. and gastric ca., I will follow up the biopsy result (Lt hypopharynx and stomach) next Monday (10/30) and discuss the treatment plan with medical oncologist Dr. Hsia accordingly. Thank you very much.
  • 2023-10-26 Hemato-Oncology
    • Q
      • This 68 year old man is a case of Squamous cell carcinoma of esophageal cancer, middle third, moderately differentiated, cT2N2M0, stage IIIB. He will received port A insertion and jejunostomy on 2023/10/30. We are consulted for CCRT.
      • Please check HBsAg, Anti HBc, Anti HBs, Anti HCV before chemotherapy.
      • We will disucss with patient about CCRT with PF. Thanks for your consultation.

[surgical operation]

  • 2023-10-30
    • Surgery: Laryngomicrosurgery    
    • Finding: Left arytenoid and AE fold uneven mucosal surface
  • 2023-10-30
    • Surgery: Feeding jejunostomy + port-A insertion.
    • Finding
      • 8.0 Fr. Polysite, left cephalic vein, cut-down method.
      • 18 Fr. silicon Foley catheter as jejunostomy tube.

[chemotherapy]

  • 2023-12-18 - NS 500mL 2hr (before CDDP) + cisplatin 75mg/m2 110mg NS 500mL 4hr + NS 500mL 2hr (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL D1-4
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-01-04

The patient is properly hydrated and Cefim (cefepime) has been dose adjusted for the patient’s renal function. G-CSF (filgrastim) is used for neutropenia. No medication discrepancies are found.

2023-12-19

The entirety of the oral medications listed on the active medication list are compatible with enteral feeding administration.

2023-11-06

All of the oral drugs on the list of active medications can be fed by tube.

700175387

240104

[exam findings]

  • 2024-01-01, 2023-12-11 KUB

    • Scoliosis of the L-spine with convex to right side.
    • Wedge deformity at right lateral aspect of L2 vertebral body is noted.
  • 2023-12-12 MRI - brain

    • Old lacuna infarcts over right putamen and inferior capsule.
    • One lobulated mass lesion (40.8mm) over left carotid space, encasement of ICA and ECA. R/O neurogenic tumor or enlarged nodes or metastatic lesion. Suggest check enhanced study.
  • 2023-10-20 Patho - bone exostosis

    • Labeled as “L4 spine”, CT guided biopsy — diffuse large B cell lymphoma, non-germinal center type.
    • Section shows tissue diffusely infiltrated by diffuse large B cell lymphoma, non-germinal center type.
    • IHC stais: CD3 (focal +), CD20 (-), CD20 repeat stain: (-), CD79a (diffuse +), PAX5 (diffuse +), bcl-2 (+), bcl-6 (+) MUM-1 (+, > 30%), C-myc (-), Ki-67 (90%), CD23 (-), cyclin-D1: (-).
  • 2023-10-18 Nerve Conduction Velocity, NCV

    • Findings
      • Prolonged distal latenies in bilateral medial and ulnar CMAPs. Decreased amplitudesin all sampling CMAPs. Slowed CNVs in right medial, bilatal ulnar, peroneal and tibial CMAPs.
      • Proloned distallatencies and slowed NCVs in bilateral medial, ulnr and sural sNAPs.
      • Prolonged f-wave latencies followed all sampling nerve stimulations.
      • Absence of H-refelx peaks followed bilatral tibial nerve stimulations.
    • Conclusions
      • This abnormal NCV study suggested mix-type sensorimotor polyneuropathy superiposed polyradiculopathy.
  • 2023-10-17 PET

    • The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on both sides of the diaphragm and extralymphatic organ involvement as mentioned above (stage IV).
    • In comparison with the previous study on 2022/09/16, the previous FDG avid lesions in the lower mediastinum and upper abdomen are less evident or disappeared. However, more new FDG avild lesions are noted.
  • 2023-10-16 CT - chest

    • Indication: Diffuse large B-cell lymphoma, extranodal and solid organ sites
    • Findings:
      • Lungs: dependent band subsegmental consolidation or atelectasis at Rt lower lobe.
      • Chest wall and lower neck: extensive lymphadenopathies in left neck from the level of the nasopharynx to the supraclavicular fossa. enlarged LNs at Rt supraclavicular fossa.
      • Mediastinum and hila: no enlarged LN or mass.
        • mild coronary arterial calcification
      • Thoracic aorta: normal caliber, mild atherosclerotic change of Heart: normal size of cardiac chambers.
      • Pleura: no effusion but Rt posterior pleural thickeing.
      • Visible abdominal-pelvic contents: large soft-tissue mass in Rt lower posterior retroperitoneum involving the psoas muscles.
        • a 13mm low attenuation in the spleen.
        • mild soft tissue lesion in para-aortic and para-cava spaces stationary
        • unremarkable of the liver, GB, both adrenal glands, pancreas, and both kidneys.
        • marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • Diffuse large B-cell lymphoma, in both sites of diaphgram with extranodal and solid organ sites.
  • 2023-10-14 MRI - L-spine

    • Indication: Diffuse large B cell lymphoma, non- GCB, stage III, S/P chemotherapy with R-CHOP
    • Thoraco-lumbar spine MRI without and with IV Gd-DTPA administration shows:
      • Abnormal abundant soft tissue in right low parasinal and psoas muscle regions.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Dilated right ureter, likely due to tumor obstruction.
      • A small focal right L4 body leison.
      • Thick and well enhanced nerve roots in low lumbar spine due to tumor infiltration?
      • Correlation with previous imaging study for comparison is suggested.
  • 2023-10-13 L-spine AP + Lat. (including sacrum)

    • Scoliosis of the L-spine with convex to right side.
    • Wedge deformity at right lateral aspect of L2 vertebral body is noted. Please correlate with clinical symptom and history.
  • 2023-10-12 MRI - brain

    • Imaging finding:
      • Old lacuna infarcts over right putamen and internal capsule.
      • The size of the cerebral ventricles is normal.
      • There is no space occupying lesion in the brain or midline shift of the brain supratentorially or infratentorially.
      • The intracranial vessels are normally signal-void.
      • The paranasal sinuses and mastoid air cells are aerated.
      • The globes, optic nerve and extraoccular muscles are sketchyily intact in the non-FatSat images.
      • 3D TOF MR angiography of circle of Willis reveals no aneurysm or vascular malformation. The intracranial vessels in the territories of anterior, middle and posterior cerebral arteries and vertebro-basilar arteries are of normal in calibres and flows. No focal stenosis is identified.
    • Impression:
      • Old lacuna infarcts over right putamen and internal capsule.
  • 2023-10-12 CT - brain

    • Mild cortical brain atrophy. Old right putamen-corona radiata infarct. Abnormal abundant soft tissue mass? in left skull base, anterior lateral C1 region, nature?
    • With abnormal soft tissue in left anterior lateral skull base/C1 region, nature?
  • 2023-10-06 Nasopharyngoscopy

    • B cell lymphoma
    • left neck mass, progressive recent weeks
  • 2023-10-06 SONO - ENT head and neck soft tissue

    • Clinical Impression/Intent: LEFT NECK MASS LEVEL II
    • Sonographic Impression: LEFT NECK LEVEL II MULTIPLE LAP, ROUND NO CENTRAL HILUM, R/O MALIGNANCY
  • YYYY-MM-DD many omitted …

  • 2022-09-30 KUB

    • Stool impaction at the abdominal cavity is noted.
    • Phlebolith at pelvic cavity is also found.
  • 2022-09-19 CXR

    • Blunted bilateral CP angle is found.
  • 2022-09-16 Whole body PET scan

    • The FDG PET findings are compatible with lymphoma involving the huge confluent soft tissue masses in the retroperitoneal space, stomach, multiple focal areas in the abdominal and pelvic cavities and some focal areas in the mediastinum. Please correlate with other clinical findings for further evaluation.
  • 2022-09-09 CT - abdomen

    • Findings:
      • There is huge confluent soft tissue masses in retroperitoneal space with total encasement of celiac trunk, superior mesenteric artery, abdominal aorta, and bilateral renal artery. The largest cranial-caudal dimension of this mass measuring 19 cm in size.
        • In addition, There are multiple enlarged nodes in the omentum, mesentery, gastrohepatic ligament, para-aortic space, bilateral common iliac chain.
        • Malignant lymphoma is highly suspected.
      • There is mild ascites in the pelvis.
      • There are minimal pleura effusion in bilateral posterior basal CP angle.
    • Impression:
      • Malignant lymphoma is highly suspected.
        • CT-guided biopsy is indicated.
  • 2022-09-08 Patho - stomach biopsy

    • Stomach, AW of low body, biopsy — Diffuse large B cell lymphoma, non- GCB
    • Histology type: B-cell neoplasms — Diffuse large B-cell lymphoma (any subtype)
    • Immunohistochemical stain profiles: Ki-67 index: 90%, CK(-), CD20(+), CD3(-, immunoreactive at background T cells), CD10(focal +), MUM-1(+), Bcl-2(+), CD23(-), CD5(focal+), C-myc (-, < 30%), cyclin D1(-).
  • 2022-09-08 Esophagogastroduodenoscopy, EGD

    • Highly suspected gastric cancer, Borrmann type III, AW of low body, s/p biopsy
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, s/p CLO test
    • Pseudodiverticula and deformed bulb
  • 2022-09-08 SONO - abdomen

    • Finding: A huge retroperitoneal lesion measured at least 13 cm was noted.
    • Diagnosis: Retroperitoneal tumor, huge
  • 2022-09-02 ECG

    • Sinus tachycardia
    • Possible Left atrial enlargement
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2021-10-12, 2020-11-02 SONO - neurology

    • Mild atheromatous lesions in R subclavian artery.
    • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
    • Poor temporal windows for transcranial insonation.
  • 2019-12-02 Carotid phonoangiograph, CPA

    • Sonographic diagnosis:
      • Mild atheromatous lesions in R distal CCA.
      • Normal extracranial carotid, vertebral, and L intracranial basal cerebral arterial flows.
      • Poor R temporal windows for transcranial insonation.

[MedRec]

  • 2017-03-22 SOAP Neurology Xiao ZhenLun
    • Diagnosis
      • Cerebral artery occlusion, with cerebral infarction [I63.511]
      • Essential hypertention, unspecified [I10]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Prescription x3
      • Romicon-A (dextromethorphan, cresolsulfonate, lysozyme) 1# TID
      • Allegra (fexofenadine 60mg) 1# BID
      • Mefno (mephenoxalone 200mg) 1# BID
      • Tonec (aceclofenac 100mg) 1# BID
      • Pentop (pentoxifylline 400mg) 1# BID
      • Robestar (rosuvastatin 10mg) 1# QD
      • Uformin (metformin 500mg) 0.5# BIDCC
      • Bokey (aspirin 100mg) 1# QD

[consultation]

  • 2023-12-14 Rehabilitation
    • A
      • P
        • Rehabilitation programs: arrange bedside PT and OT rehabilitation programs.
        • Goal: recondition; maintain ROM; improve endurance and muscle strength.
  • 2023-12-12 Radiation Oncology
    • Q
      • for radiotherapy evaluation
      • This is a 64 years-old female who has the history of Old CVA at right cerebral artery, hypertension, type II DM, hyperlipidemia with medication control, Diffuse large B cell lymphoma, non-GCB , stage III s/p R-CHOP and regular follow-up at our OPD.
      • The patient complaints edema at left eye, and Diplopia noted for 2 days, follow-up brain MRI (2023/12/12) revealed 1. Old lacuna infarcts over right putamen and inferior capsule. 2. One lobulated mass lesion (40.8mm) over left carotid space, encasement of ICA and ECA. R/O neurogenic tumor or enlarged nodes or metastatic lesion. Suggest check enhanced study, so we need your help for radiotherapy evaluation, thanks a lot!!
    • A
      • Diagnosis: Diffuse large B cell lymphoma, non-GCB, origin from stomach, stage III s/p 7th R-CHOP on 2023/04/28 with relapse and involvement of right low paraspinal and psoas muscle & nerve roots in low lumbar spine, r stage IV; ECOG 3.
      • Plan: R/T to left retro-pharyngeal tumor for 2500cGy/10 fx is suggested for symptom control & neurological sequela. CT simulation is arranged on Dec 13 15:30 and possible RT toxicity is told. Diet education.
  • 2023-10-26 Rehabilitation
    • A
      • Due to deconditioning, we were consulted for bedside PT rehabilitation programs
      • Premorbid status
        • Walk ID / BADL ID
      • Physical examination
        • 2023/10/26 20:05 T/P/R: 36.2’C / 119bpm / 18bpm BP:154/79mmHg
        • Body weight: 42.5
          • Consciousness: E4V5M6
          • Cognition: grossly intact
          • Sphincter: urinary and stool incontinence with diaper
          • Muscle power:
            • RUE/RLE 2/2
            • LUE/LLE 4/3
          • Functional status: roll ID; sit up under modA with poor to fair balance
          • BADL: light hygiene modA / heavy hygiene: maxA
      • Assessment
        • Diffuse large B cell lymphoma, non- GCB, involving multiple lymph node regions on both sides of the diaphragm and extralymphatic organ involvement as right psoas muscle, lower lumbar spines, sacrum and possible adjacent nerve roots (stage IV), status post chemotherapy with R-CHOP
        • Old lacuna infarcts over right putamen and internal capsule about 7 years ago with mild left hemiparesis
        • Mix-type sensorimotor polyneuropathy superiposed polyradiculopathy
      • Plan
        • Rehabilitation programs: arrange bedside PT rehabilitation programs.
        • Goal: recondition; maintain ROM; improve endurance and muscle strength.
  • 2023-10-18 Radiation Oncology
    • Q
      • for radiotherapy evaluation
      • This is a 64 years-old female who has the history of Old CVA at right cerebral artery, hypertension, type II DM, hyperlipidemia with medication control, Diffuse large B cell lymphoma, non-GCB, stage III s/p R-CHOP and regular follow-up at our OPD.
      • The patient complaints bilateral lower limbs numbness, and right side weakness, T-L spine MRI revealed A small focal right L4 body leison, neck-chest CT: large soft-tissue mass in Rt lower posterior retroperitoneum involving the psoas muscles, marginal spurs of multiple vertebrae due to spondylosis, so we need your help for radiotherapy evaluation, thanks a lot!!
    • A
      • Subjective:
        • History: This is a 64 years-old female who has the history of diffuse large B cell lymphoma, non- GCB , stage III s/p 7th R-CHOP on 2023/4/28 and regular follow-up at our OPD. The patient complaints bilateral lower limbs numbness, and right side weakness. Her T-L spine MRI on 10/14 revealed abnormal abundant soft tissue in right low parasinal and psoas muscle regions; dilated right ureter, likely due to tumor obstruction; a small focal right L4 body lesion; thick and well enhanced nerve roots in low lumbar spine due to tumor infiltration. Neck-chest CT showed large soft-tissue mass in Rt lower posterior retroperitoneum involving the psoas muscles, marginal spurs of multiple vertebrae due to spondylosis. PET scan showed increased FDG uptake in the right psoas muscle (SUVmax early: 14.12, delay: 17.59), in the lower lumbar spines, sacrum and possible adjacent nerve roots (SUVmax early: 13.30, delay: 18.71); but no FDG uptake over C spines.
          • Previous RT: denied.
          • Other disease: Old CVA at right cerebral artery; hypertension; type II DM; hyperlipidemia with medication control.
          • Family history: denied.
            • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
            • Married. Caregiver: her husband (survivor of buccal cancer s/p OP, R/T > 10 years ago). Job: housewife. Mild or no economic stress at least.
            • Language: Mandarin. Taiwanese.
            • Religion: Buddhism.
      • Objective:
        • General Condition-ECOG: 3.
        • PE, 2023/10/18: Multiple LAPs over bilateral necks and SCFs. Rt upper and lower limb muscle power: only 2/5.
        • Pathology, 2022/9/08, Stomach, AW of low body, biopsy— Diffuse large B cell lymphoma, non- GCB.
        • Images:
          • Brain MRI, 2023/10/12: Old lacuna infarcts over right putamen and internal capsule.
          • T-L spine MRI, 2023/10/14 revealed abnormal abundant soft tissue in right low parasinal and psoas muscle regions; dilated right ureter, likely due to tumor obstruction; a small focal right L4 body lesion; thick and well enhanced nerve roots in low lumbar spine due to tumor infiltration.
          • CT, 2023/10/16: Chest wall and lower neck: extensive lymphadenopathies in left neck from the level of the nasopharynx to the supraclavicular fossa. Enlarged LNs at Rt supraclavicular fossa. Pleura: no effusion but Rt posterior pleural thickening. Large soft-tissue mass in Rt lower posterior retroperitoneum involving the psoas muscles. A 13mm low attenuation in the spleen. Mild soft tissue lesion in para-aortic and para-cava spaces, stationary. Imp: Diffuse large B-cell lymphoma, in both sites of diaphragm with extranodal and solid organ sites.
          • PET scan, 2023/10/17: There was increased FDG uptake in the left neck and left supraclavicular lymph nodes (SUVmax early: 23.30, delay: 31.55), right lower neck and right supraclavicular lymph nodes (SUVmax early: 16.33, delay: 24.67), bilateral axillary lymph nodes (SUVmax early: 17.01, delay: 26.20), some mediastinal lymph nodes (SUVmax early: 13.49, delay: 23.66), multiple right abdominal and pelvic lymph nodes (SUVmax early: 19.24, delay: 25.43), right inguinal lymph nodes (SUVmax early: 11.61, delay: 16.12) and possible lymph nodes in bilateral thighs (SUVmax early: 19.01, delay: 31.93).
            • Besides, there was increased FDG uptake in the right psoas muscle (SUVmax early: 14.12, delay: 17.59), in the lower lumbar spines, sacrum and possible adjacent nerve roots (SUVmax early: 13.30, delay: 18.71). IMP: The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on both sides of the diaphragm and extralymphatic organ involvement as mentioned above (stage IV). In comparison with the previous study on 2022/09/16, the previous FDG avid lesions in the lower mediastinum and upper abdomen are less evident or disappeared.
          • Shoulder X-ray, 2023/10/13: No significant abnormality is seen in this study.
      • Diagnosis: Diffuse large B cell lymphoma, non- GCB, origin from stomach, stage III s/p 7th R-CHOP on 2023/04/28 with relapse and involvement of right low parasinal and psoas muscle & nerve roots in low lumbar spine, r stage IV; ECOG 3.
      • Plan: C spine MRI may be considered to R/O tumor involvement of C spinal cord and nerve root or intramedullary lesion. R/T to L spines, nerve roots and psoas muscle for 2500cGy/10 fx is suggested for symptom control & neurological sequela. CT simulation is arranged on Oct 19 08:30 and possible RT toxicity is told. Diet education and psychological support.
  • 2023-10-17 Neurology
    • Q
      • for bilateral lower limbs numbness, and right side weakness.
      • This is a 64 years-old female who has the history of Old CVA at right cerebral artery, hypertension, type II DM, hyperlipidemia with medication control, Diffuse large B cell lymphoma, non-GCB , stage III s/p R-CHOP and regular follow-up at our OPD.
      • The patient complaints bilateral lower limbs numbness, and right side weakness, T-L spine MRI revealed A small focal right L4 body leison, neck-chest CT: large soft-tissue mass in Rt lower posterior retroperitoneum involving the psoas muscles, marginal spurs of multiple vertebrae due to spondylosis, so we need your help for evaluation, thanks a lot!!
    • A
      • This 64 y/o female p’t is a case of olf right hemisphere infarction, HTN, DM, and hyperlipidemia with regular F/U at our OPD. He is also a caw of B-cell lymphoma with regular F/U at Hema OPD.
      • Since 2023/08/24, easy chocking and bulatral leg numbness was noted. She visited our ER on 8/29 and I arranged brain CT for excluded recurrent stroke in left hemisphere but no no newly lesion was noted.
      • This time, she admitted at Hema ward. Due to right leg weakness became worse, brain MRI and L-spine MRI was performed. So, we were consulted for further evaluation .
        • E4V5M6
        • Pupil: 3+/3+
        • EOM: Full
        • dysarthria:-
        • Dysphagia:+/- (no obvious chnage when compared to 8/29)
        • sensory:Bilateral leg numbness (smilar to 8/29)
        • MP:Rl: 2, RU:4Left limbs: all 4
        • DTR: bilateral knee:+, left ankle:+, right ankle: -
      • Imp:
        • right lumbosacral radiculopathy, highly suscepted tumor related
        • old Left henmisphere infarction
        • B-cell lymphoma
        • DM
        • HTN
        • Hyperlipidemia
      • Suggestion:
        • We agreed your treatment plan for tumor biopsy
        • may consider arrange lower limb NCV study (motor, sensory, F-wave, H-reflex), but this study only for pre-treatment baseline data collection.
        • Due to complainted right leg radiation pain, may increase neurontin to 2# tid, may titrate to 3# tid if necessary
        • Consider tramacet 1# prnHS
        • F/U consultation prn.
  • 2023-10-16 Radiation Oncology
    • Q
      • for biopsy at L4
      • This is a 64 years-old female who has the history of Old CVA at right cerebral artery, hypertension, type II DM, hyperlipidemia with medication control, Diffuse large B cell lymphoma, non- GCB , stage III s/p R-CHOP and regular follow-up at our OPD.
      • The T-L spine MRI revealed A small focal right L4 body leison, so we need your help for biopsy, thanks a lot!!
    • A
      • According to the clinical condition and imaging findings, biopsy is indicated.
  • 2022-10-24 Infectious Disease
    • Q
      • This time, PortA blood culture yeild Candida albicans. Blood cultrure yield yeast-like, Pending culture result. WBC:18.26 *10^3/uL . we need your help, thank you a lot!
    • A
      • Consultatiaon for anti-fungal Mycamine
        • There was MRSA and Enterococcus bacteremia on 2022-10-14, followed by Candida albicans candidemia on 2022-10-20.
        • Peripheral blood and Port-A blood culture all shows Candida albicans isolate.
        • Use of Candin drug acceptable.
        • Since there is no GNB isolate, further use of Mepem can be stopped.
        • For MRSA bacteremia, Targocid can be shifted to oral Avelox or Cipro as sequential therapy to complete 3-week treatment course.
      • Suggestion:
        • DC Mepem and fluconazole
        • Add oral Avelox or Cipro
        • Add Mycamine 100mg iv qd for one week first
        • Repeat Port-A and peripheral blood culture 3 days later, to see if there is sterile blood.
  • 2022-10-15 Infectious Disease
    • A
      • Consultation for Mepem antibiotic
        • Covid-19 related right lung pneumonia and post-chemotherapy neutropic fever with severe sepsis case.
        • Now Mepem and Targocid use.
        • Preliminary blood culture shows GPC isolate.
      • Suggestion:
        • Continue Mepem and Targocid for 3 days first.
        • Check blood and sputum culture report for further antibiotic adjustment.

[immunochemotherapy]

  • 2024-01-04 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + methylprednisolone 500mg NS 100mL 30min D1-4 + etoposide 40mg/m2 50mg NS 150mL 1hr D1-4 + cisplatin 25mg/m2 30mg NS 500mL 18hr D1-4 + cytarabine 2000mg/m2 2000mg NS 500mL 2hr D5 (R-ESHAP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug D1,4 + NS 250mL D1,4
  • 2023-12-11 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + methylprednisolone 500mg NS 100mL 30min D1-4 + etoposide 40mg/m2 50mg NS 150mL 1hr D1-4 + cisplatin 25mg/m2 30mg NS 500mL 18hr D1-4 + cytarabine 2000mg/m2 2000mg NS 500mL 2hr D5 (R-ESHAP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug D1,4 + NS 250mL D1,4
  • 2023-11-16 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + methylprednisolone 500mg NS 100mL 30min D1-4 + etoposide 40mg/m2 50mg NS 150mL 1hr D1-4 + cisplatin 25mg/m2 30mg NS 500mL 18hr D1-4 + cytarabine 2000mg/m2 2000mg NS 500mL 2hr D5 (R-ESHAP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug D1,4 + NS 250mL D1,4
  • 2023-10-24 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + methylprednisolone 500mg NS 100mL 30min D1-4 + etoposide 40mg/m2 50mg NS 150mL 1hr D1-4 + cisplatin 25mg/m2 30mg NS 500mL 18hr D1-4 + cytarabine 2000mg/m2 1500mg NS 500mL 2hr D5 (R-ESHAP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug D1,4 + NS 250mL D1,4
  • 2023-04-28 - rituximab 375mg/m2 550mg NS 500mL 4hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (R-CHOP Q3W)
    • [diphenhydramine 30mg + acetaminophen 500mg PO + methylprednisolone 40mg + NS 250mL] (before Mabthera) + dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL
  • 2023-04-07 - rituximab 375mg/m2 550mg NS 500mL 4hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (R-CHOP Q3W)
    • [diphenhydramine 30mg + acetaminophen 500mg PO + methylprednisolone 40mg + NS 250mL] (before Mabthera) + dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL
  • 2023-02-24 - rituximab 375mg/m2 540mg NS 500mL 4hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (R-CHOP Q3W)
    • [diphenhydramine 30mg + acetaminophen 500mg PO + methylprednisolone 40mg + NS 250mL] (before Mabthera) + dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL
  • 2023-02-01 - rituximab 375mg/m2 540mg NS 500mL 4hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (R-CHOP Q3W)
    • [diphenhydramine 30mg + acetaminophen 500mg PO + methylprednisolone 40mg + NS 250mL] (before Mabthera) + dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL
  • 2023-01-17 - rituximab 375mg/m2 540mg NS 500mL 4hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (R-CHOP Q3W)
    • [diphenhydramine 30mg + acetaminophen 500mg PO + methylprednisolone 40mg + NS 250mL] (before Mabthera) + dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL
  • 2022-12-22 - (R-CHOP Q3W)
  • 2022-12-01 - (R-CHOP Q3W)
  • 2022-10-03 - (R-CHOP Q3W)

R-ESHAP (rituximab, etoposide, methylprednisolone, cytarabine, cisplatin) - from 2023-11-17 https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-patients-who-are-medically-fit

  • Administration - R-ESHAP refers to
    • rituximab 375 mg/m2 on day 1,
    • etoposide 40 mg/m2/day as a one-hour infusion on days 1 to 4,
    • methylprednisolone 250 to 500 mg/day as a 15-minute infusion on days 1 to 5,
    • cisplatin 25 mg/m2/day as a continuous infusion from day 1 to 4, and
    • cytarabine 2 g/m2 as a two-hour infusion on day 5,
    • every three or four weeks.
  • Adverse effects
    • Hematologic toxicity is universal, with significant rates of neutropenic fever (30 percent) if growth factors are not used.
    • Other AEs (eg, nausea, vomiting, diarrhea, nephrotoxicity, electrolyte disturbances) are generally mild.
  • Outcomes
    • A retrospective study of 163 patients reported that R-ESHAP for relapsed DLBCL was associated with a 75 to 86 percent ORR and 41 to 50 percent CR, while for primary refractory DLBCL, ORR was 33 percent and CR was 8 percent.

==========

2024-01-04

The latest lab results, drawn on 2024-01-03, show that the patient’s neutropenia has resolved.

  • 2024-01-04 WBC 11.05 x10^3/uL
  • 2023-12-27 WBC 11.88 x10^3/uL
  • 2023-12-25 WBC 0.33 x10^3/uL ***
  • 2023-12-18 WBC 1.21 x10^3/uL **
  • 2023-12-07 WBC 28.29 x10^3/uL

The sputum aerobic culture, drawn on 2023-12-22, grew S. aureus (MRSA). The patient was started on Targocid (teicoplanin) on 2023-12-12 and continued on this medication until 2024-01-02. Avelox (moxifloxacin) was started on 2023-12-27 and is still being used.

Both CRP and PCT levels on 2024-01-04 were undetectable. Given this, kindly reassess whether the patient still exhibits any potential signs of infection.

2023-11-17

Leukopenia was observed in early Nov, approximately 1 to 2 weeks after the patient first started the R-ESHAP regimen on 2023-10-24. The WBC reading has since returned to almost normal, and no further treatment is currently required.

  • 2023-11-16 WBC 3.29 x10^3/uL
  • 2023-11-08 WBC 1.28 x10^3/uL ** Granocyte (lenograstim 250ug administered)
  • 2023-11-02 WBC 1.83 x10^3/uL **
  • 2023-10-30 WBC 4.47 x10^3/uL
  • 2023-10-22 WBC 5.52 x10^3/uL
  • 2023-10-19 WBC 6.69 x10^3/uL

2022-10-14

  • Tube feeding is possible with all oral medications included in the active prescription.

  • The CNS depressant estazolam might enhance the CNS depressant effect of tramadol, so please monitor any adverse effects as always.

2022-10-03

  • In the case of this patient, who has recently been diagnosed with DLBCL, RCHOP might be an option for treatment.
  • Under prescribed medications, blood pressure and blood sugar levels were in acceptable ranges.
  • Serum electrolyte imbalances (lab data 2022-10-03) are treated with corresponding supplements currently.
  • Hypoalbuminemia (2.6 g/dL 2022-10-03), could it be due to albumin loss in the urine in the nephrotic syndrome? due to decreased hepatic albumin synthesis?
  • There is no issue with the active prescription.

700532258

240104

[exam findings]

  • 2023-12-26 CXR erect
    • Solitary pulmonary nodule at RUL.
  • 2023-12-26 SONO - abdomen
    • Two hepatic cyst measuring 1 cm and 0.8 cm at S3.
    • Multiple gallstones (< 1 cm) are noted.
  • 2023-10-11 CT - chest
    • Indication: breast cancer with lung metastasis
    • With and without contrast enhancement CT of chest shows:
      • s/p mastectomy.
      • Mild regression of left axillary lymph nodes.
      • Small nodules in both lung fields, mild in regression.
      • Hyperdense gallstones.
    • Impression
      • Brease CA, s/p operation
      • Lung and left axillary lymph node metastasis, mild in regression
  • 2023-10-05 SONO - abdomen
    • Sonography of hepatobiliary system revealed:
      • Left liver cysts (0.66x0.95cm, 0.73x0.91cm).
      • Gallbladder stones (up to 0.86cm).
    • IMP:
      • Left liver cysts (0.66x0.95cm, 0.73x0.91cm). Gallbladder stones (up to 0.86cm).
  • 2023-04-10 CT - chest
    • Indication: left breast cancer s/p MRM with lung and LN mets
    • Findings: comparison was made with previous CT dated on 2022/07/07
      • Lungs:
        • multiple nodules as miliary and small nodular patterns in bilateral lungs consistent with lung metastases, seem stationary as compared with CT on 2022/07/07
      • Mediastinum and hila no enlarged LN or mass.
        • old tiny calcified LNs in both hila.
      • Chest wall and lower neck: stastionary of small left axillary LAP as compared with CT on 2022/7/7. s/p Lt MRM.
      • Visible abdominal contents: tiny gall bladder stones.
      • Visualized bones: marginal spurs of vertebrae and no lytic or blastic change.
    • Impression:
      • left breast ca s/p MRM with stationary of lung metastass as compared with CT on 2022/07/07
  • 2022-12-27 SONO - abdomen
    • Two hepatic cyst measuring 1 cm and 0.8 cm at S3.
    • Multiple gallstones (< 1 cm) are noted.
  • 2022-11-03 CT - abdomen
    • S/P left MRM.
    • Left liver cysts (up to 7.6mm).
    • Hyperplasia of left adrenal gland.
    • Gallbladder stones (2-4mm).
  • 2022-10-04 SONO - abdomen
    • Two hepatic cyst measuring 1 cm and 0.8 cm at S3.
    • Multiple gallstones (< 1 cm) are noted.
  • 2022-07-07 CT - chest
    • Hx
      • Lt breast ca biopsied at Far Eastern Hospital.
      • Lt breast ca s/p MRM at our hospital on 2013-03-29
      • Adjuvant C/T (FEC) since 2013-04-15
    • Chest CT with and without IV contrast ehnancement shows:
      • Mild atelectatic change at bilateral basal lungs is found.
      • Non-specific lymph nodes are found at left axillary region. In comparison with CT dated on 202-01-20, the lesion is stationary.
      • One calcified dot at right upper lobe up to 0.43cm in largest dimension.
      • There is stone at dependent portion of GB. GB stone(s) are noted.
    • Imp:
      • S/P mastectomy at left side.
      • Non-specific lymph nodes at left axillary region. Stable.
      • Right upper lobe calcified dot. Old granulation is favored.
  • 2022-01-20 CT - chest
    • Hx
      • Lt breast ca biopsied at Far Eastern Hospital.
      • Lt breast ca s/p MRM at our hospital on 2013-03-29
      • Adjuvant C/T (FEC) since 2013-04-15
      • AI since 2013-08-26 and extension therapy or E/T 5 yrs
    • Chest CT with and without IV contrast ehnancement shows:
      • Calcified dot at right upper lobe up to 0.3cm in largest dimension is found. (Se9 IM22).
      • Several tiny nodular lesions scattered at both lungs are found. LUng meta is considered. In comparison with CT dated on 2021-08-03, the lesions are stationary.
      • S/P mastectomy at left side.
      • Scoliotic alignment of the thoracolumbar spine is noted.
      • Degenerative change of the bony structure with marginal osteophyte formation is identified.
      • The GB is well distended without soft tissue lesion
    • Imp:
      • S/P mastectomy at left side.
      • Diffuse lung meta. Stationary.
  • 2021-09-23 Tc-99m MDP bone scan
    • In comparison with the previous study on 2020/9/29, the lesions in the lower C-spine, lower T-spine and L4-5 spines are either stationary or a little less evident. Degenerative change may show this picture.
    • The previous faint hot spots in bilateral rib cage and the lesion in the distal portion of the sternal body are less evident, possibly more benign in nature.
    • Increased activity in the maxilla and mandible. Dental prolbem may show this picture.
    • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
  • 2021-08-03 CT - chest
    • Impression: left breast ca s/p MRM with stationary of lung and left axillary LN metastass as compared with CT on 2021/02/16
  • 2021-02-16 CT - chest
    • Impression: left breast ca s/p MRM with stationary of lung metastases and regression of left axillary LN metastass as compared with CT on 2020/09/08.
  • 2020-09-29 Tc-99m MDP bone scan
    • Increased activity in the lower C-spine, lower T-spine and L4-5 spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Increased activity in the maxilla and mandible. Dental prolbem may show this picture.
    • Some faint hot spots in bilateral rib cage and mildly increased activity in the distal portion of the sternal body. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.

[MedRec]

  • 2023-11-13 SOAP Neurology
    • S
      • 2023/11/13: neurological condition stable
      • 2023/08/21: more cramp, try requip bid
      • 2023/05/29: more cramp, add trental –> improved
      • 2022/12/07: keep plavix qw1357 prevention (self-pay)
      • 2022/09/19: clinical stable, keep current dose, 3m
      • 2022/06/27: clinical stable, 3m
      • 2022/03/30: f/u carotid sono: mild P, right SCA, bil BIF, little progression, f/u carotid sono every year, keep low dose plavix prevention
      • 2022/01/05: less cramp with current dose, 3m
      • 2021/10/13: vital signs stable, 3m
      • 2021/07/19: clinical stable, taper plavix, 3m
      • 2021/04/26: clinical stable, 3m
      • 2021/02/01: less cramp, keep current dose, 3m
      • 2020/12/07: easy cramp, less effect with rivotril, try rivotril +requip, 2m
      • 2020/10/14: NCV: WNL, electrolyte: WNL, easy cramp at night, increase rivotril dose
      • 2020/09/07: left leg soreness and weakness, 1 month, check NCs and ABI
      • 2020/06/15: clinical stable, 3m
      • 2020/03/23: f/u carotid sono: mild P, left BIF, improved, keep current dose, 3m
      • 2020/02/24: no discomfort with plavix, f/u carotid sono for medication adjustment
      • 2020/02/17: gemfibrozil was added at LMD, severe HA with pletaal, try plavix(self-pay)
      • 2020/02/03: epigastric pain with licodin, try pletaal, TG 250, diet control, f/u
      • 2019/11/04: stable, 3m
      • 2019/09/16: less pain but numbness, increase licodin dose
      • 2019/07/22: WBC 4200, Cr 0.7, stable with current dose
      • 2019/06/24: stable with current dose, f/u CBC and renal function
      • 2019/06/17: little effect, no sleepy, increase dose, carotid sono: mod P, RSCA, mild P, bil BIF, epigastric pain with ASA, try licodin
      • 2019/06/03: more fullness and tingling discomfort over bil feet, less effect with neurontin this time, try lyrica; neck stiffness and pain and limited motion, try celebrex PRN
      • 2019/05/06: HA with cerenin, less tingling pain and numbness, consider to taper neurontin next time
      • 2019/04/08: no discomfort with cerenin, keep current dose, increase neurontin dose
      • 2019/03/25: HA with trental, try cerenin, check electrolyte & vit B12, Hb
      • 2019/02/25: s/s recurred, related to weather change, re-add rivotril, trental & neurontin
      • 2018/07/02: improved, more cramp recently, increase rivotril dose, 2m
      • 2018/06/04: no response to neurontin 2# bid, try cymbalta
      • 2018/05/07: sometimes more pain and sleepy, DC TCa, increase neurontin
      • 2018/03/12: sometimes more tingling discomfort, increase neurontin
      • 2018/01/15: sometimes more tingling discomfort, related to weather change
      • 2017/12/18: still numbness, no severe pain, try neurontin
      • 2017/11/20: blood exam: WNL, less tingling pain, still numbness, increase trental, keep TCA
      • 2017/11/06: still bil feet numbness, try TCA, check metabolic condition
      • 2017/10/9: HA with TCA, clinical improved with rivotril & trental, increase dose
      • 2017/09/25: NCV: right C4 radiculopathy and left L45 radiculopathy; less cramp and tingling pain still numbness, try TCA
        • bil feet numbness and tingling pain, easy cramp, years, more severe after op
      • Hx
        • Lt breast ca biopsied at Far Eastern Hospital.
        • Lt breast ca s/p MRM at our hospital on 2013-03-29
        • Adjuvant C/T (FEC) since 2013-04-15
        • AI since 2013-08-26 and extension therapy
    • Diagnosis
      • Cerebral atherosclerosis [I67.2]
      • Polyneuropathy [G62.9]
      • Cramp [R25.2]
    • Prescription x3
      • Lyrica (pregabalin 75mg) 1# Q12H
      • Rivotril (clonazepam 0.5mg) 1# HS
      • Pentop (pentoxifylline 400mg) 0.5# HS
      • Mirapex (pramipexole 0.375mg) 1# HS

[chemotherapy]

  • 2024-01-03 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-12-06 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-11-10 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-10-11 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-09-14 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-08-17 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-07-19 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-06-21 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-05-25 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-04-26 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-03-30 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-03-01 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-02-01 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-12-28 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-11-30 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-11-02 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-10-05 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-09-07 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-08-10 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-07-13 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-06-15 - fulvestrant 500mg IM - Zhang YaoRen OPD
  • 2022-05-18 - fulvestrant 500mg IM - Zhang YaoRen OPD
  • 2022-04-20 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-03-23 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-02-23 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-01-26 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-12-29 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-12-01 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-11-03 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-10-06 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-09-08 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-08-11 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-06-16 - fulvestrant 500mg IM - Zhang YaoRen OPD
  • 2021-05-19 - fulvestrant 500mg IM - Zhang YaoRen OPD
  • 2021-04-21 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-03-24 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-02-24 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-01-27 - fulvestrant 500mg IM - Zhang YaoRen
  • 2020-12-30 - fulvestrant 500mg IM - Zhang YaoRen
  • 2020-12-02 - fulvestrant 500mg IM - Zhang YaoRen
  • 2020-10-07 - fulvestrant 500mg IM - Zhang YaoRen

Ibrance (palbociclib 125mg -> 100mg since 2024) 1# QDCC - 2022-09-07 ~ 2024-01-24 ongoing (21 days of 28 days) Kisqali (ribociclib 200mg) 3# QD - 2020-10-07 ~ 2022-08-03 (21 days of 28 days)

Femara (letrozole 2.5mg) 1# QD - 2017-02-20 ~ 2018-10-01 (repeat prescription)

==========

2024-01-04

[neutropenia]

The patient’s WBC count has been gradually declining for a long time. In late 2023, the count dropped to less than 2K/uL, which is considered grade 3 neutropenia.

  • 2023-12-26 WBC 1.83 x10^3/uL ** Neutrophil 45.5% => ANC 833/uL, grade 3
  • 2023-10-05 WBC 2.92 x10^3/uL *
  • 2023-07-05 WBC 2.16 x10^3/uL *
  • 2023-04-10 WBC 2.91 x10^3/uL *
  • 2023-03-01 WBC 2.32 x10^3/uL *
  • 2022-12-27 WBC 2.75 10^3/uL
  • 2022-11-30 WBC 2.55 10^3/uL
  • 2022-11-02 WBC 2.14 10^3/uL
  • 2022-10-30 WBC 2.89 10^3/uL
  • 2022-10-05 WBC 2.47 10^3/uL
  • 2022-09-19 WBC 2.22 10^3/uL
  • 2022-09-07 WBC 3.36 *10^3/uL
  • 2022-07-07 WBC 2.61 10^3/uL
  • 2022-04-12 WBC 2.47 10^3/uL
  • 2022-01-20 WBC 2.61 10^3/uL
  • 2021-11-03 WBC 3.79 *10^3/uL
  • 2021-09-07 WBC 3.15 *10^3/uL
  • 2021-06-16 WBC 2.77 10^3/uL
  • 2021-05-19 WBC 2.15 10^3/uL
  • 2021-04-21 WBC 3.62 *10^3/uL
  • 2021-02-16 WBC 3.49 *10^3/uL
  • 2020-12-30 WBC 3.12 *10^3/uL
  • 2020-12-02 WBC 3.73 *10^3/uL
  • 2020-11-04 WBC 3.03 *10^3/uL
  • 2020-10-21 WBC 3.12 *10^3/uL
  • 2020-10-05 WBC 5.40 *10^3/uL
  • 2020-08-31 WBC 5.06 *10^3/uL

The patient is currently taking fulvestrant and palbociclib as the main treatment medications. Fulvestrant was started on 2020-10-07, and palbociclib was started on 2020-09-07, to replace ribociclib.

The incidence of neutropenia for fulvestrant is 2%, with 1% grade 3 and <1% grade 4. The incidence of neutropenia for palbociclib is 80-83%, with 55-56% grade 3 and 10-11% grade 4. Therefore, neutropenia is more likely to be attributed to palbociclib.

It is recommended considering a palbociclib dose reduction in future cycles if recovery from grade 3 neutropenia is prolonged (>1 week) or if grade 3 neutropenia recurs on day 1 of subsequent cycles.

There is no evidence of prolonged neutropenia yet, but the dose of palbociclib has been reduced from 125mg daily to 100mg daily since 2024. This is a conservative approach.

701011695

240104

{not completed}

[past history]

  • Hypertension in 2009 with Diovan F.C 160mg 1# po QD control.
  • Bladder diverticulum s/p open repair 20 years ago.    
  • Left inguinal hernia s/p LESS TEP repair on 2019/07/31.
  • Bladder small cell neuroendocrine carcinoma and invasive urothelial carcinoma, high-grade, cT1N0M0, stage I s/p transurethral resection of bladder tumor on 110/12/01; s/p chemotherapy with etoposide + cisplatin for 4 times from 2022/01/12~2022/03/22.

[family history]

  • There is no family history of cancer.
  • Father and Mother: Hypertension. 

[exam findings]

  • 2023-11-28 Antegrade Pyelography
    • Antegrade pyelography revealed stricture of right ureter-neobladder anastomosis. The double-J catheter can not pass through the stricture site.
  • 2023-11-17 CT - abdomen
    • History: small cell neuroendocrine carcinoma and UC of bladder, cT1N0M0, s/p Robotic-assisted radical cystoprostatectomy (RARC) with neobladder reconstruction on 2022/04/11, ypT1N0(0/25) M0.
      • 20230317 s/p VATS RUL, RML, RLL wedge resection: lung metastases
      • 20231107 Renal US: right hydronephrosis.
    • Indication: right hydronephrosis r/o cancer related
    • Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
    • Findings: Comparison: prior CT dated 2023/07/03.
      • There is mild wall thickening at right M/3 ureter (Srs:7 Img:94-97), causing hydroureteronephrosis but no delayed contrast excretion of right kidney. Recurrent tumor is highly suspected.
      • Prior CT identified multiple metastases on both lungs are noted again, mild increasing in size and number. please correlate with clinical condition.
      • S/P radical cystoprostatectomy with neobladder reconstruction
      • Liver and renal cysts (up to 3.3cm).
      • S/P cholecystectomy.
    • Impression:
      • Recurrent tumor at right M/3 ureter is highly suspected.
      • Prior CT identified multiple metastases on both lungs are noted again, mild increasing in size and number.
  • 2023-11-10 Intravenous pyelography and post-voiding study, IVP
    • Findings
      • Dilatation of right pelvicaliceal system and ureter with obstruction level around anastomosis region.
      • S/P cystectomy and neobladder reconstruction.
    • IMP:
      • S/P cystectomy with neobladder reconstruction.
      • Right hydronephrosis and hydroureter with obstruction around the anastomosis region.
  • 2023-11-07 Bladder Sonography
    • PVR: 1.65 mL
  • 2023-09-28 CT - chest
    • Indication: Bladder Cancer with lung mets
    • Chest CT without IV contrast ehnancement shows:
      • Nodular lesions are found at both lungs up to 1.6cm at left lower lobe is found. (Se401 Im33), In comparison with CT dated on 2023-07-03, the lesions are enlarged slightly.
      • S/p port-A placement with its tip at Superior vena cava.
      • Hepatic cysts at both lobes of liver up to 3.09cm at dome is found.
      • s/p total cystectomy with ileoneobladder.
    • Imp:
      • Bilateral lung meta, slightly in enlargement.
  • 2023-07-21 All-RAS + BRAF mutation
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene.
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-07-03 CT - abdomen
    • Indication
      • Small cell neuroendocrine carcinoma and UC of bladder, cT1N0M0, s/p neoadjuvant Etoposide and cisplatin (4), s/p RARC with neobladder reconstruction on 2022/04/11, ypT1N0 (0/25) M0 with lung metastasis s/p VATS RUL, RML, RLL wedge resection + LND on 2023/03/17 and chemotherapy with EP (Etoposide 80mg/m2 x3 days / Cisplatin 25mg/m2 x3 days) on 2023/04/20~ check from pelvis to chest, please 3Q
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • S/p port-A placement with its tip at Superior vena cava.
        • s/p right upper lobe,
        • Tiny nodule at right lower lobe measuring 0.2cm is found. Some perifissural nodule at right lower lobe measuring 0.3cm is also noted. still other comet tail like nodule at left lingula lobe up to 0.4cm, right upper lobe tup to 0.2cm, 0.6cm and left upper lobe measuring 0.23cm are found. In comparison with CT dated on 2023-02-04, the lesions are statianry.
      • Visible abdomen:
        • s/p ileoneobladder.
        • s/p cholecystectomy.
    • Imp:
      • s/p cystectomy and ileoneobladder.
      • Recurrent/residual tumor at both lung fields. Stationary.
  • 2023-06-08, -05-09, -05-02 CXR
    • S/P port-A implantation.
    • There is multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
  • 2023-04-18 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 25 dB HL, LE 25 dB HL
    • bil normal to mild SNHL
  • 2023-04-11 CXR
    • Port-A catheter inserted into cavo-atrial junction via right subclavian vein.
    • elevation of Rt hemidiaphragm
    • Multiple nodules of variable sizes in both lungs due to metastases
    • a Rt minor fissure loculated effusion 44mm?
  • 2023-03-17 Patho - lung wedge biopsy
    • PATHOLOGIC DIAGNOSIS:
      • Lung, right, upper lobe, wedge resection —- small cell neuroendocrine carcinoma, in favor of metastatic
      • Lung, right, middle lobe, wedge resection —- small cell neuroendocrine carcinoma, in favor of metastatic
      • Lung, right, lower lobe, wedge resection —- small cell neuroendocrine carcinoma, in favor of metastatic
      • Lymph node, right, group No.9, lymphadenectomy —- Negative for malignancy (0/1)
      • Lymph node, right, group No.10, lymphadenectomy —- Negative for malignancy (0/1)
      • Lymph node, right, group No.11, lymphadenectomy —- Negative for malignancy (0/2)
  • 2023-02-14 CT guide biopsy
    • RUL nodule, s/p CT-buided biopsy
  • 2023-02-04 CT - chest
    • Indication: Urinary bladder with lung mets
    • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • S/p port-A placement with its tip at Superior vena cava.
        • Diffuse nodular lesions scattered at both lungs are found. Lung meta is considered. In comparison with CT dated on 2022-01-09, the lesions are enlarged in size and numbers.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Hepatic cysts at both lobes of liver is found.
        • s/p cholecystectomy.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp: Bilateral lung meta. In progression.
  • 2023-02-02 CT - abdomen
    • History and indication: Bladder tumor
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P urinary bladder operation.
      • Some nodules at bil. lungs.
      • Liver and renal cysts (up to 3.5cm).
      • Normal appearance of spleen, pancreas, adrenals.
      • S/P cholecystectomy.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
    • IMP:
      • S/P urinary bladder operation.
      • Some nodules at bil. lungs suspected metastases.
  • 2022-11-09, -08-17 CT - abdomen
    • History: small cell neuroendocrine carcinoma and UC of bladder, cT1N0M0, s/p neoadjuvant Etoposide and cisplatin (4), s/p Robotic-assisted radical cystoprostatectomy (RARC) with neobladder reconstruction on 2022-04-11, ypT1N0(0/25)M0
    • Indication: FU
    • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • S/P radical cystoprostatectomy with neobladder reconstruction
      • Liver and renal cysts (up to 3.3cm).
      • S/P cholecystectomy.
      • Others
        • There is no focal abnormality in the biliary system, pancreas, and spleen.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • S/P radical cystoprostatectomy with neobladder reconstruction
        • There is no evidence of tumor recurrence.
      • Detailed findings, please see description.
  • 2022-08-18, -05-26 Uroflowmetry
    • Q max: low
    • Flow pattern: obstructive
  • 2022-08-18 Bladder Sonography
    • PVR 1.59mL (post-void residual)
  • 2022-05-26 Bladder Sonography
    • PVR 1mL (post-void residual)
  • 2022-05-26 SONO - urology
    • Miction pain, treated outside in 2020-09, and 2021-02, s/p diverticulectomy, open 20 years ago. nocturia 3/n, SUI(+), wound: well
    • Diagnosis:
      • Right hydronephrosis
      • Bilateral renal stones
      • Left renal stone
  • 2022-04-20 Cystography
    • Cystography via foley catheter administration revealed:
      • The bladder capacity is about 100cc.
      • No evidence of contrast medium leakage.
  • 2022-04-12 Patho - urinary bladder partial/total resection
    • PATHOLOGIC DIAGNOSIS:
      • Urinary bladder, Robotic-assisted radical cystoprostatectomy (s/p TURBT) — infiltrating urothelial carcinoma, high-grade
      • Prostate, RARC (s/p TURP) — Non-invasive papillary urothelial carcinoma, high-grade (at prostatic urethra) — Free of apex margin
      • Seminal vesicles, bilateral, RARC — Negative for malignancy
      • Ureter cuff end, right, RARC — low-grade urothelial dysplasia
      • Ureter cuff end, left, RARC — Negative for malignancy
      • Lymph node, left iliac, dissection — Negative for malignancy (0/1)
      • Lymph node, right iliac, dissection — Negative for malignancy (0/3)
      • Lymph node, left obturator, dissection — Negative for malignancy (0/9)
      • Lymph node, right obturator, dissection — Negative for malignancy (0/12)
      • AJCC 8th edition Pathology stage: pT1N0(if cM0); AJCC pathologic stage I
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: Robotic-assisted radical cystoprostatectomy
      • Specimen size:
        • Urinary bladder: (12) x (8) x (5) cm
        • Prostate: (4.8) x (3.5) x (3.2) cm
        • Tumor size: 0.5 cm
        • Tumor site: Posterior wall
        • Sections are taken and labeled as: F2022-153FSC: right cuff end, F2022-153FSD: left cuff end, A1-11: prostate, A12: bil seminal vesicles, A13-20: bladder, B: left iliac LN, C: right iliac LN, D1-2: left obturator LN, E1-2: right obturator LN
    • MICROSCOPIC EXAMINATION (for urinary bladder):
      • Histological type
        • Urothelial: Papillary urothelial carcinoma, invasive
      • Histological grade: High grade
      • Pathological staging (pTNM, AJCC 8th edition):
        • TNM Descriptors: (required only if applicable) (select all that apply)
          • m (multiple primary tumors)
          • r (recurrent)
          • y (posttreatment)
        • Primary tumor (pT): pT1: Tumor invades lamina propria (subepithelial connective tissue)
        • Regional lymph nodes (pN): pN0: No lymph node metastasis
        • Distant metastasis (pM): N/A
      • Section margins:
        • Involved by noninvasive low-grade urothelial carcinoma/ urothelial dysplasia, site:right ureter curr end
      • Explanatory note:
        • Immunohistochemical stain for prostate: AMACR(-), 34BE12(+) and GATA3(+).
  • 2022-04-11 Frozen Section
    • Left ureter cuff end, frozen section — Negative for malignancy
    • Right ureter cuff end, frozen section — High-grade dysplasia
    • Right ureter cuff end, frozen section — Low-grade dysplasia
    • Left ureter cuff end, frozen section — Negative for malignancy
  • 2022-03-23 CT - abdomen
    • History and indication: Bladder tumor
    • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is diffuse wall thickening of the urinary bladder and few calcifications within the wall that is c/w urothelial cell carcinoma. Please correlate with cystoscopy.
      • Liver and renal cysts (up to 3.8cm).
      • S/P cholecystectomy.
    • Impression:
      • There is diffuse wall thickening of the urinary bladder and few calcifications within the wall that is c/w urothelial cell carcinoma. Please correlate with cystoscopy.
  • 2022-03-23 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (90 - 14) / 90 = 84.44%
      • M-mode (Teichholz) = 84.2
    • Dilated LA - Adequate LV, RV systolic function with normal wall motion
    • LV hypertrophy, Impaired LV relaxation
    • Mild MR, TR, AR, PR
  • 2022-02-09 Spirometry
    • Normal spirometry
  • 2021-12-21 MRI - prostate
    • With and without enhancement MRI: Prostate
    • Findings
      • Mucosal thickening at lower portion of urinary bladder and near urinary bladder orifice. suspected urinary bladder tumors.
      • Relative wall thickening at right urinary bladder wall.
      • Outpouching lesion in right aspect of urinary bladder, suggesting urinary bladder diverticulum.
      • Non-enhancing tumors in the liver, 4.1cm in S8 and 2.6cm in S2, suspected liver cysts.
      • Non-enhancing tumors in bilateral kidneys, up to 1.97cm in left kidney, suspected renal cysts.
      • No enlarged lymph node in the pelvic cavity and paraaortic region.
      • No ascites.
    • Impression:
      • Mucosal thickening at lower portion of urinary bladder and near urinary bladder orifice. suspected urinary bladder tumors.
      • Relative wall thickening at right urinary bladder wall.
      • Urinary bladder diverticulum.
      • LIver and renal cysts.
  • 2021-12-07 Tc-99m MDP whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the lower C-spine, some L-spines, bilateral shoulders, hips and knees in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the lower C-spine and some L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
  • 2021-12-02 CT - abdomen
    • History and indication: Bladder tumor
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of urinary bladder with adjacent fat stranding and regional LAP. S/P foley catheter indwelling.
      • Liver and renal cysts (up to 3.5cm).
      • Normal appearance of spleen, pancreas, adrenals.
      • S/P cholecystectomy.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • No abnormal density at bilateral basal lungs.
    • Addendum Imaging Report Form for Urinary Bladder Carcinoma
      • Impression (Imaging stage) : T:T4b(T_value) N:N2(N_value) M:M0(M_value) STAGE:IVA(Stage_value)
  • 2021-12-01 Patho - prostate TUR
    • Prostate, TUR-P biopsy — Small cell neuroendocrine carcinoma and invasive urothelial carcinoma, high-grade
    • The sections show a picture of small cell neuroendocrine carcinoma, composed of sheets of poorly differentiated tumor cells seperated by scant stroma. The neoplastic cells have small to intermediate-sized, round to oval nuclei and high N/C ratio. Mitosis are numerous.
      • IHC shows: CD56(+), synaptophysin(+), and PSA(-).
    • The overlying urothelium shows invasive urothelial carcinoma, high-grade. Tumor cell invades subepithelial connective tissue.
      • IHC, these tumor cells reveal: CK5/6(focal+), GATA3(+).
  • 2021-12-01 Patho - urinary bladder TUR
    • Urianry bladder, TURBT — Invasive papillary urothelial carcinoma, high-grade
    • The sections show following features:
      • Histologic type: Papillary urothelial carcinoma, invasive
      • Histologic grade: High-grade
      • Tumor configuration: Papillary
      • Muscularis propria: Present
      • Lymphovascular invasion: Not identified
      • Microscopic tumor extension: Tumor invades subepithelial connective tissue
  • 2021-11-13 Uroflowmetry
    • Q max: fair
    • flow pattern: obstructive
  • 2021-11-13 Bladder Sonography
    • PVR 107mL (post-void residual)
  • 2021-04-30 Bone densitometry - hip
    • Hip BMD performed by DXA revealed:
      • Left hip, BMD is 0.616 gms/cm2, about 2.1 SD below the peak bone mass (72%) and 1.2 SD below the mean of age-matched people (83%).
    • Impression
      • Osteopenia
  • 2021-04-30 SONO - abdomen
    • Diagnosis
      • Liver cyst, S2 and S7
      • Liver hemangioma, S6
      • post cholecystectomy
      • Renal stone, right
      • Renal cyst, left
      • Dilated pelvis of left kidney
      • pancreatic body and tail masked by gas.
    • Suggestion
      • ultrasound follow up
      • visit urology if symptoms revealed.
  • 2021-04-10 Bladder Sonography
    • PVR 148mL (post-void residual)
  • 2021-04-10 Uroflowmetry
    • Q max: fair
    • flow pattern: obstructive

[MedRec]

  • 2023-05-02 SOAP Hemato-Oncology
    • O
      • Cancer Treatment Radiotherapy/Targeted Therapy Side Effect Assessment (2023-05-02)
        • Sensory abnormalities: G1: Asymptomatic; loss of DTR (Deep Tendon Reflex) or abnormal skin sensation.
          • Management of sensory abnormalities: Observation.
        • White blood cell reduction: G1: 3000 - 4000/mm3
          • Management of white blood cell reduction: Observation.
  • 2023-03-30 SOAP Hemato-Oncology
    • P: Admission for 24 hours CCr, Audiometry and EP
  • 2023-03-30 SOAP Thoracic Surgery
    • A: small cell neuroendocrine carcinoma, metastatic.
    • P: refer back to Onco. Dr. Xia for adjuvant therapy.
  • 2023-02-23 SOAP Thoracic Surgery
    • A/P: arrange admission on 3/16; 3/17 VATS RML, RLL wedge, for tissue proof.
  • 2023-02-09 SOAP Hemato-Oncology
    • A/P: Admission for CT-guided biopsy (Already discuss with radiologist Dr. Chang)
  • 2023-02-02 SOAP Hemato-Oncology
    • A/P
      • Arrange Chest CT
      • May consider Biopsy after Chest
      • Then discuss the appropriate regimen of treatment
  • 2022-04-28 SOAP Urology
    • O
      • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2022-04-25
        • Subsequent imaging follow-up, focusing on chest imaging.
      • 2022-01-12 ~ 2022-03 - neoadjuvant Etopside, cisplatin (4) - AE: nasuea, vomiting, hicccup
  • 2022-01-25 SOAP Urology
    • O
      • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2022-01-03
        • The patient is considering cystectomy and may need to undergo urethrectomy again.
      • Cancer Multidisciplinary Team Meeting Conclusion> Meeting Date: 2021-12-20
        • Recommend neoadjuvant chemotherapy + radical cystectomy
        • Prostate cancer workup (Lung CT, prostate MRI, PSA) for double cancer.

[surgical operation]

  • 2023-03-17
    • Surgery
      • VATS RUL, RML, RLL wedge resection + LND.
    • Finding
      • Multiple lung nodules over RUL, RML and RLL, size range from 1.2cm to 0.5cm.
      • One 24 Fr. straight chest tube was inserted via right 8th ICS.
  • 2022-04-11
    • Surgery
      • Robotic-assisted radical cystoprostatectomy with neobladder reconstruction.  
    • Finding
      • Bladder tumor over dome.
      • severe adhesion over anterior bladder wall
      • blood loss: 1000ml (urine included)
      • console time: 300 mins    
  • 2021-12-01
    • Surgery
      • TUR-BT
      • TUR prostate biopsy
      • EC of bladder diverticulum
    • Finding
      • Mild kissing prostate appearance
      • Papillary uneven prostate mucosa over bilateral lobes, right side dominate
      • Papillary bladder tumors over BN 4-5 o’clock
      • Papillary bladder tumors over right posterolateral wall to bladder dome, large amount
      • Large diverticulum over right side lateral wall
      • Papillary tumors in diverticulum
      • Perfrom EC after tumor resection
      • Clear urine output from bilateral UO
      • Bilateral UO and ES remained intact after the procedure

[chemotherapy]

  • 2023-12-29 - leucovorin 400mg/m2 685mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (Yang MuJun)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-08 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3
  • 2023-07-19 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3
  • 2023-06-29 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3
  • 2023-06-08 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3
  • 2023-05-16 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3
  • 2023-04-20 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO] D1-3
  • 2022-03-22 - [etoposide 100mg/m2 160mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 200mL 3hr] D1-3 (You ZhiQin)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3
  • 2022-03-01 - [etoposide 100mg/m2 160mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 200mL 3hr] D1-3 (You ZhiQin)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3
  • 2022-02-08 - [etoposide 100mg/m2 160mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 200mL 3hr] D1-3 (You ZhiQin)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3
  • 2022-01-12 - [etoposide 100mg/m2 160mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 200mL 3hr] D1-3 (You ZhiQin)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3

==========

2024-01-04

[neutropenia]

(not used) The patient’s last chemotherapy treatment before the lab result on 2023-12-28 was on 2023-08-08. Due to the long time interval between the treatment and the neutropenia episode, it is difficult to conclude with certainty that the neutropenia was directly caused by the previous chemotherapy.

A 28-day supply of oral etoposide was prescribed on 2023-11-16. This medication carries a known risk of leukopenia, with an incidence ranging from 60% to 91%. The severity can reach grade 4 in 3% to 17% of cases, with the nadir typically occurring 7 to 14 days after administration and recovery expected by day 20.

  • 2023-12-28 WBC 3.67 x10^3/uL = Neutrophil 28.7 => ANC 1.53K/uL grade 2 neutropenia
  • 2023-12-14 WBC 6.94 x10^3/uL
  • 2023-11-26 WBC 4.79 x10^3/uL
  • 2023-11-16 WBC 4.49 x10^3/uL
  • 2023-10-19 WBC 4.21 x10^3/uL

In response to the patient’s leukopenia, two days of Granocyte (lenograstim 250ug) were promptly administered.

2023-08-09

The patient recently renewed his repeat prescription for Diovan (valsartan) for a 28-day supply on 2023-08-07. This medication has been added to the active list of medications without an identified reconciliation problem.

2023-06-30

According to the PharmaCloud database, this patient regularly refills his prescription for Diovan (valsartan) to treat his primary hypertension. This medication was correctly added to the active formulary and no issues were identified during the medication reconciliation process.

2023-06-09

According to PharmaCloud data, this patient has only sought medical treatment at our hospital. No issues with medication reconciliation were identified.

The latest lab data, collected on 2023-06-06, shows largely normal results and readings from the TPR panel are stable. There are no issues with the current prescription.

2023-05-17

The patient’s prostate cancer was pathologically confirmed as small cell neuroendocrine carcinoma on 2021-12-01. Given the histologic characteristics of small cell components, the regimens used for small cell lung cancer (SCLC) are considered preferable. Therefore, the patient received both cisplatin (25mg/m2) and etoposide (100mg/m2) on days 1 to 3 for 4 cycles in the first quarter of 2022. The same regimen was restarted (etoposide at 80mg/m2) on 2023-04-20 due to a lung wedge biopsy performed on 2023-03-17 that indicated metastatic small cell neuroendocrine carcinoma. The treatment is currently ongoing.

There were no notable abnormalities found in the TPR panel and lab data from 2023-05-16. In addition, no medication reconciliation issues were identified.

700524385

240102

[MedRec]

  • 2023-12-12 SOAP NeuroSurgery Xi XianDa
    • Prescription x3
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Siliverzine (silver sulfadiazine 10mg/g) QD EXT for head wound
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# Q6H
      • Nexium (esomeprazole 40mg) 1# QDAC stool OB 3+
  • 2023-11-07 SOAP Nephrology Wu ZheXiong
    • Diagnosis
      • HCVD, unspecified, without CHF [I11.9].
      • Mixed hyperlipidemia [E78.2].
      • Coronary atherosclerosis of native coronary artery [I25.10].
      • With unspecified pathological lesion in kidney [N05.9].
    • Prescription x3
      • Pentop (pentoxifylline 400mg) 0.5# BID
      • Euricon (benzbromarone 50mg) 0.5# QD
  • 2023-10-31 ~ 2023-11-04 POMR NeuroSurgery Xu XianDa
    • Discharge diagnosis
      • Cervical spinal stenosis and compression of cervical cord with myelopathy at C3-4-5-6-7.
      • Retention of urine
      • Fracture of right 4th, 5th, 7th, 9th, 10th ribs, and left 4th, 5th, 8th, 9th, 10th ribs.
      • Poor healing wound of scalp with tissue necrosis and defect.
      • Anemia post blood transfusions
      • Atherosclerotic heart disease of native coronary artery without angina pectoris
      • Rheumatic aortic stenosis
      • Hypertensive heart disease without heart failure
      • Mixed hyperlipidemia
      • Chronic kidney disease, stage 3 (moderate)
    • CC
      • Less urine output for one day.
    • Present illness
      • This 90-year-old female patient had several underlying health conditions, including:
        • Hypertensive heart disease
        • Atherosclerotic heart disease of the native coronary artery without angina pectoris
        • Chronic kidney disease, stage 3 (moderate)
      • According to medical records and her daughter’s account, she suffered a head injury from a fall down the stairs on 2023-10-18. Subsequently, she was admitted due to COVID-19 virus infection from 2023-10-18 to 2023-10-25. However, on 2023-10-31, decreased urine output was observed, prompting her visit to our emergency room for assistance. A Foley catheter was inserted for urine retention. The patient displayed weakness in motor function, with the right-side extremities graded as 1, the left upper limb as grade 3, and the left lower limb as grade 2.
      • A cervical spine MRI revealed severe spinal stenosis at the C3-4-5-6-7 levels, along with compression of the cervical cord leading to myelopathy. After consultation with a Neurosurgeon, she was admitted for further management.
      • No cervical surgery
      • No cancer histroy
    • Course of inpatient treatment
      • Following admission, a neck collar was applied for protective purposes. The patient experienced severe pain when changing positions. A bilateral rib X-ray revealed injuries to the right 4th, 5th, 7th, 9th, and 10th ribs, as well as the left 4th, 5th, 8th, 9th, and 10th ribs. Consultation with Thoracic Surgery specialists confirmed the absence of hemopneumothorax. To manage the pain, analgesics were prescribed, and the use of a ThoraxBelt for stabilizing the chest wall was recommended.
      • Anemia was also identified, with a hemoglobin level of 7.5 mg/dL, leading to a prescription for a blood transfusion. Once the patient’s neurological condition had improved to an acceptable level, she was discharged home with plans for outpatient follow-up care.
    • Discharge prescription
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Siliverzine (silver sulfadiazine 10mg/g) QD EXT for head wound
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# Q6H
      • Nexium (esomeprazole 40mg) 1# QDAC stool OB 3+
      • Sindine (povidone iodine Aq Soln) ASORDER EXT for wound dressing change
  • 2023-10-11 SOAP Cardiology Zhang HengJia
    • Prescription x3
      • Concor (bisoprolol 5mg) 0.5# QD
      • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
      • Doxaben (doxazosin 4mg) 1# QN
      • Crestor (rosuvastatin 10mg) 1# QD

==========

2024-01-02

Upon comparing the refilled repeat prescription with patient records in PharmaCloud and HIS5, all medications were successfully integrated into the active medication list without any discrepancies.

701496796

240102

[exam findings]

  • 2023-12-19 Bronchodilator Test
    • mild to moderate restrictive ventilatory impairment with partial bronchodilator ressposne
  • 2023-12-14 CT - chest
    • Indication: esophageal cancer, clinical stage II, status post operation in 2022/12 and due to N(+), s/p CCRT (25 fx) in 2023/02. PET on 2023/9/25 showed cervical esophagus recurrence. s/p cervical esophgeal tumor palliative RT in Oct 2023.
    • Chest CT with and without IV contrast ehnancement shows:
      • S/p port-A placement with its tip at Superior vena cava.
      • s/p esophagectomy and gastric tube reconstruction
      • Diffuse soft tissue change at superior mediastinum is found. In comparison with CT dated on 2023-09-13, the lesion is slightly progressed.
      • s/p jejunalstomy.
      • The GB is well distended without soft tissue lesion
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
    • Imp:
      • s/p esophagectomy and gastric tube reconstruction
      • Mediastinal lymphadenopathy s/p C/T, in slightly progression.
  • 2023-11-22 Tc-99m MDP bone scan
    • Faint hot spots in the sternum and both rib cages, respectively, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, some C-, T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, hips, knees, and feet.
  • 2023-11-10 CT - abdomen
    • Abdominal CT with and without enhancement revealed:
      • s/p gastric tube reconstruction at chest region.
      • There is stone at dependent portion of GB. GB stone(s) are noted. The GB wall is not thickening
      • s/p jejunostomy.
      • Normal heart size. Mild pericardial effusion is found.
      • Elevation of right hemidiaphragm is found.
    • Imp:
      • s/p gastric tube reconstruction at chest region.
      • Gallstones.
      • No evidence of free air is noted at the subphrenic region.
  • 2023-11-10 KUB
    • Scoliotic alignment of the lumbar spine is found.
    • The psoas shadow is clear.
    • s/p drainage tube placement.
    • Increased intestinal gas is found.
  • 2023-09-26 PET
    • A glucose hypermetabolic lesion in the retrotracheal and prevertebral space, extending from the level of the cricoid carlage to the upper mediastinun at the level of aortic arch, compatible with recurrent esophageal maliangncy. Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in a left paratracheal lymph node, in a lymph node in the right paravertebral region at the level of T4 spine and in three right precarinal lymph nodes. Metastatic lymph nodes may show this picture.
  • 2023-09-25 Patho - stomach/small bowel polyp
    • Soft tissue, jejunostomy outlet, left upper, excisison — Granulation tissue
  • 2023-09-22 Standing KUB
    • S/P feeding jejunostomy at left upper abdomen.
  • 2023-09-18, -09-11 CXR
    • surgical clips over left apical hemithorax
    • Rt superior mediastinal widening with thickening of paratracheal stripes and Rt shift of trachea s/p reconstructed esophagus, may be recurrent tumor
  • 2023-09-11 Nasopharyngoscopy
    • Bilateral vocal cord paralysis.
  • 2023-09-07 ECG
    • Sinus tachycardia
    • Incomplete right bundle branch block
    • Possible Right ventricular hypertrophy
  • 2023-09-07 CXR
    • Rt-sided convexity of the azygoesophageal recess interface

[MedRec]

  • 2023-10-20 SOAP Radiation Oncology Wang YuNong
    • Diagnosis: esophageal cancer, clinical stage II, status post operation in 2022/12 and due to N(+), s/p CCRT (25 fx) in 2023/02 and dysphagia post esophageal balloon dilatation procedure 5 times between 2023/07 to 2023/08 at NTUH, Jejunostomy at NTUH in 2023-07and s/p 5 times of esophageal dilatation procedures but failed. PET on 2023/9/25 showed cervical esopahgus recurrence.
    • S: less blood in saliva, r/o esophageal tumor oozing. no melena this week. numbness over the chin.
    • O: 2023/9/28~ RT to the cervical esophagus and adjacent lymphatic drainage area: 28 Gy/ 14 fx.
    • Plan to deliver 20 Gy/ 10 fx to the esophgeal tumor below the superior border of the manubrium. The above esophageal tumor and lymphatic drainage area: at least 50 Gy/ 25 fx.
  • 2023-09-07 ~ 2023-10-17 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Eesophageal cancer, squamous cell carcioima, cT2N1M0, stage II, s/p single-port minimally ivasive tri-incision esophagectomy and reconstruction with gastric tube via posterior mediastinum on 2022/12/02 at NTUH s/p CCRT in 2023/02 s/p balloon dilatation on 2023/07/05, 2023/08/11, 2023/08/15, 2023/08/23, post Jejunostomy in 2023/07/21, recurrent esophageal cancer at neck and upper mediastinum lymph node metastases, s/p left Port-A implantation on 2023/09/18,
      • Eesophageal cancer, squamous cell carcioima, s/p radiotherapy 30 Gy/ 15 fractions for the esophageal tumor from 2023/09/28~ and Concurrent chemotherapy with Q2W PF(CDDP 50mg/m2, 5FU 2000mg/m2 IVF 48hrs) on 2023/10/06(C1D1)
      • Insomnia, unspecified
      • Constipation, unspecified
      • Chronic viral hepatitis B without delta-agent
      • Fever, unspecified
      • Anemia due to antineoplastic chemotherapy
    • CC
      • Difficult swallowing of fluid since 2023-07.
    • Present illness
      • A 55-year-old man had underlying diseases of esophageal cancer status post operation in 2022/12 and post CCRT in 2023/02 at NTUH, and dysphagia post esophageal balloon dilatation procedure 5 times between 2023/07 to 2023/08 at NTUH, Jejunostomy at NTUH in 2023-07, and hepatitis B infection under Baraclude and insomnia.
      • According to his statement, esophageal cancer stage II was diagnosed in 2022-11 and he received esophagestomy with gastric tube recontruction at NTUH in 2022-12. Due to lymph nodes metastasis, he received CCRT in 2023-02 at NTUH. Then he was admitted to NTUH due to pancreatitis in 2023-06. He started to feel difficult swallowing of fluid in 2023-07, and admitted to NTUH for Jejunostomy and esophageal dilatation procedure. After 5 times of esophageal dilatation procedure, he still couldn’t drink water and re-contruction of esophageal was suggested but he wanted to try dilatation procedure again, thus he came to this hospital chest surgery department on 2023-09-05. After well discussed with the doctor about the successful rate, benifit and complication, he decided to undergo endoscopic esophageal dilatation. At ward he couldn’t take anything by mouth and hoarseness was noticed since yesterday.
    • Course of inpatient treatment
      • After admitted, Follow-up suspected GI bleeding condition with Panzolec 1pc iv Q12H from 2023/09/19~2023/09/25.
      • Esophageal obstruction status post endoscopic inspection on 2023-09-11 and image showed recurrence of esophageal cancer on 2023-09-13.
      • Chest CT on 2023/09/13 showed recurrent esophageal cancer at neck and upper mediastinum with metastatic mediastinal LAP s/p esophagectomy and gastric tube reonstruction.
      • Port-A catheter insertion on 2023/09/18.
      • Ultracet 1# po Q6H and Tramadol 100mg iv PRNQ6H for pain control.
      • Sodicon 1# po QID, Shitan 1# po TID and NS 3ml I/H QID for cough with sputum.
      • Whole body PET on 2023/09/26 showed esophageal cancer with left paratracheal, right paravertebral lymph node and upper mediastinun lymph node metastatic.
      • Radiotherapy 30 Gy/ 15 fractions for the esophageal tumor from 2023/09/28~.
      • Concurrent chemotherapy with PF(CDDP 50mg/m2, 5FU 2000mg/m2 IVF 48hrs)(C1D1) on 2023/10/06~2023/10/09 -> 2023/10/08 Hold chemotherapy for fever, R/O spesis.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
      • NS 500ml Q8H IVF hydration.
      • Double lower teeth shake with consult Dentistry on 2023/10/02 IMP: #27, 313235, 414245: suggest ext at os.
      • Consult OS on 2023/10/03 IMP:Tooth #27, #31, #32, #35, #41, #42, #45 chronic periodontitis A:1.Tooth 35 45 extracted under local anestheia 2.We will arrange stitches removal on 2023/10/10.
      • Cough Mixture 5ml po QID for cough. Allegra 1# po BID for runny nose.
      • Comfflam spray (self pay) 1 puff MOSP PRNQ4H for sore throat.
      • Insomnia with Mirtapine 1# po HS, Zolon F.C 1# po HS and Xanax 1# po HS.
      • Constipation with MgO 2# po Q6H -> DC for diarrhea and Sennoside 2# po HS -> DC for diarrhea.
      • Chronic viral hepatitis B without delta-agent (Anti-HBc(+)) with Baraclude 0.5mg 1# po QDAC.
      • Fever with Antibiotic therapy with Rocephin 2000mg iv QD from 2023/09/23~2023/10/05 and Antibiotic with Tapimycin 4.5gm iv Q6H from 2023/10/08~2023/10/16 and Panadol 1# po PRNQ6H for BT >38^C.
      • Anemia(Hb:9.1 -> 8.5 -> 9.7g/dL) with BT P-RBC 2u on 2023/09/26, 2023/10/02. Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, he was discharged on 2023/10/17 and OPD followed up later.
    • Discharge prescription
      • Allegra (fexofenadine 60mg) 1# BID
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Lysozyme (lysozyme 90mg) 1# TID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Sodicon (dextromethorphan 15mg) 1# QID
      • Zolon (zopiclone 7.5mg) 1# HS
      • Alpraline (alprazolam 0.5mg) 1# HS
      • Cough Mixture (platycodon) 5mL QID
      • Mirtapine (mirtazapine 30mg) 1# HS
      • Shitan (bromhexine 8mg) 1# TID
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
  • 2023-09-05 SOAP Thoracic Surgery Xie MinXiao
    • S
      • Esophageal ca. s/p op + adjuvant CCRT.
      • complicated with eso. stricture.
    • P
      • arrange admission 9/7
      • 9/8 endoscopic eso. dilatation.

[chemotherapy]

  • 2023-12-26 - docetaxel 75mg/m2 114mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-11-03 - cisplatin 50mg/m2 80mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 30mL 10min (after CDDP) D2 + fluorouracil 2000mg/m2 3100mg NS 500mL 48hr D2 (PF CCRT Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-2
  • 2023-10-06 - cisplatin 50mg/m2 80mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 30mL 10min (after CDDP) D2 + fluorouracil 2000mg/m2 3100mg NS 500mL 48hr D2 (PF CCRT Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2024-01-02

[tube feeding]

All medications currently listed on the active drug list for oral administration are suitable for enteral tube feeding.

[reconciliation]

The PhamaCloud database did not contain any records of the patient’s medical history from other healthcare facilities. No medication discrepancies were identified.

2023-12-22

[tube feeding]

All medications currently listed for oral administration on the active medication list are suitable for enteral feeding via tube.

2023-11-06

The patient has been a long-term patient at NTUH before seeking treatment at our institution. Currently, there are no valid repeat prescriptions issued by NTUH. No discrepancies with medication reconciliation have been identified.

701502074

240102

[MedRec]

  • 2024-01-01 ProgressNote
    • Problem #1: Squamous cell carcinoma of the right and posterior oropharyngeal wall, p16 (+, > 70%), AJCC, 8th, stage cT3N2M0 (prognostic stage II)
      • Assessment:
        • severe dysphagia
        • hold R/T since 12/27
        • CRP 8.1 mg/dL
        • WBC 600 uL
        • PLT 44000 uL
        • port-a insertion on 12/29
        • OB 2+, clear urine bacteria 1+
      • Plan:
        • pending for blood culture
        • Filgrastim (G-CSF) 300 mcg QD for three days 12/28-12/30
        • empirical antibiotic with Cefim 2000 mg Q12H 12/28-
        • Actein Effervescent 1# BID for sputum
        • MgO 1# TID, through 1# HS for constipation
        • fluid supplement with TPN since 12/29, check finger sugar Q6H
        • consult GI for PEG, hesitate
    • Problem #2: DM, CKD, BPH, A-fib, AMI 7 years ago s/p stent x5
      • Assessment:
        • unable to take oral medications for one week
        • The patient and his family have been informed of the risks of stopping oral medication, and they all expressed their understanding.
      • Plan:
        • Doxaben 1# QD, hold if BP < 110
        • Concor 1# QD, hold if BP < 110
        • Pentop 1# BID
        • Feburic 0.5# QD
        • Canaglu 1# QDAC
        • Crestor 1# QD
        • Bokey 1# QD
        • Ulstop 1# QD
        • Ezetrol 1# QD
  • 2023-10-27 SOAP Oral and Maxillofacial Surgery Xia YiRang
    • S: He is referred by Dr. Huang becuause of throat cancer and in the process of radiation therapy.
    • O: under-bridge caries of #31 and #41 with local inflammation are noted. Poor long bridge is noted. gingivitis and gingival recession of residual teeth are noted. no crown and no wisdom teeth are noted.
    • A:
      • under-bridge caries of #31 and #41 with local inflammation
      • Hypertension, heart disease, anticoagulants (Keelung ChangGung). Laryngeal cancer.
    • P
      • His panoramic film showed periodontal bone loss and no bone lesion.
      • Explain the finding and treatment plan to the patient and his family memberes
      • Debridement and curetage at the right mandible to remove food debris and necrotic tissue
      • premedication before tooth extraction
      • oral hygiene instruction and closely follow up.
  • 2023-10-26 SOAP Radiation Oncology Huang JingMin
    • S: For CCRT due to oropharyngeal carcinoma.
      • PI: The patient suffered from sore throat and swallowing difficulty since 2023-01. Under the impression of squamous cell carcinoma of the right and posterior oropharyngeal wall, p16 (+, >70%), AJCC, 8th, stage cT3N2M0 (stage III), he was referred for CCRT.
      • Family history: (gastric carcinoma)
      • Cancer site specific factors: Alcohol (+); Smoking (+); Betel nut (-).
      • Personal Hx: DM (+); HTN (+)
      • Previous RT Hx: (-)
    • O: ECOG: 1
      • PE: neck and bil SCF: neg.
      • CXR (2023-10-19): No cardiomegaly. No active lung lesion. Tortuosity of the aorta with atherosclerotic change. Degenerative joint disease of T-spine with marginal osteophytes.
      • PET (2023-10-20): 1. A glucose hypermetabolic lesion involving the right oropharyngeal wall and posterior pharyngeal wall, compatible with primary malignancy in this region. 2. Glucose hypermetabolism in a left retropharyngeal lymph node and some right neck level II lymph nodes. Metastatic lymph nodes may show this picture.
      • Abd sono (2023-10-23): 1. Calcified spot in right lobe liver. 2. Gallbladder polyp. 3. Bilateral renal cysts.
      • CT scan of neck (2023-10-23): 1. extensive nucosal thickening from the right lateral wall and posterior wall of the oropharynx to the posterior wall of the hypopharynx. 2. a necrotic lymph node in the left rtropharyngeal space.
      • Pathology (S2023-20804, 2023-10-24): Labeled as “right lateral pharyngeal wall”, punch biopsy — squamous cell carcinoma. IHC stains: CK5/6 (+), p40 (+), p16 (+, > 70%).
    • A: Squamous cell carcinoma of the right and posterior oropharyngeal wall, p16 (+, > 70%), AJCC, 8th, stage cT3N2M0 (stage III)
    • P: CCRT is indicated for this patient with the following indicators: stage T3N2M0
      • Goal: curative
      • Treatment target and volume: oropharyngeal wall tumor to bilateral neck.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5000cGy/25 fractions of the oropharyngeal to bilateral neck, and 7000cGy/35 fractions of the oropharyngeal tumor bed and involved nodal lesions. The treatment modality and the possible effects of radiotherapy were well explained to the patient. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-11-02.
      • Refer to Dental OPD for pre RT dental evaluation and management.
  • 2023-10-26 SOAP Ear Nose Throat Su WangYu
    • S: 2023/10/26 R para-ph ca (SCC, p16+) + L retro-ph LN(+) = cT3N2M0 (stage II), PET = bil neck+
    • O:
      • 2023/10/24 PATHO - stomach biopsy
        • Stomach, antrum, biopsy — Helicobacter-associated non-atrophic chronic gastritis
      • 2023/10/23 CT: Neck
        • extensive nucosal thickening from the right lateral wall and posterior wall of the oropharynx to the posterior wall of the hypopharynx
        • a necrotic lymph node in the left rtropharyngeal space.
      • 2023/10/19 PATHO - Gingival/oral mucosa biopsy
        • Labeled as “right lateral pharyngeal wall”, punch biopsy — squamous cell carcinoma.
        • IHC stains: CK5/6 (+), p40 (+), p16 (+, >70%).
    • Prescription
      • Acetal (acetaminophen 500mg) 1# Q6H
      • Lindacin (clindamycin 150mg) 2# Q6H
      • Mefno (mephenoxalone 200mg) 1# BID
      • Parmason Gargle Solution (chlorhexidine) TID GAR

[radiotherapy]

[chemotherapy]

  • 2023-12-12 - carboplatin AUC 2 150mg D5W 250mL 1hr + NS 500mL 1hr (after carboplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + NS 250mL
  • 2023-12-05 - carboplatin AUC 2 150mg D5W 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-11-28 - carboplatin AUC 2 150mg D5W 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-11-21 - carboplatin AUC 2 150mg D5W 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

==========

2024-01-02

Culture results from both sputum and urine samples collected on 2023-12-29, reported on 2024-01-01, revealed mixed normal flora and less than 1000 CFU/mL, respectively. This, along with the declining CRP level, might suggest a positive response to ongoing cefepime 2000mg Q12H therapy.

  • 2024-01-02 CRP 3.3 mg/dL
  • 2023-12-28 CRP 8.1 mg/dL

Additionally, G-CSF administered since 2023-12-28 has effectively mitigated the leukopenia.

  • 2024-01-02 WBC 2.12 x10^3/uL *
  • 2023-12-28 WBC 0.60 x10^3/uL ***
  • 2023-12-25 WBC 0.98 x10^3/uL ***
  • 2023-12-18 WBC 2.67 x10^3/uL *
  • 2023-12-11 WBC 4.12 x10^3/uL
  • 2023-12-04 WBC 5.67 x10^3/uL
  • 2023-11-28 WBC 5.23 x10^3/uL
  • 2023-11-16 WBC 6.13 x10^3/uL
  • 2023-10-19 WBC 6.45 x10^3/uL

No medication discrepancies were identified during reconciliation.

701510054

240102

[exam findings]

  • 2023-12-29 SONO - abdomen
    • Diagnosis:
      • Liver tumor, left
      • Left pleural effusion, moderate
      • Suspected GB polyp
    • Suggestion:
      • Please correlate with other image
      • Check AFP, CA-199, CEA, HBV, HCV
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • 2023-12-25 CT - brain
    • Brain atrophy.

[MedRec]

  • 2023-12-30 MultiTeam - Multidisciplinary Team Recommendations - Palliative Care
    • Consultation Date: 2023-12-29
    • Response Content:
      • During the visit, the patient was conscious and reported no pain or difficulty breathing, feeling more fatigued.
      • The palliative care team established a relationship and explained the concept of shared palliative care.
      • The patient was somewhat guarded but nodded in agreement to shared care.
      • The patient’s ex-husband, who was caring for her, mentioned that the patient verbally expressed not wanting resuscitation but had not yet completed the advance directive for palliative care.
      • The patient’s father and younger brother lean towards not resuscitating, letting the patient pass naturally and comfortably.
      • Diagnosed with breast cancer at the end of last year at another hospital, the first phase of chemotherapy (May and June 2023) was very effective, with the tumor disappearing. Radiation therapy was recommended, but the patient did not proceed.
      • The tumor grew again around August-September with a wound, and subsequent chemotherapy was ineffective, leading to the current large wound.
      • The patient is still struggling to accept the disease’s progression.
      • The ex-husband left with the shared care consent form to be signed by the family later. Follow-up is planned.
    • Conclusion and Recommendations: Shared palliative care and follow-up on the advance directive for palliative care.
    • Responder: Chen Hui
    • Response Date: 2023-12-29 18:35
    • Doctor’s Response: 12/30 02:16 Response by Zhang JiaYu: Noted
  • 2023-12-28 MultiTeam - Multidisciplinary Team Recommendations - Psycho-Oncology
    • Consultation Date: 2023-12-26
    • Reason for Consultation: Stress events due to illness: Psychological stress response due to physical illness or deciding on treatment options, Emotional distress: Anxiety, fear, depression, anger; shyness, shock, and other emotional categories.
    • Conclusion:
      • S
        • Visit on 12/27, accompanied by the ex-husband.
        • The patient reported severe mouth pain, painful to talk and swallow, unsure of the next steps or what to ask.
        • The ex-husband mentioned they are applying for medical records from TPEVGH, using spray powder for mouth sores, and glutamine for temporary relief, expecting slow recovery.
        • The patient was unprepared and needed time to think, sleeping a lot these past two days, and will see how it goes in the next few days.
      • O
        • Breast cancer diagnosed in 11/12, radiation therapy in November, last chemotherapy on 12/19, wound on the left breast, self-dressing; lost consciousness at home for 5 minutes on 12/25 and recovered, fever started three days ago, admitted on 12/26, inpatient doctor referred for psychosomatic stress response.
      • I
        • Care for the family’s care expectations.
      • AP
        • The ex-husband and patient appeared worried but did not express it explicitly, still hoping to discuss palliative treatment plans, should consider overall treatment tolerance, enhance prognosis awareness and preparedness, and timing for shared palliative care. Counseling psychologist Huang XiaoFang
    • Responder: Huang XiaoFang
    • Response Date: 2023-12-27 17:53
    • Doctor’s Response: 12/28 08:06 Response by Zhang JiaYu: Noted
  • 2023-12-27 ProgressNote
    • Problem #1: Left breast cancer
      • Assessment:
        • under chemotherpy at TPEVGH
        • R/T done in 2023/11
        • Hb 5.1 -> 6.4 -> 8.1 g/dL, WBC 240 -> 130 uL, PLT 58000 -> 86000 -> 52000 uL
        • CRP 26.4 mg/dL
        • blood transfusion with LPRBC 2u on 12/25, 2u on 12/26, LRP 1u on 12/25
        • 12/25 CXR: Left pleural effusion
        • stool OB 3+
      • Plan:
        • keep OPD medications:
          • Xeloda 2# Q12H,
          • Cartil 1# Q8H,
          • Jardiance 1# QD,
          • Eltroxin 1# QDAC,
          • Zcough 1# TID,
          • Trand 1# BID -> shift to IV form,
          • Tramacet PRN for pain,
          • Megest 5ml QD
        • fungus infection told at TPEVGH:
          • keep FLU-D 2# QD,
          • Avelox 1# QDAC,
          • Nystatin 1# TID
        • wound care (consult wound nurse)
        • check finger sugar QDAC, HS
        • fluid supplement with normal saline BID
        • empirical antibiotic with Cefim 2mg Q8H since 12/26
        • Filgrastim (G-CSF) 300 mcg QD
        • Loperamide PRN for diarrhea
        • Hemoclot 500mg Q12H
  • 2023-12-26 MultiTeam - Multidisciplinary Team Recommendations - Wound Care
    • Consultation Date: 2023-12-26
    • Reason for Consultation: Malignant fungating ulcer wound care, Other: Cancer wound
    • Response Content:
      • The left breast has a malignant fungating tumor wound, with 100% yellow necrotic tissue in the wound bed, moderate exudate (yellow-green in color), and a strong foul odor (++).
      • The wound was cleaned with saline solution using cotton swabs, and some necrotic tissue was locally debrided.
      • It is recommended to apply Aq-BI + N/S 1:1 wet dressing BID.
      • The skin under the left armpit and the inner side of the upper arm is damaged due to friction, showing red granulation tissue. After cleaning, a foam silver ion dressing was applied (to be changed during the visit on 12/29).
    • Responder: Chen ShuRong
    • Response Date: 2023-12-26 16:09
    • Doctor’s Response: 12/26 16:33 Response by Zhang JiaYu: Noted, will proceed as recommended.

==========

2024-01-02

[tube feeding]

This hospital offers Const-K 750mg, the only oral potassium supplement available. Each extended-release tablet delivers 10 mEq of potassium, equivalent to about 4.5 medium bananas. While a single banana can provide some potassium (2.2 mEq per inch, 0.9 mEq per cm), Const-K offers a concentrated and stable dose for easier dietary supplementation. For easier swallowing, the tablet can be crushed into fine particles and mixed with water.

700784315

231228

[exam findings]

  • 2023-12-18, -12-14, -12-11, -12-07, -12-05, -11-30, -11-28, -11-27 CXR
    • Normal heart size and contour.
    • Increased bilateral parahilar peribronchial /interstitial and low lungs infiltration.
  • 2023-11-29 Patho - brain biopsy
    • Brain, right FT lobe, stereotactice biopsy — astrocytic glioma, IDH wild type, in favor of high grade
    • Microscopically, sections shows astrocytic glioma characterized by hypercellular astrocytic neoplasm with hyperchromatic, elongated nuclei and irregular nuclear membranes. It shows microvascular proliferation with multilayered, small caliber vessels with glomeruloid appearance. Mitotic activity is not frequent and no geographic-like necrosis is identified in current specimen. A small piece of non-tumor choroid plexus tissue is also noted.
    • Immunohistochemical stains reveals IDH-1 (-), GFAP (+), CK (+ at glial filaments), p53: wild-type (scanty, weak, <1%), EMA (-), SOX10 (focal+), LCA (-).
  • 2023-11-24 CT - chest
    • chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images and axial slab MIP images shows:
      • lungs: a small thin-walled cyst at RUL.
        • mild centrilobular nodules at RML..
        • minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine. normal appearance of left lung.
      • Mediastinum and hila: no enlarged LN or mass.
        • moderate coronary arterial calcification
      • Thoracic aorta: dilated ascending aorta (4cm). extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Visible abdominal-pelvic contents: a 5mm Lt hepatic cyst.
        • enlarged prostate with tiny calcifications indenting the bladder base.
        • questionable wall thickening the urinary bladder.
        • mild atherosclerotic change of the abdominal aorta and bilateral common iliac arteries.
        • marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • no lung tumor. no abnormal mass in abdomen.
      • BPH
      • Mild RML bronchiolitis.
  • 2023-11-23 MRI - brain
    • Past History: Azihemier disease.
    • Surgical history: s/p cata
    • Pre- and post-contrast multiplanar cerebral MRI (including axial and coronal T1W, axial and sagittal T2W, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) and cerebral TOF MRA reveal:
      • A well-defined extra-axial enhancing tumor, about 39 mm at the largest dimension, with diffusion restriction at midline of anterior frontal base.
      • An intra-axial well-enhancing tumor, about 24 mm at the largest dimension, with central necrosis and diffusion restriction in tumor bulk involving right mesial temporal lobe, associating with extensive perifocal white matter edema and diffuse infiltrative parenchymal enhancement and irregular thick enhancement along cistern spaces (including interhemispheric fissure, right hippocampal sulcus, right Sylvian fissure, basal cistern and walls of bilateral frontal horns).
      • Elevation of bilateral A1 segments due to mass effect from frontal base tumor. Otherwise, no remarkable finding at major intracranial arteries in MRA study (including bilateral ICAs, MCAs, ACAs, PCAs and VAs and BA).
    • IMP:
      • Tumors at frontal base and right mesial temporal lobe associating with white matter edema, parenchymal and leptomeningeal enhancement.
      • D/D: meningioma or/and lymphoma, metastases.
  • 2023-11-23 CT - brain
    • Imp: Brain atrophy. A large isodense frontal base and right parasellar, medial temporal mass, favor a meningioma.

[consultation]

  • 2023-12-11 Infectious Disease
    • Q
      • This is a 79-year-old male patient with medical history of Alzheimer’s disease. This time, he had drolling, slurred speech, impaired response and muscle weakness at left extremities were noticed for 2 days. He was then brought to our emergent department for evaluation.
      • Brain CT showed a large isodense frontal base and right parasellar, medial temporal mass, favor a meningioma.
      • Neuro-surgeon was consulted and further survey was done.
      • Brain MRI revealed tumors at frontal base and right mesial temporal lobe associating with white matter edema, parenchymal and leptomeningeal enhancement, r/o meningioma,lymphoma or metastases.
      • After he received brain tumor biopsy on 11/18.
      • The frozen section revealed No evidence of lymphoma or metastasis, pending pathology data.
      • During SICU, under keppra and Hemotastic use.
      • The GCS around E3VTM6, try weaning ventilator and extubation on 11/29.
      • The respiratory pattern smooth, under the general condition became stable, he was transferred to NS ward on 11/30.
      • During ward, solwly taper mannitol.
      • Rehabiliation therapy were undertaken.
      • Brain biopsy report show astrocytic glioma, consultation radiation oncology suggest radiotherapy to brain tumor for 5000cGy/20 fx for tumor control with concurrent temozolamide if feasible.
      • We give applying Temodal for NHI.
      • Suputum culture showed pseudomonas aeruginosa, we shift antibiotic to Ciprofloxacin.
      • Current problem:
        • Fever was noted on 12/17, and brosym was give for pneumonia.
        • Suputum culture showed pseudomonas aeruginosa, we shift antibiotic to Ciprofloxacin since 12/8.
      • We need your expertise for further management. Thank you for your reply.
    • A
      • Serial CxR films has shown marked pneumonia regression and patient has received antibiotic more than 2 weeks.
        • Sputum culture grew P.aeruginosa.
        • IV Cipro can be shifted to oral Ciproxin.
      • Suggestion:
        • Continue inhaled Colimycin for one more week
        • DC IV ciprofloxacin
        • Add oral ciprofloxacin as sequential therapy.
  • 2023-12-04 Radiation Oncology
    • Q
      • This is a 79-year-old male patient with medical history of
        • Alzheimer’s disease
        • Bilateral cataract, status post operation
      • According to his sons’ statement, he was ADL/iADL partially dependent within his usual status. Conversation was intact but mild delayed. However, drolling, slurred speech, impaired response and muscle weakness at left extremities were noticed for 2 days. He was then brought to our emergent department for evaluation.
      • Brain CT showed a large isodense frontal base and right parasellar, medial temporal mass, favor a meningioma. Neuro-surgeon was consulted and further survey was done.
      • Brain MRI revealed tumors at frontal base and right mesial temporal lobe associating with white matter edema, parenchymal and leptomeningeal enhancement, r/o meningioma,lymphoma or metastases. Tumor markers was collected and the result was pending. As a result, admission for close monitoring and possible intervention was suggested and accpeted after explanation of pros and cons.
      • Chest CT revealed no lung tumor. no abnormal mass in abdomen. BPH. Mild RML bronchiolitis. Tumor marker was arranged.
      • He received brain tumor biopsy on 11/18. The pathology reported astrocytic glioma, IDH wild type, in favor of high grade. Thus we need your expertise for further CCRT. Temodal applying in advance. Thanks very much!
    • A
      • Subjective:
        • History: This is a 79-year-old male patient was ADL/iADL partially dependent within his usual status. Conversation was intact but mild delayed. However, saliva drooling, slurred speech, impaired response and muscle weakness at left extremities were noted for 2 days. He was brought to our emergent department for evaluation. Brain CT showed a large isodense frontal base and right parasellar, medial temporal mass, favor a meningioma. Brain MRI revealed tumors at frontal base and right mesial temporal lobe associating with white matter edema, parenchymal and leptomeningeal enhancement, r/o meningioma, lymphoma or metastases. Chest CT revealed no lung tumor; no abnormal mass in abdomen; BPH; mild RML bronchiolitis. He received brain tumor biopsy on 11/18. The pathology reported astrocytic glioma, IDH wild type, in favor of high grade.
          • Previous RT: denied.
          • Other disease: Alzheimer’s disease noted since 2023/01 (CDR?); bilateral cataract, status post operation.
          • Family history: denied.
            • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
            • Married. Caregiver: special nurse (his wife, 3 sons). Job: retired cloth merchant. No or mild economic stress at least.
            • Language: Mandarin. Taiwanese.
        • Objective:
          • General Condition-ECOG: 3.
          • PE, 2023/12/05: no SCF LNs; muscle weakness at left extremities. NG feeding.
          • Pathology, 2023/12/04: Brain, right FT lobe, stereotactic biopsy—astrocytic glioma, microvascular proliferation, few mitosis & no necrosis; IDH wild type, in favor of high grade. IHC: IDH-1(-), GFAP(+), CK(+at glial filaments), p53: wild-type (scanty, weak, < 1%), EMA(-), SOX10(focal+), LCA (- ).
          • Images:
            • Brain MRI, 2023/11/23: A well-defined extra-axial enhancing tumor, about 39 mm at the largest dimension, with diffusion restriction at midline of anterior frontal base. An intra-axial well-enhancing tumor, about 24 mm at the largest dimension, with central necrosis and diffusion restriction in tumor bulk involving right mesial temporal lobe, associating with extensive perifocal white matter edema and diffuse infiltrative parenchymal enhancement and irregular thick enhancement along cistern spaces (including interhemispheric fissure, right hippocampal sulcus, right Sylvian fissure, basal cistern and walls of bilateral frontal horns).
            • Chest CT, 2023/11/24: no lung tumor; no abnormal mass in abdomen; BPH; Mild RML bronchiolitis.
            • Tumor marker, 2023/11/24: SCC, CEA, PSA (negative); aFP 21.0, CA199 106.53.
        • Diagnosis: Astrocytic glioma, IDH wild type, in favor of high grade, involving anterior frontal base, right mesial temporal lobe, cistern spaces (including interhemispheric fissure, right hippocampal sulcus, right Sylvian fissure, basal cistern and walls of bilateral frontal horns), s/p stereotactic brain tumor biopsy on 2023/11/18; ECOG =3.
        • Plan:
          • I suggest RT to brain tumor for 5000cGy/20 fx for tumor control with concurrent temozolamide if feasible.
          • I informed him & his family possible radiation toxicity (radiation dermatitis & IICP). I will arranged CT simulation on 2023-12-07 09:30. RT will be initiated 2-3 days later.
  • 2023-11-23 Neurosurgery
    • A
      • A case of 79 y/o male, Alzheimer disease under treatment at TSGH.
      • BWL for > 6 months. Progressive left side weakness for days.
      • A brain CT showed A large isodense frontal base and right parasellar, medial temporal mass, favor a meningioma.
      • A brain MRI showed Tumors at frontal base and right mesial temporal lobe associating with white matter edema, parenchymal and leptomeningeal enhancement. D/D: meningioma or/and lymphoma, metastases.
      • P: check tumor markers; Chest CT for staging; Brain stereotactic biopsy if needed.

[radiotherapy]

[chemotherapy]

  • 2023-12-13 ~ undergoing - temozolomide 100mg QW12345 (1 hr before CCRT)

==========

2023-12-28

[body weight loss]

According to the weight records revealed by the TPR panel, the patient’s weight was 48kg on 2023-11-23, 37.6kg on 2023-12-13, and 37.2kg on 2023-12-27. CCRT with temozolomide QW12345 began on 2023-12-13. It can be found that the patient’s weight loss mainly occurred before temozolomide initialization. Therefore, temozolomide is less likely to be the main cause of the patient’s weight loss.

It is worth noting that the incidence of anorexia with temozolomide is 27%, nausea (49% to 53%; grades >= 3: 1% to 10%), vomiting (29% to 42%; grades >= 3: 2% to 6%), and lymphocytopenia (grades 3/4: 55%). The patient is currently receiving tube feeding. It is important to monitor the patient’s nutritional intake, observe for nausea and vomiting, and monitor CBC and WBC counts.

[lymphopenia]

The patient’s lymphocyte percentage in WBC DC consistently falls below the normal range of 20% to 45% across all available data points, both pre- and post-CCRT. This persistent lymphopenia might suggest a potential impairment in the patient’s capacity for orchestrated and specific immune responses, which could impact their ability to fight the cancer.

  • 2023-12-28 Lymphocyte 5.7 %
  • 2023-12-25 Lymphocyte 9.5 %
  • 2023-12-18 Lymphocyte 10.0 %
  • 2023-12-14 Lymphocyte 5.9 %
  • 2023-12-11 Lymphocyte 7.7 %
  • 2023-12-07 Lymphocyte 8.7 %
  • 2023-12-05 Lymphocyte 10.7 %
  • 2023-11-30 Lymphocyte 1.9 %
  • 2023-11-28 Lymphocyte 4.8 %
  • 2023-11-27 Lymphocyte 9.6 %
  • 2023-11-23 Lymphocyte 12.4 %

701488243

231228

[exam findings]

  • 2023-12-27 CT - chest
    • Indication: left breast cancer
    • Comparison was made with CT on 2023/6/29
      • Lungs: miliary lesions bilateral lungs still visible.
      • Mediastinum and hila: no enlarged LN or mass.
      • Chest wall and visible lower neck: interval decreased size of left breast tumor and left axillary LAP. s/p breasts augmentation.
      • Visible abdominal contents: many hepatic cysts measuring up to 35mm.
      • Visualized bones: diffuse blastic change in spine and bones of thoracic cage.
    • Impression:
      • left breast cancer, axillary LNs, lung meta and diffuse bone metastases, in regression as compared with CT on 2023/6/29
  • 2023-10-04 SONO - abdomen
    • Real-time sonographic evaluation of the abdomen was performed - Findings:
      • The liver shows normal in size and echogenicity.
        • There are several hepatic cysts in both lobes (the largest one in S2 shows septum formation and 3.73 x 2.42 cm in size).
        • Portal vein flow: patent.
        • Bile ducts: not dilated.
      • The gallbladder appears normal in wall thickness and size.
        • There is no evidence of stone, polyp or sludge.
      • The pancreatic head and body shows normal in size and texture.
        • The pancreatic tail is obscured by overlying bowel gas.
      • The spleen shows normal in size and echogenicity without focal lesion.
      • Right side Pleura effusion.
    • Impression:
      • There are several hepatic cysts in both lobes (the largest one in S2 shows septum formation and 3.73 x 2.42 cm in size).
      • Right side Pleura effusion.
  • 2023-07-10 Patho - breast biopsy (no need margin)
    • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (+, 100%, strong intensity), PR(+, 10%, intermediate intensity), Her2/neu: negative(score= 1+), Ki-67(<10 %), E-cadherin (+). An addendum report of the result of Her2/neu DISH will be followed.
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • 2023-07-08 MRI - breast
    • Clinical history: 61 y/o female patient with malignancy with bone mets.
    • With and without enhancement MRI of breast (axial T1, T1FS, sagittal T2, T2FS, axial and sagittal T1FS contrast, dynamic study):
      • S/P bilateral breast augmentation.
      • R/O diffuse siliconomas in bilateral breasts.
      • There are irregular tumors (6.7x3.1cm) with enhancemant in left breast, with skin involvement, r/o malignancy.
      • Left axillary lymph nodes, r/o lymph nodes metastasis.
      • Right pleural effusion.
      • R/O bone metastasis.
    • Impression:
      • S/P bilateral breast mammoplasty.
      • Left breast malignancy with skin invasion and axillary lymph nodes metastasis, bone metastasis.
      • Right pleural effusion.
    • BI-RADS:
      • Category 6 - proven malignancy
  • 2023-07-05 PET
    • Increased FDG uptake in the left breast and left axillary lymph nodes, highly suspected left breast cancer with regional lymph nodes metastases.
    • Increased FDG uptake in the left pulmonary hilar lymph nodes, in the right lower lung, and in the right cervical lymph nodes, the nature is to be determined, suggesting investigation.
    • Increased FDG uptake in skeleton including the skull, spines, sacrum, bilateral pelvic bones, sternum, both rib cages, clavicles, scapulae, humeri, and femurs, highly suspected multiple bone metastases.
    • Left breast cancer, cTxN2aM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-06-29 CT - chest
    • Indication: suspected left breast cancer with lung and ribs mets
    • Chest CT with and without IV contrast ehnancement shows:
      • s/p breast augmentation.
      • Minimal soft tissue mass enhancement at left breast is found. The possiblity of neoplasm should be suspected.
      • Very tiny nodular lesion are found at both lung fields.
      • Diffuse blastic change at whole bony structure is found. Breast cancer with bone meta is considered.
      • Patent airway is found.
      • Enarged lymph node at left hilar region and left axillary lymphadenopathy is found.
      • Mild right pleural effusion is found.
      • Hepatic cysts at both lobes of liver up to 3.67cm in largest dimension. Simple cysts are considered.
    • Imp:
      • s/p breast augmentation with left breast cancer, axillary lymphadenopathy, lung meta and diffuse bone meta.
  • 2023-06-26 Tc-99m MDP bone scan SPECT
    • Highly suspected malignancy (lung, breast, or other site ?) with multiple bone metastases, suggesting chest CT and breast sono for further investigation.

[MedRec]

  • 2023-12-06 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • Prescription
      • Ibrance (palbociclib 75mg) 1# QDCC 21D
      • Femara (letrozole 2.5mg) 1# QD 28D
      • Zobonic (zoledronic acid 4mg) ST IVD
      • NS 100mL ST IVD
      • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
  • 2023-10-11 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • Prescription
      • Ibrance (palbociclib 75mg) 1# QDCC 21D
      • Femara (letrozole 2.5mg) 1# QD 28D
      • Stilnox (zolpidem 10mg) 1# HS 7D
      • BioCal chewable tablets (tribasic calcium phosphate 1203mg, cholecalciferol 330IU) 1# BID 28D
  • 2023-09-13 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • Prescription
      • Ibrance (palbociclib 75mg) 1# QDCC 21D
      • Ibrance (palbociclib 75mg) 1# QDCC 21D (freebie)
      • Femara (letrozole 2.5mg) 1# QD 28D
      • Stilnox (zolpidem 10mg) 1# HS
      • Zobonic (zoledronic acid 4mg) ST IVD
      • NS 100mL ST IVD
  • 2023-08-16 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • Prescription
      • Zobonic (zoledronic acid 4mg) ST IVD
      • NS 100mL ST IVD
      • NS 500mL QD IVD 1D
      • Femara (letrozole 2.5mg) 1# QD 28D
  • 2023-08-07 ~ 2023-08-12 POMR General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Left breast invasive carcinoma with lymph nodes and bone metastasis, cT4bN1M1, stage IV. ECOG:2
      • Agranulocytosis secondary to cancer chemotherapy
      • Anemia, unspecified
    • Course of inpatient treatment
      • After admission, general weakness was noted after car accident since last month.
      • Thrombocytopenia, anemia and neutropenia fever. Hold Ibrance and Cefa was given. PRNC, PLT transfusion. GCSF x2 days.
      • After stable condition, she was discharge today. OPD will be arrange.
    • Discharge prescription
      • Ibrance (palbociclib 75mg) 1# QDCC 5D
      • Femara (letrozole 2.5mg) 1# QD 7D
      • BioCal chewable tablets (tribasic calcium phosphate 1203mg, cholecalciferol 330IU) 1# BID 30D
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Megejohn (megestrol acetate 160mg) 1# QD
      • cephalexin 500mg) 1# QID
      • Celebrex (celecoxib 200mg) 1# QD
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
  • 2023-07-20 ~ 2023-07-21 POMR General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Left breast invasive carcinoma with lymph nodes and bone metastasis, cT4bN1M1, stage IV. ECOG:0
    • CC
      • noted left shoulder pain over 5 months.
    • Present illness
      • This 61-year-old female patient denied any past history including hypertension, diabetes mellitus or heart disease. HBV was noted from 2023/07. She denied any TOCC histories in recent 3 months.
      • She noted left shoulder pain over 5 months. Suspected malignancy with bone mets by shoulder MRI at JingMei Hospital. She came to our hospital for help.
      • Bone scan was arranged revealed highly suspected malignancy (lung, breast, or other site ?) with multiple bone metastases. She refer to GS OPD for survey.
      • Breast sono showed diffuse subcutaneous tissue thickening of left breast r/o malignancy.
      • Core needle biopsy revealed invasive carcinoma, ER(100%), PR(10%), Her2/neu( 1+), Ki-67: <10%. CA-153:234.040 U/ml, CEA:36.463 ng/ml.
      • Lung CT was arranged very tiny nodular lesion are found at both lung fields.
      • PET showed multiple lymph nodes and bone metastasis.
      • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
      • PE: siliconomas in bilateral breasts. A hard, nontender, movable mass and irregular margin at left breast around 11x13x7 cm without discharge. The nipple was retraction. The left breast skin has multiple scar wounds.
      • Palliative CDK4/6 inhibitor and Zometa was suggest.
      • Under the impression of left breast invasive carcinoma with multiple lymph nodes and bone metastasis, she was admitted for CDK4/6 inhibitor.
    • Course of inpatient treatment
      • After admission, consulted Radiation Oncology Dr Chang YouKang due to left shoulder pain. R/T to right humerus for 3000cGy/10 fx is suggested for pain control. CT simulation is arranged on 2023-07-24.
      • Consulted GI due to HBV carrier. CDK4/6 inhibitor was given. Under stable condition, she was discharged today. Arrange next admitted after 15 days.
    • Discharge prescription
      • Ibrance (palbociclib 125mg) 1# QDCC 16D
      • Stilnox (zolpidem 10mg) 1# HS 7D
      • BioCal chewable tablets (tribasic calcium phosphate 1203mg, cholecalciferol 330IU) 1# BID 30D
  • 2023-07-17 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • O
      • 2023/07/10 PATHO-breast biopsy
        • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
        • IHC stains: ER (+, 100%, strong intensity), PR(+, 10%, intermediate intensity), Her2/neu: negative(score= 1+), Ki-67(<10 %), E-cadherin (+).
        • An addendum report of the result of Her2/neu DISH will be followed.
      • 2023/07/10 PATHO-lymphnode biopsy
        • Labeled as “right lateral neck lymph node”, core needle biopsy — benign lymph node.
        • IHC stain: E-cadherin (-).
      • 2023/07/08 MRI: Breast
        • S/P bilateral breast mammoplasty.
        • Left breast malignancy with skin invasion and axillary lymph nodes metastasis, bone metastasis.
        • Right pleural effusion.
      • 2023/07/05 PET scan
        • Increased FDG uptake in the left breast and left axillary lymph nodes, highly suspected left breast cancer with regional lymph nodes metastases.
        • Increased FDG uptake in the left pulmonary hilar lymph nodes, in the right lower lung, and in the right cervical lymph nodes
        • Increased FDG uptake in skeleton including the skull, spines, sacrum, bilateral pelvic bones, sternum, both rib cages, clavicles, scapulae, humeri, and femurs, highly suspected multiple bone metastases.
        • Left breast cancer, cTxN2aM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
      • 2023-06-26 BONE SCAN
        • Highly suspected malignancy (lung, breast, or other site ?) with multiple bone metastases, suggesting chest CT and breast sono for further investigation.
    • Prescription
      • Zobonic (zoledronic acid 4mg) ST IVD
      • NS 100mL ST IVD
      • BioCal chewable tablets (tribasic calcium phosphate 1203mg, cholecalciferol 330IU) 1# BID 7D
      • Femara (letrozole 2.5mg) 1# QD
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H

==========

2023-12-28

[leukopenia]

The patient’s primary medications include the cyclin-dependent kinase inhibitor palbociclib and the aromatase inhibitor letrozole. Palbociclib was initially prescribed at a daily dose of 125mg starting from late July this year, which was then reduced to 75mg daily from early August. Letrozole has been consistently administered at a daily dose of 2.5mg. The bone mineral density loss associated with the use of AI letrozole and bone metastases are being managed with zoledronic acid and calcium supplements.

Neutropenia, including grades 3 and 4, is a common observation in patients taking palbociclib. The median duration of neutropenia of grade >=3 is approximately 7 days. Cases of febrile neutropenia and neutropenic sepsis have also been reported. Neutropenia caused by palbociclib is rapidly reversible upon stopping the medication.

  • Mechanism: The neutropenia is dose-related and occurs due to the inhibition of CDK6, a crucial regulator of hematopoietic precursor proliferation. Inhibiting CDK6 leads to cytostatic effects on the cell cycle of neutrophils.
  • Onset: The median onset for any grade of neutropenia is around 15 days, with the median onset for grade ≥3 neutropenia being about 28 days.

Our hospital currently stocks Ibrance (palbociclib) in 125mg, 100mg, and 75mg dosages. However, the patient is already on the lowest recommended dose of 75mg. Other CDK4/6 inhibitors like abemaciclib and ribociclib also have similar adverse effects of leukopenia.

According to the latest NCCN guidelines, for postmenopausal patients with ER (+), PR (+), Her2 (-) stage IV breast cancer, the recommended treatments include:

  • Aromatase inhibitor + CDK4/6 inhibitor
  • Fulvestrant + CDK4/6 inhibitor

Both options involve the use of a CDK4/6 inhibitor. Given that the CT scan on 2023-12-27 showed disease regression, indicating that the current regimen is still effective in controlling the disease.

While some research suggests that G-CSF isn’t always necessary for managing neutropenia in CDK4/6 inhibitor-based treatments, it’s important to consider the differences between this and chemotherapy-induced neutropenia. Ref: Management of adverse events during cyclin-dependent kinase 4/6 (CDK4/6) inhibitor-based treatment in breast cancer. Ther Adv Med Oncol. 2018 Sep 3;10:1758835918793326.

Key Points: - CDK4/6 inhibitor-induced neutropenia (usually with palbociclib and fulvestrant) is typically less severe: - Grade 3/4 neutropenia usually resolves within 7 days. - Missing pancytopenia and lower infection rates compared to chemotherapy. - G-CSF may not be necessary. - Chemotherapy-induced neutropenia is more severe and frequent: - Grade 4 neutropenia in over 30% of patients within the first 4 cycles. - Up to 23% experience febrile neutropenia. - Mortality rate of around 5%. - CDK4/6 inhibitor-induced neutropenia shows a favorable profile: - Lower rates of both grade 4 neutropenia and febrile neutropenia compared to chemotherapy. - Neutropenia often decreases with each treatment cycle, suggesting no cumulative toxicity. - Aligns with the targeted mechanism of CDK4/6 inhibitors.

If the patient does not object, it may be possible to add testing for PIK3CA or AKT1/PTEN-activating mutations for reference in the future selection of drugs.

701233507

231227

[MedRec]

  • 2023-12-26 Multi-team consultation - Psycho-oncology
    • Consultation date: 2023-12-25
    • Consultation reason: Others: Cancer in-hospital patient simplified health scale >=10 points
    • Conclusion:
      • S
        • On 2023-12-25, the patient’s wife said that she filled in the score for him because she was right next to him and knew his mood best.
        • The patient said that when he first started chemotherapy, the numbness would slowly go away after 3-4 days, but it didn’t go away after that. He would feel pain when he touched something cold, and his feet would also hurt. He couldn’t walk for long distances.
        • “If this is how it’s going to be for the rest of my life, then what’s the point of living?” The patient’s wife said that she was afraid that he would be disabled.
        • The patient said that if he wanted to create a work of art, the ability to control the fine details was very important. Even a small difference could make a big difference. Now, he didn’t even know if he was tying his shoelaces too tightly.
        • The patient’s wife said that she would discuss with the doctor whether the last two rounds of chemotherapy could omit the drug that caused numbness in the hands and feet. The patient said that he had to complete the treatment plan. He would go to see a Chinese medicine doctor after that to see if it would help. If the case manager had any methods, that would be great.
      • O
        • The patient was diagnosed with colon cancer (stage II) in 2012/06. He is undergoing post-operative chemotherapy. He was admitted to the hospital on 2023-12-25 for his 11th round of chemotherapy. His BSRS score was 15 (severe), and his suicidal ideation score was 1 (mild).
      • I
        • Care for the impact of side effects on life. Affirm the patient’s positive attitude towards recovery.
      • AP
        • The patient is actively cooperating with the treatment plan, but is concerned about the impact of the side effect (numbness in the hands and feet) on his life and work. This part is transferred to the case manager for educational care.
    • Responder: Huang Xiaofang
    • Response date: 2023-12-25 17:56
    • Doctor’s response: 2023-12-26 08:06 Lu Zongru Response: Acknowledged
  • 2023-06-05 ~ 2023-06-10 POMR Colorectal Surgery Xiao GuangHong
    • Discharge diagnosis
      • Sigmoid tumor post tattooed status post 3 dimensions single-incision laparoscopic (SILS) sigmoidectomy on 2023/06/07
    • CC
      • bright red blood on toilet paper since last year and epigastric dull discomfort in recent weeks.
    • Present illness
      • This 59 years old man patient has the history of
        • Calculus of gallbladder for 20-30 years
        • Hyperlipidemia without medication
        • Superficial gastritis without medication
        • Mitral valve prolapse
        • Appendicitis s/p traditional open appendectomy for 30+ years at JingMei Hospital
        • Puckering of macula, right eye, status post 25G pars plana vitrectomy and epiretinal membrane peeling on 2022/08/17.
      • He suffered from bright red blood on toilet paper since last year and epigastric dull discomfort in recent weeks.
      • He came to GI OPD for help and colonoscopy revealed
        • One sessile polyp was noted in the transverse colon Size 0.8 cm. (90 cm from anal verge)
        • One large polypoid tumor lesion was noted in the sigmoid colon Size 3.0 cm. (20 cm from anal verge).
      • Upper gastrointestinal endoscopy showed superficial gastritis.
      • Abdominal CT revealed focal wall thickening of S-colon.
      • Therefore he was referred ro CRS OPD for further evaluation. After fully explained of the condition, the surgical intervention was indicated and the patient understood and agreed.
      • This time, he is admitted to our ward for preoperative preparation and surgical treatment.
    • Course of inpatient treatment
      • After admission with ward routine and pre-op study were done. After well explain the risk of surgery including heart, lung complications and risk of leakage.
      • Operation of 3D SILS sigmoid colectomy under general anesthesia were performed on 2023-06-07.
      • NPO and adequate IV fluid supplement. His wound pain is acceptable by Dynastat.
      • Early activity is encouraged. Chewing cookies, toast, rice with gum was started at op day.
      • The wound healing well and no erythema change. He had flatus passage and abdominal wound pain subsided. So he started to take oral diet well and no abdominal discomfort after meal. He had passed stool with normal bowel movement. Oral intake with soft diet is tolerated well. His abdominal wound pain had got much better.
      • In stable condition, he was discharged on 2023-06-10 and will receive OPD follow up next week.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H

[chemotherapy]

  • 2023-12-25 - leucovorin 400mg/m2 720mg NS 250mL 2hr + fluorouracil 2800mg/m2 5045mg NS 1000mL 46hr (Lv ZongRu)
    • betamethasone 4mg + metoclopramide 10mg + NS 250mL
  • 2023-11-27 - oxaliplatin 85mg/m2 149mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4900mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-07 - oxaliplatin 85mg/m2 149mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4900mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-10-19 - oxaliplatin 85mg/m2 149mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4933mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-10-02 - oxaliplatin 85mg/m2 149mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4914mg NS 1000mL 46hr (FOLFOX Q2W. Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-09-14 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 715mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-28 - oxaliplatin 85mg/m2 148mg D5W 250mL 2hr + leucovorin 400mg/m2 698mg NS 250mL 2hr + fluorouracil 2800mg/m2 4891mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-14 - oxaliplatin 85mg/m2 149mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4920mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-01 - oxaliplatin 85mg/m2 148mg D5W 250mL 2hr + leucovorin 400mg/m2 698mg NS 250mL 2hr + fluorouracil 2800mg/m2 4891mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-07-17 - oxaliplatin 85mg/m2 148mg D5W 250mL 2hr + leucovorin 400mg/m2 698mg NS 250mL 2hr + fluorouracil 2800mg/m2 4891mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-07-03 - oxaliplatin 85mg/m2 147mg D5W 250mL 2hr + leucovorin 400mg/m2 694mg NS 250mL 2hr + fluorouracil 2800mg/m2 4858mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-12-27

[chemotherapy-induced peripheral neuropathy]

Due to concerns about the developed peripheral neuropathy, oxaliplatin was not included in the FOLFOX protocol administered during this hospital stay.

Recent guidelines support the use of duloxetine for managing chemotherapy-induced peripheral neuropathy (CIPN). Both the 2020 ASCO guideline and the joint ESMO/EONS/EANO guideline recommend duloxetine as a treatment option for neuropathic pain in this setting. (Reference: Loprinzi CL, et al. J Clin Oncol 2020; 38:3325)

For adult patients with CIPN, duloxetine is typically started at 30mg orally once daily for the first week, then increased to 60mg once daily thereafter. This dosing recommendation is based on a large, randomized clinical trial by Smith et al. (Reference: Smith EM, et al. JAMA 2013;309(13):1359-67)

There is Cymbalta (duloxetine 30mg capsules) readily available within our stock to be prescribed.

700147427

231226

[exam findings]

  • 2023-12-25 CT - brain
    • Indication: dyspnea with much sputum for 2 days
    • Past history: hx of NSTEMI, duodenal ulcer, gastric ulcer s/p op, HTN
    • Without contrast helical Head CT - 4mm thickness in each slice from the axial and saggital projections showed
      • moderate dilated intraventricular and extraventricular CSF spaces
      • moderate bilateral periventricular leukoaraiosis; old lacunar infarction in the bilateral basal ganglia
      • unremarkable change in the skull base
    • IMP:
      • no acute intracranial hemorrhage
  • 2023-12-24 CXR (erect)
    • cardiomegaly
    • Lung markings: focal increased desity in the left upper and left retrocardiac lung fields.
    • blunting left costophrenic angle

[MedRec]

  • 2023-12-07 SOAP Cardiology Zhou XingHui
    • Prescription x3
      • Norvasc (amlodipine 5mg) 1# QD
      • Plavix (clopidogrel 75mg) 1# QOD
      • Eurodin (estazolam 2mg) 1# HS
  • 2020-04-09 SOAP Cardiology Zhou XingHui
    • Prescription x3
      • Concor (bisoprolol 1.25mg) 1# QD
      • Plavix (clopidogrel 75mg) 1# QD

==========

2023-12-26

Based on the findings of the upright CXR performed on 2023-12-24, which showed cardiomegaly, focal consolidation in the left upper and retrocardiac lung fields, and blunted left costophrenic angle, empirical Sintrix (ceftriaxone) was initiated while culture results are pending.

The patient’s persistent hypertension (170/75 mmHg since admission) could suggest exploring a target systolic blood pressure (SPB) of 150 mmHg. Amlodipine 5mg QD and hydralazine 50mg PRNBID have been prescribed for blood pressure control.

701008186

231226

[lab data]

2023-11-13 HBV-DNA-PCR Target Not Detected IU/mL
2023-11-08 HBsAg Nonreactive
2023-11-08 HBsAg (Value) 0.34 S/CO
2023-11-08 Anti-HBs 538.50 mIU/mL
2023-11-08 Anti-HBc Reactive
2023-11-08 Anti-HBc-Value 6.16 S/CO
2023-11-08 Anti-HCV Nonreactive
2023-11-08 Anti-HCV Value 0.11 S/CO

[exam findings]

  • 2023-11-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (191 - 62.3) / 191 = 67.38%
      • M-mode (Teichholz) = 67.4
    • Conclusion:
      • Dilated LA, LV, Ao
      • Adequate LV, RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Mild PR,TR
      • Mild Pulmonary HTN
  • 2023-11-14 PET
    • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm, stomach, lung, liver, spleen and multiple bone/bone marrow as mentioned above (stage IV).
  • 2023-11-13 Patho - bone marrow biopsy
    • Bone marrow, iliac, clinicallyL gastric lymphoma, biopsy — Negative for malignancy.
  • 2023-11-03 CT - abdomen
    • Indication: Abdominal fullness for weeks tarry stool. BW loss. poor appetite
      • 20231102 gastroscopy: One over 2cm ulcerative base with necrotic tissue were noted at fundus/upper body, GC, s/p biopsy. favor gastric cancer.
    • Findings:
      • There is an ill-defined ulcerated soft tissue mass in the greater curvature side of the gastric fundus/high body, 4 cm in size (the largest dimension), with suggestive extra-gastric omentum invasion.
        • Adenocarcinoma of the stomach (T4b) is highly suspected.
        • The differential diagnosis includes lymphoma.
      • There are twelve enlarged nodes in the peri-gastric fundus/high body area and gastrohepatic ligament.
        • Regional lymph nodes metastases (N3a) are highly suspected.
        • The differential diagnosis includes lymphoma.
      • There are several kissing poor enhancing masses on right hepatic lobe, 8 cm in size (the largest dimension), and several poor enhancing masses in the spleen.
        • Liver and spleen metastases (M1) are highly suspected.
        • The differential diagnosis includes lymphoma with liver and spleen involvement.
        • In addition, there is a soft tissue mass 3 cm in RLL of the lung. Lung metastasis is highly suspected.
        • The differential diagnosis includes lymphoma with lung involvement.
        • Please correlate with chest CT.
      • There are multiple enlarged nodes in para-aortic space and para-cava space. Non-regional lymph nodes metastases are highly suspected.
        • The differential diagnosis includes lymphoma.
      • There is long segmental circumferential mild asymmetrical wall thickening at the terminal ileum and one enlarged node 2.7 cm in the adjacent mesentery.
        • Lymphoma at the terminal ileum is highly suspected.
        • Please correlate with colonoscopy.
      • There are several renal cysts on both kidney and the largest one measuring 2.3 cm in size at right middle pole.
      • Abdominal aorta shows atherosclerosis and ectasia 2.4 cm.
    • Impression:
      • Gastric cancer with liver, spleen, lung, and non-regional LNs metastases is highly suspected.
        • The differential diagnosis includes lymphoma with stomach, liver, spleen, lung, and lymphadenopathy involvement.
        • Please correlate with PET scan.
      • Lymphoma at the terminal ileum is highly suspected.
        • Please correlate with colonoscopy.
  • 2023-11-03 Patho - stomach biopsy (Y1)
    • Stomach, fundus, biopsy — B-cell lymphoma
    • Final diagnosis: Suggestive of diffuse large B-cell lymphoma, GCB
    • Microscopically, it shows dense proliferation of monotonous B-cell type lymphoid cells with architectural effacement and focal necrosis. No H.pylori are identified.
    • Immunohistochemical stain reveals CK(- at tumor), CD56(-), CD20(diffuse +), CD3(patchy+ at background T cells), Ki67 index: >90%.
    • IHC stain: Bcl-6(+), c-myc(-, < 40%), MUM1(-), SOX11(-), CD10(-), lambda(+), kappa(+), cyclin D1(-), Bcl-2(focal+)
  • 2023-11-03 Patho - stomach biopsy (Y1)
    • Stomach, body, GC, biopsy — B-cell lymphoma;
    • Final diagnosis: Suggestive of diffuse large B-cell lymphoma, GCB
    • Microscopically, it shows diffuse proliferation of B-cell type lymphoid cells with architectural effacement and focal necrosis. No H.pylori are identified.
    • Immunohistochemical stain reveals CD20(diffuse +), CD3(patchy+ at background T cells), CK(- at tumor), Ki67 index: >90%, CD56(-).
    • IHC stain: Bcl-6(+), c-myc(-, < 40%), MUM1(-), SOX11(-), CD10(-), lambda(+), kappa(+), cyclin D1(-), Bcl-2(focal+)

[MedRec]

  • 2023-12-20 SOAP Hemato-Oncology He JingLiang
    • Prescription x3
      • Harnalidge (tamsulosin 0.4mg) 1# QDAC 28D
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD 28D
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD 28D
      • Gasmin (dimethylpolysiloxane 40mg) 1# TID 14D
      • Ulstop (famotidine 20mg) 1# QN 14D
      • Through (sennoside 12mg) 2# HS 14D
  • 2023-11-12 ~ 2023-11-23 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • B-cell lymphoma, intra-abdominal lymph nodes, involving multiple lymph nodes on both sides of the diaphragm, stomach, lung, liver, spleen and multiple bone/bone marrow as mentioned above, stage IV.
      • Gout
      • port-a catheter insertion at left cephalic vein on 2023/11/15.
      • upper gastrointestinal bleeding, stool OB:4+
      • hypomagnesemia
    • CC
      • for chemotherapy
    • Present illness
      • This 78 year-old male has the histories of 1) Hypertension, 2) Gastric cancer with liver, spleen, lung, and non-regional LNs metastases,T4bN3aM1, stage: IVB.
      • Followed-up Colonoscopy (2023/11/02) showed: No immediate complication. esophagogastroduodenoscopy (2023/11/02) revealed Gastric ulcerative lesions, body, GC, s/p biopsy(A). Gastric ulcer with necrotic lesion, fundus/upper body, GC, s/p biopsy(C). Reflux esophagitis LA Classification grade A-. Duodenal erosion, bulb, s/p biopsy(B), and the biopsy (2023/11/03): IHC stain: Bcl-6(+), c-myc(-, < 40%), MUM1(-), SOX11(-), CD10(-), lambda(+), kappa(+), cyclin D1(-), Bcl-2(focal+). Final diagnosis: Suggestive of diffuse large B-cell lymphoma, GCB. Immunohistochemical stain reveals CK(- at tumor), CD56(-), CD20(diffuse +), CD3(patchy+ at background T cells), Ki67 index: >90%.
      • Abdomen CT (2023/11/03): 1. Gastric cancer with liver, spleen, lung, and non-regional LNs metastases is highly suspected. The differential diagnosis includes lymphoma with stomach, liver, spleen, lung, and lymphadenopathy involvement. 2. Lymphoma at the terminal ileum is highly suspected.
      • He sufferred from abdominal fullness and back pain for days. No TOCC history was noted. He was admitted for further survey and management.
    • Course of inpatient treatment
      • After be admitted, he received bone marrow was done on 2023/11/13, the biopsy: Negative for malignancy.
      • Followed-up whole body PET (2023/11/14) revealed the FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm, stomach, lung, liver, spleen and multiple bone/bone marrow as mentioned above (stage IV).
      • He suffered from bloody and tarry stool noted last night, now, no bloody syool, no tarry stool, and the lab of CBC/DC showed anemia, so gave PPI with Pantolc, Transamine, blood transfusion with LPRBC treatment.
      • After treatment, the symptom of bloody and tarry stool improved, so he received C1 chemothwerapy with R-COP on 2023/11/17. The port-a catheter insertion at left cephalic vein on 2023/11/15. Family meeting was done on 2023/11/15.
      • He suffered from fever noted, so gave antibiotic with Cravit for infection control, pending the cultures data. After treatment, he denide having a fever, vomiting, shortness of breathing, or tarry stool, no any bleeding signs.
      • Under the stable condition, he can be discharged on 2023/11/23, take oral antibiotic back, and the OPD follow-up will be arranged.
    • Discharge prescription
      • Alpraline (alprazolam 0.5mg) 0.5# HS
      • Harnalidge (tamsulosin 0.4mg) 1# QDAC
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
      • Actein Effervescent (acetylcysteine 600mg) 1# BID
      • Gasmin (dimethylpolysiloxane 40mg) 1# TID
      • MgO 250mg 2# TID
      • Mosapin (mosapride citrate 5mg) 1# TID
      • Through (sennoside 12mg) 2# HS
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Cravit (levofloxacin 500mg) 1.5# QDAC
  • 2023-11-08 SOAP Gastroenterology Chen HongDa
    • S
      • explained EGD and colonoscopy report and abd CT scan report. and patho report
      • we’ve explained about terminal ileum lesion: may discuss with the oncologist or consider laparoscopic exam + biopsy of small bowel
      • PATHO: B-cell lymphoma
      • refer to Oncologist (11/8 AM Prof. Ho)
    • O
      • 2023/11/03 CT: ABD — whole abdomen, pelvis
        • Gastric cancer with liver, spleen, lung, and non-regional LNs metastases. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for gastric cancer: T4b N3a M1; stage: IVB
        • Lymphoma at the terminal ileum is highly suspected.
      • 2023/11/03 PATHO - stomach biopsy
        • Stomach, fundus and body GC, biopsy — B-cell lymphoma
    • Prescription x3
      • Nexium (esomeprazole 40mg) 1# QDAC

[immunochemotherapy]

  • 2023-12-11 - rituximab 375mg/m2 300mg NS 490mL 8hr + cyclophosphamide 75mg/m2 990mg NS 250mL 30min + vincrestine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 40mg/m2 40mg BID PO D1-5 (R-COP; R 70%, C 70%)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + acetaminophen 500mg PO + aprepitant 125mg PO
  • 2023-11-16 - rituximab 375mg/m2 300mg NS 300mL 8hr + cyclophosphamide 75mg/m2 700mg NS 250mL 30min + vincrestine 1.4mg/m2 1mg NS 50mL 10min + prednisolone 40mg/m2 40mg BID PO D1-5 (R-COP; R 50%, C 50%, O 50%)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + acetaminophen 500mg PO + aprepitant 125mg PO

==========

2023-12-26

[reconciliation]

Following lab findings on 2023-12-25 (CRP 11.5 mg/dL and erect CXR demonstrating right lower lung consolidation and blunted costophrenic angles), Brosym (cefoperazone/sulbactam) was initiated. The patient’s fever has favorably responded, decreasing to 37’C as of 2023-12-26. No medication discrepancies were noted.

2023-12-11

This patient is currently undergoing the R-COP regimen and is also taking Vemlidy (tenofovir alafenamide) due to being anti-HBc positive. The patient’s vital signs are stable, and no discrepancies in medication have been identified.

700322331

231225

[exam findings]

  • 2023-12-15 Patho - bone marrow biopsy
    • Bone marrow, biopsy — B-cell lymphoproliferative disorder
    • The specimen submitted consists of two pieces of gray-brown and hard bony tissue, measuring 1.5 x 0.3 x 0.3 cm. All for section after decalcification.
    • The sections show normocellular marrow (25%). The M/E ratio about 3:1. The megakaryocytes are slightly increased in number with occasional small megakaryocytes. Small aggregates and scattered small to medium-sized immature lymphoid cells, account 40% of marrow cells are present.
    • IHC, the immature lymphoid cells show: CD79a(+), CD3(-), CD20(-), CD34(-), CD117(-), TdT(-), and MPO(-). B-lymphoblastic leukemia/lymphoma should be considered in differential diagnosis. Suggest bone marrow smear evaluation, cytogenetic study, and clinic correlation.
  • 2023-12-14 CT - chest
    • Indication: Left breast cancer
    • Chest CT without IV contrast ehnancement shows:
      • Soft tissue mass at left breast with size reduction as compared with previous CT on 2023-06-12. Regional lymphadenopathy is also found at left axillary and bilateral paratracheal region.
      • Consolidation of right upper lobe and right lower lobe is found. Right pleural effusion is also found. Lung meta with superimposed pneumonia is considered.
      • Calcified coronary arteries is found.
      • Cardiomegaly is noted.
    • Imp:
      • Left breast cancer with axillary and mediastinal lymphadenopathy. In regression but pneumonic patch with pleural effusion at right hemithorax
  • 2023-12-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (126 - 42.8) / 126 = 66.03%
      • M-mode (Teichholz) = 66
    • Conclusion:
      • Dilated LA
      • Adequate LV and RV systolic function
      • Moderate MR, mild TR and PR , trivial AR
      • Possibly mild to moderate pulmonary HTN
      • No regional wall motion abnormalities
  • 2023-10-31 Patho - stomach biopsy
    • Stomach, high body, GC, biopsy— fundic gland polyp. No H.pylori present
  • 2023-10-30 EGD
    • Reflux esophagitis LA Classification grade A-
    • Superficial gastritis
    • Gastric polyps, body, s/p biopsy
  • 2023-08-07 CT - brain
    • Mild cortical brain atrophy. Chronic mastoiditis.
  • 2023-07-11 Tc-99m MDP bone scan with SPECT
    • Increased activity in the lower C- and lower T-spines and L3-5 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the mandible. Dental problem may show this picture.
    • Increased activity in bilateral shoulders, knees and feet, compatible with benign joint lesions.
  • 2023-06-27 Her-2/neu DISH
    • RESULT OF HER2 IN SITU HYBRIDIZATION:
      • HER-2 (by in situ hybridization) — Negative (NOT amplified)
    • METHOD AND DETAILS:
      • Number of observers: 1
      • Number of invasive tumor cells counted: 20
      • Average number of HER2 signals per cell: 3.55
      • Average number of CEP17 signals per cell: 2.25
      • HER2/CEP17 ratio: 1.58
      • Heterogeneous signals: Absent
      • Origin slide and block number: S2023-12716
      • Specimen: Formalin-fixed paraffin embedded tissue
      • Adequacy of sample for evaluation: Yes
      • Method of in situ hybridization: CISH (Ventana INFORM HER2 Dual ISH DNA Probe Cocktail Assay, Roche company)
    • APPENDIX:
      • ASCO/CAP scoring criteria (2018):
        • Group 1 = HER2/CEP17 ratio >=2.0; >=4.0 HER2 signals/cell
        • Group 2 = HER2/CEP17 ratio >=2.0; <4.0 HER2 signals/cell
        • Group 3 = HER2/CEP17 ratio <2.0; >=6.0 HER2 signals/cell
        • Group 4 = HER2/CEP17 ratio <2.0; >=4.0 and <6.0 HER2 signals/cell
        • Group 5 = HER2/CEP17 ratio <2.0; <4.0 HER2 signals/cell
      • Negative:
        • Group 5
        • Group 2 and concurrent IHC 0-1+ or 2+
        • Group 3 and concurrent IHC 0-1+
        • Group 4 and concurrent IHC 0-1+ or 2+
      • Positive:
        • Group 2 and concurrent IHC 3+
        • Group 3 and concurrent IHC 2+ or 3+
        • Group 4 and concurrent IHC 3+
        • Group 1
  • 2023-06-27 Patho - breast biopsy (no margin)
    • DIAGNOSIS: Breast, left, core needle biopsy — Invasive carcinoma of no special type
    • GROSS DESCRIPTION: The specimen submitted consisted of 5 strips of tan irregular tissue measuring up to 1.5 x 0.1 x 0.1 cm. All for section in one cassette.
    • MICROSCOPIC DESCRIPTION: Section shows cores of breast tissue with irregular neoplastic glands infiltration and focal tumor necrosis. The immunohistochemical stain of CK5/6 is negative.
    • IMMUNOHISTOCHEMICAL STUDY
      • ER (Ab): Positive (> 95%, strong)
      • PR (Ab): Positive (30%, moderate)
      • Her-2/neu (Ab): Equivocal (2+)
      • Ki-67: 15%
  • 2023-06-13 Mammography
    • Impression: Dense breast. Left breast malignancy with bilateral axillary lymph nodes, r/o malignancy with lymph nodes metastasis.
    • BI-RADS: Category 5: highly suggestive of malignancy-appropriate action should be taken.
  • 2023-06-12 CT - chest
    • Findings
      • Lungs: a spiculated tumor with pleural tails at RLL (35mm in longest dimension), an ill-defined part solid nodule (25mm) at posterior RUL, tethering on the major fissure.
        • multiple small nodules and centrilobular nodular opacities at Rt lung, a 16mm ground glass nodule at RUL, and mild centrilobular nodular opacities at LUL too.
      • chest wall: a large soft-tissue mass in Lt breast (polylobular borders at least 60mm in longest dimension) involving overlying skin.
        • extensive lymphadenopathy at both axillary regions.
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels: mild calcified plaques of the LAD, and LCX, and right coronary arteries.
      • Thoracic aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: dilated LA.
      • Pleura: reace Rt-sided effusion
      • Visible abdominal contents: normal appearance of gall bladder
        • several hepatic cysts measuring up to 12mm.
        • unremarkable of the spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
        • Extensive atherosclerotic change of the abdominal aorta and bilateral common iliac arteries.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis. no destructive lytic or blastic lesion.
    • Impression:
      • Lt breast cancer with bilateral axillary LNs metastasis. RUL and RLL synchronous cancer with ipsilateral lung metastasis? or r/o breast ca with lung metastasis and inflammatory bronchiolitis and Rt lung and LUL.
  • 2023-06-12
    • Findings
      • Parenchymal pattem: Homogeneously sonodense
      • Focal sonographic lesion: Yes
    • Diagnosis
      • Highly suspicious of malignancy,with sonographic positive axillary LAP
    • Treatment
      • Sono-guided biopsy,Core-needle biopsy,Open biopsy
    • Suggestion
      • Arrange mammography, Arrange breast MRI, Arrange excisional biopsy, Admission for surgical intervention
    • BI-RADS:
      • 5-Highly Suggestive of Malignancy (>95% malignant) Appropriate Action Should Be Taken

[MedRec]

  • 2023-12-06 ~ 2023-12-21 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Pneumonia over right lung
      • Left breast cancer, of left breast, stage unknow
      • Gastro-esophageal reflux disease with esophagitis
      • Leukocytosis and blast
      • Anemia
      • mild to moderate pulmonary hypertension
    • CC
      • Fever off and on, general malaise and SOB in recently 3days
    • Present illness
      • This 83 years old female has history of
        • Lt breast cancer on hormone therapy & Palbociclib, RUL and RLL synchronous cancer with ipsilateral lung metastasis? or r/o breast ca with lung metastasis and inflammatory bronchiolitis and Rt lung and LUL
        • GERD
        • Leukocytosis and Anemia cause ?
      • She regullar followed up in our GS OPD
      • Three days prior to this admission, fever off and on, SOB with chest tightness and general malaise was noted, she was went to our ER for aid. The TOCC with COVID-19 (son).
      • At MER, the vital sign : BP:116/56; HR:73; BT:36.6’C; RR:18; Con’s:E4V5M6.
      • The laboratory studies disclosed WBC 20800 , N.seg/Lym 16/69 %, HB 6.3 g/dL, Na/K 127/3.5 mmol/L, Glucose 129 mg/dL, BUN/ Cre 26/1.32 mg/dL, Alt 19 mg/dL, and CRP 15.3 mg/dL.
      • The influenza and COVID-19 survey yield negative.
      • The CXR showed consolidations in right lung.
      • Under the impression of Pneumonia and r/o asthma AE, she was admitted to CM ward for management.
    • Course of inpatient treatment
      • After admission, empiric antibiotic with Cravit IV and Colimycin inhalation were used for pneumonia control.
      • Antitussive, mucolytic agents and other palliative treatment were given for symptomatic relief.
      • Bronchodilator with Atrovent plus with Butanyl inhalation was also prescribed for dyspnea with wheezing.
      • Do sputum culture, urine culture and blood culture evalution to identify pathogen.
      • Atypical infection profile (Streptococcus pneumoniae Antigen, Legionella pneumophila urine antigen test, M.Pneu. Ab ) were checked and all revealed negative findings.
      • VS explaint condition for her son and she received bone marrow was done, pending report.
      • Follow up CXR, her pneumonia condition got significant regression.
      • Sudden onset, fever without chills was noted, negtive of PCT and fever subside later.
      • Under the stable condition, she can be discharged on 2023/12/21. OPD follow up is arranged.
    • Prescription
      • Morcasin (sulfamethoxazole 400mg, trimethoprim 80mg) 1# Q12H 6D
      • Mecater (procaterol 25ug) 1# BID 6D
      • Rivotril (clonazepam 0.5mg) 1# HS 6D
      • Through (sennoside 12mg) 2# HS 6D
      • Trand (traxenamic acid 250mg) 1# BID 6D
      • Actein Effervescent (acetylcysteine 600mg) 1# BID 6D
  • 2023-11-15 SOAP General and Gastrointestinal Wang ShengLin
    • S: poor appetite
    • Prescription
      • Femara (letrozole 2.5mg) 1# QD 28D
      • Ibrance (palbociclib 100mg) 1# QD 21D
      • diphenidol 25mg 1# 28D
      • Biofermin-R (antibiotics-resistant lactic acid bacteriae 1g) 1# TID 7D
  • 2023-10-18 SOAP General and Gastrointestinal Wang ShengLin
    • S: no adverse effect
    • Prescription
      • Femara (letrozole 2.5mg) 1# QD 28D
      • Ibrance (palbociclib 100mg) 1# QD 21D
      • diphenidol 25mg 1# 28D
  • 2023-09-20 SOAP General and Gastrointestinal Wang ShengLin
    • O
      • sensory neuropathy grade 1
      • hand-foot syndrome grade 1
    • Prescription
      • Femara (letrozole 2.5mg) 1# QD 28D
      • Ibrance (palbociclib 100mg) 1# QD 21D
      • diphenidol 25mg 1# 28D
      • Parmason Gargle Soln (chlorhexidine) BID GAR 7D
  • 2023-08-30 SOAP General and Gastrointestinal Wang ShengLin
    • S/O:
      • Hormone therapy: Femera
      • CDK 4/6 inhibitor: Ibrance
      • Mild dizziness, no significant brain metastasis: diphenidol
    • A: Luminla B:
      • ER (Ab): Positive (> 95%, strong)
      • PR (Ab): Positive (30%, moderate)
      • Her-2/neu (Ab): Equivocal (2+)
      • Ki-67: 15%
    • P:
      • Oral hormone therapy: Femera
      • Oral CDK 4/6 inhibitor: Ibrance
      • regular OPD follow up
    • Prescription
      • Ibrance (palbociclib 100mg) 1# QD 21D
      • diphenidol 25mg 1# TID
  • 2023-08-23 SOAP General and Gastrointestinal Wang ShengLin
    • S/O:
      • Mild dizziness: no significant brain metastasis => add diphenidol
      • Brain CT: Mild cortical brain atrophy. Chronic mastoiditis.
    • A/P:
      • Oral hormone chemotherapy
      • Oral CDK 4/6 inhibitor
      • regular OPD follow up
    • Prescription
      • Femara (letrozole 2.5mg) 1# QD 28D
      • Ibrance (palbociclib 100mg) 1# QDAC 7D
      • diphenidol 25mg 1# TID 7D
  • 2023-07-24 SOAP General and Gastrointestinal Wang ShengLin
    • S:
      • Abdominal distension improved
      • no significant side effects
    • A: Luminla B:
      • ER (Ab): Positive (> 95%, strong)
      • PR (Ab): Positive (30%, moderate)
      • Her-2/neu (Ab): Equivocal (2+)
      • Ki-67: 15%
    • P:
      • Oral hormone chemotherapy
    • Prescription
      • Femara (letrozole 2.5mg) 1# QD 28D
  • 2023-07-10 SOAP General and Gastrointestinal Wang ShengLin
    • S: Abdominal distension with constipation
    • O: Pathology
      • Breast, left, core needle biopsy — Invasive carcinoma of no special type
      • IMMUNOHISTOCHEMICAL STUDY
        • ER (Ab): Positive (> 95%, strong)
        • PR (Ab): Positive (30%, moderate)
        • Her-2/neu (Ab): Equivocal (2+)
        • Ki-67: 15%
    • Prescription
      • MgO 250mg 1# TID 14D
      • Femara (letrozole 2.5mg) 1# QD 14D
      • Promeran (metoclopramide 3.84mg) 1# TIDAC 14D
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID 14D
  • 2023-06-27 SOAP General and Gastrointestinal Wang ShengLin
    • S/O: irregular tumor, 6.7cm in UOQ of left breast
    • A/P: arrange left breast core needle biopsy
    • Prescription
      • fusidic acid 20mg/gm BID EXT 3D
      • Acetal (acetaminophen 500mg) 1# QID 3D
      • cephalexin 500mg 1# Q6H 3D
  • 2023-06-12 SOAP General and Gastrointestinal Wang ShengLin
    • S/O: Left breast palpable tumor noted for several days
    • A/P:
      • Breast echo
      • Chest X-ray
      • Chest CT
      • Mammography

==========

2023-12-25

[tube feeding]

Concor 5mg administration via Simple Suspension Method (SSM):

For patients requiring enteral nutrition, dissolve the Concor 5mg tablet using the SSM. This efficient method involves:

  • Dissolving: Crush the tablet and add it to a container of warm drinking water.
  • Soaking: Allow the mixture to stand for 5-10 minutes, allowing the tablet to fully dissolve.
  • Stirring/Shaking (optional): Gently stir or shake the container at intervals to facilitate dissolving.
  • Administration: Once completely dissolved, administer the suspension directly through a feeding tube.

Benefits of SSM:

  • Dissolution in warm water: SSM effectively dissolves tablets and capsules even in lukewarm water, suitable for both suspension and feeding tube administration.
  • Improved compliance: This method simplifies medication administration for patients with swallowing difficulties, potentially enhancing adherence to treatment.

701114210

231225

[MedRec]

  • 2023-10-24 SOAP Metabolism and Endocrinology Hu YaHui
    • Diagnosis
      • Corticoadrenal insufficiency [E89.6]
      • Malignant neoplasm of rectum [C20]
      • Goiter, unspecified [E04.9]
      • Malignant adrenal gland neoplasm [C74.02]
      • Anemia [D64.9]
    • Prescription x3
      • Crestor (rosuvastatin 10mg) 1# QD
      • Decone (dexamethasone 0.5mg) 1# QD
      • Florinef (fludrocortisone 0.1mg) 1# QD
      • Lipanthyl Supra (fenofibrate 160mg) 1# QD
      • MgO 250mg 1# BID
      • Ezetrol (ezetimibe 10mg) 1# QD
      • cortisone acetate 25mg 2# PRNBID if headache or fever
  • 2023-07-25 SOAP Metabolism and Endocrinology Hu YaHui
    • Diagnosis
      • Corticoadrenal insufficiency [E89.6]
      • Malignant neoplasm of rectum [C20]
      • Goiter, unspecified [E04.9]
      • Malignant adrenal gland neoplasm [C74.02]
      • Anemia [D64.9]
    • Prescription x3
      • Docone (dexamethasone 0.5mg) 1# QD
      • Florinef (fludrocortisone 0.1mg) 1# QD
      • Crestor (rosuvastatin 10mg) 1# QD
      • Lipanthyl Supra (fenofibrate 160mg) 1# QD
      • cortisone acetate 25mg 2# PRNBID if headache or fever
  • 2023-06-21 ~ 2023-06-29 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • K-RAS wild type Rectum cancer, pT3N0M0 post neoadjuvant with concurrent chemoradiotherapy, status post low anterior resection in 2018-08 WITH recurrence post palliative chemotherapy. Multiple LNs, lung and liver metastases in 2023-04.
      • Secondary malignant neoplasm of right adrenal gland
      • Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
    • CC
      • for further management
    • Present illness
      • This 68-year-old male, a pt of rectal adeno CA, cT3N0M0 s/p neoadjuvant CCRT, s/p LAR in Aug 2018 by Dr Xiao GuangHong, s/p post-Op adjuvant Xeloda & R adrenal mets s/p bil adrenectomy in 2020-01 by Dr Cai YaoZhou, s/p post-Op palliative C/T with FOLFIRI / Avastin from April to July 2020 by Dr Liu JunHuang & recurrenec at para-aortic LN mets in 2021-01.
      • KRAS: wild type., s/p 2nd line palliative C/T wt CapeOx x 12 from Feb to Nov 2021 wt Dz in progress at new hepatic tumor, s/p 3rd line palliative C/T wt FOLFIRI / Erbitux IV Q2W x 12 since 12/7 21.
      • L adrenal tumor with rapid increase in size after surgery, Adrenal gland, R, lap.
      • Adrenalectomy (2/21 20) proved mets adenoCA, favoring colorectal origin. Adrenal MRI (1/20 20) showed mets in right adrenal gland is highly suspected. Right adrenaltumor enlargment suspect adrenal mets, suggest LPS adrenalecotmy. Lt adrenalectomyin 06/2019 & Rt adrenalectomy on 2020/02/21.
      • A left para-aortic glucose-hypermetabolic soft tissue lesion, metastasis in a leftpara-aortic lymph node was noted.He was referred to our clinic on 5/25 20 for continuous C/T by Dr Liu JunHuang. #5 chemotherapy with Avastin / FOLFIRI IV Q2W x 8 on 6/8 20, #6 on 6/22 20. #7 on7/6 20. #8 on 7/20 20 (finished).
      • Follow-up abd CT (7/15 20) showed s/p LAR with autosuture retention at the rectum.No evidence of tumor recurrence. CEA: 1.4 (7/15 20), CEA: 1.0 (12/28 20).FCXR & abd sono (9/28 20): negative. Abd CT (1/228 20) revealed rectal CA s/p Op. A LN (1.8cm) at paraaortic region r/o tumor mets. Newly developed para-aortic LNs;biopsy (1/12 21) proved adenocarcinoma. IHC stain: CK20(+), c/w lcolorectal recurrence.
      • We explain to pt about the indication & risk / benefit of 2nd line palliative C/T wt mFOLFOX IV Q2W x 12.
      • Follow-up abd CT (12/28 20) showed rectal CA s/p Op. A LN (1.8cm) at paraaortic region r/o tumor mets.newly developed para-aortic LNs; biopsy (1/12 21) proved adenocarcinoma. IHC stain: CK20(+), c/w colorectal recurrence.
      • 2nd line palliative C/T wt mFOLFOX IV Q2W x 1 on 2/1 21. (DC it due to SE & pt declined it). Due to SE, may shift to CapeOx.will shift to CAPEOX ( Capecitabine 1000mg/m2 PO BID D1~14 Q3W + Oxaliplatin 130mg/m2 ) IV Q3W .
      • 2nd line palliative C/T wt CapeOx ( Capecitabine 700mg/m2 ( 2# ) PO BID D1~14 Q3W + Oxaliplatin 60mg/m2 IV Q3W ) x 6 on 2/23 21, #2 CapeOx ( Capecitabine 1000mg/m2 (3#) + Oxaliplatin 70mg/m2 IV Q3W x 6 on 3/16 21, #3 on 4/6 21, #4 on 4/27 21. #5 on 5/18 21. #6 on 6/30 21. #7 ( Oxalip 100mg/m2 ) on 7/13 21. #8 ( Oxalip 110mg/m2 ) on 8/3 21. #9 ( Oxalip 120mg/m2 ) on 8/24 21. #10 on 9/14 21. #11 ( Oxalip 130mg/m2 ) on 10/5 21. #12 on 11/2 21. ( portable ).Abd CT (5/4 21) (8/4 21) showed s/p R hemicolectomy, post-op at rectum with left paraaortic recurrence, stationary.
      • Abd CT (11/16 21) revealed s/p RAR. L perirenal space metastatic lymphadenopathy, stable. New hepatic tumor at dome. r/o meta.#1A 3rd line palliative C/T wt FOLFIRI / Erbitux IV Q2W x 12 on 12/7 21.Erbitux 400mg/m2 (give 600mg) IVF 2 hr then 250mg/m2 ( give 400mg ) IVF 1 hr QW x8, plus FOLFIRI as 3rd line palliative C/T.
      • RTC 1 wk later on 5/10 22 for #3 4th palliative C/T wt FOLFIRINOX / Erbitux IV Q2W x 12 (the last biochemotherapy on 2022/7/5).
      • Followed CT of abdominal on 2023/5/16 revealed S/P colon operation. Multiple LNs, lung and liver metastases. He was admitted for further management
    • Course of inpatient treatment
      • After admission,CT guide biopsy was administered on 2023/6/23 revealed Metastatic adenocarcinoma, consistent with colorectal primary.
      • Chemotherapy with C1D1 FOLFIRI (dose adjusted to 20% off) was administered on 2023/6/26-28 after fully explaination.
      • Adequate hydration. selfpaid of Emend and PRN Dexamethasone for chemotherapy related emesis.
      • With the relatively stable condition, he was discharged on 2023/06/29 and will OPD follow up later
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H as painkiller
      • loperamide 2mg 1# PRNQ6H if diarrhea
      • Limeson (dexamethasone 4mg) 1# PRNBID as antiemetic
  • 2019-08-07 SOAP Metabolism and Endocrinology Hu YaHui
    • Diagnosis
      • Corticoadrenal insufficiency [E89.6]
      • Malignant neoplasm of rectum [C20]
      • Goiter, unspecified [E04.9]
      • Malignant adrenal gland neoplasm [C74.02]
      • Anemia [D64.9]
    • Prescription x3
      • cortisone acetate 25mg 2# PRNBID
      • Compesolon (prednisolone 5mg) 0.5# BID
  • 2018-03-29 SOAP Colorectal Surgery Xiao GuangHong
    • S: A case of newly diagnosed rectal cancer at 8cm from AV

[chemotherapy]

  • 2023-12-05 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-11-21 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-11-07 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-10-24 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-10-03 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-09-19 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2860mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-08-17 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2860mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-07-12 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 430mg NS 250mL 2h4 + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (FOLFIRI Q2W. Iri, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-06-26 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 430mg NS 250mL 2h4 + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (FOLFIRI Q2W. Iri, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-07-05 - (FOLFOXIRI)

  • 2022-06-21 - (FOLFOXIRI)

  • 2022-06-07 - (FOLFOXIRI)

  • 2022-05-24 - (FOLFOXIRI)

  • 2022-05-10 - (FOLFOXIRI)

  • 2022-04-12 - (FOLFOXIRI)

  • 2022-03-22 - (FOLFOXIRI)

  • 2022-03-08 - (cetuximab + FOLFOXIRI)

  • 2022-02-22 - (cetuximab + FOLFOXIRI)

  • 2022-02-08 - (cetuximab + FOLFOXIRI)

  • 2022-01-18 - (cetuximab + FOLFOXIRI)

  • 2022-04-04 - (cetuximab + FOLFOXIRI)

  • 2021-12-07 - (cetuximab + FOLFOXIRI)

  • 2021-11-02 - (Oxa)

  • 2021-10-05 - (Oxa)

  • 2021-09-14 - (Oxa)

  • 2021-08-24 - (Oxa)

  • 2021-08-03 - (Oxa)

  • 2021-07-13 - (Oxa)

  • 2021-06-09 - (Oxa)

  • 2021-05-18 - (Oxa)

  • 2021-04-27 - (Oxa)

  • 2021-04-06 - (Oxa)

  • 2021-03-16 - (Oxa)

  • 2021-02-23 - (Oxa)

  • 2021-02-01 - (FOLFOX)

  • 2020-07-20 - (Avastin + FOLFIRI)

  • 2020-07-06 - (Avastin + FOLFIRI)

  • 2020-06-22 - (Avastin + FOLFIRI)

  • 2020-06-08 - (Avastin + FOLFIRI)

  • 2020-05-25 - (Avastin + FOLFIRI)

  • 2020-05-06 - (Avastin + FOLFIRI)

  • 2020-04-15 - (Avastin + FOLFIRI)

  • 2020-04-01 - (Avastin + FOLFIRI)

  • 2020-03-20 - (Avastin + FOLFIRI)

==========

2023-12-25

[reconciliation]

It is noted that not all of the drugs prescribed on 2023-10-24 by our endocrinologistare currently reflected on the active medication list. To prevent any potential misunderstandings and to ensure timely access to necessary medications, it might be beneficial to double-check and update the list if needed.

2023-08-18

Our endocrinologist issued a repeat prescription for Docone (dexamethasone), Florinef (fludrocortisone), Crestor (rosuvastatin), and Lipanthyl Supra (fenofibrate), all of which are currently in use, with no medication reconciliation problems found.

700039896

231222

[chemotherapy]

  • 2023-12-20 - bortezomib 1.3mg/m2 2mg SC (VTd QW)

Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma - 2023-12-21 - https://www.uptodate.com/contents/image?imageKey=ONC%2F101205

  • Cycle length: 28 days.

  • Regimen

    • Bortezomib
      • 1.3 mg/m2 SC
      • Given as a single SC injection.
      • Days 1, 8, 15, and 22
    • Thalidomide
      • 100 mg for first 14 days then 200 mg per day thereafter by mouth
      • Take with water on an empty stomach at least one hour after the evening meal.
      • Daily, days 1 through 21
    • Dexamethasone (“low dose”)
      • 40 mg by mouth
      • Take with food (after meals or with food or milk) in the morning.
      • Days 1, 8, 15, and 22
  • Pretreatment considerations:

    • Emesis risk
      • MINIMAL TO LOW.
    • Prophylaxis for infusion reactions
      • Routine premedication is not indicated. If a hypersensitivity reaction (not including local reactions) occurs with bortezomib or thalidomide, then neither drug should be readministered.
    • Antithrombotic prophylaxis
      • Routine antithrombotic prophylaxis is warranted. Thromboembolism (grade 3 and 4) was reported in 3% of patients in a clinical trial receiving VTd despite antithrombotic prophylaxis. In addition, reported risk of thromboembolism (grade 3 and 4) was 5% in the Td arm of this study.
    • Infection prophylaxis
      • Bortezomib therapy may be associated with an increased risk of herpes zoster and infections not related to neutropenia. Antiviral prophylaxis (eg, acyclovir 400 mg orally twice a day) should be administered to all patients receiving VTd. Some clinicians also administer trimethoprim-sulfamethoxazole double strength once daily on Mondays, Wednesdays, and Fridays during treatment. Primary prophylaxis with G-CSF is not indicated.
    • Vesicant/irritant properties
      • Bortezomib is an irritant.
    • Dose adjustment for baseline liver or renal dysfunction
      • Bortezomib: No dosage adjustment for bortezomib secondary to renal insufficiency is necessary. For patients undergoing hemodialysis, bortezomib should be administered after dialysis. Patients with moderate or severe hepatic impairment (serum bilirubin level >1.5 times the upper limit of normal) should be started on bortezomib at a reduced dose of 0.7 mg/m2 per injection during the first cycle, with further dose modifications based upon patient tolerance.
      • Thalidomide: Dosage adjustment of thalidomide is not required for either preexisting renal or hepatic dysfunction.
    • Pregnancy warning
      • Thalidomide can result in severe, life-threatening human birth defects. Pregnancy testing is required within 24 hours prior to initiation of thalidomide therapy.
  • Monitoring parameters:

    • Assess CBC with differential, electrolytes, renal function, liver function, and M protein prior to starting each cycle. A CBC should also be performed prior to the dose of bortezomib on days 1, 8, 15, and 22.
    • Monitor for signs of neuropathy. Many clinicians provide a prophylactic bowel regimen for patients taking thalidomide.
    • Monitor for hypotension during therapy; adjustment of antihypertensives and/or administration of IV hydration may be needed.
    • Monitor for signs of rash, infection, or thrombotic event periodically.
  • Suggested dose modifications for toxicity:

    • Neuropathy
      • Dose adjustment guidelines for bortezomib in patients who develop peripheral neuropathy or neuropathic pain are available.
      • Thalidomide should be discontinued or dose reduced if a patient develops paresthesias accompanied by pain, motor deficit, or interference with activities of daily living.
    • Rash
      • Thalidomide has been associated with rashes including SJS and TEN. If a rash develops, thalidomide should be discontinued and the rash further evaluated. Thalidomide should not be administered again if the rash is exfoliative, purpuric, or bullous, or if SJS or TEN is suspected.
    • Thrombotic microangiopathy
      • Rarely, bortezomib has been associated with TMA, which can present with Coombs-negative hemolysis, thrombocytopenia, renal failure, and/or neurologic findings.[3] If TMA is suspected, stop bortezomib and evaluate.
    • Other nonhematologic toxicity
      • For grade 3 or 4 nonhematologic toxicity other than neuropathy, bortezomib should be held. Once symptoms have resolved to grade 1 or baseline, bortezomib may be reinitiated with one dose level reduction (from 1.3 mg/m2 to 1 mg/m2, or from 1 mg/m2 to 0.7 mg/m2).

==========

2023-12-22

[hyperuricemia]

Hyperuricemia was detected on 2023-12-22 with a serum uric acid level of 11.7 mg/dL. Two potential treatment options for this elevated uric acid level might be considered:

  • Fasturtec (rasburicase 1.5mg/mL/vial is available): This is a medication that directly breaks down uric acid in the blood, offering a rapid and effective way to lower its levels. It may be an appropriate choice for patients with severe hyperuricemia or those who require a quick reduction in uric acid levels.
  • Urinary alkalinization: This approach aims to make the urine more alkaline, which can help uric acid dissolve and be excreted more easily through the kidneys. This can be achieved through various medications, including acetazolamide and sodium bicarbonate. However, the specific choice and effectiveness of these medications for controlling hyperuricemia remain an area of ongoing research and debate.

2023-12-21

[anemia]

The patient’s HGB level has been consistently below normal since admission. The lowest level was observed on 2023-12-21. Bortezomib was administered on 2023-12-20 and is associated with anemia in 12-23% of patients (grades 3-6). It is possible that bortezomib exacerbated the existing anemia.

  • 2023-12-21 HGB 7.2 g/dL *
  • 2023-12-18 HGB 9.2 g/dL
  • 2023-12-14 HGB 9.6 g/dL
  • 2023-12-11 HGB 8.1 g/dL
  • 2023-12-09 HGB 8.4 g/dL
  • 2023-12-09 HGB 8.5 g/dL
  • 2023-12-07 HGB 8.0 g/dL
  • 2023-12-05 HGB 8.7 g/dL
  • 2023-12-04 HGB 7.7 g/dL
  • 2023-12-02 HGB 9.7 g/dL
  • 2023-12-01 HGB 9.7 g/dL
  • 2023-11-27 HGB 9.8 g/dL

The patient should receive red blood cell transfusions as clinically indicated.

[VTd regimen administration schedule]

VTd regimen is supposed to be administered as following:

  • Bortezomib
    • 1.3 mg/m2 SC
    • Given as a single SC injection.
    • Days 1, 8, 15, and 22
  • Thalidomide
    • 100 mg for first 14 days then 200 mg per day thereafter by mouth
    • Take with water on an empty stomach at least one hour after the evening meal.
    • Daily, days 1 through 21
  • Dexamethasone
    • 40 mg by mouth
    • Take with food (after meals or with food or milk) in the morning.
    • Days 1, 8, 15, and 22

Bortezomib and dexamethasone were administered on 2023-12-20 (C1D1). However, thalidomide 100 mg daily was started ahead of schedule on 2023-12-14. To align with the administration cycle (28 days) and discontinue thalidomide on C1D22, it should be stopped on 2024-01-10.

[CMV viral load detected]

As of 2023-12-18, the CMV viral load was measured at 190 IU/mL. Depending on the clinical context and your concerns about this level, valganciclovir 900mg BID could be a potential treatment option.

700971109

231222

[exam findings]

  • 2023-11-14 CT - chest
    • Indication: Diffuse large B-cell lymphoma, NOS, non-germinal center B-cell subtype, CD3(-), CD20(+), BCL2(+), CD10(-), BCL6(+), MUM1(+) and MYC(-). Bone marrow involvement. Lugano stage IV, IPI 4.
    • Without & with contrast enhancement, coronal and sagittal reconstructed images shows: comparison made with CT on 2023/07/04
      • Lungs: patchy ground-glass opacities and septal thickening at nondependent LUL and medial RUL.
        • subpleural reticulation at both lower lungs, associated scattered patchy ground-glass opacities.
        • residual enlarged LN at left anterior perivascular space of the mediastinum.
        • resolution of lymphadenopathy at bilateral lower neck involving bilateral thoracic inlet, bilateral axillary, splenic hilum, paraaortic and left inguinal region as well as at left anterior chest wall.
      • Visible abdomen:
        • hyperplasia of left adrenal gland, stable.
        • interval significant decrease in size of low density at right lobe liver measuring 1cm and Lt renal tumor based on this F/U exam.
        • extensive coronary arterial calcification
      • Thoracic aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: dilated LA, s/p MVR.
      • Pleura: no effusion
    • Impression:
      • resolution of the diffuse B-cell lymphoma in both sides of diaphgram and in extra-nodular locations, as compared with previous CT on 2023/07/04. post treatment related change in lungs.
  • 2023-07-26 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — lymphoma involvement
    • Section shows piece(s) of bone marrow with one nodule of lymphoma involvement.
  • 2023-07-25 CXR (erect)
    • S/P median sternotomy with metalic wires fixation. Please correlate with clinical history.
    • S/P mitral valve replacement.
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
  • 2023-07-24 PET scan
    • Glucose hypermetabolism lesions in bilateral neck regions, SCF, ICF, axillae, mediastinum, abdomen, pelvis, left upper thigh and left inguinal regions, and spleen, highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
    • Glucose hypermetabolism lesions in the right lobe of the liver, and in C2 spine, right rib cage, bilateral pelvic bones and femurs, highly suspected lymphoma with involvement of liver, bones and/or bone marrow.
    • B-cell lymphoma, c-stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-07-11 Patho - lymph node region resection
    • Lymph node, inguinal, left, excision — Diffuse large B-cell lymphoma, NOS, non-germinal center B-cell subtype
    • Immunophenotyping: CD3(-), CD20(+), BCL2(+), CD10(-), BCL6(+), MUM1(+) and MYC(-)
  • 2023-07-04 CT - chest
    • Generalized enlarged lymph nodesHe was informed to have abnormal LN enlargement over Rt axillary and Rt lower neck and Lt inguinal region
    • Chest CT with and without IV contrast ehnancement shows:
      • Lymphadenopathy at bilateral lower neck involving bilateral thoracic inlet, bilateral axillary, mediastinum, splenic hilum, paraaortic and left inguinal region.
      • One enlarged soft tisuse at left anterior chest wall, r/o meta.
      • s/p sternotomy with metalic wire fixation of the sternum.
      • s/p thymectomy.
      • Enlarged left adrenal gland is found.
      • Low density at right lobe liver is found with target appearance measuring 2.3cm in largest dimension. Liver meta is considered.
      • Soft tissue mass at left renal cortex measuring 3.58cm in largest dimension. r/o renal meta
    • Imp:
      • Extensive lymphadenopathy from lower neck to mediastinum and abdominal cavity as well as left inguinal region.
      • Liver, left adrenal and left renal soft tissue mass, meta is favored.
      • r/o thymoma with recurrence
  • 2023-06-05 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 37) / 93 = 60.22%
      • M-mode (Teichholz) = 59
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Dilated LA, septal hypertrophy
      • Trivial MR, mild AR and mild TR
      • Preserved RV systolic function

[MedRec]

  • 2023-08-18 SOAP Cardiology Xie JianAn
    • Prescription x3
      • Caduet (amlodipine 5mg, atorvastatin 20mg) 1# QD
      • Plavix (clopidogrel 75mg) 1# QD
      • carvedilol 6.25mg 0.5# QD (hold if HR < 60)

[immunochemotherapy]

  • 2023-12-21 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 50mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2
  • 2023-11-14 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 48mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2
  • 2023-10-19 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 48mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2
  • 2023-09-19 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 48mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2
  • 2023-08-21 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 48mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2
  • 2023-07-26 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 47mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2

==========

2023-12-22

Serum uric acid levels sometimes exceed the normal range, and Feburic (febuxostat) has been prescribed for treatment. No medication discrepancies have been identified.

2023-10-06

[reconciliation]

The patient’s PharmaCloud records are not currently available. However, after reviewing HIS5, no medication discrepancies were found.

[leukopenia]

Leukopenia was noted in early Oct, approximately 2 weeks after his last R-CHOP treatment (3rd dose) on 2023-09-19. On 2023-10-04, the patient was started on G-CSF (filgrastim) 300mg SC QD. A slight improvement in WBC count was observed on 2023-10-06. There is no problem with the treatment.

2023-10-06 WBC 0.85 x10^3/uL
2023-10-04 WBC 0.65 x10^3/uL
2023-09-26 WBC 3.37 x10^3/uL
2023-09-18 WBC 4.63 x10^3/uL

2023-09-19

  • On 2023-08-18, our cardiologist provided a repeat prescription for Caduet (amlodipine, atorvastatin), Plavix (clopidogrel), and carvedilol, each with a 3x28-day supply. These medications are currently being taken as prescribed without any reconciliation issues detected.

700021401

231219

[lab data]

  • 2023-11-26 Aerobic Culture - Wound/Pus
    • Proteus mirabilis Growth:3+
      • Doripenem(S), Amilkacin(S =2), Flomoxef(S =2), Gentamicin(S =1), Imipenem(S), Ceftriaxone(S =1), Ampicillin(R >=32), Cefazolin(other)(R 8), Cefoperazone/Sulbactam(S =8), Ciprofloxacin(S =0.25), Amoxicillin/Clavulanic Acid(R), Cefazolin(Urine)(S 8), Piperacillin/tazobactam(S =4), Levofloxacin(S =0.12)
    • Escherichia coli Growth:3+
      • Gentamicin(S =1), Flomoxef(S =2), Cefazolin(Urine)(R >=64), Ceftriaxone(R >=64), Ciprofloxacin(S =0.25), Levofloxacin(S =0.12), Cefazolin(other)(R >=64), Piperacillin/tazobactam(S =4), Ampicillin(R >=32), Doripenem(S =0.12), Imipenem(S =0.25), Cefoperazone/Sulbactam(S 16), Amilkacin(S =2), Amoxicillin/Clavulanic Acid(R)
    • VREfm(E.faecium) Growth:3+
      • Teicoplanin(R >=32), Vancomycin(R >=32), Gentamicin High Level Resistance(S SYN-S), Penicillin(R >=64), Linezolid(S), Erythromycin(R >=8)
  • 2023-11-25 Blood Culture - Whole Blood - Gram Strain: GNB
    • Pseudomonas aeruginosa
      • Piperacillin/tazobactam(S 8), Amilkacin(S =2), Cefepime(S =1), Levofloxacin(S 1), Ceftazidime(S 4), Imipenem(S 1), Ciprofloxacin(S =0.25), Colistin(S =0.5), Gentamicin(S =1)
  • 2023-11-25 Blood Culture - Whole Blood - Gram Strain: GNB
    • Pseudomonas aeruginosa
  • 2023-10-10 Aerobic Culture - Wound/Pus
    • Escherichia coli Growth:3+
      • Flomoxef(S =2), Ciprofloxacin(S =0.25), Cefoperazone/Sulbactam(S 16), Amoxicillin/Clavulanic Acid(R), Doripenem(S =0.12), Cefazolin(Urine)(R >=64), Gentamicin(S =1), Cefazolin(other)(R >=64), Piperacillin/tazobactam(S 8), Ceftriaxone(R >=64), Ampicillin(R >=32), Levofloxacin(S =0.12), Imipenem(S =0.25), Amilkacin(S =2)
  • 2023-10-10 Anaerobic Culture - Wound/Pus
    • Bacteroides fragilis Growth:2+
      • Clindamycin(S), Tetracycline(R), Metrenidazole(S), Ampicillin/Sulbactam(I), Penicillin(R), Cefoperazone(R)
  • 2023-10-03 Aerobic Culture - Sputum
    • Mixed normal flora Growth:4+
    • Staphylococcus aureus Growth:4+
      • Rifampin(S =0.5), Vancomycin(S 1), Erythromycin(R >=8), Linezolid(S 2), Trimethoprim/Sulfamethoxazole(S =10), moxifloxacin(S =0.25), Daptomycin(S 0.25), Fusidic Acid(S =0.5), Penicillin(R >=0.5), Teicoplanin(S =0.5), Tetracycline(R >=16), Tigecycline(S =0.12), Oxacillin MIC(S), Clindamycin(S =0.25)

[exam findings]

  • 2023-12-06 ENT Hearing Test
    • Reliabilty Poor
    • PTA
      • R’t : 55 dB HL, moderate to severe mixed type HL
      • L’t : 63 dB HL, moderateto profound mixed type HL
    • Tymp
      • Bil Type C
    • ART
      • Bil absent.
  • 2023-12-05 ECG
    • Atrial fibrillation with premature ventricular or aberrantly conducted complexes
    • Right bundle branch block
    • T wave abnormality, consider inferolateral ischemia
  • 2023-12-05 CXR
    • S/P Port-A infusion catheter insertion.
    • Patch density at RUL.
    • Atherosclerosis of the aorta.
  • 2023-11-25 CXR
    • S/P port-A implantation.
    • Patchy consolidation projecting at right upper lung is noted. Please correlate with clinical condition to rule out Bronchopneumonia.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2023-11-07 Patho - brain biopsy
    • PATHOLOGIC DIAGNOSIS
      • Left hippocampus tumor, frozen + stereotactic biopsy — Diffuse large B-cell lymphoma
    • MACROSCOPIC DESCRIPTION
      • Operation procedure: stereotactic biopsy
      • Topology: left hippocampus
      • Specimen size and number: multiple fragments, up to 0.4 x 0.2 x 0.1 cm
      • All embedded for section [Reference: frozen, F2023-00496 one tiny piece measured 0.2 x 0.1 x 0.1 cm]
    • MICROSCOPIC EXAMINATION
      • Histology type: diffuse large B-cell lymphoma shows large atypical lymphoid cells with nucleoli, frequent mitoses and starry-sky feature
      • Immunohistochemistry: CK(-), GFAP(-), CD3(-), CD20(+), Bcl-2(+), CD10(-), Bcl-6(+), C-MYC(+, 30%), MUM-1(+) and Ki-67(>90%) for tumor cells. Clinical correlation is advised.
  • 2023-11-07 CXR
    • Supine chest film shows:
      • Presence of borderline cardiomegaly by cardiac/thoracic ratio.
      • Presence of calcification of the intima at the aortic knob.
      • No obvious lung patchy density or nodule.
  • 2023-11-07 Frozen Section
    • Left hippocampus tumor, frozen — Atypical lymphoid hyperplasia. Please pending for followed IHC for final diagnosis.
  • 2023-11-06 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2023-11-06 ECG
    • Atrial fibrillation
    • Right bundle branch block
    • Abnormal ECG
  • 2023-11-02 CT - brain for navigator
    • Clinical information: R/O secondary CNS lymphoma
    • Cranial CT scans from the vertex to the mid-maxillary level were performed with i.v. contrast injection.
    • Impression:
      • One lobulated enhancing lesion (3.5cm in size) over left medial temporal lobe.
      • The size of the lateral and third ventricles appears normal.
      • Prominent peritumoral edema.
  • 2023-10-31 MRA - brain
    • Clinical information: R/O secondary CNS lymphoma
    • Findings:
      • Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis. Suggest clinical correlation.
      • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
      • MR angiography of the brain shows normal intracranial vessel including circle of willis.
  • 2023-10-31 EEG
    • The back ground activity were composed by alpha rhythm with 8-12 Hz, 20-50 uv in bilateral occipito-temporal area.
    • There were diffuse beta waves with 15-25 Hz, 1-5 uV in bilateral hemisphere.
    • No epileptiform discharge was noted. Intermittent muscle artifact may interference with interpretation.
    • The above findings may suggest normal EEG study. Advice clinical correlation
  • 2023-09-29 CT - abdomen
    • History and indication: Two weeks ago, the patient had chemotherapy. Now he feel unwell all over his body, and his bowel movements are not smooth.
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Some small LNs at retroperitoneum and right axillary region.
      • Splenomegaly.
      • Renal cysts (up to 2.4cm).
      • Mild enlargement of prostate.
      • Hyperplasia of right adrenal gland.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • Focal GGO at bilateral lungs.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Some small LNs at retroperitoneum and right axillary region.
      • Splenomegaly.
  • 2023-09-08 PET
    • In comparison with the previous study on 2023/03/10, the previous FDG avid lesions in multiple lymph nodes on both sides of the diaphragm and in the right lung, liver, spleen and multiple bones/bone marrow disappeared.
    • Increased FDG uptake in some focal areas in bilateral lungs and in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammation/infection may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Increased FDG uptake in a focal area in the left aspect of the maxilla. Dental problem is more likely.
    • Increased FDG uptake in a focal area in the left lobe of the liver, in a focal area in the region about the spinal cord of T12 level and in the region about the lower portion of the rectum. The nature is to be determined (inflammation/infection? other nature?). Please also correlate with other clinical findings for further evaluation.
  • 2023-09-07 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Linear infiltration over right upper lung and left middle lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2023-08-25 CT - abdomen
    • History and indication: reccurent DLBCL involving right lung, liver, spleen and multiple bone marrow, Lugano stage IV
    • Findings:
      • There are several newly developed patchy ground-glass opacities with air-bronchogram at both lungs. Bronchopneumonia is highly suspected.
      • Prior CT identified some LNs (up to 1.2cm) at para-aortic space and para-cava space are noted again, decreasing in size to 0.6 cm.
      • Prior CT identified enlarged node at right axillary region is noted again, stationary.
      • Prior CT identified some low attenuations in the spleen are noted again, stationary that may be old infarction.
      • Renal cysts (up to 2.4cm).
      • Hyperplasia of right adrenal gland.
      • There is mild bilateral Pleura effusion and pericardial effusion.
      • There is a poor enhancing lesion 7 mm in S4 of the liver that may be cyst. Please correlate with sonography.
    • Impression:
      • There are several newly developed patchy ground-glass opacities with air-bronchogram at both lungs. Bronchopneumonia is highly suspected. please correlate with clinical condition.
  • 2023-08-16 SONO - abdomen
    • Diagnosis:
      • cholecystopathy, unknown etiology
      • GB polyp
      • Renal cyst, left
      • pancreatic neck cystic lesion, suspicious, IPMN
      • splenomegaly, mild
      • Pleural effusion, left
      • Enteropathy, uknown etiology.
    • Suggestion:
      • correlate with other image
  • 2023-08-07 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (78 - 29) / 78 = 62.82%
      • LVEF(%) = 63
      • M-mode(Teichholz) = 63
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated LA; atrial fibrillation (elevated average E/e’).
      • Normal RV systolic function.
      • Aortic valve sclerosis with no AS and AR; mild MR; mild to moderate TR.
      • Minimal pericardial effusion without tamponade and constriction sign.
  • 2023-08-02 24hr portable ECG
    • Atrial fibrillation thoughout the holter recording period
    • HR:47-165 bpm, AVE:85 bpm
    • Intraventricular conduction delay
    • Longest R-R interval 2.01 secs at 04:40
  • 2023-05-25 CT - abdomen
    • History and indication: reccurent DLBCL involving right lung,liver,spleen and multiple bone marrow, Lugano stage IV
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Some LNs (up to 1.2cm) at retroperitoneum and right axillary region.
      • Some low attenuations in spleen.
      • Renal cysts (up to 2.4cm).
      • Hyperplasia of right adrenal gland.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Some LNs (up to 1.2cm) at retroperitoneum and right axillary region.
      • Some low attenuations in spleen.
  • 2023-03-13 Peropheral Vascular Test - AV fistula
    • Result: adequate size of RIJV
  • 2023-03-10 PET
    • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm and involving right lung, liver, spleen and multiple bones/bone marrow as mentioned above (stage IV).
    • In comparison wih the previous study on 2022/05/05, more new FDG avid lesions are noted, suggesting lymphoma in progression.
  • 2023-01-31 Spirometry
    • DLCO 48 -> 66 -> 73%
    • TLC: 88%
  • 2022-11-08 CXR
    • RRt paratracheal stripe thickening
    • reticular opacities and hazy areas of increased opacities over both lungs scatteredly
    • Thoracic aortic arch calcified atheriosclerotic plaque
    • mild enlarged cardiac silhoutte
  • 2022-11-02 Spirometry
    • TLC: 82%.
    • DLCO 66% improved
    • FEV1/FVC<75%.
  • 2022-08-16 Spirometry
    • TLC: 68%.
    • DLCO 48%.
  • 2022-05-05 PET
    • The FDG PET findings are compatible with recurrent lymphoma involving multiple lymph nodes on both sides of the diaphragm as mentioned above and involving the bone marrow of left femoral shaft (stage IV).
    • Glucose hypermetabolism in a a focal area in the left humeral shaft. The nature is to be determined (lymphoma? other nature?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in multiple focal areas in bilateral lung fields. Inflammation is more likely.
  • 2022-04-26 CT - chest
    • History of relapsed lymphoma over neck and mediastinum post autoPBSCT
    • Comparison made with previous CT dated on 2022/01/11
      • Lungs:
        • extensive centrilobular micronodular and branching opacities associated scattered lobular areas of ground-glass opacity
        • focal minimal paraspinal fibrosis in RLL, related to osteophytes of spine.
        • a subpleural paraseptal emphysema at medial right apical lung region.
      • Pleura:
        • minimal bilateral pleural effusions.
        • small pericardial effuion.
      • Mild atherosclerotic change of the aortic arch and descending thoracic aorta. mild coronary arterial calcification.
      • An irregular soft-tissue lesion at Rt axilla (19 mm in longest axial dimension), stationary in size as compared with CT on 2022/1/11
      • Neck, mediastinum and hila: multiple enlarged LNs in visceral space of the mediastinum.
      • Visible abdomen and pelvis:
        • unremarkable of the liver, Rt kidney, spleen, adrenal glands, and pancreas. Several left renal cysts up to 25 mm.no enlarged LNs. mild enlarged prostate.
    • Impression:
      • post treatment change in Rt axillary region, stationary.
      • lung infection, infectious bronchiolitis.
      • new neoplastic LAP in the mediastinum.
  • 2022-02-15 SONO - chest
    • Echo diagnosis:
      • pleural effusion, trivial amounts located over left CP angle.
      • Favor arrhythmia, heart failure related pleural effusion and history of pneumonia before.
  • 2022-02-14 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-01-18 ECG
    • Sinus rhythm with Premature atrial complexes
    • Possible Left atrial enlargement
    • Right bundle branch block

[MedRec]

  • 2023-10-02 ~ 2023-12-19 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Recurrent Diffuse large B-cell lymphoma involving right lung, liver, spleen and multiple bones/bone marrow, Lugano stage IV, status post autoPBSCT on 2021/11/03, 11/04. Recurrent brain metastsis on 2023/11/07 S/P Left navigation assisted biopsy for temporal hippocampus lesion
      • neutropenia with Sepsis blood culture: GNB -> Pseudomonas aeruginosa
      • Aspiration pneumonia progression sputum culture; Staphylococcus aureus Growth:4+ on 2023/10/03 and the CXR film revealed LUL cavitation, despite broad spectrum antibiotic, S/P receiving high-flow nasal cannula
      • nystagmus due to brain metastasis and brainstem compression
      • anal perianal abscess S/P fistulotomy + debridement + drainage on 2023/11/29 pus culture: Escherichia coli Growth:3+
      • Hypomagnesemia
      • Anemia due to Myelosuppression
      • Thrombocytopenia due to Myelosuppression
      • Hypokalemia
      • memory loss due to brain metastasis related
    • CC
      • fever without chills and dyspnea for 4 days
    • Present illness
      • This 71-year-old man was relatively well until June 2019. He first noticed a mass lesion at right side axillary when June 2019. He went to the ZhengXing Hospital for workups and splenic lesion was demonstrated as well. The axillary LN biopsy confirmed the diagnosis of diffuse large B cell lymphoma.
      • The PET examination also disclosed dissimentated involvement of the disease, including multiple LNs, spleen, skull, spine and bone marrow, Lugano stage IV. The Bone marrow biopsy from the iliac bone (2019-08-22) also had bone marrow involvement of lymphoma with IHC characteristics of the following: CD3 (-), CD20 (+). bcl-2 (+), bcl-6 (equivocal, -/+), CD10 (-).
      • After the above staging workups, he had chemotherapy with R-DA-EPOPCH regimens for 6 cycles (from 2019/08/23 to 2020/01/03) without special events for his diffuse large B cell lymphoma with bone marrow involvement, Lugano stage IV with R-DA-EPOPCH with recurrence, he was admitted to hematology ward (from 2021/04/18 to 05/03) for restaging workups.
      • Bone marrow biopsy was done on 2021/04/19, and the pathology report no lymphoma involvement in the bone marrow. The left side neck LN’s pathology confirmed the DLBCL in nature.
      • Chemotherapy with R-DHAP (C1) on 2021/4/29 to 2021/5/2 but he tolerated it poorly.
      • He received C1 Pola-BR (Polatuzumab 1.8mg/kg on D1, Mabthera 375mg/m2 on 2021/5/28 D1, self paid of Bendamustine 90mg/m2 on D2-D3) on 2021/5/28-30.
      • C2 P-BR on 6/28-30 and received autologus stem cell transplantation on 2022/10/29-11/3.
      • PET was performed on 2023/3/10 revealed lymphoma involving multiple lymph nodes on both sides of the diaphragm and involving right lung, liver, spleen and multiple bones/bone marrow as mentioned above (stage IV).
      • Under the impression of Recurrent Diffuse large B-cell lymphoma involving right lung, liver, spleen and multiple bones/bone marrow, Lugano stage IV, status post autoPBSCT on 2021/11/3, 11/4, PS 1, post C1 selfpaid of P-BR on 2023/03/15 - 03/16.
      • C2 selfpaid of P-BR on 2023/4/25-4/26. C3 selfpaid of P-BR on 2023/05/24-25. Neulasta was given after the chemotherapy. C4 P-BR on 2023/07/17 - 07/18, C5 P-BR on 2023/09/15 - 09/16.
      • Follow-up abdominal CT (2023/08/25) showed there are several newly developed patchy ground-glass opacities with air-bronchogram at both lungs. Bronchopneumonia is highly suspected.
      • PET scan (2023/09/08) revealed lesions in multiple lymph nodes on both sides of the diaphragm and in the right lung, liver, spleen and multiple bones/bone marrow disappeared. Increased FDG uptake in some focal areas in bilateral lungs and in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammation/infection may show this picture.
      • This time, general malasie for 2-3 days and mild dyspnea were noted on 09/29 23 and visited to ER for aid and antibiotic with Cefim was given then shifted to Ceficin 2# po q12h x 3 days for take home. Fever (37.1 degree C) without chills and mild cough without sputum and dyspnea were also developed on 9/30 23 and came to our infection OPD for aid and laboratory shwoed leukopenia (WBC = 1.46 x10^3/uL) and Lenograstim 250mcg sc x 2 days was given. The Laboratory shwoed WBC = 0.46 x10^3/uL, seg:6.2% ANC: 28.5, Monocyte = 47.5 %, Creatinine = 1.36 mg/dL.
      • Under the impression of neutropenia fever. He was admitted for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, hydration, antibiotic with Cefim/Targocid/G-CSF 300mg sc were given for neutropenia fever. The White blood cells rise slowly was noted. Blood transfusion with LPRBC 2U & LRP 2PH was given on 10/5 23 for anemia & thrombocytopenia.
      • Sudden onset of dysuria & bladder distension and residual urine volume about 400cc by ICP were noted and we consulted uro for difficulty intubating and advisted to I have successfully inserted a 22Fr three-way Foley catheter. Please keep the catheter in place for at least one week and prescribe Harnalidge to increase the success rate of catheter removal.
      • Intravenous KCL/Const-K and MgSo4 were administered for hypokalemia & hypomagnesemia. He complained of tenderness perianal and anal canal about 6o’clock region, no fluctuation, no pus discharge for days and rectal surgical Dr was consulted for evaluation and advisted to empyric antibiotic drugs treatment/Biomycin onitment for topic use/if s/s got worse then call us again for I&D.
      • Blood transfusion with LRP 2PH was given on 10/9 23 and anal absecss I & D was done and collected pus culture.
      • Blood transfusion with LPRBC 2U 10/11 & LRP 2PH was given on 10/13 & 10/16 23 for anemia & thrombocytopenia. The pus culture Aerobic/Anaerobic yeilded Escherichia coli Growth:3+/Bacteroides fragilis Growth:2+ and antibiotic shifted to Tapimycin 4.5mg ivd q6h since 10/17 23 by infection Dr suggested. Sudden onest of hematuria & blood colt obstruction via foley cather was developed on 10/17 23 at 3:00 AM and foley irrgation with normal saline 2000cc qd and Transamin 1# po bid were given and contact uro Dr for evaluation again.
      • Blood transfusion with LPRBC 2U 10/16 & LRP 2PH was given on 10/23 23 for anemia & thrombocytopenia. Tapimycin 4.5mg ivd q6h qas given since 10/17 23 for anal infection.
      • Blood transfusion with LRP 2PH was given on 10/26 23 & LPRBC 2U on 10/28 23 for anemia & thrombocytopenia. Tapimycin 4.5mg ivd q6h qas given since 10/17 to 10/30 23 for anal infection. He complained of memory loss in recent 3 days and we consulted neuro for further evaluation.
      • Blood transfusion with LRP 2PH was given on 10/31, 11/3, 11/5 23 for thrombocytopenia. CT Brain for Navigator (11/2 23) showed one lobulated enhancing lesion (3.5cm in size) over left medial temporal lobe. The size of the lateral and third ventricles appears normal. Prominent peritumoral edema.  We consulted neurosurgery for biopsy evaluation and will arrange biopsy on 11/7 23. Intravenous Dexa 4mg ivd q6h + Mannitol 100ml IVD q8h were added for peritumoral edema & IICP sign. Keppra 500mg ivd q12h was added. Anti-fungus infection was suspected by brain MRA exam and anti-fungus drugs was added by Dr 李啟誠 suggested.
      • Brain MRA (10/31 23) showed Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis. Suggest clinical correlation. 2. Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation. 3. MR angiography of the brain shows normal intracranial vessel including circle of willis.
      • Brain biopsy was done on 11/7 23 and he was transferred to SICU for further treatment on 11/7 23.
      • G-CSF 300mg sc was given for neutropenia. Blood transfusion with LRP 2PH was given on 10/31, 11/3, 11/5 23 for thrombocytopenia.
      • Left hippocampus tumor, frozen + stereotactic biopsy (11/10 23) proved Diffuse large B-cell lymphoma, Immunohistochemistry: CK(-), GFAP(-), CD3(-), CD20(+), Bcl-2(+), CD10(-), Bcl-6(+), C-MYC(+, 30%), MUM-1(+) and Ki-67(>90%) for tumor cells.  
      • Keppra shifted to oral form since 11/14 23. We consulted radiologist for radiotherapy evaluation and advisted to preliminary planning dose: 2340cGy/13 fractions of the whole brain, and 3600cGy/20 fractions of the metastatic brain tumor. Radiotherapy started since 11/14 23 and Dexa 4mg ivd was added.
      • Right face reddish, swelling and pain was noted cellulitis was suspected and septic work-up was performed and antibiotic with Augmentin was given since 11/14 23. He complained of severe anal pain and pus yellowish dischage in recent days and constact rectal surgical again for evaluation and suggested to Fistulotomy or fistulectomy,compliitated subcutaneous on next week. Ultracet 1# po q6h was added for pain control.
      • Fistulotomy or fistulectomy,compliitated subcutaneous on 11/27 23. Owing to abnormal liver function was noted and Ultracet change to prn used. Sudden onest of fever with chills was developed on 11/25 23 night and septic work-up was performed and G-CSF 300mcg sc qd + antibiotic with Cefim 2mg ivd q8h were administered for neutropenia fever with sepsis. The blood culture (port-A & peripheral )showed GNB. Sudden onest of fall down (the patient walked out of the bathroom and fell forward without knowing how it happened) was found on 11/26 23 and without any discomfort or trauma wound. He complained of his jaw had been always clenched for days and neuro was consulted for evaluation.
      • G-CSF 300mcg sc qd + antibiotic with Cefim 2mg ivd q8h were administered for neutropenia fever with sepsis. The blood culture (port-A & peripheral )showed Pseudomonas aeruginosa. Consulted Neuro for evaluation and advisted to arranged EEG. Anal culture revealed E coli & VRE to sensitive anti treatment. blood transfusion with LRP 2PH was given on 12/3 23. Repeat blood culture x 2 on 11/30 23.
      • Blood transfusion with LRP 2PH was given on 12/7 23. Repeat blood culture x 2 showed negative. Romiplate 250mcg was given on 12/8 23.
      • Hold Radiotherapy on 12/11 23 due to poor condition. G-CSF 300mcg sc qd .Blood transfusion with LRP 2PH & LPRBC 2U were given on 12/12-12/14 23. Sudden onest of fever with chills and dyspnea were noted on 12/11 23 and CXR showed ARDS, bilateral pneumonia and pulmonary edema and septic work-up was performed and antibiotic with antibiotic with Bestnem 500mg ivd q6h since 12/11, Targocid 600mg ivd qd since 12/12, Mycamine 100mg ivd qd since 12/11 for R/O fungus infection hydration/ Albumin 50mg (self-paid)+ Lasix 1amp ivd q12h on 12/12-12/14 23 & Sevatrim 10mg in N/S 250ml IVD q8h and Norepinephrine 8mg + D5W 250ml were given and O2 therapy with HFNC total flow:60L, O2 flow:40L/74%/Medason 40mg ivd q8h were added for sepsis with septic shock , ARDS, pulmonary edema and bilateral pneumonia. Intravenous KCL 10cc in N/S 250ml IVF 2hrs was given for hypokalemia. Follow-up CXR showed pulmonary edema improving and bilateral pneumonia remain.
      • There is pneumonia progression and the lastest yeterday CXR film revealed LUL cavitation, despite broad spectrum antibiotic, including Tienam, Targocid, iv Baktar, and Mycamine combination therapy.Suspect seizure with hand tremor noted yesterday, which may be related to Tienam use.Since there is cavitation and high PCT level one week ago, that PJP possibility is not hight.Patient is receiving high-flow nasal cannula now, that intubation indicated for him.But patient refused intubation and DNR consent already been signed. antibiotic shifted to DC Tienam, Targocid, Mycamine and PJP/Add Mepem, Zyvox, and Cresemba. Follow up serum Aspergillus antigen titer again by infection De suggested.
      • Owing to nystagmus was happened on 12/16 afternoon and Keppar shifted to IV from 750mg q12h for symptom relief. Neurologist revisits patient again on 12/18 23 and explained his poor condition to his family and suggested add Morphine 3mg ivd prnq6h for symptom relief.
      • Consciousness coma & dyspnea were noted and EKG monitor showed asystole, no respiratory movement, pupil size dilated and he was expired at 04:24 AM on 11/19 23.
      • skin: right upper lip black scab & left 2nd hand reddsih scab, Pseudomonas aeruginosa infection related by infection Dr said, if wound pus will collect pus culture and wating blood culture report.
      • The patient reported shortness of breath but refused intubation. The patient’s wife was informed of the current condition and that not intubating would lead to respiratory failure. The patient and the wife expressed they could understand clearly. Infection specialist Dr. Peng MingYe visited the patient and explained the current condition and medication treatment to the family. Oxygen can be changed to high flow used. The patient still refused to put in a nasogastric tube.
  • 2023-09-18 SOAP Cardiology Ye GuanHong
    • Prescription x3
      • Urief (silodosin 8mg) 1# HS
      • spironolactone 25mg 0.5# QD
      • Multaq (dronedarone 400mg) 1# BID
      • Lixiana (edoxaban 30mg) 1# QD
      • Atozet (ezetimibe 10mg, atorvastatin 20mg) 1# QN
      • Wecoli (bethanechol 25mg) 1# BID
      • Nirandil (nicorandil 5mg) 1# BID

[consultation]

  • 2023-11-10 Radiation Oncology
    • Q
      • For radiotherapy evaluation
      • This 71 year old man is a retired Oral and Maxillofacial Surgery Chief of the Tri-Service General Hospital (underline CAD, HTN and PAf), a case of Diffuse large B cell lymphoma, diagnosis on 2019-08, Lugano stage IV with R-DA-EPOPCH with recurrence s/p Pola-BR and then autologoud stem cell transplantation on 2022-11-03, disease recurrent on 2023-03, s/p Pola-BR with image complete remission (2023-09 PET).
      • This time, he was admiited due to neutropenia fever after chemotherapy. During this time, he suffered from memory loss in recent 3 days. Brain MRA showed Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis.
      • The Left hippocampus tumor, frozen + stereotactic biopsy (11/9 23) proved diffuse large B-cell lymphoma, Immunohistochemistry: CK(-), GFAP(-), CD3(-), CD20(+), Bcl-2(+), CD10(-), Bcl-6(+), C-MYC(+, 30%), MUM-1(+) and Ki-67(>90%) for tumor cells.
      • We need your expertise for further evaluation thanks!
    • A
      • The patient’s history was reviewed and patient was examined.
      • S: For radiotherapy due to brain metastasis with memory loss.
        • PI: The patient suffered from memory loss for about 2 weeks. MRI of brain (2023-10-31) showed focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis.
        • Family history: (-)
        • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
        • Personal Hx: DM (-); HTN (-)
      • O: ECOG: 1
        • PE: poor memory function.
        • PET (2019-8-16): 1. The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm, spleen and multiple bones or bone marrow as mentioned above. Please correlate with other clinical findings for further evaluation. 2. A mild glucose hypermetabolic lesion in the upper lobe of right lung. The nature is to be determined (lymphoma? inflammatory process? other nature?).
        • Pathology (S2019-14043, 108-8-26): Bone marrow, iliac, clinical history of diffuse large B cell lymphoma dignosed inJune 2019, biopsy — Lymphoma involvement, B cell type, IHC stains: CD3 (-), CD20 (+). bcl-2 (+), bcl-6 (equivocal, -/+), CD10 (-). The pattern is compatible with large B cell lymphoma.
        • CT scan of lung (2019-11-27): normal appearance of lungs based on this follow up CT study. Rt axillary tumor lesion.
        • CT scan of lung (2020-3-17): Minimal nonspecific inflammation in RLL, paravertebral region. Rt axillary mass lesion, in regression.
        • PET (2020-3-25): 1. Almost all glucose-hypermetabolic lesions disappear including multiple lymph node regions on both sides of the diaphragm, spleen, and skeleton compared with the previous study on 2019-08-16, indicating lymphoma with good response to current therapy. 2. Glucose hypermetabolism involving vocal cord and post. wall of pharynx, probably inflammation process. 3. Glucose hypermetabolism in the myocardium of the right ventricle, suggesting pulmonary dysfunction.
        • Pathology (s2020-05124, 2020-4-28): Bone marrow, iliac, history of lymphoma in 2019, biopsy — Negative for malignancy. IHC stains: LCA (15% of the nucleated cells). CD and CD20 no monoclonality. Bcl-2 (-), bcl-6 (-).
        • CT scan of lung (2020-6-16): Minimal nonspecific inflammation or fibrosis in RLL related to aging, paravertebral region. Rt axillary mass lesion, stationary based on CT exam.
        • RT (2020-7-3 ~ 2020-7-31): 3600cGy/20 fractions of the right axillary area.
        • CT: Lung/Mediastinum/Pleura (2020-9-17): Right axillary lesion. Mildly decreased in size. Splenic lesion, r/o hemangioma. Suggest MRI, if necessary. Enlarged prostate, please correlate with PSA.
        • PET (2023-9-8): 1. In comparison with the previous study on 2023/03/10, the previous FDG avid lesions in multiple lymph nodes on both sides of the diaphragm and in the right lung, liver, spleen and multiple bones/bone marrow disappeared. 2. Increased FDG uptake in some focal areas in bilateral lungs and in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammation/infection may show this picture. 3. Increased FDG uptake in a focal area in the left aspect of the maxilla. Dental problem is more likely. 4. Increased FDG uptake in a focal area in the left lobe of the liver, in a focal area in the region about the spinal cord of T12 level and in the region about the lower portion of the rectum. The nature is to be determined (inflammation/infection? other nature?).
        • MRI of brain (2023-10-31): 1. Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis. Suggest clinical correlation. 2. Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation. 3. MR angiography of the brain shows normal intracranial vessel including circle of willis.
        • Pathology (S2023-22180, 2023-11-9): Left hippocampus tumor, frozen + stereotactic biopsy — Diffuse large B-cell lymphoma
      • A: Large B cell lymphoma, stage IV, s/p chemotherapy, with residual tumor over right axillary area, s/p radiotherapy, with recurrence s/p autologous stem cell transplantation, with brain metastasis.
      • P: Radiotherapy is indicated for this patient with the following indicators: brain metastasis
        • Goal: palliation
        • Treatment target and volume: brain
        • Technique: 2D and VMAT/IGRT
        • Preliminary planning dose: 2340cGy/13 fractions of the whole brain, and 3600cGy/20 fractions of the metastatic brain tumor
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, the treatment planning of radiotherapy will be started at 1330, 2023-11-13.
  • 2023-11-01 Neurosurgery
    • Q
      • For tissue biopsy?
      • This 71 year old man, retired Oral and Maxillofacial Surgery Chief of the Tri-Service General Hospital (underline CAD, HTN and PAf), is a case of Diffuse large B cell lymphoma, diagnosis on 2019-08, Lugano stage IV with R-DA-EPOPCH with recurrence s/p Pola-BR and then autologoud stem cell transplantation on 2022-11-3, disease recurrent on 2023-3, s/p Pola-BR with image complete remission (2023-09 PET). This time, he was admiited due to neutropenia fever after chemotherapy. During this time, he suffered from memory loss in recent 3 days.
      • Brain MRA showed Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis.
      • We need your expertise for further evaluation (tissue biopsy?). Thanks a lot.
    • A
      • A case of 71 y/o male, Diffuse large B cell lymphoma s/p C/T. Fever?
        • Memory impairment noted for days; NS is consulted for left temporal intraaxial lesion. Biopsy evalaution.
        • A brain MRI showed Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size).
      • P: please arrange brain CT with contrast for NAVIGATION; Brain biopsy will be performed after well explanation of surgical benefits and risks to him.
  • 2023-10-30 Neurology
    • Q
      • for memory loss in recent 3 days
      • The 71 y/o man has DLBCL s/p auto-PBSCT. This time, he was admitted for neutropenia fever stage. He complained of memory loss in recent 3 days. We need expertise to his condition thanks!
    • A
      • O
        • CN: intact
        • MP: full
        • Gait: intact
      • Suggestion:
        • Arrange EEG
        • Arrange brain MRA with contrast in case of secondary CNS lymphoma
        • Check free T4, TSH, vit B12, folic acide, homocysteine, and RPR
      • I will F/U this case
        • Thanks for consultation
        • Feel free to contact me if you have any problem
  • 2023-10-03 Urology
    • Q
      • for dysuria and feeling like he can’t finish urinating
      • The 71 y/o man has DLBCL /p auto-PBSCT. This time, he was admitted for with neutropenia fever stage. Due to anal pain progression noted for days. We need expertise to his condition thanks!
    • A
      • I have successfully inserted a 22Fr three-way Foley catheter.
      • Please keep the catheter in place for at least one week and prescribe Harnalidge to increase the success rate of catheter removal.
      • Arrange Dr. Hsu’s OPD’s follow up after discharge. Thank you for your consultation!
  • 2023-10-03 Colorectal Surgery
    • Q
      • for anal pain progression
      • The 71 y/o man has DLBCL /p auto-PBSCT. This time, he was admitted for with neutropenia fever stage. Due to anal pain progression noted for days. We need expertise to his condition thanks!
    • A
      • This is a 71-yr old man with anal pain for days
        • hx: DLBCL /p auto-PBSCT
        • DRE: tenderness perianal and anal canal about 6o’clock region, no fluctuation, no pus discharge
      • A: anal pain, R/I perianal abscess, R/I DLBCL induce anal pain
      • P: empyric antibiotic drugs treatment
        • Biomycin onitment for topic use
        • if s/s got worse then call us again for I&D
        • we will also closely follow up this case
    • A 2023-10-09 17:50:49
      • CC: much anal pain was told
      • PE: fluctuation was found
      • A/P: perianal abscess
        • I&D with epineprhine gaunze wet dressing was done
        • explaint the possilbe of anal fistula
    • A 2023-11-11 08:18:16
      • CC: bloody discharge was told 2 days ago
      • PE: one 0.2cm pin hole over 6 o’clock region with clear fluild discharge when compression
      • A: R/I anal fistula over 6 o’clock region
      • P: wound cd and biomycin local treatment
  • 2023-08-21 Colorectal Surgery
    • Q
      • The 71 y/o man has DLBCL /p auto-PBSCT. This time, he was admitted for sepsis with neutropenia stage. Due to anal pain, so we need your help for management. Thanks!
    • A
      • This is a 71-yr old man with anal pain for 2 days
        • hx: DLBCL /p auto-PBSCT
        • DRE: tenderness perianal and anal canal about 6 o’clock region,no fluctuation, no pus discharge, mild tenderness over 12 o’clock region
      • A: anal pain, R/I perianal abscess, R/I DLBCL induce anal pain
      • P: empyric antibiotic drugs treatment add alcos anal onitment topic treatment
        • if s/s got worse then call us again for I&D
  • YYYY-MM-DD xxxxxxxxxx
  • YYYY-MM-DD xxxxxxxxxx
  • YYYY-MM-DD xxxxxxxxxx

[surgical operation]

  • 2023-11-29 - Op Method: fistulotomy + debridement + drainage
    • Finding:
      • one anal fistula over 6o’clock region (extra-sphincter type)
    • Procedure:
      • Under IVG anesthesia ,the outer and internal opening was wide opening and curretage and irrigation with large amount of H2O.
      • The internal opening was closed with 3-0 vicryl and outer opening was layed opened.
      • Check bleeding and pack the wound with gaunze.
  • 2023-11-07   - Op Method: Left navigation assisted biopsy for temporal hippocampus lesion
    • Finding:
      • Four pieces of soft yellowish brain tissue obtained by stereotactic biopsy from left temporal lobe.
    • FROZEN SECTION REPORT
      • Left hippocampus tumor, frozen — Atypical lymphoid hyperplasia. Please pending for followed IHC for final diagnosis
    • Procedure:
      • Under ETGA, Mayfield clamp was appied and Metronic NAVIGATION was set for target plans. After proper disinfection and draping, A 3 cm-long scalp incision was made in left temporofrontal region. A burr hole was made and the dura was tented to the pericranium. The dura was incised in the cruciate fashion. The side-cutting type biopsy needle was inserted. The obtained specimens were sent to pathology for diagnosis. Frozen section, cultures and permient section were harvested. Hemostasis with bipolar coagulation and FLOSEL. The wound was closed in layers. 

[chemoimmunotherapy]

  • 2023-09-15 - polatuzumab vedotin 1.8mg/kg 90mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 142mg NS 250mL D1-2 (BR, Q4W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
  • 2023-07-17 - polatuzumab vedotin 1.8mg/kg 105mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
  • 2023-05-24 - polatuzumab vedotin 1.8mg/kg 112mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
  • 2023-04-25 - polatuzumab vedotin 1.8mg/kg 112mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
  • 2023-03-15 - polatuzumab vedotin 1.8mg/kg 112mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
  • 2021-10-27 - busulfan 3.2mg/kg 210mg NS 300mL 3hr D1-3 + etoposide 400mg/m2 690mg NS 250mL 6hr D3-4 + cyclophosphamide 50mg/kg 3300mg NS 500mL 4hr D5-6
    • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + palonosetron 250ug D1-3 + granisetron D4-6 + NS 250mL D1-2
  • 2021-09-03 - etoposide 500mg/m2 400mg NS 1000mL 4hr D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] Q12H D1-3
  • 2021-06-28 - polatuzumab vedotin 1.8mg/kg 113mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 6hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D2-3 + NS 250mL D1-3 + acetaminophen 500mg PO D1
  • 2021-05-28 - polatuzumab vedotin 1.8mg/kg 113mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 6hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D2-3 + NS 250mL D1-3 + acetaminophen 500mg PO D1
  • 2021-04-29 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cisplatin 100mg/m2 170mg NS 500mL 24hr D2 + cytarabine 2000mg/m2 3400mg Q12H D2-3 + dexamethasone 20mg BID PO D1-5
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + acetaminophen 500mg PO D1 + palonosetron 250ug D2-4 + NS D1-3
  • 2020-01-30 - rituximab 375mg/m2 600mg NS 500mL 6hr D1 + [etoposide 50mg/m2 84mg doxorubicin 10mg/m2 16mg vincristine 0.4mg/m2 0.5mg NS 1000mL] 24hr D1-4 + prednisolone 60mg/m2 50mg PO BID D1-5 + cyclophosphamide 750mg/m2 1200mg NS 100mL 30min D5 (R-DA-EPOCH Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + acetaminophen 500mg PO
  • 2020-01-03 - rituximab 375mg/m2 600mg NS 500mL 6hr D1 + [etoposide 50mg/m2 84mg doxorubicin 10mg/m2 16mg vincristine 0.4mg/m2 0.5mg NS 1000mL] 24hr D2-5 + prednisolone 60mg/m2 50mg PO BID D1-5 + cyclophosphamide 750mg/m2 1200mg NS 100mL 30min D6 (R-DA-EPOCH Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + acetaminophen 500mg PO

Romiplate (romiplostim 250ug) ST SC

  • 2023-11-17 IPD
  • 2023-10-31 IPD
  • 2023-10-24 IPD
  • 2023-09-07 OPD
  • 2023-08-31 OPD
  • 2023-08-26 IPD
  • 2023-08-08 OPD
  • 2023-07-27 OPD
  • 2023-07-20 OPD

==========

2023-11-23

[atrial fibrillation]

Multaq (dronedarone) and Lixiana (edoxaban) were prescribed for the patient’s atrial fibrillation (AF) in a repeat prescription issued by our cardiologist on 2023-09-18. These medications are not currently being used. Please confirm whether there is a contraindicated condition or if the medications are no longer necessary.

2023-07-17

Our cardiologist prescribed Urief (silodosin), spironolactone, Multaq (dronedarone), Lixiana (edoxaban), Atozet (ezetimibe, atorvastatin), Wecoli (bethanechol), and Nirandil (nicorandil) on 2023-06-28, and these drugs are correctly included in the active formulary, so no reconciliation issues were found.

700843887

231219

[exam findings]

  • 2023-11-02 SONO - abdomen
    • Diagnosis:
      • Propable liver cyst, left
      • Suspected fatty infiltration of pancreas
      • S/p cholecystectomy
      • Suboptimal examination of liver,especially the subcostal view due to poor echo window (disruption of the transmission of US waves by bowel gas and patient’s body habitus)
    • Suggestion:
      • OPD f/u
      • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
  • 2023-10-27 Patho - lymphnode biopsy
    • Neck mass, right, sono-guide biopsy — Squamous cell carcinoma
    • Microscopically, the section shows a picture of squamous cell carcinoma with moderate differentiation characterized by solid tumor nests infiltrating in desmoplastic stroma.
  • 2023-10-13 MRI - nasopharynx
    • Findings
      • a nodular lesion in the right thyroid gland
      • a heterogeneous enhancing nodular lesion, about 29.7mm, in the right upper neck, just anterior to the right SCM with tumor attachment to it. THe other heterogeneous enhancing nodular, about 9.8mm in the right carptod spaces.
      • unremarkable change in the nasopharynx, oropharynx and hypopharynx.
      • post-OP change in the right oral cavity.
    • IMP:
      • heterogeneous enhancing nodules in the right neck.
  • 2023-04-10 Patho - oral cancer (wide excision without lymph node)
    • Diagnosis:
      • Oral mucosa, right floor of mouth, wide excision —- Squamous cell carcinoma, moderately differentiated, AJCC 8th edition: pStage IVA, pT4aNx (if cM0)
      • Mandible, right side, marginal mandibulectomy —- Squamous cell carcinoma, by direct invasion
      • Mandible, right side, alveolar bone, large, marginal mandibulectomy —- Squamous cell carcinoma, by direct invasion
      • Mandible, right side, alveolar bone, small, marginal mandibulectomy —- Squamous cell carcinoma, by direct invasion
    • Microscopic examination
      • Histologic Type: Squamous cell carcinoma,
      • Histologic Grade: G2: Moderately differentiated,
      • Microscopic Tumor Extension: (specify) bone (main specimen), alveolar bone large, and alveolar bone small.
      • Lymph-Vascular Invasion: present
      • Perineural Invasion: not identified
      • Neck Lymph Nodes: not recived
      • F2023-00154:
        • Sections of specimens A, B, C, and D show fibrous tissue without malignancy.
        • Section os specimen E ulcerated tissue with granulation tissue and acute and chronic inflammation. No malignancy is seen.
  • 2023-04-06 MRI - nasopharynx
    • Findings:
      • The current study was compared to the prior one obtained on 2022/09/09.
      • Known a case of right buccal cancer and right mouth floor cancer S/P operation. Newly-developed enhancing lesion (1.7cm) over right mouth floor. May be recurrent tumor. Suggest tissue proof.
      • Normal appearance of both mastoid air-cells.
      • Mild paranasal sinusitis.
  • 2023-03-29 Patho - gingival/oral mucosa biopsy
    • Labeled as “right lower gingiva”, biopsy — squamous cell carcinoma.
    • Section shows squamous cell carcinoma.
    • IHC stain: p16 (-).
  • 2022-09-09 MRI - nasopharynx
    • Findings
      • post-OP change at the right buccogingical region
      • a heterogeneous enhancing lesion, abour 23mm, in the left lower buccogingival mucosa.
      • no neck LAP
    • IMP:
      • r/o a tumor in the left lower buccogingical mucosa.
  • 2021-08-23 MRI - nasopharynx
    • Findings
      • Post-operation change with flap reconstruction at right part of oral tongue and cheek.
      • Post-operation change with right neck for lymph node dissection.
      • Post resection of right submandibular gland.
    • IMP:
      • Post OP for right oral CA with neck LNs dissection. No local recurrence. No neck LAP.
  • 2020-10-26 CT - brain
    • Indication: R/O hydrocephalus
    • Without-contrast CT of brain shows:
      • Prominent sulci, fissures, and cisterns. Dilatation of the ventricles.
      • s/p right F-T craniotomy.
      • Atherosclerosis of intracranial ICAs, cavernous portion, and vertebral arteries.
    • IMP:
      • Brain atrophy, ventriculomegaly, and intracranial atherosclerotic disease
  • 2020-10-22 MRI - nasopharynx
    • Findings
      • Post-operation change with flap reconstruction at right part of oral tongue and cheek.
      • Post-operation change with right neck for lymph node dissection.
      • General brain atrophy.
      • Partial opacification of bilateral ethmoid sinuses and mucosal thickening in bilateral maxillary sinuses.
      • Scoliosis of C-spine.
    • IMP:
      • C/W oral cancer s/p operation, without evidence of recurrence.
  • 2020-05-12 Patho - soft tissue tumor, extensive resection
    • PATHOLOGIC DIAGNOSIS
      • Right mouth floor and mandibular gingiva, wide excision — mderaterly differentiated squamous cell carcinoma
      • Sulingual gland, right, wide excision — involved by tumor
      • Margin, right mouth floor and mandibular gingiva, wide excision — free (1 mm away from anterior margin)
      • Tissue, labeled “Sublingual gland”, wide excision — no evidence of tumor
      • Pathology stage: pT2NX
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure(s): wide excision
      • Specimen Type:
        • Main location: Right mouth floor and mandibular gingiva
        • Other part(s) included: right sulingual gland
        • Lymph node dissection: no
      • Specimen Integrity: intact
      • Specimen Size: Greatest dimensions: A, main tumor: 3.5 x 2.8 x 2.2 cm; B:sublingual gland: 1.3x 0.8x 0.7 cm
      • Tumor Site: Right mouth floor
      • Tumor Focality : single focus
      • Tumor Size: Greatest dimension: 2 cm
      • Depth of Invasion (for pT1 to pT3 tumors only): 10 mm of DOI
      • Mucosal Surface : ulcerated
      • Gross Tumor Extension : extenstion to sublingual gland
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Squamous cell carcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Microscopic Tumor Extension: extenstion to sublingual gland
      • Margins: Margins free, Distance from closest margin: 0.1 cm away from anterior margin
      • Lymph-Vascular Invasion: present
      • Perineural Invasion: not identified
      • Neck Lymph Nodes: Not included
        • Ipsilateral: N/A
        • Number examined: N/A
        • Number involved: N/A
        • Contralateral: N/A
        • Number examined: N/A
        • Number involved: N/A
        • Size (greatest dimension) of the largest metastatic deposit: N/A
        • Extranodal extension (not identified / present / indeterminate): N/A
  • 2020-04-30 MRI - nasopharynx
    • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage) : T:2(T_value) N:0(N_value) M:x(M_value) STAGE:II(Stage_value)
  • 2020-04-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (120 - 42) / 120 = 65.00%
      • M-mode (Teichholz) = 64
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Dilated LA, possible LV diastolic dysfunction, Gr II
      • Trivial MR and trivial TR
      • Preserved RV systolic function
  • 2018-06-22 Surgical pathology Level IV
    • PATHOLOGIC DIAGNOSIS
      • Lower gingiva, right, wide excision — Squamous cell carcinoma
      • Pathology stage: rT1Nx(cMx), stage I at least
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure: Wide excision
      • Specimen Type:
        • Main location: Right lower gingiva
        • Lymph node dissection: No
      • Specimen Integrity: Intact
      • Specimen Size: 3.0 x 2.4 x 1.2 cm
      • Tumor Site: Lower gingiva, Laterality : Right
      • Tumor Focality: Single focus
      • Tumor Size: Greatest dimension: 1.5 cm
      • Additional dimensions (if available): 1.1 cm
      • Depth of Invasion (for pT1 to pT3 tumors only): 2 mm
      • Mucosal Surface : Ulcerated
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Squamous cell carcinoma
      • Histologic Grade: G2 (Moderately differentiated)
      • Microscopic Tumor Extension: To subepitheliall connective tissue
      • Margins: Free, Distance from closest margin: 0.3 cm (deep margin)
      • Lymph-Vascular Invasion: Not identified
      • Perineural Invasion: Not identified
      • Neck Lymph Nodes: Not submitted
      • IHC for p16: Negative (Reference: path 2018-09723)
  • 2018-06-21 Tc-99m MDP bone scan
    • Mildly increased activity in the middle and lower T-spines. Degenerative change may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and knees, compatible with benign joint lesion.
  • 2018-06-20 MRI - nasopharynx
    • Indication: SCC of right lower gingiva
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration showed:
      • Post fat-containing flap reconstruction surgery at right anterior buccal region with heterogeneous enhancement in the right lower buccogingival region. .
      • Post LNs dissection, right.
      • No evident abnormal enlarged lymph node in the visible neck.
      • unremarkable change in the skull base.
    • Impression:
      • Post-OP of right buccal CA with suspicious recurrent right buccogingival tumor.
  • 2018-06-11 Surgical pathlogy Level IV
    • RIGHT LOWER GINGIVA, biopsy — Squamous cell carcinoma.
    • IHC stain: p16 (-).

[immunochemotherapy]

  • 2023-12-13 - cetuximab 250mg/m2 400mg 1hr + carboplatin AUC 2 150mg NS 300mL 3hr - He ChengHan
    • ………………. diphenhydramine 30mg
  • 2023-12-04 - cetuximab 250mg/m2 400mg 1hr + carboplatin AUC 2 150mg NS 300mL 3hr - He ChengHan
    • ………………. diphenhydramine 30mg + metoclopramide 10mg
  • 2023-11-27 - cetuximab 250mg/m2 400mg 1hr + carboplatin AUC 2 150mg NS 300mL 3hr - He ChengHan
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-11-16 - cetuximab 250mg/m2 450mg 1hr - He ChengHan
    • ………………. diphenhydramine 30mg
  • 2023-11-07 - cetuximab 400mg/m2 700mg 30mg + carboplatin AUC 2 150mg NS 300mL 3hr - He ChengHan
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-10-31 - …………………………. carboplatin AUC 2 150mg NS 500mL 3hr - He ChengHan
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-09-16 - docetaxel 40mg/m2 70mg NS 150mL 2hr + carboplatin AUC 2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1700mg NS 1000mL24hr + leucovorin 100mg/m2 170mg 24hr (TPFL: docetaxel, carboplatin, 5FU, LV) - Xu BoZhi
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-09-08 - docetaxel 40mg/m2 70mg NS 150mL 2hr + carboplatin AUC 2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1700mg NS 1000mL24hr + leucovorin 100mg/m2 170mg 24hr (TPFL: docetaxel, carboplatin, 5FU, LV) - Xu BoZhi
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-08-27 - docetaxel 40mg/m2 70mg NS 150mL 2hr + carboplatin AUC 2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1700mg NS 1000mL24hr + leucovorin 100mg/m2 170mg 24hr (TPFL: docetaxel, carboplatin, 5FU, LV) - Xu BoZhi
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-08-04 - docetaxel 40mg/m2 70mg NS 150mL 2hr + carboplatin AUC 2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1700mg NS 1000mL24hr + leucovorin 100mg/m2 170mg 24hr (TPFL: docetaxel, carpoplatin, 5FU, LV) - Xu BoZhi
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-07-23 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr + leucovorin 100mg/m2 170mg 22hr (TPFL: docetaxel, cisplatin, 5FU, LV) - Xu BoZhi
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-07-06 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr + leucovorin 100mg/m2 170mg 22hr (TPFL: docetaxel, cisplatin, 5FU, LV) - Xu BoZhi
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-06-15 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr + leucovorin 100mg/m2 170mg 22hr (TPFL: docetaxel, cisplatin, 5FU, LV) - Xu BoZhi
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-06-08 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr + leucovorin 100mg/m2 170mg 22hr (TPFL: docetaxel, cisplatin, 5FU, LV) - Xu BoZhi
    • ………………. diphenhydramine 30mg + granisetron 1mg

==========

2023-12-19

[mucositis]

Combining the suggestions from both the MASCC/ISOO 2020 guidelines and the JCO Oncology Practice, here’s a pointwise summary of the recommendations:

Preventive Measures

  • Benzydamine mouthwash for head and neck cancer patients undergoing moderate-dose radiotherapy (MASCC/ISOO).
  • Photobiomodulation therapy with low-level laser for prevention in adult patients undergoing hematopoietic stem cell transplantation (MASCC/ISOO).
  • Oral cryotherapy for preventing mucositis in patients receiving high-dose melphalan during autologous HSCT (MASCC/ISOO).

General Management

  • Recognize the risk of infections and increased mortality associated with mucositis (JCO).
  • Consider the financial implications of mucositis management (JCO).

Pain Management and Symptom Relief

  • Avoid alcohol and tobacco use until symptom resolution (JCO).
  • Use 2% morphine mouthwash swish and spit for head and neck cancer patients (JCO).
  • Dexamethasone mouthwash for mTOR inhibitor-induced mucositis; in severe cases, high-dose systemic steroids (JCO).
  • 2% viscous lidocaine swish and spit (JCO).
  • Doxepin-containing mouthwashes and systemic opiates (JCO).
  • Transdermal formulations of morphine or fentanyl for long-lasting background pain control (JCO).

Hospital Admission Considerations

  • Severe cases with intractable pain, dehydration, inability to tolerate oral intake, end-organ damage, neutropenia or neutropenic fever, systemic infection (JCO).
  • Patient-controlled analgesia with morphine for severe pain (JCO).

Diet and Oral Care

  • Bland rinses (normal saline or salt and soda) for mild to moderate cases (JCO).
  • Diet modification to manage symptoms (JCO).

Use of Specific Agents

  • Avoiding sucralfate and glutamine for certain patient groups (MASCC/ISOO).

Ref:

  • Management of Cancer Therapy - Associated Oral Mucositis. JCO Oncology Practice. 2020;16(3):103-109. doi:10.1200/JOP.19.00652

  • MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2020;126(19):4423-4431. doi:10.1002/cncr.33100

700898653

231218

[lab data]

2023-08-04 HBV DNA-PCR (quantative) Target Not Detected IU/mL
2023-08-04 Anti-HCV (NM) Negative
2023-08-04 Anti-HCV Value (NM) 0.044
2023-08-04 Anti-HBc (NM) Negative
2023-08-04 Anti-HBc Value (NM) 1.110
2023-08-04 Anti-HBs (NM) Positive
2023-08-04 Anti-HBs Value (NM) 45.800 mIU/mL
2023-08-04 HBsAg (NM) Negative
2023-08-04 HBsAg Value (NM) 0.362
2023-08-04 HBsAg Nonreactive
2023-08-04 HBsAg (Value) 0.27 S/CO
2023-08-04 Anti-HBs 45.52 mIU/mL
2023-08-04 Anti-HBc Nonreactive
2023-08-04 Anti-HBc Value 0.48 S/CO
2023-08-04 Anti-HCV Nonreactive
2023-08-04 Anti-HCV Value 0.22 S/CO

[exam findings]

  • 2023-12-14 2D transthoracic echocardiography
    • Clinical diagnosis: ARDS s/p V-V ECMO
    • LVEF = (LVEDV - LVESV) / LVEDV = (52 - 23) / 52 = 55.77%
      • M-mode (Teichholz) = 55
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Mild to moderate MR, moderate AR, trivial TR
      • Mild pulmonary hypertension
      • Possible LV diastolic dysfunction, Gr 1
      • Preserved RV systolic function
  • 2023-12-13 CT - chest
    • Indication: SOB, Bil. pneumonia, ARDS S/P ETTI decrease SpO2 down to 70% since 4 days ago
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.5 mm collimation & 1.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest without contrast enhancement, coronal and sagittal reconstructed images shows:
      • dependent moderate bilateral pleural effusions and large volume of right pneumothorax.
      • lungs: diffuse consolidation in both lower lobes and diffuse ground glass opacity with interlobular septal thickening at both upper lobes and RML.
      • Mediastinum and hila: extensive coronary arterial calcification
      • Thoracic aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal size of cardiac chambers. minimal pericardial effusion.
      • Visible abdominal contents: Rt renal cyst measuring 1.9cm.
    • Impression:
      • moderate bilateral pleural effusions and large volume of right pneumothorax and ARDS and/or diffuse pneumonia d/d AIP
  • 2023-12-13 SONO - chest
    • Echo diagnosis: Right side pneumohydrothorax. Although small volume, 14 Fr. pig-tail catheter was still needed to insert under echo-guidance since the patient was a victim of ARDS on ECMO treatment. Due to emergent, picture was not captured.
  • 2023-08-04 CXR (erect)
    • S/P Port-A infusion catheter insertion.
    • Presence of scoliosis of the lumbar spine.
    • Ground glass opacity in RLL.
  • 2023-08-01 PD-L1 (22C3)
    • Block No. S2023-14496 A4
    • RESULTS:
      • Combined Positive Score(CPS) assessment: CPS<1
      • Combined Positive Score(CPS): 0
  • 2023-07-21 Patho - breast mastectomy with regional lymph nodes
    • Diagnosis
      • Breast, right, simple mastectomy —- Invasive carcinoma of no special type
      • Resection margin: free
      • Lymph node, right axilla, sentinel, lymphadenecomy —- Negative for malignancy (0/6)
      • Soft tissue, right axilla, excision —- Negative for malignancy (0/0)
      • AJCC 8 th edition, Pathology stage: Anatomic stage: pStage IIA, pT2N0(sn)(if cM0); Prognostic stage: IIA
    • Gross Description
      • Breast: Size: S2023-14496: 18.5 x 15.5 x 3.0 cm
      • Skin: Size: S2023-14496: 17.3 x 6.0 cm.
      • Nipple: S2023-14496: Not retracted
      • Tumor: Size: S2023-14496: 2.2 x 2.0 x 1.1 cm.
      • Resection Margin: S2023-14496: Free, 0.5 cm from the deep margin
      • Lymph node: F2023-00329: sentinel; S2023-14496: axilla soft tissue
      • Sections are taken and labeled as:
        • F2023-00329: All lymph nodes are dissected and labeled as: FsA1: a bisected sentinel lymph node; FsA2: lymph node, sentinel, for frozen examination.
        • S2023-14496: Representative sections are taken and labeled as: A1: nipple; A2: skin; A3: breast; A4-8: tumor; B: right axillary soft tissue.
    • Microscopic Description
      • For Invasive Carcinoma
        • Histologic type: Invasive carcinoma of no special type
        • Size of invasive carcinoma (mm): 22 x 20 x 11 mm
        • Histologic grade (Nottingham histologic score): grade II (score 6)
          • Tubule formation: score 3
          • Nuclear pleomorphism: score 2
          • Mitotic count: score 1
        • Extent of tumor (required only if the structures are present and involved)
          • Skin involvement: Absent
          • Chest wall invasion deeper than pectoralis muscle: Absent
      • For Ductal Carcinoma In Situ
        • Tumor size (mm): 12 x 18 mm (mixed with invasive carcinoma)
        • Nuclear grade: 2
        • Architectural pattern: Non-comedo (cribriform)
        • Tumor necrosis: Present
      • Margins: Negative, Closest margin (5 mm from deep margin)
      • Nodal status: Negative, sentinel
        • No. examined: sentinel: 6; axilla soft tissue: 0
        • No. macrometastases (>2 mm): sentinel: 0; axilla soft tissue: 0
        • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): sentinel: 0; axilla soft tissue: 0
        • No. isolated tumor cells (<=0.2 mm and <=200 cells): sentinel: 0; axilla soft tissue: 0
      • Treatment Effect: patient not received
      • Lymphovascular invasion: present
      • Perineural invasion: present
      • Immunohistochemical Study: S2023-13126
      • Tumor infiltrating lymphocytes (TILs): < 10%
  • 2023-07-20 SONO - abdomen
    • Diagnosis:
      • Fatty liver, mild
      • Liver lesions, left. Suspected focal fat-spared area or true liver lesion (?)
      • Suspected right renal cyst
      • Pancreas not shown
      • Suboptimal examination of liver, especially the subcostal view due to poor echo window
    • Suggestion:
      • OPD f/u
      • Because of poor echo window, please follow sono abd 3-6 months later or correlate with other image
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • 2023-07-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (68 - 21) / 68 = 69.12%
      • M-mode (Teichholz) = 67
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Septal hypertrophy; impaired LV relexation
      • Trivial MR, trivial AR and mild TR
      • Preserved RV systolic function
  • 2023-07-10 Tc-99m MDP bone scan
    • Faint hot spots in the sternum and both rib cages, respectively, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, mandible, some C-, T- and L-spine, bilateral shoulders, and knees.
  • 2023-07-03 Her-2/neu DISH
    • RESULT OF HER2 IN SITU HYBRIDIZATION:
      • HER-2 (by in situ hybridization) — Negative (NOT amplified)
    • METHOD AND DETAILS:
      • Number of observers: 1
      • Number of invasive tumor cells counted: 20
      • Average number of HER2 signals per cell: 2.55
      • Average number of CEP17 signals per cell: 2.15
      • HER2/CEP17 ratio: 1.19
      • Heterogeneous signals: Absent
      • Origin slide and block number: S2023-13126
      • Specimen: Formalin-fixed paraffin embedded tissue
      • Adequacy of sample for evaluation: Yes
      • Method of in situ hybridization: CISH (Ventana INFORM HER2 Dual ISH DNA Probe Cocktail Assay, Roche company)
    • APPENDIX:
      • ASCO/CAP scoring criteria (2018):
        • Group 1 = HER2/CEP17 ratio >=2.0; >=4.0 HER2 signals/cell
        • Group 2 = HER2/CEP17 ratio >=2.0; <4.0 HER2 signals/cell
        • Group 3 = HER2/CEP17 ratio <2.0; >=6.0 HER2 signals/cell
        • Group 4 = HER2/CEP17 ratio <2.0; >=4.0 and <6.0 HER2 signals/cell
        • Group 5 = HER2/CEP17 ratio <2.0; <4.0 HER2 signals/cell
      • Negative:
        • Group 5
        • Group 2 and concurrent IHC 0-1+ or 2+
        • Group 3 and concurrent IHC 0-1+
        • Group 4 and concurrent IHC 0-1+ or 2+
      • Positive:
        • Group 2 and concurrent IHC 3+
        • Group 3 and concurrent IHC 2+ or 3+
        • Group 4 and concurrent IHC 3+
        • Group 1
  • 2023-07-03 Patho - breast biopsy (no need margin)
    • DIAGNOSIS:
      • Breast, right, core biopsy — Invasive carcinoma of no special type
    • GROSS DESCRIPTION:
      • The specimen submitted consisted of three strips of tan irregular tissue measuring up to 0.8 x 0.1 x 0.1 cm. All for section in one cassette.
    • MICROSCOPIC DESCRIPTION:
      • Section shows cores of breast tissue with irregular neoplastic glands infiltration. The immunohistochemical stain of E-cadherin is positive.
    • IMMUNOHISTOCHEMICAL STUDY
      • ER (Ab): Negative (Internal control: positive)
      • PR (Ab): Negative (Internal control: positive)
      • Her-2/neu (Ab): Equivocal (2+)
      • Ki-67: 10%

[MedRec]

  • 2023-10-27 ~ 2023-10-28 POMR General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Right breast invasive carcinoma. pT2N0M0, stage IIA. Triple negative. ECOG:0
      • Encounter for antineoplastic chemotherapy
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
    • CC
      • for chemotherapy
    • Present illness
      • Breast sono showed a lesion, Right 9/1.7 cm , size: 1.4x1.38 cm, r/o malignancy suggest biopsy. Core needle biopsy revealed invasive carcinoma, ER(-), PR(-), Her2/neu(2+) but FISH negative, Ki-67 10%. CA-153 22.384 U/ml, CEA 1.670 ng/ml.
      • Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis. Surgery of right breast simple mastectomy + SLNB on 2023/07/21. pT2N0M0, stage IIA.
      • Adjuvant chemotherapy with Lipo dox 30mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 4 cycles. Add keytruda since 2023/08/25 by family reguest.
      • Under the impression of right breast invasive carcinoma, she was admitted for 5th adjuvant chemotherapy with weekly Taxol 80mg/m2 + Keytruda 200mg Q3W.
    • Course of inpatient treatment
      • After admission, 5th adjuvant chemotherapy with weekly Taxol 80mg/m2 + Keytruda 200mg Q3W were given. No discomfort after chemotherapy.
      • Under the stable condition, she was discharged today, arrange next admission three weeks later.
    • Discharge prescription
      • Limeson (dexamethasone 4mg) 1# BID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
  • 2023-08-03 ~ 2023-08-05 POMR General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Right breast cancer status post port A insertion on 2023/08/04. pT2N0M0, stage IIA. Triple negative, ECOG:0
      • Encounter for antineoplastic chemotherapy
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
    • CC
      • for chemotherapy
    • Present illness
      • This 78-year-old female patient has past history of hypertension over 30 years with regular medicine control. Type II diabetes mellitus for 5 years with regular medicine control. She went to United States on 2023/05.
      • She noted a palpable mass at right breast over 6 months. She came to our OPD for help. Breast sono showed a lesion, Right 9/1.7 cm , size: 1.4x1.38 cm, r/o malignancy suggest biopsy. Core needle biopsy revealed invasive carcinoma, ER(-), PR(-), Her2/neu(2+) but FISH negative, Ki-67 10%. CA-153 22.384 U/ml, CEA 1.670 ng/ml.
      • Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis. Surgery of right breast simple mastectomy + SLNB on 2023/07/21. pT2N0M0, stage IIA.
      • Adjuvant chemotherapy with Lipo dox 30mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 4 cycles.
      • Under the impression of right breast invasive carcinoma, she was admitted for surgery of port A insertion. Adjuvant chemotherapy with Lipo dox 30mg/m2 + Endoxan 600mg/m2 on 2023-08-05.
    • Course of inpatient treatment
      • After admission, port A insertion was performed on 2023/08/04. 1st adjuvant chemotherapy with Lipo dox 30mg/m2 + Endoxan 600mg/m2 were given. The wound is clean and dry. No discomfort after chemotherapy.
      • Under the stable condition, she was discharged today, wound will be follow up on 8/9. And arrange next admission three weeks later.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Emend (aprepitant 125mg) 1# QD 2D for 8/6 and 8/7
      • Promeran (metoclopramide 3.84mg) 1# TIDAC 3D for 8/8, 8/9, 8/10
      • loperamide 2mg 2# PRNQ6H if diarrhea > 2 per day
  • 2023-07-20 ~ 2023-07-22 POMR General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Right breast invasive carcinoma status post simple mastectomy + sentinel lymph node biopsy on 2023/07/21. cT2N0M0, stage IIA. Triple negative. ECOG 0
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
    • CC
      • noted a palpable mass at right breast over 6 months.
    • Present illness
      • This 79-year-old female patient has past history of hypertension over 30 years with regular medicine control. TypeII diabetes mellitus for 5 years with regular medicine control. She wnet to United States on 2023/05.
      • She noted a palpable mass at right breast over 6 months. She came to our OPD for help. Breast sono showed a lesion, Right 9/1.7 cm , size: 1.4x1.38 cm, r/o malignancy suggest biopsy. Core needle biopsy revealed invasive carcinoma, ER(-), PR(-), Her2/neu(2+) but FISH negative, Ki-67 10%. CA-153 22.384 U/ml, CEA 1.670 ng/ml.
      • Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis.
      • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
      • PE: symmetrical of bilateral breasts. A hard, nontender, movable mass and irregular margin at right breast around 2x2 cm without discharge. The nipple was dimping without exudative nor bloody discharge and no retraction. The right breast skin had no cellulitis change.
      • Under the impression of right breast invasive carcinoma, she was admitted for surgery of simple mastectomy + SLNB.    
    • Course of inpatient treatment
      • After admission, right breast simple mastectomy + SLNB was performed on 2023/07/21. The wound is clean and dry. Under the stable condition, she was discharged today, wound will be follow up in OPD.
    • Discharge prescripton
      • Acetal (acetaminophen 500mg) 1# QD

[surgical operation]

  • 2023-12-13
    • Surgery
      • VV ECMO
    • Finding
      • 15Fr A cannula at right IJV, fixed 15cm.
      • 19Fr V cannula at right CFV, fixed 45cm.
  • 2023-08-04
    • Surgery
      • Port-A insertion, L’t after L’t cephalic vein exploration        
    • Finding
      • We explore and identify the L’t cephaic vein & use cutdown method to insert the 7 Fr cathter into it. We also use intra-operative EKG to check its position.  
  • 2023-07-21
    • Surgery
      • Simple mastectomy and sentinel lymph node biopsy        
    • Finding
      • a 2.5 x 2 x 1.5 cm slight firm mass in rt breast
      • SLN 0/6 

[immunochemotherapy]

  • 2023-12-04 - paclitaxel 80mg/m2 115mg D5W 250mL 90min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-11-27 - paclitaxel 80mg/m2 117mg D5W 250mL 90min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-11-20 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 80mg/m2 117mg D5W 250mL 90min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-11-13 - paclitaxel 80mg/m2 117mg D5W 250mL 90min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-11-06 - paclitaxel 80mg/m2 117mg D5W 250mL 90min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-10-27 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 80mg/m2 117mg D5W 250mL 90min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-10-06 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 880mg NS 500mL 1hr + liposome doxorubicin 30mg/m2 45mg D5W 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-09-15 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 875mg NS 500mL 1hr + liposome doxorubicin 30mg/m2 45mg D5W 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-08-25 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 875mg NS 500mL 1hr + liposome doxorubicin 30mg/m2 45mg D5W 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-08-04 - cyclophosphamide 600mg/m2 898mg NS 500mL 1hr + liposome doxorubicin 30mg/m2 45mg D5W 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

[acute respiratory distress syndrome, ARDS]

Treatment course

  • 2023-08-04: AC(lipo) initiated Q3W for 4 cycles after the patient recovered from mastectomy on 2023-07-21.
  • 2023-10-27 onward: weekly paclitaxel.
  • 2023-08-25, 2023-09-15, 2023-10-06, 2023-10-27, 2023-11-17: pembrolizumab 200mg administered Q3W as per patient’s family request (noted in discharge document).

ARDS and pembrolizumab considerations

  • Recent: ARDS developed.
  • Pembrolizumab association: Pneumonitis is a known risk associated with anti-PD-1 monoclonal antibodies like pembrolizumab, with documented cases of grade 3, 4, and fatal severity. The incidence is higher compared to anti-PD-L1 agents. Recurrence is possible after symptom resolution, regardless of re-challenge with immune checkpoint inhibitors. Chronic courses can also occur. The mechanism is non-dose-related and immunologic, with a median onset of approximately 3 months. Treatment-naive patients are at higher risk.

Current status and recommendation

  • Patient currently on VV-ECMO.
  • Recommendation: Due to ARDS and pembrolizumab’s association with pneumonitis, further re-challenge with pembrolizumab is not advisable.

Ref:

700938533

231218

[exam findings]

  • 2023-12-14 20:46 ECG
    • Sinus tachycardia
    • Left axis deviation
  • 2023-12-14 CXR
    • Tortuosity of the aorta with atherosclerotic change.
    • Increased lung markings over both lungs.
    • R/O right pleural effusion.
    • Degenerative joint disease of T-spine with marginal osteophytes.
    • S/P port-A catheter insertion.
  • 2023-12-14 18:08 ECG
    • Sinus tachycardia
    • Right superior axis deviation
  • 2023-12-11 MRI - brain
    • Findings
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
      • The interhemispheric fissure is centered on the midline.
      • Sella and pituitary are normal. The parasellar structures are unremarkable.
      • Favor bilateral cerebral and cerebellar metastases in leptomeninges, cortex and subcortical region, also a deep lesion in right basal ganglia.
      • Patchy or nodular abnormal enhancement after contrast administration of those lesions were found.
    • Imp:
      • Mild cortical brain atrophy. Bilateral cerebral and cerebellar metastases.
  • 2023-11-07 Patho - stomach biopsy (Y1)
    • Labeled as “upper abdominal tumor”, CT guided biopsy — adenocarcinoma. IHC stains: CK19 (+), CA19-9 (-), CK7 (-), CK20 (-), CDX-2 (-). An addendum report of the result of IHC stain of TTF-1 will be followed.
    • Section shows adenocarcinoma in papillary and cribriform patterns.
    • IHC stains: CK19 (+), CA19-9 (-), CK7 (-), CK20 (-), CDX-2 (-).
    • Additional IHC stains: amylase-A (-), TTF-1 (-).
  • 2023-11-07 Patho - colon biopsy
    • Colorectum, ascending colon. Cold snaring polypectomy (A) — Hyperplastic polyp
    • Colorectum, transverse colon. Cold snaring polypectomy (B) — Tubular adenoma with low grade dysplasia
    • Colorectum, descending colon. Cold snaring polypectomy (C) — Hyperplastic polyp
    • Colorectum, rectum. Polypectomy (D) — Tubulovillous adenoma with low grade dysplasia.
  • 2023-11-07 Patho - stomach biopsy
    • Stomach, antrum, biopsy — Chronic gastritis, H pylori NOT present
  • 2023-11-06 EGD
    • Reflux esophagitis, lower esophagus, LA classification, grade A
    • Superfical gastritis, antrum
    • Gastric ulcer, multiple, antrum, s/p biopsy
  • 2023-11-06 Colonoscopy
    • Findings
      • The scope had been inserted up to cecum.
      • A 0.6 cm IIa polyp was noted at ascending colon. Cold snaring polypectomy was done (A).
      • A 0.6 cm IIa polyp was noted at transverse colon. Cold snaring polypectomy was done (B).
      • A 0.6 cm IIa polyp was noted at descending colon. Cold snaring polypectomy was done (C).
      • Active oozing from wound was noted. Clip was applied on wound with hemostasis.
      • An about 2 cm Ip polyp was noted at rectum. Polypectomy was done after submucosal injection (D).
      • Active oozing from wound was noted. Clips were applied on wound with hemostasis.
      • Several smaller polyps less then 0.5 cm were noted from transverse colon to sigmoid colon.
      • Several diverticulum were noted at ascending colon.
      • Internal hemorrhoid was noted
    • Diagnosis:
      • Colon polyp, ascending colon, s/p polypectomy
      • Colon polyp, tranverse colon, s/p polypectomy
      • Colon polyp, descending colon, s/p polypectomy + cliping
      • Colon polyp, rectum, s/p polypectomy + cliping
      • Colon diverticulum, ascending colon
      • Multiple small colon polyp, trasnverse colon to sigmod colon
      • Internal hemorrhoid
  • 2023-11-04 CT - abdomen
    • History and indication: Abdominal pain and nudules
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A large mass (10.8cm) at upper abdomen with duodenum, stomach, celiac trunk, common hepatic artery, splenic artery, SMA, SMV, splenic vein and portal vein invasion. Indistinct contour of pancreatic body and tail. Enlarged LNs around the tumor. Some soft tissues in peritoneal cavity.
      • Liver cirrhosi with portal hypertension, GV, collateral circulation, ascites and splenomegaly.
      • Atherosclerosis of aorta.
    • IMP:
      • A large mass (10.8cm) at upper abdomen with duodenum, stomach, celiac trunk, common hepatic artery, splenic artery, SMA, SMV, splenic vein and portal vein invasion r/o pancreatic tumor.
      • Enlarged LNs around the tumor. Some soft tissues in peritoneal cavity r/o tumor seeding.
      • Liver cirrhosi with portal hypertension, GV, collateral circulation, ascites and splenomegaly.
  • 2023-11-04 SONO - abdomen
    • Findings
      • Bile duct: Hard to access CBD because of cavenous transformation of main portal vein
      • Portal vein: Cavenous transformation of protal vein at hilar area
      • Pancreas: Part of head and part of tail masked. The relationship of tumor and pancreas is hard to access
      • Spleen: Measured 6.8 x 4.7 cm
      • Ascites: Massive
      • A huge, more than 11 cm heteroechoic, multi-nodular tumor was noted upper abdomen with celiac trunk involve.
    • Diagnosis:
      • Upper abdominal tumor, huge, with celiac trunk involve
      • Cavenous transformation of main portal vein
      • Splenomegaly, mild
      • Ascites, massive
    • Suggestion:
      • arrange admission for work up

[MedRec]

  • 2023-11-17 SOAP Radiation Oncology Wang YuNong
    • Plan: Palliative CCRT is indicated.
      • CT-simulation will be arranged on 2023/11/20.
      • Plan to deliver 45 Gy/ 25 fx to the gross tumor and LAPs with partial simultaneous boost.
      • RT will start around 11/23.
  • 2023-11-15 SOAP Hemato-Oncology He JingLiang
    • S: abdominal adenocarcinoma, but CA199 WNL
      • apply major illness, refer to GS for port-A
      • C/T with FOLFOX
  • 2023-11-04 ~ 2023-11-09 POMR Gastroenterology Su WeiZhi
    • Discharge diagnosis
      • Pancreatic tumor, rule out pancreatic cancer, status post biopsy
      • Alcoholic cirrhosis of liver
    • CC
      • abdominal distension and weight loss (12kg in 2 months)
    • Present illness
      • This 50-year-old man without medical history was refferred to to our GI OPD on 2023-11-05 from LMD. His chief complaint was abdominal distension and weight loss (12kg in 2 months). Accompanied symptoms included mild abdmonial pain sometimes, dyspepsia, soft stool passage for months. There were no no fever, no chills, no nausea, no vomitting, no chest tightness, no dysuria. Alcoholic abuse was told.
      • Echo 2023/11/04: upper abdomianl huge tumor with celiac trunk involve. Ascites was told by LMD. Lab data showed no leukocytosis of WBC:7.77K, HB:9.1, TBI:1.88, r-GT:24, ALP:111.
      • Physical examination showed abdominal distension with lower abdominal tenderness.
      • Under the impression of abdmonial pain and ascites, r/o upper abdomianl huge tumor, he was admitted for further evlauaiton and managemnt.
    • Course of inpatient treatment
      • After admission, we kept monitoring his vital sign and prescribed medication for hypertension.
      • KUB showed stool retention in bowl.
      • ABD Liver CT with contrast on 11/4 showed (1) a large mass (10.8cm) at upper abdomen with duodenum, stomach, celiac trunk, common hepatic artery, splenic artery, SMA, SMV, splenic vein and portal vein invasion r/o pancreatic tumor. (2) enlarged LNs around the tumor. (3) some soft tissues in peritoneal cavity r/o tumor seeding. (4) liver cirrhosis with portal hypertension, GV, collateral circulation, ascites and splenomegaly.
      • Adequate iv hydration with nako.5 500ml QD for NPO.
      • We arranged anesthetic EGD and colonscopy on 11/6. EGD showed Reflux esophagitis, LA classification, antrum gastric ulcer, multiple, antrum, s/p biopsy. Colonscopy revealed multiple small colon polyp, trasnverse colon to sigmod colon, s/p polypectomy + cliping, and internal hemorrhoid. Nexium QD was given since 2023-11-07.
      • CT guided biopsy was arranged on 2023-11-07, pending pathology report. Follow-up lab data on 2023-11-08 showd mildanemia with HB:8.3. LPRBC 2U was given.
      • Under stable condition, he was discharged and turned to OPD folloed-up.
    • Discharge prescription
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Acetal (acetaminophen 500mg) 1# PRNQ8H if pain

[chemotherapy]

  • 2023-11-30 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 30min (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-21 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 30min (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-12-18

On 2023-12-18, the patient exhibited pancytopenia, including severe grade 3 anemia. Blood product transfusion was administered the same day.

  • 2023-12-18 WBC 2.95 x10^3/uL
  • 2023-12-18 HGB 6.7 g/dL
  • 2023-12-18 PLT 98 *10^3/uL

Low levels of serum sodium, potassium, calcium, magnesium, and albumin were also detected. Taita No.5 electrolyte solution, KCl, and MgSO4 were prescribed.

  • 2023-12-18 Na (Sodium) 130 mmol/L
  • 2023-12-18 K (Potassium) 3.0 mmol/L
  • 2023-12-18 Albumin (BCG) 3.1 g/dL
  • 2023-12-18 Ca (Calcium) 1.91 mmol/L
  • 2023-12-18 Mg (Magnesium) 1.6 mg/dL

A positive stool occult blood test (1+) was identified on 2023-12-17. The patient is currently receiving Panzolec (pantoprazole) and Hemoclot (tranexamic acid).

Medication reconciliation found no discrepancies.

701500949

231218

[lab data]

2023-11-02 Ferritin 667.6 ng/mL
2023-10-26 FLT3-D835 (bone marrow) Undetectable
2023-10-25 MPO stain Positive (3+)
2023-10-25 ANAE stain Negtive
2023-10-25 CAE stain Positive
2023-10-18 NPM1 (qualitative)(BM) Undetectable
2023-10-18 FLT3/ITD (bone marrow) Undetectable
2023-10-18 JAK2-single site (BM) Undetectable
2023-10-18 BCR/abl (BM) PhiladChr (qual) Undetectable
2023-10-16 Von willebrand factor 100.8 %
2023-10-13 HBV-DNA-PCR Target Not Detected IU/mL
2023-10-12 TSH (NM) 2.348 uIU/ml
2023-10-12 T3 (NM) 95.975 ng/dl
2023-10-12 Free T4 (NM) 1.190 ng/dl

2023-10-13 HBV-DNA-PCR Target Not Detected IU/mL
2023-10-12 HBsAg Nonreactive
2023-10-12 HBsAg (Value) 0.41 S/CO
2023-10-12 Anti-HBc Reactive
2023-10-12 Anti-HBc-Value 4.57 S/CO
2023-10-12 Anti-HCV Nonreactive
2023-10-12 Anti-HCV Value 0.10 S/CO

[exam findings]

  • 2023-11-18 CXR (supine)
    • S/P PICC catheter insertion via left forearm.
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2023-11-15, -10-13 CXR (erect)
    • S/P PICC catheter insertion via left forearm.
    • Borderline cardiomegaly
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2023-10-16 SONO - abdomen
    • mild fatty liver (incomplete exam of liver)
    • gallbladder polyps
    • fatty infiltration of pancreas
    • bilateral renal cysts
  • 2023-10-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (131 - 43) / 131 = 67.18%
      • M-mode (Teichholz) = 66
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Mitral valve prolapse, posterior mitral leaflet with moderate MR
      • Concentric LVH; impaired LV relexation
      • Mild AR (aortic regurgitation), trivial TR (tricuspid regurgitation) and trivial PR (pulmonary regurgitation)
      • Preserved RV systolic function
  • 2023-10-13 Peripherally Inserted Central Catheters, PICC
    • Indication of PICC: leukemia
    • Under the echo guiding, we successful puncture left basilic vein. PICC catheter was advanced to SVC smoothly, total into 35 cm.
    • SVO2 65%, estimated Fick Cardiac index 2.86L/min/m2 (normal range cardiac index 2.5~4 L/min/m2)
  • 2023-10-12 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Acute myeloid leukemia
    • Specimen submitted in formalin consists of a piece of tan, rod shape bone marrow tissue measuring 2.5 cm in length. All for section in one cassette after decalcification.
    • Sections show 80-90% cellularity. Blasts account for about 40-50% of all nucelated cells.
    • The immunohistochemical stains CD34(+), CD117(+), MPO(+), CD68(+), CD163(focal +), CD3(-), and PAX5(-). The results are consistent with acute myeloid leukemia. Please correlate with the clinical presentation and lab studies.

[MedRec]

  • 2023-11-12 ~ 2023-11-23 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Acute myeloblastic leukemia, not having achieved remission; Blast:41%, immunohistochemical stains CD34(+), CD117(+), MPO(+), CD68(+), CD163(focal +), CD3(-), and PAX5(-) S/P chemotherapy with 7 + 3 (Cytarabine + Idarubicin) on 10/13-10/20 23
      • Essential (primary) hypertension
      • Chronic viral hepatitis B without delta-agent
      • Urinary tract infection, urine culture growth Enterococcus faecalis
    • CC
      • for C2 chemotherapy with 5 + 2 (Cytarabine + Idarubicin).
    • Present illness
      • This 72-year-old, had history of hypertension for 3 years under oral medication treatment at LMD.
      • He suffered form spontaneous ecchymosis over bilateral hands & bilateral thight and gum bleeding for 1-2 months and body weight loss about (70 -> 65kg within 1 month and poor appetite were also noted. The patient did not take painkillers or chinese herbal medicines. He visited to LMD for aid and ecchymosis & gum bleeding progression was developed in recent one week and transferred to our ER on 10/11 23.
      • At arrival to ER, the laboratory showed WBC:30610, Hb:9.8, PLT:11K, LDH:1038, Seg:18, Metamyelocyte:4.0%, Myelocyte:10%, promyelocyte:3%, Blast:41% on 2023/10/9. Under the impression of Leukocytosis rule out acute myeloblastic leukemia, not having achieved remission Blast:41%.
      • The bone marrow was done on 10/12 23 and pathology (10/17 23) proved acute myeloid leukemia, immunohistochemical stains CD34(+), CD117(+), MPO(+), CD68(+), CD163(focal +), CD3 (-), and PAX5(-). The BCR/abl/NPM1/FLT3/ITD/JAK2 showed Undetectable. Blood transfusion with LPRBC 2U was given on 10/23 23. The FLT3-D835/NPM1/FLT3/ITD/JAK2 - single site/MPO/ANAE/CAE/(AML+ALL/Myeloid/AML/21-30/BcR/abL Philadelphia chromosome/bone marrow cell chromosomes (self-paid) were checked. PICC was inserted on 10/13 23.
      • Chemotehrapy with 7 + 3 (Cytarabine + Idarubicin) was administered on 10/13-10/20 23, smoothly without obvious side effect.
      • Vemlidy 1# po qd was added due to anti-Hbc positive.
      • We arranged abdominal sono & heart echo for perpare chemotherapy evaluation and which showed mild fatty liver (incomplete exam of liver) gallbladder polyps and LVEF 66%, adequate LV systolic function with normal resting wall motion, mitral valve prolapse, posterior mitral leaflet with moderate MR , concentric LVH; impaired LV relexation, mild AR, trivial TR and trivial PR.
      • Chemotehrapy with 7 + 3 (Cytarabine + Idarubicin) was administered, C1 on 10/13-10/20 23.
      • This time, he is admitted for C2 chemotherapy with 5+2 (Cytarabine + Idarubicin).
    • Course of inpatient treatment
      • After admission, blood transfusion with LPRBC for anemia, hydration, chemotehrapy with 5+2 (Cytarabine + Idarubicin) was administered on 11/13-11/17 23,
      • Vemlidy 1# po qd was added due to anti-Hbc positive.
      • After chemotherapy, he suffered from fever noted, so gave Cefim for infection control, followed-up PICC culture growth Staphylococcus epidermidis, and remove PICC catheter, blood culture not growth, urine culture growth Enterococcus faecalis.
      • Followed-up the lab of CBC/DC showed neutropenia (WBC: 1830/uL, Neutrophil: 49%, ANC: 896.7), so gave protective isolation.
      • Re checked the lab of CBC/DC showed WBC: 1510/uL, Neutrophil: 52.1%, ANC: 789.
      • After treatment. he denide having a fever, vomiting, diarrhea, or any uncomfortable. He can be discharged on 2023/11/23, take oral antibiotic with Ceficin back home, the OPD follow-up will be arranged.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
      • Smecta (dioctahedral smectite 3mg) 1# PRNTIDAC
      • Urosin (atenolol 100mg) 0.5# QD
      • Mosapin (mosapride citrate 5mg) 1# TID
      • Ulstop (famotidine 20mg) 1# BID
      • Ceficin (cefixime 100mg) 2# Q12H
  • 2023-11-01 SOAP Hemato-Oncology He JingLiang
    • O: 2023-11-01 Plt 6K
    • P: 2023-11-01 BT Plt 2u
  • 2023-10-11 ~ 2023-10-28 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Acute myeloblastic leukemia, not having achieved remission Blast:41%, immunohistochemical stains CD34(+), CD117(+), MPO(+), CD68(+), CD163(focal +), CD3(-), and PAX5(-) S/P chemotherapy with 7 + 3 (Cytarabine + Idarubicin) on 10/13-10/20 23
      • Essential (primary) hypertension
      • Chronic viral hepatitis B without delta-agent
    • CC
      • spontaneous ecchymosis over bilateral hands & bilateral thight for 1-2 months
    • Present illness
      • This 72-year-old, had history of hypertension for 3 years under oral medication treatment at LMD. He suffered form spontaneous ecchymosis over bilateral hands & bilateral thight and gum bleeding for 1-2 months and body weight loss about (70 -> 65kg) within 1 month and poor appetite were also noted. The patient did not take painkillers or chinese herbal medicines.
      • He visited to LMD for aid and ecchymosis & gum bleeding progression was developed in recent one week and transferred to our ER on 10/11 23.
      • At arrival to ER, the laboratory showed WBC:30610, Hb:Hb:9.8, PL:11K, LDH:1038, Seg:18, Metamyelocyte:4.0%, Myelocyte:10%, promyelocyte:3%, Blast:41% on 2023/10/9.
      • Under the impression of Leukocytosis rule out acute myeloblastic leukemia, not having achieved remission Blast:41%. He was admitted for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, hydration and bone marrow was done on 10/12 23 and pathology was pending. The FLT3-D835/NPM1/FLT3/ITD/JAK2-single site/MPO/ANAE/CAE/(AML+ALL/Myeloid/AML/21-30/BcR/abL Philadelphia chromosome/bone marrow cell chromosomes (self-paid) were checked.
      • PICC was inserted on 10/13 23. Chemotehrapy with 7 + 3 (Cytarabine + Idarubicin) was administered on 10/13-10/20 23, smoothly without obvious side effect.
      • Vemlidy 1# po qd was added due to anti-Hbc positive.
      • We arranged abdominal sono & heart echo for perpare chemotherapy evaluation and which showed mild fatty liver (incomplete exam of liver) gallbladder polyps and LVEF:66%, adequate LV systolic function with normal resting wall motion, mitral valve prolapse, posterior mitral leaflet with moderate MR , concentric LVH; impaired LV relexation, mild AR, trivial TR and trivial PR.
      • The WBC idex from 30610 -> 25680 -> 3490 and blast:41%–>40.9%–>2.9 were noted post C/T treatment.
      • Bone marrow, iliac, biopsy (10/17 23) proved acute myeloid leukemia, immunohistochemical stains CD34(+), CD117(+), MPO(+), CD68(+), CD163(focal +), CD3 (-), and PAX5(-). The BCR/abl/NPM1/FLT3/ITD/JAK2 showed Undetectable.
      • Blood transfusion with LPRBC 2U was given on 10/23 23. Followed-up the lab of CBC/DC showed neutropenia (WBC: 1010/uL, Band: 1.2%, Neutrophil: 9.9%, ANC: 112.11). No more fever was noted and good appetite. He was discharged on 10/28 23 under stable condition and will follow-up at OPD.
    • Discharge prescription
      • MgO 250mg 2# TID
      • Through (sennoside 12mg) 1# HS
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
  • 2023-10-11 - SOAP Medical Emergency Lin QingXiang
    • S: Triage Revised As Needed System: 3
      • The patient’s white blood cell count was high on an outpatient blood test, and they were suspected of having leukemia and transferred in.
    • O:
      • BP: 191/86; HR: 112; BT: :36.2’C; RR: 18;
      • SpO2: 97%
      • GCS: E4V5M6 alert, and oriented.
      • General-looking: acute ill looking
      • HEENT: supple neck, no injected throat, no pale conjunctiva, no icteric sclera
      • Heart: no murmur, regular heart beat
      • Chest: bilateral clear breathing sounds. symmetrical
      • Abdomen: flat and soft, normal bowel sound, no tenderness
      • Extremitis: warm, freely movable, no pitting edema
      • Neurologic: well muscle power of four limbs, stable gait. isocoric pupil with light reflex
    • A
      • preliminary impression: R23.3 Spontaneous ecchymoses
      • Limb Ecchymosis, Oral bleeding, suspect leukemia, WBC 31k, Hb 9.8, Plt 11k -> LRP 2U, OA Hema (GBard: outpatient hematology)
      • HTN
      • Lab
        • 2023/10/09 20:53 ALT = 27 U/L;
        • 2023/10/09 20:53 Creatinine = 0.95 mg/dL;
        • 2023/10/09 20:53 CRP = 0.3 mg/dL;
        • WBC = 30.61 x10^3/uL; HGB = 9.8 g/dL;
        • PLT = 11 x10^3/uL;
  • 2023-10-09 - SOAP Family Medicine Ye JiaZe
    • S
      • Multiple ecchymosis red papules non itchy over ext, off and on for days
        • tarry stool -
        • bloody stool -
        • recent URI -
        • body weight loss (BWL) -
        • referred from LMD
      • 2023-10-09 2040 voice chat consultation
      • Occupation: noodle/pasta, retired
      • Current med: atenolol, losartan, red yeast rice
    • O
      • BP: 186/93 mmHg; HR: 123 pulse/min; Weight: 65.6 kg
      • Lab
        • 2023/10/09 D-dimer = 704.00 ng/mL(FEU);
        • 2023/10/09 INR = 1.06;
        • 2023/10/09 CBC
          • WBC = 30.61 x10^3/uL;
          • HGB = 9.8 g/dL;
          • PLT = 11 x10^3/uL;
          • Blast = 41.0 %;
      • hard & soft palate ecchymosis
      • general skin red papules
    • P
      • hema OPD F/U
      • ER if condition deteriorated

[chemotherapy]

  • 2023-12-15 - idarubicin 10mg/m2 15mg NS 100mL 30min D1-2 + cytarabine 100mg/m2 160mg NS 500mL 24hr D1-5 ((2+5) idarabicin/cytarabine Q4W)
    • dexamethasone 4mg + palonosetron 250ug D1,3 + NS 250mL D1,3
  • 2023-11-13 - idarubicin 10mg/m2 15mg NS 100mL 30min D1-2 + cytarabine 100mg/m2 160mg NS 500mL 24hr D1-5 ((2+5) idarabicin/cytarabine Q4W)
    • dexamethasone 4mg + palonosetron 250ug D1,3 + NS 250mL D1,3
  • 2023-10-13 - idarubicin 10mg/m2 15mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 160mg NS 500mL 24hr D1-7 ((3+7) idarabicin/cytarabine Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug D1,4 + NS 250mL D1,4

Acute myeloid leukemia: Induction therapy in medically-fit adults - 2023-10-16 - https://www.uptodate.com/contents/acute-myeloid-leukemia-induction-therapy-in-medically-fit-adults

  • AML without mutated FLT3 - For newly diagnosed AML without mutated FLT3, we recommend treatment with a seven-day continuous infusion of cytarabine plus an anthracycline for three days (so-called “7+3 therapy”), based on the favorable balance of outcomes and toxicity.
    • Administration – The regimen that is most often used is:
      • Cytarabine - 100 to 200 mg/m2/day by continuous intravenous (IV) infusion for days 1 to 7
      • Anthracycline
        • Daunorubicin - 60 to 90 mg/m2 IV on days 1 to 3 or
        • Idarubicin - 12 mg/m2 IV on days 1 to 3
  • AML with mutated FLT3 - For patients with FLT3-mutated AML, we recommend addition of either midostaurin (for any FLT3 mutation) or quizartinib (for FLT3 with internal tandem repeats [ITD]) to intensive induction chemotherapy
    • Administration
      • Midostaurin
        • Administered orally 50 mg twice daily on days 8 through 21. Cytarabine and an anthracycline are administered, as described above. (See ‘AML without mutated FLT3’ above.)
        • Strong CYP3A4 activators and inhibitors may alter exposure to midostaurin and its active metabolites; alternatives to agents that strongly affect CYP3A4 should be considered [17].
      • Quizartinib
        • Administered 35.4 mg orally once daily on days 8 to 21 of 7+3 therapy.
        • A boxed warning for quizartinib notes QT prolongation, torsades de pointes, and cardiac arrest. The QT interval should be assessed prior to initiating quizartinib and periodically during treatment. Hypokalemia and hypomagnesemia should be corrected. Treatment should not be initiated if the QT interval (corrected by Fridericia’s formula [QTcF]) is >450 ms. The dose of quizartinib should be reduced when used concomitantly with strong CYP3A inhibitors.
      • The US Food and Drug Administration (FDA) and the European Medicines Agency approved midostaurin in combination with chemotherapy for newly diagnosed AML with mutated FLT3 in adults. The US FDA approved quizartinib in combination with 7+3 induction therapy for AML that is positive for FLT3-ITD, but not for other FLT3 mutations; quizartinib is available only through a Risk Evaluation and Mitigation Strategy (REMS) in the US.

==========

(not posted yet)

2023-11-01 WBC 2.15 x10^3/uL
2023-10-28 WBC 1.40 x10^3/uL
2023-10-27 WBC 1.01 x10^3/uL
2023-10-25 WBC 0.96 x10^3/uL
2023-10-23 WBC 0.87 x10^3/uL
2023-10-21 WBC 1.07 x10^3/uL
2023-10-19 WBC 1.82 x10^3/uL
2023-10-16 WBC 3.49 x10^3/uL
2023-10-12 WBC 25.68 x10^3/uL
2023-10-09 WBC 30.61 x10^3/uL

2023-11-01 HGB 7.7 g/dL
2023-10-28 HGB 8.0 g/dL
2023-10-27 HGB 8.1 g/dL
2023-10-25 HGB 8.7 g/dL
2023-10-23 HGB 7.6 g/dL
2023-10-21 HGB 8.1 g/dL
2023-10-19 HGB 7.7 g/dL
2023-10-16 HGB 8.9 g/dL
2023-10-12 HGB 10.3 g/dL
2023-10-09 HGB 9.8 g/dL

2023-11-01 PLT 6 10^3/uL
2023-10-28 PLT 40
10^3/uL
2023-10-27 PLT 56 10^3/uL
2023-10-25 PLT 91
10^3/uL
2023-10-23 PLT 17 10^3/uL
2023-10-21 PLT 32
10^3/uL
2023-10-19 PLT 9 10^3/uL
2023-10-16 PLT 48
10^3/uL
2023-10-12 PLT 148 10^3/uL
2023-10-09 PLT 11
10^3/uL

preparing blood on 2023-11-29, -11-12, -10-28, -10-23, -10-19, -10-11

2023-12-18

[anemia]

Pre-existing anemia was identified in this patient prior to the initiation of the standard 7+3 regimen on 2023-10-13. Following completion of three cycles (one 7+3 and two 5+2), it is anticipated to possibly lead to pancytopenia within three weeks. Therefore, RBC transfusions should be provided as needed to manage the patient’s anemia.

2023-10-25

[WBC nadir 870/uL on 2023-10-23, no blast found after 2023-10-16]

In AML patients undergoing the 7+3 induction chemotherapy regimen, a nadir leukocyte level, specifically below 200/uL, was linked to a higher probability of achieving complete remission (CR). This indicates that patients who experience a more significant decrease in their leukocyte levels during chemotherapy tend to have a more favorable prognosis in terms of reaching CR. Ref: Association of leukocyte nadir with complete remission in Indonesian acute myeloid leukemia patients undergoing 7+3 remission induction chemotherapy. F1000Res. 2022 May 5;11:495. doi: 10.12688/f1000research.110320.2. PMID: 35721596; PMCID: PMC9194516.

The patient started the standard 7+3 regimen on 2023-10-13 and recent lab data suggest that the nadir was reached on 2023-10-23 with a WBC of 960/uL. Based on the aforementioned study, this correlates with a reduced chance of achieving CR.

  • 2023-10-25 WBC 0.96 x10^3/uL
  • 2023-10-23 WBC 0.87 x10^3/uL *
  • 2023-10-21 WBC 1.07 x10^3/uL
  • 2023-10-19 WBC 1.82 x10^3/uL
  • 2023-10-16 WBC 3.49 x10^3/uL
  • 2023-10-12 WBC 25.68 x10^3/uL
  • 2023-10-09 WBC 30.61 x10^3/uL

However, looking at the percentage of blasts in the WBC differential count, no blasts were detected after 2023-10-16. This indicates at least a short-term effect of the treatment.

  • 2023-10-16 Blast 2.9 %
  • 2023-10-12 Blast 40.9 %
  • 2023-10-09 Blast 41.0 %

2023-10-20

[pancytopenia]

The onset of pancytopenia is an expected consequence following the initiation of the standard 7+3 chemotherapy regimen on 2023-10-13. In response to this, the patient received a transfusion of 2 units of leukocyte-poor red blood cells (LPRBC) and 2 units of leukocyte-reduced platelets (LRP) on 2023-10-19, a standard procedure in such cases. This intervention proceeded without any complications.

  • 2023-10-19 WBC 1.82 x10^3/uL

  • 2023-10-16 WBC 3.49 x10^3/uL

  • 2023-10-12 WBC 25.68 x10^3/uL

  • 2023-10-19 HGB 7.7 g/dL

  • 2023-10-16 HGB 8.9 g/dL

  • 2023-10-12 HGB 10.3 g/dL

  • 2023-10-19 PLT 9 *10^3/uL

  • 2023-10-16 PLT 48 *10^3/uL

  • 2023-10-12 PLT 148 *10^3/uL

2023-10-18

[von Willebrand factor (VWF)]

The von Willebrand factor (VWF) test results showed normal on 2023-10-16, it means that the amount of VWF in the blood is within the normal range. However, this does not necessarily mean that the person does not have von Willebrand disease (VWD).

There are several types of VWD, and some people with VWD may have normal VWF levels. For example, people with type 2N VWD have normal levels of VWF antigen and VWF activity, but the VWF molecules are not functioning properly.

Other possible reasons for normal VWF levels in a person with VWD include:

  • The person has a mild form of VWD. (unknown)
  • The person is taking a medication that is increasing VWF levels. (less likely, this patient is not taking desmopressin, tranexamic acid or aminocaproic acid)
  • The person has recently had a blood transfusion. (probably, blood transfusion done at MER on 2023-10-11)
  • The person is pregnant or breastfeeding. (not applicable)

If a person with normal VWF levels has a history of bleeding or a family history of VWD, they may still need further testing to rule out VWD. This may include tests such as the ristocetin cofactor (RCo) assay and the VWF multimer analysis.

2023-10-16

[leukopenia]

There is no identified history of AML and/or MDS from PharmaCloud or HIS5 records, suggesting this is a newly diagnosed de novo AML in this patient.

The patient was started on the standard 7+3 cytarabine/idarubicin chemotherapy regimen on 2023-10-13. The patient’s white blood cell count (WBC) was high on 2023-10-09, but quickly decreased to 3.49K/uL on 2023-10-16. While a WBC of 3.49K/uL is considered mild leukocytopenia, a decrease in all three types of blood cells (pancytopenia) is expected within the first three weeks after starting the 7+3 regimen.

  • 2023-10-16 WBC 3.49 x10^3/uL
  • 2023-10-12 WBC 25.68 x10^3/uL
  • 2023-10-09 WBC 30.61 x10^3/uL

[hypertension]

Per the records, the patient visited the family medicine department on 2023-10-09 and has a history of hypertension, managed with atenolol, losartan, and red yeast rice. Although no antihypertensive medications are currently listed as active, the latest blood pressure reading of 130/63 mmHg (taken on 10/16 at 08:39) does not indicate significant hypertension. Therefore, there’s no immediate necessity to reintroduce antihypertensive agents. However, it’s advisable to continue monitoring blood pressure to determine if there’s a need to resume these medications.

[risk stratification]

If AML is strongly suspected, genetic analysis is recommended for risk stratification and to determine the presence of actionable mutations (such as FLT3), which may warrant the consideration of additional treatments like midostaurin or potentially quizartinib.

[antiviral prophylaxis]

  • Lab
    • 2023-10-12 Anti-HBc Reactive
    • 2023-10-12 Anti-HBc-Value 4.57 S/CO

The American Society of Clinical Oncology and the Infectious Disease Society of America recommend that severely neutropenic patients undergoing intensive chemotherapy receive prophylactic antibacterial and antifungal therapy and that patients who are seropositive for hepatitis B core antibody or herpes simplex virus with leukemia receive antiviral prophylaxis. Ref: Antimicrobial Prophylaxis for Adult Patients With Cancer-Related Immunosuppression: ASCO and IDSA Clinical Practice Guideline Update. J Clin Oncol. 2018 Oct 20;36(30):3043-3054. doi: 10.1200/JCO.18.00374. Epub 2018 Sep 4. PMID: 30179565.

Vemlidy (tenofovir alafenamide) is currently used to reduce the risk of reactivation of HBV infection. However, laboratory results for herpes simplex virus are not yet available.

[prophylaxis of bacterial infection in neutropenia]

Severe and prolonged cytopenias are a common occurrence with intensive remission induction therapy, as the patient is likely to develop pancytopenia within three weeks of receiving the standard 7+3 regimen. Transfusions of red blood cells and platelets should be given as needed. However, the routine use of granulocyte colony-stimulating factor (G-CSF; filgrastim) and other myeloid growth factors is not usually recommended.

High-risk patients of chemotherapy-induced neutropenia are those who are expected to be neutropenic (ANC < 500 cells/uL) for > 7 days.

Guidelines from the American Society of Clinical Oncology (ASCO) and Infectious Diseases Society of America (IDSA) recommend consideration of fluoroquinolone prophylaxis in patients at high risk for profound prolonged neutropenia (anticipated ANC <= 100 cells/uL for > 7 days)

Consensus-based National Comprehensive Cancer Network (NCCN) guidelines suggest strong consideration of fluoroquinolone prophylaxis for high-risk patients: those undergoing allogeneic HCT, neutropenic patients receiving induction chemotherapy for acute leukemia, and any patient in whom the duration of anticipated neutropenia is > 10 days.

Ciprofloxacin and levofloxacin have been studied most extensively. Ciprofloxacin has greater in vitro activity than levofloxacin against P. aeruginosa, but levofloxacin has greater in vitro activity against gram-positive bacteria (eg, alpha-hemolytic streptococci) and is given only once daily compared with twice daily for ciprofloxacin.

[prophylaxis of invasive fungal infection in neutropenia]

Continuing from the previous pharmacist’s note:

  • Prophylaxis against Candida infections:
    • For patients with acute leukemia undergoing initial-induction or salvage-induction chemotherapy who are expected to develop severe oral and/or gastrointestinal mucositis, fluconazole (400 mg orally once daily) is recommended.
    • Alternative agents include itraconazole, voriconazole, posaconazole, micafungin, caspofungin, and anidulafungin.
  • Prophylaxis against invasive mold infections and Candida spp:
    • For selected patients who are expected to experience prolonged severe neutropenia (ANC < 500 cells/uL for > 7 days) due to intensive chemotherapy for AML or advanced MDS, it is suggested that prophylaxis with posaconazole or voriconazole rather than targeted anti-Candida prophylaxis with fluconazole.
    • An alternative for patients who cannot receive voriconazole or posaconazole is isavuconazole.
  • Dosing of posaconazole and voriconazole:
    • Posaconazole delayed-release tablets:
      • Loading dose: 300 mg (three 100 mg tablets) every 12 hours on the first day
      • Maintenance dose: 300 mg (three 100 mg tablets) daily starting on the second day
    • Posaconazole oral suspension: 200 mg three times daily
    • Voriconazole: 200 mg orally twice daily

[chemotherapy dose to remain the same for patient with normal lab results]

For patients receive standard 7+3 regimen, it is recommended to assess for comorbidities that may affect the ability to tolerate intensive therapy.

  • Heart disease
    • Special attention to cardiac function is required because of the large volumes of intravenous (IV) fluids administered during remission induction therapy and the routine use of anthracyclines.
  • Liver disease
    • Liver disease may affect the dose and schedule of anthracycline administration.
  • Kidney disease
    • Renal insufficiency might affect the schedule and dose of cytarabine and influence management of tumor lysis syndrome.

The patient’s liver and kidney function tests on 2023-10-16 were normal. His 2D transthoracic echocardiography on the same day showed an M-mode Teichholz measurement of 66, adequate left ventricular systolic function, and normal resting wall motion. There is no evidence of tumor lysis syndrome (no serum phosphate was tested). Therefore, there is no need to adjust the patient’s current standard 7+3 chemotherapy dose.

  • 2023-10-16 AST 14 U/L

  • 2023-10-16 ALT 21 U/L

  • 2023-10-16 BUN 18 mg/dL

  • 2023-10-16 Creatinine 0.70 mg/dL

  • 2023-10-16 eGFR 117.82 ml/min/1.73m^2

  • 2023-10-16 Bilirubin total 0.60 mg/dL

  • 2023-10-16 Bilirubin direct 0.08 mg/dL

  • 2023-10-16 DBI/TBI 13.33 %

  • 2023-10-16 K(Potassium) 3.6 mmol/L

  • 2023-10-16 Uric Acid 6.3 mg/dL

  • 2023-10-16 Ca (Calcium) 2.08 mmol/L

[nadir response assessment]

A bone marrow biopsy is done at the lowest point of the patient’s blood counts (hematologic nadir), which is usually between days 14 and 22 of treatment. However, for patients who are not receiving midostaurin (a drug used to treat AML), the nadir assessment does not have to be done on day 22.

Further treatment decisions are based on the results of the bone marrow biopsy:

  • Hypoplasia: If the biopsy shows that the bone marrow is hypoplastic (meaning that there are fewer than 20% blood cells) and that the blasts (cancer cells) have been cleared (meaning that there are fewer than 5% blasts remaining), the patient’s blood counts will be monitored and they will receive supportive care until their blood counts recover.
  • Persistent blasts: If the biopsy shows that the bone marrow is not hypoplastic and/or that there are 5% or more blasts remaining, the patient should start a second cycle of induction therapy without delay, if they are able to tolerate it.

If the results of the bone marrow biopsy are unclear, another bone marrow biopsy should be done 5 to 7 days later.

700726873

231215

[MedRec]

  • 2023-11-14, -07-18 SOAP Metabolism and Endocrinology Zhang JiaHui
    • Diagnosis
      • Inflammatory spondylopathies in disease classified elsewhere [M49.80]
      • Chondromalacia of patella [M22.40]
      • Contusion of knee [S80.00XA]
      • Unspecified monoarthritis, lower leg [M13.161]
      • Contracture of joint, other specified sites [M24.50]
      • Chondromalacia of patella [M22.40]
      • Unspecified internal derangement of knee [M23.90]
      • Degeneration of lumbar or lumbosacral intervertebral disc [M51.36]
      • Unspecified monoarthritis, lower leg [M13.161]
      • Contracture of joint,other specified sites [M24.50]
      • Psychoneurosis with fibromyalgia [F48.9]
      • Herpes zoster [B02.9]
    • Prescription x3
      • cortisone acetate 25mg 2# QD
      • cortisone acetate 25mg 0.5# QN
      • Tulip (atovastatin 20mg) 0.5# QD

700199573

231214

[exam findings]

  • 2023-09-13 CT - abdomen
    • Findings:
      • There is long segmental dilatation of the small intestine and the transition zone in the right upper pelvis mesentery.
        • Adhesion band induce mechanical small bowel obstruction is suspected.
      • Prior CT identified several enlarged nodes in aortocaval space are noted again, stationary.
        • Non-regional metastatic lymph nodes (M1b) are highly suspected.
        • Please correlate with PET scan.
      • S/P hysterectomy
      • There is ascites.
      • S/P nasogastric tube insertion
    • Impression:
      • Adhesion band induce mechanical small bowel obstruction is suspected.
      • Non-regional metastatic lymph nodes (M1b) in aortocaval space are highly suspected. Please correlate with PET scan.
  • 2023-08-29 Patho - soft tissue tumor, extensive resection
    • PATHOLOGIC DIAGNOSIS
      • Ovarian mass, left, frozen + debulking surgery — High-grade serous carcinoma
        • Fallopian tube, left, ditto — Tumor invasion microscopically
      • Endometrium, uterus, debulking surgery — Free of tumor invasion
      • Myometrium, uterus, ditto — Free of tumor invasion
      • Cervix, uterus, ditto — Free of tumor invasion
      • Ovary, right, ditto — Tumor invasion microscopically
        • Fallopian tube, right, ditto — Tumor invasion
      • Omentum ttissue, omentectomy — Tumor invasion microscopically
      • Peritoneal tumors, excision — Tumor invasion
      • Lymph node, L’t iliac, dissection — Free of tumor metastasis (0/6)
      • Lymph node, L’t obturator, ditto — Free of tumor metastasis (0/5)
      • Lymph node, R’t iliac, ditto — Free of tumor metastasis (0/8)
      • Lymph node, R’t obturator, ditto — Free of tumor metastasis (0/13)
      • Lymph node, L’t paraaortic, ditto — Tumor metastasis (3/3) with extracapsular extension (1/3)
      • Lymph node, R’t paraaortic, ditto — Tumor metastasis (4/5) with extracapsular extension (2/4)
      • AJCC Pathologic staging: pT3cN1b, if cM0; stage IIIC
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: frozen + debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND + bilateral paraaortic LN dissection + peritoneal tumor excision)
      • Specimen type: uterus, peritoneal tumors, omentum and lymph nodes
      • Specimen size:
        • L’t ovary (frozen): opened, solid and cystic mass measured 19.7 x 19.3 x 5.2 cm with necrosis and serous fluid
        • L’t fallopian tube (frozen): normal appearance, 5 cm in length, up to 0.5 cm in diameter
        • R’t ovary (frozen): normal appearance, 2 x 1.7 x 0.7 cm
        • R’t fallopian tube (frozen): solid mass at fimbrial area measured 6.5 x 6.2 x 3.5 cm
        • Uterus: 7.8 x 3.9 x 3.3 cm and 66 gm, no tumor seeding
        • Omentum: 28 x 12 x 0.5 cm, normal appearance
        • Peritoneal tumors: five tumors, up to 3.6 x 2.8 x 1.3 cm
      • Tumor site: left ovary
      • Tumor size: 19.7 x 19.3 x 5.2 cm
      • Tumor appearance: solid and cystic mass
      • Specimen integrity: intact
      • Lymph nodes: pelvic lymph nodes + bilateral paraaortic LNs
      • Representative sections as A1: bilateral parametria, A2-A3: cervix, A4: endometrium+ myometrium, B1-B2: peritoneal tumors, C: omentum, D: L’t iliac LNs, E: L’t obturator LNs, F: R’t iliac LNs, G: R’t obturator LNs, H: L’t paraaortic LNs and I: R’t paraaortic LNs [Reference: frozen section: F2023-00383 FSA1-A2: L’t ovarian tumor, A1: fallopian tube and A2-A8: ovarian mass, FSB: R’t tubal mass, B1-B2: R’t tubal tumor, B3: ovary and B4-B5: R’t fallopian tube]
    • MICROSCOPIC EXAMINATION
      • Histologic type: serous carcinoma
      • Histologic grade: high grade
      • Tumor side ovarian surface involvement: present
      • Contralateral ovary involvement: tumor invasion microscopically
      • Right tube involvement: present
      • Left tube involvement: tumor invasion microscopically
      • In situ adenocarcinoma in right &/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: present
      • Left adnexa soft tissue involvement: present
      • Pelvic soft tissue involvement: present
      • Bilateral parametria: tumor invasion
      • Uterine serosa involvement: absent
      • Omentum involvement: tumor invasion microscopically
      • Uterine Cervix involvement: absent
      • Endometrium involvement: absent
      • Myometrium involvement: absent
      • Lymph nodes metastasis: tumor metastasis (7/40) with extracapsular extension (3/7) in total number
      • Immunohistochemistry: WT-1(+), PAX-8(+), P53(aberrant expression), ER(+, scatter) and vimentin(-)
      • Ascites cytology: positive
      • Perineural invasion: present
      • Lymphovascular space invasion: present
  • 2023-08-29 Body fluid cytology - ascites
    • DIAGNOSIS: Adenocarcinoma
    • MACROSCOPIC DESCRIPTION: 40cc, orange, turbid
    • MICROSCOPIC DESCRIPTION: Smears show dense clusters of atypical tumor cells with nuclear hyperchromasia and irregular contour.
  • 2023-08-29 Frozen Section
    • L’t ovary tumor, FSA1-FSA2 — Adenocarcinoma
    • R’t ovary tumor, FSB — Adenocarcinoma
  • 2023-07-11 CT - abdomen
    • With and without contrast enhancement CT of abdomen - whole:
      • There are large cystic tumors (up to 18cm)in bilateral adnexa, r/o bilateral ovarian malignancy.
      • There are peritoneal tumors, r/o peritoneal carcinomatosis.
      • Diffuse enlarged lymph nodes in aortocaval region.
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T3c(T_value) N:N1b(N_value) M:M0(M_value) STAGE:IIIA__(Stage_value)
    • Impression:
      • Bilateral ovarian tumors with peritoneal tumors, aortocaval lymph nodes, r/o ovarian malignancy with carcinomatosis and lymph nodes metastasis.
      • If proven ovarian malignancy, cstage T3cN1M0.
  • 2023-07-10 Gynecologic ultrasonography
    • Imp: R/O Bilateral Ovarian mass

[MedRec]

  • 2023-08-27 ~ 2023-09-25 POMR Obstetrics and Gynecology Chen GuoHu
    • Discharge diagnosis
      • Left ovarian cancer (High-grade serous carcinoma) AJCC Pathologic staging: pT3cN1bcM0; stage IIIC status post debulking surgery on 2023/08/29
      • Female pelvic peritoneal adhesions (postinfective)
      • Acute posthemorrhagic anemia
      • Ileus, unspecified
      • Left ovarian mass, frozen + debulking surgery —> High-grade serous carcinom, AJCC Pathologic staging: pT3cN1bcM0; stage IIIC
    • CC
      • Abdominal mass noted for 1 month.
    • Present illness
      • This is a 49 years old unmarried female, G1P0AA1, without ANY underlying disease. She had found a palpable mass at her abdomen since 2023/07. Accompanied with mild decreased appetite. She denied marked abdominal fullness, dysuria, bowel behavior change or abnormal vaginal bleeding. Her menstrual cycle was as follows: duration/interval 2days/28days.
      • Due to the palpable mass, she went to LMD for help and the echogram revealed suspected adnexa mass. Therefore, she was transferred to our hospital for further evaluation.
      • The GYN echogram on 2023/07/10 revealed uterus 6027mm with EM 5.8mm and a fundal myoma 4X4cm, right adnexa mass 5130mm, left adnexa mass 154*101mm, bilateral hydronephrosis and asites.
      • The abdominal CT checked on 2023/07/11 revealed large cystic tumors (up to 18X16cm) in bilateral adnexa, peritoneal tumors and diffuse enlarged lymph nodes in aortocaval region, suspected bilateral ovarian malignancy, cstage T3cN1M0.
      • The tumor marker examination revealed CA125 level was 633.1U/mL, CA199 level was 3.67U/mL, and CEA level was 1.35ng/mL. Under the impression of huge pelvic cystic tumor with solid parts, suspected bilateral ovarian malignancy with carcinomatosis, she was admitted for further cancer survey, work-up (GI panendoscopy) and further treatment.
    • Course of inpatient treatment
      • The female was admitted on 2023/08/27 because of ovarian cancer, stage IIIc, and she underwent debulking and enterolysis on 2023/08/29. After flatus, her eating, defecation and self voiding were okay. However, nausea and vomit occurred since 2023/09/07 after eating for almost one week.
      • KUB revealed ileus, and she started to NPO with IV fluid. Her ileus improved on 9/15, 9/17, 9/19 and 9/25 plain abdomen; bowel sound was also improved day by day. We kept observation, and started to let her undergo water and juice intake since 2023/09/16 am. She could tolerated well when trying porridge and fulldiet. Her urination and ambulation were also okay.
      • An episode of fever was noted on 9/19, which subsided later, and the blood culture yieleded GPC. We gave augmentin to her, and there were no more fever with normal CRP. Since all of her condition were improved, she may be discharged on 2023/09/25 with OPD follow up.
    • Discharge prescription
      • naproxen 250mg 1# TID
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • MgO 250mg 2# QID

[surgical operation]

  • 2023-08-29
    • Surgery: debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND + para-aortic LN dissection + pelvic tumor excision) + enterolysis
    • Finding
      • left ovary and tube (unruptured during surgery, removed intact and then cut open outside the body)
        • LOV – 17x15cm tumor with mixed solid mass and multicystic parts with some brown fluid (>1000 c.c) inside, suspected LOV cancer
        • Frozen report – high grade (serous?) adenocarcinoma
        • left tube – np
      • right ovary and tube (unruptured during surgery, removed intact and then cut open outside the body)
        • ROV – 2x2cm, grossly no tumor invasion
        • right tube – enlarged 6x6cm tumor with solid mass, suspected cancer invasion,
        • Frozen report – high grade (serous?) adenocarcinoma
      • uterus: seemed free of cancer invasion
      • peritoneal tumors 3~4#, 1~2cm over low pelvis (CDS site between cervix and rectum), cancer invasion likely
      • omentum – seemed free of cancer invasion
      • left iliac LNs
      • left obturator LNs
      • right iliac LNs
      • right obturator LNs
      • left para-aortic LNs – enlarged mass 1~2cm, cancer metastasis?
      • right para-aortic LNs – enlarged mass 2~3cm, cancer metastasis?
      • liver, bwoels and other peritoneum – seemed free of cancer invasion
      • After the operation, optimal debulking surgery was achieved.
      • Residue tumor: 3~4 small tumors < 1cm , over low pelvis (CDS site between cervix and rectum)
      • A 7mm JP drain was placed in CDS

[chemotherapy]

  • 2023-12-14 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 425mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-11-16 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 580mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-10-21 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2023-12-14

According to the eGFR laboratory data since Nov, the patient’s renal function has decreased in the past two weeks. The dose of carboplatin has been adjusted accordingly (2023-12-14 425mg <- 2023-11-16 580mg), while the dose of paclitaxel does not require adjustment due to the change in renal function.

  • 2023-12-13 eGFR 72.29 ml/min/1.73m^2
  • 2023-11-29 eGFR 124.35 ml/min/1.73m^2
  • 2023-11-15 eGFR 119.82 ml/min/1.73m^2
  • 2023-11-01 eGFR 122.29 ml/min/1.73m^2

Furthermore, no adjustments are needed for the drugs listed on the active medication list other than those used in chemotherapy, based on the renal function test results from 2023-12-13.

700734229

231214

[lab data]

2023-12-13 Influenza A Ag Negative
2023-12-13 Influenza B Ag Negative

2023-12-04 Rubella IgM Negative Index
2023-12-04 Rubella IgM Value 0.05
2023-12-04 Measles virus IgM Ab Negative Ratio
2023-12-04 MeaslesIgM Value 0.1 Ratio
2023-12-04 Mumps Virus IgG Positive AU/mL
2023-12-04 Mumps Virus IgGValue >300.0 AU/mL
2023-12-04 Mumps Virus IgM Negative Index
2023-12-04 Mumps IgM Value <0.5 Index

2023-11-27 Anti-HBs 13.70 mIU/mL

2023-11-27 Anti-HCV Nonreactive
2023-11-27 Anti-HCV Value 0.12 S/CO

2023-11-27 HBsAg Nonreactive
2023-11-27 HBsAg (Value) 0.37 S/CO

2023-11-27 Anti-HAV IgM Nonreactive
2023-11-27 Anti-HAV IgM Value 0.20 S/CO
2023-11-27 Anti-HAV IgG Reactive
2023-11-27 Anti-HAV IgG Value 9.77 S/CO

[MedRec]

  • 2023-11-22 ~ 2023-12-04 POMR Qiu ShengKang
    • Discharge diagnosis
      • Sepsis, suspect EBV infection
      • Fever, suspect EBV infection
      • Mixed hyperlipidemia
      • single vessel coronary artery disease status post percutaneous coronary intervention with drug eluting stenting toleft anterior descending artery on 2022/11/23
      • Chronic ischemia heart diseasae
      • Hypertensive heart disease
      • Unspecified abdominal pain
    • CC
      • fever and chills for 4 days.
    • Present illness
      • This is a 65-year-old male ex-smoker (2ppd 20+ years and quit 20+ years) with the past history of Hypertension, mixed Hyperlipidemia for years, Chronic ischemic heart disease by CT scan at 2020/06 showed mod calcification (score 192) with 20-50% stenosis of LAD and LCX and erosive esophagitis LA Classification grade A, Superficial gastritis, gastric ulcers, multiple, antrum, duodenal ulcers by PES on 2021/10/21 under regular medication control at our OPD.
      • He sufferes from fever and chills for 4 days. He came to our ER for help on 11/21. He came back from Thaiand on 11/19. At ER, vital sign showed BP:143/83; PR:113; BT:39.5’C; RR:18; Con’s:E4V5M6, SPO2:93%. Lab data showed WBC:8420, CRP:4, Cr:1.19. Influenza A and B Ag showed negative. Urine analysis showed negative. CxR showed no infiltration. Abdomen CT with and without showed fatty liver, grade 5 and gallstones.
      • Empirical antibiotic with Cefoxitin was givne for infection control.
      • Under the impression of fever cause unknown, he is admitted to our ward for treatment on 2023-11-22.
    • Course of inpatient treatment
      • After admission, empirical antibiotic with Cefoxitin was shifted to Mepem and Doxymycin were given for fever flarep since 11/24. Urine culture showed Group B streptococci. Pending culture. we consulted Meta Qiu QuanTai for TG>2000 on 11/23. We checked Myocardial perfusion SPECT with persantin and no obvious finding. We kept follow up lab data. Cardiac and abdominal echo were done and no obvious abnormality. For the diffused rash over skin, we consulted dermatology and they suggested Sinpharderm and Mycomb used. Spike fever and chills persisted during admission. Series of studies for fever of unknown origin were taken.
      • Fever subsided after above. Lab data finally showed Epstein-Barr virus infection. His WBC and CRP decreased. We shifted tagocid + mepem to cefoxitin. He complaint of palpable mass in his anus and above his anus so we consulted CRS. The mass was ligated.
      • His vital sign was stable today so he was discharged and referred for OPD foolow up.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNTID
  • 2022-11-22 ~ 2022-11-25 POMR Cardiology Ke YuLin
    • Discharge diagnosis
      • Angina pectoris
      • single vessel coronary artery disease status post percutaneous coronary intervention with drug eluting stenting toleft anterior descending artery on 2022/11/23
      • Hypertensive heart disease
      • Mixed hyperlipidemia
      • Erosive esophagitis, Los Angeles Classification grade A, Superficial gastritis, gastric ulcers, multiple, antrum, duodenal ulcers by Panendoscopy on 2021/10/21
    • CC
      • episode of short of breath with moving a Sofa from 1st floor to 4th floors about three months ago and still exertional dyspnea with chest discomfort while walking up to 2nd floor and exacerbated in recent two weeks
    • Present illness
      • This is a 64-year-old male ex-smoker (2ppd 20+ years and quit 20+ years) with the past history of Hypertension, mixed Hyperlipidemia for years, Chronic ischemic heart disease by CT scan at 2020/06 showed mod calcification (score 192) with 20-50% stenosis of LAD and LCX and erosive esophagitis LA Classification grade A, Superficial gastritis, gastric ulcers, multiple, antrum, duodenal ulcers by PES on 2021/10/21 under regular medication control at our OPD.
      • This time, he was admitted via our OPD because of episode of short of breath with moving a Sofa from 1st floor to 4th floors about three months ago and still exertional dyspnea with chest discomfort while walking up to 2nd floor and exacerbated in recent two weeks. The symptoms without associated with cold sweating or radiation pain to back, without dizziness, palpitation or acid regurgitation. It may be relieved after rest without try NTG, the duration was several minutes. So he came to our CV OPD for further help.
      • At CV OPD, heart CTA was arrange on 2022/11/11 and revealed Calcification of the coronary arteries (LAD=60, LCX=14, RCA=8, Left main trunk=82, total calcium score=219, uisng AJ-130 method); Left anterior descending coronary artery: 50% stenosis at S6. (Se402 IM78); Left circumflex coronary artery: >75% stenosis at S11. (Se402 IM87) and Right coronary artery: 50% stenosis at S1. (Se402 Im113)
      • Cardiac catheterization was indicated and suggested. After well explanation the risk and the procedures to the patient and family, he was admitted to ward for further evaluation and management.
    • Course of inpatient treatment
      • During admission, cardiac catheterization was arranged on 11/23 after well explained the risks and the procedures to the patient and family. N/S hydration was given to reduce the incidence of contrast induced renal injury.
      • Coronary angiography was done via right radial artery smoothly which revealed single vessel coronary artery disease status post percutaneous coronary intervention with drug eluting stenting to left anterior descending artery.
      • The patient denied any chest discomfortable but chronic exertional dyspnea persistent after PCI.
      • After intervention, we go on aspirin 1# qd and added plavix 1# qd use. The right wrist cath wound healed well. Neither ecchymosis nor hematoma developed. Follow up cardiac markers and EKG after PCI were unremarkable. His urine output remained adequate after PCI and follow up renal function is improving.
      • We also arrange echocardiography on 2022-11-24 for dyspnea evaluation andrevealed
        • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
        • Normal LV and RV systolic function(78%)
        • Mild aortic valve sclerosis with trivial AR; mild MR.
        • Mildly dilated proximal ascending aorta (35 mm), mild aortic root calcification.
      • Under stable hemodynamics, he was discharged on 11/25 and OPD followed up was arranged.
    • Discharge prescription
      • Bokey (aspirin 100mg) 1# QD
      • Concor (bisoprolol 5mg) 1# QD
      • Linicor (niacin 500mg, lovastatin 20mg) 1# HS
      • Lipanthyl Supra (fenofibrate 160mg) 1# QD
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Norvasc (amlodipine 5mg) 1# QD
      • Olmetec (olmesartan medoxomil 20mg) 1# QD
      • Plavix (clopidogrel 75mg) 1# QD
  • 2017-01-04 Gastroenterology Xu RongYuan
    • Diagnosis
      • Mixed hyperlipidemia [E78.2]
      • Chronic hepatits, unspecified [K73.9]
    • Prescription x3
      • Olbetam (acipimox 250mg) 1# BID
      • Lipanthyl Supra (fenofibrate 160mg) 1# QD

700783400

231214

[exam findings]

  • 2023-11-24 CTA - chest
    • Without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Chest
        • Moderate Rt pleural effusion with dependent volume loss of RLL and patchy opacities at LLL as well as a nodular lesion lingula of the lungs.
        • Mediastinum and hila: no enlarged LN or mass.
        • Thoracic aorta: normal caliber, minimal atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber and well opacification.
        • Heart: normal size of cardiac chambers. conventric LVH?
        • Pleura: unremarkable, no effusion or thickening or nodule.
        • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal-pelvic contents:
        • a large soft-tissue tumor in the lower part of Rt kidney (at 92mm in longest dimension) and a huge soft-tissue tumor at Rt posterior perirenal/pararenal space (15cm in longest dimension).
        • with several LAP at para-aortic region.
        • several small renal cysts and atrophic pancreatc tail.
        • unremarkable of the liver, GB, spleen, Lt adrenal gland,
        • bile ducts: No dilatation.
        • Mild atherosclerotic change of the abdominal aorta and bilateral common iliac arteries.
        • marginal spurs of multiple vertebrae due to spondylosis.
        • compression fracture of L2 vertebral body
    • Impression:
      • large Rt renal cancer and largest malignant tumor in Rt posterior perirenal/pararenal space with several metastatic LAP at para-aortic region.
      • Lt lung metastasis or infection?

[MedRec]

  • 2023-12-13 ~ 2023-12-14 POMR Family Medicine Ye JiaZe

    • Discharge diagnosis
      • B-cell lymphoma without treatment, diagnosed at Taipei Veterans General Hospital in 2017.
      • Hyperkalemia
      • Right pleural effusion
      • Chronic kidney disease, stage 3 (moderate)
    • CC
      • decline of consciousness level and dyspnea on 2023/12/13 morning.
      • vomiting once after NG tube feeding
    • Present illness
      • The 83-year-old man had past history of
        • Hypertension
        • Type II diabetes mellitus
        • Arrythmia
        • Urolithiasis status post DJ insertion
        • Low grade B-cell lymphoma on 2017/11
      • According to his son, the patient had B-cell lymphoma without treatment in 2017, diagnosed at TPEVGH. He was admitted to our Oncology ward on 2023/11/24 for disturbance. Laboratory data revealed hypercalcemia. Chest CTA (2023/11/24) showed large Rt renal cancer and largest malignant tumor in Rt posterior perirenal/pararenal space, with several metastatic LAP at para-aortic region. Lt lung metastasis or infection? Renal biopsy was suggested to the family, they refused schedule and preferred supportive care.
      • This time, he had decline of consciousness level and dyspnea on this morning. Vomiting once after NG tube feeding was also note. There was no cough, abdominal pain, nor tarry stool. Desaturation with SpO2: 75% by EMT. He was sent to our ER for help. At ER, his GCS was E2V1M1. TPR: 37.9, 130, 26. BP: 102/54mmHg. PE showed bilateral breathing sounds rhonchi. Abdomen flat and soft. Laboratory data showed anemia, HGB 8.3g/dL, elevation for Lactic Acid 7.3 mmol/L, hs-Troponin I 216.5 pg/ml, CRP=11.8 mg/dL. U/A showed pyuria. CXR disclosed Right pleural effusion and ground glass opacity in right lung and LLL. Pending B/C and S/C. Due to poor prognosis, the family asked for palliative care. FM was consulted for hospice care. The patient was admitted to our hospice ward on 2023/12/13.
    • Course of inpatient treatment
      • After admission, vital signs were unstable. Morphine was given as 3mg SC Q6H, other sedatives were given PRN as neccessary according to his symptoms. His condition had downhilled fast which low blood pressure was noticed during the night. He had expired on 2023.12.14 04:54. We had informed the family and mental support was done to the family.
  • 2023-11-24 ~ 2023-12-08 POMR Hemato-Oncology Gao WeiYao

  • 2023-11-24 VS Note on Admission Day

    • Summary
      • The 83 y/o man has HTN, DM, ARRYTHMIA, UROLITHIASISS/P DJ INSERTION.
      • He was admitted through ER with the chief complaint of concious disturbance for 6 days. A series of studies at ER supported that a large Rt renal cancer and largest malignant tumor in Rt posterior perirenal/pararenal space. with several metastatic LAP at para-aortic region. Lt lung metastasis and HYPERCALCEMIA and hypernatremia were noted.
    • Plan to do:
      • On critical condtition
      • Correct hypercalcemia, hyperuricemia, hypernatremia and blood sugar.
      • Tissue proof of Rt renal tumor (lymphoma or kidney ca ??) with regional and distant metastases.
  • 2021-11-06 ~ 2021-11-19 POMR Urology

    • Discharge diagnosis
      • Left ureteral stone status post left ureterorenoscopic lithotripsy with double J stenting on 2021/11/17
      • Left hydronephrosis status post left percutaneous nephrostomy on 2021/11/10
      • Urinary tract infection with E-coli
      • Infectious gastroenteritis and colitis, unspecified
      • Type 2 diabetes mellitus with hyperglycemia
      • Hypertensive heart disease without heart failure
    • CC
      • Tenesmus and chills for 1 day
    • Present illness
      • This is a 81-year-old male with underlying parkinsonism, type II diabetes mellitus with insulin control for years, BPH, Hypothyroidism under medication control, arrhythmia under Eliquis and hypertension for years. This time, he had tenesmus and chills last night, and symptoms relieved after defecated soft stool twice.
      • He had tenesmus and chills last night, and symptoms relieved after defecated soft stool twice. He came to our ER for help. At ER, PE found pale conjunctiva. Lab data showed WBC 17550, Hb 10.8, CRP 8.83, Cre 1.54, Pyuria (WBC >100, OB 3+, Bact 3+), Stool OB 2+.
      • KUB revealed Compression fracture of L2, Radiopaque spot(s) at left renal region r/o renal stone(s), Stool retention in the bowel.
      • Under the impression of UTI, he came to our ward to do further management and examination.
    • Course of inpatient treatment
      • After admission, the surgery of left percutaneous nephrostomy on 2021/11/10. Antibiotic with Tapimycin (11/11~) due to his fever not improved. After antibiotic treatment, his fever much improved.
      • The surgery of left ureterorenoscopic lithotripsy with double J stenting on 2021/11/17. With clinical improvement and stable condition, she was discharged and would be followed up.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
      • Urief (silodosin 8mg) 1# QN
      • Ceficin (cefixime 100mg) 1# BID

==========

2023-11-27

[enhancing patient care through shared medical records from Far Eastern Memorial Hospital]

Per the PharmaCloud database, the patient was diagnosed with “Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT-lymphoma)” at Far Eastern Memorial Hospital, with his last visit on 2023-08-24. The patient should be requested to provide the examination results and treatment details from that hospital to enable our medica team a more comprehensive consideration of the current situation.

[optimizing calcitonin Use for hypercalcemia management]

The patient, who has hypoalbuminemia, shows a corrected calcium level of 3.1 mmol/L (12.4 mg/dL) and is currently receiving Miacalcic (calcitonin) at 100 IU SC Q6H.

  • 2023-11-27 Ca (Calcium) 2.91 mmol/L

  • 2023-11-26 Ca (Calcium) 3.03 mmol/L

  • 2023-11-24 Ca (Calcium) 3.08 mmol/L

  • 2023-11-27 Albumin (BCG) 3.0 g/dL

  • 2023-11-24 Albumin (BCG) 3.2 g/dL

For severe hypercalcemia, the maintenance dose of calcitonin can be up to 8 units/kg Q6H to Q12H, starting with an initial dose of 4 units/kg Q12H. Since the current administration of 100 IU Q6H is below the recommended dosage, this may extend the duration of therapy. It’s advisable to limit calcitonin therapy to a period of 24 to 48 hours to avoid tachyphylaxis.

Given that the serum calcium level has not exceeded 3.5 mmol/L (14 mg/dL) and is trending downwards, the combined use of calcitonin with bisphosphonates for a long-term effect may not be essential.

[basal insulin initiation for consistent hyperglycemia]

All recorded blood glucose levels in the TPR panel fall between 230 and 380 mg/dL during this hospitalization, frequently exceeding 300 mg/dL, despite the current use of Insulin Actrapid, NovoRapid, and Trajenta. Therefore, it is advisable to introduce basal insulin (a long-acting type) starting with a daily dose of 2 units, with evaluations every other day to determine if further adjustments are necessary.

[replacing D5W with NS in hyperglycemic hydration plan]

Given the patient’s obvious hyperglycemia, it is advisable to switch from D5W to NS for hydration purposes.

[evaluating causes of hypercalcemia: beyond hyperthyroidism]

The lab results showed no elevation in TSH, Free-T4, or T3, suggesting that hyperthyroidism is an unlikely cause of the hypercalcemia. Could osteolytic bone metastases and local cytokines be contributing factors?

  • 2023-11-27 TSH 1.012 uIU/mL
  • 2023-11-27 Free-T4 1.08 ng/dL
  • 2023-11-27 T3 0.31 ng/mL

700175888

231213

[exam findings]

  • 2023-09-26 Tc-99m MDP bone scan with SPECT
    • Increased activity in the lower T-spines. Either severe degenerative change or bone metastases may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Mildly increased activity in the L5 and L5-sacrum junction. Degenerative change may show this picture.
    • Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, knees and feet, compatible with benign joint lesions.
  • 2023-09-14 CT - abdomen
    • History and indication: Adenocarcinoma of middle rectum with impending obstruction and liver metastases and possible LLL metastases, cT4aN2bM1a, stage IVA
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P operation. Mild regression of rectal cancer and liver metastases.
      • Splenomegaly.
      • Regression of LLL nodule.
      • Some LNs at pelvic cavity.
      • Bony erosion of T12.
      • Atherosclerosis of aorta.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P operation. Mild regression of rectal cancer and liver metastases.
  • 2023-06-26 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A
      • Suspect Barrett’s esophagus, s/p biopsy
      • Superficial gastritis, s/p CLO test
      • Pseudodiverticulum, bulb
      • Deformed pylorus and bulb
    • CLO test: Positive
  • 2023-06-19 CT - abdomen
    • History and indication: Adenocarcinoma of middle rectum with impending obstruction and liver metastases and possible LLL metastases, cT4aN2bM1a, stage IVA
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P operation. Much regression of rectal cancer but progression of liver metastases.
      • A nodule (5mm) at LLL.
      • Splenomegaly.
      • Some LNs at pelvic cavity.
      • Atherosclerosis of aorta.
    • IMP:
      • S/P operation. Much regression of rectal cancer but progression of liver metastases. A nodule (5mm) at LLL.
  • 2023-06-19 Sigmoidoscopy
    • Rectal cancer s/p CCRT with partial regression (middle rectum, 8-9cm AAV)
  • 2023-06-17 CXR
    • Tortuosity of the aorta with atherosclerotic change.
    • Increased lung markings over both lungs.
  • 2023-06-01 Esophagogastroduodenoscopy, EGD
    • Superfical gastritis, antrum
    • Duodenal ulcer scar, bulb, AW, LC
  • 2023-03-22 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2023-03-03 PET
    • Glucose hypermetabolism involving the rectosigmoid colon, compatible with primary colon malignancy.
    • Glucose hypermetabolism in a regional lymph node. A metastatic lymph node may show this picture.
    • Mild glucose hypermetabolism in some small regional lymph nodes. The nature is to be determined (metastatic lymph nodes of low FDG uptake? inflammation?). Please correlate with other clinical findings for further evaluation.
    • Multiple glucose hypermetabolic lesions in the right and left lobes of the liver, suggesting multiple liver metastases.
    • No prominent FDG uptake was noted in the small nodule in the upper lobe of left lung delineated in the CT scan. Please follow up chest CT scan for further evaluation.
    • Increased FDG uptake/accumulation in a small focal area in the soft tissue in the left upper arm. The nature is to be determined (physiological FDG uptake/accumulation in the vein of the left upper arm? other nature?).
  • 2023-03-01 All-RAS + BRAF gene mutation
    • ALL-RAS:
      • There was no variant detected in the KRAS/NRAS gene
    • BRAF
      • There was no variant detected in the BRAF gene.
  • 2023-02-21 CT - abdomen
    • Clinical history: 61 y/o female patient with Newly diagnosis of middle rectal adenocarcinomafor staging
    • With and without contrast enhancement CT of abdomen - whole:
      • Thickening wall at rectosigmoid colon with pericolonic infiltrates, r/o colon malignancy.
      • There are liver tumors, up to 3cm in left lobe, r/o liver metastasis.
      • There are lymph nodes in pericolonic and bilateral obturator regions.
      • Left upper lung nodular density, nature?
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4aT_value) N:N2bN_value) M:M1a(M_value) STAGE: IVa Stage_value)
    • Impression:
      • Rectosigmoid colon cancer with lymph nodes and liver metastasis. cstage T4aN2bM1a.
      • Left upper lung nodular density, nature?
  • 2023-02-13 Patho - colon biopsy
    • Tumor, middle rectum, biopsy — Adenocarcinoma
    • Microscopically, the sections show a picture of adenocarcinoma characterized by cribriform or glandular tumor cell infiltration with desmoplasia.
    • Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.

[MedRec]

  • 2023-10-17 SOAP Hemato-Oncology Xia HeXiong
    • Prescription
      • Nexium (esomeprazole 40mg) 1# QDAC EGD 2023-06-01
      • Strocain (oxethazine, polymigel; 5mg) 1# TIDAC
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
      • TieShrShuPap (flurbiprofen) QD EXT
      • Revolade (eltrombopag 25mg) 1# QDAC 9D
  • 2023-03-15 SOAP Hemato-Oncology
    • A
      • adenocarcinoma of middle rectum with impending obstruction and liver metastasis and possible LLL metastasis, cT4aN2bM1a, stage IVa (at least)
    • P
      • suggest CCRT followed by C/T + target therapy, then re-evaluation for curative surgery 3-6 months later
      • admission for CCRT with FOLFOX with targeted therapy (already discuss with beva or cetuximab)

[consultation]

  • 2023-06-20 Hemato-Oncology
    • Q
      • For continue chemotherapy ?
      • The 61 years old female patient had hepatitis B carrier, and is a case of adenocarcinoma of middle rectum with impending obstruction and liver metastases and possible LLL metastases, cT4aN2bM1a, stage IVA status post T-loop colostomy on 2023/03/02, radiotherapy to rectal tumor and LAPs from 2023/03/16~ and concurrent chemotherapy with FOLFOX (Oxalip 85mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 5FU 2400mg/m2) from 2023/03/23~
      • This time, she suffered from massive bloody stool noted on yesterday evening (6/17), accompanying with dizziness, abdominal pain, chills, sweating, and back pain. Also, colostomy bag had much blood clot was told. She denied having fever, dysuria, or shortness of breath. While visited our emergency department, her vital signs showed hypotension (98/53mmHg) and tachycardia (107 bpm). Drowsiness consciuosness was found. With the impression of lower GI bleeding, she was admitted for further management.
      • Lab data: Hb: 9.8 (6/17) -> 8.4 -> 10.5 g/dl (6/19).
      • Now the patient no dizziness, no passage bloody stool. So we consult you for evaluation of continue chemotherapy ?
    • A
      • This 61 year old woman is a case of middle rectum with impending obstruction and liver metastases cT4aN2bM1a, stage IVA status post post T-loop colostomy on 2023/03/02, radiotherapy to rectal tumor and LAPs from 2023/03/16~4/28 and concurrent chemotherapy with FOLFOX [FOLFOX on 2023/03/23(C1D1), FOLFOX on 2023/04/11(C1D15), FOLFOX on 2023/04/28(C2D1), FOLFOX on 2023/05/29(C2D15). + Avastin].    
      • She was admiited due to massive bloody stool and accompanying with dizziness, abdominal pain, chills, sweating, and back pain. Also, colostomy bag had much blood clot was told.
      • Sigmoid scopy show rectal cancer s/p CCRT with partial regression (middle rectum, 8-9cm AAV). BUT the scope can not pass through it due to lumen stenosis. Some blood clots retention but no active bleeding. Abdominal CT 2023/6/19 show much regression of rectal cancer but progression of liver metastases. We are consulted for further evaluation.
      • Please arrange panendoscopy and keep PPI and transamin. We will take over this case. Please transfer to 11A and 10B. On Dr Xia.
  • 2023-03-03 Hemato-Oncology
    • Q
      • For further evaluation of CCRT
      • A 61 year-old female patient was admitted for adenocarcinoma of middle rectum with impending obstruction and liver metastasis and possible LLL metastasis, cT4aN2bM1a, stage IVA. After fully explained of the condition, T-loop colosotmy first for tumor impending obstruction then suggest CCRT and C/T+ target therapy. Surgery of T-loop colostomy will arrange on 2023/03/02 on call. We needs your expert experience for evaluation. Thanks a lot !!
    • A
      • This 61 year old woman is a case of middle rectal adenocarcinoma with liver metastasis and possible LLL metastasis, cT4aN2bM1a, stage IVA. She will receive T-loop colostomy on 3/2. We are consulted for CCRT.
      • Systemic chemotherapy +/- target therapy is indicated for metastasis rectal cancer.
      • Please arrange port A insertion. Consider arrange PET scan for complete work up. Check All-RAS/BRAF.
      • Arrange our OPD after discharge. Thanks for your consultation.
  • 2023-03-02 Radiation Oncology
    • Q
      • For further evaluation of CCRT
      • A 61 year-old female patient was admitted for adenocarcinoma of middle rectum with impending obstruction and liver metastasis and possible LLL metastasis, cT4aN2bM1a, stage IVA. After fully explained of the condition, T-loop colosotmy first for tumor impending obstruction then suggest CCRT and C/T+ target therapy. Surgery of T-loop colostomy will arrange on 2023/03/02 on call. We needs your expert experience for evaluation. Thanks a lot !!
    • A
      • This 61 year-old female patient was admitted for adenocarcinoma of middle rectum with impending obstruction and liver metastasis and possible LLL metastasis, cT4aN2bM1a, stage IVA. Plan to establish T-loop colosotmy first for tumor impending obstruction then suggest CCRT and C/T+ target therapy.
      • CT-simulation will be arranged on 3/14. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor (with the invaded uterus) and LAPs to 50.4 Gy/ 28 fx. RT will start around 3/16 or 17. If resection is not feasible by the end of the planned CCRT and C/T + target therapy course, additional RT to the rectal tumor might be considered for longer local control. Thank you very much.
  • 2022-12-30 Ophthalmology
    • Q
      • Acute or sudden change in vision - Black spot appears in the right eye, ophthalmological examination reveals retinal detachment.
      • RD, arrange OP today
      • NKDA
    • A
      • S
        • VFD today
      • O
        • Acute floaters for 3 days
        • visited LMD and RRD was told
        • VAcPG od 0.6 os 0.6
        • Pupil od iatrogenic dilated os 3mm +/+
        • Conj np ou
        • K clear ou
        • AC D/clear ou
        • Lens ns+ ou
        • Fd od RRD 11-2 oc, flap tear at 12oc, macula on, fovea on
      • A
        • Phakic RRD od
      • P
        • Arrange admission TKS
        • OP will be arrange today
        • inform the risk of operation

[radiotherapy]

[chemotherapy]

  • 2023-12-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-11-09 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-09-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-09-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-08-17 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (A-FOLFIRI; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-01 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (A-FOLFIRI; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-12 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (A-FOLFIRI; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-26 - oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX, Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-29 - bevacizumab 5mg/kg 300mg NS 200mL 90min + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 400mg/m2 580mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFOX, Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-28 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 400mg/m2 580mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX, Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-11 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 400mg/m2 580mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX, Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-23 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 250mL 10min + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr (FOLFOX, Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-12-13

[thrombocytopenia]

Thrombocytopenia was first observed in April 2023 and has not yet returned to the lower limit of normal range (150K/uL). Since December, platelet counts have been consistently below 50K/uL. Bevacizumab was started in August 2023.

  • 2023-12-11 PLT 41 *10^3/uL
  • 2023-12-08 PLT 41 *10^3/uL
  • 2023-11-30 PLT 70 *10^3/uL
  • 2023-11-16 PLT 45 *10^3/uL
  • 2023-11-07 PLT 80 *10^3/uL
  • 2023-10-17 PLT 57 *10^3/uL
  • 2023-10-11 PLT 65 *10^3/uL
  • 2023-09-20 PLT 77 *10^3/uL
  • 2023-09-13 PLT 69 *10^3/uL
  • 2023-09-08 PLT 65 *10^3/uL

Both bevacizumab and fluorouracil are known to cause thrombocytopenia, with bevacizumab showing a higher incidence rate of up to 58% (grades 3/4: 20% to 40%).

According to UpToDate recommendations, in cases of hemorrhage caused by bevacizumab, such as hemoptysis (recent history of >= 2.5 mL), bevacizumab should be withheld. For Grade 3 or 4 hemorrhage, bevacizumab should be discontinued. As there has been no recent documentation of hemorrhage found in the medical records, it may not be necessary to temporarily stop the use of bevacizumab at this time.

Blood transfusion has been scheduled according to the progress note.

2023-07-13

The patient has only visit our hospital in the last 3 months according to the PharmaCloud database, our gastroenterologist prescribed Baraclude (entecavir) for she is a carrier of viral hepatitis B. Baraclude is in the active medication list, no reconciliation issues found.

2023-06-20

On 2023-06-18, the patient’s fecal occult blood test was 2+, indicating a possible GI bleeding. On this date, the patient has been prescribed lansoprazole and tranexamic acid. The prescription for lansoprazole is set to expire on 2023-06-21. It would be beneficial to evaluate whether signs of bleeding persist to decide whether to continue the PPI.

700701383

231213

[MedRec]

  • 2023-12-05 Cardiac Surgery Xu ZhanYang
    • Discharge diagnosis
      • Adenocarcinoma of the gastric antrum; status post subtotal gastrectomy on 2023-11-02; status post Port-A catheter implantation through the right internal jugular vein on 2023-12-06
      • Prostate cancer; status post radical prostatectomy and pelvic lymph node dissection on 2019-06-26
      • Hypertension
      • Type 2 diabetes mellitus
      • Asthma
      • Hepatitis B carrier
    • CC
      • Expected hospitalization for Therapeutic catheter implantation - Port-A catheter implantation surgery.
    • Present illness
      • This is a 62-year-old male patient with a history of hypertension, type 2 diabetes, and asthma for several years. He is also a carrier of Hepatitis B. His surgical history includes:
        • C5-6-7 herniated intervertebral disc (HIVD) and stenosis; status post discectomy and spinal fusion on 2013-07-30
        • Anal fistula and hemorrhoids; status post fistulotomy and hemorrhoidectomy on 2015-07-08
        • Benign prostatic hyperplasia; status post transurethral resection of the prostate on 2019-04-17
        • Prostate cancer; status post radical prostatectomy and pelvic lymph node dissection on 2019-06-26
        • Prostate cancer and phimosis; status post bilateral orchiectomy on 2019-12-25.
      • He was diagnosed with adenocarcinoma of the gastric antrum in 2023 and underwent subtotal gastrectomy on 2023-11-02 at National Yang Ming Chiao Tung University Hospital.
      • Further chemotherapy is needed. The patient was then referred to the cardiovascular surgery department for Port-A catheter implantation. The surgery is scheduled for 2023-12-06, and the patient was admitted on 2023-12-05 for elective Port-A catheter implantation.
    • Course of inpatient treatment
      • After admission, the patient underwent Port-A catheter implantation through the right internal jugular vein on 2023-12-06. Following the surgery, wound management skills education was performed. The patient was discharged home on 2023-12-06.
    • Discharge prescription
      • Sindine Aq Soln (povidone iodine 10%) QD EXT
      • Acetal (acetaminophen 500mg) 1# QID
      • Lactul (lactulose 666mg/mL) 10mL PRNTID
  • 2023-11-23 SOAP Hemato-Oncology Gao WeiYao
    • A:
      • Metchronous double cancer (prostate first and gastric ca later 2023)
        • The term metachronous is used in oncology to refer to two (or more) independent primary malignancies, when the second (or third, etc.) malignancy arose more than six months after the diagnosis of the first malignancy. These may be in the same, or in different, organs.
        • The term synchronous is used in oncology to refer to two (or more) independent primary malignancies, when the second (or third, etc.) malignancy arose within six months of the diagnosis of the first malignancy. These may be in the same, or in different, organs.
      • Adenocarcinoma of gasric antrum , pT3N3aMx, stage IIIb post subtotal gastrectomy on 2023-11-02 at YiLan YanMing Hospital.
  • 2019-11-11 SOAP Urology LinJiaDa
    • O: Cancer Multidisciplinary Team Meeting Conclusion, Date: 2019-10-07
      • Start androgen deprivation therapy (ADT) on 2023-10-01. Monitor for efficacy for a period of time.
      • If the prostate-specific antigen (PSA) level does not decrease by at least 50% after 6 months, chemotherapy should be considered.
      • Germline mutation testing should be considered.
  • 2019-04-16 ~ 2019-04-19 POMR Urology Lin JiaDa
    • Discharge diagnosis
      • N40.1 Benign prostatic hyperplasia status post transurethral resection of the prostate on 2019/04/17
      • R97.2 Elevated prostate specific antigen status post Transrectal ultrasound guided (TRUS) biopsy on 2019/04/17
    • CC
      • urinary frequency, weak stream and nocturia 4-6 times/night.
    • Present illness
      • This 58-year-old man has histories of 1) C5-6-7 HIVD was diagnosed at CGMH 4-5 years ago; 2) Hemorrhoid s/p operation 13 years ago at CGMH; 3) Anal fistula post fistulotomy on 2015/07/08; 4) BPH under medication treatment for 2+ years.
      • He has LUTS such as urinary frequency, weak stream and nocturia 4-6 times/night. He received follow-up at urologic clinic periodically for BPH treatment. He complained symptoms more severe in this month and visited our urologic clinic ask surgery.
      • PSA:7.619 ng/mL. Transrectal echo revealed benign prostatic hyperplasia (36.8 cc). Though some alpha-blockers were prescribed, but no significant effect was noted.
      • Under the impression of benign prostatic hyperplasia and elevated prostate specific antigen (PSA), we advised the patient to receive laser TURP and TRUSP biopsy. After well explaining, the patient agreed.
      • This time, he was admitted for further evaluation and management.
    • Course of inpatient treatment
      • After admission, the surgery of transurethral resection of the prostate and transrectal ultrasound guided (TRUS) biopsy was performed on 2019/04/17.
      • Postoperative course was uneventful and continued N/S bladder irrigation.
      • Removed Foley done smoothly on 4/19 with fair urination, he was discharged today and would be followed up at urologic clinic.
    • Discharge prescription
      • Atanaal (nifedipine 5mg) 2# PRNQ6H
      • MgO 250mg 1# QID
      • Lactam (acetaminophen 500mg) 1# QID
      • cephalexin 500mg 1# QID

[surgical operation]

[chemotherapy]

  • 2023-12-13 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 720mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-12-13

The PharmaCloud records show that this patient recently refilled his prescription for metformin and Sevikar (amlodipine, olmesartan) on 2023-12-03 for a 28-day supply. These drugs have been included in the active medication list.

Zytiga (abiraterone) has been in use since early 2021 and continues to be part of the patient’s treatment regimen. Androcur (cyproterone) was administered from 2019-10 to 2020-01, with two doses of Leuplin (leuprorelin) given on 2019-10-01 and 2019-10-31 prior to the initiation of Zytiga.

It is advisable that patients receiving abiraterone should also receive a gonadotropin-releasing hormone (GnRH) analog concurrently (or have had a bilateral orchiectomy).

700796645

231213

[exam findings]

  • 2023-03-28 Patho - uterus (with or without SO) neoplastic
    • PATHOLOGIC DIAGNOSIS
      • Uterus, endometrium, total hysterectomy — Carcinosarcoma with heterologous element
      • Ovaries and fallopian tubes, bilateral, BSO — No remarkable change
      • Lymph nodes, pelvic and para-aortic, bilateral, BPLND+PALND— Negative for malignancy (0/51)
      • AJCC 8 th edition, Pathology stage: pT2N0(cM0); stage II; FIGO stage II
    • MACROSCOPIC EXAMINATION
      • Procedure: total hysterectomy + BSO + omentectomy + BPLND + bilateral para-aortic LN dissection
      • Specimen Size: 20.5 x 12.0 x 8.0 cm(uterus), 3.0 x 2.0 x 2.0 cm (Lt ovary), 4.5 x 1.0 cm (Lt tube), 3.0 x 2.0 x 2.0 cm (Rt ovary), 4.5 x 1.0 cm (Rt tube), and 24 x 12 x 2.0 cm (omentum)
      • Specimen Integrity: Intact
      • Tumor Site: Endometrium
      • Tumor Size: 19.5 x 10.5 cm
      • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, left para=aortic, and right para-aortic. Representative parts are taken for section and labeled as: A1-A2= left iliac LNs, B= left obturator LNs,C1-C2= right iliac LNs, D1-D3= right obturator LNs, E= left para-aortic LNs, F= right para-aortic LNs, G1-G2= left ovary and fallopian tube, G3-G4= right ovary and fallopian tube, G5-G13= uterine corpus, G14-G15= cerivx, H1-H2= omentum.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Carcinosarcoma with heterologous (chondrosarcomatous) component
      • Histologic Grade: High-grade
      • Depth of tumor invasion: Tumor invading > 1/2 of the myometrium
      • Uterine Serosal Involvement: Not identified
      • Cervical Stromal Involvement: Present
      • Other Tissue/Organ Involvement: Not identified
      • Peritoneal/Ascitic Fluid: Negative
      • Margins: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin: 0.1 cm from parametrium
      • Lymphvascular Invasion: Present
      • Regional Lymph Nodes: All lymph nodes negative for tumor cells (0/51)
        • number of lymph node examined: 16 (left iliac), 4 (left obturator), 7 (right iliac), 13 (right obturator), 5 (left para-aortic), 6 (right para-aortic)
        • number with metastases > 2 mm: 0
        • number with metastases > 0.2 mm and up to 2 mm or less: 0
        • number with isolated tumor cells (<= 0.2mm): 0
      • Pathologic Stage
        • Primary Tumor: pT2 (tumor invading the stroma of the cervix)
        • Regional Lymph Nodes: pN0 (no regional lymph node metastasis
        • Distant Metastasis: cM0
      • FIGO Stage: Stage II
      • AdditionalPathologic Findings
        • Cervix: Chronic cervicitis with Nabothian cyst
        • Myometrium: Leiomyoma
        • Ovary, right: No remarkable change
        • Ovary, left: No remarkable change
        • Fallopian tubes, blateral: No remarkable change
        • Omentum: Free of carcinoma
  • 2023-03-24 CT - chest
    • Minimal interstitial change at Right lower lobe and left lower lobe
    • Calcified coronary arteries is found.
    • Right upper lobe tiny nodule. 0.2cm, meta is less likely but follow up is suggested.
  • 2023-03-20 MRI - pelvis
    • Clinical history: 68 y/o male patient with Vagina, excisional biopsy — Carcinosarcoma.
    • With and without contrast enhancement MRI: Pelvis
      • Diffuse soft tissue tumors(up to 10cm) in the uterine cacvity, involving more than half of myometrium, focal soft tissue in the uterine cervical region.
      • Focal soft tissue tumor in border of left uterine surface, r/o adnexal or parametrium invasion.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE: IIIB_(Stage_value)
  • 2023-03-17 Gynecologic ultrasonography
    • Findings
      • Uterus Position : AVF
        • Size: 104 x 88 mm
      • Endometrium:
        • Thickness: 71.8 mm
      • Adnexae:
      • CUL-DE-SAC: with fluid
      • Other: Bilateral adnexae free
    • IMP: R/O EM:71.8mm (RI:0.51), or Uterus mass?
  • 2023-03-10 Patho - vaginal biopsy
    • Vagina, excisional biopsy — Carcinosarcoma
    • The sections show a picture of carcinosarcoma, composed of both malignant epithelial and mesenchymal components. The epithelial component arranged in glandular and solid patterns. The sarcomatous components composed of fascicles of spindle-shaped neoplastic cells with focal hyalinized stroma and focal chondroid differentiation. Surface ulcer, moderate inflammatory cells infiltrate, and granulation tissue are present. The surgical margin is involved by tumor.
    • IHC: CK (+ for epithelial component), Vimentin (+ for both epithelial and mesencymal components), PAX8 (+), ER (-), PR (+) and Napsin A (-).

[consultation]

  • 2023-05-18 Radiation Oncology
    • Q
      • The patient is an 68-year-old female with a history of 1. hypothyroidism s/p medical control, 2. hyperlipidemia s/p medical control, 3. Carcinosarcoma with heterologous element of the uterine endometrium, stage cT3bN0M0, s/p Staging surgery (Total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + omentectomy), stage pT2N0cM0; stage II; FIGO stage II.
      • This time, she suffered from fever with chillness since 2023/05/03, last chemotherapy on 2023/05/02, until symptoms worsen, so she was brought to our ER for help. Associated symptoms included poor appetite, frequent urination, fever with chillness. Denied painful urination, cough or URI symptoms and abdominal pain. At ER he conscious level is E4V5M6, vital sign BP:121/69; PR:112; BT:38; RR:18. Physical examination showed abdominal OP scar clear, breathing sound clear. Lab data showed Sediment-WBC >=100 /HPF; Bacteria = 3+ /HPF; Creatinine = 2.51 mg/dL; CRP = 36.8 mg/dL; WBC = 13.14 x10^3/uL. Under the tentative diagnosis of Urinary tract infection. So, she was admitted to our ward for further evaluation and management.
      • For radiotherapy, we need your further evaluation and management.
    • A
      • The patient’s history was reviewed and patient was examined.
      • S: Recovery from urinary tract infection.
        • PI: Carcinosarcoma with heterologous element of the uterine endometrium, stage cT3bN0M0, s/p Staging surgery (Total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + omentectomy) on 2023-03-27, stage AJCC 8 th edition, Pathology stage: pT2N0(cM0); stage II; FIGO stage II.
        • Chemotherapy: since 2023-05-02
        • Family history: (-)
        • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
        • Personal Hx: DM(-); HTN(-)
        • Allergy(-)
      • O:
        • ECOG: 0
        • PE: neck and bil SCF: neg; abdomen: surgical scars.
        • CXR (2023-03-03): No active lung lesion. No cardiomegaly. Thoracic spondylosis.
        • MRI of pelvis (2023-03-20): Diffuse soft tissue tumor in the uterine cavity, with focal soft tissuse tumor in left uterine border, r/o parametrial/adnexal invasion. Clinical biopsy vaginal carcinosarcoma, cstage T3bN0M0.
        • Operation (2023-03-27): Staging surgery (Total hysterectomy + bilateral salpingo - oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + omentectomy)
        • Ascites (2023-01154, 2023-03-29): neg.
        • Pathology (S2023-05755, 2023-03-30): 1. Uterus, endometrium, total hysterectomy — Carcinosarcoma with heterologous element. 2. Ovaries and fallopian tubes, bilateral, BSO — No remarkable change. 3. Lymph nodes, pelvic and para-aortic, bilateral, BPLND + PALND — Negative for malignancy (0/51). 4. AJCC 8 th edition, Pathology stage: pT2N0(cM0); stage II; FIGO stage II. Lymphvascular Invasion: Present.
        • RT (2023-04-28 ~): at 900cGy/5 fractions (10MV photon) of the pelvic area.
      • A: Carcinosarcoma with heterologous element of the uterine endometrium, stage cT3bN0M0, s/p Staging surgery (Total hysterectomy + bilateral salpingo - oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + omentectomy), stage AJCC 8 th edition, Pathology stage: pT2N0(cM0); stage II; FIGO stage II.
      • P: The patient interrupted radiotherapy after 2023-05-05 due to urinary tract infection. Because she already recovery from that, radiotherapy can be continued.
  • 2023-05-12 Neurology
    • Q
      • The patient is a 68-year-old female with a history of 1. hypothyroidism s/p medical control, 2. hyperlipidemia s/p medical control, 3. Carcinosarcoma with heterologous element of the uterine endometrium, stage cT3bN0M0, s/p Staging surgery (Total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + paraaortic lymph node dissection + omentectomy), stage pT2N0cM0; stage II; FIGO stage II.
      • She presented with chronic migraine for many years, under treatment (ponstan) at LMD, but renal function has worsened. For chronic migraine, we need your further evaluation and management.
    • A
      • If renal function is poor, consider using the following (all are PRN, used only when having a headache):
        • acetaminophen
        • ultracet/tramadol
        • ergotamine/caffeine: limited to one a day, not recommended for those with cardiovascular disease
        • imigran: limited to 50mg a day, no more than twice a week, at most 8 tablets a month
      • You can use (choose one from 1, 2) in combination with (choose one from 3, 4)
      • The patient has used inderol 10mg qd as a prophylactic for migraines in the past (June 2019 neurology clinic), and the effect was good, it can be tried again.

[chemotherapy]

  • 2023-12-13 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO
  • 2023-11-17 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO
  • 2023-10-03 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO
  • 2023-09-01 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-2
  • 2023-08-11 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-2
  • 2023-07-17 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-2
  • 2023-06-20 - carboplatin AUC 2 150mg D5W 2hr (weekly CDDP changed to carboplatin, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-06-13 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-06 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-30 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-22 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-02 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-09-04

The leukopenia observed on 2023-08-24 (WBC 1.5K/uL) was likely a result of the paclitaxel and carboplatin administered on 2023-08-11. Following a 3-day course of G-CSF from 2023-08-24 to 2023-08-26, no further instances of leukopenia have been observed.

A new cycle of the treatment regimen was initiated on 2023-09-01, and prophylactic G-CSF is scheduled for 2023-09-06, 2023-09-07, and 2023-09-08.

2023-08-31 WBC 3.20 x10^3/uL
2023-08-24 WBC 1.50 x10^3/uL
2023-08-08 WBC 5.12 x10^3/uL
2023-07-25 WBC 3.29 x10^3/uL
2023-07-17 WBC 5.76 x10^3/uL
2023-07-12 WBC 4.41 x10^3/uL
2023-07-03 WBC 1.64 x10^3/uL
2023-06-28 WBC 1.69 x10^3/uL
2023-06-19 WBC 2.08 x10^3/uL
2023-06-12 WBC 2.72 x10^3/uL
2023-06-05 WBC 4.78 x10^3/uL
2023-05-30 WBC 3.99 x10^3/uL
2023-05-22 WBC 4.35 x10^3/uL
2023-05-15 WBC 4.67 x10^3/uL
2023-05-12 WBC 4.78 x10^3/uL
2023-05-09 WBC 8.17 x10^3/uL
2023-05-09 WBC 13.14 x10^3/uL
2023-04-19 WBC 5.07 x10^3/uL
2023-04-03 WBC 5.23 x10^3/uL
2023-03-28 WBC 13.97 x10^3/uL
2023-03-23 WBC 7.35 x10^3/uL
2023-03-03 WBC 5.22 x10^3/uL

2023-09-01

The Eltroxin (levothyroxine) prescribed by our endocrinologist on 2023-08-01 is currently listed in the active medications without any reconciliation discrepancies identified.

2023-08-11

Our endocrinologist wrote a repeat prescription for Eltroxin (levothyroxine) on 2023-08-01 and the drug is included in the formulary with no reconciliation issue identified.

2023-07-18

[reconciliation]

The patient was seen by our urologist on 2023-07-12 who prescribed Cero (cefaclor 250mg) 2# TID and Celebrex (celecoxib 200mg) 1# QD for a period of 7 days to treat suspected UTI infection or catheter-related discomfort. These medications are not currently on the active medication list, so it’s advisable to confirm resolution of these symptoms.

701260169

231213

[exam findings]

  • 2023-04-14 Patho - breast mastectomy with regional lymph nodes
    • PATHOLOGIC DIAGNOSIS
      • Breast tumor, right, simple mastectomy —- Solid papillary carcinoma with invasion
      • Resection margins, ditto — Free of tumor invasion
      • Lymph node, right axillary sentinel area, frozen (F2023-00167) — Free of tumor metastasis (0/2)
      • AJCC Pathologic Anatomic Stage — pT2N0, if cM0, stage IIA; Prognostic Stage — Stage IA
    • MACROSCOPIC EXAMINATION
      • Breast: 19.9 x 18.2 x 3.4 cm
      • Skin: 17.2 x 4.4 cm
      • Nipple: 1.6 x 1.3 cm
      • Tumor: 2.7 x 1.9 cm
      • Resection margins: Free, 0.7 cm away from closest base, at least 2.8 cm away from peripheral margins
      • Lymph node: right axillary sentinel LNs, sent for frozen section (F2023-00167)
      • Representative sections as A1: four peripheral margins, A2: base, A3-A7: tumor, A8: skin + nipple [Reference: frozen F2023-00167 FSA1-A2: right axillary sentinel LNs}
    • MICROSCOPIC EXAMINATION
      • Histologic type: solid papillary carcinoma with invasion and focal ductal carcinoma in situ, intermediate grade
      • Size of invasive carcinoma: 2.7 x 1.9 cm
      • Histologic grade (Nottingham histologic score): Grade II (score 6) including (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1
      • Margins: Free of tumor invasion
      • Nodal status: Free of tumor metastasis (0/2)
      • Treatment Effect: N/A
      • Lymphovascular space invasion: not identified
      • Perienural invasion: not identified
    • IMMUNOHISTOCHEMISTRY
      • Synaptophysin(+, diffuse), chromogranin-A(+, diffuse) for tumor and P63(+, rim pattern) for DCIS
      • Please refer to S2023-05519 for ER, PR, Her2/neu and Ki67 status
  • 2023-03-24 Patho - breast biopsy (no margin)
    • Breast, right, core needle biopsy — Invasive carcinoma of no special type
    • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in solid architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism and increased N/C ratio.
    • Immunohistochemical study demonstrates ER: positive (strong, 99%), PR: positive (strong, 99%), Her2/neu: negative (0), Ki-67 inedex: 40%, p63: negative.

[MedRec]

  • 2023-05-10 SOAP General and Gastroenterological Surgery Zhang YaoRen
    • O: Conclusion of the Multidisciplinary Cancer Team Meeting - Meeting Date: 2023-04-28
      • FEC x6 followed by AI for 5 years.
  • 2023-05-01 ~ 2023-05-03 POMR General and Gastroenterological Surgery Zhang YaoRen
    • Discharge diagnosis
      • Malignant neoplasm of unspecified site of right female breast
      • Right breast invasive carcinoma status post port A insertion on 2023/05/02. pT2N0M0, stage IIA. ECOG:0.
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
    • Present illness
      • Under surgery of right breast simple mastectomy + SLNB on 2023/04/14.
      • Pathology: solid papillary carcinoma with invasion,size 2.7 cm,Gr 2, pT2N0M0, stage IIA.
      • Adjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 for 4 cycles were suggest.
      • Under the impression of right breast invasive carcinoma, she was admitted for surgery of port A insertion. Arrange 1st adjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 on 2023-05-03.
  • 2023-04-13 ~ 2023-04-15 POMR General and Gastroenterological Surgery
    • Discharge diagnosis
      • Right breast invasive carcinoma status post simple mastectomy + sentinel lymph node biopsy  on 2023/04/14. cT2N0M0, stage IIA. ECOG:0.
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
    • CC
      • noted a palpable mass at right breast and stabbing pain over 2 months.
    • Present illness
      • This 40-year-old female patient has past history of hypertension and Type 2 diabetes mellitus over 3 years with regular medicine control. She denied cancer history. She denied any TOCC histories in recent 3 months.
      • She noted a palpable mass at right breast and stabbing pain over 2 months. She came to our OPD for help. Breast sono showed right breast heteregeneous tumor, 10’ region, suggest biopsy. Right breast 9’ region and left 12’ region angulated tumors, suggest close follow up. Core needle biopsy revealed invasive carcinoma, ER: positive (strong,99%), PR: positive (strong,99%), Her2/neu: negative (0), Ki-67 inedex: 40%, p63: negative. CA-153:10.123 U/ml, CEA:2.247 ng/ml. PET and abdomen echo showed no obvious lesion for metastasis. She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss. PE: symmetrical of bilateral breasts. A hard, nontender, movable mass and irregular margin at right breast around 4x4 cm without discharge. left breast P scar. The nipple was dimping without exudative nor bloody discharge and no retraction. The right breast skin had no cellulite change.
      • Under the impression of right breast invasive carcinoma, she was admitted for surgery of simple mastectomy + SLNB.  
    • Course of inpatient treatment
      • After admission, right breast simple mastectomy + SLNB was performed on 2023/04/14. The wound is clean and dry. Under the stable condition, she was discharged today, wound will be follow up in OPD.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
  • 2023-04-10 SOAP General and Gastroenterological Surgery
    • O
      • 2023/03/31 PET scan
        • A glucose hypermetabolic lesion in the right breast, compatible with primary breast malignancy.
        • Mild glucose hypermetabolism in two small right axillary lymph nodes, in a small left axillary lymph node and in the right pulmonary hilar region. Inflammatory process is more likely.
        • Glucose hypermetabolism in a focal area in the body of the pancreas.
        • Increased FDG accumulation in both kidneys and colon.
      • Lab
        • 2023/03/31 Anti-HCV (NM) = Negative;
        • 2023/03/31 Anti-HCV Value (NM) = 0.032;
        • 2023/03/31 Anti-HBc (NM) = Negative;
        • 2023/03/31 Anti-HBc Value (NM) = 2.410;
        • 2023/03/31 Anti-HBs (NM) = Positive;
        • 2023/03/31 Anti-HBs value (NM) = 480.000 mIU/mL;
  • 2023-03-29 SOAP General and Gastroenterological Surgery
    • S: Rt breast ca proved by CNB on 2023-03-24
    • O
      • 2023/03/24 PATHO - breast biopsy (no need margin)
        • Breast, right, core needle biopsy — Invasive carcinoma of no special type
        • ER: positive (strong,99%), PR: positive (strong, 99%), Her2/neu: negative (0), Ki-67 inedex: 40%, p63: negative.
  • 2023-03-22 SOAP General and Gastroenterological Surgery
    • S: breast lump
    • O
      • premenopausal
      • menarche 13 y/o
      • G0P0
      • FH of breast ca (-)
      • Hormone (-)
      • A 4 cm elastic firm mass in rt breast
  • 2021-05-14 SOAP Metabolism and Endocrinology
    • Prescription x3
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QDAC
      • Ankomin (metformin 500mg) 1# BIDAC
      • Zulitor (pitavastatin 4mg) 1# QNAC
      • Amepiride (glmepiride 2mg) 0.5# QDAC
      • Galvus Met (vidagliptin 50mg, metformin 500mg) 1# BIDAC
  • 2021-01-22 SOAP Metabolism and Endocrinology
    • Prescription x3
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
      • Ankomin (metformin 500mg) 2# BIDCC
      • Zulitor (pitavastatin 4mg) 1# QN
  • 2020-12-12 SOAP Metabolism and Endocrinology
    • A/P
      • Complete metabolic profiles
      • Diet control
      • Prescribe metformin 500 TID
      • SMBG QDAC at home
      • RTC 2 W later
    • Prescription
      • Ankomin (metformin 500mg) 1# TIDCC

[surgical operation]

  • 2023-04-14
    • Surgery: Simple mastectomy and sentinel lymph node biopsy        
    • Finding:
      • a 3x2x2 cm slight firm mass in rt breast
      • SLN 0/1  

[chemotherapy]

  • 2023-09-27 - docetaxel 75mg/m2 138mg NS 250mL 1hr (D Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-09-07 - docetaxel 75mg/m2 138mg NS 250mL 1hr (D Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-08-17 - docetaxel 75mg/m2 138mg NS 250mL 1hr (D Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-07-28 - docetaxel 75mg/m2 140mg NS 250mL 1hr (D Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-07-06 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 1100mg NS 500mL 1hr (AC(lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-06-15 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 1100mg NS 500mL 1hr (AC(lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-05-25 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 1088mg NS 500mL 1hr (AC(lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-05-03 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 1083mg NS 500mL 1hr (AC(lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

2023-12-13

[leukopenia, diarrhea]

Review of lab data from HIS5 reveals that the last documented episode of leukopenia occurred on 2023-10-04, exceeding two months ago. Serial WBC counts demonstrate a period of low values approximately one week after docetaxel administration. However, recent data is insufficient to confirm or rule out the current presence of leukopenia.

  • 2023-10-04 WBC 1.52 x10^3/uL <- leukopenia
  • 2023-09-27 WBC 6.85 x10^3/uL <- docetaxel
  • 2023-09-13 WBC 3.17 x10^3/uL
  • 2023-09-07 WBC 6.27 x10^3/uL <- docetaxel
  • 2023-08-23 WBC 2.94 x10^3/uL
  • 2023-08-17 WBC 7.32 x10^3/uL <- docetaxel

This patient is currently taking Nolvadex (tamoxifen citrate 10mg/tablet) 1# BID, a medication that is generally not linked to leukopenia.

Moreover, the lab results indicate increased levels of myelocytes and metamyelocytes. It might be important to investigate further to determine if these findings have clinical significance.

No significant episodes of diarrhea were found documented in the recent medical history.

2023-08-21

[leukopenia]

The patient underwent 4 rounds of liposome doxorubicin and cyclophosphamide treatment on 2023-05-03, 2023-05-25, 2023-06-15, and 2023-07-06 without any signs of leukopenia.

However, a week following the initial dose of docetaxel on 2023-08-04, leukopenia was detected. Consequently, Granocyte (lenograstim 250ug) was administered the same day.

  • 2023-08-17 WBC 7.32 x10^3/uL <- docetaxel
  • 2023-08-06 WBC 3.47 x10^3/uL
  • 2023-08-04 WBC 1.12 x10^3/uL <- leukopenia
  • 2023-07-28 WBC 4.20 x10^3/uL <- docetaxel
  • 2023-07-06 WBC 4.19 x10^3/uL
  • 2023-06-15 WBC 4.65 x10^3/uL
  • 2023-05-25 WBC 7.70 x10^3/uL
  • 2023-05-10 WBC 7.11 x10^3/uL
  • 2023-04-13 WBC 5.66 x10^3/uL

Docetaxel is associated with a high incidence of leukopenia. (UpToDate: 84% to 99%; grades 3/4: 49%; grade 4: 32% to 44%)

The patient received a second dose of docetaxel on 2023-08-17. Prophylactic G-CSF is scheduled for 2023-08-22 and 2023-08-23. Currently, there’s no indication of newly emerging leukopenia.

701496322

231213

[lab data]

2023-11-28 HLA A-high 11:01
2023-11-28 HLA A-high 24:02
2023-11-28 HLA B-high 27:04
2023-11-28 HLA B-high 35:01
2023-11-28 HLA C-high 08:01
2023-11-28 HLA C-high 12:02

2023-11-28 HLA DQ-high 03:01
2023-11-28 HLA DQ-high 03:03

2023-11-28 HLA DR-high 12:01
2023-11-28 HLA DR-high 12:02

2023-09-13 FLT3-D835 (bone marrow) Undetectable
2023-09-11 CD2 NA
2023-09-11 CD3 3.4
2023-09-11 CD4 NA
2023-09-11 CD5 1.3
2023-09-11 CD7 98.6
2023-09-11 CD8 NA
2023-09-11 CD10 2.4
2023-09-11 CD11b 32.8
2023-09-11 CD13 94.7
2023-09-11 CD14 1.2
2023-09-11 CD15 NA
2023-09-11 CD16 0.76
2023-09-11 CD19 6.2
2023-09-11 CD19/kappa NA
2023-09-11 CD19/Lambda NA
2023-09-11 CD20 1.8
2023-09-11 CD23 NA
2023-09-11 CD25 NA
2023-09-11 CD33 85.2
2023-09-11 CD34 90.6
2023-09-11 CD38 NA
2023-09-11 CD56 0.4
2023-09-11 CD103 NA
2023-09-11 CD117 98.5
2023-09-11 CD138 NA
2023-09-11 FMC7 NA
2023-09-11 HLA-DR 99.1
2023-09-11 MPO NA
2023-09-11 TdT NA
2023-09-11 FLT3/ITD (bone marrow) Presence of mutation
2023-09-11 NPM1 (bone marrow) Undetectable
2023-09-11 LDH 276 U/L
2023-09-09 LDH 513 U/L
2023-09-05 LDH 2394 U/L

2023-09-04 HBsAg Nonreactive
2023-09-04 HBsAg (Value) 0.57 S/CO
2023-09-04 Anti-HBc Nonreactive
2023-09-04 Anti-HBc-Value 0.43 S/CO
2023-09-04 Anti-HCV Nonreactive
2023-09-04 Anti-HCV Value 0.14 S/CO

2023-09-03 LDH 1578 U/L

2023-08-31 Uric Acid 9.2 mg/dL
2023-08-31 LDH 1428 U/L

2023-08-31 WBC 351.74 x10^3/uL
2023-08-31 HGB 8.4 g/dL
2023-08-31 PLT 33 x10^3/uL

[exam findings]

  • 2023-10-20 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy
    • Microscopically, it shows normal cellularity (approximately 45%), 3:1 of M:E ratio . Both myeloid and erythroid lineages demonstrate maturation. Megakaryocytes are present in normal in numbers (2-3 per HPF) and demonstate no significant morphologic abnormalities. Blast-like cells (CD117+, <1%) are present.
    • Immunohisotchemical stain reveals CD34 (-), CD138 (focal+, 1%), MPO (+), CD71 (+), CD61 (+), TdT (-).
    • NOTE: Correlation of bone mrrow smear, peripheral blood data, molecular cytogenetic study, flow cytometery and clinical findings is recommended.
  • 2023-10-20 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (106 - 30.3) / 106 = 71.42%
      • M-mode (Teichholz) = 71.4
    • Conclusion:
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Trivial MR and AR, mild TR and PR
      • Impaired LV relaxation
      • Dilated LA, thick IVS and LVPW
  • 2023-10-19 CXR
    • S/P PICC catheter insertion via left forearm.
    • Spondylosis of the T-spine
    • Large gallstone is highly suspected. Please correlate with CT.
  • 2023-10-19 Cardiac Catheterization
    • We perform PICC at our cath room
      • Under the peripheral echo guiding, we successful puncture left basilic vein, Under the fluroscopy guiding, PICC one way catheter was implanted to SVC smoothly.
    • We check SvO2 64%.
      • Estimated Fick Cardiac index 1.81 L/min/m2 (normal cardiac index 2.4~4L/min/m2)
      • Cardiac output 2.76 L/min
  • 2023-09-05 Cardiac Catheterization
    • Indication: for chemotherapy
    • We perform PICC under the cath room (fluroscopy guiding)
      • Under the peripheral echo guiding, we successful puncture left basilic vein. Then wire advanced smoothly under the fluroscopy. Then microcatheter was advanced in basilic vein. The PICC catheter was advnaced to left SVC to atrium junction.
  • 2023-09-04 Patho - bone marrow biospy
    • Bone marrow, iliac crest, biopsy — Compatible with acute myeloid leukemia with maturation
    • The sections show hypercellular marrow (80%). The marrow space is replaced by a population of medium to large-sized immature cells with round to oval nucleus and moderate amount cytoplasm.
    • IHC, markedly increased CD34+ and or CD117+ blasts, constitue 80% of marrow cells. Most immature cells are also positive for MPO and some are positive for CD163 (10%).
    • The finding is compatible with acute myeloid leukemia with maturation. Suggest bone marrow smear evaluation and clinic correlation.
  • 2023-09-01 SONO - abdomen
    • Diagnosis:
      • Fatty liver,mild
      • Suspected fatty infiltration of pancreas
      • Propable liver cysts, bil
      • Mild hydronephrosis, left
      • GB not shown due to non-fasting
    • Suggestion:
      • Consult GU for Mild hydronephrosis, left
      • Follow liver function test and AFP
      • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
  • 2023-08-31 CXR (erect)
    • Thoracic spondylosis

[MedRec]

  • 2023-08-31 ~ 2023-10-02 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Flt3-ITD mutated acute myeloblastic leukemia, not having achieved remission
      • Bacteremia
      • Severe sepsis with septic shock
      • Agranulocytosis secondary to cancer chemotherapy
      • Fever, unspecified
      • Spontaneous ecchymoses
    • CC
      • whole body spontaneous ecchymosis for one month
    • Present illness
      • This 63-year-old female denied any past medical history.
      • This time, she suffered from some spontaneous ecchymosis was noted over whole body for 1+ weeks. Associate with SOB, fatigue, dizziness and dry cough for 5-6 days. She denied of lost of appetite, unintentional weight loss, abdominal or urinary tract disconfort. The patient initially went to Cardinal Tien Hospital for help, however they refered patient to our hospital for better medical care, so he was sent to our ER for help on 2023/08/31.
      • At ER, vital signs: BT:38C, HR:99/min, RR:20/min, BP:128/80 mmHg, SpO2:96% under room air. Physical exam showed ecchymosis all over the body. The laboratory data showed anemia (8.4 g/dL), leukocytosis (351.74 x10^3/uL) (Blast:95%), thromocytopenia (PLT 33*10^3/uL), elevated serum CRP (12.4 mg/dL), normal PT/aPTT level, elevated uric acid 9.2 mg/dL and elevated LDH 1428 U/L. CXR showed no obvious lung marking.
      • Under the impression of suspected AML without remission, so she was admitted to our ward for further evaluation and management on 2023/08/31.  
    • Course of inpatient treatment
      • After admitted to ward, she received critical care and antibiotics with Mepem + Targocid for infection control at first. IVF hydration and Feburic 1# qd for elevated UA level. Bone marrow showed AML. CXR showed infiltraction over both lower lung. Hydrea 2# tid for leukocytosis, but hold it during 7+3 chemo as Dornorubicin + Ara-C on 9/4-9/10. Keep antibiotics as Mepem + Targocid + Mycamine + oral form Baktar. Continue posaconazole 3# qd and added Rydapt 2# q12h since 9/13-10/4.
      • Sudden onset, she suffered vomitting, weakness and high fever were noted on 9/18 17:30. B/C from PICC and peripheral were yield Klebsiella pneumoniae.
      • On 9/19 morning, BP dropped and dizziness were noted. Fluid resuscitation and foley, CVC insertion for shock monitor. Drawn the series of cultures, DIC profiles and broadspectrum antibiotic as Mepem and Targocid.
      • Due to unstable hemodynamic and impressed with bacteremia with sepsis, she was transferred to MICU for intensive care on 2023/09/19.
      • After transferred to MICU, she received oxygen therapy with O2 nasal cannula supply and kept protective isolation. Empirical antibiotic with Mepem (9/18-) + Targocid (9/18-) + Baktar PO (9/19-) were prescribed for infection control. Blood transfusion with FFP for 3 days (9/19-9/21) and adequate IV fluid were administered to manage shock status. LRP transfusion was also given to correct thrombocytopenia. Acetal ragularly used due to fever on and off.
      • AML treatments were continued as Rydapt 2# PO Q12H (9/13-10/4) + Posaconazole 3# PO QD (9/6-10/4). We administered KCL, Const-K, Calglon, Magnesium Sulfate, and MgO to correct imbalance of electrolyte (hypokalemia, hypocalcemia, and hypomagnesemia). Blood transfusion with LPRBC was prescribed to correct anemia and stool OB was obtained, which showed 3+. Thus, self-payment PPI with Nexium was given.
      • We collected AFS/TB culture(3 sets) and sputum PJP as well as obtained blood Aspergillus Ag and Crypto. Ag on 9/25 for further infection survey. Localized warmth and erythema in the right shoulder area was noticed and suspected cellulitis. Therefore, we added antibiotic with Ciprofloxacin (9/22-) for infection control and consulted PS physician who replied this is a case of cellulitis of right shoulder. Then the conservative treatment (antibiotic use) is suggested. As a result of relief of shock status and stable conditions after all treatments, she will be transferred to ordinary ward if the bed is available.
      • After transfer to ONC ward on 2023/09/27. Her WBC level increase and no fever or SOB. Right shoulder cellulitis without discharge or tenderness. After treatment, her general condition got improvement, so she can be discharged on 2023/10/02. OPD follow up is arranged.
    • Discharge prescription
      • Posanol (posaconazole 100mg) 3# QD
      • Cinolone (ciprofloxacin 250mg) 2# BIDAC
      • Rydapt (midostaurin 25mg) 2# Q12H
  • 2023-08-31 SOAP Medical Emergency Jian DaSen
    • A: preliminary impression: C92.00 Acute myeloblastic leukemia, not having achieved remission

[consultation]

  • 2023-10-18 Cardiology
    • Q
      • The 63 y/o woman has Flt3-ITD mutaed acute myeloblastic leukemia. She was admitted for 2nd chemotherapy, so we need your help for PICC insertion one way. Thanks!
    • A
      • Chemotherapy was planed We will arrange PICC after well explain the procedure, possible risk and benefit for patient and familes.
      • It will be arrange on Oct. 19 morning (around 8:10 AM)
  • 2023-09-25

[chemotherapy]

  • 2023-12-11 - daunorubicin 45mg/m2 70mg NS 100mL 30min D1-2 + cytarabin 100mg/m2 156mg NS 500mL 24hr D1-5
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-5
  • 2023-10-25 - daunorubicin 45mg/m2 68mg NS 100mL 30min D1-2 + cytarabin 100mg/m2 152mg NS 500mL 24hr D1-5
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-5
  • 2023-09-04 - daunorubicin 45mg/m2 70mg NS 100mL 30min D1-3 + cytarabin 100mg/m2 158mg NS 500mL 24hr D1-7
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-7

==========

2023-10-26

[restarting posaconazole after discontinuation]

If posaconazole has been discontinued for several days (considered as washed out), it’s recommended to reintroduce the drug with a loading dose, specifically, 300 mg BID for two doses, then switch to a maintenance dose of 300 mg QD.

2023-09-14

[leukopenia]

The patient was administered her initial dose of the cytarabine/daunorubicin (7+3) regimen on 2023-09-04. A week later, on 2023-09-11, her WBC count reached its lowest point at 0.84K/uL, after which an upward trend was noted.

2023-09-13 WBC 1.23 x10^3/uL 2023-09-11 WBC 0.84 x10^3/uL * 2023-09-10 WBC 1.02 x10^3/uL 2023-09-09 WBC 1.05 x10^3/uL 2023-09-08 WBC 1.09 x10^3/uL 2023-09-07 WBC 1.69 x10^3/uL 2023-09-06 WBC 8.35 x10^3/uL 2023-09-06 WBC 24.86 x10^3/uL 2023-09-05 WBC 247.70 x10^3/uL 2023-09-04 WBC 355.71 x10^3/uL 2023-09-03 WBC 366.64 x10^3/uL 2023-09-02 WBC 370.59 x10^3/uL 2023-09-02 WBC 361.09 x10^3/uL 2023-09-01 WBC 335.15 x10^3/uL

[thrombocytopenia]

Prior to receiving her first dose of the cytarabine/daunorubicin (7+3) regimen on 2023-09-04, the patient was already in a state of thrombocytopenia. Following the administration of chemotherapy, her platelet count (PLT) continued to decline, reaching 23K/uL on 2023-09-13, the day a blood transfusion was performed. Blood transfusions were also administered on the following dates: 2023-08-31, 2023-09-04, and 2023-09-08.

2023-09-13 PLT 23 x10^3/uL * 2023-09-11 PLT 54 x10^3/uL
2023-09-10 PLT 83 x10^3/uL
2023-09-09 PLT 124 x10^3/uL
2023-09-08 PLT 29 x10^3/uL
2023-09-07 PLT 52 x10^3/uL
2023-09-06 PLT 102 x10^3/uL
2023-09-06 PLT 125 x10^3/uL
2023-09-05 PLT 48 x10^3/uL
2023-09-04 PLT 69 x10^3/uL
2023-09-03 PLT 79 x10^3/uL
2023-09-02 PLT 75 x10^3/uL
2023-09-02 PLT 102 x10^3/uL
2023-09-01 PLT 111 x10^3/uL

2023-09-01

For this admission, the patient was initially admitted through the emergency department and this is her first time seeking medical care at this hospital. There are no records available from PharmaCloud and no medication reconciliation issues have been identified.

701352988

231211

[exam findings]

  • 2023-10-19 MRI - pelvis
    • Clinical history: 73 y/o female patient with Peritoneal cancer post Subtotal hysterectomy + Bilateral salpingo-oopherectomy + Pelvic mass excision on 2023/09/18.
    • With and without contrast enhancement MRI: Pelvis:
      • S/P subtotal hysterectomy.
      • Large soft tissue tumors in the pelvic cavity, up to 11.3x7.4cm in the pelvic cavity, could be due to recurrent tumors.
      • Enlarged lymph nodes in the pelvic cavity (obturator, iliac regions and mesentery), r/o lymph nodes metastasis.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • No ascites.
    • Impression:
      • S/P subtotal hysterectomy with recurrent tumors and metastatic lymph nodes.
  • 2023-10-18 Pure Tone Audiometry
    • PTA: Reliability FAIR
    • Average RE 20 dB HL; LE 24 dB HL.
    • Bil normal to moderate.
  • 2023-09-18 Patho - uterus (with or without SO) neoplastic (Y1)
    • PATHOLOGIC DIAGNOSIS
      • Tumor, right pelvic wall, excision — High-grade serous carcinoma
      • Ovary, bilateral, BSO — Free of tumor invasion, corpus albicans
      • Fallopian tube, bilateral, BSO — Free of tumor invasion
      • Endometrium, uterus, subtotal hysterectomy — Free of tumor invasion, endometrial polyps
      • Myometrium, uterus, ditto — Free of tumor invasion, leiomyomas
      • Cervix, uterus, ditto — Not received
      • Lymph node — Not received
      • Initial AJCC Pathologic staging — pT2, if cN0 and cM0, stage II
      • Revised diagnosis: AJCC Pathologic staging — pT2M1b, if cN0, stage IVB
      • Reason for revision: according to the report of S2023-14979 for rectum biopsy
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: subtotal hysterectomy + bilateral salpingo-oopherectomy + pelvic mass excision
      • Specimen type: partial uterus with bilateral adnexa and right pelvic wall tumor
      • Specimen size:
        • R’t ovary: 1.8 x 1.6 x 0.8 cm, normal appearance
        • R’t fallopian tube: 5.2 cm in length, 0.5 cm in diameter, normal appearance
        • Left ovary: 2.2 x 1.2 x 0.9 cm, normal appearance
        • Left fallopian tube: 5 cm in length, 0.4 cm in diameter, normal appearance
        • Uterus: 6.8 x 6.2 x 5.3 cm and 100 gm contains multiple myomas measure up to 4.2 x 3.7 cm and two endometrial polyps measure up to 2 x 0.4 cm
        • Right pelvic wall tumor: five fragments, up to 3.2 x 3.2 x 2.3 cm
      • Tumor site: peritoneum
      • Tumor size: five fragments, up to 3.2 x 3.2 x 2.3 cm
      • Tumor appearance: solid mass
      • Specimen integrity: fragmented
      • Lymph nodes: Not received
      • Representative sections as A1-A5: right pelvic wall tumor, B1: R’t F-tube, B2: R’t ovary, B3: L’t F-tube, B4: L’t ovary, B5-B6: myoma+ endometrial polyps
    • MICROSCOPIC EXAMINATION
      • Histologic type: high-grade serous carcinoma
      • Histologic grade: G3, high grade
      • Contralateral ovary involvement: absent
      • Tumor side ovarian surface involvement: absent
      • Contralateral ovary involvement: absent
      • Right tube involvement: absent
      • Left tube involvement: absent
      • In situ adenocarcinoma in right &/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: absent
      • Left adnexa soft tissue involvement: absent
      • Uterine serosa involvement: absent
      • Uterine Cervix involvement: not received
      • Endometrium involvement: absent
      • Myometrium involvement: absent
      • Lymph nodes metastasis: Not received
      • Immunohistochemistry: CK7(+), WT-1(+), PAX-8(+), P53(+, aberrant expression) and CDX2(-) for tumor
      • Ascites cytology: negative
  • 2023-09-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 30) / 79 = 62.03%
      • M-mode (Teichholz) = 62
    • Conclusion:
      • Normal LV filling pressure.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis; mild TR; mild PR.
  • 2023-08-04 CT - abdomen
    • Indication: rectal malignancy for staging
    • Findings:
      • There is a lobulated heterogeneous enhancing soft tissue mass in the pelvis, measuring 11 cm (the largest dimension), with directly attached the uterus and the rectum, and partial encasement the rectum.
        • Ovarian cancer with rectum invasion is highly suspected.
        • Please correlate with IHC stain of the rectal tumor and laparoscopy.
        • In addition, there are four enlarged nodes in the sigmoid mesocolon that are c/w metastatic nodes.
      • There are several gallstones (< 6 mm).
      • There is a heterogeneous soft tissue mass in left upper mediastinum with calcification component, measuring 9 cm (the largest dimension), that may be intrathoracic goiter.
        • Non-visualization of left lobe thyroid in left thyroid fossa is noted.
        • please correlate with clinical condition.
    • Impression:
      • Ovarian cancer with rectum invasion is highly suspected.
      • Please correlate with IHC stain of the rectal tumor and laparoscopy.
  • 2023-07-28 Patho - colon biopsy (Y2)
    • Intestine, large, rectum, biopsy — adenocarcinoma
    • Microscopically, it shows adenocarcinoma composed of a proliferation of neoplastic cells with solid to glandular architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • IHC stain — CK(+), EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
    • IHC stain — CK20: negative, p53: aberrant-type, PAX-8: positive, WT-1: positive, CK7: positive,
    • NOTE: Based on the result of IHC stain, the tumor is compatible with non-colorectal origin and in favor of ovary origin. However, correlation with image study and clinical findings is recommended.

[MedRec]

  • 2023-09-16 ~ 2023-09-28 POMR Obstetrics and Gynecology Huang SiCheng
    • Discharge diagnosis
      • Peritoneal cancer post Subtotal hysterectomy + Bilateral salpingo-oopherectomy + Pelvic mass excision on 2023/09/18
      • Female pelvic peritoneal adhesions (postinfective)
    • CC
      • Change in bowel habit with mucus passage and tenesmus for months, diarrhea 3-5 times
      • 202308 she was found colonoscope biopsy rectal adenocarcinoma, with elevated CA-125 level (451.3 U/mL); abdomen CT scan revealed ovarian cancer with rectum invasion is highly suspected.
    • Present illness
      • This 73-year-old, G2P2 (vaginal delivery) woman denied any medical history and surgical history.
      • This time, she came to our GI OPD on 2022/04/23 with the complaint of CHANGE IN BOWEL HABITS, WATEREY DIARRHEA 3-5 TIMES FOR SEVERAL MONTHS. She denied body weight loss, decreased appetite, progressively weakness or urinary frequency. Watery stool noted but no tarry or bloody stool. There was no fever, dyspnea, vaginal bleeding or other specific discomfort. No cancer family history was mentioned. Her symptoms didn’t relieved after medication, therefore, further survey was arranged as below:
        • 20230728 colonoscopy: One large polypoid lesion with overlaying mucosa noted at the rectum and parts of the surface had lost micro-surface and microvascular pattern. Rectal subepithelial lesion, R/O malignancy. Biopsy and pathology: adenocarcinoma.
        • 20230804 CEA and CA199: normal, CA125:451.3 U/mL (<35).
        • 20230804 Abdomen CT: Ovarian cancer (enhancing soft tissue mass 11 cm in lengh) with rectum invasion is highly suspected.
      • Under the impression of PELVIC MASS IN WHICH OVARIAN CANCER CANNOT BE EXCLUDED, WITH RECTAL ADENOCARCINOMA, debulking surgery was suggested.
      • On arrival to our ward, the vital signs were stable. Blood test showed Hgb level as 13.9 g/dL, WBC level as 5,700 /uL and albumin level as 4.0 g/dL. We will arranged 2023/09/18 combined GYN (gynecology) debulking surgery with CRS (colon and rectal surgery), and consulted GU (division of urology) for double-J stenting insertion. We will closely follow her condition and complete pre-operation preparation.
    • Course of inpatient treatment
      • The patient was admitted on 2023-09-16 due to pelvic mass suspected ovarian cancer. She underwent subtotal hysterectomy and bilateral salpingo-oopherectomy + pelvic mass excision on 2023-09-18. The pathologic staging —Tumor, right pelvic wall, excision — High-grade serous carcinoma. stage IVB (pathology report: stage II if N0M0; after board conference, confirmed staging IVB).
      • The GYN tumor board conference suggest the patient to receive chemotherapy. Her postoperative course due to elevated D-dimer, Clexane was administered for prophylactic use. Self voiding was smooth. She was discharged on 2023-09-18. Her follow up appointment is scheduled on 2023-10-05.
    • Discharge prescription
      • MgO 250mg 2# QID
      • Acetal (acetaminophen 500mg) 1# QID
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
      • cephalexin 500mg) 1# QID
      • plavix (clopidogrel 75mg) 1# QD
      • tetracycline 15mg/tube TID EXT

[surgical operation]

  • 2023-09-18
    • Surgery
      • Bilateral ureter catheterization
    • Finding
      • Patent bilateral ureter orifices
      • No tumor was noted in the bladder
  • 2023-09-18
    • Surgery
      • Diagnosis:
        • Pelvic mass, origin unspecified, r/o ovarian origin
        • Pelivc adhesion
      • Operation:
        • Subtotal hysterectomy + Bilateral salpingo-oopherectomy + Pelvic mass excision
    • Finding
      • Uterus: normal size, severe pelvic adhesion
      • LAD: grossly normal
      • RAD: grossly normal
      • Right pelvic wall mass, about 6 X 5 cm, papillary content
      • CDS: ascites(-), adhesion (+, severe)
      • Anti-adhesive agent: nil
      • Estimated blood loss: 150ml
      • Blood transfusion: nil
      • Complication: nil
  • 2023-09-18
    • Surgery
      • Exploratory laparotomy
    • Finding
      • A huge hard tumor with irregular shape and densely invasion of pelvia side wall and whole rectum , which is unresectable and difficult to get R0 or R1 resection. We had informed her fanmily this condition, and GYN Dr had got some tissue for definite pathological report. No bowel trauma or leak was noted.

[chemotherapy]

  • 2023-12-09 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-11-10 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-20 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

700136759

231208

[exam findings]

  • 2023-11-30 CT - neck
    • CT scans of the neck from the level of hard palate to the level of infraclavicular region using a 64-sliced multi-detector row volumetric CT after intravenous injection of 100 c.c. iodinated contrast agent.
    • Coronal reformation was performed. The slice thickness is 5 mm.
    • Findings:
      • No identifiable source of infection is seen in the neck.
      • The oral cavity shows no evidence of focal lesion.
      • The mouth floor and submandibular regions are normal. No focal lesion is identified.
      • The salivary and submandibular gland remain intact.
      • No neck lymphadenopathy is visualized.
      • The thyroid appears normal in size and enhancement.
      • Fibrocalcified change over right apical lung, may be old TB.
  • 2023-12-04, -11-27, -11-22 CXR
    • Linear infiltration projecting at both lung is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
    • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
    • Scoliosis of the T-spine with convex to right side.
    • Enlargement of cardiac silhouette.
    • Old fracture of left 7th rib.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-11-23 CT - chest
    • Indication: multiple myeloma, R/O ITP pneumonia over bilateral lungs
    • Chest CT with and without IV contrast ehnancement shows:
      • Diffuse interstitial change at bilateral lung fields with sparing of the peripheral lungs and combined with mild right pleural effusion is found. Pneumonia is considered. Viral or bacterial infection are possible. PCP or CMV infection is less likely.
      • Fibrocalcified lesions are noted at right upper lobe and lu ill-defined opacity is found.
      • Permeative change of the bony structure is found. Multiple myelooma is compatible
    • Imp:
      • Diffuse interstitial change at bilateral lung fields with sparing of the peripheral lungs and combined with mild right pleural effusion is found. Pneumonia is considered.
  • 2023-11-20, -11-17 CXR
    • Linear and patchy infiltration projecting at both lung is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
    • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
    • Scoliosis of the T-spine with convex to right side.
    • Enlargement of cardiac silhouette.
    • Old fracture of left 7th rib.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-11-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (127 - 29.7) / 127 = 76.61%
      • M-mode (Teichholz) = 73.1
      • 2D (M-Simpson) = 67.8
    • Conclusion:
      • Normal AV with mild AR
      • Normal MV with mild MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, dilated IVC size
  • 2023-11-07 Patho - bone marrow biopsy
    • PATHOLOGIC DIAGNOSIS
      • Bone marrow, biopsy — Plasma cell myeloma
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consists of a piece of gray-brown and hard bony tissue, measuring 1.0 x 0.3 x 0.3 cm. All for section after decalcification.
    • MICROSCOPIC EXAMINATION
      • The sections show hypercellular marrow (50%). The marrow space is largely replaced by a population of small to medium-sized immature and mature CD138+ plasma cells, constitue 90% of marrow cells. The plasma cells also shows lambda light chain restriction and negative for kappa light chain .
  • 2023-11-07 Skull AP + Lat.
    • Multiple nodular defects in the skull are suspected. Please correlate with brain CT.
  • 2023-11-07 Long Bones series
    • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
  • 2023-11-06 Patho - bone marrow biopsy
    • Bone marrow, post iliac creast, biopsy — plasma cell myeloma
    • The specimen submitted consists of 1 bone marrow tissue fragment measuring 3.4x 0.2x 0.2 cm in size, fixed in formalin. Grossly, it is brownish and elastic to hard.
    • Microscopically, it shows hypercellularity (about 60%) and marked proliferation of plasma cells (>=70% of bone marrow cellularity). Some mature eryhtroid cells and megakaryocytes are present. No blast is identified.
    • Immunohisotchemical stain reveals CD34(-), CD117(-), CD138 (diffuse +), MPO(+), CD71(focal+), CD61(focal +), Kappa chain(-), lambda chain(+, restriction).
  • 2023-10-20 KUB + L-spine Lat.
    • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
    • S/P posterior longitudinal transpedicular screws and rods fixation with paraspinal bone grafting or disc cage implantation L3-5.
  • 2023-10-13 Patho - interveterbral disc
    • Bone and joint, vertebra, L3-4-5 TPS-RF revision and L3-4 TLIF — Confirmed
    • Specimen submitted in formalin consists of multiple pieces of tan, irregular tissue with the largest piece measuring 1 x 0.5 x 0.3 cm. All tissue for section in one cassette after decalcification.
    • Section shows pieces of bone, degenerated ligament, and cartilage.
  • 2023-10-06 MRI - L-spine
    • Without-contrast multiplanar spine MRI revealed:
      • post-OP change from L4 to L5.
      • high SI chnage on STIR in the sacral multifidus muscles. Moderate to severe atrophic change in the bilateral lower L-spine multifidus muscles, more on the left side was noted.
      • unremarkable change in the visible cord.
      • decreased SI on T2WI in the L2/3, L4/5 and L5/S1 disc spaces; high SI change on T2WI in the L3/4 disc; focal high SI change on T2WI in the posterior aspects of the L5/S1 and L4/5 discs. Herniated disc in the L3/4 disc caused moderate bilateral L3-4 lateral recess stenosis and moderate anterior indentation on the L3-4 thecal sac.
      • hyperemic endplate change in the lower L3 vertebral body and upper S1 vertebral body. Focal high SI change on STIR in the bilateral iliac bones was noted.
      • degenreative change at the L-spine facet joints.
    • IMP
      • moderate bilateral L4-5 lateral recess stenosis;
      • high SI change on bone marrow of the bilateral iliac bones. Please correlate with contrast-enhanced study.
      • r/o discitis in the L3/4 disc.
  • 2023-09-25 Exercise Electrocardiogram, Treadmill exercise test (TET)
    • Findings
      • The patient exercised according to the CORNELL for 11:40 min:s, achieving a work level of max METS: 8.3.
      • The resting heart rate of 70 bpm rose to a maximal heart rate of 146 bpm.
      • This value represents 100 % of the maximal, age-predicted heart rate.
      • The resting blood pressure of 143/77 mmHg, rose to a maximum blood pressure of 146/72 mmHg.
      • The exercise test was stopped due to Target heart rate maximal, Arrhythmias, Fatigue.
    • Conclusion
    • Positive for myocardial ischemia
    • PVCs that develop with exercise
  • 2023-09-25 Bronchodilator Test
    • Normal ventilatory function
    • Not significant bronchodilator reversibility
  • 2023-04-06 ECG - 8C high level
    • Sinus bradycardia with 1st degree A-V block
    • ICRBBB in V2
  • 2023-04-06 Bone densitometry - Hip
    • Hip BMD performed by DXA revealed: Hip, BMD is 0.726 gms/cm2, about 1.8 SD below the peak bone mass (77%) and 0.0 SD at the mean of age-matched people (100%).
    • IMP: osteopenia
  • 2023-04-06 CT - chest
    • Low dose spiral CT of the chest without contrast enhancement for screening of lung tumor showed:
      • Lungs: Fibrotic change at bilateral apical lungs is found. Pleural based nodule at left upper lobe measuring 0.53cm in largest dimension.
    • IMP: Fibrotic change at bilateral apical lungs. Pleural based nodule at left upper lobe.

[MedRec]

  • 2023-10-30 SOAP Cardiology Zhang HengJia
    • S: stable CAD, PAC, PVC, Anxiety possible old TB, has no UAP and DOE is not getting worse, Home BP: WNL, BS: no crackles, no rales, no wheezes, HS: no s3, s4, no sys m, no leg edema, s/p spine op, uneventful
    • A/P: regular exercise and diet control, F/U blood biochemistry, keep current Rx; F/U in 1 m, then she will go back to California
    • Prescription
      • Concor (bisoprolol 5mg) 0.5# QD
      • Bokey (aspirin 100mg) 1# QD
      • Crestor (rosuvastatin 10mg) 0.5# QD
  • 2023-10-11 ~ 2023-10-16 POMR Neurosurgery Li DingZou
    • Discharge diagnosis
      • L3-4 stenosis and spondylolsihtesis, compatable with adjacent syndrome status post L3-4-5 Transpedicular screw fixation revision and L3-4 Transforaminal Lumbar Interbody Fusion on 2023/10/12
      • Postlaminectomy syndrome
      • Cardiac arrhythmia
      • Hyperlipidemia
    • CC
      • Low back and right buttock pain with right knee pain in reccent two months.
    • Present illness
      • This 75-year-old female patient who hyperlipidemia and cardiac arrhythmia umder medicinal control. She complained of low back and right buttock pain with right knee pain in reccent two months. It would be worsened by arising, forward bending or prolonged sitting/standing, and relieved by bed rest. There was intermittent claudication. She visited our neurosurgery clinic for help. L-spine x-ray showed status post L4-5 trans-pedicular screw-rod fixation. Lumbar spine MRI showed L3-4 stenosis and spondylolsihtesis, compatable with adjacent syndrome. We had fully inform to patient and her family about the condition, treatment plan, surgical procedure and risks. She was admitted for revision diskectomy.
      • No trauma history
      • No cancer history        
    • Course of inpatient treatment
      • Post-operative course was uneventful. Analgesic agents was used for wound pain control. Her discomfort was relieved a lot. The wound was clear and dry. She was discharged home and outpatient follow-up was mandatory.
    • Discharge prescription
      • MgO 250mg 1# TID
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# QID
      • Celebrex (celecoxib 200mg) 1# BID
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
      • Lyrica (pregabalin 75mg) 1# BID
      • Toricam (piroxicam 10mg/gm) ASORDER TOPI
  • 2023-10-06 ~ 2023-10-07 POMR Neurosurgery Li DingZou
    • Discharge diagnosis
      • L3-4 spondylolsihtesis, spinals stenosis and compatable with adjacent syndrome.
      • Postlaminectomy syndrome, not elsewhere classified
      • Mixed hyperlipidemia
      • Cardiac arrhythmia, unspecified
      • Anxiety disorder, unspecified
      • Insomnia, unspecified
    • CC
      • low back pain with right knee pain in reccent two months
    • Present illness
      • This 75-year-old female patient who hyperlipidemia and cardiac arrhythmia umder medicinal control. She complained of low back pain with right knee pain in reccent two months. It would be worsened by arising, forward bending or prolonged sitting/standing, and relieved by bed rest. There was intermittent claudication.
      • She visited our neurosurgery clinic. L-spine x-ray showed status post L4-5 trans-pedicular screw-rod fixation. Lumbat spine MRI on schedule.
      • She had serve painful this night. She came to our ER for help. Tramadol IVD st for pain control.
      • Lumbar spine MRI showed L3-4 stenosis/ spondylolsihtesis, compatable with adjacent syndrome. Revision surgery considerated.
      • Previous NSAID was ineffective. She was admitted for pain control.
      • No trauma history
      • No cancer history        
    • Course of inpatient treatment
      • After admission. pain control was given.
      • A MRI at ER showed L3-4 stenosis/spondylolsihtesis, compatable with adjacent syndrome.
      • Explained the image finding to her and her daughter. Revision surgery considerated. Hold Aspirin since today. The surgery is scheduled for next Wednesday. She was arrange discharge today. Re-admission on next Tuesday.
  • 2023-10-06 SOAP Ophthalmology Xu WeiCheng
    • S: 2013-07 glaucoma under xalatan, no discomfort
    • Prescription x3
      • Xalatan (latanoprost 50ug/mL) 1 drop HS OU
      • Ementin (emedastine 2.5mg/5mL) 1 drop BID OU
  • 2023-10-06 SOAP Neurosurgery Li DingZou
    • S: LBP and right knee radiated pain for 2 weeks; ineffective to pain killer; relief by rest;
    • Prescription
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# PRNTID
      • Neurontin (gabapentin 100mg) 1# PRNTID
  • 2023-10-02 SOAP Cardiology Zhang HengJia
    • A: newly Dx of CAD, with mild TET ischemic changes, PFT is WNL
    • P: GDMT with ASA, BB and statin, regular exercise and diet control, F/U in one m
    • Prescription
      • Concor (bisoprolol 5mg) 0.5# QD
      • Bokey (aspirin 100mg) 1# QD
      • Crestor (rosuvastatin 10mg) 0.5# QD
      • Nitrostat (nitroglycerin 0.6mg) 1# ASORDER SL for angina
  • 2023-09-06 SOAP Cardiology Zhang HengJia
    • S: a case of PAC, arrhythmia and DOE referred after health wellness checkup, by TC V Yang Lee Hwua; no UAP, DOE is not getting worse, home BP WNL, BS: no rales, no wheezes, HS: No s3, s4, no systolic murmur, no leg edema, Lab exam: anemia
    • A: Cardiac dysrhythmia, PAVC, PVC, Anxiety possible old TB, Insomnia,
    • P: TET for DOE and chest pain, and PFT for possible restrictive lung, also advise hema clinic W/U for anemia

[consultation]

  • 2023-11-13 Infectious Disease
    • Q
      • for pnrumonia over both lungs
      • This 75-year-old woman, a patient of myltiple myeloma IgG type was diagnosed in Nov 2023.
      • This time, fever with chills and dyspnea were noted and antibiotic with Cefim + Targocid was given and CXR (11/12 23) showed bilateral pnrumonia.
      • We need expertise to evaluate her condition thanks!
    • A
      • 75-year-old multiple myeloma female patient has low grade fever for 6 days during hospitalization, followed by diffuse alveolar infiltrations over both lungs on this morning chest X-ray film, especially right lung.
      • Acute pulmonary edema is the first impression, that IV diuretic recommended first.
      • Pulmonary edema may be related to frequent transfusion and underlying impaired heart function.
      • For possible superimposed pneumonia, patient is receiving Targocid, Mepem and oral Baktar now.
    • Suggestion:
      • Continue the present antibiotic regimen
      • Arrange echocardiography and give diuretic.
      • Follow up CxR 2 days later.
      • Check sputum culture report, PJP-PCR.
  • 2023-10-07 NeuroSurgery
    • Q
      • CC: pain over lower back and right thigh to knee with right leg paralysis and numbness for 2 weeks
        • paralysis, numbness, severe pain over right knee and thigh, cannot walk freely
        • bending down can alleviate the symptoms
      • PHx:
        • lumbar laminectomy L4-5 in TSGH 20 years ago
        • arrthymia
      • lumbar spine X ray and knee X ray already done in clinic –> came here for MRI
    • A
      • A case of 75 y/o female, arrythmia under aspirin tx; s/p L4-5 TPS-RF 20 yrs ago.
      • LBP with right knee pain for weeks.
      • A MRI at ER showed L3-4 stenosis/spondylolsihtesis, compatable with adjacent syndrome.
      • P: pain control; Revision surgery considerated;

[immunochemotherapy]

  • 2023-12-07 - Velcade (bortezomib) 1.3mg/m2 1.9mg ST SC (VTd C1D15)
  • 2023-11-30 - Velcade (bortezomib) 1.3mg/m2 1.9mg ST SC (VTd C1D8)
  • 2023-11-23 - Velcade (bortezomib) 1.3mg/m2 1.9mg ST SC (VTd C1D1)

Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma - 2023-12-01 - https://www.uptodate.com/contents/image?imageKey=ONC%2F101205

  • Cycle length: 28 days.

  • Regimen

    • Bortezomib
      • 1.3 mg/m2 SC
      • Given as a single SC injection.
      • Days 1, 8, 15, and 22
    • Thalidomide
      • 100 mg for first 14 days then 200 mg per day thereafter by mouth.
      • Take with water on an empty stomach at least one hour after the evening meal.
      • Daily, days 1 through 21
    • Dexamethasone (“low dose”)
      • 40 mg by mouth
      • Take with food (after meals or with food or milk) in the morning.
      • Days 1, 8, 15, and 22
  • Pretreatment considerations:

    • Emesis risk
      • MINIMAL TO LOW.
    • Prophylaxis for infusion reactions
      • Routine premedication is not indicated. If a hypersensitivity reaction (not including local reactions) occurs with bortezomib or thalidomide, then neither drug should be readministered.
    • Antithrombotic prophylaxis
      • Routine antithrombotic prophylaxis is warranted. Thromboembolism (grade 3 and 4) was reported in 3% of patients in a clinical trial receiving VTd despite antithrombotic prophylaxis. In addition, reported risk of thromboembolism (grade 3 and 4) was 5% in the Td arm of this study.
    • Infection prophylaxis
      • Bortezomib therapy may be associated with an increased risk of herpes zoster and infections not related to neutropenia. Antiviral prophylaxis (eg, acyclovir 400 mg orally twice a day) should be administered to all patients receiving VTd. Some clinicians also administer trimethoprim-sulfamethoxazole double strength once daily on Mondays, Wednesdays, and Fridays during treatment. Primary prophylaxis with G-CSF is not indicated.
    • Vesicant/irritant properties
      • Bortezomib is an irritant.
    • Dose adjustment for baseline liver or renal dysfunction
      • Bortezomib: No dosage adjustment for bortezomib secondary to renal insufficiency is necessary. For patients undergoing hemodialysis, bortezomib should be administered after dialysis. Patients with moderate or severe hepatic impairment (serum bilirubin level >1.5 times the upper limit of normal) should be started on bortezomib at a reduced dose of 0.7 mg/m2 per injection during the first cycle, with further dose modifications based upon patient tolerance.
      • Thalidomide: Dosage adjustment of thalidomide is not required for either preexisting renal or hepatic dysfunction.
    • Pregnancy warning
      • Thalidomide can result in severe, life-threatening human birth defects. Pregnancy testing is required within 24 hours prior to initiation of thalidomide therapy.

Bortezomib - 2023-11-24 - https://www.uptodate.com/contents/bortezomib-drug-information

  • Multiple myeloma, first-line therapy: Note: Bortezomib regimens also containing melphalan should be avoided in patients who are potential candidates for hematopoietic cell transplantation.
    • VMP regimen: IV, SUBQ: 1.3 mg/m2 on days 1, 4, 8, 11, 22, 25, 29, and 32 of a 42-day treatment cycle for 4 cycles, followed by 1.3 mg/m2 on days 1, 8, 22, and 29 of a 42-day treatment cycle for 5 cycles (in combination with melphalan and prednisone). Retreatment may be considered for patients who had previously responded to bortezomib (either as monotherapy or in combination) and who have relapsed at least 6 months after completing prior bortezomib therapy; initiate at the last tolerated dose.
    • First- line therapy, other dosing/combinations: Note: Refer to protocol for dosage adjustment details.
      • VRd (or RVd) regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with lenalidomide and dexamethasone) for 8 cycles or 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with lenalidomide and dexamethasone) for up to 8 induction cycles, followed by 1.3 mg/m2 on days 1, 8, 15, and 22 of a 42-day treatment cycle (as a single agent) for 4 maintenance cycles or 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with lenalidomide and dexamethasone) for 3 cycles, followed by conditioning/transplant, followed (after hematologic recovery in patients without progression) by 1.3 mg/m2 (or last tolerated dose from cycle 3) on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with lenalidomide and dexamethasone) for 2 cycles.
      • VRd (or RVd) regimen: SUBQ: 1.3 mg/m2 on days 1, 8, 15, and 22 of a 35-day treatment cycle (in combination with lenalidomide and dexamethasone) for 9 induction cycles, followed by 1.3 mg/m2 (or last tolerated dose from cycle 9) on days 1 and 15 of a 28-day treatment cycle (in combination with lenalidomide) for 6 consolidation cycles or 1.3 mg/m2 on days 1, 4, 8, and 11 of a 28-day treatment cycle (in combination with lenalidomide and dexamethasone) for 6 induction cycles (with mobilization after the third induction cycle), followed by conditioning/transplant, followed by 2 additional consolidation cycles 3 months after transplant.
      • VTd regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for 3 induction cycles (in combination with thalidomide and dexamethasone), followed by tandem transplant, followed by (3 months after second transplant) 1.3 mg/m2 on days 1, 8, 15, and 22 every 35 days for 2 consolidation cycles (in combination with thalidomide and dexamethasone).
      • VTd regimen: SUBQ: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with thalidomide and dexamethasone) for 4 induction cycles, followed by conditioning/transplant.
      • CyBorD (or VCd) regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for up to 8 induction cycles (in combination with cyclophosphamide and dexamethasone), followed by 1.3 mg/m2 on days 1, 8, 15, and 22 of a 42-day treatment cycle (as a single agent) for 4 maintenance cycles or 1.5 mg/m2 on days 1, 8, 15, and 22 of a 28-day treatment cycle for 4 cycles (may continue beyond 4 cycles) in combination with cyclophosphamide and dexamethasone.
      • PAD regimen: IV: Induction: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 28-day treatment cycle for 3 cycles (in combination with doxorubicin and dexamethasone), followed by conditioning/transplantation, and then maintenance bortezomib 1.3 mg/m2 once every 2 weeks for 2 years.
      • Daratumumab-containing regimens: SUBQ: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day cycle (in combination with daratumumab, lenalidomide, and dexamethasone; DVRd regimen) for 4 induction cycles and 2 post-transplant consolidation cycles or 1.3 mg/m2 on days 1, 4, 8, and 11 of a 28-day cycle (in combination with daratumumab, thalidomide, and dexamethasone; DVTd regimen) for up to 4 pretransplant induction cycles and 2 posttransplant consolidation cycles or 1.3 mg/m2 two times a week during weeks 1, 2, 4, and 5 of the first 6-week cycle (cycle 1; 8 doses/cycle), followed by 1.3 mg/m2 once a week during weeks 1, 2, 4, and 5 for eight 6-week cycles (cycles 2 to 9; 4 doses/cycle) in combination with daratumumab, melphalan, and prednisone; after cycle 9, daratumumab is continued as a single agent.
      • VD regimen: IV: Induction: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with dexamethasone) for 4 cycles, followed by autologous cell transplantation.
      • Patients ≥65 years of age: IV: 1.3 mg/m2 on days 1, 8, 15, and 22 of a 35-day treatment cycle for 9 cycles, in combination with either melphalan and prednisone or melphalan, prednisone, and thalidomide.
    • Maintenance therapy in transplant-eligible patients (following induction and transplant; in patients intolerant to or unable to receive maintenance therapy with lenalidomide): IV: 1.3 mg/m2 once every 2 weeks for 2 years. For high-risk patients, maintenance therapy with a proteosome inhibitor ± lenalidomide may be considered.
  • Multiple myeloma, relapsed/refractory:
    • Single-agent therapy: IV, SUBQ: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle. Therapy extending beyond 8 cycles may be administered by the standard schedule or may be given once weekly for 4 weeks (days 1, 8, 15, and 22), followed by a 13-day rest (days 23 through 35). Retreatment may be considered for patients who had previously responded to bortezomib (either as monotherapy or in combination) and who have relapsed at least 6 months after completing prior bortezomib therapy; initiate at the last tolerated dose. Administer twice weekly for 2 weeks on days 1, 4, 8, and 11 of a 21-day treatment cycle (either as a single agent or in combination with dexamethasone) for a maximum of 8 cycles.
    • Relapsed or refractory disease, other dosing/combinations: Note: Refer to protocol for dosage adjustment details.
      • VRd (or RVd) regimen: IV: 1 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for up to 8 cycles (in combination with lenalidomide and dexamethasone), followed by maintenance therapy (if response or stable disease) of 1 mg/m2 (or the dose tolerated in cycle 8) on days 1 and 8 of a 21-day treatment cycle (± lenalidomide and/or dexamethasone) until disease progression or unacceptable toxicity.
      • DVd regimen: SUBQ: 1.3 mg/m2 on days 1, 4, 8, and 11 every 21 days (in combination with daratumumab and dexamethasone) for up to 8 cycles.
      • VPd regimen: IV, SUBQ: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for 8 cycles, followed by 1.3 mg/m2 on days 1 and 8 of a 21-day treatment cycle until disease progression or unacceptable toxicity (in combination with pomalidomide and dexamethasone).
      • SVd regimen: SUBQ: 1.3 mg/m2 on days 1, 8, 15, and 22 every 35 days (in combination with selinexor and dexamethasone) until disease progression or unacceptable toxicity.
      • Bortezomib/Doxorubicin (liposomal) regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for at least 8 cycles or until disease progression or unacceptable toxicity (in combination with liposomal doxorubicin).
      • CyBorD (or VCD) regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for up to 8 cycles, followed by 1.3 mg/m2 on days 1, 8, 15, and 22 of a 35-day treatment cycle for up to 3 cycles (in combination with cyclophosphamide and dexamethasone).
      • Bendamustine/Bortezomib/Dexamethasone regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 28-day treatment cycle for 4 cycles (if no response) or for up to a maximum of 8 cycles (in combination with bendamustine and dexamethasone).

==========

2023-12-08

[thrombocytopenia]

The C1D15 dose of Velcade (bortezomib) in the VTd regimen was administered on 2023-12-07. As mentioned in the pharmacist’s note from 2023-12-04, the severe thrombocytopenia observed may not be entirely due to the VTd regimen.

  • 2023-12-07 PLT 49 *10^3/uL
  • 2023-12-04 PLT 16 *10^3/uL
  • 2023-12-01 PLT 33 *10^3/uL

Severe thrombocytopenia, with platelet counts falling below 30K to 50K/uL, significantly increases the risk of bleeding and often necessitates treatment. However, the relationship between platelet count and bleeding risk can vary depending on the underlying condition and may be unpredictable. Therefore, platelet product transfusion may be required in this situation.

2023-12-04

[thrombocytopenia]

Severe thrombocytopenia emerged in mid and late Nov, necessitating multiple blood transfusions.

  • 2023-12-04 PLT 16 *10^3/uL BT (scheduled on 2023-12-05)
  • 2023-12-01 PLT 33 *10^3/uL
  • 2023-11-30 PLT 44 *10^3/uL
  • 2023-11-29 PLT 12 *10^3/uL
  • 2023-11-28 PLT 12 *10^3/uL
  • 2023-11-27 PLT 11 *10^3/uL
  • 2023-11-26 PLT 2 *10^3/uL
  • 2023-11-25 PLT 1 *10^3/uL BT
  • 2023-11-24 PLT 1 *10^3/uL
  • 2023-11-23 PLT 2 *10^3/uL
  • 2023-11-22 PLT 2 *10^3/uL
  • 2023-11-21 PLT 4 *10^3/uL
  • 2023-11-20 PLT 1 *10^3/uL
  • 2023-11-19 PLT 1 *10^3/uL BT
  • 2023-11-18 PLT 3 *10^3/uL
  • 2023-11-17 PLT 1 *10^3/uL
  • 2023-11-15 PLT 2 *10^3/uL
  • 2023-11-13 PLT 6 *10^3/uL BT
  • 2023-11-11 PLT 7 *10^3/uL
  • 2023-11-09 PLT 28 *10^3/uL BT
  • 2023-11-08 PLT 6 *10^3/uL
  • 2023-11-07 PLT 71 *10^3/uL
  • 2023-11-06 PLT 44 *10^3/uL
  • 2023-11-05 PLT 27 *10^3/uL
  • 2023-11-04 PLT 3 *10^3/uL BT
  • 2023-10-16 PLT 79 *10^3/uL
  • 2023-10-14 PLT 93 *10^3/uL BT (2023-10-12)
  • 2023-10-06 PLT 176 *10^3/uL BT
  • 2023-07-12 PLT 172 *10^3/uL
  • 2023-04-06 PLT 180 *10^3/uL

The initial session of the VTd regimen was given on 2023-11-23. Notably, the thrombocytopenia episode was present even prior to this treatment. Anemia and thrombocytopenia are frequent complications in multiple myeloma (MM) patients (Ref: Patients With Multiple Myeloma Have a Disbalanced Whole Blood Thrombin Generation Profile. Front Cardiovasc Med. 2022 Jun 27;9:919495. doi: 10.3389/fcvm.2022.919495. PMID: 35833182; PMCID: PMC9271700). The thrombocytopenia should not be solely attributed to the use of bortezomib.

2023-12-01

[antiviral prophylaxis key to reducing HZ]

Bortezomib therapy may be associated with an increased risk of herpes zoster and infections not related to neutropenia. It is recommended that antiviral prophylaxis (eg, acyclovir 400 mg orally twice a day) should be administered to all patients receiving VTd. Some clinicians also administer trimethoprim-sulfamethoxazole double strength once daily on QW135 during treatment. Primary prophylaxis with G-CSF is not indicated.

700193556

231208

[diagnosis] - 2023-04-18 admission note

  • Malignant neoplasm of retroperitoneum
  • Retroperitoneum extraskeletal Ewing sarcoma, s/p tumor resection 2022/11/18, pT2N0M0, Stage IIIA
  • Chronic viral hepatitis B without delta-agent
  • Hypertension
  • Anxiety disorder, unspecified
  • Generalized anxiety disorder
  • Dysthymic disorder

[past history] - 2023-04-18 admission note

  • Hypertension,under medication control
  • s/p LM on 2018-07
  • Dysthymic disorder,under medication control
  • s/p hernia operation
  • s/p uterine myoma operation
  • TAE, open radical nephrectomy,partial intestine resection were performed on 2022/11/17, 11/18

            

[allergy]

Demerol 50 mg/1 mL/amp (Meperidine):anaphylactic shock

[family history]

Father:DM No cancer, CVA, CAD history in her family

[exam findings]

  • 2023-10-30 Gynecologic ultrasonography
    • R/O Uterine myoma
  • 2023-10-26 KUB
    • Spondylosis with scoliosis of the L-spine with convex to right side
  • 2023-10-26 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
  • 2023-10-05 CT - abdomen
    • History and indication: Retroperitoneum Ewing sarcoma s/p OP and C/T
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P left nephrectomy. S/P Port-A infusion catheter insertion.
      • A patchy density (2.2cm) at RLL.
      • Colonic diverticula.
      • Grade 4 fatty liver with liver cysts (up to 2.2cm).
      • Tiny renal cysts.
      • Gallbladder stones (up to 1.3cm).
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • S/P left nephrectomy. No evidence of tumor recurrence.
  • 2023-07-31 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (88 - 26) / 88 = 70.45%
      • M-mode (Teichholz) = 70.5
    • Conclusion:
      • Mild septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Trivial pulmonary regurgitation; mildly dilated pulmonary trunk (27 mm).
  • 2023-07-10 CT - abdomen
    • Indication: Retroperitoneum extraskeletal Ewing sarcoma
    • Abdominal CT with and without enhancement revealed:
      • There is stone at dependent portion of GB. GB stone(s) are noted. The GB wall is not thickening
      • s/p colon. op.
      • Hepatic cysts at S2 of liver up to 2.0cm in largest dimension is found.
      • s/p left nephrectomy.
    • Imp:
      • s/p left nephrectomy.
      • s/p colon. op.
      • NO evidence of recurrent/residual tumor in the study.
  • 2023-04-12 MRA - abdomen
    • History
      • 20221107 CT: A heterogeneous tumor (8.5cm) at left paraaortic region with mass effect at left kidney causing left hydronephrosis. R/O liposarcoma
      • 20221121 PATHO - Kidney total resection
        • Retroperitoneum, tumor excision — Compatible with extraskeletal Ewing sarcoma/primitive neuroectodermal tumor (PNET)
        • Kidney, left, radical nephrectomy — Focal infarction and free of tumor involvement
        • Pathologic stage: pT2N0G2; Stage IIIA if cM0
        • refer to oncology and RT
    • Findings:
      • S/P left nephrectomy.
      • There are several hepatic cysts in both lobes and the largest one 1.8 cm in size at S3.
      • Two gallstones (up to 1.3 cm) are noted.
      • Tiny renal cysts on right kidney.
      • There is no focal abnormality in the biliary system, pancreas, spleen.
      • There is no evidence of ascites or lymphadenopathy.
      • The abdominal aorta and IVC are grossly unremarkable.
    • IMP:
      • S/P left nephrectomy.
      • There is no evidence of tumor recurrence.
  • 2023-03-15 SONO - nephrology
    • Chronic change with right small sized kidney.
    • Abscent of left kidney.
  • 2023-02-20 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (78 - 24) / 78 = 69.23%
      • M-mode (Teichholz) = 68
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Trivial MR and trivial TR
      • LV diastolic dysfunction, Gr 1
      • Preserved RV systolic function
  • 2022-12-10 SONO - Joint soft tissue
    • Finding:
      • Focal engorgement and non-compressible to probe of left cephalic vein
      • Hyperechoic lesion was noted within left cephalic vein; however, partial flow was still noted
    • Impression And Suggestions:
      • Suspected left cephalic vein thrombosis
  • 2022-11-21 Patho - kidney partial/total resection
    • PATHOLOGIC DIAGNOSIS
      • Retroperitoneum, tumor excision — Compatible with extraskeletal Ewing sarcoma/primitive neuroectodermal tumor(PNET)
      • Kidney, left, radical nephrectomy — Focal infarction and free of tumor involvement
      • Pathologic stage: pT2N0G2; Stage IIIA if cM0
    • MACROSCOPIC EXAMINATION
      • Procedure: Radical nephrectomy + retroperitoneal tumor excision
      • SpecimenSize: 16.5 x 12.3 x 5.6 cm and 590 gm, including left kidney: 9.5 x 5.9 x 4.8 cm and Gerota fascia: 2.5 cm in thickness
      • Tumor Site: Retroperitoneum
      • Tumor Size: 7.0 x 6.2 x 4.5 cm
      • Gross Tumor Pattern: Well circumscribed, dark brown and hemorrhagic mass
      • Representative parts are taken for section and labeled: A1= margins, A3-A10= tumor, A11= Retroperitoneal soft tissue, A12= kidney.
    • MICROSCOPIC EXAMINATION
      • Histologic type: Compatible with extraskeletal Ewing sarcoma/PNET
      • Mitotic rate: 5/10 high power fields
      • Necrosis: Present (5%)
      • Histologic Grade (FNCLCC): Grade 2
        • Tumor Differentiation: Score=3
        • Mitosis Count: Score=1 (0 to 9 mitosis per 10 HPF)
        • Necrosis: Score=1 (<50%)
      • Margins: Free; Distance of sarcoma from closest margin: 0.1 cm
      • Lymphvascular invasion: Present
        • Renal artery invasion: Present
      • Pathologic staging
        • Primary tumor: pT2 (tumor > 5 cm and <=10 cm)
        • Regional lymph nodes: Negative (0/4 regional LN) (Number of involved/Number of examined)
        • Distant metastasis: Not applicable
      • IHC: Cytokeratin(-), LCA(-), S100(-), CD56(focal+), Synaptophysin(-), and CD99(strong and diffuse membrane staining)
      • Kidney: Free of tumor with mild interstitial nephritis and focal infarction
  • 2022-11-21 Patho - small intestine resection for tumore
    • Small intestine, jejunum, segmental resection – Heterotopic pancreas
    • The sections show a picture of heterotopic pancreas, composed of nests of admixture of pancreatic acini, ducts and islets in submucosa and mascularis propria. The adjacent small intestine shows mild acute serositis.
  • 2022-11-17 Embolization (TAE) - abdomen
    • TAE of left renal artery via right common femoral artery puncture using Seldinger technique revealed:
      • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
      • Under local anesthesia, a 4 Fr arterial sheath was inserted into right common femoral artery smoothly.
      • The RH-catheter was inserted into left renal artery.
      • No definite tumor stain.
      • TAE of left renal artery was performed using 10mg some gelfoam pieces.
      • No procedure-related complication during the whole procedure. Thanks for your further care.
  • 2022-11-16 CXR
    • Intimal calcification of thoracic aorta.
  • 2022-11-07 CTA - abdomen
    • History and indication: left retroperitoneal massfor evaluation and surgery
    • With and without contrast CT of abdomen-pelvis revealed:
      • A heterogeneous tumor (8.5cm) at left paraaortic region with mass effect at left kidney causing left hydronephrosis.
      • Colonic diverticula.
      • Grade 4 fatty liver with left liver cyst (1.8cm).
      • Tiny renal cysts.
      • Normal appearance of spleen, pancreas, adrenals.
      • Gallbladder stones (up to 1.3cm).
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • No abnormal density at bilateral basal lungs.
    • IMP:
      • A heterogeneous tumor (8.5cm) at left paraaortic region with mass effect at left kidney causing left hydronephrosis.
  • 2022-10-31 Whole body PET scan
    • The left retroperitoneal tumor shown on the previous abdomen MRI reveals mildly increased FDG uptake; the nature is to be determined (liposarcoma or others ?), suggesting biopsy for further investigation.
    • Glucose hypermetabolic lesions in the esophagus, D/3 and bilateral palatine tonsils, probably chronic inflammation process, suggesting follow-up.
    • Glucose hypermetabolism in level II lymph nodes of bilateral cervical regions, probably reactive nodes.
    • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    • No other focal area of abnormal increased FDG uptake from head to bilateral thigh regions.
  • 2022-10-29 Gynecologic ultrasonography
    • Uterus Position: AVF
      • Size: 69 x 33 mm
    • Endometrium
      • Thickness: 4.0 mm
    • Cul-De-Sac: No fluid
    • Bilateral adnexae: free
    • IMP: EM 4.0 mm
  • 2022-10-13 Myocardial perfusion SPECT with treadmill
    • The Tc-99m MIBI stress myocardial perfusion SPECT performed after stress revealed mildly decreased perfusion of radioactivity to the apex of LV. The Tc-99m MIBI rest myocardial perfusion SPECT revealed reperfusion of radioactivity to the defect. The stress and rest LVEFs were 90% and 90%, respectively. The cine wall motion study revealed synchronized contraction of LV.
    • IMPRESSION:
      • Probably mild myocardial ischemia at the apex of LV.
      • Normal performance of global LV cardiac function.
  • 2022-10-13 CT - low dose for lung cancer screening, without contrast
    • Low dose spiral CT of the chest without contrast enhancement for screening of lung tumor showed:
      • Lungs: Paraspinal fibrotic change at right lower lobe is found.
        • Minimal wedge shaped infiltration at left lower lobe, r/o recent inflammation.
    • IMP: Right lower lobe paraspinal fibrosis. Suspected focal fibrosis at left lower lobe
  • 2022-10-13 MRI - cerebrovascular
    • Without-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial FLAIR images and axial DWI), cerebral TOF MRA revealed:
      • Mild brain atrophic change. Mild periventricular white matter small vessel disease.
      • Tortuosity of intracranial and extracranial arteries in MRA studies (including bilateral subclavian arteries, CCAs, ICAs, ECAs, MCAs, ACAs, PCAs and VAs and BA).
    • IMP: Mild Brain atrophy. Mild periventricular white matter small vessel disease. Mild arteriosclerosis with vessel tortuosity.
  • 2022-10-13 MRI - upper abdomen with and without contrast
    • Imaging study of upper abdomen for health examination revealed:
      • Retroperitoneal soft tissue mass about 7.3cm in largest dimension at left side with heterogenoeus appearance, suspected liposarcoma or others.
      • Hepatic cyst at left lobe liver up to 2.1cm is found.
    • IMP:
      • Retroperitoneal tumor at left side, 7.3cm, r/o liposarcoma. Suggest further treatment.
  • 2022-04-16 Gynecologic ultrasonography
    • Uterus Position: AVF
      • Size: 58 x 35 mm
    • Endometrium
      • Thickness: 3.2 mm
    • Cul-De-Sac: No fluid
    • Bilateral adnexae: free
    • IMP: EM 3.2 mm
  • 2020-08-08 Gynecologic ultrasonography
    • Uterus Position: AVF
      • Size: 55 x 33 mm
    • Endometrium
      • Thickness: 4.3 mm
    • Cul-De-Sac: No fluid
    • Bilateral adnexae: free
    • IMP: EM 4.3 mm

[MedRec]

  • 2023-10-25 SOAP Infectious Disease Peng MingYe
    • S: Right leg dog bite 3 days ago, now wound healing, no surrounding erythema or swelling
    • A: No sign of wound infection or cellulitis, topical Biomycin first
    • Prescription
      • Biomycin (neomycin, tyrothricin) BID TOPI
  • 2023-02-17 ~ 2023-02-21 POMR Hemato-Oncology
    • Discharge diagnosis
      • Malignant neoplasm of retroperitoneum
      • Retroperitoneum sarcoma, pT2N0G2; Stage IIIA if cM0
      • Positve of anti-HBc
      • Anxiety
    • Present illness
      • This is a 59-year-old female with past history of
        • Hypertension, under medication control
        • s/p LM on 2018-07
        • Dysthymic disorder, under medication control
        • s/p hernia operation
        • s/p uterine myoma operation
      • According to the patient,left kidney tumor was noted after examination. She came to our uro OPD for further examination. MRI showed Retroperitoneal tumor at left side, 7.3cm, r/o liposarcoma.Surgery was suggested.
        • 2022/10/31 PET scan showed 1. The left retroperitoneal tumor shown on the previous abdomen MRI reveals mildly increased FDG uptake; the nature is to be determined (liposarcoma or others ?) 2. Glucose hypermetabolic lesions in the esophagus, D/3 and bilateral palatine tonsils, probably chronic inflammation process, suggesting follow-up. 3. Glucose hypermetabolism in level II lymph nodes of bilateral cervical regions, probably reactive nodes. 4. Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
        • 2022/11/07 Abdomen CTA showed a heterogeneous tumor (8.5cm) at left paraaortic region with mass effect at left kidney causing left hydronephrosis.
        • 2022/11/17 Abd TAE was done and smooth.
        • 2022/12/26 Focal engorgement and non-compressible to probe of left cephalic vein showed suspected left cephalic vein thrombosis.
      • RT to the preOP tumor bed (Lt kidney region): 36 Gy/ 18 fx since 2022/12/14-2023/01/22.
      • Under the impression of Retroperitoneum sarcoma, pT2N0G2; Stage IIIA if cM0, so she was admission for adjuvant C/T on 2023/02/17.
    • Course of inpatient treatment
      • After admission, she received Baraclude 0.5mg/tab (Entecavir) 1# qdac for postive og anti-HBc. Anxiety improves after session with psychologist before chemotherapy. Regimen Q3W as alternating between team A and B every three weeks for approximately 17 times.
        • Team A = Vincristin 2mg (D1) 10 mins + Adriamycin 37.5mg/m2 (D1-D2) 15 mins + Endoxan 1200mg/m2 (D1) 1 hour on 2023/2/20-2/21.
        • Team B = IFx 1800mg/m2 (D1-D5) drip 1 hour + VP-16 100mg/m2 (D1-D5) drip 1-2 hrs (next time).
      • Under the stable condition without GI tract problem, so she can be discharge on 2023/02/21. OPD follow up is arranged.
  • 2023-01-19 SOAP Hemato-Oncology
    • O: s/p adjuvnat R/T with 44 Gy/ 22 fx to the pre-OP tumor bed, from 2202-12-13 or -14 to 2023-01-12
  • 2022-12-22 SOAP Hemato-Oncology
    • A/P
      • Strategy: Adjuvant R/T followed by adjuvant C/T
      • Already suggest discuss with her psychiatrist for the phobia of C/T
  • 2022-12-06 SOAP Radiation Oncology
    • Plan: Adjuvant RT then adjuvant C/T is suggested. CT-simulation will be arranged on 2022/12/08. Plan to deliver 44~45 Gy/ 22~25 fx to the preOP tumor bed. RT will start around 12/12 or 13.

[consultation]

  • 2023-03-15 Nephrology
    • Q
      • This is a 59-year-old female with past history of
        • Hypertension, under medication control
        • s/p LM on 2018-07
        • Dysthymic disorder, under medication control
        • s/p hernia operation
        • s/p uterine myoma operation.
      • Retroperitoneum sarcoma, pT2N0G2; Stage IIIA if cM0, she received adjuvant chemotherapy on 2023/02/20-21(C1).
        • Regimen Q3W as alternating between team A and B every three weeks for approximately 17 times.
          • Team A = Vincristin 2mg (D1) 10mins + Adriamycin 37.5mg/m2 (D1-D2) 15mins + Endoxan 1200mg/m2 (D1) 1hour on 2023/2/20-2/21.
          • Team B = IFx 1800mg/m2 (D1-D5) drip 1hour + VP-16 100mg/m2 (D1-D5) drip 1-2hrs (next time).
      • This time, she suffered from poor intake for 2 weeks. Blood analysis showed Impaired renal function (BUN/Cr: 39/2.19 mg/dl and hyperkalemia: 5.2 mmol/L)
      • For acute kidney injury, favor dehydration due to poor intake related, we need your further evaluation and management.
    • A
      • This 59-year-old madam with a history of retroperitoneum sarcoma, s/p operation, pT2N0G2; Stage IIIA if cM0, received adjuvant chemotherapy (Vincristine, Adrimycin, Endoxan) on 2023/2/20-21(C1). I’m consulted for impaired renal function. The patient stated her appetite was decreasing after last hospitalization, but she tried to drink water around 2000ml per day and she ate fish, eggs and mild with salty flavor recently. She has started taking Entecavir and Chinese herbal medicine recently. She denied use of medications from other hospital, LMD or pharmacy. She also did not use of NSAIDs recently. There’s no fever, chills, diarrhea, decreasing urine output, or obvious body weight loss. Renal echo on 2023/03/15 shows no evidence of hydronephrosis of right kidney.
      • Impression: AKI, dehydration? Medication (Chinese herbal medicine or entecavir)?
      • Suggestion:
        • Hydration with saline based intravenous fluid, such as D5S or NS and follow up her renal function. You could also follow up serum calcium next time while checking the laboratory data.
        • Check urinalysis.
        • May temporarily discontinuation of Chinese herbal medicine if renal funcition dose not improve or even worse.
      • Thank you for your consultation. I’ll follow up this patient.
  • 2022-11-24 Cardiology
    • Q
      • For hypertension control
      • This is a 59-year-old female with past history of
        • Hypertension, under Norvasc 1# QD, Cardiolol 1# QD (previously PRNQD), Atanaal PRNQ8H, control
        • s/p LM on 2018-07
        • Dysthymic disorder
        • s/p hernia operation
        • s/p uterine myoma operation
      • This time she was admitted for TAE (2022/11/17) and open radical nephrectomy (2022/11/18).
      • In recent 4 days,her BP control was not good,highest up to 180-190.
      • She suffered from stomache distension, GERD-like sensation,nausea, vomitting in recent three days. Pantoprazole and imperan was prescribed
      • 2022/11/21: Creatinine: 1.37, eGFR: 41.94, CrCl 48, height: 158cm, weight: 72.4kg
      • We consult for your further evaluation and management, thank you!
    • A
      • I was consulted for poor BP control
      • O
        • Formerly controoled with Norvasc 1# QD and inderal 1# QD
        • Lab
          • 2022-11-21 BUN 8 mg/dL
          • 2022-11-21 Creatinine 1.37 mg/dL
          • 2022-11-19 BUN 26 mg/dL
          • 2022-11-19 Creatinine 1.94 mg/dL
        • EKG: NSR
        • CXR: normal heart size
      • Impression:
        • Hypertension, poor contorl
      • Sugggestion:
        • The causes of poor control of BP during admission, including insomnia, pain, NS hydration, abdomen distension and any other discomfort, if present such problem, please correct it.
        • May uptitrate Norvasc to 1# BID PO
        • if high BP > 150/90 mmHg still, may add Carvedilol (6.25) 1# BID PO
  • 2022-11-22 Psychosomatic medicine
    • Q
      • For post-op anxiety evaluation and medication adjustment.
      • This is a 59-year-old female with past history of
        • Hypertension,under medication control
        • s/p LM on 2018-07
      • She had regular follow up in our psy OPD before, and was diagnosed with dysthymic disorder, and GAD.
      • Medication Zoloft 1# QD and Eurudin 0.5# HS was used now.
      • This time,under the impression of left kidney tumor, suspected liposarcoma, she was admitted to our ward for scheduled TAE (2022/11/17), open radical nephrectomy and resection of segmental of small intestine (2022/11/18).
      • After operation, she complained about having nightmare during these days. She was abnormally sensitive to pain and very scared, even scared of nurses.
      • She is in a very anxious mood. We consulted for your further evaluation and management, thank you!
    • A
      • This 59 y/o married woman, now still work as an administrative staff, has been followed up in our PSY OPD since 2020/07 for low and anxious mood, anhedonia, insomnia, psychomotor retardation, muscle tension, distracted attention, fatigue, guilty feeling or inattention, suicidal and negative thinking for more than 6 months. Stressor: the passing of her mother at that time. After regularly took meds in our PSY OPD, her mood symptoms improved, but still has decreased sleep lasting: only sleeping for 3 hours, because she didn’t want to rely on sleeping pills, she took only half a tablet of Eurodin.
      • In recent few days, she developed low and anxious, even agitated mood, hypervigilance, decreased frustration tolerance, phobic and avoidant behaviors, guilty feelings, worthlessness feelings, grief reaction, suicidal ideation, rumination of the past events, following the stressors: her father passed away recently, she has to be hospitalized and can’t participate in the funeral arrangements, experienced sudden pain during TAE and was shocked by the doctor’s reaction, felt terrible because she was too scared and it took three attempts to complete the examination, felt extremely nervous and scared about undergoing invasive treatments, cried when the TAE area hurt, and thought about jumping off a building at that time.
      • She also had transient VH following the procedure, seeing ice cream and SpongeBob. (ChatGPT: In the context of psychology or psychotherapy, “VH” typically stands for “vividness of mental imagery” or “vividness of hallucinations.”)
      • MSE: tearfulness, low and anxious mood, distressful feelings, anticipatory anxiety about the following procedure: removing stitches.
      • IMP:
        • Adjustment reaction with anxious and fearfulness mood
        • r/o Persisted depressive disorder
        • Generalized anxiety disorder
      • Suggestion:
        • Carthasis and mental support, discuss the coping skill.
        • Keep Zoloft and Eurodin. Anxiedin 0.5mg 1# BID. Alprazolam 0.5mg 1# PRNQ8H if anxious or before procedure.
        • Arrange PSY OPD follow up.
  • 2022-11-18 Diagnostic Radiology
    • Q
      • This is a 59-year-old female with past history of
        • Dysthymic disorder
        • s/p hernia operation
        • s/p uterine myoma operation
      • This time she was admitted for TAE and open radical nephrectomy.
      • 2022/10/13 MRI: Retroperitoneal soft tissue mass about 7.3cm in largest dimension at left side with heterogenoeus appearance, r/o liposarcoma or others
      • 2022/11/07 CTA: Retroperitoneal soft tissue mass about 7.3cm in largest dimension at left side with heterogenoeus appearance, r/o liposarcoma, suspect Psoas muscle invsion and renal vessel invasion.
      • We consulted for left kidney and Tumor TAE,thank you !
    • A
      • According to the clinical history and imaging findings, TAE is indicated.

[chemotherapy]

  • 2023-12-08 - vincristine 2mg NS 50mL 10min D1 + cyclophosphamide 1200mg/m2 2000mg NS 500mL 1hr D1 (omitting doxorubicin for single kidney and SOB)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-01 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 1650mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 120mg NS 500mL 2hr] D1-3 (less ifosfamide)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
  • 2023-09-22 - vincristine 2mg NS 50mL 10min D1 + cyclophosphamide 1200mg/m2 2000mg NS 500mL 1hr D1 (omitting doxorubicin for single kidney and SOB)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-25 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 1650mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 120mg NS 500mL 2hr] D1-3 (less ifosfamide)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
  • 2023-07-26 - vincristine 2mg NS 50mL 10min D1 + doxorubicin 37.5mg/m2 60mg NS 100mL 15min D1-2 + cyclophophamide 1200mg/m2 2000mg NS 500mL D1
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL + aprepitant 125mg D1-3
  • 2023-07-06 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 1650mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 120mg NS 500mL 2hr] D1-3 (less ifosfamide)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
  • 2023-06-19 - vincristine 2mg NS 50mL 10min D1 + doxorubicin 37.5mg/m2 60mg NS 100mL 15min D1-2 + cyclophophamide 1200mg/m2 2000mg NS 500mL D1
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL + aprepitant 125mg D1-3
  • 2023-05-24 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 2000mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 130mg NS 500mL 2hr] D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
  • 2023-04-18 - vincristine 2mg NS 50mL 10min D1 + doxorubicin 37.5mg/m2 60mg NS 100mL 15min D1-2 + cyclophophamide 1200mg/m2 2000mg NS 500mL D1
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL + aprepitant 125mg D1-3
  • 2023-03-20 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 2000mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 130mg NS 500mL 2hr] D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
  • 2023-02-20 - vincristine 2mg NS 50mL 10min D1 + doxorubicin 37.5mg/m2 60mg NS 100mL 15min D1-2 + cyclophosphamide 1200mg/m2 2000mg NS 500mL D1
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

Granocyte (lenograstim 250ug) CGRAN01

  • 2023-04-23 3# 2023-04-18 IPD
  • 2023-03-28 3# 2023-03-28 OPD
  • 2023-03-27 3# 2023-03-14 IPD
  • 2023-03-25 2# 2023-03-25 EPD
  • 2023-03-24 2# 2023-03-14 IPD
  • 2023-03-14 1# 2023-03-14 IPD
  • 2023-03-07 2# 2023-03-07 OPD
  • 2023-03-01 3# 2023-03-01 OPD

WBC

  • 2023-04-11 WBC 6.19 x10^3/uL 2023-04-23 G-CSF x3
  • 2023-03-28 WBC 1.93 x10^3/uL * 2023-03-28 G-CSF x3
  • 2023-03-23 WBC 2.23 x10^3/uL * 2023-03-24 G-CSF x2, 2023-03-25 G-CSF x2, 2023-03-27 G-CSF x3
  • 2023-03-20 WBC 12.17 x10^3/uL 2023-03-20 ifosfamide + etoposide
  • 2023-03-19 WBC 28.21 x10^3/uL
  • 2023-03-17 WBC 1.99 x10^3/uL *
  • 2023-03-14 WBC 3.29 x10^3/uL 2023-03-14 G-CSF x1
  • 2023-03-07 WBC 2.41 x10^3/uL * 2023-03-07 G-CSF x2
  • 2023-03-01 WBC 0.35 x10^3/uL * 2023-03-01 G-CSF x3
  • 2023-02-17 WBC 3.17 x10^3/uL 2023-02-20 vincristine + doxorubicin + cyclophosphamide
  • 2023-01-19 WBC 3.65 x10^3/uL

VDC/IE (vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide) - Bone Cancer - Version 3.2023 - 2023-04-04 - https://www.nccn.org/professionals/physician_gls/pdf/bone.pdf - BONE-B, 2 OF 6, p27

  • ref
    • Addition of ifosfamide and etoposide to standard chemotherapy for Ewing’s sarcoma and primitive neuroectodermal tumor of bone. N Engl J Med 2003;348:694-701.
    • Randomized controlled trial of interval compressed chemotherapy for the treatment of localized Ewing sarcoma: A report from the Children’s Oncology Group. J Clin Oncol 2012;30:4148-4154.

Treatment for Localized Disease, Neoadjuvant chemotherapy - Treatment of Ewing sarcoma - 2023-06-20 - https://www.uptodate.com/contents/treatment-of-ewing-sarcoma

  • Interval-compressed VDC/IE
    • For patients age < 18 years with localized ES, we recommend interval-compressed therapy with alternating cycles of vincristine/doxorubicin/cyclophosphamide (VDC) and ifosfamide/etoposide (VDC/IE) given every two weeks with hematopoietic growth factor support, rather than every three weeks without growth factor support.

Interval compressed chemotherapy for Ewing sarcoma - 2023-06-20 - https://www.uptodate.com/contents/image?imageKey=ONC%2F110260

  • ref
  • Induction chemotherapy
    • Regimen A
      • Timing
        • Weeks 1, 5, and 9
      • Drug
        • Vincristine
          • 2 mg/m2 (maximum 2 mg)
          • IV over 1 minute
          • day 1
        • Doxorubicin
          • 37.5 mg/m2
          • IV over 1 to 15 minutes
          • days 1 and 2
        • Cyclophosphamide
          • 1200 mg/m2
          • IV over 30 to 60 minutes
          • day 1, with mesna
        • Filgrastim
          • 5 mcg/kg per day (maximum 300 mcg)
          • starting day 3
            • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.
    • Regimen B
      • Timing
        • Weeks 3, 7, and 11
      • Drug
        • Ifosfamide
          • 1800 mg/m2
          • IV over 1 hour
          • days 1 to 5, with mesna
        • Etoposide
          • 100 mg/m2
          • IV over 1 to 2 hours
          • days 1 to 5
        • Filgrastim
          • 5 mcg/kg per day (maximum 300 mcg)
          • starting day 6
            • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.
  • Consolidation chemotherapy (Local therapy between weeks 13 and 15. Surgery at week 13, if it is planned. Start of RT delayed to week 15 if surgery also undertaken.)
    • Regimen A
      • Timing
        • Surgery alone - Weeks 15 and 19
        • RT alone - Weeks 13 (with the start of RT) and 25
        • Surgery and RT - Weeks 15 (with the start of RT) and 27
      • Drug
        • Vincristine
          • 2 mg/m2 (maximum 2 mg)
          • IV over 1 minute
          • day 1
        • Doxorubicin
          • 37.5 mg/m2
          • IV over 1 to 15 minutes
          • days 1 and 2
        • Cyclophosphamide
          • 1200 mg/m2
          • IV over 30 to 60 minutes
          • day 1, with mesna
        • Filgrastim
          • 5 mcg/kg per day (maximum 300 mcg)
          • starting day 3
            • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.
    • Regimen B
      • Timing
        • Surgery alone - Weeks 17, 21, 25, and 29
        • RT alone - Weeks 15, 19, 23, and 27
        • Surgery and RT - Weeks 17, 21, 25, and 29
      • Drug
        • Ifosfamide
          • 1800 mg/m2
          • IV over 1 hour
          • days 1 to 5, with mesna
        • Etoposide
          • 100 mg/m2
          • IV over 1 to 2 hours
          • days 1 to 5
        • Filgrastim
          • 5 mcg/kg per day (maximum 300 mcg)
          • starting day 6
            • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.
    • Regimen C
      • Timing
        • Surgery alone - Weeks 23 and 27
        • RT alone - Weeks 17 and 21
        • Surgery and RT - Weeks 19 and 23
      • Drug
        • Vincristine
          • 2 mg/m2 (maximum 2 mg)
          • IV over 1 minute
          • day 1
        • Cyclophosphamide
          • 1200 mg/m2
          • IV over 30 to 60 minutes
          • day 1, with mesna
        • Filgrastim
          • 5 mcg/kg per day (maximum 300 mcg)
          • starting day 3
            • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.

==========

2023-12-08

[reconsidering doxorubicin in VDC/IE regimen for enhanced efficacy]

The VDC/IE regimen typically includes doxorubicin as a component, but it has been excluded since 2023-09-22. Given that the last 2D echocardiography on 2023-07-31 showed a LVEF of 70% with no apparent cardiotoxicity from doxorubicin, reintroducing doxorubicin could be considered if the patient tolerates it well. This would ensure the completeness of the regimen and potentially enhance its therapeutic effectiveness.

The patient’s condition of having a single kidney should not necessitate the omission of doxorubicin, as there is no requirement for dosage adjustment of doxorubicin for any level of kidney impairment.

The risk of cardiomyopathy associated with doxorubicin is related to the cumulative dose, with incidences ranging from 1% to 20% for cumulative doses between 300 mg/m2 and 500 mg/m2. According to our hospital records, the patient’s cumulative dose is still significantly below 300 mg/m2. Additionally, the chemotherapy preparation room is vigilant in monitoring cumulative doses, ensuring they do not exceed the safe lifetime limit, and will notify the relevant parties as the patient approaches this threshold.

2023-07-27

Upon review of the PharmaCloud database and hospital HIS5 records, no medication reconciliation issues were identified.

[leukopenia and anemia]

The administration of the alternating chemotherapy regimen of VDC/IE and the nadir of WBC (< 1K/uL) and HGB (< 9g/dL) are as follows. It seems that the trough of WBC occurs around the 10th day after the administration of VDC, indicating a stronger correlation with VDC in terms of timing than with IE. As for HGB, the changes are not as dramatic as for WBC, but it can be confirmed that during the patient’s receipt of the VDC/IE regimen, the overall HGB level shows a decreasing trend. In addition, it’s worth mentioning that the patient received several transfusions and G-CSF during the treatment period, which are also factors influencing WBC and HGB.

2023-07-26 VDC regimen 2023-07-12 HGB 7.9 g/dL 2023-07-06 IE regimen 2023-06-28 WBC 0.16 x10^3/uL 2023-06-28 HGB 8.1 g/dL 2023-06-19 VDC regimen 2023-06-01 HGB 8.6 g/dL 2023-05-24 IE regimen 2023-04-27 WBC 0.33 x10^3/uL 2023-04-18 VDC regimen 2023-03-20 IE regimen 2023-03-17 HGB 8.7 g/dL 2023-03-01 WBC 0.35 x10^3/uL 2023-02-20 VDC regimen

2023-06-20

  • Based on the PharmaCloud database, all of this patient’s medical requirements have been addressed at our hospital over the past three months. Therefore, we have not identified any issues related to medication reconciliation.
  • The patient is currently undergoing an alternating chemotherapy regimen of VDC/IE, and has been admitted for her 3rd round of VDC treatment during this hospitalization. Although no instances of hemorrhagic cystitis have been reported after the first two doses of cyclophosphamide, the protocol of the source trial for this treatment (http://ascopubs.org/doi/suppl/10.1200/jco.2011.41.5703/suppl_file/Protocol_JCO.2011.41.5703.pdf) specifically mandates the use of mesna with cyclophosphamide and ifosfamide (see page 11). If the decision is made to continue administering cyclophosphamide without mesna, it would be prudent to increase the patient’s hydration and strongly encourage frequent voiding.

2023-04-19

  • To prevent potential neutropenia, granulocyte colony-stimulating factor (G-CSF) is prescribed prophylactically.
  • This patient primarily seeks medical care at our hospital, and no medication reconciliation issues have been found for the time being.

700599605

231208

[exam findings]

  • 2023-12-20 CT - chest
    • Indication: right breast cancer s/p chemotherapy dyspnea r/o ILD
    • Chest and abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Lungs: areas of decreased attenuation at RML, LLL, and RLL.
        • linear opacities at lower medial region of RLL.
      • Mediastinum and hila: no enlarged LN or mass.
        • the trachea and main bronchi are normallly identified without endobronchial lesion.
      • Vessels:
        • the great vessels in the hila and mediastinum are normal in distribution and appearance. no coronary arterial calcificatiion.
      • eart: normal size of cardiac chambers.
      • Chest wall and visible lower neck: s/p Lt mastectomy.
      • Visible abdominal contents:
        • unremarkable of the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
      • Visualized bones: unremarkable.
    • Impression:
      • suspect mild obstructive small airway disease in lungs.
      • mild linear atelectasis or interstial inflammation at lower medial region of RLL.
  • 2023-08-31, -03-16 SONO - abdomen
    • Fatty metamorphosis of pancreas
    • Mild fatty liver.
  • 2023-07-18 Patho - breast biopsy (no need margin)
    • Breast, left, core needle biopsy — Chronic inflammation, fibrosis, and hematoma
  • 2023-07-17 Patho - soft tissue debridement
    • Breast, right, debridement — mastitis with necrosis
  • 2023-04-12 Patho - breast simple/partial mastectomy
    • PATHOLOGIC DIAGNOSIS
      • Tumor, R’t breast, nipple sparing simple mastectomy — Invasive carcinoma of no special type with focal neuroendocrine differentiation, 10%
      • Skin and nipple, ditto — Free of tumor invasion
      • Surgical margins and base, ditto — Free of tumor invasion, 0.3 cm at closest base margin
      • Lymph nodes, R’t axillary, dissection — Free of tumor metastasis (0/5)
      • AJCC Pathologic Anatomic Stage — pT2N0, if cM0, stage IIA; Prognostic Stage — Stage IA
    • MACROSCOPIC EXAMINATION
      • Breast: 18.3 x 16.3 x 5.2 cm
      • Skin: 13.9 x 4.9 cm
      • Nipple: detached, 1.7 x 1.2 x 1.0 cm
      • Tumor: 3.3 x 2.7 cm
      • Resection margins: Free, 0.3 cm away from closest base
      • Representative sections as follows: A1: nipple, A2: four unlabelled peripheral margins, A3: base, A4–A6: lesion at skin site, A7: skin, A8-A9: non-tumor breast, A10-A14: tumor [Reference: F2023-00159, FSA1-A2: R’t axillary sentinel LNs, FSB: breast safety margin, FSC: tumor site safety margin]
    • MICROSCOPIC EXAMINATION
      • Histologic type: Invasive carcinoma of no special type with focal neuroendocrine differentiation, 10%
      • Size of invasive carcinoma: 3.3 x 2.7 cm
      • Histologic grade (Nottingham histologic score): grade II (score 6) including (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1
      • Margins: Free, 0.3 cm from closest base margin and at least 3.6 cm away from unlabelled peripheral margins
      • Nodal status: free of tumor metastasis (0/5)
      • Treatment Effect: N/A
      • Lymphovascular space invasion: Present
      • Perienural invasion: not identified
      • Lesion at skin site: 0.9 x 0.6 cm, ruptured epidermal cyst with foreign body reaction and abscess
      • Immunohistochemistry:
        • Please refer to S2023-05808
        • E-cadherin(+), synaptophysin(+, focal), chromogranin-A(-) and P63(-) for tumor
  • 2023-04-10 CT - abdomen
    • Findings
      • Heterogeneous density of pancreatic head and body. Some LNs at hepatic hilar region.
      • A nodule (1.1cm) at duodenum.
      • Liver cysts (up to 0.6cm).
      • Cystic lesions (1.2cm, 3.5cm) at bil. adnexa.
      • Duodenal diverticulum.
    • IMP:
      • Heterogeneous density of pancreatic head and body. Some LNs at hepatic hilar region.
      • A nodule (1.1cm) at duodenum.
  • 2023-03-28 Patho - breast biopsy (no need margin)
    • Breast, right, 11 o’clock, core needle biopsy — Invasive carcinoma of no special type
    • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in solid to ductal architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic activity.
    • Immunohistochemical study demonstrates:
      • ER: positive (moderate, 95%)
      • PR: positive ( strong, 90%)
      • Her2/neu: negative (1+)
      • Ki-67 inedex: 30%
      • E-cadherin: positive
      • p63:negative.
  • 2023-03-22 Tc-99m MDP bone scan
    • Faint hot spots in both rib cages, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, mandible, a lower C or upper T-spine, left sternoclavicular junction, bilateral shoulders, S-I joints, hips, knees, and feet.
  • 2023-03-14 Patho - breast biopsy (no need margin)
    • DIAGNOSIS:
      • Breast, right, 1 o’clock, core needle biopsy — Invasive carcinoma of no special type
      • Breast, right, 11 o’clock, core needle biopsy — fibrocystic change
    • Immunohistochemical study demonstrates
      • ER: positive (strong, > 95%),
      • PR:positive (moderate, 80%),
      • Her2/neu: negative (1+),
      • p63: negative,
      • Ki-67 inedex: 10%.

[MedRec]

  • 2023-12-20 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • S: Zoladex (goserelin) 3M since 2023-12-20
    • A: Dermatitis, hand foot syndrome after chemotherapy
    • Prescription x3
      • Nolvadex (tamoxifen citrate 10mg) 1# BID
  • 2023-11-06 SOAP Gastroenterology Chen JianHua
    • Prescription x3
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
  • 2023-10-26 ~ 2023-10-31 POMR Plastic and Reconstructive Surgery Wei LinGui
    • Discharge diagnosis
      • Cellulitis over medial supra-malleolar region of right lower leg
      • Right breast invasive carcinoma, pT2N0M0, stage IIA. ER(95%) PR(90%) HER(1+) Ki67:30%. ECOG:1
      • Carrier of viral hepatitis B
    • CC
      • Suffered from right leg redness for a month ago
    • Present illness
      • This 42-year-old female patient was a viral hepatitis B carrier for 10 years with regular medicine control.
      • She also was a victim of Right breast invasive carcinoma s/p simple mastectomy and axillary lymph node sentinel lymph node + bilteral low-costal advancement flaps resurface of bilateral anterior thoracic soft tissue defects and left prophylactic mastectomy on 2023/04/11.
      • Pathology showed invasive carcinoma of no special type with focal neuroendocrine differentiation, 10%, size 3.3 cm, Gr 2, pT2N0M0, stage IIA.
      • She received 3rd adjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 on 2023/06/14.
      • She suffered from right leg redness for a month ago, because using the fascia gun too hard. Physical assessment revealed right leg wound about 3X3 cm, which was red, swollen, locally heated, and swelling painful, with no discharge or foul smell.
      • Under the impression of right leg cellulitis, she was admitted for antibiotic treatment. she was admitted to our PS ward for further vealuation and treatment.  
    • Course of inpatient treatment
      • After admission, right foot wound redness, swelling, local heat, no discharge and foul smell.
      • Under antibiotic with Soonmelt 1200mg Q8H.
      • Right leg wound care with Aq-BI wet.
      • Analgesic agent was given.
      • Attention wound condition.
      • Because her wound was well healing and her whole condition was stable, she was discharged and OPD follow-up was arranged.
    • Discharge prescription
      • Curam (amoxicillin 875mg, clavulanic acid 125mg; 1000mg) 1# Q12H 7D
  • 2023-10-04 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • O: neutrpenia 187, give g-CSF x3
    • P: 5th chemotherapy with Taxotere
    • Prescription
      • cephalexin 500mg 1# QID 3D
      • Granocyte (lenograstim 250ug) SC 3D
  • 2023-09-27 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • P: Taxotere since 2023/09/27
  • 2023-09-20 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-09-08
      • The patient’s liver enzymes have increased due to chemotherapy.
      • So chemotherapy is not recommended at this time.
      • The patient will receive a combination of R/T + Tamoxifen + menopausal hormone therapy. The pharmacist will be consulted to determine whether anti-hormone drugs have any impact on hepatitis.
  • 2023-09-11 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • A/P: GOT,GPT elevation–>hold chemotherapy
  • 2023-04-10 ~ 2023-04-16 POMR General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Right breast invasive carcinoma status post bilateral nipple sparing mastectomy + right sentinel lymph node biopsy + bilateral low-costal advancement flaps resurface of bilateral anterior thoracic soft tissue defects on 2023/04/11. cT2N0M0, stage IIA. ECOG:0
      • Carrier of viral hepatitis B
    • CC
      • noted a palpable mass at right breast over 2 months.
    • Present illness
      • This 42-year-old female patient has past history of carrier of viral hepatitis B over 10 years with regular medicine control. She denied cancer history. She went to Janpan on 2023/03.
      • She noted a palpable mass at right breast over 2 months. She came to our OPD for help. Breast sono showed a lesion right breast tumor (1’region, 11’region) r/o malignancy suggest biopsy.
      • Core needle biopsy revealed invasive carcinoma, ER positive (strong, >95%), PR positive(moderate, 80%), Her2/neu negative(1+), p63 negative, Ki-67 inedex 10%. CA-153 14.159 U/ml, CEA 1.383 ng/ml.
      • Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis.
      • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
      • PE: symmetrical of bilateral breasts. A hard, nontender, movable mass and irregular margin at right breast around 3x3 cm without discharge. The nipple was dimping without exudative nor bloody discharge and right nipple retraction. The right breast skin had no cellulite change.
      • Under the impression of right breast invasive carcinoma, she was admitted for surgery of right nipple sparing mastectomy + SLNB and left breast prophylactic simple mastectomy .        
    • Course of inpatient treatment
      • After admission, right nipple sparing mastectomy + SLNB and left breast prophylactic simple mastectomy was performed on 2023/04/11. The wound is clean and dry.
      • Under the stable condition, she was discharged today, wound will be follow up in OPD.
    • Discharge prescription
      • Acetal (acetamnophen 500mg) 1# QID
      • Zcough (benzonatate 100mg) 1# TID
      • Actein (acetylcysteine 200mg) 1# TID

[surgical operation]

[chemotherapy]

  • 2023-11-29 - docetaxel 75mg/m2 143mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-11-09 - docetaxel 75mg/m2 145mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-10-18 - docetaxel 75mg/m2 140mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-09-27 - docetaxel 75mg/m2 140mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-07-18 - cyclophosphamide 600mg/m2 1118mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-06-14 - cyclophosphamide 600mg/m2 1127mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr
    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2023-05-24 - cyclophosphamide 600mg/m2 1127mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-05-03 - cyclophosphamide 600mg/m2 1127mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

TAC (Docetaxel, Doxorubicin and Cyclophosphamide) (breast) - https://www.swagcanceralliance.nhs.uk/wp-content/uploads/2020/10/TAC-1.pdf

==========

2023-12-21

A review of the patient’s medical records on 2023-12-20, revealed the development of dermatitis or hand-foot syndrome following chemotherapy treatment.

It is noteworthy that the patient is concurrently receiving 3 medications for her breast cancer - docetaxel, tamoxifen, and goserelin (Zoladex Depot - goserelin 10.8mg/syringe, SC on 2023-12-20, Q3M) - all of which have been associated with dermatological adverse reactions in the literature. The reported incidence of these reactions for each medication is as follows:

  • Docetaxel:
    • Alopecia: 56% to 76% (potentially permanent)
    • Dermatological reactions: 20% to 48% (5% with severe presentation)
    • Nail disease: 11% to 41%
    • Onycholysis: <1%
  • Tamoxifen:
    • Skin changes: 6% to 19%
    • Skin rash: 13%
    • Alopecia: 5%
    • Diaphoresis: 6%
  • Goserelin:
    • Acne vulgaris (females): 42%
    • Diaphoresis (females: 16% to 45%; males: 6%)
    • Seborrhea (females: 26%)
    • Alopecia (females: 1% to 5%)
    • Ecchymoses (females: 1% to 5%)
    • Hair disease (females: 4%)
    • Pruritus: 2%
    • Skin discoloration (females: 1% to 5%)
    • Skin rash: 6%
    • Xeroderma (females: 1% to 5%)

The development of subsequent skin symptoms may be difficult to definitively attribute to docetaxel, and further observation and follow-up is warranted.

As for the skin symptoms that have already occurred, the preliminary recommendation is to prescribe Sinphraderm and/or Mycomb to relieve them.

2023-12-08

The TAC regimen, which includes docetaxel at 75 mg/m2 Q3W (initiated on 2023-09-27), followed 4 courses of doxorubicin and cyclophosphamide from 2023-05-03 to 2023-07-18. Docetaxel has been linked to dermatologic side effects such as alopecia (56% to 76%, with potential permanence), skin reactions (20% to 48%; severe reactions in 5%), and nail disorders (11% to 41%), as per UpToDate. To address these skin issues, a consultation with a dermatologist is recommended. The aim is to manage the patient’s comfort effectively while maintaining the current chemotherapy schedule and dosage.

Leukopenia episodes were noted on 2023-08-09, 2023-10-04, and 2023-11-15. Prompt administration of G-CSF was carried out in response to these occurrences. Currently, there are no indications of leukopenia.

  • 2023-11-15 WBC 2.68 x10^3/uL
  • 2023-10-04 WBC 1.03 x10^3/uL
  • 2023-08-09 WBC 2.21 x10^3/uL

700811854

231207

[exam findings]

  • 2023-11-17 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Old fracture of right clavicle.
  • 2023-11-17 ECG
    • Sinus rhythm with short PR
    • Low voltage QRS
    • Borderline ECG
  • 2023-11-15, -11-13, -11-07 KUB
    • S/P CBD and p-duct stenting.
    • Degeneration and spondylosis of L-S spine.
    • Non-specific small bowel and colon gas pattern.
  • 2023-11-06 Endoscopic Retrograde Cholangiopancreatography, ERCP
    • Indication: biliary decompression
    • Symptoms: panc CA with Jaundice
    • Diagnosis:
      • Obstructive jaundice, pancreatic head cancer related, s/p TPS, EST and biliary stenting
      • GB non-opacification
      • S/P P duct stenting
      • Reflux esophagitis
    • Suggestion:
      • f/u amylase & lipase
  • 2023-11-03 Peripheral Vascular Test - Artery, lower limbs
    • Atherosclerosis: Mild
    • Conclusions:
      • Bilateral common femoral arteries distal segment mild plaques, no stenosis
      • Right superficial femoral artery very proximal segment and distal segment mild plaques, no stenosis; left superficial femoral artery very proximal segment mild plaques, no stenosis
      • Bilateral popliteal arteries proximal segment mild plaques, no stenosis
      • Bilateral posterior tibial arteries no significant stenosis
      • Right anterior tibial artery middle segment plaques with mild stenosis; left anterior tibial artery no significant stenosis
  • 2023-10-30 PET scan
    • Increased FDG uptake in the pancreatic head region, compatible with the adenocarcinoma of pancreas with regional lymph node metastasis.
    • Two small nodules 5 mm in S5 and S6 of the liver showm on the previous abdomen MRI, however, reveal no increased FDG uptake. Please correlate with other imaging modalities for further evaluation.
    • Increased FDG accumulation in bilateral kidneys, bilateral ureters, and colon, probalby physiological uptake of FDG.
  • 2023-10-28 CT - chest
    • Indication: For pancreas head tumor survey
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Calcified coronary arteries is found.
        • The lung fields are clear.
        • Senile fibrotic change is noted at lung fields.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
      • Visible abdomen:
        • Low density lesion at pancreatic uncinate process measuring 5.4cm in largest dimension. Regional lymphadenopathy (n=2) are found.
        • The IHDs and CBD are dilated probably due to tumor compression.
        • One enhanced dot at liver dome is found. The lesion is too small to be characterized.
        • There is no evidence of destructive bone lesion.
        • Linear gallstone is found.
        • Suggest clinical correlation
    • Imp:
      • pancreatic cancer at uncinate process of the pancreas. 5.4cm with regional lymphadenopathy
      • Gallstone.
  • 2023-10-27, -10-24 CXR
    • Old fracture of right clavicle.
    • Atherosclerosis of the aorta.
    • Ground glass opacity in bilateral lower lungs.
    • Normal appearance of trachea and bil. main bronchus.
  • 2023-10-23 Patho - pancreas biopsy
    • Labeled as “pancreas”, EUS fine needle biopsy — adenocarcinoma.
    • Section shows necrotic tissue with adenocarcinoma.
    • IHC stains: CA19-9 (+), CK7 (+), CK20 (focal +), CEA (+), CK19 (+).
  • 2023-10-23 SONO - abdomen
    • Diagnosis:
      • Pancreatic head tumor
      • Fatty liver, mild
      • Liver calcification, right
      • CBD dilatation
      • Bilateral IHD dilatation
      • GB stone
      • Renal cysts, LK
      • Minimal ascites
      • Right pleural effusion
    • Suggestion:
      • the two liver tumors noted by MRI in S5 and S6 could not be found.
  • 2023-10-20 MR Cholangiography, MRCP
    • Indication: r/o Pancreatic head tumor
      • 20231017 CEA:5.14 ng/mL (<5), CA199:487.67 U/mL (<35).
    • Findings:
      • There is a well-defined, mild heterogeneous mass in the pancreatic head, measuring 4.6 cm in size (the largest dimension), causing marked dilatation of the CBD, CHD, IHDs, and pancreatic duct.
        • This mass shows hypointensity on T1WI and mild hyperintensity on both T2WI and DWI. During dynamic study, this tumor shows poor contrast enhancement.
        • Adenocarcinoma of the pancreatic head (T3) is highly suspected.
        • Please correlate with EUS.
      • There is one enlarged node 1 cm in RMQ mesentery that is c/w metastatic node (N1).
      • There are two small nodules 5 mm in S5 and S6 of the liver, showing equivocal mild hyperintensity on T2WI (Srs:3 Img:18) and marked hyperintensity on DWI (Srs:104 Img:19).
        • Metastases (M1) are highly suspected.
        • Please correlate with sonography.
        • Follow up MRI 3 months later is indicated.
      • A stone 4 x 1 cm in the gallbladder is suspected. Please correlate with sonography.
      • There are several renal cysts on both kidney and the largest one measuring 2.1 cm in size at left upper pole.
      • Minimal right side Pleura effusion is highly suspected.
      • Mild ascites is highly suspected. Please correlate with sonography.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage): T: T3 (T_value) N: N1 (N_value) M: M1 (M_value) STAGE: IV (Stage_value)
  • 2023-10-17 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (91 - 25) / 91 = 72.53%
      • M-mode (Teichholz) = 72
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated both atria and RV, grade 1 LV diastolic dysfunction
      • Mild AR, MR, TR
  • 2023-10-16 CXR
    • Fracture of right clavicle.
    • Atherosclerosis of the aorta.
  • 2023-10-16 ECG
    • Sinus bradycardia
    • Left axis deviation
  • 2023-10-15 ECG
    • Sinus rhythm with short PR with occasional Premature ventricular complexes
    • Left axis deviation
    • Abnormal ECG

[MedRec]

  • 2023-10-15 SOAP Medical Emergency Chen YuLong
    • S: JUST AAD FROM DaJia KuangTien Hospital, TOCC(-)
      • GENERAL DISCOMFORT 2 DAYS AGO, BW LOSS FOR 10+ KG IN RECENT 6 MO
      • PH; HTN, DM NKDA
      • Cloud:
        • 2023/10/14
          • WBC 7.2k Hb12.3 MCV 90.1 PLT 141k
          • K 3.17 Na 140 Glu 193 BUN 16 Cr 1.19 GPT 279 Ti- CRP 0.2 Alb 3.1 TBI 1.9 GGT 293 ALP 133 Lip 42 NH 3 56
          • PT 10.5 sec APTT 29.2sec
          • PH 7.428 PCO2 34.6
          • Urine Light Yellow, Clear
        • Stool (2023/10/15) Brown Soft N/A
      • 2023/10/15 Discharge diagnosis (DaJia KuangTien Hospital)
        • Biliary sepsis due to acute cholangitis
        • Biliary obstruction due to suspect malignant tumor at pancreatic head
        • Acute gastric erosions with H. pylori
        • GERD Gr.A
        • CAD with 3 VD
        • DM
        • HCVD
      • Medication:
        • GLIMET
        • CONCOR 1.25
        • QTERN 5MG/10MG (Dapagliflozin;Saxagliptin)
        • Aspirin
        • Isosorbide 5-Mononitrtate (60)
        • NORVASC
        • DOXABEN XL
    • O:
      • Vital Sign: BP:105/62; HR:85; BT:36.5’C; RR:16;
      • Con’s:E4V5M6
      • SpO2:96%
      • MILD ICTERIC, ANEMIC
      • CLEAR BS, RHB
      • ABD; SOFT AND CONVEXED, NONTENDER
      • EXT; NO EDEMA
    • Preliminary impression: C25.9 Malignant neoplasm of pancreas, unspecified
      • Pancrea head tumor, ?GB stones, CBD dilatation, ALT 279, TBI 1.9, GGT 293, Alp 133, AAD from DaJia KuangTien Hospital. No fever, V/S stable in ER observation. OA GI
      • HTN; DM
  • 2023-10-11 SOAP General and Gastrointestinal Surgery
    • S
      • Chief complaint: a palpable mass over L’t upper back for years
      • Present illness: According to the patient & family, the patient suffered from a palpable mass over L’t upper back for years. Due to pain, sign & symptom exacerbation, the patient called at our OPD for help.
      • Past history: No Hx of operation, No Hx of type 2 DM, HTN
      • Allergy: NKA
      • Travel Hx: Nil
      • Family Hx: No significant finding in pedigree
    • O
      • Skin: a 4x4 cm plapble soft mass over L’t upper back with local tenderness,
    • A
      • L’t back tumor
    • P
      • suggest excision or closely observation, education, & OPD follow up
      • F/U the tumor yearly

700348263

231206

[lab data]

2023-07-26 HBsAg Nonreactive
2023-07-26 HBsAg (Value) 0.24 S/CO
2023-07-26 Anti-HBs 39.06 mIU/mL
2023-07-26 Anti-HBc Nonreactive
2023-07-26 Anti-HBc-Value 0.31 S/CO
2023-07-26 Anti-HCV Nonreactive
2023-07-26 Anti-HCV Value 0.11 S/CO

[exam findings]

  • 2023-12-02 KUB
    • There is no evidence of destructive bone lesion.
    • Stool impaction at the abdominal cavity is noted.
    • Non-specific bowel gas at abdominal cavity is found.
    • s/p stent placement at right iliac region.
  • 2023-12-02 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • Massive right pleural effuison
    • There is no evidence of destructive bone lesion.
  • 2023-11-22 SONO - chest
    • Echo diagnosis
      • Pleural effusion, moderate, to massive right
      • Atelectasis, RLL
  • 2023-10-27 PET
    • A glucose hypermetabolic lesion in the right lower lung field and multipe small glucose hypermetabolic lesions in the upper and lower lobes of left lung, compatible with multiple lung metastases.
    • Prominent glucose hypermetabolism in the right lateral chest wall. Metastasis should be watched out.
    • Glucose hypermetabolism in a lymph node in the right anterior prevascular space and in a right paratracheal lymph node, suggesting metastatic lymph nodes.
    • Glucose hypermetabolism in a focal area in the right supraclavicular fossa. A metastatic lymph node can not be ruled out.
    • Mild glucose hypermetabolism in a pleura-based focal area in the anterior aspect of the upper lobe of right lung. The nature is to be determined (inflammation? metastasis of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in both kidneys and bilateral ureter. Physiological FDG accumulation may show this picture.
  • 2023-10-03 CT - chest
    • Indication: ca of lung, pStage IIIB, pT3N2M0.
    • Comparison was made with CT on 2023/04/14
      • Lungs:s/p right upper lobe lobectomy, staple line along superior posterior Rt major fissure.
        • no abnormal nodule or mass in the Rt remnant lungs or bronchial stump. a 5mm nodule in inferior lingular segment.
        • mosaic attenuation changes in both lungs on inspiratory images.
      • Mediastinum and hila: enlarged LNs in Rt paratracheal space and Rt anterior prevascular space.
        • extensive coronary arterial calcification
      • Thoracic aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: dilated right (3.3cm) and left pulmonary arteries.
      • Heart: normal size of cardiac chambers. midseptal hypertrophy of IVS and extensive calcified mitral annulus
      • Pleura: moderate Rt-sided effusion with loculation.
      • Chest wall and visible lower neck: unremarkable.
      • Extensive atherosclerotic change of the abdominal aorta.
      • marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • enlarged Rt mediastinal LNs, lymph nodes recurrent tumor? moderate pleural effusion and pulmonary hypertension.
      • lingular nodule 5mm.
      • extensive 2V-CAD.
  • 2023-08-01 Nerve Conduction Velocity, NCV
    • Findings
      • MNCV: decreased CMAPs amplitude of left median nerve and left tibial nerve; slow motor conduction of bilateral ulnar nerves across elbow
      • SNCV: decreased SNAPs amplitude of all examined nerves; slow sensory conduction velocity of bilateral median and ulanr nerves
      • F-wave: delayed responses of right ulnar and left tibial nerves
      • H-reflex: delayed responses of bilateral lower limbs
      • Thermal quantitative sensory test showed abnormal warm threshold in left upper and lower limbs.
    • Conclusion
      • This NCV study suggested bilateral lumbosacral radiculopathy with left tibial axonal injury, bilateral ulnar neuropathy across elbow, bilateral median distal neuropathy with the possibility of right lower cervical radiculopathy.
      • Thermal quantitative sensory test suggested small fiber neuropathy.
      • Please correlate with clinical features.
  • 2023-06-26 Patho - lung total/lobe/segmental
    • PATHOLOGIC DIAGNOSIS:
      • Lung, right, upper lobe, lobectomy —- Squamous cell carcinoma, moderately differentiated
      • Lymph node, lobar, lymphadenectomy —- Squamous cell carcinoma, metastatic (1/4)
      • Lymph node, right, group No.2+4, lymphadenectomy —- Squamous cell carcinoma, metastatic (2/3)
      • Lymph node, right, group No.7, lymphadenectomy —- Squamous cell carcinoma, metastatic (1/ 4)
      • Lymph node, right, group No.9, lymphadenectomy —- Negative for malignancy (0/2)
      • Lymph node, right, group No.10, lymphadenectomy —- Squamous cell carcinoma, metastatic (2/4)
      • Lymph node, right, group No.11, lymphadenectomy —- Squamous cell carcinoma, metastatic (1/2)
      • Lymph node, right, group No.12, lymphadenectomy —- Squamous cell carcinoma, metastatic (3/4)
      • AJCC 8th edition pTNM Pathology stage: pStage IIIB, pT3N2(if cM0)
    • MACROSCOPIC EXAMINATION:
      • Specimen: Lung, size: 16.2 x 9.5 x 3.5 cm, 210 g
        • Lymph nodes, 6 bottles, group 2+4, 7, 9, 10, 11, 12; maximal size: 2.6 x 1.5 cm
      • Tumor Site: Periphery
      • Tumor Size: Solitary: 6.0 x 4.5 x 2.8 cm
      • Gross tumor patterns: poorly defined
      • Tissue for sections: A1: bronchial and vascular resection margins; A2: parenchymal resection margin; A3: lymph node, lobar; A4: lung, non-tumor; A5-8: tumor; B: lymph node, group 2+4; C: lymph node, group 7; D: lymph node, group 9; E: lymph node, group 10; F: lymph node, group 11; G: lymph node, group 12.
    • Microscopic Description
      • Tumor Focality: Single tumor
      • Histologic Type (select all that apply): Invasive squamous cell carcinoma, keratinizing
      • Histologic Grade: G2: Moderately differentiated
      • Spread Through Air Spaces (STAS): Not identified
      • Visceral Pleura Invasion: Not identified
      • Lymphovascular Invasion (select all that apply): Present, Lymphatic and Venous
      • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
      • Margins (select all that apply): All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin (centimeters): 1.9 cm
        • Specify closest margin: parenchymal resection margin
        • Bronchial resection margin: 2.1 cm
      • Treatment Effect: No known presurgical therapy
      • Regional Lymph Nodes: please see diagnosis
      • Extranodal Extension: Not identified
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): not applicable
        • Primary Tumor (pT): pT3: Tumor >5 cm but <=7 cm in greatest dimension;
        • Regional Lymph Nodes (pN): pN2: Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
      • Additional Pathologic Findings (select all that apply): None identified
  • 2023-06-12 Cardiopulmonary Exercise Testing
    • Conclusions
      • submaximal exercise by RER < 1.09
      • low exercise capacity (VO2 50%, WR 23%)
      • spirometry was moderate obstructive ventialtory impairment with significant reversibility (FVC 78 -> 90%, FEV1 66 -> 83%)
      • low inpiratory muscle strength (MIP 51%, MEP 84%)
      • No SpO2 desaturation below 90%
      • normal cardiac response during exercise
      • slow HR response slope during exercise
      • work efficiency low
      • anaerobic threshold indeterminant
      • oxygen pulse normal
      • BP response high
      • EKG: no specific findings
      • Health-related quality of life, CAT= 5,
    • Impression and suggestion:
      • Treat underlying asthma
      • Exercise training for low exercise capacity
      • Treat obstructive ventilatory impairment
      • Perform breathing exercise for low respiratory muscle strength
      • Survey and treat slow HR response
  • 2023-06-09 Tc-99m MDP bone scan
    • Mildly increased activity in the middle to lower T-spines, some L-spines and sacrum. Degenerative change may show this picture.
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Increased activity in bilateral shoulder, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2023-06-08 PET
    • A glucose hypermetabolic lesion in the upper lobe of right lung, compatible with primary lung malignancy.
    • Glucose hypermetabolism in a right paratracheal lymph node. The nature is to be determined (inflammation? a metastatic lymph node of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the right pulmonary hilar region. Inflammation is more likely.
    • Increased FDG accumulation in the colon, both kidneys and left ureters. Physiological FDG accumulation may show this picture.
  • 2023-06-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (155 - 39) / 155 = 74.84%
      • M-mode (Teichholz) = 74
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Dilated LA, septal hypertrophy; impaired LV relexation
      • Mild MR, mild AR, mild to moderate TR
      • Mild pulmonary hypertension
      • Preserved RV systolic function
  • 2023-06-07 ECG
    • Left axis deviation
    • Left anterior fascicular block
  • 2023-05-29 Patho - pleural/pericardial biopsy
    • Lung, RUL, CT-guide biopsy —- squamous cell carcinoma, moderately differentiated
    • Sections show solid sheets of hyperchromatic tumor cells infiltrating in a fibrotic stroma with focal tumor necrosis. Focal keratinization is seen.
    • The immunohistochemical stains reveal CK5/6(+), p40(+), TTF-1(-), and CD56(focal +). The results are supportive for the diagnosis.
  • 2023-04-19 24hr Holter ECG
    • Baseline was sinus bradycardia (average HR: 53bpm, range between: 48-61bpm)
    • Chronotropic incompetence noted
    • A few isolated VPCs / VPC couplets
    • A few isolated APCs / APC couplets
    • 4 episodes of short-run AT, max 21 beats
    • No long pause
  • 2023-04-19 MRA - brain
    • acute ischemia stroke
    • Image quality: no gross motion artifacts
      • moderate dilated intraventricular and extraventricular CSF spaces
      • old lacunar infarction in the bilateral basal ganglia and right thalamus.
      • unremarkable change in the skull base
      • MRA of the intracranial vessels revealed mild stenosis at left distal VA; mild prominent bilateral PCom infundibuli.
    • IMP:
      • no evidence of recent infarction
  • 2023-04-18 Neurosonology
    • Moderate atheromatous lesions in L CCA bifurcation; mild to moderate atheromatous lesions in R distal CCA to CCA bifurcation; mild atheromatous lesions in R ICA and ECA.
    • Elevated resistance (RI) and decreased flow in bilateral cervical VAs, suspect distal stenosis.
    • Normal extracranial carotid, vertebral, and intracranial basal cerebral arterial flows except relatively elevated flow velocity in R M1 (PS/ED= 126/15 cm/s)
    • Normal bilateral ophthalmic arterial flows.
  • 2023-04-18 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (146 - 30) / 146 = 79.45%
      • M-mode (Teichholz) = 79
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, LV and AoR, LVH, grade 1 LV diastolic dysfunction
      • Mild AR, MR, TR and PHTN
  • 2023-04-15 CT - brain
    • Indication: acute ischemia stroke
    • Without contrast helical Head CT - 4mm thickness in each slice from the axial and saggital projections showed
    • Image quality: no motion artifacts
      • mild dilated intraventricular and extraventricular CSF spaces
      • unremarkable change in the brain parenchyma
      • unremarkable change in the skull base
      • artherosclerotic change at the bilateral distal VAs and bilateral cavernous ICAs.
    • IMP: no acute intracranial hemorrhage
  • 2023-04-14 CT, CTA - brain (head, neck)
    • Head CT with IV contrast enhancement shows:
      • Marked artherosclerotic change of biilateral CCA, ICA and intracrenial arteries is found.
      • The ACAs, MCAs and VA are patent.
      • Marked prominent sulci, fissue and dilated ventricles indicate brain atrophy.
      • No evidence of ICH, SAH or SDH.
      • No evidence of space occupying lesion in the brain parenchyma is found.
      • Suggest clinical correlation
    • IMp:
      • Marked artherosclerotic change of biilateral CCA, ICA and intracrenial arteries is found.
      • The ACAs, MCAs and VA are patent.
  • 2023-04-14 CT - chest
    • hest CT without IV contrast ehnancement shows:
      • Mass like lesion at right upper lobe measuring 5.6cm in largest dimension is found.
      • Calcified coronary arteries is found.
    • Imp:
      • Right upper lobe lung mass, lung cancer is favored.
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-04-14 CT - brain
    • Imp
      • Brain atrophy
      • No evidence of ICH, SAH or SDH.
      • No evidence of space occupying lesion in the brain parenchyma is found.
  • 2023-04-14 ECG
    • Normal sinus rhythm
    • Left anterior fascicular block
    • Abnormal ECG
  • 2017-09-07 Surgical pathology Level IV
    • PATHOLOGIC DIAGNOSIS
      • Prostate, right, needle biopsy — Prostatic adenocarcinoma (Gleason score 7 = 4 + 3) involving 3 of 5 strips of prostatic tissue by the number of involved strips or 60 % by the involved volume of the specimen.
        • The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
    • MACROSCOPIC EXAMINATION
      • Size: 5 strips, with the longest piece measuring 1 x 0.1 x 0.1 cm.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Prostatic adenocarcinoma
      • Histologic Grade: (Gleason score 7 = 4 + 3)
      • Tumor Quantitation: involving 3 of 5 strips of prostatic tissue by the number of involved strips or 60 % by the involved volume of the specimen.
        • The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
  • 2017-09-07 Surgical pathology Level IV
    • PATHOLOGIC DIAGNOSIS
      • Prostate, left, needle biopsy — Prostatic adenocarcinoma (Gleason score 7 = 4 + 3) involving 4 of 5 strips of prostatic tissue by the number of involved strips or 80 % by the involved volume of the specimen.
        • The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
    • MACROSCOPIC EXAMINATION
      • Size: 5 strips, with the longest piece measuring 1 x 0.1 x 0.1 cm.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Prostatic adenocarcinoma
      • Histologic Grade: (Gleason score 7 = 4 + 3)
      • Tumor Quantitation: involving 4 of 5 strips of prostatic tissue by the number of involved strips or 80 % by the involved volume of the specimen.
        • The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.

[MedRec]

  • 2023-11-19 ~ 2023-11-22 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Squamous cell carcinoma over right upper lobe, pT3N2M0 stage IIIB, post operation 3 dimensions video-assisted thoracoscopic surgery right upper lobe lobectomy and radical lymph node dissection on 2023/06/26.
      • Essential (primary) hypertension
      • Prostate cancer status post androgen deprivation therapy
      • Enlarged prostate with lower urinary tract symptoms
      • Right lower limb peripheral arterial occlusion disease post stent x 1
      • Acute ischemic stroke status post Tissue plasminogen activator on 2023/04/14
      • Zoster without complications, herpes zoster on the right chest region
      • Right side pleural effusion
    • CC
      • for on port-A and chemotherapy
    • Present illness
      • This is a 79-year-old male with past history of
        • Squamous cell carcinoma over right upper lung, moderately differentiated, cT3N0Mx, pT3N2M0, pStage IIIB.
        • Prostate cancer status post androgen deprivation therapy;
        • Acute ischemic stroke status post tissue plasminogen activator on 2023/04/14
        • Right lower limb peripheral arterial occlusion disease post stent x 1
        • Hypertension.
      • He used to smoking 2~3 packs per day for about 40 year and quit smoking for 17 years. According to patient statement and his medical record, he was brought to our ER due to acute ischemic stroke status with dizziness, upper limbs weakness and slurry speech which was noted at around 7 pm on 2023/04/14. Brain CT showed no evidence of hemorrhage. Chest X-ray and lung computer tomograph revealed mass like lesion at right upper lobe, measuring 5.6cm in size at lung window setting.
      • Therefore, He was then refered to out patient department of chest surgeon for further investigation. Computer tomograph guide biopsy was performed on 2023/05/29 and pathology roport showed squamous cell carcinoma, moderately differentiated.
      • Then, he was admission for cancer survey on 2023/06/07 and he was done PET on 2023/06/08 showed
        • A glucose hypermetabolic lesion in the upper lobe of right lung, compatible with primary lung malignancy.
        • Glucose hypermetabolism in a right paratracheal lymph node.
      • WBBS on 2023/06/09 showed Mildly increased activity in the middle to lower T-spines, some L-spines and sacrum. Degenerative change may show this picture.
      • Cariac echogram showed 1. Adequate LV systolic function with normal resting wall motion 2. Dilated LA, septal hypertrophy; impaired LV relexation 3. Mild MR, mild AR, mild to moderate TR 4. Mild pulmonary hypertension 5. Preserved RV systolic function.
      • Bronchoscope on 2023/06/12 showed no obvious abnrmality.
      • He was underwent operation for 3D VATS RUL lobectomy + RLND on 2023/06/26.
      • RT dose: 6000cGy/30 fractions (6 MV photon) to RUL bronchial stumo and mediastinal /SCF, 2023/7/27 to 9/07.
      • Oral navelbine on 7/26, 8/02, 8/09, 8/16, 8/23, 8/30, 9/05.
      • Chest CT, 2023/10/03: enlarged Rt mediastinal LNs, lymph nodes recurrent tumor? moderate pleural effusion and pulmonary hypertension.
      • PET, 2023/10/27: A glucose hypermetabolic lesion in the right lower lung field and multipe small glucose hypermetabolic lesions in the upper and lower lobes of left lung, compatible with multiple lung metastases.
      • 2023-10-31 tumor progression, suggest C/T with CDDP+Gemzar
      • 2023-10-16 herpes zoster on the right chest region under Famvir 250 mg PO TID x 5 days.
      • This time, he was admitted for on port-A and chemotherapy.  
    • Course of inpatient treatment
      • After admission, consult CS for Port-A implantation on 2023/11/20, he can tolerance procedure well.
      • He received weekly Gemcitabine (1000mg/m2) + Cisplatin (30mg/m2) on 2023/11/21 (C1D1) smoothly.
      • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
      • Tramacet 37.5 & 325mg/tab 1# PO Q6H for pain control.
      • Right side pleural effusion was noted, pleural puncture was done on 2023/11/22, pleural effusion, moderate, to massive right, 1200ml serosanguious fluid was drained and sent for routine, BCS, bacteria/TB/fungus cultures and cell block and TB-PCR.
      • Atelectasis, RLL.
      • Hypertension with Exforge F.C. 5mg & 160mg/tab 1# PO QD.
      • Enlarged prostate with lower urinary tract symptoms with Urief F.C 8mg/tab 1# PO QN, Minirin Melt 60mcg/tab 1# PO HS.
      • Acute ischemic stroke status post Tissue plasminogen activator on 2023/04/14 with Bokey 100mg/cap 1# PO QD, Rivotril 0.5mg/tab 0.5# PO RRNHS if cramp, Nicametate Citrate 50 mg/tab 1# PO QD.
      • PD-L1 (22C3) was sent on 2023/11/22. Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, he was discharged on 2023/11/22 and OPD followed up later.    
  • 2023-05-24 ~ 2023-05-30 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Right upper lung mass, pending pathology on 2023/05/29
      • Essential (primary) hypertension
      • Cerebral infarction, unspecified
      • Enlarged prostate with lower urinary tract symptoms
      • Past history of right lower limb Peripheral Arterial Occlusion Disease post stent x1
    • CC
      • BW loss 4kg and need do the tumor survey
    • Present illness
      • This 78-year-old male has histories of HTN, PAOD post stenting under anti-platelet therapy for 6 years at VGHTPE, left /p TKR, prostate cancer, T3bN0M0 under androgen deprivation therapy. Last time, he suffered from dizziness, upper limbs weakness and slurry speech around 7PM. Study image brain CT and chest x-ray were arranged, it revealed no evidence of hemorrhage by brain CT and pleural based mass like lesion at right upper lobe.
      • After Neurologist consulting, he received tPA therapy for acute ischemic stroke with National Institute of Health Stroke Scale 8 points. Post tPA therapy, the brain CTA was folllow-up, it revealed marked artherosclerotic change of biilateral CCA, ICA and intracrenial arteries. Due to lung mass, the chest CT was arranged, it revealed right upper lobe lung cancer (5.6cm) T3N0M0.
      • This time, he has BW loss 4kg in one month, but no cough, SOB or fever. He was admitted for lung biopsy on 2023/05/24.
    • Course of inpatient treatment
      • After admission, he hold Aspirin for lung biopsy 3 days. Radiologiest was consulted and aspiration smoothly on 2023/05/29. No evidence of pneumothorax after lung biopsy for 4 hours. Under the stable condition, he can be discharged on 2023/05/30. OPD follow up is arranged.
  • 2023-04-14 ~ 2023-04-20 POMR Neurology Chen PeiYa
    • Discharge diagnosis
      • Acute ischemic stroke status post Tissue plasminogen activator on 2023/04/14 (TOAST classification 4, cancer related )
      • Right upper lobe lung cancer, undetermined
      • Prostate cancer status post androgen deprivation therapy
      • Left lower limb peripheral arterial occlusive disease
      • Essential (primary) hypertension
      • Modified ranking scale 0
    • CC
      • acute dizziness, limbs weakness and slurred speech around 7PM pm 4/14
    • Present illness
      • This 78-year-old male has histories of HTN, PAOD post stenting under anti-platelet therapy (aspirin) and prostate cancer s/p androgen deprivation therapy but lost follow-up.
      • He was normal until acute generalized weakness during dinner at around 7pm on 4/14. He could barely stand on his own and presented with slurred speech. Therefore he was sent to our ER. At ER, his consciousness was E4V5M5-6 and he presented with dysarthria and generalized weakness with lower limb more prominent weakness. Vital signs showed BT 36.6’C, HR 74, RR 18, BP 187/88mmHg. NIHSS was 8. Brain CT showed no evidence of hemorrhage and and CXR revealed pleural based mass like lesion at right upper lobe.
      • After evaluation and explanation to the family about the indication as well as risk of IV rt-PA therapy, he underwent rt-PA therapy (93.9Kg, 0.6mg/kg, total 56mg) smoothly. Due to lung mass, the chest CT was arranged with brain CTA which confirmed no large vessle occlusion and revealed right upper lobe lung cancer (5.6cm) T3N0M0. Then within a hour of rtPA therapy, his symptoms/signs were recovered. Hence he was admitted to SICU for post-rtPA therpay monitor and management.
    • Course of inpatient treatment
      • At SICU, we gave adequate IV hydration and kept post-rtPA therapy monitor with tight control BP. Transient oral cavity blood clot and mild bleeding were noted during the first few hours and the patien claimed that tooth extraction was done about 3 days before this event.
      • Follow-up brain CT on 3/15 showed no acute intracranial hemorrhage. There was no recurrent symptoms or focal weakness noted after admission. With stablized and improved condition, he was transfered to ward for subsequent managment and treatment.
      • After transfer, we arranged associated survey for stroke risk factor evaluation. CPA/TCD revealed moderate atheromatous lesion in carotid arteries and other cerebral atherosclerosis. ABI study suggested left lower limb PAOD. Heart echography showed LVEF 79% without significal structural abnormality. 24 hours Holter EKG report was pending. We consulted physiatrist for rehabilitation activitiy.
      • About cancer issue, we had explained to the patient about further evaluation and mangement which were necessary and we will arrange oncologist for it. With good recovery, the patient asked to be discharged soon. Hence he was discharged with oral medication and scheduled OPD follow-up including urology and oncology.
    • Discharge prescription
      • Bokey (aspirin 100mg) 1# QD
      • Diovan (valsartan 160mg) 1# QD
      • Duodart (dutasteride 0.5mg, tamsulosin 0.4mg) 1# QD
      • Norvasc (amlodipine 5mg) 1# QD
  • 2018-02-05 Urology Lin JiaDa
    • S: PCa T3bN0M0, ADT since 2017/10/16 (androgen deprivation therapy)
    • Diagnosis
      • Enlarged prostate with lower urinary tract symptoms [N40.1]
      • Malignant neoplasm of prostate [C61]
    • Prescription
      • Leuplin depot (leuprorelin 3.75mg) Q1M SC
      • Harnalidge (tamsulosin 0.4mg) 1# QDAC
      • Androcur (cyproterone acetate 50mg) 1# TID

[consultation]

  • 2023-04-14 Neurology
    • Q
      • CVA Call
    • A
      • This 78 y/o man has a history of PAOD s/p stent and on Aspirin, HTN, and prostate cancer. He was normal until acute generalized weakness during dinner. He could barely stand on his own and presented with slurred speech. Therefore he was sent to our ER.
        • NE E4V5M5-6
        • CNs: normal EOM
        • moderate dysarthria
        • MP upper >4/>4 lower >3/>3
        • sensation: intact
        • FNF: no dysmetria
        • brain CT: no ICH
        • NIHSS 001 000 1122 00010 (8) at 21:05
        • CXR: right lung field mass lesion
      • impression: acute ischemic stroke
      • suggestion:
        • give rt-PA therapy 56mg (93.9Kg., 0.6mg/kg, total 56mg) with family’s agreement
        • do brain + chest CTA, consider EVT if LVO
        • arrange neurology ICU admission.
    • A 22:30
      • brain CTA: no LVO
      • improved dysarthria and MPs
      • had explained to the family

[chemotherapy]

  • 2023-11-28 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + cisplatin 30mg/m2 40mg NS 350mL 3hr
    • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-11-21 - gemcitabine 1000mg/m2 1800mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 350mL 3hr
    • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2023-12-06

[leukopenia improved]

The administration of Granocyte (lenograstim) for 3 consecutive days, starting from 2023-12-03, has effectively improved the patient’s condition of leukopenia.

  • 2023-12-06 WBC 2.78 x10^3/uL
  • 2023-12-04 WBC 0.91 x10^3/uL
  • 2023-12-02 WBC 0.33 x10^3/uL

2023-12-04

[leukopenia]

Two rounds of the gemcitabine and cisplatin regimen were given on 2023-11-21 and 2023-11-28. A leukopenia episode occurred on 2023-12-02, reaching a nadir WBC count of 0.33K/uL, and was treated with three consecutive days of Granocyte (lenograstim 250ug). Following this treatment, an initial increase in white blood cell count was observed.

  • 2023-12-04 WBC 0.91 x10^3/uL
  • 2023-12-02 WBC 0.33 x10^3/uL nadir
  • 2023-11-28 WBC 2.21 x10^3/uL
  • 2023-11-20 WBC 3.28 x10^3/uL
  • 2023-10-31 WBC 4.52 x10^3/uL

The second session of treatment involved a reduced dose compared to the first, utilizing two-thirds of the gemcitabine dose and 80% of the cisplatin dose. The use of G-CSF did not present any issues.

[thrombocytopenia]

Thrombocytopenia has developed, and leukocyte-reduced platelet pheresis (LRP) is being administered (2023-12-04). Please continuously monitor the patient’s PLT levels.

  • 2023-12-04 PLT 29 *10^3/uL
  • 2023-12-02 PLT 51 *10^3/uL
  • 2023-11-28 PLT 96 *10^3/uL
  • 2023-11-20 PLT 164 *10^3/uL
  • 2023-10-31 PLT 171 *10^3/uL

[EGFR testing for SCC lung cancer]

Based on the available evidence, testing for EGFR mutations in patients with squamous cell carcinoma (SCC) of the lung is a topic of debate and ongoing research. While EGFR mutations are more commonly associated with lung adenocarcinoma, there is evidence to suggest that a small percentage of SCC patients also harbor EGFR mutations (Si et al., 2022; Nishimura et al., 2023). The presence of EGFR mutations in SCC lung cancer patients is important because these mutations can predict sensitivity to EGFR tyrosine kinase inhibitors (TKIs) (Shigematsu & Gazdar, 2006). However, the efficacy of EGFR-TKIs in SCC patients with sensitive EGFR mutations remains unclear (Chang et al., 2021). Additionally, the prevalence of EGFR mutations in SCC patients has been reported to be about 1-5% Si et al. (2022).

  • Ref:
    • Si et al (2022). Clinical outcomes of egfr-tkis in advanced squamous cell lung cancer. Neoplasma, 69(04), 976-982. https://doi.org/10.4149/neo_2022_220329n348
    • Nishimura et al (2023). Next‐generation sequencing clarified why first‐line treatment with osimertinib was ineffective in an autopsied case of egfr‐mutated lung squamous cell carcinoma. Thoracic Cancer, 14(7), 709-713. https://doi.org/10.1111/1759-7714.14807
    • Shigematsu et al (2006). Somatic mutations of epidermal growth factor receptor signaling pathway in lung cancers. International Journal of Cancer, 118(2), 257-262. https://doi.org/10.1002/ijc.21496
    • Chang et al (2021). Epidermal growth factor receptor mutation status and response to tyrosine kinase inhibitors in advanced chinese female lung squamous cell carcinoma: a retrospective study. Frontiers in Oncology, 11. https://doi.org/10.3389/fonc.2021.652560

700040427

231205

[exam findings]

[MedRec]

  • 2023-07-11 ~ 2023-07-15 POMR Colorectal Surgery Chen ZhuangWei
    • Discharge diagnosis
      • Rectal cancer with lumen narrowing and impending obstruction, cT4bN1M1a, stage IVa (r/o right upper lobe, right lower lobe and left upper lobe metastases) status post Loop-T colostomy and port-A implatation on 2023/07/12
      • Prostatic acinar adenocarcinoma (Gleason score 9 = 4 + 5 ), grade group 5, iPSA 129, stage cT4N1M0, very high risk group, status post radiotherapy, chemotherapy, and status during androgen deprivation therapy
      • Carrier of viral hepatitis B
      • Hypertension
    • CC
      • Tenesmus about 20 times per day, abdominal fullness, sometimes fecal incontinence and weight loss 10kg for about 3 months.
    • Present illness
      • A 66-year-old male had history of
        • Prostate adenocarcinoma, Gleason score 4+5, PSA 129, cT4N1M0, grade group 5 status post transurethral resection of the prostate on 2022/09/28, status post adjuvent concurrent chemoradiotherapy (2022/11~2023/2) and Androgen deprivation therapy (2023/2~), well controlled.
        • Bladder stone status post cystolithotripsy on 2021/11/01
        • Hepatitis B carrier
        • Hypertension
      • This time, he sufferred from tenesmus about 20 times/day, abdominal fullness, sometimes fecal incontinence and weight loss 10kg in 3 months. He visited GI OPD and sigmoidoscopy revealed a ulcerative tumor at lower rectum with lumen narrowing.
      • Lab data revealed CEA 166.710 ng/ml. Biopsy showed adenocarcinoma. So, he was referred to CRS OPD. At OPD, digital examination revealed a palpable tumor lesion at middle rectum, 6cm from anal verge.
      • Chest and abdominal CT revealed thickening wall at the rectum abutting to seminal vesicle. Bilateral upper lung and right lower lung nodules, suspect metastasis. cT4bN1M1a, stage IVA.
      • PET CT also showed 1. Glucose hypermetabolism in the rectum with invasion to seminal vesicle, 2. Three glucose hypermetabolic lesions in the upper and lower lobes of the right lung and upper lobe of the left lung respectively. Lung metastases can not be ruled out.
      • After discussion with patient, he was admitted for T-loop colostomy and port-A implanation for chemotherapy and target therapy.
    • Course of inpatient treatment
      • After admission, we consulted GS for port-A implanation. Pre-op and anesthesia assessment was done. Loop-T colostomy and port-A implanation were performed smoothly on 2023/07/12.
      • After operation, no specific complain except for mild decreased appetite, bloating and wound pain, subsided by medicine.
      • Under relative stable condition, we arranged his discharge on 2023/07/15 and OPD follow up.
    • Discharge prescription
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • Acetal (acetaminophen 500mg) 1# QID

[surgical operation]

  • 2023-07-12
    • Surgery: T-loop colostomy        
    • Finding: T-colon was identified and T-loop colostomy was created at RUQ abdomen wall. The whole procedure was smooth. 

[radiotherapy]

[immunochemotherapy]

  • 2023-12-04 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 375mg D5W 250mL 90min + leucovorin 400mg/m2 830mg NS 250mL 2hr + fluorouracil 2400mg/m2 5000mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-10-30 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2400mg/m2 4900mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-10-09 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2400mg/m2 4850mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-09-18 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-08-28 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 780mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-08-14 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 790mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-07-26 - + irinotecan 160mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2022-12-21 - docetaxel 75mg/m2 120mg NS 250mL 1hr (docetaxel, Q3W)
  • 2022-11-21 - docetaxel 75mg/m2 140mg NS 250mL 1hr (docetaxel, Q3W)

==========

2023-09-18

The patient recently obtained a 28-day supply of Norvasc (amlodipine) and Diovan (valsartan) on 2023-09-12, to manage his primary hypertension. These drugs have been added to the active medication list, and there were no reconciliation issues identified.

700101071

231204

[diagnosis] - 2023-03-20 admission note

  • Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites
  • Peripheral T-cell lymphoma T3N3M1 stage4
  • Type 2 diabetes mellitus without complications
  • Essential (primary) hypertension
  • Mixed hyperlipidemia
  • Constipation, unspecified
  • Chronic viral hepatitis B without delta-agent
  • Insomnia, unspecified

[past history] - 2023-03-20 admission note

  • Type 2 diabetes mellitus and hypertension for 20+ years under medications treatment.
  • Mixed hyperlipidemia for 5 years with medications control and cancle medications treatment recently
  • Past operation history: VATS exciosion of mediastinal nodules on 2022/12/06

[exam findings]

  • 2023-09-13 MRI - brain
    • Without-contrast multiplanar cerebral MRI revealed (Image quality: no gross motion artifacts)
      • moderate dilated intraventricular and extraventricular CSF spaces
      • punctate white amtter gliosis in the supratentorial brain; mild bilateral periventricular leukoaraiosis; old lacunar infarction in the bilateral basal ganglia.
      • unremarkable change in the skull base
    • IMP: brain atrophy; no evidence of brain tumors.
  • 2023-09-12 PET
    • The FDG PET findings are compatible with lymphoma involving the nasopharynx, bilateral tonsils and multiple lymph nodes on both sides of the diaphragm. In comparison with the previous study on 2022/12/16, the glucose hypermetabolism in some neck lymph nodes, some axillary lymph nodes, mediastinal and bilateral pulmonary hilar lymph nodes and some inguinal lymph nodes are a little more evident. Lymphoma in a little more progression should be considered.
    • Inhomogenously and mildly increased FDG uptake in the spleen and in the bone marow of the skeleton. Lymphoma involving the spleen and bone marow can not be ruled out. Please correlate with other clinical findings for further evaluation.
    • Mildly increased FDG uptake in some focal areas in the lower lobes of bilateral lungs. Inflammation may show this picture.
  • 2023-09-11 CT - chest
    • Comparison was made with CT on 2023/06/16
      • interval increased size and number of multiple enlarged LNs at neck, bilateral axillary regions, mediastinum, retroperitoneum, mesentery and bil. inguinal regions as compared with previous CT on 6/16.
      • Lungs:a 6mm solid nodule at medial LLL and focal nodular septla thickening at RLL-superior segment.
        • mosaic attenuation changes in both lungs on inspiratory images.
      • extensive 3-vessls coronary arterial calcification
        • small anterior pericardial effusion.
      • Pleura: no effusion
      • moderate splenomegaly.
      • no abnormal density and size of the liver, GB, both adrenal glands, pancreas, and both kidneys.
    • Impression:
      • T-cell lymphoma involving both sides of diaphgram s/p C/T, in progression as compared with previous CT on 2023/06/16.
      • LLL and RLL lesions, secondary involvvement or infection.
  • 2023-06-16 CT - abdomen
    • History: T cell lymphoma
    • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ perfusion status can not be determined without IV contrast.
    • Findings: Comparison prior CT dated 2022/12/15.
      • Prior CT identified multiple enlarged LNs at neck, bil. axillary regions, mediastinum, gastrohepatic ligament, celiac trunk, para-aortic space, para-cava space, mesentery and bil. inguinal regions are noted again, marked decreasing in size that is c/w T-cell lymphoma S/P C/T with partial response.
      • Prior CT identified splenomegaly (the largest dimension: 15.5 cm) is noted again, stationary.
      • Prior CT identified some nodules (up to 7mm) at bil. lungs are noted again, mild decreasing in size.
    • IMP:
      • T-cell lymphoma S/P C/T show partial response.
  • 2023-06-10 Nasopharyngoscopy
    • Findings:
      • lump in throat and odynophagia for one month, patient has strong gap reflex, hard to assess NP and larynx by mirror
    • Diagnosis/conclusion
      • Nasopharyngoscope findings: Smooth NP, Laryngx: mild edematous change of laryngeal mucosa
  • 2023-04-13 SONO - nephrology
    • right mild hydroureter
    • left renal cyst
  • 2023-04-12 KUB
    • increased air in nondistended loops of small bowel over LUQ and RUQ, could be paralytic ileus.
    • The size & contour of the kidneys, visualized portion of spleen and liver, and psoas shadows, properitoneal & pelvis fat lines, are unremarkable.
    • Rt L5-S1 facet joint osteoarthritis.
    • s/p foley catheter insertion in the urinary bladder.
  • 2023-02-27 CXR
    • Atherosclerotic change of aortic arch
    • Linear infiltration over both lung zone are noted. please correlate with clinical symptom to rule out inflammatory process.
    • Please correlate with CT.
  • 2023-02-27 Nerve Conduction Velocity, NCV
    • Findings
      • The NCV study showed (1) absence of CMAP in left peroneal nerve, (2) prolonged distal motor latency in bilateral median, bilateral ulnar, and left tibial nerves, (3) reduced CMAP amplitude in all the sampled nerves, (4) decreased motor nerve conduction velocity in all the sampled nerves, (5) absence of SAP in left sural nerve, (6) reduced SAP amplitude in left median and ulnar nerves, (7) decreased sensory nerve conduction velocity in all the sampled nerves.
      • The F-wave study showed (1) absence of F-wave in left peroneal nerve, (2) prolonge minimal F-wave latency in all the sampled nerves.
      • The H-reflex study showed (1) absence of H-wave in left tibial nerve, (2) prolonged H-wave latency in right tibial nerve.
      • The EMG showed (1) poor recruitment of MUAP in right biceps brachii and right rectus femoris muscles, (2) fasciculation, fibrillation, and poor recruitment of MUAP in right tibialis anterior muscles.
    • Conclusion
      • The above findings suggest sensorimotor polyneuropathy with demyelinating pattern. Advise clinical correlation.
  • 2023-02-15 MRI - L-spine
    • diffuse high SI change on T2WI in the bilateral L-spine posterior perivertebral muslces and bilateral gluteal muscles.
    • herniated disc in the L4/5 idsc.
    • discitis in the L4/5 disc.
  • 2023-02-14 CXR
    • Atherosclerotic change of aortic arch
    • Linear infiltration over left lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Few nodular opacities projecting at left lung are suspected.
    • Please correlate with CT.
  • 2023-02-13 SONO - abdomen
    • cholecystopathy
    • renal cyst, LK
    • small amouont ascites
  • 2022-12-20 ECG
    • Sinus tachycardia
    • poor wave progression
  • 2022-12-16 Whole body PET scan
    • The FDG PET findings are compatible with lymphoma involving the nasopharynx, bilateral tonsils and multiple lymph nodes on both sides of the diaphragm.
    • Inhomogenously increased FDG uptake in the spleen and in the bone marow of the skeleton. Lymphoma involving the spleen and bone marow should be considered. Please correlate with other clinical findings for further evaluation.
  • 2022-12-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (75 - 25) / 75 = 66.67%
      • M-mode (Teichholz) = 66
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
  • 2022-12-15 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Positive for malignant T-cell lymphoma
    • Microscopically, it shows bone marrow tissue with presence of aggregations of T-cell lymphomatous cells.
    • Immunohistochemical stain reveals CD5(+), CD3(+), CD20(-), CD117(-), CD34(-), CD71(focal+), MPO(+),and CD138(-).
  • 2022-12-15 CT - abdomen
    • Findings
      • Enlarged LNs at neck, bil. axillary regions, mediastinum, retroperitoneum, peritoneal cavity and bil. inguinal regions.
      • Splenomegaly.
      • Some nodules (up to 7mm) at bil. lungs.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP
      • Lymphoma as described.
  • 2022-12-08, -12-06 CXR
    • s/p right chest tube in place, its tip directed medially, projecting over 6th intercostal space
    • minimal right pneumothorax .
    • widening of Rt paratracheal stripe
    • Platelike lung atelectasis over Lt lower lung zone
  • 2022-12-06 Patho - lymph node region resection
    • Lymph node, right, paratracheal, excision — Malignant T-cell lymphoma
    • Specimen submitted in formalin consists of 4 pieces of tan, irregular tissue measuring up to 5.0 x 2.0 x 1.5 cm. Several enlarged lymph nodes, measuring up to 3.5 x 2.0 x 1.5 cm, are founs and all for section in 3 cassettes A1-3 (A1-2: the same level).
    • Sections show lymph nodes with diffusely infiltration of medium-sized lymphocytes. Vascular proliferation and hyperplasia of follicular dendritic cells are seen.
    • The immunohistochemical stains reveal CK(-), CD3(+), CD5(+), CD4(+), CD8(+), CD20(-), CD56(-), Granzyme B(-), TdT(-), BCL2(+), CD30(-), CD10(-), BCL6(-), PD1(-), ICOS(-), and SAP(-).
    • The results are consistent with peripheral T-cell lymphoma, NOS. Please correlate with the clinical presentation and image study.
  • 2022-11-22 CT - chest
    • Findings
      • Lungs:
        • an oval-shaped LUL-S1/2 solid nodule adjacent to the najor fissure (7.6 mm srs).
        • an oval-shaped RML solid nodule(4mm srs).
        • favor intrapulmonary lymph node
        • normal pulmonary attenuation on inspiratory images, with mild patchy areas air-trapping in both lower lobes.
        • differential diagnosis include obstructive chronic airway disease, hypersensitive pneumonitis, and bronchiolitis obliterans,
      • Mediastinum and hila: enlarged LNs in the visceral space and small LNs in visceral and left anterior prevascular spaces
      • Vessels:
        • calcified plaques of the coronary arteries, extensive in LAD artery
        • Aorta: normal caliber, minimal atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
        • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
      • Chest wall and visible lower neck: multiple enlarged LNs at supraclavicular fossae and both axillary regions.
      • Visible abdominal contents: moderate splenomegaly,
    • Impression:
      • lymphoma or other hematological disease or metastatic tumors in aforementioned regions.
      • suspected obstructive small airways disease in lowef lobes of lungs.
  • 2019-10-14 Thyroid Ultrasound
    • Suspected Autoimmune thyroid disease

[MedRec]

  • 2022-12-14 ~ 2022-12-23 POMR Hemato-Oncology Wan XiangLin
    • Discharge diagnosisw
      • Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites
      • Gout, unspecified
      • Hyponatremia
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
      • Mixed hyperlipidemia
      • Constipation, unspecified
      • Chronic viral hepatitis B without delta-agent
      • Insomnia, unspecified
    • CC
      • for lymphoma staging work-up
    • Present illness
      • This 59 year-old patient has past history of type II diabetes mellitus and hypertension for 20+ years under medications treatment; mixed hyperlipidemia for 5 years and cancle medications treatment recently; new diagnosis lymphoma in 2022/12.
      • According patient’s statement, he suffered from dry cough persist for 3 months. He denied has fever, chilliness, chest pain, chest tightness or hemoptysis noted occured. Chest CT revealed mediastinum and hila has enlarged LNs in the visceral space and small LNs in visceral and left anterior prevascular spaces; impression of lymphoma or other hematological disease or metastatic tumors in aforementioned regions; r/o obstructive small airways disease in lowef lobes of lungs. The patient also told of appetite decrease and body weight loss about 10 kg in recent 6 months (abdout 70 kg decrease to 57 kg). Operation of video-assisted thoracoscopic surgery exciosion of mediastinal nodules was performed smoothly on 2022/12/06. Pathology oral presentation T cell lymphoma, waiting for formal report.
      • This time, he was admitted for staging work-up with whole body CT, bone marrow, PET-CT, Port-A insetion.
    • Course of inpatient treatment
      • After admission, bone marrow was done on 2022/12/15 and the report showed positive for malignant T-cell lymphoma.
      • Pathology showed Lymph node, right, paratracheal, excision — Malignant T-cell lymphoma, peripheral T-cell lymphoma, NOS on 2022/12/15.
      • ROMICON-A  20,20,90mg/cap 1# PO TID、Actein 66.7 mg/gm 1pk PO TID for cough.
      • Abdominal CT (from ABD to Chest) on 2022/12/15 showed enlarged LNs at neck, bil. axillary regions, mediastinum, retroperitoneum, peritoneal cavity and bil. inguinal regions; splenomegaly; some nodules (up to 7mm) at bil. lungs => IMP: Lymphoma as described, atherosclerosis of aorta, iliac arteries.
      • PET scan on 2022/12/16 showed 1. The FDG PET findings are compatible with lymphoma involving the nasopharynx, bilateral tonsils and multiple lymph nodes on both sides of the diaphragm; 2. Inhomogenously increased FDG uptake in the spleen and in the bone marow of the skeleton.
      • 2D echo on 2022/12/16 showed LVEF 66%, preserved LV and RV systolic function with normal wall motion, grade 1 LV diastolic dysfunction.
      • Port-A implantation on 2022/12/19, given Acetal 500 mg/tab 1# PO PRNQ6H if VAS>3.
      • Hyponatremia (Na 129 mmol/L) with N/S 1500ml hydration from 2022/12/14.
      • Type 2 diabetes mellitus with Glimet F.C 2mg & 500mg/tab 1# PO BIDCC, Dibose F.C. 100mg/tab 1# PO BIDCC and Soliqua 3mL/pre-filled pen 16 Unit SC QN, monitor blood sugar by one touch, due to Hypoglycemia was noted, adjust to 12 unit SC QN.
      • Hypertension with Aprovel 300mg/tab (Irbesartan) 1# PO QD and Aspirin 100 mg/cap 1# PO QD.
      • Mixed hyperlipidemia with Tulip F.C. 20mg/tab 1# PO QD.
      • Constipation with Through 12mg/tab 1# PO HS.
      • Chronic viral hepatitis B (Anti-HBc : reactive) with Vemlidy 25 mg/tab 1# PO QDCC.
      • Insomnia with Anxiedin 0.5mg/tab # PO PRNHS if insomnia.
      • Discussion with patient and family about disease condition and future treatment on 2022/12/19 and transfer service to Dr. Wan on 2022/12/20.
      • After transferring to Dr. Wan’s service, we checked HTLV-1,2 which showed nonreactive. After discussion with the patient and his family, they decided to undergo chemotherapy.
      • Chemotherapy (CHOP) prepare including blood test, normal saline 500ml + rolikan 40ml BID, Feburic 1# QD were arranged. We then arranged chemotherapy with CHOP on 2022/12/22.
      • Also, we checked finger sugar QIDAC, and adjusted insulin dosage to Tresiba 8 Unit HS + NovoRapid 4 Unit TIDAC with scale by meta doctor’s suggestion.
      • He had no significant discomfort after chemotherapy. Under stable condition, he discharged on 2022/12/23 and OPD follow up was arranged.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQID
      • Actein (acetylcysteine 200mg) 1# TID
      • Feburic (febuxostat 80mg) 1# QD
      • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
      • Through (sennoside 12mg) 1# HS
      • Ulstop (famotidine 20mg) 1# QD
      • Vemlidy (tenofovir alafenamide 25mg) 1# QDCC
      • Compesolon (prednisolone 5mg) 9# QD
      • Compesolon (prednisolone 5mg) 9# QN
      • Alpraline (alprazolam 0.5mg) 1# PRNHS
  • 2022-12-05 ~ 2022-12-09 POMR Chest Surgery Xie MinXiao
    • Discharge diagnosis
      • Malignant T-cell lymphoma status post video-assisted thoracoscopic surgery exciosion of mediastinal nodules on 2022-12-06
      • Mediastinal lymphadenopathy status post video-assisted thoracoscopic surgery exciosion of mediastinal nodules on 2022-12-06
      • Type 2 diabetes mellitus without complications
      • Essential hypertension
      • Mixed hyperlipidemia
    • Course of Inpatient Treatment
      • After admission, pre-op assessment was done.
      • Operation of video-assisted thoracoscopic surgery exciosion of mediastinal nodules was performed smoothly at 2nd admission day. No complication was noted. Prophylactic antibiotics was prescribed for 1 day.
      • Dysuria was noted after removal foley and ICP U/O 350 ml ST at post op day 1, Bethanechol were prescribed and voiding smoothly by patient himself.
      • Right chest tube with LPS -18 cmH2O was done. Chest tube was removed at post-op 2nd day. He was discharged under stable hemodynamics at post-op 3rd day.
    • Prescription
      • Actein (acetylcysteine 66.7mg) 1# TID
      • MgO 250mg 1# TID
      • Wecoli (bethanechol 25mg) 1# TIDAC
      • Acetal (acetaminophen 500mg) 1# QID
      • Sindine (povidone iodine) QD EXT (for wound dressing change)
  • 2022-11-29 SOAP Chest Surgery
    • P
      • arrange admission on 12/5
      • VATS mediastinal nodule excision on 12/6.
  • 2022-11-28 SOAP Chest Medicine
    • S: dry cough persist for 3 months, no short of breath
    • O: 2022/11/22 CT: lymphoma or other hematological disease or metastatic tumors in aforementioned regions; r/o obstructive small airways disease in lowef lobes of lungs; calcified plaques of the coronary arteries, extensive in LAD artery
    • P
      • refer to chest surgeon for mediastinal lymphadenopathy suspected lymphoma
      • refer to oncologist for mediastinal lymphadenopathy suspected lymphoma
  • 2017-10-30 SOAP Metabolism
    • S: Drugs will be collected at our hospital in the future. referred to the PharmaCloud.
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
    • Prescription
      • Aprovel (irbesartan 300mg) 1# QD
      • Tulip (atorvastatin 20mg) 1# QOD
      • Bokey (aspirin 100mg) 1# QD
      • Forxiga (dapagliflozin 10mg) 1# QDCC
      • Glimet (glimepiride 2mg, metformin 500mg) 1# QDCC
  • 2017-10-23 SOAP Ophthalmology
    • Diagnosis
      • Vitreous hemorrhage, right eye [H43.11]
      • Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema [E11.351]
  • 2017-10-18 SOAP Metabolism
    • S: type 2 DM since 2012 , hypertension , irregular Tx before , hyperlipidemia , hyperuricemia, poor control, family Hx of DM: (+)
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
  • 2017-10-17 SOAP Ophthalmology
    • S
      • refer from LMD vitrous hemorrha OD
      • Blurred visionBlurred vision
      • DM for fundus exam
      • DM+, HTN-, NKA
    • Diagnosis
      • Vitreous hemorrhage, right eye [H43.11]
    • Prescription
      • Trand (tranexamic acid 250mg) 1# BID

[consultation]

  • 2023-05-12 Ear Nose Throat
    • Q
      • for right ear pain & sorethroat R/O otitis media
      • He complained of right ear pain & sorethroat for days. We need expertise to evaluate his condition thanks!
    • A
      • Ear: bilateral cerumen impaction, after removal, bilateral ear drum intact without middle ear effusion.
      • Oral cavity and oropharynx: injected posterior pharyngeal wall.
      • Portable nasopharyngoscopy: smooth nasopharynx, oropharynx and hypopharynx. Patent airway.
      • Impression: Impending acute tonsillitis, bilateral cerumen impaction
      • Plan: Please give sulconazole solution Exelderm for bilateral ear, and please provide Curam for 5 days and analgesic agent if not contraindicated.
  • 2023-02-09 Dermatology
    • Q
      • This 60 year-old patient has past history of type II diabetes mellitus and hypertension for 20+ years under medications treatment; mixed hyperlipidemia for 5 years and cancle medications treatment recently; new diagnosis lymphoma in 2022/12.
      • He was under CHOP (cyclophosphenide + doxorubicin + vincrinstine + compesolon) chemotherpay with C1 on 2022/12/22 and C2 on 2023/01/13. This time, he was admitted for C3 CHOP chemotherapy.
      • We strongly need your expertise for lips rash and ulcer, suspected Herpes skin rash. Mucosa inside the mouth showed no ulcer, but there were ulcer noted at his lips. Due to immunosuppression state under chemotherapy, we strongly need your expertise for evaluation and management. Thank you very much.
    • A
      • The patient had sufferred from perioral scaling crust with erythematous macules (upper and lower lips and corners of the mouth) with mild stinging and itchy sensation.
      • Under the impression of exfoliative chelitis with secondary candidasis.
      • The following sugeetion:
        • Tetracycline onit 2 tube topical bid use first (First, apply it broadly, which can be used as a base for lip balm).
        • Mycomb cream 1 tube topical bid use over regional erythematous scaling lesions (use it locally on areas with surrounding redness and flaking skin).

[surgical operation]

  • 2022-12-06 - Op Method: VATS exciosion of mediastinal nodules
    • Finding: Multiple enlarged mediastinal LNs.

[chemoimmunotherapy]

  • 2023-06-16 - cyclophosphamide 750mg/m2 800mg NS 250mL 30min + doxorubicin 50mg/m2 40mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP, 75% Endoxan for poor renal function, 60% Adriamycin for GPT 88)
    •                 dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug                       + NS 250mL
  • 2023-05-15 - cyclophosphamide 750mg/m2 790mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP, reduced Endoxan for poor renal function)
    •                 dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL
  • 2023-03-24 - cyclophosphamide 750mg/m2 780mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP, reduced Endoxan for poor renal function)
    •                 dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL
  • 2023-02-14 - cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + doxorubicin 50mg/m2 60mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP)
    • betamethasone 4mg + dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL
  • 2023-01-13 - cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 74mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP)
    • betamethasone 4mg + dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL
  • 2022-12-22 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + doxorubicin 50mg/m2 80mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID D1-5 (CHOP)
    • betamethasone 4mg + dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL

==========

2023-07-17

It appears that there is a suspicion of AKI in this patient due to the decline in renal function.

  • 2023-07-16 Creatinine 4.13 mg/dL

  • 2023-07-03 Creatinine 1.68 mg/dL

  • 2023-07-16 eGFR 15.77

  • 2023-07-03 eGFR 44.52

  • 2023-07-16 BUN 71 mg/dL

  • 2023-07-03 BUN 29 mg/dL

Based on the patient’s current renal status, the dosage of drugs in the active formulary has been reviewed and no adjustment is required.

2023-06-26

  • According to the PharmaCloud database, our hospital has been the sole provider of all required medical services and medications for this patient for the past 3 months.

  • Our endocrinologist recently prescribed a refillable regimen of Tresiba Flex Touch (insulin degludec), Relinide (repaglinide), Trajenta (linagliptin), Aprovel (irbesartan), Tulip (atorvastatin), and Bokey (aspirin) on 2023-06-20. These drugs were added to the patient’s active medication list. As a result, no medication reconciliation issues were identified.

  • The most recent administration of CHOP was on 2023-06-16, and subsequent lab results indicate that leukopenia is still progressing. The use of G-CSF is covered by NHI when WBC < 1000/uL or ANC < 500/uL. Therefore, if the patient’s lab results meet these criteria, the use of G-CSF could be an appropriate management strategy. Please continue monitoring the patient’s WBC and ANC levels to make informed decisions about future treatment strategies.

    • 2023-06-26 WBC 1.24 x10^3/uL
    • 2023-06-25 WBC 1.43 x10^3/uL
    • 2023-06-14 WBC 4.84 x10^3/uL

2023-06-15

  • Upon review of the PharmaCloud database, it is observed that the patient has exclusively sought medical care at our hospital for the past three months. No issues related to medication reconciliation have been identified.

  • The patient’s renal function has remained insufficient over the past month, with an eGFR of 26 on 2023-06-15. The dose of cyclophosphamide in the CHOP regimen has been adjusted in response to this renal insufficiency. Please continue to monitor the patient’s renal function and consider whether further dose adjustments are necessary.

    • 2023-06-15 Creatinine 2.64 mg/dL
    • 2023-06-14 Creatinine 2.92 mg/dL
    • 2023-05-26 Creatinine 2.41 mg/dL
    • 2023-05-15 Creatinine 2.11 mg/dL
    • 2023-06-15 BUN 54 mg/dL
    • 2023-06-14 BUN 56 mg/dL
    • 2023-05-26 BUN 64 mg/dL
    • 2023-05-15 BUN 44 mg/dL
  • In addition, the LFT also demonstrated an increase in ALT. According to Folyd’s 2006 recommendations, when a patient’s transaminases are 2 to 3 times the ULN, the dose of doxorubicin should be reduced to 75% of the standard dose. (The manufacturers’ guidelines suggest adjusting doses based on serum bilirubin levels. However, the most recent test results show that this patient’s bilirubin level is within the normal range.)

    • 2023-06-14 S-GPT/ALT 88 U/L
    • 2023-05-26 S-GPT/ALT 27 U/L

2023-05-12

  • Based on the PharmaCloud database, the patient has only visited our hospital for medical needs in the past three months. After reviewing the database, no medication reconciliation issues were identified.

  • Lab results on 2023-05-11 indicate creatinine 3.26 mg/dL, eGFR 20.72, BUN 83 mg/dL, demonstrating the patient’s renal insufficiency. The rationale for dose adjustment in the CHOP regimen for patients with renal impairment is as follows:

    • cyclophosphamide
      • There are no dosage adjustments provided in the manufacturer’s labeling
      • Aronoff 2007
        • CrCl >=10 mL/minute: No dosage adjustment required.
        • CrCl <10 mL/minute: Administer 75% of normal dose.
      • KDIGO 2012: Lupus nephritis
        • CrCl 25 to 50 mL/minute: Administer 80% of normal dose.
        • CrCl 10 to <25 mL/minute: Administer 70% of normal dose.
    • doxorubicin
      • There are no dosage adjustments provided in the manufacturer’s labeling; however, adjustments are likely not necessary given limited renal excretion.
    • vincristine
      • No dosage adjustment necessary
    • prednisolone
      • No dosage adjustment necessary
  • The cyclophosphamide dose has been reduced to 75% since the last administration on 2023-03-24 as indicated without an issue.

  • The other medications listed in the active prescription should be used with caution, considering the patient’s renal insufficiency (ref: UpToDate):

    • cimetidine
      • There are no dosage adjustments provided in the manufacturer’s labeling; use with caution. Severe kidney impairment: 300 mg every 12 hours; may increase frequency with caution. When hepatic impairment is also present, further reductions in dosage may be necessary.
      • Alternate recommendations (Aronoff 2007):
        • GFR >50 mL/minute: No dosage adjustment necessary.
        • GFR 10 to 50 mL/minute: Administer 50% of normal dose.
        • GFR <10 mL/minute: 300 mg every 8 to 12 hours.
    • silodosin
      • CrCl >50 mL/minute: No dosage adjustment necessary.
      • CrCl 30-50 mL/minute: 4 mg once daily.
      • CrCl <30 mL/minute: Use is contraindicated.
    • tenofovir alafenamide
      • Tenofovir is renally cleared, and exposures are increased in patients with CrCl <30 mL/minute and those receiving hemodialysis. Close monitoring for adverse effects in the advanced stages of kidney dysfunction is recommended.
      • Kidney impairment prior to treatment initiation:
        • CrCl >=15 mL/minute: No dosage adjustment necessary.
        • CrCl <15 mL/minute: Use is not recommended.
  • Please continue to monitor regularly and consider dose adjustments as needed based on patient renal function.

2023-03-21

  • The acute kidney injury (AKI) episode that occurred in late Feb 2023 appears to have subsided.
    • 2023-03-21 Creatinine 2.78 mg/dL
    • 2023-03-20 Creatinine 3.24 mg/dL
    • 2023-03-02 Creatinine 2.60 mg/dL
    • 2023-02-27 Creatinine 3.43 mg/dL
    • 2023-02-25 Creatinine 3.80 mg/dL
    • 2023-02-23 Creatinine 4.66 mg/dL
    • 2023-02-22 Creatinine 5.21 mg/dL
    • 2023-02-21 Creatinine 5.15 mg/dL
    • 2023-02-14 Creatinine 1.50 mg/dL
    • 2023-02-10 Creatinine 1.13 mg/dL
    • 2023-02-09 Creatinine 1.22 mg/dL
    • 2023-02-08 Creatinine 1.84 mg/dL
    • 2023-01-20 Creatinine 0.95 mg/dL
    • 2023-01-12 Creatinine 1.00 mg/dL
    • 2023-01-06 Creatinine 1.41 mg/dL
    • 2023-01-03 Creatinine 1.16 mg/dL
    • 2023-01-01 Creatinine 1.15 mg/dL
  • 2023-03-21 CrCl 19mL/min, eGFR 24.98.
    • Silodosin use is not recommended for patients with a CrCl below 30 mL/minute.
    • Metformin use is contraindicated for patients with an eGFR below 30 mL/minute/1.73m2.
    • For patients with an eGFR between 15 and 60 mL/min/1.73m2, glimepiride use may result in reduced renal clearance of active metabolites, increasing the risk of hypoglycemia.
    • Acarbose use is generally not advised for patients with a serum creatinine level above 2 mg/dL or a CrCl below 25 ml/minute/1.73m2, as the systemic area under the curve (AUC) may increase six-fold.

2023-01-13

  • Since around 2022/2023 new year’s eve, there has been no sign of neutropenia in the lab data.
    • 2023-01-12 WBC 9.41 x10^3/uL
    • 2023-01-06 WBC 51.96 x10^3/uL
    • 2023-01-03 WBC 1.66 x10^3/uL
    • 2023-01-01 WBC 0.16 x10^3/uL
    • 2022-12-30 WBC 0.30 x10^3/uL
    • 2022-12-22 WBC 6.75 x10^3/uL
    • 2022-12-14 WBC 9.13 x10^3/uL
    • 2022-12-05 WBC 7.96 x10^3/uL
    • 2022-11-29 WBC 10.69 x10^3/uL
  • A grade 4 neutropenia developed around new year’s eve, just about 10 days after the patient had received last chemotherapy on 2022-12-22. The date of this chemotherapy was 2023-01-12, approximately one to two weeks after that date, when the Chinese New Year holiday is approaching. In order to prevent potential neutropenia during the long holidays, it is recommended to take steps in advance.

701506934

231201

[lab data]

2023-11-30 HBsAg Nonreactive
2023-11-30 HBsAg (Value) 0.35 S/CO
2023-11-30 Anti-HBc Reactive
2023-11-30 Anti-HBc-Value 6.35 S/CO
2023-11-30 Anti-HCV Nonreactive
2023-11-30 Anti-HCV Value 0.12 S/CO

[exam findings]

  • 2023-11-29 CT - abdomen
    • Without and with contrast Abdomen CT showed
      • A fat containing tumor, about 82mm x 83mm x 79mm, in the right kidney was noted.
      • Partial calcified rim was noted in the lower pole of the right kidney.
      • High density fat stranding in the right perirenal space was noted.
      • Some air within the lesion was noted.
    • IMP:
      • r/o Angiomyolipoma in the right kidney with rupture and superimposed infectious process. Please correlate with U/A.

[consultation]

  • 2023-11-29 Urology
    • Q
      • CC: cough and fever (up to 39’C) on and off for a month
      • Phx: renal tumor s/p
      • 2023-11-10 CT: A 8.4-cm right renal angiomyolipoma with hydronephrosis, rupture, and presence of adjacent hematoma.
    • A
      • This 42 y/o female has intermittent for about 1 month.
        • According to her statement, low grade fever happened weeks ago.
        • In mid November, she suffered from sudden weakness and was sent to ER at Chang-hua where abdominal echo showed right renal mass.
        • She was then transferred to Chang-hua Christian Hospital for further evaluation.
        • Abdominal CT on 11/23 revealed a 8cm right renal tumor with hematoma formation.
        • TAE was done but fever persisted in the following days.
        • She received antibiotic treatment but the condition was not improved.
        • Therefore, the patient decided to came to our ER for personal reason.
        • At our ER, lab data showed abnormal differential count.
        • Mild leukocytosis with elevated CRP level were also noted.
        • Furthermore, thrombocytosis to 1055k/ul was revealed in hemogram.
        • Follow-up abdominal CT showed stable size of right renal tumor and hematoma.
      • Imp:
        • Right renal tumor rupture, status post TAE on 2023/11/23
        • Thrombocytosis and abnormal differential count, cause to be determined
      • Plan:
        • Pain control
        • Please do further survey for hematology problem that could cause thrombocytosis and abnormal differential count.
        • Since the patient just received TAE about 1 week ago, there might be inflammation or tissue reaction. Emergent surgery was not indicated if her vital sign is stable.
        • Follow-up abdominal image would be needed if there is possibility of renal abscess formation
        • Please contact us if there is any related problem

==========

2023-12-01

[thrombocytosis]

Thrombocytosis improves, cause remains unclear.

  • 2023-12-01 PLT 686 *10^3/uL
  • 2023-11-30 PLT 863 *10^3/uL
  • 2023-11-29 PLT 1055 *10^3/uL

Elevated D-dimer levels, in conjunction with elevated fibrinogen, can further indicate the increasing risk of thrombosis and cardiovascular complications. The combination of elevated fibrinogen and D-dimer levels is considered a stronger risk factor for thrombosis than either one alone. Close monitoring is essential.

  • 2023-11-30 Fibrinogen (quant) 581.5 mg/dL
  • 2023-11-30 D-dimer 5399.00 ng/mL(FEU)

701373652

231130

[diagnosis] - 2023-03-23 admission note

  • Adenocarcinoma of sigmoid colon with liver metastasis, pT3N1cM1b, Stage IVB, with nearly total obstruction s/p sigmoid colectomy on 2022/11/09, with EGFR RAS gene wildtype, s/p chemotherapy with FOLFIRI from 2022/12/12 ~ 2023/02/21, plus Panitumumab from 2023/02/21, progression of LNs, bones and liver metastases s/p FOLFOX from 2023/03/09
  • Localized skin eruption due to drugs and medicaments taken internally
  • Chronic viral hepatitis B without delta-agent
  • Iron deficiency anemia, unspecified
  • Hypertension
  • Constipation, unspecified
  • Encounter for antineoplastic chemotherapy

[past history]

  • Hypertension for many years, regular medication with Norvasc                   

[allergy]

  • NKDA

[family history]

  • No known congenital disease was noted  
  • No cancer in his family  

[lab data]

  • 2022-11-18 Anti-HCV Nonreactive
  • 2022-11-18 Anti-HCV Value 0.07 S/CO
  • 2022-11-18 Anti-HBc Reactive
  • 2022-11-18 Anti-HBc-Value 6.67 S/CO
  • 2022-11-18 Anti-HBs 74.91 mIU/mL
  • 2022-11-02 HBsAg(nuclear medicine) Negative
  • 2022-11-02 HBsAg Value(nuclear medicine) 0.446

[exam findings]

  • 2023-09-07, -06-08 CT - abdomen
    • S/P colon operation. Mild regression of LNs and liver metastases. Stable condition of bony metastases.
  • 2023-03-09 CT - abdomen
    • History and indication: Adenocarcinoma of sigmoid colon with liver metastasis
    • IMP: S/P colon operation. Progression of LNs, bones and liver metastases.
  • 2023-02-03 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spot in the right rib cage and increased activity in the maxilla, mandible, L4-5 spines, bilateral shoulders, sternoclavicular junctions, hips and knees in whole body survey.
    • IMPRESSION:
      • Increased activity in the L4-5 spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
      • Increased activity in the maxilla and mandible. Dental problem may show this picture.
      • Some faint hot spot in the right rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2022-12-15 All-RAS + BRAF mutation
    • Tissue block No. S2022-19716 A3
    • RESULTS
      • All-RAS:
        • There was no variant detect in the KRAS/NRAS gene.
      • BRAF
        • There was no variant detect in the BRAF gene.
  • 2022-12-15 KUB
    • There are Eqivocal osteoblastic change at L-spine and bilateral ilium that may be bony metastases? Please correlate with bone scan.
  • 2022-12-08 ECG
    • Left anterior fascicular block
    • Minimal voltage criteria for LVH, may be normal variant
    • Septal infarct, age undetermined
  • 2022-11-30 Patho - liver bipsy needle/wedge
    • Liver, CT guide biopsy — Metastatic adenocarcinoma, consistent with colorectal primary
    • The sections show moderately differentiated adenocarcinoma, composed of nests columnar neoplastic cells, arragned in glandular and cribrifrom patterns, in fibrous stroma. Dirty tumor necrosis is present.
    • IHC shows: CK7(-), CK20(focal +) and CDX2(+). The finding is consistent with metastatic colorectal adenocarcinoma.
  • 2022-11-29 Patho - peritoneum biopsy
    • Labeled as “LN at retroperitoneum”, CT guided biopsy — poorly differentiated carcinoma.
    • IHC stains: CK (+), Ki-67 (15%), trypsin (-), CK20 (-), S-100 (-), CD56 (-), LCA (-), CD3 (-), CD20 (-), chromogranin A(-), synaptophysin (-).
    • Section shows round blue cell tumor with pseudo-lumina or pseudo-rossette-like pattern.
  • 2022-11-10 - Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, sigmoid colon, laparoscopic sigmoid colectomy —- Adenocarcinoma, moderately differentiated
      • Resection margins: free
      • Lymph node, mesocolic, dissection -
        • Negative for malignancy (0/24)
        • Four tumor deposits are seen
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: pStage IIIB, pT3N1c(if cM0) or pStage IVB, pT3N1c(if cM1b(by CT finding)); please correlate with the clinical presentation.
    • Gross Description:
      • Operation procedure: laparoscopic sigmoid colectomy
      • Specimen site: sigmoid colon
      • Specimen size: 10.5 cm in length
      • Tumor size: 6.5 x 5.0 x 1.5 cm; annularly ulcerated
      • Tumor location: 2.6 cm and 1.5 cm away from the two resection margins, respectively.
      • Depth of invasion grossly: mesocolic soft tissue
      • Mucosa elsewhere: a polyp measuring 0.7 x 0.5 x 0.4 cm is seen
      • Macroscopic Tumor Perforation: Not identified
      • Sections are taken and labeled as: A1: colon, non-tumor; A2: polyp; A3-6: tumor; A7-10: lymph node, mesocolic; B: proximal cut end; C: distal cut end.
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: very close, Distance of tumor from margin: < 1 mm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Tumor Budding: Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: not available
      • Tumor Deposits: Present, Specify number of deposits: 4
      • Regional Lymph Nodes: Number of Lymph Nodes Involved/Examined: 0/24
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): not applicable
        • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN): pN1c: No regional lymph nodes are positive, but there are tumor deposits in the subserosa, mesentery, or nonperitonealized pericolic, or perirectal/mesorectal tissues.
        • Distant Metastasis (pM): CT finding: if cM1b: Metastasis to two or more sites or organs is identified without peritoneal metastasis
      • Additional Pathologic Findings
        • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
        • A tubulovillous adenoma is seen.
  • 2022-10-31 CT - abdomen
    • History and indication: Advanced sigmoid cancer (15-20AAV), s/p tattooed
    • Findings
      • Wall thickening of S-colon with adjacent fat stranding and regional LAP. Enlarged LNs at retroperitoneum.
      • Poor enhancing tumors in liver.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Collapse of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • No abnormal density at bilateral basal lungs.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2b(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)

[MedRec]

  • 2022-11-17 SOAP Hemato-Oncology Xia HeXiong
    • P
      • Arrange Port-A on 2022-11-22
      • After SDM with patient for the selection of bevacizumab or cetuximab/panitumumab, patient choice cetuximab/panitumumab
  • 2022-11-17 SOAP Colorectal Surgery Xiao GuangHong
    • A: Sigmoid cancer with obstruction, liver metastasis, Stage IV
    • P: Suggest colectomy first then target + chemotherapy due to partial obstruction then re-evaluation of liver resection
  • 2022-11-08 ~ 2022-11-22 POMR Colorectal Surgery Xiao GuangHong
    • Discharge diagnosis
      • Advanced sigmoid cancer with nearly total obstruction with retroperitoneal lymph nodes and liver metastasis, cT4aN2bM1b, stage: IVB status post 3 dimensions Laparoscopic sigmoid colectomy on 2022/11/09
      • Malignant neoplasm of sigmoid colon
      • Hypertension
    • CC
      • Abdominal fullness, frequent defecation, tarry stool and body weigh loss 2kg within 1 years
    • Present illness
      • This is a 74-year-old male with underlying disease of hypertension. This time, he suffered from abdominal fullness, frequent defecation, tarry stool and body weigh loss 2kg within 1 years. Tracing back to his history, he had been to LMD (Dr Chen ZiLiang) for medical help and advanced sigmoid cancer (15-20AAV), s/p tattooed was told. Thus, he came to our CRS Dr. Xiao’s OPD for second opinion and Abdominal CT survey. Blood test done on 10/31 revealed HB 7.2 g/dL and no other special finding. Abdominal CT done on 10/31 showed colonrectal cancer T4aN2bM1b, STAGE:IVB. Due to above finding he was admitted to our ward for further pre-operation survey.
    • Course of inpatient treatment
      • This 74-year-old male patient was a case of sigmoid colon cancer, T4aN2bM1b, STAGE:IVB. He admitted on 2022-11-08 and 3D Laparoscopic sigmoid colectomy was performed on the days of admission. The post-operative course was relatively smooth without complication. The bowel function, urinary function were normal and the wound pain was tolerable. He was discharged on 2022-11-12 and will follow up in our out-patient department next 2 week
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
  • 2022-11-03 SOAP Colorectal Surgery Xiao GuangHong
    • A: Suggest colectomy first then target + chemotherapy due to partial obstruction

[consultation]

  • 2023-03-23 Dermatology
    • Q
      • The 74 y/o man has adenocarcinoma of sigmoid colon with liver metastasis, pT3N1cM1b, Stage IVB, with nearly total obstruction s/p sigmoid colectomy on 2022/11/09, with EGFR RAS gene wildtype, s/p chemotherapy with FOLFIRI from 2022/12/12 plus Panitumumab from 2023/02/21. Red hot swelling sensation over face s/p target therapy with Panitumumab.
      • For paronychia and keloid with pus on the chest, sent culture on 2023/03/22, we need your consultation for evaluation. Thanks a lot!!!
    • A
      • The patient had sufferred from paronychia with granulation formation over toenail and keloid with seocndary wound formation over chest.
      • Under the impression of paronychia with granulation, keloid with seocndary wound & bacterial infection.
      • The following sugeetion:
        • paronychia over fingernail, Tetracycline onit 1 tube topical bid use.
        • for limbs and hand xerosis, sinphraderm cream 1 tube topical QN use.(enahcne mositurization)
        • for keloid wound, keep wound CD and might consider Siliverzine cream 1 tube antibiotic use for wound occlusion effect.
  • 2023-03-09 Dermatology
    • Q
      • The 74 y/o man has adenocarcinoma of sigmoid colon with liver metastasis, pT3N1cM1b, Stage IVB, with nearly total obstruction s/p sigmoid colectomy on 2022/11/09, with EGFR RAS gene wildtype, s/p chemotherapy with FOLFIRI from 2022/12/12 plus Panitumumab from 2023/02/21. Red hot swelling sensation over face s/p target therapy with Panitumumab. follow up in your OPD on 2023/03/02.
      • For red hot swelling sensation over face, We need your consultation for evaluation. Thanks a lot!!!
    • A
      • The patient had sufferred from facial flush with scales and pruritus. Besides, dry xerosis was noted over lower legs.
      • Under the impression of seborrheic dermatitis and xerotic dermatitis
      • The following sugeetion:
        • for fisuriform wound protection, Tetracycline onit 1 tube topical bid use first.
        • for facial erythema, Free gel 1 tube topical bid use over erythematous rash over face (Can be used extensively on the face).
        • for itchy papules and sclaes, Mycomb cream 1 tube topical PRN bid use.

[MedRec]

  • 2023-03-30 SOAP Dermatology
    • S: refill medication use
    • Prescription
      • Allegra (fexofenadine 60mg) 1# BID
      • Free Gel (metronidazole) BID TOPI
      • tetracycline BID EXT
  • 2023-03-22 SOAP Hemato-Oncology
    • O: Cancer Treatment Chemoradiotherapy/Targeted Therapy Side Effects Assessment (2023-03-22)
      • Skin rash: G2: Moderate rash, or single moist desquamation, mostly in skin folds and moderate edema
  • 2023-03-02 SOAP Dermatology
    • S: red hot swelling sensation over face, cancer target therapy.
    • O: Bilateral facial flush with tightness and burning sensation for weeks.
      • Impression: rosacea
    • P:
      • Education about drug side effec and explain
      • Strongly suggested OPD f/u
    • Prescription
      • Allegra (fexofenadine 60mg) 1# BID
      • doxycycline 100mg 1# BID
      • Free Gel (metronidazole) BID TOPI
  • 2023-01-05 SOAP Hemato-Oncology
    • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2022-11-22
      • target + chemotherapy due to partial obstruction then re-evaluation of liver resection
  • 2022-11-17 SOAP Hemato-Oncology
    • O: Now on FOLFIRI +/- anti-EGFR
    • P: After SDM with patient for the selection of bevacizumab or cetuximab/panitumumab, patient choice cetuximab/panitumumab
  • 2022-11-03 SOAP Colorectal Surgery
    • A: Suggest colectomy first then target + chemotherapy due to partial obstruction

[surgical operation]

  • 2022-11-09
    • Surgery: 3D Laparoscopic sigmoid colectomy    
    • Finding: Sigmoid cancerwith nearly total obstruction, much stool in proximal colon and D-colon dilatation

[immunochemotherapy]

  • 2023-11-29 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2h4 + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-30 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2h4 + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-02 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-14 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-22 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-31 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-18 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-29 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-16 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-31 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX, Oxa 75)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-04 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX, Oxa 65)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-11 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-23 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-09 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-21 - panitumumab 6mg/kg 500mg NS 250mL 1hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-03 - irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-16 - irinotecan 150mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-26 - irinotecan 150mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-12 - irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

[note]

Acneiform eruption secondary to epidermal growth factor receptor (EGFR) and MEK inhibitors 2023-04-12 https://www.uptodate.com/contents/acneiform-eruption-secondary-to-epidermal-growth-factor-receptor-egfr-and-mek-inhibitors

  • Acneiform eruption is the prototypical cutaneous adverse reaction associated with all epidermal growth factor receptor (EGFR) inhibitors, which include monoclonal antibodies and oral small molecules used for the treatment of certain advanced or metastatic cancers, such as non-small cell lung cancer (afatinib, erlotinib, gefitinib, osimertinib, mobocertinib, necitumumab, amivantamab), pancreatic cancer (erlotinib), breast cancer (lapatinib, neratinib), colon cancer (cetuximab, panitumumab), and head and neck cancer (cetuximab). Acneiform eruption is also one of the most frequent adverse effects of inhibitors of the EGFR downstream mitogen-activated protein kinase kinase (MEK) signaling pathways MEK1 and MEK2 (eg, trametinib, cobimetinib, binimetinib, selumetinib), especially when used as monotherapy.
  • Several studies have noted an association between acneiform eruption and increased overall response rate or survival.
  • Preemptive therapy
    • We suggest prophylactic oral antibiotics in conjunction with topical corticosteroids for patients initiating treatment with EGFR inhibitors. Treatment is started on the same day as EGFR inhibitor therapy and continued for six weeks. We typically use doxycycline 100 mg twice a day, minocycline 100 mg daily, or oxytetracycline 500 mg twice daily for six weeks. Alternative antibiotics include cephalosporins (eg, cefadroxil 500 mg twice daily) or trimethoprim-sulfamethoxazole (160 mg/800 mg twice daily).
    • A low-potency topical corticosteroid (eg, hydrocortisone 2.5%, alclometasone 0.05% cream) is applied twice daily to the face and chest.

==========

2023-10-31

CT scans from 2023-09-07 and 2023-06-08 both indicate mild regression of lymph nodes (LNs) and liver metastases, with a stable condition of bony metastases. This suggests that the Vectibix + FOLFOX regimen, initiated in Mar 2023, continues to be effective against the disease.

[potential folate-dependent anemia]

The patient has been on long-term iron supplementation, yet the MCV value is at the upper limit of the normal range (97.3 fL on 2023-10-30). While iron deficiency anemia typically presents with a low MCV, the observed decrease in HGB might be attributed to potential Vitamin B12 deficiency, folate deficiency, liver disease, or bone marrow dysfunction.

5-FU, a component of the FOLFOX regimen, disrupts DNA synthesis in cells. It acts by inhibiting the enzyme thymidylate synthase, which relies on folate for its activity. By inhibiting this enzyme, 5-FU can decrease the availability of active folate forms within cells. It’s plausible that the patient’s reduced HGB is related to folate deficiency.

2023-08-23

After reviewing HIS5 records, there are no medication reconciliation issues. PharmaCloud is not accessible currently.

2023-08-01

There are no medication reconciliation issues after review of PharmaCloud and HIS5 records.

2023-06-30

According to the PharmaCloud database, our hospital has been the only medical institution providing care and prescriptions for this patient over the past three months. The Hemato-Oncology department is solely responsible for the patient’s recent medications. Hence, no medication reconciliation issues were detected.

2023-05-04

  • An episode of leukopenia with a WBC count of less than 3K/uL (2.92K/uL on 2023-05-03) was observed for the first time since the patient started chemotherapy in mid-December 2022. It is important to closely monitor the patient’s WBC and check whether the leukopenia persists.
  • Over the past 7 months, the patient’s anemia has improved with the administration of Foliromin (ferrous sodium citrate). Given the expected decrease in marginal benefit of iron supplementation as the mean corpuscular volume (MCV) approaches 100 fL, it is recommended to either discontinue the medication or decrease the frequency from twice daily (BID) to once daily (QD) and/or assess body iron stores such as ferritin, transferrin to ensure that iron levels are adequate.
  • The patient’s rash, which is a side effect of the EGFR inhibitor panitumumab, is currently being managed with self-provided topical ointments without complications.

2023-04-12

  • Lab data on 2023-04-06 showed normal readings.

  • The patient’s anemia has improved with the use of Foliromin (ferrous sodium citrate) for the past 6 months. It is recommended to either discontinue or reduce the frequency of the medication from twice daily (BID) to once daily (QD) due to an expected decline in the marginal effect of iron supplementation, as the mean corpuscular volume (MCV) is approaches 100 fL.

    • 2023-04-06 HGB 12.0 g/dL
    • 2023-03-22 HGB 11.7 g/dL
    • 2023-03-07 HGB 11.8 g/dL
    • 2023-02-21 HGB 11.5 g/dL
    • 2023-02-02 HGB 11.3 g/dL
    • 2023-01-05 HGB 10.1 g/dL
    • 2022-12-22 HGB 9.9 g/dL
    • 2022-11-28 HGB 8.5 g/dL
    • 2022-10-31 HGB 7.2 g/dL
    • 2023-04-06 MCV 96.6 fL
    • 2023-03-22 MCV 94.2 fL
    • 2023-03-07 MCV 92.3 fL
    • 2023-02-21 MCV 93.8 fL
    • 2023-02-02 MCV 88.2 fL
    • 2023-01-05 MCV 82.4 fL
    • 2022-12-22 MCV 79.4 fL
    • 2022-11-30 MCV 76.7 fL
    • 2022-11-28 MCV 77.9 fL
    • 2022-10-31 MCV 71.7 fL
  • In late Feb/early Mar 2023, the patient developed a localized skin eruption secondary to the epidermal growth factor receptor (EGFR) inhibitor panitumumab. He is currently adequately being treated with a topical regimen of tetracycline, metronidazole, silver sulfadiazine, and urea.

2023-03-24

  • Although the CT scan on 2023-03-09 showed progression of lymph nodes, bone, and liver metastases, the CEA readings have been trending down towards normal. The two trends are not consistent with each other.
    • 2023-03-22 CEA 2.67 ng/mL
    • 2023-03-08 CEA 6.12 ng/mL
    • 2023-01-06 CEA 7.53 ng/mL
  • The chemotherapy regimen was changed from FOLFIRI to FOLFOX on 2023-03-09. The FOLFIRI regimen was used a total of five times prior to the change.
  • The patient has been experiencing continued dermatologic adverse reactions, and a dermatologist has been consulted on 2023-03-23. To alleviate these symptoms, the dermatologist has prescribed topical medication for the patient.
  • Other FOLFOX-related adverse events, in addition to the dermatologic adverse events caused by panitumumab, are not significant. Mild anemia, loss of appetite and constipation all have corresponding medications.

2023-03-08

  • 2022-11-10 a segment of colon was surgically removed due to a tumor that tested positive for EGFR.
  • 2022-12-15 no variants were detected in the KRAS/NRAS genes.
  • The patient is eligible for reimbursement for panitumumab and combination therapy with FOLFIRI or FOLFOX as a first-line treatment for metastatic colorectal cancer with EGFR RAS gene wildtype. The patient received his first dose of panitumumab during his previous hospitalization during 2023-02-21 ~ 23.
  • Panitumumab can cause various dermatologic adverse reactions. Skin or ocular toxicity from panitumumab typically develops after 12 days and resolves in about 14 weeks. The severity of dermatologic toxicity is predictive of response, with grades 2 to 4 skin toxicity correlating with improved progression-free survival and overall survival compared to grade 1 skin toxicity (Peeters 2009; Van Cutsem 2007). The patient developed a red, hot, and swollen sensation on his face and saw our dermatologist who prescribed oral fexofenadine, doxycycline, and topical metronidazole for one week on 2023-03-02. The prescription is only valid until 2023-03-09. It is recommended to check if the dermatologic symptoms have improved before deciding whether to refill the prescription.

2022-12-01

  • 2022-11-30 Hemoglobin 8.2 g/dL, MCV 76.7 fL, Ferritin 9.5 ng/mL, 2022-11-29 iron-bound Fe 36 ug/dL. Initialization of Foliromin (ferrous sodium citrate 50mg/tab) 1# QD is recommended.
  • 2022-11-30 the SBP remained around 170 ~ 190 mmHg under the single antihypertensive agent Norvasc (amlodipine 5mg/tab) 1# QD. An addition of Labtal (labetalol 200mg/tab) 1# BID might be an option to alleviate hypertension.

701496429

231130

{DLBCL}

[exam findings]

  • 2023-09-22 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (91 - 31.7) / 91 = 65.16%
      • M-mode (Teichholz) = 65.2
    • Conclusion:
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Trivial AR and MR, mild TR and PR
      • Impaired LV relaxation
      • Mildly thick IVS and LVPW
  • 2023-09-21 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Pleura effusion of left costal-phrenic angle
    • Old fibrothorax at left CP angle.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2023-09-15 Patho - peritoneum biopsy
    • Peritoneum, CT-guide biopsy — Diffuse large B-cell lymphoma, GCB type
    • Specimen submitted in formalin consists of 2 strips of tan, irregular tissue measuring up to 1.3 x 0.1 x 0.1 cm.
    • Section shows cores of atypical large lymphoid cells.
    • The immunohistochemical stains reveal CK(-), CD3(-), CD20(+), CD10(+), BCL2(+), BCL6(+), MUM1(+), c-MYC(+), Cyclin D1(-), CD30(-), CD56(-), and CD5(-). The Ki-67 is about 60%.
  • 2023-09-13 PET
    • Glucose hypermetabolism lesions in bilateral lower neck regions, SCF, mediastinum, bilateral para-aortic space, common iliac chains, and pelvis, highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
    • Glucose hypermetabolism lesions in the left pleural effusion, pleurae of the left upper, left lower and right upper lungs, and in skeleton including T11 spine, L5 spine and sacrum, highly suspected lymphoma with involvement of lungs and bone marrow.
    • Highly suspected lymphoma, c-stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-09-11 CT - abdomen
    • History and indication: Hydronephrosis with AKI, suspected Malignancy
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Enlarged LNs at retroperitoneum and pelvic cavity.
      • Wall thickening of rectum and S-colon.
      • Bil. pleural effusion with adjacent lung collapse.
      • Liver and renal cysts (up to 2.1cm).
      • Tiny gallbladder stones.
      • Atherosclerosis of aorta.
      • S/P bilateral double J catheters insertion.
      • S/P foley catheter indwelling. Wall thickening of urinary bladder.
    • IMP:
      • Enlarged LNs at retroperitoneum and pelvic cavity.
      • Wall thickening of rectum and S-colon.
      • Bil. pleural effusion with adjacent lung collapse.
      • Wall thickening of urinary bladder.
  • 2023-09-06 Patho - colon biopsy
    • Colorectum, ascending colon and biopys removal — Tubular adenoma with low grade dysplasia.
  • 2023-09-01 CT - abdomen
    • CC: swelling all over the body for 3-4 days, decreased urination, dyspnea on exertion, abd. fullness +.
      • no fever, no vomiting, constipation +, dark color stool?
      • back pain noted for one week, no trauma.
    • PH: HTN under medical Tx
    • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ perfusion status can not be determined without IV contrast.
    • Findings:
      • Wall thickening at the rectosigmoid junction is suspected that may be normal variation and tumor. Please correlate with colonoscopy.
      • There are multiple enlarged nodes in the perirectal space, bilateral internal iliac chain, bilateral external iliac chain, and bilateral common iliac chain.
        • In addition, there are multiple enlarged nodes in para-aortic space and para-cava space, causing bilateral hydroureteronephrosis (obstructive uropathy). There are few small nodes in the mesentery.
      • Lymphoma is highly suspected.
        • The differential diagnosis includes metastatic nodes.
      • There is a hypodense lesion 1.7 cm in S6 of the liver.
        • The differential diagnosis includes Metastasis and lymphoma.
      • There are bilateral Pleura effusion and old fibrothorax at left CP angle.
      • Both lobe thyroid show enlarged in size and few hypodense nodules.
        • Please correlate with sonography to R/O nodular goiter.
      • There is multiple enlarged nodes in left hilum and left anterior mediastinum.
      • There is fatty stranding at the subcutaneous fat layer of the lower pelvic wall.
      • There is minimal ascites in the Morison pouch.
    • IMP:
      • Lymphoma is highly suspected.
        • The differential diagnosis includes multiple metastatic nodes.
        • Please correlate with contrast enhanced dynamic CT.
      • Wall thickening at the rectosigmoid junction is suspected that may be normal variation and tumor. Please correlate with colonoscopy.

[MedRec]

  • 2023-09-01 ~ 2023-09-23 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Peritoneum, CT-guide biopsy — Diffuse large B-cell lymphoma, GCB type, immunohistochemical stains reveal CK(-), CD3(-), CD20(+), CD10(+), BCL2(+), BCL6(+), MUM1(+), c-MYC(+), Cyclin D1(-), CD30(-), CD56(-), and CD5(-). The Ki-67 is about 60%.
      • Hydronephrosis, status post double J (DJ) stent insertion, bilateral on 2023/09/08
      • Urinary tract infection with Urine culture: After 48 hours < 1000 CFU/ml on 2023/09/01
      • Gastric fungated ulcer, middle body, and Gastric ulcers, Forrest classification type III, antrum, and Reflux esophagitis LA Classification grade A (panendoscopy on 2023/09/05)
      • Colon polyp, ascending colon and Internal hemorrhoid (colonoscopy on 2023/09/05)
      • Hypertension
      • Paroxysmal atrial fibrillation
    • CC
      • edema in bilateral legs for 1 week, with dyspnea on exertion
    • Present illness
      • This patient is a 82-year-old male with underlying Af and hypertension. This time, he came with the complaint of edema in bilateral legs for 1 week, with dyspnea on exertion. According to the patient, he did not have a past history of kidney or liver diseases, and had never experienced similar symptoms before. Therefore he came to our ER for help.
      • At the ER, his vital signs were BP:143/65; PR:84; BT:35.2’C; RR:18; Con’s:E4V5M6; SpO2:97%. During physical examination, crackles were heard in bilateral lung fields.
      • Lab data revealed hyperkalemia, metabolic acidosis and elevated BUN and creatinine levels. Urinalysis showed nitrate (3+) and WBC (>100 HPF).
      • CT was performed which revealed
        • Lymphoma is highly suspected. The differential diagnosis includes multiple metastatic nodes. Please correlate with contrast enhanced dynamic CT.
        • Wall thickening at the rectosigmoid junction is suspected that may be normal variation and tumor. Please correlate with colonoscopy.
      • Urologist was consulted and suggested.
      • The CT showed multiple lymph node with compression effect of bilateral ureter ( right side beneath IVC, Aorta- IVC and left side lateral to Aorta) tumor stent may not pass.
      • PCND for acute renal failure may be more effective (right side seems better).
      • Foley for better record of urine output is recommended Under the impression of post-renal AKI and UTI, antibiotics were given, and a Foley catheter was inserted.
      • He was then admitted to our ward for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, Lasix was administered for AKI with edema in bilateral legs.
      • GU was also consulted for multiple lymph node with compression effect of bilateral ureter.
      • Empiric antibiotics with Rocephin was administered from 9/1(D5) due to right lower lung and left lung infiltration, pending culture.
      • Owing to still anemia susepct GI bleeding, EGD was performed on 2023/9/5 showed Gastric fungated ulcer, middle body, AW, s/p biopsy, r/o malignancy (B); Gastric ulcers, Forrest classification type III, antrum, GC, body, AW and PW, s/p biopsy (A) Reflux esophagitis LA Classification grade A.
      • Pathology showed
        • Stomach, body, AW, s/p biopsy (A), Chronic gastritis, H pylori NOT present.
        • Stomach, middle body, AW, s/p biopsy (B), Chronic gastritis, H pylori NOT present.
      • Colonscopy also done on 2023/09/05 showed Tubular adenoma with low grade dysplasia.
      • PPI with Nexium was prescribed.
      • As the renal function continued to deteriorate, the urology department was contacted, and a D-J catheter was implanted on 2023/9/08.
      • (selfpaid) PET was performed on 2023/09/13 for suspect lymphoma which revealed There was increased FDG uptake in lymph nodes in bilateral lower neck regions, SCF, mediastinum, in bilateral para-aortic space, common iliac chains, and pelvis. In addition, there was increased FDG uptake in the left pleural effusion and pleurae of the left upper, left lower and right upper lungs and in skeleton including T11 spine, L5 spine and sacrum.
      • CT guide biopsy was performed on 2023/9/15 and the pathology proved Diffuse large B-cell lymphoma, GCB type.
      • The immunohistochemical stains reveal CK(-), CD3(-), CD20(+), CD10(+), BCL2(+), BCL6(+), MUM1(+), c-MYC(+), Cyclin D1(-), CD30(-), CD56(-), and CD5(-). The Ki-67 is about 60%.
      • Bone marrow aspiration and biopsy was done on 2023/9/19 and report which showed negative for malignancy.
      • He was transferred to our ward for chemotherapy on 9/21 23.
      • C1 chemotherapy with R-COP was given on 9/22 23, smoothly without obviuous side effect.
      • He was discharged on 9/23 23 under stable condition and will follow-up at OPD.
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • MgO 250mg 1# TID
      • Norvasc (amlodipine 5mg) 1# QD
      • Nexium (esomeprazole 40mg) 1# QDAC (for 2023-09-05 EGD result)
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Through (sennoside 12mg) 2# HS
      • Compesolon (prednisolone 5mg) 9# BID 4D (9/22 ~ 9/26 18:00 end)

[chemotherapy]

  • 2023-12-21 - rituximab 375mg/m2 550mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1100mg NS 250mL + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID PO D1-5 (R-COP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO
  • 2023-11-29 - rituximab 375mg/m2 550mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1100mg NS 250mL + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID PO D1-5 (R-COP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO
  • 2023-11-02 - rituximab 375mg/m2 550mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1100mg NS 250mL + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID PO D1-5 (R-COP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO
  • 2023-10-11 - rituximab 375mg/m2 550mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1100mg NS 250mL + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID PO D1-5 (R-COP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO
  • 2023-09-22 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1200mg NS 250mL + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-COP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO

==========

2023-12-22

A review of PharmaCloud and HIS5 records revealed no medication discrepancies. However, the patient’s serum LDH level has shown a concerning upward trend this month. Previously, it remained stable following the initiation of the R-COP regimen on 2023-09-22. This recent rise warrants considering an update of the medical images to better assess the effectiveness of the treatment on the underlying disease.

  • 2023-12-21 LDH 348 U/L
  • 2023-12-19 LDH 285 U/L
  • 2023-12-11 LDH 156 U/L
  • 2023-12-04 LDH 181 U/L

2023-11-30

[hypoalbuminemia]

Hypoalbuminemia is emerging, and Plasbumin (human albumin) treatment was started on 2023-11-29.

  • 2023-11-28 Albumin(BCG) 2.8 g/dL
  • 2023-11-14 Albumin(BCG) 3.2 g/dL
  • 2023-11-07 Albumin(BCG) 3.5 g/dL

Given the patient’s recent lab results indicating normal liver and kidney function, the likelihood of hypoalbuminemia resulting from albumin loss in urine due to nephrotic syndrome or reduced hepatic albumin synthesis is lower. Please verify if the patient is experiencing malnutrition and/or edema.

2023-11-06

[leukopenia]

Episodes of leukopenia were noted approximately 1 to 2 weeks following the first cycle of R-COP on 2023-09-22 and the second cycle on 2023-10-11, specifically on 2023-10-04 and 2023-10-24. Granocyte (lenograstim) was appropriately administered for two periods of three consecutive days on these dates. Currently, there are no signs of leukopenia.

  • 2023-11-02 WBC 14.02 x10^3/uL
  • 2023-10-24 WBC 1.46 x10^3/uL **
  • 2023-10-11 WBC 9.39 x10^3/uL
  • 2023-10-09 WBC 6.92 x10^3/uL
  • 2023-10-06 WBC 11.69 x10^3/uL
  • 2023-10-05 WBC 3.04 x10^3/uL
  • 2023-10-04 WBC 0.87 x10^3/uL ***
  • 2023-09-27 WBC 9.86 x10^3/uL
  • 2023-09-20 WBC 7.14 x10^3/uL
  • 2023-09-18 WBC 6.52 x10^3/uL
  • 2023-09-11 WBC 9.71 x10^3/uL
  • 2023-09-07 WBC 8.61 x10^3/uL
  • 2023-09-04 WBC 8.06 x10^3/uL
  • 2023-09-02 WBC 7.49 x10^3/uL
  • 2023-09-01 WBC 6.92 x10^3/uL

According to the National Health Insurance medication reimbursement regulations, short-acting G-CSF injections, such as filgrastim and lenograstim, are indicated for use after intravenous chemotherapy for hematologic malignancies. This patient should meet the criteria for such coverage.

700360518

231129

[diagnosis] - 2023-05-01 admission note

  • Diffuse large B-cell lymphoma, intra-abdominal lymph nodes
  • Other malaise
  • Malignant neoplasm of pyloric antrum
  • Cardiomegaly
  • Peritonitis, unspecified
  • Enterococcus as the cause of diseases classified elsewhere
  • Resistance to vancomycin
  • Type 2 diabetes mellitus with diabetic chronic kidney disease
  • Chronic kidney disease, stage 3 (moderate)
  • Heart failure, unspecified
  • Chronic atrial fibrillation
  • Alcoholic cirrhosis of liver with ascites
  • Hypo-osmolality and hyponatremia
  • Hypocalcemia
  • Other disorders of plasma-protein metabolism, not elsewhere classified
  • Pleural effusion in other conditions classified elsewhere
  • Chronic obstructive pulmonary disease, unspecified
  • Mixed hyperlipidemia
  • Enlarged prostate with lower urinary tract symptoms
  • Unspecified symptoms and signs involving the genitourinary system
  • Other ascites
  • Hyperkalemia

[past history]

  • HFmrEF
  • Af under edoxaban
  • DM
  • dyslipidemia
  • alcoholic liver cirrhosis.    

[allergy]

  • NKDA     

[family history]

  • Father: pancreatic cancer
  • Mother: hypertension

[exam findings]

  • 2023-10-05 ECG
    • Atrial fibrillation with rapid ventricular response
    • Low voltage QRS of limb leads
    • Nonspecific ST abnormality
    • Abnormal ECG
  • 2023-08-30 SONO - abdomen
    • Real-time sonographic evaluation of the abdomen findings:
      • The liver shows normal in size and echogenicity but mild irregular contour that may be cirrhosis.
        • Portal vein flow: patent.
        • Bile ducts: not dilated.
      • The gallbladder appears normal in wall thickness and size.
        • There is no evidence of stone, polyp or sludge.
      • The pancreatic head and body shows normal in size and texture.
        • The pancreatic tail is obscured by overlying bowel gas.
      • The spleen shows enlarged in size (long axis: 15.81 cm) and echogenicity without focal lesion.
      • Abdominal aorta and IVC show unremarkable finding.
      • There is no evidence of para-aortic lymphadenopathy or ascites.
      • Both kidney show normal echopattern and size.
        • There is no evidence of stone or hydronephrosis.
    • Impression:
      • No focal wall thickening or mass lesion in the gallbladder. Follow up is indicated.
      • Cirrhosis of the liver with portal hypertension is suspected.
  • 2023-08-30 Maximal Venous Outflow (MVO), Segmental Venous Capacitance (SVC)
    • Conclusion:
      • No evidence of DVT, bilateral upper arm
      • Bilateral upper arm MVO/SVC is normal
    • Suggestion:
      • keep anticoagulation as lixiana, because of history of atrial fibrillation if no contraindication.
  • 2023-08-30 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (186 - 98) / 186 = 47.31%
      • M-mode (Teichholz) = 47
    • Conclusion:
      • Dilated LV with global hypokinesis; impaired LV systolic function.
      • Mild RV hypertrophy with preserved RV systolic function.
      • Aortic valve sclerosis with mild AR; mild MR; mild to moderate TR.
      • Possible mild to moderate pulmonary hypertension (the estimated systolic PA pressure 53 mmHg).
      • Mild aortic root calcification; mildly dilated proximal ascending aorta (35 mm).
      • Atrial fibrillation; severely dilated LA/RA.
      • No intracardiac vegetation was found by TTE study.
  • 2023-08-25 CT - abdomen
    • Indication: Double hit diffuse large B-cell lymphoma with stomach and intra-abdominal lymph nodes involvement, status post laparoscopic subtotal gastrectomy and D2 lymph node dissection on 2023/03/23, Lugano stage III
    • Findings:
      • S/P subtotal gastrectomy
      • There is splenomegaly and the greatest cranial-caudal dimension measuring 15 cm. The liver shows mild irregular contour that may be cirrhosis. please correlate with clinical condition.
      • There is focal wall thickening at the gallbladder body, measuring 7 mm in wall thickness, that may be tumor.
      • There are several enlarged nodes in para-aortic space and para-cava space that is c/w lymphoma. Follow up is indicated.
      • There is mild bilateral Pleura effusion.
        • There is a calcification 7 mm in RUL of the lung that is c/w old granuloma. In addition, there are few enlarged nodes in paratracheal space. Follow up is indicated.
    • Impression:
      • Splenomegaly.
      • There is focal wall thickening at the gallbladder body, measuring 7 mm in wall thickness, that may be tumor. Follow up is indicated.
      • There are several enlarged nodes in para-aortic space and para-cava space that is c/w lymphoma. Follow up is indicated.
  • 2023-06-12 ECG
    • Atrial fibrillation
    • Low voltage QRS
    • Abnormal ECG
  • 2023-05-24 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Spondylosis of the T-spine
  • 2023-05-02 KUB
    • Spondylosis of the L-spine is noted.
    • Disc space narrowing with marginal osteophyte formation at left lateral aspect of L4-5.
    • Splenomegaly is highly suspected.
  • 2023-04-17 PET
    • Glucose hypermetabolism lesions in the gastric wall (Deauville score 5), in the celiac chain (Deauville score 5), in the left sub-diaphragm lymph nodes (Deauville score 5), in soft tissue in the RLQ of abdomen (Deauville score 5), and in lymph nodes of peritonium (Deauville score 5), highly suspected diffuse large B-cell lymphoma with involvement of stomach and intraabdominal lymph nodes.
    • Glucose hypermetabolism lesion in a peri-cardial lymph node (Deauville score 5), highly suspected diffuse large B-cell lymphoma with involvement of regional lymph node.
    • Diffuse large B-cell lymphoma, c-stage III or IV (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2023-03-30 KUB
    • Degeneration and spondylosis of L-S spine.
    • S/P operation with retention of surgical clips.
  • 2023-03-30 CXR
    • S/P operation with retention of surgical clips.
    • Degeneration of T-L spine.
    • Right catheterization to SVC in position.
    • Normal appearance of trachea and bil. main bronchus.
    • Left pleural effusion.
    • Cardiomegaly.
  • 2023-03-26 ECG
    • Atrial fibrillation with rapid ventricular response with premature ventricular or aberrantly conducted complexes
  • 2023-03-24 Patho - stomach subtotal/total (tumor)
    • Diagnosis
      • Stomach, antrum, laparoscopic subtotal gastrectomy (S2023-5511) with frozen section for margins (F2023-124) — Diffuse large B cell lymphoma, non-germinal center type.
        • IHC stains: CD3 and CD20: a predominant B cell sub-population. Bcl-2 (+), Bcl-6 (+), CD10 (-), MUM-1 (+, > 30%), c-myc (-), Ki-67: 95%, CK (-), CD23 (-) .
      • Margins, bilateral cut ends: free. radial surface postive for tumor.
      • Lymph node, perigastric, D2 dissection — free. CD3, CD20, Bcl-2, and Bcl-6 demonstrate a reactive pattern.
      • Omentum, omentectomy — Free
    • Microscopic Description:
      • Histologic Type - Diffuse large B cell lymphoma, non-germinal center type.
      • Histologic Grade - high grade, non-germinal center type.
      • Tumor Extension - Tumor invades the serosa (visceral peritoneum)
      • Margins
        • Proximal margin: uninvolved
        • Distal margin: uninvolved
        • Radial margin: involved
      • Lymphovascular Invasion: not identified
      • Perineural Invasion: not identified
      • Regional Lymph Nodes: free
        • S2023-5511A: LN1 (0/0); B1-3: LN3 (0/10); C1-4: LN4 (0/8); D1-2: LN5-6 (0/17); E1-2: LN7-8-9 (0/7); F1-2: LN12 (0/5); G1-4: omentum (0/1);
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition) : Further work up is needed for staging.
  • 2023-03-22 ECG
    • Atrial fibrillation
    • Low voltage QRS
    • Abnormal ECG
  • 2023-03-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (186 - 106) / 186 = 43.01%
      • M-mode (Teichholz) = 43
    • Conclusion:
      • Dilated LV with global hypokinesis; impaired LV systolic function.
      • Mild RV hypertrophy with mild global hypokinesis and borderline RV systolic function.
      • Aortic valve sclerosis with mild AR; mild MR; mild to moderate TR.
      • Possible mild pulmonary hypertension (the estimated systolic PA pressure 46 mmHg).
      • Mild aortic root calcification.
      • Atrial fibrillation; severely dilated LA/RA.
  • 2023-03-06 Flow Volume Loop
    • Mild obstructive ventilatory impairment
  • 2023-03-04 Esophagogastroduodenoscopy, EGD
    • Superficial gastritis, s/p CLO test
    • Gastric ulcer, antrum, suspected malignancy, s/p biopsy
  • 2023-03-04 SONO - abdomen
    • Liver parenchymal disease (suboptimal exam of liver)
    • mild gallbladder wall thickening
    • splenomegaly
    • chronic renal parenchymal disease
    • bilateral pleural effusion
  • 2023-03-02 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • S/P NG tube placement.
    • Increased pulmonary vasculature is found.
    • Osteopenia of the bony structure is noted.
  • 2022-10-06 ECG
    • Atrial fibrillation
    • Low voltage QRS of limb leads
    • Abnormal ECG
  • 2022-10-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (190 - 102) / 190 = 46.32%
      • M-mode (Teichholz) = 46
      • 2D (M-simpson) = 48
    • Conclusion:
      • Dilated LA, LV, RA, RV and IVC; mildly abnormal LV systolic function with global hypokinesia
      • Moderate MR, mild AR, mild to moderate TR and trivial PR
      • Preserved RV systolic function
      • Atrial fibrillation with HR 62~83 bpm.
  • 2019-12-11 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (224 - 102) / 224 = 54.46%
      • M-mode (Teichholz) = 54
    • Conclusion:
      • Dilated LV with mild global hypokinesis and borderline LV systolic function.
      • Preserved RV systolic function.
      • Moderate MR and moderate TR (both due to chamber dilatation); mild AV sclerosis with trivial AR.
      • Possible mild to moderatre pulmonary hypertension (the estimated systolic PA pressure 50 mmHg).
      • Atrial fibrillation; severely dilated LA/RA.

[MedRec]

  • 2023-04-24 SOAP Hemato-Oncology
    • S
      • 3 daughters (the elderest daughter works in another hospital)
      • her daughter came to OPD for him
  • 2023-04-12 SOAP General and Digestive Surgery
    • A:
      • Gastric antrum lymphoma, cT4N0M0, stage II, ECOG:1, s/p laparoscopic subtotal gastrectomy and D2 lymph node dissection on 2023/03/23
      • Peritonitis, culture: VREfm (E.faecium)
      • Heart failure, New York Heart Association functional classification II
      • Chronic kidney disease, stage 3
      • Chronic atrial fibrillation
      • Alcoholic liver cirrhosis
      • Type 2 diabetes mellitus
      • Mixed hyperlipidemia
      • Hypocalcemia
      • Hypoalbuminemia
      • Hypo-osmolality and hyponatremia
      • Pleural effusion, bilateral sides
      • Massive ascites
      • Suspected Chronic Obstructive Pulmonary Disease
      • Enlarged prostate with lower urinary tract symptoms
    • P:
      • refer to ONC for further study and chemotherapy evaluation
      • PPI, vita B12, education, & OPD follow up
  • 2018-04-19 SOAP Cardiology
    • S: adjust carvedilol dose; add ARB for BP control
    • Prescription
      • Blopress (candesartan 8mg) 1# QD
      • Uretropic (furosemide 40mg) 1# Q3D
      • Lixiana (edoxaban 30mg) 1# QD
      • Robestar (rosuvastatin 10mg) 0.5# QD
      • Through (sennoside 12mg) 2# HS
      • Glucobay (acarbose 100mg) 1# BID
      • Syntrend (carvedilol 6.25mg) 1# QD
  • 2017-03-16 SOAP Cardiology
    • Diagnosis
      • Heart failure, unspecified [I50.9]
      • Atrial fibrillation [I48.2]
      • Cirrhosis of liver without mention of alcohol [K74.69]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Mixed hyperlipidemia [E78.2]
      • Neuralgia and neuritis, unspecified [M79.2]
    • Prescription
      • Robestar (rosuvastatin 10mg) 0.5# QD
      • Through (sennosides 12mg) 2# HS
      • Glucobay (acarbose 100mg) 1# BID
      • Syntrend (carvedilol 6.25mg) 0.5# QD
      • Bokey (aspirin 100mg) 1# QD
      • Aldactin (spironolactone 25mg) 0.5# QD

[consultation]

  • 2023-03-06 General and Digestive Surgery
    • Q
      • for management of gastric cancer. Pending pathology.
      • This 70 y/o man with history of heart failure, Af, DM, hyperlipidemia, alcoholic liver cirrhosis with medication (Lixiana) control. This time, he suffered from passage tarry stool, vomiting blood, general weakness, dizziness since 20230227 morning. Abdominal CT showed gastric cancer T3N0M0. Under the impression of Gastrointestinal hemorrhage and suspected gastric cancer, he was admitted to MICU for further care on 2023-02-27.
      • After admitted MICU, the patient received anti with Sintrix (2/27~) for Infection prevention. kept NPO and high does PPI pump (2/27~3/2), then taper to Pantoloc 40mg IVD Q12H (3/2~), also disconnect Lixiana since 2/26. IV fluid for supply. Blood transfusion with LRBC for correct anemia (Hb: 7.9 => 9.2). There was no coffee ground or tarry stool was noted after try oral diet. However, dyspnea on exertion with breathing sound wheezing grade 1 was note, broncodilator with Butanyl plus Ipratran was prescribed. IV fluid and Const-K for correct imbalance electrolyte. The symptom got improvement after medical treatment, he will transfer to ward for further treatment and arrange 2nd PES (for supected gatric cancer biopsy).
      • At GI ward, his vital signs stable. Checked breathing sound: no wheezing. Try oral intaking but his care giver said easy choking.
      • Second look of EGD and the biopsy were all done, Now, we need your management of gastric cancer. Thanks a lot !!!
    • A
      • S:
        • Due to CT and panendoscopy highy suspected gastric antrm cancer, surgical treatment is consulted.
      • O: vital signs: stable, no fever
        • abdomen: soft, ovoid, normal bowel sound, no tenderness, no rebounding pain
        • lab data: see chart
      • A: Gastric antrum Ca, cT3N2M0, stage III, ECOG I
      • P:
        • I will take over this case for pre-op evaluation including heart echo and lung function test and nutritional support such as PPN
        • If heart & lung function is OK and the patietn is willing to receive operation, I will arrange laparoscopic resection later.

[surgical operation]

  • 2023-03-23
    • Surgery
      • Laparoscopic subtotal gastrectomy and D2 lymph node dissection
      • Post-OP Dx: gastric antrum Ca, cT3N2M0, stage III, ECOG 1       
    • Finding
      • An ulcerative tumor about 5x7 cm over antrum, lesser curvature site of antrum posterior wall with suspect serosal invasion.
      • Enlarged lymph nodes over area 3, 5, 7, 8, 9, 12 were noted.
      • Proximal cutting end 10 cm form tumor and distal cutting end 1 cm from tumor. Both cutting ends were margin free via frozen section.

[immunochemotherapy]

  • 2023-09-28 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-mCHOP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-07-18 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-mCHOP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-06-13 - rituximab 375mg/m2 693mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-mCHOP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-05-24 - rituximab 375mg/m2 693mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-mCHOP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-05-03 - rituximab 375mg/m2 660mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-COP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2

==========

2023-11-29

[proactive measures for leukopenia and renal function management]

After initiating the 5th cycle of R-COP/R-mCHOP on 2023-09-28, the patient experienced leukopenia in early Oct.

  • 2023-11-29 WBC 7.84 x10^3/uL
  • 2023-11-28 WBC 2.68 x10^3/uL *
  • 2023-11-10 WBC 4.23 x10^3/uL
  • 2023-10-23 WBC 4.01 x10^3/uL
  • 2023-10-16 WBC 5.72 x10^3/uL
  • 2023-10-13 WBC 5.46 x10^3/uL
  • 2023-10-10 WBC 0.76 x10^3/uL ***
  • 2023-10-09 WBC 0.72 x10^3/uL ***
  • 2023-10-05 WBC 2.64 x10^3/uL *
  • 2023-09-28 WBC 3.18 x10^3/uL

With a new session scheduled during this hospital stay, there’s a possibility of another leukopenia episode. Therefore, it may be advisable to have prophylactic G-CSF ready for use.

The patient has impaired renal function, but it is not severe enough to require dose adjustments for current medications. However, if the eGFR falls below 50 or creatinine exceeds 1.5, it’s important to consider adjusting the doses of Allegra (fexofenadine) and Lixiana (edoxaban).

  • 2023-11-28 BUN 28 mg/dL
  • 2023-11-28 Creatinine 1.36 mg/dL
  • 2023-11-28 eGFR 54.90 ml/min/1.73m^2

2023-07-07

[reconciliation]

  • According to the PharmaCloud database, besides our hospital, this patient has also visited a local dermatology clinic for problems related to skin and subcutaneous tissue infections on 2023-06-25, and for irritant contact dermatitis on 2023-06-04. Both times, he was prescribed medications for 7 days and 3 days respectively, which are now expired. No reconciliation issues were identified in this context.
  • Our cardiologist had prescribed Lixiana (edoxaban), Blopress (candesartan), Hexal (carvedilol), Dibose (acarbose), Glimet (glimepiride, metformin), and Galvus Met (vildagliptin, metformin) on 2023-06-15. All these drugs are included in the current active medication list without any identified reconciliation issues.

[to adjust Dibose (acarbose) from BID to BIDCC]

  • The optimal usage of Dibose (acarbose) involves taking it with the first bite of each main meal or immediately before starting a meal to ensure maximum effectiveness. Therefore, it is suggested that the patient’s current BID prescription should be adjusted to BIDCC. Ref: The effect of the timing and the administration of acarbose on postprandial hyperglycaemia. Diabet Med. 1995;12(11):979-984. doi:10.1111/j.1464-5491.1995.tb00409.x

2023-05-03

  • Given the patient’s history of heart failure, doxorubicin may not be an appropriate component of the treatment regimen. Instead of R-CHOP, R-COP was chosen as the treatment regimen to avoid the potential cardiotoxic effects of doxorubicin.

  • On 2023-05-03, the progress note indicated that the patient had increased frequency of vomiting and difficulty with oral intake due to NG tube cough. Metoclopramide, a dopamine (D2) receptor antagonist, is currently prescribed. If symptoms persist, the addition of serotonin (5-HT3) receptor antagonists (such as ondansetron, granisetron, or palonosetron) and/or neurokinin-1 (NK1) receptor antagonists (such as aprepitant, fosaprepitant, rolapitant, or netupitant) may be considered. These medications work through different mechanisms to control nausea and vomiting and may provide additional relief for the patient.

  • Dibose (acarbose) should be taken with the first bite of each main meal or just before starting a meal for best results. Acarbose works by slowing down the digestion of carbohydrates in the intestines, helping to control blood sugar levels. Taking it at the beginning of a meal ensures its optimal effect on carbohydrate digestion. It is recommended to change the medication from current BID to BIDCC.

700884793

231129

[exam finding]

  • 2023-10-04 SONO - abdomen
    • Parenchymal liver disease
    • Liver cyst, S6/7
    • post ERBD in CBD and left IHD
    • Pneumobilia, mild, left IHD
    • Renal cyst, left
    • Suspicious, focal dilated main pancreatic duct, pancreatic neck
    • Ascites, moderate
  • 2023-10-01 Abdomen - Standing (Diaphragm)
    • S/P metalic stent implantation at the bile duct and duodenum.
    • S/P plastic stent implantation at the left lobe IHD and duodenum.
    • Fecal material store in the colon.
    • There is ascites. Please correlate with sonography.
    • Disc space narrowing with marginal osteophyte formation of L4-5.
  • 2023-09-27 Endoscopic Retrograde Cholangiopancreatography, ERCP
    • Indication: CBD stricture s/p metal stent placement, with obstruction
    • Symptoms: Jaundice
    • Premedication: Buscopan 20mg + Alfentanil 0.25mg IV
    • Anesthesia: IV anesthesia
    • Equipment: TJF-260V
    • Management:
      • After C duct cannulation, retrieval balloon lithrotripsy was done before cholangiography and much sludge and pus were swept out from IHD and CBD. Selective cannulation of left IHD was done and mild dilated left IHD was found. One 14cm 7 Fr Gadelius Through The Mesh™ stent was performed at left IHD.
    • Diagnosis:
      • Malignant biliary stricture, s/p metal stent, with obstruction with much sludge and pus in IHD and CBD, s/p retrieval balloon lithrotripsy
      • Mild left IHD dilatation, s/p stenting with plastic stent
      • Chronic cholangitis
      • Duodenal swelling mucosa with luminal narrowing, 2nd portion
      • Reflux esophagitis, Gr. A
  • 2023-09-23 CT - abdomen
    • History and indication: Fever
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Some soft tissues in peritoneal cavity.
      • Liver and renal cysts (up to 3.9cm).
      • Normal appearance of spleen, pancreas, adrenals.
      • Invisible gallbladder. S/P CBD stenting. Mild dilatation of biliary tree and p-duct.
      • Small caliber of extrahepatic portal vein.
      • Degeneration and spondylosis of L-S spine.
    • IMP:
      • Some soft tissues in peritoneal cavity.
      • S/P CBD stenting. Mild dilatation of biliary tree and p-duct.
      • Small caliber of extrahepatic portal vein.
  • 2023-09-23 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Abnormal ECG
  • 2023-08-02 CT - abdomen
    • Findings:
      • S/P metalic stent implantation at the CHD, CBD and duodenum.
      • Prior CT identified dilatation of the IHDs on both hepatic lobes are noted again, mild decreasing in size.
      • Prior CT identified pancreatic duct dilatation is noted again, mild increasing in size.
      • The mesentery root shows fatty stranding and several enlarged nodes. please correlate with clinical condition.
      • S/P cholecystectomy.
      • There is no focal lesion in both lung and mediastinum.
      • A renal cyst measuring 3.9 cm in left upper pole is noted.
      • Abdominal aorta shows atherosclerosis and ectasia 2.2 cm.
    • Impression:
      • S/P metalic stent implantation at the CHD, CBD and duodenum.
      • Prior CT identified dilatation of the IHDs on both hepatic lobes are noted again, mild decreasing in size.
      • Prior CT identified pancreatic duct dilatation is noted again, mild increasing in size.
      • The mesentery root shows fatty stranding and several enlarged nodes. please correlate with clinical condition.
  • 2023-06-05 CT - abdomen
    • Abdominal CT with and without enhancement revealed:
      • s/p biliary stent placement at CBD is found. Dilated IHDs and proximal CBD is found.
      • The pancreatic duct is dilated.
      • Minimal pneumobilia is found.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • Left renal cyst up to 4.02cm is found.
      • The spleen, liver, pancreas and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • The urinary bladder is well distended without soft tissue lesion.
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
    • Imp:
      • s/p biliary stent placement at CBD is found. Dilated IHDs and proximal CBD is found.
      • The pancreatic duct is dilated. No signficant soft tissue mass is found. But correlation with other finding is suggested.
  • 2023-03-07 MRI - MR Cholangiography, MRCP
    • History and indication: Malignant neoplasm of biliary tract
    • With and without contrast MRI of liver revealed:
      • S/P CBD stenting with artifact. S/P cholecystectomy. Mild dilatation of IHD.
      • Liver and renal cysts (up to 3.9cm).
    • IMP:
      • S/P CBD stenting with artifact. S/P cholecystectomy. Mild dilatation of IHD.
  • 2022-11-08 Abdomen - standing (diaphragm)
    • Degeneration and spondylosis of L-S spine.
    • Contrast medium retention in the bowel.
    • S/P CBD stenting.
  • 2022-11-07 Endoscopic Retrograde Cholangiopancreatography, ERCP
    • Indication: CBD stricture s/p metal stent placement
    • Symptoms: for pre-Op. evaluation
    • Premedication: Buscopan 20mg + Alfentanil 0.25mg IV
    • Anesthesia: IV anesthesia
    • Equipment: TJF-260V
    • Diagnosis:
      • Malignant biliary stricture s/p metal stent with no evidence of narrowing site
      • Chronic cholangitis
      • Juxta-papillary diverticulum
      • Reflux esophagitis, Gr. A
      • Gastric angioectasias, low body
  • 2022-11-08 SONO - abdomen
    • Indication: CBD cancer
    • Symptoms: fever
    • Diagnosis:
      • Asymmetric CBD wall thickening
      • Pneumobilia, both lobes
      • Metallic stent in the CBD
      • Prob. Parenchymal liver disease
  • 2022-08-08 CT - abdomen
    • History and indication
      • cholangiocarcinoma
    • Findings
      • A cystic lesion (4.3cm) at left kidney. Tiny liver and renal cysts.
      • Invisible gallbladder. S/P CBD stenting with pneumobilia.
    • IMP:
      • S/P CBD stenting with pneumobilia.
      • No interval change of peritoneal lesions.
  • 2022-07-06 CT - abdomen
    • History and indication
      • tea color urine for 10 days due to obstructive jaundice
      • SGOT: 103, SGPT: 141, HBsAG (-), antiHCV(-) (2022-01)
      • 20220114 CT: Cholangiocarcinoma at the CHD is noted.
        • Metastatic lymphadenopathy at gastrohepatic ligament, hepatoduodenal ligament and para-aortic space are suspected.
        • cT2N2M1, cStage:IV
      • 20220214 CBD tumor, serosa, laparotomy — Poorly cohesive carcinoma with signet-ring cell differentiation
    • Findings:
      • Prior CT identified soft tissue lesions in the omentum at LUQ abdomen are noted again, stationary.
      • Prior CT identified several enlarged nodes in gastrohepatic ligament, hepatoduodenal ligament, and para-aortic space (non-regional nodes) are noted again, mild decreasing in size.
      • S/P metalic stent implantation from CHD to duodenum.
      • S/P cholecystectomy.
      • Pneumobilia on left lobe IHD is noted.
      • There is no evidence of IHD dilatation.
      • A renal cyst measuring 4 cm in left upper pole is noted.
      • Abdominal aorta shows atherosclerosis and ectasia 2.2 cm.
      • There is no focal lesion in both lung and mediastinum.
      • Prior CT identified few hepatic cysts in both lobes are noted again, stable in size. The largest one 0.8 cm in S8.
    • Impression
      • Prior CT identified soft tissue lesions in the omentum at LUQ abdomen are noted again, stationary.
  • 2022-05-24 KUB
    • S/P clips projecting at the liver hilum.
    • S/P metalic stent implantation at CHD, CBD and duodenum.
    • Pneumobilia on left lobe IHDs.
    • Fecal material store in the colon.
  • 2022-05-23 Endoscopic Retrograde CholangioPancreatography, ERCP
    • diagnosis
      • Malignant biliary stricture s/p FCSEMS (Kaffes stent, 5 cm and 8 mm ) (FCSEMS = Fully Covered, Self Expanding Metal Stent)
      • Chronic cholangitis
      • Juxta-papillary diverticulum
      • Reflux esophagitis, Gr. A
    • suggestion
      • f/u amylase & lipase
  • 2022-05-22 ECG
    • Normal sinus rhythm
    • Left anterior fascicular block
    • Abnormal ECG
  • 2022-05-12 SONO - abdomen
    • Liver cyst, right lobe
    • Post cholecystectomy
    • Mild left IHD dilatation
    • Pneumobilia, left
    • Post CBD stenting
    • Renal cyst, left kidney
  • 2022-05-04 CT - abdomen
    • Pneumobilia on left lobe IHD is noted.
    • Carcinomatosis is suspected. Please correlate with ascites cytology.
  • 2022-04-20 Cholangiography
    • Cholangiography via PTCD catheter administration revealed:
      • Patency of the catheter and stent.
      • S/P operation with retention of surgical clips.
  • 2022-04-18 ECG
    • Normal sinus rhythm
    • Left anterior fascicular block
  • 2022-04-18 Endoscopic Retrograde CholangioPancreatography, ERCP
    • diagnosis
      • Biliary stricture s/p plastic stent exchange
      • Chronic cholangitis
      • Reflux esophagitis Gr.A
    • suggestion
      • f/u amylase & lipase
  • 2022-03-12 Percutaneous transhepatic cholangio drain, PTCD (drainage)
    • The necessarity and risks of the procedure was well explanined to patient family before the PTCD. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
    • Dilatation of the biliary tree (by CT images). S/P CBD stenting.
    • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree via left IHD smoothly.
    • No procedure-related complication during the whole procedure.
  • 2022-03-09 CXR
    • Atherosclerotic change of aortic arch
  • 2022-03-09 CT - abdomen
    • Cholangiocarcinoma at the CHD and metastatic nodes show stationary.
    • Mild ascites is noted.
  • 2022-02-15 Patho - duodenum biopsy
    • PATHOLOGIC DIAGNOSIS
      • CBD tumor, serosa, laparotomy — Poorly cohesive carcinoma with signet-ring cell differentiation
      • Gallbladder, open cholecystectomy — Chronic cholecystitis and free from tumor
      • Lymph nodes, post-pancreatic region (LN 16), frozen section — Free from tumor metastasis (0/11)
    • MICROSCOPIC EXAMINATION
      • CBD tumor, serosa: poorly cohesive carcinoma characterized by tumor cells arranged in linear or individual pattern with signet-ring cell differentiation.
        • Immunohistochemistry of CK(+), CK7(+), CK20(+, focal) and CDX2(+) for tumor.
      • Gallbladder: chronic cholecystitis with serosal hemorrhage and free from tumor invasion
      • Lymph nodes, post-pancreatic region (LN 16): free from tumor metastasis (0/11)
  • 2022-02-14 CXR
    • S/P operation with retention of surgical clips.
    • S/P Port-A infusion catheter insertion.
    • S/P CBD stenting.
    • Right CVP inserted to SVC in position.
    • Ground glass opacity in RLL.
  • 2022-01-26 SONO - abdomen
    • CBD wall thickening with upstram ductal dilatation
    • pneumobilia, both lobes
    • stent in the CBD
    • pancreatic cystic lesion
    • Prob. Parenchymal liver disease
  • 2022-01-25 Body fluid cytology
    • Bile duct brushing: atypia
  • 2022-01-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (87 - 26) / 87 = 70.11%
    • Conclusion
      • Preserved LV and RV systolic function with normal wall motion
      • Grade 1 LV diastolic dysfunction
      • Mild MR, TR
  • 2022-01-24 Endoscopic Retrograde CholangioPancreatography, ERCP
    • diagnosis
      • Biliary stricture s/p brushing cytology & plastic stent placement
      • Chronic cholangitis
      • Reflux esophagitis Gr.A
    • suggestion
      • f/u amylase & lipase
  • 2022-01-14 CT - abdomen
    • Cholangiocarcinoma at the CHD is highly suspected.
      • Please correlate with CEA, CA199, ERCP and biopsy.
      • Metastatic lymphadenopathy at gastrohepatic ligament, hepatoduodenal ligament and para-aortic space are suspected.
      • According to American Joint Committee on Cancer(AJCC)staging system, 8th edition for bile duct cancer: T2 N2 M1, Stage:IV
    • Mild wall thickening at the gastric antrum and duodenum is noted. Please correlate with gastroscopy.
  • 2022-01-14 SONO - abdomen
    • Parenchyaml liver disease
    • Hepatic cyst
    • Bilateral IHD dilatation
    • Bilateral renal cysts
    • Pancreatic cyst
  • 2019-11-17 ECG
    • Sinus bradycardia
    • Left anterior fascicular block
    • Nonspecific ST abnormality
  • 2018-08-06 CT - abdomen
    • Distention of urinary bladder with irregular wall. Enlargement of prostate.
    • A cystic lesion (4.0cm) at left kidney.

[consultation]

  • 2023-11-15 Infectious Disease

    • A
      • The is a case of cholangiocarcinoma at common hepatic duct. Cholangitis is suspected.
      • Agree with your use with finibax.
      • Please adjust antibiotic according to culture results and clinical conditions.
  • 2023-09-25 Gastroenterology (not completed)

  • 2023-09-25 Infectious Disease

    • Q
      • Empiric antibiotics with Cefotaxime was administered.
      • Under the impression of Cholangiocarcinoma, cT2N2M1, stage IV suspect cholangitis. He was admitted for further management.
      • Due to B/C: GNB, so we need your help for antibiotic evaluation, thanks a lot!!
    • A
      • B/C: GNB, E. coli.
      • Agree with your use of brosym for the GNB sepsis.
      • Please keep IV antibiotics for 7~10 days.
      • Please adjust antibiotic according to culture results and clinical conditions.
  • 2022-04-20 Radiation Oncology

    • Q
      • This is a 71 year-old male had past histories of
        • BPH s/p RaSP + bil TAPP on 2018/12/05.
        • Polyp status post polypectomy on 2019/11/12.
        • Common bile duct poorly cohesive carcinoma with signet-ring cell differentiation, pT4N0M0, stage IIIB.
        • Unresectable Bile duct tumor status post open cholecystectomy and port-A insertion on 2022/02/14.
        • Cholangitis with dilatation of the biliary tree. S/P CBD stenting.Percutaneous Transhepatic Cholangiography and Drainage on 2022/03/12.
        • He was regular follow up at our GI OPD.
        • Due to ERCP revealed Biliary stricture s/p plastic stent exchange on 20220418, we need arrange cholangiography, thank you~
    • A
      • According to the clinical condition and imaging findings, cholangiography is indicated.
  • 2022-03-12 Radiation Oncology

    • Q
      • This 71-year-old male,a case of Common bile duct poorly cohesive carcinoma with signet-ring cell differentiation, pT4N0M0, stage IIIB under XRT since 20220301, chemotherapy with 5-FU (200mg/m2) on 20220307~20220311. Spiking fever was noted on 20220311 morning, laboratory test revealed hyperbilirubinemia. Empiric antibiotics with Flumarin was administered. We need your expertise for further management, thanks.
    • A
      • According to the clinical condition and imaging findings, PTCD is indicated.
  • 2022-02-15 Radiation Oncology

    • Q
      • He was admitted for CBD tumor resection.
      • Because of unresectable CBD tumor, invasion to panceratic head, right hepatic artery and portal vein.
      • The procedure changed to open cholecystectomy and port-A insertion on 2022/02/14.
      • Pathology report was pending.
      • After explanation, he preferred neoadjuvant CCRT
      • After CCRT surgery will be asssessed in the future.
      • Therefore, we need your expertise to evaluate, manage his current condition.
    • A
      • Subjective:
        • History: This is a 71 years old male suffered from obstructive jaundice s/p ERCP with Biliary stricture s/p brushing cytology & plastic stent placement on 2022/01/24. He was admitted for CBD tumor resection. Because of unresectable CBD tumor, invasion to panceratic head, right hepatic artery and portal vein was noted during OP. The procedure changed to open cholecystectomy and port-A insertion on 2022/02/14. Pathology report was pending. Neoadjuvant CCRT was suggested by Tumor Board.
          • Previous RT: denied.
          • Other disease: BPH s/p RaSP+bilateral TAPP on 2018/12/05. Polyp status post polypectomy on 2019/11/12.
          • Family history: denied.
        • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
        • Widower. Caregiver: his only son. Job: retired business. Mild economic stress.
        • Language: Mandarin. Taiwanese.
        • Religion:
      • Objective:
        • General Condition-ECOG: 1.
        • PE, 2022/02/15: No SCF LAPs.
        • Pathology, 2022/2/14, pending.
        • OP finding: distended GB and dilated proximal CBD; an indurated hard tumor at distal CBD with serosa, right hepatic artery and portal vein invasion, tumor extended to pancreatic head; multiple LN at para-aorta and hepatoduodenal ligament and common hepatic artery.
        • Images:
          • CT, 2021/12/17: There is mild wall thickening (8 mm in wall thickness) and abrupt narrowing at the CHD, causing marked dilatation of proximal CHD and both lobe IHDs. Cholangiocarcinoma at the CBD is highly suspected. There are several enlarged nodes in gastrohepatic ligament, hepatoduodenal ligament, and para-aortic space (non-regional nodes) that may be metastatic nodes. Imp: 1. Cholangiocarcinoma at the CHD is highly suspected. Metastatic lymphadenopathy at gastrohepatic ligament, hepatoduodenal ligament and para-aortic space are suspected. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for bile duct cancer: T2 N2 M1, Stage:IV
          • CXR, 2022/01/17: No metastasis.
        • CA199: 103.38 (2022/1/15).
      • Diagnosis:
        • Cholangiocarcinoma, distal CBD with serosa, right hepatic artery and portal vein invasion with gastrohepatic ligament, hepatoduodenal ligament and para-aortic space s/p brushing cytology & plastic stent placement on 2022/01/24, s/p open cholecystectomy and port-A insertion on 2022/02/14; ECOG: 1.
      • Suggest: Radiotherapy.
        • Goal: Curative (Preoperative).
        • RT Plan:
          • Target & Volume: CBD tumor and LAPs.
          • Technique: VMAT & IGRT.
          • Dose & Fractionation: 4500cGy/25 fractions.
        • Plan: CCRT is suggested for locoregional control. CT simulation is arranged on Feb 22 09:30 am. Possible treatment toxicity (radiation gastritis and enteritis) is told. Diet education & psychological support is given.
  • 2022-02-14 Gastroenterology

    • Q
      • For changing of biliary tract metallic stent evaluation and management.
      • This is a 71 years old male had past histories of
        • BPH s/p RaSP + bil TAPP on 2018/12/05.
        • Polyp status post polypectomy on 2019/11/12.
      • ERCP with Biliary stricture s/p brushing cytology & plastic stent placement on 2022/01/24.
      • He was admitted for CBD tumor resection.
      • Because of nonresectable CBD tumor, invasion to panceratic head, right hepatic artery and portal vein.
      • The procedure changed to open cholecystectomy and port-A insertion on 2022/02/14.
      • After explanation, he preferred neoadjuvant chemotherapy, and for biliary tract management, metallic stent was suggested.
      • Therefore, we need your help to performed the procedure (ERCP)
    • A
      • Please confirm if he needs Radiation therapy or not before metalic stenting.
  • 2022-01-25 General and Gastrointestinal Surgery

    • Q
      • Suspected cholangiocarcinoma for further management
      • This is a 71 years old male had past histories of 1.) BPH s/p RaSP + bil TAPP on 20181205. 2.) Polyp status post polypectomy on 20191112.
      • This time, due to he suffered from jaundice and tea color urine for 10+ days. There was no fever, no dizziness, no URI symptoms, no chest tightness, no epigastirc pain, no tarry/bloody stool, no TOCC found. He visited to our GI OPD for help. At GI OPD, follow up blood test that showed hyperbilirubinemia, no leukocystosis nor PT prolong found. Abdominal sonography wsa done revealed parenchyaml liver disease; hepatic cyst; bilateral IHD dilatation; bilateral renal cysts and pancreatic cyst. Abdominal CT with contrast was also done for further survey which revealed cholangiocarcinoma at the CHD is highly suspected. ERCP was arrnged and showed 1. Biliary stricture s/p brushing cytology & plastic stent placement 2. Chronic cholangitis 3. Reflux esophagitis Gr.A. So we need you evaluation and suggestion of this patient. Thank you very much ~
    • A
      • Assessment
        • A case impressed of CBD tumor with obstruction suspected malignancy
      • Suggestion
        • arrange f/u cardiopulmonary function
        • check tumor marker of CEA, CA199
        • triflow training (self-paid)
        • arrange GS OPD on 20220208
        • planing for further operation with total CBD resection after TBI < 6

[surgical operation]

  • 2022-02-14
    • Surgery
      • open cholecystectomy
      • port-A insertion
    • Finding
      • distended GB and dilated proximal CBD
      • an induration hard tumor at distal CBD with serosa, right hepatic atery and portal vein invasion, tumor extended to pancreashead
      • multiple LN at pararota and hepatoduodenal ligament adn common hepatic artery
  • 2022-12-05 Suprapubic prostatectomy
    • pre-op, post-op diagnosis: BPH
    • PCS code: 79404C
    • findings: adenoma 51 gm was resected, bilateral mixed type.

[radiotherapy]

  • 2022-03-01 ~ 2022-04-08 - 5000cGy/25 fractions (15 MV photon).

[chemoimmunotherapy]

  • 2023-11-08 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (gemcitabine + cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-10-18 - pembrolizumab 100mg NS 100mL 30min + gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (Keytruda + gemcitabine + cisplatin)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-10-11 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (gemcitabine + cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-09-12 - pembrolizumab 100mg NS 100mL 30min + gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (Keytruda + gemcitabine + cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-09-05 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (gemcitabine + cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-22 - pembrolizumab 100mg NS 100mL 30min + gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (Keytruda + gemcitabine + cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-15 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (gemcitabine + cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-01-16 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3960mg NS 500mL 46hr (neoadjuvant FOLFIRINOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + atropine 1mg + NS 250mL
  • 2022-12-26 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3980mg NS 500mL 46hr (neoadjuvant FOLFIRINOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + atropine 1mg + NS 250mL
  • 2022-11-30 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3970mg NS 500mL 46hr (neoadjuvant FOLFIRINOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + atropine 1mg + NS 250mL
  • 2022-11-17 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3980mg NS 500mL 46hr (neoadjuvant FOLFIRINOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + atropine 1mg + NS 250mL
  • 2022-09-29 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3960mg NS 500mL 46hr (neoadjuvant FOLFIRINOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + atropine 1mg + NS 250mL
  • 2022-09-14 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 660mg 2hr + fluorouracil 2400mg 3970mg 46hr (neoadjuvant FOLFIRINOX, Q2W)
  • 2022-08-31 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 3950mg 46hr
  • 2022-08-17 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 3900mg 46hr
  • 2022-07-29 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 3900mg 46hr
  • 2022-07-14 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 3900mg 46hr
  • 2022-06-28 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 640mg 2hr + fluorouracil 2400mg 3800mg 46hr
  • 2022-06-14 - oxaliplatin 70mg/m2 100mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg 3800mg 46hr
  • 2022-05-19 - oxaliplatin 60mg/m2 90mg 2hr + irinotecan 140mg/m2 200mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg 3800mg 46hr
  • 2022-05-03 - oxaliplatin 60mg/m2 90mg 2hr + irinotecan 140mg/m2 200mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg 3700mg 46hr
  • 2022-03-28 - fluorouracil 200mg/m2 300mg 24hr D1-2
  • 2022-03-21 - fluorouracil 200mg/m2 300mg 24hr D1-2
  • 2022-03-17 - fluorouracil 200mg/m2 300mg 24hr D1-2
  • 2022-03-07 - fluorouracil 200mg/m2 300mg 24hr D1-2

==========

2023-11-29

[Brosym dosage assessment for the patient with jaundice and poor renal function]

This patient has severe jaundice and poor kidney function, and is currently being treated with Brosym (cefoperazone, sulbactam) 4g IVD Q12H.

  • 2023-11-27 AST 90 U/L
  • 2023-11-27 ALT 54 U/L
  • 2023-11-27 BUN 36 mg/dL
  • 2023-11-27 Creatinine 1.32 mg/dL
  • 2023-11-27 eGFR 56.51 ml/min/1.73m^2
  • 2023-11-27 Bilirubin total 13.76 mg/dL
  • 2023-11-27 Bilirubin direct 7.85 mg/dL
  • 2023-11-27 Alkaline phosphatase 208 U/L
  • 2023-11-27 r-GT 181 U/L

Sanford Guide:

  • Cefoperazone is extensively excreted in bile and the serum half-life is usually prolonged with urinary excretion of the drug increased in patients with hepatic diseases and/or biliary obstruction. Even with severe hepatic dysfunction, therapeutic concentrations of Cefoperazone are obtained in bile and only a 2- to 4-fold increase in half-life is seen.
  • Dose modification may be necessary in cases of severe biliary obstruction, severe hepatic disease or in cases of renal dysfunction associated with either of those conditions.
  • In patients with hepatic dysfunction and concomitant renal impairment, dosage should not exceed 2 g/day of Cefoperazone without close monitoring of serum concentrations.

The current dosage of Brosym is twice the recommended amount according to the Sanford Guide. Please consider reducing the dosage based on the clinical situation.

2023-11-16

[biweekly gemcitabine-cisplatin and monthly pembrolizumab demonstrate sustained response]

The current treatment regimen, which includes biweekly administrations of gemcitabine and cisplatin, along with monthly pembrolizumab, initiated on 2023-08-15, seems to remain effective. This effectiveness is indicated by the decreasing trend in CA-199 levels and the stable readings of CEA.

  • 2023-11-14 CA-199 (NM) 79.720 U/ml

  • 2023-11-07 CA-199 (NM) 78.021 U/ml

  • 2023-10-24 CA-199 (NM) 190.180 U/ml

  • 2023-10-17 CA-199 (NM) 208.840 U/ml

  • 2023-09-19 CA-199 (NM) 210.380 U/ml

  • 2023-09-08 CA-199 (NM) 148.890 U/ml

  • 2023-08-25 CA-199 (NM) 593.460 U/ml

  • 2023-08-22 CA-199 (NM) 850.900 U/ml

  • 2023-07-28 CA-199 (NM) 1253.210 U/ml

  • 2023-05-26 CA-199 (NM) 23.184 U/ml

  • 2023-03-10 CA-199 (NM) 11.934 U/ml

  • 2022-11-18 CA-199 (NM) 11.891 U/ml

  • 2022-11-07 CA-199 10.940 U/mL

  • 2022-10-07 CA-199 (NM) 8.593 U/ml

  • 2022-08-10 CA-199 (NM) 9.805 U/ml

  • 2022-05-05 CA-199 (NM) 8.925 U/ml

  • 2022-04-29 CA-199 (NM) 18.368 U/ml

  • 2022-03-09 CA-199 (NM) 21.032 U/ml

  • 2022-01-15 CA-199 103.380 U/mL

  • 2023-11-14 CEA (NM) 7.340 ng/ml

  • 2023-11-07 CEA (NM) 6.487 ng/ml

  • 2023-10-24 CEA (NM) 7.002 ng/ml

  • 2023-10-17 CEA (NM) 8.315 ng/ml

  • 2023-09-19 CEA (NM) 5.347 ng/ml

  • 2023-09-08 CEA (NM) 6.293 ng/ml

  • 2023-08-25 CEA (NM) 7.052 ng/ml

  • 2023-08-22 CEA (NM) 7.820 ng/ml

  • 2023-07-28 CEA (NM) 6.275 ng/ml

  • 2023-05-26 CEA (NM) 3.872 ng/ml

  • 2023-03-10 CEA (NM) 4.042 ng/ml

  • 2022-11-18 CEA (NM) 3.139 ng/ml

  • 2022-11-07 CEA 3.090 ng/mL

  • 2022-10-07 CEA (NM) 3.624 ng/ml

  • 2022-08-10 CEA (NM) 2.325 ng/ml

  • 2022-05-05 CEA (NM) 2.259 ng/ml

  • 2022-04-29 CEA (NM) 3.142 ng/ml

  • 2022-03-09 CEA (NM) 1.678 ng/ml

  • 2022-01-15 CEA 3.380 ng/mL

[assessing the risk of edema in the context of increasing hypoalbuminemia]

The patient is exhibiting a trend of worsening hypoalbuminemia. Factors such as impaired liver function, suspected cholangitis, and infection could be contributing to this condition. It is advisable to check for the presence of edema, as indicated by the weight increase from 56.4 kg on 2023-11-08 to 60.8 kg on 2023-11-15.

  • 2023-11-15 Albumin (BCG) 2.5 g/dL
  • 2023-11-08 Albumin (BCG) 2.5 g/dL
  • 2023-11-01 Albumin (BCG) 2.8 g/dL
  • 2023-10-18 Albumin (BCG) 3.3 g/dL
  • 2023-10-11 Albumin (BCG) 2.9 g/dL
  • 2023-10-04 Albumin (BCG) 2.8 g/dL
  • 2023-10-02 Albumin (BCG) 2.8 g/dL
  • 2023-09-28 Albumin (BCG) 2.7 g/dL
  • 2023-09-26 Albumin (BCG) 2.6 g/dL
  • 2023-09-12 Albumin 3.1 g/dL
  • 2023-09-05 Albumin 3.0 g/dL
  • 2023-08-22 Albumin 3.2 g/dL
  • 2023-08-15 Albumin 3.0 g/dL
  • 2023-07-25 Albumin 3.0 g/dL
  • 2023-01-16 Albumin 3.9 g/dL
  • 2023-01-09 Albumin 3.6 g/dL
  • 2022-12-26 Albumin 4.0 g/dL

701470461

231129

[MedRec]

  • 2023-02-06 ~ 2023-02-21 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Multiple myeloma not having achieved remission
      • Multiple myeloma, IgG type, ISS stage II
      • Spondylosis without myelopathy or radiculopathy, lumbar region
      • Low back pain
    • CC
      • back pain for 5 month
    • Present illness
      • This is a 66-year-old male with history of Hypertension, hyperlipidemia and Gout for 20 years, BPH s/p for 3 years, Colon polyps s/p for 10 years with regular medication control, he was admitted due to back pain since Oct 2022.
      • This time, he suffered from fall down in Oct 2022 and took analgesic agent for one month ago but in vain and visited to YiLan YangMing Hospital for aid and was admitted at that hospital in Dec 2022 due to L 4/5 listhesis s/p Bil MIS Rt L 4/5 transforaminal laminectomy + discectomy for nerve root decompression + i-TLIF cage implantation + Bil L 4-5 TPS fixation + Lt L4/5 laminotomy on 111/12/24 & BPH S/P LASER.
      • Two months later follow-up spine x-ray showed compression fracture and bone cement was done on 2023-02-02. Owing to difficulty urinating was noted and foley cather was inserted on 2023-02-04. Poor appetite, body weight loss about 5 kg and both lower legs weakness and massive yellowish sputum were also since 2023-01-21. Will arranged spine biopsy on 2023-02-06 at YiLan YangMing hospital but the patient was refused and transferred to our ER for treatmetn.
      • Under the impression of back pain for 5 month, R/O spine tumor, R/O prostate cancer with multiple bone mets, R/O multiple myeloma and increase infilitration over both lungs R/O aspiration pneumonia. He was admitted for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, pain control with Tramacet 37.5 & 325mg/tab 1# PO Q6H.
      • Consult NS for evaluation and management, persue tumor marker report; on brace prn; May consult radiologist for CT guide biosy (left T11 vertebrae body?); or bone marrow biopsy as your expertise.
      • R/O aspiration pneumonia, antibiotic with Cefuroxime 1500mg IVD Q8H from 2023/02/06~2023/02/13, tapper to oral form with Cinolone 250mg/tab 3# PO Q12H* 7days.
      • Bome marrow on 2023/02/08, pathology showed myeloma. IHC stains: CD138: 20-25%, kappa and lambda: a predominant kappa sub-population;  CD117: %; CD34: <1 %; MPO: 20 % (of the nucleated cells).
      • Consult dental for Xgeva use, no deep caries were noticed. no pathological findings could be obtained due to lack of dental panoramic film and mild periodontitis of full mouth was noticed. Xgeva 120mg/1.7mL/vial 1vial was give on 2023/02/14.
      • VTD regimen for MM, Bortezomib is applied, Thado 50mg/cap 2# PO HS since 2023/02/14, Limeson 4mg/tab 10# PO QW3 since 2023/02/15.
      • Patient tolerated the treatment of multiple myeloma. With the stable condition, he was discharged on 2023/02/21 and OPD followed up later.  
  • 2023-02-06 SOAP Medical Emergency Hu YuHui
    • S
      • Admitted at National Yang Ming Chiao Tung University Hospital in 2022/12:
        • L 4/5 listhesis s/p Bil MIS Rt L 4/5 transforaminal laminectomy + discectomy for nerve root decompression + i-TLIF cage implantation + Bil L 4-5 TPS fixation + Lt L4/5 laminotomy on 2022/12/24 BPH S/P LASER
      • 2023-02-02 chest/abdomen CT:
        • Multiple osteolytic lesions at thoracic vertebra and suspicious bilateral ribs.
        • D/Dx: metastasis, multiple myeloma, metabolic bone disorder.
        • Suggest further clinical evaluation.
    • A
      • Preliminary impression:
        • M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region

[chemotherapy]

  • 2023-11-19 - melphalan 100mg/m2 160mg NS 500mL 1hr D1-2 (D-2,-1 conditioning regimen prior to APBSCT D0 2023-11-21)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-09-26 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

  • 2023-09-19 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

  • 2023-07-07 - cyclophosphamide 3000mg/m2 4800mg NS 500mL 2hr (for PBSC harvest)

  • 2023-06-16 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

  • 2023-06-09 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

  • 2023-06-02 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

  • 2023-05-26 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

  • 2023-05-19 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

  • 2023-05-12 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

  • 2023-05-05 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

  • 2023-04-28 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

  • 2023-04-21 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

  • 2023-04-14 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

  • 2023-04-07 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

  • 2023-03-31 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

  • 2023-03-24 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

  • 2023-03-17 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

  • 2023-03-09 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma - 2023-11-29 - https://www.uptodate.com/contents/image?imageKey=ONC%2F101205

  • Cycle length: 28 days.

  • Regimen

    • Bortezomib
      • 1.3 mg/m2 SC
      • Given as a single SC injection.
      • Days 1, 8, 15, and 22
    • Thalidomide
      • 100 mg for first 14 days then 200 mg per day thereafter by mouth.
      • Take with water on an empty stomach at least one hour after the evening meal.
      • Daily, days 1 through 21
    • Dexamethasone (“low dose”)
      • 40 mg by mouth
      • Take with food (after meals or with food or milk) in the morning.
      • Days 1, 8, 15, and 22

==========

2023-11-29

[APBSCT day 8: minor WBC rise, no PLT improvement]

Today is Day 8 post-APBSCT, and there is a slight increase in the WBC level observed. However, the PLT remains low and has not shown any signs of rising.

  • 2023-11-29 WBC 0.73 x10^3/uL D08

  • 2023-11-27 WBC 0.03 x10^3/uL D06

  • 2023-11-26 WBC 0.02 x10^3/uL D05 nadir

  • 2023-11-25 WBC 0.53 x10^3/uL D04

  • 2023-11-24 WBC 4.25 x10^3/uL D03

  • 2023-11-23 WBC 11.14 x10^3/uL D02

  • 2023-11-22 WBC 3.81 x10^3/uL D01

  • 2023-11-20 WBC 5.23 x10^3/uL D-1

  • 2023-11-29 PLT 18 *10^3/uL D08

  • 2023-11-27 PLT 53 *10^3/uL D06

  • 2023-11-26 PLT 78 *10^3/uL D05

  • 2023-11-25 PLT 28 *10^3/uL D04

  • 2023-11-24 PLT 51 *10^3/uL D03

  • 2023-11-23 PLT 75 *10^3/uL D02

  • 2023-11-22 PLT 98 *10^3/uL D01

  • 2023-11-20 PLT 143 *10^3/uL D-1

Based on the lab results from 2023-11-29, the patient’s liver and kidney functions are normal, indicating no need for dosage adjustments due to liver or renal concerns.

[tube feeding]

Concor 5mg - For administration, employ the Simple Suspension Method (SSM). This involves dissolving the tablet in warm drinking water, leaving it for 5-10 minutes, and occasionally stirring or gently shaking the container until the tablet fully dissolves. Once dissolved, it can be administered through a feeding tube. This technique is particularly useful for dissolving tablets and capsules in warm water, making them suitable for suspension and feeding tube administration.

Harnalidge 0.4mg - Since Harnalidge (tamsulosin 0.4mg) is not appropriate for tube feeding, it is advised to transition to Urief (silodosin 8mg) as a suitable alternative to meet the patient’s requirements.

2023-11-16

[minutes of interprofessional practice and family meeting]

Today, at 11:00 on 2023-11-16, an interprofessional practice and family meeting was convened by the attending physician, Dr. Gao, in the conference room of Ward 11A. The patient, along with his wife and only son, attended the meeting.

Dr. Gao provided the patient and his family with a comprehensive explanation about the current status of the disease, prognosis, the expected outcomes and risks associated with autologous PBSCT, and asked several questions to assess whether the family fully understood the situation.

Before the meeting, I visited the family and informed that the patient’s bilirubin levels were slightly elevated, but renal function was normal, and there was currently no need to adjust dosages due to liver or kidney function status.

As the patient’s hearing has been gradually declining, I suggested during the post-meeting casual conversation that, once the transplantation procedure is completed and the patient is in a stable condition, he should consider consulting an otolaryngologist to explore further corrective measures, such as getting a hearing aid.

701456176

231127

[exam findings]

[MedRec]

  • 2023-09-21 SOAP Hemato-Oncology Xia HeXiong
    • S: NGS BRCA2 C9515G (Leu3172A) > Uncertain Significance
    • P: Due to aberrant BRCA2 -> The follow-up CY will include the ovarian site.
  • 2023-08-30 ~ 2023-09-01 POMR Hemato-Oncology Xia HeXiong
    • Admission diagnosis
      • Left breast invasive carcinoma, cT1cM0N0, stage IA.ER: Negative, PR : Negative, HER-2/Neu: Equivocal (2+), DISH: negative, Ki-67: 10%. ECOG:0.
    • Discharge diagnosis
      • Malignant neoplasm of unspecified site of left female breast
      • Left breast invasive carcinoma, cT1cM0N0, stage IA, ER: Negative, PR : Negative, HER-2/Neu: Equivocal (2+), DISH: negative, Ki-67: 10%, s/p chemotherapy with Liposome Doxorubicin/Cyclophosphamide from 2023/08/31~
      • Chronic viral hepatitis B without delta-agent
      • Hyperlipidemia, unspecified
    • CC
      • for prepare chemotherapy        
    • Present illness
      • This 46-year-old female patient had 1). Mitral Valve prolape without follow up it for many years ago; 2). HBV with follow up it for many years ago; 3). Hyperlipidemia with medicine control for many years. She denied any TOCC histories in recent 3 months.
      • She noted a mass at left bresat on 2023/05 by health examination. She came to our outpatient department for help.
      • Breast sono on 2023/06/15 showed Left subareolar, size: 1.10x0.76 cm and 1.45x1.29 cm, ill-defined irregular shape lesion, suggested biopsy. Right 2/1.20 cm , size: 1.06x1.90 cm, fibroadenomas as described. Left breast core needle biopsy was done on 2023/06/20 showed invasive carcinoma. ER: Negative, PR : Negative, HER-2/Neu: Equivocal (2+), DISH: negative, Ki-67: 10%. CEA: 0.744 ng/ml, CA-153 :10.386 U/ml.
      • Chest CT on 2023/06/30 showed 1). nodular lesion with enhancement at left breast measuring 1.91cm in largest dimension is found; 2). There is no evidence of mediastinal LAP. 3). No evidence of bilateral pleural effusion. 4). The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • Bone scan on 2023/07/03 showed a hot area in the sternum, the nature is to be determined (post-traumatic change, early bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
      • Physical examination: symmetrical of bilateral breasts. a hard, nontender, movable mass and irregular margin at left breast around 2x2 and 2x2 cm without discharge. The left nipple without dimping, exudative nor bloody discharge and no retraction. The left breast skin had no cellulite change. a hard, nontender, movable mass and irregular margin at right breast around 2x2 cm without discharge. The right nipple without dimping, exudative nor bloody discharge and no retraction. The right breast skin had no cellulite change.
      • She received left breast simple mastectomy + sentinel lymph node biopsy and right breast partial mastectomy were performed on 2023/07/26.
      • This time, she was admitted for prepare chemotherapy.        
    • Course of inpatient treatment
      • After admission, arrange echocardiography for survey before chemotherapy, was done on 2023/08/31 showed LVEF: 75.6%, atypical mitral valve and tricuspid valve proplapse, adequate LV and RV performance with normal wall motion at resting state, mild MR, TR, normal LV and RV relaxation, then she receive Liposome Doxorubicin (30mg/m2, self paid) + Cyclophosphamide (600mg/m2) on 2023/08/31 smoothly.
      • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
      • Strocain 5mg/tab 1# PO TIDAC for stomach discomfort.
      • Chronic viral hepatitis B with Baraclude 0.5mg/tab 1# PO QDAC.
      • Hyperlipidemia wity Tulip F.C 20mg/tab 1.5# PO QOD.
      • Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, she was discharged on 2023/09/01 and OPD followed up later.
    • Discharge prescription
      • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Sinpharderm Cream (urea) BID TOPI
      • Emend (aprepitant 125mg) 1# QD
      • Tulip (atorvastatin 20mg) 0.5# QOD (QN)
  • 2023-08-16 SOAP Hemato-Oncology Xia HeXiong
    • S: For further management
      • HBsAg (+), Anti-HBc (+), Anti-HBs (-), AHCV (-)
      • Mitral valve prolapse
      • Hyperlipidemia (+)
    • A
      • left breast cancer, TNBC, Ki-67: 10%, pT1cN0M0
    • P
      • Arrange admission for heart echo. Liopo-Dox / Cyclophoasmide x 4 followed by docetaxel x 4
      • Genetic test BRCA1/2
  • 2023-07-26 ~ 2023-07-29 POMR General and Gastrointestinal Surgery Chen YenZhi
    • Discharge diagnosis
      • Left breast invasive carcinoma status post simple mastectomy+sentinel lymph node biopsy on 2023/07/26. cT1cM0N0, stage IA. ER: Negative, PR : Negative, HER-2/Neu: Equivocal (2+), DISH: negative, Ki-67: 10%. ECOG:0.
      • Right breast fibroadenoma status post partial mastectomy on 2023/07/26.
    • CC
      • noted a mass at left bresat on 2023/05 by health examination.
    • Present illness
      • This 46-year-old female patient had 1). Mitral Valve prolape without follow up it for many years ago; 2). HBV with follow up it for many years ago; 3). Hyperlipidemia with medicine control for many years. She denied any TOCC histories in recent 3 months.
      • She noted a mass at left bresat on 2023/05 by health examination. She came to our outpatient department for help.
      • Breast sono showed Left subareolar, size: 1.10x0.76 cm and 1.45x1.29 cm, ill-defined irregular shape lesion, suggested biopsy. Right 2/1.20 cm , size: 1.06x1.90 cm, fibroadenomas as described.
      • Left breast core needle biopsy showed invasive carcinoma. ER: Negative, PR : Negative, HER-2/Neu: Equivocal (2+), DISH: negative, Ki-67: 10%. CEA: 0.744 ng/ml, CA-153 :10.386 U/ml.
      • Chest CT showed 1). nodular lesion with enhancement at left breast measuring 1.91cm in largest dimension is found; 2). There is no evidence of mediastinal LAP. 3). No evidence of bilateral pleural effusion. 4). The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • Bone scan showed a hot area in the sternum, the nature is to be determined (post-traumatic change, early bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
      • Physical examination: symmetrical of bilateral breasts. a hard, nontender, movable mass and irregular margin at left breast around 2x2 and 2x2 cm without discharge. The left nipple without dimping, exudative nor bloody discharge and no retraction. The left breast skin had no cellulite change. a hard, nontender, movable mass and irregular margin at right breast around 2x2 cm without discharge. The right nipple without dimping, exudative nor bloody discharge and no retraction. The right breast skin had no cellulite change.
      • Under the impression of left breast invasive carcinoma and right breast tumor, she was admitted for surgery of 1). left simple mastectomy + sentinel lymph node biopsy; 2) right partial mastectomy.
    • Course of inpatient treatment
      • After admission, left breast simple mastectomy + sentinel lymph node biopsy and right breast partial mastectomy were performed on 2023-07-26.
      • The post-operative course was relatively smooth without complication. The wounds are clean and dry.
      • Under the stable condition, she was discharged today and the final report will be follow up at outpatient department.
    • Discharge diagnosis
      • Acetal (acetaminophen 500mg) 1# QID
      • MgO 250mg 1# QID
      • Gaslan (dimehylpolysiloxane 40mg) 1# TID
      • Through (sennoside 12mg) 1# HS

[surgical operation]

[chemotherapy]

  • 2023-11-25 - docetaxel 75mg/m2 100mg NS 250mL 1hr (D, Q3W)
    • dexamethasone 4mg + metoclopramide 10mg + NS 250mL
  • 2023-11-02 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL (AC(Lipo) Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
  • 2023-10-12 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL (AC(Lipo) Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
  • 2023-09-21 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL (AC(Lipo) Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
  • 2023-08-31 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL (AC(Lipo) Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2

701499763

231127

[exam findings]

  • 2023-10-30 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (101 - 18.9) / 101 = 81.29%
      • M-mode (Teichholz) = 81.3
    • Conclusion:
      • Dilated aortic root, normal AV with mild AR
      • Normal MV with trivial MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • No PR, mild TR, normal IVC size
  • 2023-10-30 Miniprobe Endoscopic Ultrasound
    • Diagnosis:
      • Esophageal cancer, middle to lower esophagus, multifocal: T3Nx at least (lesion C), T1b (lesion B), unspecified T stage at lesion A
      • Hypopharyngeal cancer
      • Suboptimal study of EUS (related to difficulty in water immersion and suboptimal patient’s tolerance due to frequent coughing)
    • Suggestion:
      • Correlate with other imaging
  • 2023-10-28 MRI - brain
    • Large area of old infarction over left anterior amd middle MCA territories.
    • Passive dilatation of left lateral ventricle.
  • 2023-10-27 PET
    • Glucose hypermetabolism involving the right hypopharynx and posterior pharyngeal wall, compatible with primary hypopharyngeal malignancy.
    • Glucose hypermetabolism in bilateral retropharyngeal lymph nodes, bilateral neck level III and IV and left supraclavicular lymph nodes, suggesging metastatic lymph nodes.
    • Glucose hypermetabolism in the L5 spine. Bone metastasis should be watched out. Please correlate with other imaging modalities for further evaluation.
    • Glucose hypermetabolism in some focal areas in the middle and lower portions of the esophagus and in multiple lymph nodes around the EG junction. Synchronous esophageal malignancy with multiple regional lymph node metastases may show this picture.
    • Mild glucose hypermetabolism in the right shoulder and in bilateral pulmonary hilar lymph nodes. Inflammatory process may show this picture.
  • 2023-10-26 CT - chest
    • Indication: suspect esophageal cancer
    • Chest CT with and without IV contrast ehnancement shows:
      • Lymphadenopathy at bilateral thoaracic inlet is found. Compatible with hypopharyngeal cancer meta.
      • Wall thickening at lower esophagus with extension into gastric cardiac portion is found measuring 8.5cm in largest dimension. Esophageal cancer is considered. Regional lymph nodes are found at perigatric region (n=5)
      • Mild to moderate Emphysematous change over both lungs is found.
      • Calcified coronary arteries is found.
      • Dilatation of the infrarenal aorta measuring 2.4cm is found.
      • Wall thickening at cardiac portion of the stomach. Suggest correlate with endoscopy to exclude synchronous gastric cancer.
      • Diffuse wall thickening at hypophrynx with regional lymphadenopathy. Extensive hypopharyngeal cancer is considered.
    • Imp:
      • Esophageal cancer with gastric cardiac extension and regional lymphadenopathy.
      • Synchronous esophageal cancer.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-10-25 Tc-99m MDP bone scan
    • Faint hot spots in the posterolateral aspect of the right 10th rib and right scapula, respectively, and increased activity in the lower C-spine and right S-I joint, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in some T-spine, right shoulder, right elbow, and left S-I joint.
  • 2023-10-25 Patho - esophageal biopsy
    • Esophagus, lower, biopsy — Squamous cell carcinoma, moderately differentiated
    • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation is evident. Tumor necrosis is present.
  • 2023-10-24 MRI - larynx
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • A large right hypopharyngeal tumor, extending to left site, highly suspect with right carotid space invasion.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Enlarged right retropharyngeal LN and bil. neck LNs. Highly with ENE (+) at left low neck, supraclavicular fossa.
    • IMP:
      • Right hypopharyngeal CA, T4bN3Mx stage IVB
    • Imaging Report Form for Hypopharynx Carcinoma
      • Impression (Imaging stage) : T: 4b(T_value) N: 3b(N_value) M: 0(M_value) STAGE: IVB (Stage_value)
  • 2023-10-24 EGD
    • Diagnosis:
      • Tumor, lower esophagus, s/p biopsy, suspect metastasis, r/o primary lesion
      • C/W hypopharyngeal cancer
    • Suggestion:
      • Pursue pathology report
  • 2023-10-24 SONO - abdomen
    • Findings
      • Hypoechoic leison up to 2.8cm was noted near the S3 and EC junction.
    • Diagnosis:
      • Suspect lymph node metastasis
    • Suggestion:
      • EGD and CT study
  • 2023-10-12 Patho - larynx biopsy
    • Labeled as “Right arytenoid papillary tumor”, LMS biopsy — squamous cell carcinoma.
    • Section shows squamous cell carcinoma.
    • IHC stains: Ki-67: 70%, p16 (-).
  • 2023-10-02 Nasopharyngoscopy
    • smooth NP, right posterior pharyngeal wall bulging tumor, also right vocal plasy??

[MedRec]

  • 2023-10-02 SOAP Ear Nose Throat Huang YunCheng
    • S:
      • lump in throat, dysphagia and easy choking for3 months
      • patient has strong gap reflex, hard to assess NP and larynx by mirror
    • O:
      • Nasopharyngoscope findings: Smooth NP, right posterior pharyngeal wall bulging tumor, also right vocal plasy??
      • breathing smooth
    • P:
      • suggest LMS biopsy

[consultation]

  • 2023-11-02 Oral and Maxillofacial Surgery
    • Q
      • This 56-year-old man had Right MCA infarct on 2023/06. Operation histiory of left scalp laceration status post repair on 2023/06.
      • This time, he complained about cough with blood-tingled sputum, lump in throat, dysphagia and easy choking since 2023/01.
      • He admitted for cancer workup, after the examination done, hypopharyngeal cancer and esophageal cancer were diagnosed. CCRT was indicated.
      • We had consult your expertise on 10/24. You suggest that extraction of all hopeless teeth (12,17,23,27,38 and 44) .
      • The patient has shceduled port-A implant and juojenostomy on 2023/11/03.
      • The patients to have a tooth extraction during the thoracic surgery, but after reconfirming with the thoracic department, the surgery might only start around noon. The patient won’t be discharged in the short term, so we can arrange for the tooth extraction to be done in separate sessions
    • A
      • Dear doctor, we will arrange the surgery.
  • 2023-10-26 Gastroenterology
    • Q
      • For arrange miniprobe EUS
      • This 55-year-old man had Right MCA infarct on 2023/06. Operation histiory of left scalp laceration status post repair on 2023/06.
      • This time, he complained about cough with blood-tingled sputum, lump in throat, dysphagia and easy choking since 2023/01.
      • Then, he went to our ENT OPD for help, where nasopharyngoscope was done and showed right posterior pharyngeal wall bulging tumor.
      • He recevied laryngomicrosurgery on 2023/10/11. Pathology result squamous cell carcinoma. IHC stains: Ki-67: 70%, p16 (-).
      • Under the impression of hypopharyngeal cancer. This time, the patient was admitted for cancer work-up.
      • Laryngeal MRI was arranged and showed right hypopharyngeal CA, T4bN3Mx, stage IVB.
      • Abd echo arranged and showed hypoechoic leison up to 2.8cm was noted near the S3 and EC junction, suspect lymph node metastasis.
      • PES arrange and showed a few polypoid and nodularity lesions were noted from 30cm below incisors to EC junction, suspect metastasis, r/o primary lesion.
      • Bone scan was done on 10/25 and pending result. We consulted CS for suspect eshopharygeal cancer evalution, which suggest arrange miniprobe EUS. We need your help, thank you very much!!
    • A
      • This is a 55-year-old male who was admitted due to newly found right hypopharyngeal cancer.
        • EGD showed a few polypoid and nodularity lesions noted 30cm below incisors to EC junction, suspect metastasis, r/o second primary cancer.
        • We are consulted for EUS.
      • S
        • dysphagia, solid and liquid food
        • smoking and betelnut before, quit
      • O
        • E4V5M6, cons clear
        • Conjunctiva: not pale
        • Sclera: anicteric
        • Abdomen: soft and flat, no tenderness
      • Impression
        • Right hypopharyngeal cancer, T4bN3Mx
        • Suspected esopharyngeal malignancy, suspect second primary cancer
      • Suggestions
        • EUS may be arranged.
  • 2023-10-26 Radiation Oncology
    • A: The patient’s history was reviewed and patient was examined.
      • S: For CCRT due to hypopharyngeal carcinoma and esophageal carcinoma.
        • PI: The patient suffered from right MCA infarct on 2023/06. He complained about cough with blood-tingled sputum, lump in throat, dysphagia and easy choking since 2023/01. Then, he went to our ENT OPD for help, where nasopharyngoscope was done and showed right posterior pharyngeal wall bulging tumor. He recevied laryngomicrosurgery on 2023/10/11.
          • Pathology showed squamous cell carcinoma. IHC stains: Ki-67: 70%, p16 (-). The diagnosis was right hypopharyngeal carcinoma, stage cT4bN3M0, stage IVB. In addition, PES showed a few polypoid and nodularity lesions were noted from 30cm below incisors to EC junction, suspect metastasis, r/o primary lesion. Referred for CCRT.
        • Family history: (-)
        • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
        • Personal Hx: DM (-); HTN (-)
        • Previous RT Hx: (-)
      • O: ECOG: 2
        • PE: neck and bil SCF: a palpable nodal lesion over right middle neck. CVA with right upper limb weakness.
        • CXR (2023-10-11): Tortuosity of the aorta with atherosclerotic change.
        • Pathology (S2023-20303, 2023-10-16): Labeled as “Right arytenoid papillary tumor”, LMS biopsy — squamous cell carcinoma. IHC stains: Ki-67: 70%, p16 (-).
        • Abd sono (2023-10-24): Hypoechoic leison up to 2.8cm was noted near the S3 and EC junction. Diagnosis: Suspect lymph node metastasis.
        • UGI panendoscopy (2023-10-24): Tumor, lower esophagus, s/p biopsy, suspect metastasis, r/o primary lesion. C/W hypopharyngeal cancer.
        • MRI of larynx (2023-10-24): Right hypopharyngeal CA, T4bN3Mx stage IVB
        • Bone scan (2023-10-25): Faint hot spots in the posterolateral aspect of the right 10th rib and right scapula, respectively, and increased activity in the lower C-spine and right S-I joint, the nature is to be determined (post-traumatic change or other nature?)
        • Pathology (S2023-21165, 2023-10-26): Esophagus, lower, biopsy — Squamous cell carcinoma, moderately differentiated
      • A:
        • Squamous cell carcinoma, p16 (-), of the right hypopharynx, stage cT4bN3M0 (stage IVB).
        • Squamous cell carcinoma of the low third esophagus.
      • P:
        • CCRT is indicated for this patient with the following indicators: hypopharyngeal carcinoma, stage cT4bN3M0 (stage IVB); esophageal carcinoma.
        • Goal: palliation
        • Treatment target and volume: 1. hypopharyngeal tumor to bilateral neck; 2. low third esophageal carcinoma and peripheral area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5000cGy/25 fractions of the hypopharyngeal tumor to bilateral neck, and 7000cGy/35 fractions of the hypopharyngeal tumor bed and involved nodal lesion. 5040cGy/28 fractions of the esophageal tumor (if surgery no tplanned).
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0900, 2023-11-2.
        • Please consult Dental department for pre-RT dental evaluation and management.
  • 2023-10-25 Hamato-Oncology
    • Q
      • For CCRT further evaluation
      • This 55-year-old man had Right MCA infarct on 2023/06. Operation histiory of left scalp laceration status post repair on 2023/06.
      • This time, he complained about cough with blood-tingled sputum, lump in throat, dysphagia and easy choking since 2023/01.
      • Then, he went to our ENT OPD for help, where nasopharyngoscope was done and showed right posterior pharyngeal wall bulging tumor.
      • He recevied laryngomicrosurgery on 2023/10/11. Pathology result squamous cell carcinoma. IHC stains: Ki-67: 70%, p16 (-).
      • Under the impression of hypopharyngeal cancer. This time, the patient was admitted for cancer work-up.
      • Laryngeal MRI was arranged and showed right hypopharyngeal CA, T4bN3Mx, stage IVB.
      • Abd echo arranged and showed hypoechoic leison up to 2.8cm was noted near the S3 and EC junction, suspect lymph node metastasis.
      • PES arrange and showed a few polypoid and nodularity lesions were noted from 30cm below incisors to EC junction, suspect metastasis, r/o primary lesion.
      • Bone scan was done on 10/25 and pending result. We consulted CS for suspect eshopharygeal cancer evalution, which arrange staging for eshopharygeal cancer, neoadjuvant CCRT will be first considered.
      • We need your help for CCRT further evaluation. Thank you very much!!
    • A
      • This 55 year old man had inderline disease of right MCA infarction on 2023/06. We are consulted CCRT for 1. Hypopharygear cancer, cT4bN3Mx, stage IVB and 2. Suspect esophageal cancer, pending pathology result.
      • Suggestion:
        • We will discuss with patient about CCRT.
        • Pending esophageal cancer biopsy result and complete esophageal cancer staging (chest CT+/-contrast, PET/CT scan…).
        • Additionally, Please check HBsAg, Anti HBc, Anti HBs, Anti HCV before chemotherapy.
        • And arrange port A and jejunostomy before chemotherapy.
  • 2023-10-24 Thoracic Surgery
    • Q
      • For suspect esophageal caner
      • This 55-year-old man had Right MCA infarct on 2023/06. Operation histiory of left scalp laceration status post repair on 2023/06. This time, he complained about cough with blood-tingled sputum, lump in throat, dysphagia and easy choking since 2023/01. Then, he went to our ENT OPD for help, where nasopharyngoscope was done and showed right posterior pharyngeal wall bulging tumor.
      • He recevied laryngomicrosurgery on 2023/10/11. Pathology result squamous cell carcinoma. Under the impression of hypopharyngeal cancer. This time, the patient was admitted for cancer work-up. Laryngeal MRI was arranged and showed right hypopharyngeal CA, T4bN3Mx, stage IVB. Abd echo arranged and showed hypoechoic leison up to 2.8cm was noted near the S3 and EC junction, suspect lymph node metastasis. PES arrange and showed a few polypoid and nodularity lesions were noted from 30cm below incisors to EC junction, suspect metastasis, r/o primary lesion. We need your help for further evaluation. Thank you very much!!
    • A
      • I will arrange staging for eso. ca. After staging, I will explain the following management with him and his family.
      • Neoadjuvant CCRT will be first considered. Feeding jejunostomy and port-A insertion will be arranged before treatment.
  • 2023-10-24 Oral and Maxillofacial Surgery
    • Q
      • For tooth evaluation
      • This time, the patient was admitted for cancer work-up. We will arrange CCRT for him. We need your help for tooth evaluation. Thank`s a lot
    • A
      • After examing the intraoral condition.
      • Possible treatment plan
        • Treatment option A
          • extraction of all hopeless teeth (12,17,23,27,38 and 44) to prevent RT-related osteonecrosis and risk of cellulitis
          • Possible risk: relative contraindication due to recent right MCA infarction this June.
        • Treatment option B
          • conservative treatment (toothbrushing)
          • Possible risk: osteonecrosis and risk of cellulitis
      • patient’s father and his wife understands and will consider about it. thank you for your consultation

[radiotherapy]

[chemotherapy]

  • 2023-11-21 - NS 500mL 1hr (before CDDP) + cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-06 - NS 500mL 1hr (before CDDP) + cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-11-27

[Akynzeo use for prolonged nausea control post-chemotherapy]

On 2023-11-21, the patient was administered cisplatin at 40mg/m2, with premedication including dexamethasone, diphenhydramine 30mg, palonosetron 250ug, and NS hydration.

Post-treatment, the patient experienced nausea and vomiting for an additional three days, leading to the prescription of metoclopramide.

For subsequent chemotherapy sessions, it may be beneficial to consider Akynzeo, available in this hospital. Akynzeo, containing netupitant, an NK-1 receptor antagonist with a 96-hour half-life, could provide prolonged anti-emetic effects.

[hypomagnesemia and hypokalemia]

Cisplatin is a common cause of hypomagnesemia and hypokalemia due to renal magnesium (Mg) and potassium (K) losses.

  • 2023-11-27 K (Potassium) 3.1 mmol/L

  • 2023-11-24 K (Potassium) 3.8 mmol/L

  • 2023-11-23 K (Potassium) 4.9 mmol/L

  • 2023-11-27 Mg (Magnesium) 1.8 mg/dL

  • 2023-11-06 Mg (Magnesium) 1.9 mg/dL

Magnesium (MgO) and potassium (Const-K) supplements are currently in use. There is no problem with the supplementation.

[mild hyponatremia]

Based on the laboratory data, mild hyponatremia has been consistently observed for the past month and a half, and it may be considered to investigate the possible underlying causes.

  • 2023-11-27 Na (Sodium) 133 mmol/L
  • 2023-11-24 Na (Sodium) 134 mmol/L
  • 2023-11-23 Na (Sodium) 133 mmol/L
  • 2023-11-06 Na (Sodium) 133 mmol/L
  • 2023-10-11 Na (Sodium) 134 mmol/L

[elevated BUN]

Cisplatin primarily injures the S3 segment of the proximal tubule. Urea undergoes a more complex process involving reabsorption and secretion in different parts of the tubules, while creatinine is not significantly reabsorbed after filtration. The elevated BUN may be a vague indication of cisplatin nephrotoxicity.

  • 2023-11-27 BUN 35 mg/dL
  • 2023-11-23 BUN 21 mg/dL
  • 2023-11-14 BUN 15 mg/dL

2023-11-06

Every oral medication listed as currently active is suitable for administration via a feeding tube.

700032025

231124

[MedRec]

  • 2023-11-14 SOAP Heamto-Oncology He JingLiang
    • S: ca of stomach with liver mets
    • P: arrange C/T with FOLFOX
  • 2023-11-14 SOAP Gastroenterology Gong ZiXiang
    • S
      • Gastric cancer with liver metastasis, r/o HCC or cholangiocarcinoma (r/o double cancer) -> refer to GS, Oncology, keep PPI
        • GS suggest: tissue aquitition is needed for liver tumor
    • O
      • 2023/11/03 CT: ABD — whole abdomen, pelvis - Impression (Imaging stage): T4aN2M1, stage: IVB
        • There is a huge heterogeneous poor enhancing mass in S4-7-8 of the liver, measuring 9 cm in size
      • 2023/10/30 PATHO - Stomach, cardia, biopsy — poorly differentiated adenocarcinoma
        • IHC stain— Her2/neu: negative (0)
    • Prescription
      • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
      • Pariet (rabeprazole 20mg) 1# QDAC
  • 2017-01-26 SOAP Cardiology Xu ShunYi
    • Diagnosis
      • Pure hyperglyceridemia [E78.1]
      • Essential hypertention, unspecified [I10]
      • Chronic airway obstruction (COPD) ,NEC [J44.9]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type [E11.9]
    • Prescription x3
      • Diovan (valsartan 160mg) 0.5# QD
      • Norvasc (amlodipine 5mg) 1# QD
      • Concor (bisoprolol 5mg) 0.5# QD

[consultation]

  • 2023-11-20 Radiation Oncology
    • Q
      • for liver mass for R/T
      • This is a 71-year-old male with past history of HTN and hyperlipidemia, Type 2 DM, Ankylosing Spondylitis and Gastric adenocarcinoma, cT4aM1N2, stage IVB status with metastatic nodes with huge heterogeneous poor enhancing mass in S4-7-8 of the liver, measuring 9 cm in size.
      • He used to smoking 1 packs per week for about 20-30 year and had tea, coffee ocasionally.
      • According to patient statement and his medical record, he had burning sensation at night, poor digestion progressive for a half year, more severe on October. He went to our GI OPD for help.
      • EsophagoGastroDuodenoscopy was arranged on 10/30 and showed gastric ulcer, cardia, AW-LC, suspected malignancy, s/p biopsy.
      • Abdominal CT was arranged on 11/03 and revealed Adenocarcinoma of the stomach and HCC 9 cm in S4-7-8 of the liver is highly suspected, imaging stage: T4aN2M1,stage:IVB.
      • Panendoscopy biopsy pathological report revealed poorly differentiated adenocarcinoma. CT guide of liver was arranged for R/O HCC huge central type.
      • Liver, CT-guided biopsy showed Adenocarcinoma. This time, he was admitted for on port-A and chemotherapy.
      • We sincerely need your professional assistance!!
    • A
      • The patient’s history was reviewed and patient was examined.
      • S: For radiotherapy of the metastatic liver tumor.
        • PI: The patient was a case of gastric adenocarcinoma, stage cT4aN2M1 (IVB), status with metastatic nodes with huge heterogeneous poor enhancing mass in S4-7-8 of the liver, measuring 9 cm in size. Pathology (S2023-22725, 2023-11-15) showed liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with metastatic gastric adenocarcinoma. Referred for radiotherapy of the metastatic liver tumor.
        • Family history: (father: hepatoma)
        • Cancer site specific factors: Alcohol (-); Smoking (quit); Betel nut (-).
        • Personal Hx: DM (-); HTN (+); HBV (+); ankylosing spondylitis
        • RT Hx: (-)
      • O: ECOG: 1
        • PE: neck and bil SCF: neg; abdomen: mild induration of the upper abdomen.
        • UGI panendoscopy (2023-10-30): Reflux esophagitis LA Classification grade A. Superficial gastritis, s/p CLO test. Gastric ulcer, cardia, AW-LC, suspected malignancy, s/p biopsy. CLO test: Negative.
        • Pathology (S2023-21538, 2023-11-1): ADDENDUM: IHC stain — Her2/neu: negative (0). DIAGNOSIS: Stomach, cardia, biopsy — poorly differentiated adenocarcinoma
        • CT scan of abdomen (2023-11-14): 1. Adenocarcinoma of the stomach. 2. HCC 9 cm in S4-7-8 of the liver is highly suspected. The differential diagnosis includes Metastasis. Please correlate with dynamic MRI. 3. Detailed findings, please see description.
        • Pathology (S2023-22725, 2023-11-15): Liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with metastatic gastric adenocarcinoma
      • A: Poorly differentiated adenocarcinoma of the stomach, stage cT4aN2M1(IVB) with liver metastasis.
      • P: Radiotherapy is indicated for this patient with the following indicators: large metastatic liver tumor
        • Goal: palliation
        • Treatment target and volume: metastatic liver tumor
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5000cGy/25 fractions of the metastatic liver tumor.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2023-11-22.

[radiotherapy]

[chemotherapy]

  • 2023-11-23 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

700377453

231124

[exam findings]

[MedRec]

  • 2023-04-17 ~ 2023-04-21 POMR Colorectal Surgery Xiao GuangHong
    • Discharge diagnosis
      • Sigmoid tumor obstruction status post T-loop colostomy on 2023/04/17
    • CC
      • diffuse abdominal distension with no stool passage for 10 more days
    • Present illness
      • This 48-year-old male denied any systemic diseases. According to patient’s statement and previous medical record, the patient felt diffuse abdominal distension with no stool passage for 10 more days. He also had intermittent cramping pain with nausea and vomiting since 2 days ago. Associated with poor appetite and fatigue. The patient denied having fever, diarrhea, bloody stool, tarry stool, chest pain. Due to symptoms persisted, the patient visited our emergency department.
      • At our triage, vital signs were stationary. No fever noted. Physical examination showed distended abdomen without tenderness over four quardrant. No muscle guarding, no rebounding pain found. Laboratory data showed elevated CRP level (1.86 mg/dL). KUB showed increased air in nondistended loops of small bowel over LUQ, and colonic segments, visible rectal air, and scanty amount of fecal material filled D-colon and rectum, paralytic or partial mechanical ileus.
      • Abdominal CT showed apple core like narrowing of the sigmoid colon measuring 3.5cm in largest dimension is found. The colon is severely dilated. One fistula tract is found abutting from sigmoid colon narrowing region is found. Sigmoid colon fistula is more favored but colon cancer cannot be excluded. CRS doctor was consulted and emergent colostomy was suggested.
      • With the impression of obstruction ileus, the patient received T-loop colostomy on 2023/04/17 and admitted to our ward for postoperative management.
    • Course of inpatient treatment
      • After admission, we arranged post-op care and colostomy care. Education of colostomy was also done. He was under regular diet due to well bowel movement without abdominal discomfort. He was able to tolerate diet.
      • Sigmoidoscopy was arranged which suspected sigmoid cancer obstruction, biopsy was done and the pathology report was still pending.
      • He discharged on 4/21 due to stable condition and OPD follow up was arranged.
    • Discharge prescription
      • Actein Effervescent (acetylcysteine 600mg) 1# BID
      • Acetal (acetaminophen 500mg) 1# PRNQ6H

[surgical operation]

[immunochemotherapy]

  • 2023-11-21 - (Avastin + FOLFIRI) Xia He Xiong

  • 2023-11-01 - (Avastin + FOLFIRI) Xia He Xiong

  • 2023-10-13 - (Avastin + FOLFIRI) Xia He Xiong

  • 2023-09-22 - (FOLFIRI) Xia He Xiong

  • 2023-09-01 - (FOLFIRI) Xia He Xiong

  • 2023-08-22 - (FOLFOX) Chen XinHong

  • 2023-08-07 - (FOLFOX) Xiao GuangHong

  • 2023-07-24 - (FOLFOX) Xiao GuangHong

  • 2023-07-10 - (FOLFOX) Xiao GuangHong

  • 2023-06-26 - (FOLFOX) Xiao GuangHong

  • 2023-06-12 - (FOLFOX) Xiao GuangHong

  • 2023-05-29 - (FOLFOX) Xiao GuangHong

700617345

231124

[lab data]

2023-04-07 Anti-HBs 64.07 mIU/mL
2023-04-07 Anti-HBc Nonreactive
2023-04-07 Anti-HBc Value 0.08 S/CO
2023-04-07 Anti-HCV Nonreactive
2023-04-07 Anti-HCV Value 0.06 S/CO
2023-04-07 HBsAg Nonreactive
2023-04-07 HBsAg (Value) 0.47 S/CO

[exam findings]

  • 2023-10-03 CT - abdomen
    • S/P hysterectomy.
    • Liver cyst, 0.4cm in S2-3.
    • R/O left renal cyst, 0.5cm.
  • 2023-07-17 EGD
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis, antrum
  • 2023-03-29 Patho - uterus (with or without SO) neoplastic
    • Diagnosis:
      • Uterus, endometrium, total hysterectomy with frozen section — endometrioid adenocarcinoma grade 2.
      • Uterus, myometrium, total hysterectomy — tumor invasion, 1 mm; <1/2 thichness of the thickness of the myometrium; one myoma present.
      • Uterus, cervix, total hysterectomy — free
      • Ovaries and fallopian tubes, bilateral, BSO — No malignancy. Endometriosis and corpora lutea present.
      • Lymph node, bilateral pelvic and para-aortic, dissection — Free
      • Omentum, partial omentectomy — Free
      • pT1a pN0 (if cM0); AJCC 8th edition Pathology stage: IA
    • Gross description:
      • Procedure (select all that apply) - staging surgery: Total hysterectomy and bilateral salpingo-oophorectomy, partial Omentectomy: uterus: 10 x 8 x 5 cm with polypoid endometrial tumor at fundus. Left ovary: 3.5 x 2.5 x 1.5 cm. Left tube: 5.5 x 1 x 1 cm; right ovary: 3.5 x 2.5 x 1.5 cm; right tube: 5 x 1 x 1 cm. Omentum: 6 x 3.5 x 1.5 cm
        • For information about lymph node sampling, please refer to the Regional Lymph Node section.
      • Tumor Site (select all that apply)- Endometrium, fundus, > 4.5 cm from cervical margin.
      • Tumor Size:
        • Greatest dimension: 5 cm
          • Additional dimensions (centimeters): 3.5 x 0.5 cm
      • Sections are taken and labeled as:
        • Tissue for section: A: left external iliac lymph nodes; B: left obturator lymph nodes; C: right external iliac lymph nodes; D: right obturator lymph nodes; E: left para-aortic lymph nodes; F: right para-aortic lymph nodes; G1: left ovary; G2: left tube; G3: right ovary; G4: right tube; G5-8: endometrial tumor; G9: non-tumrous endometrium and uterine corpus and myoma; H1-3: omentum.
    • Microscopic Description:
      • Histologic Type: Endometrioid carcinoma
      • Histologic Grade: FIGO grade 2 (low-grade)
      • Myometrial Invasion: present, 1 mm in depth; < 1/2 thichness of the thickness of the myometrium
      • Uterine Serosa Involvement - Not identified
      • Cervical Stromal Involvement - Not identified
      • Other Tissue / Organ Involvement: Not identified
      • Bilateral ovaries: free
      • Omentum: free
      • Margins (required only if cervix and/or parametrium/paracervix is involved by carcinoma)
        • Ectocervical/Vaginal Cuff Margin: ree
        • Parametrial/Paracervical Margin: Free
      • Lymphovascular Invasion: Absent
      • Regional Lymph Nodes: free= 0/48= A: left external iliac lymph nodes (0/10); B: left obturator lymph nodes (0/10); C: right external iliac lymph nodes (0/11); D: right obturator lymph nodes (0/11); E: left para-aortic lymph nodes (0/3); F: right para-aortic lymph nodes (0/3).
        • Right Pelvic Node: (Number of lymph nodes with metastasis) / (Number of total lymph nodes examined): free 0/22
        • Left Pelvic Node: (Number of lymph nodes with metastasis) / (Number of total lymph nodes examined): 0/20
        • Para-aortic Node: (Number of lymph nodes with metastasis) / (Number of total lymph nodes examined): free (0/6)
      • Additional Pathologic Findings - myoma
  • 2023-03-23 CT - abdomen
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T:T1a(T_value) N:N0(N_value) M:M0(M_value) STAGE: IA_(Stage_value)
  • 2023-03-16 Patho - endometrium curretage / biopsy
    • Uterus, endometrium, D&C — endometrioid carcinoma with focal clear cell carcinoma
    • Sections show atypical crowded and cribriform endometrioid carcinoma (grade 1) with focal clear cell carcinoma.
    • Immunohistochemically, the endometrioid carcinoma shows PAX8(+), WT-1(-), p53(No aberrant expression), Napsin A(-), and PR(+).
    • Immunohistochemically, the clear cell carcinoma shows PAX8(+), WT-1(-), p53(No aberrant expression), Napsin A(+), and PR(-).

[MedRec]

  • 2023-04-11 SOAP Radiation Oncology Huang JingMin
    • A: Endometrioid carcinoma with focal clear cell carcinoma of the uterine endometrium, stage pT1a pN0 (cM0); AJCC 8th edition Pathology stage: IA, s/p staging surgery.
    • P: Radiotherapy is indicated for this patient with the following indicators: invasive clear cell carcinoma, stage IA.
      • Goal: curative
      • Treatment target and volume: pelvic area
      • Technique: VMAT/IGRT and IVRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions via IVRT to vaginal cuff mucosa surface.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her mother. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-04-25.
  • 2023-04-11 SOAP Hemato-Oncology Xia HeXiong
    • S: This 36 year old woman is a case of Endometrioid adenocarcinoma grade 2. pT1a pN0 (if cM0); AJCC 8th edition Pathology stage: IA  post Staging surgery on 2023/03/29
    • Plan:
      • Arrange CCRT with CDDP and then C/T with TP
      • Simulation on 2023/04/25
      • May start weekly CDDP on 2023-05-02
  • 2023-03-28 ~ 2023-04-07 POMR Obstetrics and Gynecology Huang SiCheng
    • Discharge diagnosis
      • Endometrioid adenocarcinoma grade 2.pT1a pN0 (if cM0); AJCC 8th edition Pathology stage: IA  post Staging surgery on 2023/03/29
      • Abnormal vaginal bleeding
      • Epilepsy
    • CC
      • Abnormal intermittent uterine bleeding for 1 year
    • Present illness
      • This is a 36 y/o woman who had no sexual history, G0P0, LMP 2023/03/26, menstral cycle irregular with duration/interval of 7/28-30 days.
      • She had past history of (1) epilepsy s/p epilepsy surgery twice (2013, 2014) and vagus nerve stimulation therapy (2021.08.25), currently on anticonvulsant drugs, (2) Mixed hemorrhoids. She is allergic to carbamezepine. She denied oral contraceptives or hormone use.
      • According to the patient, she noticed abnormal intermittent uterine bleeding for 1 year. During menstration, heavy menstrual bleeding was noticed which she must use night sanitary pads and change at least 3 times a day, blood clots could be found, with fresh red color. She denied dysmenorrhea. Intermenstrual spotting with scanty, brownish discgarge was noted during the past 6 months. Epileptic seizures were triggered by menstration, and during menstration the frequency and duration of seizure increase. She denied abdominal pain, nausea, vomiting, tarry or bloody stool, constipation, unintentional body weight loss, or disuria or urinary frequency.
      • She turned to our GYN OPD for help, and some examination was done. The transvaginal sono on 2023.03.07 revealed endometrial polyp in size of 13*12mm. Hysteroscopy was performed on 2023.03.08 and multiple endometrial polyps with abberant vessels were found. D&C on 2023.3.16 revealed endometrioid carcinoma with focal clear cell carcinoma and chronic cervicitis. Abdominal CT was also done on 2023.03.23 and revealed soft tissue in the uterine cavity, r/o endometrial malignancy, stage T1aN0M0. Tumor marker showd CA125 = 34.5 U/mL; CEA = 2.16 ng/mL. And Hb level was 7.6 g/dL. Under the impression of endometrial clear cell carcinoma, she was admitted on 2023.03.28 for staging operation.        
    • Course of inpatient treatment
      • The patient was admitted on 03/29/2023 and underwent laparoscopic GYN cancer staging surgery (bil salpingo-oophoretomy + BPLND + partial omentectomy) and laparoscopic adhesiolysis the next day.
      • The surgical pathology revealed, The surgical pathology frozen section, endometrioid adenocarcinoma grade 2. Pathology stage: IA , pT1a pN0 (if cM0); AJCC 8th edition.
      • The Gyn tumor conference suggest further chemotherapy and radiotherapy for her after operation. Arrange port-A for checmotherapy and removed JP drain on 04/06. The vital sign was stable after surgery. She is discharged on 04/07/2023 and her followup appointment is scheduled on next week.
    • Discharge prescription
      • cephalexin 500mg 1# QID
      • Acetal (acetaminophen 500mg) 1# QID
      • Gaslan (dimethylpolysiloxane 40mg) 2# TID
      • Through (sennoside 12mg) 2# HS

[consultation]

  • 2023-04-06 Neurology
    • Q
      • For evaluation of epilepsy therapy during chemo/radiotherapy.
      • The 36-year-old female patient with underlying of epilepsy under medication and s/p vagal nerve stimulator in 2021 was admitted on 03/29/2023 and underwent laparoscopic GYN cancer staging surgery (bil salpingo-oophoretomy + BPLND + partial omentectomy) and laparoscopic adhesiolysis the next day. The surgical pathology revealed: endometrioid adenocarcinoma grade 2; Pathology stage: IA , pT1a pN0 (if cM0); AJCC 8th edition. Her postoperative course was uneventful. Her Eating and urination by self voiding was smooth. The vital sign was stable after surgery. The Gyn tumor conference was arranged and chemo/radiotherapy will be arranged.
      • Due to her underlying of epilepsy with medication and vagal nerve stimulator, we need your expertise for evaluation of treatment.
      • Current medication: Lacosamide, Lamotrigine, Clobazam, Topiramate, Perampanel, Rufinamide.
    • A
      • This 36 year fenalt P’t is a case of Epilsy since 10+ years old and persis poor control even under 6 ASMs within therapy range and lesionnectomy. VNS was placed last year but still under titration of stimulation amplitudes and frequent.
      • She admitted to our GYN ward for sndometrioid adenccarcinoma and received bil salpingo-oophoretomy + BPLND + partial omentectomy on 3/29. Now, due to need further chemo/radiotherapy, we were consulted for evaluation the condition and further suggestion.
      • Imp:
        • Drug resistent epilepsy under ASMs and VNS
        • endometrioid adenocarcinoma s/p bil salpingo-oophoretomy + BPLND + partial omentectomy
      • Suggestion:
        • Due to all ASM within therapeutic dosage and no obvious drug-drug interation, we suggested keep present treatment.
        • Keep VNS therapy, needn’t adjust during chemo/radiotherapy
        • We had explained to patient and family that seizure rate may elevated during chemo/radiotherapy. But treatment plan of epilepsy needn’t adjust right now.
        • We also explained the possibility of status epiepticus and promised Neuroogist will help as soon as possible.
        • If seizure attack and persist over 5 minutes, give ativan iv 2 amp st, and depakine iv 30mg/kg quickly loading within 5~10 minutes. Consult Neuro emergency for further management of status epilepticus.

[surgical operation]

  • 2023-04-06
    • Surgery
      • Operation
        • Port-A (47080B)
        • Fluoroscopy (32026C)        
    • Finding
      • Insertion via right subclavian vein.
      • Port: Polysite, 3007, 7Fr,
      • Fluorosopy: catheter tip in SVC above RA
  • 2023-03-29
    • Surgery
      • Diagnosis: Endometrial cancer
      • Surgery: Staging surgery
    • Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, tense contact with bladder
      • Bilateral adnexa: grossly normal
      • CDS: mild adhesion (+), ascites (+)
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • Omentum: grossly normal
      • Estimated blood loss: 300 mL
      • Blood transfusion: nil
      • Complication: nil
    • Procedure
      • Put the patient on the lithotomy position
      • Vaginal douching, insert Foley catheter, skin disinfection with beta-iodine, and skin draping.
      • Make midline vertical skin incision and open the abdominal wall layer by layer.
      • Serous ascites, send for cytology
      • Apply auto-retractor and pack up the intestine to expose the uterus.
      • Clamp, ligate and cut left round ligament
      • Clamp, cut andligate left infundibulo-pelvic ligament
      • Repeat step 6-7 at the right side.
      • Dissect the densely adherent posterior leaf of broad ligaments overlying the uterosacral ligaments bilaterally.
      • Dissect and reflect the bladder downwards and off the uterus.
      • Clamp, cut andligate the ascending branches of uterine arteries bilaterally at the level of isthmus of cervix.
      • Clamp, cut and ligate the paracervical vessels along lateral borders of cervix step by step downwards bilaterally till the level of lateral vaginal fornix.
      • Cut the uterus and grasp the vaginal stump
      • Suture the bilateral angles of vaginal stump with 1-0 Vicryl
      • Suture the vaginal stump with 1-0 Vicryl
      • Step by step clamp, cut and ligate the omentum.
      • Irrigate the pelvic cavity with normal salin.
      • Check bleeding and hemostasis.
      • Insert J-VAC X 2 at the cul-de-sac.
      • Close the abdomen layer by layer.
      • Skin approximation.
  • 2023-03-16
    • Surgery
      • Diagnosis: R/O endometrial hyperplasia
      • Surgery: Fractional dilatation and curettage        
    • Finding
      • Uterus: Anteversion, 7 cm.
      • Scanty endocervical and some endometrial tissue were curetted out.
      • Mild laceration wound at 4 o’clock of the hymen.
      • Estimated blood loss:5 mL, Blood transfusion: nil, complication: nil.        
    • Procedure
      • Put the patient on lithotomy position.
      • Douching, skin disinfection and skin draping as usual.
      • Sounding: Anteversion, 7 cm.
      • Cervical dilatation to Hegar No. 7.
      • Curette the endocervical canal and uterine cavity.
      • Check bleeding.
      • Pack one piece of Bosmin gauze in the vagina to compress the hymen laceration wound.

[radiotherapy]

  • 2023-05-04 ~ 2023-06-16 - 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT.

[chemotherapy]

  • 2023-11-23 - paclitaxel 105mg/m2 160mg NS 500mL 3hr + cisplatin 45mg/m2 70mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3 + lorazepam 2mg IVD Q12H D1-3
  • 2023-10-30 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3 + lorazepam 2mg IVD Q12H D1-3
  • 2023-10-04 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3 + lorazepam 2mg IVD Q12H D1-3
  • 2023-09-12 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-03 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-14 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-08 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-01 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-25 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-18 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-11 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-04 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-11-24

[reduced chemotherapy dosage in this hospitalization]

The dosage of the paclitaxel-cisplatin regimen given during this hospital stay was decreased to 60% of the previous amount, taking into account the patient’s ability to tolerate the treatment.

While the CEA and CA125 markers are within normal limits, the rising CA199 levels may indicate underlying conditions that are yet to be identified and warrant further investigation.

  • 2023-11-14 CA199 1260.46 U/mL
  • 2023-10-17 CA199 1545.37 U/mL
  • 2023-09-06 CA199 633.28 U/mL
  • 2023-08-22 CA199 351.27 U/mL
  • 2023-07-26 CA199 3.92 U/mL
  • 2023-05-02 CA199 3.90 U/mL

2023-10-31

The drugs prescribed by VGHTPE on 2023-10-16 are currently in use, no medication discrepancy is found.

2023-10-03

The drugs rufinamide, lamotrigine, topiramate, lacosamide, perampanel, and clobazam refilled on 2023-09-08 to treat the patient’s “localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus” are currently in use with no discrepancy found.

2023-09-12

No medication discrepancy has been found.

2023-08-04

[reconciliation]

This patient recently refilled a 30-day prescription on 2023-07-24, provided by Taipei Veterans General Hospital, for rufinamide, lamotrigine, topiramate, lacosamide, perampanel, and clobazam to manage her “localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus.” However, these medications are not currently in use. Please verify if there is no longer a need for these drugs.

2023-07-14

[leukopenia]

The organization of WBC level changes is as follows, where * represents WBC < 3K/uL, ** represents WBC < 2K/uL. Leukopenia, which occurred in late May and worsened in mid-June, is more likely the result of the cumulative effects of multiple CCRTs when considering the treatment timeline. After each dose of Granocyte (lenograstim 250ug) administered on 2023-06-29 and 2023-07-01, leukopenia is currently no longer present.

2023-07-13 WBC 5.96 x10^3/uL 2023-07-06 WBC 4.03 x10^3/uL
2023-06-29 WBC 1.64 x10^3/uL ** Granocyte (lenograstim 250ug) 06/29, 07/01 2023-06-15 WBC 1.59 x10^3/uL ** concurrent CDDP 06/08 2023-06-07 WBC 2.05 x10^3/uL * concurrent CDDP 06/01 2023-05-31 WBC 2.02 x10^3/uL *
2023-05-24 WBC 2.22 x10^3/uL * concurrent CDDP 05/18, 05/25 2023-05-17 WBC 3.21 x10^3/uL concurrent CDDP 05/11 2023-05-10 WBC 3.47 x10^3/uL concurrent CDDP 05/04 2023-05-02 WBC 5.00 x10^3/uL
2023-03-30 WBC 10.44 x10^3/uL
2023-03-28 WBC 3.01 x10^3/uL
2023-03-08 WBC 3.31 x10^3/uL
2021-07-12 WBC 3.97 x10^3/uL

[paclitaxel administered, leukopenia needs to be monitored in the coming weeks]

  • It is worth noting for the future that the paclitaxel, which we started administering today on 2023-07-14, is also expected to cause bone marrow suppression. Among these, neutropenia is the main dose-limiting hematologic toxicity of paclitaxel. Severe, grade 4 neutropenia and febrile neutropenia have been reported. Neutrophil nadir is generally rapidly reversible. The onset is intermediate, with neutrophil nadir typically occurring at a median of 11 days. Risk factors include higher doses, longer duration of infusion, and extent of prior cytotoxic chemotherapy.
  • In addition to paclitaxel, cisplatin is also being used simultaneously. The latter causes leukopenia (25% to 30%; nadir: Day 18 to 23; recovery: By day 39; dose-related).
  • Therefore, it is suggested to closely monitor the patient over the next few weeks.

700648329

231124

[lab data]

2023-08-04 Anti-HBc Reactive
2023-08-04 Anti-HBc-Value 7.10 S/CO
2023-08-04 Anti-HBs 205.76 mIU/mL
2023-08-04 HBsAg Nonreactive
2023-08-04 HBsAg (Value) 0.27 S/CO
2023-08-04 Anti-HCV Nonreactive
2023-08-04 Anti-HCV Value 0.10 S/CO

[exam findings]

  • 2023-08-25 Venous Ultrasound
    • Report: Thrombus None
      • Right side:
        • SVC: 3.3 mmHg ; 3.9 mmHg ;
        • MVO/SVC: 100 % ; 100 % ;
        • Average MVO/SVC: 100 %
      • Left side:
        • SVC: 11.0 mmHg ; 11.4 mmHg ;
        • MVO/SVC: 78 % ; 82 % ;
        • Average MVO/SVC: 80 %
    • Conclusion:
      • No evidence of deep vein thrombosis at bilateral lower limbs (by color flow filling, direct compression, and distal augmentation response)
      • Right lower limb soft tissue edema; mild right long saphenous vein engorgement
  • 2023-08-23 ECG
    • Normal sinus rhythm
    • T wave abnormality, consider anterior ischemia
    • Prolonged QT
    • Abnormal ECG
  • 2023-08-21 Peripheral Vascular Test - Artery. lower limbs
    • Atherosclerosis: Minimal
    • Doppler : Normal
    • Conclusions:
      • Patent bilateral CFA, SFA, PFA and popliteal arteries.
        • Mild atherosclerosis with mild stenosis at bilateral PTAs, ATAs and DPAs.
      • Tissue edema at right leg.
  • 2023-08-18 Cell block
    • 50 cc brown turbid pleural effusion — Positive for malignancy
    • The smears and cell block show lymphocytes, reactive mesothelial cells and some atypical epithelial cells which immunocytochemistry shows GATA-3(+), TTF-1(-), and P40(-). According to clinical information and cytomorphologic findings, it is compatible with metastatic breast carcinoma.
  • 2023-08-17 CXR (erect)
    • Bilateral pleural effusion.
    • Multiple nodules at bil. lungs.
  • 2023-08-12, -08-11 CXR (erect)
    • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-08-11 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade B with ulcer, suspect Mallory-Weiss syndrome, s/p biopsy
      • Superficial gastritis
      • Gastric polyps, body
    • Suggestion:
      • pursue pathology
      • PPI and sucralfate therapy
  • 2023-08-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (77 - 39) / 77 = 49.35%
      • M-mode (Teichholz) = 70
    • Conclusion
      • Adequate LV systolic function with normal resting wall motion
      • Septal hypertrophy
      • Trivial MR and trivial TR
      • Preserved RV systolic function
  • 2023-08-08 Tc-99m MDP bone scan
    • Increased activity in the lower T-spines and L3-4 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in biateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2023-08-07 PET
    • Increased FDG uptake in the left breast, compatible with the primary breast cancer.
    • Increased FDG uptake in the left mid- and high-axillary lymph nodes, highly suspected breast cancer with regional lymph nodes metastases.
    • Increased FDG uptake in multiple lobes of bilateral lungs and in both lobes of the liver, highly suspected cancer with distant metastases.
    • Left breast cancer, cTxN3aM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-08-04 Patho - breast biopsy
    • DIAGNOSIS: Breast, left, biopsy — ductal carcinoma in situ, intermediate-grade
    • Microscopically, section shows intermediate-grade ductal carcinoma in situ characterized by a proliferation of atypical ductal epithelial cells with central necrosis of comedo-type. The tumor cells exhibit round to oval nuclei, nuclear pleomorphism, hyperchromasia and increased N/C ratio.
    • Immunohistochemical stain reveals
      • ER: negative
      • PR: negative
      • Her2/neu: positive(3+)
      • CK5/6: negative
      • p63: positive for myoepithelium.
  • 2023-08-04 SONO - breast
    • Left breast malignancy with axillary lymph nodes metastasis.
    • BI-RADS: Category 5: highly suggestive of malignancy-appropriate action should be taken.
  • 2023-08-03 CXR
    • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-06-20 CT - abdomen
    • History and indication: abdominal pain
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Left breast tumor (5.4cm).
      • Multiple lung and liver tumors.
      • Right renal stone (3mm).
    • IMP:
      • Left breast cancer with lung and liver metastases.

[MedRec]

  • 2023-09-28 SOAP Hemato-Oncology Xia HeXiong
    • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-08-11
      • Use TCHP first, and then add R/T if needed based on the effectiveness.
  • 2023-08-03 ~ 2023-09-18 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Left breast ductal carcinoma in situ, intermediate-grade with left mid- and high-axillary lymph nodes, bilateral lungs and in both lobes of the liver, cTxN3aM1, stage IV, ER(-), PR(-), Her/neu(3+)
      • Malignant neoplasm of unspecified site of unspecified female breast
      • Intraductal carcinoma in situ of left breast
      • Abnormal results of liver function studies
      • Chronic viral hepatitis B without delta-agent, Anti-HBc (+)
      • Anemia, unspecified
      • Fever, unspecified
      • Agranulocytosis secondary to cancer chemotherapy
      • Abnormality of albumin
      • Hypokalemia
      • Hypomagnesemia
    • CC
      • breast ca is considered, admission for biopsy of left side breast
    • Present illness
      • The 57 years-old woman deny any past medical history. Initial symptoms with left side breast mass redness and swelling was found since 2018, no treatment. Since 2021, she return to taiwan received Chinese medicine treatment until now, but progression in 2023/04.
      • She visted to LMD, free echo showed much tumor in abdominal then referral to our ER. She suffered from shortness of breathing off and on, bilateral low leg edema and poor appetite for least two months. body weight loss 14 kg more than a year. Denied TOCC history in recent three months.
      • Accroding to the abdominal CT image on 2023/06/20, report showed Left breast cancer with lung and liver metastases.
      • This time, she was admitted, the PE showed left side breast mass, bilateral low leg edema 3-4+.
      • Under the impression of Left breast cancer with lung and liver metastases, so she admitted to our ONC ward for biopsy.
    • Course of inpatient treatment
      • After admission, left side breast mass 6x6 cm was found, highly suspected malignancy, 2023/06/20 CT image showed Left breast cancer with lung and liver metastases. Check lab and tumor marker and viral hepatitis. Consult Diagnostic Radiology and arrange breast sono and biopsy of breast on 2023/08/04.
      • Breast sono showed Left breast malignancy with axillary lymph nodes metastasis, biopsy was done, pathology showed Breast, left, biopsy — ductal carcinoma in situ, intermediate-grade, ER:negative, PR:negative, Her/neu:positive(3+), CK5/6:negative, p63:positive for myoepithelium, and sent Major Illness (+).
      • Cancer survey was arranged: PET on 2023/08/07 showed 1. Increased FDG uptake in the left breast, compatible with the primary breast cancer, 2. Increased FDG uptake in the left mid- and high-axillary lymph nodes, highly suspected breast cancer with regional lymph nodes metastases, 3. Increased FDG uptake in multiple lobes of bilateral lungs and in both lobes of the liver, highly suspected cancer with distant metastases, 4. Left breast cancer, cTxN3aM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan;
      • Bone scan on 2023/08/08 showed 1. Increased activity in the lower T-spines and L3-4 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation, 2. Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation, 3. Increased activity in biateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
      • Cardiac echo on 2023/08/09 showed LVEF:70%, 1. Adequate LV systolic function with normal resting wall motion, 2 .Septal hypertrophy, 3. Trivial MR and trivial TR, 4. Preserved RV systolic function. Tramacet 37.5 & 325mg/tab 1# PO QD and 1# PO Q6HPRN for painn control.
      • Malignant fungating wound was noted, no acute bleeding, consult wound care practitioner for woun care, wound CD with Biomycin ointment 40gm/tube and Framycin Gause Dressing 18mg/patch cover.
      • Bao-gan 150mg/cap 1# PO TID was given for Abnormal results of liver function studies.
      • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for AntiHBc (+).
      • Family meeting on 2023/08/09, discussion with patient and daughter ablut disaease condition and treatment plan, and consult CS for Port-A implantation on 2023/08/11.
      • Anemia was noted, blood transfusion to correct with LRBC 2unit for 2days (8/10, 8/11).
      • Collect stool/routine for check showed OB:3+, add ULSTOP F.C 20mg/tab 1# PO BID and arrange PES on 2023/08/11 showed Reflux esophagitis LA Classification grade B with ulcer, suspect Mallory-Weiss syndrome, s/p biopsy, Superficial gastritis, Gastric polyps, body. Then shift to Nexium 40mg/tab 1# PO QDAC. PES sent pathology for survey, report ulcer.
      • Add Plasbumin-20, 20% 10g/50mL/bt 1bot self paid mix lasix 1amp IVD QD *3day for low leg edema and suspect lung edema and bil. leg edema, add Plasbumin-20, 20% 10g/50mL/bt 1bot (self paid) mix lasix 1amp IVD BID.
      • She receive chemotherapy with Docetaxel (35mg/m2) on 2023/08/12, Dorison 1# po BID and Famotidine 1# po BID x3 day for prevention chemotherapy allergy from 2023/08/11~2023/08/13.
      • Shortness of breathing off and on, follow up D-dimer showed high, arrange Doppler for survey on 2023/08/21 showed 1. Patent bilateral CFA, SFA, PFA and popliteal arteries, Mild atherosclerosis with mild stenosis at bilateral PTAs, ATAs and DPAs, 2. Tissue edema at right leg, Venous Duplex was arrange on 2023/08/25 no DVT.
      • Consult hospice care for lymphatic massage for low leg edema relief on 2023/08/25.
      • Arranged chest echo for chest tapping on 2023/08/15, hepatomegaly was noted; minimal amount pleural effusion; thoracocentesis was not performed due to high risk of complications. Left thorax: no pleural effusion.
      • Progression shortness of breathing, arranged chest echo for chest tapping again on 2023/08/18 showed right side minimal amount of pleural effusion, 600cc serosangious fluid was aspirated for analysis.
      • Fever was noted, CRP: 9.9 mg/dL, Cravit 250mg/50mL/bot 750mg IVD QD from 2023/08/16~2023/08/20.
      • After chemotherapy with Docetaxel (35mg/m2) on 2023/08/12, Neutropenia was noted on 2023/08/21, Granocyte 250mcg/vial 250 mcg SC QD was given from 2023/08/21~2023/08/23 and Tapimycin 4.5g/vial 4.5 gm IVD Q6H from 2023/08/21~2023/08/24, due to Blood culture showed no growth and no fever, stop use.
      • Family meeting on 2023/08/19, discussion with patient and daughter about disaease condition and treatment plan again.
      • No infection status, she received chemotherapy with Liposome Doxorubicin (20mg/m2) + Cyclophosphamide (300mg/m2) on 2023/08/28(C1), received 2nd chemotherapy on 2023/09/11 (C2).
      • Fever was noted, empirical antibiotic with Tapimycin 4.5g/vial 4.5g IVD Q6H for infection control from 2023/09/01~2023/09/08, due to Blood culture showed no growth and no fever, stop use.
      • Acetal 500 mg/tab 1# PO Q6H for suspect tumor fever. Left eye redness and itch was noted, diagnosis was Allergic conjunctivitis, os. Emedastine 1gtt BID os, Inform red flags, come back earlier if s/s worsen and OPD f/u. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2023/09/18 and OPD followed up later.  
    • Discharge prescription
      • BaoGan (silymarin 150mg) 1# TID
      • Baraclude (entecavir 0.5mg) 1# HS
      • Cough Mixture (platycodon) 5mL TID
      • MgO 250mg 1# TID
      • Nexium (esomeprazole 40mg) 1# QODAC
      • Spironolactone 25mg) 1# BID
      • Through (senosside 12mg) 1# HS hold if diarrhea
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# QD
      • Transamin (tanexamic acid 250mg) 1# PRNQD SKIN for wound bleeding
      • Biomycin Ointment (neomycin, tyrothricin) 1# QD TOPI
      • Framycin Gause Dressing (fradiomycin 18mg/patch) 1# PRNQD EXT for wound care use
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ12H if VAS > 3
  • 2023-08-02 SOAP Hemato-Oncology Xia HeXiong
    • P: Arrange admission for biops. Consult GS for breast biopsy or sono-guided biopsy and lab.
  • 2023-06-23 SOAP Hemato-Oncology He JingLiang
    • S
      • multiple liver and lung mets
      • ca of breast is considered
      • suggest breast biopsy

[chemotherapy]

  • 2023-11-07 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 400mg/m2 600mg NS 500mL 1hr (AC(Lipo))
    • dexamethasone 4mg + granisetron 3mg + NS 250mL
  • 2023-10-18 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 400mg/m2 600mg NS 500mL 1hr (AC(Lipo))
    • dexamethasone 4mg + granisetron 3mg + NS 250mL
  • 2023-10-04 - liposome doxorubicin 20mg/m2 20mg D5W 250mL 2hr + cyclophosphamide 300mg/m2 500mg NS 500mL 1hr (AC(Lipo))
    • dexamethasone 4mg + granisetron 3mg + NS 250mL
  • 2023-09-11 - liposome doxorubicin 20mg/m2 20mg D5W 250mL 2hr + cyclophosphamide 300mg/m2 500mg NS 500mL 1hr (AC(Lipo))
    • dexamethasone 4mg + granisetron 3mg + NS 250mL
  • 2023-08-28 - liposome doxorubicin 20mg/m2 20mg D5W 250mL 2hr + cyclophosphamide 300mg/m2 500mg NS 500mL 1hr (AC(Lipo))
    • dexamethasone 4mg + granisetron 3mg + NS 250mL
  • 2023-08-12 - docetaxel 35mg/m2 60mg NS 250mL 1hr (DHP(SC/loading))
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL

==========

2023-11-24

[abnormal liver function test results point to possible liver damage]

Laboratory findings indicate elevated liver function test (LFT) values, suggesting possible liver damage.

  • 2023-11-23 AST 79 U/L
  • 2023-11-23 ALT 48 U/L
  • 2023-11-23 Bilirubin total 1.08 mg/dL
  • 2023-11-23 Bilirubin direct 0.39 mg/dL
  • 2023-11-23 DBI/TBI 36.11 %

The patient has been receiving Baraclude (entecavir) and BaoGan (silymarin), and is prescribed Nexium (esomeprazole 40mg), taken as 1# QOD, no medication problem identified.

[dosing adjustments in hepatic impairment: guidelines for AC(Lipo) components]

The AC(Lipo) regimen being administered to this patient includes pegylated liposomal doxorubicin and cyclophosphamide.

  • Liposomal Doxorubicin Dosing for Hepatic Impairment (Adults):
    • General Note: No specific dosage adjustments in the U.S. manufacturer’s labeling. However, reduction is advised for serum bilirubin >= 1.2 mg/dL.
    • Dosage Adjustments:
      • Krens 2019 Recommendations:
        • Bilirubin >1.2 to <3 mg/dL: Reduce to 75% of original dose.
        • Bilirubin 3 to 5 mg/dL: Reduce to 50% of original dose.
        • Bilirubin >5 mg/dL: Not recommended.
      • Canadian Labeling (Caelyx) Recommendations:
        • Bilirubin 1.2 to 3 mg/dL:
          • Breast/Ovarian Cancer: Start with 75% of normal dose; may increase to full dose in cycle 2 if tolerated.
          • AIDS-related Kaposi Sarcoma: Start with 50% of normal dose.
        • Bilirubin >3 mg/dL:
          • Breast/Ovarian Cancer: Start with 50% of normal dose; may increase to 75% in cycle 2, then to full dose in subsequent cycles if tolerated.
          • AIDS-related Kaposi Sarcoma: Start with 25% of normal dose.
  • Cyclophosphamide Dosing for Hepatic Impairment (Adults):
    • General Note: No specific dosage adjustments in the manufacturer’s labeling. Efficacy may be reduced in severe hepatic impairment.
    • Dosage Adjustments:
      • Floyd 2006 Recommendations:
        • Serum bilirubin 3.1 to 5 mg/dL or transaminases >3 times ULN: Administer 75% of dose.
        • Serum bilirubin >5 mg/dL: Avoid use.
      • Krens 2019 Recommendations:
        • Mild/Moderate Impairment: Likely no adjustment needed.
        • Severe Impairment: Not recommended due to reduced efficacy risk.

2023-11-07

Medication not found to be mismatched.

2023-10-05

No discrepancy in the medication is found.

The AST to ALT ratio has been greater than 1 since the earliest available data from 2023-08-03. Please exclude the possibility of alcohol abuse in this patient. In addition, the subsequent initiation of cyclophosphamide from 2023-08-28 may also lead to hepatotoxicity.

2023-08-30

[leukopenia]

A single dose of docetaxel (35mg/m2) was administered on 2023-08-12 before an episode of leukopenia was observed on 2023-08-21. Following a single injection of Granocyte (lenograstim 250ug), no further episodes of leukopenia have been observed to date.

2023-08-28 WBC 15.29 x10^3/uL
2023-08-23 WBC 19.11 x10^3/uL
2023-08-21 WBC 1.84 x10^3/uL 2023-08-16 WBC 6.88 x10^3/uL
2023-08-14 WBC 12.40 x10^3/uL
2023-08-12 WBC 7.95 x10^3/uL
2023-08-10 WBC 10.92 x10^3/uL
2023-08-03 WBC 9.67 x10^3/uL
2023-06-19 WBC 11.37 x10^3/uL
2023-08-28 Neutrophil 82.5 %
2023-08-25 Neutrophil 77.4 %
2023-08-23 Neutrophil 55.7 %
2023-08-21 Neutrophil 7.6 %
2023-08-16 Neutrophil 77.2 %
2023-08-14 Neutrophil 94.2 %
2023-08-10 Neutrophil 68.9 %
2023-08-03 Neutrophil 74.5 %
2023-06-19 Neutrophil 76.0 %

[monitor cardiac function going forward]

While 2D transthoracic echocardiography on 2023-08-09 showed preserved right ventricular systolic function, ECG on 2023-08-23 showed T-wave abnormalities consistent with anterior ischemia and prolonged QT interval. Since anthracyclines such as doxorubicin may prolong the QT interval, it would be prudent to monitor the condition after administration of (liposomal) doxorubicin (on 2023-08-28).

2023-08-09

2023-08-04 breast biopsy pathology IHC revealed: ER (-), PR (-), Her2/neu (3+), CK5/6 (-), p63 (+ for myoepithelium).

NHI coverage for pertuzumab is applicable under the following conditions: 1. Pertuzumab, in combination with trastuzumab and docetaxel, is used to treat patients with HER2-positive (IHC3+ or FISH+) metastatic breast cancer who have not previously received treatment with anti-HER2 therapy or chemotherapy for metastasis. 2. Prior approval is required for usage, and after approval, efficacy assessment data must be provided every 18 weeks for re-application. If the disease worsens, re-application should not be pursued. The maximum coverage duration for each patient is limited to 18 months.

If doxorubicin is intended for use, it is advisable to conduct a pre-treatment 2D transthoracic echocardiography to establish the baseline heart function.

701502017

231124

[MedRec]

  • 2023-10-19 SOAP Hemato-Oncology Xia HeXiong
    • S
      • Hx of breast cancer, ER 1% (weak) PR (-), Her-2 1+, Ki67 78%
        • Neoadjuvant TC x 4 followed by EC x 4 -> SD
        • R/T to primary
        • maintain with xeloda x 6 months
        • Follow up
      • Now recurrence over brain, lung, liver, bone, completed with lower limbs weakness
    • O
      • Anti-HCV (-), AntiHBs (+), AntiHBs (-), AntiHBc (-)
      • 2023-10-19: BP:105/76; HR:91;
      • 2023-10-09 CT of abeomen
        • Multiple liver mets
        • R/O bilateral renal mets
        • R/O bone mets with pathological fracture at L2 vertebra
      • 2023-10-09 CT of chest
        • Compatible with right breast cancer, smaller
        • Multiple metastases at bilateral lungs and left pleura
      • 2023-10-09 CT of Brain
        • Multiple metastases at brain and left cerebellum
        • A prominent right partoid LN
    • A/P
      • Suggest Enhertu
      • Suggest R/T to brain and bone and Arrange Port-A insertion

[consultation]

  • 2023-10-20 Radiation Oncology
    • Q
      • This 45-year-old woman had past history of Right breast cancer, ER (1%, weak), PR (-), Her-2 (1+), status post
        • Neoadjuvant chemotherapy with TC (Docetaxel + Cyclophosphamide) x 4 followed by EC (Epirubicin + Cyclophosphamide) x 4 –> stable disease
        • Partial mastectomy and sentinel lymph node dissection in 2022/6
        • Radiotherapy to primary tumor
        • Maintain with Xeloda (Capecitabine) x 6 months
      • She used to follow up at NTUH.
      • CT on 2023/10/9 showed (1) multiple metastases at brain and left cerebellum (2) multiple metastases at bilateral lungs and left pleura (3) multiple liver metastases, r/o bilateral renal metastases, r/o bone metastases with pathological fracture at L2 vertebra. Oral Dexamethasone was prescribed for brain metastases.
      • She went to our Oncology OPD for help on 2023/10/19. Under the impression of right breast cancer, with recurrence and metastasis over brain, lung, liver, and bone, she was admitted to our ward for further evaluation and management.  
      • We need your expertise for evaluation and management of radiotherapy for brain and bone metastases, thank you!
    • A
      • She is now sufferred from brain swelling sensation and lower back pain. Suggest bone scan and brain MRI (previous MRI at NTUH on 2023/7/29 showed no metastasis).
      • CT-simulation will be arranged on 10/24.
      • Plan to devlier 30 Gy/ 10 fx to the whole brain first, around 10/25 or 26.
      • RT for the lower back bone metastatses will wait for bone scan result for better treatment field design.
      • Thank you very much.

[MultiTeam]

  • 2023-11-24 Multi-Team Recommendations - Palliative Care
    • Referral Date: 2023-11-24
    • Response Content:
      • The co-care nurse and Dr. Xia from the family medicine department visited together.
      • Outside the ward, they explained the concept of palliative care to the patient’s husband, who expressed a wish for home-based palliative care (residing in XinZhuang).
      • The co-care nurse explained that the patient, being conscious, needs to fill out an advance directive for palliative care.
      • During the visit, the patient was observed with closed eyes and a furrowed brow, using nasal cannula, and breathing with slight difficulty.
      • The patient reported headaches, coughing, pain from a bedsore on the buttocks, and aching in the hips and legs.
      • The main complaint was a desire to go home and “die at home,” expressing a wish not to be resuscitated and to be comfortable without suffering.
      • The advance directive for palliative care was completed.
      • The co-care nurse suggested preparing an oxygen concentrator and an electric bed at home, and to return home once pain management is under control.
      • The co-care nurse will assist in inquiring about local home-based palliative care resources and will provide the information to the family next Monday.
      • The co-care nurse’s contact number was left for further inquiries about palliative care.
    • Conclusion and Recommendations: Joint Palliative Care
    • Responder: Chen Hui
    • Response Date: 2023-11-24 18:20
  • 2023-11-01 Multidisciplinary Team Recommendations - Psycho-Oncology
    • Referral Date: 2023-10-19
    • Reason for Referral: Other: Cancer Inpatient Brief Health Scale Score >= 10 points
    • Conclusion:
        • On 10/20, the patient was visited with her husband present. She was holding her forehead, indicating a headache. Pain medication had been prescribed, but she was still unaware of the treatment plan.
        • On 10/26, during another visit when a friend was visiting and her husband was working outside the ward, she mentioned her headache had lessened. She expressed that her husband was having a hard time as he was taking care of everything. As a couple, they wanted to know how the treatment would proceed. She advised ’not to think, but to be optimistic (tears fell), and wondered what to do with negative thoughts.
        • She had difficulty reading due to loss of vision in her left eye. Her friend mentioned reading three pages a day and recording it to send to her, which made her smile and said she would assign this task to her husband too.
        1. Breast cancer diagnosis in October 110, post-CCRT surgery in June 111, brain metastasis in July 112, and bone, liver, and lung metastases in October. She was admitted to our hospital on 10/19 seeking a second opinion, with a BSRS score of 12 points (moderate).
        1. Focused on caring for the patient’s emotional adjustment, encouraging self-dialogue methods as suggested in the book “The Healing Power Within.”
      • (AP) The patient’s family is inclined towards active cooperation with the current possible treatment methods. The team is requested to continue assisting with symptom relief, discussing the treatment plan, and being mindful of the timing for palliative co-care.
    • Counseling Psychologist Huang XiaoFang
    • Responder: Huang XiaoFang
    • Response Date: 2023-10-27 17:50
  • 2023-10-23 Multidisciplinary Team Recommendations - Social Services
    • Referral Date: 2023-10-19
    • Reason for Referral: Other: Inpatient Brief Health Scale Score >= 10 points
    • Case Status: No case opened
    • Reason for Not Opening Case: Consultation with the patient and her husband on 2023-10-20
    • Family Situation:
      • The patient is 45 years old and married. Her husband accompanied her during the hospital stay.
    • Assessment and Treatment:
      • During the ward visit, the patient appeared somewhat indifferent, only mentioning that she had slept better the previous night, without elaborating further. Her husband also noted that she had slept better the previous night and during the conversation, it was understood that the patient did not use sleeping pills. It was mainly the relief of pain and other discomforts that improved her sleep. The patient and her husband were informed that if they need to talk to a social worker in the future, they can proactively notify the team, and they were receptive to this.
      • This consultation assessed that the patient’s family support is adequate, with no emerging issues at present. If there is a need for social worker assistance in the future, a referral can be made again. Thank you.
    • Responder: Luo Yuquan”
    • Response Date: 2023-10-20

[immunochemotherapy]

  • 2023-11-20 - trastuzumab deruxtecan 5.4mg/m2 100mg D5W 100mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-11-24

Enhertu (trastuzumab deruxtecan) dosing

  • Kidney Impairment
    • CrCl >=30 mL/minute: No dosage adjustment necessary. Monitor more frequently for interstitial lung disease in patients with moderate impairment.
    • CrCl <30 mL/minute: There are no dosage adjustments provided in the manufacturer’s labeling (a recommended dose has not been established).
  • Hepatic Impairment
    • Mild (total bilirubin ≤ ULN and any AST > ULN or total bilirubin >1 to 1.5 times ULN and any AST) or moderate (total bilirubin >1.5 to 3 times ULN and any AST) impairment: No dosage adjustment necessary. Monitor closely for toxicities in patients with moderate impairment.
    • Severe impairment (total bilirubin >3 to 10 times ULN and any AST): There are no dosage adjustments provided in the manufacturer’s labeling (a recommended dose has not been established).

Lab data

  • 2023-11-23 AST 136 U/L
  • 2023-11-23 Bilirubin total 0.64 mg/dL
  • 2023-11-23 Creatinine 0.23 mg/dL
  • 2023-11-23 eGFR 347.44 ml/min/1.73m^2

Although the suggested dosage of the medication is 5.4mg/m2, the dose actually given was only around 40% of this recommendation. This significant reduction in dosage may lead to less than optimal treatment outcomes. (Enhertu is currently not covered by the NHI).

Please monitor for and promptly investigate signs and symptoms including cough, dyspnea, fever, and other new or worsening respiratory symptoms. Permanently discontinue fam-trastuzumab deruxtecan in all patients with >= grade 2 ILD/pneumonitis. Advise the patient of the risk and the need to immediately report symptoms.

701279426

231123

[exam findings]

  • 2023-09-27 CT - abdomen
    • History
      • 20210428 CT: rectal cancer, T3N0M1a, STAGE: IVA
      • 20211124 S/P LAR: Adenocarcinoma of rectum with liver metastasis, ypT2N1M1a, ypStage IVA
    • FINDINGS: Comparison: prior CT dated 2023/06/27.
      • Prior CT identified multiple metastases on both hepatic lobes are noted again, increasing in size that are c/w multiple liver metastases S/P C/T with progressive disease.
      • There is soft tissue nodule 8 mm at RLL of the lung that is c/w lung metastasis.
      • S/P LAR with autosuture retention over the rectum.
      • There are several hepatic cysts in both lobes and the largest one is measured about 4.1cm in size at S6.
      • In addition, there are several soft tissue masses in the uterus that are compatible with myomas.
    • Impression:
      • Multiple liver metastases S/P C/T show progressive disease.
      • Lung metastasis 8 mm at RLL is noted.
      • Follow up CT of the abdomen (include lung) 3 months later is indicated.
  • 2023-06-27 CT - abdomen
    • History and indication:
      • Adenocarcinoma of rectum with liver metastasis, ypT2N1M1a, ypStage IVA status post closure of loop ileostomy on 2021/11/24, liver metastasis in progression on 2023/03/04
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Rectal cancer s/p operation.
      • Progression of liver metastases.
      • A nodule (4mm) at RLL.
      • Some osteolytic lesions in spine r/o metastases.
      • Enlargement of uterus with nodules r/o myomas.
      • Atherosclerosis of aorta, iliac arteries.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Rectal cancer s/p operation.
      • Progression of liver metastases.
      • A nodule (4mm) at RLL.
  • 2023-03-04 CT - abdomen
    • With and without contrast enhancement CT of abdomen shows:
      • Colon cancer, s/p operation.
      • Progression of liver metastasis.
      • Presence of uterine myomas.
    • Impression
      • Colon cancer, s/p operation
      • Multiple liver metastasis, in progression
  • 2022-11-28 CT - abdomen
    • Indication
      • Malignant neoplasm of rectum
      • Secondary malignant neoplasm of liver and intrahepatic bile duct
    • Abdominal and Chest CT with and without IV contrast ehnancement shows:
      • S/p port-A placement with its tip at left brachiocephalic vein.
      • s/p LAR.
      • Low density lesions are found at both lobes of liver up to 4.38cm in largest dimension. Liver meta is considered. In comparison with CT dated on 2022-08-02, the lesions are stationary.
    • Imp:
      • Colon cancer s/p LAR.
      • Diffuse liver meta. stationary.
  • 2022-08-02 CT - abdomen
    • Clinical history: 57 y/o female patient with Rectal cancer, T3NoM1a status post laparoscopic low anterior resection, ileostomy on 2021/09/01.
    • With and without contrast enhancement CT of abdomen–whole:
      • Post-op at the colon.
      • There are multiple liver tumors in both lobes of liver, could be due to liver metastasis, stationary.
      • There are uterine tumors, could be due to uterine myomas.
      • Right anterior chest wall tumor, 1.2cm, stationary.
    • Impression:
      • Psot-op at the colon.
      • Liver tumors, r/o metastasis, stationary.
      • Right anterior chest wall tumor, 1.2cm, stationary.
      • Uterine tumors, r/o myomas.
  • 2022-04-16 CT - abdomen
    • History and indication: 56 y/o female, a pt of rectal CA wt liver mets
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Rectal cancer s/p operation.
      • Stable condition of liver metastases.
      • Some osteolytic lesions in spine r/o metastases.
      • Enlargement of uterus with nodules r/o myomas.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • Rectal cancer s/p operation with adjacent fatstranding.
      • Stable condition of liver and spine metastases.
  • 2021-11-04 Tc-99m MDP bone scan
    • Mildly increased activity in the lower L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, elbows, hips and knees, compatible with benign joint lesions.
  • 2021-10-28 CT - abdomen
    • History and indication: 56 y/o female, a pt of rectal CA wt liver mets
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Rectal cancer s/p operation with adjacent fatstranding.
      • Stable condition of liver metastases.
      • Some osteolytic lesions in spine r/o metastases.
      • Enlargement of uterus with nodules r/o myomas.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • Rectal cancer s/p operation with adjacent fatstranding.
      • Stable condition of liver metastases.
      • Some osteolytic lesions in spine r/o metastases.
  • 2021-09-02 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Large intestine, rectum, laparoscopic low anterior resection —- Adenocarcinoma, moderately differentiated, s/p chemotherapy
      • Ovary, right, oophorectomy —- Consistent with endometrioma
      • Ovary, left, oophorectomy —- Negative for malignancy
      • Fallopian tube, bilateral, salpingectomy —- Negative for malignancy
      • Uterus, myometrium, myomectomy —- Leiomyoma
      • Resection margins: free
      • Lymph node, mesocolic, dissection —- Negative for malignancy (0/14) —- A tumor deposit is found
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: ypStage IVA, ypT2N1c(if cM1a)
    • MACROSCOPIC EXAMINATION
      • Operation procedure: laparoscopic low anterior resection, bilateral salpingo-oophorectomy, myomectomy
      • Specimen site: rectum
      • Specimen size: Rectum: 9.5 cm in length; right ovary:5.8 x 4.3 x 2.6 cm; right fallopian tube: 4.8 cm in length and 0.4 cm in diameter; left ovary: 2.7 x 2.0 x 1.0 cm; left fallopian tube: 5.5 cm in length and 0.4 cm in diameter; myoma: 2.8 x 2.8 x 2.0cm
      • Tumor size: 1.6 x 1.4 cm
      • Tumor location: 6.5 cm and 0.9 cm away from the two resection margins, respectively
      • Depth of invasion grossly: muscularis propria
      • Mucosa elsewhere: congestion
      • The right ovary is cystic and containing chocholate material.
      • The left ovary and bilateral fallopian tubes are unremarkable. The cut surfaces of the leiomyoma show whorls of bundles without hemorrhage, or necrosis.
      • Representative sections are taken and labeled as: A1-4: tumor; A5:colon, non-tumor; A6: circumferential resection margin; A7-12: lymph nodes, mesocolic; B: proximal resection margin; C: distal resection margin; D1: right fallopian tube; D2-4: right ovary; E1: left fallopian tube; E2: left ovary; F: myoma.
    • MICROSCOPIC EXAMINATION
      • Histology: adenocarcinoma
      • Histology Grade: moderately differentiated
      • Depth of invasion: muscularis propria
      • Angiolymphatic invasion: Present.
      • Perineural invasion: Present.
      • Discontinuous extramural tumor extension: Not identified.
      • Circumferential (radial) margin of rectum: Uninvolved, 15 mm from the margin,
      • Lymph node metastasis, mesocolic:0/14
      • Lymph node metastasis, IMA / SMA: not received
      • Extranodal involvement: Not identified.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): pT2: Tumor invades the muscularis propria
        • Regional Lymph Nodes (pN): pN1c: No regional lymph nodes are positive, but there are tumor deposits in the subserosa, mesentery, or nonperitonealized pericolic, or perirectal/mesorectal tissues.
        • Distant Metastasis (pM): if cM1a
      • Type of polyp in which invasive carcinoma arose: Tubulovillous adenoma.
      • Additional pathologic findings:
        • S2021-07002: ADDENDUM: IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
        • A tumor deposit is found in mesorectal tissues.
        • Tumor Budding: Low score (0-4)
        • The right cystic ovarian tissue reveals aggregation of hemosiderin ladened histiocytes. No resiual epithelium is seen. The morphology is consistent with a endometrioma.
        • The left ovary and bilateral fallopian tubes are unremarkable and free of malignancy.
        • The leiomyoma reveals whorls of bland smooth muscle bundles without hypercellularity, nuclear atypia or mitosis.
      • TNM descriptors: y (Post-treatment).
      • Tumor regression grading S/P CCRT: Modified Ryan scheme for tumor regression score: 2, Residual cancer with evident tumor regression, but more than single cells or rare small groups of cancer cells (partial response).
  • 2021-07-27 CT - abdomen
    • Indication: Colon cancer, S/P neoadjuvant C/T
    • Abdominal CT with and without enhancement revealed:
      • Several low density lesions (n>10) are found at both lobes of liver up to 1.93cm in largest dimension. Liver meta is considered. In comparison with CT dated on 2021-04-28, these lesions decreased in size.
      • Increased intestinal gas is found.
      • Swelling of the rectum is found up to 2.01cm in largest dimension. In regression.
      • Several uterine myomas are found.
      • Right ovarian cyst up to 5.3cm in largest dimension.
    • Imp:
      • Rectal cancer with liver meta. The primary tumor and metastatic lesions regressed.
  • 2021-05-11 PET
    • Prominent glucose hypermetabolism in the rectum, compatible with primary malignancy of the rectum.
    • Multiple glucose hypermetabolic lesions in both lobes of the liver. Multiple liver metastases may show this picture. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in both lobes of the thyroid gland. The nature is to be determied (thyroiditis? hyperthyroidism?). Please also correlate with other clinical findings for further evaluation.
  • 2021-05-10 CT - chest
    • Indication: stage W/U to exclude lung mets.
    • Impression:
      • no evidence of lung metastasis.
      • hepatic metastatic tumors and simple cysts.
  • 2021-05-04 Patho - colorectal polyp
    • Rectal cancer s/p biopsy — Adenocarcinoma.
    • Section shows piece(s) of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2 (+), MLH1 (+).

[MedRec]

  • 2021-05-21 ~ 2021-05-23 POMR Hemato-Oncology Zhang ShouYi
    • Discharge diagnosis
      • Malignant neoplasm of rectum
      • Rectum cancer with liver metastasis
    • CC
      • for #1 chemotherapy with FOLFIRI
    • Present illness
      • This 56-year-old female, a pt of rectal cancer with liver mets Dx in May 2021, suffered from initial presentation of abnormal vaginal bleeding in April 2021 & bloody stool passage weeks later. She came to our Pro Huang SiCheng arranged abd CT & colonscopy in May 2021.
      • Surgical pathology with rectal cancer s/p biopsy (5/4 21) proved adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1(+). Stomach, fundus, s/p biopsy (5/4 21): Hyperplastic polyp.
      • Image study with abd CT (4/28 21) showed a cystic lesion, 5 x 4.7 cm in R adnexa, R/I endometrioma or cystic tumor. several soft tissue masses in the uterus that are compatible with myomas. Several poor enhancing lesions on both hepatic lobes, R/I mets. D/D: cysts with old hemorrhage or atypical hemangioma? The largest one (2.6 cm) in S6. several hepatic cysts in both lobes, the largest one (2.9 cm) in size at S6. soft tissue mass-like lesion or fecoloma 2.8 cm in the rectum. Imp: T3N0M1a stage IVA.
      • She came to referred to our hemato-oncologic clinic on 5/8 21 for pre-Op neoadjuvant C/T by Dr Xiao GuangHong due to rectal cancer with suspected liver mets.
      • Dr Xiao GuangHong suggested to do pre-Op neoadjuvant C/T first then wlll do abd CT then Op.
      • HBsAg, anti-HBc, anti-HCV (5/11 21) showed negative.
      • K-RAS / N-RAS mutation test was done and report was pending.
      • Port-A was inserted on 5/12 21.
      • XRT started since 5/20 21 by Dr Huang JingMin for rectal tumor.
      • We explain to pt & her sister about the indication & risk / benefit of pre-Op neoadjuvant C/T wt FOLFIRI / Avastin IV Q2W x 4~6 then do abd CT & Op.
      • The chest CT (5/10 21) showd no evidence of lung metastasis; hepatic metastatic tumors and simple cysts.
      • The PET scan (5/12 21) revealed Prominent glucose hypermetabolism in the rectum, compatible with primary malignancy of the rectum. Multiple glucose hypermetabolic lesions in both lobes of the liver. Multiple liver metastases may show this picture. Please correlate with other clinical findings for further evaluation. Mild glucose hypermetabolism in both lobes of the thyroid gland. The nature is to be determied (thyroiditis? hyperthyroidism?).
      • Today. she was admitted for #1 palliative chemotherapy with FOLFIRI on 5/21 21.
    • Course of inpatient treatment
      • After admission, chemotherapy with Campto (160mg/m2) plus Leucovorin (400mg/m2) and 5-FU (2800mg/m2) were given on 5/21-5/23 21, smoothly without obvious side effect. She was discharged on 5/23 21 under stable condition and will follow-up at OPD.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • loperamide 2mg 1# PRNQ6H if watery diarrhea > 3 times
  • 2021-05-11 SOAP Radiation Oncology Huang JingMin
    • S:
      • For radiotherapy due to rectal cancer.
      • PI: The patient is a case of rectal CA with suspectde liver mets Dx in May 2021. She suffered from initial presentation of abnormal vaginal bleeding in April 2021 & bloody stool passage wks later.
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM (-); HTN (-)
      • Previous RT Hx: (-)
    • O:
      • ECOG: 0
      • PE: neck and bil SCF: neg.
      • CT scan of abdomen (2021-04-28): 1. There is a cystic lesion measuring 5 x 4.7 cm in right adnexa without contrast enhancement that may be endometrioma or cystic tumor. Please correlate with CA125. In addition, there are several soft tissue masses in the uterus that are compatible with myomas. 2. There are several poor enhancing lesions on both hepatic lobes that may be metastases. The differential diagnosis include cysts with old hemorrhage or atypical hemangioma? Please correlate with sonography and MRI.
      • The largest one measuring about 2.6 cm in S6 (Srs:4 Img:34). 3. There are several hepatic cysts in both lobes and the largest one is measured about 2.9 cm in size at S6. 4. A soft tissue mass-like lesion or fecoloma 2.8 cm in the rectum. Stage cT3N0M1a.
      • Colonoscopy (2021-05-04):One mass was noted in the rectum 8 cm from AV. Diagnosis: Rectal cancer s/p biopsy
      • Pathology (S2021-07002, 2021-05-05): ADDENDUM: IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+). DIAGNOSIS: Rectal cancer s/p biopsy — Adenocarcinoma. An addendum report of the result of IHC stains of EGFR, PMS2, MSH6, MSH2, and MLH1 will be followed.
      • CT cscan of lung (2021-05-10): no evidence of lung metastasis. hepatic metastatic tumors and simple cysts.
      • Lab:
        • 2021/04/27 CA125 = 11.9 U/mL
        • 2021/04/27 CA199 = 188.31 U/mL
        • 2021/04/27 CEA = 13.18 ng/mL
    • A:
      • Adenocarcinoma of the rectum, stage cT3N0M1a, with liver metastases.
    • P:
      • Radiotherapy is indicated for this patient with the following indicators: stage cT3N0M1a.
      • Goal: palliation.
      • Treatment target and volume: pelvic area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed area.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her sister. They understand and agree to receive radiotherapy. The treatment planning of radiotherapy will be started at 11AM, 2021-05-12.
  • 2021-05-08 SOAP Hemato-Oncology Zhang ShouYi
    • S
      • referred to our hemato-oncologic clinic on 5/8 21 for pre-Op neoadjuvant C/T by Dr Xiao GuangHong
        • rectal CA wt suspected liver mets.
      • Dr Xiao GuangHong suggested to do pre-Op neoadjuvant C/T first then wlll do abd CT then Op (5/8 21).
    • P
      • will do HBsAg, anti-HBc, anti-HCV (5/8 21).
      • will do K-RAS / N-RAS mutation test (5/8 21).
      • will consult Dr Chen YanZhi for Port-A installation (5/8 21).
      • will consult Dr Huang JingMin for R/T to rectal tumor.
      • will do PET scan to evaluate liver tumor & pelvic tumor (5/8 21).
      • will do chest CT to exclude lung mets (5/8 21).
      • explain to pt & her sister about the indication & risk / benefit of pre-Op neoadjuvant C/T wt FOLFIRI / Avastin IV Q2W x 4~6 then do abd CT & Op. (5/8 21).
      • will give post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T then post-CCRT adjuvant C/T wt PF ( 2 days ) IV Q2W x 4~6 mo.
      • Adm on 5/6 16 for #1 palliative C/T wt Oxaliplatin + PF ( 2 days ) IV Q2W.
      • RTC 1 wk later on 5/4 20 for CBC & DC, CXR, abd no report.
  • 2021-05-06 SOAP Colerectal Surgery Xiao GuangHong
    • S
      • Rectal cancer
      • Liver metastasis; Ovarian tumor
    • O
      • 2021/05/04 Colonoscopy: Rectal cancer s/p biopsy
        • Pathology: Rectal cancer s/p biopsy — Adenocarcinoma.
          • An addendum report of the result of IHC stains of EGFR, PMS2, MSH6, MSH2, and MLH1 will be followed.
    • P
      • Suggest chemotherapy + target therapy then evaluation of resection
  • 2021-04-29 SOAP Colorectal Surgery Xiao GuangHong
    • S:
      • First visit, ovarian tumor, liver metastasis
    • O:
      • 2021/04/27 CA199 = 188.31
      • 2021/04/27 CEA = 13.18
      • 2021/04/27 HGB = 10.5
      • 2021/04/28 CT: ABD — whole abdomen, pelvis
        • Metastases on both hepatic lobes are suspected.
          • The differential diagnosis include cysts with old hemorrhage or atypical hemangioma? Please correlate with sonography and MRI.
        • Right adnexa lesion, nature?
          • The differential diagnosis include endometrioma or cystic tumor.
          • Please correlate with CA125.
        • A soft tissue mass-like lesion or fecoloma 2.8 cm in the rectum is suspected. Please correlate with physical examination.
    • P:
      • Arrange colonoscopy and inform the risk of complication including bleeding and perforation

[consultation]

  • 2023-03-22 Dermatology
    • Q
      • for skin rash, itchy for 10 days
      • This 57-year-old female, a pt of rectal cancer with liver mets Dx in May 2021, suffered from initial presentation of abnormal vaginal bleeding in April 2021 & bloody stool passage weeks later. She came to our Pro Huang SiCheng arranged abd CT & colonscopy in May 2021.
      • This time, she is admitted for chemotherapy, then she complaints the skin rash, and itchy for 10days when after chemotherapy, so we need your help, thanks a lot!!
    • A
      • The patient had sufferred from reddish papules on the neckalce and grouped pigmented macules over buttock (previous erythematous papules with fine vesicles)
      • Under the impression of intertrigo eczmea over neck, favor post-herpes simplex infection over buttock.
      • The following suggetion:
        • Mycomb cream 1 tube as a good choice for neck lesions.
        • for pigmentation macules over buttock, consider Sinphraderm 1 tube topical QN use over the residual pigmentation lesions of the buttock.
        • enhane body mositurization after body clean to prevent furtehr xerosis skin texture.
  • 2023-03-04 Obstetrics and Gynecology
    • Q
      • This 57-year-old female, a pt of rectal cancer with liver mets Dx in May 2021, suffered from initial presentation of abnormal vaginal bleeding in April 2021 & bloody stool passage weeks later.
      • Surgical pathology with rectal cancer s/p biopsy (5/4 21) proved adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1(+). Stomach, fundus, s/p biopsy (5/4 21): Hyperplastic polyp.
      • Image study with abd CT (4/28 21) showed a cystic lesion, 5 x 4.7 cm in R adnexa, R/I endometrioma or cystic tumor. several soft tissue masses in the uterus that are compatible with myomas.
      • She was admitted for #16 chemotherapy with Avastin (self-paid)/FOLFOX today, however, blood was noted after wiping.     
      • We would like to consult you for your expertise, thank you.
    • A
      • This is a 57-year-old female patient with rectal cancer with liver metastasis in May 2021, s/p CCRT, currently admitted for #16 Avastin (self-paid)/FOLFOX.
        • She received concurrent laparoscopic bilateral salpingo-oophorectomy on 2021-09-01 for right ovarian tumor, and pathology showed right ovarian endometrioma, with left ovary and bilateral tubes all negative for malignancy.
        • According to the patient, she noted blood while wiping after defecation 2 days ago.
      • O
        • G0, sex(-), menopause around 52-53 y/o
        • PV: narrowing atrophic vagina (suspect radiotherpy related), no active bleeding nor blood clots noted.
        • TVS: AVF uterus 66x39mm, endometrium 4.7mm, subserosal and intramural myomas (15x11, 16x13, 15x10), pelvis free of other GYN lesion, no ascites.
      • Imp: bleeding point not favored GYN origin due to thin endometrium (<5mm) and no endometrial lesions (eg, polyp or submucosal myoma) noted
        • Suggest survey other origin of the bleeding
        • Educated the patient to receive pap smear at OPD f/u
      • Contact us if any problems!!
  • 2023-03-03 Colorectal Surgery
    • Q
      • This 57-year-old female, a pt of rectal cancer with liver mets Dx in May 2021, suffered from initial presentation of abnormal vaginal bleeding in April 2021 & bloody stool passage weeks later.
      • Surgical pathology with rectal cancer s/p biopsy (5/4 21) proved adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1(+). Stomach, fundus, s/p biopsy (5/4 21): Hyperplastic polyp.
      • Image study with abd CT (4/28 21) showed a cystic lesion, 5 x 4.7 cm in R adnexa, R/I endometrioma or cystic tumor. several soft tissue masses in the uterus that are compatible with myomas.
      • She was admitted for #16 chemotherapy with Avastin (self-paid)/FOLFOX today, however, blood was noted after wiping.     
      • We would like to consult you for your expertise, thank you.
    • A
      • This is a 57-year old woman with anal bleeding after defecation for 2 days
      • DRE:
        • mild internal hemorrhoids, acute anal fissure over 6 o’clock region
        • yellowish stool
      • A/P:
        • add alcos anal onitment bid and prn topic use
        • add laxative drugs, such as MgO 2# Bid
        • if s/s persisted than sigmoidoscopy should be considered

[radiotherapy]

[chemotherapy]

  • 2023-06-26 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4120mg NS 500mL 46hr (Avastin + FOLFOXIRI; Q2W)

  • 2023-05-18

  • 2023-04-20

  • 2023-03-21

  • 2023-03-03 - (Avastin + FOLFOX; Q2W)

  • 2023-02-01 - (Avastin + FOLFOX; Q2W)

  • 2022-12-23 - (Avastin + FOLFOX; Q2W)

  • 2022-12-02 - (Avastin + FOLFOX; Q2W)

  • 2022-11-15 - (Avastin + FOLFOX; Q2W)

  • 2022-10-20 - (Avastin + FOLFOX; Q2W)

  • 2022-09-16 - (Avastin + FOLFOX; Q2W)

  • 2022-08-18 - (Avastin + FOLFOX; Q2W)

  • 2022-08-01 - (Avastin + FOLFOX; Q2W)

  • 2022-07-08 - (Avastin + FOLFOX; Q2W)

  • 2022-06-17 - (Avastin + FOLFOX; Q2W)

  • 2022-04-26 - (Avastin + FOLFOX; Q2W)

  • 2022-04-08 - (Avastin + FOLFOX; Q2W)

  • 2022-03-08 - (Avastin + FOLFOX; Q2W)

  • 2022-02-10 - (Avastin + FOLFOX; Q2W)

  • 2022-01-07 - (Avastin + FOLFOX; Q2W)

  • 2021-12-21 - (Erbitux + FOLFOX; Q2W)

  • 2021-11-03 - (Erbitux + FOLFOX; Q2W)

  • 2021-10-18 - (Avastin + FOLFIRI; Q2W)

  • 2021-09-29 - (Avastin + FOLFIRI; Q2W)

  • 2021-07-29 - (Avastin + FOLFIRI; Q2W)

  • 2021-07-09 - (Avastin + FOLFIRI; Q2W)

  • 2021-06-25 - (Avastin + FOLFIRI; Q2W)

  • 2021-06-07 - (Avastin + FOLFIRI; Q2W)

  • 2021-05-21 - (Avastin + FOLFIRI; Q2W)

FOLFOXIRI chemotherapy for metastatic colorectal cancer - 2023-11-23 - https://www.uptodate.com/contents/image?imageKey=ONC%2F70559

  • Cycle length: 14 days.
  • Regimen
    • Irinotecan
      • 165 mg/m2 IV
      • Dilute with 500 mL D5W to a final concentration of 0.12 to 2.8 mg/mL and administer over 60 minutes.
      • Day 1
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute with 500 mL D5W and administer over two hours after irinotecan. Administer concurrently with leucovorin in separate bags via y-line connection. Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • LEVOleucovorin
      • 200 mg/m2 IV
      • Dilute with 250 mL D5W and administer over two hours, concurrent with oxaliplatin.
      • Day 1
    • Fluorouracil (FU)
      • 2400 to 3200 mg/m2 IV
      • Dilute in 500 to 1000 mL D5W and administer over 48 hours, after leucovorin. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL). The original protocol used 3200 mg/m2, but many United States oncologists use a lower starting dose (2400 mg/m2) and escalate as tolerated to reach a final dose of 3200 mg/m2.
      • Day 1

FOLFIRINOX chemotherapy for metastatic pancreatic cancer - 2023-11-23 - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571

  • Cycle length: 14 days.
  • Regimen
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 180 mg/m2 IV
      • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 400 mg/m2 IV bolus
      • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
      • Day 1
    • FU
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

Modified FOLFIRINOX chemotherapy for pancreatic cancer - 2023-11-23 - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546

  • Cycle length: 14 days.
  • Regimen
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 150 mg/m2 IV
      • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

==========

2023-11-23

[rising tumor markers and progressive disease]

This patient has a history of multiple lines of treatment for her cancer, including:

  • Avastin + FOLFOXIRI (since March 2023 and undergoing)
  • Avastin + FOLFOX (January 2022 to March 2023)
  • Erbitux + FOLFOX (November 2021 to December 2021)
  • Avastin + FOLFIRI (May 2021 to October 2021)

Both CEA and CA199 have been rising for the past two months, consistent with the progressive disease seen on the CT scan on 2023-09-27.

  • 2023-11-21 CEA (NM) 382.930 ng/ml

  • 2023-10-24 CEA (NM) 130.315 ng/ml

  • 2023-09-26 CEA (NM) 95.670 ng/ml

  • 2023-11-21 CA-199 (NM) 4220.750 U/ml

  • 2023-10-24 CA-199 (NM) 2298.450 U/ml

  • 2023-09-26 CA-199 (NM) 1177.830 U/ml

As the liver metastases are more severe, more intensive monitoring of liver function might be advisable.

[mixed acid-base disorder?]

Here’s a breakdown of the results of the venous blood gas (VBG - 2023-11-22) values:

  • pH: 7.451
    • This is higher than the normal venous pH range (7.31-7.41), indicating mild alkalemia (increased alkalinity in the blood).
  • HCO3 (Bicarbonate): 28.1 mmol/L
    • This is elevated. Normal venous HCO3 levels are typically around 22-26 mmol/L.
  • ctCO2 (Total Carbon Dioxide): 29.4 mmol/L (23-27 mmol/L).
  • Base Excess (BE) and BEecf: 3.6 mmol/L and 4.1 mmol/L, respectively
    • These values are slightly elevated, indicating a mild excess of base in the blood.
  • SBC (Standard Bicarbonate): 27.4 mmol/L (22-26 mmol/L).
  • O2 Saturation: 73.5%
    • The oxygen saturation might be a concern, depending on the clinical context.

The results suggest a mild metabolic alkalosis, as indicated by the slightly elevated pH and bicarbonate levels, along with a positive base excess.

Meanwhile, lactic acid was elevated (2023-11-22 2.5 mmol/L), this could indicate lactic acidosis, a condition where there is an accumulation of lactic acid in the body, often due to inadequate oxygen delivery to tissues (hypoxia), shock, or other metabolic issues.

In the context of the mild metabolic alkalosis suggested by the vein blood gas results, elevated lactic acid could point towards a mixed acid-base disorder. This is where more than one acid-base imbalance is occurring simultaneously.

O2 cannula 3L/min has been ordered and the updated SpO2 is 95% (2023-11-23).

700324847

231122

[exam findings]

  • 2023-05-27 MRI - brain
    • No brain nodule or metastasis.
  • 2023-05-15 KUB
    • Bilateral pleural effusion.
    • Presence of ileus.
    • Intact bony structure(s).
  • 2023-05-15 CXR
    • Bilateral pleural effusion.
    • Ground glass opacities in bil. lungs.
  • 2023-05-12 CT - chest
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Loculated bilateral pleural effusion at bilateral interlobular fissure and lower hemithorax is found.
        • Consolidation over right lower lobe and left lower lobe is found.
        • Enlarged lymph nodes are found at bilateral paratracheal region.
        • Patent airway is found.
      • Visible abdomen:
        • Moderate ascites formation is found.
        • Increased intestinal gas is found.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
    • IMp:
      • Pneumonic patch at both lungs with bilateral massive pleural effusion.
      • Moderate ascites formation.
  • 2023-05-12 CXR
    • Bilateral Pleura effusion.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Enlargement of cardiac silhouette.
  • 2023-05-05 SONO - CXR
    • Echo diagnosis:
      • right side minimal amount of pleural effusion
      • left side small amuont of pleural effusion, 600cc serosangious fluid was drained out for symptom relief.
  • 2023-04-24 SONO - breast
    • Suggestion and Plan
      • Calcifications in right breast.
      • R/O enlarged lymph nodes in left axillary region, suggest biopsy.
    • BI-RADS: Category 4a: low suspicious abnormality-biopsy should be considered.
  • 2023-04-22 MRI - pelvis
    • With and without contrast enhancement MRI:
      • Cystic tumor, 8.6cm in right adnexa, with mural soft tissue, r/o right ovarian malignancy.
      • Another cystic tumor, with internal hemorrhage, 2.8cm in left adnexa, r/o ovarian malignancy with hemorrhage.
      • There are enlarged lymph nodes in bilateral obturator regions and right common iliac region, r/o lymph nodes metastasis.
      • Presence of ascites.
      • There are soft tissue tumors in the mesentery, r/o peritoneal carcinomatosis.
      • Left pleural effusion.
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T: T3c_(T_value) N: N1b(N_value) M: M1(M_value) STAGE: IV (Stage_value)
    • Impression:
      • Ovarian cystic tumor with carcinomatosis and lymph nodes, left pleural effusion, r/o ovarian malignancy with carcinomatosis, lymph nodes metastasis and left pleural effusion. cstage T3cN1bM1.
  • 2023-04-20 Gynecologic ultrasonography
    • R/O Pelvis mass: 101 x 78mm (Multuple papillary, solid mass: 26 x 25mm)
    • R/O LT Ovarian mass
  • 2023-04-19 CT - abdomen
    • Findings:
      • There is ascites and soft tissue nodules in the omentum. Carcinomatosis is suspected. Please correlate with ascites cytology.
      • There is a mild hyperdense lesion in the pelvis at pre-contrast CT, measuring 9.1 x 10.4 x 8.5 cm (width x depth x cranial-caudal length) in size, and poor enhancement in portal venous phase images except suspicious few ill-defined enhancing mural nodules.
        • The uterus shows posterior displacement by the upper described mass.
        • Cystic adenocarcinoma of the ovary is highly suspected.
        • Please correlate with GYN. sonograph, MRI and CA125.
      • There is a mild hyperdense lesion in left adnexa at non-enhanced CT, measuring 3.4 cm in size, and it shows poor enhancement in portal venous phase images except a mural nodule shows enhancement.
        • Cystic tumor of left ovary is highly suspected.
        • The differential diagnosis includes left ovarian cyst with hemorrhage.
      • S/P pigtail catheter implantation at right CP angle.
        • There is massive left side Pleura effusion.
    • Impression:
      • Carcinomatosis is suspected. Please correlate with ascites cytology.
      • Cystic adenocarcinoma of the ovary is highly suspected. Please correlate with GYN. sonograph, MRI and CA125.
  • 2023-04-18 CT - chest
    • Findings
      • moderate Lt pleural effusion and residual minimal Rt pleural effusion s/p pigtail drain placement.
      • lungs:extensive, patchy and centrilobular ground-glass opacities with interbular septal thickening, at both lower lobes.
        • minimal patchy ground-glass opacities at LUL.
        • dependent relaxation subsegmental atelectasis at LLL.
      • Mediastinum and hila: many enlarged LNs in the visceral space and left anterior prevascular space.
      • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal contents: normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
        • mild ascitic fluid and dirty omentum.
      • Visualized bones: unremarkable.
    • Impression:
      • bilateral lower lobes lung edema or pneumonitis and transudative left pleural effusion, due to connective tissue disease?
      • abdominal ascites, cause? due to lesion in pelvic cavity?
  • 2023-04-18 Cell block - pleural effusion
    • Cytological diagnosis: Malignancy
    • Smears and cell block show clusters of pleomorphic tumor cells. Metastatic carcinoma is favored. Please correlate with the clinical presentation.
  • 2023-04-17 Cell block - pleural effusion
    • Cytological diagnosis: Malignancy
    • Smears and cell block show clusters of pleomorphic tumor cells. The immunohistochemical stains reveal CK7(+), CK20(-), PAX8(+), WT-1(+), TTF-1(-), Napsin A(-), p40(-), GATA3(-), Calretinin(-), and CD56(-). The results are consistent with metastatic carcinoma from ovary. Please correlate with the clinical presentation.
  • 2023-04-15 SONO - chest
    • Echo diagnosis:
      • Pleural effusion, massive amount, right, s/p pig-tail insertion
      • Pleural effusion, massive amount, left, s/p thoracentasis (1100ml)
  • 2023-04-14 ECG
    • Sinus tachycardia
    • Anteroseptal infarct, age undetermined
    • Abnormal ECG
  • 2018-05-16 Gynecologic ultrasonography
    • Suspected RT ovarian cyst
    • Suspected LT endometrioma

[MedRec]

  • 2023-05-15 SOAP Emergency
    • S
      • Dyspnea for 2 days
      • s/p thoracocentesis on 5/12 700ml
      • Poor intake for 2 days
      • Nausea and vomiting after inake
      • Phx: Ovarian cancer
      • Allergy: NKA
  • 2023-05-12 SOAP Hemato-Oncology
    • S: Today explain to patient 40 minutes for chemotherapy. But she still hestitate to receive chemotherapy.
    • P: explain the possibility of chemotherapy to control tumor, but patient still hestitate to receive C/T.
      • F/U weekly
      • refer to ER for chest tapping

[consultation]

  • 2023-09-10 Urology

    • Q
      • This is a 52 y/o woman with Ovarian malignancy with carcinomatosis, lymph nodes metastasis and left pleural effusion. cstage T3cN1bM1, status post neo-adjuvant chemotherapy (paclitaxel and carboplatin).
      • She will be recieving Debluking surgery + HIPEC on 112-09-11. We sincerely needed your expertise on double J tube insertion. Thank you very much!
    • A
      • We will arrange the procedure
  • 2023-06-08

  • 2023-05-19

  • 2023-05-18

  • 2023-05-17

  • 2023-04-21 Hemato-Oncology

    • Q
      • For ovarian cancer neuadjuvant chemotherapy
      • We have consulted GYN, who suggested neoadjuvant chemotherapy first, followed by debulking surgery and HIPEC.
      • Due to the above reasons, we sincerely need your expertise for the neoadjuvant chemotherapy. Thank you very much!
    • A
      • This 51 year old woman is a case of ovarian cancer with peritoneal carcinomatosis and bilateral pleura effusion. Pleura effusion cell block show pleomorphic tumor cells CK7(+), CK20(-), PAX8(+), WT-1(+), TTF1(-), NAPsin A(-), P40(-), GATA3(-),calretinin(-), and CD56(-), the result consistent with metastatic carcinoma from ovary.
      • Arrange 24 urine CCR, anti HBc, anti HBs, HBsAg, Anti HCV, breast echo and port A insertion. apply Major Disease” C56.9 stageIV.
      • We will arrange chemotherapy (palitaxel + carboplatin ) the next day of port A insertion (Expected to have chemotherapy next Tuesday). Arrange our OPD after discharge.
  • 2023-04-20 Obstetrics and Gynecology

    • Q
      • For evaluation of suspected ovarian cystic adenocarcinoma
      • This is a 51-year-old female with no underlying diseases. She presented to our ER with progressive dyspnea for 3 weeks, while CXR showed massive bilateral plerual effusion. Bilateral thoracentesis and right pigtail drainage was performed for symptom relief. Examination of the drainage showed to be exudative in nature.
        • Cancer/Tumor:
          • 4/18 Chest CT: bilateral lower lobes lung edema or pneumonitis and transudative left pleural effusion, due to connective tissue disease? abdominal ascites, cause? due to lesion in pelvic cavity?
          • 4/19 Abdominal CT: 1. Carcinomatosis is suspected. Please correlate with ascites cytology. 2. Cystic adenocarcinoma of the ovary is highly suspected. Please correlate with GYN. sonograph, MRI and CA125.
        • Tumor markers: pending results
        • TB, fungus, infection: pending results
        • Autoimmune: negative
      • Due to the above reasons, we sincerely need your expertise to evaluate the pelvic mass, suspect ovarian cystic adenocarcinoma. Thank you very much!
    • A
      • This is a 51 y/o woman who was hospitalized due to pleural effusion. Image survey with abdominbal CT showed suspected carcinomatosis of which ovarian cystic adenocarcinoma was highly suspected. Tumor markers were checked with the results pending. We were consulted for evaluation.
        • CC: Progressive dyspnea for 3 weeks.
        • ObGyn history: Sex(+), P0, menopaused
        • Sono: Pelvic mass, 101 x 78 mm (multiple papillary, with solid mass: 26 x 25 mm)
      • Impression
        • Huge pelvic mass, malignancy could not be ruled out
      • Suggestion
        • Please pursue the level of tumor markers.
        • Arrange EGD and colonoscopy.
        • Surgical intervention (laparotomy and frozen section) is suggested for diagnostic and therapeutic value. If malignancy is proven intraoperatively, debulking surgery is indicated.
        • Further cancer staging if malignancy is proven.
      • Addendum to consultation response 2023-04-21 14:45:54
        • Highly suspected cystic adenocarcinoma of the ovary with carcinomatosis and malignant plerual effusion, at least cstage IVA
        • Well explained current treatment plan and survival rate:
          • arrange EGD and colonoscopy first
          • consulted GS for port-A insertion and consulted Oncologist for neoadjuvant chemotherapy 3-4 times and followed debulking surgery and HIPEC

[chemotherapy]

  • 2023-11-22 - paclitaxel 175mg/m2 170mg NS 250mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr + [docetaxel 30mg/m2 30mg + cisplatin 30mg/m2 30mg + gentamicin 40mg + sodium bicarbonate 3800mg + NS 1000mL] IP 1hr (70%)

    • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-10-19 - paclitaxel 175mg/m2 170mg NS 250mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + gentamicin 40mg + sodium bicarbonate 3800mg + NS 1000mL] IP 1hr (70%)

    • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-09-11 - [liposome doxorubicin 30mg/m2 40mg D5W 250mL + carboplatin AUC 5 900mg NS 250mL] IP 90min

  • 2023-08-21 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr

    • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-07-31 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr

    • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-07-06 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr

    • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-06-08 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr

    • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-05-18 - paclitaxel 175mg/m2 135mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr

    • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-04-25 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 375mg NS 250mL 2hr

    • dexamethasone 4mg 5# PO Q6H at D0 2300 and D1 0500 + dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + NS 250mL

==========

2023-08-21

No medication reconciliation issues were found after reviewing PharmaCloud and HIS5.

2023-05-17

  • The patient’s serum albumin level has shown a decrease, potentially due to nausea and vomiting post-ingestion and several days of insufficient nutrition intake. Severe hypoalbuminemia could potentially exacerbate the patient’s pleural effusion. It might be necessary to provide additional nutritional support.
    • 2023-05-12 Albumin 3.1 g/dL
    • 2023-04-22 Albumin 3.5 g/dL
  • The recommendation is to include antiemetics as part of the premedication protocol for the upcoming dose of the current paclitaxel and carboplatin regimen.

700605406

231122

[exam findings]

  • 2023-11-16 CT - abdomen
    • History and indication:
      • Primary cutaneous CD30-positive T-cell proliferations, primary cutaneous CD30-positive anaplastic large cell lymphoma (T cell and CD-30 positive), stage IV
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Swelling of left lower extremity. Skine thickening of left thigh. Enlarged LNs at retroperitoneum, pelvic cavity, left thigh and bil. inguinal regions. General subcutaneous edema.
      • A fatty tumor (3.1cm) at left pelvic cavity.
      • A poor enhancing nodule (1.5cm) at S7 of liver.
      • Some lucent lesions in sacrum.
      • Minimal ascites.
    • IMP:
      • Swelling of left lower extremity. Skine thickening of left thigh. Enlarged LNs at retroperitoneum, pelvic cavity, left thigh and bil. inguinal regions. Disease progression is noted.
      • General subcutaneous edema.
      • A fatty tumor (3.1cm) at left pelvic cavity.
      • A poor enhancing nodule (1.5cm) at S7 of liver.
      • Some lucent lesions in sacrum.
  • 2023-09-15 Patho - bone marrow biopsy
    • PATHOLOGIC DIAGNOSIS
      • Bone marrow, biopsy — No evidence of T-cell lymphoma with bone marrow involvement
    • MICROSCOPIC EXAMINATION
      • The sections show hypercellular marrow (60%). M/E ratio = 6:1. The myeloid cells show good maturation. The megakaryocytes are increased in number with a few small megakaryocytes. No lymphoid aggregates.
      • IHC, scattered small CD3+ T-cells and CD20+ B lymphocytes in interstitium are present. No CD30+ T lymphocyte can be found. There is no evidence of T-cell lymphoma with bone marrow involvement. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2023-09-14 PET
    • The [F-18]Fluorodeoxyglucose (FDG) PET scan from head to upper thigh regions was performed at 40 minutes after i.v. injection 235 MBq of FDG. Fasting for at least 6 hours was required prior to this examination. Images were reconstructed iteratively with CT scan attenuation correction.
    • There was increased FDG uptake in the left supraclavicular lymph nodes (SUVmax early: 11.51, delay: 12.73), multiple abdominal and pelvic lymph nodes (SUVmax early: 18.92, delay: 20.04), multiple bilateral inguinal lymph nodes (SUVmax early: 17.54, delay: 19.32), some focal areas in the spleen (SUVmax early: 4.82, delay: 5.90) and multiple focal areas in the left upper thigh (SUVmax early: 13.20, delay: 16.80). Besides, there was increased FDG uptake in the bone marow of the skeleton (SUVmax early: 4.42, delay: 6.30).
    • IMPRESSION: The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on both sides of the diaphragm, spleen, bone marrow and left upper thigh (stage IV).
  • 2023-09-13 Patho - skin cyst/tag/debridement
    • DIAGNOSIS:
      • Labeled as “left thigh”, incisional biopsy — T cell lymphoma
    • GROSS DESCRIPTION:
      • Specimen submitted in formalin consists of 1 piece(s) of tan, irregular tissue measuring 4.0 x 2.0 x 1.3 cm. Representative tissue for section(s) in 2 cassette(s).
    • MICROSCOPIC DESCRIPTION:
      • Sections show skin with infiltration of abundant atypical lymphoid cells with many pleomorphic large neoplastic cells. IHC stains: CD3 and CD20: a predominant T cell sub-population. The large cells are CD30 (+), CD15 (+), ALK (-), cutaneous cd30-positive t-cell lymphoproliferative disorder is considered.
  • 2023-09-01 Patho - lymphnode biopsy
    • PATHOLOGIC DIAGNOSIS
      • Lymph node, groin, left, core needle biopsy— Peripheral T cell lymphoma, NOS
    • MACROSCOPIC DESCRIPTION
      • Operation procedure: core needle biopsy
      • Topology: left groin
      • Specimen size and number: 3 pieces, 1x 0.1x 0.1 cm
    • MICROSCOPIC EXAMINATION
      • Histology type:
        • T-cell neoplasms
        • Peripheral T-cell lymphoma, NOS
      • Immunohistochemical stain profiles: CK(-), CD3(+, diffuse), CD4(+, diffuse), CD20(focal + at background B cells), CD8(+), Ki-67 index: 50%, CD56 (focal +, < 5%), Granzyme B(-), EBV(-), CD15 (-), CD30 (+, 40%), CD10 (focal weak+), TdT(-), CD5(+), EBER(-)
      • ADDENDUM: IHC stain — ALK1: negative
      • ADDENDUM: Based on histopathologic and immunohistochemical features, the possibility of anaplastic large cell lymphoma (ALK negative) cannot be complelely excluded. Clinical correlation is necessary.
  • 2023-08-28 Peripheral Vascular Test - Artery, lower limbs
    • Clinical diagnosis: Leg swelling
    • Conclusions: Patent bilateral lower limbs arteries. Increased flow velocities at left CFA, SFA and PFA.
  • 2023-08-17 CTA - lower extremity
    • Indication: CT”V” r/o DVT
    • CTV of lower extremity shows:
      • multiple enlarged lymphadenopathy at bilateral inguinal regions, pelvic side wall and iliac chains, causing compression to left external iliac vein and left common femoral vein. There are also some smaller lymph nodes at left paraaortic region.
      • irregular skin thickening at left posterior thigh with enhancement, etiology to be determined.
      • swelling and subcutaneous edema of left lower extremity, probably due to venous compression by the left inguinal and iliac lymphadenopathy.
      • two 2.7cm fat attenuated nodules in the pelvic cavity, probably adnexal origin. Terotoma or others?
      • enlarged and heterogeneous enhancement of uterus.
      • mild ascites in the cul de sac.
      • a 1.5cm hypoenhancing nodule in S7 liver, nature to be determined.
    • Impression:
      • Multiple enlarged lymphadenopathy at bilateral inguinal regions, pelvic side wall and iliac chains, causing compression to left external iliac vein and left common femoral vein. Some smaller lymph nodes at left paraaortic region. Suggest tissue proof.
      • Irregular skin thickening at left posterior thigh. Suggest further evaluation.
      • Two fat-density nodules in the pelvic cavity, suspect teratoma? Enlarged uterus. Mild ascites. Suggest correlation with GYN ultrasound.
      • A 1.5cm hepatic nodule, nature to be determined.

[MedRec]

  • 2023-09-12 ~ 2023-09-22 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Cutaneous T-cell lymphoma, unspecified, lymph nodes of multiple sites
      • Primary cutaneous CD30-positive T-cell proliferations, primary cutaneous CD30-positive anaplastic large cell lymphoma (T cell and CD-30 positive), stage IV
    • CC
      • For further survey of suspected subcutaneous T cell lymphoma
    • Present illness
      • The patient is a 39 y/o female with previous unerlying disease, with only medication history of HTN treatment recieved during pregnancy. This time, she was admitted for further survey of suspected subcutaneous T cell lymphoma.
      • According to the patient herself and her husband, she had noted multiple pruritic erytheamtous papule-vesicles over medial posterior side of left thigh for months (before pregnancy) with progressed erythematous change, but she did not search for medical help after labor.
      • She first went to PS OPD, and was referred to CVS afterwards. At CVS OPD, multiple check ups were done. Venous sonography reported: Venous thrombosis at bilateral superficial epigastric veins and superficial circumflex iliar veins were detected. The intra-abdominal veinous occlusion or compression couldn’t be ruled out completely, please correlate with clinical presentations and other image modalities.
      • CTA of lower extremitiy reported: 1. Multiple enlarged lymphadenopathy at bilateral inguinal regions, pelvic side wall and iliac chains, causing compression to left external iliac vein and left common femoral vein. Some smaller lymph nodes at left paraaortic region. Suggest tissue proof. 2. Irregular skin thickening at left posterior thigh. Suggest further evaluation. 3. Two fat-density nodules in the pelvic cavity, suspect teratoma? Enlarged uterus. Mild ascites. Suggest correlation with GYN ultrasound. 4. A 1.5cm hepatic nodule, nature to be determined.
      • Thus, she was prescribed with the medication of Eliquis and Furosemide, and was referred to GYNOPD for evaluation.
      • At GYN OPD, sonography reported: 1. Uterine myoma, 2. R/O Bilateral Teratoma, 3. R/O Lt adnexal mass: 90x50mm, so after explanation, she was referred to GS OPD for evaluation on the pelvic mass and bilateral teratoma.
      • After evaluation on previous history and image findings, sono guide biopsy of left inguinal lymph node was done by GS Dr. Li ChaoZhu, and pathology results later reported peripheral T cell lymphoma, so she was thus referred to Dr. Gao WeiYao’s OPD for furtehr management.
      • At Dr. Gao’s OPD. admission was arranged after evaluation on previous medical record and the patient’s condition. Besides from the skin lesion over her left thight, she also had accompanied symtpoms of fever up to 38.7’C with chillness for 2-3 days which could be partially relieved by antipyretics, night sweats for 1-2 weeks, and LLQ abdominal distension pain for a week. She had no headache or dizziness, no cough or rhinorrhea, no chest pain or dyspnea, no nausea or vomiting, no diarrhea or urinating pain.
      • Under the impression of suspected subcutaneous T cell lymphoma, she was admitted for further evaluation and management.
    • Course of inpatient treatment
      • After admission, we did routine follow up on the patient’s lab data, chest X-ray and EKG, and since the patient’s left thigh skin lesion was suspected cutaneous T cell lymphoma, we consulted PS doctor for skin biopsy.
      • PET/CT was arranged and done, and we consulted CVS doctor for port-A insertion. Skin biopsy and port-A insertion were combined and done on 2023-09-13, and the patient did not show continuous bleeding.
      • PET/CT was done on 2023-09-14, and the report showed lymphoma involving multiple lymph node regions on both sides of the diaphragm, spleen, bone marrow and left upper thigh (stage IV).
      • Antibiotic of Targocid was used since admission due to the patient had fever going on and off, and there was no more fever noted since 2023-09-13.
      • Chemotherapy with CHOEP had started on 2023-09-18, and lab data was followed up every day.
      • The patient showed no fever, no nausea or vomiting, no abdominal pain or dysuria during chemotherapy, but her body weight had increased 5kg in recent 1 week with edema noted at left thigh, so we added IV form of Lasix 20mg QD.
      • Under stable condition, the patient was discharged on 2023-09-22, with oral medications brought back and OPD follow up arranged on 2023-09-26.
    • Discharge prescription
      • Compesolon (prednisolone 5mg) 10# QN
      • Uretropic (furosemide 40mg) 1# PRNQD (if BW increase)
  • 2023-03-30 ~ 2023-04-02 POMR Obstetrics and Gynecology Zhang YinGuang
    • Discharge diagnosis
      • Term pregnancy at 40+4 weeks with mild preeclampsia for labor induction status post vaginal delivery on 2023/03/31
      • Mild to moderate pre-eclampsia, third trimester
      • Second degree perineal laceration during delivery
      • Streptococcus, group B, as the cause of diseases classified elsewhere
    • CC
      • Pregnancy at 40+3 weeks for labor induction        
    • Present illness
      • This 39 y/o, G2P1 (termination at GA 20 weeks due to cleft palate and holoprocencephaly), married woman with history of HTN which start medication control since pregnancy was currently pregnant at 40+3 weeks of gestation (LMP: 2022/05/28, EDC: 2023/03/27). She did not smoke, drink alcohol, or use illicit drugs.
      • She had received routine prenatal care at our hospital where normal maternal status and fetal development were diagnosed. There was no RPR/VDRL, HBsAg, HbeAg, Rubella IgG, HIV Ab, HPV 16 & 18, or Group B Streptococci infection. No gestational complication such as pregnancy induced hypertension, preclampsia or gestational diabetes mellitus. The labetalol 0.5# BID used for HTN control and aspirin used for preeclampsia prevention. Transabdominal ultrasound on 38+5 week revealed estimated fetal body weight (EFBW) as 3328gm. After discussed with the patient, she came to our delivery room on 2023/03/30 for the scheduled induction.
      • On examination, the blood pressure was 133/96mm Hg, the pulse 80 beats per minute, other vital signs and the remainder of the examination were normal. The fundus was firm; the height was consistent with the gestational age. Bilateral lower limbs edema 1+ noted on admission. Pelvic examination showed the cervix was 1 cm dilated and poor effaced. The fetal heart-rate tracing showed a rate of 130 to 139 beats per minute. She was then admitted to our ward for preparation of delivery. 
    • Course of inpatient treatment
      • This is a 33 years old female. G2P2 pregnancy at 40+4 weeks and admitted due to labor induction. Under local anesthesia, vaginal delivery was performed on 03/31/2023. A live female newborn with body weight 2925 gm, height 47 cm. Apgar score:9->9, EBL:200 ml. The breast engorgement without mass. EP wound without swelling and healed well. Uterine contraction was well. The Lochia showed redness and normal amount. Urination by self voiding was smooth. She was discharged & RTC after 6 weeks.
    • Discharge prescription
      • MgO 250mg 1# QID
      • Acetal (acetaminophen 500mg) 1# QID
      • Alcos-Anal Oint (sodium oleate) BID EXT
      • Through (sennoside 12mg) 1# HS
  • 2023-03-04, 2022-11-12, -08-20 SOAP Cardiology Liu GuanLiang
    • Diagnosis: Primary HTN
    • Prescription x3
      • Trandate (labetalol 200mg) 0.5# BID

[consultation]

  • 2023-09-13 Cardiology
    • Q
      • The patient is a 39 y/o female with previous unerlying disease, with only medication history of HTN treatment recieved during pregnancy. She had noted multiple pruritic erytheamtous papule-vesicles over medial posterior side of left thigh for months (before pregnancy, currently 5 months after labor) with progressed erythematous change, and after multiple evaluation, she was diagnosed with peripheral T cell lymphoma.
      • This time, she was admitted for further survey of suspected subcutaneous T cell lymphoma, and skin biopsy was arranged ib 9/13 12:00.
      • We need your expertise on the patient’s port-A insertion, thank you very much!
    • A
      • I have had the pleasure of involving with this patient’s care. In brief, the patient is a 39 year old female seen in consultation for opinion regarding treatment options for port-A insertion for chemotherapy access.
        • The pt’s hx/Dx was noted for 1. Non-Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb
        • Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites
        • Lab/CXR reviewed.
      • SUGGESTION & PLAN:
        • Port-A insertion will be arranged on today right side, LMA combined with Dr Wei

[chemotherapy]

  • 2023-11-17 - cyclophosphamide 750mg/m2 1500mg NS 250mL + doxorubicin 50mg/m2 100mg NS 100mL 10min + vincristine 2mg/m2 2mg NS 50mL 10min + etoposide 100mg/m2 200mg NS 500mL 1hr D1-3 + prednisolone 50mg PO BID D1-5 [CHOEP]
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3
  • 2023-10-16 - cyclophosphamide 750mg/m2 1400mg NS 250mL + doxorubicin 50mg/m2 96mg NS 100mL 10min + vincristine 2mg/m2 2mg NS 50mL 10min + etoposide 100mg/m2 190mg NS 500mL 1hr D1-3 + prednisolone 50mg PO BID D1-5 [CHOEP]
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3
  • 2023-09-18 - cyclophosphamide 750mg/m2 1400mg NS 250mL + doxorubicin 50mg/m2 96mg NS 100mL 10min + vincristine 2mg/m2 2mg NS 50mL 10min + etoposide 100mg/m2 190mg NS 500mL 1hr D1-3 + prednisolone 50mg PO BID D1-5 [CHOEP]
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3

==========

2023-11-22

[brentuximab vedotin] (not posted)

Health Insurance Medication Coverage Regulations (2023-10-24 version)

  • Brentuximab vedotin (such as Adcetris) is limited to use in adult patients with systemic anaplastic large cell lymphoma (sALCL):
      1. For use in combination with cyclophosphamide, doxorubicin, and prednisone in adult patients with previously untreated systemic anaplastic large cell lymphoma (sALCL) that is ALK-negative.
      1. For the treatment of relapsed or refractory systemic anaplastic large cell lymphoma (sALCL).
      1. Use requires prior review and approval:
      • I. For patients mentioned in (1): The initial application for treatment is limited to 4 cycles. Subsequent applications should include assessment data from previous treatment results. If the patient has achieved complete remission, an additional 2 cycles may be covered; if the condition worsens, use must be discontinued. Health insurance coverage is limited to a maximum of 6 cycles.
        1. For patients mentioned in (2): Each application for treatment is limited to 4 cycles. Subsequent applications should include assessment data from previous treatment results. If the patient has achieved complete remission, an additional 4 cycles may be covered; if the condition worsens, use must be discontinued.
        1. The total lifetime coverage for the same patient under (1) and (2) is limited to a maximum of 16 cycles.

[family meeting] (not posted)

On the morning of 2023-11-22, at 10:00 AM in the 11A ward meeting room, a family meeting for the patient was convened by the attending physician, Dr. Gao. Attendees included the patient, her father, mother, elder sister, younger brother, and husband.

During the meeting, Dr. Gao thoroughly explained the current status of the disease, prognosis, and the conditions for health insurance coverage of targeted medications. The meeting particularly focused on ensuring that the patient’s family support network has a correct understanding of the condition and can provide timely support to the patient. The patient was also encouraged to actively raise any questions or concerns she might have during the treatment process and seek assistance from the medical team.

In an informal conversation after the meeting, outside the patient’s room, I further explained to the patient and her family about the risks of “tumor lysis syndrome” and “infusion reaction,” as well as the key points to cooperate with during treatment. The patient seemed willing to comply with the treatment.

700384230

231121

[lab data]

2023/03/17 Anti-HBc (NM) = Positive; 2023/03/17 HBsAg (NM) = Negative; 2023/03/17 HBsAg Value (NM) = 0.454; 2023/03/17 Anti-HBs (NM) = Positive; 2023/03/17 Anti-HCV (NM) = Negative;

[MedRec]

  • 2023-10-04 ~ 2023-10-16 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Ampulla vater ductal adenocarcinoma invading pancreatic head, pT3bN0(cM0) Stage: IIB status post pancreato-duodenectomy whipple procedure with reconstruction with lymph node dissection on 2023/08/07 s/p chemotherapy with FOLFOX from 2023/10/12~
      • Chronic viral hepatitis B without delta-agent
      • Cachexia
      • Constipation, unspecified
    • CC
      • For prepare chemotherapy.
    • Present illness
      • This 63-year-old man patient suffered from discharged from our GI ward for obstructive jaundice then distal CBD with stnosis s/p ERCP with stent.
      • After discharge, he was keep follow up at our OPD. Body weight loss 16kg (70 -> 61 -> 54kg) from 2022/12 ~ 2023/05 ~ 2023/10.
      • Laparoscope choledocho-duodenostomy LC and Distal CBD biopsy on 2022/12/15 and Gallbladder, laparoscopic cholecystectomy pathology showed acute cholecystitis and Common bile duct, distal pathology showed chronic inflammation.
      • Abdominal CT on 2023/02/10 showed 1. Metastasis 1.5 x 1 cm in S6 liver is highly suspected, the differential diagnosis include atypical hemangioma, please correlate with MRI and biopsy. 2. Prior CT identified few enlarged nodes in hepatoduodenal ligament are noted again, mild increasing in size. 3. Poor enhancing lesions in the hepatic hilum and ligamentum teres are suspected that may be metastatic nodes or lymphedema?
      • Abdominal echo on 2023/03/06 showed liver parenchymal disease, probable liver tumor: S6, GB sac not seen, pneumobilia, bilateral renal cysts and fatty infiltration of pancreas.
      • Liver MRI on 2023/03/15 showed 1. Prior CT identified a well-defined poor enhancing lesion 1.5 x 1 cm in S6 of the liver at portal venous phase images is not noted in the current MRI. 2. Prior CT identified poor enhancing lesions in the hepatic hilum and ligamentum teres are noted again, stationary, follow up is indicated and mild dilatation of both lobe IHDs and CHD.
      • PES on 2023/04/13 showed reflux esophagitis LA Classification grade A, superficial gastritis and duodenitis with stenosis, proximal of 2nd portion, s/p biopsy. Duodenum, proximal of 2nd portion, biopsy showed chronic erosive duodenitis.
      • EUS on 2023/05/11 showed rule out pancreatic tumor, head, abdominal lymphadenopathy and mild dilated left intrahepatic duct.
      • Abdominal SONO on 2023/05/12 showed 1. S/P cholecystectomy. 2. Pneumobilia. 3. There are several renal cysts on both kidney and the largest one measuring 2.86 cm in size at left upper pole. 4. Otherwise, no significant abnormal finding is noted.
      • Abdominal CT on 2023/07/07 showed prior CT identified few enlarged nodes in hepatoduodenal ligament are noted again, mild increasing in size, in addition, there are several new developed enlarged nodes in the omentum and mesentery of RUQ abdomen.
      • EUS on 2023/07/19 showed 1. Lymphadenopathy, liver hilum and peripancreas, s/p CEH/EUS-FNB 2. Dilated CBD & MPD 3. Duodenal stenosis, SDA.
      • Upper GI series on 2023/07/20 showed 1. Luminal narrowing with irregularity contour at duodenum 1-2nd portion. 2. Flow of contrast medium into the IHDs and CBD (s/p duodenocholedochostomy?).
      • Pancrease fine needle biopsy showed soft tissue with marked bland lymphoid cells infiltration, in favor of chronic pancreatitis. IHC stains: CD3 and CD20: no predominant subpopulation.
      • Abdominal echo on 2023/07/20 showed postcholeycstectomy, pneumobilia, renal cyst, bilateral, dilated main pancreatic duct and abdominal lymphadenopathy.
      • Pancreato-duodenectomy whipple procedure with reconstruction on 2023/08/07 and pathology showed ampulla vater adenocarcinoma invading pancreatic head, IHC stains: CK7(+), CK20(-), CA19-9(weak +), CA125(-), CK19(+), pT3bpN0(if cM0); pStage: IIB, at least.
      • Port-A catheter implantation on 2023/10/03. Poor appetite with weaknees and weekly to LMD for intravenous nutrition injection from 2023/08.
      • Now, he was admitted to ward for prepare chemotherapy.  
    • Course of inpatient treatment
      • After admitted, Bfluid (self pay) + Lyo-povigent (self pay) and IVF suplementation for poor appetiet.
      • Gascon 1# po TID, Mopride 1# po TID and Cimetidine 1# po TID for abdominal distention.
      • Panadol 1# po PRNQ6H for Port-A wound pain control.
      • Explain his condition to his family (wife and son) on 2023/10/09.
      • Chemotherapy with FOLFOX (Oxalip (self pay) 50mg/m2, LV 300mg/m2, 5FU 300mg/m2 and 2400mg/m2) (C1D1) from 2023/10/12 ~ 2023/10/14.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H fro nausea and vomiting.
      • Chronic viral hepatitis B without delta-agent (Anti HBc(+)) with Vemlidy 1# po QD.
      • Cachexia with Megest 10ml po QD.
      • Constipation with Sennoside 2# po HS and MgO 2# po TID.
      • Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, he was discharged on 2023/10/16 and OPD followed up later.   
    • Discharge prescription
      • Gasmin (dimethylpolysiloxane 40mg) 1# TID
      • Megest (megestrol 40mg/mL) 10mL QD
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • MgO 250mg 2# TID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
  • 2023-09-14 SOAP Hemato-Oncology Xia HeXiong
    • A/P
      • Based on the pathological report, the pancreaticobiliary ad mixed typeis favored. The ajuvant treatemnt is favored.
      • Options:
        • Adjuvant chemotherapy alone
        • Adjuvnat chemotherapy plus CCRT
      • Regimens (Patient is weak and poor nutirion, may consider not too strong C/T, and nutrition support during admission)
        • HDFL / Capecitabine
        • Gem alone
        • Gem/CDDP
        • Gem/Cap
        • FOLFOX/CapOx -> Favored
        • mFOLFIRINOX
  • 2023-07-19 ~ 2023-08-18 POMR General and Gastrointestinal Surgery Wu ChaoQun
    • Discharge diagnosis
      • Ampulla vater ductal adenocarcinoma invading pancreatic head, pT3bN0(cM0) Stage: IIB status post pancreato-duodenectomy whipple procedure with reconstruction with lymph node dissection on 2023/08/07. ECOG:1
      • Gastro-esophageal reflux disease with esophagitis
      • Essential (primary) hypertension
      • Acute pancreatitis, unspecified
      • Cholangitis
    • CC
      • enlarged nodes in hepatoduodenal ligament for scheduled EUS FNB
    • Present illness
      • This 62-year-old man with past medical history of
        • Hypertension.
        • Gout.
        • Hyperlipidemia.
        • Distal common bile duct stricture status post laparoscopic choledochoduodenostomy and cholecystectomy on 2022/12/15.
      • He was regular follow up at GS OPD.
      • At GS OPD, abdominal CT was performed on 2023/07/07 and reported prior CT identified few enlarged nodes in hepatoduodenal ligament are noted again, mild increasing in size,there are several new developed enlarged nodes in the omentum and mesentery of RUQ abdomen. CA 199 from 903.59 U/mL(2023/05/02) up to 1317.82 U/mL(2023/06/08). He had poor appetite, general weakness and weight loss 14 kg (2022/12 70kg -> 2023/07 56kg) after operation. Fever up to 38.4 on 2023/07/17 and deep yellowish urine for 3 days were found. There was no URI symptoms, no chest tightness, no TOCC history found.
      • Under the impresison of enlarged nodes in hepatoduodenal ligament and new developed enlarged nodes in the omentum and mesentery of RUQ abdomen,he was admitted for scheduled EUS FNB.
    • Course of inpatient treatment
      • After admission, NPO with adquaet IV fluid supportwith PPN, Empirical antibiotic with Brosym was given.
      • The EUS FNB was performed smoothly on 2023/07/19, and reported
        • Lymphadenopathy, liver hilum and peripancreas, s/p CEH/EUS-FNB
        • Dilated CBD & MPD
        • Duodenal stenosis, SDA.
      • The Double contrast study of UGI series revealed:
        • Luminal narrowing with irregularity contour at duodenum 1-2nd portion.
        • Flow of contrast medium into the IHDs and CBD (s/p duodenocholedochostomy?)
      • Try liquid diet as toelrable and mild abdomen distension was noted depite medication treatment.
      • The pathology of Pancreas biopsy reported pancrease fine needle biopsy — soft tissue with marked bland lymphoid cells infiltration, in favor of chronic pancreatitis. IHC stains: CD3 and CD20: no predominant subpopulation. Consulted GS then he was tranferred to our ward for further treatment and pre-operation evaluation.
      • He underwent operation of Whipple on 2023/08/07, then he was transferred to SICU for post op care. We kept infection control with Brosym use. After trying weaning from ventilator, extubation was done smoothly on 2023/08/08, and he was then transfered to ordinary ward for care.
      • We monitor his vital sign and condition closely. Adequate pain control was given for patient. During the hospitalization course he has some numbness of right legs resulting from PCA usage. The problem resolved after we contacted anesthetia department and halt PCA usage. Throughout the hospitalization course there was no major complication.
      • Under stable vital sign and condition we discharged him with OPD follow up and take home medication.
    • Discharge prescription
      • Celebrex (celecoxib 200mg) 1# Q12H
      • MgO 250mg 1# TID
      • Mopride (mosapride citrate 5mg) 1# TID
      • Protase (pancrelipase 280mg) 1# TIDCC
      • Rich (lansoprazole 30mg) 1# QDAC
      • Through (sennoside 12mg) 2# HS
      • Xyzal (levocetirizine 5mg) 1# HS
      • Flu-D (fluconazole 150mg) 1# QD
      • Cravit (levofloxacin 500mg) 1.5# QDAC
  • 2022-12-14 ~ 2023-01-02 POMR General and Gastrointestinal Surgery Wu ChaoQun
    • Discharge diagnosis
      • Distal common bile duct stricture status post laparoscopic choledochoduodenostomy and cholecystectomy on 2022/12/15
      • Intraabdomen leakage with infection (Candida, Enterococcus and Escherichia coli)
      • Wound infection due to Enterococcus releved
      • Hyperlipidemia, unspecified
      • Essential (primary) hypertension
    • CC
      • Distal CBD stricture then s/p stent was noted since 3 months ago
    • Present illness
      • This 62-year-old man with past medical history of
        • hypertension,
        • gout,
        • hyperlipidemia.
        • distal CBD with stenosis s/p ERBD with stent on 2022/09/26.
      • According for his statement and medical record, he was discharged from our GI ward for obstructive jaundice then distal CBD with stnosis s/p ERCP with stent. After discharge, he was keep follow up at our OPD. Furhter MRI was performed and showed stenosis of distal CBD. S/P CBD stenting. A cystic lesion (1.0cm) in ucinate process of pancreas. Enlargement of pancreatic head. Mild dilatation of p-duct (3.6mm).
      • Due to no evidence of tumor or cancer result, he referred to our OPD for surgical intervention. He denied of nausea, vomit, abdominal pain, jaundice or loss of body weight in recently. After fully explain of surgical method, laparoscopic choledochoduodenostomy with cholecystectomy was planning. This time. he was admitted to our ward for surgical management.
    • Course of inpatient treatment
      • After admission, he received laparoscope choledocho-duodenostomy and cholecystectomy was processed successfully on 2022/12/15. Post operaively, we observed patient recovery and keep empiric antibiotic, stool softener and analgesic agent were administered and the wound management was performed. He try to introduced soft diet and can tolerate well to oral intake. However, bile leakage was noted since 2022/12/20. Then we kept NPO and nutrition support with PPN.
      • Bile culture showed CRKP and E-coli, we keep antibiotic with Tienam + Doripenam + Unasym support.
      • Due to intraabdomen leakage, GI was also consulted then ERBD was indicated. However, bile leakage was reduced on 2022/12/26, then ERBD procedure was canceled. On the other side, wound reddness with pus dischrge was noted, then we kept Aqucel-Ag wet for wound care. His generally well beings and relativley stable. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable.
      • JP drainage with no pus dischrge then removal was done smoothly on 2022/12/31, then final ascites culture showed candida. Infection men was also consulted who suggest keep Flucon support.
      • Under improved general condition, he was allowed to discharge today and OPD follow up was arranged.
    • Discharge prescription
      • Celebrex (celecoxib 200mg) 1# QD
      • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
      • Ulstop (famotidine 20mg) 1# QD
      • Mopride (mosapride citrate 5mg) 1# TID
      • Flu-D (fluconazole 150mg) 1# QD
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
  • 2022-09-25 ~ 2022-09-28 POMR Gastroenterology Hong Yulong
    • Discharge diagnosis
      • Suspect malignant biliary obstrcution with lymphadenopathy, status post brushing and biopsy on 2022/09/26
      • Biliary obstrcution ststus post endoscopic retrograde biliary drainage with placement of a plastic stent
    • CC
      • For ERCP + IDUS
    • Present illness
      • This 62-year-old man with past medical history of hypertension, gout, hyperlipidemia. He was regular follow up at Rheu OPD.
      • He just discharged from GI ward for Obstructive jaundice s/p ERCP, Distal biliary stenosis, s/p precut with NKF, s/p EST, s/p ERBD with placement of a plastic stent.
      • Due to Painless jaundice for 2 wks visited GI OPD then admission, CT and MRI showed distal CBD stricture but no obvious tumor noted. ERCP showed distal CBD stricture also s/p ERBD, jaundice improving after ERCP then discharge.
      • For further survay, the EUS (on 2022/08/26) showed dilated CBD and sludge but no tumor. Had talked about IDUS. He agreed then arrange admssion 2022/09/25 for ERCP + IDUS on 2022/09/26. There was no fever, no dizziness, no URI symptoms, no chest tightness, no epigastric pain, no tarry stool. He also denied TOCC history.
    • Course of inpatient treatment
      • After abmission to GI ward, ERCP and IDUS were arranged after explain indication and risk.
      • ERCP with IDUS was performed smoothly on 2022/09/26 and revealed suspect malignant biliary obstrcution with lymphadenopathy, s/p STERIS Infinity brushing and biopsy, s/p ERBD with placement of a plastic stent.
      • The pathology was pending. Analgesic agent for pain relief was prescribed. There was no fever episode after procedure.
      • Oral intake trying was administered and there was no abdominal discomfort.
      • Follow up laboratory data revealed mild leukocytosis and elevaeted pancreas enzyme.
      • Some patient in the same room was diagnosed to have COVID-19 infection then he was discahrged this early morning.
      • OPD follow-up was arranged.
  • 2022-08-08 SOAP Rheumatology and Immunology Chen JunXiong
    • Diagnosis
      • M10.00 - Idiopathic gout, unspecified site
      • M06.4 - Inflammatory polyarthropathy
      • E78.5 - Hyperlipidemia, unspecified
    • Prescription x3
      • Tulip (atorvastatin 20mg) 1# QD
      • colchichine 0.5mg 1# QD
      • Euricon (benzbromarone 50mg) 1# BID
  • 2022-07-21 ~ 2022-07-26 POMR Gastroenterology Hong Yulong
    • Discharge diagnosis
      • Distal common bile duct stenosis with obstructive jaundice, nature to be determinated
      • Chronic kidney disease
      • Duodenal ulcer
      • Acute diarrhea
    • CC
      • tea color urine and clay stool for 5 days
    • Present illness
      • This is a 62-year-old man with past medical history of 1. hypertension, 2. gout, 3. hyperlipidemia. He was regular follow up at Rheu OPD. He was admitted due to tea color urine and clay stool for 5 days.
      • According to the patient himself and the past medical record, he suffered from tea color urine and clay stool for 5 days. He denied abdominal pain or weight loss. He had a health exam on 2022/07/05 and elevated ALT up to 143 was noted. He then visited our hospital for help. There was no fever, no dizziness, no URI symptoms, no chest tightness, no epigastric pain, no tarry stool.She also denied TOCC history.
      • At OPD, the laboratory tests showed AST/ALT 205/398, TBI/DBI 6.87/4.52, CRE 1.71. CT was done and showed dilatation of bilateral IHDs and CBD with segmental wall thickening at distal CBD; no CBD stone or tumor was found in the exam.
      • Under the impression of obstructive jaundice. He was admitted to GI ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission, ERCP was performed on 2022/07/22 and distal CBD stanosis was noted but definite cause unknown. Platic stent was inserted. Besides, DU was also noted during the exam so oral Pariet was used. Blood test showed elevated pancreatic enzymes but no significant abdominal pain, the he start intake again.
      • Pancras MRI + MRCP was performed on 2022/07/23 and no definite lesion was seen in the CBD or pancreatic head. The jaundice improving after stent insertion.
      • The IgG4 level was normal. Because IgG4 related disease still couldn’t be excluded, EUS + FNB was arranged on 2022/07/26 to check tumor or random biopsy.
      • However, diarrhea about 10 times was noted since 2022/07/25 especially after the evening despide medication use.
      • The patient decided not to receive the EUS examination just because diarrhea couldn’t improve soon (bad mood).
      • Then he was discharged on 2022/07/26 and GI OPD follow-up was arranged.
    • Discharge prescription
      • Smecta (dioctahedral smecitite) 1# TIDAC
      • Pariet (rabeprazole 20mg) 1# QDAC
      • Buscopan (hyoscien-N-butylbromide 10mg) 1# TIDAC

[consultation]

  • 2023-08-17 Hemato-Oncology
    • Q
      • Ampulla vater cancer s/p whipple for further chemotherapy
      • This 62-year-old man with past medical history of
        • Hypertension.
        • Gout.
        • Hyperlipidemia.
        • Distal common bile duct stricture status post laparoscopic choledochoduodenostomy and cholecystectomy on 2022/12/15.
      • He was regular follow up at GS OPD.
      • He noted for CBD stricture with repet pancreatitis for half years. This time, he was admitted and received further operation of Whipple’s op on 2023/08/07.
      • Final pathology showed ampulla vater cancer invading pancreatic head with ductal adenocarcinoma. pT3bpN0(cM0); pStage: IIB.
      • Now, he tolerance well of semi-liquid diet. We need your help for further adjuvant chemotherapy for this case. Thanks for your time!!
    • A
      • This 62 year old man is a case of ampulla vater adenocarcinoma. pT3bpN0(cM0); pStage: IIB s/p Whipple’s op on 2023/08/07. He had underline disease of HTN, Gout, Hyperlipidemia, and Distal common bile duct stricture status post laparoscopic choledochoduodenostomy and cholecystectomy on 2022/12/15. We are consulted for cancer treatment.
      • Please arrange port A insertion. We will discuss with patient about further ajuvant chemotherapy (5-FU + leucovorin or gemcitabine (self-paid) or other regiment). Please arrange our OPD after discharge. Thanks for your consultation.
      • Ref:
        • The ESPAC-3 trial demonstrated significant improvements in DFS and overall survival (OS) with use of postoperative gemcitabine or 5-fluorouracil (5-FU) as adjuvant chemotherapy versus observation in resectable ampullary adenocarcinoma.
        • ESPAC-3 study results showed no significant difference in OS between 5-FU/leucovorin versus gemcitabine following surgery. When the groups receiving adjuvant 5-FU/leucovorin and adjuvant gemcitabine were compared, median survival was 23.0 months and 23.6 months, respectively.
  • 2023-07-25 General and Gastrointestinal Surgery
    • Q
      • This 62-year-old man with past medical history of
        • Hypertension.
        • Gout.
        • Hyperlipidemia.
        • Distal common bile duct stricture status post laparoscopic choledochoduodenostomy and cholecystectomy on 2022/12/15.
      • He was regular follow up at GS OPD.
      • At GS OPD,abdominal CT was performed on 2023/07/07 and reported prior CT identified few enlarged nodes in hepatoduodenal ligament are noted again, mild increasing in size,there are several new developed enlarged nodes in the omentum and mesentery of RUQ abdomen.
      • CA 199 from 903.59 U/mL(2023/05/02) up to 1317.82 U/mL(2023/06/08).
      • He had poor appetite,general weakness and weight loss 14 kg (2022/12 70kg -> 2023/07 56kg) after operation.
      • Fever up to 38.4 on 2023/07/17 and deep yellowish urine for 3 days were found.
      • There was no URI symptoms, no chest tightness, no TOCC history found.
      • Under the impresison of enlarged nodes in hepatoduodenal ligament and new developed enlarged nodes in the omentum and mesentery of RUQ abdomen, he was admitted for scheduled EUS FNB.
      • The EUS FNB pathology was pending, we need your expertise for his Distal common bile duct stricture Thanks~
    • A
      • Please TPN for nutrition support for pre-op
      • Further OP method: Whipple op or GJ bypass
  • 2022-12-31 Infectious Disease
    • Q
      • bile leakage with intraabdomen infection
      • ascites showed CRKP, E-coli, enterococcus, and yeast
      • This 62 y/o male was a case of distal CBD stricture with stent since 3 months ago. This time, he was admitted and received laparoscope choledocho-duodenostomy and LC on 2022/12/15. However, post operation with bile leakage was noted since 2022/12/20.
      • Bile culture showed CRKP, enterococcus and E-coli, we keep antibiotic with Tienam + Doripenam + Unasym support. Unbilical wound infection was also noted and culture also revealed enterococcus. 2022/12/29 recheck ascites still show yeast like and WBC: 13300, CRP:2.21 was noted.
      • Now, we kep tienam + oral ciproxin and zyvox + flucon support for intraabdomen infection control. We need your help for further antibiotic recommendation.
    • A
      • Consultation for Zyvox and Culin (Tienam) antibiotic use.
        • Postoperative polymicrobial cholangitis and umbilical wound infection case.
        • Inital ascites culture showed CRKP and Enterococcus faecalis on 2022/12/16, follow up ascites culture on 2022/12/20 revealed MDR-E.coli and Eneterococcus.
        • The latest ascites on 2022/12/29 showed Yeast.
        • Patient is receiving the 2nd week Culin, oral Cipro, iv fluconazole and newly-added oral Zyvox.
        • Antibioticv adjustment indicated.
      • Suggestion:
        • Culin de-escalted to Brosym,
        • DC Zyvox, since no MRSA or VRE evidence.
        • DC oral Cipro since no effect for E.coli.
        • Continue iv fluconazole for the most possible Candida superinfection.
  • 2022-12-23 Gastroenterology
    • Q
      • post laparoscope choledocho-duodenostomy with bile leakage for endo stent
      • This 62 y/o male was a case of distal CBD stricture with stent since 3 months ago. This time, he was admitted and received laparoscope choledocho-duodenostomy and LC on 2022/12/15. However, post operation with bile leakage was noted since 2022/12/20. Bile culture showed CRKP and E-coli, we keep antibiotic with Tienam + Doripenam + Unasym support. We need your help for endo stent replacement for bile leakage control. Thanks for your time!!
    • A
      • Pre-ERCP evaluation
        • Indication: post operation bile leakage
        • Medication anti-coagulant: denied
        • Previous operation history: laparoscope choledocho-duodenostomy and LC
      • Suggestion
        • Please check amylase and lipase “before” ERCP
        • Set IC in right arm (if no contraindication)
        • ERCP intervention could be arranged on 2022/12/26 in the afternoon
          • well inform-consent to the patient and the family, including the current condition, the indication for ERCP, the risks (aspiration pneumonia/respiratory failure, arrhythmias/cardiovascular events, organ perforation, biliary tract infection, post-ERCP pancreatitis, post-ERCP bleeding, etc.)
          • if the patient and families all understand ERCP intervention, may take the risk, and sign permit for ERCP, we would arrange ERCP
          • please keep NPO at least 8 hours before ERCP as possible
          • correct bleeding tendency, and avoid any antiplatelets/anticoagulants before ERCP;
        • Keep current empirical antibiotics use and IV line before ERCP, and closely follow up the patient’s clinical condition for fear of further septic shock due to biliary tract infection;
        • Please inform us if any clinical sign deterioation before and after ERCP

[surgical operation]

  • 2023-08-07
    • Surgery
      • Pancreato-duodenectomy whipple procedure with reconstruction.
      • Including:
        • Partial gastrectomy
        • pancreato-duodenal anastomosis +
        • Billroth II
        • Braun anastomosis
    • Finding
      • Severe adhesion of previous operation site.
      • Solid medium-hard of Vater region was noted from resecction tissue, malignancy suspected.
      • Pending pathology report.
  • 2022-12-15
    • Surgery
      • laparoscope choledocho-duodenostomy
      • LC
      • Distal CBD biopsy
    • Finding
      • distal CBD stricture with stent in place

[chemotherapy]

  • 2023-11-20 - oxaliplatin 75mg/m2 125mg D5W 250mL 2hr + leucovirin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-01 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovirin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-12 - oxaliplatin 50mg/m2 80mg D5W 250mL 2hr + leucovirin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-11-21

After the surgical operation on 2023-08-07 (Pancreato-duodenectomy Whipple procedure with reconstruction, which included partial gastrectomy, pancreato-duodenal anastomosis, Billroth II, and Braun anastomosis), the tumor marker CA199 significantly decreased from four digits to two digits.

  • 2023-11-20 CA199 55.17 U/mL
  • 2023-09-14 CA199 59.52 U/mL
  • 2023-08-03 CA199 1754.46 U/mL
  • 2023-06-08 CA199 1317.82 U/mL
  • 2023-05-03 CA199 903.59 U/mL
  • 2023-04-13 CA199 806.27 U/mL
  • 2023-03-06 CA199 698.53 U/mL
  • 2023-01-31 CA199 653.74 U/mL

Lab data from 2023-11-20 indicates that, apart from slightly impaired renal function, liver function, electrolytes, and blood counts are largely within normal ranges.

No medication discrepancies identified.

700507094

231120

==========

2023-11-20

[vancomycin TDM]

U-Vanco (vancomycin) has been administered at a dose of 1000mg Q12H IVD since 2023-11-18, with scheduled administration times at 09:00 and 21:00. The blood sample was drawn on 2023-11-20 at 02:25:37, following the administration at 20:19 on 2023-11-19, and before the next dose at 12:47 on 2023-11-20. If the aim is to measure the trough level, the ideal time for blood sampling should be within half an hour before the next dose. Please confirm if the timing of the blood draw was correct.

If after confirmation, the blood draw timing is deemed accurate (indicating a vancomycin concentration of 22 mg/L is reliable), then the current dosage of 1000mg Q12H should be reduced to 750mg Q12H.

700710186

231120

[exam findings]

  • 2023-10-16 MRI - nasopharynx
    • Indication: NPC s/p C/T
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows: comparison: 2023/06/21 MRI
      • Well regression of left clivus-skull base-nasopharynx-cavernous sinus tumor with residual tumor mass.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor..
      • Markedly regression of bil. neck LAPs. Markedly regression of left parotid gland LNs.
      • Well regression of left temporal lobe brain edema.
  • 2023-07-13 Pure Tone Audiometry, PTA
    • Reliability FAIR to POOR (tinnitus+, inconsistent response)
    • Average RE 24 dB HL; LE 65 dB HL.
    • RE normal to moderately severe SNHL.
    • LE mild to severe mixed type HL.
  • 2023-06-23 Tc-99m MDP bone scan
    • Increased activity in the skull base. Malignancy with local bony involvement may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in a middle T-spine. The nature is to be determined (degenerative change? other nature?). Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the lower L-spine. Degenerative change may show this picture.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2023-06-21 MRI - nasopharynx
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:4(T_value) N:3(N_value) M:0(M_value) STAGE:IVA(Stage_value)
    • Findings
      • The left nasopharyngeal tumor involving left side of clivus, longus colli muscle, foramen ovale, foramen lacerum, and cavernous sinus, and encasing left ICA.
      • White matter edema in left anterior temporal lobe also noted.
      • Enlarged lymph nodes at both sides of the neck, also at left parotid gland and right paratracheal region.
  • 2023-06-13 Patho - nasopharyngeal/oropharyngeal
    • DIAGNOSIS:
      • Nasopharynx, left, biopsy — Non-keratinizing nasopharyngeal carcinoma, undifferentiated
    • GROSS DESCRIPTION:
      • Specimen submitted in formalin consists of several pieces of tan, irregular tissue measuring up to 0.3 x 0.2 x 0.1 cm. All for section in one cassette.
    • MICROSCOPIC DESCRIPTION:
      • Section shows several pieces of nonkeratinzing squamous cell carcinoma.
      • The immunohistochemical stains reveal CK(+) and p40(+).
    • MICROSCOPIC EXAMINATION:
      • Histologic Type (select all that apply): Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B)
      • Treatment Effect (applicable to carcinomas treated with neoadjuvant therapy): patient not received
      • Additional Pathologic Findings (select all that apply): None identified
      • Ancillary Studies: not applicable
      • Clinical History (select all that apply): Neoadjuvant therapy: No
  • 2023-06-15 Nasopharyngoscopy
    • left NP tumor, with extension to lateral pharyngeal wall
    • easily touch bleeding, biopsy done

[MedRec]

  • 2023-10-11 SOAP Radiation Oncology Huang JingMin
    • S: The patient was referred for radiotherapy due to NPC s/p induction chemotherapy.
      • PI: The patient suffered from left headache, left tinnitus, left neck pain, and left face numbness for about several months.
      • Induction chemotherapy: 2023-07-18 ~ 2023-09-29
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM (+); HTN (+)
      • Allergy (-)
      • Previous RT Hx: (-)
    • A: Non-keratinizing nasopharyngeal carcinoma, undifferentiated, stage cT4N3M0 (IVA), s/p induction chemotherapy.
    • P: Induction chemotherapy followed by CCRT is indicated for this patient with the following indicators: stage cT4N3M0 (IVA)
      • Goal: curative
      • Treatment target and volume: nasopharyngeal tumor, peripheral involved, to bilateral neck.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5000cGy/25 fractions of the nasopharyngeal tumor, peripheral involved, to bilateral neck, and 7000cGy/35 fractions of the involved nasopharyngeal tumor and bilateral neck nodal lesions.
      • The treatment planning of radiotherapy will be started at 1330, 2023-10-17.
  • 2023-10-13 SOAP Metabolism and Endocrinology Zhou Fan
    • Prescription x2
      • Galvus Met (vidagliptin 50mg, metformin 500mg) 1# QD
      • Dibose (acarbose 100mg) 1# TIDAC
      • Glimet (glimepiride 2mg, metformin 500mg) 1# QDAC
      • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
      • Concor (bisoprolol 5mg) 1# QD
  • 2023-06-19 ~ 2023-06-24 POMR Ear Nose Throat
    • Discharge diagnosis
      • Malignant neoplasm of nasopharynx T4N3M0, STAGE:IVA
    • CC
      • Blood-tinged rhinorrhea and headache for 2 months
    • Present illness
      • This is a 68-year-old woman with underlying hypertension, hyperlipidemia and diabetes mellitus under medication control for over 2 years. She had noticed blood-tinged rhinorrhea and left headache for 2 month. Left tinnitus, left neck pain and left face numbness were noted too, no body weight loss.
      • She visited LoTung PohAi Hospital for help, left nasopharyngeal lesion was noted and suggested biopsy. Denied drinking, cigarette and betel nuts. Therefore, she came to our ENT OPD for second opinion. Fiberscopic exam showed left nasopharyngeal tumor, with extension to lateral pharyngeal wall. Left otitis media with effusion and left neck mass about 8cm, can’t movable, tenderness. Biopsy of the tumor was done, and the pathology report non-keratinizing nasopharyngeal carcinoma, undifferentiated. Admission for further examination was suggested, and she agreed after thorough consideration. Therefore, under the impression of nasopharyngeal cancer, she was admitted for cancer work-up.   
    • Course of inpatient treatment
      • After admission, serial tests were arranged for tumor staging work up. Nasopharyngeal MRI showed nasopharyngeal carcinoma T4N3M0, STAGE IVA. Abdominal sonography showed gall stone. Whole body bone scan showed increased activity in the skull base. Malignancy with local bony involvement may show this picture. Under relative stable condition, the patient was dishcarged with OPD follow up.
    • Discharge prescription
      • OxyNorm (oxycodone 5mg) 1# Q6H 7D

[consultation]

  • 2023-09-01 Ophthalmology
    • Q
      • This 67-year-old woman patient is a case of Non-keratinizing nasopharyngeal carcinoma, undifferentiated, cT4N3M0, stage IVA s/p chemotherapy with TPF from 2023/07/14~. Type 2 diabetes mellitus medical history.
      • This time. for sepsis with 2023-08-28 Blood Culture showed Klebsiella pneumoniae bacteremia and Urinary tract infection 2023/08/29 Urine/C showed Klebsiella pneumoniae bacteriuria.
      • Now, for evaluate endophthalmitis of Type 2 diabetes mellitus medical history and Klebsiella pneumoniae bacteremia. Thank you.
    • A
      • S: For DR survey (HbA1c=6.7% at 2023/07), and endophthalmitis screen due to bacteremia
        • No bv
        • Admitted due to sepsis
        • 08/28 B/C: Klebsiella pneumoniae
        • 08/29 U/C: Klebsiella pneumoniae
        • phx: HTN, DM, nasopharyngeal carcinoma stage IVA s/p chemotherapy
      • O:
        • BCVA: OD 0.5X+2.00/-2.25X70 OS 0.3X0/-1.25X15
        • PT: 17/16mmHg
        • Pupil: 3mm, light reflex + ou, no RAPD
        • Conj: np ou
        • K: clear ou
        • ac: deep/clear ou
        • lens: CO2+, NS+, PSC+ ou
        • c/d 0.4
        • Fundus: exudate at paramacula od, blod hemorrahge os, c/w mild NPDR ou
        • no infiltration/no vitritis ou
      • A:
        • Mild NPDR ou
        • Cataract ou
        • No evidence of endophthalmitis at present
      • P:
        • kary 1gtt BID ou for cataract
        • Keep control underlying diseasse
        • If increased floater/red eye/increaed discharge/blurred vision, please contact us ASAP
        • I will f/u this case about 1 wk later
    • A 2023-09-08 12:00:52
      • F/U 1wk, no increased bv, no increased floater, no discharge, no FBS
        • BCVA: OD 0.15X(0.2x+2.50/-2.50X50) OS 0.0.2(0.3x+1.0/-2.00x100)
        • PT: 18/17mmHg
        • Pupil: 3mm, light reflex + ou, no RAPD
        • Conj: np ou
        • K: clear ou
        • ac: deep/clear ou
        • lens: CO2+, NS+, PSC+ ou
        • c/d 0.4
        • Fundus: exudate at paramacula od, blood hemorrahge os, c/w mild NPDR ou
        • no infiltration/no vitritis ou
      • A: No evidence of endophthalmitis at present
      • P:
        • keep kary 1gtt BID ou for cataract
        • Keep control underlying diseasse
        • If increased floater/red eye/increaed discharge/blurred vision, please contact us ASAP
        • oph opd f/u 6M for cataract and DR survey

[radiotherapy]

[chemotherapy]

  • 2023-11-06 - carboplatin AUC 2 130mg D5W 250mL 1hr (QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-10-30 - carboplatin AUC 2 130mg D5W 250mL 1hr (QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-09-25 - docetaxel 40mg/m2 60mg NS 200mL 1hr D1 + carboplatin AUC 4 300mg NS 250mL D2 + fluorouracil 1000mg/m2 1000mg NS 500mL D2-5 (TPF Q3W)
    • dexamethasone 4mg D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4 + NS 250mL D1-4
  • 2023-08-07 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + carboplatin AUC 4 300mg NS 250mL D2 + fluorouracil 1000mg/m2 1200mg NS 500mL D2-5 (TPF Q3W)
    • dexamethasone 4mg D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4 + NS 250mL D1-4
  • 2023-07-14 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + carboplatin AUC 4 300mg NS 250mL D2 + fluorouracil 1000mg/m2 1200mg NS 500mL D2-5 (TPF Q3W)
    • dexamethasone 4mg D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4 + NS 250mL D1-4

==========

2023-11-20

[Kidney function fluctuates downward]

Lab:

  • 2023-11-17 eGFR 60.17 ml/min/1.73m^2

  • 2023-11-06 eGFR 80.68 ml/min/1.73m^2

  • 2023-11-17 BUN 44 mg/dL

  • 2023-11-06 BUN 19 mg/dL

It is recommended that 50% of the usual total daily dose of metoclopramide be given if CrCl falls between 10 and 60 mL/minute.

2023-10-31

[decline in renal function over the last month]

The patient’s renal function has deteriorated over the past 30 days.

  • 2023-10-26 BUN 60 mg/dL

  • 2023-10-11 BUN 48 mg/dL

  • 2023-10-05 BUN 34 mg/dL

  • 2023-09-25 BUN 19 mg/dL

  • 2023-10-26 Creatinine 1.12 mg/dL

  • 2023-10-11 Creatinine 0.99 mg/dL

  • 2023-10-05 Creatinine 0.92 mg/dL

  • 2023-09-25 Creatinine 0.85 mg/dL

Carboplatin is associated with decreased creatinine clearance (27%), increased blood urea nitrogen (14% to 22%)

Valsartan may be associated with increased serum creatinine and/or acute kidney injury. Increases in serum creatinine secondary to angiotensin receptor blockers usually stabilize within 20% to 30% from baseline and are expected; additional increases may indicate renal artery stenosis or volume depletion.

Adverse events reported post-marketing include interstitial nephritis with famotidine, acute interstitial nephritis with amlodipine, and acute kidney injury, Fanconi syndrome, proximal tubular nephropathy, and renal tubular necrosis with tenofovir alafenamide.

2023-08-30

After reviewing the PharmaCloud and HIS5 records for this admission, no medication reconciliation issues were identified.

2023-08-08

No medication reconciliation issues were found when this admission after reviewing PharmaCloud and HIS5.

700893323

231120

[lab data]

2023-07-24 Anti-HCV Nonreactive
2023-07-24 Anti-HCV Value 0.25 S/CO
2023-07-24 Anti-HBc Reactive
2023-07-24 Anti-HBc-Value 6.92 S/CO
2023-07-24 Anti-HBs 7.37 mIU/mL
2023-07-24 HBsAg Nonreactive
2023-07-24 HBsAg (Value) 0.27 S/CO

[exam findings]

  • 2023-08-01 Patho - gingival/oral mucosa biopsy
    • Oral cavity, root of tooth 37, biopsy— acute and chronic inflammation
  • 2023-07-26 Tc-99m MDP bone scan
    • A hot spot in the left 5th rib, and increased activity in bilateral femurs, tibiae, and left ankle, the nature is to be determined (post-traumatic change or other nature ?), suggesting folllow-up with bone scan in 3 months of reinvestigation.
    • Suspected benign lesions in both rib cages, maxilla, mandible, some T- and L-spine, L-S junction, bilateral shoulders, and hips.
  • 2023-07-26 Patho - gingival/oral mucosa biopsy
    • Lower lip, left, incisional biopsy — Squamous cell carcinoma, moderately differentiated
    • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and subtle stromal invasion. Keratin formation is evident. Tumor necrosis with bacterial colonies can be found also.
  • 2023-07-25 MRI - nasopharynx
    • Findings
      • Tumor mass in left low lip and left buccal region, up to 33 mm.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Multiple enlarged LNs in left level I-II space, some of them clustered.
      • No evident bony destructive lesion.
    • IMP: Left buccal and low lip CA, T2N2bMx stage IVA.
  • 2023-07-14 Ribs Bilat.
    • fractures at left 2nd and 5th ribs
  • 2023-07-14, -04-14 SONO - abdomen
    • Liver cirrhosis, with splenomegaly
  • 2023-03-17 Nerve Conduction Velocity, NCV
    • Findings: The NCV study showed (1) Prolonged distal motor latency in most sampled nerves. (2) Decreased CMAP amplitude in bilateral median and bilateral peroneal nerves. (3) Slowing motor and sensory conduction velocity in most sampled nerves. The F wave study showed prolonged latency in most sampled nerves. The H reflex study showed both prolonged. The QST study showed abnormal heat and cold sensation in lower limb.
    • Conclusion: The above findings suggest sensorimotor polyneuropathy and small fiber disease. Advise clinical correlation.
  • 2023-03-11 L-spine AP + Lat (including sacrum)
    • compression fracture at L2 vertebral body
    • moderate decreased disc space in the L5/S1 disc.
    • blurred nargins of the L5 vertebral body.
  • 2022-11-21 CT - abdomen
    • Swelling of the cecum, ascending colon is found. Colitis is considered.
    • Dilated esophagus with out-poutching at lower third esophagus is found. Diverticulum or othere is considered.

[MedRec]

  • 2023-08-16 SOAP Oral and Maxillofacial Surgery He ChengHan
    • P: The subsequent chemotherapy was arranged by Dr. Xia HeXiong from the Hematology-Oncology department. Oral UFUR
    • Prescription
      • UFT (tegafur 100mg, uracil 224mg) 2# BID
  • 2023-08-08 SOAP Hemato-Oncology Xia HeXiong
    • A/P
      • 24 hours CCr, audiometry, 5-FU in D5W
      • Refer to CS Chief Hsieh for Port-A implantation
  • 2023-07-24 ~ 2023-08-01 POMR Oral and Maxillofacial Surgery He ChengHan
    • Discharge diagnosis
      • Squamous cell carcinoma of left lower gingiva and lower lip, cT2N2bM0, cstage IVA
      • Inflammatory conditions of jaws
      • Hyperkalemia
      • Cirrhosis of liver
      • Splenomegaly
      • Gout, unspecified
      • Essential (primary) hypertension
      • Functional dyspepsia
      • Functional intestinal disorder
    • CC
      • I had PROTRUDING mass lesion of my left lower lip for 1+ months.
    • Present illness
      • According to his statement, the present illness should be traced back to 1+ moths. This 54 year-old male patient, he felt an unhealed and protruding mass lesion of his left lower lip. He did not pay attention to it it in the beginning. Until he FOUND OUT THE MASS on his left lower lip KEPT GROWING and it because much more painful and swelling than it was. He visited to our oral & Maxillary clinic on 2023/07/17, which mouth finding showed protruding, ulcerative mass of left lower lip with induration, more than 2.5cm large. No palpable neck mass was palpated. Suspected malignancy of left lower gingiva and lower lip was impressed. After we had adequately explained the finding and treatment plans to the patient. He was admitted to ward for tumor survery and further management.
    • Course of inpatient treatment
      • After admission, we had arrange physcial examination was done and hyperkalemia (K+ 6.6 mmol/L) was found. RI infusion, hydration and Kalimate were prescribed. Incisional biopsy of left mandibular gingiva under local anesthesia on 2023/07/25. The pathology report showed squamous cell carcinoma. Then we had arrange tumor survey for him. The nasopharynx MRI showed tumor mass in left low lip and left buccal region, up to 33 mm, cT2N2bM0, cstage IVA. Abdomen sona showed liver cirrhosis, with splenomegaly. Whole body bone scan no evidence of distance metastasis. Another, his Anti-HBc(+) with cirrhosis. Due to the result of tumor work-up, we had consulted GI men and oncologist. We had well explained patient`s treatment plans in the future to patient and his family.
      • Complicated extraction of tooth 37, 38 and sent for pathological examination under local anesthesia on 2023/08/01. kept antibiotic agent and analegsic agent were prescribed. Ice packing and cool soft diet was educated.
      • Because of his general condition were stable, he was discharged and OPD follow up.
    • Discharge Prescription
      • UFT (tegafur 100mg, uracil 224mg) 2# BID
      • Acetal (acetaminophen 500mg) 1# Q4H
      • amoxicillin 250mg 2# Q8H
      • Parmason Gargle Solution (chlorhexidine) QD GAR
  • 2023-07-17 SOAP Oral and Maxillofacial Surgery He ChengHan
    • S
      • The patient mentioned that the swelling of the lower left lip only started in the last two weeks.
      • betel nut chweing: more than 20 years, on and off
      • PH: anemia under iron Tx; left ribs fx
      • Allergy: keto
    • O
      • Protruding, ulcerative mass of left lower lip with induration, more than 2.5cm large
      • no palpable neck mass was palpated
      • tooth 36 severe attrition, dentinal hypersensitivity was noted.
      • Panoramic findings:
        • Missing: 13
        • Impaction: nil
        • Crown and Bridge: 14
        • Caries: nil
        • Periodontal condition: chronic periodontitis
      • extensive bony destruction of left posterior mandible
    • Assessment:
      • suspected malignancy of left lower gingiva extenidng to left lower lip
    • Plan:
      • explain the current condition to the patient
      • arrange incisional biopsy
  • 2023-06-10 SOAP Neurology Xu BoRen
    • S
      • Alcholism
      • Slow progressive four limb weakness or four since 2022/10
      • arthritis
      • sphincter problem (+)
      • 2023/03/11
        • marked improved of limb weakness, no sphincter problem now
        • need cane to walk
        • The patient doesn’t see the original infectious disease specialist and wants me to prescribe the medication from there.
      • 2023/03/24
        • stable, no further weakness
      • 2023/06/10
        • stable
    • O
      • 2023/03/11 Suggest GI OPD for gall bladder or liver disease
    • A/P
      • General weakness, hypo Mg related
      • may taper PPI and Fe next time
    • Prescription x3
      • Anxiedin (lorazepam 0.5mg) 1# TID
      • Cardilol (propranolol 10mg) 1# BID
      • Foliromin (ferrous sodium citrate 50mg) 1# BID
      • Feburic (febuxostat 80mg) 1# QD
      • Rich (lansoprazole 30mg) 1# QDAC 20221121 EGD GERD LA-A doudenal ulcer scar
      • Through (sennoside 12mg) 2# HS
      • Utapine (quetiapine 25mg) 0.5# HS
      • MgO 250mg 1# TID
      • Acetal (acetaminophen 500mg) 1# PRNBID
      • Kentamin (B1 50mg, B6 50mg B12 500ug) 1# QD
  • 2023-01-14 SOAP Infectious Disease
    • S
      • Visit for refill medicine as usual.
      • History: alcoholism.
    • P
      • Symptomatic treatment as needed.
    • Prescription
      • Anxiedin (lorazepam 0.5mg) 1# QID
      • Cardiolol (propranolol 10mg) 1# BID
      • Foliromin (ferrous sodium citrate 50mg) 1# BID
      • Feburic (febuxostat 80mg) 1# QD
      • Takepron (lansoprazole 30mg) 1# QDAC 20221121 EGD GERD LA-A doudenal ulcer scar
      • Through (sennoside 12mg) 2# HS
      • Utapine (quetiapine 25mg) 0.5# HS
      • Acetal (acetaminophen 500mg) 1# PRNQD
  • 2018-01-11 SOAP Rheumatology and Immunology
    • Diagnosis
      • Gout, unspecified [M10.9]
      • Carpal tunnel syndrome [G56.00]
      • Peptic ulcer, site unspecified, unspecified as acute or chronic, without haemorrhage or perforation [K27.9]
      • Essential hypertention, unspecified [I10]
      • Unspecified inflammatory polyarthropathy [M06.4]
    • Prescription
      • colchicine 0.5mg 1# QD
      • Feburic (febuxostat 80mg) 1# QD
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQD
  • 2017-11-04 SOAP Rheumatology and Immunology
    • S
      • acute urticaria after medication from ER (for SOB)
      • HBV told(?)
      • Crea:1.5->1.2->1.4
      • UA:5.8
      • ANA(-)RF(-)CCP(-)B27(-)
      • alcoholism
      • susp. drug allergy
      • steroid contraindicated due to possible HBV carrier
      • suggest hold current medication
      • suggest ER visit if necessary
      • suggest avoid alcohol
    • O
      • Drug allergy: NSAID, PCN
      • PH: gout? RA? (erosion?)
    • Diagnosis
      • Allergic urticaria [L50.0]
    • Prescription
      • Sinbaby Lotion (zinc oxide, diphenhydramine, dibucaine hydrochloride, dl-camphor) BID TOPI
      • Welizen (famotidine 20mg) 1# BID
      • Kefen KFT112 (ketotifen 1mg) 1# HS
      • Estimin (ebastine 5mg) 1# BID

[consultation]

  • 2023-09-13 Family Medicine
    • Q
      • This 54 year-old male patient had gout, GERD, HTN, liver cirrhosis, probably due to hepatitis B and hyperkalemia due to possible acute kidney injury. He had suffered from squamous cell carcinoma of left cT2N2bM0, cstage IVA. He had consulted for hospice combined care. Thanks !!
    • A
      • A 54 year-old male, case of terminal stage of squamous cell carcinoma of left mandibular gingiva (cT2N2bM0, cstage IVA), liver cirrhosis, hepatitis B and hyperkalemia due to possible acute kidney injury.
      • IPP held on 9/13 and had discussed about further treatment plan with patient and his family.
      • Patient decided try agressive treatment.
      • We will arrange hospice combine care and follow up his condition.
      • Indication: left mandibular gingiva squamous cell carcinoma
      • Plan: hospice combined care
  • 2023-08-23 Nephrology
    • Q
      • This 54 year-old male patient, diagnosis was Squamous cell carcinoma of left lower gingiva extenidng to left lower lip, cT2N2bM0, Stage IVA.
      • PH:
        • Liver cirrhosis, with splenomegaly and irregular follow up GI clinic.
        • Hypertension
        • Gout
        • Peptic ulcer and acute cholecystitis
        • Bilateral carpel tunnel syndrome, status post relased over left side on 2015/09/08
        • Right THR on 2007/11/15, status post closed reduction on 2009/10/04, 2010/06/11, 2010/06/26, 2010/07/20, 2010/11/29, 2012/01/30, 2012/03/14 and 2012/04/10 due to dislocation
      • For poor renal function and hyperkalemia was noted, we need your consultation for evaluation. Thanks a lot!!
    • A
      • Based on our medical record, he developed acute kidney injury when he was found to have hyperkalemia during his previous visit on 7/14. Over the course of hospitalization recently (7/24-8/1), his blood tests showed elevated levels of creatinine and potassium.
      • This time, blood test showed hyperkalemia and slightly elevated creatinine and BUN levels (not obtained on the same day)
        • 2023-08-23 Creatinine 1.29 mg/dL
        • 2023-08-23 K(Potassium) 4.6 mmol/L
        • 2023-08-23 K(Potassium) 4.3 mmol/L
        • 2023-08-22 K(Potassium) 5.0 mmol/L
        • 2023-08-22 K(Potassium) 5.9 mmol/L
        • 2023-08-22 K(Potassium) 5.0 mmol/L
        • 2023-08-21 K(Potassium) 6.2 mmol/L
        • 2023-08-21 BUN 29 mg/dL
      • Our impressions are as follows:
        • Hyperkalemia due to possible acute kidney injury
      • Our advices are as follows:
        • Record daily I/O and BW
        • Review current medications, avoid nephrotoxic agents (e.g. NSAID) and medications that cause hyperkalemia (e.g. Spironolactone)
        • Follow up serum potassium levels closely at least QD, and monitor for typical EKG changes of hyperkalemia
        • If follow up serum K remains elevated, perform the following survey:
          • Urine K, Osm, Cre, Na (to evaluate urine K excretion and distal Na delivery)
          • Serum K, Osm, Cre (to evaluate TTKG)
        • Please be assured that we will continue to follow up on this patient. Feel free to contact us should you require further assistance. Thank you.
  • 2023-07-28 Hemato-Oncology
    • Q
      • For neoadjuvant chemotherapy.
      • This is a 55-year-old male patient suffering from malignant tumor of left lower lip and was admitted to our ward for further managment on 2023/07/24.
      • After admitted, biopsy was done and showed moderately-differentiated squamous cell carcinoma.
      • Nasopharynx MRI revealed left buccal and low lip CA, T2N2bMx stage IVA.
      • However, based on our clinical examination, mandibular bone invasion was highly suspected, thus the staging might be cT4aN2bM0, stage IVA.
      • After discussing with the patient and his family, neoadjuvant chemotherapy before surgery is preferred.
      • Thus, we need your expertise for further management of neoadjuvant chemotherapy for the patient. Thanks for your time
    • A
      • This 55 year old man is a case Squamous cell carcinoma, moderately differentiated of left lower lip, cT2N2bM0, stage IVA, Liver cirrhosis, with splenomegaly, Hypertension, Gout, Peptic ulcer, ACKD, and anti HBc positive. We are consulted for neoadjuvant chemotherapy.
      • Pathology show
        • Lower lip, left, incisional biopsy — Squamous cell carcinoma, moderately differentiated
        • The specimen submitted consists of three pieces of gray-tan soft tissue, measuring up to 1.0 x 0.4 x 0.1 cm. All for section.
        • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and subtle stromal invasion. Keratin formation is evident. Tumor necrosis with bacterial colonies can be found also.
      • Suggestion:
        • Adequate hydration for AKI with hyperkalemia
        • Antibiotic for bacterial colonies found at pathology
        • Arrange our OPD after discharge. We had well explaint to patient about high risk of chemotherapy due to cirrhosis underline and renal insuffiency.
  • 2023-07-28 Gastroenterology
    • Q
      • This 54 year-old male patient, had suffered from unhealed and protruding mass lesion of his left lower lip for 1+ months ago. Suspected malignancy of left lower gingiva and lower lip was impressed, he was admitted to ward for further management. However, his abdomen sona showed liver cirrhosis, with splenomegaly. Anti-Hbc reactive, value 6.92, Anti-Hbs (-) and HbsAg (-). We need your further evaluation and suggestion.
    • A
      • S: 54 years old man was admitted for oral cancer and preoperation survey. However, due to Anti-HBc(+) under cirrhosis, we are consulted.
      • O
        • conscious: clear
        • chest: smooth breath pattern
        • abdomen: soft and flat
        • Lab
          • 2023-07-24 Anti-HCV Nonreactive
          • 2023-07-24 Anti-HBs 7.37 mIU/mL
          • 2023-07-24 Anti-HBc Reactive
          • 2023-07-24 HBsAg Nonreactive
          • 2023-07-24 PT 10.4 sec
          • 2023-07-24 S-GOT/AST 27 U/L
          • 2023-07-24 S-GPT/ALT 9 U/L
          • 2023-07-24 Bilirubin total 0.52 mg/dL
        • 2023-07-14 abdominal echo Diagnosis: Liver cirrhosis, with splenomegaly
      • impression
        • Occult HBV infection
        • Liver cirrhosis, probably due to hepatitis B
        • Left buccal and low lip CA, T2N2bMx stage IVA, pending pathology
      • suggestion
        • The prophylactive antiviral treatment of HBV is indicated during the chemotherapy
        • GI OPD follow-up is indicated for the condition of liver cirrhosis
        • Contact us to prescribe the antiviral agent when the chemotherapy is to be launched
  • 2023-07-14 Oral and Maxillofacial Surgery
    • Q
      • no fever
      • no vomiting
      • left chest pain after contusion accidentally (when moving things) noted in recent one week
      • left toothache and lip swelling noted for 2~3 weeks
      • PH: anemia under iron supplement Tx; left ribs fx
      • Allergy: keto
    • A
      • This 54-year-old-man took blood test today, and was sent to ER due to hyperkalemia. The ER found that the patient has a protruding mass on his lower lip.
        • General codition: HTN, HBV??
        • Alcholism, Betal nut and cigarette history for 20~30 years, have quitted for 6 months.
      • S: I have swelling over lower lip for 3~4 weeks, there’s no pain at all. I have pain over my lower left tooth.
      • O:
        • Protruding, ulcerative mass of left lower lip with induration
        • tooth 36 severe attrition, dentinal hypersensitivity was noted.
        • lab data:
          • CRP 2.8 mg/dL
          • K(Potassium) 6.8 mmol/L
          • WBC 8.51 x10^3/uL
      • A:
        • Unspecified soft tissue tumor of lower left lip, highly sespect oral cancer
        • Pulpitits of tooth 36 due to attrition
      • P:
        • Physical examination. Explain the findings to the patient and his wife.
        • Please contact us after the patient’s general condition is stable.
  • 2022-11-25 Psychosomatic Medicine
    • Q
      • This is a 50-year-old man with previous history of gout, GERD, HTN, and right ulnar styloid fracture.
      • The patient developed general weakness for one month, and the weakness got even worse in the past two weeks.
      • He is a alcoholism, generalized tremor was found, we consulted Neurologist for alcoholic tremor, they suggested check TSH, Free T4, CK and arrange NCV.
      • We added Cardiolol PO and Ativan po for irritable and tremor. He also has visual hallucination for recent days. We need your expertise and evaluation! Thanks a lot!
    • A
      • Psychiatric impression:
        • Acute agitated state
        • r/o Acute delirium
        • r/o Alcohol dependence with withdrawal
      • Symptoms and course:
        • This is a 50 y/o male patient with underlying alcoholism, gout, GERD. He was admitted this time under the impression of: UGI bleeding, cellulitis of foot, and colitis of ascending colon and cecum, the patient was admitted for further evaluation and management. We were consulted for the irritable mood and suspect visual hallucination at night.

        • According to the patient and his wife: A 50-year-old male, living with his wife and son, was a logistics driver for over 10 years and has no history of psychiatric treatment. He left his job a month ago, stating that he resigned due to disagreements with his supervisor. He began social drinking in high school, and over time, the amount and strength of alcohol consumed gradually increased. He now drinks 350ml bottles of sorghum liquor, 1-2 bottles daily. When not drinking, he experiences cravings and withdrawal symptoms, and when drunk, he talks nonsense and reports seeing strange things.

        • The patient and his family indicate that about three weeks ago, after leaving his job, he resolved to stop drinking. He claims that he has not touched alcohol since that day (though his account is somewhat inconsistent). He has been staying at home feeling gloomy, depressed, and irritable, but denies having suicidal thoughts. His wife notes that he was mentally clear during this period but started feeling general weakness before admission to the hospital. After admission, he exhibited irritability, restlessness, incoherent speech, and possible visual hallucinations.

        • Upon visit, he showed mild muddy spirit, limited orientation to time, people and place, rather stable mood. Coherant but sometimes irrelevant speech. Currently denied suicide ideation, denied hallucination. Poor memory function for years. Confabulation(+/-), nystagmus(+), unsteady gait, withdrawal symptom(+): tremor, palpitation.

      • Suggestion:
        • Check and correct underlying cause for the delirium: Infectin, anemia, electrolyte imbalance, blood gas, ammonia, pain, urine retention…
        • Utapine (25mg) 1# HS for the agitation and VH at night; Anxicam 0.5amp IM PRNQ6H if noted still irritable
        • Adequate IVF support, add B-complex IV 1amp QD , can gradually switch to thiamine PO 2# QD
        • Anxiedin 1# QID to reduce the withdrawal symptoms, gradually tapper anxiedin if showed improved autonomic hyperarousal signs (hypertension and tachycardia)
        • Arrange brain CT for evaluation
        • Maintain daylight exposure and activity during the day, reduce noise and light at night, and reposition frequently.
        • Arrange PSY OPD follow up
  • 2022-11-22 Neurology
    • Q
      • This is a 50-year-old man with previous history of gout, GERD, HTN, alcoholism and right ulnar styloid fracture.
      • The patient developed general weakness for one month, and the weakness got even worse in the past two weeks. Generalized limbs tremor was found. Erythenatous change with mild tenderness over left ankle and foot was note. Laboratory data showed leukocytosis, normocytic anemia, and stool OB 3+. Gastrscopy showed suspected duodenal ulcer and large esophageal diverticulum. Abdominal CT revealed esophageal diverticulum colitis of ascending colon and cecum.
      • Due to generalized limbs tremor and weakness, we need your expertise and evaluation! Thanks a lot!
    • A
      • O
        • CN: intact
        • MP: RU:4+ RL:4- LU:4+ LL:4-
        • Bil action tremor was noted for more then one year
      • Imp:
        • general weakness, cause to be determined
        • bil hand action tremor, r/o alcoholic tremor, r/o essential tremor
      • Suggestion:
        • Check CK, TSH and free T4
        • Arrange NCV (upper and lower limbs, both sensory and motor, F wave, H refelx, QST)
        • may try propranolol #1 BID for action tremor if no contraindication such as asthma or bradycardia

[chemotherapy]

  • 2023-11-22 - docetaxel 40mg/m2 60mg NS 150mL 1hr + carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. Carbo AUC 1.5)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-16 - docetaxel 40mg/m2 60mg NS 150mL 1hr + carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. Carbo AUC 1.5)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-11 - docetaxel 40mg/m2 60mg NS 150mL 1hr + carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. Carbo AUC 1.5)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-14 - docetaxel 30mg/m2 45mg NS 150mL 1hr + carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. Carbo AUC 1.5)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-22 - carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. no taxel; Carbo AUC 1.5)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-15 - carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr (TPF Q3W. no taxel; CrCl 47 Carbo AUC 1.5; 5FU C1 24hr)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-22 - docetaxel 40mg/m2 0mg NS 250mL 1hr + cisplatin 40mg/m2 0mg NS 500mL + fluorouracil 2000mg/m2 0mg NS 500mL 46hr (TPF Q3W) [TEMP] (not conducted)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2

==========

2023-11-20

[hyperkalemia episodes]

Episodes of hyperkalemia have occurred several times in the past 5 months. During this period, the highest recorded serum creatinine level was 1.8mg/dL, and the eGFR consistently remained above 40 mL/min/1.73m^2, suggesting that the kidneys should still have the capacity to excrete excess potassium.

  • 2023-11-20 K(Potassium) 4.7 mmol/L
  • 2023-11-16 K(Potassium) 4.1 mmol/L
  • 2023-11-13 K(Potassium) 4.2 mmol/L
  • 2023-11-10 K(Potassium) 4.9 mmol/L
  • 2023-11-07 K(Potassium) 5.9 mmol/L *
  • 2023-10-13 K(Potassium) 4.8 mmol/L
  • 2023-10-11 K(Potassium) 5.9 mmol/L *
  • 2023-10-03 K(Potassium) 6.6 mmol/L ***
  • 2023-09-20 K(Potassium) 3.4 mmol/L
  • 2023-09-13 K(Potassium) 3.9 mmol/L
  • 2023-09-12 K(Potassium) 6.0 mmol/L **
  • 2023-09-11 K(Potassium) 5.9 mmol/L *
  • 2023-09-06 K(Potassium) 5.6 mmol/L *
  • 2023-08-25 K(Potassium) 4.2 mmol/L
  • 2023-08-24 K(Potassium) 4.3 mmol/L
  • 2023-08-23 K(Potassium) 4.5 mmol/L
  • 2023-08-23 K(Potassium) 4.6 mmol/L
  • 2023-08-23 K(Potassium) 4.3 mmol/L
  • 2023-08-22 K(Potassium) 5.0 mmol/L
  • 2023-08-22 K(Potassium) 5.9 mmol/L *
  • 2023-08-22 K(Potassium) 5.0 mmol/L
  • 2023-08-21 K(Potassium) 6.2 mmol/L **
  • 2023-07-25 K(Potassium) 5.0 mmol/L
  • 2023-07-24 K(Potassium) 6.0 mmol/L **
  • 2023-07-24 K(Potassium) 6.6 mmol/L ***
  • 2023-07-14 K(Potassium) 4.5 mmol/L
  • 2023-07-14 K(Potassium) 5.3 mmol/L
  • 2023-07-14 K(Potassium) 6.8 mmol/L ***

Upon reviewing the patient’s recent medication history, it was found that olmesartan, a component of Sevikar, could be a potential cause of hyperkalemia, especially considering the patient’s risk factors such as renal dysfunction, diabetes mellitus, concurrent use of potassium-sparing diuretics, potassium supplements, and/or potassium-containing salts. Sevikar has already been discontinued. Additionally, propranolol, which is currently being used, has been sporadically reported in post-marketing studies to be associated with hyperkalemia, although it is considered a less likely cause.

Could hypoaldosteronism be a potential cause in this case?

2023-11-09

[reconciliation]

On 2023-10-18, this patient just refilled his repeat prescription for a 28-day supply of MgO, lansoprazole, sennoside, Kentamin, sodium ferrous citrate, propranolol, febuxostat, quetiapine fumarate, lorazepam. No discrepancies have been found with these medications currently in use.

[alcohol abstinence]

Abstaining from alcohol is the foundation of managing alcohol-associated cirrhosis. This abstinence has been linked to improvements in fibrosis, as well as lower hepatic venous pressure gradients.

Lab tests (2023-11-07) revealed normal AST, ALT, and total bilirubin levels. If the cirrhosis worsens and becomes decompensated, Baraclude (entecavir 1mg) may be a viable treatment option.

2023-08-22

[reconciliation]

Recent MCV and MCH levels have consistently been on the upper end of their normal range, suggesting that iron deficiency anemia is less probable. The ongoing use of the iron supplement Foliromin (ferrous sodium citrate) may be reduced.

  • 2023-08-21 MCV 92.3 fL

  • 2023-07-24 MCV 93.0 fL

  • 2023-07-14 MCV 92.6 fL

  • 2023-06-10 MCV 92.3 fL

  • 2023-08-21 MCH 31.0 pg

  • 2023-07-24 MCH 30.6 pg

  • 2023-07-14 MCH 30.2 pg

  • 2023-06-10 MCH 30.6 pg

701453601

231120

[exam findings]

  • 2023-09-22 Patho - omentum biopsy
    • Soft tissue, left para-aortic space, CT-guide biopsy — Metastatic neuroendocrine carcinoma
    • Microscopically, the sections show a picture of small blue round cells with focal crush artifact, which immunohistochemistry shows CK (equivocal), CD56 (+) and synaptophysin (+, focal). No lymph node parenchyma is included. According to histopathologic findings and patient’s past history, it is compatible with metastatic neuroendocrine carcinoma.
  • 2023-09-06 CT - abdomen
    • History: small cell neuroendocrine carcinoma of gastric with a 4.2cm ulcerative mass, cT2N2M0, s/p radical subtotal gastrectomy with D2 LN dissection Roux-en-Y GJ anastomosis, pathology showed Neuroendocrine carcinoma, pT4aN3a(cM0), stage IIIB on 3/14, with Perineural invasion+, Lymphovascular invasion, Ki-67= 60%.
    • Findings:
      • There are several newly developed enlarged nodes in left para-aortic space and the largest one 2.4 x 1.8 cm in size.
        • Metastatic nodes are highly suspected.
      • Abdominal aorta shows atherosclerosis, ectasia 2.2 cm and mild intramural thrombus formation.
      • S/P subtotal gastrectomy
      • Right. renal stones (<5mm).
    • Impression:
      • Metastatic nodes in left para-aortic space are noted.
  • 2023-06-12 CT - abdomen
    • History and indication: Gastric tumor
    • IMP:
      • S/P gastric operation. No evidence of tumor recurrence.
      • Bil. renal stones (2-4mm).
      • R/O CBD stone (5mm).
  • 2023-04-01 Pure Tone Audiometry, PTA
    • Reliabilty Fair
    • R’t : 41 dB HL, normal to severe mixed type HL
    • L’t : 45 dB HL, normal to profound mixed type HL.
  • 2023-03-17 CXR
    • S/P Port-A infusion catheter insertion.
    • Interstitial pattern at LLL.
  • 2023-03-10 Patho - stomach subtotal/total (tumor)
    • PATHOLOGIC DIAGNOSIS
      • Stomach, subtotal gastrectomy — Neuroendocrine carcinoma
      • Margins, bilateral cutting ends, subtotal gastrectomy — Free of tumor invasion
      • Lymph nodes, D2 LN dissection — Metastatic neuroendocrine carcinoma (10/28)
      • AJCC Pathologic staging — pT4aN3a(cM0), stage IIIB
    • MACROSCOPIC EXAMINATION
      • Specimen type: Stomach and regional lymph nodes
      • Specimen size: 22.5 cm along greater curvature and 12.5 cm along the lesser curvature
      • Number of lesions: Solitary
      • Tumor site: Low body, lesser curvature, 6.0 cm from distal margin
      • Tumor size: 4.8 x 4.2 cm in size
      • Tumor configuration: Ulcerative mass
      • Representative sections as follows: A1= proximal margin, A2= distal margin, A3-A6= tumor, B= LN 1, C= LN 3, D1-D2= LN 4, E= LN 5, F= LN 6, G1-G3= LN 7,8,9,11p
    • MICROSCOPIC EXAMINATION
      • Histologic type: Neuroendocrine carcinoma, combined small cell and large cell types
      • Histologic grade: Poorly differentiation (G3)
      • Depth of tumor invasion: Tumor invades the serosa
      • Margins: Radial margin is involved by carcinoma
      • Perineural invasion: Present
      • Lymphovascular space invasion: Present
      • Regional lymph nodes: Metastatic carcinoma (10/28)
        • 0 (LN 1), 5/5 (LN 3), 1/3 (LN 4), 0/1 (LN 5), 0/3 (LN 6), 4/16 (LN 7, 8, 9, 11p); (Number of LN involved/Number of LN examined)
      • Extracapsular extension: Present
      • Additional pathologic findings: Non-atrophic chronic gastritis
      • Pathologic Staging: pT4aN3a(cM0), stage IIIB
      • IHC (S2023-03207): CK(+), CD56(+), Synaptophysin(+), TTF-1(+), Ki-67= 60%
  • 2023-03-007 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 30) / 116 = 74.14%
      • M-mode (Teichholz) = 74
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated LA; impaired LV relaxation.
      • Normal RV systolic function.
      • Moderate MR; mild to moderate AR; mild to moderate TR; mild PR.
      • Mildly dilated ascending aorta.
      • A calcified atheroma (1.04cm of thickness) at aortic root.
  • 2023-03-06 ECG
    • Normal sinus rhythm
    • ST & T wave abnormality, consider inferolateral ischemia
    • Abnormal ECG
  • 2023-02-27 CT - abdomen
    • Abdominal CT with and without enhancement revealed:
      • Ulcerative mass at gastric body measuring 4.2cm in largest dimension is found. Huge lymph nodes are found at celiac trunk (3.4cm) and gastrohepatic ligment (n=4) is found.
    • Imp: Gastric cancer at body with reiongal lymphadenopathy (n=4)
    • Imaging Report Form for Gastric Carcinoma
    • Impression (Imaging stage): T:T2(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-02-22 Patho - stomach biopsy
    • Stomach, angularis, biopsy — small cell neuroendocrine carcinoma, origin?, please see microdescription
    • Sections show gastric mucosa with infiltration of large nests of small hyperchromatic tumor cells, scanty cytoplasm and marked crushing artifact.
    • The immunohistochemical stains reveal CK(+), CD56(+), Synaptophysin(+), TTF-1(+), and LCA(-). The Ki-67 is about 60%. Small cell neuroendocrine carcinoma of stomach may also be positive for TTF-1. Please correlate with the clinical presentation and image study to confirm tumor origin from lung, stomach, or other area.
  • 2023-02-22 Esophagogastroduodenoscopy, EGD
    • Findings
      • Esophagus: No mucosa break was seen. No definite lesion.
      • Stomach: One A2 ulcer (large 3.5 cm , deep with some old blood clot) over angularis, biopsy was done
    • Diagnosis
      • Gastric ulcer, big, A2 ulcer over angularis

[MedRec]

  • 2023-09-12 SOAP General and Gastrointestinal Surgery Wu ChaoCun
    • Prescription x3
      • hydroxocobalamin 1mg/mL/amp Q2W IM
      • Mopride (mosapride citrate 5mg) 1# TID
      • Foliromin (ferrous sodium citrate 50mg) 1# BID
      • Ulstop (famotidine 20mg) 1# BID
  • 2023-04-28 ~ 2023-04-30 POMR Hemato-Oncology
    • Course of inpatient treatment
      • After admission, he receice chemotherapy with EP (Cisplatin 75mg/m2 D1 –> due to Cr:1.31, eGFR :57, change to Carboplatin AUC:5, Etoposide 100mg/m2 D1-D3) on 2023/04/28-04/30, with adequate hydration. Mopride 5mg/tab 1# TID and Primperan 1amp IVD PRNQ6H for nausea and vomiting. Chronic viral hepatitis B with Baraclude 0.5mg/tab 1# PO QDAC. Chronic gastric ulce with Nexium 40mg/tab 1# PO QDAC. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/04/30 and OPD followed up later.
    • Prescription
      • Granocyte (lenograstim 250ug) QD SC 3D (on 2023-05-04,05,06)
      • Acetal (acetaminophen 500mg) 1# PRNQ6H (post GCSF, if bone pain or BT > 38’C)
  • 2023-04-27 SOAP Hemato-Oncology
    • O - AE: Gr 4 neutropenia -> improved
  • 2023-04-20 SOAP Hemato-Oncology
    • O - AE: Gr 4 neutropenia
  • 2023-04-13 SOAP Hemato-Oncology
    • O
      • Cancer Treatment - Chemoradiation/Targeted Therapy Side Effects Assessment (2023-04-13)
        • Renal function (Creatinine level): Grade 2: > 1.5-3 times the upper limit of normal.
        • Renal function (Creatinine level) Management: Supportive care.
  • 2023-03-31 ~ 2023-04-06 POMR Hemato-Oncology
    • Discharge diagnosis
      • Small cell neuroendocrine carcinoma, cT2N2M0, s/p radical subtotal gastrectomy with D2 lumph node dissection and Roux-en-Y gastrojejunostomy anastomosis on 2023/03/09, pT4aN3a(cM0), stage IIIB, with Perineural invasion+, lymphovascular space invasion
      • Chronic viral hepatitis B without delta-agent
    • Course of inpatient treatment
      • After admission, he received PTA and record 24 hrs Ccr before chemotherapy, PTA on 2023/04/01 showed reliabilty fair, 24 hrs Ccr showed 101.0 mL/min, total urine 1300ml. He receice chemotherapy with EP (Cisplatin 75mg/m2 D1, Etoposide 100mg/m2 D1-D3) on 2023/04/03-04/05, with adequate hydration. Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H for nausea and vomiting. Chronic viral hepatitis B with Baraclude 0.5mg/tab 1# PO QDAC. Patient tolerated the chemotherapy with mild nausea without vomiting and hiccup were noted, after treatment improving. With the stable condition, he was discharged on 2023/04/06 and OPD followed up later.
    • Prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Through (sennoside 12mg) 2# HS
      • Bafen (baclofen 5mg) 1# PRNQ8H
  • 2023-03-28 SOAP Hemato-Oncology
    • S
      • For further management of the disease
      • Hbs Ag (-), Anti-HBc (+), Anti-HBs (+), Anti-HCV (-)
    • O
      • 2023/03/16 HBsAg = Nonreactive;
      • 2023/03/16 HBsAg (Value) = 0.42 S/CO;
      • 2023/03/16 Anti-HCV = Nonreactive;
      • 2023/03/16 Anti-HCV Value = 0.11 S/CO;
      • 2023/03/16 Anti-HBs = >1000.00 mIU/mL;
      • 2023/03/16 Anti-HBc = Reactive;
      • 2023/03/16 Anti-HBc-Value = 5.76 S/CO;
    • P
      • admisision
        • chest CT (+/- contrast) for complete work up
        • check 24 urine CCR, auditory test,
        • Adjuvant chemotherapy (4-6 cycle platinum-based chemotherapy [etoposide plus cisplatin or carboplatin]).
        • Prophylatic anti HBV medication
      • Arrange admission for 24 hours CCr, audiometry and C/T with EP
  • 2023-03-06 ~ 2023-03-18 POMR General and Digestive Surgery
    • Discharge diagnosis
      • Neuroendocrine carcinoma of gastric lower body, pT4aN3a(cM0), stage IIIB status post radical subtotal gastrectomy with D2 lumph node dissection and Roux-en-Y gastrojejunostomy anastomosis on 2023/03/09. ECOG:1
      • Encounter for adjustment and management of vascular access device with port-A on 2023/03/17
    • CC
      • Epigastric pain and regurgitation for 6 months.       
    • Present illness
      • This is a 73-year-old man without specific past history. The patient had epigastric pain for 6 months, so he went to OPD for help since 2022/09. However, symptoms did not improved even after medication by H2 bloker. The pain was postprandially but did not refer to back or RUQ. Paendoscopy was arranged on 2023/02/22 with a finding of a big ulcer at gastric angularis. Pathology showed small cell neuroendocrine carcinoma. Thus, under the impression of Gastric cancer, he is admitted to our ward for subtotal gastrectomy.    
    • Course of inpatient treatment
      • After admmision, he was arranged with radical subtotal gastrectomy with D2 LN dissection with Roux-en-Y GJ anastomosis. After OP, he had moderate pain at wound and surgical site. The pain was tolerable after given pain killer PCA for post OP pain control. TPN starting on 2023/03/10 with NPO and NG decompression, NG removed. He had flatulence on 2023/03/13 and watery diarrhea passage on 2023/03/14. We started PG1 diet and the patietnt tolerated well without nausea or vomiting. Pathology of stomach tumor came out on 2023/03/14, showing Neuroendocrine carcinoma AJCC Pathologic staging pT4aN3a(cM0), stage IIIB. We consulted hematology doctor for further evaluation. Port-A was arranged on 2023/03/17 for future chenotherpay usage. Under good condition with good pain control and diet recovery to PG3 diet, he was discharged on 2023/03/18 for OPD followup and further treatment.
    • Prescription
      • Mopride (mosapride citrate 5mg) 1# TID
      • Pariet (rabeprazole 20mg) 1# QDAC
      • Acetal (acetaminophen 500mg) 1# QID

[consultation]

  • 2023-03-18 Hemato-Oncology
    • Q
      • This is a 73-year-old man without specific past history. The patient had epigastric pain for 6 months, Panendoscopy was arranged on 2023/02/22 showed a small cell neuroendocrine carcinoma of gastric with a 4.2cm ulcerative mass, cT2N2M0, s/p radical subtotal gastrectomy with D2 LN dissection Roux-en-Y GJ anastomosis on 2023/03/09, pathology showed Neuroendocrine carcinoma, pT4aN3a(cM0), stage IIIB on 2023/03/14.
      • We need your expertise for further evaluation and treatment, Thx!!
    • A
      • Pathology showed Neuroendocrine carcinoma, pT4aN3a(cM0), stage IIIB, with Perineural invasion+, Lymphovascular space invasion+, margin+, Ki-67= 60%. We are consulted for further evaluation and treatment.
      • Please arrange chest CT(+/- contrast) for complete work up.
      • Adjuvant chemotherapy +/- RT is indicated in this case (4-6 cycle platinum-based chemotherapy [etoposide plus cisplatin or carboplatin]).
      • Please check 24 urine CCR, auditory test, HbsAg, antiHbs, AntiHbc, anti HCV. Arrange port A insertion.
      • Arrange our OPD after discharge. Thanks for your consultation.

[surgical operation]

  • 2023-03-09
    • Surgery
      • radical subtotal gastrectomy with D2 LN dissection
      • Roux-en-Y GJ anastomosis
    • Finding
      • 4.5 x 4.5 cm ulcerative mass at lower body lesser curvature with serosa invole
      • large LN4 cm at station 9

[chemotherapy]

  • 2023-11-17 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr +leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-30 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr +leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-06 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr +leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-24 - etoposide 80mg/m2 140mg NS 500mL 2hr D1-3 + carboplatin AUC 4 370mg NS 250mL 2hr D1 (Fytosid 100mg/m2 -> 80mg/m2. eGFR 67 carbo AUC 4)
    • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3 + NS 250mL D1-3
  • 2023-06-30 - etoposide 80mg/m2 140mg NS 500mL 2hr D1-3 + carboplatin AUC 4 370mg NS 250mL 2hr D1 (Fytosid 100mg/m2 -> 80mg/m2. eGFR 69 WBC 2980 carbo AUC 4)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3 + NS 250mL D1-3
  • 2023-06-13 - etoposide 100mg/m2 175mg NS 500mL 2hr D1-3 + carboplatin AUC 5 400mg NS 250mL 2hr D1
    • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3 + NS 250mL D1-3
  • 2023-05-22 - etoposide 100mg/m2 175mg NS 500mL 2hr D1-3 + carboplatin AUC 5 400mg NS 250mL 2hr D1 (Cre 1.08, CrCl 59, carbo AUC 5)
    • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3 + NS 250mL D1-3
  • 2023-04-28 - etoposide 100mg/m2 175mg NS 500mL 2hr D1-3 + carboplatin AUC 5 400mg NS 250mL 2hr D1 (Cre 1.31, cis -> carbo AUC 5)
    • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3 + NS 250mL D1
  • 2023-04-03 - etoposide 100mg/m2 175mg NS 500mL 2hr D1-3 + NS 500mL 3hr (before cisplatin) + cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + NS 1000mL 3hr (post cisplatin)
    • dexamethasone 4mg D1-3 + palonosetron 250ug D1 + aprepitant 125mg PO D1-2 + NS 250mL D1

==========

2023-11-20

[elevated LDH: a sign of underlying tissue and/or liver damage?]

An increasing trend in LDH levels might suggest potential tissue or liver damage, warranting further investigation.

  • 2023-11-17 LDH 362 U/L *
  • 2023-10-30 LDH 314 U/L *
  • 2023-10-18 LDH 263 U/L
  • 2023-10-03 LDH 243 U/L
  • 2023-09-12 LDH 138 U/L
  • 2023-09-05 LDH 126 U/L
  • 2023-08-08 LDH 129 U/L
  • 2023-07-19 LDH 132 U/L
  • 2023-07-12 LDH 116 U/L
  • 2023-06-27 LDH 116 U/L
  • 2023-06-08 LDH 102 U/L
  • 2023-06-01 LDH 110 U/L
  • 2023-05-16 LDH 154 U/L
  • 2023-05-09 LDH 96 U/L

2023-07-25

As per the available records, the patient’s general and gastroenterology surgeon issued a prescription on 2023-06-20, following the subtotal gastrectomy. The prescribed medications include B-Red (hydroxocobalamin), Mopride (mosapride citrate), Foliromin (ferrous sodium citrate), and Ulstop (famotidine). These medications were appropriately incorporated into the active medication list, and there were no identified reconciliation problems.

2023-07-03

As per the records, our general and gastroenterological surgery department prescribed a 28-day course of B-Red (hydroxocobalamin), Mopride (mosapride citrate), Foliromin (ferrous sodium citrate), and Ulstop (famotidine) to this patient on 2023-06-20 due to his post subtotal gastrectomy status. These drugs have been correctly incorporated into the active medication list, and no reconciliation issues were identified.

2023-05-23

  • A review of the PharmaCloud database shows that all of the patient’s most recent medications were prescribed by our hospital, and no medication reconciliation issues were identified.
  • This patient was diagnosed with advanced neuroendocrine carcinoma of the stomach. The patient underwent radical subtotal gastrectomy with D2 lymph node dissection on 2023-03-09. Following this surgery, a chemotherapy regimen of cisplatin and etoposide was initiated on 2023-04-03. However, due to alternations in the patient’s renal function, the chemotherapy regimen was changed to carboplatin and etoposide on 2023-04-28. Neutropenia was noted with a white blood cell (WBC) count of 2.29K/uL on 2023-04-20. Prophylactic granulocyte colony stimulating factor (G-CSF) was prepared for the patient prior to the next round of chemotherapy.
  • Lab data on 2023-05-16 showed grossly normal readings and vital signs in the TPR panel indicate that the patient’s condition is stable. All current medications seem appropriate and there appear to be no concerns found with the patient’s current drug regimen.

701504241

231120

[exam findings]

  • 2023-11-18 CXR - abdomen
    • Clinical history: 83 y/o female patient with cecal soft tissue mass is suspected. Liver low density lesion. Colon cancer with liver meta?
    • With and without contrast enhancement CT of abdomen:
      • Thickening wall at the sigmoid colon with pericolonic infiltrates and abutting pelvic side wall, r/o sigmoid colon malignancy.
      • Edema/thickening wall at the cecum, syncrhonous colon malignancy?
      • Irregular cystic tumor, 2.4cm in S8 liver, complicated cyst or cystic metastasis? Suggest further study.
      • Bilateral renal cysts, up to 3.2cm in left kidney.
      • Liver cysts.
      • Fibrocalcified infiltrates in right upper lung.
      • Irregular contour of urinary bladder, r/o chronic cystitis.
      • T12 and L3 compresion fractures.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N1(N_value) M:Mx(M_value) STAGE:____(Stage_value)
    • Impression:
      • Sigmoid colon malignany, cstage T4N1Mx(cystic liver tumor, r/o complicated cyst or cystic metastasis, suggest further study).
      • Edema/thickening wall at the cecum, syncrhonous colon malignancy? Suggest colonoscope study.
  • 2023-11-17 ECG
    • Sinus rhythm with Premature atrial complexes
    • Otherwise normal ECG
  • 2023-11-17 CXR (erect)
    • Fibro-calcified shadows of right upper lung are noted, which may be due to old TB. Please correlate with clinical history.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis with scoliosis of the T-spine with convex to right side
  • 2023-11-10 KUB
    • Fecal material store in the colon.
    • Spondylosis of the L-spine is noted.
    • Compression fracture of T12 and L3 vertebral body.
  • 2023-11-06 CT - abdomen
    • Indication: a case of uterine ca s/p (10 yrs ago; loss F/U) RLQ pain for 1 m. appetite: OK. stool: OK. refer for GYN. dysuria (-). fever (-)tx at LMD in vain R/O colon leison
    • Abdominal CT without IV enhancement revealed:
      • Diffuse swelling of the cecum measuring 7.45cm in largest dimension is found. Some lymph nodes (n=4) are found at RLQ of the abdomen.
      • Low density lesion at S7/8 of liver measuring 2.35cm in largest dimension. Nature?
      • Left renal cyst measuring 3.55cm is found.
      • The spleen, pancreas, both adrenals are intact.
    • Imp:
      • Cecal soft tissue mass is suspected.
      • Liver low density lesion.
      • Colon cancer with liver meta? Suggest further study.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)

700127430

231116

[lab data]

  • 2021-09-01
    • HBsAg Nonreactive
    • HBsAg Value 0.36 S/CO
    • Anti-HBc Reactive
    • Anti-HBc Value 4.02 S/CO
    • Anti-HBc IgM Nonreactive
    • Anti-HBs >1,000mIU/mL

[exam findings] (not completed)

  • 2023-11-16 CT - abdomen
    • History and indication: Ovarian Cancer, pT3bN0Mx, stage IIB
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. Stable condition of recurrent cancer at vaginal stump. S/P Port-A infusion catheter insertion. S/P right side double J catheter insertion. A nodule (2.0cm) at left pelvic cavity.
      • Colonic diverticula. Small size of left kidney.
      • Gallbladder stone (2.0cm). R/O distal CBD stones (2-3mm).
      • Atherosclerosis of aorta.
    • IMP:
      • S/P hysterectomy. Stable condition of recurrent cancer at vaginal stump.
  • 2023-11-07 KUB
    • S/P double J catheter insertion in place, right side.
    • Round calcification, 2.2cm in RUQ, r/o gallbladder stone.
  • 2023-11-07 SONO - kidney (urology)
    • Diagnosis: Left renal cyst
  • 2023-11-07 Bladder Sonography
    • PVR:5.8ml
  • 2023-09-06 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • A calcified gallstone is noted.
    • S/P double J catheter insertion, right side urinary tract.
  • YYYY-MM-DD XXX…

[MedRec]

  • 2017-01-06 SOAP Hemato-Oncology Wan XiangLin
    • S
      • Ovarian cancer, S/P op and C/T (C8, 20161109), for recheck, poor appetite after chemotherpay.
      • Gall stone at last abdominal CT examination.
      • S/P lab. test for tumor markers.
    • O
      • 20161205 abdominal CT
        • Findings
          • S/P operation.
          • Gall stone (1.5cm).
        • Impression:
          • S/P operation. No evidence of tumor recurrence.
          • Gall stone (1.5cm).
    • Diagnosis
      • Malignant ovary neoplasm [C56.2]
      • Leiomyoma of uterus, unspecified [D25.9]
    • Prescription
      • Agglutex (heparin 25000U/5mL) 5mL ST
      • NS 20mL ST
  • 2017-01-06 SOAP Neurology
    • Diagnosis
      • Cerebral artery occlusion, with cerebral infarction [I63.50]
      • Malignant ovary neoplasm [C56.2]
      • Essential hypertension, benign [I10]
      • Dyslipidemia; other and unspecified hyperlipidemia [E78.5]
      • Myalgia and myositis,unspecified [M79.1]
    • Prescription x3
      • Eurodin (estazolam 2mg) 0.5# HS
      • Schnin (ginkgo biloba 9.6mg) 1# BID

[chemotherapy]

  • 2023-11-15 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-10-13 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-09-06 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-08-02 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-07-04 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-05-30 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-03-28 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-02-15 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-01-13 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2022-01-06 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2021-11-26 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2021-11-06 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2021-10-14 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2021-09-23 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2021-09-02 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

700136377

231116

[lab data]

2023-05-05 Anti-HBc Reactive
2023-05-05 Anti-HBc-Value 6.66 S/CO
2023-05-05 Anti-HBs 414.12 mIU/mL
2023-05-05 Anti-HCV Nonreactive
2023-05-05 Anti-HCV Value 0.08 S/CO

[exam findings]

  • 2023-08-26 CT - abdomen
    • History and indication: S-colon cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P colon operation. Right liver metastases s/p operation with biloma formation (2.9cm).
      • Left renal cyst (8mm).
      • Right ovary cyst (2.4cm).
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P colon operation. Right liver metastases s/p operation with biloma formation (2.9cm).
  • 2023-04-20 All-RAS + BRAF gene mutation analysis
    • ALL-RAS: Detected (KRAS codon 146 GCA>CCA, p.A146P)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-04-20 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS
      • Liver, S6, partial resection — Metastatic colonic mucinous adenocarcinoma
    • MACROSCOPIC EXAMINATION
      • Procedures: S6 partial resection
      • Specimen Size: 6.2 x 4.0 x 3.0 cm and 39.2 gm
      • Tumor Focality: Solitary
      • Tumor Site: S6
      • Tumor Size: 3.0 x 2.5 x 2.5 cm
      • Large vessel involvement: Not identified
      • Non-tumorous part: Not cirrhotic
      • Sections are taken and labeled as: A1-A5
    • MICROSCOPIC EXAMINATION
      • Diagnosis: Metastatic colonic mucinous adenoarcinoma
      • Histologic grade: Moderately differentiated
      • Tumor growth pattern: Pushing
      • Tumor pseudocapsule: Present
      • Tumor necrosis: Absent
      • Parenchymal margin: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margins: 1.7 cm
      • Vascular invasion: Not identified
      • Perineural invasion: Not identified
      • Non-neoplastic liver parenchyma: Moderate to mild lymphocytic portal inflammation, and mild fatty change (5%)
  • 2023-04-19 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, sigmoid colon, colectomy —- Adenocarcinoma, moderately differentiated
      • Peritoneum, left abdominal wall, excision —- Adenocarcinoma, by direct invasion
      • Uterus, excision —- Negative for malignancy
      • Resection margins: free
      • Lymph node, mesocolic, dissection —- metastatic adenocarcinoma (2/19)
      • Lymph node, IMA / SMA, dissection —- not received
      • AJCC 8th edition Pathology stage: pStage IVA, pT4bN1bM1a
    • Gross Description:
      • Operation procedure: sigmoid colectomy with a portion of left abdominal wall and uterus
      • Specimen site: sigmoid colon
      • Specimen size: Colon: 8.0 cm in length; left abdominal wall: 3 x 3 x 0.9 cm; uterus: 2 x 1 x 0.8 cm
      • Tumor size: 4 x 3.5 cm
      • Tumor location: 2.2 cm and 1.7 cm away from the two resection margins, respectively.
      • Depth of invasion grossly: left abdominal wall
      • Mucosa elsewhere: congestion
      • Macroscopic Tumor Perforation: Not identified
      • Sections are taken and labeled as:
        • A1: colon, non-tumor; A2-6: tumor (A2 and A3: with left abdominal wall; A4: with uterus); A7-9: lymph node, mesocolic; A10: tumor, ink serosa; B: proximal cutend; C: distal cutend.
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor directly invades adjacent structures (specify: left abdominal wall)
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Uninvolved, Distance of tumor from margin: 1 mm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Tumor Budding: Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: tubulovillous adenoma
      • Tumor Deposits: Present, Specify number of deposits: 4
      • Regional Lymph Nodes: Number of Lymph Nodes Involved/Examined: 2/19
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): not applicable
          • Primary Tumor (pT):pT4b: Tumor directly invades or adheres to adjacent organs or structures
          • Regional Lymph Nodes (pN): pN1b: Two or three regional lymph nodes are positive
          • Distant Metastasis (pM): pM1a: Metastasis to one site or organ is identified without peritoneal metastasis (S2023-07515)
      • Additional Pathologic Findings (select all that apply): None identified
  • 2023-03-31 CT - abdomen
    • CC: One mass was noted in the sigmoid colon (25 cm from anal verge)
    • Indication: adenocarcinoma of the sigmoid colon, CT staging
    • Findings:
      • There is segmental circumferential asymmetrical wall thickening at the sigmoid colon, measuring 8 cm in length, with irregular contour and suggestive direct invasion left round ligament.
        • It is c/w adenocarcinoma of the sigmoid colon (T4b).
        • In addition, there are seven enlarged nodes in the adjacent mesocolon that are c/w metastatic nodes (N2b).
      • There is a poor enhancing mass 2.6 cm in S6 of the liver that is c/w metastasis (M1a).
      • There are several renal cysts on both kidney and the largest one measuring 0.8 cm in size at left middle pole.
      • There is no focal lesion in both lung and mediastinum.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
  • 2023-03-31 Patho - colorectal polyp
    • DIAGNOSIS:
      • Colon, sigmoid, 25 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    • GROSS DESCRIPTION:
      • Specimen submitted in formalin consists of 3 pieces of tan, irregular tissue measuring up to 0.5 x 0.3 x 0.1 cm. All for section in one cassette.
    • MICROSCOPIC DESCRIPTION:
      • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
      • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).

[MedRec]

  • 2023-04-18 ~ 2023-04-27 POMR Colorectal Surgery Xiao GuangHong
    • Discharge diagnosis
      • Adenocarcinoma of sigmoid with direct invasion to left abdominal wall, and liver metastasis , cT4bN2bM1a, stage IVA status post sigmoid colectomy and liver resection on 2023/04/19, pStage IVA, pT4bN1bM1a
    • CC
      • intermittent lower abdominal pain for three months
    • Present illness
      • This is a 74-year-old female without any underlying diseases. She suffered from intermittent lower abdominal pain for three months. Bowel habit change with loose stool for one year was also mentioned. She had no diarrhea, no tarry stool, no anal fresh bleeding, no significant body weight loss. She then visited colon and rectum surgery outpatient department for help. After series of work-up, she was diagnosed with adenocarcinoma of sigmoid with liver metastasis, cT4bN2bM1a, stage4a. This time, she was admitted to our ward for sigmoid colectomy and liver resection on 2023/04/19.   - Course of inpatient treatment
      • After admission with ward routine, operation of sigmoid colectomy and liver resection were done on 2023/04/19 under general anesthesia. After the operation, wound healing went well without erythema change. Chewing cookies, toast, rice with gum was started at op day. The wound pain was tolerated under PCEA. Lab data checked on 4/20 showed Hb 7.9, WBC 11730, GOT 192, GPT 216, total bilirubin 0.38, direct bilirubin 0.07, CRP 6.76. Blood transfusion of LPRBC 2u and K1 supplement were arranged. Empirical antibiotic with Cefoxitin and self-pay Plasbumin were given for three days. There were no nausea and no vomiting. Flatus and stool passage were noted after operation. She was able to tolerate low residual diet. During her stay at our ward, there were no fever.
      • The final pathology report revealed liver, S6, partial resection metastatic colonic mucinous adenocarcinoma; large intestine, sigmoid colon, colectomy, adenocarcinoma, moderately differentiated/peritoneum, left abdominal wall, excision, adenocarcinoma, by direct invasion; Uterus, excision, negative for malignancy, pT4bN1bM1a.
      • Under stable condition, she discharged on 2023/04/27 and OPD follow up was arranged.
    • Discharge prescription
      • Deflam-K (diclofenac 25mg) 1# PRNQ8H
      • Actein Effervescent (acetylcysteine 600mg) 1# BID
      • MgO 250mg 1# TID
  • 2020-02-24 SOAP Neurosurgery Dai BoAn
    • Diagnosis
      • Other spondylosis with myelopathy, site unspecified [M47.10]
      • Other spondylosis with radiculopathy, lumbar region [M47.26]
    • Prescription
      • U-Ca (calcitriol 0.25ug) 1# QD
      • CaCO3 500mg 2# QD
      • Vit B1 (thiamine 100mg) 1# QD
      • Arcoxia (etoricoxib 60mg) 1# QD
      • Stidine (tizanidine 2mg) 1# HS

[consultation]

  • 2023-10-26 Dermatology
    • Q
      • The patient is an 74-year-old female with a history of Adenocarcinoma of sigmoid with direct invasion to left abdominal wall and liver metastases, cT4bN2bM1a, stage IVA status post sigmoid colectomy and liver resection on 2023/04/19, pT4bN1bM1a, pStage IVA s/p chemotherapy with FOLFOX from 2023/05/24~.
      • She presented left armpit with redness and itchy was found about for 2 weeks. We need your further evaluation and management.
    • A
      • Under the impression of tinea corprois et intertrigo eczema over axilla.
      • The following sugeetion:
        • Zalain cream 1 tube topical bid use over large area of axilla first.
        • Mycomb cream 1 tube topical PRN bid use over itchy area.
  • 2023-08-10 Dermatology
    • Q
      • The patient is an 73-year-old female with a history of Adenocarcinoma of sigmoid with direct invasion to left abdominal wall and liver metastases, cT4bN2bM1a, stage IVA status post sigmoid colectomy and liver resection on 2023/04/19, pT4bN1bM1a, pStage IVA s/p chemotherapy with FOLFOX from 2023/05/24~.
      • She presented with Hand-foot syndrome was found, after chemotherapy. we need your further evaluation and management.
    • A
      • The patient had sufferred from reedish swelling over digitals.
      • Under the impression of hand foot syndrome with remssion stage.
      • The following sugeetion:
        • Enhance skin mositurzation first. Topysm cream 1 tube topical bid use over erythematous swelling lesions.
        • Sinphraderm 1 tube topical QN use over thick/ scales lesions.

[surgical operation]

  • 2023-04-19
    • Surgery: S6 partial resection of liver
    • Finding: 3 x 2.5 x 2.5 cm metastatic tumor
  • 2023-04-19
    • Surgery: Sigmoid colectomy     
    • Finding
      • tumor direct invasion to uterus and left abdominal wall    
      • Splenic flexure was mobilized    

[chemotherapy]

  • 2023-10-27 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, omitting 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-28 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, omitting 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-14 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, omitting 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-28 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, omitting 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-10 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, reduced Oxa)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-24 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, reduced Oxa due to ANC 1076)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-10 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-23 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-07 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-24 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-27

There were no issues found during medication reconciliation, and based on the patient’s latest lab results indicating normal renal and liver function, no dose adjustments are required.

700352403

231113

[MedRec]

  • 2018-12-07 ~ 2018-12-14 POMR Gastroenterology Li ZhongXian
    • Discharge diagnosis
      • K63.3 - Post polypectomy wound with propable recent bleeding
      • K52.9 - Colitis of A colon
      • C20 - Malignant rectum neoplasm, DUKE C(T3N1M0) s/p surgery and chemotherapy
      • E87.1 - Hyponatremia
      • I11.9 - Hypertensive heart disease
    • CC
      • Passage of bloody stool and fever, general weakness, abdominal pain for one day AFTER COLON POLYPECTOMY
    • Present illness
      • This 73 year old MAN had history of
        • HCVD
        • cerebral artherosclerosis
        • rectal cancer s/p surgery with lung metastses and had been taking drugs for many years as prescribed.
      • He regularly follow up with appointment at Neurolgy and Oncology specialist.
      • He just received colon scope examination yesterday afternoon and polypectomy was performed.
      • After discharged, he presented with passage of bloody stool and fever, general weakness, abdominal pain.
      • Hence the patient was brought to our ER for evaluation and management.
      • An examination of the patient’s abdomen in the ER showed soft and flat, no abdomen tenderness, no rebound tenderness, no icteric sclera, no pale conjuctiva A series of examinations including blood routine, blood biochemistry, cultures, urine routine and image were performed.
      • CT of the abdomen showed Bowel wall thickeing at ascending colon. Nature to be determined; propable left renal cyst; propable left adrenal tumor.
      • Under the tentative diagnosis of LGI bleeding.Propable post polypectomy wound bleeding and Leukocytosis and fever.
      • Propable colitis of A colon, the patient was admitted for further evaluation and treatment.
    • Course of inpatient treatment
      • Patient was admitted to our hospital due to passage of bloody stool and fever,general weakness,abdominal pain for one day.CT of the abdomen showed Bowel wall thickeing at ascending colon.
      • One day before admission, he received polypectomy at our surgery departement. Under the impression of lower GI bleeding, we underwent colon fiberoscopy and sawed polypectomy site was identified at A-colon and a clip was placed no bleeding was seen.
      • We observed his condition after colonscopy.There was no bloody stool after medical treatment. Abdominal pain improved. Normal yellow color stool passage was told.
      • We also consulted social worker for post colon polypectomy condition. The issue was reported and will keep close contact with family members and patient.Under stable condition he was discharge and OPD follow up
    • Discharge prescription
      • Ulstop (famotidine 20mg) 1# BID
      • Trand (tranexamic acid 250mg) 1# BID
      • Cero (cefaclor 250mg) 2# Q8H
  • 2017-01-02 SOAP Neurology Lin XinGuang
    • Diagnosis
      • Cerebral atherosclerosis [I67.2]
      • Essential hypertention, unspecified [I10]
      • Neuralgia, neuritis, and radiculitis, unspecified [M79.2]
      • Intervertebral disc disorder with myelopathy, unspecified region [M51.9]
      • Arthropathy, unspecified,unspecified sites [M12.9]
    • Prescription x3
      • Ancogen (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRN
      • Licodin (ticlopidine 100mg) 1# QD
      • Trandate (labetalol 200mg) 1# QD
      • Norvasc (amlodipine 5mg) 1# BID
      • Trileptal (oxcarbazepine 600mg) 1# BID

==========

2023-11-13

[reconciliation]

On 2023-10-18, the patient attended JingMei Hospital for treatment of polyneuropathy and received a 28-day prescription for mecobalamin, chlorzoxazone, brotizolam, and trazodone. These medications have not been recorded in the current medication list. Please verify if this constitutes a discrepancy.

700041739

231110

[MedRec]

  • 2021-05-17 ~ 2021-05-24 POMR Colorectal Surgery Xiao GuangHong
    • Discharge diagnosis
      • Cecal adenocarcinoma with mesocolon and visceral peritoneum involvement, moderately differentiated, EGFR (+) PMS2(+) MSH6(+) MSH2(+) MLH1 (+), pT4aN2b(cM0) stageIIIC, status post right hemicolectomy on 2021-05-18
      • Iron deficiency anemia, unspecified
    • CC
      • Intermittent right lower quadrant abdominal pain with lower grade fever since 1 month ago
    • Present illness
      • This 64 years old male who denied systemic or surgic history presented with RLQ abdominal pain for 1 week in April of 2021. He went to local clinics with 3-day antibiotics and analgesics and condition much improved, but the pain progressively recurred 2 days later. He traveled to ChangHua on 2021/04/10 and fever with RLQ pain were noted. He visited ChangHua Christian Hospital and was diagnosed with acute appendicitis by CT. He was transferred to our ED due to living nearby. Antibiotic treatment with Flumarin was given and his fever was subsided. However, stool occult blood revaled 3+ then add PPI for prevent gastric ulcer. He was discharged after one week of treatment. PES and colonoscopy were arranged and cecal tumor with lumen obstruction at 130cm AAV was noted. Tracing back his clinical symptom and sign, he had abdominal fullness and decreased appetite. No body weight loss of bloody/tarry stool was noted.
      • The pathology disclosed adnocarcinoma of cecum. Therefore, he was referred to CRS OPD and surgical intervention was recommanded. After knowning the benefits and the risks of the operation, he was admitted to our ward for right hemicolectomy.
    • Course of inpatient treatment
      • The patient was admitted to our ward after finishing the pre-op assessments. The COVID-19 rapid test showed negative result. Mild anemia was found in hemogram. Other data were within normal limits. He received right hemicolectomy on 110-05-18 uneventfully. (1) Cecal cancer with obstruction, (2) anastomosis by GIA 75/4.8mm x2, and (3) One jp drain at pelvic area were noted intraoperatively. The patient tolerated the procedure well. He tried water and oral chewing on the operation day. Flatus and stool passage occurred on 110-05-20. Oral feeding with low residue soft diet was recruited then. The pathology showed cecal adenocarcinoma pT4aN2b(cM0) stageIIIC and we had applied Major Illness. Foley catheter and J-vac were removed smoothly during recovering course. Under a realtive stable clinical condition, he was discharged and OPD f/u will be arranged on 2021-05-31.
    • Discharge prescription
      • Meitifen (diclofenac 75mg) 1# PRNQD
      • MgO 250mg 2# BID
      • Acetal (acetaminophen 500mg) 1# QID
  • 2021-04-10 ~ 2021-04-17 POMR General and Gastrointestinal Surgery Zhang JianHui
    • Discharge diagnosis
      • Acute appendicitis with perforation and tumor formation
      • Anemia
    • CC
      • RLQ abdominal pain for 1 week.
    • Present illness
      • This 64 years old male who denied systemic or surgic history presented with RLQ abdominal pain for 1 week. At the second day, he went to local clinics with 3-day antibiotics and analgesics and condition much improved, But 2 days after the pain progressively recurred. Today when he traveled to ChangHua, fever and RLQ pain were noted and came to ChangHua Christian Hospital diagnosed with acute appendicitis by CT then transferred to our ED due to living nearby.
      • Arrived ER, vital sign TPR: 36.5/100/19, BP:152/96mmHg, clear of consciousness. Physical examination showed abdomen soft and flat, RLQ tenderness, no rebound tenderness, no muscle guarding. Under the impression of acute appendicitis with perforation and tumor formation, GS doctor was consulted who suggest admitted for antibiotic treatment and further care.
    • Course of inpatient treatment
      • After admission, Blood examination was done that revealed leukocytosis and Anemia, then antibiotic with Flumarin was given. We check stool occult blood revaled 3+ then add PPI for prevent gastric ulcer. After improved of condition and lab data. He was discharged today and take medication with antibiotic and PPI. He will be follow up at GS and GI OPD.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNTID
      • MgO 250mg 1# TID
      • Pariet (rabeprazole 20mg) 1# QDAC stool OB 3+
      • Cinolone (ciprofloxacin 250mg) 2# BIDAC
      • Through (sennoside 12mg) 1# PRNHS
  • 2021-04-10 SOAP Medical Emergency He YaoCan
    • Diagnosis:
      • K35.80 Unspecified acute appendicitis
    • Prescription:
      • Lifoxitin (cefoxitin 1g/vial) 1 ST IVD
      • NS 500mL ST IVD

[surgical operation]

  • 2022-12-14
    • Surgery
      • Right ureteral catheterization
    • Finding
      • High bladder neck
      • No gross bladder tumor in the urinary bladder
      • A 6Fr. ureteral catheter inserted into right ureter
  • 2022-12-14
    • Surgery
      • Resection of retroperitoneal tumor, small bowel resection with anastomosis    
    • Finding
      • Retroperitoneal tumor with dense invaded to right testicular vessel and small bowel mesentery, close to right ureter (Right RP was inserted)
      • Iatrogenic small bowel perforation due to enterolysis and dense adhesion
  • 2021-05-18
    • Surgery
      • Right hemicolectomy        
    • Finding
      • Cecal cancer with obstruction
      • Anastomosis by GIA 75/4.8mm x2
      • One jp drain at pelvic area

[chemotherapy]

  • 2023-11-09 A-FOLFIRI He JingLiang

  • 2023-10-19 A-FOLFIRI He JingLiang

  • 2023-09-22 A-FOLFIRI He JingLiang

  • 2023-09-01 A-FOLFIRI He JingLiang

  • 2023-08-07 A-FOLFIRI He JingLiang

  • 2023-07-24 A-FOLFIRI He JingLiang

  • 2023-07-06 A-FOLFIRI He JingLiang

  • 2023-06-15 A-FOLFIRI He JingLiang

  • 2023-05-19 A-FOLFIRI Wan XiangLin

  • 2023-05-05 A-FOLFIRI Wan XiangLin

  • 2023-04-07 A-FOLFIRI Wan XiangLin

  • 2023-03-20 A-FOLFIRI Wan XiangLin

  • 2023-03-03 FOLFIRI Wan XiangLin

  • 2023-02-14 FOLFIRI Zhang ShouYi

  • 2022-12-27 FOLFIRI Zhang ShouYi

  • 2021-10-28 XELOX Xiao GuangHong

  • 2021-10-07 XELOX Xiao GuangHong

  • 2021-09-16 XELOX Xiao GuangHong

  • 2021-08-26 XELOX Xiao GuangHong

  • 2021-08-05 XELOX Xiao GuangHong

  • 2021-07-15 XELOX Xiao GuangHong

  • 2021-06-24 XELOX Xiao GuangHong

  • 2021-06-03 XELOX Xiao GuangHong

Medication

  • UFT

700130863

231110

{S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis on 2019-09-11 s/p post-Op adjuvant chemotherapy FOLFOX finishing in 2020-04 with periotneal seeding s/p laparoscope rt diaphram tumor excision 2021-06-09}

[past history]

  • Left thyrioid goiter for 3-4 years with follow up at Taipei City Hospital FuYou Branch

  • Gastric polyp, body s/p biopsy (biopsy: Hyperplastic polyp) in 2019/08

  • past operation

    • S/P ovarian cystectomy 30+ years ago
    • S/P tubal ligation surgery 30+ years ago
  • double cancer

    • Adenocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 2019/09/11.
    • RUL cancer, adenocarcinoma,pT1NoMi(cMx), stage IA1 if cM0, status post 3D VATS RUL lobectomy + RLND on 2019/09/30.
    • Left port-a implantation was done on 2019/10/07.
    • Lung, right upper lobe, lobectomy 2019/09/11 pathology showed minimally invasive adenocarcinoma, pT1miN0(cMx), Stage IA1 if cM0.

[lab data]

  • 2021-07-19 All-RAS mutations assay
    • S2021-8200
    • There was no variant detected in the KRAS/NRAS gene.
  • 2021-06-30 BRAF mutations assay
    • S2021-08200
    • There was no variant detected in the BRAF gene.
  • 2021-06-25 EGFR
    • S2021-08200
    • No mutation was detected at exons 18, 19, 20, 21 of EGFR gene in this specimen.
  • 2021-06-29 Anti-HBc Reactive
  • 2021-06-29 Anti-HBc-Value 1.89 S/CO
  • 2021-06-10 Anti-HBs 33.61 mIU/mL
  • 2021-06-10 HBsAg Nonreactive
  • 2021-06-10 HBsAg (Value) 0.40 S/CO
  • 2021-06-10 Anti-HCV Nonreactive
  • 2021-06-10 Anti-HCV Value 0.22 S/CO

[exam findings]

  • 2023-09-25 KUB
    • Contrast medium in collecting system
    • L2 pathologic fracture
  • 2023-09-25 CXR
    • Right apical pleural thickening
    • A pathologic fracture of L2
  • 2023-09-25 CT - abdomen
    • Indication: Sigmoid cancer with peritoneal carcinomatosis
    • Abdominal CT with and without enhancement revealed:
      • Low density lesions are found at S7/8 of liver measuring 2.46cm, S5/6 measuring 1.86cm and S2 measuring 1.97cm in largest dimension. In comparison with CT dated on 2023-06-21, these nodules are new. Liver meta is considered.
      • Several soft tissue nodules are found in the peritoneal space, peritoneal seeding is considered. In enlargement.
      • Wall thickening at rectum is found. Stable.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • s/p double J catheter placement at both sides.
      • s/p right upper lobe lobectomy.
      • S/p port-A placement with its tip at Superior vena cava.
      • Loculated effusion at right apical lung is found.
    • Imp:
      • rectal cancer with peritoneal tumor seeding, in progression. New liver meta and bone meta.
  • 2023-08-02 KUB
    • S/P double J catheter insertion in place, both sides.
    • Lumbar spondylosis.
  • 2023-08-01 ECG
    • Normal sinus rhythm
    • Left anterior fascicular block
  • 2023-06-21 CT - abdomen
    • History:
      • 20190902 CT: S-colon cancer, cT3N2aM0 s/p LAR n 2019/09/11 s/p post-Op adjuvant C/T wt FOLFOX finishing in 2020/04,
      • 20190826 CT: lung: an irregular GGO 16 mm with central solid component 5mm in RUL. path: Minimal invasive adenocarcinoma, pT1miNoMo, pStage:IA1
      • 20210531 CT: Multiple metastases at peritoneal cavity.
      • 20211203 CT: Omentum metastases S/P C/T show stable disease.
    • FINDINGS: Comparison prior CT dated 2023/03/29.
      • Prior CT identified an enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vagina invasion 1.1 cm is noted again, mild increasing in size to 1.5 cm.
        • Tumor seeding S/P C/T with stable disease is highly suspected.
      • S/P LAR with autosuture retention over the sigmoid colon.
        • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, mild increasing in size.
      • Liver and renal cysts (up to 2.4cm).
        • S/P double J catheter insertion, right and left side urinary tract.
        • There are marked bilateral hydroureteronephrosis.
        • Please correlate with retrograde pyelography.
      • There is no focal lesion in mediastinum.
        • There is a lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
        • please correlate with clinical history.
    • IMP:
      • Tumor seeding in the rectum S/P C/T show stable disease. please correlate with clinical condition.
      • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, mild increasing in size.
      • There are marked bilateral hydroureteronephrosis. Please correlate with retrograde pyelography.
  • 2023-05-30 CXR
    • Prior plain chest film identified Patchy opacity projecting at right apical lung with lung volume decrease is noted again, stationary.
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2023-03-29 CT - abdomen
    • FINDINGS: Comparison prior CT dated 2022/12/28.
      • Prior CT identified an enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vagina invasion is noted again, marked decreasing in size to 1.1 cm.
        • Tumor seeding S/P C/T with stable disease is highly suspected.
      • S/P LAR with autosuture retention over the sigmoid colon.
        • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, mild increasing in size.
      • Liver and renal cysts (up to 2.4cm).
      • There is no focal lesion in mediastinum.
        • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
        • please correlate with clinical history.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen.
        • There is no ascites or lymphadenopathy.
        • There is no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
    • IMP:
      • Tumor seeding in the rectum S/P C/T show stable disease. please correlate with clinical condition.
      • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, mild increasing in size.
  • 2023-01-30 PET
    • Glucose-hypermetabolism lesions in the perirectal region and in bilateral inguinal lymph nodes are new compared with the previous study on 2021-05-17, the nature is to be determined, suggesting biopsy for investigation.
    • Glucose-hypermetabolism in bilateral mediastinal lymph nodes and bilateral pulmonary hilar lymph nodes, probably reactive nodes.
    • Glucose-hypermetabolism in the left adrenal region, probably benign or malignant tumor of the left adrenal gland.
    • Increased FDG accumulation in the left kidney and ureter, suggesting left GU tract obstruction (resulting from perirectal tumor ?).
    • A glucose hypometabolism lesion in the right upper lung, compatible with right lung cancer s/p treatment.
  • 2023-01-12 Sigmoidoscopy
    • Left lateral rectal wall scar , suspect extrarectal tumor with regression
  • 2023-01-09 KUB
    • S/P double J catheter insertion in place, left side.
    • Non-specific bowel gas pattern.
    • Calcifications in LUQ, r/o left renal stones.
    • Lumbar spondylosis.
  • 2023-01-09 Body fluid cytology - urine
    • Atypia, favor reactive change
    • Smears show lymphocytes, crystals and instrument-associated cellular urothelial clusters with mild nuclear atypia and crush artifact, favor reactive atypia and less likely a neoplasm. Follow up.
  • 2023-01-05 ECG
    • Normal sinus rhythm
    • S1-S2-S3 pattern, consider pulmonary disease, RVH, or normal variant
    • Left anterior fascicular block
    • Abnormal ECG
  • 2022-12-28 CT - abdomen
    • FINDINGS: Comparison prior CT dated 2022/06/10.
      • Prior CT identified a newly-developed enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vagina invasion is noted again, marked decreasing in size and poor margination.
        • Tumor seeding S/P C/T with partial response is highly suspected.
      • S/P LAR with autosuture retention over the sigmoid colon.
        • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, stable in size.
      • Liver and renal cysts (up to 2.4cm).
      • There is no focal lesion in mediastinum.
        • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
        • please correlate with clinical history.
    • IMP:
      • Tumor seeding in the rectum S/P C/T show partial response. please correlate with clinical condition.
      • Multiple omentum metastases S/P C/T show stable disease.
  • 2022-10-27, -03-21 Anoscopy
    • Mixed hemorrhoid and posterior fissure
  • 2022-09-29 CT - abdomen
    • History and indication: Sigmoid cancer with peritoneal seeding and local recurrence s/p OP, s/p R/T, s/p C/T
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Mild regression of peritoneal seeding.
      • Liver and renal cysts (up to 2.4cm).
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • Mild regression of peritoneal seeding.
  • 2022-09-23, -09-21 KUB
    • Fecal material store in the colon.
    • S/P LAR with autosuture retention over the sigmoid colon.
  • 2022-09-03 Foot Lt
    • left 5th metatarsal neck fracture
    • Acceptable alignment with few callus
  • 2022-06-10 CT - abdomen
    • FINDINGS: Comparison prior CT dated 2022/03/11.
      • There is a newly-developed enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vagina invasion, measuring 3.2 x 2.1 cm in size (Srs:7 Img:115) .
        • Tumor seeding is highly suspected.
        • The differential diagnosis include rectal cancer.
      • S/P LAR with autosuture retention over the sigmoid colon.
        • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, stable in size.
      • Liver and renal cysts (up to 2.4cm).
      • There is no focal lesion in mediastinum.
        • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
        • please correlate with clinical history.
    • IMP:
      • Tumor seeding in left lateral anterior aspect of the rectum with left uterine cervix and vaignal invasion is suspected.
        • The differential diagnosis include rectal cancer. please correlate with clinical condition.
      • Multiple omentum metastases S/P C/T show stable disease.
  • 2022-03-20 CXR
    • Opacification of right apical lung.
  • 2022-03-20 KUB
    • Presence of ileus.
    • Degeneration and spondylosis of L-S spine.
  • 2022-03-20 ECG
    • Normal sinus rhythm
    • Left anterior fascicular block
  • 2022-03-11 CT - abdomen
    • FINDINGS: Comparison prior CT dated 2021/12/03.
      • S/P LAR with autosuture retention over the sigmoid colon.
      • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, stable in size.
      • Liver and renal cysts (up to 2.4cm).
      • There is no focal lesion in mediastinum.
        • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
        • please correlate with clinical history.
    • IMP:
      • Multiple omentum metastases S/P C/T show stable disease.
  • 2021-12-23 Nasopharyngoscopy
    • Findings: smooth NPx, oropharynx, hypopharynx; bloody crust coating over right inferior and bilateral middle turbinates.
    • Conclusion: epistaxis, no nasal or nasopharynx tumor found
  • 2021-12-16, -10-07 CXR
    • Patchy opacity projecting at right apical lung with lung volume decrease was noted. Please correlate with CT.
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2021-12-03 CT - abdomen
    • FINDINGS: Comparison prior CT dated 2021/09/03.
      • S/P LAR with autosuture retention over the sigmoid colon.
      • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, mild decreasing in size (up to 1.5cm, srs:302, img:73,75,79,83,87,90,93,96,98,101).
      • Prior CT identified a mixed soft tissue and fat lesion in left upper pelvis wall is not noted in the current CT.
      • Liver and renal cysts (up to 2.4cm).
      • There is no focal lesion in mediastinum.
        • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
        • please correlate with clinical history.
    • IMP:
      • Multiple omentum metastases S/P C/T show stable disease.
  • 2021-09-03 CT - abdomen
    • FINDINGS:
      • S/P LAR with autosuture retention over the sigmoid colon.
      • Multiple soft tissue nodules in the omentum are noted that are compatible with omentum metastases (up to 1.9cm, srs:301, img:71,74,78,85,89,91,95).
      • There is a mixed soft tissue and fat lesion in left upper pelvis wall (Srs:301 Img:82) that may be tumor seeding or post-operative change.
      • Liver and renal cysts (up to 2.4cm).
    • IMP:
      • Multiple omentum metastases S/P C/T show stable disease.
      • Metastasis or post-operative change in left upper pelic wall ?
  • 2021-06-09 Patho - colon ca s/p at 2018 with intraabd recurrent, including bilat diaphragm, T-colon stomach surface and rt liver surface
    • Tumor, R’t diaphragm, biopsy - Metastatic colonic adenocarcinoma
    • IHC: CK7(-), CK20(+), CDX2(+) and TTF-1(-) for tumor.
    • IHC: EGFR (+, weakly); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+)
    • According to clinical information and above histopathologic findings, it indicated a case of metastatic colonic adenocarcinoma.
  • 2021-05-31 CT - whole abdomen, pelvis
    • S/P colon operation. Multiple metastases at peritoneal cavity.
  • 2021-05-17 Whole body PET scan
    • Glucose-hypermetabolism in the right mediastinal lymph nodes, probably recurrent lung cancer with regional lymph nodes involvement.
    • Glucose-hypermetabolism in the left mediastinal lymph nodes and left pulmonary hilar lymph nodes, probably reactive nodes or recurrent lung cancer with regional lymph nodes involvement.
    • Glucose-hypermetabolism in bilateral adrenal regions, probably recurrent lung cancer with bilateral adrenal glands metastases.
    • Glucose-hypermetabolism in peritoneal lymph nodes in the epigastric region, right hypochondriac region, and bilateral lumbar regions of abdomen, probably recurrent colon cancer with peritoneal metastases.
    • S-colon cancer s/p treatment with tumor recurrence, rcTxNxM1c, stage IVC (AJCC 8th ed.); right lung cancer s/p treatment with tumor recurrence, rcTxN2-3M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2021-05-14 MRI - MR Cholangiography (MRCP)
    • Multiple cysts on both hepatic lobes.
  • 2019-08-26 CT - lung cancer screening (Low-dose CT)
    • RUL lung cancer TmiNOMO stage IA1
  • 2019-10-09 Patho - Uterus, cervix, biopsy
    • Chronic cervicitis with reactive aypia
    • IHC, the epithelial cells are negative for p16 and ki-67 proliferation index <5%.
  • 2019-10-01 Patho - Lung, right upper lobe, lobectomy
    • Minimally invasive adenocarcinoma
    • Lymph nodes, group 2+4, 7, 11; RLND - No metastatic carcinoma
    • pTNM Pathology stage: pT1miN0(cMx), Stage IA1 if cM0
  • 2019-09-12 Patho - Malignant sigmoid colon neoplasm
    • Sigmoid colon, LAR - Adenocarcinoma, moderately differentiated
    • Lymph node, mesocolic, dissection - Positive for tumor metastasis (4/16) with extracapsular extension (3/4)
    • AJCC pathologic stage - pT4bN2aMx, stage IIIC at least
  • 2019-09-02 CT - liver, spleen, biliary duct
    • T3N2aMx
  • 2019-08-29 Whole body PET scan
    • A glucose hypermetabolic lesion in the sigmoid colon, compatible with colon malignancy.
    • A faint glucose hypermetabolic lesion in the upper lobe of right lung. The nature is to be determined.
    • Glucose hypermetabolism in the right pulmonary hilar region. The nature is to be determined.
    • Mild glucose hypermetabolism in the left lobe of the thyroid gland.
  • 2019-08-26 Patho - colon, sigmoid or rectosigmoid junction, biopsy
    • Ademocarcinoma
    • IHC: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).

[MedRec]

  • 2023-10-19, -07-20, -04-11, -01-17 SOAP Psychosomatic Medicine Li JiaFu
    • Diagnosis
      • F32.1 - Major Depressive Disorder, Single Episode, Moderate
      • G47.00 - Insomnia, Unspecified
    • Prescription x3
      • Lexapro (escitalopram 10mg) 0.5# QN
      • Mirtapine Orally Disintegrating (mirtazapine 30mg) 1# QN
  • 2023-10-17 SOAP Hemato-Oncology Xia HeXiong
    • P: Already provide two options:
      • TAS-102 plus self-pay bevacizumab -> Favored by patient and family
      • Regorafenib
      • Trial
    • Prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Through (sennoside 12mg) 2# HS
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Stogamet (cimetidine 300mg) 1# BID
  • 2023-09-05 SOAP Hemato-Oncology Xia HeXiong
    • Prescription
      • Xeloda (capecitabine 500mg) 2# BID 28D
      • Sinpharderm Cream (urea) BID TOPI
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Through (sennoside 12mg) 2# HS
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Stogamet (cimetidine 300mg) 1# BID
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# HS
      • Actein Effervescent (acetylcysteine 600mg) 1# BID
  • 2023-04-06 SOAP Hemato-Oncology Xia HeXiong
    • A/P
      • Because the maximal effect of Erbitux-FOLFIRI is achieved based on the findings of CT on 2023-03-29, oral C/T is suggested on 2023-04-06.
    • Prescription
      • Xeloda (capecitabine 500mg) 2# BID 28D
      • Sinpharderm Cream (urea) BID TOPI
  • 2019-09-29 ~ 2019-10-08 POMR Thoracic Surgery Xie MinXiao
    • Discharge diagnosis
      • C34.91 - Minimally invasive adenocarcinoma of lung ove right upper lobe status post three dimensional video-assisted thoracic surgery right upper lobectomy and radical lymph node dissection on 2019/09/30, pT1miN0M0, Stage IA1.
      • C18.7 - Adenocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 2019/09/11
    • CC
      • Abnormal findings were noted on CT during health exam
    • Present illness
      • This 76 years old famale patient has history of
        • Adenocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 2019/09/11
        • left thyrioid goiter for 3-4 years with follow up at Taipei City Hospital FuYou Branch
        • s/p ovarian cystectomy
        • s/p tubal ligation surgery 30+ years ago.
      • This time, she had been received health examination and the chest CT revealed RUL part solid nodule (about 16 mm), seems stationary as compared with CT on 2018/08/15, favors malignant nodule. Whole body PET scan revealed glucose hypermetabolic lesion in the sigmoid colon, upper lobe of right lung, right pulmonary hilar region. She was referred to our CRS OPD (Adenocarcinoma of sigmoid with partial obstruction, cT3N2aM0 was dignosed, status post laparoscopic anterior resection and enterolysis on 2019/09/11) and CS OPD for further evaluation and primary lung cancer was impressed. After discussing with the patient and her family on the benefits of surgical treatment as well as subsequent risks and possible complications, she was admitted for VATS RUL lobectomy + RLND.
    • Course of inpatient treatment
      • After admission, pre-op assessment was done. Operation of 3D VATS RUL lobectomy and RLND was performed smoothly on 2019/09/30. No complication was noted. Prophylactic antibiotics was prescribed for 1 day. Right chest tube with free drainage was done due to mild air leak. Chest tube was removed and left port-a implantation was done on 2019/10/07. We also consulted hemo-onlcologist and radiation-oncologist for further treatment. She was discharged under stable hemodynamics on 2019/10/08. CT simulation will be arranged on 2019/10/09 and treatment will be started 4-5 days later. She will be admitted to hemo-onlcology ward for adjuvant chemotherpay on 2019/10/15.
    • Discharge prescription
      • Bafen (baclofen 5mg) 1# Q12H
      • Mopride (mosapride citrate) 1# TID Zofran (ondansetron 8mg) 1# QD
  • 2019-09-10 ~ 2019-09-16 POMR Colorectal Surgery Xiao GuangHong
    • Discharge diagnosis
      • C18.7 - Adenocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis
      • J98.4 - Part solid nodule (about 16 mm) in right upper lobe, suspect primary lung cancer
    • CC
      • admission for surgical treatment of sigmoid cancer with partial obstruction, cT3N2aM0
      • intermittent upper abdominal fullness and had passage of bloody stool twice in 2019/08.
    • Present illness
      • This 76 years old famale patient has history of left thyrioid goiter for 3-4 years with follow up at Taipei City Hospital FuYou Branch; and s/p ovarian cystectomy and s/p tubal ligation surgery 30+ years ago.
      • This time, she had been received health examination and colonscopy showed colon Ca, sigmoid colon or rectosigmoid junction with stenosis s/p biopsy; mixed hemorrhoid on 2019/08/26. The biopsy proved adenocarcinoma. She also complained of intermittent upper abdominal fullness and had passage of bloody stool twice in 2019/08. The lund CT revealed RUL part solid nodule (about 16 mm), seems stationary as compared with CT on 2018/08/15, favors malignant nodule. Whole body PET scan revealed glucose hypermetabolic lesion in the sigmoid colon, upper lobe of right lung, right pulmonary hilar region. She was referred to our CRS OPD and CS OPD for further evaluation and primary lung cancer was impressed. Arrange abdominal CT revealed S-colon cancer, cstage T3N2aMx on 2019/09/02. Surgical treatment of 3D laparoscopic LAR was suggested. After fully explaination, she was admitted to our ward for preoperative preparation and surgical treatment.
    • Course of inpatient treatment
      • After admission with ward routine and blood examination were done. Operation of laparoscopic anterior resection and enterolysis under general anesthesia were performed on 2019/09/11. NPO and IV fluids support; analgesics treatment for pain relief. Nausea with vomit were noted post op day and improved after IV fluids hydration and medications by Novamin were treated. The wound healing well and no erythema change. Chewing cookies, toast, rice with gum was started at op day. No nausea and no vomiting, flatus passage. Try eat semi-liquid diet at post-op day 2 with tolerance and then on low residual diet was started at post-op day 3. Well bowel movement and stools passage (+) with diet well tolerated. No fever and no complication. Removal of JP drain at post-op day 3. Discharged in general condition stable on 108/09/16 and will follow up in our out-patient department next week. Suspected primary lung cancer by lund CT and whole body PET scan result; she will further evaluation and treatment at CS OPD.
    • Discharge diagnosis
      • Lactam (acetaminophen 500mg) 1# PRNQ6H
  • 2017-02-21 SOAP Gastroenterology Lin XianHong
    • Diagnosis
      • Pure hypercholesterolemia [E78.0]
      • Dyspepsia & other specified disorders of function of stomach [K30]
    • Prescription x3
      • Dexilant (dexlansoprazole 60mg) 1# QDAC

[consultation]

  • 2022-12-10 Dermatology
    • Q
      • This 80-year-old woman patient is a case of S-colon cancer, cT3N2aM0, stage IVC s/p laparoscopic anterior resection and enterolysis on 2019/09/11 s/p post-Op adjuvant chemotherapy with FOLFOX finishing in 2020/04 with periotneal seeding s/p laparoscope right diaphram tumor excision on 2021/06/09 s/p palliative chemotherapy with FOLFIRI from 2021/07/01~2022/07/27 and Avastin from 2021/10/08~2022/07/27 with tumor seeding in left lateral anterior aspect of the rectum with left uterine cervix and vaignal invasion s/p radiotherapy to anal tumor s/p palliative chemotherapy with Erbitux/FOLFIRI from 2022/09/08. She was adnmitted for chemotheraopy with Erbitux/FOLFIRI(C4D1).
      • This time, for right thumb nail gap redness, swelling with pain, suspected paronychia.
    • A
      • This patient suffered from dyskeratotic nails for months and erytheamtous patches for days
      • Imp:
        • Tinea unguim
        • Asteatotic dermatitis
      • Suggestion:
        • Excelderm solution (sulconazole) x 4 BT/Bid
        • Mycomb (nystatin, neomycin, triamcinolone acetonide, gramicidin) x 4 tubes/bid
  • 2022-08-27 Psychosomatic Medicine
    • Q
      • This 79-year-old woman patient is a case of S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis on 2019/09/11 s/p post-Op adjuvant chemotherapy wt FOLFOX finishing in 2020/04 with periotneal seeding s/p laparoscope rt diaphram tumor excision on 2021/06/09. He was admitted for palliative chemotherapy. This time, for depression, anxiety. Now, for evaluate drug therapy. Thank you.   
    • A
      • This 79-year-old woman, our YiDe Mama. She was diagnosed as colon cancer in 2018. She could tried hard to cope with it, untill 2021/5, she developed RLQ pain and exams revealed relapse and metastesis of cancer. She started to develop low and anxious mood, unspokable distress, lack of pleasure and poor appetite, and rumination of negative thoughts. Psychiatrist was consulted in 2021/11 and she also started a conseling with onco-psychologist. The mood condition has been partially improved under mirtazapine 30mg 1# HS, however she still percieved low and tense mood (invisible stress all day), lack of appetite, preoccupation on the somatic distress, ruminated thoughts about the intrafamilial issue (worried that her daughters will not get along well), some demoralize feelings about treatment (she feels that chemotherapy is a long way off, and there is no hope). She tried to cope with walking outside with daughter and watching TV show but lack of true pleasure.
      • She denied obvious impairment on cognitive function, denied sleep problem nor suicidal ideation.
      • MSE: Low and anxious mood, inner tension, ruminated and negative thoughts, hopelessness and demoralized feelings. lack of pleasure and motivation.
      • IMP: Depressive disorder
        • suspected Adjustment disorder with depressive mood
      • Suggestion:
        • Keep mirtazapine 30mg 1# HS.
        • Add sulpiride 50mg 1# HS for adjuctive therapy of depression.
        • Carthasis and empathy. Psychoeducation to the family and the patient.
        • Arrange PSY OPD follow up.
  • 2021-11-18 Mental Health
    • Clinical impression:
      • Depressive disorder
      • Adjusment disorder
    • Clinical course:
      • This 78-year-old female patient is a case of S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis s/p post-Op C/T with periotneal seeding s/p laparoscope rt diaphram tumor excision. She was admitted for chemotherapy with Avastin/FOLFIRI(C5D1).
      • We were consult for depressed mood and poor appetite.
      • According to past medical record, during admission in July for chemotherapy, psychiatric department was consulted once for panic symptoms, but no further OPD follow up.
      • At bedside, the patient is conscious clear, lying on the bed resting, with her daugher at the bedside. She started to percieved dysphoric and low mood since she was diagnosed with cancer on 2018, but she tried hard to modify her mindset and cope with the distress, and able to maintain acceptable mood. Until this year 2021-05, she suffered from right lower abdominal pain, and PET scan found metastatis of the cancer, and started to recieved treatment again.
      • Recently, she noted that she began to be easily irritable and dysphoric, unspoken stressfulness feeling, high inner tention, decrease of reward sensation and low mood, decrease appetite, negative thoughts, sleep disturbance (poor maintainence, unstable), got worse in recnent 2 weeks.
      • She received psychotherapy in recent half year, feel better at first, but noticing unable to control now.
    • MSE:
      • Kempt, polite. Frowning and distressful look. Sometimes she smiles when talk about the people who support her so much.
      • Coherent and relevant speech, articulate
      • Fair attention lasting
      • Depressed mood, low drive and energy, fatigue
      • Ruminated thought
      • Denied hopeless or helplessness, denied suicide ideation
      • Poor appetite and insomnia
    • Suggestion:
      • Psychoeducaiton and emotional support
      • Add mirtapine (30) 1#HS for depressive mood, enhacing appetite. Eurodin 1#HS for insomnia
      • Arrange psychiatric OPD follow up
  • 2021-07-20 Mental Health
    • Psychiatric impression:
      • Panic attack
      • Suspected anxiety disorder
    • Psychiatric history:
      • This 78-year-old female patient is a case of S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis on 2019/09/11 s/p post-Op adjuvant chemotherapy (FOLFOX) finishing in 2020/04 and peritoneal seeding s/p laparoscope Rt. diaphragm tumor excision 2021/06/09. Palliative chemotherapy with FOLFIRI(Campto 90mg/m2, LV 400mg/m2, 5FU 2400mg/m2)(C1D15) was done during 2021/07/15~2021/07/17. We were consult for anxiety. According to the patient, she suffered from episodic chest tightness, dizziness, general weakness, tremors and feeling loss of control since early July. She also perceived low mood and negative thinking intermittently for several weeks. During this admission, frequent experience of chest tightness, hands tremor, limb numbness and parathesia (hot and cold sensation). She feeling frustration form physical discomfort and these panic like symptoms.
    • MSE:
      • Coherent and relevant speech
      • Fair attention lasting
      • Depressed mood, low drive and energy, fatigue
      • Ruminated thought
      • Denied hopeless or helplessness, denied suicide ideation
      • Poor appetite and insomnia with terminal type under stilnox
    • Suggestion:
      • Psychoeducaiton and emotional support
      • Add mirtapine (30) 0.5mg HS
      • Arrange psychiatric OPD follow up
  • 2021-06-09 Hemato-Oncology
    • Q
      • for chemotherapy
      • This is a 78y/o female with past history of 1) Adenocarcinoma of sigmoid colon with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 2019/09/11, s/p post-Op adjuvant C/T wt FOLFOX finishing in 2020/4; 2) Bilateral thyroid tumors status post bilateral thyroidectomy on May 26, 2020; 3) Minimal invasive adenocarcinoma of lung over RUL, s/p VATS segmentectomy + RLND, pT1miN0M0, stage IA1 on 2019/09/30; 4) s/p ovarian cystectomy; 5) s/p tubal ligation surgery 30+ years ago.
      • This time she was visited our OPD due to LLQ abdominal pain for about 3 months, which several examination were arranged, MRI on 5/14 showed multiple cysts on both hepatic lobes;
      • Whole body PET scan on 5/18 revealed 1. Glucose-hypermetabolism in the right mediastinal lymph nodes, probably recurrent lung cancer with regional lymph nodes involvement. 2. Glucose-hypermetabolism in the left mediastinal lymph nodes and left pulmonary hilar lymph nodes, probably reactive nodes or recurrent lung cancer with regional lymph nodes involvement. 3. Glucose-hypermetabolism in bilateral adrenal regions, probably recurrent lung cancer with bilateral adrenal glands metastases. 4. Glucose-hypermetabolism in peritoneal lymph nodes in the epigastric region, right hypochondriac region, and bilateral lumbar regions of abdomen, probably recurrent colon cancer with peritoneal metastases. 5. S-colon cancer s/p treatment with tumor recurrence, rcTxNxM1c, stage IVC (AJCC 8th ed.); right lung cancer s/p treatment with tumor recurrence, rcTxN2-3M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
      • Abdominal CT on 5/31 showed Multiple metastases (up to 2.4cm) at peritoneal cavity. Therefore under impression of multiple tumor recurrance and metastases, she was admitted to GS ward on 6/3.
      • She received operation with laparoscopic and showed multiple tumor seedind was noted right diaphragm (2) and right liver surface, gasric antrum surface(1), left diaphragm (2). T-colon (3) left lower quadrant (1), PCI: 9/39 and liver metas was noted. So further percedure with laparoscope right diaphram tumor excision and HIPEC with Oxalip 300mg/M2(408mg) for 60mins was processed successfully on 6/9. We need your help for further chemotherapy evaluation of 5FU since 6/10. Thanks for your time!!
    • A
      • Patient examined and Chart reviewed. A case of sigmoid colon cancwer is noted. I am conslted for further management.
      • My suggestions would be:
        • Please prescribe the 5-FU as follows: 5-FU 1200 mg/m2 NS 500 mL IVD 24 hours for 2 days, LV 120 mg/m2 in NS 500 mL IVD 24 hours for 2days.
        • Please arrange my OPD appointment after being discharged.
        • Any issue, please let me know.
  • 2020-03-30 Colorectal Surgery
    • Q
      • This 77 years old famale patient has history denocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 108/09/11 (Bloody stool on 108/8) under chemotherapy as FOLFOX. Due to hemorrhoid with bleeding bother her, so we need your help for management.
    • A
      • We had visited the patient that she was a case of mild mixed hemorrhoids.
      • PE:
        • No induration, no redness, no perianal pain
        • No palpable mass around low rectum, no obvious bloody clot on gloves
      • IMP:
        • Mild mixed hemorrhoids, no obvious external hemorrhoid
      • Suggest:
        • Alcos-anal ointment was considered
        • Change habit of stool passage
        • Education about sitz bath and have more water/fiber food
        • Arrange CRS OPD if she still have hemorrhoidal problems

[surgical operation]

  • 2023-01-09
    • Surgery
      • Ureterorenoscopic exam & double-J stenting (tumor stent), left.        
    • Finding
      • Left lower and upper ureter stricture and kinking.
  • 2021-06-09
    • Surgery
      • Laparoscope rt diaphram tumor excision
      • HIPEC with oxalip 300mg/m2 for 60 mins
    • Finding
      • right diaphragm (2) and right liver surface
      • gasric antrum surface (1), left diaphragm (2). T-colon (3) left lower quadrant (1)
      • PCI: 9/39 and liver mets
      • ascite: nil
  • 2020-05-26
    • Surgery
      • L’t lobectomy + right partial thyroidectomy
    • Finding
      • enlargement of left thyroid gland with multiple goiter lesions and trachea deviation noted
      • some goiter lesions over right thyroid gland also noted
  • 2019-09-30 Thoracoscopic Lobectomy
  • 2019-09-11 Laparoscopic anterior resection and anastomosis, sigmoid colon resection, tumor

[radiotherapy]

[immunochemotherapy]

  • 2023-03-24 - cetuximab 500mg/m2 500mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-08 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-24 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-06 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-13 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-21 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-09 - irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-25 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-07 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-10-21 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-10-07 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-09-21 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-09-08 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-08-26 - irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
  • 2022-08-12 - irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
  • 2022-07-27 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
  • 2022-07-15 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
  • 2022-06-29 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
  • 2022-06-17 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
  • 2022-06-01 - irinotecan 150mg/m2 190mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-05-20 - irinotecan 150mg/m2 190mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-05-06 - irinotecan 150mg/m2 190mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-04-24 - irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-04-08 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-03-25 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-03-11 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-02-25 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-02-07 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-01-14 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-12-30 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-12-15 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-12-03 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-11-17 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-11-05 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-10-22 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 175mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-10-08 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 150mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-09-20 - irinotecan 120mg/m2 150mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-09-03 - irinotecan 120mg/m2 150mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2600mg/m2 3200mg 46hr
  • 2021-08-20 - irinotecan 120mg/m2 140mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2600mg/m2 3200mg 46hr
  • 2021-07-15 - irinotecan 120mg/m2 140mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2600mg/m2 3200mg 46hr
  • 2021-07-01 - irinotecan 90mg/m2 120mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2600mg/m2 3200mg 46hr
  • 2021-06-10 - leucovorin 120mg/m2 165mg 24hr D1-2 + 5-Fu 1200mg/m2 1635mg 24hr D1-2
  • 2021-06-09 - oxaliplatin 300mg/m2 408mg 90min
  • 2021-04-13 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr
  • 2021-03-30 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
  • 2021-03-16 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
  • 2021-03-02 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
  • 2021-02-14 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
  • 2021-01-31 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
  • 2021-01-09 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

==========

2023-11-10

[Lonsurf combination therapy for mCRC: dosage considerations in patients with low BSA]

Both tumor markers CEA and CA199 trend upward in 2023.

  • 2023-10-17 CEA 79.30 ng/mL

  • 2023-09-05 CEA 34.28 ng/mL

  • 2023-07-18 CEA 20.55 ng/mL

  • 2023-05-30 CEA 12.06 ng/mL

  • 2023-05-05 CEA 5.88 ng/mL

  • 2023-04-03 CEA 4.42 ng/mL

  • 2023-03-08 CEA 4.25 ng/mL

  • 2023-01-31 CEA 3.12 ng/mL

  • 2023-01-06 CEA 2.70 ng/mL

  • 2023-10-17 CA199 389.11 U/mL

  • 2023-09-05 CA199 69.02 U/mL

  • 2023-07-18 CA199 71.84 U/mL

  • 2023-05-30 CA199 60.36 U/mL

  • 2023-05-05 CA199 56.00 U/mL

  • 2023-04-03 CA199 82.57 U/mL

  • 2023-03-08 CA199 85.56 U/mL

  • 2023-01-31 CA199 83.54 U/mL

  • 2023-01-06 CA199 69.10 U/mL

On 2023-10-17, at the patient’s Hemato-Oncology outpatient department visit, it was recorded that the patient and her family have opted for further treatment with TAS-102 (Lonsurf) along with bevacizumab, which they will be self-financing.

Lonsurf (two dosage combinations: trifluridine 15mg + tipiracil 7.065mg; trifluridine 20mg + tipiracil 9.42mg) is a temporary purchase item in our hospital currently.

Lonsurf combination therapy for patients with metastatic colorectal cancer: Oral 35 mg/m2/dose (based on the trifluridine component) twice daily on days 1 to 5 and days 8 to 12 of a 28-day cycle (in combination with bevacizumab; maximum per dose: trifluridine 80 mg); continue until disease progression or unacceptable toxicity.

The patient has a relatively low BSA. 2023-10-09 BH 150cm, BW 40.8kg -> BMI 18.1kg/m2, BSA 1.30m2.

Recommended trifluridine/tipiracil metastatic colorectal cancer dosagea according to the patient’s BSA will be 45mg (based on the trifluridine component) BID, i.e., [trifluridine 15mg + tipiracil 7.065mg] 3# BID.

2023-03-09

  • The patient has been diagnosed with major depressive disorder and a sleep disorder and is currently receiving regular follow-up care from our psychologist. The medications Lexapro (escitalopram) and Mirtapine (mirtazapine) are appropriately added to her active drug list and there are no issues with reconciliation.
  • Lab data showed that her TSH and T4 levels have been within the normal range for the past six months. Her hypothyroidism is being well-managed with a weekly dosage of 850ug of Eltroxin (levothyroxine).
  • New glucose-hypermetabolism lesions detected in perirectal region and bilateral inguinal lymph nodes in 2023-01-30 PET scan. Nature of lesions unknown. In addition, the PET result also revealed that glucose-hypermetabolism has been detected in bilateral mediastinal and pulmonary hilar lymph nodes, which are likely reactive nodes. (The patient underwent a 3D VATS RUL lobectomy and RLND on 2019-09-30, for her adenocarcinoma in the RUL, which was classified as pT1NoMi(cMx), stage IA1 if cM0.)
  • There are no issues with the current prescription.

2022-06-30

  • CT images on 2022-06-10 showed a newly-developed enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vaginal invasion. A number of small soft tissue nodules were identified in the omentum (mets) and were still stable in size as compared to prior CTs under FOLFIRI (administered since 2021-07). Therefore, the newly developed lesion might be different from the original in some respects.

2022-06-02

  • The patient received FOLFOX during 2020-01 to 2020-04 and has been receiving FOLFIRI since 2021-06 (plus bevacizumab since 2021-10).
  • A time series of CT scans showed that the size of omentum mets stayed stable from 2021-09 to 2022-03-11 (most recent). The regimen is considered to be effective at keeping the disease stable.
  • Hypothyroidism is still an active problem and Eltroxin (levothyroxine) can be found in recent PharmaCloud records. It is recommended that levothyroxine be prescribed as a self-carried item until the problem is resolved.

2022-03-11

  • the last exam report is dated on 2021-12-23, no updated image; CEA, CA199 readings remain stable around 9ng/mL, 53U/mL, respectively; most WBC and CBC items and all the liver, kidney function tests (reported on 2022-03-09) were in normal range; the systolic blood pressure was slightly higher (159mmHg) at 13:14 2022-03-11.
  • the underlying diseases are treated with the drugs in the current medication list without issue.

2022-02-08

  • according to time-serial CT images, CEA, CA199 readings, the disease remains stable in recent months under current regimen.
  • no drug allergy recorded in database, no issue found with active medication.

2021-08-13

[loss of appetite]

visiting the patient (with her daughter accompanied) at around 16:20 on 2021-08-13.

S:

  • the patient does not feel like to eat these days.

O:

  • poor appetite, not eat much.
  • cachexia still in problem list.

A:

  • chemo not applied yet since this hospitalization, not chemo induced poor appetite for sure, could be psychogenic.
    • psychological counselor had visited the patient on 2021-08-09.
  • some appetite stimulant could be of help.

Suggestion

  • Megejohn (megestrol 160mg/tab) PO QD could be an option to serve as appetite stimulant.
    • dronabinol and oxandrolone are not available in the hospital.

700171570

231109

[exam findings]

[MedRec]

  • 2023-08-18 SOAP Cardiology Xie JianAn
    • Prescription x3
      • Xarelto (rivaroxaban 15mg) 1# QDCC
      • Ulstop (famotidine 20mg) 1# QD
      • Concor (bisoprolol 1.25mg) 1# QD
  • 2023-08-05 ~ 2023-08-18 POMR Obstetrics and Gynecology Huang SiCheng
    • Discharge diagnosis
      • Malignant neoplasm of left ovary -> Debulking surgery (abdominal total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + bilateral paraaortic lymph node dissection + infracolic omentectomy + cytoreductive surgery) on 2023-08-07
      • Malignant neoplasm of right ovary
    • CC
      • Abdominal bloating since April this year.
    • Present illness
      • This is a 58 years old female, denied sexual experience before and menopaused at 53 years old, with underlying disease of
        • Ovarian cancer with carcinomatosis and multiple metastatic nodes, cT3N1 stage III at least, status post neoadjuvant chemotherapy with paclitaxel + carboplatin on 2023/05/22, 06/12, 07/04.
        • Right lower limbs deep vein thrombosis, under Rivaroxaban 1# QDCC PO since 2023/04/21 and CV OPD follow up.
      • According to the patient, she had noted abdominal bloating for 3 weeks since April 2023. She denied nausea, vomiting, tarry or bloody stool, dysuria, poor appetite, body weight loss or vaginal bleeding. She first went to our GI OPD for help. The KUB checked and showed much stool in the colon. The medication was used, but the symptoms had limited improvement.
      • She then revisited GI OPD and laboratory data on 2023/04/22 with elevated CEA 17.24 ng/mL and D-dimer 7318 ng/mL. Abdominal CT on 05/05 reported ascites and highly suspected ovarian cancer with carcinomatosis and multiple metastatic lymph nodes and one ill-defined mass over liver S4 that may be metastasis.
      • Therefore, she was transferred to our GYN OPD and the GYN sonography showed ascites and masses in pelvis (1) 128x76mm, RI: 0.67 and (2) 125x83mm. The CA125 found 782.1 U/mL and D-dimer dropped to 5085 ng/mL.
      • Acites with cell block on 05/16 showed positve for maligancy, favor ovarian origin [IHC stain — CK7(+), CK20(-), PAX8(+), WT-1(+)]. Bone scan on 05/19 showed negative for bone metastasis.
      • The tumor conference suggested chemotherapy for advanced ovarian cancer, she was admitted to HEMA ward with Port-A insertion on 05/19 and 3 courses of neoadjuvant chemotherapy with paclitaxel(175mg/m2) plus carboplatin (AUC:5, 600mg) were administered on 2023/05/22, 06/12, 07/04 respectively. Patient tolerated the chemotherapy.
      • For further management of her ovarian cancer with carcinomatosis and multiple metastatic nodes, cT3N1 stage III at least, she was admitted today to GYN ward for Debulking and HIPEC 2023/08/07.
    • Course of inpatient treatment
      • The surgical pathology revealed carcinosarcoma,pathology stage: ypT3cN1bM1b; FIGO IVB , right JP drain was removed then on 2023-08-17.
      • The Gyn tumor conference suggest further chemotherapy and radiotherapy for her after operation. self voiding was smooth. The vital sign was stable.
      • She is discharged on 2023-08-18 aftrenoon and her followup appointment is scheduled on next week.
    • Discharge prescription
      • naproxen 250mg 1# TID
      • MgO 250mg 2# QID
      • cephalexin 500mg 1# QID
      • Miyarisan BM (clostridium butyricum miyairi 40mg) 1# TID
      • Nexium (esomeprazole 40mg) 1# QDAC (relux esophagitis LA classification grade A 5/16 EGD)
      • Gaslan (dimethylpolysiloxane 40mg) 2# TID
      • Biomycin (neomycin, tyrothricin) BID TOPI

[consultation]

  • 2023-08-05 Urology
    • Q
      • Currently, patient with good appetite and ambulation, she stopped anticoagulant on 7/31. Laboratory data with leukopenia (2.71x10^3/uL) due to chemotherapy and no other significant findings. We will arrange debulking on 8/7 followed by Tenckhoff tube insertion with HIPEC by VS Li ChaoShu.
      • We need your expertise on urinary catheter insertion for this patient.
    • A
      • We will arrange bilateral DBJ insertion on 08/07. Surgical consent has been signed and the purpose of the procedure has been explained to the patient.
  • 2023-05-18 Hemato-Oncology
    • Q
      • This is a 58 y/o female suspect ovarian cancer with carcinomatosis and multiple metastatic lymph nodes and ascites cell block showed IHC stain — CK7(+), CK20(-), PAX8(+), WT-1(+) carcinomatosis. Under the impression of ovarian cancer stage III, the tumor conference suggest chemotherapy. She may need your help. Thank you!
    • A
      • We are consulted for neoajuvant chemotherapy.
      • We had discuss with patient about further neoajuvant cheomotherapy with paclitaxel and carboplatin. Patient agree with systemic chemotherapy after realizing the benefit and side effect of chemotherapy.
      • Please arrange port A insertion and check 24 urine CCR. Due to lower back pain, r/o bone meta, please arrange bone scan. In addition, we will take over this case.

[surgical operation]

  • 2023-08-07
    • Operation
      • Excision of intraabdominal malignancy tumors
      • Omentectomy
      • Adhesionolysis
      • HIPEC
      • Tenckhoff tube insertion   - Finding:
      • Several scatted tumors in pelvic cavity and right paracolic gutter
      • PCI: total = 6
        • [##] region – score
        • [00] central – 0
        • [01] RU – 0
        • [02] epigastrium – 0
        • [03] LU – 0
        • [04] left flank – 0
        • [05] LL – 2
        • [06] pelvis – 2
        • [07] RL – 2
        • [08] right flank – 0
        • [09] upper jejunum – 0
        • [10] lower jejunum – 0
        • [11] upper ileum – 0
        • [12] lower ileum – 0
      • HIPEC regimen: Lipo-dox 30mg/m^2 + carboplatin AUC 5
      • Drain: 15 Fr J-VAC x2 in the pelvic cavity
      • HIPEC log    
  • 2023-08-07
    • Op Method:
      • Diagnosis:
        • Ovarian cancer with carcinomatosis and multiple metastatic nodes, cT3N1 stage III at least, status post neoadjuvant chemotherapy with Taxol/Carboplatin x 3 cycles.
      • Operation:
        • Debulking surgery (abdominal total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + bilateral paraaortic lymph node dissection + infracolic omentectomy + cytoreductive surgery)   - Finding:
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, tense contact with bladder, peritoneum dut to tumor mass accupied. One cervical myoma, 7x5cm, intramural type was noted.
      • Adnexa:
        • LOV: 5x4 cm , capsule intact, with multi-cystic papillary tumor grow out from surface and invasion to posterior uterine wall , intra-op rupture(-)
        • ROV: 6x5 cm , capsule intact, capsule intact, with multi-cystic papillary tumor grow out from surface and invasion to posterior uterine wall, intra-op rupture(-)
        • Fallopian tube: bilateral grossly normal
      • CDS: invisible due to tumor mass occupied.
      • Ascites: bloody , about 50ml, washing cytology was done
      • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
      • Omentum: multiple hard, variablesized nodules (5~20 mm in diameter)
        • infracolic omentectomy was done.
      • Liver: grossly normal & smooth. Subdiaphragmatic surface: miliary tumor seeding(-)
      • Appendix: grossly normal.
      • Bladder: severe adhesion to anterior uterine wall, with several papillary tumor lesions over the bladder surface, s/p excision.
      • Other: Tumor seeding(+++); multiple papillary tumor lesions over sigmoid and descending colon,s/p excision.
      • Residual tumor: R0=no residual tumor; optimal debulking surgery was achieved.
      • Estimated blood loss:600ml
      • Blood transfusion:pRBC
      • Complication:   

[chemotherapy]

  • 2023-11-09 - bevacizumab 7.5mg/m2 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Avastin + paclitaxel + carboplatin; Q3W)

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-10-09 - paclitaxel 150mg/m2 270mg NS 250mL 6hr + carboplatin AUC 5 700mg NS 250mL 2hr + [docetaxel 30mg/m2 55mg + cisplatin 30mg/m2 55mg + gentamicin 40mg + NaHCO3 2800mg + NS 800mL] IP 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-09-18 - paclitaxel 150mg/m2 270mg NS 250mL 6hr + carboplatin AUC 4 500mg NS 250mL 2hr + [docetaxel 30mg/m2 54mg + cisplatin 30mg/m2 54mg + gentamicin 40mg + NaHCO3 2800mg + NS 800mL] IP 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-08-28 - paclitaxel 150mg/m2 270mg NS 250mL 6hr + carboplatin AUC 4 500mg NS 250mL 2hr (paclitaxel + carboplatin; Q3W)

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
  • 2023-08-24 - bevacizumab 5mg/kg 600mg NS 500mL 90min (Avastin)

  • 2023-08-07 - [liposome doxorubicin 30mg/m2 60mg D5W 250mL + carboplatin AUC 5 750mg NS 250mL] IP 90min (HIPEC)

  • 2023-07-04 - paclitaxel 175mg/m2 300mg NS 250mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 500mL + aprepitant 125mg PO D1-2
  • 2023-06-12 - paclitaxel 175mg/m2 300mg NS 250mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 500mL + aprepitant 125mg PO D1-2
  • 2023-05-22 - paclitaxel 175mg/m2 300mg NS 250mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 500mL + aprepitant 125mg PO D1-2

==========

2023-11-09

[sustained response to neoadjuvant and adjuvant therapy]

The patient underwent 3 cycles of paclitaxel and carboplatin neoadjuvant chemotherapy between 2023-05-22 and 2023-07-04. On 2023-08-07, she underwent surgery for ovarian cancer debulking, removal of intraabdominal malignant tumors, omentectomy, adhesiolysis, and HIPEC. Since then, she has received several cycles of paclitaxel and carboplatin adjuvant therapy. Both tumor markers, CA125 and CEA, continue to decrease, suggesting that the treatment is still effective.

  • 2023-10-20 CA-125 (NM) 24.145 U/ml

  • 2023-10-03 CA-125 (NM) 30.618 U/ml

  • 2023-09-11 CA-125 (NM) 53.641 U/ml

  • 2023-08-29 CA-125 (NM) 58.890 U/ml

  • 2023-07-25 CA-125 (NM) 105.698 U/ml

  • 2023-07-07 CA-125 (NM) 945.500 U/ml

  • 2023-06-27 CA-125 (NM) 1417.280 U/ml

  • 2023-06-06 CA-125 (NM) 1071.020 U/ml

  • 2023-05-13 CA-125 782.100 U/mL

  • 2023-10-20 CEA (NM) 6.433 ng/ml

  • 2023-10-03 CEA (NM) 7.930 ng/ml

  • 2023-09-11 CEA (NM) 9.771 ng/ml

  • 2023-08-29 CEA (NM) 8.772 ng/ml

  • 2023-07-25 CEA (NM) 74.188 ng/ml

  • 2023-07-07 CEA (NM) 113.983 ng/ml

  • 2023-06-27 CEA (NM) 95.131 ng/ml

  • 2023-06-06 CEA (NM) 22.970 ng/ml

  • 2023-04-22 CEA 17.240 ng/mL

2023-09-18

Based on the PharmaCloud database, our hospital has been the exclusive healthcare provider for this patient in the past three months. Additionally, according to HIS5 records, our cardiologist issued a repeat prescription on 2023-08-18, which included Xarelto (rivaroxaban), Ulstop (famotidine), and Concor (bisoprolol). All of these medications have been added to the active medication list, and there were no issues identified during the reconciliation process.

701045543

231109

[exam findings]

  • 2023-11-08 CT - abdomen
    • With and without contrast enhancement CT of abdomen shows:
      • s/p resection of rectosigmoid junction and end sigmoid colostomy.
      • Dilatation of small bowel with collapse of distal ileum and colon, r/o obstruction
      • A low density lesion, 1.6 x 0.6cm, in right liver dome (S4). Liver cysts.
      • Mild fat stranding in pelvis.
      • No enlarged lymph nodes in para-aortic and pelvic regions.
      • No bony destructive lesion on these images.
    • Impression
      • Post-OP change
      • Small bowel obstruction
      • Right liver dome lesion, stationary
  • 2023-11-07 KUB
    • Dilatation of small bowel
  • 2023-11-02 PET
    • Glucose hypermetabolism in the lower pelvic region near the previous operative area. Recurrent malignancy can not be ruled out. Please correlate with other clinical findings for further evaluation. However, no prominent FDG uptake was noted in the S7 dome of the subphrenic space.
    • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
    • Increased FDG accumulation in both kidneys. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-09-22 CT - abdomen
    • Findings: Comparison prior CT dated 2023/05/13.
      • S/P Hartmann operation and autosuture in the sigmoid colon.
      • S/P hysterectomy.
      • Prior CT identified a soft tissue lesion 1.6 cm in S7 dome of the subphrenic space is noted again, decreasing in size to 1 cm.
      • There are several hepatic cysts in both lobes and the largest one 1.6 cm in size at S4.
    • Impression:
      • S/P Hartmann operation and autosuture in the sigmoid colon.
        • There is no evidence of tumor recurrence.
      • Prior CT identified a soft tissue lesion 1.6 cm in S7 dome of the subphrenic space is noted again, decreasing in size to 1 cm.
        • Follow up is indicated.
  • 2023-08-18 KUB
    • Radiopaque spots at pelvic region.
    • Presence of ileus.
  • 2023-06-15 SONO - breast
    • Diagnosis: Bil. fibroadenomas
    • BI-RADS: 2. benign finding
  • 2023-05-19 Mammography
    • Indication: Screening.
    • No previous mammography is available for comparison.
    • Mammography of bilateral breasts with craniocaudal (CC) and mediolateral oblique (MLO) views shows:
      • Composition: The breast tissue is heterogeneously dense, and this may decrease the sensitivity of mammography.
      • No definite masses.
      • No asymmetric density.
      • No clustered microcalcification.
      • No architectural distortion.
      • Benign coarse calcifications in bilateral breasts.
      • Diffuse punctate round microcalcifications loosely scattered in left breast, favor benign.
    • Final assessment:
      • BI-RADS category 2, Benign finding.
      • Suggest annual mammographic follow up.
  • 2023-05-13 CT - abdomen
    • Abdominal CT with and without IV contrast ehnancement shows:
      • Visible Chest:
        • Bilteral tiny nodules at both thyroid glands is found.
        • One enhanced nodule at right breast measuring 1.6cm is found. Breast tumor is favored. Suggest mamography and sonography.
        • The lung fields are clear.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • s/p LAR and colostomy with its orifice at LLQ.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs
        • The urinary bladder is well distended without soft tissue lesion.
        • No evidence of abnormal soft tissue mass at pelvic cavity.
        • No definite inguinal or pelvic sidewall LAP
    • Imp:
      • s/p LAR and colostomy.
      • No evidence of recurrent/residual tumor in the study.
      • Right breast tumor. 1.6cm. Suggest further study.
  • 2023-03-27 KUB
    • S/P colostomy of left lower abdominal wall
    • S/P metalic autosuture projecting at the middle pelvis.
    • Transitional vertebra of L5-S1, left side.
  • 2023-03-24 CT - abdomen
    • With and without contrast enhancement CT of abdomen shows:
      • s/p Hartmann operation and descending colostomy.
      • Dilatation of small bowel and collapse of colon, r/o obstruction.
      • Presence of ascites.
      • Several liver cysts, up to 1.8cm. A soft tissue density, 1.6cm, at liver dome, stationary.
      • No enlarged lymph nodes in para-aortic and pelvic regions.
      • No bony destructive lesion on these images.
    • Impression
      • s/p Hartmann operation
      • Small bowel obstruction
      • Ascites
  • 2023-03-23 KUB
    • s/p descending colostomy
    • A metallic clip over pelvis
  • 2023-03-10 PET
    • A glucose hypermetabolic lesion in the lower pelvic region near the previous operative area. Either residual malignancy or post-operative inflammation may show this picture. However, no prominent FDG uptake was noted in the S7 dome of the subphrenic space.
    • Glucose hypermetabolism in a focal area in the right paraaortic region. The nature is to be determined (inflammatory process? a metastatic lymph node of low FDG uptake? other nature?). Please correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in some focal areas in the colon. The nature is to be determined (physiological FDG accumulation? other nature?). Please also correlate with other clinical findings for further evaluation.
  • 2023-02-17 CT - abdomen
    • History:
      • 20221117 CT: S-colon CA wt uterus invasion, cT4bN2bM0, stage IIIC
      • 20221223 CT: S-colon CA with perforation is highly suspected.
      • 20221224 S/P Hartmann operation:S-colon CA wt uterus invasion and involving bil. ovaries (Two sites?).pT4bN0M1b; pstage: IVB.
    • Findings:
      • S/P Hartmann operation and autosuture in the sigmoid colon.
        • S/P hysterectomy.
      • There is mild dilatation of the terminal ileum.
        • please correlate with clinical condition.
      • A soft tissue lesion 1.6 cm in S7 dome of the subphrenic space is highly suspected, nature? Follow up is indicated.
      • There are several hepatic cysts in both lobes and the largest one 1.6 cm in size at S4.
      • There is no focal lesion in both lung and mediastinum.
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
      • There is no evidence of ascites and lymphadenopathy.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
    • Impression:
      • S/P Hartmann operation and autosuture in the sigmoid colon.
        • There is no evidence of tumor recurrence.
      • There is mild dilatation of the terminal ileum.
        • please correlate with clinical condition.
      • A soft tissue lesion 1.6 cm in S7 dome of the subphrenic space is highly suspected, nature? Follow up is indicated.
  • 2023-02-03 KUB
    • Stool retention in the bowel.
  • 2023-01-13, -01-06, -01-05 KUB
    • Presence of ileus.
  • 2022-12-26 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, rectosigmoid colon, exploratory laparotomy with Hartmann operation — Adenocarcinoma, moderately differentiated
      • Resection margins: bilateral margins free; radial margin involved.
      • Lymph node, mesocolic, dissection — free (0/13)
      • pT4b pN0 pM1b, at least; Pathology stage: IVB, at least. NOTE: Please correlate with clinical and image findings.
    • Gross Description:
      • Procedure - exploratory laparotomy with Hartmann operation
      • Tumor Site - Rectosigmoid region
      • Tumor Size: 4.5 x 3.5 x 3.5 cm.
      • Macroscopic Tumor Perforation: Present
      • Macroscopic Intactness of Mesorectum - Incomplete
      • Sections are taken and labeled as: A1-2: bilateral cut ends; A3-8: tumor; A9-10: lymph nodes.
    • Microscopic Description:
      • Histologic Type - Adenocarcinoma
      • Histologic Grade - G2: Moderately differentiated
      • Tumor Extension - Tumor invades the visceral peritoneum and involving myometrium as well as bilateral ovaries.
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Involved
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Not identified
      • Tumor Budding- none.
      • Type of Polyp in Which Invasive Carcinoma Arose: none.
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes - free
        • Number of Lymph Nodes Involved/Examined: 0/13
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) - not applicable.
        • Primary Tumor (pT) - pT4b: Tumor directly invades or adheres to adjacent organs or structures
        • Regional Lymph Nodes (pN) - pN0: No regional lymph node metastasis
        • Distant Metastasis (pM) - pM1b: Metastasis to two or more sites or organs is identified without peritoneal metastasis
      • Additional Pathologic Findings - None identified
      • Ancillary Studies – result of S2022-20393. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • REFERENCE: S2022-23261: uterus and bilateral adnexae: involved by tumor.
  • 2023-12-26 Patho - uterus with or without SO non-neoplastic/prolapse
    • DIAGNOSIS:
      • Uterus, cervix, total abdominal hysterectomy — No pathological changes.
      • Uterus, endometrium, total abdominal hysterectomy — Polyp, Proliferative phase
      • Uterus, corpus, total abdominal hysterectomy — adenocarcinoma, invasion of myometrium.
      • Adenxae, bilateral, bilateral salpingo-oophorectomy — adenocarcinoma, involving bilateral ovaries.
    • GROSS DESCRIPTION:
      • Specimen submitted in formalin consists of one uterus weighing 230 gm and measuring 10 x 6 x 3 cm. The external surface of the uterus is mucoid in appearance. On cut, there are multiple foci of mucoid tumor invading the outer half of the myometrium.
      • The endometrial cavity is 5 x 4 x 3 cm in size and the endometrium is 0.2 cm in thickness. One polyp measuring 0.8 x 0.3 x 0.3 cm is present in the endometrial cavity. The cervix measuring 4 x 3 x 2 cm is normal in appearance. The left ovary and tube measuring 6 x 4 x 3 cm and 5 x 0.5 x 0.4 cm and the right ovry and tube measuring 8 x 7 x 6 cm and 5 x 0.5 x 0.5 cm show tumor invasion of bilateral ovaries. Representative tissue for sections in the following cassettes: A1-2: left ovary and tube; A3-6: right ovary and tube; A7-10: endometrium and uterine corpus; A11: cervix.
    • MICROSCOPIC DESCRIPTION:
      • Section of the cervix shows no pathological changes. The endometrium and polyp show proliferative phase. The myometrium shows adenocarcinoma with abundant mucinous pools invading the external half of the myometrium. The bilateral ovaries are involved by adenocarcinoma with abundant mucinous pools.
  • 2022-12-23 CT - abdomen
    • Findings:
      • There is pneumoperitoneum with more gas bubbles in the lower pelvis omentum, and mild fatty stranding of the omentum that is c/w hollow organ perforation and highly suspicious sigmoid colon cancer perforation?
        • please correlate with clinical condition.
      • There is smudggy appearnace of the lower pelvis omentum that may be peritonitis or carcinomatosis?
      • Prior CT identified sigmoid colon cancer and regional LNs metastases is noted again, stationary.
        • The proximal colon, beyond sigmoid colon, shows dilatation and Eqivocal pneumatosis?
        • Sigmoid colon cancer induce near complete obstruction is suspected.
      • There are several hepatic cysts in both lobes and the largest one 1.6 cm in size at S4.
      • Prior CT identified left ovary dermoid cyst (3.9cm), Right ovary cyst (6.2cm), and some csytic lesions (up to 1.3cm) in the uterus are noted again, stationary.
    • Impression:
      • Pneumoperitoneums is noted.
      • Sigmoid colon cancer perforation is highly suspected.
  • 2022-11-25 All-RAS + BRAF mutations assay
    • Detected (KRAS codon 12 GGT>GAT, p.G12D)
    • There was no variant detect in the BRAF gene.
  • 2022-11-28 KUB
    • Transitional vertebra of L5-S1, left side.
  • 2022-11-22 Exercise Electrocardiogram Bruce
    • Findings
      • The patient exercised according to the BRUCE for 06:14 min:s, achieving a work level of max METS: 7.3.
      • The resting heart rate of 59 bpm rose to a maximal heart rate of 130 bpm.
      • This value represents 71 % of the maximal, age-predicted heart rate.
      • The resting blood pressure of 110/76 mmHg, rose to a maximum blood pressure of 159/70 mmHg.
      • The exercise test was stopped due to Dyspnea, Frequent PVCs, Fatigue.
    • Conclusion
      • Resting ECG: normal sinus rhythm
      • Arrhythmia: VPC bigeminy during exam
      • Interpretation: No significant ST-T change during exercise and recovery phases.
      • Conclusion Inconclusive, submaximal stress
  • 2022-11-22 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (108 - 35) / 108 = 67.59%
      • M-mode (Teichholz) = 67.9
    • Conclusion
      • Preserved LV and RV systolic function with normal wall motion
      • Normal chamber size
      • Mild MR, PR
  • 2022-11-18 Patho - colorectal polyp
    • Colorectum, rectosigmoid 15 cm above anal verge, biopsy — Adenocarcinoma.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • Specimen submitted in formalin consists of 2 pieces of tan, irregular tissue measuring 0.4 x 0.2 x 0.1 cm.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • 2022-11-17 CT - abdomen
    • History and indication: Abdominal pain
    • Findings
      • Wall thickening of S-colon with uterus invasion and regional LAP.
      • Liver cysts (up to 1.3cm).
      • Suspected left ovary dermoid cyst (3.9cm). Right ovary cyst (6.2cm). Some csytic lesions (up to 1.3cm) in uterus.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2022-11-17 ECG
    • Sinus rhythm with short PR
    • T wave abnormality, consider inferior ischemia
    • Abnormal ECG
  • 2022-11-17 Sigmoidoscopy
    • Findings
      • Rectosigmoid cancer with partial obstruction at 15 cm from AV, biopsy was done
      • Tattooing was performed
    • Diagnosis
      • Rectosigmoid cancer with partial obstruction s/p biopsy and tattooed
    • Suggestion
      • Elective colectomy
    • Complication
      • No immediate complication

[MedRec]

  • 2023-03-03 SOAP Gastroenterology Su WeiZhi
    • S: AFP 11, anti-HBs (+)
    • Prescription x3
      • Baraclude (entecavir 0.5mg) 1# QDAC
  • 2022-12-05 SOAP Gastroenterology Su WeiZhi
    • S: Anti-HBc (+); HBsAg (-) HBV DNA undetectable, check anti-HBs
    • Prescription x3
      • Baraclude (entecavir 0.5mg) 1# QDAC
  • 2022-11-23 ~ 2023-11-28 POMR Hemato-Oncology Zhang ShouYi
    • Discharge diagnosis
      • Malignant neoplasm of sigmoid colon
      • S-colon CA wt uterus invasion, cT4b N2b M0, stage III
    • CC
      • for #1 CCRT with FOLFOX
    • Present illness
      • This 46-year-old female, a pt of S-colon CA wt uterus invasion, cT4b N2b M0, stage III, Dx in Nov 2022 by Dr Xiao GuangHong, suffered from initial presentation of bloody stool passage since Sep 2022 and body weight loss 3-5kg, poor appetite were also noted.
      • Image study with sigmoidoscopy (11/17 22) showed rectosigmoid cancer with partial obstruction at 15 cm from AV, s/p biopsy. Abd CT (11/17 22) revealed Wall thickening of S-colon with uterus invasion and regional LAP.Imp: T4b N2b M0, stage III,
      • Surgical pathology with colorectum, rectosigmoid 15 cm above anal verge, biopsy (11/18 22) proved adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • She referred to our hemato-oncologic clinic on 11/21 22 for pre-Op CCRT by Dr Xiao GuangHong.
      • We explain to pt & her husband about the indication & risk / benefit of pre-Op CCRT with FOLFOX plus R/T then do abd CT for response evaluation.
      • HBsAg, anti-HCV (11/22 22) showed negative and anti-Hbc: positive under anti-virus Tx.
      • R/T to rectal tumor by Dr Wang YuNong on 11/28 22.
      • Will give pre-Op adjuvant CCRT with mFOLFOX6 IV Q2W x 6 plus R/T.
      • Today, she was admitted for #1 pre-Op adjuvant CCRT with mFOLFOX6 IV Q2W x 6 on 11/23 22.
    • Course of inpatient treatment
      • After admission, repeat pathology (11/18 22) proved Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • Chemotherapy with Oxalip (70mg/m2) plus leucovorin (400mg/m2) and 5-FU (2800mg/m2) were given on 11/25-11/27 22, smoothly without obvious side effect.
      • She complained of abdominal pain and constipation post C/T and KUB showed massive stool impaction in colon.
      • Ultracet 1# po was given for pain control.
      • She felt abdominal pain much better and she was discharged on 11/28 22 under stable condition and will follow-up at OPD.
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
      • Megejohn (megestrol acetate 160mg) 1# QD
  • 2022-11-21 SOAP Radiation Oncology Wang YuNong
    • A: Advanced RS cancer with uterus, ovary invasion, cT4bN2bM0
    • P: Suggest CCRT then OP
      • CT-simulation will be arranged on 11/24. Plan to deliver 45 Gy/ 25 fx to the pelvis.
      • Then boost the S-colon tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 11/28.

[consultation]

  • 2023-11-08 Colorectal Surgery
    • Q
      • right abdominal pain since yesterday, radiation to periumbilical area
      • nausea and vomiting, once eating
      • watery stool from colostomy noted today
      • Past history:
        • Sigmoid colon cancer with uterus invasion, cT4b N2b M0, stage III status post Hartmann operation (resection of rectosigmoid junction and end S colostomy ) on 2022/12/24. T4bN0M1b stage IVb
        • Hepatitis B, Anti-Hbc : positive
        • Allergy: denied
    • A
      • S: Sigmoid colon cancer with uterus invasion, cT4b N2b M0, stage III status post Hartmann operation (resection of rectosigmoid junction and end S colostomy ) on 2022/12/24. T4bN0M1b stage IVb under paliative chemotherapy, CEA keeping growing.
      • O: ileus is noted and consider carcinomatosis and ileus.
      • P: pleasea medical treatment first.
  • 2023-03-24 Colorectal Surgery
    • Q
      • CC: low abd pain for 5 hours
        • vomiting once
        • mild epigastric pain +
        • chest pain +
        • no headache, no dyspnea, no diarrhea, no fever
      • past history:
        • Sigmoid colon cancer with uterus invasion, cT4b N2b M0, stage III status post Hartmann operation (resection of rectosigmoid junction and end S colostomy) on 2022/12/24. T4bN0M1b stage IVb s/p OP
      • nka
    • A
      • suspect ileus by CT image, still has defecation.
      • medical treatment first including antibiotics treatment
  • 2022-12-23 Colorectal Surgery
    • Q
      • for tenderness at RLQ, LLQ noted, suspect S-colon rupture.
      • This 46-year-old female, a pt of S-colon CA wt uterus invasion, cT4b N2b M0, stage III, Dx in Nov 2022 by Dr Xiao GuangHong, suffered from initial presentation of bloody stool passage since Sep 2022 and body weight loss 3-5kg, poor appetite were also noted.
      • she was admitted for #3 pre-Op adjuvant CCRT with mFOLFOX6 IV Q2W x 6 on 12/22 22. Then the patient complaints abdomen pain since last night, and took the painkillers with Tramacet twice, not useful.
      • She suffered from tenderness at RLQ, LLQ noted, follow-up abdomen CT, and pending report, so we need your help, thanks a lot!
    • A
      • suspect RS colon cancer with obstruction and rupture with sepsis
      • suggest emergent Hartman’s operation and ICU care.
  • 2022-12-23 General and Gastrointestinal Surgery
    • Q (same question as colorectal surgery on the same day)
      • Due to symptoms got worse, CT was arranged and hollow organ perforation is suspected.
    • A
      • O: vital signs: BP:97/56; HR:78; BT:36.8’C; RR:18; SpO2:96%
        • abdomen: soft, ovoid, decrease bowel sound, low abdojminal tenderness and muscle guarding, positive rebounding pain, tympanic percussion
        • lab data: see chart
        • CT: free air accumulation in low abdomen
      • A: hollow organ perforation, suspect colon tumor related perforation
      • P: Please consult CRS for further evaluation

[surgical operation]

  • 2022-12-24
    • Surgery
      • Impression:
        • Advanced RS cancer with uterus , ovary invasion, cT4bN2bM0, stage IIIC
        • r/o rupture of right ovarian cyst
        • Pelvic adhesion
      • Procedure:
        • Abdominal total hysterectomy+ bilateral salpingoophorectomy  +pelvic/abdominal adhesiolysis
    • Finding
      • Uterus: one 2x1cm subserosal uterine myoma at left anterior uterine wall; severe adhesion between posterior wall to sigmoid colon and CDS.
      • RAD: suspected rupture of right ovarian cyst before, r/o tumor invasion, severe adhesion to sigmoid colon, adhesion lysis was performed smoothly
      • LAD: a 4x3 cm left ovarian cystic lesion
      • CDS: severe adhesion between lower sigmoid colon and posterior uterine wall, adhesion lysis was performed.
      • Estimated blood loss: 400ml
      • Blood transfusion: pRBC 4U
      • Complication: nil  
  • 2022-12-24
    • Surgery: Hartmann operation (resection of RS colon and end S colostomy )
    • Finding
      • tumor of S colon invasion to uterin + bilateral ovary and right side ovary necrosis and rupture with S colon cancer.
      • much pus/ascites over abdomen

[radiotherapy]

[chemotherapy]

  • 2023-10-18 - irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-09-26 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-08-30 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-08-02 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-07-05 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-06-07 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-05-11 - irinotecan 180mg/m2 295mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-04-13 - irinotecan 170mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2400mg/m2 3840mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-03-16 - irinotecan 160mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2400mg/m2 3840mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-02-16 - irinotecan 160mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + aprepitant 125mg PO + NS 250mL
  • 2022-12-08 - oxaliplatin 70mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3970mg NS 500mL 46hr (FOLFOX Q2W)
    • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + NS 250mL
  • 2022-11-25 - oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX Q2W)
    • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + NS 250mL

==========

2023-11-09

[monitoring CEA levels post-Hartmann surgery: signs of emerging resistance to FOLFIRI regimen]

The Hartmann procedure was performed on 2022-12-24, after which the tumor marker CEA significantly decreased to within normal limits and remained so until August 2023. Recently, there has been an increase in the CEA levels, which could indicate the potential emergence of resistance to the current treatment regimen FOLFIRI which has been initiated since 2023-02-16.

  • 2023-11-07 CEA (NM) 16.050 ng/ml **
  • 2023-10-24 CEA (NM) 13.781 ng/ml **
  • 2023-10-03 CEA (NM) 9.779 ng/ml *
  • 2023-09-22 CEA (NM) 8.919 ng/ml *
  • 2023-09-05 CEA (NM) 7.765 ng/ml *
  • 2023-08-01 CEA (NM) 4.826 ng/ml
  • 2023-07-04 CEA (NM) 3.796 ng/ml
  • 2023-02-20 CEA (NM) 4.302 ng/ml
  • 2022-11-25 CEA (NM) 73.723 ng/ml ***
  • 2022-11-23 CEA (NM) 75.097 ng/ml ***

[small bowel obstruction]

On 2023-11-08, a CT scan revealed a small bowel obstruction (SBO) in the patient, with a prior episode of postoperative ileus evidenced by KUB imaging in January 2023.

Patients with SBO may experience significant fluid loss, metabolic acidosis or alkalosis, and electrolyte imbalances. This is particularly true for patients with prolific vomiting from a proximal SBO, those with symptoms lasting several days before presentation, or those with an obstruction that results in large-volume fluid sequestration within the bowel. The patient is currently on an intravenous regimen of normal saline 500mL twice daily and Taita No.5 solution 500mL every 12 hours, which is considered an appropriate treatment.

In cases of SBO with significant distension, nausea, and/or vomiting, nasogastric tube decompression may be considered. Patients with these symptoms likely have a complete or high-grade obstruction; decompression can improve comfort and minimize the worsening of distension due to swallowed air.

Antibiotics are indicated if there is a suspicion of bowel compromise, such as ischemia, necrosis, or perforation.

2022-12-23

  • Loperamide is an opioid medication that is used to treat diarrhea. Loperamide works by slowing the movement of the intestines, which helps to reduce the frequency of diarrhea.
  • Lactulose is a type of laxative that is used to treat constipation and to help regulate bowel movements. Lactulose works by drawing water into the intestines, which helps to soften stools and make them easier to pass.
  • When loperamide and lactulose are coadministered (the current situation), there is no specific expected effect on the body.

700382293

231108

[exam findings]

  • 2023-10-16 ENT Hearing Test
    • PTA
      • Reliabilty Fair
      • R’t : 43 dB HL, normal to severe mixed type HL
      • L’t : 21 dB HL, normal to moderate SNHL
    • Tymp
      • R’t : Type C
      • L’t : Type A
    • ART
      • R’t : absent
      • L’t : contra absent.
  • 2023-10-02 Nasopharyngoscopy
    • NPC undergoing CCRT
    • MRI validation done
    • will receive further C/T
    • grossly smooth NP
  • 2023-09-28 MRI - nasopharynx
    • The current study was compared to the prior one obtained on 2023/06/27.
    • Known a case of NPC S/P indction C/T. Shrinkage of this tumor, but still large residual tumor (>6.0cm) at nasopharyngeal space with invasion of right parapharyngeal space, masticator space, cavernous sinus, PPF, and paranasal sinuses.
    • Right otitis media.
    • Right mastoiditis.
  • 2023-09-22 ENT Hearing Test
    • Tymp:
      • Bil type A.
    • ART:
      • Bil reduced and absent.
    • E-tube function test:
      • Bil Poor.
    • PTA:
      • Reliability FAIR
      • Average RE 44 dB HL; LE 21 dB HL.
      • RE normal to moderately severe SNHL.
      • LE normal to mild SNHL.
  • 2023-09-18 Nasopharyngoscopy
    • 9/18 fiber = s/p induction C/T*3 (smooth NP now), then MRI validatiaon + then CCRT
    • R MEE+ tinnitus, PTA =
    • 2023/6/19 NPC, R= NK, diff ca (cT4N2M0, stage IVA) [RT Wang + CT Gao]
  • 2023-07-10 KUB
    • S/P double J catheter insertion, left side urinary tract.
    • Fecal material store in the colon.
  • 2023-07-10 SONO - kidney
    • Diagnosis: Bilateral renal stones
    • Suggestion:
      • L’t Kidney :
        • Size: 10 x 4.9 cm
        • Cortex: 1.2 cm
        • Calculus:(Max) Lower calyx 0.5 cm 0.3 cm
      • R’t Kidney :
        • Size: 11 x 5.8 cm
        • Cortex: 2.1 cm
        • Calculus:(Max) Lower calyx 0.3 cm 0.1 cm
  • 2023-07-04 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
  • 2023-07-01 CT - abdomen
    • Clinical history: 52 y/o male patient with NPC cT4N2M0, left hydronephrosis r/o maligancy or stone.
    • With and without contrast enhancement CT of abdomen–whole:
      • Dilatation of left pelvicaliceal system and upper ureter due to left upper ureteral stone (2.4cm).
      • Small bilateral renal caliceal stones.
      • Right renal cyst, 1.3cm.
      • Liver cysts, up to 1.7cm in liver dome.
      • Presence of gallbladder sludge.
      • R/O atelectasis in right lower near diaphragm, suggest follow up study.
    • Impression:
      • Left upper ureteral stone with hydronephrosis.
      • Small bilateral renal caliceal stones.
      • Right renal cyst.
      • R/O liver cysts.
      • R/O atelectasis in right lower near diaphragm, suggest follow up study.
      • Gallbladder sludge.
  • 2023-06-29 PET scan
    • A large glucose hypermetabolic lesion involving the nasopharynx, right parapharyngeal space, right oropharynx, right maxillary sinus, right pterygoid muscles, skull base, sphenoid sinus and invasion to the right temporal lobe of the brain, compatible with advanced nasopharyngeal malignancy with intracranial invasion.
    • Glucose hypermetabolism in the left retropharyngeal and multiple bilateral neck level II to III lymph nodes. Multiple metastatic lymph nodes may show this picture.
    • Increased FDG accumulation in both kidneys. Physiological FDG accumulation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2023-06-28 SONO - abdomen
    • Diagnosis:
      • Fatty liver, moderate
      • Liver cysts, both lobes
      • Hydronephrosis, left kidney
      • Pancreatic calcified lesions
    • Suggestion:
      • Urology for hydronephrosis survey
      • Regular abdominal ultrasound follow up
  • 2023-06-27 MRI - nasopharynx
    • Indication: nasopharyngeal carcinoma, for cancer work up
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • A larage lobulated mass lesion (> 12 cm in largest dimension), mainly at right nasopharygeal space, with invasion of oropharynx, paranasal sinuses, both cavernous sinuses, right temporal fossa, right medial pterygoid muscle, right PPF and right parapharyngeal space.
      • Tumor also invasion to right posterior fossa, CP angle.
      • Multiple enlarged necrotic nodes (max: 4.1 cm) over both level II and III of neck and left retropharyngeal space. All above the low border of cricoid cartilage.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor and LNs.
    • IMP: Right NPC, T4N2Mx, stage IVA.
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:4(T_value) N:N2(N_value) M:0(M_value) STAGE:IVA (Stage_value)
  • 2023-06-27 ENT Hearing Test
    • Tymp:
      • RE type C; LE type A.
    • ART:
      • Bil absent.
    • PTA
      • Reliability FAIR
      • Average RE 29 dB HL; LE 21 dB HL.
      • RE normal to moderate SNHL with 4k Hz A-B gap.
      • LE normal to mild SNHL.
  • 2023-06-20 CT - neck
    • One huge lobulated mass lesion (> 8cm in largest dimension), mainly at right nasopharygeal space, with invasion of paranasal sinuses, both cavernous sinuses, right temporal fossa, right medial pterygoid muscle, right PPF and right parapharyngeal space. Suggest tissue proof to rule out malignancy.
    • Multiple enlarged necrotic nodes (max: 4.5cm) over both level II and III of neck, favor malignant nodes.
  • 2023-06-19 Patho - nasopharyngeal/oropharyngeal biopsy
    • DIAGNOSIS:
      • Nasopahrynx, punch biopsy — Non-keratinizing squamous cell carcinoma, differentiated (WHO-2A)
    • GROSS DESCRIPTION:
      • Specimen submitted in formalin consists of several pieces of tan, irregular tissue measuring up to 1.2 x 0.7 x 0.3 cm. All for section in one cassette.
    • MICROSCOPIC DESCRIPTION:
      • Histologic Type: Non-keratinizing carcinoma, differentiated (WHO-2A); The immunohistochemical stains reveal CK(+) and p63(+).
      • Treatment Effect (applicable to carcinomas treated with neoadjuvant therapy): patient not received
      • Additional Pathologic Findings (select all that apply): None identified
      • Ancillary Studies: patient not received
      • Clinical History (select all that apply): absent
  • 2023-06-19 Nasopharyngoscopy
    • smooth OPx, HPx
    • crust with mild bulging over right upper adenoid pad
    • fair inf. turbinate, mucopus over left superior meatus

[MedRec]

  • 2023-10-06 SOAP Radiation Oncology Wang YuNong
    • Plan
      • The bil. neck: 50 Gy/ 25 fx. The preC/T NP tumor and LAPs involved area: 70 Gy/ 35 fx.
  • 2023-08-15 SOAP Radiation Oncology Wang YuNong
    • Plan
      • Arrange MRI and EBV DNA test in Sep 2023 (after induction C/T completes). Refer to ENT Dr. Su for NP response assessment.
      • CT-simulation will be arranged on 9/26.
      • The RT regimen: The NP, oropharynx, bil. neck lymphatic drainage area: 50 Gy/ 25 fx. The gross NP tumor and LAPs: 70 Gy/ 35 fxs. RT will start around 10/2.
      • RTC: 9/26.
  • 2023-06-26 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Right nasopharyngeal carcinoma, cT4N2M0, stage IVA, EBV DNA: 4460
      • Left ureter stone with left hydronephrosis s/p Flexible ureteroscopic lithotripsy & double J stenting, left side on 7/4
      • Localized swelling, mass and lump, neck
      • Chronic sinusitis, unspecified
      • Personal history of COVID-19
      • Calculus of ureter
    • CC
      • Right progressive painless neck mass for a year
    • Present illness
      • This is a 52-year-old man with past history of Inguinal hernia status post operation
      • A(+, seldom)/B(-)/C(+, 1 PPD for 30 +years)
      • He was brought to our outpatient department with chief complaint of right progressive painless neck mass for a year. Accompanying symptoms included trismus and intermittent epistaxis. No facial palsy, odynophagia, dysphagia, easy chocking, hemoptysis, otalgia, voice change, dyspnea, diplopia, recent body weight loss, fever were noticed. Physical exam showed a 6*4 cm firm and unmovable mass over right neck level II region. Fiberscopic exam showed bulging over right upper adenoid pad and right posterior oropharyngeal wall. Biopsy of the nasopharyngeal tumor was done, and the pathology report prooved malignancy. Admission for further examination was suggested, and the patient agreed after thorough consideration. Therefore, under the impression of nasopharyngeal cancer, the patient was admitted for cancer work-up.
    • Course of inpatient treatment
      • After admission, serial tests were arranged for tumor staging work up. MRI showed nasopharyngeal carcinoma, cT4N2Mx, stage IVA. Abdominal sonography showed negative for malignancy but left hydronephrosis. Whole body PET scan showed advanced nasopharyngeal malignancy with multiple metastatic lymph nodes over bilateral level II/III and intracranial invasion.Tooth extraction was unnescessary after consulting OS doctor. After consulting with oncologist and radiation oncologist, induction chemotherapy first and then concurrent chemoradiotherapy was favored. Under relative stable condition, the patient will be transferred to oncology ward for further systemic treatment arrangement.
      • After transfer to oncology ward, we consult CVS for port A insertion and check anti-HBc for chemotherapy preparation. Additionally, we arrange abdominal CT for left hydronephrpsis survey. Abdominal CT show Left upper ureteral stone (2.4cm)with hydronephrosis. Consult GU doctor and arrange lexible ureteroscopic lithotripsy & double J stenting, left side on 7/4. In addiiton, due to urine routein show pyuria, add cefuroxime noted.
      • Remove foley on 7/5 morning and voiding smoothly. Under relative stable condition, he was discharge with oral form antibiotic.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQID
      • Mefno (mephenoxalone 200mg) 1# Q12H
      • Ulstop (famotidine 20mg) 1# BID
      • Meitifen (diclofenac Na 75mg) 1# Q12H
      • Allegra (fexofenadine 60mg) 1# BID
      • Ceficin (cefixime 100mg) 2# Q12H

[consultation]

  • 2023-07-03 Urology
    • Q
      • This 52 year old man is a case of NPC cT4N2M0, stage IVA. He will receive induction chemotherpy follow by CCRT. During staging, left ureter stone (2.4cm) with left hydronephrosis was noted. We need your help before we begin chemotherapy.
    • A
      • This 52 year old man is a case of NPC cT4N2M0, stage IVA. We were consulted for left ureteral stone with hydronephrosis.
      • He will receive induction chemotherpy follow by CCRT.
      • Left URSL will be arranged on 2023/07/04 morning on call.
      • Please collect U/A today
  • 2023-06-30 Hemato-Oncology
    • Q
      • for concurrent chemoradiotherapy arrangement
      • This is a 52-year-old man with past history of inguinal hernia status post operation A(+, seldom)/B(-)/C(+, 1 PPD for 30 +years)
      • This time, he was admitted to our ward for NPC cancer work up.
        • Pathology: Non-keratinizing squamous cell carcinoma, differentiated (WHO-2A)
        • 6/27 MRI: cT4N2Mx, stage IVA
        • 6/28 Abdominal echogram: negative for malignancy
        • 6/29 Whole body PET scan: local regional disease. No distant metastases.
        • EBV DNA: 4460.
      • Under the impression of NPC, cT4N2Mx, stage IVA , we need your expertise for postoperative concurrent chemoradiotherapy arrangement.
    • A
      • This 52 year old man is a case of NPC, cT4N2M0 stage IVA, EBV DNA 4460. We are consulted for further evaluation.
      • For advanced NPC, induction chemotherapy [TPF: three cycles of intravenous docetaxel (60 mg/m2 on day 1), intravenous cisplatin (60 mg/m2 on day 1), and continuous intravenous fluorouracil (600 mg/m2 per day from day 1 to day 5) every 3 weeks] followed by CCRT [weekly cisplatin] is suggested.
      • We will discuss with patient about further systemic chemotherapy. Please arrange port A insertion and check anti HBc. Additionally, please arrange abdominal CT for hydronephrosis survey. We will take over this case if you agree.
  • 2023-06-30 Radiation Oncology
    • Q
      • (same as consulting Hemato-Oncology on the same day)
    • A
      • Under the impression of NPC, cT4N2Mx, stage IVA, according to the current NCCN guideline, induction chemotherapy followed by CCRT is the category 1 choice.
      • After induction C/T finishs, please refer back for CCRT arrangement by then.
      • The RT regimen: The NP, oropharynx, bil. neck lymphatic drainage area: 50 Gy/ 25 fx. The gross NP tumor and LAPs: 70 Gy/ 35 fxs. Thank you very much.

[radiotherapy]

[chemotherapy]

  • 2023-10-25 - cisplatin 40mg/m2 68mg NS 500mL 2hr (CDDP QW CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 1hr (before CDDP) + NS 500mL 1hr (after CDDP)
  • 2023-10-18 - cisplatin 40mg/m2 68mg NS 500mL 2hr (CDDP QW CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 1hr (before CDDP) + NS 500mL 1hr (after CDDP)
  • 2023-10-11 - cisplatin 40mg/m2 68mg NS 500mL 2hr (CDDP QW CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 1hr (before CDDP) + NS 500mL 1hr (after CDDP)
  • 2023-10-04 - cisplatin 40mg/m2 68mg NS 500mL 2hr (CDDP QW CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 1hr (before CDDP) + NS 500mL 1hr (after CDDP)
  • 2023-09-08 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 60mg/m2 100mg NS 500mL 2hr D1 + fluorouracil 600mg/m2 1000mg NS 500mL 24hr D1-5 (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-08-03 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 60mg/m2 100mg NS 500mL 2hr D1 + fluorouracil 600mg/m2 1000mg NS 500mL 24hr D1-5 (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-07-10 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 60mg/m2 100mg NS 500mL 2hr D1 + fluorouracil 600mg/m2 1000mg NS 500mL 24hr D1-5 (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2023-11-08

[leukopenia, thrombocytopenia]

The weekly administrations of cisplatin on 2023-10-04, 2023-10-11, 2023-10-18, and 2023-10-25 are an integral part of the current concurrent chemoradiotherapy (CCRT) treatment. However, the patient’s WBC and PLT recovery appears to be insufficient, resulting in a continued decline in WBC and PLT counts. Consequently, chemotherapy has been temporarily suspended, and a regimen of G-CSF (filgrastim) 300mg SC QD was commenced on 2023-11-07. A platelet transfusion will also be performed today (2023-11-08).

  • 2023-11-08 WBC 1.73 x10^3/uL **

  • 2023-11-07 WBC 1.30 x10^3/uL **

  • 2023-10-31 WBC 2.33 x10^3/uL *

  • 2023-10-24 WBC 3.36 x10^3/uL

  • 2023-10-17 WBC 4.63 x10^3/uL

  • 2023-10-09 WBC 6.55 x10^3/uL

  • 2023-10-03 WBC 6.27 x10^3/uL

  • 2023-11-08 PLT 34 10^3/uL **

  • 2023-11-07 PLT 30 10^3/uL **

  • 2023-10-31 PLT 67 *10^3/uL **

  • 2023-10-24 PLT 142 10^3/uL

  • 2023-10-17 PLT 250 *10^3/uL

  • 2023-10-09 PLT 299 *10^3/uL

  • 2023-10-03 PLT 314 *10^3/uL

There is a slight increase in WBC and PLT, according to the preliminary observation today.

[acute otitis media]

Ref: Otitis Media, Acute, Empiric Therapy - https://webedition.sanfordguide.com/en/sanford-guide-online/disease-clinical-condition/otitis-media

In treating adult acute otitis media (AOM) without prior antibiotic exposure in the preceding month, the following therapeutic options can be considered:

  • Amoxicillin high dose 1000 mg tid
  • Amoxicillin-clavulanate 875 /125 mg po bid
  • Cefdinir 300 mg q12h or 600 mg q24h
  • Cefpodoxime proxetil 200 mg bid
  • Cefprozil 250-500 mg bid

For patients who have received antibiotics in the previous month, alternative treatments include:

  • Amoxicillin-clavulanate 875/125 mg bid
  • Levofloxacin 750 mg q24h x 5 days
  • Moxifloxacin 400 mg q24h

The standard duration for treatment is 10 days, although it is important to note that the course for Levofloxacin is 5 days.

At present, the patient is being treated with Soonmelt (amoxicillin 500mg, clavulanic acid 100mg) 1200mg IVD Q8H, which is considered an appropriate treatment.

[alarming trend: kidney function deteriorates over the past two months]

Kidney function has shown a worsening trend in the last two months.

  • 2023-11-07 eGFR 51.44 ml/min/1.73m^2
  • 2023-10-31 eGFR 49.19 ml/min/1.73m^2
  • 2023-10-24 eGFR 65.68 ml/min/1.73m^2
  • 2023-10-17 eGFR 69.58 ml/min/1.73m^2
  • 2023-10-09 eGFR 60.01 ml/min/1.73m^2
  • 2023-10-03 eGFR 66.93 ml/min/1.73m^2
  • 2023-09-22 eGFR 71.70 ml/min/1.73m^2
  • 2023-09-15 eGFR 85.37 ml/min/1.73m^2
  • 2023-09-07 eGFR 80.60 ml/min/1.73m^2
  • 2023-09-03 eGFR 81.52 ml/min/1.73m^2

The current dose of cisplatin used in concurrent chemoradiotherapy (CCRT) is lower than that used in the earlier TPF regimen, and adequate hydration has been provided during administration. To further protect renal function after recovery from the recent leukopenia and thrombocytopenia event, and if CCRT treatment is to continue, additional renal protective options include:

  • Ethyol (amifostine): A cytoprotective agent that can be administered prior to cisplatin to guard against nephrotoxicity by selectively shielding normal tissues from the harmful effects of chemotherapy. However, this medication is currently not available at our institution.

  • Magnesium Supplementation: To counteract the magnesium wasting caused by cisplatin, which can lead to nephrotoxicity, magnesium supplements may be administered to prevent hypomagnesemia.

  • Potassium Supplementation: Administered to replenish potassium lost during cisplatin treatment, as cisplatin can cause potassium to be excreted in the urine, potentially leading to hypokalemia.

  • N-acetylcysteine (NAC): An antioxidant considered to protect the kidneys from damage induced by cisplatin through the reduction of oxidative stress.

  • Diuretics: Agents like mannitol may be used alongside hydration to induce diuresis, which can help prevent the accumulation of cisplatin in the kidneys.

700763275

231107

[exam findings]

  • 2023-12-14 Gynecologic ultrasonography
    • CUL-DE-SAC: No fluid
    • Other: ATH+BSO
    • IMP: No obvious uterine or ovarian lesion
  • 2023-11-28 CT - abdomen
    • History and indication: Bilateral ovarian cancers (high-grade serous carcinoma) with peritoneal and lymphonode metastasis, AJCC Pathologic staging: pT3cN1a, stage IIIC.
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Ovary cancer with peritoneal carcinomatosis s/p operation.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Ovary cancer with peritoneal carcinomatosis s/p operation.
      • No definite mass lesion in peritoneal cavity.
  • 2023-08-30 Patho - soft tissue tumor, extensive resection
    • PATHOLOGIC DIAGNOSIS
      • Ovarian mass, right, frozen + debulking surgery — High-grade serous carcinoma
        • Fallopian tube, left, ditto — Free of tumor invasion
      • Ovary, left, ditto — High-grade serous carcinoma
        • Fallopian tube, right, ditto — Free of tumor invasion
      • Endometrium, uterus, debulking surgery — Free of tumor invasion
      • Myometrium, uterus, ditto — Tumor invasion, leiomyomas with calcification and ossification
      • Cervix, uterus, ditto — Free of tumor invasion
      • Parametria, bilateral, ditto — Tumor invasion
      • Omentum ttissue, omentectomy — Tumor invasion
      • Central peritoneal tumor, excision — Tumor invasion
        • Left peritoneal tumors, excision — Tumor invasion
        • R’t and L’t peritoneal tumors, excision — Tumor invasion
      • Lymph node, L’t iliac, dissection — Tumor metastasis (3/7) without extracapsular extension (0/3)
      • Lymph node, L’t obturator, ditto — Tumor metastasis (1/8) without extracapsular extension (0/1)
      • Lymph node, R’t iliac, ditto — Free of tumor metastasis (0/7)
      • Lymph node, R’t obturator, ditto — Free of tumor metastasis (0/6)
      • AJCC Pathologic staging: pT3cN1a, if cM0; stage IIIC
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: frozen + debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND + peritoneal tumor excision)
      • Specimen type: uterus, peritoneal tumors, omentum and lymph nodes
      • Specimen size:
        • L’t ovary (frozen): multiple fragments, up to 8.3 x 7.8 x 4.3 cm with blood
        • L’t fallopian tube (frozen): normal appearance, 4.2 cm in length, up to 0.4 cm in diameter
        • R’t ovary (frozen): ruptured solid mass, 6.6 x 6.5 x 2.9 cm
        • R’t fallopian tube (frozen): normal appearance, 4.3 cm in length, up to 0.4 cm in diameter
        • Uterus: 6.3 x 5.2 x 4.5 cm, 79 gm, tumor seeding at anterior and posterior surface and parametria. Besides, two firm hard myomas measure up to 4.4 x 3.2 x 2.2 cm are also included
        • Omentum: 38 x 18 x 3.2, diffusely tumor invasion with solid and nodular patterns
        • Central peritoneal tumor: one piece, 6 x 4.3 x 3.6 cm
        • Left peritoneal tumors: multiple pieces, up to 2.6 x 1.7 x 1.2 cm
        • Right and left peritoneal tumors: multiple pieces, up to 2.2 x 0.8 x 0.7 cm
      • Tumor site: uncertain, favor left ovary, but clinical correlation is needed
      • Tumor size: multiple fragments, up to 8.3 x 7.8 x 4.3 cm
      • Tumor appearance: solid and cystic mass
      • Specimen integrity: ruptured
      • Lymph nodes: pelvic lymph nodes
      • Representative sections as A1-A2: myomas, A3: parametrium, A4 and A10: anterior surface of uterus, A5: posterior surface of uterus, A6: L’t mesosalpinx, A7-A8: cervix, A9: endometrium+ myometrium, B1-B2: omentum, C1-C2: central peritoneal tumor, D: left peritoneal tumors, E: R’t and L’t peritoneal tumors, F: L’t iliac LNs, G: L’t obturator LNs, H: R’t iliac LNs, I: R’t obturator LNs [Reference: frozen section: F2023-00385 FSA: R’t ovarian tumor, A1: R’t fallopian tube and A2-A5: R’t ovarian mass, FSB: L’t ovary tumor, B1: L’t fallopian tube and B2-B8: L’t ovary tumor]
    • MICROSCOPIC EXAMINATION
      • Histologic type: serous carcinoma
      • Histologic grade: high grade
      • Tumor side ovarian surface involvement: present
      • Contralateral ovary involvement: present
      • Right tube involvement: absent
      • Left tube involvement: absent
      • In situ adenocarcinoma in right &/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: present
      • Left adnexa soft tissue involvement: present
      • Pelvic soft tissue involvement: present
      • Bilateral parametria: tumor invasion
      • Uterine serosa involvement: present
      • Omentum involvement: tumor invasion
      • Uterine Cervix involvement: absent
      • Endometrium involvement: absent
      • Myometrium involvement: minimal tumor invasion, leiomyomas with calcification and ossification
      • Lymph nodes metastasis: tumor metastasis (4/28) without extracapsular extension (0/4) in total number
      • Immunohistochemistry: WT-1(+), PAX-8(+), P53(aberrant expression), ER(+), Napsin-A(-) and vimentin(-)
      • Ascites cytology: Negative
      • Perineural invasion: present
      • Lymphovascular space invasion: present
  • 2023-08-28 EGD
    • Reflux esophagitis, lower esophagus, LA classification, grade A
    • Superfical gastritis, antrum
    • Gastric submucosal leison, fundus
  • 2023-08-07 CT - abdomen
    • Indication
      • Periumbilical pain
      • Irritable bowel syndrome with diarrhea
    • Abdominal CT with and without enhancement revealed:
      • Massive ascites formation is found.
      • Soft tissue mass at bilateral ovaries up to 8.4cm at left side and 5.9cm at right side is found. Ovarian meta is favored.
      • Diffuse nodular lesions at peritoneum and mesentery is found. Cancerous peritonitis with omental cake is considered.
      • The stomach is collapsed.
      • No significant soft tissue mass is found along the course of the colon.
      • Prominent uterine cervix is found.
    • Imp:
      • cancerous peritonitis with bilateral ovarian mass, origin?
      • Prominent uterine cervix is suspected.
  • 2023-08-07 Gynecologic ultrasonography
    • R/O LT mass (90mmX74mm)
    • Asites (+)
  • 2023-08-05 SONO - abdomen
    • Diagnosis:
      • probable liver parenchymal disease
      • ascites: moderate to large amount
      • suspected mass lesions in lower abdomen, size 8.2cm and 5.3cm
    • Suggestion:
      • suggest CT scan

[MedRec]

  • 2023-09-24 ~ 2023-09-26 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Bilateral ovarian cancers (high-grade serous carcinoma) with peritoneal and lymphonode metastasis < AJCC Pathologic staging: pT3cN1a, stage IIIC > C 56.9
      • Chronic viral hepatitis B without delta-agent
    • CC
      • for C1 chemotherapy with Taxol / Carboplatin
    • Present illness
      • This 55-year-old woman, a patient of bilateral ovarian cancers (high-grade serous carcinoma) with peritoneal and lymphonode metastasis < AJCC Pathologic staging: pT3cN1a, stage IIIC was diagnosed on 2023-09-04, suffered from bowel behavior change fron once per day to 6 times per day and body weight gain since 2023/07. Abdominal fullness with nausea, periumbilical pain and sometimes dyspena. She visited to our GYN OPD for further evaluation and survey.
      • Image study with abdominal sono (2023-08-05) showed probable liver parenchymal diseaseascites: moderate to large amount, suspected mass lesions in lower abdomen. Gyn sono (2023-08-07) revealed R/O LT mass:(90mmX74mm), Asites(+) and abdominal CT (2023-08-07) showed cancerous peritonitis with bilateral ovarian mass, origin? Prominent uterine cervix is suspected. Frozen section report (2023-08-29) proved 1. R’t ovarian tumor, FSA — Adenocarcinoma, 2. L’t ovarian tumor, FSB — Adenocarcinoma. Ascites cytology (2023-08-31) showed negative.
      • Operation Procedure: frozen + debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND + peritoneal tumor excision) on 2023-09-04 which showed ovarian mass, right, frozen + debulking surgery — High-grade serous carcinoma. Myometrium involvement: minimal tumor invasion, leiomyomas with calcification and ossification. Lymph nodes metastasis: tumor metastasis (4/28) without extracapsular extension (0/4) in total number. Immunohistochemistry: WT-1(+), PAX-8(+), P53(aberrant expression), ER(+), Napsin-A(-) and vimentin(-) AJCC Pathologic staging: pT3cN1a, if cM0; stage IIIC.
      • The tumor marker showed CA-125: 337U/ml on 2023-09-21. Hepatitis markers showed HBsAg, Anti-HCV: negative and anti-Hbc: positive.
      • Today, she was admitted for C1 chemotherapy with Taxol/Carbopaltin on 2023-09-24.
    • Course of inpatient treatment
      • After admission, Limeson 5# po q6h & q12h before C/T was given for preventive allergy.
      • Chemotherapy with Taxol (175mg/m2) plus Carboplatin (AUC:5) were administered on 2023-09-25, smoothly without obvious side effect.
      • Entecavir 1# po qd was added for anti-Hbc positive.
      • She was discharged on 9/26 23 under stable condition and will follow-up at OPD.
    • Discharge prescription
      • MgO 250mg 1# TID
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Baraclude (entecavir 0.5mg) 1# HS
  • 2023-09-21 SOAP Obstetrics and Gynecology Chen GuoHu
    • O
      • sonar: unremarkable findings, ascites about 50c.c -> ascites 20c.c
      • change dressing: wound ok, remove stitchs
  • 2023-09-18 ~ 2023-09-21 POMR General and Gastrointestinal Surgery Li ChaoShu
    • Discharge diagnosis
      • Left pneumothroax
      • Bilateral ovarian cancers (high-grade serous carcinoma) with peritoneal and lymphonode metastasis < AJCC Pathologic staging: pT3cN1a, stage IIIC > C 56.9
      • Neoplastic (malignant) related fatigue
    • CC
      • Chest X-ray exam revealed left pneumothorax post port-a inserted
    • Present illness
      • This is a 55 years old, pP0, SEX(-) female with history of
        • bilateral ovarian high-grade serous carcinomas with peritoneal and LN metastasis; AJCC Pathologic staging: pT3cN1a, stage IIIC.
        • right benign follicular nodule s/p right thyroidectomy on 2020/10/16.
      • Port-A infusion catheter insertion was performed on 2023/09/18 morning, left chest pain radiation to back was noticed at afternoon while receiving post-op Chest X-ray exam ,which revealed left pneumothorax. Thus, she was called back to our ER for initial treament, O2 nasal canula 2L was given and then adimitted to GS ward for further intervention and observation.
    • Course of inpatient treatment
      • After admittion, Port-A catheter implatation on the left side was performed on 2023/09/18. The post-operative course was relatively smooth but CXR revealed left pneumothorax. As such, was admitted for further intervention and observation. There was no special complain and improved of CXR. Under the stable condition, she was discharged today and will be arrange OPD follow up.
  • 2023-09-18 SOAP Medical Emergency He YaoCan
    • S: insert artificial vessal for C/T of ovarian cancer earlier today.
    • A: preliminary impression: 93.9 Pneumothorax, unspecified
  • 2023-09-14 SOAP Hemato-Oncology He JingLiang
    • A/P: C/T with carboplatin + paclitaxel
  • 2023-08-27 ~ 2023-09-08 POMR Obstetrics and Gynecology Chen GuoHu
    • Discharge diagnosis
      • Bilateral ovarian cancers (high-grade serous carcinoma) with peritoneal and lymphonode metastasis < AJCC Pathologic staging: pT3cN1a, stage IIIC > C 56.9
      • Female pelvic peritoneal adhesions (postinfective)
      • Acute posthemorrhagic anemia
      • Iron deficiency anemia secondary to blood loss (chronic)
      • bilateral ovarian cancers (adenocarcinoma) with carcinomatosis -> debulking surgery on 2023-08-29
    • CC
      • Abdominal fullness and nausea for 2 months.
    • Present illness
      • This is a 55 years old, pP0, SEX(-) female with a history of right benign follicular nodule s/p right thyroidectomy on 2020/10/16.
      • According to the patient, she had noted bowel behavior change fron once per day to 6 times per day and body weight gain since 2023/07. Abdominal fullness with nausea, periumbilical pain and sometimes dyspena also were found. She first came to our GI OPD for help on 2023/08/04. The abdominal echogram showed moderate to large amount ascites and suspected two mass lesion in the lower abdomen.
      • The abdominal CT on 2023/08/07 revealed cancerous peritonitis with bilateral ovarian mass measured 8-10 cm and massive ascites. She was transferred to GYN OPD for further survey.
      • The GYN sonography showed uterus 56*23mm, EM 6.2mm with a fundal myoma 4X4cm, left adnexa mass 90x74mm with solid part and massive ascites. The tumor marker examination revealed CA125 level was 3487 U/mL, CEA level was 0.87 ng/mL and CA199 level was < 0.8U/mL.
      • Under the impression of cancerous peritonitis with bilateral ovarian mass, suspected bilateral ovarian cancers with carcinomatosis, she was admitted for cancer survey and surgical intervention.
    • Course of inpatient treatment
      • After admission, preoperative evaluation was done, and there were no contraindications for surgery. Hence, debulking surgery and enterolysis were performed on 2023/08/29. A total amount of 7000 c.c. ascites was suctioned out during the surgery, and total blood loss was 1700 c.c.
      • After total hysterectomy, bilateral salpingo-oopherectomy, bilateral pelvic lymph node dissection, tumor resection and partial omentectomy were done, a 15 Fr JP drain was inserted into the cul de sac and the wound was closed. However, hypotension and rapid blood filling into the VAC were noted. CVC was inserted by the anesthesiologist.
      • Despite aggresive component therapy and Levophed use, her systolic blood pressure remained around 40-70 mmHg. The wound was re-opened for a second look before extubation. Massive blood clots were removed, with an accumulation of total blood loss of 5500 c.c. Multiple oozing sites were identified, and were handled with suture techniques, compression and Surgicel use.
      • She received a total blood transfusion of pRBC 18U, FFP 16U and PH 1U. The wound was closed again after her bleeding stablized. Due to massive intraoperative bleeding and unstable condition, she was transferred to ICU afterwards.
      • During SICU, blood transfusion pRBC 6U, FFP 4U and Plt 1U was given for her anemia. Antibiotic with cefazolin, gentamycin, SABS was given. Smoothly extubation after well weaning profile was performed on 2023/09/01. We gave PPI and nutrition support. Pain relief was done with PCA shift to morphine PRN. Her general condition became stable and she was transfered to GYN ward on 2023/09/02.
      • During GYN ordinary ward, the patient was under stable vital signs, and the abdominal wound was about 16cm in length, without active bleeding. The wound had steri-strip cover, without infection signs; a right JP drain was checked with decreased amount and light red color, and was removed on 2023/09/06. TPN and albumin for nutrition support were given at first and she was changed to feed with oral diet as tolerance. Normal bowel movement and smooth voiding after foley removal were observed.
      • The Pathology result showed bilateral ovarian high-grade serous carcinomas with peritoneal and LN metastasis; AJCC Pathologic staging: pT3cN1a, stage IIIC.
      • Under a stable condition, the patient may be discharged on 2023/09/07 and OPD follow-up is mandatory for further discussion on futher management.
    • Discharge prescription
      • cephalexin 500mg 1# QID
      • Actein (acetylcysteine 200mg) 1# TID
      • C.B. Ointment BID TOPI
      • MgO 250mg 1# QID
      • Cough Mixture (platycodon) 5mL TID
      • Acetal (acetaminophen 500mg) 1# QID
      • Eurodin (estazolam 2mg) 1# PRNHS if insomia
      • Uretropic (furosemide 40mg) 0.5# QD
  • 2023-08-10 SOAP Obstetrics and Gynecology Chen GuoHu
    • O
      • 2023/08 CA125 3487, CEA 0.87, CA199 <0.8
      • 2023/08 abdominal CT report Imp:
        • cancerous peritonitis with bilateral ovarian mass, origin?
        • Prominent uterine cervix is suspected.
  • 2023-08-07 SOAP Obstetrics and Gynecology Chen GuoHu
    • S
      • 55y/o sex(-)?
      • prev abd op(-)
      • menopause
      • prev follow up in 2019
      • F/U myoma
      • abd sono - 2 mass in low abd 8cm and 4xcm, myomas?
      • abd fullness and nausea, occaional SOB
      • abd CT was arranged
    • O
      • 2014-08-07 pap smear by ENT cotton swap (-)
      • 2014/08 FSH:86.99/LH:125.31/E2:144.80
      • 2014/08/07 CA-125:9.425 U/ml
      • 2014-11-14 hymen incision + hysteroscopic polypectomy + D&C on 2014-11-14 (-)
      • 2019-05-02 sonar: AVF 99 x 37 mm, EM 7.4mm; myoma (calcilication) 45x30 mm
      • 2023-08-07 vaginal sonar (TVS) - EM 0.67cm
        • LOV tumor 9x8cm, solid part(+)
        • ascites(+) > 2000c.c
    • P
      • arrange tumor marker + CXR,
      • suggest lapa (ATH + BSO, change to debulking if LOV cancer confirmed by frozen)
  • 2023-08-05 SOAP General and Gastrointestinal Surgery Chen YanZhi
    • S
      • acites? refer to GS survey.
      • HBV(-), HCV(-)
    • O
      • RUQ and LUQ tenderness, no rebounding pain
      • no tarry stool/bloody stool
      • abdomiinal pain(+)
      • no vaginal bleeding(+)
      • no tarry/bloody stool passage
      • no hematemesis
      • umbilical mass, suspect tumor carcinomatosis, suspect GI or GYN cancer related
    • Prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
  • 2023-08-04 SOAP Gastroenterology Xu RongYuan
    • S
      • change of bowel habit fron one time/day to 6 times/day in recent one month
      • BW:52.7 to 55.2; abdominal fullness; suspected ascites
    • O
      • PE: abdomen: mild ovoid in shape, soft, mild periumbilica tenderess
  • 2020-10-15 ~ 2020-10-17 POMR General and Gastrointestinal Surgery Lai JieWen
    • Discharge diagnosis
      • Right thyroid tumor status post right thyroidectomy on 2020/10/16
    • CC
      • For receiving thyroid operation.
    • Present illness
      • Miss Guo, a 52-year-old service industrial worker, was admitted to our ward for receiving thyroid operation.
      • According to the patient’s statements and previouscharts, she denied any other specific systemic, hereditary, or malignant disease histories. Around 1~2 years before admission, the patient gradually noticed that she had palpable difference between bil. neck (right side was enlarged then the left side).
      • She received further examinations and regular OPD follow up at our Metabolism Dr. Guo’s OPD since 2018/04 under the tentative diagnosis as right thyroid nodule, and no specific positive findings were noted by the fine needle aspiration.
      • However, further follow up fine needle aspiration (FNAB) on 2020/09 showed atypia results, but the patient denied intermittent fever, chillness, general weakness, fatigue, involuntary weight loss, dyspnea, dysphagia, palpitation, easy sweating, any specific voice changes, or bil. upper/lower limbs numbness in recent 1 year (Addendum: The patient reported that she felt hoarseness in recent 2 months but the symptoms got relatively improvement after having some water).
      • Due to above clinical information, the posibillity of malignancy could not be ruled out. She was then referred to our GS Dr. Lai’s OPD for receiving further evaluation of surgical intervention. After fully explanation and discussion to the patient and her families about the current conditions, she decided to visit our hospital for seeking further medical attention.
      • At our hospital, the patient was sitting on the bed with mild distress apperance and alert consciousness. Physical examinations showed no specific positive findings on her HEENT, chest, and abdomen areas. Her neck showed no specific goiter, no specific palpable mass, nor swallowing disability. Further lab data, ECG, and chest roentography all showed no specific positive findings except incomplete right bundle branch block on the V2 lead.
      • According to the above clinical information, right thyroid tumor with the atypia FNAB results, was the tentative diagnosis. She was then admitted to our ward for receiving right thyroidectomy on 2020/10/16.
    • Course of inpatient treatment
      • After admitted to our ward, we arranged right thyroidectomy for the patient on 2020/10/16. She tolerated the operation well and then was sent back to our ordinary ward for further evaluation and treatment. Her admission period status post surgical intervention was smooth and uneventful except left upper limb numbness was noted on 2020/10/16 night. Further calcium level follow up showed no specific positive findings. We then arranged surgical wound CD since 2020/10/17 and showed good wound status without speicific local redness/swelling/purulent discharge.
      • Her surgical wound pain got relatively improvement status post having Acetaminophen 500 mg/tab 1tab PO QID. Since all the patient’s general conditions were relatively stable without specific toxic signs or any other specific discomfort sensations such as severe dysphagia, dyspnea, aggrevated hoarseness, or all 4 limbs numbness. We arranged discharged for her on 2020/10/17 with further OPD follow up of the patient’s surgical wound recovery status, and final pathology reports.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Antica (orciprenaline, bromhexine, doxylamine; 120mL/bot) 10mL TID
      • Strocain (oxethazaine 5mg, polymigel 244mg) 1# TIDAC
  • 2019-05-02 SOAP Obstetrics and Gynecology Hong ZhengXiu
    • Diagnosis
      • Menopausal or female climactericstates [N95.1]
      • Other insomnia [G47.00]
      • Leiomyoma of uterus, unspecified [D25.9]

[surgical operation]

  • 2023-08-29
    • Surgery
      • debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND + pelvic tumor excision) + enterolysis
    • Finding
      • left ovary and tube (spontaneously ruptured during surgery, completely removed ex vivo)
        • LOV – 10x8cm tumor with soft solid mass, suspected LOV cancer,
        • Frozen report – adenocarcinoma
        • left tube – adhered
      • right ovary and tube (spontaneously ruptured during surgery, completely removed ex vivo)
        • ROV – 8x7cm tumor with soft solid mass, suspected ROV cancer,
        • Frozen report – adenocarcinoma
        • left tube – adhered
      • uterus: corpus seemed free of cancer invasion; uterine myoma 4x4cm noted, but ant and post surface seemed involved by cancer seeding
      • omentum – indurated, suspected cancer invasion
      • central peritoneal soft solid tumors, 6x6cm over low pelvis (CDS site between cervix and rectum), cancer invasion likely
      • left peritoneal soft solid tumors, 4x4cm over left low pelvis, cancer invasion likely
      • right and left peritoneal soft solid tumors, over bil round ligaments, cancer invasion likely
      • left iliac LNs
      • left obturator LNs
      • right iliac LNs
      • right obturator LNs
      • liver, bowels – seemed free of cancer invasion
      • After the operation, suboptimal debulking surgery was achieved.
      • Residue tumor: small tumors 1-2cm, on the appendix surface; small tumor 1x1cm on the mesentary area; 2x2cm 2~3# on the top of right diaphragm
      • A 7 mm JP drain was placed in CDS
      • ascites 7000c.c , sent for cytology
  • 2020-10-16
    • Surgery: R’t lobectomy + neck lymph node excision
    • Finding
      • Some well-defined goiter lesions over R’t thyroid gland noted
      • Some enlarged pre-trachea LNs noted

[chemotherapy]

  • 2023-12-22 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 250mL NS 250mL 3hr + carboplatin AUC 5 460mg NS 250mL 2hr (Avastin + paclitaxel + carboplatin; Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-11-27 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 250mL NS 250mL 3hr + carboplatin AUC 5 460mg NS 250mL 2hr (Avastin + paclitaxel + carboplatin; Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-11-07 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 540mg NS 250mL 1hr (Avastin + paclitaxel + carboplatin; Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-10-16 - paclitaxel 175mg/m2 245mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr (paclitaxel + carboplatin; Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-09-25 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (paclitaxel + carboplatin; Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2023-12-22

Lab results remained largely unremarkable on 2023-12-21. Medication reconciliation confirmed no discrepancies.

Notably, the addition of bevacizumab to the paclitaxel + carboplatin regimen since 2023-11-07 has been associated with a sustained decline in CA-125 levels. Additionally, no adverse events related to bevacizumab, such as hypertension, gastrointestinal perforation, bleeding, or thromboembolic events, have been reported to date.

  • 2023-12-11 CA-125 (NM) 74.990 U/ml
  • 2023-11-20 CA-125 (NM) 121.277 U/ml
  • 2023-10-30 CA-125 (NM) 237.600 U/ml

2023-11-07

Upon review of the PharmaCloud database, the patient’s medication records are consistent with no discrepancies.

Following the cytoreductive surgery performed on 2023-08-29 and 2 subsequent cycles of the paclitaxel and carboplatin regimen administered on 2023-09-25 and 2023-10-16, there was a significant reduction in the tumor marker CA-125.

  • 2023-10-30 CA-125 (NM) 237.600 U/ml
  • 2023-10-09 CA-125 (NM) 431.500 U/ml
  • 2023-09-21 CA-125 (NM) 337.560 U/ml
  • 2023-08-07 CA 125 3487.0 U/mL

Avastin (bevacizumab) has been added to the treatment protocol beginning with the 3rd cycle. The patient should be closely monitored for signs of hypertension, gastrointestinal perforation, bleeding or thromboembolic events.

701464962

231107

[exam findings]

  • 2023-10-24 CT - abdomen
    • History and indication: Malignant neoplasm of rectum
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Rectal cancer s/p operation.
      • Multiple nodules in liver.
      • Renal cysts (up to 0.8cm).
      • A cystic lesion (2.8cm) at right iliacus muscle.
      • Tiny gallbladder stones.
      • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
      • Emphysema at bil. upper lungs. Some GGO at bil. lungs.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Rectal cancer s/p operation. Multiple liver metastases.
  • 2023-10-24, -09-21, -08-17 Sigmoidoscopy
    • Rectal cancer s/p op, anastomotic leakage with improvement
  • 2023-08-04 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, rectum, status post concurrent chemoradiotherapy, Transanal Transabdominal Total Mesorectal Excision — adenocarcinoma, moderately differentiated. Margins free.
      • Lymph node, pericolonic, dissection — metastatic adenocarcinoma.
      • Anastomosis, proximal site, excision — free
      • Anastomosis, distal site, excision — free
      • ypT3 ypN1b (if cM0); ypStage: IIIB, at least
    • Gross Description:
      • Procedure - Transanal Transabdominal Total Mesorectal Excision: 12 x 5 x 5 cm
      • Tumor Site - Rectum, 0.5 cm from resection margin
      • Tumor Size: 6 x 4.5 x 4.5 cm.
      • Macroscopic Tumor Perforation: Not identified
      • Macroscopic Intactness of Mesorectum - Complete
      • Sections are taken and labeled as: A1-6: tumor; A7: tumor cut ends; A8-15: lymph nodes; B: Anastomosis, proximal site; C: Anastomosis, distal site.
    • Microscopic Description:
      • Histologic Type - Adenocarcinoma
      • Histologic Grade - G2: Moderately differentiated
      • Tumor Extension - Tumor invades through the muscularis propria into pericolorectal tissue
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Uninvolved
        • Distance of tumor from margin: 5 mm
      • Lymphovascular Invasion: Not identified
      • Perineural Invasion: Not identified
      • Tumor Budding
        • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2) - Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: not applicable
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes
        • Number of Lymph Nodes Involved/Examined: 3/15 with extranodal extension.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition) ; yp Stage: IIIB, at least.
        • TNM Descriptors (required only if applicable) - y (posttreatment)
        • Primary Tumor (pT) - pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN) - pN1b: Two or three regional lymph nodes are positive
        • Distant Metastasis (pM) - if cM0
        • NOTE: According to AJCC staging manual 2017 8th edition page 10. “Pathologist should not report any M category unless appropriate for the specimen evaluated.”, “Only the managing physician can assign cM0 after taking into account physical examination, image, and other information”. However, the pathologists are ordered by this hospital adminstration (including the chiefs of cancer committee, medical department (director) and radiation oncology) to assign the “cM” category, although pathologists are not in the position of doing so.
      • Additional Pathologic Findings (select all that apply) - None identified
      • Ancillary Studies : result of S2022- 22864 : IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-07-17 CT - abdomen
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Stable condition of rectal cancer.
      • Renal cysts (up to 0.8cm).
      • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
      • Emphysema at bil. upper lungs. Some GGO at bil. lungs.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Stable condition of rectal cancer.
  • 2023-07-13 Sigmoidoscopy
    • ectal cancer s/p CCRT; a ulcerative mass at 10 cm from AV
  • 2023-07-07 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 18.7) / 104 = 82.02%
      • M-mode (Teichholz) = 82.0 - 75.0
    • Conclusion:
      • Normal AV with mild AR
      • Normal MV with mild MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, normal IVC size
      • Dilated LA
  • 2023-04-11 CT - abdomen
    • History and indication:
      • A case of newly diagnosed rectal cancer at 10-14 cm AAV Advanced rectal cancer, cT4aN2bM0 pre-op CCRT
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Stable condition of rectal cancer.
      • Renal cysts (up to 0.8cm).
      • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
      • Emphysema at bil. upper lungs.
    • IMP:
      • Stable condition of rectal cancer.
  • 2023-04-11 ECG
    • Sinus bradycardia with occasional Premature ventricular complexes
  • 2023-04-11 Colonoscopy
    • Rectal cancer s/p CCRT, mild regression
  • 2023-03-16 CT - abdomen
    • History and indication:
      • Adenocarcinoma, moderately differentiated, of the rectum, stage cT4aN2bM0
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Mild regression of rectal cancer.
      • Renal cysts (up to 0.8cm).
      • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
      • Emphysema at bil. upper lungs.
    • IMP:
      • Mild regression of rectal cancer.
  • 2023-03-01 CXR
    • Atherosclerotic change of aortic arch
  • 2023-02-06 KUB
    • Spondylosis of the L-spine is noted.
  • 2023-01-30 CXR
    • Atherosclerotic change of aortic arch
  • 2023-01-04 ECG
    • Sinus bradycardia with 1st degree A-V block
    • Nonspecific ST abnormality
  • 2022-12-22 Patho - colrectal polyp
    • Rectum, 10 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    • The sections show adenocarcinoma, moderately differentiated, composed of low columnar to couboidal neoplastic cells, arranged in glandular and cribrifrom patterns with desmoplastic stromal reaction. Mucosal ulcer is present.
    • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
  • 2022-12-20 Sigmoidoscopy
    • Rectal cancer s/p biopsy
    • Rectal polyp s/p polypectomy
  • 2022-12-19 CT - abdomen
    • History and indication: A case of newly diagnosed rectal cancer at 10-14 cm AAV
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of rectum with adjacent fat stranding and regional LAP.
      • Renal cysts (up to 0.8cm).
      • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
      • Emphysema at bil. upper lungs.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T: T4a(T_value) N: N2b(N_value) M: M0(M_value) STAGE: IIIC(Stage_value)

[MedRec]

  • 2023-02-16 SOAP Colorectal Surgery
    • A/P
      • radiotherapy on 2023-01-05 ~ 2023-02-13
      • CCRT with FOLFOX IV Q2W x 4~6 months
  • 2023-02-21 SOAP Radiation Oncology
    • O: RT (2022-12-30 ~ 2023-02-13): 4500cGy/25 fractions (15 MV photon) of the pelvic, and 5040cGy/28 fractions (15 MV photon) of the rectal tumor bed area.
  • 2023-02-06 SOAP Hemato-Oncology
    • S: c/o vague abd discomfort, KUB: stool impact, give Lactulose.
  • 2023-01-10 SOAP Hemato-Oncology
    • S
      • HBsAg, anti-HCV (12/26 22): negative. anti-HBc: positive… on Baraclude
      • On R/T to rectal tumor by Dr Huang Jingmin.
      • Owing to advanced stage of rectal CA, pre-Op CCRT wt FOLFOX is preferred rather than lower dose 5-FU 24 hr QD x 5 per wk x 6 plus R/T (20230110).
      • #1 pre-Op CCRT wt mFOLFOX6 IV Q2W x 3 plus R/T on 20230103.
      • Adm on 20230130 for #2 pre-Op CCRT wt mFOLFOX6 IV Q2W x 3 plus R/T.
  • 2023-01-03 ~ 2023-01-05 POMR Hemato-Oncology
    • Discharge diagnosis
      • Adenocarcinoma, moderately differentiated, of the rectum, stage cT4aN2bM0 (IIIC).
      • Chronic viral hepatitis B without delta-agent, 2022/12/26 Anti-HBc: postive
      • Porta catheter insertion at right Internal Jugular Vein on 2023/01/4
    • Present illness
      • This a 77 year-old male, who has hypertension for years, a patient of Adenocarcinoma, moderately differentiated, of the rectum, stage cT4aN2bM0 (IIIC), diagnosis in Dec 2022.
      • He suffered from initial presentation of jaundice & clay-colored stool in May 2016. The palpatedv small elastic nodule, 3 cm in size, painless & non-tender, movable at upper back from June 2015. So, he went to GS OPD for help on 2022/12/19.
      • Follow-up Abdomen CT (12/19 22): Adenocarcinoma, moderately differentiated, of the rectum, stage cT4aN2bM0 (IIIC).
      • Sigmoidoscopy : Rectal cancer s/p biopsy. Rectal polyp s/p polypectomy on 2022/12/20.
      • The rectum, 10 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated. IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+) on 2022/12/20.
      • He was referred to our hemato-oncologic clinic on 12/26 14 by Dr Xiao Guanghong for CCRT with FOLFOX Q2W IV x 4-6 months.
      • Consult Dr. Huang Jingmin for CCRT enaluation. Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed. Starting on 2022/12/30.
      • HBsAg, Anti-HBc, Anti-HCV: negative on 12/26 22.
      • Port-a insertion on 2023/1/4 by Dr. Chen Yanzhi
      • This time, he is admitted for CCRT with FOLFOX Q2W IV x 4-6 months.
    • Course of Inpatient Treatment
      • After be admitted, he received radiotherapy with deliver 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed, since 2022/12/30 until now.
      • CCRT with #1 FOLFOX (oxalip 6070mg/m2, covorin 400mg/m2, 5-FU 2400mg/m2) IV Q2W x 6 on 1/3-1/5 22, Imperan + Promeran for vomitin, hydration, and Baraclude 0.5mg/tab 1tab QDAC for Anti-HBC(+). The port-a catheter insertion at right Internal Jugular Vein on 2023/01/04.
      • After chemotherapy, he denied having a fever, chillness, vomiting, diarrhea, and the surgery wound condition stably.
      • Under the stable condition, he can be discharged on 2023/01/05, the OPD follow-up and the next admission will be arranged.
  • 2022-12-22 SOAP Radiation Oncology
    • A: Adenocarcinoma, moderately differentiated, of the rectum, EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+), stage cT4aN2bM0 (IIIC).
    • P: Radiotherapy is indicated for this patient with the following indicators: stage T4aN2bM0
      • Goal: curative
      • Treatment target and volume: pelvic area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his family. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2022-12-27.
  • 2022-12-22 SOAP Colorectal Surgery
    • A: Advanced rectal cancer , cT4aN2bM0
    • P: Suggest pre-op CCRT (favor TNT) then OP
  • 2022-12-19 SOAP Colorectal Surgery
    • S
      • A case of newly diagnosed rectal cancer at 10-14 cm AAV
      • PH: HTN
    • O
      • pre-op study
      • Arrange sigmoidoscopy for R/O colonic lesion

[surgical operation]

  • 2023-08-02
    • Surgery
      • Transanal Transabdominal Total Mesorectal Excision        
    • Finding
      • Large rectal cancer s/p CCRT, narrow pelvis and the tumor and rectum occupied the pelvic cavity     
      • Tumor location: 8 cm from Av    

[radiotherapy]

  • 2022-12-30 ~ 2023-02-13 - 4500cGy/25 fractions (15 MV photon) of the pelvic, and 5040cGy/28 fractions (15 MV photon) of the rectal tumor bed area.

[chemotherapy]

  • 2023-11-06 - irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (FOLFIRI Q2W 80% dose)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-06-23 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 730mg NS 200mL 2hr + fluorouracil 2400mg/m2 4380mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-06-09 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 730mg NS 200mL 2hr + fluorouracil 2400mg/m2 4380mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-26 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 730mg NS 200mL 2hr + fluorouracil 2400mg/m2 4380mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-11 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 735mg NS 200mL 2hr + fluorouracil 2400mg/m2 4410mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-26 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 735mg NS 200mL 2hr + fluorouracil 2400mg/m2 4435mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-12 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 735mg NS 200mL 2hr + fluorouracil 2400mg/m2 4415mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-15 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4450mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-01 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-13 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-30 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4450mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-03 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4510mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-11-07

The patient’s repeat prescription from WanFang Hospital, which includes clopidogrel, nicorandil, indapamide, nifedipine, rosuvastatin, and benzbromarone, was last filled on 2023-10-17. However, not all of these medications are listed as currently active. Verification is required to determine if the medications not in use have been intentionally discontinued.

2023-05-29

  • According to the PharmaCloud database, the patient had visited WanFang Hospital and a local clinic for upper respiratory symptoms in late March and early May. However, the prescriptions from these healthcare providers have now expired. No medication reconciliation issues were identified during this patient’s current admission.

2023-05-12

  • According to the PharmaCloud database, the patient visited WanFang Hospital on 2023-03-27 for his unspecified chronic bronchitis and visited Dr. Wu’s local clinic on 2023-03-29 for an unspecified acute upper respiratory infection. To date, no current respiratory problems have been reported and no medication reconciliation issues have been identified.
  • The patient underwent radiotherapy with 4500 cGy/25 fractions (15 MV photon) to the pelvic region and 5040 cGy/28 fractions (15 MV photon) to the rectal tumor bed from 2022-12-30 to 2023-02-13. Concurrently, the patient has been receiving chemotherapy with the FOLFOX regimen since 2023-01-03. The initial treatment plan was to reduce the tumor size for possible surgical resection. However, the CT scans of 2023-04-11 showed stable disease compared to 2023-03-16, which showed a slight regression, suggesting that the treatment may not be as effective as it once was. It would be recommended to obtain new tumor marker lab data to assist in evaluating the efficacy of the current treatment.

701476645

231106

[exam findings] (not completed)

  • 2023-10-13 CT - chest
    • Chest CT with and without IV contrast ehnancement shows:
      • Fusiform like necrotic tumor at left breast measuring 4.2cm in largest dimension is found. In comparison with CT dated on 2023-07-28, the lesion is stationary.
      • Lymphadenopathy at left axillary region is found. In enlargement.
      • Minimal interstitial change at bilateral lungs is found. However, the changes improved markedly as compared with previous CT.
    • Imp:
      • Left breast tumor. stable
      • Left axillary lymphadenopathy, in marked enlargment
      • The opacities over bilateral lungs regressed markedly.
  • 2023-09-11 Patho - lymph node region resection
    • PATHOLOGIC DIAGNOSIS
      • Breast, left, partial mastectomy — Invasive carcinoma of no special type
      • Resection margin, breast, left, partial mastectomy — Free of carcinoma
      • Lymph node, axillary sentinel and axillary, LND — Metastatic carcinoma (2/4)
      • AJCC 8 th edition, Pathology stage: ypT2N1a(cM0); Anatomic stage IIB; Prognostic stage IIIA
    • MACROSCOPIC EXAMINATION
      • Breast Size: 14.5 x 11.5 x 3.8 cm
      • Skin Size: 13.0 x 3.4 cm
      • Nipple: Not retracted
      • Tumor Size: 3.4 x 1.8 x 1.0 cm
      • Resection Margin: Free, 1.2 cm from the deep margin
      • Lymph node: Axillary sentinel and axillary
      • Representative parts are taken for section and labeled: F2023-00408. FSA1= 12’, 3’, 6’ margins, FSA2= 9’ and deep margins, FSB= axillary sentinel LNs, A1= nipple, A2= skin + tumor, A3-A6= tumor, A7= non-tumor. S2023-18125= axillary lymph nodes
    • MICROSCOPIC EXAMINATION
      • Microscopy
        • Histologic type: Invasive carcinoma of no special type
        • Size of invasive carcinoma: 3.4 x 1.8 x 1.0 cm
        • Histologic grade (Nottingham histologic score): Grade 3 (score= 8)
        • Skin involvement: Absent
        • Ductal carcinoma in situ: Present; Extensive DCIS: Negative
      • Margins: Negative; Closest margin: 12 mm from deep margin
      • Nodal status: Metastatic carcinoma (2/4)
        • number of lymph node examined: 2 (sentinel), 2 (axillary)
        • number with macrometastases (>2mm): 2
        • number with micrometastases (>0.2~2mm and/or >200 cells): 0
        • number with isolated tumor cells (<=0.2mm and <=200 cells): 0
        • Extranodal extension: Present
      • Treatment Effect:
        • Treatment effect in the breast: Probable or definite response to presurgical therapy in the invasive carcinoma
        • Treatment effect in the lymph nodes: Two sentinel lymph nodes metastasis. Another two axillary lymph nodes show fibrous scar, possibly related to prior lymph node metastasis with pathologic complete response
      • Lymphovascular invasion: Present
      • Perineural invasion: Absent
      • Tumor-infiltrating lymphocytes: 5%
    • IMMUNOHISTOCHEMICAL STUDY (S2023-06120)
      • ER (Ab): Negative
      • PR (Ab): Negative
      • HER-2/Neu (Ab): Negative (score 1+)
      • Ki-67: 80-90%
  • 2023-09-11 Patho - lymph node region resection
    • PATHOLOGIC DIAGNOSIS
      • Breast, left, partial mastectomy — Invasive carcinoma of no special type
      • Resection margin, breast, left, partial mastectomy — Free of carcinoma
      • Lymph node, axillary sentinel and axillary, LND — Metastatic carcinoma (2/4)
      • AJCC 8 th edition, Pathology stage: ypT2N1a(cM0); Anatomic stage IIB; Prognostic stage IIIA
    • MACROSCOPIC EXAMINATION
      • Breast Size: 14.5 x 11.5 x 3.8 cm
      • Skin Size: 13.0 x 3.4 cm
      • Nipple: Not retracted
      • Tumor Size: 3.4 x 1.8 x 1.0 cm
      • Resection Margin: Free, 1.2 cm from the deep margin
      • Lymph node: Axillary sentinel and axillary
      • Representative parts are taken for section and labeled: F2023-00408FSA1= 12’, 3’, 6’ margins, FSA2= 9’ and deep margins, FSB= axillary sentinel LNs, A1= nipple, A2= skin + tumor, A3-A6= tumor, A7= non-tumor. S2023-18125= axillary lymph nodes
    • MICROSCOPIC EXAMINATION
      • Type
        • Histologic type: Invasive carcinoma of no special type
        • Size of invasive carcinoma: 3.4 x 1.8 x 1.0 cm
        • Histologic grade (Nottingham histologic score): Grade 3 (score= 8)
        • Skin involvement: Absent
        • Ductal carcinoma in situ: Present; Extensive DCIS: Negative
      • Margins: Negative; Closest margin: 12 mm from deep margin
      • Nodal status: Metastatic carcinoma (2/4)
        • number of lymph node examined: 2 (sentinel), 2 (axillary)
        • number with macrometastases (> 2mm): 2
        • number with micrometastases (> 0.2~2mm and/or > 200 cells): 0
        • number with isolated tumor cells (<= 0.2mm and <= 200 cells): 0
      • Extranodal extension: Present
      • Treatment Effect:
        • Treatment effect in the breast: Probable or definite response to presurgical therapy in the invasive carcinoma
        • Treatment effect in the lymph nodes: Two sentinel lymph nodes metastasis. Another two axillary lymph nodes show fibrous scar, possibly related to prior lymph node metastasis with pathologic complete response
      • Lymphovascular invasion: Present
      • Perineural invasion: Absent
      • Tumor-infiltrating lymphocytes: 5%
    • IMMUNOHISTOCHEMICAL STUDY (S2023-06120)
      • ER (Ab): Negative
      • PR (Ab): Negative
      • HER-2/Neu (Ab): Negative (score 1+)
      • Ki-67: 80-90%
  • 2023-08-17 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (72 - 11.3) / 72 = 84.31%
      • M-mode (Teichholz) = 84
    • Conclusion:
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Mild MR, TR and PR, trivial AR
      • No regional wall motion abnormalities
  • 2023-08-10 Flow volume loop chart
    • r/o mild restrictive ventilatory defect
  • 2023-07-28 CT - chest
    • Indication: Left breast invasive carcinoma, cT2N0M0, stage IIA. ER(-, 0%), PR(-, 0%), Her2/neu(-, 1+), Ki-67: 80-90%. ECOG performance: 0
    • Chest CT with and without IV contrast ehnancement shows:
      • Some lymph nodes are found at both sides of the mediastinum.
      • Diffuse ground glass opacities over both lungs are found. Chemothorapy related pneumonitis is suspected.
      • Necrotic mass at left breast measuring 2.9cm is noted. Stable.
      • Minimal bilateral pleural effusion is noted.
    • Imp:
      • Diffuse ground glass opacities over both lungs are found. Chemothorapy related pneumonitis is suspected.
  • 2023-07-01 CT - chest
    • Indication: left breast cancer
    • Chest CT with and without IV contrast ehnancement shows:
      • S/p port-A placement with its tip at Superior vena cava.
      • Mass like lesion at left breast measuring 3.34cm is found. In comparison with CT dated on 2023-03-30, the lesion is stationary.
      • Small lymph nodes are found at left axillary region.
    • Imp:
      • Left breast cancer with left axillary lymph nodes s/p C/T. Stationary.
  • 2023-06-05 SONO - breast
    • diagnosis
      • Highly suspicious of malignancy,with sonographic positive axillary LAP
    • treatment
      • Open biopsy
    • suggestion
      • Follow up breast sonography in next OPD visit, Admission for surgical intervention
    • BI-RADS:
      • 6-Known Biopsy - Proven Malignancy
  • 2023-04-14 Patho - lymphnode biopsy
    • Labeled as “left axilla”, biopsy — invasive carcinoma.
    • Section shows lymph node with invasive carcinoma.
    • IHC stain: GATA-3 (+).
  • 2023-04-14 Tc-99m MDP bone scan
    • Mildly increased activity in the lower L-spines, bilateral S-I joints and sacrum. Degenerative change may show this picture.
    • Some faint hot spots in bilateral rib cages and a faint hot spot in the left pubic bone. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, hips, right knee and both feet, compatible with benign joint lesions.
  • 2023-04-13 Flow volume loop chart
    • Mild restrictive ventilatory impairment
  • 2023-04-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (50 - 9) / 50 = 82.00%
      • M-mode (Teichholz) = 82
    • Conclusion:
      • Normal LV filling pressure.
      • Normal LV and RV systolic function.
      • Trivial MR; trivial AR; mild PR.
  • 2023-04-12 PD-L1 (22C3)
    • Tissue block No.: S2023-06120
    • RESULTS:
      • Combined Positive Score(CPS) assessment: CPS<1
      • Combined Positive Score(CPS): 0.5
  • 2023-04-12 Mammography
    • Impression: Dense breast.
      • Focal asymmetry in left breast, around 12’region, clinical proven malignancy.
      • Benign calcifications in bilateral breasts.
    • BI-RADS: Category 6-proven malignancy.
  • 2023-03-31 Patho - breast biopsy (no need margin)
    • Breast tumor, left 1/3 cm region, core needle biopsy — Invasive carcinoma of no special type
    • Microscopically, the sections show a picture of invasive carcinoma of no special type characterized by tumor cells arranged in linear or nest pattern infiltrating in the stroma with focal necrosis and microcalcification.
    • Immunohistochemistry shows P63(-), E-cadherin(+), ER(-, 0%), PR(-, 0%), Her2/neu(-, Dako score 1+) and Ki-67: 80-90% for tumor.
  • 2023-03-30 CT - chest
    • Indication: Disorder of breast, unspecified; Unspecified lump in breast
    • Chest CT with and without IV contrast ehnancement shows:
      • Low density lesion at left breast with marginal enhancement measuring 2.63cm in largest dimension. Breast cancer is considered first but infection cannot be excluded.
      • Enlarged lymph nodes are found at left axillary region.
    • Imp:
      • Left breast tumor. 2.63cm, r/o breast cancer or others.
      • Lymphadenopathy at left axillary region.
  • 2023-03-27 SONO - breast
    • diagnosis
      • Highly suspicious of malignancy,with sonographic negative axillary LNs
    • treatment
      • Sono-guided biopsy, Core-needle biopsy, Open biopsy
    • suggestion:
      • Arrange mammography, Arrange breast MRI, Arrange excisional biopsy, Admission for surgical intervention
    • BI-RADS:
      • 5-Highly Suggestive of Malignancy (>95% malignant) Appropriate Action Should Be Taken

[MedRec]

  • 2023-04-12 ~ 2023-04-15 POMR General and Gastrointestinal Surgery Wang ShengLin
    • Discharge diagnosis
      • Left breast invasive carcinoma status post port-A insertion on 2023/4/13. cT2N0M0, stage IIA. ER(-, 0%), PR(-, 0%), Her2/neu(-, 1+), Ki-67: 80-90%.
      • For 1st neoadjuvant chemotherpy with Lipo-dox + Endoxan + Keytruda.
    • CC
      • noted a palpable mass at left breast on 2023/03.
    • Present illness
      • This 70-year-old women patient denied any past history including DM, HTN, HBV, heart disease or cancer. She denied any TOCC histories in recent 3 months.
      • She noted a palpable mass at left breast on 2023/03. Then she came to our OPD for help. Breast SONO showed Left breast heterogenous hypoechoic lesion at 1/3cm, size:2.63cmx2.63cm, highly suspicious of malignancy, suggested core needle biopsy. Chest CT showed 1) Left breast tumor. 2.63cm, r/o breast cancer or others. 2) Lymphadenopathy at left axillary region. Left breast core needle biposy showed invasive carcinoma, ER(-, 0%), PR(-, 0%), Her2/neu(-, 1+), Ki-67: 80-90%. She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss. PE:1). symmetrical of bilateral breasts. a hard, nontender, movable mass and irregular margin at left breast around 5*5cm without discharge. The left nipple was dimping without exudative nor bloody discharge and no retraction. The bilateral breast skin had no cellulite change. no clinical palpable mass in left axillary. SDM for this patient.
      • Neoadjuvent chemotherapy with Lipo-dox 35mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 and Keytruda. Operation, in the future were suggest.
      • Under the impression of left breast invasive carcinoma, she was admitted for surgery of port a insertion and 1st neoadjuvant chemotherpy with Lipo-dox 35mg/m2 + Endoxan 600mg/m2 and Keytruda.
    • Course of inpatient treatment
      • After admission, port-A insertion was performed on 2023/04/13. Bone scan and abdomen echo showed no obvious lesion for metastasis. Cardiac echo showed LVEF:82%. Lung funsion test showed Mild restrictive ventilatory impairment. SONO Guiding for marker clips for left breast tumor was done on 2023-04-14. Sono-guided biopsy for left axillary lymph node was dones on 2023-04-14, final report was pending. 1st neo-adjuvant chemotherapy with Lipo dox + Endoxan and keytruda were given. The port-A wound is clean and dry. No discomfort after chemotherapy. Under the stable condition, she was discharged today, wound will be follow up OPD. And arrange next admission three weeks later.
    • Discharge prescription
      • MgO 250mg 1# TID
      • Through (sennoside 12mg) 1# HS
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Acetal (acetaminophen 500mg) 1# QID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Emend (aprepitant 125mg) 1# QD

[surgical operation]

  • 2023-09-08
    • Surgery
      • Left partial mastectomy + ALND (2/2)
    • Finding
      • Left breast cancer at 12/1cm, size: 2.5x2.2cm
      • Left axillary sentinel lymph node metastasis (2/2) -> ALND
  • 2023-03-31
    • Surgery
      • Left breast core needle biopsy
    • Finding
      • Left breast heterogenous hypoechoic lesion at 1/3cm, size: 2.63cmx2.63cm

[immunochemotherapy]

  • 2023-11-03 - paclitaxel 80mg/m2 120mg NS 250mL 120min (T QW adjuvant)
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-10-27 - paclitaxel 80mg/m2 120mg NS 250mL 120min (T QW adjuvant)
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-10-20 - paclitaxel 80mg/m2 120mg NS 250mL 120min (T QW adjuvant)
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-10-13 - paclitaxel 80mg/m2 118mg NS 250mL 120min (T QW adjuvant)
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-06-30 - pembrolizumab 200mg NS 100mL 30min + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 928mg NS 500mL 1hr (AC(Lipo) Q3W neoadjuvant)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-06-05 - pembrolizumab 200mg NS 100mL 30min + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 913mg NS 500mL 1hr (AC(Lipo) Q3W neoadjuvant)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL + lenograstim 250ug
  • 2023-05-12 - pembrolizumab 200mg NS 100mL 30min + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 919mg NS 500mL 1hr (AC(Lipo) Q3W neoadjuvant)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-04-15 - pembrolizumab 200mg NS 100mL 30min + liposome doxorubicin 35mg/m2 52mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 899mg NS 500mL 1hr (AC(Lipo) Q3W neoadjuvant)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

2023-11-06

[leukopenia; G-CSF administration is usually begun 24 to 72 hours after cessation of chemotherapy]

Continuing from the previous pharmacist note replied on 2023-10-30.

New episodes of leukopenia were observed in late Oct and early Nov. Granocyte (lenograstim) was administered on 2023-11-03, just prior to paclitaxel chemotherapy.

  • 2023-11-03 WBC 1.97 x10^3/uL
  • 2023-10-27 WBC 1.86 x10^3/uL
  • 2023-10-20 WBC 5.36 x10^3/uL
  • 2023-10-13 WBC 5.27 x10^3/uL

Timing of G-CSF - When used for primary and secondary prophylaxis, therapy is usually begun 24 to 72 hours after cessation of chemotherapy. (https://www.uptodate.com/contents/use-of-granulocyte-colony-stimulating-factors-in-adult-patients-with-chemotherapy-induced-neutropenia-and-conditions-other-than-acute-leukemia-myelodysplastic-syndrome-and-hematopoietic-cell-transplantation)

  • Macaire et al. (2020) conducted a study on the impact of granulocyte colony-stimulating factor (G-CSF) on FOLFIRINOX-induced neutropenia. They found that pegylated-G-CSF administration 24 hours after the end of chemotherapy may be an optimal schedule to reduce neutropenia. (Impact of granulocyte colony‐stimulating factor on folfirinox‐induced neutropenia prevention: a population pharmacokinetic/pharmacodynamic approach. British Journal of Clinical Pharmacology, 86(12), 2473-2485. https://doi.org/10.1111/bcp.14356)
  • Mackey et al. (2020) emphasized that delaying supportive G-CSF therapy to 6-7 days after chemotherapy can mitigate myelosuppressive effects. (The timing of cyclic cytotoxic chemotherapy can worsen neutropenia and neutrophilia. British Journal of Clinical Pharmacology, 87(2), 687-693. https://doi.org/10.1111/bcp.14424)
  • Salem et al. (2016) compared different post-chemotherapy G-CSF administration regimens and suggested that administration from Days 2-5 or Days 5-9 cycles may have optimal effects on immune cell recovery and antigen-specific immune responses. (Effect of administration timing of postchemotherapy granulocyte colony-stimulating factor on host-immune cell recovery and cd8+ t-cell response. Journal of Immunotoxicology, 13(6), 784-792. https://doi.org/10.1080/1547691x.2016.1194917)
  • Yankelevich et al. (2008) mentioned that delaying G-CSF until 5 days after completion of chemotherapy has not resulted in a longer duration of neutropenia. (Efficacy of delayed administration of post-chemotherapy granulocyte colony-stimulating factor: evidence from murine studies of bone marrow cell kinetics. Experimental Hematology, 36(1), 9-16. https://doi.org/10.1016/j.exphem.2007.08.019)

2023-10-30

[leukopenia]

Several episodes of leukopenia have been observed since the start of immunochemotherapy on 2023-04-15. The most recent episode occurred on 2023-10-27 with WBC at 1.86K, neutrophil and band at 58.9%, and ANC at 1095. This coincided with the administration of adjuvant paclitaxel. Paclitaxel has a known association with leukopenia (90%; grade 4: 17%). It’s generally not recommended for patients with solid tumors who have a baseline neutrophil count below 1500/uL. If there’s a high risk of infection, the use of G-CSF is recommended.

  • 2023-10-27 WBC 1.86 x10^3/uL **
  • 2023-10-20 WBC 5.36 x10^3/uL
  • 2023-10-13 WBC 5.27 x10^3/uL
  • 2023-09-06 WBC 4.46 x10^3/uL
  • 2023-08-10 WBC 5.95 x10^3/uL
  • 2023-08-03 WBC 5.20 x10^3/uL
  • 2023-07-31 WBC 6.15 x10^3/uL
  • 2023-07-29 WBC 1.85 x10^3/uL **
  • 2023-07-28 WBC 3.71 x10^3/uL
  • 2023-07-06 WBC 5.56 x10^3/uL
  • 2023-06-30 WBC 5.41 x10^3/uL
  • 2023-06-12 WBC 2.71 x10^3/uL *
  • 2023-06-05 WBC 2.71 x10^3/uL *
  • 2023-06-05 WBC 3.31 x10^3/uL
  • 2023-05-18 WBC 3.32 x10^3/uL
  • 2023-05-11 WBC 3.92 x10^3/uL
  • 2023-05-05 WBC 1.44 x10^3/uL **
  • 2023-04-20 WBC 5.36 x10^3/uL
  • 2023-04-12 WBC 4.24 x10^3/uL

701487478

231106

[exam findings]

  • 2023-03-15 MRI - abdomen (Yonghe Cardinal Tien Hospital)
    • Irregular to nodular thickening of gallbladder wall, neogrowth cannot be ruled out, suggest further evaluation;
    • Enlarged lymph nodes in hepatic hilar, retropancreatic, paraaortic and aortocaval regions, up to 1.5cm in size, more in favor of metastatic lymphadenopathy.

[MedRec]

  • 2023-07-11 SOAP Hemato-Oncology He JingLiang
    • S: 2023-07-11 first C/T with CDDP + gemzar
    • Prescription
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Hepac Lock Flush (heprarin sodium) 10mL IRRI
  • 2023-06-25 ~ 2023-07-01 POMR General and Gastrointestinal Surgery Li ChaoZhu
    • Discharge diagnosis
      • Malignant neoplasm of gallbladder
      • Gallbladder cancer, adenocarcinoma, billiary type, poorly differentiated, pT2bN1(cM1), stage IV with multiple retroperitoneal and left supraclavicular (Virchow’s node) lymph nodes metastases status post laparoscopic cholecystectomy and lymph node dissection on 2023-0626; ECOG 0
      • post Port-A insertion on 2023-06-30
    • CC
      • noted tea-colored urine, intermittent right epigastric dull pain without radiating to back on 2023/01.
    • Present illness
      • This is a 61 years old woman patient, she denied any past history including cancer, hypertention, diabetes mellitus, cancer and heart disease. She denied any TOCC histories in recent 3 months.
      • She noted tea-colored urine, intermittent right epigastric dull pain without radiating to back on 2023/01. No aggravating factors and relieving factors. She went to Yonghe Cardinal Tien Hospital and National Taiwan University Hospital for help. Abdomen magnetic resonance imaging showed 1). Irregular to nodular thickening of gallbladder wall, neogrowth cannot be ruled out, suggest further evaluation; 2). Enlarged lymph nodes in hepatic hilar, retropancreatic, paraaortic and aortocaval regions, up to 1.5cm in size, more in favor of metastatic lymphadenopathy, on 2023/3/15 in Yonghe Cardinal Tien Hospital. Due to personal reason, she for persaol reason came to our outpatient department for help. Abdominal sono showed suspicious of gallblader tumor.
      • Physical examination showed pink conjunctiva and anicteric sclera, abdomen: soft and ovoid, normal bowel sound. No tenderness, Murphy’s sign positive, rebounding pain and no tympanic percussion. She denied fever, fatigue or appetite change. She had jaundice, but no clay stool.
      • Under suspicious of gallblader tumor was impressed. After fully explaination the treatment surgical of method, this patient decided to treat surgically. She admitted for laparscopic cholecystectomy and further management.       
    • Course of inpatient treatment
      • After admission, laparoscopic cholecystectomy and laparoscopic lymph node dissection (for the pathologic report disclosed malignancy) was performed on 2023/06/26. The post-operative course was relatively smooth.
      • Due to pathology report showed Gallbladder adenocarcinoma, lymph node metastatic carcinoma, arrange bone scan, the report showed some faint hot spots in the skull.
      • Consult Hematologic-Oncology and Radiation Oncology for future treatment.
      • Consult psychosomatic medicine and an oncology psychologist for insomnia at night and psychological suicide risk factors: 13 points.
      • Follow up PET for bone scan showed some faint hot spots in the skull. PET scan showed 1). Glucose hypermetabolism in multiple lymph nodes in the retropancreatic, aortocaval and bilateral paraaortic regions, compatible with multiple metastatic lymph nodes; 2).Glucose hypermetabolism in multiple left supraclavicular lymph nodes. Metastatic lymph nodes should be watched out.
      • Port-A insertion was performed on 2023/06/30. Arrange SONO Guide biopsy-Lymph nodes (left neck) on 6/30.
      • The wound is clean and dry. Under the stable condition, she was discharged today and final report will be follow up in OPD.
    • Discharge prescription
      • MgO 250mg 1# TID
      • Acetal (acetaminophen 500mg) 1# TID
      • Alpraline (alprazolam 0.5mg) 1# HS
      • Eurodin (estazolam 2mg) 1# HS

[chemmotherapy]

  • 2023-11-06 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 2400mg/m2 3900mg NS 500mL 45hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-10-11 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 55mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C5D8)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-10-04 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 55mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C5D1)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-09-20 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 55mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C4D8)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-09-13 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 55mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C4D1)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-08-30 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 55mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C3D8)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-08-23 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C3D1)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-08-09 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C2D1)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-08-02 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C2D1)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-07-19 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C1D8)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-07-11 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C1D1)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL

Gemcitabine and cisplatin for locally advanced or metastatic biliary tract and pancreatic cancer - 2023-11-06 - https://www.uptodate.com/contents/image?imageKey=ONC%2F89633

  • Cycle length: 21 days.

  • Duration of therapy: Maximum of 8 cycles.

  • Regimen

    • Cisplatin
      • 25 mg/m2 IV daily
      • Dilute in 1000 mL NS with 20 mEq (20 mmol) of potassium chloride and 2 grams (8 mmol) of magnesium sulfate and administer over 60 minutes. Do not administer with aluminum needles or IV sets. Follow infusion with 500 mL NS over 30 minutes.
      • Days 1 and 8
    • Gemcitabine
      • 1000 mg/m2 IV daily
      • Dilute in 250 mL NS (concentration no more than 40 mg/mL) and administer over 30 minutes after cisplatin and IV fluid.
      • Days 1 and 8

==========

2023-11-06

[reconciliation]

The patient recently renewed her prescriptions for lorazepam and alprazolam on 2023-10-31 at a community pharmacy. Alprazolam is listed as currently in use, but lorazepam is not included in the active medication list. It might be advisable to ascertain if lorazepam is no longer required.

700295999

231103

[exam findings]

  • 2023-08-21 Patho - uterus (with or without SO) neoplastic
    • Diagnosis:
      • Ovary, left, debulking surgery — Mixed carcinoma (composed of 70% of low-grade serous carcinoma and 30% of Malignant Brenner tumor), and Ovarian abscess
      • Ovary, right, debulking surgery — Mixed carcinoma, and Ovarian abscess
      • Fallopian tube, bilateral, debulking surgery — Negative for malignancy
      • Cervix, debulking surgery — Endocervical polyp
      • Endometrium, debulking surgery — Negative for malignancy
      • Myometrium, debulking surgery — Adenomyosis, and multiple leiomyomas
      • Serosa, debulking surgery — Serous carcinoma seeding (revise)
      • Appendix, debulking surgery — Serous carcinoma seeding
      • Omentum, debulking surgery — Negative for malignancy
      • Lymph node, left iliac, dissection — Negative for malignancy
      • Lymph node, left obturator, dissection — Negative for malignancy
      • Lymph node, right iliac, dissection — Negative for malignancy
      • Lymph node, right obturator, dissection — Metastatic carcinoma
      • Lymph node, left paraaortic, dissection — Negative for malignancy
      • Lymph node, right paraaortic, dissection — Negative for malignancy
      • AJCC 8th edition pathology stage: pT3aN1a (if cM0); FIGO stage IIIA1i; Prognostic stage IIIA2
    • Gross description:
      • Procedure (select all that apply)
        • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy + appendectomy)
        • Specimen size:
          • Left ovary: 10x 8 x 6 cm in size, 220 gm in weight
          • Right ovary: 10x 9 x 5 cm in size, 240 gm in weight
          • Uterus: 9x 7.5 x 4.5 cm cm in size, 120 gm in weight
          • Appendix: 5.5 cm in length and 0.4 cm in greatest diameter
          • Omentum: 42x 14x 2 cm in size
          • Note: For information about lymph node sampling, please refer to the Regional Lymph Node section.
      • Specimen Integrity
        • NOTE: For primary ovarian tumors, if the ovary containing primary tumor is removed intact into a laparoscopy bag and ruptured in the bag by the surgeon without spillage into the peritoneal cavity (to allow for removal via laparoscopy port site or small incision), the specimen integrity should be listed as “capsule intact” with a comment explaining this in the report.
        • Specimen Integrity of Right Ovary (if applicable): ruptured
        • Specimen Integrity of Left Ovary (if applicable): ruptured
        • Specimen Integrity of Right Fallopian Tube (if applicable): Serosa intact
        • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
      • Tumor Site:
        • Note: Please select the primary tumor site only
        • Bilateral ovaries
      • Ovarian Surface Involvement (required only if applicable)
        • Present (Left)
      • Fallopian Tube Surface Involvement (required only if applicable)
        • Absent
      • Tumor Size
        • Note: For bilateral tumors, please report maximum dimension for each primary tumor, specifying by laterality.
        • Greatest dimension (centimeters), left side: 8 cm
          • Additional dimensions (centimeters): 6 x 5 cm
        • Greatest dimension (centimeters), right side: 8 cm
          • Additional dimensions (centimeters): 7 x 4 cm
      • Sections are taken and labeled as:A1:left iliac, A2:left obturator, A3:right iliac, A4-5:right obturator, A6:left paraaortic, A7:right paraaortic, A8:CX, A9:right adnexae, A10-12:corpus and myomas, A13-16:left ovarian tumor, A17-19:right ovarian tumor, A20:serosa, A21:appendix, A22:omentum
    • Microscopic Description:
      • Histologic Type:
        • Mixed carcinoma (composed of 70% of low-grade serous carcinoma component and 30% of Malignant Brenner tumor component)
      • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors)
        • Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.)
        • WHO Grading System: Not applicable
      • Implants (required for advanced stage serous/seromucinous borderline tumors only)
        • Note: Serous tumor implants that were formerly classified as “invasive implants” are now classified as low-grade serous carcinoma of the peritoneum.
        • Present (specify sites): appendix and serosa
      • Other Tissue/ Organ Involvement (select all that apply):
        • Not identified
      • Largest Extrapelvic Peritoneal Focus (required only if applicable)
        • Microscopic
      • Peritoneal/Ascitic Fluid
        • Malignant (positive for malignancy); N2023-03213
      • Regional Lymph Nodes:
        • Lymph node, left iliac: Negative for metastasis ( 0 / 3 )
        • Lymph node, left obturator: Negative for metastasis ( 0 / 7 )
        • Lymph node, right iliac: Negative for metastasis ( 0 / 3 )
        • Lymph node, right obturator: Positive for Metastasis (1/ 12)
        • Lymph node, left paraaortic, dissection— Negative for metastasis ( 0 / 5 )
        • Lymph node, right paraaortic, dissection— Negative for metastasis ( 0 / 7 )
      • Additional Pathologic Findings
        • Adenomyosis
        • Intramural, submucosal and subserosal leiomyomas
        • Endocervical polyp
      • Immunostains - Napsin A (-), WT-1 (focal+), p53 wild-type, p16 (-), GATA3 (+), CK20 (-), vimentin (focal+).
  • 2023-08-21 Body fluid cytology - ascites
    • Malignancy - positive for malignancy present;
    • GROSS DESCRIPTION: 40 ml turbid
    • MICROSCOPIC DESCRIPTION: few clusters of adenocarcinoma, many red blood cells, lymphocytes and mesothelial cells present.
  • 2023-08-17 CT, CTA - chest
    • Indication: advance ovary cancer
    • Chest CT with and without IV contrast ehnancement shows:
      • Some fluid accumulation at abdominal cavity is found. Dirty appearance of the mesentery is also noted. Suggest correlate with tumor marker.
      • Suggest clinical correlation
    • Imp:
      • No evidence of pulmonary embolism nor aortic dissection is found.
      • Some fluid accumulation at abdominal cavity is found. Dirty appearance of the mesentery is also noted. Suggest correlate with tumor marker.
  • 2023-08-15 SONO - abdomen
    • Diagnosis:
      • Hepatic cyst
      • Renal cyst, right
      • Renal lesion, left, rule out angiomyolipoma, rule out renal stone
    • Suggestion:
      • Please correlate with other image study
  • 2023-08-14 Gynecologic Ultrasonography
    • Findings
      • Uterus Position : AVF
        • Size: 80 * 49 mm
      • Endometrium:
        • Thickness: 7.3 mm
      • Adnexae:
        • ROV: Mass: 117 * 75 mm
        • LOV: Mass: 96 * 74 mm
      • CUL-DE-SAC: No fluid
    • IMP:
      • R/O Bilateral Ovarian mass
  • 2023-07-03 Patho - soft tissue tumor, extensive resection (Y1)
    • DIAGNOSIS:
      • Tissue, labeled as “epiploic appendages”, LSC biopsy — Invasive carcinoma
      • NOTE: The differential diagnosis includes serous carcinoma, endometrioid carcinoma,and etc.
    • Microscopically, it shows nests of invasive carcinoma with psammoma bodies, stromal fibrosis and mixed inflammatory infiltrate.
    • Immunohistochemical stain reveals CK (+), p53: wild-type (focal patchy+, < 10%), WT-1 (focal+), PAX8 (-), calretinin (-).
    • ADDENDUM: IHC stain — CK7 (+), CK20 (-), GATA3 (focal+), Napsin A (-), ER (focal weak+). Correlation with image and clinical findings is advised.
  • 2023-06-24 CT - abdomen
    • Clinical history: 57 y/o female patient with watery discharge noted for a year, pinkish discharge today, received chinese medicine, covid (+) last May.
    • With and without contrast enhancement CT of abdomen–whole:
      • There are heteregeneous tumors in bilateral adnexa(4.6cm in right adnexa and 5.2cm in left adnexa), r/o malignancy.
      • Uterine tumor, 2.4cm, r/o uterine myoma.
      • Cystic tumor, 3.1x1.6cm in right subhepatic region, r/o peritoneal seeding.
      • Small left renal cysts.
      • There are small aortocaval region lymph nodes.
      • Minimal ascites.
      • There are small peritoneal nodules, r/o carcinomatosis.
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T3c(T_value) N:N0(N_value) M:M0(M_value) STAGE:IIIc__(Stage_value)
    • Impression:
      • Bilateral ovarian tumors with peritoneal tumors, r/o ovarian malignancy with carcinomatosis, cstage T3cN0M0.
      • Small aortocaval region lymph nodes.
  • 2023-04-26 Clinical Dementia Rating
    • CDR score: 0.5
  • 2023-04-26 Mini-Mental State Examination
    • MMSE score: 28
  • 2023-02-22 CT - brain
    • No evidence of intracranial lesion.
  • 2023-01-09 Mammography
    • BI-RADS category 1, Negative.
  • 2023-08-14 Gynecologic Ultrasonography
    • Uterine myoma

[MedRec]

  • 2023-08-31 Psychosomatic Medicine Chen WenJiang
    • Prescription x3 (doubling of doses to date since 2022-08-15)
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Valdoxan (agomelatine 25mg) 0.5# HS
  • 2023-08-11 ~ 2023-08-29 POMR Obstetrics and Gynecology Huang SiCheng
    • Discharge diagnosis
      • Malignant neoplasm of unspecified ovary
      • Ovarain cancer -> mixed carcinoma (composed of 70% of low-grade serous carcinoma and 30% of Malignant Brenner tumor) AJCC 8th edition pathology stage: pT3aN1a (if cM0); FIGO stage IIIA1i; Prognostic stage IIIA2
      • Bilateral tubo-ovarian abscess
      • Abdominal pain
    • CC
      • for fever and abdominal pain since 8/11
    • Present illness
      • This 57 years old female with history of asthma and anxiety under medication control. She was menopaused at 51 years old. She had previous followed up at our GYN OPD for urine incontinence and vaginal itchness.
      • Since May 2023, lower abdominal fullness and FLANK SORENESS WAS noted and she came to our GYN OPD on 2023/05/18, the GYN echogram revealed left ovarian mass 2.5x2.2cm and mild adenomyosis. Intermittent right lower abdominal pain WAS also occurred. She went to GI OPD for help and symptomatic treatment given. The colonscopy arranged. Pink vaginal discharge noted on 06/21 and the vaginal sonography found bilateral ovarian mass, 5.5x4cm at right side and 5x3.1cm at left side. The abdominal CT on 06/26 revealed bilateral ovarian tumors with peritoneal tumors, r/o ovarian malignancy with carcinomatosis, cstage T3cN0M0. The tumor marker CEA 19.87 ng/mL and CA125 4621.9 U/mL on 06/23. The Upper G-I panendoscopy and Colon fiberoscopy were arranged for work up and tumor survey. She underwent exploratory laparoscopy for biopsy on 2023/07/03, the pathology showed invasive carcinoma.
      • Due to high D-dimer (> 10000) with Clexan 60 mg injection on 7/5 and 7/6. Port-A insertion on 2023/07/07. C1 neoadjuvant Taxel + Carbo on 2023/07/24.
      • This time, she has fever and abdominal distention with tenderness, so she was brought to our ED for help on 2023/8/11. There were no nausea/vomiting, no cough,no dysuria, no abdominal pain, no diarrhea, but vegina discharge got more.
      • At ER, vital signs: BP:132/61mmHg, PR:123bpm, BT:39’C, RR:20/min, Con’s:E4V5M6, SpO2:94%. Lab revealed WBC 8970/uL, with neutrophil predominant: 73%. CRP:13.7mg/dL, HGB = 9.4 g/dL.
      • Under the impression of Malignant neoplasm of unspecified ovary, the patient was admitted to our hema ward for further evaluation and treatment.
      • CA125                       
        • 2023-06-23 4621.9 U/mL                
        • 2023-08-07 7804.2 U/ml        
    • Course of inpatient treatment
      • The patient was admitted the hematology and oncology ward. Consultation GYN arrange sonography show right ovarian mass 117x75 mm side. The tumor marker CA125 4621.9 -> 8/7 7804.2 (U/mL), D-dimer > 10000, with Clexan 60 mg Q12H.
      • She and underwent GYN cancer debulking surgery (Abdominal Total Hysterectomy + bil salpingo-oophoretom + BPLND+ infracolic omentectomy + appendectomy) on 08/21/2023. Her postoperative course was uneventful. Her Eating and urination by self voiding was smooth. The vital sign was stable after surgery. JP drain was removed then on 08/25 and 08/28 morning. The Gyn tumor conference was arranged thursday.
      • She is discharged on 008/29/2023 pm and her followup appointment is scheduled on next week.
    • Discharge prescription
      • Actein (acetylcysteine 200mg) 1# TID
      • Bokey (aspirin 100mg) 1# QD
      • Acetal (acetaminophen 500mg) 1# Q4H
      • Through (sennoside 12mg) 2# HS
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • cephalexin 500mg 1# QID
  • 2023-07-23 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Invasive carcinoma of bilateral ovarian, c-stage T3cN0M0, cstage IIIc post 1st neoadjuvant chemotherapy on 20230725
    • CC
      • for first chemotherapy
    • Present illness
      • This 57 years old female with history of asthma and anxiety under medication control. She was menopaused at 51 years old. She had previous followed up at our GYN OPD for urine incontinence and vaginal itchness. Since May 2023, lower abdominal fullness and FLANK SORENESS WAS noted and she came to our GYN OPD on 2023/05/18, the GYN echogram revealed left ovarian mass 2.5x2.2cm and mild adenomyosis. Intermittent right lower abdominal pain WAS also occurred. She went to GI OPD for help and symptomatic treatment given. The colonscopy arranged. Pink vaginal discharge noted on 06/21 and the vaginal sonography found bilateral ovarian mass, 5.5x4cm at right side and 5x3.1cm at left side. The abdominal CT on 06/26 revealed bilateral ovarian tumors with peritoneal tumors, r/o ovarian malignancy with carcinomatosis, cstage T3cN0M0. The tumor marker CEA 19.87 ng/mL and CA125 4621.9 U/mL on 06/23. The Upper G-I panendoscopy and Colon fiberoscopy were arranged for work up and tumor survey.
      • She underwent exploratory laparoscopy for biopsy on 2023/07/03, the pathology showed invasive carcinoma.
      • Due to high D-dimer (> 10000) with Clexan 60 mg injection on 7/5 and 7/6. Port-A insertion on 2023/07/07.
      • This time, she was admitted for first chemotherapy on 2023/7/23.
    • Course of inpatient treatment
      • After admission, she received dexamethasone 5# q6h on 7/24 2300 and 7/25 0500.
      • Baraclude 0.5mg/tab 1# qdac for postive of anti-HBc.
      • C1 Taxel + Carboplatin on 2023/7/25.
      • Primepram 1# tidac for prevent vomit.
      • Under the stable condition, she can be discharged on 2023/7/26. OPD follow up is arranged.
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Through (sennoside 12mg) 2# HS
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNTID
      • Emend (aprepitant 125mg) 1# PRNQDAC
  • 2023-07-02 POMR Obstetrics and Gynecology Huang SiCheng
    • Discharge diagnosis
      • Malignant neoplasm of unspecified ovary
      • Bilateral ovarian cancer (for pelvic tissue biopsy report ) post Laparoscopic tumor biopsy on 2023/07/03
      • Abdominal pain
      • Myoma uteri
    • CC
      • Lower abdominal fullness for 2 months
    • Present illness
      • This 57 years old female with history of asthma and anxiety under medication control. She was menopaused at 51 years old. She had previous followed up at our GYN OPD for urine incontinence and vaginal itchness.
      • Since May 2023, lower abdominal fullness and FLANK SORENESS WAS noted and she came to our GYN OPD on 2023/05/18, the GYN echogram revealed left ovarian mass 2.5x2.2cm and mild adenomyosis. Intermittent right lower abdominal pain WAS also occurred. She went to GI OPD for help and symptomatic treatment given. The colonscopy arranged. Pink vaginal discharge noted on 06/21 and the vaginal sonography found bilateral ovarian mass, 5.5x4cm at right side and 5x3.1cm at left side.
      • The abdominal CT on 06/26 revealed bilateral ovarian tumors with peritoneal tumors, r/o ovarian malignancy with carcinomatosis, cstage T3cN0M0. The tumor marker CEA 19.87 ng/mL and CA125 4621.9 U/mL on 06/23.
      • After discussed with the patient, she was admitted for laparoscopic ovarian biopsy WILL BE arrange on 2023/07/03.
    • Course of inpatient treatment
      • The patient was admitted on 2023/07/02.The Upper G-I panendoscopy and Colon fiberoscopy were arranged for work up and tumor survey.
      • She underwent exploratory laparoscopy for biopsy on 2023/07/03. We gave her Cefazolin IV form for 2 day and then shifted her antibiotics to Cephalexin oral form.
      • Post-operation wound was dry and clean without dehiscence, discharge, or oozing. Her lab data on 2023/07/04 also showed no specific positive findings.
      • The pathology reported showed invasive carcinoma.
      • Due to high D-dimer (> 10000) with Clexan 60 mg injection on 7/5 and 7/6.
      • After GYN tumor conference on 2023/07/06 and the neo-adjuvant will be arrange. We was consulted GS/GU for port-A insertion and breast echo and cystoscopic on 2023/07/07.
      • Since all her general conditions were all improved and relatively stable, we arranged discharge on 2023/07/07 and Gyn/HemOnc OPD follow up of her recovery status and surgical wound conditions.     
    • Discharge prescription
      • Bokey (aspirin 100mg) 1# QD
      • MgO 1# QID
      • Acetal (acetaminophen 500mg) 1# QID
      • cephalexin 500mg 1# QID
  • 2022-08-15 Psychosomatic Medicine Chen WenJiang
    • Prescription x2
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Valdoxan (agomelatine 25mg) 0.5# HS
  • 2022-08-15 Chest Medicine Su WenLin
    • Prescription x2
      • Actein (acetylcysteine 600mg) 1# BID
      • Allegra (fexofenadine 60mg) 1# BID
      • Symbicort Turbuhaler (budesonide, formoterol) 2 puff BID INHL
      • Trisonin Nasal Spray (triamcinolone acetonide micronized 55ug/dose, 120dose/bt) 2 puff QD

[consultation]

  • 2023-08-18 Urology
    • Q
      • For arrange insert ureteral catheter
      • This is a 57y/o, G2P2 (NSD X 2), menopause (+, 51y/o) woman with invasive carcinoma of bilateral ovaries, cstage T3cN0M0, cstage IIIc, s/p laparoscopic tumor biopsy and 1st neoadjuvant chemotherapy in 2023/07.
      • This time, she was hospitalized due to symptoms of abdominal pain. Due to increased vaginal discharge, we were consulted for evaluation. She will accept the debulking surgery + HIPEC on 08/21/2023 on call. We need your expertise to evaluate this patient. Thank you very much!
    • A
      • Due to advance pelvic tumor, DBJ may be inserted during pelvic surgery
  • 2023-08-16 Obstetrics and Gynecology
    • Q
      • The 57 y/o woman has advance of ovarian cacner /p neoadjuvant chemo as C1 Taxel + Carbo on 2023/7/24. We need your help for surgical intervention next Monday.
    • A
      • This is a 57y/o, G2P2 (NSD X 2), menopause (+, 51y/o) woman with invasive carcinoma of bilateral ovaries, cstage T3cN0M0, cstage IIIc, s/p laparoscopic tumor biopsy and 1st neoadjuvant chemotherapy in 2023/07.
      • This time, she was hospitalized due to symptoms of abdominal pain. Due to rapid tumor progression, we were consulted for evaluation.
      • ObGyn history
        • G2P2, NSD X 2
        • Menopause (+, 51y/o)
        • Invasive carcinoma of bilateral ovaries, cstage T3cN0M0, cstage IIIc
        • 2023/07/03 Exploratory laparoscopy for tumor biopsy and cell block
        • 2023/07/25 Paclitaxel + Carboplatin C1D1
      • Lab
        • CA125 06/23: 4621.9 -> 8/7: 7804.2 -> 8/15: 13679.2 (U/mL)
        • 2023-08-16
          • WBC 8.95K
          • Hb 8.9g/dL
          • BCS WNL
          • CRP 14.0 mg/dL
          • D-dimer > 10000
      • Impression
        • Advanced ovarian cancer with tumor progression
      • Suggestion
        • Please give LPpRBC 3U transfusion for anemia.
        • Please give Clexane for elevated D-dimer.
        • We plan to transfer her to the GYN ward on W5 08/18. Bowel prepare on W5.
        • We will arrange surgery on W1 08/21: debulking surgery with self-paid HIPEC.
  • 2023-08-16 General and Gastrointestinal Surgery
    • Q
      • The 57 y/o woman has advance of ovarian cacner. We need your help for surgical intervention tomorrow. Thanks!
    • A
      • I’ll arrange combined opeartion for her (CRS + HIPEC).
  • 2023-08-14 Obstetrics and Gynecology
    • Q
      • The 57 y/o woman has Invasive carcinoma of bilateral ovarian, c-stage T3cN0M0, cstage IIIc post 1st neoadjuvant chemotherapy on 20230725. She has fever with abdominal and vagina discharge. We need your help for management.
    • A
      • This is a 57y/o, G2P2 (NSD X 2), menopause (+, 51y/o) woman with invasive carcinoma of bilateral ovaries, cstage T3cN0M0, cstage IIIc, s/p laparoscopic tumor biopsy and 1st neoadjuvant chemotherapy in 2023/07.
      • This time, she was hospitalized due to symptoms of abdominal pain. Due to increased vaginal discharge, we were consulted for evaluation.
      • CC
        • Abdominal pain and increased vaginal discharge for/since
      • ObGyn history
        • G2P2, NSD X 2
        • Menopause (+, 51y/o)
        • Invasive carcinoma of bilateral ovaries, cstage T3cN0M0, cstage IIIc
        • 2023/07/03 Exploratory laparoscopy for tumor biopsy and cell block
        • 2023/07/25 Paclitaxel + Carboplatin C1D1
      • Lab
        • CA125 06/23: 4621.9 -> 8/7: 7804.2 (U/mL)
        • 2023-08-11
          • WBC 8.97K
          • Hb 9.4g/dL
          • BCS WNL
          • CRP 13.7 mg/dL
          • U/A clear
      • PV
        • Mild amount of light yellow discharge -> s/p culture
        • No active bleeding
        • smooth cervix
      • Sono
        • Uterus: AVF, 80*49mm
        • EM: 7.3mm
        • RT mass: 117*75mm
        • LT mass: 96*74mm
        • CDS: no fluid
      • Impression
        • Advanced ovarian cancer
      • Suggestion
        • keep current neoadjuvant chemotherapy for bilateral ovarian cancer
        • please treat side effect of chemotherapy as your expertise
        • pending vaginal culture report
  • 2023-07-06 Urology
    • Q
      • For cystoscopy
      • Patient underwent Exploratory laparoscopy for biopsy on 07/03/2023. pathology report showed Invasive carcinoma. After GYN tumor conference.(cystoscopy is suggested). We need consult you for further management. Thank a lot!
    • A
      • We will arrange CUS on 2023/07/06 pm.

[chemotherapy]

  • 2023-11-03 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-10-10 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 800mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-09-18 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 800mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-07-25 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 800mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL

701503831

231103

  • 2023-10-31 CXR
    • Increased infiltration in both lung fields
    • Partial atelectasis of left lung
    • s/p port A insertion
  • 2023-10-31 CT - brain
    • No definite intracranial lesion
  • 2023-10-31 ECG
    • Sinus tachycardia
    • ST & T wave abnormality, consider inferior ischemia
    • ST & T wave abnormality, consider anterolateral ischemia

==========

2023-11-03

[tube feeding]

All of the oral medications on the active medication list can be administered through a feeding tube.

700787059

231101

[exam findings]

  • 2023-10-07 CT - abdomen
    • Indication: Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, hold Glimet F.C 2mg & 500mg/tab (10/5~10/7)
    • With and without contrast enhancement CT of abdomen shows:
      • Colon and rectal CA, s/p operation. Nodular lesions in RUQ, in progression.
      • A cystic lesion, 2.6cm, in liver dome.
      • Some lymph nodes in para-aortic region.
    • Impression
      • Colon and rectal CA, s/p operation
      • Peritoneal nodules in RUQ, in progression
      • Para-aortic lymph nodes
  • 2023-06-29 CT - abdomen
    • History and indication:
      • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I s/p CCRT and chemotherapy with FOLFOX, s/p Low AR + loop ileostomy and Right hemicolectomy and chemotherapy with FOLFOX
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P colon operation. Some nodules at bil. lungs.
      • A poor enhancing lesion (2.5cm) at liver dome.
      • Renal cysts (up to 3.6cm).
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • S/P colon operation. Some nodules at bil. lungs.
      • A poor enhancing lesion (2.5cm) at liver dome.
  • 2023-06-24 CXR
    • Cardiomegaly is noted.
    • S/p port-A placement with its tip at Superior vena cava.
    • Tortous aorta with calcification is noted.
    • Faint aveolar opacity over left upper lobe is found.
    • Emphysematous change over both lungs.
  • 2023-06-21 Joint soft tissue sonography
    • Left shoulder supraspinatus calcific tendinopathy
  • 2023-06-16 Shoulder Lt
    • Normal bone alignment
    • moderate decreased left shoulder joint space
    • moderate left subacromial spur formation.
    • a nodular lesion in the left upper lung field
  • 2023-04-04, -03-21, -03-17, -03-14 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • Old fracture of right clavicle shows mild angulation deformity but good union.
  • 2023-03-27 Ga-67 Whole body inflammation scan with SPECT
    • The whole-body gallium-67 inflammation scan with SPECT was performed at the 24th and 48th hour after injecting 6 mCi of Ga-67 to the patient. The images showed increased radiotracer uptake in a focal area in the left supraclavicular fossa, in a focal area in the left anterior upper chest wall, in the right upper anterior mediastinum, in bilateral pulmonary hilar regions and in the posterior aspect of bilateral lower lung fields and in both kidneys.
    • IMPRESSION:
      • Increased radiotracer uptake in a focal area in the left supraclavicular fossa, in a focal area in the left anterior upper chest wall, in the right upper anterior mediastinum, in bilateral pulmonary hilar regions and in the posterior aspect of bilateral lower lung fields. Infection/inflammation involving these regions should be watched out. Please correlate with other clinical findings for further evaluation.
      • Mildly increased radiotracer uptake in both kidneys. The nature is to be determined (inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
  • 2023-03-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (97.3 - 25.3) / 97.3 = 74.00%
      • M-mode (Teichholz) = 74.0
    • Conclusion:
      • Thickened AV with no AR
      • Thickened MV with mild MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • Normal LV wall motion
      • No PR, trivial TR, normal IVC size
  • 2023-03-11 CTA - chest
    • Findings
      • Bil. pleural effusion with adjacent lung collapse. Ground glass opacities at bil. lungs.
      • S/P operation. Minimal ascites.
      • Renal cysts (up to 3.6cm).
      • S/P Port-A infusion catheter insertion.
    • IMP
      • Bil. pleural effusion with adjacent lung collapse. Ground glass opacities at bil. lungs.
  • 2023-03-11 ECG
    • Sinus tachycardia
    • Left bundle branch block
  • 2023-03-10 KUB
    • Presence of ileus.
    • Degeneration and spondylosis of L-S spine.
  • 2023-02-16 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Tumor, ascending colon, R’t hemicolectomy (s/p CCRT) — Mucinous adenocarcinoma
      • Resection margins, bilateral, ditto — Free of tumor invasion
      • Lymph node, mesocolic, dissection — Free of tumor metastasis (0/18)
      • Appendix — Free of tumor invasion
      • AJCC pathologic stage — ypT3N0, if cM0, stage IIA
    • MACROSCOPIC EXAMINATION
      • Operation procedure: R’t hemicolectomy
      • Specimen site: Ascending colon, terminal ileum and appendix
      • Specimen size: (a) A-colon: 27.7 cm in length, up to 8.4 cm in circumference, (b) Terminal ileum: 2.3 cm in length, 2.3 cm in diameter and (c) Appendix: 2.2 cm in length, 0.7 cm in diameter
      • Tumor size: 4.7 x 3.8 cm
      • Tumor location: ascending colon, 14.8 and 9 cm away from bilateral resection margins
      • Tumor appearance: protruding mass
      • Depth of invasion grossly: pericolonic fat
      • Representative sections as follows: A1: ileum + colonic resection margin, A2: appendix, A3-A6: tumor, A7-A10: lymph nodes
    • MICROSCOPIC EXAMINATION
      • Histology: mucinous adenocarcinoma
      • Histology Grade: G2, moderately differentiated
      • Depth of invasion: pericolonic fat
      • Angiolymphatic invasion: not identified
      • Perineural invasion: not identified
      • Discontinuous extramural tumor extension: not present
      • Circumferential (radial) margin of rectosigmoid: not involved
      • Lymph node metastasis, mesocolic: free of tumor metastasis (0/18)
      • Lymph node metastasis, IMA / SMA: N/A
      • Extranodal involvement: N/A
      • Pathological TNM Stage: ypT3N0
      • Type of polyp in which invasive carcinoma arose: N/A
      • Additional pathologic findings: mucin production
      • TNM descriptors: Y
      • Tumor regression grading S/P CCRT: grade 5
  • 2023-02-16 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Tumor, rectum, laparoscopic LAR (s/p CCRT) — Adenocarcinoma
      • Resection margins, ditto — Free of tumor invasion
      • Lymph nodes, mesocolic, dissection — Tumor metastasis (1/6)
      • AJCC pathologic stage — ypT4aN1a, if cM0, stage IIIB
    • MACROSCOPIC EXAMINATION
      • Operation procedure: laparoscopic LAR
      • Specimen site: rectum
      • Specimen size: 7.7 cm in length, 3.1 cm in diameter
      • Tumor size: 1.5 x 1.3 cm with perforated hole 2.6 x 0.9 cm
      • Tumor location: 4.5 cm and 0.5 cm away from bilateral resection margins
      • Tumor appearance: subserosal nodule and perforated hole
      • Depth of invasion grossly: visceral peritoneum
      • Proximal margin: 3.2 x 1.2 x 0.9 cm
      • Distal margin: 1.8 x 1.3 x 0.9 cm
      • Representative sections as follows: A1-A3: perforated hole (ink) + subserosal tumor, A4-A6: perforated hole (ink) + mucosa, A7-A9: LNs, B: Proximal margin and C: distal margin
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: G2, moderately differentiated
      • Depth of invasion: visceral peritoneum (<0.1 cm from serosa layer)
      • Angiolymphatic invasion: present
      • Perineural invasion: present
      • Discontinuous extramural tumor extension: absent
      • Circumferential (radial) margin of rectosigmoid: not involved
      • Lymph node metastasis, mesocolic: Tumor metastasis (1/6)
      • Lymph node metastasis, IMA / SMA: N/A
      • Extranodal involvement: not involved (0/1)
      • Pathological TNM Stage: ypT4aN1a
      • Type of polyp in which invasive carcinoma arose: N/A
      • TNM descriptors: Y
      • Tumor regression grading S/P CCRT: G3
  • 2023-02-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (105 - 34) / 105 = 67.62%
      • M-mode (Teichholz) = 68
    • Conclusion
      • Mild septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Prominent posterior mitral annulus calcification with mild MR; mild aortic valve sclerosis .
      • Mild aortic root calcification with sessile atheromas.
  • 2023-01-31 Sigmoidoscopy
    • Rectal cancer s/p CCRT , significant tumor regression
  • 2023-01-26 CT - abdomen
    • History and indication:
      • Locally advanced rectal cancer with large pelvic LNs A-colon cancer with intussusception (no obstruction sign) –> Suggest pre-op CCRT for better resectability and local control, 20221205 RT finish
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Much regression of rectal and A-colon cancer and metastatic LAP. A tiny nodule at RML.
      • Renal cysts (up to 3.6cm).
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • Much regression of rectal and A-colon cancer and metastatic LAP. A tiny nodule at RML.
  • 2022-10-28 All-RAS + BRAF mutations assay
    • All-RAS mutations assay
      • Detection range
        • KRAS codon 12, 13, 59, 61, 117, 146
        • NRAS codon 12, 13, 59, 61, 117, 146
      • Results
        • Detected (KRAS codon 12 GGT>GAT, p.G12D)
      • Interpretation
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF mutations assay
      • Detection range
        • BRAF codon 600
      • Results
        • There was no variant detected in the BRAF gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • 2022-10-24 CXR
    • Ground glass opacity in RLL.
  • 2022-10-17 CT
    • Indication: synchronous rectal cancer and A-colon cancer
    • Findings
      • Chest:
        • Small lymph nodes are found at both sides of the mediastinum.
        • No evidence of bilateral pleural effusion.
        • Calcified coronary arteries is found.
        • The lung fields are clear.
        • No pleural effusion is found.
      • Visible abdomen:
        • DIffuse wall thickening at rectum about 4.2cm in length with regional lymphadenopathy is found. Rectal cancer is considered. Regional lymphadenopathy is found.
        • Annular lesion at ascending colon near hepatic flexure about 3cm is found. suspected colon cancer with intussusception.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • Non-specific bowel gas at abdominal cavity is found.
        • There is no evidence of destructive bone lesion.
        • No definite inguinal or pelvic sidewall LAP
        • No evidence of abnormal soft tissue mass at pelvic cavity.
        • Suggest clinical correlation
    • IMp:
      • Rectal cancer with regional lymphadenopathy, T4N2M0
      • Ascending colon cancer. T2N0M0.
  • 2022-10-17 ECG
    • Normal sinus rhythm
    • Left axis deviation
  • 2022-10-06 Patho - colorectal polyp
    • Colorectum, ascending colon, biopsy — Adenocarcinoma.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • 2022-10-06 Patho - colorectal polyp
    • Colorectum, rectum about 11 cm above anal verge, biopsy — Adenocarcinoma.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • 2022-10-06 Colonoscopy
    • Colon cancer, rectum, s/p biopsy
    • Colon polyp, sigmoid colon, s/p polypecotmy + cliping
    • Colon polyp, descending colon, s/p polypectomy + cliping
    • Colon cancer, ascending colon, s/p biopsy
    • Internal hemorrhoid

[MedRec]

  • 2023-05-16 SOAP Metabolism and Endocrinology
    • Diagnosis
      • NIDDM with unspecified complication, not stated as uncontrolled [E11.8]
      • Dyslipidemia; other and unspecified hyperlipidemia [E78.5]
    • Prescription
      • Glimet (glimepiride 2mg, metformin 500mg) 0.5# BID
      • Trajenta (linogliptin 5mg) 1# QL
  • 2023-03-11 POMR Cardiology
    • Discharge diagnosis
      • Severe sepsis with septic shock
      • Bacteremia with Serratia marcescens on 2023/03/11 and pan-drug resistant (PDR) Klebsiella pneumoniae on 2023/03/22
      • Port A catheter infection with pan-drug resistant (PDR) Klebsiella pneumoniae (by tip culture on 2023/03/24), status post removal on 2023/03/24
      • Urinary tract infection with urosepsis by urine culture grewed Enterobacter cloacae complex on 2023/03/11
      • Non-ST elevation myocardial infarction, favor Type 2 myocardial infarction by infection related
      • Type 2 diabetes mellitus
      • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I post neoadjuvant concurrent chemoradiotherapy status post low anterior resection with loop ileostomy, ypT4aN1aM0, stage IIIB and right hemicolectomy, ypT3N0M0, stage IIA on 112/02/14
      • Iron deficiency anemia
      • Gastrointestinal (GI) bleeding (stool occult blood 1+)
      • Hypokalemia, resolved
      • Hypomagnesemia, resolved
      • Hypocalcemia, improving
      • Constipation
    • CC: fever and chillness at 20230311 night
    • Present illness
      • This 79 y/o male patient has the past history of
        • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I post neoadjuvant concurrent chemoradiotherapy status post low anterior resection with loop ileostomy, ypT4aN1aM0, stage IIIB and right hemicolectomy, ypT3N0M0, stage IIA on 2023/02/14
        • Type 2 diabetes mellitus with OHA control
        • Postoperative Ileus
      • the patient regular follow up at our OPD and just admitted at our proctology service from 2023/02/14 to 2023/03/09 for his adenocarcinoma of the rectum operation.
      • According to the statement of the patient’s families and ER medical record. This time, the patient suffered from fever and chillness at 22:00, so he was sent to our ER on 20230310. At MER, his GCS was E4V5M6 and vital signs showed BP:149/76 mmHg; HR:120 BPM; BT:38.4’C; RR:20 BPM; SpO2:95%. Covid-19 rapid test showed negative. The patient complained upper back pain at 00:05. However, consciousness changed to GCS:E4V1M4 at 00:22 combined with cold sweating, air hunger and blood pressure couldn’t measure, so bosmin 1mg iv stat was given.
        • The laboratory disclosed increased in cardiac enzyme Troponin I:46.8->3918.7->14527.3pg/mL, CK:163ng/mL, D-dimer:7591.06ng/mL, Lactic acid:4.8mmol/L, CPR:1.15mg/dl, band:5.0%, urine analysis (NIT:2+, WBC:>=100 and bacteria:3+) and ABG showed hypoxia (PO2:31.7, SpO2:63.7%). CXR revealed presence of ileus. The first EKG showed sinus tachycardia, the secondary EKG (post Bosmin) showed ST depression in V4~V6, suspect AMI and the third and fourth EKG restored to normal sinus rhythm. Arranged chest CTA disclosed bilateral pleural effusion with adjacent lung collapse, ground glass opacities at bilateral lungs. Cardiology was consulted and who suggested that the subsequent ECG change is associated with bosmin effect, which will lead to transient vasoconstriction, not true MI. Also, KUB revealed presence of ileus and degeneration and spondylosis of L-S spine. Under the impression of Urinary tract infection with urosepsis, NSTEMI, he was admitted to MICU for further evaluation and management on 2023/03/11.
    • Course of inpatient treatment
      • After admitted to MICU, we administered empirical antibiotic with IV Cravit (03/11~03/15) according to his previous (2023/03/01) urine culture grew Enterobacter cloacae complex for infection control and IV hydration for favor poor intake with dehydration and septic shock status, DAPT with Bokey and plavix for AMI and PPI with Nexium for prevent stress ulcer.
        • Echocardiography was done on 03/13 disclosed LVEF: 74%, 1.Thickened AV with no AR; 2.Thickened MV with mild MR; 3.Normal LV chamber size and wall thickness; 4. Preserved LV and RV systolic function; 5.Normal LV wall motion; 6. No PR, trivial TR, normal IVC size. Later, hypokalemia and hypomagnesemia were found, thus 0.298%KCL in NaCL and MgSO4 were given. The blood culture x 2 set grew Serratia marcescens and urine culture grew Enterobacter cloacae complex, single dose of tapimycin was used first on 3/13 and INF was consulted to adjust antibiotic for his infection control. Hb drop from 9.5 to 7.7 g/dl was also found, LPRBC transfusion was given to correct anemia. His condition was relative stable, he was transferred to cardiology general ward for further care on 03/14.
      • At ordinary ward, his consciousness was alert but weakness and vital signs were stable, no dyspnea or chest discomfort was complained, respiratory pattern smooth under nasal cannula support. Cravit was changed to Tapimycin (03/13, 03/15) for his bacteremia with Serratia marcescens and UTI with Enterobacter cloacae complex. Continue to use other current medication to control the underlying disease and closely monitor his vital signs and clinical symptoms.
        • The INF recommend antibiotic treatment with Tienam or Mepem for S. marcescens bacteremia and E. cloacae UTI for 7 to 10 days, thus Tapimycin was shifted to Tienam used on 03/16. We also arrange thallium scan for CAD survey and stool OB, ion profiles examination for his anemia surveyed. Then stool OB was 1+ and iron profiles reported Fe 19 ug/dL, TIBC 272 ug/dL, UIBC 253 ug/dL, so we kept Nexium used and added Foliromin F.C. 50mg/tablet (Sodium Ferrous Citrate). The thallium scan was done on 2023/03/17, and reported probably mild myocardial ischemia at the inferoapical wall and inferolateral wall. Medical treatment was prescribed first.
      • Another episode of fever with chills developed at 23:21 on 03/21, Cravit was added. Gallium whole body inflammation scan was arranged for fever survey. The tracking initial blood culture on 03/22 report GNB. Tienam plus Cravit was changed to Doripenem (03/23~03/26) after contacting the infection doctor. Due to recurrent bacteremia, suspected to be related port-A infection, we consulted with a general surgeon, and port-A was removed on 03/24 with the signed consent of the family.
        • The 2023/03/22 blood culture officially reported as PDR-Klebsiella pneumonia, so Doripenem was changed to Tygacil plus UFO (fosfomycin) after contacting the infectious department. Later, port-A TIP culture on 03/24 also grew PDR-Klebsiella pneumonia. All Abx was shifted to Zavicefta since 03/28 by ID suggestion. Gallium inflammation scan on 2023/03/29 reported increased radiotracer uptake in a focal area in the left supraclavicular fossa, in a focal area in the left anterior upper chest wall, in the right upper anterior mediastinum, in bilateral pulmonary hailer regions and in the posterior aspect of bilateral lower lung fields. Infection/inflammation involving these regions should be watched out. We followed his blood culture results after 3 days of Zavicefta treatment (03/31) and results are pending.
        • During 7-day treatment course of Zavicefta, he had no fever or other infection signs. On 4/4, lab data were all within acceptable range. Blood culture on 3/31 also showed negative findings. Under the stable hemodynamic status, he was discharged on 4/6.
  • 2023-01-03 SOAP Hemato-Oncology
    • S: 2022-11-14 RAS G12D
  • 2022-12-14 Radiation Oncology
    • O
      • RT (2022-10-27 ~ 2022-12-05): 4500cGy/25 fractions (15MV photon) of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed area.
  • 2022-11-24 Radiation Oncology
    • A/P
      • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2022-10-25
        • CCRT (Concurrent Chemoradiotherapy) first, then surgery.
        • For the liver nodule, it is suggested to evaluate with abdominal sonography for staging purposes.
  • 2022-10-28 POMR Hemato-Oncology
    • Discharge diagnosis
      • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I
      • Malignant neoplasm of rectum
      • Type 2 diabetes mellitus with unspecified complications
      • Unspecified viral hepatitis B without hepatic coma
      • Other constipation
    • Present illness
      • This time, he admitted for concurrent chemoradiotherapy with 5-Fu on 2022/10/28 and 2022/10/31-2022/11/03 (5 days).
    • Course of inpatient treatment
      • After admission, CCRT with 5-Fu (225mg/m2 -> 350mg) x 5days on 2022/10/28, stop 2022/10/31-2022/11/03 treatment, change to FOLFOX regimen (Oxalip 85mg/m2 -> 110mg, Leucovorin 400mg/m2 -> 600mg, 5-Fu 2400mg/m2 -> 3700mg) from 2022/10/31 (well treatment for two site tumor), and explain to family (wife and son) and patient.
        • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
        • Type 2 diabetes mellitus with Monitor blood sugar QDAC
        • Glimet F.C 2mg/500mg/tab 1# PO BID.
        • Viral hepatitis B (Anti-HBc (+)) with Baraclude 0.5mg/tab 1# PO QDAC.
        • Constipation (suspect EMEND related, next cycle DC) with Bisacodyl supp 10mg/pill 2 supp RECT ST on 2022/11/02, Through 12mg/tab 1# PO HS, no stool passage add to 2# for MBD.
      • He can tolerance chemotherapy. The patient was discharged on 2022/11/03 under stable condition. ONC OPD follow up was advised.
  • 2022-10-20 SOAP Radiation Oncology
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed.
  • 2022-10-20 SOAP Colorectal Surgery
    • A
      • Locally advanced rectal cancer with large pelvic LNs
      • A-colon cancer with intussusception (no obstruction sign)
    • P
      • Suggest pre-op CCRT for better resectability and local control
  • 2017-01-07 SOAP Metabolism
    • Diagnosis
      • NIDDM with unspecified complication, not stated as uncontrolled [E11.8]
      • Dyslipidemia; other and unspecified hyperlipidemia [E78.5]
    • Prescription
      • Pitator (pitavastatin 2mg) 1# QD
      • Glimet (glimepiride 2mg, metformin 500mg) 0.5# TID

[consultation]

  • 2023-08-09 Dermatology
    • Q
      • This 79-year-old man patient is a case of Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC s/p concurrent chemoradiotherapy and chemotherapy with FOLFOX from 2022/10/31~2023/06/09(for 9 cycles) with tumor dense invasion/adhesion to anterior pelvic wall, lymph node enlarged narropw pelvis s/p Low anterior resection + loop ileostomy and Right hemicolectomy on 2023/02/15 with bil.lung and liver metastases s/p chemotherapy of FOLFIRI from 2023/06/30 and Avastin from 2023/07/13. He was admitted for chemotherapy with Avastin(C3)/FOLFIRI(C2D15).
      • This time, for left toe wound of injuried. Now, for evaluate left toe wound medication therapy. Thank you.
    • A
      • The patient had sufferred from thicekening nail bed with scales and erosive wound formation.
      • Under the impression of onychomycosis and onycholysis with wound formation
      • The following suggestion:
        • for wound lesion, Tetracyclie onit 1 tube topical bid use.
        • for tinea unguium, Exelderm lotion 1 bot. topical bid use over nail-fold (to put the drug into the affected area between the nail seams).
  • 2023-03-15 Infectious Disease
    • Q
      • for Serratia bacteremia
      • This 79 y/o male patient has the past history of
        • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I post neoadjuvant concurrent chemoradiotherapy status post low anterior resection with loop ileostomy, ypT4aN1aM0, stage IIIB and right hemicolectomy, ypT3N0M0, stage IIA on 2023/02/14
        • Type 2 diabetes mellitus with OHA control
        • Postoperative Ileus
      • This time,the impression of
        • Urinary tract infection with urosepsis (20230301 urine culutre yeild Enterobacter cloacae complex)
        • NSTEMI
        • Syncope, suspect dehydration related
      • He was admitted to MICU for further evaluation and management on 2023-03-11. We gave empirical antibiotic with Cravit (since 20230311) used. His Blood culture (20230311) yeild serratia marcescens. We really need your experience for treatment suggestion, thanks!!!
    • A
      • Hx review as mentioned above and Lab data check
      • Suggestion:
        • Recommend antibiotic Rx with Tienam or Mepem for S. marcescens bacteremia and E. cloacae UTI for 7 to 10 D
        • Repeat B/C
        • Monitor CRP
  • 2023-03-11 Cardiology
    • A
      • This patient presented with sepsis syndrome in advanced colon C, not acute coronary syndrom
        • The CXR didnot show medistianl wideing, the aortic dissection is less likely
        • The subsequent ECG change is associated with bosmin effect, which will lead to transient vasoconstriction
        • not true MI
      • please treat underlying diseae, maintain optimal Bp
        • f/u echocardiography for wall motin assessment
  • 2023-03-07 Dermatology
    • Q
      • For bilateral perianal skin rash
      • This is a 79-year-old male with past history of synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I post neoadjuvant concurrent chemoradiotherapy.
        • He went through low anterior resection, loop ileostomy and right hemicolectomy on 20230215.   
        • During the surgery, advanced rectal cancer s/p CCRT , tumor dense invasion/adhesion to anterior pelvic wall, LN enlarged Narropw pelvis was found.
        • After surgery, ileus was noted and NG decompression was applied. Now NG has been removed.
      • However, he experienced bilateral multiple perianal rash for 2 days.
        • The rash was painless but pruritus.
        • No vesicles were noted.
        • Mycomb was applied for now.
      • We need your expertise for further evaluation. Thank you so much for your help.
    • A
      • The patient had sufferred from annular lesions with peripheral active borders on the bilateral thigh and genital area.
      • Under the impression of tinea cruris et intertrigo eczema.
      • The following suggetion:
        • Exelderm cream 1 tube topical QN use over large area of lesions after body clean and Mycomb cream 1 tube topical PRN Bid use over regional erythema itchy area.
        • keep body dry, clean and avoid further friction or compression.

[radiotherapy]

  • 2022-10-27 ~ 2022-12-05 - 4500cGy/25 fractions (15MV photon) of the pelvic, and 4680cGy/26 fractions of the rectal tumor bed area. (20221201 OPD)

[chemoimmunotherapy]

  • 2023-10-31 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-09 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-18 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-29 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-09 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-13 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-30 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-09 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-05-12 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-04-21 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-01-06 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-21 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-07 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-25 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-14 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-10-31 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-10-28 - fluorouracil 225mg/m2 350mg NS 250mL 10min D1-5 (CCRT)
    • [dexamethason 4mg + NS 250mL] D1-5

==========

2023-11-01

[hyperglycemia]

During this hospital stay, the patient’s blood glucose levels have consistently been elevated (216 -> 376 -> 294 mg/dL).

It is advisable to introduce acarbose 50mg PO TIDCC, with the patient instructed to take each dose at the beginning of every main meal.

2023-09-19

On 2023-08-08, our endocrinologist provided a repeat prescription for Glimet (glimepiride, metformin) and Trajenta (linagliptin), which the patient is currently taking without discrepancies. However, the patient’s blood glucose levels have been consistently high, >= 285 mg/dL for these 2 days. As a recommended addition to his treatment plan, the prescription of Dibose (acarbose 100mg) is advised to be taken as 0.5# TID, with the first bite of each main meal.

2023-07-28

Glimet (glimepiride, metformin) and Trajenta (linagliptin) were refilled on 2023-07-05 as a repeat prescription prescribed by our endocrinologist on 2023-05-16. Both medications have been added to the active medication list without any identified issues.

At 20:14 on 2023-07-27, there was a spike in blood glucose to 269 mg/dL. If this elevation persists, it may require re-evaluation and possible modification of the antidiabetic treatment plan.

There appears to be an upward trend in liver enzyme levels. Given this situation, the addition of BaoGan (silymarin) could be considered as an optional measure if there are no other specific concerns.

  • 2023-07-25 S-GPT/ALT 73 U/L

  • 2023-07-13 S-GPT/ALT 50 U/L

  • 2023-07-13 S-GPT/ALT 51 U/L

  • 2023-06-28 S-GPT/ALT 31 U/L

  • 2023-06-15 S-GPT/ALT 28 U/L

  • 2023-07-25 S-GOT/AST 49 U/L

  • 2023-07-13 S-GOT/AST 34 U/L

  • 2023-07-13 S-GOT/AST 33 U/L

  • 2023-06-28 S-GOT/AST 26 U/L

  • 2023-06-15 S-GOT/AST 27 U/L

2023-06-29

According to the PharmaCloud database, our hospital has been the sole provider of the patient’s medical services for the past three months. On 2023-06-24, our Thoracic Department issued a 7-day prescription for Curam (amoxicillin, clavulanic acid), Actein (acetylcysteine), Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), and MgO. Due to changes in the patient’s condition, Curam and MgO are not currently on the active formulary, indicating that these medications may no longer be needed. Therefore, no evidence of medication reconciliation discrepancies was identified.

701496820

231101

[lab data]

2023-09-20 Anti-HBc Reactive
2023-09-20 Anti-HBc Value 3.40 S/CO
2023-09-20 Anti-HBs 191.16 mIU/mL
2023-09-20 Anti-HCV Nonreactive
2023-09-20 Anti-HCV Value 0.12 S/CO
2023-09-20 HBsAg Nonreactive
2023-09-20 HBsAg (Value) 0.32 S/CO

[exam findings]

  • 2023-09-28 Pure Tone Audiometry
    • Reliabilty Fair
    • PTA
      • R’t : 94 dB HL, moderate to profound mixed type HL
      • L’t : 54 dB HL, mild to profound SNHL.
  • 2023-09-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (70 - 24) / 70 = 65.71%
      • M-mode (Teichholz) = 71.1
    • Conclusion:
      • Adequate LV,RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Mild MR, AR
  • 2023-09-05 Nasopharyngoscopy
    • Finding: NPC
    • NpScope: right NP crusting and exudate coating

[MedRec]

  • 2023-10-11 SOAP Hemato-Oncology Xia HeXiong
    • Prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Granocyte (lenograstim 250ug) QD SC 3D
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • MgO 250mg 2# TID
      • Smecta (dioctahedral smectite 3g) 1# PRNQ8H
      • NS 500mL ST IVD
  • 2023-09-25 ~ 2023-10-06 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Malignant neoplasm of nasopharynx, unspecified
      • Nonkeratinizing, undifferentiated nasopharyngeal carcinoma, cT3N1M0, Stage III, s/p CCRT with proton (6996cGy/33 Fx, from 2022/09/19~2022/11/07), s/p chemotherapy with gemcitabine plus cisplatin (from 2022/08/10~2022/10/19), recurrence in 2023/05, rT4N0M0, Stage IVA, s/p docetaxel plus cisplatin from 2023/06/07~2023/08/30, progression with involving with right nasopharyngeal space, parapharyngeal space, skull base and very close to ICA
      • Anemia, unspecified
      • Hypomagnesemia
      • Chronic viral hepatitis B without delta-agent
      • Enlarged prostate with lower urinary tract symptoms
      • Other insomnia not due to a substance or known physiological condition
    • CC
      • for scheduled chemotherapy        
    • Present illness
      • This 70 y/o man was quite robust before. He had the initial presentation with right side hearing loss for one more months.
      • He visited CGMH where the diagnosis of nonkeratinizing, undifferentiated NPC was made by the biopsy on 2022-07-20. The initial stage was cT3N1M0, Stage III.
      • Then he received the CCRT with proton (6996cGy/33 Fx, from 2022-09-19 to 2022-11-07) and biweekly gemcitabine plus cisplatin (from 2022-08-10 to 2022-10-19).
      • The follow-up nasopharyngoscopic examination found a suspicious lesion and the biopsy was done on 2023-05-02.
      • The result of biopsy confirmed the recurrence. On 2023-05-26, the follow-up MRI showed the disease was in progression, with a clinical stage of rT4N0M0, Stage IVA.
      • On 2023-06-16, the PET-CT confirmed the local residual tumor. Then he received the salvage chemotherapy with biweekly docetaxel plus cisplatin from 2023-06-07 to 2023-08-30.
      • On 2023-08-18, the follow-up MRI disclosed the tumor still in progression, involving with right nasopharyngeal space, parapharyngeal space, skull base and very close to ICA, which was unresectable.
      • Denied TOCC history in recent three months. Then he visited our hospital for further management.
    • Course of inpatient treatment
      • After admission, collect 24hr Ccr on 2023/09/26 showed 83.7 mL/min and arrange 2D echo for survey, on 2023/09/27 showed LVEF:71.1%, Adequate LV, RV systolic function with normal wall motion, Impaired LV relaxation, Mild MR, AR.
      • PTA was done on 2023/09/28 showed R’t : 94 dB HL, moderate to profound mixed type HL、L’t : 54 dB HL, mild to profound SNHL.
      • Anemia was noted, BT LRBC 2unit on 2023/09/27.2023/09/28, then get improved.
      • Hypomagnesemia with MgO 250mg/tab 2# PO TID for support.
      • He received chemotherapy with MEPFL (Mitomycin-C 8mg/m2、Epirubicin 60mg/m2、Cisplatin 60mg/m2 on D1 / Leucovorin 30mg/m2、5-Fu 450mg/m2 on D8) from 2023/09/28 (C1D1), 2023/10/05(C1D8).
      • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
      • Enlarged prostate with lower urinary tract symptoms, TONE 25mg/tab 1# PO BID, Betmiga 50mg/tab 1# PO QDAC was given for relief.
      • Insomnia with Stilnox 10mg/tab 0.5# PO HS, Modipanol 1mg/tab 2# PO HS.
      • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for Anti-HBc:reactive.
      • Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, he was discharged on 2023/10/06 and OPD followed up later.   
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • MgO 250mg 2# TID
      • Smecta (dioctahedral smecitite 3g) 1# PRNQ6H
  • 2023-09-19 SOAP Hemato-Oncology Xia HeXiong
    • S: s/p CCRT (Proton) with Gem/Platinum
      • Due to recurrence, s/p docetaxel/Platinum
    • A/P:
      • Suggest admission for salvage C/T with MEPFL.
      • Admission for echocardiography, 24 hours CCr, audiometry
  • 2023-09-08 SOAP Ear Nose Throat Huang YunCheng
    • O: r/o r T3N0M0, suggest repeat CCRT or proton therapy?
      • He has received chemotherapy + proton therapy, but still recurrence tumor noted, He looked for 2nd opinion.
    • A: salvage sugery is not indicated due to near ICA
  • 2023-09-05 SOAP Ear Nose Throat Huang YunCheng
    • S: NPC, s/p CCRT at LinKou ChangGung Hospital?
    • O: NpScope: right NP crusting and exudate coating
    • P: Apply course of treatment from LinKou ChangGung

[chemotherapy]

  • 2023-10-31 - mitomycin-C 6mg/m2 10mg NS 100mL 30min + epirubicin 50mg/m2 80mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 24hr (MEPFL C2D1)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-05 - leucovorin 30mg/m2 50mg NS 250mL 1hr + fluorouracil 450mg/m2 700mg NS 250mL 2hr (MEPFL C1D8)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-09-28 - mitomycin-C 8mg/m2 12mg NS 100mL 30min + epirubicin 60mg/m2 90mg NS 250mL 30min + cisplatin 60mg/m2 90mg NS 500mL 24hr (MEPFL C1D1)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

Induction Chemotherapy With Mitomycin, Epirubicin, Cisplatin, Fluorouracil, and Leucovorin Followed by Radiotherapy in the Treatment of Locoregionally Advanced Nasopharyngeal Carcinoma - https://sci-hub.se/10.1200/JCO.2001.19.23.4305

  • Neoadjuvant Chemotherapy
    • Serotonin antagonist and corticosteroids were routinely given for prophylaxis of nausea and vomiting.
    • The MEPFL chemotherapy consisted of intravenous (IV) administration of
      • D1
        • mitomycin 8 mg/m2,
        • epirubicin 60 mg/m2, and
        • cisplatin 60 mg/m2 on day 1 with hydration and diuresis.
      • D8
        • Fluorouracil 450 mg/m2 and
        • leucovorin 30 mg/m2 were given on day 8.
    • This cycle was repeated every 3 weeks if hemogram measurements were adequate (leukocyte count >= 3,500/L and platelet count >= 100,000).
    • If the leukocyte count was between 3,000 and 3,500/L or the platelet count was between 75,000 and 100,000/L on day 28, the subsequent cycle was modified by a 20% reduction in the dosage of mitomycin and epirubicin.
    • Three cycles were planned unless severe side effects occurred.
  • Radiotherapy
    • Curative radiotherapy began within 3 weeks after completion of the last cycle of chemotherapy.
    • Megavoltage photons (6 MV) were used and the irradiation fields were designed according to the extension of the tumor.
    • The initial treated target volume was the gross target volume with a 2-cm margin in all directions and shrinkage to avoid excessive irradiation to the pons and spinal cord after 46 Gy.
    • All patients, except those with stage N3b disease, were treated with bilateral opposing portals to cover the primary tumor and neck; the fraction size was 2 Gy.
    • After 36 Gy, the primary and neck were treated by the split-field technique.
    • The primary was irradiated with shrinkage bilateral opposing fields, using 2.5 Gy as the fraction size, and an additional 10 Gy was given.
    • The intracranial lesion was excluded from the treatment portal after 46 Gy.
    • An additional 24 Gy in 10 fractions to the nasopharynx was delivered via bilateral anterior oblique infraorbital portals.
    • The accumulated radiation dose to nasopharynx was 70 Gy in 32 fractions, whereas the accumulated dose to intracranial lesion was 46 Gy in 22 fractions.
    • For patients with nasal or ethmoid involvement, the three-field technique (anterior field and bilateral opposing fields) was used instead of infra-orbital portals, with 24 Gy in 12 fractions.
    • The neck was treated using anterior-posterior opposing portals after 36 Gy in 18 fractions for patients with N0 to N3a disease, with the spinal cord shielded.
    • For N3b cases, the neck was treated using anterior-posterior opposing portals initially and blocked spinal cord after 40 Gy in 20 fractions.
    • The accumulated dose was 50 Gy in 25 fractions to uninvolved neck and 60 Gy in 30 fractions to involved regions.
    • An additional 5 Gy in two fractions was given to residual neck masses after 60 Gy.

==========

2023-11-01

Access to the patient’s PharmaCloud records is currently unavailable.

Following the initial cycle of the MEPFL regimen, leukopenia was noted for several days. Prompt intervention with G-CSF effectively alleviated this episode.

  • 2023-10-31 WBC 4.60 x10^3/uL 10/31 MEPFL C2D1
  • 2023-10-18 WBC 7.17 x10^3/uL
  • 2023-10-11 WBC 0.99 x10^3/uL *** 10/11,12,13 Granocyte (lenograstim)
  • 2023-10-04 WBC 2.53 x10^3/uL * 09/28 MEPFL C1D1, 10/05 MEPFL C1D8
  • 2023-09-25 WBC 4.55 x10^3/uL
  • 2023-09-19 WBC 4.55 x10^3/uL

The second cycle of the MEPFL regimen incorporated a “scaled-down” version of the “MEP” components (mitomycin 6mg/m2, epirubicin 50mg/m2, cisplatin 50mg/m2) compared to the first cycle (mitomycin 8 mg/m2, epirubicin 60 mg/m2, cisplatin 60 mg/m2), as per the original trial (https://doi.org/10.1200/jco.2001.19.23.4305). This modification aimed to mitigate the recurrence of such episodes.

There is no discrepancy found in the medication.

700307466

231031

[MedRec]

  • 2022-09-05 ~ 2022-09-09 POMR General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Malignant neoplasm of unspecified site of right female breast
      • Right breast cancer with right axillary lymph nodes metastatic, cT4bN1M0. stage IIIB, ER (2+, 90%), PR (-) and HER2 (+, Dako score 3+) status post port implantation on 2022/09/06. ECOG:0
      • For neo-adjuvant chemotherapy with 1th Taxotere 75mg/m2 + Carboplatin 450mg + Herceptin 600mg SC + Perjeta 420mg.
      • Hypertension
    • CC
      • for implantation port-a catheteriplatation and arrange neo-adjuvant chemotherapy with 1st TCPH (Taxotere 75mg/m2 + Carboplatin 450mg + Herceptin 600mg SC + Perjeta 420mg)
    • Present illness
      • This 62-year-old female patient had past history of 1) hypertension 2) peritonitis s/p for 20+ years at TaiNan ChiMei Hospital. She denied any TOCC histories in recent 3 months.
      • She noted a mass at right breast for 1 years ago, it grew larger quickly recently. She came to DaLin TzuChi Hospital for help first. Breast sono guide biopsy, pathology showed invasive carcinoma, IHC staining: ER (positive, 100% tumor nuclei stained), PR (negative, 0% tumor nuclei stained), HER2/neu (positive, 3+) and Ki-67 index: 10. She tranferred to our hospital for sencond opinion. She denid of local edema, nipple bloody discharge or nipple retraction. After examination, palpabled a 5x4x2.5 xm firm mass with skin invasion over right breast. Sono guide biopsy of right axillary lymph nodes was performed. Pathology showed metastatic carcinoma. The tumor marker showed CA-153:16.684 U/ml, CEA:1.793 ng/ml. Tc-99m MDP whole body bone scan showed no obvious lesion for metastasis.
      • Under the impression of right breast invasive carcinoma with axillary LN metastsis, cTbN1M0, stage IIIB. After well explain including pathology and the possible treatment modality were well explained to the patient. She was admitted for for implantation port-a catheteriplatation and arrange neo-adjuvant chemotherapy with 1st TCPH (Taxotere 75mg/m2 + Carboplatin 450mg + Herceptin 600mg SC + Perjeta 420mg).
    • Course of inpatient treatment
      • After admittion, follow up breast MRI for further survry. Breast MRI showed right breast malignancy with skin invasion and lymph node metastasis and left breast oval shaped tumor. After fully explaination the finally pathology. She underwent of Port-A catheter implatation on the left side on 2022/09/06. Arrange heart echo for cardiac toxicity of herceptin, data showed no obvious lesion for pre-chemo survey. We prescribed 1st neo-adjuvant chemotherapy with TCPH (Taxotere 75mg/m2 + Carboplatin 450mg + Herceptin 600mg SC + Perjeta 420mg).
      • Arrange whole bady PET scan for cancer survry on 2022/09/08. The whole bady PET scan report showed glucose hypermetabolism in the right breast with skin invasion, compatible with primary breast malignancy with skin invasion, some right axillary lymph nodes. Metastatic lymph nodes may show this picture and mild glucose hypermetabolism in a focal area in the medial aspect of left breast. During the process, she complain of vomiting, cold sweats and itchy rashes on limbs. Therefore, extended chemotherapy injection time. Under the stable condition, she was discharged today and and OPD follow up was suggested next week.
    • Discharge prescription
      • Limeson (dexamethasone 4mg) 1# BID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Parmason Gargle Solution (chlorhexidine) BID GAR
      • Exforte (amlodipine 5mg, valsartan 160mg) 1# QD
      • Saline (nicametate citrate 50mg) 1# BID
      • Vit B6 (pyridoxine 50mg) 1# BID
      • Stilnox (zolpidem 10mg) 1# PRNHS
  • 2022-08-31 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • S: breast lump. Rt breast ca proved by CNB on 2022-08-18 at DaLin TzuChi Hospital.
    • O
      • postmenopausal 50 y/o
      • menarche 15 y/o
      • G2P2
      • FH of breast ca (-)
      • HRT(-)
      • A 5x4x2.5 xm firm mass with skin invasion over rt breast
      • rt axillary papale LN
      • 2022-08-18 DaLin TzuChi Hospital
        • The specimen submitted consists of 4 strips of breast tissue, measuring up to 1.2x0.2x0.2 cm, fixed in formalin.
        • Grossly, the tissue is gray fleshy and soft. All for section.
        • Microscopically, the section shows an invasive carcinoma with focal duct differentiation. The tumor demonstrates moderate cellular atypia, in solid nests, Indian filing pattern, relative hyperchromatic nuclei, nucleoli, not infrequent mitoses, >10/10HPF and infiltrative pattern with marked tissue desmoplasia.
        • Immunohistochemically, the tumor cells positive for ER (100% tumor nuclei stained) and E-Cadherin, negative for PR (0% tumor nuclei stained), with a Ki-67 proliferating index of 10% in hot area. The stain for HER2/neu is positive (3+, complete intense circumferential membranous staining in >10% of invasive tumor cells).
        • The morphological picture is invasive carcinoma of no special type, grade II, score 6 (tubule formation: 2, nuclear pleomorphism; 2, mitotic count: 2).
        • Results of the IHC staining: ER (positive, 100% tumor nuclei stained), PR (negative, 0% tumor nuclei stained), HER2/neu (positive, 3+) and Ki-67 index: 10% in hot area.
        • IHC stains (Bondmax, Leica, Australia): ER (SP1/Zeta, 50X), PR (1E2/Ventana, 4X), HER2/neu (CB11/Leica, 200X), Ki-67 (GM010/Genemed, 300X) and E-cadherin (GM016/Genemed, 50X).

[surgical operation]

  • 2023-06-13
    • Surgery
      • Dx: suspected epidermal cyst over posterior side of right ear
      • OP: excision
    • Finding
      • 1.5cm, egg-shaped, capsulated, subcutaneous tumor over posterior side of right ear
  • 2023-01-10
    • Surgery
      • right breast MRM        
      • Intraop ICG reverse mapping of axillary lymphatic duct
    • Finding
      • breast tumor, 1.5cm, 8”/3cm
      • axillary multiple LN

[immunochemotherapy]

  • 2023-09-13 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-08-23 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-07-31 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-07-06 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-06-12 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-05-22 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-04-27 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-04-06 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-03-16 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-02-22 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-01-30 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-01-09 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2022-12-21 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min + docetaxel 75mg/m2 124mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-11-30 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min + docetaxel 75mg/m2 123mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-11-09 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min + docetaxel 75mg/m2 123mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-19 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min + docetaxel 75mg/m2 123mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-09-28 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min + docetaxel 75mg/m2 123mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-09-07 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 60min + docetaxel 75mg/m2 123mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr (pertuzumab loading)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

==========

2023-10-31

[grade 3 diarrhea]

Based on the bowel movement records from the HIS5’s TPR panel, the patient has not had any instances of bowel movements reaching seven times in a day during her last three hospital stays.

It has been documented that the occurrence of diarrhea is linked with trastuzumab (7% to 25%), pertuzumab (46% to 67%), and neratinib (diarrhea at 95%; severe diarrhea: 2%). Given that the use of trastuzumab and pertuzumab started in Sep 2022 and has been continuous since then, and neratinib was only introduced in mid-Sep 2023, and its likelihood of causing diarrhea is higher than the former two, it is plausible that the recent episode of grade 3 diarrhea is more likely attributed to neratinib.

The prescription of Smecta and loperamide is an appropriate measure.

The patients should be reminded to maintain a fluid intake of approximately 2 L/day to prevent dehydration. Once the diarrhea improves to grade 1 or returns to baseline, it is recommended to initiate loperamide at 4 mg with each subsequent dose of neratinib.

700734842

231031

{Prostate cancer, pT3bN1cM0, s/p RARP on 2015-06-30, s/p adjuvant radiotherapy on 2015-09-25 and hormone therapy with refractory, progression of metastatic paraaortic lymph nodes and bone metastases, T0N0M1a, stage IV}

[exam findings]

  • 2023-10-03 Bone densitometry - spine, hip
    • L-spines BMD performed by DXA revealed:
      • AP L-spines, BMD of L1-4 0.842 gms/cm2, about 1.9 SD below the peak bone mass (80%) and 0.5 SD below the mean of age-matched people (90%).
    • Hip BMD performed by DXA revealed:
      • Left hip, BMD is 0.720 gms/cm2, about 1.2 SD below the peak bone mass (85%) and 0.1 SD above the mean of age-matched people (101%).
    • Impression
      • Osteopenia
  • 2023-09-15 MRA - brain
    • Post-operation change at left frontal lobe, without evidence of residual or recurrent tumor.
  • 2023-08-25 CT - abdomen
    • History: Prostate cancer, pT3bN1cM0, s/p RARP, s/p adjuvant R/T and hormone therapy with refractory, progression of metastatic paraaortic lymph nodes and bone metastases, T0N0M1a, stage IV
      • 20230825 PSA:38.479 ng/mL (<4).
    • Findings:
      • Prior CT identified some LNs (up to 1 cm) in para-aortic space are noted again, marked increasing in size to 2 cm that is c/w progressive disease.
      • There is an ill-defined osteoblastic lesion with central osteolytic change at right lateral aspect of L3 vertebral body that is c/w bony metastasis. In addition, there are few small osteoblastic nodules in L1, L2, and L4 vertebral body that are also c/w bony metastases.
      • There are several hepatic cysts in both lobes and the largest one 2.5 x 1.5 cm in size at S2.
      • A gallstone 1.2 cm is noted.
      • S/P prostatectomy.
    • Impression:
      • Prior CT identified some LNs (up to 1 cm) in para-aortic space are noted again, marked increasing in size to 2 cm that is c/w progressive disease.
  • 2023-08-22 MRI - L-spine
    • Findings: Multiple ill-defined bony lesions with T1- and T2-hypointensity and faint enhancement involving L1-4 vertebral bodies and S1 vertebral body, most severe at L3 vertebral body. Compatible with metastases.
  • 2023-08-15 Tc-99m MDP bone scan
    • In comparison with the previous study on 2023/05/10, the hot spot at the left 9th costovertebral junction is less evident.
    • The lesion in the middle T-spine is slightly more evident. The nature is to be determined (degenerative change in a little more severe status? other nature?). Please follow up bone scan for furhter investigation.
    • No prominent change is noted in other bone lesions, suggesting in stable condition.
  • 2023-06-08 MRI - L-spine
    • Bony metastases involving L1-4 and S1 vertebral bodies.
    • Mild lumbar spondylosis.
  • 2023-06-01 CT - abdomen
    • History and indication: Prostate Ca with L-spine mets
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P prostate operation.
      • Left liver cyst (2.5cm).
      • Some LNs (up to 1.0cm) at retroperitoneum.
      • Some bony metastases at spine.
      • Gallbladder stone (0.9cm).
      • Minimal ascites.
      • Atherosclerosis of aorta, iliac arteries.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P prostate operation. Some LNs (up to 1.0cm) at retroperitoneum. Some bony metastases at spine.
      • Gallbladder stone (0.9cm).
  • 2023-05-10 Tc-99m MDP bone scan
    • In comparison with the previous study on 2023/03/03, the hot spot at the left 9th costovertebral junction is new, and the nature is to be determined (new bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
  • 2023-03-03 Tc-99m MDP bone scan
    • In comparison with the previous study on 2022/11/28, the lesion in the left sternoclavicular junction is a little less evident, possibly more benign in nature.
  • 2023-03-02 CT - abdomen
    • S/P prostate operation. Some LNs (up to 0.9cm) at retroperitoneum. R/O bony metastases at spine.
    • Gallbladder stone (0.9cm).
  • 2022-12-17 MRI - L-spine
    • Known a case of prostate cancer. Multiple enhancing nodular lesions within visible thoracic-lumbar vertebral bodies. Compatible with metastatic lesions.
    • Retrolisthesis of L2 on L3, grade I.
    • Spondylolisthesis of L4 on L5, grade I.
  • 2022-11-30 SONO - chest
    • Pleural effusion, minimal, bilateral
    • Atelectasis, LLL and RLL
  • 2022-11-28 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2022/06/30, there is a new lesion of increased activity at the left sternoclavicular junction; probably benign in nature.
    • No prominent change is noted in other bone lesions.
  • 2022-11-28 Peripheral Vascular Test - vein, lower limbs
    • Report:
      • Right side:
        • SVC: 23.8 mmHg ; 27.3 mmHg ;
        • MVO/SVC: 98 % ; 92 % ;
        • Average MVO/SVC: 95 %
      • Left side:
        • SVC: 23.1 mmHg ; 27.2 mmHg ;
        • MVO/SVC: 95 % ; 87 % ;
        • Average MVO/SVC: 91 %
      • Thrombus : None
        • Varicose vein at L’t LSV
    • Conclusion:
      • Significant venous reflux at left saphenofemoral junction with varicose change of left LSV from upper to lower leg level.
      • Slow venous return flow at left poplital vein; a large perforator vein draining from left distal PTV to LSV was detected.
      • No evidence of venous thrombosis at bilateral lower limbs venous systems.
      • Tissue edema at bilateral lower legs.
      • The ratios of MVO and SVC of bilateral legs were within normal limits.
  • 2022-11-26 CT - abdomen
    • Findings
      • S/P prostate operation.
      • Left liver cyst (2.1cm).
      • Bil. pleural effusions.
      • Some LNs (up to 0.8cm, mild regression) at retroperitoneum.
      • Suspected bony metastases at spine.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Gallbladder stone (0.9cm).
      • Patency of portal vein.
      • Minimal ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • S/P prostate operation. Bil. pleural effusions.
      • Some LNs (up to 0.8cm, mild regression) at retroperitoneum.
      • Suspected bony metastases at spine.
      • Gallbladder stone (0.9cm).
  • 2022-07-19 Nasopharyngoscopy
    • clear middle meatus, inferior turbinate hypertrophy, smooth NPX
  • 2022-06-30 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20220311, the previous bone lesions in the upper and middle T-spines, L3 spine and left iliac bone are all a little less evident.
    • No prominent change is noted in other bone lesions.
  • 2022-06-29 CT - abdomen
    • Findings:
      • Prior CT identified some LNs (up to 1.6cm) in para-aortic space and left external iliac chain are noted again, mild decreasing in size that is c/w partial response.
      • There is an ill-defined osteoblastic lesion with central osteolytic change at right lateral aspect of L3 vertebral body that is c/w bony metastasis.
      • There are several hepatic cysts in both lobes and the largest one 2.5 x 1.5 cm in size at S2.
      • A gallstone 1.2 cm is noted.
      • S/P prostatectomy.
    • Impression:
      • Prior CT identified some LNs (up to 1.6cm) in para-aortic space and left external iliac chain are noted again, mild decreasing in size that is c/w metastatic nodes S/P C/T with partial response.
      • There is an ill-defined osteoblastic lesion with central osteolytic change at right lateral aspect of L3 vertebral body that is c/w bony metastasis.
  • 2022-04-19 Water’s view
    • Opacification of right maxillary sinus.
  • 2022-03-11 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20210723, the lesions in the upper and middle T-spines are less evident. However, the lesion in the left iliac bone is a little more evident.
    • The lesions in the right humeral head and L3 spine are new. Bone metastases should be watched out. Please correlate with other clinical findings for further evaluation.
  • 2022-03-10 CT - abdomen, pelvis
    • S/P prostate operation.
    • Some LNs (up to 1.6cm, mild regression) at retroperitoneum.
    • Suspected bony metastases at spine.
    • Gallbladder stone (0.9cm).
  • 2021-11-16 CT
    • S/P prostatectomy.
    • Progression of metastatic paraaortic lymph nodes and bone metastasis.
    • GB stones.
    • Fatty content liver tumor, 2.6cm in S2 liver.
  • 2021-07-23 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20200715, the lesions in the upper and middle T-spines and left iliac bone are new. Bone metastases should be watched out.
    • No prominent change is noted in the previous two faint hot spots in the left frontal region of the skull and posterior aspect of the left 11th rib, possibly more benign in nature.
    • Increased activity in the left aspect of maxilla. The nature is to be determined (dental problem? other nature?).
    • Mildly increased activity in the lower L-spines. Degenerative change is more likely.
    • Suspected benign jount lesions in the right sternoclavicular junction, bilateral shoulders, hips, knees and boh feet.
  • 2021-07-22 MRI
    • S/P prostatectomy.
    • Regression of paraaortic lymph nodes in paraaortic lymph node.
    • Liver cyst.
    • Gallbladder stones.
  • 2021-07-13 CT
    • metastatic Lt supraclavicular fossa and left retroperitoneal paraaortic lymphadenopathy.
  • 2021-03-24 MRI
    • S/P prostatectomy.
    • Suspected metastatic lymph nodes in paraaortic regions. Regression as compare with MRI study on 2020-11-12.
    • Liver cyst.
    • Gallbladder stones.
  • 2021-07-15 Tc-99m MDP whole body bone scan
    • Two faint hot spots in the left frontal region of the skull and post. aspect of the left 11th rib, probably post-traumatic change, suggesting follow-up.
    • Suspected benign lesions in the maxilla, right sternoclavicular junction, bilateral shoulders, and hips.
  • 2019-05-19 MRA - Brain
    • A frontal base meningioma. Left exophthalmus.
  • 2019-01-15 MRI
    • S/P prostatectomy.
    • Suspected metastatic lymph nodes in left common iliac and paraaortic regions.
    • Liver cyst.
  • 2019-01-08 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20180207, the previous lesions in the maxilla, left 11th rib and the left femoral neck are stationary, indicating more benign in nature.
    • Other bone lesions are also stationary. Probably degenerative change in the upper T-spine, bilateral sternoclavicular junctions and bilateral sacroiliac joints, bilateral shoulders, and bilateral hips.
  • 2018-02-07 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 20161103, the lesions in the left 11th rib and the left femoral neck had become very faint, indicating benignity in nature.
    • Probably degenerative change in the upper T-spine, sternoclavicular junctions and sacroiliac joints.
    • Increased radiotracer uptake in the maxilla, local inflammatory change such as sinusitis may show such a picture.
  • 2016-04 MRI
    • Prostate cancer with extracapsular extension and seminal vesicle invasion, mainly in left aspect.
    • Metastatic left obturator lymph node. Stage T3N1Mx.
  • 2015-06-30 Patho (HuaLien TzuChi)
    • Prostate gland, radical prostatectomy, adenocarcinoma (Glason score: 5+4=9) (pT3bN1).
    • Urethra, prostatic, radical prostatectomy, squamous metaplasia.
    • Seminal vesicle, right, radical prostatectomy, adenocarcinoma, invasion.
    • Seminal vesicle, left, radical prostatectomy, adenocarcinoma, invasion.
    • Lymph node, right, lymphadenectomy, no lymph node retrived.
    • Lymph node, left, lymphadenectomy, adenocarcinoma, metastatic (1/2).
    • Prostate gland, apex, resection, adenocarcinoma. Urinary bladder, neck, resection, negative for malignancy.
    • Extraprostatic Extension: Present.
    • Seminal Vesicle Invasion (invasion of muscular wall required): Present.
    • Lymph-Vascular Invasion: Present.
    • Perineural Invasion: Present.

[MedRec]

  • 2023-09-26 SOAP Hemato-Oncology Xia HeXiong
    • Prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Casodex (bicalutamide 50mg) 1# QD
      • Zoladex (goserelin 3.6mg) Q4W SC
      • Xgeva (denosumab 120mg) Q4W SC
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
  • 2023-08-29 SOAP Hemato-Oncology Xia HeXiong
    • A/P: On 2023-08-29, after discussion with patient, the progression over left para-aortic LAP, he want keep ADT and AR blocker, not R/T, not C/T.

[consultation]

  • 2022-12-01 Dermatology
    • Q
      • This 66-year-old man patient is a case of Prostate cancer, pT3bN1cM0, s/p RARP on 2015/06/30, s/p adjuvant radiotherapy on 2015/09/25 and hormone therapy with refractory, progression of metastatic paraaortic lymph nodes and bone metastases, T0N0M1a, stage IV s/p chemotherapy with Taxotere from 2021/11/17, partal response.
      • He was admitted cellulitis for left lower swelling with redness with antibiotic therapy. This time, for bilateral toe nails onychomycosis. Now, for evaluate bilateral toe nails onychomycosis therapy. Thank you.
    • A
      • The patient had sufferred from prostate cancer s/p chemotherapy. Dry skin patern was noted over lower legs and thickening nail with deformity
      • Under the impression of tinea unguium et pedis, xerotic dermatitis on the lower leg.
      • The following suggestion:
        • Exelderm lotion (sulconazole nitrate) 2 tube topical QN use over nail fold and footbase.
        • Sinphraderm cream (urea 100mg/gm) 1 tube topical QN use on the dry skin of lower legs.
  • 2021-12-30 Mental Health
    • A
      • This is a 65 y/o male patient with prostate cancer, admission for palliative chemotherapy today. He has no psychiatric history.
      • Upon visit, the patient is sitting on his bed, with wife at bedside.
      • The patient is in euthymic, smiley and inviting. Greeting and appropriate speech. He deny depressed mood, deny suicide thought, able to percieve fair night sleep under current medication, fair appetite.
      • No extra medication is needed.
  • 2021-11-15 Hemato-Oncology
    • Q
      • This is a 65 y/o male with underlying hypertension, hypothyroidism and dyslipidemia. He was previous diagnosed prostate cancer, pT3bN1cM0 s/p radical prostatectomy + radiotherapy + hormone therapy with refractory, s/p Zytiga 360# since 2020-02 with poor response, s/p Zoladex and Androcur since 20210109, Pamorelin (Q3M) + Casodex on 20210206. However, follow-up lung CT still showed metastatic lymph nodes in Lt supraclavicular fossa. Bony metastasis of upper, middle T spine and left iliac bone was also noted in bone scan on 20210723. Serial PSA level since 2021 April showed 8.74 -> 12.47 -> 14.19 -> 17.40 -> 28.39. He only complained about back pain in recent few months. There was no decreased appetite or body weight loss. Due to progressed disease, he was admitted for port-A insertion and further systemic chemotherapy.
      • We need your expertise for further systemic chemotherapy regimen suggest after port-A insertion.
    • A
      • A case of castration-resistant prostate cancer is noted.
      • Based on the failure to LHRH + Andreocur and Casodex and further abiraterone, palliative chemotherapy with docetaxel is indicated.

[surgical operation]

  • 2015-06-30 at HuaLien TzuChi - radical prostatectomy
    • prostate adhesion to bladder wall, suspicious invasion to bladder neck.
    • tumor invasion in seminal vesicle was also suspected. bilateral neurovascular bundles (NVB) did not preserved.

[radiotherapy]

  • 2021-07-28 ~ 2021-08-23: 4560cGy/19 fractions (6 MV photon) to left SCF LAPs.
  • 2020-12-10 ~ 2021-01-14: 5000cGy/25 fractions (15 MV photon) to paraaortic LAPs.
  • 2015-08-05 ~ 2015-09-25: 4500cGy/25 fractions of the pelvic, 5040cGy/28 fractions of the tumor bed and peripheral, and 6480cGy/36 fractions of the reduced tumor bed area.

[chemotherapy]

  • 2023-10-30 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-09-28 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-03-17 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-02-06 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-01-04 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-12-16 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-11-01 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-10-11 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-09-20 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-08-30 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-08-10 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-07-22 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-06-30 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-06-09 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-05-19 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-04-26 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-04-06 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-03-11 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-02-15 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-01-25 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1
  • 2021-12-30 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1
  • 2021-12-10 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2021-11-17 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • certain medication
    • Xgeva (denosumab) CXGEV01
      • 2023-01-04 120mg ST SC OPD
      • 2022-11-24 120mg ST SC IPD
      • 2022-10-25 120mg Q1M SC OPD
      • 2022-08-31 120mg Q1M SC OPD
      • 2022-08-30 120mg Q1M SC IPD
      • 2022-08-03 120mg Q1M SC OPD
    • Zoladex (goserelin) CZOLA01
      • 2022-10-25 3.6mg Q4W SC OPD
      • 2022-08-30 3.6mg Q4W SC IPD
      • 2022-08-03 3.6mg Q4W SC OPD
      • 2022-06-28 3.6mg Q4W SC OPD
      • 2022-05-31 3.6mg Q4W SC OPD
      • 2022-04-26 3.6mg Q4W SC OPD
      • 2022-03-23 3.6mg Q4W SC OPD
      • 2022-02-08 3.6mg Q4W SC OPD
      • 2021-01-09 3.6mg Q4W SC OPD
    • Andreocur (cyproterone) KANDR
      • 2018-02-03 ~ 2022-04-03 50mg TID OPD
      • 2017-02-11 ~ 2018-01-20 50mg QD OPD
    • bicalutamide KBICA01
      • 2018-05-12 ~ 2020-01-11 50mg QD OPD
    • Casodex (bicalutamide) KCASO01
      • 2021-02-06 ~ 2022-01-07 50mg QD OPD
    • Pamorelin (triptorelin) CPAMO02
      • 2021-10-15 11.25mg Q3M IM OPD
      • 2021-07-28 11.25mg Q3M IM OPD
      • 2021-05-08 11.25mg Q3M IM OPD
      • 2021-02-06 11.25mg Q3M IM OPD
    • Zytiga (abiraterone) KZYTI01 poor response
      • 2020-02-08 1000mg QDAC PO OPD
    • Leuplin Depot (leuprorelin)
      • 2018-12 ~ 2020-08 Q3M
  • G-CSF, granulocyte colony-stimulating factor
    • 2022-09-01 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2022-08-30
    • 2022-08-17 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2022-08-10
    • 2022-07-22 Granocyte (lenograstim 250mg) QD SC 3 days IPD
    • 2022-07-12 Granocyte (lenograstim 250mg) QD SC 3 days OPD
    • 2022-06-15 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2022-06-08
    • 2022-05-25 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2022-05-19
    • 2022-05-04 Granocyte (lenograstim 250mg) QD SC 3 days OPD
    • 2022-04-06 Granocyte (lenograstim 250mg) QD SC 3 days IPD
    • 2022-03-16 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2022-03-09
    • 2022-02-23 Granocyte (lenograstim 250mg) QD SC 3 days OPD
    • 2022-01-04 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2021-12-30
    • 2021-12-15 Granocyte (lenograstim 250mg) QD SC 3 days IPD 2021-12-09
    • 2021-11-24 Granocyte (lenograstim 250mg) QD SC 3 days OPD

==========

2023-01-05

  • 2023-01-04 lab data were generally normal, except for a slight decrease in WBC and HGB levels. The vital signs of the patient are stable during this hospitalization.

  • All underlying conditions, including HBV, hypothyroidism, and insomnia, are managed with appropriate medication.

2022-08-31

  • The PSA reading has been trending downward during the last half year (2022-08-14 10 <- 2022-02-15 43). Currently, it appears that the disease is under control and is in a relatively stable state.
  • In recent months, G-CSF has been used triweekly on three consecutive days to protect the patient against neutropenic complications caused by a previously administered chemotherapy.

2022-06-09

  • This patient with an advanced, refractory prostate cancer with paraaortic lymph nodes and bone metastases is being treated with docetaxel palliatively.
  • CT (2022-03-10) confirmed that some LNs (up to 1.6cm) had mild regression at the retroperitoneum. PSA floats in the 20s (unit ng/mL) since March 2022. As of now, the disease appears to be still under control.
  • Underlying diseases such as HBV, hypothyroidism, hyperlipidemia are currently managed with Baraclude (entecavir), Eltroxin (levothyroxine), Zulitor (pitavastatin), respectively.
  • SpO2 has been around 95% these two days, please keep an eye on the reading.
  • No issue with active prescription.

2023-05-20

  • This patient has advanced prostate cancer that is refractory with progression of paraaortic lymph nodes and bone metastases.
  • Docetaxel is being administered to the patient palliatively and is generally well tolerated.
  • Lab data reported on 2022-05-16 showed grossly normal results, except for a slight pancytopenia and a high PSA (26.464ng/mL).
  • Underlying health condition are managed with corresponding self-carried drugs. No issue with active prescription.

2023-04-27

  • After using hormone therapy from 2017-01 to 2021-10 and proving the disease castration-resistant (2021-11-16 CT showed progression), the patient has begun taking docetaxel since 2021-11-17.
  • Bone scans on 2022-03-11 revealed new lesions in the right humeral head and L3 spine, and CTs on 2022-03-10 showed LNs up to 1.6 cm in the retroperitoneum.
  • Lab results on 2022-04-26 showed that blood cell counts, liver and kidney function, serum electrolytes were grossly normal, however PSA 27 ng/mL remained high.
  • Underlying health condition are managed with corresponding drugs
    • postprocedural hypothyroidism - Eltroxin (levothyroxine)
    • chronic viral hepatitis B without delta-agent - Baraclude (entecavir)
    • hyperlipidemia - Zulitor (pitavastatin)
    • duodenal ulcer - Nexium (esomeprazole)
    • insomnia - Anxiedin (lorazepam)

2022-04-07

assessment

  • Novel hormone therapies include abiraterone, enzalutamide, darolutamide, or apalutamide received for metastatic castration-naïve disease, M0 CRPC, or previous lines of therapy for M1 CRPC.
  • After using hormone therapy from 2017-01 to 2021-10 and proving the disease castration-resistant (2021-11-16 CT showed progression), the patient has begun taking docetaxel since 2021-11-17.
  • The bone scan on 2022-03-11 revealed new lesions in the right humeral head and L3 spine, however, the PSA level decreased slightly (26.9ng/mL 2022-03-23 <- 43.2ng/mL 2022-02-15).

suggestion

  • Tumor testing for microsatellite instability-high (MSI-H) or deficient mismatch repair (dMMR) is recommended in patients with metastatic castration-resistant prostate cancer and may be considered in patients with regional or castration-naïve metastatic prostate cancer.
  • Tumor mutational burden (TMB) testing may be considered in patients with metastatic castration-resistant prostate cancer.
  • Cabazitaxel 20 mg/m2 plus carboplatin AUC 4 mg/mL per min with growth factor support can be considered for fit patients with aggressive variant prostate cancer (visceral metastases, low PSA and bulky disease, high LDH, high CEA, lytic bone metastases, neuroendocrine prostate cancer histology) or unfavorable genomics (defects in at least 2 of PTEN, TP53, and RB1). source: Cabazitaxel plus carboplatin for the treatment of men with metastatic castration-resistant prostate cancers: a randomised, open-label, phase 1-2 trial https://pubmed.ncbi.nlm.nih.gov/31515154/

2022-02-16

assessment

  • image findings showed the disease progresive and lab data PSA readings keep elevating from 8.7ng/mL (2021-04-05) to 43.2ng/mL (2022-02-15)
  • the patient is undergoing hormone therapy triptorelin since 2021-02 (last dose 2021-10) and receiving chemotherapy docetaxel since 2021-11.
  • systemic therapies for metastatic castration-resistant prostate cancer such as abiraterone/prednisone, enzalutamide, Ra-223, docetaxel, cabazitaxel, and mitoxantrone have all been shown to reduce skeletal-related events and improve bone pain.

suggestion

  • triptorelin could be continued with another dose if there is no contraindication. -tumor testing for microsatellite instability-high (MSI-H) or deficient mismatch repair (dMMR) is recommended in patients with metastatic castration-resistant prostate cancer and may be considered in patients with regional or castration-naïve metastatic prostate cancer. -tumor mutational burden (TMB) testing may be considered in patients with metastatic castration-resistant prostate cancer.

701257674

231031

[lab data]

2023-09-20 HBsAg Nonreactive
2023-09-20 HBsAg (Value) 0.36 S/CO
2023-09-20 Anti-HBc Reactive
2023-09-20 Anti-HBc-Value 5.86 S/CO
2023-09-20 Anti-HCV Nonreactive
2023-09-20 Anti-HCV Value 0.06 S/CO

[exam findings]

  • 2023-09-20 Pure Tone Audiometry
    • Reliabilty Fair
    • PTA
      • R’t : 45 dB HL, mild to moderately severe conductive HL
      • L’t : 19 dB HL, WNL.
  • 2023-09-16 MRI - brain
    • No evidence of brain metastasis.
  • 2023-09-15 Tc-99m MDP bone scan
    • Increased activity in some C-spines, lower L-spines and L5-sacrum junction. Degenerative change is more likely.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Some faint hot spots in bilateral rib cages and mildly increased activity in the lesser trochanter of left femur. The nature is to be determined. Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2023-09-14 Whole body PET scan
    • A glucose hypermetabolic lesion involving the lower portion of the esophagus, compatible with primary esophageal malignancy.
    • Glucose hypermetabolism in a left upper paratracheal lymph node. A metastatic lymph node may show this picture.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
  • 2023-09-14 Patho - esophageal biopsy
    • Esophagus, lower, 33 cm below incisors, biopsy — Squamous cell carcinoma, moderately differentiated
    • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation is evident.
  • 2023-09-13 Miniprobe Endoscopic Ultrasound
    • Endoscopic findings
      • One circumferencial fungated lesion was noted from 33cm below incisors. Panendoscopy was not able to pass through the esophagus at 35 cm below incisors. Biopsy was done.
    • EUS findings
      • EUS showed a mucosal lesion invading into the adventitia of esophageal wall at the lesion site. At least 1 lymph node was noted.
    • Diagnosis
      • Esophageal cancer, at least cT3N1, 33cm below incisor. s/p chromoendoscopy and biopsy
  • 2023-09-12 CT - chest
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N1 or N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
    • Findings
      • Lungs: mild reticular opacities at Rt apical lung may be due fibrotic change.
      • Mediastinum and hila: circumferential wall thickening of distal third of thoracic esophagus, causing severe luminal narrowing, and preserved periesophageal fat plane, possibly involving E-G junction.
        • enlarged LN at left upper paratracheal space.
        • the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance. Heart: normal size of cardiac chambers.
      • Pleura: unremarkable.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal contents: unremarkable of the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys.
        • small lymph nodes along celiac axis.
    • Impression: L/3 esophageal cancer T3N1 or N2Mx (E1)

[consultation]

  • 2023-09-15 Hemato-Oncology
    • Q (same as the Q for Radiation Oncology)
    • A1
      • This 59-year-old man is a newly diagnosed SCC of L/3 Esophageal cancer, cT3N2 (at least, pending brain MRI). We are consulted for neoadjuvant CCRT.
      • We will discuss with the patient about CCRT with PF. Please check HBsAg, Anti HBc, Anti HBs, Anti HCV, and port A insertion before chemotherapy. Please arrange 24 urine CCR and an auditory examination. Thanks for your consultation.
    • A2 Additional reply 2023-09-18 15:30:13
      • We had see patient (he lives in ZhongLi and is a member of TzuChi). Paitent received port A insertion and jejunostomy today. We had well explaint to patient about neoajuvant CCRT. We may take over this case (Please book 11A or 10B) if you agree.
  • 2023-09-15 Radiation Oncology
    • Q
      • A 59-year-old man denied any past systemic disease. His operation history was Pterygium OU post operation in 2019 at HuaLien TzuChi Hospital.
      • According to his statement, he started to felt difficult swallowing of solid food in mid-August, because the condition didn’t improve, he went to local clinic for examination. He under upper endoscopic examination on 2023/09/07 and found middle third esophageal tumor that highly suspicious of malignancy. Therefore he was transferred to this hospital for further studies. At ward, he was good ambuation, no nausea and vomitus, cigarette smoking and alcohol drinking were quit for at least 10 years. He used to drink hot soup years ago. Weight loss about 4kg in recent one month was told and he denied chest pain and burning. This times, under the impression of esophageal cancer he was admitted for cancer staging and treatment.
      • Lab exam
        • 9/12 CT: L/3 esophageal cancer T3N1 or N2Mx(E1)
        • 9/13 EUS: Esophageal cancer, at least cT3N1, 33cm below incisor, One circumferencial fungated lesion, panendoscopy wasn’t able to pass through the esophagus at 35 cm below incisors, post biopsy, the biopsy is pending
        • 9/14 PET A glucose hypermetabolic lesion in the lower portion of the esophagus and left upper paratracheal lymph node
        • 9/15 bone scan: pending
        • 9/16 brain MRI: pending
      • Due to the lower third esophageal cancer cT3N2Mx
      • We need your expertise to arranged further treatment, neoadjuvant CCRT
      • Thank you very much
    • A
      • Neoadjuvant CCRT is indicated. He will have port-A and jejunostomy done on 9/18.
      • CT-simulation will be arranged on 9/19. Plan to deliver 45 Gy/ 25 fx to the esophagus and adjacent lymphatic drainage area. Then boost the L/3 esophageal tumor and upper mediastinal LAP to 50.4 Gy/ 28 fx.
      • RT will start around 9/22. We will check the brain MRI result on 9/18. Thank you very much.
  • 2023-09-12 Gastroenterology
    • Q
      • A 59-year-old man present with middle thired esophageal tomor which found during a upper endoscopy examination on 2023-09-07 at a clinic in ZhongLi, the biopsy was pending.
      • He is dysphagia of solid food for about a month.
      • PH: denied past systemic disease
      • This times, he was admitted for esophageal cancer examination.
      • We have arranged several studies as below
        • 9/14 PET
        • 9/15 Bone scan
        • 9/16 MRI
      • We need you to help us to perfromed EUS with biopsy if possible on 9/13.
      • He wanted and agreeded to receive painless EUS
      • We need your expertise to arrange EUS and abdominal sonography for cancer studies on 9/13.
      • Thank you very much
    • A
      • We are consulted for EUS with biopsy on 9/13.
      • Patient was not at bedside.
      • Lab
        • 2023-09-12 HGB 15.4 g/dL
        • 2023-09-12 PLT 324 *10^3/uL
        • 2023-09-12 APTT 28.8 sec
        • 2023-09-12 PT 10.9 sec
        • 2023-09-12 INR 1.06
      • CT revealed suspect cancer at lower third of thoracic segment.
      • A: middle thired esophageal tomor
      • P:
        • EUS for esophageal SCC staging is indicated.
        • Already arrange EUS on 9/12 PM on call.
        • Please prescribe J CROWS Lugols solution (self-paid TWD 1500) and bring it to the exam room.

[chemotherapy]

  • 2023-10-30 - cisplatin 60mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 30min (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL D1-4 (PF Q4W CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-25 - cisplatin 60mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 30min (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL D1-4 (PF Q4W CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-31

A potassium supplement was prescribed due to hypokalemia (K level of 3.3 mmol/L on 2023-10-30). Currently, no medication discrepancies have been identified.

2023-10-30

[tube feeding]

All oral medications on the active drug list can be tube-fed.

[trend towards anemia]

The lab data indicates a trend towards anemia. HGB levels during CCRT have been consistently decreasing. Please continue to monitor the levels and determine if a blood transfusion is necessary.

  • 2023-10-30 HGB 11.9 g/dL
  • 2023-10-18 HGB 13.2 g/dL
  • 2023-10-05 HGB 14.3 g/dL
  • 2023-09-12 HGB 15.4 g/dL

2023-09-25

All of the oral medications on the list of active medications can be administered by tube feeding.

2023-09-20 Anti-HBc Reactive indicates tenofovir or entecavir as preventive therapy for potential hepatitis B virus reactivation prior to planned CCRT.

701481418

231031

[lab data]

  • 2023-07-14 BM Chromosome Analysis
    • Chromosome Analysis:
      • Tissue Examined: Bone marrow
      • Staining Method: G-Banding
      • Colony number: NA
      • Bands level: 500
      • Chromosome Counts:
        • 45-(2)、46-(17)、47-()、Other-(1) Total-(20)
      • Karyotype: 46,XX[16]
    • Interpretation:
      • Analysis of this bone marrow sample shows a female having 46,XX[16] karyotype. There was no significant clonal chromosomal abnormality detected. However, from 20 cells analyzed, four cells with abnormal karyotypes [44,XX,-14,-21; 45,XX,-11; 45,XX,-22 and 46,XX,t(2;7)(q11.2;q11.2), respectively] were observed. No clinical significance can be ascribed to these non-clonal findings at the present time.
    • Note:
      • ROUTINE BANDED LEVEL DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF RESOLUTIONS.

[exam findings]

  • 2023-10-05 Tc-99m MDP bone scan
    • Increased activity in the left S-I joint and right femoral head. The nature is to be determined. Please correlate with other imaging modalities for further evaluation and to ule out the possibility of bone metastases.
    • Increased activity in the middle and lower C-spines, middle T-spines, L5 and right S-I joint. Degenerative change may show this picture. Please also correlate with other imaging modalities for further evaluation.
    • Increased activity in bilateral shoulders, left hip and left knee, compatible with benign joint lesions.
  • 2023-09-20 CT - abdomen
    • Findings: Comparison prior CT dated 2023/05/02.
      • Prior CT identified enlarged in size and diffuse poor enhancing masses in the spleen and multiple enlarged nodes in para-aortic space are noted again, marked decreasing in size that is c/w malignant lymphoma of the spleen and para-aortic LNs S/P C/T with partial response to complete response. Follow up is indicated.
      • There are few geographic poor enhancing areas in the spleen that may be infarction secondary to prior TAE.
      • Prior CT identified cystic lesion with enhancing wall in left adnexa is noted again, stationary. Please correlate with GYN. sonography.
      • There is mild ascites in the cul-de-sac.
      • Prior CT identified a calcified stone in the distal CBD is noted again, stationary. A gallstone 0.6 cm is also noted.
    • Impression:
      • Malignant lymphoma of the spleen and para-aortic LNs S/P C/T show partial response to complete response. Please correlate with clinical condition. Follow up is indicated.
  • 2023-06-26 Patho - bone marrow biopsy
    • Bone marrow, biopsy — No evidence of lymphoma involvement
    • The sections show normocellular marrow (35%). M/E ratio = 4:1. The myeloid cells show good maturation with mild neutrophilia. The megakaryocytes are normal in number and morphology. No lymphoid aggregates can be found.
    • IHC, there is no evidence of lymphoma involvement in CD3 and CD20 immunostains. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2023-06-19 CT - chest
    • Indication: Diffuse large B-Lymphoma
    • Comparison was made with abdominal CT on 2023/05/02
      • Lungs: partial relaxation atelectasis of LLL and lingula.
        • band subsegmental atelectasis at RML and basal segments of RLL.
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels:
        • mild calcified plaques of the LAD coronary artery.
        • Thoracic aorta: normal caliber, mild atherosclerotic change of aortic arch.
        • Central pulmonary arteries: mild dilated trunk (3.4cm) and right (2.8cm) pulmonary artery.
      • Heart: normal size of cardiac chambers.
      • Pleura: moderate Lt-sided effusion.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal contents: marked splenomegaly with extensive poorly enhanced masses. abnormal masses in the pancreatic tail
        • extensive lymphadenopathy at the para-aortic, splenic hilum, retroperitoneum (peripancreatic region), and pelvic (bilateral iliac chains).
        • mild Lt hydronephrosis and delayed parenchymal enhancement due to compression at U-P junction lymphadenopahty.
        • unremarkable of the liver, GB, spleen, both adrenal glands
    • Impression:
      • no lymphadenopathy in the chest but moderate Lt pleural effusion.
      • intra-abdominal extensive lymphadenopathy with splenic and pancreatic involvement, in progression increase in size as compared with the previous abdominal CT on 2023/05/02
  • 2023-06-16 PET
    • Findings: There was increased FDG uptake in multiple lymph node regions in the abdomen and pelvis and in multiple focal areas in the spleen.
    • IMPRESSION: The FDG PET findings are compatible with lymphoma involving the spleen and involving multiple lymph node regions below the diaphragm as mentioned above.
  • 2023-06-02 Patho - peritoneum biopsy
    • Lymph node, para-aortic and left iliac, CT-guide biopsy — Diffuse large B-cell lymphoma, non-GCB type
    • Section shows cores of lymphoid and fibrous tissue with infiltration of large pleomorphic lymphoid cells.
    • The immunohistochemical stains reveal CK(-), CD3(-), CD20(+), CD10(-), BCL6(+), MUM-1(+), Cyclin D1(-), cMYC(-), and BCL2(+). The Ki-67 is about 90%.
  • 2023-05-09 Gynecologic ultrasonography
    • Uterine myoma
    • R/O Lt Ovarian mass
    • EM: 11.2mm (+fluid)
  • 2023-05-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (127 - 33) / 127 = 74.02%
      • LVEF (%) = 74
      • M-mode (Teichholz) = 74
    • Conclusion:
      • Dilated LV; normal LV systolic function with normal wall motion.
      • LV posterior wall thickeing, dilated LA; impaired LV relaxation.
      • Normal RV systolic function.
      • Aortic valve sclerosis with no AS and AR; mild MR; mild TR; mild PR.
      • Possible mild pulmonary hypertension, estimated PASP: 37 mmHg.
  • 2023-05-03 Embolization (TAE) - ABD for tumor
    • TAE of spleen via right common femoral artery puncture using Seldinger technique revealed:
      • Under local anesthesia, a 5 Fr arterial sheath was inserted into right common femoral artery smoothly.
      • Selective angiography of the splenic artery revealed splenomegaly with inhomogeneous vascularity. No definite contrast extravasation.
      • Proximal embolization with gelfoam pieces was performed. A decreased parenchymal vascularity after embolization.
      • No procedure-related complication during this procedure.
    • Impression
      • s/p proximal emobilization of left splenic artery
      • A Fr.5 arterial sheath was placed in right femoral artery. Please remove it in 3 days.
  • 2023-05-02 CT - abdomen
    • Indication: left abdominal pain, no vomit, no tarry stool. no trauma. hx of HTN; Med: Bisoprolol, Amlodipine , Olmesartan; NKA
    • With and without contrast enhancement CT of abdomen shows:
      • Enlargement of spleen. Several poor enhancing lesions in spleen.
      • Hyperdense fluid in perisplenic and pelvic regions.
      • Soft tissue mass in para-aortic and left iliac artery regions.
      • A cystic lesion, with wall enhancement, 4.5x5.1cm, in left adnexa.
      • A hyperdense stone in distal CBD.
      • No bony destructive lesion on these images.
    • Impression
      • Splenomegaly and splenic mass lesions
      • Para-aortic and left iliac lymphadenopathy
      • Left ovarian cystic mass
      • The differential diagnosis includes, but is not limited to ovarian ca with lymph node and spleen metastasis
      • Suggest further evaluation

[MedRec]

  • 2023-07-06 SOAP Hemato-Oncology Xia HeXiong
    • O
      • Conclusion of Multidisciplinary Cancer Team Meeting, Meeting Date: 2023-07-03
        • DLBCL (Diffuse Large B-Cell Lymphoma), stage IV
        • R-COP treatment plan (Start with COP x1, then add R, turning into R-COP x5).
      • Now on R-COP +/- H, C1D1 on 2023-06-27
  • 2023-06-13 SOAP Hemato-Oncology Xia HeXiong
    • O
      • 2023/06/02 PATHO-peritoneum biopsy
        • Diffuse large B-cell lymphoma, non-GCB type
      • Lab
        • 2023/06/03 B2-Microglobulin = 4325 ng/mL;
        • 2023/06/02 LDH = 709 U/L;
        • 2023/06/02 Uric Acid = 9.0 mg/dL;
  • 2023-05-18 SOAP Hemato-Oncology Xia HeXiong
    • A/P
      • CT:
        • Splenomegaly and splenic mass lesions, Favor lymphoma.
        • Para-aortic and left iliac lymphadenopathy
        • Left ovarian cystic mass
      • Suggestion:
        • antibiotic treatment
        • tumor biopsy for cancer survey
        • pain control
      • Arrange admission for CT-guided biopsy and check Beta2-microglobulin

[immunochemotherapy]

  • 2023-10-30 - rituximab 375mg/m2 600mg NS 500mL 12hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D3 + prednisolone 60mg/m2 90mg QD PO D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4
  • 2023-09-25 - rituximab 375mg/m2 600mg NS 500mL 12hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D3 + prednisolone 60mg/m2 90mg QD PO D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4
  • 2023-09-01 - rituximab 375mg/m2 600mg NS 500mL 12hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D3 + prednisolone 60mg/m2 90mg QD PO D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4
  • 2023-08-07 - rituximab 375mg/m2 600mg NS 500mL 12hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D3 + prednisolone 60mg/m2 90mg QD PO D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4
  • 2023-07-17 - rituximab 375mg/m2 600mg NS 500mL 12hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D3 + prednisolone 60mg/m2 90mg QD PO D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4
  • 2023-06-27 - rituximab 375mg/m2 600mg NS 500mL 12hr D1 + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D3 + prednisolone 60mg/m2 90mg QD PO D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg PO D2-4

==========

2023-08-08

According to the PharmaCloud database, the patient’s medical care has exclusively been provided by our hospital in the recent 3 months. Consequently, no discrepancies in medication reconciliation have been detected.

2023-07-18

Based on the PharmaCloud database, the patient has only received medical services from our hospital for the past three months. As a result, no medication reconciliation issues have been identified.

700301909

231030

[lab data]

2023-09-20 HBsAg (NM) Negative
2023-09-20 HBsAg Value (NM) 0.422
2023-09-20 Anti-HBc (NM) Positive
2023-09-20 Anti-HBc Value (NM) 0.01
2023-09-20 Anti-HCV (NM) Negative
2023-09-20 Anti-HCV Value (NM) 0.042
2023-09-20 Anti-HBs (NM) Positive
2023-09-20 Anti-HBs value (NM) 46.4 mIU/mL

[exam findings]

  • 2023-09-15 All-RAS + BRAF
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene.
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-09-14 Patho - peritoneum biopsy
    • Peritoneum, biopsy — Adenocarcinoma, moderately differentiated, metastatic, consistent with colorectal origin
    • Section shows pieces of fibroadipose tissue with metastatic adenocarcinoma.
    • The immunohistochemical stains reveal CK7(-), CK20(+), and CDX2(+). The results are consistent with metastatic colorectal adenocarcinoma.
  • 2023-09-01 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (125 - 41) / 125 = 67.20%
      • M-mode (Teichholz) = 68
    • Conclusion:
      • Normal LV filling pressure; impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis; mild MR.
      • Mildly dilated aortic root with mild calcification.
  • 2023-08-22 Flow Volume Chart
    • r/o mild restrictive ventilatory defect
  • 2023-08-14 Patho - colon biopsy
    • Colorectum, cecum base involving ileocecal junctioon (130 cm above anal verge), biopsy — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-08-04 CT - abdomen
    • Findings:
      • There is a heterogeneous poor enhancing mass in right lateral pelvis with directly attached the terminal ileum, cecum and rectosigmoid junction, measuring 7.7 cm (the largest dimension).
        • Adenocarcinoma of the terminal ileum is highly suspected.
        • The differential diagnosis includes lymphoma, malignant GIST and colon cancer with exophytic growing. Please correlate with colonoscopy.
        • In addition, this mass causes marked right hydroureteronephrosis and delayed contrast excretion of right kidney that is c/w Right pelvic mass with direct invasion M/3-L3 ureter induce obstructive uropathy.
      • There are seven enlarged lymph nodes in the sigmoid mesocolon and right internal iliac chain that are c/w metastatic nodes.
      • There are multiple soft tissue nodules in the omentum at RUQ and LUQ abdomen that are c/w carcinomatosis.
      • There is a homogeneous enhancing mass 2.3 cm in S6 of the liver that may be hemangioma. Please correlate with MRI.
      • In addition, there are three cysts on S5, S4, and S3 (the largest one 1.9 cm in S5).
    • Impression:
      • Adenocarcinoma of the terminal ileum with lymph nodes metastases and carcinomatosis is highly suspected.
      • The differential diagnosis includes lymphoma, malignant GIST, and colon cancer with exophytic growing.
  • 2023-07-28 SONO - abdomen
    • Diagnosis:
      • suspicious, colonorectal tumor or pelvic tumor
      • Liver cyst, S8
      • Hydronephrosis, right
      • Renal stone, left
      • pancreatic body and tail masked by gas.
    • Suggestion:
      • arrange abd + pelvic CT
      • consider refer to Urology.

[MedRec]

  • 2023-09-26 SOAP Urology Li MingWei
    • A
      • Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis status post diagnostic laparoscopy on 2023/09/14, cT4bN2bM1c, stage IVc
      • Right PCN was done on 2023/09/15
    • Prescription
      • Harnalidge (tamsulosin 0.4mg) 1# QN
  • 2023-09-26 SOAP Hemato-Oncology Xia HeXiong
    • P: Admission for C/T with FOLFIRI +/- avastin
  • 2023-09-26 SOAP Colorectal Surgery Chen ZhuangWei
    • A: Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis status post diagnostic laparoscopy on 2023/09/14, cT4bN2bM1c, stage IVc
    • P: refer to oncoligist for palliative chemotherapy, may bypass or ileistomy if obstructed symptoms got worse
  • 2023-09-12 ~ 2023-09-18 POMR Colorectal Surgery Chen Zhuang Wei
    • Discharge diagnosis
      • Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis status post diagnostic laparoscopy on 2023/09/14, cT4bN2bM1c, stage IVc
      • Right hydronephrosis status post right ureteral catheterization on 2023/09/14 and right percutaneous nephrostomy on 2023/09/15
    • CC
      • peri-umbilical tenderness for 2 weeks with difficult defecation
    • Present illness
      • This is a 67 y/o male with past history of ICH on 2020/3. This time he was admitted due to peri-umbilical tenderness for 2 weeks with difficult defecation.
      • According to the patient statement, he suffered from peri-umbilical tenderness for 2 weeks with difficult defecation. He denied diarrhea, melena or hematocheizia. Due to above symptoms, he went to our GI OPD for help on 7/25. Abdominal ultrasound showed right hydronephrosis, suspicious S-colon/rectal lesion. And abdominal CT on 8/4 showed adenocarcinoma of the terminal ileum with lymph nodes metastases and carcinomatosis is highly suspected. Colonoscopy showed 1. Ulcerative tumor lesion was noted in the cecum base (130cm AAV) involving ileocecal junction 2. Mucosal chnage with external compression-like effect was found at RS-colon. Pathology showed adenocarcinoma. Under impression of newly found cecal adenocarcinoma, locally advanced with possible carcinomatosis, stage IVc, this time he was admitted for further evaluation and surgical intervention.
    • Course of inpatient treatment
      • This 67 years old male patient was a case of cecal adenocarcinoma. After admission, he complained right testicular region tenderness for two weeks. Right epididymitis was suspected and cravit was given. He underwent diagnostic laparoscopy and right ureteral catheterization on 2023/09/14. However, due to right ureteral catheterization failed with suspected tumor invasion of right upper ureter, right PCN was done on 2023/09/15. And Port-A was also done on 9/15 for palliative chemotherapy. The post-operative course was relatively smooth without complication. The bowel function, urinary function were normal and the wound pain was tolerable. He was discharged on 2023-09-18 and will follow up in our out-patient department next week.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQID
      • Cravit (levofloxacin 500mg) 1.5# QDAC
      • Harnalidge (tamsulosin 0.4mg) 1# HS
      • MgO 250mg 2# BID
      • Through (sennoside 12mg) 1# HS
  • 2020-04-21 SOAP Neurosurgery
    • S: spontaneous ICH, conservative treatment 2020/03
    • Prescription x2
      • Depakine (valproic acid 500mg) 1# BID

[consultation]

  • 2023-09-16 Radiation Oncology
    • Q
      • For right side PCN
      • This is a 67 y/o male was a case of newly found cecal adenocarcinoma, locally advanced with carcinomatosis and right hydronephrosis, stage IVc.
      • He underwent diagnostic laparoscopy and right ureteral catheterization on 2023/09/14.
      • Op finding: 1) Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis over the whole peritoneal cavity including abdominal wall and omentum; 2) Right lower ureter stricture, suspected tumor invasion of right upper ureter; 3) Suspected tumor invasion of right upper ureter, URS and guidewire can not pass through.
      • Due to right ureteral catheterization failed, we needs your expert experience for further evaluation and management. Thanks a lot !!
    • A
      • According to the clinical condition and imaging findings, right PCN is indicated.
  • 2023-09-14 Hemato-Oncology
    • Q
      • For palliative chemotherapy
      • This is a 67 y/o male was a case of newly found cecal adenocarcinoma, locally advanced with possible carcinomatosis, stage IVc. He underwent diagnostic laparoscopy and right ureteral catheterization on 2023/09/14.
      • Op finding: 1) Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis over the whole peritoneal cavity including abdominal wall and omentum; 2) We got three pieces of seeding tumors over abdomen wall and omentum for pathology examination; 3) Right lower ureter stricture, suspected tumor invasion of right upper ureter.
      • After fully explained of the condition, palliative chemotherapy was suggested. So we needs your expert experience for further evaluation and management. Thanks a lot !!
    • A
      • Dear doctor: This 67 year old man is a case of cecal adenocarcinoma with carcinomatosis. We are consulted for pallative chemtoherapy.
      • For metastasis colon adenocarcinoma (Pending All RAS/BRAF), chemotherapy+/- target therapy is indicated. We had well explaint to patient and his wife. Please arrange our OPD after discharge.
      • Check HBsAg, Anti HBc, Anti HBs, Anti HCV and arrange port A insertion before chemotherapy.

[surgical operation]

  • 2023-09-14
    • Surgery: Diagnostic laparoscopy     
    • Finding
      • Diagnostic laparoscopy was performed and whole peritoneal cavity was inspected.    
      • Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis over the whole peritoneal cavity including abdominal wall and omentum    
      • We got three pieces of seeding tumors over abdomen wall and omentum for pathology examination.
      • Right ureter catherter was performed by urologist but is difficult to be done smoothly due to tumor effect.    
      • We had informed above condition to his son during the operation, further management such as right PCN and port-A are needed. 

[immunochemotherapy]

  • 2023-10-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-28 - irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-02

PharmaCloud data indicates that the patient has only been to our hospital within the last three months. Our urologist prescribed a refill of Harnalidge (tamsulosin) on 2023-09-26, and the medication is currently being used without any issues.

701306367

231030

[exam findings]

  • 2023-08-01 Neck soft tissue
    • Placement of nasogastric tube and tracheostomy.
    • Straightening alignment of cervical spine.
    • Degenerative change of the spine with marginal spur formation.
  • 2023-08-01 CXR
    • Normal heart size with tortuous aorta.
    • Placement of tracheostomy and nasogastric tube.
    • Multiple right ribs fracture, old.
    • Fibrocalcified nodules at RUL.
    • Bilateral clear costophrenic angles.
    • L2 compression fracture status post vertebroplasty.
  • 2023-07-27 CXR
    • Tortuosity of the aorta with atherosclerotic change.
    • Fibrocalcified change over right apical lung, may be old TB.
    • Old fracture of multiple ribs.
    • S/P tracheostomy.
    • S/P N-G tube insertion.
  • 2023-07-20 Tc-99m MDP bone scan
    • Increased activity in the lower C-spine and L2-4 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Some faint hot spots in bilaterla rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral hips, knees, right ankle and right foot, compatible with benign joint lesions.
  • 2023-07-19 CT - neck
    • Right tongue squamous cell carcinoma, moderately differentiated, for cancer work up
    • With and Without contrast Neck CT showed
      • The neck airway was unremarkable.
      • heterogeneous enhancing tumors in the oral cavity, oropharynx and bilateral hypopharynx.
      • multipe necrotic lymph nodes in the left carotid space, riht submandibular space and right posterior cervical space
      • The major salivary glands were unremarkable.
      • The skull base and C-spine alignment were unremarkable
    • IMP: extensive tumors in the oral cavity, oropharynx andhypopharynx with necrotic LAP in the bilateral neck.
  • 2023-07-18 EGD
    • Suboptimal study due to poor intolerance
    • Reflux esophagitis LA Classification grade C
    • Esophageal mucosal lesion, EC junction, s/p biopsy
    • Hiatal hernia
    • Superficial gastritis
    • Gastric erosions, antrum
  • 2023-07-10 Patho - tongue biopsy
    • Tongue tumor, R’t, biopsy — Squamous cell carcinoma, moderately differentiated
    • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated of the tongue tumor tissue characterized by solid tumor nests infiltration with keratin formation, hemorrhage and necrosis.
    • Immunohistochemistry shows CK(+), P40(+), P16(-) and HPV(-) for tumor.
  • 2023-07-08 Embolization (TAE) - neuro
    • The procedure was performed under general anaesthesia via right femoral artery approach with a Fr#8 angiocatheter sheath and guiding catheter.
    • Bilateral carotid angiograms reveal tumor stains over oropharyngeal space, supplied by bilateral lingual artery. .
    • Transarterial embolization of the tumor was then performed by infusion of particles (Embospheres).
    • Post embolization bilateral carotid angiograms show total embolization of this tumor.
  • 2023-07-08 Carotid angiography bilat.
    • Tumor stains over oropharyngeal space, supplied by bilateral lingual artery.
  • 2023-07-08 Aortography - thoracic
    • Type II aortic arch.
    • No critical stenosis of bilateral proximal carotid and vertebral arteries.
    • The whole procedure was smoothly done without apparent immediate complication and the patient stood it well under local anesthesia.
  • 2023-07-08 CT, CTA - brain
    • Presence of huge lobulated mass lesion over oropharyngeal space, mainly at posterior tongue, with invasion of anterior part of the tongue and the epiglottis. Large necrotic area of this tumor. The tumor was mainly supplied by bilateral lingual arteries.
    • Several necrotic nodes over left-side of the neck.
    • S/P tracheostomy.
  • 2023-04-11 Patho - doudenum biopsy
    • Duodenum, bulb, GC/PW, biopsy — Brunner’s gland hyperplasia
  • 2023-04-11 EGD
    • Reflux esophagitis LA Classification grade C
    • Duodenal polyps, bulb, s/p biopsy
    • Hiatal hernia
    • Superficial gastritis
  • 2023-04-03 EEG
    • This EEG were composed by continuous diffuse theta wave with 5-6 Hz, 10-20 uv in bilateral hemisphere with left side more severe. There were no obvious photic driving response.
    • This EEG suggest moderate diffuse cortical dysfunction left side more severe. Advise clinical correlation.
  • 2023-03-30 CT - brain
    • Small amount of chronic subdural effusions along right convexity. Minimal amount of acute SDH over right temporal fossa.
    • Traumatic head injury with right frontal scalp and face swollen change.
    • Depressed left hemicranium with thickening dura. Compressed left cerebral hemisphere with large area of old infarction.
    • S/P V-P shunt insertion.

[MedRec]

  • 2023-08-08 SOAP Hemato-Oncology
    • P: Arrange admission for CCRT with weekly CDDP
  • 2023-08-04 SOAP Radiation Oncology
    • S: Diagnosis: extensive tumors in the oral cavity, oropharynx andhypopharynx with necrotic LAP in the bilateral neck. cT4aN2cM0 at least.
    • O: 2023/07/27~ RT to the oral cavity and bil. neck lymphatic drainage area: 12 Gy/ 6 fx.
    • P: Plan to deliver 50 Gy/ 25 fx to the oral cavity, oropharynx, and bil. neck lymphatic drainage area. Then boost the gross tumor and LAPs to 70 Gy/ 35 fx.
  • 2023-07-08 ~ 2023-08-28 POMR Ear Nose Throat
    • Discharge diagnosis
      • Malignant neoplasm of overlapping sites of tongue, stage IV
      • Oropharyngeal tumor bleeding with hypovolemic shock
      • Hemoptysis
      • Acute hypoxemic respiratory failure post intubation
    • CC
      • cough with much blood sputum today, and poor intake fo 2 days
    • Present illness
      • This 51-year-old man has past history of 1.) old CVA with right weakness, 2.) alcoholism 3.) Traumatic brain injurys/p craniectomy 4.) Epilepsy 5.) s/p abdomen operation (colon).
      • According to statement of his ex-wife, he suffered from cough with much blood sputum today, and poor intake fo 2 days. He was brough to our hospital for help. At ER, Con’s:E4V5M6, TPR:37.1/112/18, BP:94/55mmHg; SpO2:99%, sudden massive blood from oral and desaturation, bradycardia, hypotension were noted, s/p Bosmin injection, difficult oral endotrachea tube installation, emergency tracheostomy with ventilator support was performed at ER. Laboratory studies showed leukocytosis, increase of segment, Imbalance electrolyte as hyperkalemia, hyponatremia. The chest film disclosed Fibrocalcified change over RUL.
      • Due to massive oral bleeding, so we arrange brain CT, which revealed 1. Presence of huge lobulated mass lesion over oropharyngeal space, mainly at posterior tongue, with invasion of anterior part of the tongue and the epiglottis. Large necrotic area of this tumor. The tumor was mainly supplied by bilateral lingual arteries. 2. Several necrotic nodes over left-side of the neck. Angiography was arranged and embolization was done. Empirical antibiotics, IV fluid challenge, and blood transfusion for hypovolemic shock were given. Under the impression of 1.) Acute hypoxemic respiratory failure post intubation 2.) oropharyngeal tumor bleeding with hypovolemic shock, he was admitted to MICU for further treatment.
      • He did not received vaccice included covid-19 and Influenza
    • Course of inpatient treatment
      • MICU 7/08-7/17
        • After admitted to MICU, on cricothyrotomy with ventilator support. Arrange tracheostomy on 7/9. Unstable hemodynamics under IVF hydration and levophed titration infusion.
        • Empiric antibiotic with tapimycin Tapimycin (7/8-) and Targocid (7/9-7/11) for infection treat. Give MgSO4, KCL IVD, Ca. gluconate and high P diet were given for correct imbalance electrolyte.
        • Transamin IV and Bosmin inhalation were given for hemoptysis. AEDs with dilantin IV shift to oral form and ativan PRN IVD for seizure control. Contact ENT for biopsy of right tongue tumor: Squamous cell carcinoma. Try T-mask overnight since 7/15 for weaning ventilator. He wil transfer to ENT ward for further care.
      • ENT ward 7/17-7/28
        • Under relative stable condition, we remove foley catheter and shift tracheostomy to shiley 6 # smoothly on 7/18.
        • Cancer work up was arranged, which revealed tongue tumor with extensive invasion the oral cavity, oropharynx andhypopharynx with necrotic LAP in the bilateral neck. Operation was not indicated due to massive invasion. Radiotherapy will be arranged from 7/27, and he will be discharged under relative stable condition.
    • Discharge prescription
      • Zalain Cream (sertaconazole nitrate 2%) BID TOPI
      • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
      • Phenytoin (diphenylhydantoin 100mg) 1# TID
      • Ulstop (famotidine 20mg) 1# BID
      • Parmason Gargle Soln (chlorhexidine) BID GAR
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
  • 2023-03-31 ~ 2023-04-12 POMR Infectious Disease
    • Discharge diagnosis
      • Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction
      • Hypostatic pneumonia, unspecified organism
      • Contusion of unspecified part of head, initial encounter
      • Contusion of eyeball and orbital tissues, right eye, initial encounter
      • Altered mental status, unspecified
      • Unspecified adrenocortical insufficiency
      • Gastritis, unspecified, without bleeding
      • Gastro-esophageal reflux disease with esophagitis
    • CC
      • Drowsy conscious and poor appetite in recent three days.
    • Present illness
      • This is a 51 year-old male patient, who has underlying histories of alcoholism, Left TBI s/p craniectomy, s/p abd op (colon), is admitted for drowsy conscious and poor appetite in recent three days.
      • According to his ex-wife, he suffered from drowsy conscious and poor appetite after fall down with hit the head before three days ago. He also accompanying symptoms of headache, right eye swelling and ecchymosis.There is no TOCC or trauma hisory. He had no previous allergy to food or drug. There is no URI or UTI symptom in recent days.
      • He was brought to our ED for help.
      • At ED, vital signs showed tachycardia (BP:129/88; HR:104; BT:35.5; RR:18). PE showed ecchymosis, swelling, local heat, painful and tenderness over right eye, sclera congestion, pupils has light reflex. Laboratory data showed leukocytosis (13200/uL), elevated Hb (Hb:18.1 g/dl), CRP (7.06mg/dL), glucose (Glu:190 mg/dl), and normal liver and renal function. Blood gas (vein) showed respiratory acidosis with metabolic compensation. Urinalysis showed elevated urobilinogen (8 mg/dl), bilirubin (1+), no pyuria. CXR showed clear both lung field. Brain CT revealed small amount of chronic subdural effusions along right convexity. Minimal amount of acute SDH over right temporal fossa.
      • Under the impression of hypostatic pneumonia, dehydration, SDH, he is admitted to the Infection ward for evaluation and management on 2023-03-31.    
    • Course of inpatient treatment
      • During the hospital stay, we use parenteral cefuroxime for empirical treatment of hyposttaic pneumonia. Consciousness was monitor due to post head injury. Raise the head of the bed up 30 degree. Neurology consulted for treatment of SDH and headache. This EEG suggest moderate diffuse cortical dysfunction left side more severe. The adequate fluid hydration due to dehydration. The Foley catheter indwelling is for monitor and record urine amount. Oncology was consulted for suspect polycythemia. Patient received JAK2, BCR ABL, therapeutic phlebotomy (maintain the hematocrit < 45 percent) and bone marrow aspiration and biopsy.
      • Patient’s ex-wife complained of no stool passage above three days and abdominal distension. KUB revealed stool impaction. Laxative, antiflatulent were given. Hiccup is noted, we also addition prokinetic treatment. Patient’s ex-wife complained of dark green stool noted, stool is submitted for stool OB. We also give recheck Hb level and adrenal function survey. No bacterial growth on blood culture is noted. Mild decreased ACTH is noted, adrenocortical insufficiency was considered.
      • We give addition systemic steroid. Panendoscopy was arrange due to anemia and stool OB 4+. Panendoscopy revealed Reflux esophagitis LA Classification grade C
      • Duodenal polyps, bulb, s/p biopsy. Hiatal hernia. Superficial gastritis. PPI was given after panendoscopy examination. Voiding is smooth after removal foley catheter. No bacterial growth on blood culture is noted. Laboratory examinaiton revealed improve. No more fever occurs. Conscious clear. Respiratory pattern is smooth. Under stable condition, he is discharged on April 12, 2023.
    • Discharge prescription
      • cortisone acetate 25mg 0.5# QD
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Mopride (mosapride citrate 5mg) 1# TID
      • Through (sennoside 12mg) 1# HS
  • 2021-07-27 SOAP Neurosurgery
    • S
      • Wedge compression fracture, L2 post vertebroplasty on 2021/07/16
      • Postoperatively, his symptom has been relieved.
    • P
      • Porlia infusion
    • Prescription
      • Prolia (denosumab 60mg) ST SC
  • 2021-07-15 ~ 2021-07-16 POMR Neurosurgery
    • Discharge diagnosis
      • Wedge compression fracture, L2 post vertebroplasty on 2021/07/16
    • CC
      • Lower back pain for 3 weeks
    • Present illness
      • This is a 49 year-old male with alcoholism, Left TBI s/p craniectomy, s/p abd op (colon).
      • This time he was suffered from lower back pain after fell down when work since 6/28. The pain became worse so he came to our NS OPD for help on 7/5.
      • At OPD, PE showed MP RUE 3 RLE 3, LUE 4 LLE, SLRT -/- Lasguest test(+). L-spine X-ray showed L2 compresion fracture. MRI of L spine revealed: L2 subacute compression fracture. After discussion with the patient, surgery would be arranged.
      • Under the impression of L2 compression fracture, he was admitted for further management.
    • Course of inpatient treatment
      • After admission, we did pre-OP prepare. L2 body bone cement augmentation was arranged on 7/16. The patient’s condition and vital sign was stable after the surgery and his symptoms was mild improved. After assessment, he will discharge on 7/16 and OPD follow up.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Sindine Aq Soln (povidone iodine) QD EXT for L-spine wound

[consultation]

  • 2023-10-19 Ear Nose Throat
    • Q:
      • PH extensive tumors in the oral cavity, oropharynx and hypopharynx with necrotic LAP in the bilateral neck; cT4aN2cM0 at least.
    • A
      • S
        • Hemoptysis since last night by family
        • Fair saturation (SpO2: 97-99% under room air) but lip with cyanotic change when visiting
        • Cuff inflation (8 ml) for airway protection before visiting
        • PHx: extensive tumors in the oral cavity, oropharynx andhypopharynx with necrotic LAP in the bilateral neck
          • s/p CCRT with weekly CDDP ( 7000 cGy / 35 Fx, from 2023/07/27~2023/09/14)
      • O
        • Portable scope: no active bleeding over trachea after cuff inflation, bloody mucus over trachea
        • Local finding: no active bleeding or oozing over tracheostomy
        • much blood clot over left tongue necrotic wound, s/p bosmin gauze compression
      • A
        • Hemoptysis, favor oral cancer bleeding related
      • P
        • S/p bosmin gauze compression -> no active oral bleeding
        • Keep Cuff inflation for airway protection
        • If active oral bleeding, angiography for embolization may be indicated -> however, patent refused futher aggresive treatment (The patient is conscious and alert. The patient was informed that there is a life-threatening risk if bleeding continues and embolization is not performed. The patient nodded in understanding. When asked if they would accept the treatment, the patient shook their head to indicate refusal. The patient’s ex-wife was also informed of the same content. She understood and expressed respect for the patient’s wishes.)
  • 2023-08-17 Family Medicine
    • Q
      • This 52 year-old man patient is a case of Tongue cancer with bilateral neck LAP metastasis, cT4aN2cM0, stage IVB s/p concurrent chemoradiotherapy from 2023/07/27. Concurrent chemotherapy with CDDP was on 2023/08/17. This time, for PS:4 with weakness and sign DNR. Now, for evaluate hospice combined care. Thank you.
    • A
      • Cons:E4V5M6. ECOG:4
      • We will arrange hospice combine care and follow up his condition.
      • Indication: Tongue cancer with bilateral neck LAP metastasis, cT4aN2cM0, stage IVB
      • Plan: Hospice combined care
  • 2023-07-24 Dermatology
    • Q
      • Itching papule over peri-inguinal region was noticed for days. We need your expertise for further evaluation and treatment.
    • A
      • This patient suffered from erytehamtous patches on L’t thigh for days.
      • Imp: Tinea corprois
      • Suggestion:
        • Mycomb * 2 tubes/bid
        • Zalain cream * 2 tubes/bid
  • 2023-07-21 Hemato-Oncology
    • Q
      • Operation may not be indicated due to masive tumor invasion. We need your expertise for concurrent or induction chemotherapy arrangement.
      • The patient’s caregiver is his ex-wife, and they have a 14-year-old underage daughter together.
    • A
      • This 51 year old man is a case of Tongue base squamous cell carcinoma, moderately differentiated, p16(-), HPV (-) with tumor bleeding, status post angiography embolization on 2023/07/08, status post tracheostomy on 2023/07/09.
      • Neck CT revealed tumor invasion over oral cavity, oropharynx and hypopharynx with necrotic LAP in the bilateral neck. We are consulted for CCRT. Please arrange port A insertion.
      • Check Anti HBc, HBsAg, Anti HCV. Arrange 24 urine CCR. Please arrange our OPD after discharge.
  • 2023-07-21 Radiation Oncology
    • A
      • This time, he was admitted to our ward for oropharyngeal tumor bleeding. Biopsy over tongue revealed squamous cell carcinoma, moderately differentiated, p16(-), HPV (-). Neck CT revealed tumor invasion over oral cavity, oropharynx and hypopharynx with necrotic LAP in the bilateral neck.
      • CCRT is indicated. CT-simulation will be arranged on 7/24. Plan to deliver 50 Gy/ 25 fx to the oral cavity, oropharynx, and bil. neck lymphatic drainage area. Then boost the gross tumor and LAPs to 70 Gy/ 35 fx. RT will start around 7/27. Thank you very much.
  • 2023-07-19 Oral and Maxillofacial Surgery
    • Q
      • tongue cancer patient, for oral cavity evaluation
      • This is a 51-year old man with past history
        • Old cerebrovascular accident with right side weakness
        • Alcoholism 
        • Traumatic brain injury status post left craniectomy more than 20 years ago
        • Epilepsy under phenytoin
        • Unknown colon lesion status post operation
      • This time, he was admitted to our ward for massive tumor bleeding. Emergent tracheostomy with tongue tumor biopsy was perfromed smoothly, and pathology report showed moderately differentiated squamous cell carcinoma. As part of cancer evaluation, we need your expertise for oral cavity evaluation.
    • A
      • After examing the intraoral condition, poor oral hygiene and multiple deep caries were noticed.
      • As the patient is unwilling to open his mouth and refuse to accept further dental evaulation.
      • Extraction of hopeless teeth might be difficult.
  • 2023-07-08 Ear Nose Throat
    • A1
      • If massive bleeding occurs again, you can pack the mouth with Bosmin gauze (4x4 unfolded gauze pieces tied together in a string).
    • A2 Supplementary Consultation Response: 2023-07-08 21:02:07
      • The procedure performed this time was a cricothyrotomy (non-tracheostomy procedure), and tracheostomy surgery will be needed in the coming days.
  • 2023-04-05 Hemato-Oncology
    • Q
      • This 51 y/o man admitted due to hypostatic pneumonia. History of smoking and trauma s/p V-P shunt. Hb:18.1 g/dl, suspect polycythemia. So we need your help for further suggestion. Thanks.
    • A
      • Please check JAK-2, BCR ABL, and arrange theraputic phlebotomy (maintain the hematocrit <45 percent).
      • Bone marrow aspiration and biopsy is indicated. Thanks for your consultation.
  • 2021-06-29 Neurosurgery
    • Q
      • CC: fell down 3 days ago? and low back pain and generalized weakness; decreased appetite; slurred speech as usual (according to the ex-wife)
      • PH: alcoholism, Left TBI s/p craniectomy on 1995, s/p abd op (colon?)
      • Allergy: denied
    • A
      • The patient had lower back pain and general weakness.
        • Recent Hx of chest trauma: undetectable
        • CT scan of the abdomen showed old fracture of right lower ribs with chronic pleural change.
        • Patient hand no chest pain and dyspnea
      • Suggestion:
        • OPD FU for CS condtion
        • Consult NS
  • 2021-06-29 Neurosurgery
    • Q
      • CC: fell down 3 days ago? and low back pain and generalized weakness; decreased appetite; slurred speech as usual (according to the ex-wife)
      • PH: alcoholism, Left TBI s/p craniectomy on 1995, s/p abd op (colon?)
      • Allergy: denied
    • A
      • This patient suffered from back pain after a fall 3 days ago. At ER, his L spine films showed L2 compression fracture. Conservative therapy, including back brace, is suggested. OPD f/u is advised.

[radiotherapy]

[chemotherapy]

==========

2023-10-30 (not posted)

[patient’s weight is too light]

A dosage of 1# QD could be considered appropriate for this patient with a less severe condition, given his body weight of 37 kg. This dosage is approximately equivalent to 1.5# QD for a patient weighing 57 kg.

2023-08-11

[reconciliation]

The patient obtained a 28-day refill of the repeat prescription for Dilantin Kapseals (phenytoin) for his “absence epileptic syndrome, not intractable, with status epilepticus” from Taipei City Hospital on 2023-08-04. However, the patient is currently not taking phenytoin (according to the active medication list). It is recommended to assess whether the patient’s neurological symptoms persist and to determine the continued necessity of the drug.

701490021

231030

[lab data]

2023-09-14 Anti-HBc Reactive
2023-09-14 Anti-HBc-Value 1.30 S/CO
2023-09-14 Anti-HBs 127.72 mIU/mL

[MedRec]

  • 2023-09-13 ~ 2023-09-18 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Ductal adenocarcinoma of pancreatic head with liver metastasis, pT3N2M1; Stage IV status post whipple’s operation with partial gastrectomy and S4b/5 partial hepatectomy and lymph noder dissection on 2023/07/31
      • Malignant neoplasm of head of pancreas
      • Chronic viral hepatitis B without delta-agent
    • CC
      • for chemotherapy
    • Present illness
      • This 69 y/o female patient denied underlying diseases, diagnosis was Ductal adenocarcinoma of pancreatic head with liver metastasis, pT3N2M1, stage IV status post whipple’s operation with partial gastrectomy and S4b/5 partial hepatectomy and lymph noder dissection on 2023/07/31.
      • Accroding to her statement, she had upper abdominal fullness and frequent postprandial vomiting for several times about these half month. Body weight loss wa noted (72kg -> 69kg for 1 month). There was no fever, no dyspnea, no diahrrea, no tarry/bloody stool passage. She went to ChiMei Hospital and image study showed 2-3 cm pancreatic head tumor. Lab data showed elevated AST/ALT, ALP, rGT and Total bilirubin level. She then went to our hospital for second opinion. Cholangiography MRI on 2032/07/11 showed a poor enhancing lesion (3.0x3.3x4.3cm) at pancreatic head with adjacent duodenal and CBD invasion causing biliary dilatation, some small LNs at retroperitoneum. Distention of gallbladder and stomach, a poor enhancing nodule (8mm) at S4-8 junction of liver、renal cysts (up to 2.3cm). Pancreatic Carcinoma T3N2M1, stage IV.
      • Endoscopic retrograde cholangiopancreatography on 2023/07/11 showed duodenal tumor with duodenum stricture: at SDA: post biopsy (failed cannulation), duodenal ulcer. Pathology showed intestine, small, duodenum, SDA, biopsy — Adenocarcinoma, IHC reveals CK7(+), CA19-9(-), CK20(1). Abdominal echo on 2023/07/12 showed probable liver parenchymal disease (incomplete exam of liver), suspected pancreas tumor (head portion), mild dilatation of pancreatic duct, gallbladder obscured, mild dilatation of CBD and bilateral IHD, right renal cyst, right pleural effusion: minimal amount.
      • Pathology showed Labeled as “pancreatic neck”, EUS needle biopsy — adenocarcinoma. IHC stains (using block S2023-13884): CA19-9 (-), CK7 (+), CK20 (-), CK19 (+), CEA (+). She received whipple op with partial gastrectomy, S4b/5 partial hepatectomy, LNstation 5,6,8,12,13 dissectio on 2023/07/31, pathology showed Liver, S4b, partial hepatectomy — Metastatic pancreatic adenocarcinoma; 1. Pancreas, Whipple operation with partial gastrectomy — Ductal adenocarcinoma, moderately differentiated; 2. Pathologic Staging: pT3N2M1, stage IV.
      • This time, she was admitted to our ward for chemotherapy with FOLFIRINOX (C1D1).
    • Course of inpatient treatment
      • After admission, she received chemotherapy with FOLFIRINOX (Oxalip 50mg/m2, Campto 100mg/m2, LV 300mg/m2, 5FU 300mg/m2 and 2400mg/m2) (C1D1) from 2023/09/14~2023/09/16 (hold 5-Fu due to fever was noted 2023/09/16, after Acetal 500 mg/tab 1# PO ST, then improving, keep continue 5-Fu).
      • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
      • Protase 1# po TID was given for pancreatic insufficiency.
      • Post chemotherapy with Oxalip given Hydroxocobalamin “T.F.” 1mg/mL/amp 1amp IM ST for avoid sensory peripheral neuropathies.
      • Blood-stinged was noted on toilet paper after urination today. No hematuria or other symptoms. consulted for GYN evaluation. Postmenopausal spotting, keep observation. Cervical polyp, keep observation. May arrange GYN OPD f/u after discharged, for recheck endometrial thickness (might consider to arrange endometrial sampling or D&C if persistent vaginal spotting or EM thickening).
      • Chronic viral hepatitis B with (Anti-HBc:reactive) with Vemlidy 25 mg/tab 1# PO QD.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2023/09/18 and OPD followed up later.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Protase (pancrelipase 280mg) 1# TIDCC
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ12H
  • 2023-09-05 SOAP Hemato-Oncology Xia HeXiong
    • P: Check Anti-HBs, Anti-HBc and Anti-HCV during admission. Already told the regimen:
      • GASL
      • GA
      • mFOLFOX
  • 2023-07-10 ~ 2023-08-18 POMR General and Gastrointestinal Surgery Wu ChaoCun
    • Discharge diagnosis
      • Ductal adenocarcinoma of pancreatic head with liver metastasis, pT3N2M1; Stage IV status post whipple’s operation with partial gastrectomy and S4b/5 partial hepatectomy and lymph noder dissection on 2023/07/31. ECOG:1
      • Pancreatic head cancer, with adjacent duodenal invasion and obstructive jaundice status post percutaneous transhepatic gallbladder drainage on 2023/07/12
      • Cholangitis
      • Obstruction of bile duct
    • CC
      • Frequent postprandial vomiting for about 2 weeks
    • Present illness
      • This 69 y/o female patient denied underlying diseases, like hypertension or type 2 diabete mellitus.
      • Accroding to her statement, she had upper abdominal fullness and frequent postprandial vomiting for several times about these half month. Body weight loss wa noted (72kg -> 69kg for 1 month). There was no fever, no dyspnea, no diahrrea, no tarry/bloody stool passage. She went to ChiMei Hospital and image study showed 2-3 cm pancreatic head tumor. Lab data showed elevated AST/ALT, ALP, rGT and Total bilirubin level. She then went to our hospital for second opinion.
      • Lab data on 7/10 showed no naemia, no CEA(3.2) CA199(1.07) level elevation, AST(337), ALT(652), Tbil(2.27), rGT(624), cholestasis type abnormal liver function and jaundice, suspected obstrution. Physical exam showed no fever, no dyspnea, no jaundice, no abdominal tenderness, normoactive bowel movement, no lower limbs pitting edema.
      • Under the impression of pancreatic head lesion causing obstructive jaundice and cholangitis, she was admitted to our ward for evaluation and management.
    • Course of inpatient treatment
      • After admitted, MRCP on 7/11 showed r/o pancreatic head tumor (2.2cm) with adjacent duodenal and CBD invasion causing biliary dilatation. Distension of gallbladder and stomach. A poor enhancing nodule (0.8cm) at S4/8 junction of liver. ERCP revealed duodenal tumor at bulb to SDA, s/p biopsy ; failed canulation.
      • PTGBD was also performed on 7/12 for bile drainage. EUS with FNB was performed on 7/12, for pancreatic mass-lesion biopsy.
      • The pathology of duodenal mass lesion showed adenocarcinoma and pancreatic mass fine needle biopst revealed malignancy.
      • GS was consulted then she was referred to GS service for further surgical intevention preparing.
      • TPN for nutrition supplement was given since 7/14.
      • Then she received whipple’s operation with partial gastrectomy and S4b/5 partial hepatectomy and LN dissection was processed successfully on 7/31.
      • Post operaively, we observed patient recovery and keep empiric antibiotic, albumin with lasix therapy, and analgesic agent were administered and the wound management was performed.
      • However, post operation with bile leakage via JP (no.2) was noted. Then we keep sandostatin support and keep well JP drainage.
      • Fever was noted on 8/4 and CXR showed ground glass opacity in bilateral lower lungs.
      • A+B inhalation and Aerobika for promote lung expansion since 8/4.
      • She try to introduced liquid diet with step by step after well flatus passage and can tolerate well for soft diet.
      • Leukocytosis was persisted then we check ascites culture on 8/7, then final report showed staphylococcus, then Zyvox support was used. However, high fever was noted on 8/16 then suspect of CVC infection and CVC removed then follow up tip culture and blood culture and removed of JP tube were done smoothly. Add antibiotic with Brosym and flucon support then fever was subside for 2 days. Recheck blood examination with no leukocytosis and CRP showed 4.8mg/dl. Under stated improvement of clinical symptoms, she was allowed to discharge today and OPD follow up was arranged.
    • Discharge prescription
      • Celebrex (celecoxib 200mg) 1# BID
      • Diovan (valsartan 160mg) 1# QD
      • LoraPsudo 24H SR FC (loratadine 10mg, pseudoephedrine 240mg) 1# QD
      • Megest (megestrol 40mg/mL) 10mL QD
      • Mopride (mosapride citrate 5mg) 1# TID
      • Rich (lansoprazole 30mg) 1# QDAC
      • Through (sennoside 12mg) 2# HS
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
      • Flu-D (fluconazole 150mg) 1# QD
      • Ceficin (cefixime 100mg) 2# BID
  • 2023-07-10 SOAP Gastroenterology Chen JiangHua
    • S
      • 70 y/o
      • 2023/07/10 vice president Dr. Hsu’s VIP, A 2-3 cm panc head tumor referred for management
      • PI: Bw loss (+/-), GOT/GPT=841/1065, ALP=77, GGT=686, Bil(T)=1.9 mg/dl, Albumin=3.8 g/dl
      • She went to XinYing ChiMei Hospital where she is told to have panc tumor
      • PHx : HTN (-) DM (-) Op (-)
      • Drug allergy : (-)
    • O
      • PE: soft abdomen and anicteric sclera

[surgical operation]

  • 2023-07-31
    • Surgery
      • whipple op with partial gastrectomy
      • S4b/5 partial hepatectomy
      • LNstation 5,6,8,12,13 dissection
    • Finding
      • 4 x 3.5 x 3.5 cm head tumor at pancreatic head
      • regional LN enlarge at 12
      • 1.2 x 1.2 x 1.0cm tumor at S4b/5
      • ascite(-)
      • seeding(-)

[chemotherapy]

  • 2023-10-27 - oxaliplatin 50mg/m2 85mg D5W 250mL 2hr + irinotecan 100mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-09 - oxaliplatin 50mg/m2 85mg D5W 250mL 2hr + irinotecan 100mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRINOX, DC 5-FU bolus, due to neutropenia was noted, post last time C/T)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-14 - oxaliplatin 50mg/m2 85mg D5W 250mL 2hr + irinotecan 100mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

700948807

231027

[exam findings]

  • 2023-08-31 C-spine AP + Lat
    • Disc space narrowing and posterior spur at C3-4-5-6-7
  • 2023-08-02 CT - abdomen
    • History and indication: D-colon cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Colon cancer s/p operation.
      • A nodule (5mm) at LLL.
      • Duodenal diverticulum.
      • Increased density of bil. breasts and lungs.
      • Liver and renal cysts (up to 1.6cm).
      • Retroversion of uterus.
      • Atherosclerosis of aorta, iliac arteries.
      • Disc space narrowing at L4/5.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Colon cancer s/p operation.
      • A nodule (5mm) at LLL.
  • 2023-06-07, -03-22 CXR
    • Atherosclerotic change of aortic arch
    • S/P metalic autosuture at right upper lung with lung volume decrease.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-15 All-RAS + BRAF mutation
    • ALL-RAS: Detected (KRAS codon 13 GGC>GAC, p.G13D)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-02-23 CXR
    • s/p right chest tube in place, its tip directed medially, projecting over 6th intercostal space
    • atelectasis of RUL
  • 2023-02-21 Patho - lung total/lobe/segmental
    • PATHOLOGIC DIAGNOSIS
      • Lung, RUL, VATS RS2 segmentectomy — Metastatic adenocarcinoma, colorectal origin
      • Lymph node, LN 7, right, dissection — Negative for malignancy ( 0 / 3 )
      • Lymph node, LN 11, right, dissection — Negative for malignancy ( 0 / 6 )
      • Lymph node, LN 12, right, dissection — Negative for malignancy ( 0 / 4 )
      • AJCC 8th edition pathology stage (for colon cancer): pTxN0M1a; AJCC stage IVA
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure(s): VATS RS2 segmentectomy
      • Specimen Type:
        • Location: Right upper lobe
        • Lymph node dissection: yes (specify): LN7, LN 11, LN 12
      • Specimen Integrity: intact
      • Specimen Size: Greatest dimensions: 10x 5 x 2.5 cm
      • Tumor Site: Right upper lobe
      • Tumor number: Multiple (Number:2 )
      • Tumor Size: Greatest dimension: 0.6 cm and 0.2 cm, respectively
      • Gross tumor patterns:poorly defined
      • Gross Tumor Extension (specify) : Not identified
      • All for sections are taken and labeled as: F2023-70FS:tumor, F2023-70A1:tumor, F2023-70A2-13”RUL, A:LN7, B:LN11, C:LN 12
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Metastatic adenocarcinoma, colorectal origin
      • Histologic Grade: G2: Moderately differentiated
      • Microscopic Tumor Extension: not identified
      • Margins: Margins free, Distance from closest margin: 2 cm
      • Visceral Pleura Invasion: not identified
      • Lymph-Vascular Invasion: present
      • Perineural Invasion: not identified
      • Regional lymph Nodes:
        • Number examined: 13
        • Number involved: 0
      • Ancillary Studies: IHC stain — CK20(+), TTF-1(-), Napsin A(-), CK7(-)
  • 2023-02-19 CXR
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • Blunting of left costophrenic angle due to pleural thickening
    • a small nodular opacity over medial RUL
    • extensive increased opacity over Lt and Rt lower lung zonesdue to breast shadows
    • partial atelectasis with bronchiectasis of inferior lingular segment
  • 2023-02-09 SONO - abdomen
    • Propable liver cyst, left
    • Suspected fatty infiltration of pancreas
  • 2023-02-07 CT - chest
    • a well-defined RUL solid nodule, increase in size (from 6mm to 8mm), and statonary of bronchiectasis and bronchiolitis at lingula, and several subpleural reticular opacities at LLL as compared with previous CT on 2022/11/03.
  • 2022-11-09 Barium Enema
    • Double contrast study of LGI series revealed:
      • The contrast medium passage from anus to terminal ileum smoothly without obstruction.
      • S/P operation.
      • Colonic diverticula.
    • IMP: S/P operation. Colonic diverticula.
  • 2022-11-03 CT - abdomen
    • History and indication: Colon cancer at splenic flexure
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Colon cancer s/p operation.
      • A nodule (6mm) at RUL.
      • Duodenal diverticulum.
      • Increased density of bil. breast.
      • Liver and renal cysts (up to 1.6cm).
      • Atherosclerosis of aorta, iliac arteries.
      • Disc space narrowing at L4/5.
    • IMP:
      • Colon cancer s/p operation.
      • A nodule (6mm) at RUL.
  • 2022-05-05 SONO - abdomen
    • Diagnosis:
      • Propable liver cyst,left
      • Suspected fatty infiltration of pancreas
      • Propable left renal cyst
    • Suggestion:
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • 2021-11-04 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Large intestine, splenic flexure colon, SILS left hemicolectomy —- Adenocarcinoma, moderately differentiated
      • Resection margins: free
      • Lymph node, mesocolic, dissection — Negative for malignancy (0/12)
      • Lymph node, IMA / SMA, dissection —- N/A.
      • Pathology stage: pT3N0(if cM0); AJCC stage IIA
    • MACROSCOPIC EXAMINATION
      • Operation procedure: SILS left hemicolectomy
      • Specimen site:splenic flexure colon
      • Specimen size: colon: 15 cm in length
      • Tumor size: 2.5 cm
      • Tumor location: 3.5cm away from the closest resection margin
      • Depth of invasion grossly: perirectal soft tissue
      • Mucosa elsewhere: Not remarkable
      • Representative sections and labeled: A1-2:bilateral margins, A3-6:LNs, A7-10:tumor
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: moderately differentiated
      • Depth of invasion: pericolorectal tissue
      • Angiolymphatic invasion: Present
  • 2021-11-01 CT - chest
    • LLL curvilinear opacity (11 mm), focal atelectasis or a primary nodule, no lung metastasis, suggest f/u CT at 6 to 12 months later.
    • lingular bronchiectasis.
  • 2021-11-01 SONO - abdomen
    • Liver cyst.
    • Hypoechoic nodule, 0.98x0.81cm in right lobe liver. Suggest follow up.
    • Right renal cyst.
  • 2021-10-28 ECG
    • Sinus bradycardia
    • Low voltage QRS of limb leads
    • Borderline ECG
  • 2021-10-20 CT - abdomen
    • History: diarrhea and abdominal pain for 3 ms. blood in stool (+). stool 3-4/day. cramp (+). fullness esp post meal. 2021/10/13 colonoscopy: One huge ulcerative tumor at just proximal to splenic flexure colon
    • Indication: colon cancer, splenic flexture, CT for staging
    • Findings:
      • There is soft tissue mass measuring 2 cm in the splenic flexure colon that is compatible with adenocarcinoma.
        • In addition, there are two lymph nodes in the adjacent mesocolon that may be metastatic nodes.
      • There is an ill-defined small poor enhancing nodule 5 mm in S8 of the liver that may be flow artifact, cyst or tumor. Please correlate with sonography.
      • A hepatic cyst measuring 1.6 cm in S2 is noted.
      • Two renal cysts 0.8 cm and 1 cm in left upper pole are noted.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N1b (N_value) M:M0 (M_value) STAGE:IIIB(Stage_value)
  • 2021-10-14 Patho - colorectal polyp
    • Colon tumor, 45-42 cm from anal verge, biopsy — Adenocarcinoma
    • Microscopically, the sections show a picture of adenocarcinoma characterized by cribriform or glandular tumor cell infiltrate with focal necrosis and desmoplasia.
    • Immunohistochemistry shows CDX-2(+); MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor cells.
  • 2021-10-13 Colonoscopy
    • Colon polyp, A-colon, s/p biopsy removal (A)
    • Highly suspect colon cancer, just proximal to splenic flexure(occupied 45 to 42cm from AV), s/p biopsy (B)
    • Colon polyp, S-colon, s/p hot snare polypectomy (C)
    • Internal hemorrhoid

[MedRec]

  • 2022-02-10 SOAP Colorectal Surgery
    • 20220210 UFT discotinue due to general malaise and poor appetite

[surgical operation]

  • 2023-02-20
    • Surgery
      • VATS RS2 segmentectomy + LND.
    • Finding
      • One nodular lesion was noted over RS2 of RUL, size about 1.5cm in diameter.
      • Frozen section: adenocarcinoma.
      • One 20 Fr. straight chest tube was inserted via right 5th ICS.
  • 2021-11-03
    • Surgery
      • SILS left hemicolectomy        
    • Finding
      • splenic flexure tumor, T3N1bMx Stage: IIIB
      • Anastomosis by GIA 75/4.8mm *2

[immunochemotherapy]

  • 2023-10-26 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-22 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-17 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-26 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-22 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-21 - irinotecan 150mg/m2 200mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-30 - irinotecan 120mg/m2 180mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-11-22 ~ 2021-12-27, 2022-02-07 ~ 2022-06-09 - UFT (tegafur 100mg, uracil 224mg) 2# BID

==========

2023-10-27

Upon reviewing both PharmaCloud and HIS5 records, no medication discrepancies were detected. However, PharmaCloud indicates that the patient visited MinSheng Hospital and received a diagnosis of an unspecified UTI on 2023-10-18. It may be prudent to verify that the UTI has been resolved.

2023-08-08

Dipeptiven ref: https://www.fresenius-kabi.com/nz/documents/Dipeptiven_Datasheet.pdf

  • Dipeptiven should be mixed with a compatible amino acid carrier solution or an amino acid containing infusion regimen prior to administration. Patients with total enteral nutrition Dipeptiven is continuously infused over 20-24 hours per day.

2023-06-27

  • Based on the information in the PharmaCloud database, our hospital has been the exclusive provider of all necessary medical services and medications for this patient for the past three months. All current medications have been prescribed by our hemato-oncology department. Therefore, no medication reconciliation issues have been identified.

  • The recent lab results indicate a decreasing trend in the patient’s CEA level, potentially suggesting that the current regimen of FOLFIRI plus Avastin is effective. On the other hand, the gradually increasing CA199 level could imply a condition related to the pancreas, which aligns with the abdomen sonography conducted on 2023-02-09 suggesting suspected fatty infiltration of the pancreas? The latest lab results from 2023-06-26 showed normal readings in CBC, electrolytes, and renal and liver functions. The dosage of irinotecan in the FOLFIRI regimen has been increased to a regular dose (180mg/m2) during this hospitalization. No adjustments to the medication dosage are currently required.

    • 2023-06-16 CEA 2.54 ng/mL
    • 2023-05-05 CEA 3.14 ng/mL
    • 2021-10-20 CEA 10.61 ng/mL
    • 2023-06-16 CA199 109.70 U/mL
    • 2023-05-05 CA199 91.76 U/mL

700948877

231027

{Left overain cacner, High grade serous carcinoma, with liver mrtastasis, s/p Debulking surgery}

[lab data]

2022-05-15 HCV Genotyping Test HCV Not Detected
2022-05-13 HCV RNA-PCR (quantative) Target Not Detected IU/mL

2022-05-12 HBsAg Nonreactive
2022-05-12 HBsAg (Value) 0.41 S/CO
2022-05-12 Anti-HBc Reactive
2022-05-12 Anti-HBc-Value 6.22 S/CO
2022-05-12 Anti-HBs 0.79 mIU/mL
2022-05-12 Anti-HCV Reactive
2022-05-12 Anti-HCV Value 15.23 S/CO

[exam findings]

  • 2023-08-16 SONO - abdomen
    • Diagnosis:
      • Fatty liver, mild
      • Liver tumor, S8, r/o hemangioma or metastasis
      • GB stone
      • suspicious, Renal stone, right
    • Suggestion:
      • encourage exercise and diet adjustment.
      • correlate with other image study.
  • 2023-07-01 CT - abdomen
    • Impression:
      • S/P hysterectomy and oophorectomy.
      • Liver tumors in S7 and S8, r/o liver metastasis, mild progression.
      • R/O lymphocele in right pelvic cavity.
      • Gallbladder stones.
      • Small lung nodule in right lower lung, stationary.
  • 2023-04-15 Gynecologic Ultrasonography
    • No obvious uterine or ovarian lesion
  • 2023-04-01 CT - abdomen
    • Findings
      • s/p hyesterectomy and salpingo-oophorectomy.
      • A poor enhancing lesion, 0.9cm, in S8 of liver.
      • Para-aortic lymph node metastasis, stationary.
      • No evidence of bowel obstruction.
      • A cystic lesion, 3.6cm, in right inguinal region, stationary.
      • No bony destructive lesion on these images.
    • Impression
      • Ovarian cancer, s/p operation
      • Liver and lymph node metastasis with stable disease
  • 2022-12-23 CT - abdomen
    • Findings: Comparison prior CT dated 2022/05/04.
      • S/P hysterectomy, oophorectomy, and omentum resection.
      • Prior CT identified two metastases 3 cm in S7 and 1.4 cm in S8 of the liver capsule area are noted again, decreasing in size that are c/w liver metastases S/P C/T with partial response.
        • In addition, prior CT identified a metastasis 0.7 cm in S8 of the liver dome is noted again, become calcification that is c/w metastasis S/P C/T with complete response.
      • Prior CT identified several metastatic nodes in para-aortic space are noted again, decreasing in size that are c/w metastatic nodes C/T with partial response.
      • There is mild wall thickening of left rectus sheath muscle at middle pelvis (Srs:303 Img:106) that may be tumor seeding or post-operative change. Follow up is indicated.
      • There is a cystic lesion 4 cm in right pelvis that may be lymphocele.
      • There is are few gallstones.
      • There is no focal abnormality in the biliary system, pancreas, spleen & both kidney.
    • Impression:
      • Liver and LNs metastases S/P C/T show partial response.
      • There is mild wall thickening of left rectus sheath muscle at middle pelvis that may be tumor seeding or post-operative change. Follow up is indicated.
      • Lymphocele 4 cm in right pelvis is highly suspected.
  • 2022-12-23 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A (minimal)
      • Superficial gastritis
    • Suggestion:
      • PPI use
  • 2022-09-14 Gynecologic Ultrasonography
    • ATH + BSO
    • IMP: Suspect RT adnexal cyst: 49x29mm
  • 2022-06-29 SONO - abdomen
    • Liver tumor, S4 and S7, suspected hemangioma
    • GB stone
  • 2022-06-16 Pure tone audiometry, PTA
    • Reliability FAIR
    • Average RE 36 dB HL; LE 31 dB HL.
    • R’t normal to moderately severe SNHL.
    • L’t normal to moderate SNHL. - 2022-06-13 CXR
    • Blunted right costophrenic angle.
  • 2022-05-19 Patho - ovary (tumor)
    • Diagnosis:
      • Lymph node, right iliac, dissection — Negative for malignancy (0/4)
      • Soft tissue, right iliac, excision — Metastatic serous carcinoma
      • Lymph node, right obturator, dissection — Negative for malignancy (0/5)
      • Lymph node, left iliac, dissection — Negative for malignancy (0/4)
      • Uterus, corpus, total hysterectomy — Negative for malignancy — Leiomyoma
      • Uterus, cervix, total hysterectomy — Negative for malignancy
      • Uterus, endometrium, total hysterectomy — Negative for malignancy
      • Ovary, right, oophorectomy — Metastatic serous carcinoma seeding on serosa
      • Fallopian tube, right, salpingectomy — Metastatic serous carcinoma seeding on serosa
      • Ovary, left, oophorectomy — High grade serous carcinoma
      • Fallopian tube, left, salpingectomy — Serous tubal intraepithelial carcinoma
      • Peritoneum, excision — Metastatic serous carcinoma
      • Omentum, infracolic omentectomy — Metastatic serous carcinoma
      • AJCC 8th edition: pStage IIIC, pT3cN0(if cM0), FIGO Stage: IIIC
        • or pStage IVB, pT3cN0(if cM1b), FIGO Stage: IVB
    • Microscopic Description:
      • Histologic Type:
        • Left ovary: High-grade serous carcinoma; The immunohistochemical stains reveal CK(+), PAX8(+), p53(aberrant expression (complete loss of expression)), WT-1(+), PR(-), and Napsin A(-).
        • Left fallopian tube: Serous tubal intraepithelial carcinoma (STIC) (0.2 x 0.1 mm)
      • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors): not available
      • Implants (required for advanced stage serous/seromucinous borderline tumors only): not available
      • Other Tissue/ Organ Involvement (select all that apply): bilateral ovaries and fallopian tubes, peritoneum, omentum, right iliac soft tissue
      • Largest Extrapelvic Peritoneal Focus (required only if applicable): Macroscopic (greater than 2 cm)
      • Peritoneal/Ascitic Fluid: N2022-01890: Negative for malignancy (normal/benign)
      • Regional Lymph Nodes: right iliac: 0/4; right obturator: 0/5; left iliac: 0/4
      • Additional Pathologic Findings: Leiomyomas are seen.
  • 2022-05-19 Patho - colorectal polyp
    • Colon, D-colon, s/p hot snare polypectomy — Tubulovillous adenoma with low grade dysplasia.
  • 2022-05-19 Patho - stomach biopsy
    • Stomach, low body, GC, s/p biopsy removal — Hyperplastic polyp
  • 2022-05-11 Gynecologic Ultrasonography
    • Pelvis mass: (1) 146x108mm, (2) 34.20mm
  • 2022-05-05 Gynecologic Ultrasonography
    • Multiple huge pelvic mass, the largest one is about 11.4x9.4cm without flow
  • 2022-05-04 CT - liver, spleen, biliary duct, pancreas
    • Findings:
      • There is a well-defined lobulated heterogeneous mass in the uterine fossa, measuring 14.2 cm in size (the largest dimension), and non-visualization of the normal uterus.
        • Leiomyosarcoma of the uterus is highly suspected.
        • The differential diagnosis include ovarian cancer.
        • Please correlate with CA125.
      • There is ascites and smudggy appearance of the omentum that may be carcinomatosis? Please correlate with ascites cytology.
      • There are two well-defined poor enhancing masses measuring 3 cm in S7 and 1.4 cm in S8 of the liver capsule area with capsule defect that may be tumor seeding with indentation the liver capsule.
        • The differential diagnosis include liver metastases.
      • There is are several enlarged nodes in para-aortic space that may be metastatic nodes.
      • S/P Chest tube insertion, right.
        • Mild left side Pleura effusion is noted.
    • Impression:
      • Leiomyosarcoma of the uterus is highly suspected.
        • The differential diagnosis include ovarian cancer.
        • Please correlate with CA125.
      • Carcinomatosis is highly suspected.
        • Please correlate with ascites cytology.
      • Tumor seeding in S7 & S8 of the liver capsule are suspected.
        • The differential diagnosis include liver metastases.
      • Metastatic nodes in para-aortic space are suspected.
  • 2022-05-04 CXR
    • resolution of Rt pleural effusion s/p chest tube and pigtail drain placement
    • small Lt pleural effusion
  • 2022-05-03 SONO - abdomen
    • IMP: Gallbladder stones (0.74cm, 0.76cm, 0.70cm).
  • 2022-05-02 Patho - lung wedge biopsy
    • Pleura, right, excision — chronic inflammation
    • Pleura, right, cyst, excision — cyst with chronic inflammation
    • Lung, RLL, wedge resection — pleural fibrosis and chronic inflammation
  • 2022-05-02 CXR
    • signficiant regression of Rt pleural effusion s/p chest tube and pigtail drain placement
    • small Lt pleural effusion
  • 2022-05-01 CXR
    • progression of moderate Rt pleural effusion as compared with previous image
    • thoracic aortic arch calcified atheriosclerotic plaque
    • small Lt pleural effusion
  • 2022-04-22 CT - lung/mediastinum/pleura
    • Massive right pleural effusion and mild left pleural effusion with consolidation over right lower lobe and left lower lobe
    • Hepatic low density lesion.
  • 2022-04-13 CXR
    • regression of Rt pleural effusion as compared with previous image
    • Linear band subsegmental atelectasis at Lt lung base
    • Thoracic aortic arch calcified atheriosclerotic plaque
  • 2022-04-06 Cell block cytology
    • pathologic diagnosis
      • Dense inflammation, reactive change
    • macroscopic examination
      • 50 cc red turbid right pleural effusion
    • microscopic examination
      • Immunocytochemistry shows TTF-1(-), Napsin-A(-), P40(-), CK7(-) and calretinin(-) for carcinoma.
  • 2022-04-06 CXR
    • moderate Rt pleural effusion
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • mild enlarged cardiac silhoutte
    • mild levoscoliosis of the spine
  • 2022-04-06 SONO - chest
    • pleural effusion, moderate to massive, right
    • consolidation, RLL
  • 2022-04-01 Bronchodilator test, BT
    • Moderate restrictive lung defect without significant reversibility
  • 2022-03-30 SONO - abdomen
    • parenchymal liver disease
    • liver hemangioma, S8
    • GB stone
    • pancreatic head masked by gas
    • ascites, minimal
    • pleural effusion, bilateral
  • 2022-03-22 Thyroid Ultrasound
    • Goiter
  • 2022-03-03 SONO - chest
    • pleural effusion, trivial amounts
    • high risk of pneumothorax during chest tapping
    • hold chest tapping procedure
  • 2022-03-02 CXR
    • Rt subpulmonary effusion or Linear band subsegmental atelectasis at lung base
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
    • mild levoscoliosis of the spine
  • 2021-09-29, 2021-03-01, 2020-08-03, 2020-02-23 SONO - abdomen
    • Diagnosis
      • GB stones
      • Hepatic tumor, suspect hemangioma, S8
      • Probable parenchymal liver disease
      • Suspect renal stones, right
    • Suggestion
      • Please follow sonography in 3-6 mon
      • Please check tumor, hepatitis markers and LFTs q3-6 mon
  • 2018-08-28 CT - abdomen
    • Small heaptic lesion at surface up to 1.9cm with marginal enhancement and filling in change is found. Hemangioma is considered.
  • 2019-07-29, 2019-01-28, 2018-07-30, 2018-01-10 SONO - abdomen
    • Parenchymal liver disease
    • Liver tumor, nature?
    • Fatty infiltration of pancreas
    • GB stones
  • 2017-06-26 SONO - abdomen
    • Diagnosis
      • suspect liver parenchyma disease, incomplete exam of liver
      • liver tumor suspected hemangioma
      • gallstones
  • 2017-01-09 SONO - abdomen
    • Suspected, Parenchymal liver disease
    • GB stone
    • Suspected, Parenchymal renal disease

[MedRec]

  • 2023-08-16 SOAP Gastroenterology
    • Prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
  • 2022-06-08 SOAP Hemato-Oncology Xia HeXiong
    • Plan
      • Arrange Port-A insertion
      • Admission for 24 houirs CCr, audiometry and then C/T with TP
  • 2022-05-17 ~ 2022-05-23 POMR Obstetrics and Gynecology Zeng LunNa
    • Discharge diagnosis
      • Malignant neoplasm of left ovary
      • Left ovarian serous carcinoma, pT3cN0(if cM1b), FIGO Stage: IVB post Debulking surgery on 2022/05/19
      • Acute posthemorrhagic anemia due to blood lose about 1200 ml
    • CC
      • Accidentally found the pelvic mass, during last hospitalization   - Present illness
      • This is a 69 y/o woman with G3P3 and LMP at 54y/o. She had past history of (1) pleural effusion s/p 3D VATS RLL wedge + pleurodesis + pleural biopsy for pleural effusion with benign pathology report. Spotting was noted once 2 weeks ago and no bleeding was mentioned. Other associated symptoms included urinary frequency, weight loss and right lower abdominal dullness. There were no pale conjunctiva, dyspnea, general malaise, orthostatic hypotension ,nausea, vomiting, no tarry/bloody stoool and brittle nails noted.
      • During last hospitalization, abdominal CT done on 2022.05.04 and leiomyosarcoma of the uterus was highly suspected. Therefore, she was tranferred to our GYN OPD for help. The GYN echo done on 2022.05.11 revealed pelvic mass (1) 14.6cmx10.8cm and (2) 3.4x2.0cm. Tumor marker was examinated on the same day and showd CA125 = 678.3 U/mL; CA199 = 5.98 U/mL; CEA = 0.42 ng/mL.
      • Under the impression of leiomyosarcoma, she was admitted on 2022.05.17 for debulking surgery.
    • Course of inpatient treatment
      • The patient was admitted on 2022/05/17 and underwent debulking surgery with abdominal hysterectomy+bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + infracolic omentectomy on 2022/05/19. Due to blood loss 1200 ml and blood transfusion LP-RBC 4U and FFP 4U were given during operation.
      • We provided cefazolin IV form for 2 day and then shifted her antibiotics to cephalexin oral form. Post-operation wound was dry and clean without dehiscence, discharge, nor oozing. Her lab data on 2022/05/20 also showed no specific positive findings. Since all her general conditions were all improved and relatively stable, she discharged and she will have her OPD follow up next week.     
    • Discharge prescription
      • Keto (ketorolac 10mg) 1# QID
      • MgO 250mg 1# QID
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# QID
      • cephalexin 500mg 1# QID
      • Cough Mixture (platycodon) 10mL QID
      • Anxiedin (lorazepam 0.5mg) 1# HS
  • 2022-05-01 ~ 2022-05-05 POMR Thoracic Surgery Xie MinXiao
    • Discharge diagnosis
      • Right pleural effusion status post three dimensional video-assisted thoracic surgery right lower lung wedge resection and pleurodesis and pleural biopsy on 2022-05-02
    • CC
      • Chest pain and exertional dyspnea for several months
    • Present illness
      • This is a 69 y/o woman who has no known systemic disease. She was a smoker who has been smoking cigarrete 1/2 ppd for 10 years. Chest pain and exertional dyspnea were noted in the past few months. The patient denied dyspnea, cough, running nose, fever nor chillness. As a result, she came to our hospital for help.
      • At the OPD of Chest Medicine, physical examination revealed decreased breathing sound in right lung field and regular heart sound. Chest X-ray showed RUL nodule and right pleural effusion. Chest sonography showed right trivial pleural effusion. Thoracentesis was done and pleural fluid analysis revealed exudate lymphocyte predominant. Pulmonary function test revealed FVC55%, compatable with lung restriction.
      • Under the impression of right pleural effusion, the patient was admitted to our ward for 3D VATS RLL wedge resection + pleurodesis + pleural biopsy.
    • Course of inpatient treatment
      • During admission, her vital signs were stable. 3D VATS RLL wedge + pleurodesis + pleural biopsy was done on 2022/05/02. She tolerated the procedure well and no discomfort was complained afterwards. Under stable condition, she will be discharged on 2022/05/05 and will be followed up at OPD.        

[consultation]

  • 2022-05-04 Obstetrics and Gynecology
    • Q
      • This 69 y/o woman with past hx of uterine myoma was admitted due to right pleural effusion. Three dimensional video-assisted thoracic surgery with right lower lung wedge resection, pleurodesis and pleural biopsy was done on 2022-05-02.
      • Urinary frequency was noted inrecent months. Body weight loss 5 kg was noted in 2 months. She denied abdominal pain, fullness, nor vaginal bleeding.
      • Abdominal CT on 2022-05-04 revealed a well-defined lobulated heterogeneous mass in the uterine fossa, measuring 14.2 cm in size (the largest dimension), and non-visualization of the normal uterus. Leiomyosarcoma of the uterus is highly suspected. The differential diagnosis include ovarian cancer.
      • Under the impression of suspected leiomyosarcoma of the uterus and ovarian cancer, we would like to consult you for evaluation.
    • A
      • S
        • 69 y/o, female, G4P3 (NSDx3)
        • Admitted on 2022/05/01 for VATS (Video-Assisted Thoracic Surgery)
        • Hx: s/p 3D VATS RLL wedge + pleurodesis + pleural biopsy on 2022/05/02
      • O
        • Abdominal CT on 5/4 revealed a well-defined lobulated heterogeneous mass in the uterine fossa
        • weight loss 5kg in 2months
        • WBC: 7510, Hb: 12.1
        • CT:
            1. Leiomyosarcoma of the uterus is highly suspected.
            • The differential diagnosis include ovarian cancer.
            • Please correlate with CA125.
            1. Carcinomatosis is highly suspected.
            • Please correlate with ascites cytology.
            1. Tumor seeding in S7 & S8 of the liver capsule are suspected.
            • The differential diagnosis include liver metastases.
            1. Metastatic nodes in para-aortic space are suspected.
            • sono: Multiple huge heterogenous pelvic mass, the largest is about 11.4x9.4cm without flow
          • CDS: no fluid
        • IMP:
          • Suspect uteine malignancy or ovarian cancer
        • P:
          • Please check CA125, CA199, CEA, SCC
          • OPD follow after 1 week

[surgical operation]

  • 2022-05-19
    • Surgery
      • Diagnosis
        • Ovarian tumor suspected malignancy with intraperitoneal seeding and liver metastasis
      • Operation
        • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy)   - Finding
      • Ovarian tumor, suspected malignancy.
      • Frozen: not performed
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, dense contact with bladder
      • Adnexa:
        • LOV: 14x10cm, capsule intact, adhesion to bowels and posterior uterine wall; intraoperative rupture (+) with papillary contents and necrotic tissue.
        • ROV: 5x4 cm, capsule not intact,adhesion to bowels and posterior uterine wall; intraoperative rupture (+) with papillary contents
        • Fallopian tube: bilateral engorged
      • CDS: invisible due to tumor mass occupied, totally obliterated
      • Ascites: bloody, about 300 ml, cytology was performed
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
        • s/p dissection of right iliac LNs, right obturator LNs and left iliac LNs
      • Omentum: infracolic omentectomy was done.
      • Liver: miliary tumor seeding(+), bean sized over liver surface
        • Subdiaphragmatic surface: miliary tumor seeding(+), bean sized
      • Appendix: not seen
      • After the operation, suboptimal debulking surgery was achieved.
      • Residual tumor: multiple tumor seeding over rectum, peritoneal wall s/p partial excision; suspected liver and subdiaphragmatic miliary tumor seeding
      • Partial intestine bowels adhesion
      • Due to the intestine was soaking in the ascites fluid, inflammation was noticed
      • Estimated blood loss: 1200ml (neovascular oozing)
      • Blood transfusion:s/p blood transfusion with pRBC 2u
      • Complication: none       
      • abdominal drainage tube x1 at right CDS
  • 2022-05-02
    • Surgery
      • 3D VATS RLL wedge + pleurodesis + pleural biopsy.
    • Finding
      • One nodualr lesion was noted over RLL, suspected intrapulmonary LN. A mount of pleural effusion was also noted over right pleural cavity, about 1450mL.
      • One 24 Fr. straight chest tube and 14 Fr. pig-tail was inserted via right 8th ICS.

[chemotherapy]

  • 2023-10-26 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 400mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-09-27 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 400mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-08-31 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 400mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-08-03 - paclitaxel 140mg/m2 200mg NS 500mL 3hr + carboplatin AUC 4 450mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-07-15 - paclitaxel 140mg/m2 200mg NS 500mL 3hr + carboplatin AUC 4 450mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-06-30 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2023-06-16 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2023-05-30 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2023-04-27 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2023-03-31 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2023-03-08 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2023-02-17 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2023-01-30 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2022-12-23 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2022-12-02 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2022-11-11 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2022-10-24 - bevacizumab 15mg/kg 600mg NS 400mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2022-09-29 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-09-08 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-09-19 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-08-02 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-07-08 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-06-17 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2023-10-27

After reviewing the PharmaCloud and HIS5 records, no concerns were found.

The CA125 levels have been within the normal range since 2022-09-09. Following a CT scan on 2023-07-01 that indicated mild progression of liver metastasis, paclitaxel and carboplatin were reintroduced at a reduced dosage compared to their administration (x6) in 2022 Jun to Sep. The latest lab results are generally within normal limits.

701208485

231027

{pancreatic cancer T4N1M0 stage III}

[exam findings]

  • 2023-08-28 MRI - pancreas

    • History and indication: Pancreatic cancer
    • With and without contrast MRI of pancreas revealed:
      • S/P CBD stenting with artifact. Mild dilatation of IHD.
      • Pancreatic head cancer (2.3cm) with distal p-duct dilatation.
      • Tiny liver cysts.
      • Mild splenomegaly. Small caliber of intrahepatic portal vein.
    • IMP:
      • S/P CBD stenting with artifact. Mild dilatation of IHD.
      • Pancreatic head cancer (2.3cm) with distal p-duct dilatation.
      • Mild splenomegaly.
  • 2023-08-17 EGD

    • ERBD, Bonastent(SEMS), insitu
    • Post status IHD plastic stent removal
    • Duodenal shallow ulcers
  • 2023-08-13 ERCP (Endoscopic Retrograde CholangioPancreatography)

    • Biliary stricture s/p removal of SEMS & s/p ERBD (Bonastent(SEMS) placement in right IHD, plastic stent in left IHD)
    • Chronic cholangitis
  • 2023-05-26 MRI - pancreas

    • Findings:
      • S/P metalic stent implantation at CHD and CBD, causing artifact in the surrounding area.
        • The distal end of this stent may be retracted from the duodenum into the distal CBD. please correlate with clinical condition.
      • There is mild dilatation of IHDs. please correlate with clinical condition.
      • Prior MRI identified adenocarcinoma of the pancreatic head and body is noted again, stationary.
        • Total encasement of splenic vein and the trifurction of splenic vein, superior mesenteric vein, and portal vein is still noted.
      • The trifurcation of celiac trunk, common hepatic artery and splenic artery shows small size that is c/w tumor encasement.
      • A renal cyst measuring 0.8 cm in right upper pole is noted.
    • Impression:
      • Prior MRI identified adenocarcinoma of the pancreatic head and body is noted again, stationary. Follow up contrast enhanced dynamic CT 3 months later is indicated.
  • 2023-02-13 MRI - pancreas

    • Findings
      • S/P CBD stenting with artifact. Mild dilatation of IHD.
      • Pancreatic head cancer (2.3cm) with p-duct stenting.
      • Tiny liver cysts.
    • IMP:
      • S/P CBD stenting with artifact. Mild dilatation of IHD.
      • Pancreatic head cancer (2.3cm) with p-duct stenting.
  • 2023-02-10 PET scan

    • Mild glucose hypermetabolism in the head and body of the pancreas. Residual malignancy should be watched out. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the central portion of the uterus. Either hyperemia or inflammation may show this picture.
    • Increased FDG accumulation in both kidneys. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-01-09 T - L spine AP + Lat.

    • S/P metalic stent implantation from IHD to duodenum.
  • 2022-12-26 ERCP (Endoscopic Retrograde CholangioPancreatography)

    • Biliary stricture s/p removal of SEMS & s/p Kaffet stent placement (8mm x 50mm)
    • Choledocholithiasis s/p retrieval balloon removal
    • Chronic cholangitis
  • 2022-12-23 CT - abdomen

    • Findings
      • S/P metalic stent implantation at CHD and CBD.
        • The distal end of this stene may be retracted from the duodenum into the distal CBD.
        • In addition, There is moderate dilatation of IHDs and CHD.
        • Obstruction of the stent is highly suspected.
      • S/P pigtail catheter implantation at the gallbladder
      • Prior CT identified adenocarcinoma of the pancreatic head and body is noted again, stationary.
        • Total encasement of splenic vein and the trifurction of splenic vein, superior mesenteric vein, and portal vein is still noted.
      • The trifurcation of celiac trunk, common hepatic artery and splenic artery shows small size that is c/w tumor encasement.
      • A renal cyst measuring 0.8 cm in right upper pole is noted.
    • Impression:
      • Obstruction of the stent in the CHD and CBD is noted.
      • Prior CT identified adenocarcinoma of the pancreatic head and body is noted again, stationary.
  • 2022-12-22 Percutaneous transhepatic gallbladder drainage, PTGBD

  • 2022-12-22 SONO - abdomen

    • Pancreatic cancer in resolution, neck part (proved by EUSFNB)
    • CBD obstruction s/p SEMS
    • Parenchymal liver disease
    • splenomegaly
  • 2022-12-07 KUB

    • S/P metalic stent implantation from IHD to duodenum.
    • Non-specific bowel gas pattern in the middle abdomen is noted. please correlate with clinical condition or CT.
    • Fecal material store in the colon.
  • 2022-12-06 ECG

    • Sinus tachycardia
    • Right axis deviation
  • 2022-10-29 CT - abdomen

    • Findings
      • Pancreatic head cancer (2.1cm, mild regression).
      • S/P CBD stenting. Wall thickening of gallbladder. Dilatation of bil. IHDs.
      • Right renal cyst (0.9cm).
      • Left liver cyst (0.3cm).
    • IMP:
      • Pancreatic head cancer (2.1cm, mild regression).
      • S/P CBD stenting. Dilatation of bil. IHDs. Wall thickening of gallbladder.
  • 2022-08-23 CT - abdomen

    • Findings
      • S/P biliary stenting. Stationary pancreatic head tumor as compare with CT study on 2022-06-23.
      • Right renal cyst, 0.8cm.
      • Cystic lesion, 2.8cm in left adnexa, r/o left ovarian cyst.
    • Impression:
      • Pancreatic head cancer, s/p stenting, with stationary.
      • Right renal cyst.
      • R/O left ovarian cyst.
  • 2022-06-23 CT - abdomen

    • Findings
      • Pancreatic head cancer (2.8cm, stable).
      • S/P CBD stenting. Wall thickening of gallbladder. Left portal vein thrombosis.
      • Right renal cyst (0.9cm).
      • Left liver cyst (0.3cm).
    • IMP:
      • Pancreatic head cancer (2.8cm, stable).
      • S/P CBD stenting. Left portal vein thrombosis.
  • 2022-05-24 KUB

    • S/P metalic stent implantation from IHD to duodenum.
    • Non-specific bowel gas pattern in the middle abdomen is noted. please correlate with clinical condition or CT.
  • 2022-04-11 CT - abdomen

    • Findings
      • Pancreatic head cancer (2.8cm).
      • S/P CBD stenting. Wall thickening of gallbladder. Left portal vein thrombosis.
      • Right renal cyst (0.9cm).
      • Left liver cyst (0.3cm).
    • IMP:
      • Pancreatic head cancer (2.8cm).
      • S/P CBD stenting. Wall thickening of gallbladder. Left portal vein thrombosis.
  • 2022-02-21 KUB

    • S/P metalic stent implantation from IHD to duodenum.
  • 2022-02-16 KUB

    • S/P biliary stenting?
    • Non-specific bowel gas pattern.
    • Calcifications in the pelvic cavity, could be due to phleboliths.
    • Mild lumbar spondylosis.
  • 2022-01-24 ERCP (Endoscopic Retrograde CholangioPancreatography)

    • biliary obstruction s/p SEMS
    • chronic cholangitis
  • 2022-01-14 CT - liver, spleen, biliary duct, pancreas

    • There is filling defects at left lobe portal vein that is c/w thrombosis and the etiology may be thrombophlebitis.
    • Adenocarcinoma of the pancreatic head-body with portal vein, splenic vein, and celiac trunk encasement is suspected.
  • 2022-01-12 Patho - pancreas biopsy

    • Pancreas, head, EUSFNB — adenocarcinoma, moderately differentiated
    • Section shows pancreas tissue with infiltration of neoplastic glands in fibrous stroma.
    • IHC: CK(+)
  • 2022-01-10 ERCP (Endoscopic Retrograde CholangioPancreatography)

    • biliary obstruction s/p brushing cytology & plastic stent placement
    • chronic cholangitis
    • reflux esophagitis

[MedRec]

  • 2023-08-22 SOAP Radiation Oncology Wang YuNong
    • Plan
      • CT-simulation will be arranged according to CCRT date.
      • Plan to deliver 45 Gy/ 25 fx to the pancreatic tumor and adjacent lymphatic drainage area.
  • 2023-08-22 SOAP Hemato-Oncology Xia HeXiong
    • Plan
      • Add IV Lorazepam and Olan. Shift Atropine to 0.5 mg SC
      • CCRT with weekly CDDP and pembrolizumab during 2023-09-05 admission

[chemotherapy] (not completed)

  • 2023-10-28 - pembrolizumab 200mg NS 100mL 1hr
    • diphenhydramine 30mg + NS 250mL
  • 2023-10-04 - carboplatin AUC 1.5 150mg NS 250mL 2hr D2 (carbo AUC 1.5, CCRT)
    •                       NS 250mL D1   + dexamethasone 4mg    + palonosetron 250ug                       + aprepitant 150mg PO + lorazepam 1mg
  • 2023-09-26 - pembrolizumab 200mg NS 100mL 1hr D1 + carboplatin AUC 3 150mg NS 250mL 2hr D2 (carbo AUC 1.5, CCRT)
    • diphenhydramine 30mg D1 + NS 250mL D1-2 + dexamethasone 4mg D2 + palonosetron 250ug D2 + lorazepam 1mg D2 + aprepitant 125mg PO D2
  • 2023-09-12 - cisplatin 40mg/m2 60mg NS 500mL 3hr D1 (CDDP, CCRT)
    • diphenhydramine 30mg D1 + NS 250mL D1 + dexamethasone 4mg D1 + palonosetron 250ug D1 + aprepitant 150mg PO D1-3
  • 2023-09-05 - pembrolizumab 200mg NS 100mL 1hr D1 + cisplatin 40mg/m2 60mg NS 500mL 3hr D2 (CDDP, CCRT)
    • diphenhydramine 30mg D1 + NS 250mL D1-2 + dexamethasone 4mg D2 + palonosetron 250ug D2 + lorazepam 1mg D2 + aprepitant 125mg PO D2
  • 2023-08-09 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
    • dexamethasone 4mg D1 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + atropine 0.5mg SC D1 + lorazepam 1mg ST D1 Q12H D2 + aprepitant 125mg PO D1-3 + NS 250mL D1 + NS 500mL Q8H D2-3
  • 2023-07-11 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL] D1 + aprepitant 125mg PO D1-3
  • 2023-06-13 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL] D1 + aprepitant 125mg PO D1-3
  • 2023-05-02 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD + NS 250mL] D1
  • 2023-04-10 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD + NS 250mL] D1
  • 2023-03-20 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 115mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 675mg NS 250mL + fluorouracil 2400mg/m2 4050mg NS 500mL 46hr
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD + NS 250mL] D1
  • 2023-02-20 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 117mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 650mg NS 250mL + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD + NS 250mL] D1
  • 2023-01-11 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 115mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 650mg NS 250mL + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD + NS 250mL] D1
  • 2022-11-29
  • 2022-11-08
  • 2022-10-18
  • 2022-09-26
  • 2022-08-15
  • 2022-07-25
  • 2022-07-12
  • 2022-06-27
  • 2022-06-13
  • 2022-05-23
  • 2022-05-04
  • 2022-04-20
  • 2022-03-30
  • 2022-03-16
  • 2022-03-02
  • 2022-02-10 ~ undergoing - FOLFIRINOX + pembrolizumab

==========

2023-10-27

[leukopenia]

The WBC count hit its lowest point in 2023 on 2023-10-26 at 1.97K/uL. The latest administration of the chemotherapy drug carboplatin took place on 2023-10-04, while the most recent radiotherapy session was on 2023-10-06. Both chemotherapy and radiotherapy can lead to leukopenia.

  • 2023-10-26 WBC 1.97 x10^3/uL *
  • 2023-09-25 WBC 4.07 x10^3/uL
  • 2023-09-18 WBC 6.05 x10^3/uL
  • 2023-09-11 WBC 5.99 x10^3/uL
  • 2023-09-05 WBC 5.88 x10^3/uL

Granocyte (lenograstim) has been prescribed to address the leukopenia, which is an undisputed intervention measure.

[timely medication switch resolves creatinine spike]

There was an increase in serum creatinine levels in late Sep compared to earlier baseline data. The cisplatin administered on 2023-09-12 was changed to carboplatin on 2023-09-26. Currently, a decrease in creatinine levels is being observed, indicating that the change in medication appears to have been a timely decision.

  • 2023-10-26 Creatinine 0.72 mg/dL
  • 2023-09-25 Creatinine 1.12 mg/dL *
  • 2023-09-18 Creatinine 0.90 mg/dL
  • 2023-09-11 Creatinine 0.58 mg/dL
  • 2023-09-05 Creatinine 0.51 mg/dL
  • 2023-08-22 Creatinine 0.44 mg/dL
  • 2023-08-13 Creatinine 0.43 mg/dL
  • 2023-08-09 Creatinine 0.44 mg/dL

2023-09-27

After reviewing both the PharmaCloud database and the HIS5 records, no reconciliation issues were identified.

After the initiation of FOLFIRINOX + pembrolizumab in 2022-02, the CEA level had been remained in the single digits between 2022-06 and 2023-02.

Then platinum-based CCRT was initiated in early 2023-09, and there was a slight decrease in the double-digit CEA level.

  • 2023-09-15 CEA (NM) 14.341 ng/ml
  • 2023-08-25 CEA (NM) 14.737 ng/ml
  • 2023-07-04 CEA (NM) 12.402 ng/ml
  • 2023-06-20 CEA (NM) 10.795 ng/ml
  • 2023-04-13 CEA (NM) 11.154 ng/ml
  • 2023-02-22 CEA (NM) 12.664 ng/ml
  • 2023-02-10 CEA (NM) 7.731 ng/ml
  • 2023-01-13 CEA (NM) 8.882 ng/ml
  • 2023-01-13 CEA (NM) 9.221 ng/ml
  • 2022-11-02 CEA (NM) 7.296 ng/ml
  • 2022-08-29 CEA (NM) 6.091 ng/ml
  • 2022-06-29 CEA (NM) 3.417 ng/ml
  • 2022-06-28 CEA (NM) 4.084 ng/ml
  • 2022-04-12 CEA (NM) 12.119 ng/ml
  • 2022-02-11 CEA (NM) 37.004 ng/ml

Based on the lab results from 2023-09-25, both AST and ALT readings are < 2x ULN (silymarin in use), with an eGFR of 55. Therefore, there is no need for medication dose adjustment.

2023-09-06

Our gastroenterologist prescribed a two-month supply of Nexium (esomeprazole) on 2023-08-17, however the drug is currently absent from the active medication list. Please verify whether this drug is no longer needed for the patient’s condition.

2022-03-31

  • Pancreatic adenocarcinoma with or without BRCA1/2 or PALB2 mutations, FOLFIRINOX is preferred; this patient has been receiving this regimen since 2022-02-10.
  • Results of liver and kidney function tests reported on 2022-03-30 were normal, CBC readings were slightly lower, the latter should not be likely to affect treatment in this hospital stay.
  • No issue with current medication.

700335852

231026

[lab data]

2023-08-03 RPR/VDRL Nonreactive
2023-08-03 HBsAg Nonreactive
2023-08-03 HBsAg (Value) 0.31 S/CO
2023-08-03 Anti-HCV Nonreactive
2023-08-03 Anti-HCV Value 0.11 S/CO
2023-08-03 HIV Ab-EIA Nonreactive
2023-08-03 Anti-HIV Value 0.09 S/CO
2023-08-03 Anti-HBc Nonreactive
2023-08-03 Anti-HBc-Value 0.11 S/CO

[exam findings]

  • 2023-10-24 Aortography - thoracic
    • Diagnostic aortography was performed
    • Imaging findings:
      • Type I aortic arch.
      • No critical stenosis of bilateral proximal carotid and vertebral arteries.
  • 2023-10-24 Carotid angiography Bilat, Vertebral angiography
    • Diagnostic intraarterial angiography of brain vasculature by way of bilateral internal carotid and left vertebral arteries was performed
    • Imaging findings:
      • Short segmental moderate stenosis of left distal ICA (petrous-cavernous segment) with wall irregularity. Compatible with encasement by tumor. Suggest placement of one stent.
      • One wide-neck saccular aneurysm (neck:5.5mm, diameter:6.8mm, depth:3.3mm) over right distal ICA (petrous segment). Suggest stent-assisted coiling.
  • 2023-10-24 CT - brain
    • Cranial CT scans from the vertex to the mid-maxillary level were performed with i.v. contrast injection.
    • Impression:
      • The brain shows normal grey and white matter attenuation without evidence of focal lesion. There is no intracranial hemorrhage seen.
      • The size of the lateral and third ventricles appears normal.
      • The posterior structures including the brain stem, cerebellum and CP angles look normal.
      • Mass lesion (5.0cm) over left nasopharyngeal space. Compatible with nasopharyngeal cancer. Invasion of left carotid space by this tumor. Encasement of left ICA by this tumor. Suggest check cerebral angiography and stenting.
  • 2023-10-24 ECG
    • Atrial fibrillation with rapid ventricular response
    • Incomplete right bundle branch block
    • Nonspecific ST abnormality
  • 2023-09-20 Transrectal Ultrasound of Prostate, TRUS-P
    • Prostate
      • Size of prostate: 4.5 (T) cm x 2 (L) cm x 4.4 (AP) cm = 22 cc
      • Size of adenoma: 3.5 (T) cm x 1.6 (L) cm x 2.8 (AP) cm = 8.3 cc
    • Seminal vesicles
      • Symmetricity:
        • Size: L’t 1.1 x 0.4 cm
        • Size: R’t 1.3 x 0.4 cm
  • 2023-09-17 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Left ventricular hypertrophy
    • Nonspecific T wave abnormality
  • 2023-08-11 CT - chest
    • no neoplastic LAP in chest and abdomen.
    • extensive emphysema and interstitial fibrosis in RLL, favor smoking related lung disease. extensive 3V-CAD.
    • extensive LAP in the neck due to lymphoma.
    • chronic cystitis?
  • 2023-08-07 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
    • Section shows piece(s) of bone marrow with 30% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • 2023-08-07 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (146 - 32) / 146 = 78.08%
      • LVEF (%) = 78
      • M-mode (Teichholz) = 78
    • Conclusion:
      • Dilated LV; normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated LA; LV diastolic dysfunction Gr 2.
      • Normal RV systolic function.
      • Aortic valve sclerosis with mild AS (AVA (Doppler) = 1.79 cm² ,Mean aortic pressure gradient = 9 mmHg); moderate MR; mild TR; mild PR.
      • Marked sinus bradycardia during exam.
  • 2023-08-04 PET scan
    • The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on the same side of the diaphragm and involving multiple bone or bone marrow as mentioned above (stage IV).
  • 2023-08-02 MRI - nasopharynx
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:3(T_value) N:3(N_value) M:____(M_value) STAGE:____(Stage_value)
  • 2023-07-25 Aspiration Cytology - thyroid
    • Left neck mass — Positive for malignant tumor, in favor of lymphoma
      • NOTE: Correlation with biopsy result and clinical findings is recommended.
    • Smears show non-cohesive high-grade tumor cells with large hyperchromatic nuclei, irregular nuclear contour, mitotic activity, variable-sized nucloeli and scanty cytoplasm.
  • 2023-07-25 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopharynx, left, biopsy — Diffuse large B-cell lymphoma, non-GCB type
    • Section shows several pieces of respiratory epithelium lined tissue with infiltration of large lymphoid cells.
    • The immunohistochemical stains show CD3(-), CD20(+), CD56(-), CK(-), CD10(-), BCL2(+), BCL6(-), Cyclin D1(-), C-MYC(+), and MUM1(+). The Ki-67 is > 90%.
  • 2023-07-25 SONO - head and neck soft tissue
    • Clinical Impression/Intent: left neck level II mass
    • Sonographic Impression: left neck level II confluent LAP, R/O malignancy
    • Diagnosis: left neck level II confluent LAP, R/O malignancy, s/p FNA

[MedRec]

  • 2023-08-01 ~ 2023-08-16 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Nasopharynx diffuse large B-cell lymphoma, non-GCB type, BCL6(-), C-MYC(+) and BCL2(+), stage IV
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
      • Hyperlipidemia, unspecified
      • Insomnia, unspecified
      • Constipation, unspecified
    • CC
      • Left tinnitus with left neck mass noted for 2 months+ odynophagia and blood tinged sputum in the morning noted for 2 weeks.
    • Present illness
      • This 75-year-old man has history of diabetes mellitus and hypertension for years under regular medication control.
      • According to the patient’s statement, left neck palpable mass noted for 2 years. The left neck mass about 1cm in size initially. Due to left neck mass enlarge with left side tinnitus, left nasal blood tinged discharge noted in recent 2 months, he came to our ENT OPD for help. Physical examination revealed left nasopharyngeal tumor, left neck palpable mass 6 cm in size. Nasopharyngeal and left neck mass biopsy was done.
      • After the biopsy, left odynophagia and left headache were complained.
      • The pathology revealed diffuse large B-cell lymphoma, non-GCB type.
      • Under the diagnosis of large B-cell lymphoma, he was admitted for cancer work up.
    • Course of inpatient treatment
      • After admission, arrange a series of study and examination. The neck MRI revealed oropharynx, nasopharynx and Pterygoid structures tumor, with unilateral lymph nodes extension below the caudal border of cricoid. The whole body PET scan revealed compatible with lymphoma involving multiple lymph node regions on the same side of the diaphragm and involving multiple bone or bone marrow as mentioned above (stage IV).
      • Due to left headache persist, pain control with Volna-K 1# po q6h, Acetal 1#po prnq6h for pain control.
      • Under the impression of large B-cell lymphoma, we consult hema-oncologist for further evaluation, hepatitis and AIDS, Syphilis titer were done.
      • The hema-oncologist has explained to the family about further work up examination and the follow up treatment include bone marrow aspiration, port-A implantation and chemotherapy etc. The patient’s family agreed with the treatment plan.
      • Bone marrow was done on 2023/08/07, pathology Section shows piece(s) of bone marrow with 30% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present. Confirmed as the IV stage after discussion at the team meeting. The port-A implantation are scheduled on 2023/08/08.
      • 2D echo was done before chemotherapy on 2023/08/07 showed LVEF: 78%, 1. Dilated LV; normal LV systolic function with normal wall motion, 2. Concentric LVH, dilated LA; LV diastolic dysfunction Gr II, 3. Normal RV systolic function, 4. Aortic valve sclerosis with mild AS (AVA(Doppler) = 1.79 cm², Mean aortic pressure gradient = 9 mmHg); moderate MR; mild TR; mild PR, 5. Marked sinus bradycardia during exam.
      • Discussion with family members about disease condition and treatment plan on 2023/08/09, they understand and consent to treatment. Follow up whole CT image on 2023/08/11 showed no neoplastic LAP in chest and abdomen, extensive emphysema and interstitial fibrosis in RLL, favor smoking related lung disease. extensive 3V-CAD, extensive LAP in the neck due to lymphoma, chronic cystitis?
      • He received chemotherapy with R-miniCHOP (Rituximab 375mg/m2, Cyclophosphamide 400mg/m2, Adriamycin 25mg/m2, Vincristine 1mg, Prednisolone 40mg) on 2023/08/11~2023/08/15(C1).
        • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
        • Tramacet 37.5 & 325mg/tab 1# PO Q6H, Limadol 100mg/2mL/amp 50mg IVD PRNQ8H for pain control.
        • Euricon 50mg/tab 1# PO QD before chemotherapy. IVF for avoid tumor lysis syndrome.
        • Type 2 diabetes mellitus with Diet control an check finger sugar. Uformin 500mg/tab 1# PO TIDCC and Trajenta 5mg/tab 1# PO QD was give for blood sugar control.
        • Hypertension with Sevikar F.C. 5 & 20mg/tab 1# PO QD.
        • Hyperlipidemia with CRESTOR 10mg/tab 1# PO QW1357.
        • Insomnia with Anxiedin 0.5mg/tab 1# PO HS.
        • Constipation with Through 12mg/tab 1# PO HS.
      • Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, he was discharged on 2023/08/16 and OPD followed up later.       
    • Discharge diagnosis
      • Euricon (benzbromarone 50mg) 1# QD
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg)
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Through (sennoside 12mg) 1# HS
  • 2023-04-16 SOAP Metabolism and Endocrinology
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular [E08.319]
      • Mixed hyperlipidemia [E78.2]
      • Essential hypertention, unspecified [I10]
      • Chronic kidney disease, stage 3 (moderate) [N18.3]
      • Nontoxic multinodular goiter [E04.2]
      • Hepatitis [K75.81]
    • Prescription
      • Crestor (rosuvastatin 10mg) 1# QW1357
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
      • Trajenta (linagliptin 5mg) 1# QD
      • Uformin (metformin 500mg) 1# TIDCC
  • 2017-03-14 SOAP Cardiology
    • Diagnosis:
      • HCVD, unspecified, without CHF [I11.9]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Dyslipidemia ; other and unspecified hyperlipidemia [E78.4]
    • Prescription
      • Eurodin (estazolam 2mg) 1# HS
      • Eazide (trichlormethiazide 2mg) 1# QD
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
  • 2017-03-14 SOAP Metabolism and Endocrinology
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Mixed hyperlipidemia [E78.2]
      • Essential hypertention, unspecified [I10]
      • Nontoxic multinodular goiter [E04.2]
      • Arterial embolism and thrombosis of lower extremity [I74.4]
    • Prescription
      • Trajenta (linagliptin 5mg) 1# QD
      • Glucobay (acarbose 100mg) 0.5# TIDAC
      • Robestar (rosuvastatin 10mg) 1# QD
      • Uformin (metformin 500mg) 1# TIDCC
  • 2017-03-14 SOAP Nephrology
    • Diagnosis: Renal failure, unspecified, uremia NOS [N19]

[consultation]

  • 2023-10-12 Radiation Oncology
    • Q
      • This 75-year-old man patient is a case of Nasopharynx diffuse large B-cell lymphoma with multiple lymph node and bone invasion, non-GCB type, BCL6(-), C-MYC(+) and BCL2(+), stage IV s/p chemotherapy with R-miniCHOP from 2023/08/11~2023/09/26 for 3 cycles.
      • This time, for left neck lymph node pain with progression (8x6cm -> 9x8cm). Now, for evaluate radiotherapy to left neck lymph node. Thank you.
    • A
      • Due to left neck lymph node pain with progression (8x6cm -> 9x8cm), palliative RT is indicated.
      • CT-simulation will be arranged on 10/19.
      • Plan to deliver at least 32.5 Gy/ 13 fx to the NP tumor and Lt neck LAPs.
      • RT will start around 10/23.
      • Possible tumor lysis symdrome should be monitored during the treatment.
  • 2023-08-02 Hemato-Oncology
    • Q
      • This 75-year-old man has history of DM and H/T for years under regular medication control.
      • The left neck palpable mass noted for 2 years. The left neck mass about 1cm in size initially. Due to left neck mass enlarge with left side tinnitus, left nasal blood tinged discharge noted in recent 2 months, he came to our ENT OPD for help. Physical examination revealed left nasopharyngeal tumor, left neck palpable mass 6 cm in size. Nasopharyngeal and left neck mass biopsy was done.
      • The pathology revealed diffuse large B-cell lymphoma, non-GCB type.
      • Under the diagnosis of large B-cell lymphoma, he was admitted for cancer work up. We request your consultation for further management.
    • A
      • Arrange PET scan for staging.
      • We will arrange bone marrow tomorrow.
      • Consult GS for port A insertion.
      • Please arrange our OPD after discharge.

[radiotherapy]

[immunochemotherapy]

  • 2023-10-16 - rituximab 375mg/m2 600mg NS 500mL 10hr + cyclophosphamide 400mg/m2 500mg NS 250mL 30min + vincristine 1mg/m2 1mg NS 50mL 10min + prednisolone 40mg/m2 60mg QD PO D1-5 (R-miniCHOP, DC Adriamycin 25mg/m2 for prepare radiotherapy to left neck lymph node)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-26 - rituximab 375mg/m2 600mg NS 500mL 10hr + cyclophosphamide 400mg/m2 500mg NS 250mL 30min + vincristine 1mg/m2 1mg NS 50mL 10min + doxorubicin 25mg/m2 30mg NS 50mL 24hr + prednisolone 40mg/m2 60mg QD PO D1-5 (R-miniCHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-01 - rituximab 375mg/m2 600mg NS 500mL 10hr + cyclophosphamide 400mg/m2 500mg NS 250mL 30min + vincristine 1mg/m2 1mg NS 50mL 10min + doxorubicin 25mg/m2 30mg NS 50mL 24hr + prednisolone 40mg/m2 60mg QD PO D1-5 (R-miniCHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-11 - rituximab 375mg/m2 600mg NS 500mL 10hr + cyclophosphamide 400mg/m2 500mg NS 250mL 30min + vincristine 1mg/m2 1mg NS 50mL 10min + doxorubicin 25mg/m2 30mg NS 50mL 24hr + prednisolone 40mg/m2 60mg QD PO D1-5 (R-miniCHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-26

[withhold doxirubicin until heart problems are ruled out]

Based on the PharmaCloud database, no medication discrepancies were found.

Given that the ECG from 2023-10-24 indicated atrial fibrillation with rapid ventricular response, incomplete right bundle branch block, and nonspecific ST abnormality, it may be prudent to temporarily suspend the use of doxorubicin in the planned R-miniCHOP until cardiac symptoms improve.

2023-10-11

On 2023-09-06, our endocrinologist provided a repeat prescription for Crestor (rosuvastatin), Kentamin (Vit B1, B6, B12), Sevikar (amlodipine, olmesartan), Trajenta (linagliptin), and Uformin (metformin) to manage the patient’s existing conditions, these drugs are currently in use. Since this hospital stay, blood glucose levels have consistently ranged from 120 to 200 mg/dL. There are no inconsistencies in medication.

Recent lab results indicate that the WBC count remains above 3K/uL and there is no evidence of tumor lysis syndrome. While the LDH level remains in the normal range, the B2 microglobulin level reached 3646 ng/mL in mid-Sep. There’s no need to adjust the dose of the current medications, as the patient’s kidney and liver function tests are within normal limits.

2023-08-09

No recent lab results for LDH or beta-2-microglobulin were found in HIS5. If needed, initiate testing to establish a baseline prior to treatment.

700685525

231026

[lab data]

Bone marrow cell morphology and cell count - 2023-10-24 Clinical diagnosis AML
- 2023-10-24 Gross: Marrow +
- 2023-10-24 Cellularity Hyper-mod.
- 2023-10-24 Fat componemt -
- 2023-10-24 Megakaryocyte dist absent.
- 2023-10-24 M/E ↑
- 2023-10-24 M/E(/) 95/5
- 2023-10-24 sites lliac. post. R
- 2023-10-24 type Aspiration
- 2023-10-24 specimen condition adequate
- 2023-10-24 smear good
- 2023-10-24 Myeloblast 81 %
- 2023-10-24 N.Myeloblast 0 %
- 2023-10-24 N.Meta 1,5 %
- 2023-10-24 N.Band 2.5 %
- 2023-10-24 N.Seg. 3.0 %
- 2023-10-24 Eo.Myeloblast 0 %
- 2023-10-24 Eo.Meta 0 %
- 2023-10-24 Eo.Band 0 %
- 2023-10-24 Eo.Seg. 0 %
- 2023-10-24 Baso 0 %
- 2023-10-24 Promyelo. 0 %
- 2023-10-24 Mono. 1 %
- 2023-10-24 Mo.blast 2 %
- 2023-10-24 Mo.promono. 0 %
- 2023-10-24 Mo.mature 0 %
- 2023-10-24 Lympho 0 %
- 2023-10-24 Lym.blast 0 %
- 2023-10-24 Lym.promono. 0 %
- 2023-10-24 Lym.mature 3 %
- 2023-10-24 Plasma Cell 0 %
- 2023-10-24 Pro-eyth. B 0 %
- 2023-10-24 Normoblast 0 %
- 2023-10-24 Nor.Baso 0 %
- 2023-10-24 Nor.polych 0 %
- 2023-10-24 Nor.ortho. 4 %
- 2023-10-24 Peroxidase Positive
- 2023-10-24 LAP -
- 2023-10-24 CAE Positive
- 2023-10-24 ANAE Negative
- 2023-10-24 Iron stain -
- 2023-10-24 PAS -
- 2023-10-24 Other stains -
- 2023-10-24 Description AML
- 2023-10-24 Comments AML CAE positive

Hepatitis B and C - 2023-10-23 HBsAg Nonreactive
- 2023-10-23 HBsAg (Value) 0.74 S/CO
- 2023-10-23 Anti-HBc Reactive
- 2023-10-23 Anti-HBc-Value 4.40 S/CO
- 2023-10-23 Anti-HBs 356.92 mIU/mL
- 2023-10-23 Anti-HCV Nonreactive
- 2023-10-23 Anti-HCV Value 0.13 S/CO

[exam findings]

  • 2023-10-24 Cardiac Catheterization
    • We perform PICC at cath room.
      • Under the peripheral echo guiding, we successful pucnture left basilic vein successful. Fluroscopy revealed the wire in true lumin. Micro-sheath was advanced. PICC catheter was implanted into SVC under the fluroscopy.
      • Total into 36 cm and fix 14cm at left upper am.
    • SvO2 was also check, it revealed 62. Estimated Fick Cardiac index 2.51 L/min/m2 and cardiac output 4.03 L/min.
  • 2023-10-23 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — acute myeloid leukemia.
    • Section shows piece(s) of bone marrow with 90% cellularity and M:E ratio of approximately 2:1. Three cell lineages are present with left shift of leukocytes and many blasts. Megakaryocytes are adequate in number.
    • IHC stains: CD117: 50%; CD34: 50 %; MPO: 60%, CD61: 5 %; CD71: 35% (of the nucleated cells).

[MedRec]

  • 2023-10-21 SOAP MER He YaoCan
    • preliminary impression: C95.90 Leukemia, unspecified not having achieved remission

==========

2023-10-26

[initiating posaconazole treatment]

According to the Sanford Guide, posaconazole should be administered with a loading dose of 300 mg BID for two doses, then switching to a maintenance dose of 300 mg QD.

700013816

231025

[lab data]

2023-10-25 HBV DNA-PCR (quantitative) 143000 IU/mL
2023-10-24 Anti-HBs 0.66 mIU/mL

2023-10-24 HBsAg Reactive
2023-10-24 HBsAg (Value) 222.81 S/CO

2023-10-24 Anti-HCV Nonreactive
2023-10-24 Anti-HCV Value 0.08 S/CO

2023-07-29 Anti-HBc Reactive
2023-07-29 Anti-HBc-Value 6.96 S/CO

2023-06-30 HLA A-high 11:01
2023-06-30 HLA A-high 33:03
2023-06-30 HLA B-high 46:01
2023-06-30 HLA B-high 58:01
2023-06-30 HLA C-high 01:02
2023-06-30 HLA C-high 03:02

2023-06-30 HLA DQ-high 02:01
2023-06-30 HLA DQ-high 03:03

2023-06-30 HLA DR-high 03:01
2023-06-30 HLA DR-high 09:01

2023-06-08 HBsAg (NM) Negative
2023-06-08 HBsAg Value (NM) 0.652
2023-06-08 Anti-HCV (NM) Negative
2023-06-08 Anti-HCV Value (NM) 0.076

2023-06-07 Aspergillus Ag Negative
2023-06-07 Aspergillus Ag Value 0.07 Ratio

[exam findings]

  • 2023-10-23 ECG
    • Normal sinus rhythm
    • Low voltage QRS
    • Nonspecific ST abnormality
    • Prolonged QT
  • 2023-10-23 CT - abdomen
    • Abdominal CT without IV enhancement revealed:
      • Minimal infiltration at perirenal fat over bilateral sides is found. r/o pancreatitis.
      • Cardiomegaly is noted.
      • Bilateral mild pleural effusion is found.
      • Calcified coronary arteries is found.
      • Increased pulmonary vasculature is found.
    • Imp:
      • Minimal infiltration at perirenal fat over bilateral sides is found. r/o pancreatitis.
      • Mild bilateral pleural effusion
  • 2023-10-23 KUB
    • Compression fracture of L2.
    • Non-specific small bowel and colon gas pattern.
    • A calcified spot at RLQ.
  • 2023-10-23 ECG
    • Sinus rhythm with Premature atrial complexes
    • Prolonged QT
  • 2023-10-20, -10-09 CXR
    • S/P PICC catheter insertion via right forearm.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-10-09 SONO - artery
    • Patent bilateral lower limbs arteries.
    • Tissue edema at bilateral lower limbs.
  • 2023-10-06 SONO - vein
    • No evidence of deep vein thrombosis at bilateral lower limbs (by color flow filling, direct compression, and distal augmentation response)
    • Bilateral posterior vein engorgement, with perforator veins draining off lower limb soft tissue edema
  • 2023-09-14 Patho - bone marrow biopsy
    • Bone marrow, iliac creast, biopsy — Negative for malignancy (1~2 % of blasts)
    • Microscopically, it shows normal ellularity of bone marrow (approximately 30%) and presence of trilineage hematopoietic cells. Myeloid and eythroid tatio is 3:1. Both myeloid and erythroid lineages demonstrate maturation. Megakaryocytes are present in normal in numbers (2 of HPF)and demonstate no significant morphologic abnormalities. Blast-like cells (CD117+, 1~2%) are present. Monocytic lineage cells are highlighted by CD68 & CD163 and demonstate no significant morphologic abnormalities.
    • Immunohisotchemical stain reveals CD34 (<1%), CD20 (<1%), CD138 (focal+, 1~2%), MPO (+), CD71 (+), TdT (-), CD61 (+).
  • 2023-09-13 Cardiac Catheterization
    • We try to puncture left basilic vein by peripheral echo guiding successful, but wire could not enter vessel
    • Then we try to pucnture right basilic vein successful. Then micro-sheath advanced. Because of prior wire demage. Another terumo wire and micro-puncture site was used.
    • Final, after successful pucnture. PICC catheter was advanced to SVC and RA junction smoothly.
  • 2023-07-24 Patho - bone marrow biopsy
    • Bone marrow, iliac creast, biopsy — Acute monocytic / monoblastic leukemia
    • Microscopically, it shows hypercellularity of bone marrow (approximately > 90%) and markedly proliferation of monocytic lineage of immature mononuclear leukemic cells (highlighted by CD68 & CD163). Erythroid lineage is decreased in numbers and demonstrate maturation. Megakaryocytes are present in normal in numbers (3 per HPF) and demonstate no significant morphologic abnormalities.
    • Immunohisotchemical stain reveals CD34 (<1%), CD20 (<1%), CD138 (focal+, 1~2%), MPO (+, >95%), CD71 (focal+, 2%), CD68 (+, >95%), TdT(<1%)., CD163 (+, 60%), CD117 (+, 5~10%).
  • 2023-06-12, -06-09 CXR
    • s/p PICC inserted via Lt arm, tip in SVC
    • extensive heterogeneous consolidation in both lungs in progression
    • moderate enlarged cardiac silhoutte
  • 2023-06-07 Cardiac Catheterization
    • We perform PICC under the cath room and fluroscopy guiding
      • Left basilic vein was puncture by peripheral echo guiding. Terumo wire in basilic to axillary vein.
      • The sheath advanced to puncture site and
      • A peripherally inserted central catheter (PICC) was implanted to SVC under the fluroscopy guiding.
    • Conclsuion
      • PICC was implanted via left brachial vein successful.
  • 2023-06-07 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Compatible with acute monoblast/monocytic leukemia
    • The sections show hypercellular marrow (85%). The marrow space is replaced by a population of medium to large-sized immature cells with round to oval, ocasional distorted nucleus, and abundant cytoplasm. Numerous mitotic figures can be found.
    • IHC: CD34 (<3% +), CD117(10% +), MPO(30%+), and CD68(70% +). The finding is compatible with acute monoblastic/monocytic leukemia. Suggest bone marrow smear, flow cytometry and clinic correlation.
  • 2023-06-07 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (178 - 93) / 178 = 47.75%
      • 2D (M-simpson) = 48
    • Conclusion:
      • Dilated LV with hypokinesia of posterior wall, lateral wall; impaired LV systolic function.
      • Preserved RV systolic function.
      • Gr II LV diastolic dysfunction and impaired RV relaxation; moderately dilated LA.
      • Degenerative changes of mitral valve with severe MR; moderate TR; mild PR; dilated aortic root with mild AR.
      • Possible moderate to severe pulmonary hypertension (the estimated systolic PA pressure > 62 mmHg).
      • Mild aortic root calcification.
  • 2023-06-06 CXR
    • S/P nasogastric tube insertion
    • S/P endotracheal intubation with the tip beyond the carina
    • extensive, multifocal consolidation, in both lungs
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2023-06-05 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2023-06-01 CXR
    • Ground glass opacity in LLL.
    • Atherosclerosis of the aorta.
  • 2023-06-01 ECG
    • Sinus rhythm with Premature atrial complexes
    • Otherwise normal ECG

[MedRec]

  • 2023-07-22 ~ 2023-08-23 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Acute monoblastic/monocytic leukemia, Karyotype:46~47,XY,+11[cp4]
      • Chronic renal failure, stage 4
      • Hypokalemia
      • hypoalbuminemia
      • Hypocalcemia
    • CC
      • for regular chemotherapy
    • Present illness
      • This 70 y/o male with type 2 DM without treatment.
      • According to his statement, he suffered from fever for one month and shortness of breath on exertional for 2 weeks. He went to our OPD for help then referred to ER for WBC 72170/uL, Plat 48K, Hgb 6.9g/dL. Leukocytosis with white count 100280/uL, Hb:7.0 g/dl, PLT:47K, hypocalcemia (Ca:1.97 mmol/L) and elevated LDH (865U/L). Urine examination revealed no pyuria. Chest film revealed no pneumonia. Feburic self-paid and blood transfusion 1U/day by hematology suggested. Under the impression of acute leukemia, he was admitted to evaluation and management on 2023/06/02, but dyspnea devloped happened, so be transffered to ICU on 2023/06/06.
      • Bone marrow was done on 2023/6/6 and report showed compatible with acute monoblast/monocytic leukemia s/p first chemotherapy as 7-3 on 2023/06/20.
      • This time, he denied fullness in this week and he was admitted for refular chemotherapy on 2023/07/22.
    • Course of inpatient treatment
      • After admission, he received bone marrow and pending report. DC Hydrea during hospitalization. Potassium and Calcium are correct during hospitalization. Comfirm VS for newly chemotherapy as FLAI. Blood transfusion frequency for anemia and thrombocytopenia. Antibiotics as Cefepime and Targocid for neutropenic fever control. No evidence of bacterermia. Proctologist was consulted for anal pain, who diagnosis of acute anal fissure over 1 o’clock, no pus now. Transamine for few bleeding sign. After treatment, his WBC with neutrophil recovery and no fever. PICC was removed on 2023/08/23. Under the stable condition, he can be discharged on 2023/08/23. OPD follow up is arranged.
    • Discharge diagnosis
      • Tresiba Flex Touch (insulin degludec) 6 unit HS SC
      • Concor (bisoprolol 1.25mg) 1# BID
      • MgO 250mg 1# TID
      • Trajenta (linagliptin 5mg) 1# QD
      • Const-K ER (potassium chloride 750mg 10mEq) 1# QD
      • Ulstop (famotidine 20mg) 1# QD
  • 2023-06-12 POMR Chest Medicine Progress Note
    • Problem List
      • R/I acute myeloid leukemia, Pending bone marrow biopsy
        • Assessment: serious
          • 20230608 HBsAg(-), Anti-HCV(-)
          • Hydroxyurea 1# QD (20230607 ~ 9)
          • 20230606 Bone marrow
        • Plan
          • BT with LPR 1U and LPRBC 2u on 20230612 for thrombocytopenia and anemia
          • Consider chemotherapy if Oncology suggest
          • Blood transfusion with LPRBC 2u and LRP 1PH on 20230612, s/p Lasix 0.5amp iv injection
      • Bilateral pneumonia, suspect leukemic lung with hypoxic respiratory failure post intubation on 2023-06-06
        • Extubation on 20230609
        • Assessment: serious
        • Plan
          • Nasal cannula supply
          • Antibiotics with Targocid plus Mepem (since 20230606) were prescribed
          • Anti-fungus agent with Mycamine (since 20230606)
          • Sevatrim oral form(IV form 20230606 ~ 10, since 20230610) for cover PJP
          • Kalimate 2pk qid was given for correct hyperkalemia (Baktar side effect)
          • Collect K qd
          • 20230605 Pending CMV and PJP result
      • EFrEF with vere MR
        • Assessment: serious
          • 20230607 Heart echo EF 48%, severe MR
        • Plan
          • Concor 1# BID
          • Diuretic with Lasix 0.5# PO QD
      • Type 2 Diabetes mellitus
        • Assessment
          • HbA1c 6.5% on 20230605
        • Plan
          • RI 14u SC TIDAC as sliding scale and Toujeo 10u SC HS
          • Tragenta 1# QD
      • Acute kidney injury and imbalance electrolyte
        • Assessment: impairment renal function
        • Plan:
          • Closely monitor renal function and electrolyte
          • Correct hypocalcemia with Calcium gluconate 1amp IVD QD
          • Add MgSO4 1amp iv infusion loading for correct hypo-Mg
    • Attending Physician’s Rounds Record and Comment
      • keep O2 support, closely monitor his respiratory pattern and O2 saturaiton
      • keep Targocid, Meropenem, Micafungin and oral Baktar for infection control, trace culture result
      • give PRBC and PLT transfusion to correct anemia and thrombocytopenia, regular hemogram f/u, if prograssive leukopenia (ANC < 500), may add G-CSF
      • keep Kalimate to correct hyperkalemia
      • because of CXR still showed pulmonary congestion, keep Diuretic used to keep I/O negative balance for CHF and severe MR
      • wait Bone marrow biopsy result
      • explained his condition to himself and his family
      • consult Hema doctor f/u, if possible, may let him transfer to Hema general ward
  • 2023-06-01 SOAP Hemato-Oncology
    • S
      • Referred from clinic for WBC 72K, PLT 48K, HGB 6.9 (20230601)
      • fever in recent days for 1 month
      • Exertional shortness of breath (dyspnea on exertion) for 2 wks
    • A
      • Suspected acute leukemia with hyperviscosity
      • Suspected coexisting infection
    • P
      • Marked leukocytosis –> refer to ER for emergent treatment and admission

[consultation]

  • 2023-06-08 Cardiology
    • Q
      • for severe MR
      • This is a 70 y/o male with type 2 DM without treatment. The impression of acute leukemia, he was admitted to Hema ward on 20230602. Due to acute hypoxic respiratopry failure, he received intubation then transffered to MICU on 20230606. At MICU, antibiotic with Targocid, Mepem, Sevatrim, Mycamine (since 20230606) for infection control. F/u Bone marrow on 20230606 (pending result), Oral chemotherapy with hydroxyurea was precribed. Arrange 2-D echo on 20230607 for heart function evaluation and which revealed EF 48%, severe MR. We really need your help for treatment suggestion, thank you!!
    • A
      • This is a 70 years old man with suspected acute leukemia, acute hypoxic respiratory failure. We were consulted for severe MR management.
      • Labs
        • Worsening renal function
      • Impression
        • Heart failure with mildly reduced EF, dilated LV with hypokinesia of posterior and lateral wall, with severe primary mitral regurgitation, with moderate to severe pulmonary HTN.
        • Acute respiratory failure with bilateral pneumonia r/o pulmonary congestion
        • Acute on chronic renal impairment, r/o prerenal type.
        • r/o acute leukemia;
      • Suggestion
        • Surgical intervention for MR is not suitable at present due to poor general condition (underlying hematolic malignancy + sepsis).
        • Keep lasix + concor use; may consider adding low dose candesarten if Cr < 2.0.
  • 2023-06-06 Infectious Disease
    • A
      • 70-year-old DM male patient is a fresh case of AML, that bone marrow study not done yet.
        • Persistent fever is noted before and during hospitalization, that leukemic fever likely.
        • Serial CxR films showed rapid onset bilateal perihilar infiltrations, especially right lung, that leukemic lung is the first consideration.
        • Possibility of PJP infection also exist, that sputum PJP-PCR study necessary.
        • IV steroid is necessary, as well as intubation for severe hypoxemia.
      • Suggestion:
        • Continue the present Mepem, Targocid and Mycamine.
        • Decrease Sevatrim dosage to 2 vials iv q12h due to AKI.
        • Send sputum for bacterial culture, PJP-PCR.
        • Check cryptococcal/Aspergillus antigen, and CMV viral load too.

[note]

Prevention of Hepatitis B Reactivation During Immunosuppressive Therapy - 2023-10-25 - https://www.hepatitis.va.gov/hbv/reactivation-prevention.asp

  • Table 1. Immunosuppressant Medications by Class
Medication Class Agents
TACE: Trans arterial chemoembolization, HCC: Hepatocellular carcinoma Doxorubicin Epirubicin (USED in TACE for HCC)
B-cell depleting agents Obinutuzumab, Ocrelizumab, Ofatumumab, Rituximab
Anthracycine derivatives Doxorubicin, Epirubicin (USED in TACE for HCC)
TNF inhibitors Adalimumab, Certolizumab, Etanercept, Infliximab
Other cytokine inhibitors and integrin inhibitors Abatacept, Mogamulizumab, Natalizumab, Ustekinumab, Vedolizumab
Tyrosine kinase inhibitors Imatinib, Nilotinib
Proteasome inhibitors Bortezomib, Carfilzomib, Ixazomib
Traditional immunosuppressive agents Azathioprine, 6-Mercaptopurine, Methotrexate
Corticosteroids Prednisone, Prednisolone, Methylprednisone, Dexamethasone
  • Table 2. HBV Reactivation Risk Determination
Medication Class HBsAg+, HBcAb+ HBsAg-, HBcAb+
B cell depleting agents High risk; Use prophylaxis High risk; Use prophylaxis
Anthracycine derivatives High risk; Use prophylaxis Moderate risk; Use prophylaxis
Corticosteroids ≥ 10 mg/day for ≥ 4 weeks High risk; Use prophylaxis Moderate risk; Use prophylaxis
Corticosteroids < 10 mg/day for ≥ 4 weeks Moderate risk; Use prophylaxis Low risk; No prophylaxis; Monitor HBsAg, HBV DNA, ALT every 3 months
HCC treatments: TACE, Surgical resection or Immunotherapy High risk; Use prophylaxis Lack of data; Use Prophylaxis
HCC: Local Ablation, Systemic therapies Moderate risk; Use prophylaxis Lack of data; Use Prophylaxis
TNF inhibitors Moderate risk; Use prophylaxis Moderate risk; Use prophylaxis
Other cytokine inhibitors and integrin Moderate risk; Use prophylaxis Moderate risk: Use prophylaxis
Tyrosine kinase inhibitors Moderate risk; Use prophylaxis Moderate risk; Use prophylaxis
Proteasome inhibitors Moderate risk; Use prophylaxis Moderate risk; Use prophylaxis
Traditional immunosuppressive agents Low risk; No prophylaxis; Monitor HBV DNA, ALT every 3 months Low risk; No prophylaxis; Monitor HBsAg, HBV DNA, ALT every 3 months
Intra-articular steroids Low risk; No prophylaxis; Monitor HBV DNA, ALT every 3 months Low risk; No prophylaxis; Monitor HBsAg, HBV DNA, ALT every 3 months
Corticosteroids: any dose for ≤ 1 week Low risk; No prophylaxis; Monitor HBV DNA, ALT every 3 months Low risk; No prophylaxis; Monitor HBsAg, HBV DNA, ALT every 3 months
  • Table 3. Recommended Nucleos(t)ide analogues for HBV
Nucleos(t)ide Analogue QD Dose Potential Side Effects Use in HIV Lowest CrCl Without Dose Adjustment Renal Dose Reductions (CrCl, mL/min)

[chemotherapy]

  • 2023-09-23 - fludarabine 30mg/m2 50mg NS 500mL 30min D1 + cytarabine 1000mg/m2 1600mg NS 500mL 4hr D1-3 + idarubicin 10mg/m2 16mg NS 100mL 10min D1 (FLAI)
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + palonosetron 250ug D1-3 + NS 250mL D1-3
  • 2023-09-19 - fludarabine 30mg/m2 50mg NS 500mL 30min D1 + cytarabine 1000mg/m2 1600mg NS 500mL 4hr D1-2 + idarubicin 10mg/m2 16mg NS 100mL 10min D2 (FLAI)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + palonosetron 250ug D1-2 + NS 250mL D1-2
  • 2023-07-31 - fludarabine 30mg/m2 50mg NS 500mL 30min D1 + cytarabine 1000mg/m2 1600mg NS 500mL 4hr D1-2 + idarubicin 10mg/m2 16mg NS 100mL 10min D2 (FLAI)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + palonosetron 250ug D1-2 + NS 250mL D1-2
  • 2023-07-28 - fludarabine 30mg/m2 50mg NS 500mL 30min D1 + cytarabine 1000mg/m2 1600mg NS 500mL 4hr D1-3 + idarubicin 10mg/m2 16mg NS 100mL 10min D1,3 (FLAI)
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + palonosetron 250ug D1-3 + NS 250mL D1-3
  • 2023-06-20 - daunorubicin 45mg/m2 75mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 160mg NS 500mL 24hr D1-7
    • dexamethasone 4mg D1-7 + diphenhydramine 30mg D1-7 + palonosetron 250ug D1-7 + NS 250mL D1-7

FLAI (Fludarabine 25 mg/sqm/day days 1–5, Ara-C 2 gr/sqm/day days 1–5, Idarubicine 10 mg/sqm/day days 1, 3, 5) https://ashpublications.org/blood/article/106/11/1857/137804/Fludarabine-Based-Regimen-FLAI-Is-an-Effective https://doi.org/10.1182/blood.V106.11.1857.1857

The FLAI regimen is given as follows: (2023-10-25 GBard)

  • Fludarabine: 25 mg/m² intravenously (IV) over 30 minutes on days 1-5
  • Cytarabine: 200 mg/m² IV over 24 hours on days 1-5
  • Idarubicin: 12 mg/m² IV over 30 minutes on days 1-3

The FLAI regimen is used as an induction treatment for newly diagnosed patients with Acute Myeloid Leukemia (AML), except acute promyelocytic leukemia (APL). The regimen includes the following drugs: (2023-10-25 BingChat https://ashpublications.org/blood/article/104/11/878/75705/Efficacy-and-Toxicity-of-FLAI-vs-ICE-for-Induction https://doi.org/10.1182/blood.V104.11.878.878)

  • Fludarabine (FLUDA): 25 mg/sqm/day for 5 days
  • Cytarabine (also known as ARA-C or HDAC): 2g/sqm/day for 5 days
  • Idarubicin (IDA): 10mg/sqm/day for 5 days

FLAI Regimen Dosing and Schedule: (2023-10-25 ChatGPT)

  • Fludarabine (Fludara):
    • Dose: Typically around 30 mg/m^2/day.
    • Schedule: Administered intravenously over 30 minutes daily for 5 days, usually from day 1 to day 5.
  • Cytarabine (Ara-C):
    • Dose: Typically around 2 g/m^2/day.
    • Schedule: Administered intravenously over 4 hours daily, immediately after the Fludarabine infusion, usually from day 1 to day 5.
  • Idarubicin:
    • Dose: Typically around 8-10 mg/m^2/day.
    • Schedule: Administered intravenously over 30 minutes daily, usually from day 1 to day 3.

Fludarabine, Cytarabine, and Attenuated-Dose Idarubicin (m-FLAI) 2023-10-25 https://doi.org/10.1182/blood.V118.21.3626.3626

  • The m-FLAI regimen was comprised of
    • fludarabine (25mg/m2, days 1–4),
    • cytarabine (1000mg/m2, days 1–4), and
    • attenuated-dose idarubicin (5mg/m2, days 1–3)

==========

2023-10-25

[HBV reactivation]

Hepatitis B virus (HBV) that has been reactivated is treated with the medication Baraclude (entecavir) today.

[HRP > Patient Safety Incident Notification > Medication Incident - HBV reactivation]

Patient medical record No. 700013816.

The lab results from 2023-07-29 indicated a reactive Anti-HBc, but there were no previous Anti-HBc test results for reference. Multiple chemotherapy sessions were administered on 2023-06-20 (standard 7+3), 2023-07-28, 2023-07-31, 2023-09-19, and 2023-09-23 (FLAI), both before and after this test result.

Due to the lack of timely preventive measures to counteract the potential reactivation of HBV infection, which can be triggered by the immunosuppressive effects of the treatment, reactivated hepatitis developed. As a response to this event, Baraclude (entecavir) was added to the patient’s active medication list on 2023-10-25.

2023-10-25 HBV DNA-PCR (quantative) 143000 IU/mL

2023-10-24 ALT 1986 U/L
2023-10-23 ALT 2487 U/L
2023-10-23 ALT 2645 U/L
2023-10-20 ALT 44 U/L
2023-10-17 ALT 37 U/L
2023-10-06 ALT 52 U/L

2023-10-24 AST 1635 U/L
2023-10-23 AST 3211 U/L
2023-10-23 AST 3758 U/L
2023-10-20 AST 36 U/L
2023-10-17 AST 27 U/L
2023-10-06 AST 28 U/L

2023-07-29 Anti-HBc Reactive
2023-07-29 Anti-HBc-Value 6.96 S/CO

There are multiple clinical practice guidelines that offer a approach to screening and managing hepatitis B virus (HBV). For example, the American Society of Clinical Oncology (ASCO) guideline recommends that all patients who are about to start systemic anticancer therapy be tested for HBV. Patients with chronic HBV who are receiving systemic anticancer therapy should receive antiviral prophylaxis throughout the course of treatment and for at least 12 months afterwards.

Ref: Hepatitis B Virus Screening and Management for Patients With Cancer Prior to Therapy: ASCO Provisional Clinical Opinion Update. J Clin Oncol. 2020 Nov 1;38(31):3698-3715. doi: 10.1200/JCO.20.01757. Epub 2020 Jul 27. PMID: 32716741.

2023-06-28

  • Patient body weight 64.7kg => CrCl 27mL/min. Considering the patient’s CrCl falls within the range of 20 to 50 mL/min, the levofloxacin dosage should be adjusted. Instead of the initially intended daily dose of 750mg, it is recommended to administer 750mg of levofloxacin every other day.
    • 2023-06-28 BUN 81 mg/dL
    • 2023-06-28 Creatinine 2.20 mg/dL
    • 2023-06-28 eGFR 31.52
  • Fluconazole in patients with CrCl ≤50 mL/minute: Reduce dose by 50%. 2# switch to 1# QD is recommended.

2023-06-12

  • The patient’s renal function is showing signs of improvement, but still remains inadequate. The administration of furosemide should continue to ensure a net outflow in the fluid balance, thus helping to alleviate pulmonary congestion, congestive heart failure (CHF), and mitral regurgitation (MR). Please note that the oral bioavailability of furosemide varies greatly, but on average it’s around 50% of the intravenous (IV) dose.
    • 2023-06-12 Creatinine 2.17 mg/dL
    • 2023-06-10 Creatinine 2.51 mg/dL
    • 2023-06-09 Creatinine 2.90 mg/dL
    • 2023-06-07 Creatinine 3.14 mg/dL

2023-06-06

[tube feeding - Concor]

  • The manufacturer’s instructions for Concor (bisoprolol 5mg/tab) advise that it should be swallowed with a drink of water and not be chewed. If the patient is receiving tube feeding, the Simple Suspension Method (SSM) may be used. In the simple suspension method, the packaged tablets can be dissolved in 55-degree Celsius water and left for 5-10 minutes, then can be flowed through a feeding tube. This method involves disintegrating tablets and capsules in warm water before suspending them for administration. This method could be applicable for administering Concor tablets through a feeding tube.

[assessment]

Since the start of Hydrea (hydroxyurea) treatment on 2023-06-02, there has been a noticeable reduction in the patient’s WBC count from a peak of 105K/uL. However, along with this, It is also seen a concurrent suppression of the patient’s HGB and PLT levels, despite the administration of blood transfusions on 2023-06-01 and 2023-06-05.

  • 2023-06-06 WBC 66.82 x10^3/uL

  • 2023-06-05 WBC 99.17 x10^3/uL

  • 2023-06-04 WBC 105.86 x10^3/uL

  • 2023-06-03 WBC 105.55 x10^3/uL

  • 2023-06-02 WBC 100.28 x10^3/uL

  • 2023-06-01 WBC 75.10 x10^3/uL

  • 2023-06-06 HGB 7.8 g/dL

  • 2023-06-05 HGB 7.9 g/dL

  • 2023-06-04 HGB 6.9 g/dL

  • 2023-06-03 HGB 7.4 g/dL

  • 2023-06-02 HGB 7.0 g/dL

  • 2023-06-01 HGB 6.3 g/dL

  • 2023-06-06 PLT 44 x10^3/uL

  • 2023-06-05 PLT 62 x10^3/uL

  • 2023-06-04 PLT 37 x10^3/uL

  • 2023-06-03 PLT 43 x10^3/uL

  • 2023-06-02 PLT 47 x10^3/uL

  • 2023-06-01 PLT 63 x10^3/uL

2023-06-06 lab Cre 2.63mg/dL, eGFR 25.72, CrCl 27. Tarcocid (teicoplanin) for CrCl <30 mL/minute:

  • If the usual indication-specific dose is 6 mg/kg once daily:6 mg/kg every 72 hours or 2 mg/kg once daily
  • If the usual indication-specific dose is 10 mg/kg once daily:10 mg/kg every 72 hours or 3.3 mg/kg once daily
  • If the usual indication-specific dose is 12 mg/kg once daily:12 mg/kg every 72 hours or 4 mg/kg once daily

The maintenance dose, which stands at 700mg Q3D, is equivalent to 9.5 mg/kg. This is within the reasonable therapeutic range.

700034834

231025

[lab data]

2023-10-11 Anti-HBc Nonreactive
2023-10-11 Anti-HBc-Value 0.38 S/CO
2023-10-11 Anti-HBs 53.10 mIU/mL
2023-10-11 HBsAg Nonreactive
2023-10-11 HBsAg (Value) 0.35 S/CO
2023-10-11 Anti-HCV Nonreactive
2023-10-11 Anti-HCV Value 0.28 S/CO

[exam findings]

  • 2023-10-13 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
    • Section shows piece(s) of bone marrow with 40 % cellularity and M:E ratio of approximately 2:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • 2023-10-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (108 - 27) / 108 = 75.00%
      • M-mode (Teichholz) = 74
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA
      • Mild MR, TR
      • Moderate AR
  • 2023-10-11 PET scan
    • Increased FDG uptake in stomach (Deauville score: 5), compatible with the diffuse large B-cell lymphoma.
    • Increased FDG uptake in lymph nodes in bilateral neck regions, left SCF, right axilla (Deauville score: 5), left upper back (Deauville score: 4), abdomen including the spleen, pelvis, and bilateral inguinal regions (Deauville score: 5), highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
    • Diffuse large B-cell lymphoma, stage IIIS (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-09-27 CT - abdomen
    • CC: epigastric pain, discomfort for 1 month, BW from 85 Kgs to 75 Kgs.
    • 20230919 gastroscopy: One large fungated mass with ulcerative surface was noted at 2nd portion duodenum, AW site.
    • Biopsy and pathology: diffuse large B cell lymphoma
    • Findings:
      • There are multiple enlarged nodes in the hepatoduodenal ligament, celiac trunk, mesentery, para-aortic space, para-cava space, bilateral common iliac chain, bilateral external iliac chain, bilateral internal iliac chain, and bilateral inguinal area that are c/w malignant lymphoma.
      • There is wall thickening at the duodenum 2nd portion that is c/w malignant lymphoma.
      • There is mild to moderate left side hydroureteronephrosis and delayed contrast excretion of left kidney that is c/w obstructive uropathy. The etiology is lymphoma in left external iliac chain with passive compression the left M/3 ureter.
        • In addition, a renal cyst 1.3 cm in left upper pole is noted.
      • There is a poor enhancing lesion 1.4 cm in the spleen that may be lymphoma with spleen involvement.
      • There is a gallstone 0.7 cm.
    • Impression:
      • Malignant lymphoma is noted. Please correlate with PET scan.
  • 2023-09-20 Patho - stomach biopsy
    • Duodenum, 2nd portion, biopsy — Diffuse large B-cell lymphoma, non-germinal-center B-cell typel
    • The sections show a picture of diffuse large B-cell lymphoma with following features:
      • Specimen: Duodenal 2nd portion
      • Procedure: Biopsy
      • Tumor site: Duodenal 2nd portion
      • Histologic type: Diffuse large B-cell lymphoma, non-germinal-center B-cell type
    • Immunophenotyping: CK(-), CD3(-), CD56(-), CD20(+), BCL2(+), BCL6(+), CD10(-), MYC(-) and MUM1(-)
  • 2023-09-19 Esophagogastroduodenoscopy, EGD
    • Diagnosis:
      • Superficial gastritis
      • Duodenal ulcerative tumor, suspicious lymphoma or adenocarcinoma, s/p biopsy
    • Suggestion:
      • pursue pathology and arrange CT for duodenal cancer survey

[MedRec]

  • 2023-09-26 SOAP Hemato-Oncology He JingLiang
    • S: DLBCL of stomach
    • P: arrange admission for staging and R-COP
    • Prescription
      • Through (sennoside 12mg) 1# HS
  • 2023-09-25 SOAP Gastroenterology Chen JiangHua
    • S: for patho result -> diffuse large B cell lymphoma -> referred to oncologist
  • 2023-09-15 SOAP Gastroenterology Xu RongYuan
    • S
      • epigastric pain, discomfort for one months
      • BW from 85 Kgs to 75 Kgs
    • Prescription
      • Ulstop (famotidine 20mg) 1# BID
      • Emetrol (domperidone 10mg) 1# TIDAC
  • 2020-09-22 ~ 2020-11-06 POMR Infectious Disease Yang QingHui
    • Discharge diagnosis
      • Gram-negative sepsis, unspecified
      • Bacteremia
      • Chronic osteomyelitis, right ankle and foot s/p operation
      • Atherosclerosis of native arteries of extremities with intermittent claudication, right leg
      • Essential (primary) hypertension
      • Gout, unspecified
      • Chronic ulcer with osetomyelitis with wound culture: Bacteroides fragilis and Fusobacterium spp., Staph. auerus, Serrentia marsensus, Escherichia coli, Pseudomonas auerginso
      • Pseudomonas auerginosa and Escherchia coli positive sepsis due to chronic ulcer with chronic osteomyelitis.
      • Chronic ulcer with osteomyelitis s/p debridment on 2020/10/05.
      • pending for HBO
      • Anemia of chornic inflammation (Chronic oseteomyelitis with wound ulcer)
    • CC
      • Fever and chills off and on for four days
    • Present illness
      • A 73-year-old male has past history of 1). Hypertension, 2). Gout, 3). Peripheral arterial occlusion disease, 4). Varicose veins of bilateral limbs, and 5). Chronic osteomyelitis of right foot post sequestrectomy for osteomyelitis.
      • He was a chief officer before. He denied travel, occupation, contact or cluster history recently, nor allergy history.
      • This time, he had intermittent fever with chills since 2020-09-18, runny nose was also noted. There was a chronic ulcerative wound over his right sole, with discharge under chronic osteomyelitis status for long times (for years). He denied dizziness or headache, no cough or sputum or dyspnea, no cheat pain or abdomen pain, no nausea or vomit, no urinary pain or hematuria, no limbs edema. Then he came to our hospital for help.
      • In the emergency department, the temperature was 40.0’C, the pulse 105 beats per minute, the blood pressure 116/58 mmHg, the respiratory rate 23 breaths per minute, and the oxygen saturation 96%. The physical examination revealed a chronic ulcerative wound over his right sole, with yellow discharge.
      • A laboratory testing revealed a peripheral-blood leukocyte count of 10.490 cells per cubic millimeter, with 88.3% polymorphonuclear cells. A biochemistry testing revealed glucose level of 141 mg/dL, C-reactive protein level of 14.43 mg/dL, creatinine level of 1.4mg/dL, and lavtic acid was 4.3mg/dL. A x ray of right foot revealed deformity of 3-5th metatarsal bones, especially 5th metatarsal bone with bone destruction and sclerotic change, compatible with chronic osteomyelitis, and osteopenia of visible bones. The patient is administrated with Brosym injection. He is hospitalized on 2020/09/22.
    • Course of inpatient treatment
      • After admission, patient received antibotic with Oxacillin and Brosym iv for sepsis control. Collect blood culture and yield E-coli noted. Fever is subside after medication. PS was consulted for right foot wound evalutaion, the wound debridement was perfomted on 9/28, he will arrange operation again at necxt week for close wound.
      • Wound culture yield Pseudomonas and OSSA, K.P, Serretia injecton, kept on current antibiotic treatment and wound care. Abdomen echo was perfomted for fever and R/O IAI, fatty liver and GB stone is noted, without IAI. During hospitalization, osteomyelitis scan was performed for HBO therapy, kept pending answer. More elevat of blood pressure is noted, we give add anti-hypertension used and noted his blood pressure became stable.
      • On 10/05, he received Deep debridement + fasciocutaneous flap coverage for chronic ulcer with osteomyelitis is found about 4 x 12 cm in size over the right lateral sole. Wound is improving and less bleeding, later we added pletaal. Post operation fever was noted and infection markers are increasing, so we added iv invanz along with ciprofloxacin. Blood culture was followed and showed GNB (Micro-organism report is still pending) and Wound culture revealed Enterococcus fecalis. Patient is relatively stable.    
      • This week, we continue antibiotic therapy : invanz and ciprofloxacin. Hyperbarric oxygen treatment was started. We noted his blood pressure is relatively stable and we taperred antihypertensive medication. Daily wound dressing and nature of the wound is improving.
      • Another week showing improving of his foot wound condition and no more newer culture results under invanz and ciproxin. Patient was afebrile however, wound was dehiscent partially and we called Dr.Zhang and suggest NS : BI2 wound dressing. Patient antibiotic were shift to per oral form (cefixime and cipro) this week. He is currently under HBO management. Due to stable condition and under antibiotic used under time, so he can be arranged for discharge today, take oral antibiotic back home, INF, PS, CV OPD follow up is arranged.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H if fever > 38’C or pain
      • Cinolone (ciprofloxacin 250mg) 2# BIDAC
      • Euricon (benzbromarone 50mg) 1# QD
      • fusidic acid 2% BID EXT for buttock wound
      • Ceficin (cefixime 100mg) 2# Q12H
      • Diovan (valsartan 160mg) 1# QD hold if SBP < 120mmHg
      • Nebilet (nebivolol 5mg) 0.5# QD
  • 2017-12-06, -09-13, -06-21, -03-29, -01-04 SOAP Cardiology Huang XuanLi
    • Diagnosis
      • Arterial embolism and thrombosis of lower extremity [I74.4]
      • Essential hypertention, unspecified [I10]
      • Neuralgia,neuritis,and radiculitis,unspecified [M54.10]
      • Gout, unspecified [M10.9]
      • Edema [R60.9]
      • Allergic rhinitis cause unspecified [J30.9]
    • Prescription x3
      • Isoptin (verapamil 240mg) 0.5# QD
      • Euricon (benzbromarone 50mg) 1# QD
      • Pletaal (cilostazol 100mg) 0.5# BIDAC
      • Blopress (candesartan 8mg) 1# QN

[consultation]

  • 2023-10-25 Infectious Disease
    • Q
      • for Neutropenia fever evaluation
      • This 73-year-old male patient has past history of 1). Hypertension, 2). Gout, 3). Peripheral arterial occlusion disease, 4). Varicose veins of bilateral limbs, and 5). Chronic osteomyelitis of right foot post sequestrectomy for osteomyelitis 6) diffuse large B cell lymphoma. He denied travel, occupation, contact or cluster history recently, nor allergy history. Due to epigastric pain. Upper G-I panendoscopy was performed on 2023/09/19 and revealed Superficial gastritis; Duodenal ulcerative tumor, suspicious lymphoma or adenocarcinoma, s/p biopsy.
      • Duodenum biopsy pathology showed Diffuse large B-cell lymphoma, non-germinal-center B-cell typel.
      • He received C1 R-COP on 2023/10/13, then he suffered from fever (BT: 39.2C), 2023/10/23 wbc: 640/uL, Band: 3.2%, Neurophoil: 65.6%, ANC: 440, Lenograstim 250mcg, followed-up cultures, and the antibiotic with Cefim was given. We need your help for infection control, thanks a lot!!
    • A
      • Thi is a case of diffuse large B-cell lymphoma, non-germinal-center B-cell type.
      • Please use cefim 2g iv q8h for q8h for neutropenic fever.
      • G-CSF use
      • Protesctive isolation and keep oral and anal region hygiene.
      • Re-evaluation clinical conidtion closely and consider add anti-MRSA agents if the patient’s condition get worse.
      • Please f/u the B/C results closely.

[immunochemotherapy]

  • 2023-10-13 - rituximab 375mg/m2 700mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 50mg BID PO D1-5 (R-COP, Endoxan 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2023-10-25

[tube feeding]

Const-K 750mg is an extended-release tablet that contains 10 mEq of potassium. One Const-K tablet provides less potassium than a single banana (which contains about 2.2 mEq/inch or 0.9 mEq/cm).

The tablet can be crushed into fine particles and swallowed with water if injectable potassium supplementation is not preferred.

[elevated PCT and CRP]

On 2023-10-24, lab results showed a moderate amount of gram-positive cocci bacteria, gram-negative bacteria, and gram-positive rods in the (sputum) sample, as well as a high number of neutrophils and a low number of epithelial cells. PCT and CRT levels were also elevated and continued to rise over these 2 days (2023-10-24 and 2023-10-25). After consultation with an infectious disease specialist, cefepime was started on 2023-10-24 and is currently being administered.

  • 2023-10-25 Procalcitonin(PCT) 3.67 ng/mL

  • 2023-10-24 Procalcitonin(PCT) 0.12 ng/mL

  • 2023-10-25 CRP 10.5 mg/dL

  • 2023-10-24 CRP 6.7 mg/dL

  • G(+) Cocci 2+, GNB 2+, GPB 4+, Neutrophil/LPF > 25, Epithilial cell/LPF < 10

The patient’s white blood cell count has passed its nadir on 2023-10-23 and returned to normal. The recovery of the patient’s immune system should help them fight off bacterial infections.

  • 2023-10-25 WBC 4.43 x10^3/uL
  • 2023-10-24 WBC 2.26 x10^3/uL *
  • 2023-10-23 WBC 0.64 x10^3/uL ***
  • 2023-10-20 WBC 1.25 x10^3/uL **
  • 2023-10-18 WBC 5.10 x10^3/uL
  • 2023-10-16 WBC 7.96 x10^3/uL
  • 2023-10-13 WBC 4.68 x10^3/uL
  • 2023-10-12 WBC 4.53 x10^3/uL

700768893

231025

[exam findings]

  • 2023-10-03 CT - brain
    • No evidence of intracranial hemorrhage.
  • 2023-08-24, -08-02, -08-01 CXR
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-07-29 KUB
    • Calcifications in the pelvic cavity, could be due to phleboliths.
  • 2023-07-29 ECG
    • Sinus tachycardia
    • Right atrial enlargement
    • Nonspecific ST abnormality
  • 2023-07-13 EGD
    • Gastric cancer, borrmann type IV
    • Reflux esophagitis LA Classification grade A
  • 2023-06-05 CT - abdomen
    • Indication: Gastric cancer s/p C/T
    • Abdominal CT with and without enhancement revealed:
      • Diffuse gastric wall thickening at antrum is found. In comparison with CT dated on 2023-01-11, the lesion is stationary.
      • The GB is well distended without soft tissue lesion
      • There is no evidence of destructive bone lesion.
      • Dilated IHDs and CBD is found.
      • s/p enterostomy with its orifice at RLQ.
      • The urinary bladder is partially distended without evidence of abnormal soft tissue lesion.
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
      • The spleen, pancreas, both kidneys and adrenals are intact.
    • Imp:
      • Diffuse gastric wall thickening, stable.
      • Dilated IHDs and CBD. Suggest close observation.
  • 2023-02-10 Lower GI Series (colon filling study)
    • Filling LGI series show
      • No evidence of abnormal filling defect along the course from rectum into descending colon.
      • Increased intestinal gas is found.
      • There is no evidence of destructive bone lesion.
  • 2023-02-06 CXR
    • Blunted left costophrenic angle.
  • 2023-02-06 ECG
    • Normal sinus rhythm
    • Low voltage QRS
  • 2023-02-06 Flow volume loop
    • moderate restrictive impairment
  • 2023-02-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (54 - 16) / 54 = 70.37%
      • M-mode (Teichholz) = 69
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • Preserved RV systolic function
  • 2023-01-13 Patho - doudenum biopsy
    • Labeled as “duodenum, SDA”, biopsy (B)— benign duodenal tissue with marked chronic inflammation and mild to moderate dilatation of lymphatics.
  • 2023-01-13 Patho - stomach biopsy
    • Stomach, GC, biopsy — Adenocarcinoma.
    • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands and isolated neoplastic signet ring-like cells.
    • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0). CD68 (-).
  • 2023-01-11 CT - abdomen
    • History:
      • 20220927 CT:Pneumoperitoneum. Swelling and wall thickening of the terminal ileum and ascending colon.
      • Emergent S/P right hemicolectomy and terminal ileostomy: A-colon perforation, Compatible with diverticulitis with perforation and suppurative peritonitis
    • Indication: weight loss
    • Impression:
      • There is dilatation of IHDs, CHD, CBD, and pacreatic duct.
        • Please correlate with serum alk-p and bilirubin level.
      • There is edematous wall thickening of the distal esophagus, stomach, and duodenum. Please correlate with gastroscopy.
      • Adhesion bands induce mechanical high grade small bowel obstruction is highly suspected.
        • please correlate with clinical condition.
      • There is edematous wall thickening of the transverse-and descending colon. Please correlate with colonoscopy to R/O ulcerative colitis or Crohn disease.
  • 2023-01-10 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
  • 2023-01-10 SONO - abdomen
    • Gallbladder sludge
    • CBD dilatation and IHD dilatation
  • 2022-12-26 Patho - stomach biopsy
    • Stomach, unspecified site, biopsy — Non-atrophic chronic gastritis, Helicobacter Pylori: NOT present
  • 2022-12-23 Esophagogastroduodenoscopy, EGD
    • Giant folds of stomach with poor distention upon air inflation, r/o inflitrated type malignancy, s/p CLO test and biopsy
    • Reflux esophagitis LA Classification grade A
  • 2022-10-14 CXR
    • Focal sclerotic change of left humerus.
    • Blunted bilateral costophrenic angles.
  • 2022-10-12 CXR
    • Bilateral pleural effusion.
    • Ground glass opacity in bilateral lower lungs.
    • Some calcifications at left humerus.
  • 2022-10-10 CXR
    • Ground glass opacity in RLL.
    • Patch density at LLL.
    • Focal sclerotic change at left humeral head.
  • 2022-10-04 CTA - chest
    • Indication: pulmonary embolism
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Status post endotracheal tube placement.
        • Consolidation over both lower lungs with bilateral pleural effusion is found.
        • Increased pulmonary vasculature is found.
        • No evidence of pulmonary embolism nor aortic dissection is found.
        • There is no evidence of mediastinal LAP
        • Patent airway is found.
      • Visible abdomen:
        • Moderate ascites at abdominal cavity is found mostly around pancreas is found. Please exclude the possibility of pancreatitis.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • Minimal infiltration at mesentery is found.
        • Suggest clinical correlation
    • Imp:
      • No evidence of pulmonary embolism nor aortic dissection is found.
      • Increased pulmonary vasculature is found.
      • BIlateral pleural effusion and consolidation over bilateral lower lungs.
      • Moderate ascites at abdominal cavity is found mostly around pancreas is found. Please exclude the possibility of pancreatitis.
  • 2022-09-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (92 - 38) / 92 = 58.70%
      • M-mode (Teichholz) = 58.5
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Mild MR and TR , trivial AR
    • No regional wall motion abnormalities
  • 2022-09-29 SONO - chest
    • Bilateral thorax: small amount pleural effusion; thoracocentesis was not performed due to high risk of complications.
  • 2022-09-27 Patho - colon resection (non tumor)
    • PATHOLOGIC DIAGNOSIS
      • Ascending colon, right hemicolectomy — Compatible with diverticulitis with perforation and suppurative peritonitis
    • MACROSCOPIC EXAMINATION
      • Operation procedure: Right hemicolectomy
      • Specimen site: Right colon
      • Specimen size: 25 cm (ascending colon), 8 cm (ileum), and 7 cm (appendix) in length, respectively
      • Grossly, the surface of intestine is coated by fibrinous exudate. There is a subtle diverticulum with a perforated hole in ascending colon is present. The appendix is congested. The ileum is unremarkable.
      • Representative parts are taken for section and labeled: A1= ascending colon with perforation, A2-A4= colon + pericolic soft tissue, A5-A6= appendix
    • MICROSCOPIC EXAMINATION
      • The sections of ascending colon show a picture compatible with diverticulitis with perforation, composed of diverticulum with transmural necrosis, moderate neutrophil infiltration, subserosal fibrosis, granulation tissue, and acute serositis. Suppurative peritonitios with bacterial colonies and abscess formation are present.
      • The sections of appendix show mucosal hyperplasia and periappendicitis.
      • The sectiobns of ileum show acute serositis.
  • 2022-09-27 CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2022-09-27 CTA - chest
    • Clinical history: 60y/o female patient with sudden low abdominal pain since 2 hours ago, epigastric pain for half month.
    • With and without contrast enhancement CT: CTA, Chest
      • Presence of ascites and pneumoperitoneum.
      • Swelling/thickening at terminal ileum.
      • Enlarged mesentery lymph nodes in right lower abdomen.
      • No abnormal fluid accumulation in the mediastinum and pleural space.
    • Impression:
      • Pneumoperitoneum with ascites, suspected hallow organ perforation.
      • Swelling/thickening at terminal ileum.
  • 2022-09-27 ECG
    • Sinus rhythm with ventricular premate complexes
    • Nonspecific ST abnormality
    • Prolonged QT

[MedRec]

  • 2023-07-25 SOAP Hemato-Oncology
    • Taking “Astragalus Root” (huang2qi2) since the beginning of chemotherapy
  • 2023-07-18 SOAP Hemato-Oncology
    • P: Changing regimen from FLOT to FOLFOX

[consultation]

  • 2023-02-23 Hemato-Oncology
    • Q
      • Gastric cancer for neoadjuvant chemotherapy
      • This 60 y/o female with past history of ascending colon diverticulitis with perforation status post Hartmann’s operation (resection of ascending colon with end ileostomy) on 2022/09/27.
      • However, poor intake, poor appetite with body weight loss was still persisted after operation.
      • Further UGI scope was performed which revealed enlarged Gastric folds prob Scirrhous s/p biopsy. Pathology showed adenocarcinoma. IHC stains: CK highlights neoplastic cells. Her2/neu: negative. (score=0). CD68 (-).
      • She was admitted to our ward for nutrition support first then further oepration was performed on 2023/02/20. Operation finding showded severe intraperitoneal adhesion (frozen peritoneal), huge gastric ca with possibly peritoneal spread. We discussion with her family then further chemotherapy will be consider first. We need your help for further managememt for chemotherapy. Port-A insertion will be arrange on 2023/02/22 PM. Thanks for your time!!
    • A
      • This 60 year old woman is a case of previously untreated, unresectable, non-HER2-positive gastric cancer with possibly peritoneal spread (pending pathology result). She had history of ascending colon diverticulitis with perforation status post Hartmann’s operation (resection of ascending colon with end ileostomy) on 2022/09/27. We are consulted for further treatment.
      • Please check PD-L1, HbsAg, AntiHbc, Anti HCV. Please arrange port A insertion. And arrange chest CT+/-contrast for complete staging.
      • Chemotherapy +/- immunotherapy is indicated in this patient. Arrange our OPD after discharge. Thanks for your consultation.
  • 2023-02-06 Anesthesiology
    • Q
      • CVC insertion for nutrition with TPN
      • This 60 y/o female was a case of 1) Ascending colon diverticulitis with perforation status post Hartmann’s operation (resection of ascending colon with end ileostomy) on 2022/09/27. 2) Gastric cancer.
      • This time, she sufferred from poor appetite with vomit then BW weight loss was noted in recent months. We need your help for CVC insertion with nutrition support. Thanks for your time!!
    • A
      • Procedure
        • After positioning via Trendelenburg position,head rotated, elevated shoulder, the skin was sterilized and anesthetized with 2% lidocaine 2 m.l..
        • The right IJV was difficult to cannulated.
        • We performed 7 fr CVC insertion to left internal jugular vein with ultrasound-guided under Seldinger technique
        • The pt tolerant the procedure well.
        • There was no sign of hematoma, pneumothorax, infection after the procedure.
      • The recommandation is as followed:
        • Please check chest roentgenography for localization.
        • Change IV set QD if TPN used or Q4D if general fliud.
        • Change OP site at least every week. IF loosening or blood accumulation please change it ASAP.
        • We do not recommand routinely change the CVC unless there are some infectious signs.
  • 2022-10-19 Cardiac surgery
    • Q
      • For further evaluation of D-dimer elevation, deep vein thrombosis ???
      • This 60 y/o female suffered from sudden low abdominal pain for hours, and epigastric pain for half month.
        • CT: Pneumoperitoneum with ascites.
        • Ascending colon diverticulitis with perforation was diagnosed. Operation of Hartmann’s operation (resection of ascending colon with end ileostomy) on 2022/09/27.
        • During hospitalization. D-dimer elevation was noted and Clexane 30mg SC QD was give since 2022/10/14. Bilateral legs no distention, and freely movable.
        • D-dimer
          • 2022-09-30 05:58 2100.45 ng/mL(FEU)
          • 2022-10-04 12:28 > 10000.00 ng/mL(FEU)
          • 2022-10-09 07:50 7286.88 ng/mL(FEU)
          • 2022-10-10 05:17 6349.13 ng/mL(FEU)
          • 2022-10-12 05:09 8695.92 ng/mL(FEU)
          • 2022-10-14 07:28 9250.27 ng/mL(FEU)
          • 2022-10-19 07:42 8570.57 ng/mL(FEU)
      • So we consult you for further evaluation and management of blood D-dimer elevation the problem. (is it possible to swift oral medication?).
    • A
      • This 60 y/o female, history reviewed as above and herself examined, consulted for elevated D-dimer under clexane therapy
        • Chest CTA 2022/10/04 no pulmonary embolism
        • PE both limb soft, without tender swelling, already off-bed ambulation, dyspnea (-)
      • Recommendation
        • no clinical evidence of significant DVT
        • may arrange duplex PRG (lower limbs sonography for peripheral vessel) to exclude DVT possibility, then DC clexance accordingly
  • 2022-10-07 Thoracic Medicine
    • Q
      • for Left pleural effusion.
      • This 60 y/o female had history of gastric ulcer. Under the impression of sigmoid colon with perforation, fecal peritonitis + necrosis of omentum and septic shock s/p emergent Hartman procedure on 2022/09/27. CXR showed Left pleural effusion on 2022/10/07. We need your help for treatment assessment (chest echo?? tapping??). Thank you so much!!!
    • A
      • Series image showed progressive bilateral pleural effuison, Left side > right side.
      • severe hypoalbuminemia : <1.9 —> 2.3 —> 2.3
      • 20221004 CT showed: peritonitis with ascites, reactive bilateral pleural effusion
      • Suggestion:
        • Please take the permit. We will arrange chest echo for chest tapping +/- 14Fr. pig-tail catheter insertion for her.
        • Change antibiotics to Unasym or consult infection to adjust antobiotics use
        • Albumin replacement to keep Albumin level = 3.5 at least
        • Lasix for remove third space edema
        • thanks and f/u prn.
  • 2022-09-27 Thoracic Medicine
    • Q
      • This 60 y/o female had history of gastric ulcer. According to her family’s history, she had got lower abdominal pain since last night. Epigastric pain had been noted for half month. At ER, dyspnea with chest pain and cold sweating were also noted. Vital signs showed BP 115/67mmHg, HR 93bpm, BT 36.9’C, RR 18. Lab data revealed: WBC 13K, CRP 1.0, Troponin within normal range, no elevated Bilirubin or Lipase. CT showed: Pneumoperitoneum with ascites, r/o hallow organ perforation and swelling terminal ileum. Brosym was prescribed and operation was arranged. Resection of A colon with ileostomy was perforemed. Under the impression of Pneumoperitoneum with ascites due to A colon perforation, she was admitted to our ICU for further care.
      • Consult purpose: decrease saturation with Bilateral pleural effusion, r/o lung compartment syndrome. consider Bronchoscopy?
    • A
      • S: short of breath
      • O:
        • 20220929 bed-side chest sono: bilateral small amount pleural effusion
        • 20220929 CRP=37, WBC=27.5K
        • 20220927 albumin < 1.5
        • 20220927 BW=63.1 Kg –> 20220929 BW=66.5Kg
        • 20220928 CXR: bilateral lung consolidation
        • 20220929 breath sound: clear
      • A:
        • ARDS, moderate to severe degree; favor secondary to intra-abdmonial infection
        • pneumoperitoneum s/p operation
      • P:
        • Bronchoscopy was relatively contra-indicated due to high oxygen demand [FiO2=100% on 20220929 PM3:00]. Bronchoscopy probably causes desaturation during and after the procedure.
        • arrange cardiac echo and check serum D-dimer and NT-proBNP for suspected pulmonary embolism and congestive heart failure
        • follow up ABG/CXR QD
        • prone position was relatively contra-indicated due to septic shock status and large surgical wound over anterior abdominal wall
        • check serum Aspergillus Ag, serum cryptococcus Ag, serum Mycoplasma IgM, serum Chlamydia IgM, and urine legionella Ag, urine streptococcus Ag for pathogen survey
        • check sputum TBPCR, TB culture, acid-fast stain and aerobic culture for pathogen survey
  • 2022-09-27 General and DigestiveSurgery
    • A
      • P,E showed regid abdomen, with muscle guarding
      • diffuse local tenderness and knocking pain, right
      • Lab and CT showed neumoperitoneum , in favor of PPU
      • Emergency op is indicated

[chemotherapy]

  • 2023-09-11 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-08-09 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-06-27 - (FLOT)
  • 2023-06-13 - (FLOT)
  • 2023-05-30 - (FLOT)
  • 2023-05-16 - (FLOT)
  • 2023-04-25 - (FLOT)
  • 2023-04-11 - (FLOT)
  • 2023-03-23 - (FLOT)
  • 2023-02-24 - docetaxel 35mg/m2 50mg D5W 160mL 1hr + oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 200mg/m2 270mg NS 250mL 2hr + fluorouracil 2600mg/m2 3500mg NS 500mL 24hr (FLOT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-20

[elevated bilirubin level with high DBI to TBI ratio]

Lab bilirubin level:

  • 2023-10-20 Bilirubin total 1.14 mg/dL

  • 2023-10-20 Bilirubin direct 0.48 mg/dL

  • 2023-10-20 DBI/TBI 42.11 %

  • 2023-10-13 Bilirubin total 1.30 mg/dL

  • 2023-10-13 Bilirubin direct 0.54 mg/dL

  • 2023-10-13 DBI/TBI 41.54 %

The direct and total bilirubin levels on 2023-10-20 appear to be slightly lower than those on 2023-10-13. Despite this decrease, the ratio of direct bilirubin (DBI) to total bilirubin (TBI) continues to be elevated, which could typically signify issues with the liver’s capacity to secrete bilirubin into the bile or an obstruction within the bile ducts, leading to a buildup of conjugated bilirubin in the bloodstream. It’s noteworthy that oxaliplatin, a component of the FOLFOX regimen, is linked to a 13% incidence of increased serum bilirubin. However, it’s been over a month since the last FOLFOX cycle was administered during the previous hospitalization.

2023-10-16

[hypocalcemia]

corrected calcium level for hypoalbuminemia

injectable calcium supplements with Bfluid

  • Two injectable calcium supplements are available from stock: Vitacal (calcium chloride, equivalent to 5.44 mEq/amp) and Calglon (calcium gluconate, equivalent to 4.65 mEq/amp).

  • Bfluid 1000 mL contains 5 mEq of calcium per liter and can be supplemented with a maximum of an additional 5 mEq of calcium per liter.

2023-09-11

[leukopenia, anemia]

FOLFOX regimen was administered on 2023-08-09 and 2023-09-11, there was no observed leukopenia (WBC < 3K/uL) since 2023-08-25, however, there was still anemia (HGB < 8mg/dL) observed on 2023-09-11.

2023-09-11 WBC 3.72 x10^3/uL
2023-09-07 WBC 5.61 x10^3/uL
2023-09-04 WBC 6.04 x10^3/uL
2023-08-31 WBC 8.23 x10^3/uL
2023-08-28 WBC 22.74 x10^3/uL
2023-08-25 WBC 8.85 x10^3/uL
2023-08-23 WBC 1.87 x10^3/uL 2023-08-21 WBC 1.08 x10^3/uL 2023-08-17 WBC 2.59 x10^3/uL * 2023-08-14 WBC 1.60 x10^3/uL ** 2023-08-09 WBC 3.03 x10^3/uL
2023-08-07 WBC 3.90 x10^3/uL
2023-08-01 WBC 7.93 x10^3/uL

2023-09-11 HGB 7.9 g/dL 2023-09-07 HGB 9.3 g/dL 2023-09-04 HGB 10.3 g/dL 2023-08-31 HGB 8.6 g/dL 2023-08-28 HGB 9.7 g/dL 2023-08-25 HGB 9.3 g/dL 2023-08-23 HGB 10.2 g/dL 2023-08-21 HGB 8.1 g/dL 2023-08-17 HGB 7.9 g/dL 2023-08-14 HGB 8.0 g/dL * 2023-08-09 HGB 9.1 g/dL 2023-08-07 HGB 9.6 g/dL 2023-08-01 HGB 12.4 g/dL

A blood transfusion was performed on 2023-09-11 without a problem.

2023-08-11

[Astragalus Root]

The patient has been consistently using Astragalus Root since starting chemotherapy (2023-07-25 Onc Opd). To assess whether Astragalus Root might impact the effectiveness of chemotherapy, a literature search was conducted, and a relevant article was found: “Meta-Analysis of Astragalus-Containing Traditional Chinese Medicine Combined With Chemotherapy for Colorectal Cancer: Efficacy and Safety to Tumor Response. Front Oncol. 2019;9:749. Published 2019 Aug 13. doi:10.3389/fonc.2019.00749

Here is a summary of the key points from the research article:

  • The article is a meta-analysis evaluating the efficacy and safety of combining Astragalus-containing traditional Chinese medicine (TCM) with chemotherapy for treating colorectal cancer, compared to chemotherapy alone.
  • 22 randomized controlled trials with a total of 1409 patients were included. Trials used various oral, injected or external TCM preparations containing Astragalus.
  • The meta-analysis found combining Astragalus-based TCM with chemotherapy significantly improved tumor response rate and quality of life compared to chemotherapy alone.
  • Combination therapy also reduced chemotherapy side effects including myelosuppression, nausea/vomiting, diarrhea and neurotoxicity.
  • No significant differences were found between groups for liver or kidney dysfunction side effects.
  • Limitations include generally low quality of included trials and all Chinese studies, reducing applicability. More rigorous research is needed.
  • Overall, the meta-analysis suggests Astragalus-containing TCM combined with chemotherapy may have benefits for colorectal cancer, but further high-quality studies are warranted.

Based on the findings of this study, there is currently no evidence to suggest that the patient should discontinue the use of Astragalus Root.

2023-03-20

  • Leukopenia was observed on 2023-03-08, approximately 2 weeks after the patient received her first cycle of FLOT regimen chemotherapy, which started on 2023-02-24. The patient then received Granocyte (lenograstim 250ug) for three consecutive days (since 2023-03-08) and has not experienced any further episodes of leukopenia.

    • 2023-03-15 WBC 9.76 x10^3/uL
    • 2023-03-08 WBC 1.76 x10^3/uL
    • 2023-02-23 WBC 5.75 x10^3/uL
    • 2023-02-21 WBC 6.51 x10^3/uL
  • According to a study, preoperative FLOT chemotherapy appears to be safe and feasible for the treatment of resectable locally advanced gastric cancer. The FLOT regimen used in the study consisted of docetaxel (60 mg/m2), oxaliplatin (85 mg/m2), leucovorin (200 mg/m2), and 5-fluorouracil (2,600 mg/m2 as a 24 hr infusion). The study suggests that FLOT may be more effective in reducing morbidity and improving overall survival compared to initial surgery followed by chemotherapy. The patient received a reduced version of the FLOT regimen, which includes docetaxel 35mg/m2, oxaliplatin 75mg/m2, leucovorin 200mg/m2, and fluorouracil 2600mg/m2. (ref: Docetaxel, oxaliplatin, leucovorin, and 5-fluorouracil (FLOT) as preoperative and postoperative chemotherapy compared with surgery followed by chemotherapy for patients with locally advanced gastric cancer: a propensity score-based analysis. Cancer Manag Res. 2019;11:3009-3020. Published 2019 Apr 10. doi:10.2147/CMAR.S200883).

  • The dose used in this patient was lower than what is recommended in our in-hospital “Prescription Collection of Chemotherapy for Gastric Cancer” protocol (dated 2022-06-21). The protocol recommends a dose of docetaxel 50 mg/m2 IV D1, oxaliplatin 85 mg/m2 IV D1, and 5-FU 1200 mg/m2 IV continuous infusion (over 24 hours daily) on D1 and D2.

  • There is no need to adjust the dosage at this time. It is recommended to continue monitoring the patient’s blood cell counts to evaluate the response after the second cycle of treatment.

700552963

231024

[exam findings]

  • 2023-09-19 SONO - abdomen
    • Liver cyst, S4
  • 2023-03-15 Patho - breast mastectomy with regional lymph nodes
    • PATHOLOGIC DIAGNOSIS
      • Breast, left, partial mastectomy — Invasive carcinoma of no special type
      • Resection margin, breast, left, partial mastectomy — Free
      • Lymph nodes, sentinel and axillary, left, lymphadenecomy — Metastatic carcinoma (2/11)
      • AJCC 8 th edition, Pathology stage: pT2N1a(cM0); Anatomic stage IIB; Prognostic stage IB
    • MACROSCOPIC EXAMINATION
      • Breast Size: 3.8 x 2.5 x 2.0 cm
      • Skin: Not included
      • Nipple: Not included
      • Tumor Size: 2.5 x 2.0 x 1.5 cm
      • Resection Margin: Free, 0.2 cm from the deep margin
      • Lymph node: Sentinel and axilla, left
      • Representative parts are taken for section and labeled: F2023-00100 FSA1= 12’, 3’, 6’ margins, FSA2= 9’ and deep margins, FSB= left axilla sentinel LNs, A1-A5= tumor. S2023-04655= left axilla LNs
    • MICROSCOPIC EXAMINATION
      • Disease Type
        • Histologic type: Invasive carcinoma of no special type
        • Size of invasive carcinoma: 2.5 x 2.0 x 1.5 cm
        • Histologic grade (Nottingham histologic score): Grade 2 (score=6)
        • Skin involvement: Not applicable
        • Muscle involvement: Present
        • Ductal carcinoma in situ: Absent
      • Margins: Negative, Closest margin ( 2 mm from deep margin)
      • Nodal status: Positive (sentinel 1/3; axillary 1/8)
        • numbers
          • number of lymph node examined: 3 (sentinel), 8 (axilla)
          • number with macrometastases (> 2mm): 1 (sentinel), 1 (axilla)
          • number with micrometastases (> 0.2~2mm and/or > 200 cells): 0
          • number with isolated tumor cells (<= 0.2mm and <=200 cells): 0
        • Extranodal extension: Present
      • Treatment Effect: No presurgical neoadjuvant therapy received
      • Lymphovascular invasion: Presnt
      • Perineural invasion: Absent
    • IMMUNOHISTOCHEMICAL STUDY (Data from VGH)
      • ER (Ab): Positive (95%)
      • PR (Ab): Positive (90%)
      • HER-2/Neu (Ab): Negative (score= 1+)
      • Ki-67: 28%
  • 2023-03-14 Frozen Section
    • 3’, 6’, 9’, 12’, upper and deep margins, breast, left, frozen section — Free of carcinoma
    • Sentinel lymph nodes, axilla, left, frozen section — Metastatic carcinoma (1/3)
  • 2023-03-14 Lymphoscintigraphy
    • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the left breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the left axilla.
    • IMPRESSION: Probably a sentinel lymph node at the left axillary region.
  • 2023-03-13 SONO - abdomen
    • fatty liver: minimal
  • 2023-03-09 Tc-99m MDP bone scan
    • Increased activity in the lower C- and lower L-spines. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, hips, knees and feet, compatible with benign joint lesions.
  • 2023-03-09 SONO - breast
    • Diagnosis
      • Bil. fibroadenomas as described
      • Left breast cancer
    • Treatment
      • explain the finding
    • Suggestion and Plan
      • further treatment
    • BI-RADS:
      • score 6. known biopsy-proven malignancy

[consultation]

  • 2023-08-28 Radiation Oncology
    • Q
      • This 57-year-old female patient denied any past history including hypertension, DM, HBV or heart disease. She denied cancer history. She had COVID infection on 2022/11.
      • She noted a palpable mass at left breast by health examination in VGH. Core needle biopsy revealed invasive carcinoma, ER(95%+) PR(90%+) HER2/neu(1+) Ki 67 28%. CA-153 11.912 U/ml, CEA 2.452 ng/ml. Due to personal reason, she came to our OPD for help.
      • Breast sono showed a lesion, left 6’/0.43 cm , size: 1.19x1.67cm. Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis. Under surgery of left partial mastectomy + ALND on 2023/03/14.
      • Pathology invasive carcinoma with axillary LN metastasis, pT2N1aM0; Anatomic stage IIB; Prognostic stage IB.
      • Adjuvant chemotherapy Lipo dox 35mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 for 4 cycles was plan.
      • AI and radiotherapy for axillary LN after chemotherapy.
      • Under the impression of left breast invasive carcinoma with axillary LN metastasis, she was admitted for 8th adjuvant chemotherapy Taxotere 75mg/m2. We need your help for radiotherapy. Thank you so much!!
    • A
      • Subjective:
        • Previous RT: denied.
        • Other disease: HTN, thyroid CA s/p thyroidectomy, HCVD, hyperlipidemia and insomnia.
        • Family history: denied.
        • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
        • Married. Caregiver: her husband. Job: accountant (rest now). Mild or no economic stress at least.
        • Language: Mandarin. Taiwanese.
        • Religion: Buddism
      • Objective:
        • General Condition-ECOG: 1.
        • PE, 2023/8/28: No palpable SCF LAPs.
        • Pathology, 2023/03/14
          • Breast, left, partial mastectomy — Invasive carcinoma of no special type, 2.5 cm, free margin (2 mm from closest deep margin); LVSI(+). ER(95%+); PR(90%+); HER2/neu(1+); Ki 67 28%.
          • Lymph nodes, sentinel and axillary, left, lymphadenecomy — Metastatic carcinoma (2/11), ECS(+).
          • AJCC 8 th edition, Pathology stage: pT2N1a(cM0); Anatomic stage IIB; Prognostic stage IB.
        • Images:
          • Breast sonogram, 2023/03: a lesion, left 6’/0.43 cm, size: 1.19x1.67cm.
          • CXR, liver echo, bone scan, 2023/03: negative for metastasis.
      • Diagnosis: Left breast cancer, invasive carcinoma, s/p partial mastectomy + ALND on 2023/03/14, pT2N1a cM0; Anatomic stage IIB; Prognostic stage IB s/p adjuvant chemotherapy Lipo dox 35mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 for 4 cycles (last on 2023/8/28); ECOG =1.
      • Plan: Adjuvant RT to left breast and SCF lymphatics for 5000cGy/25 fractions then boost scar to 6000cGy/30 fx is suggested for locoregional control. CT simulation is arranged on 9/06, 10:30. Possible RT toxicity is told. Diet education is given.

[surgical operation]

  • 2023-03-14
    • Surgery: Partial mastectomy (round-block) + axillary lymphnode dissection        
    • Finding
      • a 2.5x2x1.5 cm slight firm mass in lt breast
      • SLN 1(+)/3   

[chemotherapy]

  • 2023-08-28 - docetaxel 75mg/m2 115mg NS 250mL 1hr (D, Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + famotidine 20mg
  • 2023-08-07 - docetaxel 75mg/m2 115mg NS 250mL 1hr (D, Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-07-17 - docetaxel 75mg/m2 115mg NS 250mL 1hr (D, Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-06-21 - docetaxel 75mg/m2 114mg NS 250mL 1hr (D, Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-05-31 - cyclophosphamide 600mg/m2 900mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 52mg D5W 250mL 2hr (AC(Lipo), Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2023-05-08 - cyclophosphamide 600mg/m2 924mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr (AC(Lipo), Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2023-04-17 - cyclophosphamide 600mg/m2 920mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr (AC(Lipo), Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL + Granisetron 1mg + aprepitant 125mg PO D1
  • 2023-03-25 - cyclophosphamide 600mg/m2 920mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr (AC(Lipo), Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL + Granisetron 1mg + aprepitant 125mg PO D1

==========

2023-10-24

[grade 3 diarrhea]

The patient experienced grade 3 diarrhea (characterized by an increase of seven or more stools per day over baseline, the patient had a total of 8 bowel movements on 2023-10-23). However, the last administration of docetaxel, known to cause diarrhea in 23% to 43% of cases (with severe cases being <=6%), occurred almost two months ago, on 2023-08-28. This timeline makes it improbable that the recent severe diarrhea was solely a result of the previous docetaxel treatment.

Currently, the patient is on both loperamide and buscopan to manage the symptoms.

Additionally, it’s important to note that the patient’s current medication, abemaciclib, can also induce diarrhea. It’s advisable to temporarily discontinue abemaciclib until the diarrhea subsides to <= grade 1, after which the medication can be cautiously reintroduced.

701478306

231024

[exam findings]

  • 2023-09-21 PET
    • In comparison with the previous study on 2023/04/14, the previous FDG avid lesions involving multiple lymph node regions on both sides of the diaphragm are less evident, suggesting partial response to the treatment.
    • The FDG uptake in some focal areas in the right lung is also less evident.
    • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.
  • 2023-09-19 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy
    • Sections show 20-30 % cellularity. The M/E ratio is about 3/1. Megakaryocytes are found about 0-6/HPF. No increase of blasts is noted. There are no granulomas, nor foreign malignant cells.
    • The immunohistochemical stains reveals CD3 (scattered cells +), CD20(-), Cyclin D1(-), BCL2(scattered cells +), and BCL6(-).
  • 2023-08-08 CT - chest
    • Findings - comparison was made with CT on 2023/02/03 (other hospital)
      • massive moderate Rt pleural effusion.
      • lungs: relaxation atelectasis of RLL and RML. extensive centrilobular emphysema in both lungs, upper lobes predominance,
      • visible neck, mediastinum and hila: small residual lymphadenopathy in both axillary regions and visceral space of the mediastium,
      • visible abdominal-pelvic contents:
      • multiple residual enlarged lymph nodes in the paraaortic region and mesenetery root. prominent soft-tissue in perirectal and prescral spaces is found.
    • Impression:
      • significant of neoplastic LAP in both sides of diaphgram especially above the diaphgram, but still presence of massive Rt pleural effusion compared with CT on 2023/02/03
  • 2023-07-04, -06-06, 05-24 CXR
    • Atherosclerotic change of aortic arch
    • Pleura effusion of right costal-phrenic angle
    • Widening of the right upper mediastinum is noted that is c/w lymphoma after correlate with CT.
  • 2023-06-16 SONO - chest
    • left side minimal amount of pleural effusion
    • right side moderate amount of pleural effusion, 1000cc serosangious fluid was aspirated for analysis.
  • 2023-06-12 CXR
    • Increased infiltration in right lung zone
    • Bilateral pleural effusion, more on right side
  • 2023-06-12 SONO - chest
    • Pleural tapping - right side 1150 mL yellowish, cloudy
    • Echo diagnosis: Bilateral pleural effusion (Left minimal to small and Right massive), post right therapeutic thoracentesis.
  • 2023-05-24 SONO - chest
    • Pleural tapping - 1100mL yellow fluid was drained.
    • Echo diagnosis:
      • pleural effusion, massive, right
      • atelectasis, LLL, RLL
  • 2023-04-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (69 - 17) / 69 = 75.36%
      • M-mode (Teichholz) = 75.9
    • Conclusion:
      • Adequate LV, RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Minimal amount pericardial effusion, No tamponade, No pericardial constriction at present
      • Trivial MR
      • Moderate TR
      • Moderate Pulmonary HTN
      • Left pleural effusion
  • 2023-04-21 SONO - chest
    • Echo diagnosis
      • left side minimal amount of pleural effusion
      • right side massive amount of pleural effusion, 1200cc serosangious fluid was aspirated for analysis
  • 2023-04-17, -04-13 CXR
    • Patchy consolidation over RLL.
    • Suspected superior mediastinal lesion.
    • Increased infiltration over both lower lungs. May be active infection.
    • Bilateral pleural effusion.
  • 2023-04-13 Patho - bone marrow biopsy
    • Bone marrow, biopsy — involved by B-cell lymphoma
    • Microscopically, the bone marrow shows presence of aggregations of B-cell lymphoma. The bone marrow component shows 40% of cellularity, 3:1 of myeloid to erythroid ratio and 3 megakaryocytes of per HPF. No blast is seen.
    • Immunohistochemical stain CD20 and Bcl-2: positive at lymphoma, CD117(-), CD34(-), CD71(+ at erythroid cells), CD61( + at megakaryocytes), TdT(-).
  • 2023-04-14 PET scan
    • The FDG PET findings are compatible with lymphoma of low FDG uptake involving multiple lymph nodes on both sides of the diaphragm.
    • Mildly increased FDG uptake in some focal areas in the right lung. The nature is to be determined (inflammation? lymphoma?). Please correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in the colon and both kidneys. Physiological FDG accumulation is more likely.
  • 2023-01-13 SONO - chest
    • Echo diagnosis:
      • pleural effusion
      • Chest echography was performed first. The suitable intercostal space was selected and located.
      • Catheter was inserted with negative pressure smoothly.
      • Right side pleural effusion was drawn smoothly.
      • Watch out BP after tapping.
    • Suggestion:
      • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, cell count, and TB exam. TB PCR.
  • 2023-04-12 CXR
    • R/O mass lesion over superior mediastinum.
    • Patchy consolidation or atelectasis of RLL. Suggest check CT scan.
    • Moderate amount of right pleural effusion.
    • Small amount of left pleural effusion.
  • 2023-04-10 Nasopharyngoscopy
    • 2023/4/10 Admission
      • consult Hema (arrange staging workup and thne bed transfer + treatment)
      • multiple bil cervical LAPs since 2yr ago
      • dyspnea+, cough with much sputum, cough with blood+
      • BWL-, fever-, cold sweating-, NVR supraclavicular Bx in 2023/02 by Dr. Lin JiengFu at Mackey (refer to Hema, but he escaped? or nurse sign permit)
      • R lung effusion s/p regular tapping (around 700-1000mL)
      • fiber = much mucopus with PND, no vocal palsy

[chemoimmunotherapy]

  • 2023-10-23 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1150mg NS 250mL 30min D2 + doxorubicin 50mg/m2 75mg NS 100mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 90mg PO D2-6 (R-CHOP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + palonosetron 250ug D2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + aprepitant 125mg PO D2-4
  • 2023-09-21 - rituximab 375mg/m2 590mg NS 500mL 8hr D1 + cisplatin 75mg/m2 115mg NS 500mL 24hr D2 + cytarabine 2000mg/m2 3000mg NS 500mL 3hr Q12H D3 + dexamethasone 40mg PO QD D2-5 (R-DHAP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D2-4
  • 2023-08-09 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1150mg NS 250mL 30min D1 + doxorubicin 50mg/m2 75mg NS 100mL 30min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + prednisolone 60mg/m2 90mg PO D1-5 (R-CHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-11 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cisplatin 75mg/m2 120mg NS 500mL 24hr D2 + cytarabine 2000mg/m2 3000mg NS 500mL 3hr Q12H D3 + dexamethasone 40mg PO QD D2-5 (R-DHAP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D2-3
  • 2023-06-19 - rituximab 375mg/m2 580mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1150mg NS 250mL 30min D1 + doxorubicin 50mg/m2 75mg NS 100mL 30min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + prednisolone 60mg/m2 90mg PO D1-5 (R-CHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-2
  • 2023-05-24 - rituximab 375mg/m2 590mg NS 500mL 8hr D1 + cisplatin 75mg/m2 120mg NS 500mL 24hr D2 + cytarabine 2000mg/m2 3000mg NS 500mL 3hr Q12H D3 + dexamethasone 40mg PO QD D2-5 (R-DHAP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D2-4
  • 2023-04-20 - rituximab 375mg/m2 580mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1170mg NS 250mL 30min D1 + doxorubicin 50mg/m2 75mg NS 50mL 30min D5 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + prednisolone 60mg/m2 90mg PO D1-5 (R-CHOP where doxorubicin was administered last, is pending the results of a 2D transthoracic echocardiography)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3

R-DHAP (Rituximab, dexamethasone, high dose cytarabine, cisplatin) - DLBCL Salvage regimens - 2023-06-13 https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients

  • Administration
    • R-DHAP includes
      • rituximab (375 mg/m2 on day -1),
      • dexamethasone (40 mg/d on days 1 to 4),
      • cisplatin (100 mg/m2 on day 1 by continuous infusion), and
      • cytarabine (2 g/m2 in a three-hour infusion on day 2)
      • every three weeks.
    • For patients with pre-existent kidney insufficiency, some experts replace cisplatin with carboplatin or oxaliplatin to lessen nephrotoxicity, but there are limited outcomes data with these regimens.
  • Adverse effects
    • Hematologic toxicity is universal, with one-third of patients requiring transfusions, and grade >=3 nonhematologic adverse effects include infection (in up to one-quarter of patients) and occasional nephrotoxicity.

R-DHAP - Cisplatin, Cytarabine and Dexamethasone +/- Rituximab - ref https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2018/11/RDHAP.pdf

  • Indication
    • Salvage chemotherapy for relapsed/refractory Hodgkin’s or Non-Hodgkin’s Lymphoma
    • First line therapy in combination with alternating R-CHOP in patients with Mantle Cell Lymphoma with stage III/IV disease up to 65 years of age.
  • ICD-10 codes
    • Code with prefix C81-86
  • Regimen details
    • Day 1-4 = Dexamethasone 40mg IV or PO
    • Day 1* = Rituximab 375mg/m2 IV infusion
    • Day 1 = Cisplatin 100mg/m2 IV infusion
    • Day 2 = Cytarabine 2g/m2 BD (12 hours apart) IV infusion
      • Rituximab for B cell Non Hodgkin’s lymphoma patients only.
    • Consider starting GCSF (according to local policy, dose based on weight) either to shorten the duration of neutropenia (days 3-9) or to facilitate peripheral bloods stem cell collection (days 6-12).
  • Cycle frequency
    • Repeated every 21-28 days - as soon as blood counts recovered i.e. neutrophils >1.0x10^9/L and platelets (unsupported) > 100x10^9/L (unless cytopenias related to disease).
  • Number of cycles
    • Relapse setting: 2 cycles - then reassess disease for suitability for consolidation with stem cell transplant.
    • Non-transplant eligible: up to 6 cycles (total).
    • Mantle cell lymphoma: 3 cycles alternating with R-CHOP followed by consolidation with autograft.
  • Administration
    • Day 1
      • Rituximab is administered in 500mL sodium chloride 0.9%. The first infusion should be initiated at 50mg/hour and if tolerated the rate can be increased at 50mg/hour every 30 minutes to a maximum of 400mg/hour. Subsequent infusions should be initiated at 100 mg/hour and if tolerated increased at 100mg/hour increments every 30 minutes to a maximum of 400 mg/hour.
      • Cisplatin is administered in 1000mL sodium chloride 0.9% over 2 hours following the pre and post hydration as per protocol below:
        • Sodium Chloride 0.9% 1000mL 1 hour
        • Mannitol 20% 200mL 30 minutes or Mannitol 10% 400mL 30 minutes
        • Cisplatin in Sodium Chloride 0.9% 1000mL 2 hours
        • Sodium Chloride 0.9% + 2g MgSO4 + 20mmol KCL. 1000mL 2 hours
        • TOTAL 3200mL or 3400mL 5 hours 30 minutes
        • Ensure urine output > 100mL/hour prior to giving cisplatin. Give a single dose of furosemide 20mg IV if necessary.
      • Additional pre hydration may be given as per local policy or required for individual patients.
      • Patients with low magnesium levels (< 0.7 mmol/L) should have an additional 2g magnesium sulphate added to the pre-hydration bag.
      • An accurate fluid balance record must be kept.
      • All patients must be advised to drink at least 2 litres of fluid over the following 24 hours.
    • Day 2
      • Cytarabine is administered in 1000mL sodium chloride 0.9% over 3 hours. Start time of each infusion must be 12 hours apart. A total of 2 doses are given.
      • Pre-medication
        • Rituximab premedication:
          • Paracetamol 500mg-1g PO 30-60 minutes prior to rituximab infusion
          • Chlorphenamine 10mg IV bolus 15-30 minutes prior to rituximab infusion
          • Dexamethasone 8mg IV bolus or hydrocortisone 100mg IV bolus 15 minutes prior to rituximab infusion (may be omitted if day 1 dexamethasone has been taken at least 30 minutes prior to the start of the rituximab infusion)
      • Emetogenicity
        • This regimen has high emetic potential
      • Additional supportive medication
        • Allopurinol 300mg OD (100mg OD if CrCl < 20mL/min) for the first 2 weeks.
        • Antiemetics as per local policy
        • Antiviral prophylaxis as per local policy.
        • Prophylactic antibiotics may be required e.g. ciprofloxacin (or as per local policy) when neutrophil count < 0.5 x10^9/L.
        • Consider antifungal and PCP prophylaxis as per local policy.
        • Mouthwashes as per local policy.
        • H2 antagonist or proton-pump inhibitor if required.
        • Prednisolone 0.5% eye drops 1 drop QDS to both eyes (to avoid chemical conjunctivitis from high dose cytarabine) to start on day 2 for 5-7 days.
        • If magnesium/potassium levels < normal reference range, replace as per local policy.
      • Extravasation
        • Rituximab and cytarabine are neutral (Group 1)
        • Cisplatin is an exfoliant (Group 4)
  • Dose modifications (omitted, please refer to the original document)
    • Haematological toxicity
    • Renal impairment
    • Hepatic impairment
    • Other toxicities
  • Adverse effects (omitted, please refer to the original document)
  • Significant drug interactions (omitted, please refer to the original document)

R-CHOP/R-DHAP (Rituximab + Cyclophos­phamide + Doxorubicin + Vincristine + Prednisone + Dexamethasone + Cytarabine + Cisplatin) is a Chemotherapy Regimen for Lymphoma, Mantle Cell - 2023-06-13 https://www.chemoexperts.com/rchop-rdhap-mcl.html

  • R-CHOP

    • R - Rituximab (Rituxan)
    • C - Cyclophosphamide (Cytoxan)
    • H - Hydroxydaunorubicin (Doxorubicin, Adriamycin)
    • O - Oncovin (Vincristine)
    • P - Prednisone
  • R-DHAP

    • R - Rituximab (Rituxan)
    • D - Dexamethasone (Decadron)
    • HA - High-dose Ara-C (Cytarabine)
    • P - CisPlatin (Platinol)
  • Goals of therapy:

    • R-CHOP/R-DHAP is given to shrink tumors and decrease symptoms of mantle cell lymphoma. It is commonly given with the goal of cure, but may require a bone marrow transplant.
  • Schedule

    • Cycles
      • R-CHOP cycles:
        • Rituximab intravenous (I.V.) infusion on Day 1
        • Cyclophosphamide I.V. infusion over 30 to 60 minutes on Day 1
        • Doxorubicin I.V. push or I.V infusion over 10 to 30 minutes on Day 1
        • Vincristine I.V. infusion over 10 to 30 minutes on Day 1
        • Prednisone 100 mg (two 50 mg tablets) by mouth once daily on Days 1, 2, 3, 4, and 5
      • R-DHAP cycles:
        • Rituximab I.V. infusion on Day 1
        • Dexamethasone 40 mg (ten 4 mg tablets) by mouth once daily on Days 1, 2, 3, and 4
        • Cytarabine I.V. infusion over 3 hours every 12 hours on Day 2
        • Cisplatin I.V. infusion over 24 hours on Day 1
    • Estimated total infusion time for this treatment:
      • R-CHOP cycles: Up to 6 hours for Cycle 1; as short as 3 for the first day of next cycles if well tolerated
      • R-DHAP cycles: 24 hours for Day 1 of each cycle; 3 hours for each dose of cytarabine on Day 2
      • Infusion times are based on clinical studies but may vary depending on doctor preference or patient tolerability. Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time.
      • The R-CHOP portion of treatment is usually given in an outpatient infusion center, allowing the person to go home afterwards. The R-DHAP portion of treatment typically requires a 2 to 3 day stay in a hospital.
      • R-CHOP is alternated with R-DHAP every 21 days. When one treatment of each is given, this is known as one Cycle (one treatment of R-CHOP + one treatment of R-DHAP = 1 cycle). Each cycle may be repeated up to 3 times, depending upon the stage of the disease. Duration of therapy may last up to 5 months, depending upon response, tolerability, and number of cycles prescribed.
  • Side Effects (omitted, please refer to the original document)

  • Monitoring (omitted, please refer to the original document)

Regimen Reference Order - LYMP - R-CHOP alternating with R-DHAP - 2023-10-24 - https://www.cancercare.mb.ca/export/sites/default/For-Health-Professionals/.galleries/files/treatment-guidelines-rro-files/regimen-reference-orders/lymphoproliferative-disorders/LYMP-R-CHOP-alternating-with-R-DHAP.pdf

  • Planned Course: Every 21 days for 6 cycles
    • R-CHOP given on cycles 1, 3 and 5;
    • R-DHAP given on cycles 2, 4 and 6.
  • Indication for Use: Non-Hodgkin Lymphoma (Mantle Cell)

==========

2023-10-24

[reconciliation]

Per the PharmaCloud records, the patient hasn’t attended any medical consultations at different hospitals recently, only having appointments with a hematologist/oncologist at the present hospital. Also, there appear to be no inconsistencies in the medication records.

[R-CHOP/R-DHAP - dose adjustment for renal impairment]

The treatment initiated in 2023-04, alternating between R-CHOP and R-DHAP, appears to be yielding positive results. A PET scan from 2023-09-21, shows a reduction in the intensity of previously identified FDG avid lesions across various lymph node regions on both sides of the diaphragm. Additionally, there’s a noticeable decrease in FDG uptake in specific areas of the right lung, indicating a partial response to the therapy.

However, lab data over the past 6 months reveals a concerning trend: the patient’s eGFR has been on a notable decline, with recent measurements approximately half of what they were initially.

  • 2023-10-23 eGFR 65.07 ml/min/1.73m^2
  • 2023-10-09 eGFR 65.70 ml/min/1.73m^2
  • 2023-09-28 eGFR 68.29 ml/min/1.73m^2
  • 2023-09-18 eGFR 72.57 ml/min/1.73m^2
  • 2023-08-29 eGFR 75.71 ml/min/1.73m^2
  • 2023-08-02 eGFR 63.86 ml/min/1.73m^2
  • 2023-07-11 eGFR 82.81 ml/min/1.73m^2
  • 2023-07-04 eGFR 97.42 ml/min/1.73m^2
  • 2023-06-15 eGFR 92.44 ml/min/1.73m^2
  • 2023-06-12 eGFR 92.44 ml/min/1.73m^2
  • 2023-06-08 eGFR 65.70 ml/min/1.73m^2
  • 2023-06-01 eGFR 70.37 ml/min/1.73m^2
  • 2023-05-23 eGFR 84.79 ml/min/1.73m^2
  • 2023-05-10 eGFR 92.44 ml/min/1.73m^2
  • 2023-05-02 eGFR 107.45 ml/min/1.73m^2
  • 2023-04-24 eGFR 142.12 ml/min/1.73m^2
  • 2023-04-21 eGFR 105.90 ml/min/1.73m^2
  • 2023-04-20 eGFR 112.36 ml/min/1.73m^2
  • 2023-04-12 eGFR 82.81 ml/min/1.73m^2

If the patient’s renal function continues to decline, it might be necessary to consider dose adjustments for certain elements within the R-CHOP/R-DHAP regimen. The following are the recommended modifications:

  • cisplatin
    • CrCl >= 60 mL/minute: IV: No dosage adjustment necessary.
    • CrCl 50 to < 60 mL/minute: IV: Administer 75% of the usual indication-specific recommended dose.
    • CrCl 40 to < 50 mL/minute: IV: Administer 50% of the usual indication-specific recommended dose.
    • CrCl < 40 mL/minute: Use is not recommended.
  • cytarabine
    • CrCl 46 to 60 mL/minute: Administer 60% of dose.
    • CrCl 31 to 45 mL/minute: Administer 50% of dose.
    • CrCl <30 mL/minute: Consider use of alternative drug.
  • cyclophosphamide
    • CrCl >= 30 mL/minute: No dosage adjustment necessary.
    • CrCl 10 to 29 mL/minute: Administer 75% or 100% of normal dose.
    • CrCl < 10 mL/minute: Administer 50%, 75%, or 100% of normal dose.

2023-07-11

Lab data:

  • 2023-07-11 WBC 9.14 x10^3/uL
  • 2023-07-04 WBC 2.16 x10^3/uL *
  • 2023-06-19 WBC 16.08 x10^3/uL

Regimen administered:

  • 2023-07-11 R-DHAP
  • 2023-06-19 R-CHOP
  • 2023-05-24 R-DHAP
  • 2023-04-20 R-CHOP

The patient, who has been diagnosed with mantle cell lymphoma, is currently receiving an alternating regimen of R-CHOP and R-DHAP. The most recent cycle of R-CHOP began on 2023-06-19, and the latest cycle of R-DHAP just started today on 2023-07-11.

The lowest point of the patient’s white blood cell count (nadir) occurred on 2023-07-04, when it was recorded at 2.16K/uL. On both 2023-07-04 and 2023-07-06, the patient was administered a dose of Granocyte (lenograstim 250ug). The white blood cell count has significantly recovered by 2023-07-11, reaching 9.14K/uL, which should not hinder the delivery of the R-DHAP regimen.

2023-06-13

Lab data revealed an episode of leukopenia on 2023-06-08 with a WBC of 1.3K/uL. This was managed with a consecutive 3 day course of Granocyte (lenograstim 250ug). The leukopenia is believed to be related to the R-DHAP treatment administered on 2023-05-24, approximately 2 weeks prior to the identified episode. In addition, the first administration of R-CHOP on 2023-04-20 also resulted in a decrease in the WBC count, which reached its lowest level on 2023-05-02. Currently, the patient is not experiencing leukopenia. Instead, he is experiencing leukocytosis.

  • 2023-06-12 WBC 57.96 x10^3/uL
  • 2023-06-08 WBC 1.30 x10^3/uL
  • 2023-06-01 WBC 6.12 x10^3/uL
  • 2023-05-23 WBC 14.43 x10^3/uL
  • 2023-05-10 WBC 6.97 x10^3/uL
  • 2023-05-02 WBC 4.99 x10^3/uL
  • 2023-04-24 WBC 12.13 x10^3/uL
  • 2023-04-21 WBC 13.62 x10^3/uL
  • 2023-04-20 WBC 10.14 x10^3/uL
  • 2023-04-12 WBC 16.90 x10^3/uL

2023-04-21

  • The patient started R-COP treatment on 2023-04-20 and shortness of breath (SOB) and dyspnea were observed at 69.8 mL of Mabthera. Subsequently, a slower infusion rate was applied and the patient’s condition improved.
  • Feburic (febuxostat) has been prescribed for prophylaxis of hyperuricemia, and no issues have been identified with the current prescription.

700526640

231023

[exam findings]

  • 2023-10-21, -10-11, -09-25 KUB
    • Ascites is noted. Please correlate with sonography.
    • Spondylosis of the L-spine is noted.
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5 and L5-S1.
  • 2023-09-17 CT - abdomen
    • Findings
      • Cystic tumors in the pelvic cavity, up to 7.4cm. R/O recurrent tumors.
      • Presence of ascites with peritoneal nodularity, r/o carcinomatosis.
      • There are liver tumors, up to 3.4cm in right lobe, could be due to liver metastasis. Progression.
      • Unremarkable change of the spleen, pancreas and both kidneys.
      • S/P hysterectomy.
      • R/O calcified granuloma in left lower lung.
      • Right lower lung nodule, r/o lung metastasis.
    • Impression:
      • Peritoneal carcinomatosis.
      • Liver metastasis with progression.
      • R/O calcified granuloma in left lower lung.
      • Right lower lung nodule, r/o lung metastasis.
  • 2023-09-17 KUB
    • Small bowel ileus.
    • Lumbar spondylosis.
    • Disc space narrowing at L4/5 level.
  • 2023-09-15 Vein Sonography
    • No evidence of DVT, bilateral lower legs
    • Right CFV trivial reflux
    • Right LSV trivial reflux, involved right sphenofemoral junction (SFJ); proximal GSV size 0.41 cm,
    • Left LSV mild reflux, involved left sphenofemoral junction (SFJ); proximal GSV size 0.42 cm,
    • Left CFV mild reflux
    • Both SSV without reflux.
  • 2023-09-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (78 - 16) / 78 = 79.49%
      • M-mode (Teichholz) = 78
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Aortic valve calcification with moderate AS
      • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
      • Trivial MR, moderate TR
      • Preserved RV systolic function
  • 2023-08-13 Gynecologic ultrasonography
    • s/p staging operation(ATH + BSO + BPLND)
    • A 76.7x70.0mm pelvic mass was noted, suspected hematoma?
  • 2023-08-10 Gynecologic ultrasonography
    • ATH + BSO
    • R/O RT mass: 91mm X 82mm, no blood flow
  • 2023-06-21 Vein Sonography
    • No evidence of DVT, bilateral lower legs
    • Both LSV trivial reflux
  • 2023-06-15 Patho - ovary (non-tumor)
    • Soft tissue, pelvic, exploratoy laparotomy — Metastatic serous carcinoma
    • The sections show a picture of metastatic serous carcinoma, composed of papillary fronds lined by pleomorphic polygonal neoplastic cells, with high mitotic activity. Solid sheets of neoplastic cells admixed with reactive mesothelial cells can be found also.
  • 2023-05-30 MRI - pelvis
    • S/P hysterectomy with recurrence in the pelvic cavity, progression.
    • Stationary liver tumor, r/o liver metastasis.
    • Ascites with peritoneal enhancement, r/o peritoneal carcinomatosis.
    • Lymphocele in the pelvic cavity with regression.
  • 2023-02-16 ENT Hearing Test
    • Reliabilty Fair
    • PTA
      • R’t : 20 dB HL, normal to moderately severe SNHL
      • L’t : 19 dB HL, normal to moderate SNHL
    • Tymp
      • R’t : Type A
      • L’t : Type As
    • ART
      • R’t : absent
      • L’t : absent except Ipsi 500-1k Hz.
  • 2023-01-16 MRI - pelvis
    • S/P hysterectomy, r/o recurrent tumor in the pelvic cavity (near right vaginal stump and cul-de-sac), progression.
    • Liver tumor, 1.3cm in S8. progression, r/o liver metastasis.
    • Lymphocele in the pelvic cavity.
  • 2022-10-31 MRI - pelvis
    • S/P hysterectomy. R/O recurrent tumor in the cul-de-sac and right vaginal stump.
    • Stationary liver tumor (metastatic?), 1.1cm in S8.
    • Lymphocele in the pelvic cavity.
  • 2022-08-01 Patho - uterus with or without SO non-neoplastic/prolapse
    • PATHOLOGIC DIAGNOSIS
      • Uterus, endometrium, ATH — Serous carcinoma
      • Ovary, left, BSO — Involved by serous carcinoma
      • Lymph nodes, pelvic and para-aortic, bilateral, BPLND+PALND— Metastatic serous carcinoma (21/36)
      • Omentum, infracolic omentectomy — Invoved by serous carcinoma
      • CDS, right, excision — Involved by serous carcinoma
      • AJCC 8 th edition, Pathology stage: ypT3aN2aM1; stage IVB; FIGO stage IVB
    • MACROSCOPIC EXAMINATION
      • Procedure: ATH+BSO+infracolic omentectomy+BPLND+para-aortic LN dissection
      • Specimen Size: 12 x 8 x 5 cm (uterus), 3.0 x 2.5 x 2.0 cm (Rt ovary), 4.5 x 0.8 cm (Rt tube), 3.0 x 2.5 x 2.0 cm (Lt ovary), 4.5 x 0.8 cm (Lt tube), 28 x 15 x 2.0 (omentum), and right CDS
      • Specimen Integrity: Intact
      • Tumor Site: Endometrium
      • Tumor Size: No definite mass can be identified grossly
      • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, and bilateral para-aortic
      • Representative parts are taken for section and labeled as: A1-A2= left iliac LNs, B= left obturator LNs, C1-C2= right iliac LNs, D= right obturator LNs, E= left para-aortic LNs, F= right para-aortic LNs G1-G2= left ovary and fallopian tube, G3-G4= right ovary and fallopian tube, G5-G6= cervix, G7-G10= uterine corpus, H1-H2= omentum, I= right CDS.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Serous carcinoma
      • Histologic Grade: High-grade
      • Adenomyosis: Not identified
      • Uterine Serosal Involvement: Present
      • Cervical Stromal Involvement: Present
      • Other Tissue/Organ Involvement: Left ovary involvement
      • Peritoneal/Ascitic Fluid: Pending
      • Margins: Involved by carcinoma
      • Lymphvascular Invasion: Present
        • Regional Lymph Nodes: Metastatic serous carcinoma (21/36)
        • number of lymph node examined: 7 (left iliac), 5 (left obturator), 2 (right iliac), 8 (right obturator), 6 (left para-aortic), 8 (right para-aortic)
        • number with metastases: 5 (left iliac), 3 (left obturator), 1 (right iliac), 1 (right obturator), 5 (left para-aortic), 6 (right para-aortic)
      • Pathologic Stage
        • Primary Tumor: ypT3a (tumor involving the serosa and adnexa)
        • Regional Lymph Nodes: ypN2a (metastasis to para-aortic lymph nodes >2mm)
        • Distant Metastasis: Metastasis to omentum
      • FIGO Stage: Stage IVB
      • AdditionalPathologic Findings
        • Cervix: Involved by carcinoma
        • Myometrium: Involved by carcinoma and leiomyoma
        • Ovary, right: No remarkable change
        • Ovary, left: Involved by carcinoma
        • Fallopian tubes, blateral: No remarkable change
        • Omentum: Involved by carcinoma
        • CDS, right: Involved by carcinoma
  • 2022-07-19 Bronchodilator Test
    • Normal spirometry
    • without significant response to bronchodilator
  • 2022-07-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (75 - 21) / 75 = 72.00%
      • M-mode (Teichholz) = 71
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Grade 1 LV diastolic dysfunction
      • Mild AS, AR, TR
  • 2022-07-11 CXR + Lat. LT
    • Spondylosis of the T-spine
    • A nodular opacity projecting in the left lower medial lung, retrocardiac area, shows stationary. Old calcified granuloma is highly suspected. Follow up is indicated.
  • 2022-07-11 CT - abdomen
    • Findings
      • Low density lesion at S8 of liver about 1.69cm in largest dimension. Liver meta is considered. In comparison with CT dated on 2022-05-03, the lesion is stationary.
      • Wall thickening at endometrium is found. Endometrial cancer is considered. In regression.
      • The GB is well distended without soft tissue lesion
    • Imp:
      • Endometrial cancer, in regression.
      • Liver meta. Stable.
  • 2022-05-10 Patho - endometrium curretage/biopsy
    • DIAGNOSIS:
      • A. Labeled as “endometrium”, Dilataion and curettage with frozen section (F2022-218FSA) — Serous adenocarcinoma, high grade.
        • IHC stains: PAX-8 (+), WT-1 (focal +), Napsin-A (-), p53 (aberrant type), p16 (<70%).
      • B. Labeled as “left pelvic mass”, clinically left ovary obscured, SILS biopsy with frozen section (F2022-218FSB) — Serous adenocarcinoma, high grade.
        • IHC stains: PAX-8 (+), WT-1 (focal +), Napsin-A (-), p53 (aberrant type). ER: (-), PR (-).
    • Note: Ovarian origin is favored.
  • 2022-05-06 Ascites tapping
    • Course: 18G needle was inseted at RLQ under echo guided insertion.
    • Findings: 3000 ml yellowish color ascites were drained.
  • 2022-05-05 Patho - stomach biopsy
    • Stomach, antrum, biopsy — Chronic active gastritis, H pylori present
  • 2022-05-05 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, s/p CLO test
      • Suspected gastric ulcer scar
      • Gastric erosive lesion, suspected healing ulcer, s/p biopsy
      • Deformed prepyloric antrum
      • Duodenal ulcer scars
    • CLO test: Positive
    • Suggestion:
      • PPI therapy
      • Pursue pathology and CLO test result
  • 2022-05-05 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (66 - 18) / 66 = 72.73%
      • M-mode (Teichholz) = 72
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA,
      • Mitral inflow EA fusion due to tachycardia
      • Mild AR, AS, TR
      • 5.Presence of left pleural effusion
  • 2022-05-05 Colonoscopy
    • Colon polyps, probable adenoma (without polypectomy)
    • Colon diverticulosis
    • Failure of cecal intubation
  • 2022-05-04 Flow volume loop
    • mild restrictive impairment
  • 2022-05-03 CT - abdomen
    • Findings
      • Prominent ascites with multiple soft tissue tumors in the peritoneum, could be due to peritoneal carcinomatosis.
      • Prominent density in the uterine cavity.
      • Liver cyst, 1.9cm in left lobe.
      • Low density nodules in right lobe of the liver, up to 1.7cm in S7, r/o liver metastasis.
      • S/P right mastectomy.
      • Outpouching lesions in ascending and descending colon, suggesting diverticula.
      • R/O calcifie granuloma in left lower lung.
    • Impression:
      • Peritoneal carcinomatosis and liver metastsis.
      • Prominent density in the uterine cavity. Suggest GYN study.
      • Liver cyst.
      • S/P right mastectomy.
      • Colon diverticulosis.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N0(N_value) M:M1(M_value) STAGE:IVb(Stage_value)
  • 2022-05-03 Gynecologic ultrasonography
    • R/O Endometrial hyperplasia: 39.0mm (solid + fluid)
    • Ascites
    • R/O Rt mass: 50x44mm
  • 2022-04-30 Ascites tapping
    • paracentesis under direct sonography-guidance: an IC cath (18 gauge) was inserted into peritoneal cavity at RLQ: 2000cc yellowish ascites was drained out
  • 2022-04-30 SONO - abdomen
    • Diagnosis:
      • Peritoneal tumors, multiple, favor seeding
      • Ascites, massive
      • Hepatic tumor favor hemangioma
      • Hepatic cyst
      • Susp. parenchymal liver disease
    • Suggestion:
      • paracentesis

[MedRec]

  • 2023-07-06 SOAP Radiation Oncology Huang JingMin
    • A: Serous carcinoma of the uterine endometrium, AJCC 8 th edition, Pathology stage: ypT3aN2aM1; stage IVB; FIGO stage IVB, s/p neoadjuvant chemotherapy and Debulking surgery (ATH + BSO + BPLND + paraaortic LN dissection + infracolic omentectomy), and chemotherapy, with relapse, s/p excision.
    • P: Radiotherapy is indicated for this patient with the following indicators: tumor recurrence
      • Goal: palliation
      • Treatment target and volume: pelvic area
      • Technique: VMAT/IGRT and IVRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her husband. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-07-13.
  • 2023-07-04 SOAP Hemato-Oncology Xia HeXiong
    • P: Arrange admission for Lipo-Dox with or without Carboplatin or CCRT with plaitnum first followed by C/T
  • 2023-07-04 SOAP Obstetrics and Gynecology Huang SiCheng
    • P: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-06-29.
      • Treatment plan: Systemic therapy and consult radiation oncology
  • 2023-06-12 ~ 2023-06-26 POMR Obstetrics and Gynecology Yan XuanShang
    • Discharge diagnosis
      • Endometrial cancer
      • Pelvic cystic mass tumor–>Excision of intraabdominal tumor, malignant on 2023-06-14
      • Female pelvic peritoneal adhesions (postinfective) -> Adhesionolysis on 2023-06-14
    • CC
      • Constipation and dysuria for about 2 weeks.
    • Present illness
      • This is a 79 y/o, G4P2SA2 woman with a medical history of:
        • Endometrial cancer, high grade serous adenocarcinoma, with peritoneal carcimatosis and liver metastases, s/p SILS biopsy + dlatation and curettage and port-A insertion, s/p palliative chemotherapy (III) with Taxol / Carboplatin (2022/05/17, 2022/06/13, 2022/07/04)
        • Debulking surgery + HIPEC on 2022/08/01. Pathology report show endometrial cancer, high grade serous adenocarcinoma with stage: ypT3aN2aM1; stage IVB; FIGO stage IVB s/p palliative chemotherapy.
        • Hypertension under medical control
        • Diabetes mellitus under medical control
        • Right breast cancer, status post oeration and chemotherapy.
      • The patient, who has a history of endometrial cancer and was previously followed up at our OPD, presented this time with complaints of constipation and dysuria for approximately 2 weeks. There is no associated abdominal pain or fever. She denies symptoms such as nausea, vomiting, and tarry or bloody stool.But have lower limbs mild weakness and numbness. Laboratory data revealed elevated levels of BUN (46 mg/dL), creatinine (2.58 mg/dL), and a decreased hemoglobin level (9.8 g/dL). Additionally, CA125 was measured at 1365.6 U/mL, and CA199 was measured at 337.15 U/mL. Urine examination showed the presence of occult blood (2+) and ediment-RBC = 3-5 /HPF, Sediment-WBC = >=100 /HPF.
      • An MRI of the pelvis conducted on 2023-05-30, revealed the following findings: 1. S/P hysterectomy with recurrence in the pelvic cavity, progression. 2. Stationary liver tumor, r/o liver metastasis. 3. Ascites with peritoneal enhancement, r/o peritoneal carcinomatosis. 4. Lymphocele in the pelvic cavity with regression.
      • After discussing patient’s symptom with the patient, she decided to undergo further surgery. She was admitted on 2023-06-12, for debulking surgery, exploratory laparotomy, and HIPEC, scheduled for 2023-06-14.
    • Course of inpatient treatment
      • The patient was admitted on 2023-06-12 and underwent Excision of intraabdominal tumor, malignant + Adhesionolysis the next day. Her postoperative course was uneventful. Eating and urination by self voiding was smooth. The vital sign was stable after surgery. She is discharged on 2023-06-26 and her followup appointment is scheduled on next week.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# TID
      • Cephalexin (cephalexin 500mg) 1# TID
      • Uretropic (furosemide 40mg) 0.5# QD
      • Wecoli (bethanechol 25mg) 1# QD
  • 2022-05-16 SOAP Gastroenterology Chen ZhiXiang
    • S
      • Refer for NUC (nucleotide analogue) prophylaxis for occult HBV
      • Scheduled neo C/T for endometrial ca tomorrow
  • 2022-05-02 ~ 2022-05-12 POMR Obstetrics and Gynecology Huang SiCheng
    • Discharge diagnosis
      • Ovary cancer,suspected with cancer peritonitis
      • Right breast cancer s/p op and chemotherapy
      • Hypertension
      • Diabetes mellitus
      • Old CVA with left lower limbs mild weakness
      • Reflux esophagitis
      • colon polyps
    • CC
      • abdominal distenetion, poor appetite, acid regurgitation sensation, body weight loss, thinner in stool shape in recent 1 month
    • Present illness
      • This 78 year-old female has the histories of
        • Old CVA with left lower limbs mild weakness
        • Hypertension
        • Diabetes mellitus
        • right breast ca status post oeration and chemotherapy
      • She came to GI OPD due to progressive abdominal distenetion, poor appetite, acid regurgitation sensation, body weight loss, thinner in stool shape in recent 1 month.She denied nausea, vomiting, abdominal pain, tarry or bloody stool and no hematuria, no cough, no dyspnea, no cold sweating, no fever, no chills, no chest or back pain. She also denied TOCC history. Blood analysis showed leukocytosis (11.36x10^3/uL), and left shift (SEG: 78.8 %), no anemia (Hb: 12mg/dL), normal PT/aPTT level, normal renal function, no electrolyte imbalance, normal hepatobiliary enzyme (ALT: 6 U/L, AST: 13 U/L, TBI: 0.42 mg/dl, DBI: 0.15 mg/dl, ALP: 143 IU/L).
      • Under the impression of cancer peritonitis. She was admitted to GI ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission ward, abdominal CT was performed on 5/3 for cancer survey and revealed: 1) Peritoneal carcinomatosis and liver metastsis. 2) Prominent density in the uterine cavity. Suggest GYN study. 3) Liver cyst. 4) S/P right mastectomy. 5) Colon diverticulosis.
      • Due to the abdominal CT report, the GYN Doctor was consulted and the suggestion was given as follows: 1) suspect ovarian cancer 2) Check CA125, CA199, CEA, Albumin, FDPdimer 3) transfer to GYN ward after EGD and colonscope, operation will be arranged next week.
      • GYN sonography was done on 05/03 and showed 1) suspect ovarian cancer. 2) R/O Endometrial hyperplasia: 39.0mm (solid + fluid). 3) Ascites. 4) R/O Rt mass: 50x44mm. The Chest Medicine Department was also consulted for CXR report with solitary pulmonary nodule at left pulmonary hilar region and suggestion was given as follows: 1) The left lung nodule is stationary compared with previous CXR and may be related to previous old TB calcified lesion -> Keep F/U 2) However, 1 tiny nodule over RLL, cause unknown, should survey the etiology of the ascites.
      • EGD was performed on 05/05 and reveled 1) Reflux esophagitis LA Classification grade A. 2)Superficial gastritis, s/p CLO test. 3) Suspected gastric ulcer scar. 4) Gastric erosive lesion, suspected healing ulcer, s/p biopsy. 5) Deformed prepyloric antrum. 6) Duodenal ulcer scars.
      • The followed pathological report of stomach biopsy menifested chronic active gastritis, H pylori present.
      • Colonscopy was performed and reveled 1) Colon polyps, probable adenoma. 2) Colon diverticulosin.
      • Oral PPI was used with Nexium. After asccites tapping, her symptom relieved.
      • Cardiac sonography and pulmonary fuction test were also arranged for pre-operation prepare.
      • Aspirin was held for operation next week since 5/4.
      • The patient was transferred to GYN ward on 5/6 for further surgery. After transfer to GYN ward, we closely monitor her general condition and clinical presentation. No special complaint was noted and preoperative anesthesia evaluation was done 05/06.
      • She accepted SILS biopsy + Dilatation and curettage and Port-A insertion via left subclavian vein on 2022/05/09. Frozen section revealed endometrium adenocarcinoma and washing cytology revealed metastatic carcinoma. Her postoperative status was stable and tolerable wound pain was told. She was then discharged on 2022/05/12 under stable condition and follow-up at OPD.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • MgO 250mg 2# QID
      • cephalexin 500mg 1# QID

[surgical operation]

  • 2023-08-12
    • Surgery: Cul-do centesis
    • Finding: Vaginal bulging from 11-5 o’clock of direction; suspect pseudo cyst over CDS by TVS about 9cm; dark-brown fluid about 220ml was drained out
      • EBL 5ml Cx and BT: nil
  • 2023-06-14
    • Operation
      • Excision of intraabdominal tumor, malignant
      • Adhesionolysis
    • Finding
      • s/p midline incision with severe adhesion of small bowel and large bowel
      • A cystic tumor mass in the pelvic cavity with papillary tumor nest was encountered
      • Drain: 19Fr Blake drain x1, in the pelvic cavity

[radiotherapy]

  • 2023-07-21 ~ 2023-09-01 - 4500cGy/25 fractions of the pelvic, and 5400cGy/30 fractions of the vaginal cuff mucosa area.

[chemotherapy]

  • 2023-10-13 - docetaxel 35mg/m2 60mg NS 200mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-09-23 - docetaxel 35mg/m2 60mg NS 200mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-08-30 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-23 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-08 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-27 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-20 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-21 - topotecan 1.2mg/m2 2mg NS 40mL 0.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-04-07 - topotecan 1.2mg/m2 2mg NS 40mL 0.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-22 - topotecan 1.2mg/m2 2mg NS 40mL 0.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-08 - topotecan 0.75mg/m2 1.25mg NS 40mL 0.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-02-20 - topotecan 0.75mg/m2 1.25mg NS 40mL 0.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-02-06 - topotecan 1.2mg/m2 2mg NS 40mL 0.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-25 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 250mg NS 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2022-10-04 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 240mg NS 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2022-09-13 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2022-08-01 - [liposome doxorubicin 35mg/m2 60mg D5W 250mL + carboplatin AUC 5 450mg NS 250mL] IP 90min (HIPEC)

  • 2022-07-04 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2022-06-13 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2022-05-17 - paclitaxel 160mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

==========

2023-10-23

Lab data

  • 2023-10-23 Neutrophil 80.6 %

  • 2023-10-23 WBC 5.01 x10^3/uL

  • 2023-10-23 HGB 7.8 g/dL

  • 2023-10-23 PLT 295 *10^3/uL

  • 2023-10-23 Albumin(BCG) 2.8 g/dL

  • 2023-10-23 Creatinine 1.14 mg/dL

  • 2023-10-23 eGFR 48.87 ml/min/1.73m^2

The patient has anemia, hypoalbuminemia, and altered renal function (calculated CrCl 44 mL/min).

If the patient is scheduled to receive the same dose of docetaxel as before, there is no need to adjust the dose for any degree of kidney dysfunction. However, anemia (and/or hypoalbuminemia with edema) may need to be treated before chemotherapy can begin.

2023-10-13

[leukopenia]

Lab data showed leucopenia on 2023-10-05 at 2.26K/uL.

  • 2023-10-12 WBC 13.14 x10^3/uL
  • 2023-10-11 WBC 15.84 x10^3/uL
  • 2023-10-09 WBC 34.63 x10^3/uL
  • 2023-10-05 WBC 2.26 x10^3/uL *
  • 2023-09-28 WBC 6.10 x10^3/uL
  • 2023-09-20 WBC 4.82 x10^3/uL
  • 2023-09-17 WBC 6.34 x10^3/uL

The most recent chemotherapy treatments prior to the leukopenia event were docetaxel (35mg/m2 60mg) on 2023-09-23 and carboplatin (AUC 2 100mg) on 2023-08-30, the latter as part of CCRT.

According to the updated lab data in WBC level, there is no more leukopenia occurs after the event.

The hype of WBC level after the leukopenia event might be due to Granocyte (lenograstim 250ug) x 4 days since 2023-10-05.

2023-09-19

MgO, metformin, linagliptin, aspirin, trichlormethiazide, bisoprolol, olmesartan, rosuvastatin, and quetiapine were prescribed at NTUH on 2023-07-28 as a repeat prescription. These drugs were refilled on 2023-08-18, and with the exception of MgO, which might no longer be necessary, all the other drugs have been added to the active medication list.

701090517

231023

[MedRec]

  • 2023-09-27 SOAP Cardiology Zhou XingHui
    • Prescription x3
      • Alpraline (alprazolam 0.5mg) 1# HS
      • Concor (bisoprolol 1.25mg) 1# QD
      • Diovan (valsartan 160mg) 0.5# QD
      • Plavix (clopidogrel 75mg) 1# QD
      • Crestor (rosuvastatin 10mg) 1# QD
      • Ezetrol (ezetimibe 10mg) 1# QD
  • 2023-09-27 SOAP Urology Xu JunKai
    • Prescription x3
      • Betmiga (mirabegron 50mg) 1# QD
      • Urief (silodosin 8mg) 1# QD

==========

2023-10-23

This patient is in the hospital to have his gastrointestinal problems examined further. He is currently taking the medications prescribed by our urologist and cardiologist on 2023-09-27, and there are no discrepancies with these drugs.

701366805

231020

{High grade serous carcinoma FIGO stage IIIC, right ovarian cancer with peritoneal seeding s/p operation} (not completed)

[lab data]

  • CA125
    • 2022-04-22 401.9 U/mL
    • 2022-03-30 1091.2 U/mL
  • 2022-04-14
    • Anti-HBs 2.99 mIU/mL
    • Anti-HBc Nonreactive
    • Anti-HBc-Value 0.14 S/CO
    • Anti-HCV Nonreactive
    • Anti-HCV Value 0.15 S/CO
    • HBsAg Nonreactive
    • HBsAg (Value) 0.44 S/CO
  • 2022-03-31
    • Anti-HCV Nonreactive
    • Anti-HCV Value 0.16 S/CO
    • Anti-HBc Nonreactive
    • Anti-HBc-Value 0.13 S/CO
    • HBsAg Nonreactive
    • HBsAg (Value) 0.42 S/CO

[exam findings] (not completed)

  • 2022-05-10 Aspiration Cytology - LN
    • Left parotid tumor: Favor benign, pleomorphic adenoma
    • Two wet cellular smears show epithelial cells arranged in cord, nest or trabecular patterns and mononuclear cells in background resemble myoepithelial cells as well as chondromyxoid material in focal area. It maybe compatible with pleomorphic adenoma. Confirmatory biopsy is advised, if clinically indicated.
  • 2022-05-10 SONO - head and neck soft tissue
    • clinical impression/intent: right parotid tumor, previous cytology: atypia
    • sonographic impression: right parotid tumor
  • 2022-04-07 Patho - ovary (non-tumor)
    • Diagnosis
      • Ovary, right, oophorectomy — High grade serous carcinoma seeding on serosa
      • Fallopian tube, right, salpingectomy — High grade serous carcinoma seeding on serosa
      • F2022-00146:
        • Omentum, omentectomy — High grade serous carcinoma, metastatic (please see microdescription)
        • Ovary, left?, excision — Consistent with high grade serous carcinoma
    • Microscopic description
      • Sections show ovary and fallopian tube with high grade serous carcinoma seeding on serosa.
      • F2022-00146:
        • Sections show omentum with metastatic solid sheets and papillary tumor and psammoma bodies.
        • The cystic tumor reveals ovarian stroma with psammoma bodies. The lining epithelium is mostly denuded, and only scant tumor lining epithelial is seen.
        • The immunohistochemical stains reveal PAX(+), p53(aberrant expression +), WT-1(+), GATA3(-), Napsin A(-), PR(-), and Calretinin(-). The results are consistent with high grade serous carcinoma arising from ovary. Please correlate with the clinical presentation and image study.
        • Lymphovascular invasion is found. No fallopian tube is seen.
  • 2022-04-06 Body fluid cytology - ascites
    • Pathologic diagnosis: positive for malignancy
    • The smears show lymphocytes, reactive mesothelial cells and many hyperchromatic atypical epithelial cell clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
  • 2022-04-06 Frozen Resection
    • Preliminary diagnosis:
      • Pelvic mass, excision — Carcinoma, wait IHC for tumor origin
  • 2022-03-30 Gynecologic ultrasonography
    • Suspected rt adnexal mass: 124mm x 93mm, malignancy cannot be ruled out
    • Ascites (+)
  • 2022-03-25 CT - abdomen, pelvis
    • Findings:
      • There are lobulated enhancing soft tissue lesions in the omentum (omentum cake) and mesentery of the pelvis, and ascites that may be primary peritoneal serous carcinoma.
        • The differential diagnosis include ovarian cancer with carcinomatosis, mesothelioma, lymphoma and TB. Please correlate with CA125 and CT-guided biospy of the omentum lesion.
    • Impression:
      • Primary peritoneal serous carcinoma is highly suspected.
      • The differential diagnosis include ovarian cancer with carcinomatosis, mesothelioma, lymphoma and TB. Please correlate with CA125 and CT-guided biospy of the omentum lesion.

[consultation]

  • 2022-03-31 Hemato-Oncology
    • A
      • Impression:
        • Primary peritoneal serous carcinoma is highly suspected.
        • The differential diagnosis including stomach cancer, ovarian cancer with carcinomatosis, mesothelioma, lymphoma and TB.
      • Suggestion:
        • Arrange PES to check UGI tract lesions, GYN ultrasound and CT-guided biospy of the omentum lesion
        • may check LDH, anti Hbc, HbsAg, Anti HCV
        • Thanks for your consultation, we wound like to follow up this case. If there is any problem, please feel free to let us known.
  • 2022-03-31 Obstetrics and Gynecology
    • A
      • Objective
        • The abdomen CT on 03/25 reported: There are lobulated enhancing soft tissue lesions in the omentum (omentum cake) and mesentery of the pelvis, and ascites that may be primary peritoneal serous carcinoma.
        • Lab data: CA125 1091.2 (0~35)
        • Echo: Right ovarian cystic mass 13 cm with solid part was noted, with small amount ascite, suspected ovarian cancer
      • Plan
        • please check CA199, CEA, Albumin, D-Dimer
        • check Esophagogastroduodenoscopy (EGD) and low gastrointestinal endoscopy

[surgical operation]

  • 2022-04-06
    • Operation
      • Enterolysis
    • Finding
      • Multiple peritoneal seedings including tumor nodules in small bowel and mesentery
      • Adhesion of small bowel and large bowel
  • 2022-04-06
    • Surgery
      • Pelvic mass, peritoenal carcinomatosis?
      • Perineal cake
      • Operation:
        • RSO and omentectomy
    • Finding
      • Uterus: 4x3cm, grossly normal, with severe adhesion to pelvic wall
      • RAD: grossly normal,adhesion to pelvic wall and the mass
      • LAD: Severe adhesion to the mass
      • CDS: Severe adhesion/partial obliterated
      • During the procedure, omentum attached to the anterior wall of the pelvic cavity, adhesion lysis was performed before we entered the pelvic cavity. (due to perineal cake, severe adhesion was found during the procedure)
      • Residual tumor over colon and pelvic with size 1x1 cm.
      • Estimated blood loss: 1000 ml
      • Blood transfusion: 2 U
      • Complication: nil        

[chemoimmunotherapy] (not completed)

  • 2023-10-19

  • 2023-09-13

  • 2023-08-17

  • 2023-07-24

  • 2023-06-29

  • 2023-05-31

  • 2023-04-26

  • 2023-03-08

  • 2023-02-03

  • 2022-12-20

  • 2022-11-29

  • 2022-10-24

  • 2022-09-12

  • 2022-08-12

  • 2022-07-19 - bevacizumab 7.5mg/kg 1.5hr + paclitaxel 175mg/m2 3hr + carboplatin 600mg 2hr

  • 2022-06-27 - bevacizumab 7.5mg/kg 1.5hr + paclitaxel 175mg/m2 3hr + carboplatin 600mg 2hr

  • 2022-06-01 - bevacizumab 7.5mg/kg 1.5hr + paclitaxel 175mg/m2 3hr + carboplatin 600mg 2hr

  • 2022-05-04 - paclitaxel 160mg/m2 3hr + carboplatin 600mg 2hr

Ovarian Cancer Continue Including Fallopian Tube Cancer and Primary Peritoneal Cancer, NCCN Evidence Blocks, Version 1.2022 - January 18, 2022, p42,43

  • Principles of Systemic Therapy
    • Primary Systemic Therapy Regimens - Epithelial Ovarian/Fallopian Tube/Primary Peritoneal
      • Primary Therapy for Stage I Disease
        • High-grade serous, Endometrioid (grade 2/3), Clear cell carcinoma, Carcinosarcoma
          • Preferred Regimens
            • Paclitaxel/carboplatin q3weeks
          • Other Recommended Regimens
            • Carboplatin/liposomal doxorubicin
            • Docetaxel/carboplatin
          • Useful in Certain Circumstances
            • For carcinosarcoma:
              • Carboplatin/ifosfamide
              • Cisplatin/ifosfamide
              • Paclitaxel/ifosfamide (category 2B)
        • Mucinous carcinoma (stage IC)
          • Preferred Regimens
            • 5-FU/leucovorin/oxaliplatin
            • Capecitabine/oxaliplatin
            • Paclitaxel/carboplatin q3weeks
          • Other Recommended Regimens
            • Carboplatin/liposomal doxorubicin
            • Docetaxel/carboplatin
          • Useful in Certain Circumstances
            • None
        • Low-grade serous (stage IC)/Grade I endometrioid (stage IC)
          • Preferred Regimens
            • Paclitaxel/carboplatin q3weeks +- maintenance letrozole (category 2B) or other hormonal therapy (category 2B)
            • Hormone therapy (aromatase inhibitors: anastrozole, letrozole, exemestane) (category 2B)
          • Other Recommended Regimens
            • Carboplatin/liposomal doxorubicin
            • Docetaxel/carboplatin
            • Hormone therapy (leuprolide acetate, tamoxifen) (category 2B)
          • Useful in Certain Circumstances
            • None
      • Primary Therapy for Stage II-IV Disease
        • High-grade serous, Endometrioid (grade 2/3), Clear cell carcinoma, Carcinosarcoma
          • Preferred Regimens
            • Paclitaxel/carboplatin q3weeks
            • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7 & GOG-218)
          • Other Recommended Regimens
            • Paclitaxel weekly/carboplatin weekly
            • Docetaxel/carboplatin
            • Carboplatin/liposomal doxorubicin
            • Paclitaxel weekly/carboplatin q3weeks
          • Useful in Certain Circumstances
            • IP/IV paclitaxel/cisplatin (for optimally debulked stage II-III disease)
            • For carcinosarcoma:
              • Carboplatin/ifosfamide
              • Cisplatin/ifosfamide
              • Paclitaxel/ifosfamide (category 2B)
        • Mucinous carcinoma (stage IC)
          • Preferred Regimens
            • 5-FU/leucovorin/oxaliplatin +- bevacizumab
            • Capecitabine/oxaliplatin +- bevacizumab (category 2B for bevacizumab)
            • Paclitaxel/carboplatin q3weeks
            • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7 & GOG-218)
          • Other Recommended Regimens
            • Paclitaxel weekly/carboplatin weekly
            • Docetaxel/carboplatin
            • Carboplatin/liposomal doxorubicin
            • Paclitaxel weekly/carboplatin q3weeks
          • Useful in Certain Circumstances
            • None
        • Low-grade serous/Grade I endometrioid
          • Preferred Regimens
            • Paclitaxel/carboplatin q3weeks +- maintenance letrozole (category 2B) or other hormonal therapy (category 2B)
            • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7 & GOG-218)
            • Hormone therapy (aromatase inhibitors: anastrozole, letrozole, exemestane) (category 2B)
          • Other Recommended Regimens
            • Paclitaxel weekly/carboplatin weekly
            • Docetaxel/carboplatin
            • Carboplatin/liposomal doxorubicin
            • Paclitaxel weekly/carboplatin q3weeks
            • Hormone therapy (leuprolide acetate, tamoxifen) (category 2B)
          • Useful in Certain Circumstances
            • None
      • Primary Systemic Therapy Recommended Dosing
        • IV/IP Paclitaxel/cisplatin
          • Paclitaxel 135 mg/m2 IV continuous infusion Day 1;
          • Cisplatin 75-100 mg/m2 IP Day 2 after IV paclitaxel;
          • Paclitaxel 60 mg/m2 IP Day 8
          • Repeat every 21 days x 6 cycles
        • Paclitaxel/carboplatin q3weeks
          • Paclitaxel 175 mg/m2 IV followed by carboplatin AUC 5-6 IV Day 1
          • Repeat every 21 days x 3-6 cycles
        • Paclitaxel weekly/carboplatin q3week
          • Dose-dense paclitaxel 80 mg/m2 IV Days 1, 8, and 15 followed by carboplatin AUC 5-6 IV Day 1
          • Repeat every 21 days x 6 cycles
        • Paclitaxel weekly/carboplatin weekly
          • Paclitaxel 60 mg/m2 IV followed by carboplatin AUC 2 IV
            • Days 1, 8, and 15; repeat every 21 days x 6 cycles (18 weeks)
        • Docetaxel/carboplatin
          • Docetaxel 60-75 mg/m2 IV followed by carboplatinm AUC 5-6 IV Day 1
          • Repeat every 21 days x 3-6 cycles
        • Carboplatin/liposomal doxorubicin
          • Carboplatin AUC 5 IV + pegylated liposomal doxorubicin 30 mg/m2 IV
          • Repeat every 28 days for 3-6 cycles
        • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7)
          • Paclitaxel 175 mg/m2 IV followed by carboplatin AUC 5-6 IV, and bevacizumab 7.5 mg/kg IV Day 1
          • Repeat every 21 days x 5-6 cycles
          • Continue bevacizumab for up to 12 additional cycles
        • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (GOG-218)
          • Paclitaxel 175 mg/m2 IV followed by carboplatin AUC 6 IV Day 1. Repeat every 21 days x 6 cycles
          • Starting Day 1 of cycle 2, give bevacizumab 15 mg/kg IV every 21 days for up to 22 cycles
      • Primary Systemic Therapy Recommended Dosing for Elderly Patients (age >70 years) and/or Those with Comorbidities
        • Paclitaxel 135/carboplatin
          • Paclitaxel 135 mg/m2 IV + carboplatin AUC 5 IV given every 21 days x 3-6 cycles
        • Paclitaxel weekly/carboplatin weekly
          • Paclitaxel 60 mg/m2 IV over 1 hour followed by carboplatin AUC 2 IV over 30 minutes
          • Days 1, 8, and 15; repeat every 21 days x 6 cycles (18 weeks)

==========

2022-07-20

Lab results 2022-07-19 indicated liver and kidney function, CBC, WBC DC, electrolytes were grossly normal. TPR, PB during this hospitalization is relatively stable.

2022-06-28

No BRCA1/2 lab results were found. Patients with BRCA1/2-mutated clear cell carcinoma or carcinosarcoma may benefit from maintenance therapy with PARPi (poly ADP ribose polymerase inhibitor) if CR or PR is achieved after primary treatment with surgery and platinum-based first-line therapy

701396053

231020

[exam findings] (not completed)

[MedRec]

  • 2023-09-13 SOAP Dermatology Zhou WeiTing
    • S: severe itchy papules and plaques erupition over trunk after medication.
    • O: Height: 161.3 cm; Weight: 62.4 kg; BMI: 24
        1. urticaria/angioedema type
        1. maculopapular type
        1. urticaria-purpura type
        1. erythema multiforme SJS/TEM
        1. fixed drug eruption or AGEP rapid onset type
        1. drug hypersensitivity syndrome as DRESS
        1. lichenoid chronic progressive type
      • Suspect related medication.
    • P:
      • education about drug side effect and explain
      • Strongly suggested OPD f/u
    • Prescription
      • Topsym Cream (fluocinonide 0.05%) BID EXT
      • Orolisin (chlorpheniramine maleate 5mg, orotic acid 30mg, glycyrrhizic acid 50mg) 1# PRNTID
      • Asthan (ketotifen 1mg) 1# BID
      • Compesolon (prednisolone 5mg) 2# PRNQD
      • C.B. Ointment (chlorpheniramine, lidocaine, methy salicylate, menthol, camphor) PRNBID TOPI (for pain management)
  • 2023-09-06 SOAP Hemato-Oncology Xia HeXiong
    • A/P: Due to overall SD of liver, pancreatic tail, omentum and scalp but increasing CEA, the regimen will shift to GASL Q2/3W (TS-1 two weeks on and one week off),s o TS-1 will be given on Week 1 and Week 2, then off on Week 3
    • Prescription
      • Alpraline (alprazolam 0.5mg) 1# HS
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNQ8H
      • BaoGan (silymarin 150mg) 1# TID
      • TS-1 (tegafur, gimeracil, oteracil; 25mg) 2# BID
      • Folina (folinate 15mg) 2# BID
      • Hepac Lock Flush ST IRRI
  • 2023-08-17 SOAP Gastroenterology Chen JiangHua
    • Prescription x3
      • Vemlidy (tenofovir alafenamide 25mg) 1# QDCC
  • 2023-07-12 SOAP Hemato-Oncology Xia HeXiong
    • S: All-RAS G12V
    • A/P: On 2023-06-21, already explain Stage 4 (Scalp, invasion to spleen, R/O lung and liver) Based on PET and CT to the patient and her daughter. =>> If not working of Abraxane / Gem, may consider electron beam for scalp
  • 2023-06-21 SOAP Hemato-Oncology Xia HeXiong
    • A/P: On 2023-06-21, already explain Stage 4 (Scalp, invasion to spleen, R/O lung and liver) Based on PET and CT to the patient and her daughter.
  • 2023-06-07 SOAP Hemato-Oncology Xia HeXiong
    • A/P
      • complete C/T x 12
      • refer to the Dr. Wu for possible of resection of the tumor
      • Due to new lesion (2023/05/31 Whole body PET scan), need to consider shift regimen to Abraxane/Gemcitabine after scalp biopsy.
  • 2023-03-01 SOAP Hemato-Oncology Wan XiangLin
    • Prescription
      • Emend (aprepitant 125mg) 1# QD 3D
      • Stilnox (zolpidem 10mg) 1# HS
      • Alpraline (alprazolam 0.5mg) 1# HS
      • Hepac Lock Flush ST IRRI
  • 2023-02-14 SOAP Hemato-Oncology Zhang ShouYi
    • S
      • #1 palliative C/T wt palliative C/T wt FOLFIRINOX IV Q2W x 12 on 10/12 22.
      • #2 on 10/25 22. #3 on 11/8 22. #4 on 11/29 22. #5 on 12/13 22. #6 on 12/27 22. #7 on1/31 23. #8 on 2/14 23.
  • 2022-10-11 SOAP Gastroenterology Chen JiangHua
    • S: for NUC due to anti-HBc Ab (+) and intended to do C/T
    • Prescription
      • Vemlidy (tenofovir alafenamide 25mg) 1# QDCC
  • 2022-10-11 SOAP Hemato-Oncology Zhang ShouYi
    • A: pancreatic tail CA wt liver & lung & peritoneal mets Dx in Sep 2022 s/p EGD biopsy showing adenoCA at LMD in Sep 2022.
  • 2022-10-04 SOAP Hemato-Oncology Zhang ShouYi
    • S
      • 59 y/o female, a pt of pancreatic tail CA wt liver & lung & peritoneal mets Dx in Sep 2022 s/p EGD biopsy showing adenoCA at LMD in Sep 2022.
      • suffered from initial presentation of epigastric distended with mild pain for 1-2 week in Sep 2022. s/p UGI scope revealed gastric fundus tumor at LMD.
      • c/o back pain for days in Sep 2022.
        • no cough, no dyspnea
        • no bloody rhinorrhea, no nasal stuffness, no epistaxis
        • no dysphagia, no odynophagia, no epigastralgia
        • no fever, no weight loss, no night sweats
      • referred to our hemato-oncologic clinic on 10/4 22 by Dr Wu ChaoCun
      • pancreatic tail CA wt liver & lung & peritoneal mets.
    • P
      • will do EGD for biopsy (10/4 22).
      • explain to pt & his daughter about the indication & risk / benefit of palliative C/T wt FOLFIRINOX IV Q2W x 12 (10/4 22).
      • will do HBsAg, anti-HBc, anti-HCV (10/4 22)
      • will consult Dr Wu ChaoCun for Port-A installation (10/4 22).
      • will do chest CT (10/4 22).
      • will give palliative C/T wt FOLFIRINOX IV Q2W x 12 (10/4 22).
      • Adm on 10/11 22 for #1 palliative C/T wt palliative C/T wt FOLFIRINOX IV Q2W x 12.
      • RTC 1 wk later on 5/4 20 for CBC & DC, CXR, abd no report.
  • 2022-09-16 SOAP General and Gastrointestinal Surgery Wu ChaoCun
    • S
      • epigastric distended with mild pain for 1-2 week
      • UGI scope revealed gastric funus tumor path ADC
    • O
      • BP: 132/86; HR: 84;
      • suggest CT scan
      • DM -
      • H/T -
      • cancer staging
      • clo test ++
    • Diagnosis
      • C16. 9 Malignant neoplasm of stomach, unspecified
    • Prescription
      • Scrat (sucralfate 1g) 1# BIDAC
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Metrozole (metronidazole 250mg) 1# QID
      • Klaricid (clarithromycin 500mg) 1# BID

[chemotherapy]

  • 2023-10-12 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + nab-paclitaxel 100mg/m2 160mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-05 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + nab-paclitaxel 100mg/m2 160mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-20 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + nab-paclitaxel 100mg/m2 160mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-06 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + nab-paclitaxel 100mg/m2 160mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-23 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + nab-paclitaxel 100mg/m2 160mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-16 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + nab-paclitaxel 100mg/m2 160mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-02 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + nab-paclitaxel 100mg/m2 160mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-19 - gemcitabine 1000mg/m2 1500g NS 250mL 30min + nab-paclitaxel 100mg/m2 150mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-12 - gemcitabine 1000mg/m2 1500g NS 250mL 30min + nab-paclitaxel 100mg/m2 150mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-28 - gemcitabine 1000mg/m2 1500g NS 250mL 30min + nab-paclitaxel 100mg/m2 150mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-14 - gemcitabine 1000mg/m2 1700g NS 250mL 30min + nab-paclitaxel 100mg/m2 170mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-12 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 500mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
  • 2023-03-29 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 500mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
  • 2023-03-15 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 500mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
  • 2023-03-01 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 3900mg NS 250mL 46hr (in infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
  • 2023-02-14 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 3900mg NS 250mL 46hr (in infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
  • 2023-01-31 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
  • 2022-12-27 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
  • 2022-12-13 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
  • 2022-11-29 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
  • 2022-11-08 - oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
  • 2022-10-25 - oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL
  • 2022-10-12 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 250mL 46hr (in infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 1mg + NS 250mL

FOLFIRINOX chemotherapy for metastatic pancreatic cancer - 2023-10-20 - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571

  • Cycle length: 14 days.
  • Regimen
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 180 mg/m2 IV
      • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 400 mg/m2 IV bolus
      • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
      • Day 1
    • FU
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

Modified FOLFIRINOX chemotherapy for pancreatic cancer - 2023-10-20 - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546

  • Cycle length: 14 days.
  • Regimen
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 150 mg/m2 IV
      • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

==========

2023-10-20

According to PharmaCloud records, the patient has not visited any other hospitals in the past three months, and no discrepancies in medication have been identified.

A general urine test conducted on 2023-10-19 revealed sediment RBC 50-99/HPF and Bacteria 1+, potentially indicating the presence of urinary tract infections (UTIs) that may require further intervention.

The patient underwent a total of 12 cycles of a modified FOLFIRINOX regimen for her pancreatic tail cancer from 2022-10 to 2023-04. A new treatment protocol of gemcitabine + nab-paclitaxel was initiated on 2023-06-14, with TS-1 added to the regimen on 2023-09-06. A dermatologic adverse reaction was noted on 2023-09-13. Per today’s progress note, the patient has developed oral mucositis, and there is a plan to administer Difflam (benzydamine) spray and/or Nincort (triamcinolone acetonide) oral gel. Given that triamcinolone is a synthetic corticosteroid, its prolonged use can lead to side effects, including oral fungal infections (thrush), taste alterations, and, in rare instances, adrenal suppression. Therefore, it’s recommended to employ the lowest effective dose.

700326470

231019

[exam findings]

  • 2023-09-17 KUB
    • Scoliosis of L-spine with convex to left side.
    • S/P metalic autosuture projecting at left upper abdomen.
  • 2023-09-14 ECG (ER)
    • Sinus rhythm with short PR
  • 2023-07-28 Upper GI series
    • Indication: s/p total gastrectomy on 7/24
    • UGI series show
      • s/p total gastrectomy.
      • One linear structure at esophagointestinal junction. Nature?
  • 2023-07-25 Patho - Stomach subtotal/total (tumor)
    • PATHOLOGIC DIAGNOSIS
      • Stomach, total gastrectomy — Poorly cohesive carcinoma
      • Margins, frozen + bilateral cutting ends, ditto — Free of tumor invasion
      • Lymph nodes, LN 1, dissection — Free of  tumor metastasis (0/6)     - Lymph nodes, LN 2, ditto — Free of tumor metastasis (0/3)     - Lymph nodes, LN 3, ditto — Tumor metastasis (3/15) without extracapsular extension (0/3)     - Lymph nodes, LN 4, ditto — Tumor metastasis (4/14) with extracapsular extension (2/4), tumor deposition     - Lymph nodes, LN 5, ditto — Fat only     - Lymph nodes, LN 6, ditto — Tumor metastasis (3/13) without extracapsular extension (0/3), tumor deposition     - Lymph nodes, LN 7,8,9,11, ditto — Tumor metastasis (1/12) without extracapsular extension (0/1)     - Lymph nodes, LN 10, ditto — Fat only     - Lymph nodes, LN 12a, ditto — Free of tumor metastasis (0/2)  
      • Omentum, omentectomy — Tumor invasion, compatible with microscopically tumor seeding
      • AJCC Pathologic staging — pT4aN3aM1, stage IV
    • MACROSCOPIC EXAMINATION
      • Specimen type: stomach, lymph nodes and omentum
      • Specimen size: stomach: GC: 26.2 cm and LC: 14.2 cm
      • Number of lesions: solitary mass
      • Tumor site: from antrum to fundus
      • Tumor size: 13.2 cm in diameter
      • Tumor configuration: elevated or flat firm mass
      • Omentum: 45 x 9.5 x 1.1 cm, no obviously tumor grossly  
      • Representatively embedded for sections as A1: esophageal cutting end, A2: distal cutting end, A3-A8: tumor at fundus, A9-A12: tumor at body to antrum, A13: fat at lesser curvature, A14: non-tumor stomach, B: LN 1, C: LN 2, D1-D2: LN 3, E1-E2: LN 4, F: LN 5, G: LN 6, H1-H2: LN 7,8,9,11, I: LN 10, J: LN 12 and K: omentum. [Reference: F2023-00332 esophageal cutting end, one small piece measured 4.2 x 0.5 x 0.4 cm in size. All embedded]
    • MICROSCOPIC EXAMINATION
      • Histologic type: Poorly cohesive adenocarcinoma
      • Histologic grade: Grade 3
      • Depth of tumor invasion: serosa layer
      • Lymph nodes
        • Lymph nodes, LN 1: Free of  tumor metastasis (0/6)       - Lymph nodes, LN 2: Free of tumor metastasis (0/3)       - Lymph nodes, LN 3: Tumor metastasis (3/15) without extracapsular extension (0/3)       - Lymph nodes, LN 4: Tumor metastasis (4/14) with extracapsular extension (2/4) and tumor deposition       - Lymph nodes, LN 5: Fat only       - Lymph nodes, LN 6: Tumor metastasis (3/13) without extracapsular extension (0/3) and tumor deposition       - Lymph nodes, LN 7,8,9,11: Tumor metastasis (1/12) without extracapsular extension (0/1)       - Lymph nodes, LN 10: Fat only       - Lymph nodes, LN 12a: Free of tumor metastasis (0/2)  
      • Omentum: tumor invasion
      • AJCC Pathologic Staging: pT4aN3aM1
      • Bilateral cutting end: Free of tumor invasion
      • Additional pathologic findings: fat tissue deposition
      • Perineural invasion: Present
      • Lymphovascular space invasion: Present
      • Immunohistochemistry: CK(+) for isolet tumor cells of lymph node and tumor deposition at connective tissue
  • 2023-06-26 CT - abdomen
    • History and indication: gastric tumor: biopsy proved poorly cohesive carcinoma; for staging
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of lower gastric body and antrum with regional LAP.
      • Left ovary cyst (2.5cm).
      • Colonic diverticula.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)
  • 2023-06-16 Patho - stomach biopsy
    • Stomach, low body, biopsy — Poorly cohesive carcinoma
    • Microscopically, the sections show a picture of poorly cohesive carcinoma with focal signet-ring cell differentiation characterized by individual tumor cells infiltrating in stroma.
    • Immunohistochemistry of CK(+) for tumor. Besides, colony of Helicobacter Pylori is identified in the submitted specimen.

[MedRec]

  • 2023-09-15 ~ 2023-09-21 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Poorly cohesive carcinoma of gastric, pT4aN3aM1, stage IV, status post total gastrectomy with lymph node dissection on 2023/07/24; status post intraperitoneal chemotherapy with 5FU on 2023/08/02~2023/08/06 and Immunity therapy with Nivolumab (200mg, self paid)/FOLFOX (Oxalip 75mg/m2, Covorin 300mg/m2, 5-Fu 300mg/m2, 5-Fu 2400mg/m2 ) on 2023/09/04~
      • Vomiting, unspecified
      • Chronic viral hepatitis B without delta-agent
      • Abnormal results of liver function studies
      • Hypokalemia
      • Cachexia
      • Neutropenia, unspecified
    • CC
      • Progression nausea with vomiting for 3 days.
    • Present illness
      • (Previously stated part omitted…)
      • Tumor marker on 2023/09/04 of CEA:1.21ng/mL. She denied fever, chills dizzness, body weight loss and tarry stool passage. Complain mild poor appetite and nausea was noted.
      • Immunity therapy with Nivolumab (200mg, self paid)/FOLFOX (Oxalip 75mg/m2, Covorin 300mg/m2, 5-Fu 300mg/m2, 5-Fu 2400mg/m2 ) on 2023/09/04(C1D1).
      • This time, progression nausea with vomiting and poor appetite with weakness for 3 days. No chills with fever, dyspnea, chest pain, abdominal pain and tarry stool passage was noted.
      • Therfore, she was snet to ER and Lab deta showed leukocytopenia (WBC:2860/uL, Neu:39.2%, ANC:1121.12), Abnormal results of liver function studies (GOT:136U/L, GPT:151U/L). Now, she was admitted to ward for further treatment.
    • Course of inpatient treatment
      • After admitted, IVF supplementation for poor appettie.
      • Primperan 1pc iv Q8H for nausea and vomiting.
      • Actein 1# po BID for sputum.
      • Leukocytopenia with delay chemotherapy.
      • Chronic viral hepatitis B without delta-agent (Anti-HBc(+)) with Baraclude 0.5mg 1# po QDAC.
      • Abnormal results of liver function studies (GOT: 136 -> 49 -> 37U/L, GPT: 151 -> 61 -> 36U/L) with Silymarin 2# po BID from 2023/09/15~.
      • Hypokalemia (K: 3.0 -> 4.2mmol/L) with 0.298% KCl in NS 500ml IVF BID from 2023/09/18~2023/09/21.
      • Cachexia with Megest 10ml po QD.
      • Patient tolerated the nausea and vomiting improving. With the stable condition, she was discharged on 2023/09/21 and OPD followed up later.     
    • Discharge prescription
      • Asthan (ketotifen 1mg) 1# BID (dermatologist suggested)
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Lactul (lactulose 666mg/mL, 60mL/bot) 10mL BID
      • Belolin ointment (clobetasol 0.5mg/gm, 7gm/tube) BID TOPI (dermatologist suggested)
      • Actein Effervescent (acetylcysteine 600mg) 1# BID
      • BaoGan (silymarin 150mg) 2# BID
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • Through (sennoside 12mg) 2# HS
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
  • 2023-09-14 SOAP MER He Yaocan
    • S: Triage Level: 3 Nausea/Vomiting > Acute Persistent Vomiting. Chemotherapy ended on 9/6, currently experiencing severe vomiting.
      • CC: severe vomiting from 9/6 after chemotherapy
      • Hx: gastric ca status post total gastrectomy with lymph node dissection
      • allergy to drugs: ampicillin
      • no chest pain, abd pian, diarrhea
    • A/P
      • Preliminary impression: R11.10 Vomiting, unspecified
      • Lab
        • 2023/09/14 12:18 Creatinine = 0.47 mg/dL;
        • 2023/09/14 12:18 eGFR = 149.08;
        • 2023/09/14 12:18 S-GPT/ALT = 151 U/L;
        • 2023/09/14 12:18 S-GOT/AST = 136 U/L;
        • 2023/09/14 12:18 Na (Sodium) = 132 mmol/L;
        • 2023/09/14 12:18 K(Potassium) = 3.3 mmol/L;
        • 2023/09/14 12:08 WBC = 2.86 x10^3/uL;
        • 2023/09/14 12:08 Neutrophil = 39.2 %;
    • Prescription
      • Taita No.5 Injection (electrolyte solution) 500mL ST IVD 60cc/hr
      • Taita No.5 Injection (electrolyte solution) 500mL ST IVD
      • Vomstop (granisetron 1mg) ST IVD
      • Imperan (metoclopramide 10mg) ST IVD
      • Taita No.5 Injection (electrolyte solution) 500mL ST IVD 100cc/hr
  • 2023-09-12 SOAP General and Gastroenterological Surgery Chen JiaHui
    • S: for Port-A insertion wound follow up. Besides, she vomits several times after chemotherapy for days
    • O: PE: 2 cm suture wound over L’t subclavian region
    • Prescription
      • Roumin (prochlorperazine maleate 5mg) 1# TID
  • 2023-09-08 SOAP General and Gastroenterological Surgery Wu Chaoqun
    • Prescription
      • hydroxocobalamin 1mg IM 6 days
  • 2023-09-04 ~ 2023-09-07 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Poorly cohesive carcinoma of gastric, pT4aN3aM1, stage IV, status post total gastrectomy with lymph node dissection on 2023/07/24; status post intraperitoneal chemotherapy with 5FU on 2023/08/02-2023/08/06. ECOG:1
      • Chronic viral hepatitis B without delta-agent, Anti-HBc reactive
    • CC
      • for scheduled chemotherapy        
    • Present illness
      • This 50-year-old female was diagnosis Poorly cohesive carcinoma of gastric, pT4aN3aM1, stage IV, status post total gastrectomy with lymph node dissection on 2023/07/24; status post intraperitoneal chemotherapy with 5FU on 2023/08/02-2023/08/06. Denied TOCC history in recent three months. Initially, she sufferred from acid regurgitation with chest burning, postprandial fullness and relieved by vomiting for many weeks. She came to our GI OPD for help. Panendoscope was performed which showed gastric giant rugae, suspicious malignancy (such as gastric cancer, Borrmann type 4), low body, status post biopsy. Duodenal shallow ulcers, bulb. Pathology showed poorly cohesive carcinoma on 2023/06/15. Further abdomen CT on 2023/06/26 which showed wall thickening of lower gastric body and antrum with regional lymphadenopathy. cT3N2M0 stage III.
      • As the result, she referred to our GS OPD for surgical intervention. Then, she received total gastrectomy with EJ Roux-en-Y anastomosis and LN dissection was processed successfully on 2023/07/24, UGI series was performed on 7/28 and no evidence of anastomosis leakage was found.
      • Final pathology showed poorly cohesive adenocarcinoma, pT4aN3aM1 stage IV. Then, further IP chemotherapy with 5Fu (920mg) for 5 days (2023/08/02-08/06), and Mitomycin-C (27mg) on 2023/08/03.
      • Tumor marker of CEA:1.21ng/mL. She denied fever, chills dizzness, body weight loss and tarry stool passage. Complain mild poor appetite and nausea was noted. Under impressed of gastric cancer, she was admitted to our service for chemotherapy.
    • Course of inpatient treatment
      • After admission, he received Nivolumab (200mg, self paid) plus FOLFOX (Oxalip 75mg/m2, Covorin 300mg/m2, 5-Fu 300mg/m2, 5-Fu 2400mg/m2 ) from 2023/09/04~2023/09/06(C1D1) smoothly.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
      • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for AntiHBc (+).
      • Patient tolerated the chemotherapy with mild nausea and vomiting. With the stable condition, she was discharged on 2023/09/07 and OPD followed up later.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Baraclude (entecavir 0.5mg) 1# QDAC
  • 2023-08-15 SOAP Hemato-Oncology Xia HeXiong
    • A/P
      • arranged abd CT scan on 6/26
      • refer to GS OPD Chief Wu on 6/27 for further management such as surgery or other further management.
      • Arrange admission for FOLFOX with or without Nivolumab, 1st line of CM649 (CheckMate649)
  • 2023-07-23 ~ 2023-08-09 POMR General and Gastroenterological Surgery Wu Chaoqun
    • Discharge diagnosis
      • Poorly cohesive carcinoma of gastric, pT4aN3aM1, stage IV, status post total gastrectomy with lymph node dissection on 2023/07/24; status post intraperitoneal chemotherapy with 5FU on 2023/08/02-2023/08/06. ECOG:1
    • CC
      • Acid regurgitation with chest burning, postprandial fullness and relieved by vomiting for many weeks
    • Present illness
      • This 50-year-old female denied of systemic disease before. She sufferred from acid regurgitation with chest burning, postprandial fullness and relieved by vomiting for many weeks. She came to our GI OPD for help. Panendoscope was performed which showed gastric giant rugae, suspicious malignancy (such as gastric cancer, Borrmann type 4), low body, status post biopsy. Duodenal shallow ulcers, bulb. Pathology showed poorly cohesive carcinoma.
      • Further abdomen CT on 2023/06/26 which showed wall thickening of lower gastric body and antrum with regional lymphadenopathy. cT3N2M0 stage III. As the result, she referred to our GS OPD for further management.
      • Tumor marker of CEA:1.31ng/mL. She denied fever, chills dizzness, poor appetite, nausea, body weight loss and tarry stool passage. Under impressed of gastric cancer, she was admitted to our service for surgical intervention.
    • Course of inpatient treatment
      • After admitted, she received total gastrectomy with EJ Roux-en-Y anastomosis and LN dissection was processed successfully on 7/24. Post operaively, we observed patient recovery and keep adequate fluid, nutrition support with PPN, empiric antibiotic, albumin with lasix therapy, and analgesic agent were administered and the wound management was performed.
      • UGI series was performed on 7/28 and no evidence of anastomosis leakage was found. She try to introduced liquid diet with step by step until tolerate well for semi-liquid. Right side JP tube removal on 7/31. Final pathology showed poorly cohesive adenocarcinoma, pT4aN3aM1 stage IV.
      • Then, further IP chemotherapy with 5Fu (920mg) for 5 days (8/2-8/6), and Mitomycin-C (27mg) on 8/3 was performed smoothly.
      • Post chemotherpay with mild nausea and poor apppetite were noted, then promeran support since 8/4. Removal JP tube was done smoothly after finish of IP chemotherapy.
      • Her generally well beings and relativley stable. There were no nosocomial infection and other complications and vital signs were stable after the surgery. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. Under stated improvement of clinical symptoms without vomit and appetite improved, she was allowed to discharge today then OPD follow up was arranged.
    • Diagnosis prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Through (sennoside 12mg) 2# HS
      • Celebrex (celecoxib 200mg) 1# QD
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • BaoGan (silymarin 150mg) 1# TID
  • 2023-06-23 SOAP Gastroenterology Chen HongDa
    • S
      • easily fullness and nausea sensation after meals.
      • EGD: gastric tumor: biopsy proved poorly cohesive carcinoma;
      • DUs; CLO positive.
      • arranged abd CT scan on 6/26
      • refer to GS OPD Chief Wu on 6/27
      • we’ve informed possible side effect of HP eradication therapy: the patient understood and agreed
      • We’ve explained indication and possible complications, pros and cons of abd CT scan with contrast enhancement such as radiation exposure, allergic reaction to contrast media, contrast media related nephrotoxicity=> the patient understood and agreed with abdominal CT scan with contrast enhancement.
      • female patient: she denied pregnancy
    • O
      • 2023/06/16 PATHO - stomach biopsy
        • Stomach, low body, biopsy — Poorly cohesive carcinoma
      • PE abd soft no tenderness; no palpable mass.
      • past medical disease Hx: denied
      • allergy to drugs; denied
      • patient denied other medical disease such as chronic kidney disease; patient denied allergy to drugs; patient denied pregnancy
    • A/P
      • arranged abd CT scan on 6/26
      • refer to GS OPD Chief Wu on 6/27 for further management such as surgery or other further management.
    • Prescription
      • Pariet (rabeprazole 20mg) 1# QDAC
      • Pariet (rabeprazole 20mg) 1# QNAC
      • Mopride (mosapride citrate 5mg) 1# TID
      • Klaricid (clarithromycin 500mg) 1# BID
      • Metrozole (metronidazole 250mg) 2# BID
  • 2019-12-13 SOAP Family Medicine Xie QiPan
    • S
      • swelling pain of right dorsal hand for 4 days,
      • morning stiffness (+) duration 20 minutes
      • PH: IDA, anemia
    • O
      • BT 36.8 C, BP 140/96, HR 100
      • swelling tenderness of right MP joints of 2nd and 3rd
      • A: cellulitis or gout or OA or RA
      • P: check BCS, RF, Uric acid. Mx, f/u
    • Diagnosis
      • Osteoarthritis [M19.90]
      • Gout [M10.9]
      • Arthropathy associated with other bacterial diseases, unspecified site [M01.X0]
    • Prescription
      • cephalexin 500mg 1# Q6H
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD
      • Ulstop (famotidine 20mg) 1# BID
      • Naposin (naproxen 250mg) 1# TID
      • Compesolon (prednisolone 5mg) 1# QD
      • colchicine 0.5mg 1# QD
  • 2019-11-15 SOAP Family Medicine Lin ChunYu
    • S
      • intermittent chest tightness and palpitation for years
      • right hand numbness while wake up recently
      • had vivist Neuro OPD (EEG: ok)
      • Past hx: IDA s/p IV Fe, myoma
      • allergy: denied
    • Diagnosis
      • Chest tightness [R07.89]
      • Iron deficiency anemia, unspecified [D50.9]
      • Idiopathic insomnia [F51.01]
      • Neuralgia, neuritis, and radiculitis, unspecified [M79.2]
      • Palpitations [R00.2]
      • Acute nasopharyngitis [common cold] [J00]
      • HTN [I10]
      • Gout [M10.9]
      • Constipation [K59.00]
    • Prescription x3
      • Foliromin (sodium ferrous citrate 50mg) 1# BID
  • 2018-03-21 SOAP Obstetrics and Gynecology Chen YiLing
    • S
      • 45y/o sex+ G2P0SA1AA1 LMP 2018/03/09 28 -> 21
      • IDA under iron supplement and tachycardia
      • large amount of MC for 1 year
      • OV cyst by health exam 2 years ago
      • Hx HTN
      • for pap smear
    • O
      • RTC on 6/13 for ergonovine effect; consider TAH in the furutre
      • 2018/03/09 Hb:8.9 g/dL
      • PV VD: scanty; Cx eroded
      • 2018/03/21 TVS: EM: 11.9mm Myoma : 2.9 x 2.4 , 4.7 x 4.5 cm
    • A
      • Excessive of frequent menstruation [N92.0]
      • Other disorders of menstruation and other abnormal bleeding from female genital tract [N92.5]
      • Screening for malignant neoplasms of cervix [Z12.4]
    • Prescription
      • Naposin (naproxen 250mg) 1# TID
      • ergometrine maleate 0.2mg 1# Q8H
      • Frotin (metronidazole 250mg) 1# HS
  • 2018-03-12 SOAP Family Medicine Ye JiaZe
    • A: Iron deficiency anemia, unspecified [D50.9]
    • Prescription
      • Foliromin (sodium ferrous citrate 50mg) 1# BID
  • 2018-03-05 SOAP Family Medicine Ye JiaZe
    • O: BP:142 80 mmHg; HR:70; Height: 160 cm; Weight: 77 Kg;
    • A
      • HTN [I10]
      • Gout [M10.9]
    • Prescription
      • Tonec (aceclofenac 100mg) 1# BID

[consultation]

  • 2023-09-16 Dermatology
    • Q
      • This 50-year-old woman patient is a case of Poorly cohesive carcinoma of gastric, pT4aN3aM1, stage IV, status post total gastrectomy with lymph node dissection on 2023/07/24; status post intraperitoneal chemotherapy with 5FU on 2023/08/02~2023/08/06 and chemotherapy with FOLFOX from 2023/09/04. This time, abdominal redness rash. Now, for evaluate abdominal redness rash therapy. Thank you.
    • A
      • This patient suffered from multiple erytheamtous papules on trunk for days.
      • Imp: Miliaria rubra
      • Suggestion:
        • Zaditen 1/Bid (Ketotifen is a histamine H1 receptor blocker and mast cell stabilizer used to treat mild atopic asthma and allergic conjunctivitis.)
        • Clobatasol x 6 tubes/bid
  • 2023-08-07 Hemato-Oncology
    • A
      • This 50 year old woman is a case of Poorly cohesive carcinoma of gastric cancer, pT4aN3aM1, stage IV, s/p total gastrectomy with LN dissection on 7/24, s/p  IP chemotherapy with 5Fu 500mg/m2 for 5 days (8/2-8/6), and Mitomycin-C 20mg/m2 on day 2 (8/3). We are consulted for further evaluation.
      • We had disucssed with patient about palliative chemotherapy with immunotherapy (Nivo + FOLFOX).
      • Arrange our OPD after discharge. Arrange port A insertion before treatment.

[surgical operation]

  • 2023-07-24
    • Surgery
      • Total gastrectomy with LN1-12a dissection
      • EJ Roux-en-Y anastomosis with EndoGIA
    • Finding
      • Scirrhous type gastric ca with primary origin at distal stomach
      • multiple LN enlarge at 5,6,12,8
      • ascite (-)
      • seeding (-)
      • liver mets (-)
      • frozen section of distal esophagus: negative for ca

[immunochemotherapy]

  • 2023-10-18 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL + fluorouracil 2000mg/m2 3300mg 46hr (Opdivo + FOLFOX, Oxa 65mg/m2 for severe vomiting)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-28 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL + fluorouracil 2000mg/m2 3300mg 46hr (Opdivo + FOLFOX; due to neutropenia: Oxa 75 -> 65mg/m2, 5FU bolus DC and infusion 2400 -> 2000mg/m2)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-04 - nivolumab 200mg NS 100mL 1hr + oxaliplatin 75mg/m2 130mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL + fluorouracil 300mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg 46hr (Opdivo + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-02 - fluorouracil 500mg/m2 920mg 1hr IP D1-5 (fore IPEC via JP tube drip 1hr then retension 23hrs) + mitomycin-C 20mg/m2 37mg NS 500mL 2hr IP D2 (with pump on day 2) (IPEC)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

==========

2023-10-19

[hypokalemia, hypomagnesemia, hypoalbuminemia, hypocalcemia]

Lab data:

  • 2023-10-18 K(Potassium) 2.5 mmol/L
  • 2023-10-18 Mg (Magnesium) 1.4 mg/dL
  • 2023-10-18 Ca (Calcium) 1.68 mmol/L
  • 2023-10-18 Albumin(BCG) 2.8 g/dL

KCl and MgSO4 were given intravenously to treat hypokalemia and hypomagnesemia without any problems.

Lab results from 2023-10-18 indicated Ca 1.68 mmol/L, Albumin 2.8 g/dL. An estimated corrected serum calcium of 7.7 mg/dL, equivalent to 1.9 mmol/L, which is still beneath the normal range. Considering calcium and albumin supplements could be an optional course of action.

[severe delayed vomiting]

Severe vomiting persisted after the previous chemotherapy session (from 2023-09-04 to 2023-09-06), became intolerable, and led the patient to seek emergency care at our hospital on 2023-09-14. This type of vomiting is likely post-chemotherapy delayed vomiting.

For chemotherapy-induced delayed vomiting, NK-1 receptor antagonists (NK-1 RAs) may be preferred over 5-HT3 receptor antagonists (5-HT3 RAs). NK-1 RAs inhibit the effects of substance P, a neurotransmitter involved in vomiting, especially during the delayed phase. While 5-HT3 RAs block serotonin receptors and are most effective in the acute phase.

A study published in BMC Cancer found that the prolonged use of an NK-1 RA (fosaprepitant) in addition to a 5-HT3 RA and dexamethasone was more effective in preventing delayed Chemotherapy-Induced Nausea and Vomiting (CINV) compared to a regular dosage. The study showed a statistically significant lower incidence of nausea and slightly lower incidence of grade 1 vomiting in the delayed phase. Ref: https://bmccancer.biomedcentral.com/articles/10.1186/s12885-023-11070-3

Our hospital stocks Akynzeo, which includes netupitant, the NK-1 RA with the longest half-life at 96 hours.

700354357

231019

[diagnosis] - 2023-03-10 admission note

  • Malignant neoplasm of other parts of pancreas
  • Encounter for antineoplastic chemotherapy
  • Type 2 diabetes mellitus without complications
  • Malignant neoplasm of other parts of pancreas
  • Chronic viral hepatitis B without delta-agent
  • Chronic viral hepatitis C
  • Status post Liver transplantation
  • Cachexia

[past history]

  • Medical Hx:
    • Prostate cancer s/p R/T 37 times in 2009.
    • DM for more than 10 years
    • HCV related liver cirrhosis, liver transplantation in 2007 in China.

[allergy]

  • NKDA

[family history]

  • Family history is unremarkable.
  • There is no family history of hypertension, mental diseases or asthma.
  • No members of the family with diabetes.  
  • Mother has lung cancer

[exam findings]

  • 2023-10-05 MRI - upper abdomen
    • Indication: Pancreatic cancer
    • Abdominal MRI with and without IV contrast enhancement shows:
      • Moderate Splenomegaly is found.
      • Mild ascites in the abdominal cavity is also noted.
      • There is ill defined pancreatic neck lesion measuring 1.8cm in largest dimension and regional vascular invasion and infiltration with obliterating distal pancreatic duct is found. In comparison with CT dated on 2023-08-11, the lesion decreased in size.
      • Dilated CBD and IHDs is also noted.
      • Bilateral renal cysts are found.
      • MRCP shows dilated CBD and IHDs and distal pancreatic duct is found.
    • Imp:
      • Pancretic neck cancer with vascular invasion and distal pancreatic duct obsctruction s/p C/T with tumor decreased in size.
      • Bililary obstruction without soft tissue at distal CBD
  • 2023-08-21 ECG
    • Sinus rhythm with occasional Premature ventricular complexes RSR’’ or QR pattern in V1 suggests right ventricular conduction delay
  • 2023-08-21 Endoscopic Retrograde Cholangiopancreatography, ERCP
    • Diagnosis:
      • Malignant distal biliary stricture s/p EST & FCSEMS
      • Chronic cholangitis
      • shallow duodenal ulcers
      • GB invisible
    • Suggestion:
      • f/u amylase & lipase
  • 2023-08-11 CT - abdomen
    • Findings: Comparison: prior CT dated 2023/04/28.
      • Prior CT identified ascites in the abdomen and pelvis is noted again, decreasing in amount (only in the pelvis).
      • Prior CT identified an ill-defined poor enhancing mass lesion in the pancreatic neck is noted again, mild increasing in size and poor margination.
        • In addition, Prior CT identified tumor seeding and encasement in the celiac trunk and common hepatic artery and the distal splenic vein, (beyond the trifurcation) is noted again, mild increasing in size.
        • Prior CT identified dilatation of the upstream pancreatic duct is noted again, stationary.
      • Prior CT identified metastatic nodes in the hepatoduodenal ligament are noted again, stable in size.
        • Prior CT identified tumor direct invasion the stomach antrum or duodenum 1st portion is noted again, mild increasing in size.
      • A cystic lesion 1 cm in the pancreatic head is noted.
      • There is mild wall thickening at the gastric antrum.
        • Please correlate with gastroscopy.
      • S/P cadaveric liver transplantation and S/P cholecystectomy.
        • A hepatic cyst measuring 0.6 cm in S2 is noted.
      • A renal cyst measuring 2.1 cm in right middle pole is noted.
      • The spleen shows prominence in size (long axis: 12 cm).
    • IMP:
      • Prior CT identified ascites in the abdomen and pelvis is noted again, decreasing in amount (only in the pelvis).
      • Adenocarcinoma of the pancreatic neck S/P C/T show stable disease or mild progressive disease.
      • Follow up CT and tumor marker 3 months later is indicated.
  • 2023-04-28 CT - abdomen
    • Indication
      • 20230113 CC: wight loss from 70 to 52 Kgs in the past 2 months.
        • Anorexia since Sep 2022. Low abdominal pain since 6 Dec 2022.
        • Chronic diarrhea since 3 months ago.
        • He had undergone liver transplantation in 2007 in China.
      • 20230113 CT: Adenocarcinoma of pancreatic neck, cT4N1M0, stage III
      • 20230113 CA199: 53.89 U/mL (<35).
      • 20230117 EUS biopsy: adenocarcinoma
      • 20230202 s/p chemotherapy with FOLFIRINOX
    • Past history: Ca of prostate s/p R/T in 2009. D.M > 10 years.
    • Findings comparison prior CT dated 2023/01/13.
      • There is newly developed ascites in the abdomen and pelvis. please correlate with clinical condition.
      • Prior CT identified an ill-defined poor enhancing mass-like lesion in the pancreatic neck is noted again, mild decreasing in size and poor margination.
        • Prior CT identified dilatation of the upstream pancreatic duct is noted again, stationary.
        • In addition, Prior CT identified tumor seeding and encasement in the celiac trunk and common hepatic artery and the distal splenic vein, (beyond the trifurcation) is noted again, stationary.
      • Prior CT identified metastatic nodes in the hepatoduodenal ligament are noted again, mild decreasing in size.
        • Prior CT identified tumor direct invasion the stomach antrum or duodenum 1st portion is noted again, mild decreasing in size.
      • A cystic lesion 1 cm in the pancreatic head is noted.
      • There is mild wall thickening at the gastric antrum. Please correlate with gastroscopy.
      • S/P cadavertic liver transplantation and S/P cholecystectomy.
        • A hepatic cyst measuring 0.6 cm in S2 is noted.
      • A renal cyst measuring 2.1 cm in right middle pole is noted.
        • The spleen shows prominence in size (long axis: 12 cm).
      • Others
        • There is no focal abnormality in the biliary system.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • IMP:
      • Newly developed ascites. please correlate with clinical condition.
      • Adenocarcinoma of the pancreatic neck S/P C/T show partial response.
  • 2023-01-17 Patho - pancreas biopsy
    • Labeled as “pancreas, neck”, EUS fine needle biopsy — pancreatic adenocarcinoma.
    • IHC stains: CA19-9 (+), CK19 (+), CD56 (-), CK7 (+), CK20 (focal +).
    • Section shows few loosely cohesive neoplastic glands. IHC stains: CA19-9 (+), CK19 (+), CD56 (-), CK7 (+), CK20 (focal +).
  • 2023-01-17 ECG
    • Sinus rhythm with 1st degree A-V block
    • Right bundle branch block
  • 2023-01-13 Endoscopic Ultrasonography, EUS
    • Pancreatic neck tumor T4NxMx s/p CEH-EUS & EUS/FNB
    • Pancreatic cystic lesion, head portion
  • 2023-01-13 CT - abdomen
    • CC: wight loss from 70 to 52 Kgs in the past 2 months.
      • Anorexia since Sep 2022.
      • Low abdominal pain since 6 Dec 2022.
      • Chronic diarrhea since 3 months ago. Colon polyp was removed on 29 Nov 2022.
      • He had undergone liver transplantation in 2007 in China.
    • Past history: Ca of prostate s/p R/T in 2009. D.M > 10 years.
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is an ill-defined poor enhancing mass-like lesion in the pancreatic neck (Srs:601 Img:24), 3.7 x 2 cm in size, causing dilatation of the upstream pancreatic duct 9 mm in diameter.
        • In addition, There are soft tissue lesions in the celiac trunk and common hepatic artery surrounding area that may be tumor encasement. The distal splenic vein, beyond the trifurcation, shows small size that also may be tumor encasement.
        • Adenocarcinoma of the pancreatic neck (T4) is highly suspected.
        • Please correlate with CA199 and MRI.
      • There are soft tissue lesions in the hepatoduodenal ligament that may be metastatic nodes (N1).
      • There is fat plane obliteration between the pancreatic neck mass and the stomach antrum or duodenum 1st portion that may be tumor direct invasion.
      • A cystic lesion 1 cm in the pancreatic head is noted.
      • There is mild wall thickening at the gastric antrum.
        • Please correlate with gastroscopy.
      • S/P cadavertic liver transplantation and S/P cholecystectomy.
        • A hepatic cyst measuring 0.6 cm in S2 is noted.
      • A renal cyst measuring 2.1 cm in right middle pole is noted.
      • Others
        • There is no focal abnormality in the liver, biliary system, spleen & left kidney.
        • There is no ascites.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • IMP:
      • Adenocarcinoma of the pancreatic neck is highly suspected. Please correlate with CA199 and MRI.
      • If pancreatic cancer is finally proved by pathology. According to American Joint Committee on Cancer(AJCC) staging system, 8th edition for pancreatic cancer: T4 N1 M0, Stage:III

[MedRec]

  • 2023-03-28 Hemato-Oncology
    • O: AE Gr 3 Neutropenia -> Improved to Gr 1
  • 2023-02-22 Hemato-Oncology
    • O: AE Gr 3 Neutropenia -> Improved
  • 2023-02-15 Hemato-Oncology
    • Now on Induction FOLFIRINOX, C1D1 on 2023-02-02
    • Already mention treatment strategy
      • Induction chemotherapy with FOLFIRINOX
      • If OP is feasible, go to OP; if OP is not feasible, go to CCRT.
  • 2023-02-14 SOAP Radiation Oncology
    • S
      • For radiotherapy due to pancreatic neck adenocarcinoma.
      • PI: The patient transferred from TSGH (Dr. Chao) for CCRT due to pancreatic carcinoma. He was a case of prostate cancer s/p radiotherapy at TSGH.
      • Chemotherapy: 2023-02-02
      • Family history: (mother: lung cancer)
      • Cancer site specific factors: Alcohol (quit); Smoking (-); Betel nut (-).
      • Personal Hx: DM(-); HTN(+); s/p liver transplantation at China.
      • Allergy(-)
      • Previous RT Hx: radiotherapy of the prostate at TSGH.
    • P
      • Preliminary planning dose: 4500cGy/25 fractions of the pancreatic neck tumor, peripheral involved, and regional lymphatic area.
  • 2023-01-13 SOAP Gastroenterology
    • S
      • He came because of weight loss from 70 to 52 Kgs in the past 2 months.
      • Anorexia since Sep 2022.
      • Low abdominal pain since 6 Dec 2022.
      • Chronic diarrhea since 3 months ago. Colon polyp was removed on 29 Nov 2022.
      • He had undergone liver transplantation in 2007 in China.
      • Past history: Ca of prostate s/p R/T 37 times in 2009. D.M for more than 10 years.
    • O
      • P.E.: No icteric sclera, soft abdomen, no leg pitting edema.
      • 2023-01-13: Ca-19-9: 53.89. CT of abdomen: R/O Pancreatic Ca.

[consultation]

  • 2023-01-19 Hemato-Oncology
    • Q
      • This is a 73-year-old female with underlying disease of
        • Ca of prostate s/p R/T 37 times in 2009.
        • Liver transplantation in 2007 in China.
        • D.M for more than 10 years.
      • This time, he suffured from left upper abdominal dullness pain and weight loss (70 -> 58kg in 2 months). Associated symptom included nausea and poor appetite but denied Icterus, and back pain. Due to above reason, he came to our GI OPD for further survey.
      • Abdominal CT done on 2023/01/13 revealed suspected pancreatic Ca and blood test showed Ca-19-9: 53.89.
      • Under the impression of pancreatic cancer, he was admitted for further survey. EUS-FNB for pancreas was arranged on 2023/01/17. Thus, we request your expertise for aseessment of the administration of chemotherpy.
    • A
      • This 73 year old man is a case of suspect pancrease cancer cT4N1M0, stage III. We are consulted for further evaluation.
      • Pending EUS pathology and arrange our OPD after discharge. For unresectable pancrease cancer, systemic chemotherapy is indicated (consult GS for further operation evaluation). If pancrease cancer is proven, may check HbsAg, Anti Hbc, and anti HCV. Then, consult GS for port A insertion and complete pancrease cancer work up including chest CT (+/-contrast).

[chemotherapy]

  • 2023-10-18 - (FOLFIRINOX)

  • 2023-09-19 - (FOLFIRINOX)

  • 2023-08-29 - (FOLFIRINOX)

  • 2023-07-11 - (FOLFIRINOX)

  • 2023-06-21 - (FOLFIRINOX)

  • 2023-05-31 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 1mg IVD (before Irino) + aprepitant 125mg D1-3
  • 2023-05-10 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 1mg IVD (before Irino) + aprepitant 125mg D1-3
  • 2023-04-25 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 1mg IVD (before Irino) + aprepitant 125mg D1-3
  • 2023-04-11 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 1mg IVD (before Irino) + aprepitant 125mg D1-3
  • 2023-03-10 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX, Covorin NS 500 -> 250mL)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC (before Irino) + aprepitant 125mg D1-3
  • 2023-02-23 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC (before Irino) + aprepitant 125mg D1-3
  • 2023-02-02 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + irinotecan 90mg/m2 140mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3750mg NS 500mL 46hr (FOLFIRINOX)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC (before Irino) + aprepitant 125mg D1-3

Granocyte (lenograstim 250ug) CGRAN01

  • 2023-05-24 3 days (OPD)
  • 2023-05-16 3 days (IPD)
  • 2023-05-02 3 days (IPD)
  • 2023-04-17 3 days (IPD)
  • 2023-04-04 3 days (IPD)
  • 2023-03-28 3 days (IPD)
  • 2023-03-23 3 days (OPD)
  • 2023-03-15 3 days (IPD)
  • 2023-03-01 3 days (IPD)
  • 2023-02-15 3 days (OPD)

WBC

  • 2023-05-31 WBC 3.55 x10^3/uL
  • 2023-05-24 WBC 2.32 x10^3/uL
  • 2023-05-10 WBC 3.01 x10^3/uL
  • 2023-04-25 WBC 2.71 x10^3/uL
  • 2023-04-11 WBC 4.08 x10^3/uL
  • 2023-03-28 WBC 3.47 x10^3/uL
  • 2023-03-23 WBC 2.43 x10^3/uL
  • 2023-03-09 WBC 4.31 x10^3/uL
  • 2023-02-22 WBC 5.90 x10^3/uL
  • 2023-02-15 WBC 2.08 x10^3/uL
  • 2023-01-30 WBC 4.75 x10^3/uL
  • 2023-01-13 WBC 6.05 x10^3/uL

==========

2023-10-19

[reconcilation]

The patient had an appointment at Tri-Service General Hospital on 2023-09-23 and received prescriptions for Trajenta (linagliptin), Diovan (valsartan), Certican (everolimus), and Stilnox (zolpidem), with the latter not currently being utilized. Please verify if the discontinuation of Stilnox is intentional.

As an additional note, the patient received an injection of Zoladex (goserelin acetate) at TSGH on 2023-10-06, with the previous injection administered on 2023-07-28.

2023-07-12

This patient had an appointment at the Tri-Service General Hospital on 2023-06-24 where he was prescribed Trajenta (linagliptin), Diovan (valsartan), Certican (everolimus), and Stilnox (zolpidem). These medications have been correctly incorporated into the patient’s active medication list. No discrepancies were found during the medication reconciliation process.

2023-06-01

  • This patient had an appointment at the Tri-Service General Hospital on 2023-05-05, during which he was prescribed a single dose of Zoladex (goserelin acetate 10.8mg). As the suggested administration interval for this medication is every 12 weeks, the next scheduled dose should be on 2023-07-28. No issues were discovered during the medication reconciliation process.

  • The patient seems to be showing signs of anemia with an increasing trend towards macrocytosis. As the bilirubin level is still within the normal range, hemolytic anemia may be less likely. A single intramuscular dose of B-Red (hydroxocobalamin 1mg) is scheduled for 2023-06-02, and folate is already included in the current FOLFIRINOX regimen. At this time, there is no concrete evidence indicating a rapid progression in the severity of anemia, so please continue monitoring.

    • 2023-05-31 RBC 3.27 x10^6/uL
    • 2023-05-31 HGB 10.5 g/dL
    • 2023-05-31 HCT 33.5 %
    • 2023-05-31 MCV 102.4 fL
    • 2023-05-24 MCV 100.0 fL
    • 2023-05-10 MCV 101.5 fL
    • 2023-04-25 MCV 102.2 fL
    • 2023-04-11 MCV 102.1 fL
    • 2023-03-28 MCV 103.6 fL
    • 2023-03-23 MCV 99.7 fL
    • 2023-03-09 MCV 97.4 fL
    • 2023-02-22 MCV 95.0 fL
    • 2023-02-15 MCV 91.8 fL
    • 2023-01-30 MCV 94.1 fL
    • 2023-01-13 MCV 93.6 fL

2023-05-11

  • Zoladex (goserelin acetate) 10.8mg was administered Q3M, with the most recent administration occurring on 2023-05-05, at TSGH for the management of the patient’s prostate cancer. Furthermore, antiglycemic, antihypertensive, and anti-rejection medications prescribed at TSGH are correctly reflected in the current active medication list, presenting no issues with medication reconciliation.

  • Please be aware, there is a slow yet noticeable upward trend in both AST and ALT lab results. This should be closely monitored for possible potential liver function impairment.

    • 2023-05-10 S-GOT/AST 35 U/L

    • 2023-04-25 S-GOT/AST 42 U/L

    • 2023-04-11 S-GOT/AST 30 U/L

    • 2023-03-28 S-GOT/AST 25 U/L

    • 2023-03-23 S-GOT/AST 30 U/L

    • 2023-03-09 S-GOT/AST 23 U/L

    • 2023-02-22 S-GOT/AST 17 U/L

    • 2023-02-15 S-GOT/AST 16 U/L

    • 2023-01-30 S-GOT/AST 14 U/L

    • 2023-01-13 S-GOT/AST 19 U/L

    • 2023-05-10 S-GPT/ALT 44 U/L

    • 2023-04-25 S-GPT/ALT 55 U/L

    • 2023-04-11 S-GPT/ALT 36 U/L

    • 2023-03-28 S-GPT/ALT 32 U/L

    • 2023-03-23 S-GPT/ALT 35 U/L

    • 2023-03-09 S-GPT/ALT 27 U/L

    • 2023-02-22 S-GPT/ALT 21 U/L

    • 2023-02-15 S-GPT/ALT 22 U/L

    • 2023-01-30 S-GPT/ALT 20 U/L

    • 2023-01-13 S-GPT/ALT 20 U/L

2023-04-26

  • Certican (everolimus) has been added to the list of active medications for the patient’s post-liver transplant status without a reconciliation issue.
  • 2023-04-25 WBC 2.71K/uL, Granocyte (lenograstim) might be prepared in advance for approximately 1 week after chemotherapy.

2023-03-13

  • The patient has been receiving FOLFIRINOX since 2023-02-02, with a reduced dosage of oxaliplatin (85 -> 65mg/m2) and irinotecan (180 -> 90mg/m2) to prevent adverse reactions. Approximately 2 weeks after the first chemotherapy treatment, the patient experienced leukopenia, with a WBC count of 2.08K/uL on 2023-02-15. Following this event, prophylactic G-CSF was administered around 1 week after each subsequent chemotherapy treatment, and no further episodes of leukopenia were observed.
  • The previous 84-day refillable prescription of tacrolimus at TSGH on 2022-12-10 was changed to everolimus on 2023-03-04. To manage the trough concentration target range of 3 to 8 ng/mL, patients taking everolimus are recommended to undergo TDM.
  • If the patient develops neutropenia again, the dose of everolimus is recommended to be adjusted as follows:
    • For Grade 3 neutropenia (ANC >=500 to <1,000/uL), everolimus treatment will be temporarily interrupted until the condition improves to <= grade 2. Treatment will then be reinitiated at the same dose.
    • For Grade 4 neutropenia (ANC <500/uL), everolimus treatment will be temporarily interrupted until the condition improves to <= grade 2. Treatment will then be reinitiated at 50% of the previous dose. If the reduced dose is lower than the lowest strength available, dosing will be changed to every other day.

2023-01-31

  • Although there are case reports of pancreatic adenocarcinoma in liver transplant recipients, there are no systematic review articles on chemotherapy for pancreatic cancer in liver transplant patients found in the public domain.
  • If the patient’s performance is evaluated as ECOG 0/1, FOLFIRINOX or modified FOLFIRINOX might be considered as possible regimens for treatment.
  • The patient is taking Advagraf (tarcolimus). Tacrolimus is an immunosuppressant, in combination with chemotherapy, it is likely to have an increased immunosuppressive effect, therefore, there may result in potential opportunistic infections which should be closely monitored.

700926088

231019

[exam findings] (not completed)

  • 2023-09-11 CT - chest
    • Comparison was made with CT dated on 2023/1/5
      • Lungs:
        • interval significant increase in size of LUL tumor (6.6cm in longest dimension) with pleural tails and surrounding with inferior ground-glass opacity, that involves the hilum and adjacent mediastinal fat.
        • an ill-defined peribronchovascular ground glass nodule at RUL.
      • Mediastinum and hila: mediastinal LAP in A-P window and Lt anterior perivascular space, and left hilum.
      • Vessels: mild coronary arterial calcification
        • Aorta: normal caliber, extensive atherosclerotic change of thoracic aorta..
        • Heart: normal in size of cardiac chambers.
      • Pleura: minimal Lt-sided effusion and left upper mediastial thickening.
      • Visible abdominal contents: left renal cyst (43x50 mm).
      • Visualized bones: compression fracture of T7 and L1 vertebral bodies.
    • Impression:
      • LUL lung cancer T4N2 s/p TKI, significant in progression LUL and stationary of the RUL tumor as compared with CT on 2023/01/05
  • 2023-01-05 CT - chest
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Spiculated mass at left upper lobe and right upper lobe measuring 3.3cm and 2.52cm respectively. In comparison with CT dated on 2022-09-20, the lesion is stationary.
        • One subcutaneous nodule medial to left breast is found measuring 2.0cm in largest dimension. In enlargement. Suggest further inspection.
        • No evidence of bilateral pleural effusion.
        • Minimal opacity over right lower lobe is found.
      • Visible abdomen:
        • Left renal cyst measuring 5.3cm in largest dimension is found.
        • The spleen, liver, pancreas and adrenals are intact.
    • Imp:
      • Left upper lobe and right upper lobe lung cancer s/p TKI. stable
      • Subcutaneous nodule at left breast. 2.0cm, suggest further management.
  • 2022-09-20 CT - chest
    • Findings
      • Lungs:
        • an ill-defined peribronchovascular ground glass nodule at RUL (21 mm in largest axial dimension)
        • a spiculated nodule with pleural tails and corona radiata at LUL (23mm in largest axial dimension).
        • mild subpleural reticulation at both lower lobes.
      • Mediastinum and hila: no enlarged LN.
        • Vessels: mild coronary arterial calcification
        • Aorta: normal caliber, extensive atherosclerotic change of thoracic aorta.
      • Visible abdominal contents: left renal cyst (43x50 mm).
        • diffuse thickening wall of the urinary bladder with lateral wall diverticulum.
      • Visualized bones: compression fracture of T7 and L1 vertebral bodies.
    • Impression:
      • lung cancer s/p TKI, slightly decrease in size of LUL and RUL tumors as compared with CT on 2022/06/27
      • mild interstial fibrosis in lower lobes of lungs.
  • 2022-06-27 CT - lung
    • Findings
      • Lungs:
        • an ill-defined peribronchovascular ground glass nodule at RUL (23 mm in largest axial dimension)
        • a spiculated nodule with pleural tails at LUL (25 mm in largest axial dimension).
        • subpleural reticulation at voth lower lobes.
      • Mediastinum: no enlarged LN.
      • Hila: no enlarged LN.
      • Vessels: mild coronary arterial calcification
        • Aorta: normal caliber, extensive atherosclerotic change of thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Visible abdominal contents: left renal cyst (43 x 50 mm).
        • S/P suprapubic cystectomy.
        • marked diffuse thickening wall of the urinary bladder.
        • with lateral wall diverticulum.
      • Visualized bones: compression fracture of T17 vertebral body.
    • Impression:
      • lung cancer s/p TKI, stationary in size of LUL and RUL tumors, compared with CT on 2021/12/15
      • mild interstial fibrosis in lower lobes of lungs.
  • 2022-03-02 Neurosonography
    • Mild to moderate atheromatous lesions in L middle CCA; mild atheromatous lesions in R subclavian artery and R ICA.
    • Elevated flow velocity in R PCA (PS/ED = 234/97 cm/s), suggesting R PCA stenosis.
    • Normal extracranial carotid, vertebral, and other intracranial basal cerebral arterial flows.
  • 2022-01-24 KUB + L-spine Lat
    • Bilateral clear psoas shadows. Dilated bowel gas pattern. L1 compression fracture. Degenerative change of the spine with marginal spur formation. Grade 1 degenerative spondylolisthesis at L4-5 level. Placement of urinary catheter.
  • 2022-01-11 CT - abdomen
    • Compression fracture of L1.
    • Partial atelectasis at LLL.
    • Left renal cyst (5.0cm).
    • Atherosclerosis of aorta, iliac arteries.
    • S/P foley catheter indwelling.
  • 2022-01-11 L-spine AP + Lat (including sacrum)
    • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture(s) L1.
    • Presence of spondylolisthesis at L4/5, grade I.
  • 2022-01-07 L-spine Lat. only. (including sacrum)
    • L1 compression fracture
    • Gr.I spondylolisthesis and disc space narrowing at L4/5
    • Facet degeneration of lumbar spine
  • 2021-12-15 CT - chest
    • Comparison made with previous CT dated on 2021/09/03
      • Lungs:
        • an ill-defined peribronchovascular ground glass nodule at RUL (23 mm in largest axial dimension)
        • a spiculated nodule with pleural tails at LUL (25 mm in largest axial dimension).
      • Mediastinum:
        • no enlarged LN.
        • minimal anterior pericardial effusion.
      • Hila: no enlarged LN.
      • Vessels: mild coronary arterial calcification
        • Aorta: normal caliber, extensive atherosclerotic change of thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Visible abdominal contents: left renal cyst (43 x 50 mm).
      • Visualized bones: compression fracture of T17 vertebral body.
    • Impression:
      • lung cancer s/p TKI, decrease in size of LUL and RUL tumors, and no enlarged mediastinal LNs compared with CT on 2021/09/03
  • 2021-09-03 CT - chest
    • Indication: Lung cancer s/p TKI
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Spiculated, dense plate like lesion at left upper lobe up to 3.03cm in largest dimension is found. In comparison with CT dated on 2021-05-04, the lesion is stationary.
        • Band like opacity with spicualted change at right upper lobe is also noted. r/o synchronous lung cancer.
        • Small lymph nodes are found at bilateral paratracheal region.
        • Calcified coronary arteries is found.
        • MIld pericardial effusion is found.
        • Calcified coronary arteries is found.
      • Visible abdomen:
        • Left renal cyst up to 5.6cm in largest dimension is found.
    • Imp:
      • Left upper lobe lung cancer with mediastinal lymphadenopathy, cT2N3Mx, stable.
      • Synchronous lung cancer at right upper lobe
  • 2021-07-19 Patho - skin cyst/tag/debridement
    • Skin, eyelid, excision biopsy — Basal cell carcinoma, ulcerated with keroid pattern and pigmented pattern, involving the deep margin and un-oriented, unspecified side margins.
    • Section shows one piece of ulcerated skin with basal cells carcinoma infiltration, with keroid pattern and pigmented pattern, involving the deep margin and un-oriented, unspecified side margins.
    • IHC stain: Ber-EP4 (focal weak +), EMA (-), bcl-2 (diffuse +), CD10 (-).
  • 2021-06-02 Patho - pleural/pericardial biopsy
    • Lung, left, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma and proliferating along the alveolar wall.
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(focal weak +), and CD56(-). The results are supportive for the diagnosis.
  • 2021-05-25 MRI - brain
    • No brain nodule or metastasis
    • Old left middle corpus callosum infarct or demyelination?
    • Brain atrophy. Bilateral subcortical and periventricular white matter change (leukoaraiosis).
  • 2021-05-20 Tc-99m MDP bone scan with SPECT
    • Increased activity in the lower C-spine, middle T- and lower L-spines. Degenerative change or compression fracture may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture. However, please correlate with other clinical findings for further evaluation.
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, bilateral wrists, knees and both feet, compatible with benign joint lesions.
  • 2021-05-19 PET
    • Glucose-hypermetabolism in the left upper lung, compatible with the primary lung cancer.
    • Glucose-hypermetabolism in bilateral pulmonary hilar and bilateral mediastinal lymph nodes, probably lung cancer with regional lymoh nodes involvement.
    • Glucose-hypermetabolism in the right level V cervical lymph nodes, probably lung cancer with distant metastases, suggesting biopsy for further investigation.
    • Left upper lung cancer, cTxN3M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2021-05-04 CT - lung
    • Smoking: quit for 30-40 years
    • 20210503 CxR: LLL bronchiectasis?
    • Findings
      • Lungs:
        • an ill-defined ground glass mass at RUL (32 mm in largest axial dimension)
        • a spiculated mass with pleural tails at LUL (35.4 mm in largest axial dimension).
        • a subpleural lobularlike GGO in RLL.
        • minimal fibrosis in LLL-posterobasal segment.
        • minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine.
      • Mediastinum: small LNs in visceral and left anterior perivascular spaces. enlarged LN in subcarinal space.
        • minimal anterior pericardial effusion.
      • Hila: no enlarged LN.
      • Vessels: mild coronary arterial calcification
        • Aorta: normal caliber, extensive atherosclerotic change of thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: no effusion or thickening or nodule.
      • Chest wall: unremarkable.
      • Visible abdominal contents:
        • normal appearance of gallbladder.
        • no abnormal density in visible portion of the liver, spleen, adrenal glands, pancreas, and kidneys.
        • no enlarged lymph node.
      • Visualized bones: compression fracture of T17 vertebral body.
    • Impression:
      • LUL cancer and RUL cancer, synchronous lung cancers? without regional LN metastasis.
  • 2021-03-05 MRA - brain
    • IMP: Leukoaraiosis. General brain atrophy. Mild intracranial artherosclerosis.
  • 2021-02-10 EEG
    • This EEG study recorded background alpha rhythm (9-10 Hz) and plenty beta activity with intermittent bilateral frontal fast activity with right side more prominent.
    • No epileptiform discharge.
  • 2021-02-10 Clinical Dementia Rating, CDR
    • Score = 1, Mild
  • 2021-02-10 Mini-mental state examination, MMSE
    • Score = 24, Mild
  • 2021-01-12 NONO - nephrology
    • Bialteral chronic change of both kidneys.
    • Left renal cyst.
    • Foley in bladder.
  • 2021-01-12 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (96 - 23) / 96 = 76.04%
      • M-mode (Teichholz) = 75
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Septal hypertrophy
      • Trivial MR, trivial AR, mild to moderate TR
      • Mild pulmonary hypertension
      • Preserved RV systolic function

[MedRec]

  • 2023-10-13 SOAP Chest Medicine Yang MeiZhen
    • S: daughter: 0936 099 116, 0935 500 136
    • A
      • lung adenocarcinoma, cT4N3M1c, stage IVB
      • COPD
      • dementia, hearing impairment
  • 2023-07-03 SOAP Neurology Xiao ZhenLun
    • Prescription x3
      • Crestor (rosuvastatin 10mg) 1# QD
      • Pletaal (cilostazol 100mg) 1# BID
      • Pentop (pentoxifylline 400mg) 1# BID
  • 2023-06-19 SOAP Ophthalmology Zhan LiWei
    • A: catatact
    • Prescription x3
      • Alphagan P (brimonidine 0.15%) Q12H OU
  • 2023-06-15 SOAP Hemato-Oncology Xia HeXiong
    • A: Patient escape from 2023-01
  • 2022-03-29 SOAP Hemato-Oncology Xia HeXiong
    • P: patient has still vizimpro, indicating he does not take it everyday. Already request him to take it everyday.
  • 2021-09-16 SOAP Hemato-Oncology Xia HeXiong
    • Prescription
      • Vizimpro (dacomitinib monohydrate 30mg) 1# QD
  • 2021-09-07 SOAP Chest Medicine Yang MeiZhen
    • Prescription
      • Spiriva Respimat (tiotropium 2.5ug/puff, 60puff/bot) 2 puff QD INHL
      • Actein Effervescent (acetylcysteine 600mg) 1# BID
  • 2021-07-08 SOAP Neurology Chen PeiYa
    • Prescription x3
      • Crestor (rosuvastatin 10mg) 1# QD
      • Pletaal (cilostazol 100mg) 1# BID
  • 2021-07-06 SOAP Chest Medicine Yang MeiZhen
    • Prescription
      • Compesolon (prednisolone 5mg) 2# QD
      • Xyzal (levocetirizine 5mg) 1# HS
      • Antica Syrup (orciprenaline, bromhexine, doxylamine) 8mL BID
  • 2021-07-06 SOAP Hemato-Oncology Xia HeXiong
    • O: AEs: 1. Gr 2 Skin rash; 2. Gr 1 diarrhea; 3. Gr 1 Oral mucositis
    • Prescription
      • Oralog Orabase (triamcinolone 5mg) 1# BID TOPI
      • Royalsense (clindamycin 10mg/g, 15g/tube) BID TOPI
  • 2021-06-29 SOAP Hemato-Oncology Xia HeXiong
    • O
      • 2021/06/25 EGFR
        • EGFR G719X = not detected;
        • EGFR Exon19 del = not detected;
        • EGFR S768I = not detected;
        • EGFR T790M = not detected;
        • EGFR Exon20 ins = not detected;
        • EGFR L858R = detected;
        • EGFR L861Q = not detected;
      • 2021/06/25 ALK IHC
        • ALK IHC = Negative;
        • ALK IHC Sample No. S2021-8066;
      • 2021/06/23 PD-L1 (22C3)
        • PD-L1(22C3) = TPS<1%;
        • PD-L1(22C3) Sample No. S2021-8066;
      • 2021/06/23 PD-L1 (28-8)
        • PD-L1(28-8) = TC>=5% and <10%;
      • 2021/06/23 PD-L1 IHC XiaoYe;
    • P: Now on dacomitinib C1D1 on 2021-06-29
    • Prescription
      • Vizimpro (dacomitinib monohydrate 15mg) 3# QD
  • 2021-06-22 SOAP Hemato-Oncology Xia HeXiong
    • Prescription
      • Iressa (gefitinib 250mg) 1# QD 7D
  • 2021-06-15 SOAP Hemato-Oncology Xia HeXiong
    • S
      • COPD, Gout.
      • BUL cancer, adenocarcinoma, cT4N3M1c,stage IVB, lung to lung meta; ECOG=0, use Spiriva
      • PFT: mild OBS impairment, no BD response
      • smoking: quit for 30-40 years, NKA
    • O
      • 2021/06/02 PATHO-pleural /pericardial biopsy
        • Lung, left, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • A/P
      • Well educate and explain
      • May try TKI first
        • lung adenocarcinoma, cT4N3M1C, stage 4B
        • COPD
    • Prescription
      • Iressa (gefitinib 250mg) 1# QD 7D
  • 2021-06-01 ~ 2021-06-02 POMR Chest Medicine Huang JunYao
    • Discharge diagnosis
      • Malignant neoplasm of unspecified part of left lung s/p CT guided biopsy
      • Malignant neoplasm of unspecified part of right lung
      • Chronic obstructive pulmonary disease, unspecified
    • CC
      • Incidental finding of bilateral lung tumors on a CT 2 weeks ago.
    • Present illness
      • This is a 79 year old man who was admitted to our hospital for CT guided biopsy.
      • The patient had underlying COPD on control with medications. During one of the recent OPD follow ups with our Pulmonologist, CT on 2021/05/04 made an incidental finding of LUL cancer and RUL cancer, which are likely to be synchronous lung cancers.
      • Whole body PET scan on 5/19 showed left upper lung cancer, cTxN3M1c, stage IVB, while brain MRI on 5/25 ruled out brain metastases.
      • This time, he was admitted to our hospital for scheduled CT guided biopsy.
    • Course of inpatient treatment
      • The patient underwent CT guided biopsy on 6/2 with no obvious complications. Follow up CXR four hours later showed no apparent hemathorax or pneumothorax.
      • Since the patient patient was eager to leave the hospital due to personal reasons, he was allowed to be discharged from our hospital on 6/2, and OPD follow up was arranged.        
    • Discharge prescription
      • Transamin (tranexamic acid 250mg) 1# BID
      • Sodicon (dextromethorphan 15mg) 1# TID
  • 2021-03-18 SOAP Urology You ZhiQin
    • S
      • nocturia 3-4/night, freqency, small stream, straining, urgency, UUI(+) for months
      • improved medication, nocturia 1-2/night
    • Prescription
      • Harmalidge OCAS (tamsulosin 0.4mg) 1# QDAC
      • Vesicare (solifenacin 5mg) 1# HS
  • 2021-03-05 SOAP Ophthalmology Peng YiJie
    • S
      • BV ou -> IOP poor control
      • One left upper eyelid mass for 1-2 years
      • HTN + for 30+ years
      • Asthma +
    • A/P
      • Start antiglaucomatic medication
      • f/u 1 month
    • Prescription
      • Lumigan (bimatoprost 0.1mg/mL) HS OU
      • Simbrinza (brinzolamide 10mg/mL, brimonidine 2mg/mL) BID OU

[consultation]

  • 2023-10-18 Radiation Oncology
    • Q
      • This 82-year-old man patient is a case of BUL cancer, adenocarcinoma, cT4N3M1c,stage IVB, lung to lung metastases s/p TKI therapy.
    • A
      • Radiothearpy is indicated for tumor control. CT-simulation will be arranged on 10/23. Plan to deliver 30~45 Gy/ 10~15 fx to the LUL tumor, depending on the side effect. RT will start around 10/25 or 26. Thank you very much.

[chemotherapy]

  • 2021-06-29 ~ undergoing - Vizimpro (dacomitinib)
  • 2021-06-15 ~ 2021-06-28 - Iressa (gefitinib)

==========

2023-10-19

[reconciliation]

According to the PharmaCloud database, there’s no discrepancy between the previously prescribed medications.

The patient was diagnosed with BUL cancer, specifically adenocarcinoma, with metastases to both lung hila and bilateral mediastinal lymph nodes. Treatment was started on 2021-06-15 with Iressa (gefitinib) for two weeks before switching to Vizimpro (dacomitinib) from 2021-06-29.

The chest CT of 2023-09-11 showed significant disease progression in the LUL, while the RUL tumor remained stable compared to the previous CT of 2023-01-05. This may indicate disease heterogeneity and potential development of resistance in certain aspects of the disease after more than 2 years of use of Vizimpro.

700016937

231018

{pancreatic head cancer}

[exam findings]

  • 2023-07-31 SONO - nephrology
    • Right hydronephrosis
  • 2023-07-31 Bladder sonography
    • PVR: 72 ml
  • 2023-07-14 MRI - L-spine
    • MRI of thoracic and lumbar spine without/with Gadolinium-based contrast enhancement shows:
      • fine alignment of thoracolumbar spine.
      • degenerative change of the spine with marginal spur formation and dehydrated discs at multiple levels.
      • patchy signal intensity change and faint bone marrow enhancement at left anterior corner of L1, L2, L3 vertebral bodies. This is already seen in the abdomen MRI done on 20221004, but not seen in the lumbar spine MRI on 20140506. There are other similar bone lesions in thoracic vertebrae. This could be degenerative change but bone metastases cannot be completely excluded. Suggest correlation with other image modality and close follow up.
      • prominent disc-osteophyte complexes at multiple levels, as well as bilateral facet arthroses and hypertrophic ligamenta flava, causing severe L3-4, L4-5 central canal stenosis.
      • no evidence of abnormal signal lesion nor pathological enhancement in visible spinal cord.
    • Impression:
      • Patchy bone marrow lesions in multiple thoracic and lumbar vertebral bodies, could be degenerative change but bone metastases cannot be excluded. Suggest correlation with other image modality and close follow up.
      • Degenerative spinal and disc disease.
      • Severe L3-4, L4-5 central canal stenosis.
  • 2023-07-13 CT - abdomen
    • Findings
      • S/P operation. Focal fat stranding at mesenteric root without interval change r/o post-operative change.
      • Tiny liver cysts.
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • S/P operation. No evidence of tumor recurrence.
  • 2023-06-05 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed hot spots in several T- and L-spine, and increased activity in the maxilla, mandible, bilateral shoulders, S-I joints, hips, knees, and feet, in whole body survey.
    • IMPRESSION:
      • Hot spots in several T- and L-spine, the nature is to be determined (severe DJD or other nature ?), suggesting follow-up with bone scan in 3-6 months for investigation.
      • Suspected benign lesions in the maxilla, mandible, bilateral shoulders, S-I joints, hips, knees, and feet.
  • 2023-03-13 CT - abdomen
    • Indication: Pancreatic head cnacer (or Ampulla of Vater cancer) , pT3bN1 (3/28) cM0, pStage IIIA, s/p Whipple’s surgery
    • Abdominal CT with and without enhancement revealed:
      • s/p colon cancer op. and Whipple op.
      • Minimal soft tissue at mesenterric root is found. Post op. change? Suggest follow up.
      • Increased intestinal gas is found.
    • Imp:
      • s/p colon cancer op. and Whipple op.
      • Minimal soft tissue at mesenterric root is found. Post op. change? Suggest follow up.
  • 2023-03-10, -02-01, 2022-12-21 CXR
    • Spondylosis of the T-spine
  • 2023-02-14 MRI - brain
    • Indication: Malignant neoplasm of ampulla of Vater
    • Imp:
      • No acute infarct. No brain nodule or metastasis
      • Brain atrophy with bilateral periventricular ischemic/aging white matter change.
  • 2022-10-27 CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2022-10-25 CXR
    • Bilateral pleural effusion.
    • Ground glass opacities in bil. lungs.
  • 2022-10-21 Patho - pancreas total/subtotal resection
    • Diagnosis:
      • Small intestine, ampulla of Vater, Whipple operation — Adenocarcinoma, moderately differentiated; AJCC 8th edition: pStage IIIA, pT3bN1(if cM0)
        • Pancreas, head, Whipple operation — Adenocarcinoma, by direct invasion
        • Common bile duct, distal, Whipple operation — Adenocarcinoma, by direct invasion
        • Stomach, partial gastrectomy — Negative for malignancy
        • Lymph node, peri-pancreas, dissection — Adenocarcinoma, metastatic (3/10)
        • Lmph node, peri-gastric, dissection — Negative for malignancy (0/13)
      • Pancreas head, excision — Negative for malignancy
      • Lymph node, site ?, excision — Negative for malignancy (0/1)
      • Lymph node, retroperitoneal cavity, excision — Negative for malignancy (0/4)
    • Gross Description:
      • Procedure: Pancreaticoduodenectomy (Whipple resection), partial pancreatectomy: Pancreas: 4.7 x 3.7 x 3.0 cm; Duodenum: 16.0 cm in length; Lessser curvature: 6.0 cm in length; Greater curvature: 9.0 cm in length; Common bile duct: 4.5 cm in length;
      • Tumor Site: ampulla of Vater and invasion to pancreatic head, duodenum, distal common bile duct, peri-pancreatic soft tissue
      • Tumor Size: 2.4 x 2.0 x 1.5 cm.
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma; The immunohistochemical stains reveal CK7(+) and CK20(-).
      • Histologic Grade (applies to ductal carcinoma only) :G2: Moderately differentiated
      • Tumor Extension: Tumor invades ampulla of Vater, duodenal wall, pancreas head, peripancreatic soft tissues, distal common bile duct
      • Margins
        • All margins are uninvolved by invasive carcinoma and high-grade intraepithelial neoplasia
        • Distance of invasive carcinoma from closest margin: 2 mm.
        • Specify: posterior peripancreatic soft tissue resection margin
        • Gastric resection margin: 10 cm; Distal small intestine margin: 10.5 cm; Pancreatic margin: 3.5 cm; Common bile duct resection margin: 3.5 cm; Anterior peripancreatic soft tissue margin: 0.8 cm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Regional Lymph Nodes: Number involved/examined: peri-pancreatic: 3/10; peri-gastric: 0/13; lymph node, site ?: 0/1; LN retroperitoneal: 0/4
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable): not applicable
          • Primary Tumor (pT): pT3b: Tumor extends into peripancreatic soft tissue
          • Regional Lymph Nodes (pN): pN1: Metastasis in one to three regional lymph nodes
          • Distant Metastasis (pM): if cM0
      • Additional Pathologic Findings: None identified
  • 2022-10-07 Patho - duodenum biopsy
    • Diagnosis:
      • Major papilla, biopsy — adenocarcinoma, modertaely differentiated
    • Microscopically, it shows modertaely differentiated adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei,pleomorphism, and high N/C ratio.
    • Immunohistochemcial stain reveals CK(+), p53(focal+, 40%), Ki-67 index: 30%.
  • 2022-10-07 Endoscopic Ultrasound, EUS
    • Prominent major papilla, favor ampulla vater tumor, s/p biopsy
    • CBD dilatation
    • Reflux esopgagitis Gr.A
    • Duodenal shallow ulcers, bulb and SDA
  • 2022-10-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (53 - 7) / 53 = 86.79%
      • M-mode (Teichholz) = 87
    • Adequate LV,RV systolic function with normal wall motion
    • Impaired LV relaxation
  • 2022-10-04 MRI - pancreas
    • History and indication: An ill-defined faint poor enhancing lesion measuring 1.8 cm in the distal CBD
    • Findings
      • A soft tissue tumor (1.5x2.2cm) at pancreatic head.
      • S/P PTCD. Liver and renal cysts (3-5mm).
    • IMP: A soft tissue tumor (1.5x2.2cm) at pancreatic head suspected malignancy.
  • 2022-10-01 Percutaneous Transhepatic Cholangial Drainage, PTCD (drainage)
    • Dilatation of the biliary tree (by CT images).
    • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree smoothly.
  • 2022-09-30 CT - abdomen
    • History: T-COLON CA S/P R HEMICOLECTOMY 2005-07-21, cT3N1M0
      • 2022-09-24 Urine looked like black tea, Total bilirubin: 16.88 mg/dL (normal: < 1)
    • MD CT of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • An ill-defined faint poor enhancing lesion measuring 1.8 cm in the distal CBD and pancreatic head area is suspected and it causing marked dilatation of the proximal CBD, CHD, and IHDs.
        • The pancreatic duct appears normal in size.
        • Cholangiocarcinoma at the distal CBD is highly suspected.
        • In addition, There are few enlarged nodes in the peripancreatic head area that may be metastatic nodes.
        • There are few enlarged nodes in left para-aortic space that may be non-regional metastatic nodes? Please correlate with PET scan.
      • S/P cholecystectomy, S/P right hemicolectomy, and S/P near total right hepatectomy? please correlate with clinical history.
      • Others
        • There is no focal abnormality in the spleen & both kidney.
        • There is no ascites.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • CHOLANGIOCARCINOMA at the distal CBD is highly suspected.
      • Please correlate with ERCP (Endoscopic Retrograde CholangioPancreatography) and EUS.
  • 2022-09-24 SONO - kidney
    • bilateral renal stones
    • right hydronephrosis
  • 2022-08-27 Transrectal Ultrasound of Prostate, TRUS-P
    • benign prostatic hyperplasia

[MedRec]

  • 2023-08-28 SOAP Urology Xu JunKai
    • Prescription x3
      • Betmiga (mirabegron 50mg) 1# QD
      • Harnalidge (tamsulosin 0.4mg) 1# HS
      • Oxbu ER (oxybutynin 5mg) 1# QD
  • 2023-08-28 SOAP Metabolism and Endocrinology Yu LiJiao
    • Prescription x3
      • Trajenta (linagliptin 5mg) 1# QD
  • 2023-03-24 SOAP Hemato-Oncology
    • S: Owing to Leukopenia (WBC:2890, seg:33, ANC:971) was noted on 3/24 23 and hold C/T.
  • 2022-12-17 SOAP Hemato-Oncology
    • A: Pancreatic head CA (or Ampulla of Vater CA) , pT3bN1 (3/28) cM0, pStage IIIA, s/p Whipple’s Op on 2022-10-20

[consultation]

  • 2022-11-08 Urology
    • Q
      • for urinary pain and persisted U/A Bact 2+
      • This 73 years old male had the history of
        • T-colon cancer (T3N1M0, Duke’s C2) s/p right hemicolectomy + LN dissection on 2005-07-21, Cholecystectomy and Partial hepatectomy.
        • Ampulla of vater cancer s/p whipple with LN dissection on 2022/10/20
        • BPH with Cystitis by cystoscopy on 2022/10/01 and keep medication control
      • This time, he still sufferred urinary pain and oral medicaiton with Uropin support. But the symptom still persisted. On the other side, U/A with Bact 2+ and U/C still pending. Fever was also noted on 2022/11/05-06. Lab data with no leukocytosis but CRP showed 9.45. We need your help for evaluation for infection status. Thanks for your time!!
    • A
      • We will arrange non-invasive evaluation (UFM PVR)
      • sometimes the pain still painkiller
      • He has high bilirubin and good renal function
      • some painkiller with less burden on liver may be helpful
  • 2022-10-07 Ophthalmology
    • Q
      • for DM retinopathy
    • A
      • For DR survey
      • T-colon cancer, newly-diagnosed DM
      • O
        • od s/p phaco + IOL insertion
        • os old trauma with K scar
        • BCVA od 1.0 os 0.1(NCCLENS)
        • IOP 17/17
        • Pupil 3/3 +/+
        • conj icteric ou
        • K od clear os linear scar from paracentral to peripheral
        • AC D/cl ou
        • Lens od pciol os ns++
        • Fd c/d 0.3 , disc pinkish, no DR change ou
      • A
        • No DR change at present ou
      • P
        • Control sugar
        • inform the risk of DR change, if worsen vision, come back asap
        • regular f/u yearly
  • 2022-10-06 Metabolism and Endocrinology
    • Q
      • This 73 years old male had the history of T-colon cancer (T3N1M0, Duke’s C2) s/p right hemicolectomy + LN dissection on 2005-07-21, Cholecystectomy and Partial hepatectomy.
      • This time, he came to ER for dark urine, lethargy, poor appetite, poor activity and diarrhea for 2 months. Referred to ER from GI OPD due to high bilirubin. At MER, vital sign: BP:119/73; P:101; BT:36.4; RR:18; Con’s:E4V5M6, SPO2:97%, the CXR showed no active lung lesion. The KUB shows no ileus. Lab data revealed abnormal liver function. The abdomen CT reported 1. An ill-defined faint poor enhancing lesion measuring 1.8 cm in the distal CBD and pancreatic head area is suspected and it causing marked dilatation of the proximal CBD, CHD, and IHDs.
      • The pancreatic duct appears normal in size. Cholangiocarcinoma at the distal CBD is highly suspected. In addition, There are few enlarged nodes in the peripancreatic head area that may be metastatic nodes. Under the impression of obstructive jaundice, he was admitted to our ward for further evaluation and treatment.
      • Due to HbA1C:8.0, we need your help
    • A
      • We were consulted for blood sugar control.
      • O:
        • BH: 165 cm, BW: 75 kg
        • Diet: TPN and try low fat, soft diet
        • Medication in OPD: nil (newly diagnosed)
        • Medication during hospitalization: Oliclinomel + RI 16U, Januvia 1# QD
        • Na: 134, K: 3.7
        • ALT: 61, TBI: 28.95
        • BUN/Cr: 19/0.93 (eGFR: 84.65)
        • F/S:
          • Date 10/4 10/5 10/6
          • QDAC 153 179 170
          • QLAC 202 321 222
          • QNAC 265 272
          • HS - -
        • Blood glucose: 182 mg/dL
        • HbA1c: 8.0
        • Urine ACR: unavailable
        • OPH OPD: nil
      • A: Type 2 DM, newly diagnosed
      • Suggestions:
        • DC Januvia. Avoid any other oral anti-diabetic agent
        • Adjust to 20U RI in each Oliclinomel
        • Use Apidra PRNTIDAC with sliding scales
          • F/S 201~250, Apidra 2U
          • F/S 251~300, Apidra 3U
          • F/S > 300, Apidra 4U
        • Check lipid profile, urine ACR
        • Consult OPH for DM retinopathy
        • At present no need nutritionist for DM diet education (self-paid TWD 600) (to consult right before discharge after appetite recovering)
        • Contact us if needed. I’d like to follow up this patient. Meta-OPD F/U.

[surgical operation]

  • 2022-10-20
    • Surgery
      • Whipple operation with partial gastrectomy
      • retroperitoneal LN3,4sd,5,6,7,8,9,12,13,16 dissection
      • adhesivelyiss for 4 hrs due to previous rt hemicolectomy with LNdissection for T-colon ca and liver resection
    • Finding
      • severe small bowel adhesion
      • pancreatic head tumor 2 x 1.8 cm under papilla vater
      • CBD: 2.0 cm in diameter
      • P-duct 0.3cm with soft pancreas parenchyma
      • multiple LNat dodenal ligament and paraaorta area

[chemotherapy]

  • 2023-10-17 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Oxa 70%, Irino 80% and LV, 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-19 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 480mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Oxa 70%, Irino 80% and LV, 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-21 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Oxa 70%, Irino 80% and LV, 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-12 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Oxa 70%, Irino 80% and LV, 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-19 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Irino 80% and LV, 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-05-19 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Irino and 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-04-25 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Irino and 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-04-03 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-03-10 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 250mL 2hr + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 2400mg/m2 4075mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-02-14 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-12-19 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

Modified FOLFIRINOX chemotherapy for pancreatic cancer 2023-05-19 https://www.uptodate.com/contents/image?imageKey=ONC%2F109546

  • Cycle length: 14 days.
  • Regimen
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 150 mg/m2 IV
      • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

FOLFIRINOX chemotherapy for metastatic pancreatic cancer 2023-05-19 https://www.uptodate.com/contents/image?imageKey=ONC%2F79571

  • Cycle length: 14 days.
  • Regimen
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 180 mg/m2 IV
      • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 400 mg/m2 IV bolus
      • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
      • Day 1
    • FU
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

==========

2023-10-18

[reconciliation]

The patient is currently taking the following medications, as prescribed by their urologist and endocrinologist on 2023-08-28:

  • Betmiga (mirabegron)
  • Harnalidge (tamsulosin)
  • Oxbu ER (oxybutynin)
  • Trajenta (linagliptin)

There are no discrepancies noted in the patient’s medication list.

[CA199 goes up]

Please note that CA19-9 levels have been monotonically increasing in recent months. This might suggest that the disease has a tendency to gradually gain resistance.

  • 2023-10-03 CA-199 (NM) 37.692 U/ml
  • 2023-09-28 CA-199 (NM) 36.410 U/ml
  • 2023-09-01 CA-199 (NM) 26.718 U/ml
  • 2023-08-11 CA-199 (NM) 23.676 U/ml
  • 2023-07-28 CA-199 (NM) 22.798 U/ml
  • 2023-07-04 CA-199 (NM) 20.102 U/ml

2023-09-19

The medications Betmiga (mirabegron) and Harnalidge (tamsulosin) and Oxbu ER (oxybutynin) prescribed by our urologist, along with Trajenta (linagliptin) prescribed by our endocrinologist on 2023-08-28, are currently being taken by the patient with no discrepancies noted.

2023-08-21

Our endocrinologist’s repeat prescription (issued on 2023-06-05) for Trajenta (linagliptin) is currently on the active medication list, and there are no discrepancies noted.

2023-07-13

The patient recently refilled his prescription for Trajenta (linagliptin) on 2023-07-10 for managing his T2DM. This drug is accurately included in the active medication list, with no reconciliation issues identified.

2023-06-20

  • According to the PharmaCloud database, all of this patient’s medical requirements have been addressed at our hospital over the past three months. As a result, no issues with medication reconciliation have been detected.

  • The patient’s DM is currently managed with Trajenta (linagliptin 5mg) 1# QD. He had an increased preprandial serum glucose level of 170mg/dL on 2023-06-20 at 06:24. The most recent HbA1c level was 5.7% on 2023-05-31. This sudden rise could be a temporary fluctuation and is worth continuous monitoring.

2023-05-19

  • The patient, with a body surface area (BSA) of 1.69 m2 calculated from a recorded height of 165 cm and weight of 62.2 kg (2023-05-18), is currently receiving a modified FOLFIRINOX regimen. This regimen includes oxaliplatin and irinotecan, but omits bolus fluorouracil.
  • The dose of oxaliplatin is 100mg, which is equivalent to 59mg/m2, approximately 69% of the standard dose of 85mg/m2. Likewise, the dose of irinotecan is 200mg, equivalent to 118mg/m2, approximately 65% of the standard dose of 180mg/m2. The frequency of the treatment is every three weeks, in contrast to the standard every two weeks.
  • The patient has a relatively advanced age of 73 years and a fair ECOG performance status of 1. He has had only one episode of leukopenia with WBC < 3K/uL (2.89K/uL on 2023-03-24). No other significant adverse events have been recorded. An abdominal CT scan performed on 2023-03-13 showed soft tissue at the root of the mesentery.
  • Given these factors, and in the absence of contraindications or other clinical concerns, it might be beneficial to consider a gradual dose escalation. This could be done with the aim to bring the dose closer to the standard levels, in order to optimize therapeutic effect.

2023-03-13

  • Since 2022-12-19, the patient has been receiving FOLFIRINOX with a reduced dosage of oxaliplatin (85 -> 60mg/m2) and irinotecan (180 -> 150mg/m2), skipping the 5-FU bolus to prevent adverse reactions. Bilirubin (direct and total) returned to normal range in 2022-12, but ALT readings have fluctuated between normal and not exceeding 110U/L after treatment. As of the 2023-03-10 lab data, BUN 29mg/dL, Creatinine 0.95mg/dL, and eGFR 82.60. No dosage adjustment is currently needed for the patient’s FOLFIRINOX regimen.

2023-02-02

  • It was noted that the blood sugar level did not exceed 180 mg/dL, which was an improvement over the prior hospital stay.

  • Renal sonography (2022-09-24) found bilateral renal stones, and calcium oxalate crystals in urine (2023-02-01). Primary hyperoxalurias are rare inborn errors of glyoxylate metabolism characterized by the overproduction of oxalate, which is poorly soluble and is deposited as calcium oxalate in various organs. The kidney stones in this patient should be less likely to be associated with primary hyperoxaluria.

    • Patients with kidney stones should consume enough fluids to consistently produce at least 2 liters of urine per day. At the present time, the patient is being hydrated with NS 500mL Q12H since this hospital admission.
    • It is recommended that all patients with calcium oxalate stones limit their intake of high oxalate foods, supplemental vitamin C, sucrose, and fructose. However, excessive restriction of oxalate is unlikely to be beneficial. Patients should continue to consume a variety of fruits and vegetables while avoiding those that are very high in oxalate. Intake of sugar and/or fructose increases urine calcium independently of calcium intake and has been associated with an increased risk of kidney stones.
    • Urine pH was 5.5 (2023-02-01) WNL, however, calcium oxalate stones are not pH dependent in the physiologic range. In recent lab results, there were no readings for calcium, oxalate, citrate, and uric acid in urine.
    • In the event that high urine calcium is detected, it is recommended that patients with recurrent calcium oxalate stones who have higher than desired urine calcium be treated with a thiazide diuretic in order to lower urinary calcium excretion.
      • All patients receiving a thiazide diuretic should maintain a low-sodium diet, which is essential for the diuretic to effectively lower urinary calcium.
      • Urinary calcium and sodium excretion should be monitored after the institution of thiazide therapy. A repeat 24-hour urine collection should be performed one to two months after initiating therapy.
      • If the urine calcium does not fall as desired or the thiazide is not well tolerated, an alternative therapy is administration of 40 to 60 mEq of alkali per day as potassium bicarbonate or potassium citrate (citrate is rapidly metabolized to bicarbonate).

701489999

231018

[lab data]

2023-07-31 Anti-HBc (NM) Positive
2023-07-31 Anti-HBc Value (NM) 0.636
2023-07-31 Anti-HBs (NM) Positive
2023-07-31 Anti-HBs value (NM) 677.000 mIU/mL
2023-07-31 Anti-HCV (NM) Negative
2023-07-31 Anti-HCV Value (NM) 0.043
2023-07-25 HBsAg (NM) Negative
2023-07-25 HBsAg Value (NM) 0.418

2023-07-25 CA-199 (NM) 354.780 U/ml
2023-07-25 CEA (NM) 31.940 ng/ml

[exam findings]

  • 2023-09-18 SONO - abdomen
    • Findings
      • Liver
        • Homogenous liver parenchyma.
        • One hyperechoic tumor with hypoechoic rim was noted at S4, 3.9cm.
        • One hyperechoic tumor with hypoechoic rim was noted at S7, 2.8cm.
        • One 0.4cm hyperechoic lesion with PAS was noted at S4.
      • Pancreas
        • Some parts of pancreas blocked by bowel gas, especially head and tail
      • Spleen
        • No splenomegaly
    • Diagnosis:
      • Liver tumors, S4 and S7
      • Liver calcification, S4
  • 2023-08-11 All-RAS + BRAF gene mutation analysis
    • ALL-RAS: Detected (NRAS codon 61 CAA>AGA, p.Q61R)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-08-09 MRI - pelvis
    • Findings:
      • There is segmental irregular wall thickening of the rectosigmoid junction, measuring 5 cm in size, with direct adhesion the uterus that is c/w adenocarcinoma (T4b).
      • There are seven enlarged nodes in the adjacent mesocolon (N2b).
      • There are two poor enhancing masses 4.5 cm in S4 and 2.8 cm in S7 of the liver that are c/w liver metastases (M1a).
      • There are several masses in the uterus, showing hypointensity on T2WI that are c/w myomas. The largest one 6 cm in size.
    • IMP:
      • Rectal cancer is noted.
      • According to American Joint Committee on Cancer (AJCC) staging system,8th edition for colon cancer: T4b N2b M1a, stage: IVA
  • 2023-07-21 CT - abdomen
    • CC: Dark red bloody stool passage off and on and noted again these days, Mucoid bloody stool passage
      • 20230720 colonoscopy: One mass in the sigmoid colon, 15 cm AAV, R/O malignancy
    • Findings:
      • There is segmental irregular wall thickening of the rectosigmoid junction, measuring 5 cm in size that is c/w adenocarcinoma (T3).
      • There are four enlarged nodes in the adjacent mesocolon (N2a).
      • There are two poor enhancing masses 3.7 cm in S4 and 2 cm in S7 of the liver that are c/w metastases (M1a).
      • There are several mild poor enhancing masses in the uterus that are c/w myomas. Please correlate with GYN. sonography.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2a(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
  • 2023-07-21 Patho - colorectal polyp
    • DIAGNOSIS: Intestine, large, rectosigmoid junction, 15 cm from anal verge, biopsy — adenocarcinoma
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • 2023-07-20 Colonoscopy
    • Diagnosis:
      • Siogmoid polyp s/p polypectomy
      • Rectosigmoid cancer s/p biopsy
      • Severe melanosis coli
      • Large mixed hemorrhoids

[MedRec]

  • 2023-08-07 SOAP Nutrition Consultation
    • S
      • Occupation: Homemaker
      • Dietary Habits:
        • Breakfast (6-7 AM): Meal replacement (Shou Mei Li) with or without a slice of thick toast (butter spread) / Boiled egg
        • Morning Snack: 1 can of Ensure (consistently consumed daily)
        • Lunch: Half a bowl of porridge + 2 and a half pieces of tilapia fish + 2/3 portion of greens
        • Afternoon Snack: 1 Kiwi
        • Dinner: Same as lunch
      • Exercise: Light jogging once a day, for 40 minutes including warm-up
      • Fluid Intake: 1500-2000 ml
    • A
      • Anthropometry:
        • BMI kg/m2: normal / over weight / obesity
        • Current energy intake: adequate / inadequate
        • Nutrition problem:
          • Ensure 1-2
    • P
      • Goal: BS control
      • Education topic: DM diet principle, 6 Food Groups and food groups contain CHO, eating-out principles, Food exchange list, protein restricted diet education,Balance diet
      • Meal planning: kcal
        • Cereal : ex/d
        • Meat/Bean-choose low fat protein (soy products, egg): ex/d
        • Green vegetable: ex/d
        • Fruits: ex/d
        • Low fat milk: ex/d
        • Oil: ex/d
        • Increase physical activity: 3 times/ week, 30 min/time
        • Decrease alcohol: ex/d →
        • SMBG with diet recoard
  • 2023-07-27 SOAP Hemato-Oncology
    • P
      • CCRT with FOLFOX and followed by FOLFOX with or wtihout bevacizumab and cetuximab (need further discussion with family).
      • Admission for CCRT with FOLFOX
  • 2023-07-27 SOAP Radiation Oncology
    • P
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic and 5040cGy/28 fractions of the rectosigmoid tumor bed area.
      • The treatment planning of radiotherapy will be started at 1030, 2023-08-02.
  • 2023-07-27 SOAP Colorectal Surgery
    • A/P
      • Suggest pre-op chemotherapy + target therapy then colectomy + hepatectomy
      • Arrange MRI for differential uterine invasion; T4b ? or T3 ?
      • Refer to Radiotherapy for reducing size, better resectability

[chemotherapy]

  • 2023-10-17 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-25 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-24 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-09 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-18

[liver function]

The patient experienced a transient elevation in liver function test readings in mid-Sep, with peak values of 106 U/L for AST, 225 U/L for ALT, and 1.06 mg/dL for total bilirubin on 2023-09-18. However, the liver function test abnormalities have resolved, and there is no evidence of sustained liver injury at present.

  • 2023-10-17 AST 33 U/L

  • 2023-10-05 AST 21 U/L

  • 2023-09-25 AST 45 U/L

  • 2023-09-22 S-GOT/AST 51 U/L

  • 2023-09-18 S-GOT/AST 106 U/L

  • 2023-09-14 S-GOT/AST 96 U/L

  • 2023-09-07 S-GOT/AST 31 U/L

  • 2023-08-25 S-GOT/AST 21 U/L

  • 2023-08-09 S-GOT/AST 29 U/L

  • 2023-07-20 S-GOT/AST 15 U/L

  • 2023-10-17 ALT 41 U/L

  • 2023-10-05 ALT 25 U/L

  • 2023-09-25 ALT 86 U/L

  • 2023-09-22 S-GPT/ALT 110 U/L

  • 2023-09-18 S-GPT/ALT 225 U/L

  • 2023-09-14 S-GPT/ALT 136 U/L

  • 2023-09-07 S-GPT/ALT 40 U/L

  • 2023-08-25 S-GPT/ALT 17 U/L

  • 2023-08-22 S-GPT/ALT 17 U/L

  • 2023-08-09 S-GPT/ALT 13 U/L

  • 2023-07-20 S-GPT/ALT 11 U/L

  • 2023-10-17 Bilirubin total 0.61 mg/dL

  • 2023-10-05 Bilirubin total 0.44 mg/dL

  • 2023-09-25 Bilirubin total 0.50 mg/dL

  • 2023-09-22 Bilirubin total 0.68 mg/dL

  • 2023-09-18 Bilirubin total 1.06 mg/dL

  • 2023-09-14 Bilirubin total 0.74 mg/dL

  • 2023-09-07 Bilirubin total 0.68 mg/dL

  • 2023-08-25 Bilirubin total 0.50 mg/dL

  • 2023-08-22 Bilirubin total 0.40 mg/dL

  • 2023-08-09 Bilirubin total 0.87 mg/dL

  • 2023-07-20 Bilirubin total 1.25 mg/dL

The patient received 4 cycles of FOLFOX chemotherapy, administered on 2023-08-09, 2023-08-24, 2023-09-25, and 2023-10-17. Oxaliplatin, a drug used in FOLFOX, is associated with increased serum alanine aminotransferase (36%), increased serum alkaline phosphatase (42%), increased serum aspartate aminotransferase (54%), and increased serum bilirubin (13%). It is possible that oxaliplatin caused the elevated liver function test results in this patient.

In mid-Sep, the patient was prescribed BaoGan (silymarin), a herbal supplement that is thought to protect the liver, to mitigate the risk of liver damage.

In addition, FOLFIRI, an alternative chemotherapy regimen that contains irinotecan, is also associated with increased serum bilirubin (84%) and increased serum alkaline phosphatase (13%).

[RAS mutation detected]

Patients with colorectal cancer (CRC) who have an RAS mutation (2023-08-11 Lab result, NRAS mutation detected) are less likely to respond to targeted therapies that target EGFR. This is because NRAS mutations can activate the RAS-MAPK pathway downstream of EGFR, making the tumor resistant to anti-EGFR therapies.

The following targeted therapies are less likely to be effective in the setting of CRC with an NRAS mutation:

  • Cetuximab (Erbitux)
  • Panitumumab (Vectibix)

700186762

231017

  • 2023-10-13 SONO - breast
    • Diagnosis
      • Left fibroadenoma as described
      • s/p bil. breast operation
    • BI-RADS: 2. benign finding
  • 2023-08-11 Mammography
    • Impression:
      • Dense breast.
      • S/P right mastectomy.
      • Benign coarse calcifications in left breast.
      • Suggest clinical correlation and follow up.
    • BI-RADS:
      • Category 2: benign findings. - annual screening.
  • 2023-07-03 PET
    • In comparison with the previous study on 2023/01/16, the glucose hypermetabolic lesion at the T12 spine comes to more evident; other lesions including in some T- and L-spine, sacrum, bilateral pelvic bones and bilateral femurs disappear or become less evident, indicating breast cancer with disassociated response to current therapy.
    • However, glucose hypermetabolic lesions in the uterus are numerous and show more prominent, malignant neoplasm of uterus should be considered, suggesting biopsy for further evaluation.
    • Increased FDG accumulation in the colon and bilateral kidneys, physiological FDG uptake is more likely.
  • 2023-05-11 ECG
    • Sinus rhythm with Premature ventricular complexes
    • ST & T wave abnormality, consider lateral ischemia
    • Abnormal ECG
  • 2023-03-10 Patho - endometrium curretage/biopsy
    • Uterus, endometrium, hysteroscopic endometrial curettage — squamous metaplasia
    • Microscopically, it shows pieces of bland squamous epithelial tissue fragments.
    • Immunohistochemical stain reevals p16(-) and Ki-67 (-).
  • 2023-02-17 Gynecologic ultrasonography
    • R/O Uterine myoma
    • R/O Nabothian cyst: 48mmx26mm
    • R/O Endometrial thickening, EM: 14.6mm
  • 2023-02-10 SONO - abdomen
    • Diagnosis:
      • Fatty liver, severe
      • Poor assessment of biliary tract and PV
      • Pancreas not shown
      • Suboptimal examination of liver due to poor echo window caused by severe fatty infiltration
    • Suggestion:
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
      • Because of poor echo window, infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months
  • 2023-01-16 PET
    • In comparison with the previous study on 2022/08/02, the glucose hypermetabolism in some T- and L-spines, sacrum, bilateral pelvic bones and bilateral femurs is slightly more evident. Multiple bone metastases in stable condition may show this picture. Please correlate with other clinical findings for further evaluation.
    • At least four focal areas of increased FDG uptake in the uterus, the nature is to be determined (benign or even malignant neoplasm of uterus or other nature ?), suggesting pelvis CT or MRI for further evaluation.
    • Increased FDG accumulation in the colon, both kidneys and bilateral ureters, physiological FDG accumulaton is more likely.
  • 2022-08-02 PET
    • In comparison with the previous study on 2021/12/10, the glucose hypermetabolism in some T- and L-spines, sacrum, bilateral pelvic bones and bilateral femurs is slightly less evident. Multiple bone metastases with partial response to the current therapy may show this picture. Please correlate with other clinical findings for further evaluation.
    • Some focal areas of increased FDG uptake in the anterior pelvic region. The nature is to be determined (some kind lesions of the uterus? other nature?). Please also correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulaton is more likely.
  • 2022-04-29 MRA - brain
    • An old lacune in left basal ganglion.
  • 2022-04-26 Neurosonography
    • wall thickening on bil. common carotid arteries
    • normal flow and flow velocities on bil. extracranial carotid and vertebral arteries
    • poor left temporal windows
    • the transcranial doppler study of insonated right ACA, bil. MCA, PCA, VA and BA were normal
  • 2022-04-19 CT - brain
    • No definite intracranial lesion
  • 2022-02-22 Nerve Conduction
    • Finding
      • Motor nerve conduction study
        • Normal motor nerve conduction study in the left median nerve.
        • Conduction block noted over the left ulnar nerve across elbow level (more than 10m/s difference).
      • F-wave
        • Normal F-wave latencies in the left median and ulnar nerves.
      • Sensory nerve conduction study
        • Prolonged sensory peaked latency with decreased SNCV and normal SNAP amplitudes in the left median nerve (4D-wrist segment)
        • Prolonged sensory peaked latency with normal SNCV and normal SNAP amplitudes in the left median nerve (midpalm-wrist and 1D-wrist segments)
        • Normal sensory nerve conduction study in the left median nerve (forearm segment)
        • Normal sensory nerve conduction study in the left ulnar and superficial radial nerves.
    • Conclusion
      • Left median neuropathy at the wrist, demyelinated type.
      • Left ulnar motor neuropathy across the elbow, conduction block noted.
  • 2021-12-10 PET
    • A large focal area of mildly increased FDG uptake in the anterior pelvic region. The nature is to be determined (enlarged uterus? other nature?). Please correlate with other clinical findings for further evaluation.
    • Faint glucose hypermetabolism in multiple T- and L-spines, sacrum, bilateral pelvic bones and bilateral femurs. Either multiple bone metastases of faint FDG uptake or multiple bone metastases with response to the current therapy may show this picture. Please also correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulaton is more likely.

[MedRec]

  • 2021-11-25 SOAP General Surgery Li ChaoShu
    • S: MBCa
    • O Koo Foundation Sun Yat-Sen Cancer Center OPD
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Endocrine therapy) Letrozole FEMARA FILM-COATED TABLETS 2.5MG 28 28 110/11/18 21
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Antihistamines for systemic use) Levocetirizine Dihydrochloride XYZAL FILM-COATED TABLETS 5MG 28 28 110/11/18 21
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Antineoplastic agents) Palbociclib IBRANCE CAPSULES 125 MG 21 21 110/11/18 14
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Drugs for treatment of bone diseases) Denosumab XGEVA 1 1 110/11/18 0
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Corticosteroids,dermatological preparations) Betamethasone (Valerate) RINDERON-V CREAM 0.06% 7 1 110/11/18 0
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Endocrine therapy) Letrozole FEMARA FILM-COATED TABLETS 2.5MG 28 28 110/10/18 0
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Antineoplastic agents) Palbociclib IBRANCE CAPSULES 125 MG 21 21 110/10/18 0
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Endocrine therapy) Letrozole FEMARA FILM-COATED TABLETS 2.5MG 30 30 110/09/13 0
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Endocrine therapy) Letrozole FEMARA FILM-COATED TABLETS 2.5MG 30 30 110/09/13 0
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Antineoplastic agents) Palbociclib IBRANCE CAPSULES 125 MG 21 21 110/09/13 0
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Antineoplastic agents) Palbociclib IBRANCE CAPSULES 125 MG 21 21 110/09/13 0
  • 2020-09-04 SOAP Rehabilitation Qiu JiaYi
    • S
      • Right breast cancer s/p MRM + ALND (LNs 10/25) on 2019-06 s/p RT x 30 times with right shoulder limitation and lympehdema
      • Past Hx.: Left MCA infarction with nearly total recovery in 20170607
      • PH: HTN, hyperlipidemia
    • O
      • Body weight: 62.8 kg
      • Rt: 17.5 cm (wrist), 24.5cm (elbow), 31cm (axilla)
      • Lt: 17cm (wrist), 24cm, 30.5cm (axilla)
      • Skin: soft (pitting) edema, elevation reduces swelling, dry skin
      • ISL stage: II (early): limb elevation rarely reduces swelling
      • Other complications: Frozen shoulder +
    • Imp
      • right breast cancer s/p MRM with secondary right adhesive capsulitis and lymphedema
    • Plans
      • Consider PT: IFC, PROM, therapeutic, mobilization for Rt shoulde first, circulator for RUE; then add MLD.

[chemotherapy]

  • 2023-10-13 - fulvestrant 500mg IM 5min

==========

2023-10-17

[leukopenia]

Based on the HIS5 lab data, a leukopenia event was recorded on 2023-10-13 with a count of 1.83K/uL (marked with an asterisk in the following table). The most recent chemotherapy administered was 500mg of fulvestrant on the same day, very close in time to the WBC data collection, leaving open the possibility that the actual medication administration occurred after the blood sample was taken. Moreover, according to UpToDate, the occurrence of neutropenia (2%; grade 3: 1%; grade 4: <1%) is relatively low compared to other chemotherapy drugs. For these two reasons, it’s less likely that this drug was the main contributor to the neutropenia observed on 2023-10-13.

  • 2023-10-13 WBC 1.83 x10^3/uL *
  • 2023-06-26 WBC 3.41 x10^3/uL
  • 2023-05-11 WBC 3.23 x10^3/uL
  • 2023-03-02 WBC 3.24 x10^3/uL
  • 2023-01-16 WBC 4.02 x10^3/uL

701361625

231016

[exam findings]

  • 2023-08-19 CT - abdomen
    • Indication: Low rectal adenocarcinoma post operation with pelvic lymph node metastasis, status post Robotic low anterior resection and loop ileostomy on 2023/03/10, pT1N1b(3/19)cM0, pStage IIIA s/p chemotherapy with FOFLOX from 2023/04/18~
    • With and without contrast enhancement CT of abdomen shows:
      • s/p LAR and ileostomy. No local recurrent tumor.
      • Small para-aortic lymph nodes.
    • Impression
      • Low rectal adenocarcinoma, s/p LAR and ileostomy
      • Small para-aortic lymph nodes. Suggest clinical correlation and follow up evaluation.
  • 2023-07-19 All-RAS + BRAF gene mutation
    • ALL-RAS: Detected (KRAS codon 13 GGC>GAC, p.G13D)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-03-10 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, rectum, previously post Transanal minimally invasive surgery with local excision (2022-03-02), now rectal trsection — no residual primary tumor. Margins free.
      • Lymph node, pericolonic, dissection — metastatic adenocarcinoma (3/19), no extranodal extension. - IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • pTx pN1b (if cM0); pStage: IIIA, at least.
    • Gross Description:
      • Procedure - previously post Transanal minimally invasive surgery with local excision (2022-03-02), now rectal trsection
      • Tumor Site - Rectum 12.5 3.5 x 3.5 cm
      • Tumor Size: no rpimary tumor in this specimen.
      • Macroscopic Tumor Perforation: Not identified
      • Sections are taken and labeled as: A1-5: roevious excision site; A6-8 and X1-2: epri-rectal lymph nodes; B: separated proximal margin; C: separated distal margin.
    • Microscopic Description:
      • Histologic Type - Adenocarcinoma
      • Histologic Grade - G2: Moderately differentiated
      • Tumor Extension - No evidence of primary tumor
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Uninvolved
      • Distance of tumor from margin: > 5mm (radial margin)
      • Lymphovascular Invasion: Not identified
      • Perineural Invasion: Not identified
      • Tumor Budding - none.
      • Type of Polyp in Which Invasive Carcinoma Arose: no primary tumor in this specimen.
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes
        • Number of Lymph Nodes Involved/Examined: 3/19
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition): IIIA, at least.
        • TNM Descriptors (not applicable)
          • Primary Tumor (pT) - No residual of primary tumor
          • Regional Lymph Nodes (pN) - pN1b: Two or three regional lymph nodes are positive
          • Distant Metastasis (pM) - if cM0
      • Additional Pathologic Findings - None in this specimen identified
      • Ancillary Studies : result of S2023-4391 A6 : IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2 (+), MLH1 (+).
  • 2023-02-21 PET
    • Increased FDG uptake in two focal areas in the right pararectal region. Metastatic lymph nodes should be watched out. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the stomach. Inflammatory process may show this picture. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
  • 2023-02-14 CT - abdomen
    • With and without contrast enhancement CT of abdomen–whole:
      • Clinical rectal cancer s/p. There are enlarged lymph nodes, up to 1cm in perirectal region, progression as compare with CT study on 2022-09-01.
      • R/O liver cyst, 1.5cm in S4.
      • Low density tumor, 1.7cm in the uterus, r/o uterine myoma.
    • Impression
      • Clinical rectal cancer s/p. Progressive enlarged perirectal lymph node as compare with CT study on 2022-09-01, r/o metastatic lymph node.
      • R/O liver cyst.
      • R/O uterine myoma.
  • 2023-02-14 Colonoscopy
    • Rectal cancer s/p op
    • No evidence of recurrence
  • 2023-02-14 Esophagogastroduodenoscopy, EGD
    • Suspect duodenal SET, 2nd portion
    • Gastric polyps, body, GC
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis
  • 2022-09-01 CT - abdomen
    • History and indication: Rectal cancer at 5 cm from AV s/p polypectomy stage I
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Rectal cancer s/p operation. Small LNs (4mm, 5mm) at right pararectal region without interval change.
      • Renal cysts (up to 0.7cm).
      • Liver cysts (up to 1.8cm).
  • 2022-03-03 Patho - colon segmental resection for tumor
    • DIAGNOSIS:
      • Intestine, large, rectum, 5 cm from anal verge, transanal minimally invasive surgery (s/p polypectomy) — No residual malignant tumor — Margin free
      • Lymph node., regional, transanal minimally invasive surgery — Negative for malignancy (0/1)
    • Microscopically, it shows full-layer of colorectal tissue with a scar at the mucosa. The muscularis propria and perirectal soft tissue are not remarkable. One regional lymph node is not remarkable.
    • Immunohistochemical stain reveals CK(-).

[MedRec]

  • 2022-02-17 SOAP Colorectal Surgery
    • 20220113 Rectal cancer at 5 cm from AV s/p polypectomy stage I was diagnosed at ShuangHe Hospital, pT1, margin < 1mm

[surgical operation]

  • 2023-03-10
    • Surgery
      • Robotic LAR + Loop ileostomy    
    • Finding
      • Perirectal nodules R/O lymph nodes metastasis Redundant sigmoid colon adhesion to omentum
  • 2022-03-02
    • Surgery
      • Transanal minimally invasive surgery (TAMIS) for local excision    
    • Finding
      • Rectal cancer at right anterior wall 5 cm from AV s/p polypectomy, pT1 , margin not involve < 1mm.
      • Whole layer resection of the tumor base deep to vaginal wall anteriorly and perirectal fat

[chemotherapy]

  • 2023-10-13 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-09-22 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-09-07 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-08-21 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-07-28 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-07-10 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-06-27 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr (Y-sited 5-FU) + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 170mL 48hr (infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-05-30 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr (Y-sited 5-FU) + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 170mL 48hr (infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-05-02 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr (Y-sited 5-FU) + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 170mL 48hr (infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-04-18 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr (Y-sited 5-FU) + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 170mL 48hr (infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2023-10-16

The current FOLFOX regimen was initiated on 2023-04-18, during which time multiple leukopenia events occurred (indicated in the table below with “**” for WBC < 2K/uL and “*” for WBC < 3K/uL). Since July, the regimen has eliminated the 5-FU bolus and reduced oxaliplatin from 85 mg/m2 to 75 mg/m2. Since these adjustments, there has only been one case of WBC < 2K/uL on 2023-10-05, primarily due to the intermittent administration of Granocyte (lenograstim) based on the patient’s condition. The most recent lab data (2023-10-12) showed a WBC of 4.15K/uL, indicating no current evidence of leukopenia.

  • 2023-10-12 WBC 4.15 x10^3/uL
  • 2023-10-05 WBC 1.86 x10^3/uL **
  • 2023-09-18 WBC 3.35 x10^3/uL
  • 2023-09-07 WBC 4.37 x10^3/uL
  • 2023-08-31 WBC 23.24 x10^3/uL
  • 2023-08-18 WBC 7.02 x10^3/uL
  • 2023-08-14 WBC 2.62 x10^3/uL *
  • 2023-08-07 WBC 2.04 x10^3/uL *
  • 2023-07-28 WBC 11.71 x10^3/uL
  • 2023-07-24 WBC 2.70 x10^3/uL *
  • 2023-07-10 WBC 2.52 x10^3/uL *
  • 2023-06-26 WBC 3.33 x10^3/uL
  • 2023-06-19 WBC 1.55 x10^3/uL **
  • 2023-06-12 WBC 2.10 x10^3/uL *
  • 2023-05-29 WBC 4.57 x10^3/uL
  • 2023-05-22 WBC 2.49 x10^3/uL *
  • 2023-05-16 WBC 1.50 x10^3/uL **
  • 2023-04-28 WBC 2.94 x10^3/uL *
  • 2023-03-09 WBC 6.31 x10^3/uL
  • 2022-02-18 WBC 4.91 x10^3/uL

700204091

231013

[exam findings]

  • 2023-09-12 CT - abdomen
    • History and indication: Right ovarian endometrioid carcinoma, pT2bN0cM0, FIGO stage IIB s/p OP and treatment
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. A cystic lesion (2.7cm) at right pelvic wall.
      • Grade 4 fatty liver.
      • Renal cysts (up to 4.1cm).
      • Some LNs (up to 1.3cm) at bil. inguinal regions.
    • IMP:
      • S/P hysterectomy. A cystic lesion (2.7cm) at right pelvic wall.
      • Grade 4 fatty liver.
  • 2023-08-29 Anoscopy
    • DRE/Anoscopy: normal anal tonicity; mixed hemorrhoids with congestion and fissure at posterior
  • 2023-07-04 SONO - nephrology
    • L’t Kidney - Cyst:(Max) Upper pole 3.9 x 3.0 cm 2.7 x 3.1 cm
    • Diagnosis: left renal cyst
  • 2023-06-15 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 15 dB HL, LE 21 dB HL
    • Bil WNL
  • 2023-05-18 Patho - uterus with or without SO non-neoplastic/prolapse
    • PATHOLOGIC DIAGNOSIS
      • Ovarian tumor, right, frozen (F2023-00229) — Endometrioid carcinoma and endometrioma
        • Fallopain tube, right, ditto — Free of tumor invasion
      • Ovarian cyst, left, debulking surgery — Endometrioma and free of tumor invasion
        • Fallopain tube, left, ditto — Free of tumor invasion
      • Cervix, uterus, debulking surgery — Free of tumor invasion
        • Endometrium, uterus — Free of tumor invasion, proliferative phase
        • Myometrium, uterus — Free of tumor invasion, leiomyomas and adenomyosis
      • Uterosacral area mass, ditto — Endometrioid carcinoma
      • R’t peri-ureter tissue, ditto — Endometrioid carcinoma and endometriosis
      • R’t suspensory (IP), ditto — Free of tumor invasion
      • Omentum, omentectomy — Free of tumor invasion
      • Lymph nodes
        • Lymph node, left iliac, dissection — Free of tumor metastasis (0/5)
        • Lymph node, left obturator, dissection — Free of tumor metastasis (0/10)
        • Lymph node, right iliac, dissection — Free of tumor metastasis (0/11)
        • Lymph node, right obturator, dissection — Free of tumor metastasis (0/25)
        • Lymph node, left paraaortic, dissection — Free of tumor metastasis (0/12)
        • Llymph node, right paraaortic, dissection — Free of tumor metastasis (0/6)
      • Bilateral prametria — Free of tumor invasion
      • AJCC Pathologic staging — pT2bN0, if cM0, stage IIB / FIGO stage IIB
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: frozen sections and debulking surgery
      • Specimen type: uterus and left adnexa, pelvic and paraaortic LNs and omentum
      • Specimen size:
        • Right opened ovarian tumor (frozen): 5.2 x 4.8 cm with blood clot and one papillary tumor 1.2 x 0.7 cm
        • Right fallopian tube: 4.5 cm in length, 0.6 cm in diameter
        • Left ovarian cyst: 3.7 x 2.7 cm
        • Left fallopian tube: 3.7 cm in length, 0.7 cm in diameter
        • Uterus: 11 x 7 x 5 cm in size and 415 gm in weight, multiple myomas, up to 5.8 x 5.3 x 4.4 cm
        • Omentum: 31 x 9 x 0.5 cm
      • Uterosacral area mass: three pieces, up to 1.3 x 0.6 x 0.4 cm
      • R’t peri-ureter tissue: one piece, 3.7 x 2.6 x 2.1 cm
      • R’t suspensory (IP): one piece, 2.8 x 1.8 x 1.3 cm
      • Tumor site: R’t ovary, uterosacral area mass and R’t peri-ureter tissue
      • Tumor appearance: cystic tumor with papillary tumor at R’t ovary
      • Specimen integrity: opened ovarian tumor
      • Lymph node: pelvic and paraaortic LNs
      • Representative sections as A: left iliac LNs, B: left obturator LNs, C: right iliac LNs, D1-D3: right obturator LNs, E: L’t paraaortic LNs, F: R’t paraaortic LNs, G1-G3: uterine corpus, G4-G5: low segment of corpus + cervix, G6-G7: corpus, G8-G9: cervix, G10: endometrium, G11: myoma, G12-G14: adenomyosis, G15-G16: bilateral parametrium, H: right suspensory (IP), I: uterosacral area mass, J: omentum, K: right peri-ureter tissue [Reference: frozen section, F2023-00229 FSA1: R’t ovarian papillary nodule, FSA2: R’t ovarian cyst, A1-A2: R’t ovarian cyst and A3: R’t fallopian tube, B1: L’t fallopian tube, B2-B3: L’t ovarian cyst]
    • MICROSCOPIC EXAMINATION
      • Histologic type: Endometrioid carcinoma, endometrioma and endometriosis
      • Histologic grade: Grade 1
      • Contralateral ovary involvement: Absent
      • Tumor side ovarian surface involvement: Absent
      • Contralateral ovary surface involvement: Absent
      • Right tube involvement: Absent
      • Left tube involvement: Absent
      • In situ adenocarcinoma in right &/or left fallopian tube: Absent
      • Right adnexa soft tissue involvement: Absent
      • Left adnexa soft tissue involvement: Absent
      • Pelvic soft tissue involvement: Present
      • Uterine serosa involvement: Absent
      • Omentum involvement: Absent
      • Uterine Cervix involvement: Absent, chronic cervicitis with Nabothian cysts
      • Endometrium involvement: Absent
      • Myometrium involvement: Absent, leiomyomas and adenomyosis
      • Appendix involvement: Not received
      • Lymph nodes metastasis: Free of tumor metastasis (0/69) in total number
      • Uterosacral area mass: endometrioid carcinoma
      • R’t peri-ureter tissue: endometrioid carcinoma and endometriosis
      • Immunohistochemistry (F2023-00229 FSA1): PAX-8 (+), vimentin (+), ER (+), WT-1 (-) and P53 (wild type)
      • Ascites cytology: Negative
  • 2023-05-17 Frozen Section
    • Right ovarian cyst, frozen section — Malignancy, favor endometrioid carcinoma
  • 2023-04-25 Patho - colon biopsy
    • Colorectum, splenic flexure, s/p biopsy removal — Hyperplastic polyp
  • 2023-04-25 Patho - stomach biopsy
    • Stomach, AW side of antrum, biopsy — Ulcer, H pylori present
    • Stomach, LC side of prepyloric antrum, biopsy — Ulcer, H pylori NOT present
  • 2023-04-24 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A-
    • Gastric ulcers, antrum, s/p biopsy at antrum (AW) and prepyloric antrum (LC)
  • 2023-04-24 Colonoscopy
    • Colon polyp, splenic flexure, s/p biopsy removal
    • Diverticulosis, descending colon
    • Internal hemorrhoid
  • 2023-04-19 CT - abdomen
    • Findings:
      • There is a homogeneous enhancing mass 6.4 cm in the uterus that is c/w myoma.
      • There is cystic lesion in bilateral adnexa with mild wall thickening but no mural nodule and septum.
        • Cystic adenocarcinoma of the ovary is highly suspected.
        • In addition, there are few small soft tissue nodules in right L3 peri-ureter area that may be tumor seeding (T2b)?
        • The right and left adnexal cystic lesion are measured 6.4 cm and 3.6 cm, respectively. Please correlate with GYN. sonography and CA125.
      • Two renal cyst 4 cm and 1.5 cm in left upper pole is noted.
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T2b(T_value) N:N0(N_value) M:M0(M_value) STAGE:IIB(Stage_value)
  • 2023-04-14 Gynecologic ultrasonography
    • R/O Rt Ovarian mass: 68x49mm (papillary: 16x14mm, no blood flow)
    • Adenomyosis
    • Uterine myoma

[MedRec]

  • 2023-06-01 SOAP Hemato-Oncology
    • O
      • Cancer Multidisciplinary Team Meeting Conclusion, Date: 20230525

        Treatment Plan:
        • Postoperative adjuvant chemotherapy (referral to Dr. Xia HeXiong)
        • Provide Ovarian Cancer Treatment Shared Decision-Making (SDM) form and explanation of the condition (including genetic testing and targeted therapy).
    • P
      • Arrange admission for 24hr CCr, audiomtery and C/T with TP
  • 2023-05-16 ~ 2023-05-25 POMR Obstetrics and Gynecology
    • Discharge diagnosis
      • Malignant neoplasm of right ovary
      • Leiomyoma of uterus, unspecified
      • Female pelvic peritoneal adhesions (postinfective)
      • Debulking surgery on 20230517
    • CC
      • Irregular menstrual cycles with short intervals.
    • Present illness
      • This is a 47 year old famle, G3P2AA1 (NSD x2, with no severe complications), LMP was 20230416. She had hypertension (under medicine control) and kindey cyst (suggested regular follow up), no surgery history, no known allergens.
      • ACCORDING TO THE PATIENT, SHE HAD IRREGULAR MENSTRUAL CYCLES WITH SHORT INTERVALS SINCE APRIL 2023 (03/27, 04/04 are previous cycles, mild menstrual pain). THEREFORE, SHE WENT TO OB/GYN CLINICS FOR HELP. She was informed elevated CA125 and CA199, then she was introduced to Dr. Huang. AT DR. HUANG OPD, TRANSVAGINAL SONOGRAPHY SHOWED Myoma 6051 / 3020 mm IN SIZE, ROV mass 68*49 mm (papillary:16x14mm,no blood flow).
      • CT was performed on 04/19, the findings are as followed: 1. Uterine myoma 6.4 cm. 2. Cystic lesions in bilateral adnexa.
      • UNDER THE IMPRESSION OF UTERINE MYOMA AND OVARAIN TUMOR, MALIGNANCY CANNOT BE RULE OUT, After the evaluation, the paitent was arranged with LSC myomectomy + BSO on 20230517, she was admitted to our ward day before for the pre-operation preparation.
    • Course of inpatient treatment
      • The patient was admitted on 20230516 due to ovarian tumor. The frozen section initial diagnosis:Right ovarian cyst, frozen section — Malignancy, favor endometrioid carcinoma. She underwent Debulking operation (ATH + BSO + BPLND + bilateral paraaortic LND + Cytoreduction surgery + infracolic omentectomy on 20230517. The AJCC Pathologic staging — pT2bN0, if cM0, stage IIB / FIGO stage IIB. The GYN tumor board conference suggest the patient to receive chemotherapy on 20230525. Her postoperative course was uneventful. Self voiding was smooth. She was discharged on 20230525. Her follow up appointment is scheduled on 20230601. Keep intraperitoneal Port for chemotheraphy.      
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • Actein (acetylcysteine 200mg) 1# TID
      • cephalexin 500mg 1# QID
      • MgO 250mg 1# TID

[consultation]

  • 2023-07-04 Urology
    • Q
      • for USK evaluation
      • This 47-year-old woman, a patient of Right ovarian endometrioid carcinoma, pT2bN0cM0, FIGO stage IIB s/p Debulking operation (ATH + BSO + BPLND + bilateral paraaortic LND + Cytoreduction surgery + infracolic omentectomy), bilateral DBJ insertion and Tenckhoff tube insertion on 2023/05/17 . DBJ was removed on 20230605. We need expertise to evaluate her condition thanks!
    • A
      • we will arrnage USK to evaluate Tx effect after DBJ insertion
  • 2023-05-18 Urology
    • Q
      • For on D-J catheterization.
      • This 47-year-old female with ovarin cancer was admitted for Debulking surgery at 20230517.
      • We need your evaluation of her condition for on D-J catheterization.
    • A
      • intrapoerative finding showed tumor attached to right low ureter
      • Bilateral DBJ was inserted
      • tumor was dissected from right low ureter
      • For better healing and stablization after operation, DBJ may be kept for one month til 2023/06/05
      • I had explained to her on 2023/05/18 09:30

[surgical operation]

  • 2023-05-17
    • Surgery
      • Operation: Tenckhoff tube insertion
    • Finding
      • Tenckhoff tube over RLQ
    • Procedure
      • Under ETGA, GYN and GU performed operation at first. GS was consulted. Inserted a Tenckhoff tube with exit site over RLQ. Closed the wound with 1# Vicryl and skin staples.
  • 2023-05-17
    • Surgery
      • DBJ insertion, bilateral        
    • Finding
      • A 6 Fr 24 cm double-J catheter was inserted to left ureter.
      • A 6 Fr 24 cm double-J catheter was inserted to right ureter.
      • Bladder mucosa seems fair
      • no urin eleakage
      • Pelvic tumor is found medial to low ureter. After dissection, pelvic tumor is dissected from right low ureter as much as possible.
    • Procedure
      • With ETGA, the patient was in lithotomy position. Disinfection and draping the operation field were done as usual methods. Cystoscopy was performed to identify the ureteral orifices. After retrograde insertion of guidewire. A 6 Fr 24 cm double-J catheter was inserted to left ureter. A 6 Fr 24 cm double-J catheter was inserted to right ureter. A 14Fr Foley was inserted. Through open wound by gyn doctor, a firm pelvic tumor is found medial to right low ureter. After fine and blunt dissection, pelvic tumor is dissected from right low ureter as much as possible. The patient stood the procedures well. 
  • 2023-05-17
    • Surgery
      • Right ovarian cyst, frozen section — Malignancy, favor endometrioid carcinoma
    • Procedure
      • Debulking operation (ATH + BSO + BPLND + bilateral paraaortic LND + Cytoreduction surgery + infracolic omentectomy + )
    • Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: AVFL, with multiple uterine myomas(intramural type, 6x5 / 3x2cm)
        • Some papillary tissue over right uteroscaral ligament, medial to ritght ureter, s/p excision
      • Adnexa:
        • Severe adhesion between bilateral adnexa and posterior uterien wall + cul-de-sac, s/p adhesiolysis
        • LOV cystic mass, 5x4 cm, intraoperative rupture with chocolate-like contents
        • ROV cystic mass, 7x5 cm, intraoperative rupture with papillary tissue and -chocolate-like contents
        • Some papillary lesions was noted over right suspensory ligament and right pelvic lateral wall, s/p excision
      • CDS: severe adhesion
      • Ascites: little, s/p washing cytology
      • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
      • Omentum: diffuse chocolate spots was noted, suspect related to previous rupture of chocolate cyst; infracolic omentectomy was done.
      • Liver: grossly normal & smooth; Subdiaphragmatic surface: miliary tumor seeding(-)
      • Appendix: grossly normal
      • Previous rupture of chocolate was highly suspected, with diffused chocolate spots over the pelvic wall and and bowel adhesion were noted.
      • After the operation, optimal debulking surgery was achieved; Residual tumor: R0
      • Estimated blood loss: 400ml
      • Blood transfusion: LPRBC 2u
      • Complication: nil
      • 15Fr-Jvac x2 at bilateral Cul-de-sac
      • Antiadhesion agent: interceed x 1 piece

[immunochemotherapy]

  • 2023-10-13 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-12 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-15 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-24 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-03 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-14 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr (adjuvant Avastin 15mg/kg IVD Q3W x 6 + 12~15 for 15mo)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-13

After reviewing the PharmaCloud database and the hospital’s HIS5 records, no medication reconciliation issues were identified.

2023-08-15

The patient received a 28-day refill of rabeprazole on 2023-08-10. While the active medication list does not show any current use of PPIs, Stogamet (cimetidine) is being used. Therefore, there are no medication reconciliation concerns.

2023-07-25

There are no medication reconciliation issues identified after reviewing the PharmaCloud database and HIS5 records.

2023-07-04

  • After reviewing the PharmaCloud database, there is no prior prescription that is still valid now from other healthcare providers or other departments in this hospital.
  • However, there is no records of Norvasc refilled in the past few weeks, and this drug should be a prescription medicine which can only be ordered by a doc, and this drug has been included as a patient-carried item in the active medication list, please check if the self-carried Norvasc does not pass its expired date.

700363763

231013

[lab data]

2023-07-17 CMV viral load assay 6060 IU/mL
2023-07-07 CMV viral load assay 331 IU/mL

2023-04-25 MTBC PCR DETECTED CFU/ml
2023-04-25 MTBC PCR Value 10000 - 100000 CFU/ml

[exam findings]

  • 2023-07-11 CT - abdomen
    • History and indication: Rectal cancer with obstruction post T-loop colostomy on 4/7 23.
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Much regression of rectal cancer. Some tiny LNs at pelvic cavity.
      • Nodules (up to 14mm) at bil. lungs.
      • Renal cysts (up to 1.2cm).
      • Wall thickening of urinary bladder.
      • Small amount pericardial effusion.
      • Atherosclerosis of aorta, iliac arteries.
      • Presence of scoliosis of the lumbar spine.
      • S/P NG tube indwelling.
    • IMP:
      • Much regression of rectal cancer. Some tiny LNs at pelvic cavity.
      • Nodules (up to 14mm) at bil. lungs.
      • Wall thickening of urinary bladder.
  • 2023-07-10 CXR (erect)
    • Atherosclerotic change of aortic arch
    • Scoliosis of the T-spine with convex to right side.
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-05-15, -05-08, -05-03, -04-27 CXR
    • Port-A catheter inserted via left subclavian vein, its tip overlies Rt paratracheal stripe
    • A poorly defined mass over LUL
    • areas of hyperlucency and decreased upper lung vascular markings due to emphysematous change of both lungs upper lung predominance
    • there is also areas of pulmonary fibrosis in the lungs
    • mild enlarged cardiac silhoutte
  • 2023-04-24 Patho - lung transbronchial biopsy
    • Lung, left, CT-guide biopsy — necrotizing granulomatous inflammation with marked interstitial fibrosis
    • Sections show alveolar lung tissue with marked interstitial fibrosis and necrotizing granulomatous inflammation. Several Langhan’s multinuclear giant cells are also seen.
    • The AFB special stain is positive. The PAS special stain is negative. No definite malignancy is found. The immunohistochemical stain of CK reveals no invasive tumor.
  • 2023-04-22, -04-20 CXR
    • Patch density at LUL.
    • Blunted left costophrenic angle.
    • Presence of scoliosis of the lumbar spine.
  • 2023-04-19 PET
    • Increased FDG uptake at the R-S junction of colon, compatible with rectal malignancy.
    • Increased FDG uptake in bilateral peri-rectal lymph nodes, highly suspected rectal cancer with regional lymph nodes metastases.
    • Increased FDG uptake in bilateral upper lungs, highly suspected the secondary (priority, colon cancer with lung mets) or another primary (left or right upper lung?) cancer, suggesting biopsy, if necessary, for investigation.
    • Increased FDG uptake in bilateral pulmonary hilar and mediastinal lymph nodes, and in a left SCF lymph node, highly suspected rectal cancer with distant lymph nodes metastases (priority) or lung cancer with regional lymph nodes metastases.
    • Highly suspected rectal cancer with regional and distant lymph nodes, as well as bilateral upper lungs metastases, cTxN2M1b, stage IVB (AJCC 8th ed.), or double cancers of rectum and lung, by this F-18 FDG PET scan.
  • 2023-04-18 All RAS + BRAF
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-04-14 CT - chest
    • Indication: colon cancer with lung metastases
    • Findings
      • Spculated mass at left upper lobe with central lucency is found measuring 3.2cm in largest dimension. In comparison with CT dated on 2020-08-10, the lesion enlarged. Lung cancer is favored.
      • Severe centrilobular Emphysematous change over both lungs is found.
      • Minimal reticulation at bilateral lower lungs is found.
      • Tiny atelectatic change at left lower lobe with minimal left pleural effusion is found.
      • Small lymph nodes are found in the mediastinum. Stationary.
    • Imp: Left upper lobe spiculated mass. r/o lung cancer.
  • 2023-04-07 Patho - colon biopsy
    • Colon tumor, rectum, 10 cm above anal verge, biopsy — Adenocarcinoma
    • Microscopically, the sections show a picture of adenocarcinoma characterized by glandular tumor cell infiltrate with stromal desmoplasia.
    • Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.
  • 2023-04-01 CT - abdomen
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of S-colon with adjacent fat stranding and colon dilatation. Some LNs at pelvic cavity.
      • Nodules (up to 7mm) at bil. basal lungs.
      • Renal cysts (up to 1.2cm).
      • Atherosclerosis of aorta, iliac arteries.
      • Presence of scoliosis of the lumbar spine.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2022-09-05 CXR
    • upper lung hyperlucency and decreased upper lung vascular markings due to emphysema
    • ill-defined nodular opacity at LUL and several nodular opacities at RUL, stationary as compared with previous image
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • Mild dextroscoliosis of the T-spine
  • 2022-07-25 CT - brain
    • Findings
      • Generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • Imp: Brain atrophy.
  • 2020-08-10 CT - chest
    • Indication: RUL nodule
    • Comparison: none prior CT dated on 2017 2018 2019
      • Lungs and large airways:
        • extensive centrilobular emphysema over bilateral lungs upper predominance.
        • ill-defined, dumbell-like nodular opacity in LUL (37-mm in longest dimension) and several solid nodular opacities up to 24-mm in longest dimension in RUL, and minimal fibrotic change at lung apex in the same lobe. several small calcified granulomas in posterior RUL too.
      • Mediastinum: no LAP or mass.
        • the trachea and main bronchi are normallly identified without endobronchial lesion,
      • Hila: unremarkable.
      • Vessels:
        • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Heart: dilated RV and RA?
      • Pleura: no effusion.
      • Chest wall and lower neck: unremarkable.
      • Visible abdomen: no abnormal density in visible portion of the liver, spleen, pancreas, kidneys, adrenal glands, and GB.
        • Mild atherosclerotic change of the abdominal aorta.
      • Visualized bones: unremarkable.
    • Impression:
      • newly developed nodular lesions in both upper lobes compared
      • with CT on 2019/03/26, malignancy or MTB?
      • extensive emphysema.
  • 2020-03-02 CXR
    • Increased lung volume and areas of lucency and dirty marking due to emphysematous change of both lungs upper lung predominance
    • a small nodular opacity over RUL and a small nodular opacity (ill-defined) over LUL, may be malignant lesions, suggest do CT study Thoracic aortic arch calcified atheriosclerotic plaque
    • mild levoscoliosis of the L-spine
  • 2019-12-09 Bronchodilator test
    • mild obstructive ventilatory impairment
  • 2019-03-26 CT - chest
    • Comparison: none prior CT dated on 2017 2018 2019
      • Lungs and large airways:
        • extensive centrilobular emphysema over bilateral lungs upper predominance. minimal fibrotic change at RUL. a 6mm subpleural nodule or atelectatic lung tissue at RML.
      • Mediastinum: no LAP or mass.
        • the trachea and main bronchi are normallly identified without endobronchial lesion,
      • Hila: unremarkable.
      • Vessels:
        • Aorta: normal in caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
        • Pulmonary arteries: normal in caliber.
      • Heart: normal in size.
      • Pleura: small effusion with parietal pleural thickening, Rt.
      • Chest wall and lower neck: unremarkable.
      • Mild atherosclerotic change of the abdominal aorta.
      • Visualized bones: unremarkable.
    • Impression:
      • Rt pleural effusion, exudate.
      • a 6mm subpleural nodule or atelectatic lung tissue at RML.
      • extensive emphysema.

[MedRec]

  • 2023-09-01 SOAP Chest Medicine Huang GuoLiang
    • Prescription
      • AKruiT-4 (RIF 150mg, INH 75mg, PZA 400mg, EMB 275mg) 3# QDAC
      • Vit B6 (pyridoxine 50mg) 1# QD
      • Smecta (dioctahedral smectite 3mg) 1# BIDAC
  • 2023-08-04 SOAP Chest Medicine Chen XinYi
    • Prescription
      • AKruiT-4 (RIF 150mg, INH 75mg, PZA 400mg, EMB 275mg) 3# QDAC
      • Vit B6 (pyridoxine 50mg) 1# QD
      • Actein Effervescent (acetylcysteine 600mg) 1# BID

[consultation]

  • 2023-07-10 Gastroenterology
    • Q
      • for abnormal liver function and jaundice
      • This 79-year-old man, a patient of rectal cancer obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM0 stageIIIC S/P chemotherapy. Owing to high TBI 2.98mg/dl was noted during anti-TB drugs related. We need expertise to evaluate his condition thnaks!
    • A
      • This 79-year-old male was a case of rectal cancer obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM0 stageIIIC S/P chemotherapy. We are consulted for bilirubin elevation.
        • Communicating with a pen at bedside.
        • No abdomen pain noted
      • A: Bilirubin elevation, suspect drug-induced cholestasis, r/o biliary obstruction
      • P:
        • Pending on Abdomen CT report
        • Check AST, ALT, ALP, rGT, TBI/DBI, ALB, PT, APTT to complete liver study
        • Regular monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALP
        • Contact us, if any porblems
  • 2023-07-10 Chest Medicine
    • Q
      • for Tuberculosis of lung & anti-TB drugs evaluation
      • This 79-year-old man, a patient of rectal cancer obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM0 stageIIIC S/P chemotherapy. Owing to high TBI :2.98mg/dl was noted during anti-TB drugs related. We need expertise to evaluate his condition thnaks!
    • A
      • Suggestion:
        • hold anti-TB medication
        • arrange liver echo or abdominal CT to define liver condition. May consult GI
        • for much sputum, do sputum culture, airway clearance, give amikin inhalation for anti-inflammatory effects.
  • 2023-06-26 Gastroenterology
    • Q
      • Due to the coffee ground noted via NG and tarry stool found via colostomy, we rechecked lab data for him which was revealed decreased level of Hb (12.3 -> 7.8). Thus, we need your expertise for evaluation of PES due to suspected Upper GI bleeding. Thanks!
    • A
      • 79 male with rectal cancer, s/p chemotherapy and colonostomy. However, due to tarry stool with coffee ground, we are consulted.
        • conscious: clear
        • chest: intubation
        • abdomen: soft and flat
      • impresson
        • UGI bleeding
      • suggestion
        • well inform-consent to the patient and the family, including the indication, the risks (aspiration pneumonia/respiratory failure, arrhythmias/cardiovascular events, organ perforation, etc.), and the alternatives (conservative treatment, etc.)
        • if the patient and the family all understand the EGD intervention, would take the risk, and sign the permit for EGD, we would arrange EGD
        • Proton pump inhibitor use
        • Avoid anticoagulants/antiplatelets use, and correct bleeding tendency if any;
        • Arrange adequate blood transfusion and fluid resuscitation for fear of hypovolemic shock;
        • Inform us to follow up if bleeding condition progression or any other GI problem progression
  • 2023-06-23 Infectious Disease
    • A
      • Consultation for Mepem antibiotic
        • 79-year-old rectal cancer, COPD and pulmonary TB male patient has a new episode of severe pneumonia, BLL with respiratory failure and severe sepsis now.
        • He was just discharged from our Onco ward two days ago.
        • Use of Mepem acceptable before further culture report available.
      • Suggestion:
        • Continue Mepem for one week first
        • Check blood and sputum culture report.
  • 2023-05-24 Dermatology
    • Q
      • This is 78 y/o man who has underlying disease of 1) COPD, 2) Hypertension, 3) GERD, 4) Rectal cancer obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM0 stage IIIC, 5) Tuberculosis of lung under treatment.
      • This time, he complained of abdominal pain and distention for 3 days accompanied with constipation lasting a week. The patient denied chest tightness(-), headache(-), dizziness(-), radiated pain(-), shoetness of breating(-) nauseas(-) and vomitting(-), diarrhea(-). He also denied TOCC history.
      • For skin rash off and on was noted, we need your further evaluation and management. Thanks a lot!!! There are photos on the caregiver’s mobile phone.
    • A
      • The patient had sufferred from discrete reddish swelling papules on the abdomen without pruritus on and off for weeks.
      • xerotic dry skin with post-screthec lesions over four limbs.
      • Under the impression of acute urticaria and xerotic dermatits.
      • The following sugeetion:
        • for urticaria, consider keep allegra 1# bid po use -> consider shift to xzyal 1# HS po use if condition turn to stable.
        • for xerotic dermatitis, currently apply lotion extensively. Mycomb cream 2 tube topical bid use over itchy reddish papules and sinphraderm 1 tube topical QN use over dry scales.
  • 2023-04-28 Hemato-Oncology
    • Q
      • Consult our CRS and then operation of T-colostomy was performed for rectal cancer obstruction on 2023/04/07. General condition is stationary and then transfer to ward on 2023/04/13.
      • Follow chest CT: Left upper lobe spiculated mass, suspect lung cancer, cT2aN0M0 on 2023/04/14.
      • We needs your expert experience for further evaluation and neoadjuvant CCRT. Thaks a lot!!
    • A2 - 2023-04-28
      • This 78 year old man is a case of Rectal cancer with obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM1a stage IVa and suspect lung cancer, cT2aN0M0 on 2023/04/14. We are consulted for further evaluation and CCRT.
      • Please arrange PET CT scan, arrange port A insertion.
      • Please check All-RAS-BRAF, anti HCV, anti HBc, anti HBs, HBsAg.
      • We will discuss with patient about further systemic treatment. Thanks for your consultation.
    • A1 - 2023-04-20
      • Please consult chest surgeon for further OP evaluation. If not suitable operation, may arrange CT guide biopsy for tissue proof (left upper lung lesion).
      • In addition, may also check TB sputum culture. Pending the result. Thanks for your consultation.
  • 2023-04-26 Chest Medicine
    • Q
      • For further treatment of TB (Sputum Acid-fast Stain: Positive, MTBC PCR: detected) and take over
        • The uncle of Deputy Director Zheng Jingfeng
        • For deaf and mute individuals, please use written communication
    • A
      • Sputum Acid-fast Stain: Positive, MTBC PCR: detected. recommends isolation and treatment by Infection Control Team.
      • We takeover and give TB medication.
  • 2023-04-18 Radiation Oncology
    • A
      • A: Adenocarcinoma of the rectum, stage T4aN2aM1a (stage IVA).
      • P: Neoadjuvant CCRT is indicated for this patient with the following indicators: stage T4aN2aM1a (stage IVA)
        • Goal: palliation
        • Treatment target and volume: pelvic area
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the pelvic and 5040cGy/28 fractions of the rectal tumor bed.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his son. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-04-24.
  • 2023-04-07 Colorectal Surgery
    • Q
      • The sigmoidoscopy reveals Rectal cancer obstruction.
      • On 4/7 night, intubation for aspiration pneumonia with acute respiratory failure.
      • Due to Rectal cancer obstruction. consult for colostomy evaluaution. Thanks
    • A
      • RS colon cancer with obstruction for almost 1 week.
      • persist abdomen fullness and aspiration pneumonia
      • CRP: 8 yesterday
      • suggest T colostomy under risk, because bowel inflammation will worse for lont time obstruction.
  • 2023-04-07 Infectious Disease
    • A
      • Consultation for Mepem antibiotic
      • Rectal cancer with colon obstruction and severe sepsis case.
      • Serial CxR films showed newly developed pneumonia.
      • Please continue Mepem for 5 days first.
      • Check blood and sputum culture report.

[surgical operation]

  • 2023-04-07
    • Surgery
      • T colostomy
    • Finding
      • Severe dilation of T colon and mild ischemia
      • T colon ulcer

[radiotherapy]

[chemotherapy]

  • 2023-10-12 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg D5W 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-09-21 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg D5W 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-09-07 - oxaliplatin 65mg/m2 80mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg D5W 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-08-08 - leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg D5W 500mL 46hr (FOLFOX without Ox)
    • dexamethasone 4mg + NS 250mL
  • 2023-06-13 - leucovorin 20mg/m2 25mg NS 250mL 10min D1-5 + fluorouracil 225mg/m2 300mg NS 100mL 10min D1-5 (CCRT)
    • [dexamethasone 4mg + NS 250mL] D1-5
  • 2023-05-16 - fluorouracil 225mg/m2 300mg NS 100mL 10min D1-5 (CCRT)
    • [dexamethasone 4mg + NS 250mL] D1-5

==========

2023-10-13

After reviewing the PharmaCloud database and the hospital’s HIS5 records, no medication reconciliation issues were identified.

2023-09-05

[tube feeding]

As the adsorbent properties of this product may interfere with the rates and/or levels of absorption of other substances, it is recommended not to administer any other drugs at the same time as SMECTA. ref: https://www1.ndmctsgh.edu.tw/pharm/pic/medinsert/005SME01E.pdf

[hyperbilirubinemia follow-up]

2023-09-04 Bilirubin total 1.55 mg/dL
2023-08-11 Bilirubin total 1.61 mg/dL
2023-08-07 Bilirubin total 2.16 mg/dL
2023-07-17 Bilirubin total 1.43 mg/dL
2023-07-12 Bilirubin total 2.04 mg/dL
2023-07-10 Bilirubin total 2.98 mg/dL

2023-09-04 Bilirubin direct 0.74 mg/dL
2023-08-11 Bilirubin direct 0.64 mg/dL
2023-08-07 Bilirubin direct 1.03 mg/dL
2023-07-17 Bilirubin direct 0.59 mg/dL
2023-07-12 Bilirubin direct 1.06 mg/dL
2023-07-10 Bilirubin direct 1.61 mg/dL

At present, the patient’s bilirubin levels are lower than what was observed in mid-July, even after resuming AKruiT-4 on 2023-08-04.

It’s worth noting that AKruiT-4 is being administered alongside Smecta, which is not advisable. Smecta has the potential to alter the rate or level of AKruiT-4 absorption.

2023-07-13

[optional addition of Genurso for hyperbilirubinemia]

The addition of Genurso (ursodeoxycholic acid 100mg) #1 or #2 TID might be considered to help alleviate the patient’s hyperbilirubinemia. ref: Anti-Tuberculosis Drug Induced Liver Injury and Ursodeoxycholic Acid. Journal of Tuberculosis Research, Vol.8 No.2, 2020. https://doi.org/10.4236/jtr.2020.82007

2023-07-12

[approach to hepatotoxicity caused by antituberculous drugs]

AKuriT-4 was ceased on 2023-07-10, with bilirubin levels subsequently falling, though they still remain above twice the upper limit of normal (ULN).

  • 2023-07-12 Bilirubin total 2.04 mg/dL
  • 2023-07-10 Bilirubin total 2.98 mg/dL
  • 2023-06-26 Bilirubin total 2.15 mg/dL

As per the “Approach to hepatotoxicity caused by first-line antituberculous drugs in adults” from UpToDate (https://www.uptodate.com/contents/image?imageKey=ID%2F109447), when the bilirubin level is less than 2mg/dL and the enzyme levels are less than twice the upper limit of normal, either a regimen made up of liver-sparing drugs (like ethambutol, a fluoroquinolone or linezolid) may be considered or the gradual reintroduction of first-line agents may be done.

Another study released in the New England Journal of Medicine in 2021 titled “Four-Month Rifapentine Regimens with or without Moxifloxacin for Tuberculosis” deduced that the effectiveness of a four-month regimen based on rifapentine, with or without moxifloxacin, was not inferior to the standard six-month regimen in the treatment of tuberculosis. The manufacturer’s guidelines for rifapentine do not include suggestions for dose adjustments in patients with hepatic impairment. It is believed that the pharmacokinetics of rifapentine in patients with varying degrees of hepatic impairment are similar to those in healthy volunteers.

2023-06-07

[following up on bilirubin and albumin levels]

  • Laboratory data indicates that both total and direct bilirubin levels have started to decrease, though they have not yet returned to the normal range. This suggests that the current AKuriT-4 regimen is less likely to have a continuously damaging effect on the liver.
    • 2023-06-06 Bilirubin total 1.24 mg/dL
    • 2023-06-06 Bilirubin direct 0.53 mg/dL
    • 2023-05-29 Bilirubin total 1.54 mg/dL
    • 2023-05-29 Bilirubin direct 0.74 mg/dL
  • Moreover, the patient’s albumin level has dropped to a record low of 2.3g/dL. Given that the patient’s kidney function appears normal (Cre 0.98 mg/dL, eGFR 78, BUN 16 mg/dL), the possibility of protein loss due to nephrotic syndrome is less likely. With bowel movements recorded at less than or equal to 3 since June, protein-losing enteropathy also appears less likely. If we rule out malnutrition as a cause, reduced albumin synthesis such as that seen in liver disease could potentially be the reason, warranting further investigation. Please monitor for signs of edema.
    • 2023-06-06 Albumin 2.3 g/dL
    • 2023-05-29 Albumin 2.6 g/dL

2023-06-01

[AKuriT-4 follow-up]

  • Today, after discussing the patient’s condition with the attending physician and nurse practitioner, I learned that the changes in the patient’s liver function indicators have already been discussed with Dr. Su from the thoracic department. It is believed that there is no need to adjust the medication at this time.

2023-05-31

  • A blood transfusion was performed on 2023-05-15 due to the patient’s low hemoglobin (HGB) levels. However, recent lab results still show a decreasing trend in HGB and a stool occult blood test result of 2+, which could suggest the possibility of ongoing GI bleeding. Although the patient is currently on a PPI (esomeprazole), if an upper GI source is suspected, the addition of tranexamic acid may be beneficial to control bleeding.
    • 2023-05-29 HGB 11.0 g/dL
    • 2023-05-26 HGB 12.0 g/dL
    • 2023-05-15 HGB 9.1 g/dL
    • 2023-05-26 stool OB 2+
  • Furthermore, the patient’s serum albumin levels seem to be dropping. It’s recommended that the patient increase his protein intake, and nutritional support might be needed. If these measures are implemented and hypoalbuminemia persists, it might be necessary to consider adding an albumin supplement.
    • 2023-05-29 Albumin 2.6 g/dL
    • 2023-05-15 Albumin 2.6 g/dL
    • 2023-05-08 Albumin 2.9 g/dL
    • 2023-05-03 Albumin 2.9 g/dL
    • 2023-04-27 Albumin 3.1 g/dL
  • This patient is currently being treated for lung TB with AKuriT-4 (rifampin 150mg + isoniazid 75mg + pyrazinamide 400mg + ethambutol 275mg) since 2023-04-26. Rifampin is associated with hepatotoxicity, which can manifest in various patterns including asymptomatic abnormal liver function tests, isolated jaundice or hyperbilirubinemia, symptomatic self-limited hepatitis, or even fulminant hepatic failure and death. Despite the patient’s AST and ALT levels being within normal range as of 2023-05-29, there has been a continuous increase in the patient’s bilirubin levels in 2023-05. This continuous increase in the patient’s bilirubin levels might potentially suggest rifampin-induced hepatotoxicity, particularly once other causes of elevated bilirubin, such as hemolysis, have been ruled out.
    • 2023-05-29 Bilirubin total 1.54 mg/dL
    • 2023-05-26 Bilirubin total 1.07 mg/dL
    • 2023-05-15 Bilirubin total 0.79 mg/dL
    • 2023-05-08 Bilirubin total 0.80 mg/dL
    • 2023-05-03 Bilirubin total 0.62 mg/dL
    • 2023-05-29 Bilirubin direct 0.74 mg/dL
    • 2023-05-26 Bilirubin direct 0.44 mg/dL
    • 2023-05-15 Bilirubin direct 0.29 mg/dL
    • 2023-05-03 Bilirubin direct 0.14 mg/dL

700711453

231013

{not completed}

[exam findings]

  • 2023-10-06 SONO - abdomen

    • Diagnosis:
      • Suspected chronic liver parenchyma disease
      • Liver tumor, right. Propable metastases
      • Suspected liver cyst, right
      • Pancreatic tumor, body
      • S/p PTGBD
      • Mild IHD dilatation, bil
      • Suboptimal examination of liver, especially the subcostal view due to poor echo window
    • Suggestion:
      • Please correlate with other image, liver function test and follow AFP, CA-199
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • 2023-10-05 Abdomen - standing (diaphragm)

    • Calcified pelvic mass, probably calcified uterine fibroid.
    • marginal spurs of multiple vertebral bodies of L-spine due to spondylosis.
    • S/P Percutaneous gallbladder drainage.
  • 2023-10-02 Percutaneous Gall Bladder Drainage, PTGBD

  • 2023-10-02 CT - abdomen

    • Abdominal CT with and without enhancement revealed:
      • Severely dilated IHDs and CBD and proximal pancreatic duct is found. The GB is severely distended with wall thickening. Mass like lesion at pancreatic body with extending to celiac trunk is found. In comparison with CT dated on 2023-06-24, the mass enlarged
      • There is one low density lesio at S5/6 measuring 3.5cm is found. Traction of right lobe liver surface is found.
      • Calcified dot at uterus is found. Myoma calcification is consiered.
    • Imp:
      • Pancreatic body tumor with celiac trunk lymphadenopathy and compression of pancreatic duct and biliary tree, causing severe cholecystitis. Suggest further treatment.
  • 2023-10-02 ECG

    • Sinus tachycardia with Premature atrial complexes
    • T wave abnormality, consider anterior ischemia
    • Abnormal ECG
  • 2023-06-24 CT - abdomen

    • History and indication: Malignant neoplasm of pancreas
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Much regression of pancreatic cancer (1.1cm) and liver metastases (2.0cm). Fat stranding at upper mediastinum with vascular encasement.
      • Some calcifications (up to 3.4cm) at pelvic cavity. R/O uterine myoma (2.5cm).
      • Colonic diverticula.
      • Atherosclerosis of aorta.
    • IMP:
      • Much regression of pancreatic cancer (1.1cm) and liver metastases (2.0cm). Fat stranding at upper mediastinum with vascular encasement.
  • 2023-03-30 Patho - pancreas biopsy

    • Pancreas, EUS FNB — Ductal adenocarcinoma, poorly differentiated
    • The sections show a picture of ductal adenocarcinoma, composed of nests, cords, and single large pleomorphic neoplastic cells with abundant eosinophilic cytoplasm arranged in solid and cribriform patterns, embedded in fibrous stroma. Subtle mucin secretion is present.
  • 2023-03-30 Patho - liver biopsy needle/wedge

    • Liver, EUS FNB — Adenocarcinoma, consistent with metastatic pancreatic ductal adenocarcinoma.
    • The sections show a picture of adenocarcinoma, composed of liver tissue with nests, cords, and single large pleomorphic neoplastic cells with abundant eosinophilic cytoplasma in fibrous stroma. Focal ductal differentiation and mucin secretion are present. The finding is consistent with metastatic pancreatic ductal adenocarcinoma.
  • 2023-03-28 Patho - liver biopsy needle/wedge

    • Liver, CT-guided biopsy — Adenocarcinoma, pancreatobiliary-type, compatible with metastatic pancreatic ductal adenocarcinoma.
    • The sections show a picture of adenocarcinoma, pancreatobiliary-type, moderately differentiated, composed of nests, cords, and single large pleomorphic neoplastic cells with abundant eosinophilic cytoplasma in fibrous stroma. Focal ductal differentiation and mucin secretion are present.
    • IHC shows: CK7(+), CA19-9(+), CK20(-), and Hepatocyte(-). The finding is compatible with metastatic pancreatic ductal adenocarcinoma.
  • 2023-03-17 CT - abdomen

    • CC: Severe epigastric hunger pain and loss 6 kgs (42 to 36 Kgs) for 2 months.
      • 2023/03/14 Ca 19-9 > 150
    • Past history: Hearing impairment. Uterine myoma.
    • Findings:
      • There is an ill-defined poor enhancing mass measuring 2.6 cm in the pancreatic body-tail junction, causing the upstream pancreatic duct dilatation that is c/w adenocarcinoma.
        • In addition, there is soft tissue lesions in the celiac trunk area with encasement that is c/w tumor invasion (T4).
      • There is an ill-defined poor enhancing mass measuring 3.3 cm in right lobe liver that is c/w metastasis (M1).
        • In addition, there is another poor enhancing lesion 0.8 cm in S4 of the liver. Metastasis is also highly suspected.
      • There are three calcified masses in the pelvis, the largest one 3.3 cm, that are c/w uterine fibroids.
      • The gallbladder shows small size. please correlate with clinical condition.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T4 (T_value) N:N0 (N_value) M:M1 (M_value) STAGE:IV
  • 2022-11-09 ENT SONO - head and neck soft tissue

    • Clinical Impression/Intent:right thyroid tumor
    • Sonographic Impression:right thyroid isoechoic tumor, margin clear, with microcalcification
  • 2021-02-03 ENT SONO - head and neck soft tissue

    • Clinical Impression/Intent:thyroid nodule?
    • Sonographic Impression:bilateral thyroid nodule
  • 2021-01-27 ENT Hearing Test

    • Tymp bil type A
    • ART
      • RE absent
      • LE 1000-4000 Hz reduced thretholds
    • PTA:
      • Reliability FAIR
      • Average RE >120 dB HL, LE 53 dB HL
      • RE profound SNHL
      • LE mild to profound SNHL
  • 2018-03-19 Pure Tone Audiometry

    • Reliabilty Fair
    • R’t : >120 dB HL, profound HL
    • L’t : 49 dB HL, mild to severe SNHL

[MedRec]

[Consultation]

[chemotherapy]

  • 2023-09-05 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-08-29 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-08-15 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-08-08 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-07-25 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-07-11 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-07-04 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-06-20 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-06-13 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-05-30 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-05-23 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-05-09 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-05-02 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-04-18 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-04-10 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

[note]

gemcitabine 2023-04-11 https://www.uptodate.com/contents/gemcitabine-drug-information

  • Pancreatic cancer, locally advanced or metastatic:
    • IV: Initial:
      • 1,000 mg/m2 over 30 minutes once weekly for 7 weeks followed by 1 week rest; then administer on days 1, 8, and 15 every 28 days or
    • Off-label dosing/combinations: IV:
      • 1,000 mg/m2 days 1, 8, and 15 every 28 days (in combination with paclitaxel [protein bound]) or
      • 1,000 mg/m2 over 30 minutes days 1, 8, and 15 every 28 days (in combination with capecitabine) or
      • 1,000 mg/m2 over 30 minutes weekly for up to 7 weeks followed by 1 week rest; then weekly for 3 weeks out of every 4 weeks (in combination with erlotinib) or
      • 1,000 mg/m2 over 30 minutes days 1 and 15 every 28 days (in combination with cisplatin) or
      • 1,000 mg/m2 infused at 10 mg/m2/minute every 14 days (in combination with oxaliplatin).

==========

2023-10-13

The patient’s body weight was recorded as 33.7kg on 2023-10-09. It may be prudent to monitor for potential adverse reactions as administering standard doses to underweight individuals may increase the risk of side effects.

700736980

231013

{Neuroendocrine carcinoma}

[exam findings]

  • 2023-09-12 KUB
    • Lumbar spondylosis.
  • 2023-09-12 SONO - nephrology
    • Chronic renal parenchymal disease, moderate degree
    • Right renal cyst
    • Left hydronephrosis, mild to moderate degree
    • Left renal cysts
    • r/o mass lesion in the pelvic area
  • 2023-08-25 CT - chest
    • Indication: Malignant poorly differentiated neuroendocrine tumors of prostate with lung mets
    • Findings
      • Lungs:
        • no interval change of a subpleural solid nodule (7mm) at RLL-S9, a subpleural nodule (3mm) at LLL, and two subpleural solid nodules (up to 4mm) at RML as compared with CT on 2023/04/25.
        • resolution of Rt apical lung solid nodule.
        • a new small nodule at LLL-S9.
        • dependent subpleural nodular consolidations at both lower lobes
        • mild subpleural paraseptal emphysema at both apical lung regions.
      • Mediastinum and hila: no enlarged LN or mass.
        • moderate calcified plaques of the LAD and right coronary arteries.
      • Visible abdominal-pelvic contents:
        • progressive increase in size of infiltrative prostate tumor with adjacent organs invasion and Lt pelvic side metastatic LAP compared with CT (2023/04/25).
        • many small hepatic and renal cysts (up to 2.0cm)
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • prostate with regional organs involvement and pelvic metastatic LAP and lung metastases,in progression compared with CT (2023/04/25).
      • suspect lower lobes infection or organzing pneumonia.
  • 2023-06-07 All-RAS + BRAF mutation
    • Tissue Block No: S2023-03264
    • RESULTS:
      • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-05-03 MRI - pelvis
    • With and without enhancement MRI: Pelvis
      • Prostate malignancy with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. with progression .
      • No significant nodule in the liver.
      • Enlarged lymph nodes in left obturator, bilateral internal iliac regions, perirectal regions, could be due to metastatic lymph node.
      • No ascites.
      • Non-enhancing nodules in bilateral kidneys (up to 2cm in left kidney), r/o renal cysts.
    • Impression:
      • Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Pelvic lymph nodes metastasis. With progression.
      • R/O bilateral renal cysts.
  • 2023-04-25 CT - chest
    • Indication: Malignant poorly differentiated neuroendocrine tumors of prostate with lung mets
    • Comparison was made with previous CT dated on 2023/02/02
      • Lungs:
        • no interval change of a small subpleural solid nodule (7mm) at RLL-S9, a subpleural nodule (3mm) at LLL, and two subpleural solid nodules (up to 4mm) at RML as compared with CT on 2023/02/02.
        • a new solid nodule at Rt apical lung (7mm)
        • minimal subpleural fibrosis at both lower lobes and RML.
        • mild subpleural paraseptal emphysema at both apical lung regions.
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels:
        • mild calcified plaques of the LAD and right coronary arteries.
      • Aorta: normal caliber of thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal-pelvic contents:
        • progressive in size of infiltrative prostate tumor with adjacent organs invasion and Lt pelvic side metastatic LAP compared with previous abd. CT (2022/06/17) and MRI (2022/10/26).
        • many hepatic and renal cysts (up to 2.0cm)
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression: prostate with regional organs involvement and pelvic metastatic LAP and lung metastases.
  • 2023-03-21 SONO - nephrology
    • Chronic renal parenchymal disease, mild to moderate degree
    • Bilateral renal cysts
  • 2023-03-07 ENT Hearing Test
    • Tymp: Bil type A.
    • PTA
      • Reliability FAIR
      • Average RE 29 dB HL; LE 31 dB HL.
      • RE normal to moderate SNHL.
      • LE normal to moderately severe SNHL.
  • 2023-02-02 MRI - pelvis
    • With and without enhancement MRI: Pelvis
      • Prostate malignancy with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. with partial response.
      • Non-enhancing nodules in bilateral kidneys (up to 2cm in left kidney), r/o renal cysts.
    • Impression:
      • Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. With partial response.
      • R/O bilateral renal cysts.
  • 2023-02-02 CT - chest
    • Indication: Malignant poorly differentiated neuroendocrine tumors of prostate s/p C/T
    • Imp: No evidence of recurrent/residual tumor in the study.
  • 2022-10-26 CT - chest
    • Indication: Prostate NEC with rectal invasion s/p C/T
    • Comparison was made with previous CT dated on 2022/06/17
      • Lungs:
        • no interval change of a small subpleural solid nodule (7mm) at RLL-S9, a subpleural nodule (3mm) at LLL, and two subpleural solid nodules (up to 4mm) at RML as compared with previous CT on 2022/06/17.
        • minimal subpleural fibrosis at both lower lobes.
        • mild subpleural paraseptal emphysema at both apical lung regions.
      • Vessels:
        • mild calcified plaques of the LAD and right coronary arteries.
      • Visible abdominal-pelvic contents:
        • many hepatic and renal cysts (up to 2.0cm)
      • Visualized bones:
        • marginal spurs of multiple vertebrae due to spondylosis.
    • Impression: four small lung nodules up to 7mm, stationary, some may be intrapulmonary LNs.
  • 2022-10-26 MRI - pelvis
    • Clinical history: 61 y/o male patient with Prostate NEC with rectal invasion s/p C/T.
    • With and without enhancement MRI: Pelvis
      • Prostate malignancy with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Stationary.
      • Non-enhancing nodules in bilateral kidneys (up to 1.7cm in right kidney), r/o renal cysts.
    • Impression:
      • Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Stationary.
      • R/O bilateral renal cysts.
  • 2022-09-06 SONO - nephrology
    • Chronic renal parenchymal disease, mild degree
    • Bilateral renal cysts
  • 2022-06-17 CT - abdomen, pelvis
    • Findings
      • Prior CT identifed a well-defined heterogeneous mass in between the rectum and prostage, measuring 9 cm in size, is noted again, marked decreasing in size that is c/w neuro-endocrine carcinoma S/P C/T with partial response.
      • Prior CT identified a soft tissue nodule at RLL of the lung measuring 7 x 4 mm at lung window setting is noted again, stationary. Follow up is indicated.
      • Liver and renal cysts (up to 2.0 cm).
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, and spleen.
    • Impression
      • Neuroendocrine carcinoma with rectum and prostate invasion S/P C/T shows partial response.
  • 2022-04-08 MRI - brain
    • No evidence of intracranial lesion.
  • 2022-03-11 Pure Tone Audiometry, PTA
    • PTA
    • Reliability FAIR
    • Average RE 30 dB HL; LE 36 dB HL.
    • R’t normal to moderate SNHL.
    • L’t normal to moderately severe SNHL.
  • 2022-03-01 Patho - prostate needle biopsy
    • “pelvic tumor/peri-prostatic tumor, 9 cm with possible prostatic and recal invasion”, needle biopsy — neuroendocrine tumor.
    • IHC stains:
      • CD56 (+): neuroendocrine origin,
      • CK7 (- to equivocal), CK20 (-): dis-favor rectal adenocarcinoma,
      • vimentin (-): dis-favor sarcoma,
      • CD3 (-), CD20 (-): non-lymphoma,
      • PSA (-): non-prostatic origin.
      • Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma.
  • 2022-02-24 Transrectal Ultrasound of Prostate, TRUS-P
    • huge pelvic mass with suspected prostate invasion
  • 2022-02-24 Sigmoidoscopy
    • A hard, portuding lesion with intact mucosa was noted at rectum, anterior wall.
  • 2022-02-21 CT - abdomen, pelvis
    • A heterogeneous enhancing tumor (9cm) at pelvic cavity with rectum and prostate invasion suspected malignancy.
    • A nodule (4mm) at RLL.

[MedRec]

  • 2023-09-17 POMR Urology You Chicin
    • Course of Inpatient treatment
      • After admission, pre-operation survey was within normal range. Cystoscopic exam was smoothly done on 2023/09/18. After operation, There were no fever or infetious signs noted. We had suggested the patient to receive PCN to reserve his renal function on 09/19. However, the patient refused to receive PCN during this admission and he would like to discuss with Doctor Xia.
      • Urination was normal after removing Foley in 09/19 morning. We arranged his discharge on 2023/09/19 and his follow-up at Doctor You’s out-patient clinic on 2023/09/26.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Transamin (tranexamic acid 250mg) 1# BID
  • 2023-09-12 SOAP Nephrology Hong SiCun
    • Prescription x3
      • Pentop (pentoxifylline 400mg) 1# QD
  • 2023-08-24 ~ 2023-09-01 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Neuroendocrine carcinoma with rectum and prostate invasion and lung metastasis, Stage IV s/p chemotherapy with Etoposide/Carboplatin from 2022/03/14~2022/08/09 for 6 cycles with extracapsular, seminal vesicle and left pelvic side wall invasion and pelvic lymph nodes metastases s/p chemotherapy with Topotecan(1.5mg/m2) from 2023/05/12~2023/07/27 (5th dose), disease progression, s/p chemotherapy with FOLFOX from 2023/08/29~
      • Chronic viral hepatitis B without delta-agent
      • Gout, unspecified
      • Essential (primary) hypertension
      • Anemia due to antineoplastic chemotherapy
      • Chronic kidney disease, stage 2 (mild)
      • Hordeolum externum right lower eyelid
      • Hypomagnesemia
      • Constipation, unspecified
    • CC
      • For further anti-cancer management
    • President illness
      • This 62-year-old man patient suffered from anal protruding mass with pain and bleeding in 2022/02. The abdominal CT scan on 2022-02-21 showed a heterogeneous enhancing tumor (9cm) at pelvic cavity with rectum and prostate invasion, in addition with a suspicious metastatic nodule (4mm) at RLL. The sigmoidoscopy on 2022-02-24 showed the possibility of external compression, rectum and mixed hemorrhoid.
      • The TRUS biopsy for pelvic tumor was done on 2022-03-01 and the report of biopsy showed IHC stain: Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma, IHC stain: Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma.
      • Port-A catheter insertion was done on 2022-03-11. Chemotherapy with EP (Etoposide 80mg x3 days, Carboplatin AUC:6) on 2022/03/14(C1). 2022/04/08(C2), 2022/05/16(C3), 2022/06/14(C4), 2022/07/06(C5), 2022/08/09(C6).
      • Brain MRI on 2022/04/08 showed no evidence of intracranial lesion.
      • The follow-up abdominal CT scan on 2022-06-17 showed neuroendocrine carcinoma with rectum and prostate invasion S/P C/T shows partial response. Then he was treated with oral etoposide.
      • The follow-up Chest CT on 2023-04-25 showed prostate with regional organs involvement and pelvic metastatic LAP and lung metastases. Pelvis MRI on 2023-05-03 showed 1. Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Pelvic lymph nodes metastasis. With progression. 2. R/O bilateral renal cysts. He received chemotherapy with Topotecan (1.5mg/m2, D1~D5)(self pay) on 2023/05/12(C1), 2023/06/06(C2), 2023/06/28(C3), 2023/07/12(C4), 2023/07/27(C5). Taken altogether, his disease was in progression.
      • This time, he presented with right side lower eyelid redness and protrusion for 2-3days.
      • Now, he was admitted to ward for chest CT for re-staging and receive palliative chemotherapy with Topotecan(C6)(reduce Topotecan dose(total dose 1.8mg) for prevention thrombocytopenia after chemotherapy).
    • Course of inpatient treatment
      • After admission, Right side lower eyelid redness and protrusion for 2-3days was noted, consult oph for right side lower eyelid redness and protrusion evaluation, Hordeolum, od, s/p I&C with Cravit 1gtt QID od + Tetracycline oint 1qs BID od.
      • Chronic kidney disease, stage 2 (Cr.:1.52 mg/dL, BUN:26 mg/dL), given NS 500ml IVF Q8H hydration and Pentop 1# po QD, before chemotherapy.
      • Anemia due to antineoplastic chemotherapy, BT PRBC 2unit on 2023/08/24 for correction.
      • Arranged chest CT for cancer survey on 2023/08/25 showed prostate with regional organs involvement and pelvic metastatic LAP and lung metastases, in progression compared with CT (2023/04/25). suspect lower lobes infection or organzing pneumonia.
      • He received FOLFOX (Oxalip 85mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) due to disease progression, from 2023/08/29~2023/08/31(C1D1) smoothly.
      • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
      • Chronic viral hepatitis B with Baraclude 0.5mg 1# po QDAC.
      • Gout with Feburic 80mg 0.5# po QD.
      • Hypertension with Concor 5mg/tab 1# PO QD.
      • Hypomagnesemia with Magnesium Sulfate 10%, 20mL/amp 1amp IVD BID was given for support.
      • Constipation with Through 12mg/tab 2# PO HS.
      • Post chemotherapy with Oxalip, given B-Red 1mg/mL/amp 1amp IM ST for avoid sensory peripheral neuropathies on 2023/08/31.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/09/01 and OPD followed up later.       
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Feburic (febuxostat 80mg) 0.5# QD
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Concor (bisoprolol 5mg) 1# QD
      • Through (sennoside 12mg) 2# HS
  • 2023-07-12 ~ 2023-07-16 POMR Hemato-Oncology
    • Discharge diagnosis
      • Neuroendocrine carcinoma with rectum and prostate invasion and lung metastasis, Stage IV s/p chemotherapy with Etoposide/Carboplatin from 2022/03/14 to 2022/08/09 for 6 cycles with extracapsular, seminal vesicle and left pelvic side wall invasion and pelvic lymph nodes metastases s/p chemotherapy with Topotecan (1.5mg/m2) from 2023/05/12~    
      • Chronic viral hepatitis B without delta-agent
      • Gout, unspecified
      • Chronic kidney disease, stage 2 (mild)
      • Essential (primary) hypertension
    • CC
      • For further anti-cancer management
    • Present illness
      • This 62-year-old man patient suffered from anal protruding mass with pain and bleeding in 2022/02. The abdominal CT scan on 2022-02-21 showed a heterogeneous enhancing tumor (9cm) at pelvic cavity with rectum and prostate invasion, in addition with a suspicious metastatic nodule (4mm) at RLL. The sigmoidoscopy on 2022-02-24 showed the possibility of external compression, rectum and mixed hemorrhoid.
      • The TRUS biopsy for pelvic tumor was done on 2022-03-01 and the report of biopsy showed IHC stain: Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma, IHC stain: Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma.
      • Port-A catheter insertion was done on 2022-03-11. Chemotherapy with EP (Etoposide 80mg x3 days, Carboplatin AUC:6) on 2022/03/14(C1). 2022/04/08(C2), 2022/05/16(C3), 2022/06/14(C4), 2022/07/06(C5), 2022/08/09(C6). Brain MRI on 2022/04/08 showed no evidence of intracranial lesion. The follow-up abdominal CT scan on 2022-06-17 showed neuroendocrine carcinoma with rectum and prostate invasion S/P C/T shows partial response. Then he was treated with oral etoposide.
      • The follow-up Chest CT on 2023-04-25 showed prostate with regional organs involvement and pelvic metastatic LAP and lung metastases. Pelvis MRI on 2023-05-03 showed 1. Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Pelvic lymph nodes metastasis. With progression. 2. R/O bilateral renal cysts. He received chemotherapy with Topotecan (1.5mg/m2, D1~D5) (self pay) on 2023/05/12(C1), 2023/06/06(C2), 2023/06/28(C3). Taken altogether, his disease was in progression. Now, he was admitted to ward for palliative chemotherapy with Topotecan (C4) (reduce Topotecan dose (total dose 1.8mg) for prevention thrombocytopenia after chemotherapy) on 2023-07-12.
    • Course of inpatient treatment
      • After admitted, Palliative chemotherapy with Topotecan (C4) (reduce Topotecan dose (total dose 1.8mg) for prevention thrombocytopenia after chemotherapy) on 2023-07-12 ~ 2023-07-16.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting. Chronic viral hepatitis B with Baraclude 0.5mg 1# po QDAC. Chronic kidney disease, stage 2 (mild) (Cr.:1.26mg/dL, BUN:27mg/dL) with NS 500ml IVF BID and Pentop 1# po QD. Gout with Feburic 80mg 0.5# po QD. Hypertension with Concor 5mg/tab 1# PO QD.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/07/16 and OPD followed up later.
    • Discharge prescription
      • Febric (febuxostat 80mg) 0.5# QD
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Acetal (acetaminophen 500mg) 1# PRNQ6H for fever, BT > 38’C or bone pain after G-CSF
      • Granocyte (lenograstim 250ug) QD SC on 2023/07/20, 2023/07/21, 2023/07/22
  • 2023-06-13 SOAP Nephrology
    • S: UPCR < 0.1 -> 1.71 -> 1.43
    • Prescription x3
      • Pentop (pentoxifylline 400mg) 1# QD
  • 2022-11-01 SOAP Nephrology
    • S: UPCR < 0.1
      • ChatGPT:
        • In the medical context, UPCR stands for Urine Protein to Creatinine Ratio. This is a test often used to estimate the amount of protein being excreted in the urine, and to assess and monitor kidney function.
        • Proteinuria (protein in the urine) is a common finding in many renal diseases. Creatinine, on the other hand, is a waste product that’s typically excreted at a constant rate.
        • The ratio of protein to creatinine can provide a good estimate of protein excretion over 24 hours without needing a 24-hour urine collection. High levels of protein in the urine, indicated by a high UPCR, can be a sign of kidney disease.
    • Prescription x2
      • Pentop (pentoxifylline 400mg) 1# QD
  • 2022-10-04 SOAP Nephrology
    • S: Cr 1.89, add Trental (pentoxifylline) and follow up one month
    • Prescription
      • Pentop (pentoxifylline 400mg) 1# QD
  • 2022-09-06 SOAP Nephrology
    • S
      • CKD for follow up
      • r/o carboplatin associated kidney injury, suggest follow up at regular interval
    • A/P
      • Admission for C/T EP on 2022-07-06. Using carboplatin due to impaired renal function
      • NEC, Stage IV
  • 2022-07-27 SOAP Hemato-Oncology Xia HeXiong
    • Admission for C/T EP (Carboplatin) on 2022-08-03. Using carboplatin due to impaired renal function
    • Considered hold platinum after 6 cycles of chemotehrapy, and might shift IV VP-16 to oral VP-16 after 6 cycles of EP on 2022-08-03
    • NEC, Stage IV
    • Avoid K+ food

[consultation]

  • 2023-08-24 Ophthalmology
    • Q
      • The patient is an 62-year-old male with a history of Neuroendocrine carcinoma with rectum and prostate invasion and lung metastasis, Stage IV s/p chemotherapy with Etoposide/Carboplatin from 2022/03/14~2022/08/09 for 6 cycles with extracapsular, seminal vesicle and left pelvic side wall invasion and pelvic lymph nodes metastases s/p chemotherapy with Topotecan(1.5mg/m2) from 2023/05/12~, HTN, Chronic kidney disease, stage 2.
      • He presented with lower eyelid redness and protrusion for 2-3days, we need your further evaluation and management.
    • A
      • For right lower eyelid swelling
      • S
        • Past hx:
          • Neuroendocrine carcinoma with rectum and prostate invasion and lung metastasis, Stage IV s/p chemotherapy
          • HTN
          • Chronic kidney disease, stage 2
        • OPH hx: dneied
        • NKDA
      • O
        • nVA: 20/25 ou
        • PT: 13/14mmHg
        • pupil: 3mm, +/+, no RAPD
        • Hordeolum at right lower eyelid
        • K: cl ou
        • AC: D/C ou
        • lens: NS+ ou
      • A:
        • Hordeolum, od, s/p I&C
      • P:
        • pressure patch for 30mins, avoid water contact
        • Cravit 1gtt QID od + Tetracycline oint 1qs BID od
        • pus culture has been arranged
        • Inform the risk of progression, come back earlier if s/s worsen
        • OPD f/u
  • 2022-05-10 Oral and Maxillofacial Surgery
    • Q
      • The 61y/o male has neuroendocrine carcinoma under chemotherapy. He has toothache at the second to last molar on the lower right. He took amoxicillin for 2-3 days, but in vain, so we need your help for management. Thanks!
    • A
      • Dear doctor, this is a 61-year-old male iwth neuroendocrine carcinoma and was admitted for chemotherapy.
      • He complained of biting pain recently and we are therefore consulted
      • After examiantion (radiologic study), fractured root of right lower first molar was noted
      • Assessment:
        • Tooth fractureo of #46
      • Plan:
        • Explain the findings to the patient and his family members
        • Premedication (Continue using the current inpatient antibiotic, Augmentin.)
        • Arrange extraction of tooth 46 on Thursday (05/12) in the morning.

[surigcal operation]

  • 2023-09-18
    • Surgery: Cystoscopic exam
    • Finding
      • enlarged prostate
      • tumor invasion of bladder neck
      • bilateral UO could not be found due to tumor invasion

[chemotherapy]

  • 2023-10-12 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-20 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-29 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 400mg/m2 740mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-27 - topotecan 1.5mg/m2 1.8mg NS 60mL 30min D1-5
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
  • 2023-07-12 - topotecan 1.5mg/m2 1.8mg NS 60mL 30min D1-5 (even lower topotecan)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
  • 2023-06-28 - topotecan 1.5mg/m2 2.0mg NS 60mL 30min D1-2 + topotecan 1.5mg/m2 1.8mg NS 60mL 30min D3-5 (reduce dose for prevention thrombocytopenia after chemotherapy)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
  • 2023-06-06 - topotecan 1.5mg/m2 2.0mg NS 60mL 30min D1-5 (lower topotecan)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
  • 2023-05-12 - topotecan 1.5mg/m2 2.5mg NS 80mL 30min D1-5
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
  • 2022-08-09 - etoposide 80mg/m2 140mg 1hr D1-3 + carboplatin AUC 6 450mg 2hr D1
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-07-06 - etoposide 80mg/m2 140mg 1hr D1-3 + carboplatin AUC 6 450mg 2hr D1
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-06-14 - etoposide 80mg/m2 137mg 1hr D1-3 + cisplatin 25mg/m2 40mg 24hr D1-3
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-05-16 - etoposide 80mg/m2 140mg 1hr D1-3 + cisplatin 25mg/m2 40mg 24hr D1-3
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-04-07 - etoposide 80mg/m2 139mg 1hr D1-3 + cisplatin 25mg/m2 40mg 24hr D1-3
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-03-14 - etoposide 80mg/m2 140mg 1hr D1-3 + cisplatin 25mg/m2 40mg 24hr D1-3
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-13

According to the PharmaCloud database, there are no recent records of the patient seeking services from other medical facilities. In addition, Pentop (pentoxifylline) prescribed by our nephrologist on 2023-09-12 is currently being used without any discrepancies noted.

The 5FU bolus was omitted from the FOLFOX regimen during this hospital stay due to a reduced WBC count, recorded at 3.08K/uL on 2023-10-12.

2023-09-21

According to PharmaCloud, there are no records of this patient seeking medical care at other facilities in the past three months. Our nephrologist has issued a repeat prescription for Pentop (pentoxifylline) to manage his CKD, and the medication is currently being used with no discrepancies identified.

2023-07-28

[reconciliation]

On 2023-07-07, the patient renewed prescriptions for bisoprolol and valsartan. Currently, only bisoprolol is listed as an active medication, and valsartan has not been included. As the patient’s blood pressure has consistently remained within the normal range during this hospital stay, there may not be an immediate need to reintroduce valsartan. Nevertheless, it is crucial to continue monitoring the patient’s blood pressure to assess if any further adjustments to the medication regimen are necessary.

[renal function follow-up]

This month (July), compared to previous months, the serum creatinine has returned to the normal range, and currently, no medications require renal dosage adjustment.

[thrombocytopenia]

Since starting topotecan on 2023-05-12, the patient has experienced several episodes of thrombocytopenia. Blood transfusions were administered on 2023-06-14, 2023-06-28, and 2023-07-27 in response to these events. In addition, the dosage of topotecan was sequentially reduced from 2.5 mg to 2.0 mg and then to 1.8 mg. Despite these measures, thrombocytopenia has been observed to date, but no PLT less than 50K/uL has been observed.

2023-07-25 PLT 90 10^3/uL
2023-07-11 PLT 94
10^3/uL
2023-06-28 PLT 474 10^3/uL
2023-06-20 PLT 89
10^3/uL
2023-06-12 PLT 390 10^3/uL
2023-06-01 PLT 95
10^3/uL
2023-05-25 PLT 15 10^3/uL
2023-05-10 PLT 283
10^3/uL
2023-04-27 PLT 244 *10^3/uL

2023-07-13

[reconciliation]

The patient recently renewed his prescriptions for bisoprolol and valsartan on 2023-07-07. Currently, only bisoprolol is incorporated into the active medication list, while valsartan has been left out. Given that the patient’s blood pressure measurements have consistently fallen within the normal spectrum during this hospital stay, reintroduction of valsartan may not be mandatory at this point. However, it remains important to continually monitor the patient’s blood pressure to establish whether further alterations in his medication regimen are warranted.

2023-06-29

[reconciliation]

  • This patient regularly renews his prescriptions for Biso (bisoprolol) and Dafiro (valsartan, amlodipine) for his primary hypertension at a local pharmacy. Currently, the patient is only prescribed Concor (bisoprolol), with valsartan and amlodipine excluded. As the patient’s blood pressure readings have remained within the normal range during this hospitalization, it may not be necessary to reintroduce valsartan and amlodipine at this time. However, it is prudent to continue to monitor the patient’s blood pressure to determine if further adjustments to his medication regimen are necessary.

[thrombocytopenia]

  • This patient initiated topotecan therapy on 2023-05-12, with two additional cycles administered on 2023-06-06 and 2023-06-28. The platelet levels are compiled in the following table, where “*” represents PLT < 100K/uL and “**” represents PLT < 50K/uL.

    • 2023-06-28 PLT 474 x10^3/uL
    • 2023-06-20 PLT 89 x10^3/uL *
    • 2023-06-12 PLT 390 x10^3/uL
    • 2023-06-01 PLT 95 x10^3/uL *
    • 2023-05-25 PLT 15 x10^3/uL **
    • 2023-05-10 PLT 283 x10^3/uL
  • Intravenous Topotecan is linked with a considerable incidence of thrombocytopenia. As per UpToDate, Grade 4 thrombocytopenia occurs in 27% to 29% of patients. The lowest point (nadir) typically occurs around day 15, and the duration of the thrombocytopenia typically lasts for 3 to 5 days.

  • The dose of topotecan was reduced from 2.5g to 2.0g starting from the second cycle and was further reduced to 1.8g for the last three days of the five-day administration period. This was a strategy intended to prevent further thrombocytopenia in the patient. In addition, blood transfusions were conducted on 2023-06-14 and 2023-06-28 to alleviate the impact of this side effect.

  • Currently, the patient’s platelet count (PLT) is slightly above the ULN. Although there are no current signs of thrombocytopenia, it remains critical for the healthcare team to regularly monitor the patient’s CBC as is standard procedure.

2023-06-07

[reconciliation]

  • This patient recently visited a local clinic on 2023-06-05 for acute tonsillitis and was prescribed cimetidine, acetaminophen, fenoterol, glycyrrhiza extract, and cetirizine. In addition, he was prescribed mefenamic acid and cresolsulfonate for his acute upper respiratory tract infection on 2023-06-01, with each prescription having a short duration of only 3 days. Since there are no related symptoms listed in the admission note or current medical problem list, there appear to be no medication reconciliation issues for these conditions.
  • In addition, the patient’s prescription for bisoprolol and valsartan for hypertension management was refilled on 2023-04-28 at a local pharmacy. Currently, valsartan is not listed on the active medication list, but according to the TPR panel, the patient had no record of elevated blood pressure during this hospitalization. Therefore, there is no evidence that the current regimen of Concor (bisoprolol 5 mg) 1# PO is inappropriate.

[assessment]

  • As the patient’s renal function is compromised, with a Cockcroft-Gault formula calculated CrCl of 44 mL/min, a review of the need of adjustment to the topotecan dose should be considered.
    • 2023-06-01 Creatinine 1.51 mg/dL
    • 2023-06-01 eGFR 50.02
    • 2023-06-01 BUN 39 mg/dL
  • Suggestions for modifying topotecan dosage:
    • Manufacturer’s labeling (calculate CrCl with Cockcroft-Gault method using ideal body weight): CrCl >= 40 mL/minute: No dosage adjustment necessary.
    • Kintzel 1995: CrCl 46 to 60 mL/minute: Administer 80% of usual dose.
    • O’Reilly 1996b: CrCl >= 40 mL/minute: No dosage adjustment necessary in minimally pretreated patients; however, due to an increased potential for dose-limiting toxicities, reduce the dose from 1.5 mg/m2 to 1 mg/m2 in heavily pretreated patients.
  • The dose of Topotecan given this time has been decreased by 20% from the 1.5mg/m2 administered on 2023-05-12. The current dosage appears to be without issue.

2022-08-10

  • 2022-08-09 blood creatinine 1.66 mg/dL => CrCl 40 mL/min
  • Etoposide for patients with CrCl 15 to 50 mL/minute: Administer 75% of normal dose.
  • Entecavir for patients with CrCl 30 to <50 mL/minute: Administer 50% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 48 hours.

701090824

231013

[exam findings]

  • 2023-09-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 20) / 79 = 74.68%
      • M-mode (Teichholz) = 74
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Trivial MR, mild AR, mild TR
      • Impaired LV relexation
      • Preserved RV systolic function
  • 2023-08-09 PET
    • Glucose hypermetabolism in the left pleura and left pleural effusion, compatible with the metastatic sarcoma.
    • Glucose hypermetabolism in bilateral pulmonary hilar and mediastinal lymph nodes, the nature is to be determined (reactive or metastatic lymph nodes or other nature ?). Please correlate with other clinical findings for further evaluation.
    • Several small nodular lesions in the right middle and right lower lungs show no increased FDG uptake, suggesting no evidence of tumor metastasis by this F-18 FDG PET scan.
  • 2023-08-04 Patho - pleural/pericardial biopsy
    • Pleura, left, decortication — metastatic sarcoma
    • Sections show fibroadipose tissue with round tumor cells arranged in reticular network of lace-like strands and cords within myxoid stroma.
    • The immunohistochemical stains reveal CK(-), EMA(-), Vimentin(+), CD34(-), TTF-1(-), and S-100(focal +). The mucicarmine special stain is positive. The morphology is compatible with metastatic myxoid sarcoma.
  • 2023-08-01 CT - chest
    • left remnant lung fibrosis with volome loss and massive Lt pleural effusion, increased volume of pleural effusion.
    • nodular parietal or extrapleural fat space thickening.
    • suspect metastatic nodules in Rt lung.
    • suspect mild fibrosis at RLL and RUL, stable.
  • 2023-05-02 CT - chest
    • left remnant lung fibrosis with volome loss and moderate Lt pleural effusion, increased volume of pleural effusion
    • suspect mild fibrosis at RLL and RUL, stable.
  • 2023-03-23 Bronchodilator Test
    • mild restrictive ventilatory impairement, FEV1/FVC= 82%, FVC = 75%, FEV1= 78%, positive for provocation
    • negative for provocation
    • without significant reversibility
  • 2023-01-31 CT - chest
    • left remnant lung fibrosis with volome loss and small Lt pleural effusion, stable, post treatment related?
    • suspect mild fibrosis at RLL and RUL, stable.
  • 2022-10-25 CT - chest
    • left remnant lung fibrosis with volome loss, post treatment related? and small Lt pleural effusion, stable.
    • suspect mild fibrosis at RLL and RUL, stable.
  • 2022-07-26 CT - chest
    • left remnant lung fibrosis with volome loss, post treatment related? and small Lt pleural effusion.
    • suspect mild fibrosis at RLL and RUL.
  • 2022-04-26 CT - chest
    • left remnant infection or inflammation (drug-related disease?)
    • with small Lt pleural effusion.
    • suspect mild fibrosis at RLL and RUL.
  • 2022-01-18 PET
    • Glucose hypermetabolism in the left lateral chest wall and posteromedial aspect of left lung. Post-operative inflammation may show this picture.
    • Mild glucose hypermetabolism in the right pulmonary hilar region and a mediastinal lower right paratracheal lymph node. Inflammatory process is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2022-01-17 MRI - brain
    • No brain nodule or metastasis. Mild cortical brain atrophy.
  • 2021-09-29 ECG
    • Sinus tachycardia
    • Incomplete right bundle branch block
    • Possible Inferior infarct , age undetermined
    • Abnormal ECG
  • 2021-12-29 Patho - lung total/lobe/segmental
    • Diagnosis
      • Lung, left lower lobe, VATS lobectom — Pulmonary myxoid sarcoma, FNCLCC grade 2
      • Lymph node, LN 5, left. dissection — Negative for malignancy (0/4)
      • Lymph node, LN 7, left. dissection — Negative for malignancy (0/7)
      • Lymph node, LN 9, left. dissection — Positive for tumor (3/3)
      • Lymph node, LN 11, left. dissection — Positive for tumor (2/2)
      • Lymph node, LN 12, left. dissection — Positive for tumor (1/2)
      • TNM Pathology stage: pT1N1(if cM0); AJCC prognostic stage: There is no recommended prognostic grouping at this time.
    • Immunohistochemical study: CK(-), EMA(-),CK(-), CK7(-), CK20(-), Vimentin (+), CD34(-), SMA(-), TTF-1(-), S100(-), Napsin A(-).

[MedRec]

  • 2023-08-22 SOAP Hemato-Oncology Xia HeXiong
    • S: For further management of the disease
      • Right hip chondrosarcoma 14 years ago, s/p OP, s/p R/T
      • Pulmonary myxoid sarcoma, Left lung, FNCLCC grade 2, s/p OP, s/p R/T
      • Metastatic sarcoma s/p decortication on 2023-08-02
    • A/P: Because R/T to residual metastic sarcoma of right lung is not feasible, palliative C/T with IA/IE will be considered. Arrange heart echo.
  • 2023-08-01 ~ 2023-08-11 POMR Thoracic Surgery Xie MinXiao
    • Discharge diagnosis
      • Left pleural effusion, suspect tumor recurrence status post thoracoscopis decortication of pleura on 2023-08-02
      • Left lower lung carcinoma status post video-assisted thoracic surgery left lower lung lobectomy and radical lymph node dissection and pneumolysis on 2021-12-29
      • Hypertensive heart disease with heart failure
    • CC
      • progressing dyspnea for one month
    • Present illness
      • This 69-year-old man with the history of hypertension, heart failure and hyperlipidemia under medication control. Left lower lung pulmonary myxoid sarcoma, FNCLCC grade 2 status post video-assisted thoracic surgery left lower lung lobectomy and radical lymph node dissection and pneumolysis on 2021-12-29 and radiotherapy.
      • According to the patient himself, he suffered from left chest pain after the operation, sometimes radiated to back, neck, and head. He took pain-killer if needed for almost two years. In the rescent one month, he had progressing dyspnea. Accompanied with poor appetite, body weight loss 5kg in one month was also told. He also complaint about constipation.
      • He was under regular follow up at chest and CS OPD, CT done on 2023-08-01 showed left remnant lung fibrosis with volome loss and massive left pleural effusion, increased volume of pleural effusion, nodular parietal or extrapleural fat space thickening, suspect metastatic nodules in right lung.
      • After discussing with the patient and his family on the benefits of surgical treatment as well as subsequent risks and possible complications, he was admitted for thoracoscopis decortication of pleura on 2023-08-02.
    • Course of inpatient treatment
      • After admission, pre-op assessment was done. Operation of thoracoscopis decortication of pleura was performed smoothly on 8/2. No complication was noted. Prophylactic antibiotics was prescribed for 1 day. Left chest tube with LPS -18 cmH2O and left pig-tail were done.
      • Tumor recurrence was suspected so Hema doctor was consulted. The chest tube was removed on 8/7 and the pig-tail was removed on 8/11 before discharge. The pathology report revealed metastatic sarcoma. PET scan showed glucose hypermetabolism in the left pleura and left pleural effusion, bilateral pulmonary hilar and mediastinal lymph nodes, suspect metastatic sarcoma.
      • We followed up chest x-ray which revealed improvement of left pleural effusion. Under stable condition, he discharged today and CS, HEMA OPD follow up were arranged.
    • Discharge Prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Sindine (povidone iodine aq soln) 1# QD
      • MgO 250mg 1# TID
      • Actein 200mg 1# TID
  • 2022-03-28 SOAP Radiation Oncology Chang YouKang
    • RT dose: 6600cGy/33 fractions (6 MV photon) to LLL sacrcoma bed, bronchial stump & lymphatics, 2022/02/07 to 3/28.
    • RT Side effect evaluation, 3/28: Radiation dermatitis, grade 0; N/V, grade 0; esophagitis, grade 0; pneumonitis, grade 0.
    • Plan: Adjuvant RT finishes today.
  • 2022-01-17 SOAP Radiation Oncology Chang YouKang
    • O: Conclusion of Multidisciplinary Cancer Team Meeting, Meeting Date: 20220111
      • Suggest adding a PET scan.
    • IMP:
      • Pulmonary myxoid sarcoma, FNCLCC grade 2 with group 9, 11, 12 LN metastasis (6+/18) s/p LLL lobectomy and LN dissection on 2021/12/29.
      • Favoring second primay malignancy.
    • Plan:
      • Adjuvant RT to LLL bronchus and regional lymphatics for 6600cGy/33 fractions is suggested for locoregional control.
      • CT simulation on 2/08 13:30. Possible esophagitis and pneumonitis is told. Diet education.
  • 2022-01-13 SOAP Thoracic Surgery Xie MinXiao
    • A: Pulmonary myxoid sarcoma, FNCLCC grade 2. Primay or meta.??
    • P: refer to radio-oncologist for adjuvant RT.
  • 2021-12-28 ~ 2021-12-31 POMR Thoracic Surgery Xie MinXiao
    • Discharge diagnosis
      • Left lower lung carcinoma status post video-assisted thoracic surgery left lower lung lobectomy and radical lymph node dissection and pneumolysis on 2021-12-29
      • Hypertensive heart disease with heart failure
      • Hyperlipidemia, unspecified
    • CC
      • Left chest wall pain and coughing intermittently.
    • Present illness
      • This 67-year-old man with a history of hypertension and hyperlipidemia under medication control.
      • According to the patient complained of he finished the COVID-19 vaccine on 2021/10/26. Because of general malaise,so he went to the emergency room of MacKay memorial hospital for medical treatment. Chest CT showed lung nodule in left lower lobe and biopsy showed chronic imflamation in MacKay memorial hospital.
      • He because have ​left chest wall pain and coughing intermittently, so he refer to chest surgeon for further evaluation and treatment.
      • After discussing with the patient and his family on the benefits of surgical treatment as well as subsequent risks and possible complications, he was admitted for VATS left lower lobe wedge and lymph node dissection under lung nodule in left lower lobe.
    • Course of inpatient treatment
      • After admission, pre-op assessment was done. Operation of video-assisted thoracic surgery left lower lung lobectomy and radical lymph node dissection and pneumolysis at 2rd admission day (2021/12/29). No complication was noted. Prophylactic antibiotics was prescribed for 1 day. Left chest tube with LPS -18 cm H2O was done. Chest tube was removed at post-op 2rd day. He was discharged under stable hemodynamics at post-op 2th day. Continue to follow up at the chest surgical clinic.
    • Discharge prescription
      • Actein (acetylcysteine 200mg) 1# TID
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
      • Deflam-K (diclofenac 25mg) 1# TID
      • MgO 250mg 1# TID
  • 2021-12-18, 2018-08-04, -08-30 SOAP Orthopedics Yao DingGuo
    • Diagnosis: Malignant bone neoplasm, lower limb, short bones [C40.20]

[consultation]

  • 2023-08-04 Hemato-Oncology
    • Q
      • This is a 69-year-old man with the history of hypertension, heart failure and hyperlipidemia under medication control. Left lower lung pulmonary myxoid sarcoma, FNCLCC grade 2 status post video-assisted thoracic surgery left lower lung lobectomy and radical lymph node dissection and pneumolysis on 2021-12-29. He also underwent radiotherapy.
      • This time, he was admitted for thoracoscopis decortication of pleura on 2023-08-02 due to pleural effusion, suspect tumor recurrence. Multiple tumor seeding over left pleural cavity and pericardium was found. Bloody effusion was noted about 1650mL. We plan to remove chest tube and arrange PET scan next week. We need your help for further evaluation and treatment suggestion. Thank you very much.
    • A
      • Primary pulmonary sarcoma is extremely rare and mostly metastatic, and primary pulmonary myxoid sarcoma PPMS is a rare low-grade malignant sarcoma.
      • Suggestion:
  • Pending pathology result (Recurrent? De novo?).
  • We will follow up this case. Thanks for your consultation.

[surgical operation]

  • 2023-08-02   - Op Method: VATS decortication+ close drainage.
    • Finding:
      • Multiple tumor seeding over left pleural cavity and pericardium. Bloody effusion was noted about 1650mL.
      • One 28 Fr. straight chest tube was inserted via left 8th ICS, another one pig-tail was inserted via left 7th ICS.
  • 2021-12-29
    • Op Method: VATS LLL lobectomy + RLND + pneumolysis .
    • Finding:
      • One tumor mass was noted over LLL, size about 3.0cm in diameter.
      • Some adhesion was noted over left pleural cavity, especially around the tumor site.
      • Frozen section: carcinoma.
      • One 24 Fr. straight chest tube was inserted via left 8th ICS.

[radiotherapy]

[chemotherapy]

  • 2023-09-04 - mesna 800mg NS 250mL 1hr (before ifosfamide) D1-5 + ifosfamide 1500mg/m2 2400mg NS 500mL 1hr D1-5 + doxorubicin 37.5mg/m2 60mg NS 500mL 24hr D1-2 + mesna 800mg NS 250mL (4hr after finishing ifosfamide) D1-5 + mesna 800mg NS 250mL (8hr after finishing ifosfamide) D1-5
    • dexamethasone 4mg D1-5 + diphenhydramine 30mg D1-5 + palonosetron 250ug D1 + NS 250mL D1-5 + aprepitant 125mg PO D1-3

==========

2023-10-13

[reconciliation]

The patient was prescribed a 28-day course of Concor (bisoprolol) and Livalo (pitavastatin) at Taipei City Hospital on 2023-09-27. While the former is currently being administered, the latter does not appear on the list of active medications. Please verify that the use of pitavastatin is no longer necessary.

[hypercalcemia]

Observed hypercalcemia warrants an evaluation of the PTH level to assess the likelihood of hyperparathyroidism.

  • 2023-10-13 Ca (Calcium) 4.07 mmol/L
  • 2023-10-12 Ca (Calcium) 3.85 mmol/L
  • 2023-08-01 Ca (Calcium) 3.11 mmol/L

Recommended Actions:

  • Hydration with Isotonic Saline: Replenishes intravascular volume and enhances the excretion of calcium in the urine.
  • Calcitonin Administration: Disrupts bone resorption by interfering with osteoclast activity and encourages the excretion of calcium in the urine.
  • Loop Diuretic Usage: Amplifies the excretion of calcium in the urine by inhibiting its reabsorption in the loop of Henle.
  • Glucocorticoid Therapy: Reduces the absorption of calcium in the intestines and curtails the production of 1,25-dihydroxyvitamin D by activated mononuclear cells in patients suffering from granulomatous diseases or lymphoma.

If the initial interventions are ineffective, the following alternatives could be contemplated:

  • Bisphosphonate: Disrupts bone resorption by interfering with the recruitment and functionality of osteoclasts.
  • Calcimimetic: Acts as an agonist for calcium-sensing receptors, diminishing PTH (useful in cases of parathyroid carcinoma or secondary hyperparathyroidism in CKD).
  • Denosumab: Curbs bone resorption through the inhibition of RANKL.

2023-09-21

[pancytopenia]

Pancytopenia was noted in mid-Sep, likely attributed to the initiation of the doxorubicin + ifosfamide regimen on 2023-09-05, approximately 10 days after its commencement. Following treatment with a blood transfusion on 2023-09-18, and the initiation of a consecutive 5-day course of Granocyte (lenograstim) on the same day, pancytopenia has shown successful improvement.

2023-09-20 WBC 3.63 x10^3/uL
2023-09-18 WBC 0.20 x10^3/uL 2023-09-15 WBC 0.66 x10^3/uL 2023-09-11 WBC 8.43 x10^3/uL
2023-09-01 WBC 8.80 x10^3/uL

2023-09-20 HGB 10.3 g/dL 2023-09-18 HGB 7.4 g/dL ** 2023-09-15 HGB 9.4 g/dL * 2023-09-11 HGB 10.9 g/dL 2023-09-01 HGB 13.2 g/dL

2023-09-20 PLT 138 10^3/uL 2023-09-18 PLT 25 *10^3/uL ** 2023-09-15 PLT 65 *10^3/uL ** 2023-09-11 PLT 141 10^3/uL 2023-09-01 PLT 259 *10^3/uL

701377724

231012

[exam findings]

  • 2023-07-25 MRI - pelvis
    • Findings
      • S/P hysterectomy.
      • S/P double J catheter, right side.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
    • Impression:
      • S/P hysterectomy.
      • S/P double J catheter, right side.
      • Suggest follow up.
  • 2023-07-20 CT - abdomen
    • History and indication: Malignant neoplasm of cervix uteri
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy.
      • Atrophy of left kidney. S/P right side double J catheter insertion. Fat stranding along right renal pelvis and ureter.
      • S/P Port-A infusion catheter insertion.
      • Grade 4 fatty liver.
    • IMP:
      • S/P hysterectomy. No evidence of tumor recurrence.
      • S/P right side double J catheter insertion. Fat stranding along right renal pelvis and ureter.
  • 2023-07-10 Bladder Sonography
    • PVR 6 mL
  • 2023-06-23 All-RAS + BRAF gene mutation analysis
    • Cell block No: F2022-00402 FsA1
    • RESULTS:
      • ALL-RAS: Detected (KRAS codon 12 GGT>TGT, p.G12C)
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-05-15 Pure Tone Audiometry, PTA
    • Reliability FAIR
      • Average RE 23 dB HL; LE 15 dB HL.
      • RE WNL with 2k Hz A-B gap.
      • LE normal to moderate SNHL with 4k Hz A-B gap.
  • 2023-04-28 PET
    • Two glucose hypermetabolic lesions in the left pelvic side wall region, compatible with recurrent malignancy.
    • Glucose hypermetabolism in two left paraaortic lymph nodes and a left common iliac lymph node, compatible with metastatic lymph nodes.
    • Glucose hypermetabolism in some bilateral supraclavicular lymph nodes, suggesting distant lymph node metastases.
    • Glucose hypermetabolism in the right hip joint. Inflammation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2023-04-17 MRI - pelvis
    • Clinical history: 50 y/o female patient with cervical adenocarcinoma s/p CCRT.
    • With and without contrast enhancement MRI: Pelvis
      • S/P hysterectomy.
      • There is focal soft tissue (1.5cm) in left pelvic side wall region, r/o recurrent tumor.
      • Mild left hydronephrosis.
      • T2 hyperintensity lesions, up to 2cm in left pelvic cavity, r/o lymphocele.
      • There is paraaortic lymph node (1.4cm) in the paraaortic region, r/o paraaortic lymph node metastasis.
    • Impression:
      • S/P hysterectomy with lymphocele in left pelvic cavity.
      • R/O recurrent tumor in left pelvic side wall region.
      • R/O metastatic lymph node in paraaortic region.
  • 2023-01-11 CT - abdomen
    • S/P hysterectomy.
    • There is no evidence of tumor recurrence.
  • 2022-12-31, -12-07 SONO - nephrology
    • Right hydronephrosis
  • 2022-10-14 Intravenous Pyelography, IVP
    • Intravenous pyelography and post-voiding study:
      • S/P double J catheter insertion in place, right side.
      • Mild right hydronephrosis.
  • 2022-08-29 Patho - uterus with or without SO non-neoplastic/prolapse
    • Diagnosis:
      • Utrus, cerivx, hysterectomy with frozen section (F2022-402FS) and separated “cervix” tissue (S2022-14312G) — adenocarcinoma, grade 3. with exocervical margin and parametrial invasion.
        • IHC stain: p16 (30-40% neoplastic glands show nuclear staining; Correlation of HPV molecular test might be considered), Vimentin (-), p53 (+, abberant), Napsin-A (-), ER (+, 25 %, strong intensity)
      • Uterus, endometrium, hysterectomy — involved by tumor, lower uterine segment
      • Uterus, myometrium, hystrectomy — myomas x2. No malignancy
      • Lymph node, bilateral pelvic and para-aortic, dissection (S2022-14312A-F) — free, for details, see microscopic description.
      • Adnexae, bilateral, salpingo-oophorectomy (S2022-14312H-I) —free
      • Omemtume, omentectomy (S2022-14312J) — free.
      • pT2b, at least. pN0 (if cM0); FIGO pathological stage: IIB, at least.
    • Gross description:
      • Procedure (select all that apply) - staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + para-aortic lymphnode dissection + infracolic omentectomy)
        • Uteurs: 10 x 7 x 5 cm with cauliflower shaped tumor occupying cervix and endocervix (details see below) and two myomas up to 1.5 x 1.2 x 1.2 cm in size. Left ovary: 2.5 x 2 x 1.5 cm. The tube: 4.5 x 0.8 x 0.8 cm. Right ovary: 2.5 x 2 x 1.5 cm; right tube: 4.5 x 0.8 x 0.8 cm; Omentum: 21 x 10 x 2cm. Bilateral adnexae and ometum are grossly free.
      • Tumor Size:
        • Greatest dimension: 4.5 cm
        • Additional dimensions (centimeters): 2.5 x 2.5 cm, involving distal cut end and bilateral para-metrium.
      • Tumor Site (select all that apply)- cerivx and endocervix, involving lower uterine segment, distal cut end and bilateral para-metrium.
      • Sections are taken and labeled as:
        • Tissue for frozen section: F2022-402FSA1-3: cervical tumor.
        • Tissue for formalin fixation:
        • F2022-402 Uteurs: A1-2: myomas; A3-10: additional sampling of cervical tumor (with margins inked in black); A11-12: tumor involving serosal surface.
        • S2022-14312 A: 01: left iliac lymph nodes; B: 02. left obturator lymph nodes; C: right iliac lymph nodes; D: right obturator lymph nodes; E: left para-aortic lymph nodes; F: right para-aortic lymph nodes; 07: separated tissue laveled as “cervix”; H1-2: left adnexa; I1-2: right adnexa; J: omentum.
    • Microscopic Description:
      • Histologic Type - Adenocarcinoma, NOS, p16: <70%.
      • Histologic Grade: G3: Poorly differentiated
      • Stromal invasion:
        • Depth of stromal invasion: 9 mm, to deep 1/3 of the cervix.
      • Silva Pattern of Invasion (applicable only to invasive endocervical adenocarcinomas):
        • Pattern C: Glands or papillary structures with little intervening stroma or mucin lakes with tumor cells within the cervical stroma and filling a 4x filed (5mm)
      • Other Tissue/ Organ Involvement (select all that apply):
        • Bilateral parametrium - involved
        • Bilateral ovary - free
        • Bilateral fallopian tube - free
        • Omentum- free
      • Margins:
        • Ectocervical Margin: Not Free (Cancer present)
        • Radial (Circumferential) Margin: Not Free
      • Lymphovascular Invasion: Present
      • Regional Lymph Nodes: described as follows
        • Site: (Positive: positive nodes number/total number) (Negative: 0/total number33) :
        • Pelvic Lymph Nodes:
          • Right iliac: Negative: 0/ 4
          • Left iliac: Negative: 0/ 5
          • Right obturator: Negative: 0/ 12
          • Left obturator: Negative: 0/ 5
          • Para-aortic Lymph Nodes:
          • Right para-aortic: Negative: 0/ 2
          • Left para-aortic: Negative: 0/5
      • Distant Metastasis: (if cM0).
        • NOTE1: According to AJCC staging manual 2017 8th edition page 10. “Pathologist should not report any M category unless appropriate for the specimen evaluated.” … “Only the managing physician can assign cM0 after taking into account physical examination, image, and other information”. However, the pathologists are ordered by this hospital adminstration (including the chiefs of cancer committee, Medical Department and radiation oncology) to assign the “cM” category, although pathologists are not in the position of doing so.
      • Additional Pathologic Findings :None identified
      • Special Study: p16 immunohistochemistry: (30-40% neoplastic glands show nuclear staining)
      • Comment(s)- correlation of HPV molecular test might be considered.
  • 2022-08-27 CT - abdomen
    • Imaging Report Form for Endometrial Carcinoma
      • Impression ( Imaging stage ) : T:Tx(T_value) N:Nx(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-08-27 Gynecologic ultrasonography
    • Findings
      • Uterus Position: AVF
        • Size: 77 x 58 mm
        • Myoma: 24 x 15 mm, 22 x 18 mm
      • Endometrium
        • Thickness: 10.6 mm
      • Adnexae
        • ROV Size: 38 x 18 mm
        • LOV Size: 22 x 15 mm
    • IMP: R/O hematoma accumulation at cervix 49 x 35 mm
  • 2022-06-08, -06-03 Gynecologic ultrasonography
    • IMP
      • Adenomyosis
      • Uterine myoma
  • 2022-05-03 Gynecologic ultrasonography
    • Other: RT adnexae free
    • IMP
      • R/O Mild Adenomyosis
      • Uterine myoma

[MedRec]

  • 2022-08-28 ~ 2022-09-13 POMR Obstetrics and Gynecology Huang SiCheng
    • Discharge diagnosis
      • Malignant neoplasm of cervix uteri, unspecified
      • Acute posthemorrhagic anemia
    • CC
      • Heavy and continued menstrual bleeding with dysmenorrhea for 2 months
    • Present illness
      • This 50-year-old lady, G0P0, no sexual history, without any systemic disease, was admitted to our ward for ATH and possible BSO in figuration of malignancy due to heavy and continued menstrual bleeding for 2 months.
      • According to the patient, she had been at her usual health status until last year, her menstrual cycle had stopped for half year, but another menstrual cycle began again since 2021/12/24, and the period had persisted until now. About 6 months ago (2022/02), she visited GYN OPD, and myoma was noticed. Her menstrual cycle was regular then, with duration/interval of 6-7/26-28 days. At OPD in 2022/05, GYN sonar was done and showed mild adenomyosis and myomas in size of 1.7x1.2cm and 2.1x1.2cm. In 2022/06, her menstrual amount increased a lot with blood clots, and she visited our ER, and she would change her night sanitary pad per 5 minutes then. GYN sonar was also done and showed adenomyosis and myomas in size of 2.5x2.4cm and 3.2x2.2cm. She also received blood transfusion. CA-125 showed 46.3U/mL. In 2022/08, she started to notice dysmenorrhea, too. And painkillers could not relieve her pain. For these 2 days, she again experienced large amount of vaginal bleeding and came to our ER.
      • At our ER on 08/27, her vital signs were T/P/R: 35.4/98/20, BP: 130/80 mmHg. Her Hb decreased from 9.3 to 8.5 in a day, and she received blood transfusion 4U. GYN sonar showed hematoma accumulation at cervix in size of 4.9x3.5cm. Today, she fainted at ER toilet, and Hb decreased from 9.4 to 8.5 in 7 hours. Due to above condition, she was admitted to our ward for ATH and possible BSO in figuration of malignancy and received further management.
    • Course of inpatient treatment
      • After admission, emergent staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + para-aortic lymphnode dissection + infracolic omentectomy) was done on 8/28. Because she had anemia and mild loss of blood during the surgery, blood transfusion with pRBC was done. Bilateral drainage tube were inserted during the surgery. A total amount of 50ml clear red fluid was drained. However, drainage increased on 9/1 (vs amount on 8/31) with a yellowish color and was sent to measure its creatinine level. Creatinine result was 22.2mg/dL, suggesting a possible urinary tract injury.
      • The patient did not have unstable vital signs, abdominal pain, or other peritoneal signs. A Foley catheter was inserted. GU doctor was consulted and abdominal CT was arranged on 9/3. Right distal ureteral leak was reported. We had well exaplained the current condition, including the benefits of surgery, to the patient with GU man on 9/4. After discussed, laparoscopic urinary tract repair surgery will perform by GU surgeon on 9/6. Followed lab on 9/4 show hypoalbuminemia and hypokalemia and self paid albumin and potassium supplement were prescribed.
      • Note
        • 2022/09/05: pathology report
          • Cervical cancer, adenocarcinoma, grade 3
          • Complicated with exocervical margin and parametrial invasion.
          • Staging: pT2bN0Mx, FIGO stage: IIB
        • 2022/09/06: double J insertion
        • 2022/09/08: Gynecological Cancer Discussion Meeting
          • Oncology radiation contacted for the planning of further treatment
        • 2022/09/12: Cystography via foley catheter
    • Discharge prescription
      • Ceficin (cefixime 100mg) 2# BID
      • Metrozole (metronidazole 250mg) 1# QID
      • MgO 250mg 2# QID
      • Through (sennoside 12mg) 1# HS
      • Foliromin (ferrous sodium citrate 50mg) 1# BID
      • Acetal (acetaminophen 500mg) 1# QID if wound pain
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID

[consultation]

  • 2022-09-09 Radiation Oncology
    • A
      • A: Adenocarcinoma, grade 3, of the uterine cervix, with exocervical margin and parametrial invasion, stage pT2bN0 (cM0); FIGO pathological stage: IIB, s/p staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + para-aortic lymphnode dissection + infracolic omentectomy).
      • P: CCRT is indicated for this patient with the following indicators: exocervical margin and parametrial invasion, stage pT2bN0 (cM0); FIGO pathological stage: IIB, and staging surgery
        • Goal: curative
        • Treatment target and volume: pelvis
        • Technique: VMAT/IGRT and IVRT
        • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, 5040cGy/28 fractions of the cervical and parametrial involved margin area, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface area by IVRT.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her sister. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0930, 2022-9-22.
  • 2022-09-09 Infectious Disease
    • Q
      • This 50-year-old lady, G0P0, no sexual history, without any systemic disease. This is a case of cervical Cancer, adenocarcinoma, grade 3.with exocervical margin and parametrial invasion. pT2b, at least. pN0 (if cM0); FIGO pathological stage: IIB, at least. Status post hysterectomy and bilateral salpingo-oophorectomy on 2022/08/28. Complicated with right distal ureteral leak post double J insertion on 2022/09/06. We sent ascites (drainage from cul-de sac) for bacteria culture. The report showed growth with pseudomonas putida. As a result, we need your expertise and help for antibiotic use. Thank you.
    • A
      • Ascites culture: Pseuodomonas putida, Chryseobacter indologens
      • Cr: 0.51, CRP:0.43
      • Impression: Complicated intra-abdominal infection is impressed
      • Suggestion:
      • Empirical antibiotics with finibax 500mg iv q8h is suggested
      • Please adjust antibiotics according to clinical condition and culture susceptibility results.
  • 2022-09-02 Urology
    • Q
      • This 50-year-old lady diagnosed with endometrial tumor r/o malignancy and received staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection+ para-aortic lymphnode dissection + infracolic omentectomy ) on 2022/08/28.
      • Bilateral drainage tube were inserted during the surgery.
      • However, drainage increased and we had sent this fluid to check its creatinie. Cr was 22.2mg/dL and urinary tract injuries should be considered.
      • As we discussed at phone, we need your help for evaluation. Thanks a lot!
    • A1
      • This 50 y/o female received staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + para-aortic lymphnode dissection + infracolic omentectomy) on 2022/08/28. Increasing drainage amount with suspected urine leakage was found today. Since she still had urine output aroung 500ml/8hr, complete transection of ureter was not likely. Please arrange CTU for further evaluation first.
    • A2 2022-09-03 13:33:52
      • CT showed right lower ureter leakage
      • The deficit of ureter may be 2.5cm in ureter reimplantation setting
      • Surgical repair may be carried out on 2022/09/06 afternoon
      • Therefore, we may have plenty of time to explain situation to her and her family.
  • 2022-08-28 Obstetrics and Gynecology
    • A
      • GYN Note
        • still hypermenorrhea with blood clots
        • stronly requested admission
      • Hb-9.4 post blood transfusion packRBC 4u
      • sex[-]
      • Imp:
        • uterine myoma
        • adenomyosis
        • cervical lesion?
        • anemia
        • hypermenorrhea with blood clots
      • Plan
        • Phone contact with Professor Huang SiCheng
        • Arrange admission under service of Professor Huang SiCheng
  • 2022-08-27 Obstetrics and Gynecology
    • Q
      • Returning visit 2022-08-27 19:48
      • Excessive vaginal bleeding, hospitalization requested.
    • A
      • Due to persistent symptoms, she visited our ER again, and we were consulted for evaluation.
      • C.C.
        • Massive vaginal bleeding with blood clots for 2 days. The patient needs to be wrapped in an adult diaper, as sometimes it immediately becomes full when standing up.
      • Physical examiantion
        • Vital signs stable, afebrile
        • Active vaginal bleeding (+)
        • Pad: moderate amount of bleeding, with scanty blood clots
      • Lab
        • WBC: 7.66K
        • Hb: 9.3 -> 9.1 -> 8.5 g/dL (08/27 1am -> 7am -> 8pm)
      • Image
        • US: (1) EM: 10.6mm (2) Uterine myomas: 24X15mm, 22X18mm (3) Adenomyosis
      • Impression
        • Abnormal vaginal bleeding, cause to be determined
      • Suggestion
        • Please recheck CBC after transfusion is completed. If Hb improves and her vital signs are stable, may consider discharge with medication.
        • Please prescribe Naposin 1# TID X 2 days + Ergometrine 1# BID x 2 days after discharge. Please be sure to inform the patient to continue taking the other medications prescribed earlier, but please stop Keto and start taking Naposin! (This has been communicated to the patient, please remind again, thank you)
        • OPD follow-up at Dr. Zeng’s clinic on W3.
        • The patient has been fully informed that this is a case of abnormal bleeding. Emergency treatment will be given in the emergency room and life signs will be ensured to be stable. Further examinations and treatment will be carried out in the following outpatient follow-up. The patient expressed that they would like to return to Dr. Zeng’s clinic.
  • 2022-08-27 Obstetrics and Gynecology
    • Q
      • Triage Level: 2 Vaginal bleeding > Heavy vaginal bleeding
        • The chief complaint is vaginal bleeding starting from 5 o’clock in the evening.
        • Menstrual period started on 2021/12/14 and has not stopped till now,
        • no trauma or other concerns, GYN Dr. Shao Zhixuan said to hang in the department of internal medicine first.
        • Also experiencing menstrual pain.
    • A
      • This 50y female, sex(-), LMP: 2021/12, D/I: 5/28-30, history of adenomyosis s/p Visanne use and Leuplin on 2022/08/13, intermittent vaginal bleeding and spotting since 2021/12, episodes of massive vaginal bleeding twice in 2022/06, was admitted this time due to massive vaginal bleeding with blood clots tonight.
      • S:
        • denied systemic disease or surgical history
        • mild dizziness, no SOB
        • intermittent vaginal bleeding and spotting since 2021/12
        • massive vaginal bleeding with blood clots tonight
      • O:
        • TAS + TRS: UT 77x61x58mm, ant 22x18mm, post 24x15mm, RO 38x18mm, LO 22x15mm, R/O hematoma at cervix 49x35mm
        • PE: hymen was intact, blood clots (+), pelvic exam cannot be approached
        • BP: 130/80, HR 98, Hb: 9.3
      • A:
        • DUB, R/O perimenopausal status; cervical lesion cannot be ruled out
      • P:
        • pRBC 2u was given at ER
        • Please prescribe NSAID (keto, naproxen…), transamine, oxytocin for uterine contraction; Fe supplement after discharge
        • Consider further image for cervical lesion such as CT or MRI
        • Suggest F/U at Dr. Zeng LunNa OPD next week and discuss if surgical intervention is needed
  • 2022-06-04 Obstetrics and Gynecology
    • A
      • KEEP Acetaminophen PO, Ergonovine PO, Transamin PO for 3 days
      • OPD follow-up, already booked an appointment with Dr. Tseng on Wednesday
      • The patient visited emergency room yesterday and came to the emergency room again today for the same reason. Additional prescription of Visanne, 1 tablet orally at bedtime for 5 days (please remind the patient to take it before sleeping)
      • Please take a blood sample, Please check LH, FSH, E2, CA125
  • 2022-06-03 Obstetrics and Gynecology
    • Q
      • Triage Level: 3 Vaginal bleeding > Coagulation abnormality - moderate or mild bleeding. Family said the patient’s period has been going on for 6 months and seeing a doctor hasn’t helped. Just now there was a particularly large amount of blood loss, causing dizziness and weakness.”
        • large amount of vaginal bleeding just now
        • Changing a diaper every five minutes
        • denied sex intercourse
        • no abd pain, no chest pain, no N/V, no diarrhea
      • 2022/05/03 Gynecologic ultrasonography
        • Uterus: 10.0 x 5.3cm
        • Myometrum: Anterior/Posterior wall: 2.07/2.03 cm
        • myoma: 1.7x1.2cm, 2.1x1.2cm
        • EM: 0.81cm
        • Mild Adenomyosis
    • A
      • S
        • 49y/o, female, sex(-), LMP: 2021/12/14
        • Hx: Adenomyosis, Danazol since 5/3
        • vaginal bleeding for 6 month
      • O:
        • pregnancy test (-), WBC: 7420, Hb: 7.7
        • CRP: 1.64,
        • sono: Uterus: 11.2x5cm, EM: 0.54
        • myoma: 33x23mm, 22x15mm
        • bilateral adnexa free
        • CDS: no fluid
      • IMP:
        • Adenomyosis
        • Uterine myoma
      • P:
        • Acetaminophen PO, Ergonovine PO, Transamin PO for 3 days
        • OPD follow

[surgical operation]

  • 2022-12-20
    • Surgery
      • Endoscopic internal dilatation of right ureter    
    • Finding
      • Right lower ureter stricture, no contrast extravasation during retrograde pyelography    
      • A 7Fr. 24cm DBJ inserted to right ureter
  • 2022-08-28
    • Surgery
      • Diagnosis: endometrial tumor r/o malignancy s/p staging surgery.
      • Operation: staging surgery (ATH + BSO + bilateral pelvic lymphnode dissection + para-aortic lymphnode dissection + infracolic omentectomy)   - Finding
      • endometrial tumor r/o malignancy s/p staging surgery.
      • Frozen: malignancy
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, tense contact with bladder, peritoneum dut to tumor mass accupied, severe adhesion to bowel. frzen pelvis.
      • Adnexa:
        • LOV: 3x2x2 cm, smooth surface.
        • ROV: 3x2x2 cm, smooth surface.
        • Fallopian tube: bilateral grossly normal
      • CDS: invisible due to tumor mass occupied
      • Ascites: bloody, minimal
      • Bilateralpelvic lymph nodes: normal(-), enlarged(-), indurated(+)
      • Bilateralpara-aortic lymph nodes: normal(-), enlarged(-), indurated(+)
      • Omentum: grossly normal
      • Insert two JVAC over cu-de-sac
      • After the operation, optimal debulking surgery was achieved.
      • R0: no residual tumor
      • Estimated blood loss:
      • Blood transfusion: PRBC 6u FFP 6u
      • Complication: nil.

[radiotherapy]

[chemotherapy]

  • 2023-10-12 - bevacizumab 15mg/kg 1200mg NS 250mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-15 - bevacizumab 15mg/kg 1200mg NS 250mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-22 - bevacizumab 15mg/kg 1200mg NS 250mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-27 - bevacizumab 15mg/kg 1200mg NS 100mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-04 - bevacizumab 15mg/kg 1200mg NS 100mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-09 - bevacizumab 15mg/kg 1200mg NS 100mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-16 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 300mg D5W 500mL 3hr + cisplatin 50mg/m2 90mg NS 500mL 24hr (If NHI approved, Avastin will be changed to 1200mg)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-17 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-10 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-03 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-10-27 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-10-20 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-10-13 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (Y-sited with cisplatin) (CCRT)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1

G-CSF

  • Granocyte (lenograstim 250ug)
    • 2023-10-04 ~ 2023-10-05 OPD 2D
    • 2023-09-20 ~ 2023-09-22 IPD 3D
    • 2023-09-07 ~ 2023-09-08 OPD 2D
    • 2023-08-30 ~ 2023-09-13 OPD 14D?
    • 2023-08-28 ~ 2023-08-30 IPD 3D
    • 2023-08-09 ~ 2023-08-10 OPD 2D
    • 2023-07-31 ~ 2023-08-02 IPD 3D
    • 2023-07-10 ~ 2023-07-12 IPD 3D
    • 2023-07-13 ~ 2023-07-15 OPD 3D
    • 2023-06-14 ~ 2023-06-16 IPD 3D
    • 2023-05-25 ~ 2023-05-27 OPD 3D

==========

2023-10-12

There were no medication reconciliation issues when reviewing PharmaCloud and HIS5 records.

[Leukemia has been managed more effectively]

Leukopenia has become less severe and less frequent following the intermittent administration of prophylactic/therapeutic Granocyte (lenograstim) in accordance with chemotherapy cycles. This approach has improved the management of this side effect.

  • 2023-10-11 WBC 3.54 x10^3/uL
  • 2023-10-04 WBC 2.45 x10^3/uL *
  • 2023-09-27 WBC 4.34 x10^3/uL
  • 2023-09-14 WBC 3.82 x10^3/uL
  • 2023-09-07 WBC 2.55 x10^3/uL
  • 2023-08-30 WBC 3.34 x10^3/uL
  • 2023-08-16 WBC 3.31 x10^3/uL
  • 2023-08-09 WBC 2.66 x10^3/uL *
  • 2023-07-20 WBC 6.37 x10^3/uL
  • 2023-07-13 WBC 1.05 x10^3/uL **
  • 2023-07-03 WBC 4.49 x10^3/uL

2023-08-22

[reconciliation]

Currently, the patient’s medication records are not accessible on PharmaCloud. However, after reviewing the HIS5 records, no medication reconciliation issues were found.

[leukopenia]

At this time, the patient is not experiencing severe leukopenia. Any leukopenia events that have occurred since the start of the [bevacizumab paclitaxel cisplatin] regimen on 2023-05-26 have been treated with G-CSF administrations without reducing the dose of paclitaxel or cisplatin.

  • 2023-08-16 WBC 3.31 x10^3/uL
  • 2023-08-09 WBC 2.66 x10^3/uL * 2023-08-09 2-day G-CSF
  • 2023-07-20 WBC 6.37 x10^3/uL 2023-07-31 3-day G-CSF
  • 2023-07-13 WBC 1.05 x10^3/uL ** 2023-07-10 6-day G-CSF
  • 2023-07-03 WBC 4.49 x10^3/uL
  • 2023-06-21 WBC 3.73 x10^3/uL
  • 2023-06-14 WBC 3.03 x10^3/uL 2023-06-14 3-day G-CSF
  • 2023-06-01 WBC 5.07 x10^3/uL
  • 2023-05-25 WBC 1.16 x10^3/uL ** 2023-05-25 3-day G-CSF
  • 2023-05-11 WBC 6.21 x10^3/uL
  • 2023-05-01 WBC 7.21 x10^3/uL

2023-07-04

Based on the PharmaCloud database, this patient has exclusively attended our hospital for outpatient and inpatient services across the departments of urology, obstetrics and gynecology, radiation-oncology, and hemato-oncology in the past three months. No issues were found during medication reconciliation.

2023-06-09

[reconciliation]

  • According to the PharmaCloud database, this patient has only visited our hospital for outpatient and inpatient services in the departments of urology, obstetrics and gynecology, radiation-oncology and hemato-oncology in the past three months. No medication reconciliation issue identified.

[more intensive hydration]

  • Serum creatinine and BUN both show an upward trend and BUN has exceeded the upper limit of normal. Hypomagnesemia was also observed. Cisplatin-induced nephrotoxicity might present as kidney injury and/or as electrolyte disturbances (eg, hypomagnesemia). A total of 1350mL of fluid was supplemented during the regimen administration (NS 250mL before cisplatin, 100mL simultaneously with bevacizumab, 500mL simultaneously with cisplatin, D5W 500mL with paclitaxel), this already takes hydration into consideration. It might be considered increasing the NS volume (for instance, introducing 500mL of NS both before and after the administration of cisplatin), and encourage the patient to hydrate more during the day.
    • 2023-06-01 Creatinine 0.84 mg/dL
    • 2023-05-25 Creatinine 0.85 mg/dL
    • 2023-05-13 Creatinine 0.82 mg/dL
    • 2023-05-11 Creatinine 0.75 mg/dL
    • 2023-05-01 Creatinine 0.78 mg/dL
    • 2023-04-26 Creatinine 0.79 mg/dL
    • 2023-04-13 Creatinine 0.86 mg/dL
    • 2023-03-16 Creatinine 0.60 mg/dL
    • 2023-02-16 Creatinine 0.57 mg/dL
    • 2023-01-19 Creatinine 0.50 mg/dL
    • 2023-06-01 BUN 31 mg/dL
    • 2023-05-25 BUN 22 mg/dL
    • 2023-05-01 BUN 19 mg/dL
    • 2023-04-13 BUN 19 mg/dL
    • 2023-03-16 BUN 13 mg/dL
    • 2023-02-16 BUN 15 mg/dL
    • 2023-01-19 BUN 10 mg/dL
    • 2023-06-01 Mg (Magnesium) 1.8 mg/dL
    • 2023-04-26 Mg (Magnesium) 2.2 mg/dL

[leukopenia]

  • This patient last received paclitaxel and cisplatin on 2023-05-15 and a WBC nadir of 1.16K/uL was noted on 2023-05-25. Paclitaxel carries a Boxed Warning regarding bone marrow suppression and recommends frequent peripheral blood cell counts for all patients receiving the drug. Granocyte (lenograstim 250ug) was administered for three consecutive days starting on 2023-05-25.

  • According to the reimbursement guidelines of the Taiwan National Health Insurance, the use of G-CSF is allowed for patients with non-hematologic malignancies who have a WBC count of less than 1000/uL or an absolute neutrophil count (ANC) of less than 500/uL after chemotherapy. This patient meets the specified criteria (neutrophil 14.7%), so G-CSF can be prescribed to manage leukopenia following this round of chemotherapy.

    • 2023-06-01 WBC 5.07 x10^3/uL
    • 2023-05-25 WBC 1.16 x10^3/uL
    • 2023-05-11 WBC 6.21 x10^3/uL
    • 2023-05-01 WBC 7.21 x10^3/uL
    • 2023-05-25 Neutrophil 14.7 %

701455726

231012

[diagnosis] - 2023-03-09 admission note

  • Pancreatic ductal adenocarcinoma with doudoenal obstruction with several mesenterric tumor seeding cT4N2M1, stage IV, status post laparoscpe vagotomy with gastrojejunostomy on 2022/10/31 and chemotherapy with FOLFIRINOX from 2022/12/07
  • Chronic viral hepatitis B without delta-agent
  • Essential (primary) hypertension
  • Gastro-esophageal reflux disease with esophagitis
  • Diarrhea, unspecified
  • Unspecified hemorrhoids

[past history] - 2023-03-09 admission note

  • Hypertension in 2004 with Nifedipine S.R. 30mg 1# PO QD and Urosin 100mg 1# PO QD control.   

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-08-23 Needle Aspiration Cytology - thyroid
    • Negative; Benign
  • 2023-08-22 SONO - thyroid
    • Right 0.35 cm; 2.84 cm heterogeneous, 1.29 cm thyroid nodule
    • Suggest FNA to dominant nodule
  • 2023-07-13 CT - abdomen
    • History and indication:
      • Pancreatic ductal adenocarcinoma with doudoenal obstruction with several mesenterric tumor seeding cT4N2M1, stage IV.
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P gastro-jejunal bypass. Much regression of pancreatic cancer but still presence duodenum, SMV and portal vein invasion. Some LNs at retroperitoneum.
      • Liver cysts (up to 0.9cm).
      • Focal fat stranding along D-colon.
      • Right thyroid nodules (up to 2.0cm).
    • IMP:
      • S/P gastro-jejunal bypass. Much regression of pancreatic cancer but still presence duodenum, SMV and portal vein invasion. Some LNs at retroperitoneum.
  • 2023-06-07 All-RAS + BRAF mutation
    • Tissue Block No: S2022-17588
    • RESULTS:
      • ALL-RAS: Detected (KRAS codon 12 GGT > GAT, p.G12D)
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-03-11 CT - abdomen
    • Clinical history: 52 y/o male patient with pancreatic canceer
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P gastroenteral anastomosis and stenting.
      • There is still pancreatic head malignancy (around 3.5cm) with adjacent vascular involvement.
      • There are small liver nodules, suspected liver cysts.
      • Thyroid nodule, 2.1cm in right lobe, suspected thyroid goiter.
    • Impression:
      • Pancreatic malignancy with adjacent vascular involvement.
      • S/P gastroenteral anastomosis and stenting.
      • Suspected liver cysts. Suggest follow up.
  • 2022-12-05 Standing KUB
    • S/P metalic autosuture projecting at left middle abdomen.
    • S/P endoscopic gastrojejunostomy.
  • 2022-11-01 Patho - peritoneum biopsy
    • Labeled as “mesentery”, excision — ductal carcinoma.
    • Specimen submitted in formalin consists of 1 piece(s) of tan, irregular tissue measuring 0.5 x 0.4 x 0.3 cm. All for section(s) in one cassette(s).
    • Section shows markedly fibrotic tissue with ductal carcinoma.
    • IHC stains: CA-19-9 (weak +), CK19 (+), compatible with pamcreatic origin.
  • 2022-10-24 Panendoscopy
    • Diagnosis
      • Status post endoscopic gastroenterostomy with LAMS placement (note: LAMS, lumen-apposing metal stent)
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
      • Gastric ulcer, LAMS site
      • Edematous duodeanl mucosa, bilateral loop
    • Suggestion
      • consider tubular SEMS (note: SEMS, self-expandable metallic stent)
  • 2022-10-24 ERCP, Endoscopic Retrograde Cholangiopancreatography
    • Indication: For LAMS revision
    • Symptoms: vomiting
    • Premedication: Buscopan 20mg + Alfentanil 0.25mg IV
    • Anesthesia: IV anesthesia
    • Diagnosis:
      • Gastric outlet obstruction, s/p endoscopic gastroenterostomy with successful LAMS placment but poor functionality,
      • s/p double pigtail stenting
    • Suggestion:
      • Suggest further metal stent placement for definite treatment.
      • Liquid diet.
  • 2022-10-21 CT - abdomen
    • History:
      • 20221009 CT:pancreatic uncinate process cancer 3.6 cm with adjacent duodenum invasion (causing gastric outlet obstruction), SMA, SMV and portal vein invasion. Some LNs at retroperitoneum. cT4N2M0, cstage:III
      • 20221018 EUS guided gastroenteral anastomosis is achieved with hot AXIOS LAMS under guidance of EUS and fluoroscopy.
    • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
    • Findings:
      • S/P gastroenteral anastomosis with hot AXIOS LAMS self expanding metal stent. However, the stomach still shows marked distention with fluid collection.
        • please correlate with clinical condition.
      • Prior CT identified pancreatic uncinate process cancer with gastric outlet obstruction is noted again, stationary.
      • There is no hyper-or hypodense lesion in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
      • There is no ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • IMP:
      • S/P gastroenteral anastomosis with hot AXIOS LAMS self expanding metal stent. However, the stomach still shows marked distention with fluid collection.
  • 2022-10-20 Upper GI series
    • Findings
      • S/P gastric stenting.
      • The contrast medium passage from oral cavity through esophagus to stomach, stasis of contrast medium in the stomach with passage of some contrast medium into the duodenum.
    • Impression:
      • S/P gastric stenting, partial gastric obstruction.
  • 2022-10-18 EUS, Endoscopic Ultrasonography
    • Indication: pancreatic cancer with gastric outlet obstruction
    • Symptoms: refractory vomiting
    • Pre-EUS diagnosis: Gastaric outlet obstruction
    • Diagnosis
      • Pancreatic cancer, uncinate process, with gastric outlet obstruciton s/p AXIOS LAMS (2 cm)
      • trivial ascites
    • Suggestion
      • standing abdomen tomorrow
  • 2022-10-13 Needle Aspiration Cytology - pancreas
    • Pancreas: adenocarcinoma
  • 2022-10-13 Patho - pancreas biopsy
    • Pancreas, head, EUS-FNB — ductal adenocarcinoma
    • Microscopically, it shows ductal adenocarcinoma composed of neoplastic ductal glands with invasive growth pattern and surrounding fibrous stroma. The tumor shows nuclear hyperchromasia, pleomorphism and increased N/C ratio.
  • 2022-10-12 EUS, Endoscopic Ultrasonography
    • Indication: panc head tumor
    • Symptoms: severe abdominal pain
    • Pre-EUS diagnosis: Panc cancer
    • Diagnosis
      • Highly suspected pancreatic head cancer, s/p CH-EUS & EUS/FNB (A)
      • Duodenal narrowing, IDA to proximal 3nd portion, with partial obstruction, s/p biopsy (B)
      • Pancreatic head cystic lesion
      • Reflux esophagitis LA Classification grade D
      • Post NG insertion
      • Ascites
  • 2022-10-11 Panendoscopy
    • Indication: Abdominal distention
    • Premedication: Xylocaine local spray
    • Anesthesia: No anesthesia
    • Diagnosis
      • Suboptimal study due to much food residual retention in stomach and duodenum, favor gastric outlet obstruction cause by uncinate process tumor
      • Reflux esophagitis LA Classification grade C
    • Suggestion
      • Arrange EUS-FNB for uncinate process tumor
      • Please keep NG tube decompression for this patient
  • 2022-10-11 SONO - abdomen
    • Indication:Pancreatic lesion
    • Diagnosis (poor echo window)
      • Pancreatic tumor, uncinate process
      • suspected calcified spot, right lobe
      • Duodenal 3rd portion and gastric lumen was dilated
    • Suggestion
      • Arrange EUS-FNB for pancrease tumor
  • 2022-10-09 CT - abdomen
    • History and indication: suspect GI tract cancer
    • Findings
      • A poor enhancing tumor (3.6cm) at ucinate process of pancreas with adjacent duodenum, SMA, SMV and portal vein invasion. Some LNs at retroperitoneum.
      • Liver cysts (up to 0.9cm).
      • Small nodules at RLL.
      • Distention of stomach and duodneum.
      • Focal fat stranding along D-colon.
      • Normal appearance of spleen, adrenals and kidneys.
      • Normal appearance of gallbladder.
      • Right thyroid nodules (up to 2.0cm).
      • Intact bony structures.
      • No ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • S/P NG tube indwelling.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T4(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)

[MedRec]

  • 2023-09-21 SOAP Gastroenterology Wang JiaQi
    • S
      • Dx: Pancreatic ductal adenocarcinoma with doudoenal obstruction with several mesenterric tumor seeding cT4N2M1, stage IV, status post laparoscpe vagotomy with gastrojejunostomy on 2022/10/31 under chemotherapy with FOLFINOX from 2022/12/07
      • CH-B under tx
      • Essential (primary) hypertension
      • diarrhea for ms. stool 5-10/day even under imodium 2/day. esp post meal. gurgling (+).
      • Now stool 3/day
      • herpes zoster
      • on C/T; just discharge
      • bw stable
      • No op due to tumor near vessel
    • Prescription
      • Protase (pancrelipase 280mg) 1# TID
      • Dicetel (pinaverium bromide 100mg) 1# TID
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • loperamide 2mg 1# BID
  • 2022-11-28 ~ 2022-12-08 POMR Hemato-Oncology
    • Discharge diagnosis
      • Pancreatic head and neck carcinoma with lymph node metastasis, T4N2M0, stage III
      • Malignant neoplasm of head of pancreas
      • Essential (primary) hypertension
      • Hypokalemia
      • Diarrhea, unspecified
      • Chronic viral hepatitis B without delta-agent
      • Fever, unspecified
      • Hypomagnesemia
    • Course of inpatient treatment
      • After admitted, IVF supplementation for poor appetite. Hypokalemia (K:2.9 -> 3.2 -> 3.7mmol/L) with 0.298% KCl in NS 500ml IVF BID from 2022/11/28~2022/12/07. Hypomagnesemia (Mg:1.7 -> 2.1mg/dL) with MgSO4 1pc iv QD from 2022/11/30~2022/12/07. Diarrhea with Smecta 1pk po TIDAC and Ufunin 1# po PRNQ6H. Fever, R/O sepsis with Antibiotic with Tapimycin 4.5gm iv Q6H from 2022/11/30~2022/12/07 and Panadol 1# po PRNQ6H for BT > 38’C. Chemotherapy with FOLFIRINOX (Oxalip 65mg/m2, Campto 120mg/m2, LV 300mg/m2, 5FU 300mg/m2, 5FU 300mg/m2 and 2400mg/m2) (C1D1) from 2022/12/05~2022/12/07. Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting. Chronic viral hepatitis B with Baraclude 0.5mg 1# po QDAC. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2022/12/08 and OPD followed up later.
    • Prescription
      • Mopride (mosapride citrate 5mg) 1# TID
      • Smecta (dioctahedral smectite 3mg) 1# TIDAC
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • loperamide 2mg 1# PRNQ6H (for diarrhea > 2 times)
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Protase (pancrelipase 280mg) 1# TID
  • 2022-11-22 SOAP Hemato-Oncolgoy
    • Tx Plan: Neoadjuvant C/T with FOLFIRINOX followed by surgical intervention

[consultation]

  • 2023-08-22 Metabolism and Endocrinology
    • Q
      • This 52-year-old man patient is a case of Pancreatic ductal adenocarcinoma with doudoenal obstruction with several mesenterric tumor seeding, cT4N2M1, stage IV, status post laparoscpe vagotomy with gastrojejunostomy on 2022/10/31 and chemotherapy with FOLFINOX from 2022/12/07 and immunity therapy with Nivolumab from 2023/08/21.
      • Abdominal CT on 2023/07/13 showed S/P gastro-jejunal bypass, much regression of pancreatic cancer but still presence duodenum, SMV and portal vein invasion, some LNs at retroperitoneum and right thyroid nodules (up to 2.0cm). Now, for evaluate right thyroid nodules (up to 2.0cm) examine. Thank you.
    • A
      • According to CT, the mass seem outside the thyroid lobe, unable to rule out lymphadenopathy.
      • A thyroid echo has already been ordered, and it is also noted to examine the condition of the neck lymph nodes.
      • Further orders may be required:
        • sono, neck => for cervical lymphadenopathy survey
        • thyroid nodule FNA or lymph node FNA => for tissue proof
  • 2022-10-13 General and Digestive Surgery
    • Q
      • Under the impression of abdominal distened suspect GI tract lesion, he was admitted to ordinary ward for further evaluation and management.
      • Due to Abdominal CT was reported Pancreatic carcinoma T4N2M0, STAGE:III. EUS FNB of pancreas was performed on 20221012, the pathology was pending. We need your surgical evaluation, thank you
    • A
      • A case of pancreatic head tumor with SMA invation
      • further operation with indication of double bypass or endo stent
      • if pt want to operation, we will take over for this case
  • 2022-10-14 Hemato-Oncology
    • Q
      • This 51-year-old male has the histories of 1) Hypertension, 2) Gastric ulcer. He suffered form abdmnial distened after eating and body weight lose about 8kg since 2022/07. This time, he suffered from epigastric pain for 7 days. Poor appetite, nausea with vomiting were noted. He visited local medical clinic for help. But the symptoms did not improved. This time, he sufferred from vomiting 3 times with coffee ground vomitus since 20221007 midnight. He denied tarry stool passage, dizziness, chest tightness/pain, diarrhea/constipation, dysuria/frequency found.
      • The patient was sent to our ER for help. COVID19 rapid test showed Negative. At ER, BT:36.2C, BP:143/109 mmHg, PR:90/min, RR:18/min, SpO2:95% under room air. Con’s:E4V5M6. Physical exam showed pink conjunctiva, no JVE or bruit, symmetric chest wall expansion, breath sound:clear, Abdomen:soft, distension, epigastric tenderness, no muslce guarding or rebounding pain, normoctive bowel sound, no flank knocking pain, no lower leg pitting edema, no wound lesion, normal skin turgor and no skin rash found. Under the impression of abdominal distened suspect GI tract lesion, he was admitted to ordinary ward for further evaluation and management.
      • Due to Abdominal CT was reported Pancreatic carcinoma T4N2M0, STAGE:III. EUS FNB of pancreas was performed on 20221012, the pathology was pending, we need your evaluation and advice.
    • A
      • A case of pancreatic tumor with underlined HTN, GU is noted. I am consulted for the further evaluation and management.
      • My suggestions:
        • Well discuss with patient and family
        • May Consider Bypass and excisional tissue proof first.
        • May consider neoadjuvant chemotherapy first followed by OP (if feasible) or CCRT

[surgical operation]

  • 2022-10-31
    • Surgery
      • laparoscpe vagotomy with GJbypass
      • excision of mesenteric tumor suspected seeding
    • Finding
      • pancreatic ca with doudoenal obstruction and several mesenterroc tumor seeding (PCI:1/39)

[chemotherapy]

  • 2023-10-11 - nivolumab 3mg/kg 200mg NS 100mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 280mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Opdivo + FOLFIRINOX)
    •                 diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
  • 2023-09-18 - nivolumab 3mg/kg 200mg NS 100mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 280mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Opdivo + FOLFIRINOX)
    •                 diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
  • 2023-08-21 - nivolumab 3mg/kg 200mg NS 100mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 280mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Opdivo + FOLFIRINOX)
    •                 diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
  • 2023-08-07 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
  • 2023-07-10 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
  • 2023-06-05 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
  • 2023-05-22 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
  • 2023-05-04 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
  • 2023-04-12 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
  • 2023-03-24 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
  • 2023-03-09 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
  • 2023-02-20 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 540mg NS 500mL 2hr + fluorouracil 300mg/m2 540mg NS 100mL 10min + fluorouracil 2400mg/m2 4350mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
  • 2023-02-06 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 275mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
  • 2023-01-03 - oxaliplatin 75mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 275mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
  • 2022-12-19 - oxaliplatin 65mg/m2 125mg D5W 250mL 2hr + irinotecan 150mg/m2 275mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3
  • 2022-12-05 - oxaliplatin 65mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 225mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 500mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3

FOLFIRINOX chemotherapy for metastatic pancreatic cancer 2023-06-06 https://www.uptodate.com/contents/image?topicKey=ONC%2F2475&imageKey=ONC%2F79571

  • Cycle length: 14 days.

  • Regimen

    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin).
      • Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 180 mg/m2 IV
      • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 400 mg/m2 IV bolus
      • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
      • Day 1
    • FU
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

Modified FOLFIRINOX chemotherapy for pancreatic cancer 2023-06-06 https://www.uptodate.com/contents/image?topicKey=ONC%2F2475&imageKey=ONC%2F109546

  • Cycle length: 14 days.

  • Regimen

    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 150 mg/m2 IV
      • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

==========

2023-09-19

This patient recently refilled a 28-day supply of Urosin (atenolol) and nifedipine on 2023-08-26, and a prescription for Dicetel (pinaverium bromide), Gaslan, and Protase was refilled on 2023-08-14. While the latter group of medications has been added to the active medication list, the antihypertensive agents (atenolol and nifedipine) have not been included. Given that the patient’s blood pressure was recorded as 139/92 at 08:13 on 2023-09-19, it may be advisable to reinstate these antihypertensive drugs if the blood pressure continues to rise.

2023-08-22

Currently, the patient’s medication records are not accessible on PharmaCloud. However, after reviewing the HIS5 records, no medication reconciliation issues were found.

2023-08-08

The active medication list includes a repeat prescription by our gastroenterologist for Protase (pancrelipase), Dicetel (pinaverium bromide), and Gaslan (dimethylpolysiloxane). However, Urosin (atenolol) and nifedipine, which were refilled on 2023-07-26, are not currently being used as the patient’s blood pressure has not shown an elevation during this hospitalization. There are no medication reconciliation issues identified.

2023-07-11

The local pharmacy refilled atenolol and nifedipine on 2023-07-01. They are included in the active medication list, and no medication reconciliation issues were found.

2023-06-06

  • According to the PharmaCloud database, the refillable prescription for the patient’s primary hypertension, which was filled on 2023-04-29, has now expired. Additionally, the patient’s TPR panel does not display any instances of elevated blood pressure during this current hospitalization. Therefore, no issues have been found during the medication reconciliation process.

2023-05-23

  • There was a refillable prescription for nifedipine and atenolol to treat the patient’s primary hypertension that was filled on 2023-04-29 for another 28-day course. These two drugs, nifedipine and atenolol, are not currently on the patient’s formulary, which violates medication reconciliation principles. However, the patient’s blood pressure readings from the TPR panel have remained relatively stable during the hospitalization. It is recommended that the patient’s blood pressure continue to be monitored and that reintroduction of these medications be considered based on future blood pressure readings and the patient’s overall clinical condition.

2023-05-05

  • The patient appears to be tolerating the current treatment regimen well, with the exception of occasional episodes of leukopenia and diarrhea. However, these side effects have been manageable and reversible with the appropriate medications.

2023-04-13

  • The patient’s WBC count has shown a decreasing trend since the start of the FOLFIRINOX regimen and is unlikely to fully recover at the current dose and interval.
    • 2023-04-12 WBC 2.50 x10^3/uL
    • 2023-04-06 WBC 3.85 x10^3/uL
    • 2023-03-21 WBC 3.68 x10^3/uL
    • 2023-03-09 WBC 2.55 x10^3/uL
    • 2023-03-02 WBC 3.21 x10^3/uL
    • 2023-02-16 WBC 4.53 x10^3/uL
    • 2023-02-06 WBC 3.51 x10^3/uL
    • 2023-01-31 WBC 5.03 x10^3/uL
    • 2022-12-29 WBC 4.07 x10^3/uL
    • 2022-12-15 WBC 5.02 x10^3/uL
    • 2022-12-05 WBC 5.26 x10^3/uL

2023-03-27

  • On 2023-03-21, the patient’s WBC count remained at 3.68K/uL, which was an increase compared to 2.55K/uL on 2023-03-09 while receiving the same dose-reduced FOLFIRINOX regimen at a Q2W interval.
  • The patient experienced 5 bowel movements on 2023-03-23 and 2023-03-25, and 3 on 2023-03-26. Loperamide 2mg TIDAC was prescribed and effectively mitigated the diarrhea.
  • A low serum K level (3.1mmol/L) was noted on 2023-03-21, and potassium supplements have been properly prescribed to address this issue.
  • As of 2023-03-27 at 08:37, the patient’s blood pressure was recorded as 103/63mmHg. If the patient continues to maintain a relatively low blood pressure for an extended period of time, the discontinuation of Urosin (atenolol) may be considered while continuing nifedipine, with regularly monitoring of blood pressure.
  • There are no issues with the active prescription.

2023-03-10

  • Protase (pancrelipase 280mg/cap) is properly prescribed as 1# PO BID. Pancrelipase itself has the potential to cause various gastrointestinal signs and symptoms, including but not limited to abdominal pain, abnormal stools, constipation, diarrhea, duodenitis, dyspepsia, flatulence, frequent bowel movements, gastritis, nausea, and vomiting. It is recommended to monitor these symptoms.

  • The patient is receiving a dose-modified FOLFIRINOX regimen, which includes a lower dose of oxaliplatin (85mg/m2 reduced to 75mg/m2) and irinotecan (180mg/m2 reduced to 150mg/m2). Despite the reduction in dosage, recent lab data shows a trend towards leukopenia, which should be closely monitored.

    • 2023-03-09 WBC 2.55 x10^3/uL
    • 2023-03-02 WBC 3.21 x10^3/uL
    • 2023-02-16 WBC 4.53 x10^3/uL
    • 2023-02-06 WBC 3.51 x10^3/uL
    • 2023-01-31 WBC 5.03 x10^3/uL
    • 2022-12-29 WBC 4.07 x10^3/uL
    • 2022-12-15 WBC 5.02 x10^3/uL
    • 2022-12-05 WBC 5.26 x10^3/uL

2023-02-22

  • The patient has been admitted to receive his 5th FOLFIRINOX treatment, and he has been tolerating the treatment well.
  • Adjuvant therapy with a modified FOLFIRINOX regimen led to significantly longer survival than gemcitabine among patients with resected pancreatic cancer, at the expense of a higher incidence of toxic effects. (ref: FOLFIRINOX or Gemcitabine as Adjuvant Therapy for Pancreatic Cancer. N Engl J Med. 2018;379(25):2395-2406. doi:10.1056/NEJMoa1809775). Please continue to closely monitor the patient for any signs of adverse reactions.

2022-12-01

  • For this patient with a pancreatic CA with duodenal obstruction, a lumen-apposing metal stent revision was performed on 2022-10-24 and he is currently being treated with piperacillin and tazobactam for suspected sepsis.
  • There was a low level of K, Na, Mg, and Ca in the serum on 2022-11-30, possibly due to diarrhea (bowel movements 7 times on 28 and 4 times on 30). If the readings continue to decline, electrolyte supplements might be beneficial.
  • The regimen FOLFIRINOX might be delayed or at least initialized with a lower dose of irinotecan if the patient continues to experience diarrhea.

700575779

231009

[exam findings]

  • 2023-09-28 L-spine flex. & ext. (including sacrum)
    • Presence of spondylolisthesis at L3/4, L4/5, grade I.
  • 2023-09-28 C-spine flex. & ext. view
    • There is no evidence of spondylolisthesis or subluxation
  • 2023-09-13 CT - abdomen
    • Findings: Comparison: prior CT dated 2023/06/09.
      • Prior CT identified malignant lymphoma (confluent lymphadenopathy) in the abdomen and pelvis, encasing all visceral artery and vein, are noted again, decreasing in size that is c/w lymphoma S/P C/T with partial response.
      • Prior CT identified lymphoma 2.8 cm in S8/4 of the liver dome is noted again, decreasing in size to 1.2 cm that is c/w liver lymphoma S/P C/T with partial response.
      • Prior CT identified splenomegaly (the greatest anterior-posterior dimension: 14 cm) is noted again, mild decreasing in size to 12 cm.
    • Impression:
      • Malignant lymphoma S/P C/T show partial response.
      • Liver and spleen lymphoma S/P C/T show partial response.
  • 2023-09-11 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-07-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (81 - 18) / 81 = 77.78%
      • LVEF (%) = 78
      • M-mode (Teichholz) = 78
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Normal LV diastolic function.
      • Normal RV systolic function.
      • Mild MR; trivial TR.
  • 2023-07-13 EGD
    • Reflux esophagitis LA Classification grade A
    • Bile reflux
    • Superficial gastritis
  • 2023-06-15 PET
    • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm.
    • Increased FDG uptake in some focal areas in both lobes of the liver and in a focal area in the left lobe of the thyroid gland. Lymphoma involving the liver and left lobe of the thyroid gland should be considered. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Mildly increased FDG uptake in some focal areas in the spleen and in the bone marow of the skeleton. Lymphoma involving the spleen and bone marrow can not be ruled out.
  • 2023-06-15 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy— Positive for B cell lymphoma
    • Microscopically, it shows aggregations of B lymphomatous cells. .
    • Immunohisotchemical stain reveals CD34(-), CD117(-), CD20 (l+), CD138 (focal +, 1~2%), MPO(+), CD71(+ at erythroid cells), CD10(+), TdT(-), CD61(+ at megakaryocytes).
  • 2023-06-14 Patho - peritoneum biopsy
    • Lymph node, abdomen, CT-guide biosy — follicular lymphoma with focal high grade transformation
    • Section shows predominent small to medium sized lymphoid cells with focal large lymphoid cells (mainly in one strip).
    • The immunohistochemical stains of small to medium sized lymphoid cells reveal CD3(-), CD5(-), CD20(+), CD10(+), BCL2(+), BCL6(-), and Cyclin D1(-).
    • The immunohistochemical stains of large lymphoid cells reveal CD3(-), CD5(-), CD20(+), CD10(-), BCL2(+), BCL6(+), Cyclin D1(-), MUM1(+), C-MYC(-), and Ki-67 is about 50%.
  • 2023-06-09 CT - abdomen
    • Findings:
      • There is huge mass (confluent lymphadenopathy) in the abdomen and pelvis, measuring 22 cm (the largest dimension), with encasing all visceral artery and vein that is c/w lymphoma. Please correlate with PET scan.
      • There is a poor enhancing mass 2.8 cm in S8/4 of the liver dome that may be liver lymphoma. Please correlate with MRI.
      • There is splenomegaly and the greatest anterior-posterior dimension measuring about 14 cm.
        • Lymphoma with spleen involvement is highly suspected.
      • Left side Pleura effusion is noted.
      • There is mild ascites in the cul-de-sac.
    • Impression:
      • Malignant lymphoma is highly suspected. Please correlate with PET scan.
      • Liver and spleen lymphoma is also suspected.
  • 2023-06-09 SONO - nephrology
    • Interpretation:
      • Mild bilateral hydronephrosis
      • Splenomegaly
      • Gall stones
      • Ascites
      • r/o abdominal mass lesion with bilateral ureter compression
    • Suggestion:
      • Contrast CT scan for further investigation
  • 2023-05-12 Gynecologic ultrasonography
    • Findings
      • Uterus Position : AVF
        • Size: 72 * 43 mm
        • Myometrum: Anterior/Posterior wall: / cm
        • Myoma: Myoma: 19 x 17 mm ,
        • Congenital Anomaly:
      • Endometrium:
        • Thickness: 9.7 mm , Fluid: , Type:
        • Endometrial polyp: * mm , Doppler Flow : S/D: RI:
      • Adnexae:
        • ROV:
          • SIZE: 24 * 22 mm , Doppler Flow : S/D: RI: * mm
        • LOV:
          • SIZE: * mm , Doppler Flow : S/D: RI: * mm
        • FOLLICLE R:
        • FOLLICLE L:
      • CUL-DE-SAC: with fluid
      • Other: LT adnexae:free
    • IMP: Uterine myoma

[MedRec]

  • 2023-06-13 ~ 2023-06-19 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Follicular lymphoma with multiple lymph nodes on both sides of the diaphragm, liver and left lobe of the thyroid gland, spleen and bone marrow, Lugano stage at least III, FLIPI score:2 ,Intermediate Risk, PS:0
      • COVID-19, virus identified
      • Low back pain
    • CC
      • left flank pain for one week and body weight loss 4kg in one month.
    • Present illness
      • This 50 year-old denied any systemic disease before. She had suffered from left flank pain for one week and also body weight loss 4kg in one month. Therefore, she came to nephrology OPD for help on 2023/06/09.
      • Renal echo showed: 1) Mild bilateral hydronephrosis, 2) Splenomegaly, 3) Gall stones, 4) Ascites5. r/o abdominal mass lesion with bilateral ureter compression.
      • CT of abdominal was performed on 2023/06/09 which revealed A huge mass (confluent lymphadenopathy) in the abdomen and pelvis, measuring 22 cm (the largest dimension), with encasing all visceral artery and vein that is c/w lymphoma. Malignant lymphoma is highly suspected. Liver and spleen lymphoma is also suspected.
      • She was referred to ONC OPD today and was admitted for further management
    • Course of inpatient treatment
      • After admission, CT guide biopsy on 2023/06/14 showed follicular lymphoma with focal high grade transformation. Bone marrow aspiration and biopsy on 2023/06/15 and pending. PET scan on 2023/06/15 showed there was increased FDG uptake in some focal areas in both lobes of the liver, in a focal area in the left lobe of the thyroid gland, in some focal areas in the spleen and in the bone marow of the skeleton.
      • Pain control with Sketa 1 tab Q8H. However, sorethroat and cough with sputum was noted on 2023/06/18 and the Covid-19 showed positive. We applied the Paxlovid for 5days since 6/19.
      • With the relatively stable condition, she was discharged on 2023/06/19 and will OPD follow up later.
    • Discharge prescription
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • Actein Effervescant (acetylcysteine 600mg) 1# BID
      • Acetal (acetaminophen 500mg) 1# PRNQID
  • 2023-06-13 SOAP Hemato-Oncology Gao WeiYao
    • O: 2023/06/09 CT: ABD - whole abdomen, pelvis
      • Malignant lymphoma (10x17 cm) is highly suspected. Please correlate with PET scan.
      • Liver and spleen lymphoma is also suspected.

[immunochemotherapy]

  • 2023-10-06 - rituximab 375mg/m2 690mg NS 500mL D1 + cyclophosphamide 750mg/m2 1380mg NS 250mL D2 + doxorubicin 50mg/m2 90mg NS 50mL D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-09-11 - rituximab 375mg/m2 685mg NS 500mL D1 + cyclophosphamide 750mg/m2 1375mg NS 250mL D2 + doxorubicin 50mg/m2 90mg NS 50mL D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-08-17 - rituximab 375mg/m2 700mg NS 500mL D1 + cyclophosphamide 750mg/m2 1400mg NS 250mL D2 + doxorubicin 50mg/m2 90mg NS 50mL D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-07-24 - rituximab 375mg/m2 680mg NS 500mL D1 + cyclophosphamide 750mg/m2 1360mg NS 250mL D2 + doxorubicin 50mg/m2 90mg NS 50mL D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-07-03 - rituximab 375mg/m2 680mg NS 500mL D1 + cyclophosphamide 750mg/m2 1360mg NS 250mL D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-COP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + palonosetron 250ug D2

==========

2023-10-09

Based on the PharmaCloud database, the patient has no records of visiting other clinics. Additionally, after consultations in our medical departments, no repeat prescriptions were issued, and no medication discrepancies were identified.

On 2023-09-13, a CT scan indicated a partial response after the patient underwent 4 treatment cycles (1 R-COP followed by 3 R-CHOP). The treatment appears to remain effective to date.

700720541

231006

[lab data]

2023-02-14 Anti-HBc Nonreactive
2023-02-14 Anti-HBc-Value 0.14 S/CO
2023-02-14 Anti-HBs 0.00 mIU/mL
2023-02-14 Anti-HCV Nonreactive
2023-02-14 Anti-HCV Value 0.06 S/CO
2023-02-14 HBsAg Nonreactive
2023-02-14 HBsAg (Value) 0.33 S/CO

[exam findings]

  • 2023-05-04 Patho - uterus with or without SO non-neoplastic/prolapse Y1
    • PATHOLOGIC DIAGNOSIS
      • Endometrium, low uterine segment, radical hysterectomy — Undifferentiated carcinoma
      • Myometrium, uterus, ditto — Tumor invasion, less than half thickness
      • Cervix, uterus, ditto — Stromal invasion
      • Ovary, left, ditto — Free of tumor invasion
      • Fallopian tube, left, ditto — Free of tumor invasion
      • Ovary, right, ditto — Free of tumor invasion
      • Fallopian tube, right, ditto — Free of tumor invasion
      • Lymph node, L’t iliac, dissection — Free of tumor metastasis (0/8)
      • Lymph node, L’t oburator, ditto — Free of tumor metastasis (0/7)
      • Lymph node, R’t iliac, ditto — Free of tumor metastasis (0/3)
      • Lymph node, R’t oburator, ditto — Tumor metastasis (0/7)
      • Lymph node, L’t paraaortic, ditto — Free of tumor metastasis (0/2)
      • Lymph node, R’t paraaortic, ditto — Free of tumor metastasis (0/7)
      • Parametria, bilateral — Free of tumor invasion
      • Omentum, partial omentectomy — Free of tumor invasion
      • AJCC Pathologic stage — pT2N0, if cM0, stage II / FIGO stage II
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: radical hysterectomy
      • Specimens include: uterus with bilateral adnexa, partial omentum, pelvic and paraaortic lymph nodes
      • Specimen size:
        • uterus: 6.7 x 5.2 x 5.0 cm in size, 72 gm in weight
        • right ovary: 1.8 x 1.6 x 0.7 cm
        • left ovary: 1.9 x 0.9 x 0.6 cm
        • right fallopian tube: 6.3 cm in length, 0.4 cm in diameter
        • left fallopian tube: 5.5 cm in length, 0.5 cm in diameter
      • Tumor site: low uterine segment
      • Tumor size: 3.7 x 2.7 x 2.4 cm
      • The myometrium: 1.2 cm in thickness, tumor invasion less than half thicknes
      • The cervix: endocervical stroma is invaded by tumor
      • Bilateral adnexa: no remarkable change
      • Omentum: 5.5 x 4.5 x 1.0 cm, no remarkable change
      • Lymph nodes: left iliac LNs; left obturator LNs; right iliac LNs, right obturator LNs, L’t paraaortic LNs and R’t paraaortic LNs
      • Representative sections as A: L’t iliac LNs, B: L’t obturator LNs, C: R’t iliac LNs, D: R’t obturator LNs, E: L’t paraaortic LNs, F: R’t paraaortic LNs, G1: R’t F-tube, G2: R’t ovary, G3: L’t F-tube, G4: L’t ovary, G5: R’t parametrium, G6: L’t parametrium, G7-G8: uterine corpus to cervix, G9-G15: tumor, G16: cervix and H: omentum
    • MICROSCOPIC EXAMINATION
      • Histology type: endometrioid undifferentiated carcinoma
      • Histology grade: undifferentiated
      • Depth of invasion: less than half thickness of myometrium
      • Lymphovascular invasion: Not identified
      • The cervical stroma involvement: Present
      • Resection margins of the cervix: Free, 1.7 cm away from tumor
      • Additional pathologic findings: moderate tumor-infiltrating lymphocytes
      • Lymph nodes: free of tumor metastasis (0/35) in total number
      • Vaginal stump: free of tumor invasion
      • Perineural invasion: Not identified
      • Ascites: Negative for malignancy
      • Immunohistochemistry: CK7(+), PAX-8(+), Vimentin(+), ER(+), P16(-), P40(-) and P53(wild type) for tumor
  • 2023-04-20 MRI - pelvis
    • Findings: Soft tissue tumor in the uterine cervical region, regression size (from 4.8cm to 3cm) as compare with MRI study on 2023-02-09. Clinical biopsy proven cervical malignancy.
    • Impression: Cervical malignancy with regression size.
  • 2023-02-20 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 26 dB HL; LE 13 dB HL.
    • RE normal to moderate SNHL.
    • LE normal to mild mixed type HL.
  • 2023-02-09 MRI - pelvis
    • Finding: Soft tissue tumor in the uterine cervical region, 4.8cm. Clinical biopsy proven cervical malignancy.
    • Imaging Report Form for Cervical Carcinoma
      • Impression ( Imaging stage ) : T:T1b3(T_value) N:N0(N_value) M:M0(M_value) STAGE IB3 (Stage_value)
    • Impression: Cervical malignancy, cstage T2a2N0M0.
  • 2023-01-31 CT - abdomen
    • Finding: Soft tissue tumor, 5.3cm in the uterine cervical region, r/o cervical myoma.
    • Impression: Cervical region tumor, myoma?
  • 2023-01-30 Patho - cervix biopsy
    • Labeled as “cervix”, biopsy — poorly differentiated carcinoma.
    • Section shows poorly differentiated carcinoma with solid nests and papillary-like structures.
    • IHC stains: CK7 (+), CK20 (-), P40 (-), p16 (-), vimentin (+), ER (+, 90%, strong intensity), GATA-3 (-).
  • 2023-01-30 Gynecologic ultrasonography
    • A mass:47x31mm, RI:0.59

[MedRec]

  • 2023-07-07 SOAP Rheumatology Chen JunXiong
    • S: 2023 0707 urticaria flare last day first attack over limbs, trunk, under regular chemothrapy
    • O: acute urticaria
    • Prescription
      • Xyzal (levocetirizine 5mg) 1# HS
      • Allegra (fexofenadine 60mg) 1# TID
      • Compesolon (prednisolone 5mg) 2# PRNBID
  • 2023-06-15 SOAP Hemato-Oncology Xia HeXiong
    • Plan: CCRT with weekly carboplatin (due to impaired renal function, and self pay) followed by TP x 3 cycles
  • 2023-06-01 SOAP Radiation Oncology Huang JingMin
    • A: Undifferentiated carcinoma of the uterine cervix, stage cT2a2N0M0, s/p neoadjuvant chemotherapy and surgery (Radical hysterectomy + Bilateral Salpingo-oophorectomy + Bilateral Pelvic Lymph nodes Dissection + Bilateral paraaortic Lymph nodes Dissection + omentectomy).
    • P: Radiotherapy is indicated for this patient with the following indicators: stage cT2a2, s/p neoadjuvant chemotherapy and surgery
      • Goal: curative
      • Treatment target and volume: pelvic area
      • Technique: VMAT/IGRT +/- IVRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, +/- 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her husband. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-06-08.
  • 2023-05-02 POMR Obstetrics and Gynecology Huang SiCheng
    • Discharge diagnosis
      • Malignant neoplasm of endometrium
      • Endometrial cancer,stage II, post radical hysterectomy on 2023-05-03
      • Paralytic ileus
    • CC
      • intermittent postmenopausal bleeding for 6 months        
    • Present illness
      • This 55 y/o woman, G0P0, sex +, menopause in 2021. She had MEDICAL history of hyperlipidemia without control. She denied any food or drug allergy, and anticoagulants or hormone use. She had regular pap smear in 2021 and the result showed WNL.
      • Abnormal postmenopause bleeding was noted by patient for 6 months. According to patient statement, the discharge was pink initially. Then, the color change to brown and pus-like content, with increasing volume. No pain or burning sensation. She denied fever, weight loss, poor appetite, urinary frequency or urgency, dysuria, nocturia.
      • She came to our GYN OPD for help on 2023/01/30. PV revealed necrotic tissue and mass at os.
      • Biopsy was done and showed poorly differentiated carcinoma. IHC stains: CK7 (+), CK20 (-), P40 (-), p16 (-), vimentin (+), ER (+, 90%, strong intensity), GATA-3 (-).
      • CT in 2023/01/31 showed 5.3 cm tumor in cervical region. She was diagnosed as poorly differentiated carcinoma of cervical, pT1b3N0M0, stage 1b3.
      • After 3 cycles of neoadjuvant chemotherapy (Intaxel + Carboplatin), she was admitted for radical hysterectomy on 2023/05/03.   - Course of inpatient treatment
      • The patient was admitted on 2023-05-02 due to cervical cancer.
      • She underwent Radical hysterectomy + Bilateral Salpingo-oophorectomy + Bilateral Pelvic Lymph nodes Dissection + Bilateral paraaortic Lymph nodes Dissection + omentectomyon 2023-05-03.
      • The pathology stage: Endometrium, low uterine segment, radical hysterectomy — Undifferentiated carcinoma. AJCC Pathologic stage — pT2N0, if cM0, stage II / FIGO stage II.
      • The GYN tumor board conference suggest the patient to receive CCRT on 2023-05-11.
      • Postoperative course was uneventful. Self voiding was smooth. She was discharged on 2023-05-24. Her follow up appointment is scheduled on 2023-06-01.
    • Discharge prescription
      • Naproxen (naproxen 250mg) 1# PRNQ6H
      • Anxiedin (lorazepam 0.5mg) 1# PRNHS
      • cephalexin 500mg 1# QID
      • MgO 250mg 1# QID
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
  • 2023-02-17 ~ 2023-02-22 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • poorly differentiated carcinoma of cervical, pT1b3N0M0, stage 1b3
    • CC
      • for chemotherapy
    • Present illness
      • The 54 y/o woman has been well in the past. Menopause on 2021.
      • This time, her vagina has yellow-green discharge since 2022/09/09. Due to symptoms persisted for a while without improvement, so she came to our GYN OPD for help and pelvis MRI showed Cervical malignancy, cstage T2a2N0M0 on 2023/02/09.
      • Pathology showed poorly differentiated carcinoma. IHC stains: CK7 (+), CK20 (-), P40 (-), p16 (-), vimentin (+), ER (+, 90%, strong intensity), GATA-3 (-) on 2023/2/3.
      • Port-a insertion on 2023/2/9. Under the impression of poorly differentiated carcinoma of cervical, pT1b3N0M0, stage 1b3.
      • Plan as Neo-adjuvant x 3th then radical surgery then adjuvant treatment, so she was admitted for first chemotherapy as self paid of TP on 2023/02/17.
    • Course of inpatient treatment
      • After admission, she received 24H CCr and PTA before neo-adjuvant x 3th then radical surgery then adjuvant treatment.
      • Premedication as Dorison 20mg q6h x 2 dose since 2/20 2300 and 2/21 0500.
      • C1 selfpaid of Intaxel (175mg/m2) + Carboplatin (AUC 6) on 2023/2/21.
      • Under the stable condition, she can be discharged on 2023/2/22. OPD follow up is arranged.
    • Discharge prescription
      • Mopride (mosapride citrate 5mg) 1# TID
      • Roumin (prochlorperazine maleate 5mg) 1# TID
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
  • 2023-02-14 SOAP Hemato-Oncology Xia HeXiong
    • P: Admission for C/T with PF or TP
  • 2023-02-10 SOAP Obstetrics and Gynecology Huang SiCheng
    • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-02-09. Neo-adjuvant x 3th then radical surgery then adjuvant treatment
  • 2023-02-07 SOAP Urology You ZhiQin
    • S: cervical cancer, for r/o bladder invasion
    • O: CUS: no bladder invasion
  • 2023-02-06 SOAP Obstetrics and Gynecology Zhu ChunHong
    • O: 2023/01/31 CT ABD: Soft tissue tumor, 5.3cm in the uterine cervical region, r/o cervical myoma. Impression: Cervical region tumor, myoma? - interpretation about report, most possibility was cervical cancer

[consultation]

  • 2023-09-14 SOAP Neurology
    • Q
      • This 55-year-old woman patient is a case of Endometrial undifferentiated carcinoma with cervical invasion status post Radical hysterectomy on 2023/05/03, pT2N0, if cM0, stage II, FIGO stage II, s/p neoadjuvant chemotherapy with TP for 3 cycles, s/p Radical hysterectomy + Bilateral Salpingo-oophorectomy + Bilateral Pelvic Lymph nodes Dissection + Bilateral paraaortic Lymph nodes Dissection + omentectomyon on 2023/05/03 and concurrent chemoradiotherapy with Carboplatin from 2023/06/21~2023/08/10, and adjuvant chemotherapy with TP from 2023/08/24~. She was admitted for adjuvant chemotherapy with TP(C2). This time, for dezziness in 2023/05. No hypertension and chest pain was noted. Now, for evaluate dizziness examine and therapy. Thank you.
    • A
      • She complained of intermittent dizziness during turning head to left or right since May, 2023. She denied headache, double vision, facial palsy, slurred speech, focal weakness or clumsiness, sensory deficit, and unsteady gait.
      • NE
        • GCS: E4V5M6
        • EOM: free and full
        • pupil 3mm/3mm, light reflex +/+
        • no facial palsy
        • No tongue deviation
        • No dysarthria
        • MP: upper 5/5, lower 5/5
        • Sensory: intact
        • FNF and HKS: no dysmetria
        • Romberg test: negative
        • Gait: steady, no falling
        • Tandem gait: steady
      • Asssessment
        • peripheral vertigo while head turning left-right
        • anemia
      • Suggestion
        • Keep observation of neurological signs. There was no focal neurological deficit currently.
        • Arrange BAEP.
        • Add Diphenidol 1# TIDPRN if dizziness.
        • Consult ENT doctor for vestibular system survey and treatment.
        • Treat anemia.

[surgical operation]

  • 2023-05-03
    • Surgery
      • Diagnosis: poorly differentiated carcinoma of cervical, pT1b3N0M0, stage 1b3.
      • Procedure: Radical hysterectomy + Bilateral Salpingo-oophorectomy + Bilateral Pelvic Lymph nodes Dissection + Bilateral paraaortic Lymph nodes Dissection + omentectomy
    • Finding
      • Uterus: Avfl, 5x3 cm; cervix:enlarged with multiple papillary tissues.
      • RAD: grossly normal.
      • LAD: grossly normal.
      • CDS: little ascites s/p washing cytolgy, no adhesion bands.
      • Right parametrium: size : 3 cm, Induration (-);
      • Left parametrium: size : 3 cm, Induration (-);
      • Vagina cuff: 3 cm , gross tumor (-), section margin free (+)
      • Bilateral pelvic/ paraaortic lymph nodes: Enlarged
      • Omentum: multiple hard, infracolic omentectomy was done.
      • Adhesion between pelvic wall and bowels, s/p adhesiolysis
      • Estimated blood loss: 600ml
      • Blood transfusion: pRBC 2u
      • Complication: none  

[radiotherapy]

[chemotherapy]

  • 2023-10-06 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 550mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-09-15 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 550mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-08-24 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 550mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-08-03 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-26 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-20 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-13 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-06 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-29 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-23 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-08 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-03-18 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-02-21 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2023-10-06

There was no medication reconciliation issue identifed.

Leukopenia (WBC 1.16K/uL) was noted on 2023-09-07, approximately 2 weeks after the patient received the paclitaxel + carboplatin regimen on 2023-08-24. With Granocyte (lenograstim) administered for 3 days in early Sep, 4 days in mid-Sep, and 4 days in late Sep, the WBC finally reached above 3K/uL. Close monitoring of the WBC count may be necessary at this time.

2023-10-04 WBC 3.15 x10^3/uL 2023-09-28 WBC 2.66 x10^3/uL 2023-09-13 WBC 3.33 x10^3/uL 2023-09-07 WBC 1.16 x10^3/uL * 2023-08-23 WBC 3.41 x10^3/uL

2023-08-24

After examining both PharmaCloud and HIS5 records, no medication discrepancies were found.

700731401

231006

[exam findings]

  • 2023-09-18 Nasopharyngoscopy
    • NPC recurrence
    • ant. mild epistaxis
    • mucositis with condidiasis
  • 2023-09-11 Pure Tone Audiometry
    • Reliabilty Fair
    • PTA
      • R’t : >100 dB HL, severe to profound mixed type HL
      • L’t : >109 dB HL, profound mixed type HL.
  • 2023-08-04 Patho - nasopharyngeal/oropharyngeal biopsy
    • PATHOLOGIC DIAGNOSIS
      • Nasopharynx, right and left, biopsy — Keratinizing squamous cell carcinoma, well differentiated
      • Nasal cavity, #1 and #2, right, biopsy — Keratinizing squamous cell carcinoma, well differentiated
    • MICROSCOPIC EXAMINATION
      • The sections all five parts show a picture of keratinizing squamous cell carcinoma, composed of irregular islands of well differentiated squamous cells with keratinization, mild nuclear atypia, and focal stromal invasion.
  • 2023-07-19 PET
    • Increased FDG uptake in bilateral nasopharyngeal regions, highly suspected tumor recurrence.
    • Increased FDG uptake in lymph nodes in the right neck and right supraclavicular fossa, probably metastatic (priority) or reactive nodes.
    • Increased FDG uptake in a level III level lymph node of the left neck, probably reactive node.
    • Increased FDG uptake at the C1 spine, highly suspected tumor invasion.
    • increased FDG uptake in the stomach, probably benign in nature, suggesting follow-up.
    • NPC s/p treatment with tumor recurrence, by this F-18 FDG PET scan.

[MedRec]

  • 2023-08-17 SOAP Hemato-Oncology Xia HeXiong
    • Plan:
      • TPC x3 -> CCRT (Dr. Wang)
      • Admission on 2023-09-04 for 24 hours CCr and Audiometry and TPF
  • 2023-08-16 SOAP Oral and Maxillofacial Surgery He ChengHan
    • S: Pre-CCRT dental evaluation
    • O:
      • Panoramic findings:
        • Missing: 36,37,45,46
        • Impaction: nil
        • Crown and Bridge: 15,26,47
        • Caries: nil
        • Periodontal condition: chronic periodontitis
      • Periodontitis of tooth 46, mobility Gr(II), widened PDL space
    • Problem:
      • Squamous cell carcinoma of nasopharynx
      • periondontitis of tooth 47
    • Plan:
      • Explain the risk/benefit of the treatment to the patient (Inform about the risk of inferior alveolar nerve numbness and inform that if the tooth is not extracted, subsequent tooth infection may lead to cellulitis.)
      • Sign informed consent.
      • Block anesthesia of right mandible.
      • Complicated extraction of tooth 47
      • Suture the gingiva with Vicryl 4-0.
      • Prescribe Acetal and cephalexin
      • Teach the patient how to do home care and OPD follow-up.
  • 2023-08-02 POMR Ear Nose Throat Huang YunCheng
    • Discharge diagnosis
      • Bilateral nasopharyngeal tumor status post bilateral nasopharyngeal tumor biopsy on 2023/08/03
      • Chronic osteomyelitis with draining sinus, unspecified site
      • Chronic sinusitis, unspecified
      • Essential (primary) hypertension
    • CC
      • Right otorrhea and purulent rhinorrhea for one month.
    • Present illness
      • This 67-year-old man has history of nasopharyngeal cancer post CCRT 30 years ago at TSGH. He is regular follow up at our ENT OPD. The patient complaint purulent rhinorrhea and right otorrhea noted for one month. At our ENT OPD, physical examination revealed right external auditory canal granular tumor, biopsy was done. The pathology revealed squamous cell hyperplasia with acute and chronic inflammation. We arrange whole body PET scan shwoed NPC s/p treatment with tumor recurrence, by this F-18 FDG PET scan.
      • Under the impression of nasopharyngeal granular tumor suspect recurrence cancer, surgical biopsy was suggested.
      • After well explanation about the surgical details, he was admitted for the operation.
    • Course of inpatient treatment
      • After patient was admitted, pre-operative evaluation was done. The patient underwent the operation of bilateral nasopharyngeal tumor biopsy. Post the operation, cool soft diet, pain control with Ultracet 1# po q6h were given. There was no active tongue bleeding. Appetite and amount of food intake improved day by day. Under relative stable condition, the patient was discharge today and continue OPD follow up.    

[chemmotherapy]

  • 2023-09-12 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 70mg/m2 120mg NS 500mL 24hr D2 + MgSO4 10% 20mL 1hr furosemide 20mg 30min NS 500mL (after CDDP) D3 + fluorouracil 1000mg/m2 1800mg D5W 500mL 24hr D3-7 (TPF Q3W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

[the possibility of fever associated with the drugs being used]

Based on UpToDate database, it’s noted that Tapimycin (piperacillin, tazobactam) and Ulstop (famotidine), which the patient is currently taking, have been reported to be associated with fever as an adverse reaction. The incidence rate for the former is 2%, while for the latter, it is less than 1%.

2023-10-02

[Dipeptiven dosage and administration]

(Dipeptiven ref: https://www.fresenius-kabi.com/nz/documents/Dipeptiven_Datasheet.pdf)

Dipeptiven 100 mL (alanyl glutamine 20g) can be diluted with NS 250-1000 mL. After dilution, it can be stored at room temperature for 24 hours.

A maximum daily dosage of 2 g amino acids/or protein per kg bodyweight should not be exceeded in parenteral/enteral nutrition. The supply of alanine and glutamine via Dipeptiven should be taken into consideration in the calculation. The proportion of the amino acids supplied through Dipeptiven should not exceed approx. 30% of the total amino acids/protein supply.

  • Patients with total parenteral nutrition
    • The rate of infusion depends on that of the carrier solution and should not exceed 0.1 g amino acids/kg body weight per hour.
    • Dipeptiven should be mixed with a compatible amino acid carrier solution or an amino acid containing infusion regimen prior to administration.
  • Patients with total enteral nutrition
    • Dipeptiven is continuously infused over 20-24 hours per day. For peripheral venous infusion, dilute Dipeptiven to an osmolarity ≤ 800 mosmol/L (e.g. 100 mL Dipeptiven +100 ml saline).
  • Patients with combined enteral and parenteral nutrition
    • The full daily dosage of Dipeptiven should be administered with the parenteral nutrition, i.e. mixed with a compatible amino acid solution or an amino acid contained in infusion regimen prior to administration.

If the patient is still on port-A, based on his body weight of about 70kg, IV infusion is recommended not less than 3 hours (20g / (0.1g/kg/hr x 70kg)), 4 to 6 hours would be even better.

700030886

231005

[exam findings]

  • 2023-09-19 Patho - bone marrow biopsy
    • Bone marrow, iliac, clinically recurrent T cell lymphoma, biopsy — Negative for malignancy.
    • Section shows piece(s) of bone marrow with % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
    • IHC stains: CD30: (-); CD3: 5 %; CD20: 1%, CD4 and CD8: no predominant subpopulation. CD68: 25 %.(of the nucleated cells).
  • 2023-09-12 PET scan
    • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm, liver, spleen and multiple bones/bone marrow of the skeleton (stage IV).
    • In comparison with the previous study on 2023/03/17, more new FDG avid lesions are noted, suggesting lymphoma in progression.
  • 2023-07-12 CT - abdomen
    • Findings: Comparison prior CT dated 2023/03/08.
      • Prior CT identified a poor enhancing lesion 1.5 cm in S7 of the liver at portal venous phase image is not noted in the current CT.
      • Prior CT identified two cysts in S2/3 and S1 of the liver are noted again, stationary.
      • Prior CT identified multiple enlarged nodes in the gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space are noted again, marked decreasing in size.
        • It is c/w angioimmunoblastic T-cell lymphoma S/P C/T with partial response.
      • There are several gallstones (< 1.8 cm).
    • Impression:
      • Angioimmunoblastic T-cell lymphoma S/P C/T show partial response.
  • 2023-03-30 CT - chest
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lymphadenopathy at both sides of the mediastinum is found.
        • Bilateral lower neck lymphadenopathy is also found.
      • Visible abdomen:
        • Low density lesion at S7 of liver measuring 1.46cm in largest dimension. Lymphoma is compatible.
        • Mild splenomegaly is found.
        • Enarlged lymph nodes are found near EG junction is noted.
    • Imp:
      • Lymphadenopathy at mediastinum. Bilateral lower neck and EG junction
      • Liver low density nodule. S7, lymphoma is favored.
  • 2023-03-30 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with angioimmunoblastic T-cell lymphoma with bone marrow involvement
    • The sections show slightly hypercellular marrow (40%). The myeloid series show good maturation. The megakaryocytes are increased in number. Paratrabecular and interstitial micronodular infiltration with atypical cells, many small lymphocytes, scattered CD68+ histiocytes and eosinophils, and subtle fibrosis are evident.
    • IHC, the atypical cells reveal: CD20(-), CD3(+), CD30(focal+) and BCL6(+). The finding is compatible with angioimmunoblastic T-cell lymphoma with bone marrow involvement. Suggest bone marrow smear evaluation and clinic correlation.
  • 2023-03-23 Patho - bone marrow biopsy
    • Lymph node, right neck, excisional biopsy — Angioimmunoblastic T-cell lymphoma
    • Microscopically, the section shows a picture of totally effacement of nodal architecture and marked vascular proliferation associated with aggregates of atypical large lymphoid cells mixed with small lymphocytes, which immunohistocehmcial stains show CD30(+, focal), CD3(+, diffuse), CD20(-), Bcl-2(+, focal), C-MYC (+, 20%), CD10(-) , Bcl-6(+, scatter), CK(-), Ki-67: increased activity and PD-1(+, focal). According to above histopathologic findings, it indicates a case of angioimmunoblastic T-cell lymphoma.
  • 2023-03-17 PET
    • Prominently increased FDG uptake in multiple left neck and left supraclavicular lymph nodes. Lymphoma should be considered. Please correlate with the pathologic findings for further evaluation.
    • Mildly to moderately increased FDG uptake in multiple right neck lymph nodes, some mediastinal, left axillary and bilateral pulmonary hilar lymph nodes. Lymphoma can not be ruled out.
    • Mildly increased FDG uptake in some abdominal lymph nodes in the gastrohepatic ligament and para-aortic space. Lymphoma is less likely.
    • Increased FDG uptake in a focal area in the segment 7 of the liver. The nature is to be determined (inflammatory pseudotumor? neuro-endocrine tumor? other nature?). Please correlate with other clinical findings for further evaluation.
    • Increased FDG uptake in the stomach. Inflammation is more likely. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Mildly increased FDG uptake in the left adrenal gland and in a focal area in the pituitary fossa. Benign nature such as adenoma may show this picture.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
  • 2023-03-15 MRI - liver, spleen
    • Findings:
      • There is a well-defined homogeneous mass measuring 2.3 cm at S2 of the liver, showing isointensity on both T1WI and T2WI. Dynamic study, this mass reveals well enhancement on arterial phase images but rapidly return to be iso-intensity on portal venous phase and delayed phase images.
        • Focal nodular hyperplasia (FNH) is highly suspected.
      • There is a well-defined, homogeneous mass 1.5 cm in S7 of the liver, showing hypointensity on T1WI, mild hyperintensity on T2WI, and marked hyperintensity on DWI. During dynamic study, this tumor shows peripheral contrast enhancement in arterial phase and portal-venous phase images, and homogeneous enhancement in delayed phase images.
        • Sclerosing hemangioma is highly suspected.
        • The differential diagnosis includes inflammatory pseudotumor and neuro-endocrine tumor.
        • In addition, there are two poor enhancing lesions in S2/3 and S1 of the liver that may be cysts.
      • There are multiple enlarged nodes in the gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space. The largest one 1.9 x 1.3 cm in the hepatoduodenal ligament,
        • Reactive nodes are highly suspected.
        • The differential diagnosis includes lymphoma and metastatic nodes.
        • Please correlate with PET scan.
      • There are several gallstones (< 1.8 cm).
      • There is mild hyperplasia of left adrenal gland.
    • Impression:
      • FNH 2.3 cm in S2 of the liver is noted.
        • Follow up sonography is indicated.
        • Otherwise, please correlate with primovist-enhanced MRI.
      • Sclerosing hemangioma 1.5 cm in S7 of the liver is highly suspected.
        • The differential diagnosis includes inflammatory pseudotumor and neuro-endocrine tumor.
      • Reactive nodes are highly suspected.
        • The differential diagnosis includes lymphoma and metastatic nodes.
        • Please correlate with PET scan.
  • 2023-03-13 Patho - stomach biopsy
    • Stomach, mid body, LC side, biopsy — chronic gastritis with intestineal metplasia and H.pylori infection
    • Microscopically, it shows chronic gastritis with lymphoplasmacytic infiltrate and focal intestinal metaplasia. Mild Helicobacter-like bacilli are seen.
  • 2023-03-13 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A
      • Chronic superficial gastritis with erosions and focal atrophic gastritis, s/p CLO test
      • Gastric xanthoma
      • Gastric mucosal lesion, suspected intestinal metaplasia, mid body, LC, s/p biopsy
    • CLO test: Positive
    • Suggestion:
      • PPI therapy
      • Pursue CLO test and pathology
      • Endoscopic follow-up
  • 2023-03-08 CT - abdomen
    • Findings:
      • There is a homogeneous enhancing lesion 2.3 cm at S2 of the liver in arterial phase images but no contrast washout (isodensity) in portal venous phase and delayed phase images.
        • FNH is highly suspected.
        • The differential diagnosis includes HCC.
        • Please correlate with MRI.
      • There is a poor enhancing lesion 1.5 cm in S7 of the liver at portal venous phase image. However, this lesion is not identified in non-enhanced, arterial phase images and delayed phase images.
        • Please correlate with MRI.
        • In addition, there are two poor enhancing lesions in S2/3 and S1 of the liver that may be cysts.
      • There are multiple enlarged nodes in the gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space.
        • Lymphoma is highly suspected.
        • The differential diagnosis includes metastatic nodes.
      • There are several gallstones (< 1.8 cm).
    • Impression:
      • FNH 2.3 cm in S2 of the liver is highly suspected.
        • The differential diagnosis includes HCC. Please correlate with MRI.
      • A poor enhancing lesion 1.5 cm in S7 of the liver, nature?
      • Lymphoma is highly suspected.
        • The differential diagnosis includes metastatic nodes.
  • 2023-03-06 SONO - abdomen
    • Diagnosis:
      • Hepatic hypoechoic lesion, left lobe, nature?
      • Splenic lesion, nature?
      • Gall stone
    • Suggestion:
      • correlated with other images
  • 2023-02-20 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (123 - 43) / 123 = 65.04%
      • M-mode (Teichholz) = 65
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH; impaired LV relaxation.
      • Normal RV systolic function.
      • Aortic valve sclerosis with no AS and AR; mild MR; mild TR; mild PR.
      • Dilated aortic root and ascending aorta; aortic root calcification.
  • 2023-02-07 SONO - abdomen
    • Gall stone
    • Splenic lesion?
  • 2023-02-05 CT - abdomen
    • Some LNs (up to 1.8cm) at retroperitoneum.
    • Gallbladder stones (up to 1.5cm).

[MedRec]

  • 2023-08-24 SOAP Cardiology Duan DeMin
    • Prescription x3
      • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
      • Concor (bisoprolol 5mg) 0.5# QD
      • Through (sennoside 12mg) 2# HS
  • 2023-07-24 SOAP Oral and Maxillofacial Surgery He ChengHan
    • S: toothache for a while
    • O:
      • Panoramic findings:
        • Missing: 18-14,25,27,28,37,36,31,41
        • Impaction: nil
        • Crown and Bridge: 23,24-26
        • Caries: 32
        • Periodontal condition: chronic periodontitis
      • deep caries of tooth 32, poor prognosis.
    • A: deep caries of tooth 32
    • P:
      • Take panoramic film for evaluation
      • Explain the findings
      • Suggest removal of the lower left side premolar after the body condition stabilized post-chemotherapy.
  • 2023-07-19 SOAP Hemato-Oncology Xia HeXiong
    • P
      • Arrange PET-CT for Re-stagingafter 6 cycles of C/T
      • Already mention PBSCT again
      • Request patient RTC by themself after removing tooth
  • 2023-07-06 SOAP Hemato-Oncology Xia HeXiong
    • P
      • Granocyte on D6-8
      • Strongly request him visit Endocrinologist for DM
    • Prescription
      • Smecta (dioctahedral smecitite 3mg) 1# TIDAC
  • 2023-06-28 SOAP Neurology Chen PeiYa
    • S: CC: involuntary mouth movement (compressing lips) noted since chemotherapy
    • Prescription
      • Switane (trihexyphenidyl 2mg) 0.5# BID
  • 2023-04-12 SOAP Hemato-Oncology Xia HeXiong
    • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-04-10.
      • Angioimmunoblastic T-cell lymphoma stage IV, IPI: 3(Age, stage, BM+Sella)
      • CHOP ± steam cell transplantation.
  • 2023-03-27 ~ 2023-04-07 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Angioimmunoblastic T-cell lymphoma of right neck with lymphadenopathy at mediastinum, with bilateral lower neck and EG junction and liver, bone marrow involvement, stage IV
      • Liver tumor, suspected focal nodular hyperplasia
    • CC
      • fever up to 39 degree for 3 days
    • Present illness
      • This is a 73 years old male with underlying disease of hypertension, type 2 DM, hyperlipidemia, hepatic tumor, suspected lymphoma, regularly followed up at our CV, GI and meta OPD.
      • This time, fever up to 39 degree for 3 days, after excisional biopsy of right neck on 2023-03-23. Otherwise, there was no URI or UTI symptoms, abdominal pain, diarrhea, dysuria, nausea or vomit. TOCC history was unremarkable.
      • Due to the fever, he came to our ED for help. At ED, vital signs showed BP:125/62mmHg; HR:93 bpm; BT:37.8’C; RR:16 bpm/min; Con’s:E4V5M6, SPO2:95%. The laboratory data showed normalized white count, elevated of CRP level(26.42mg/dl), hyponatremia were also noted. The urinalysis showed no UTI picture, such as pyuria or bacteriuria. The CXR film revealed no active lung lesion.
      • Under the impression of fever cause unknown, he was admitted to our INF ward for further evaluation and management on 2023-03-27.
    • Course of inpatient treatment
      • After admission we gave abx and survey for the cause of fever, atypical antigen, autoimmune disease, virus inf. were included. However, we connected with the pathologist and the patho of neck LN showed Angioimmunoblastic T-cell lymphoma.
      • Follow up Chest CT showed lymphadenopathy at mediastinum, bilateral lower neck and EG junction, liver low density nodule. S7, lymphoma is favored.
      • After explain with family and family, he received chemotherapy with CHOP (Endoxan 750mg/m2, Doxorubicin 50mg/m2, Vincristine 1.4mg/m2 (max 2mg), Compesolon 5mg/tab PO QD on 2023/4/3-3/7 60mg/m2) on 2023/04/03.
      • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H for nausea and vomiting. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/04/07 and OPD followed up later.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
  • 2023-03-23 SOAP Ear Nose Throat Guo YanJun
    • S: for neck mass biopsy
    • O: R’t level V neck mass about 2x1.5cm excisision done
  • 2023-03-22 SOAP Ear Nose Throat Guo YanJun
    • S
      • Referred from ID OPD for arrangement of excisional biopsy for pathological confirmation of TB.
      • Serum TB antigen test positive noted on 3-18
    • O
      • PH: DM, HTN, lipid
      • Allergy(-)
      • External ear canal clean
      • Ear drum intact
      • Nasal septum: deviated to R
      • Nasal cavity: fair inf. turbinate
      • Oral cavity: N-P
      • Oropharynx :fair
      • Nasopharynx: smooth via scope
      • Larynx: epiglottis ok, vocal cords fail
      • Neck: R level V 1.5cm and L level V 1.7cm firm movable oval masses without tenderness.
      • Scope: smooth nasopharynx, oropharynx, hypopharynx.
  • 2023-03-22 SOAP Infectious Disease Peng MingYe
    • S
      • Referred from Onco OPD for positive IGRA report on Mar 18
      • suspect liver lymphoma case
      • Underlying DM, HCVD, thoracic aneurysm, GB stone
    • O
      • 20230318 IGRA (+)
      • 20230317 PET
      • 20230315 MRI of liver
      • 20230313 UGI PES
    • A
      • Positive IGRA suggest at least latent TB, can not be used for TB LN diagnosis, LN biopsy still necessary.
    • P
      • refer to ENT OPD for Neck LN excisional biopsy highly recommended for pathology, for TB-PCR and TB culture
  • 2023-03-21 SOAP Hemato-Oncology Xia HeXiong
    • A/P
      • MTB (+) -> Refer to Infection for further management
      • If TB i under control, then refer to ENT for LN Excisional Biopsy
  • 2023-03-10 ~ 2023-03-17 POMR Gastroenterology Chen HongDa
    • Discharge diagnosis
      • Suspected lymphoma
      • Liver tumor, suspected focal nodular hyperplasia
      • Reflux esophagitis LA Classification grade A
      • Chronic superficial gastritis with erosions and focal atrophic gastritis, rapid urease test:positive.
      • Mixed hemorrhoid, mild
    • CC
      • was scheduled for liver tumor study.
    • Present illness
      • This is a 73 years old male with underlying disease of hypertension, type 2 DM, hyperlipidemia. He is regularly followed up at our CV and meta OPD. He was just discharged from our hopital on 2/13 due to intra-abdominal infection.
      • Follow up abdominal echo on 3/6 reveal a hepatic hypoechoic lesion, left lobe, nature need to be ruled out.
      • He then receive CT and it reveal
        • Focal nodular hyperplasia 2.3 cm in S2 of the liver is highly suspected. The differential diagnosis includes HCC. Please correlate with MRI.
        • A poor enhancing lesion 1.5 cm in S7 of the liver, nature?
        • Lymphoma is highly suspected.
      • He denied fever, chillness, decreased appetite, cold sweating or recent body weight loss found. He also denied any discomfort in recent days.
      • PE show no icteric slcera, no murphy sign. Blood test showed no leukocytosis but elevated of CRP.
      • Tumor markers(CEA, CA19-9 and AFP) all showed negative finding. CXR show bilateral clear lung field.
      • Under the impression of 1.) Hepatic tumor 2.) Favor lymphoma. He was admitted to our ward for further survey and treatment.
    • Course of inpatient treatment
      • After admission, Antibiotic with Ciproxin IV form total three days then shifted to oral form used for infection control.
      • Tumor marker with AFP was checked and hepatitis markers with HBsAg, Anti HCV were all follow up that showed negative finding.
      • Oncologoist was consulted for management of favor lymphoma who suggested 1. check LDH level 2. consult the General surgen for intra-abdominal LN excisional biopsy 3. liver biopsy.
      • Upper GI endoscopy and colonscopy were all performed which revealed reflux esophagitis LA Classification grade A; chronic superficial gastritis with erosions and focal atrophic gastritis, s/p CLO test (+); Gastric xanthoma and gastric mucosal lesion, suspected intestinal metaplasia, mid body, LC, s/p biopsy on EGD. Colonscopy showed mixed hemorrhoid, mild. Oral form PPI with Nexium 1# po QDAC was used.
      • GS was consulted for lymph node biopsy and management of GB stones who explained the risk and possibility of surgery and may do PET by himself payment for further survey.
      • ID man was also consulted for management of elevated of CRP who suggested 1. Check U/A, urine culture, check PSA level. 2. Serum QuantiFERON-TB study for possible latent TB or active TB. 3. Consider laparoscopy for open biopsy.
      • Liver MRI with contrast was done on 3/15 that report showed 1.FNH 2.3 cm in S2 of the liver is noted. 2.Sclerosing hemangioma 1.5 cm in S7 of the liver is highly suspected. 3.Reactive nodes are highly suspected. The differential diagnosis includes lymphoma and metastatic nodes. Please correlate with PET scan.
      • on 3/16 AM: the medical condition was explained to the patient, his wife, and niece (although the patient had been informed of the explanation timing in the past couple of days, he still mentioned that his son and daughter were too busy to come to the hospital). explained EGD, Colonoscopy report. reply of consultation of oncologist, GS surgeon, infection physician. Liver MRI report.
      • for abdominal lymph adenopathy: both benign or malignant etiology was considered: we’ve suggested lymph node biopsy: but patient and family refused lymph node biopsy
      • we’ve also suggested percutaneous biopsy for liver tumor (FNH was suspected): but patient and family also refused liver biopsy; they requested for PET scan; arranged PET scan
      • PET scan was done on 3/17 without complications. There was no abdominal pain nor poor appetite found during admitted. Under a stable condition, he was discharged first and further GI/ID/Oncology OPD were arranged later.
    • Discharge prescription
      • Cinolone (ciprofloxacin 250mg) 2# BIDAC
      • Nexium (esopeprazole 40mg) 1# QDAC
  • 2017-02-09 SOAP Metabolism and Endocrinology Yu LiJiao
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertention, unspecified [I10]
      • Pure hypercholesterolemia [E78.0]
    • Prescription x3
      • Uformin (metformin 500mg) 1# QD
      • Tulip (atorvastatin 20mg) 0.5# Q4D
      • Aprovel (irbesartan 300mg) 1# QD

[consultation]

[chemotherapy]

  • 2023-10-02 - gemcitabine 1000mg/m2 1800mg NS 250mL 1hr + oxaliplatin 100mg/m2 150mg D5W 250mL 2hr (GemOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-09-20 - gemcitabine 1000mg/m2 1800mg NS 250mL 1hr + oxaliplatin 100mg/m2 150mg D5W 250mL 2hr (GemOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-16 - cyclophosphamide 750mg/m2 1400mg NS 250mL 30min + doxorubicin 50mg/m2 90mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL + prednisolone 60mg/m2 110mg PO QD D1-5 (CHOP Q3W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-26 - cyclophosphamide 750mg/m2 1400mg NS 250mL 30min + doxorubicin 50mg/m2 90mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL + prednisolone 60mg/m2 110mg PO QD D1-5 (CHOP Q3W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-28 - cyclophosphamide 750mg/m2 1400mg NS 250mL 30min + doxorubicin 50mg/m2 90mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL + prednisolone 60mg/m2 110mg PO QD D1-5 (CHOP Q3W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-19 - cyclophosphamide 750mg/m2 1400mg NS 250mL 30min + doxorubicin 50mg/m2 90mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL + prednisolone 60mg/m2 110mg PO QD D1-5 (CHOP Q3W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-03 - cyclophosphamide 750mg/m2 1400mg NS 250mL 30min + doxorubicin 50mg/m2 90mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL + prednisolone 60mg/m2 110mg PO QD D1-5 (CHOP Q3W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-05

The repeat prescription for Exforge (amlodipine, valsartan), Concor (bisoprolol), and Through (sennoside) was issued by our cardiologist on 2023-08-24, and the patient refilled these medications on 2023-09-11. The medications are currently in use with no discrepancies found.

700563689

231005

[exam findings]

[MedRec]

  • 2023-08-29 SOAP Rheumatology Chen JunXiong
    • Diagnosis
      • Rheumatoid arthritis [M05.70]
      • Essential hypertention, unspecified [I10]
      • Constipation [K59.00]
      • Peristent disorder of initiating or maintaining sleep [F51.09]
      • Other specified gastritis, without mention of hemorrhage [K29.30]
    • Prescription x3
      • Eurodin (estazolam 2mg) 1# PRNHS
      • Salazine (sulfasalazine 500mg) 1# QD
      • Celebrex (celecoxib 200mg) 1# PRNQD
      • Plaquenil (hydroxychloroquine 200mg) 1# QD
      • MgO 250mg 1# QD
      • Compesolon (prednisolone 5mg) 1# QD
  • 2023-08-02 SOAP Hemato-Oncolgoy Xia HeXiong
    • O: Multidisciplinary Cancer Team Meeting Conclusion, Meeting Date: 2023/07/13
      • Treatment Plan: 1. Adjuvant chemotherapy after surgery. 2. Staging consensus: T1c1N0M0.
    • P: Arrange admission for adjuvant chemotherapy with TP x6
  • 2023-07-04 ~ 2023-07-14 POMR Obstetrics and Gynecology Zeng LunNa
    • Discharge diagnosis
      • Malignant neoplasm of left ovary
      • Rheumatoid arthritis with rheumatoid factor of unspecified site without organ or systems involvement
      • Unspecified hydronephrosis
      • Debulking surgery on 2023-07-06
    • CC
      • Incidental computed tomography (CT) finding of left pelvic mass (105mmx68mm) on 2023/06/21
    • Present illness
      • This is a 62-year-old-woman, Gravidity2 Parity2 (G2P2) (vaginal delivery x2) with rheumatic arthritis and hypertension under medication. She came to our hospital this time due to incidental CT finding of left pelvic mass (105mmx68mm) on 2023/06/21.
      • She was in her ususal status until 2023/06/21, when Left upper qaudrant (LUQ) pain was noted. She visited our emergency department, where whole body CT with contrast was done. A 10cm well-defined pelvic mass with cystic and soft-tissue components and enhancement of solid parts was found. The tumor also caused compression of urinary bladder and left ureter, resulting in moderate hydronephrosis.
      • Gynecologist was consulted, and abdominal echo and tranvaginal echo showed a pelvic mass measuring 105mmx86mm with ascites, uterus: 5.8x3.6cm, endometrium: 1.12cm. She was first admitted to treat her acute problem of urinary tract infection, left percutaneous nephrostomy (PCN) was also performed. After compeleting the treatment, she came to our gynecology out patient department for surgical evaluation.
      • According to the patient, urinary frequency had been noted for about five years. She denied abodminal distension, no abdominal pain, no nausea or vomit, no constipation nor diarrhea, no bloody or tarry stool, no vaginal spotting or discharge. There was decrease appetite since last November, due to teeth problems, therefore a decrease of 12 kilogram (kg) was noted ever since.
      • Lab data showed normal CA125 (32.2 U/ml), normal CEA (2.08 ng/ml), normal CA199 (25.58 U/ml). Under the impression of pelvic mass, favor left ovarian origin, surgical intervention was suggested. After well explained and discussion with patient, she agreed operation.
      • Under the impression of pelvic mass, favor left ovarian origin, we will arrange admission for preoperative evaluation and preparation including panendoscopy and colonscopy as well as debulking surgery.
    • Course of inpatient treatment
      • After admission, the patient underwent upper GI panendoscope and colonoscope on 2023/07/05, both showed no signs of tumor lesions. On 07/06, she underwent debulking surgery (total hysterectomy + bilateral salphingo-ophorectomy + bilateral pelvic lymph node dissection + infracolic omentectomy) and insertion of bilateral double-J. Perioperative blood loss was 1400ml. therefore transfusion with 4u LPRBC, ferrum injection 2 amp ST, trasamin 500mg BID (07/06~07/07) were given.
      • Post-operation hemoglobulin: 8.9g/uL increased to 9.2g/uL. We checked KUB on 7/7, which showed intact left PCN and bilateral double-J, therefore, left PCN was removed in the afternoon. Left lower quadrant pain improved evidently afterwards.
      • Surgical wound was vertical, 13cm in total, there was no active woozing, no discharge.
      • Desaturation to SpO2 around 80% room air was noted on 7/9 evening, with tachypnea (22-24/min), so was fever up 39.1’C. Fever routine was performed, U/A showed pyuria, nitrite: 1+, bacteria:3+. Lab: leuocytosis with bandemia. Chest xray showed blunting of right CP angle, which resolved slightly on 7/10 CXR. Therefore empirical cravit 750mg QD was prescribed (7/9~7/10), tazocin to cover anerobes due to possible aspiration peumonia (7/11), doripenam as recommended by infection (7/12~7/13), oral cravit(7/14~).
      • Due to bilateral lung atelectasis with unstable SpO2, we consulted chest man. Aggressive chest percussion was recommended, and we also checked sputum culture, which later showed mixed growth and candida albicans. Abdominal distension with vomit were also noted, with improved a bit after abdominal massage. We also added primperan 10mg Q8H and MgO 1# QD to facilate bowel movement. Afterwards, the patient showed evident improvement in spirits and appetite. Flatus and defecation was smooth, wound pain also improved gradually.
      • Since 7/9, there had been no fever. Much yellowish sputum was still noted, so we continued actein treatment and gave oxygen support with nasal cannula when needed, and also encourage ambulation. We followed-up lab data on 7/12, CRP decreased from 16.6 to 6.4, no more bandemia. Chest Xray also showed no lower lung atelectasis.
      • Pathology report showed ovarian caner, clear cell adenocardinoma, high grade, pT1c1 pN0 (if cM0), FIGO stage 1C1. Therefore, tumor broad was arranged on 2023/07/13, and after discussion, consensus was reached to start chemotherpay for this patient. Therefore, oncolgist Dr. Shia visited the patient on 7/13 and explained on details regarding further treatment, including insertion of port-A.
      • Under stable conditions, the patient is discharged on 2023/07/14 with follow-up at gynecology and oncology outpatient department. We also arranged rheumatology follow-up for this patient to evaluate her ongoing rheumatic arthritis.
    • Discharge prescription
      • Cinolone (ciprofloxacin 250mg) 2# BIDAC
      • Gaslan (dimethylpolysiloxane 40mg) 1# BID
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
  • 2017-01-16 SOAP Rheumatology Chen JunXiong
    • Diagnosis
      • Rheumatoid arthritis [M05.70]
      • Essential hypertention, unspecified [I10]
      • Constipation [K59.00]
      • Peristent disorder of initiating or maintaining sleep [F51.09]
      • Other specified gastritis, without mention of hemorrhage [K29.30]
    • Prescription x3
      • Eurodin (estazolam 2mg) 1# PRNHS
      • Salazine (sulfasalazine 500mg) 1# BID
      • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
      • folic acid 4mg 4# QW
      • Trexan (methotrexate 2.5mg) 4# QW
      • Celebrex (celecoxib 200mg) 1# PRNBID
      • Plaquenil (hydroxychloroquine 200mg) 1# BID
      • MgO 250mg 1# QD
      • Compesolon (prednisolone 5mg) 1# QD
  • 2017-01-16 SAOP Obstetrics and Gynecology Xu YaoRen
    • O
      • 2016-12-23 cell-block pathology: Atypical squamous cells (ASCUS)
    • Diagnosis
      • Nonspecific abnormal papanicolaou smear of cervix [R87.610]
      • Erosion and ectropion of cervix [N86]
    • Prescription
      • Lindacin (clindamycin 150mg) 2# Q6H

[consultation]

[surgical operation]

[chemotherapy]

  • 2023-09-08 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 4 200mg NS 250mL 2hr (Q3W. carbo eGFR 36 CCr 23 AUC 4)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-17 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 4 360mg NS 250mL 2hr (Q3W. carbo eGFR 65 AUC 4)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-05

Most of the medications prescribed by our rheumatologist are immunomodulators and primarily immunosuppressive. As the patient is currently undergoing chemotherapy, it is advisable to monitor any changes in immune function or rheumatoid arthritis symptoms.

700906364

231005

[exam findings]

  • 2023-09-25 CT - chest
    • Comparison was made with CT on 2023/07/31
      • Lungs: s/p post op change with staple lines in lt lung and Rt lower lung.
        • multiple pleural-based solid nodular abnormalities in left lung, and nodular thickening at left interlobar fissure, stationary. several small soft-tissues nodules at RLL.
      • Mediastinum and hila: small LNs in vsceral space
      • Pleura: small Lt-sided effusion with loculation.
    • Impression:
      • lung and pleural metastases, stationary compared with CT on 2023/07/31
  • 2023-09-06 PET
    • Glucose hypermetabolic lesions in a celiac lymph node and in several left pulmonary hilar and mediastinal lymph nodes, highly suspected recurrent tumor with distant lymph nodes metastases.
    • Glucose hypermetabolic lesions in the right pulmonary hilar and mediastinal lymph nodes, probably metastatic or reactive nodes.
    • FDG-avid lesions in the right lower lung pleura, in the right upper and lower lungs with pleurae involvement, and in the left rib cage, highly suspected recurrent tumor with lung and bone metastases.
    • Glucose hypermetabolic lesions in the right fronto-temporal region of the skull, probably metastasis or post-traumatic change.
    • Recurrent rectal cancer s/p treatment with distant lymph nodes, lung and bone metastases, yrcTxNxM1b, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-08-15 Patho - stomach biopsy
    • Stomach, antrum, biopsy — chronic gastritis with Helicobacter infection
    • Microscopically, it shows chronic gastritis with lymphoplasmacytic infiltrate. Helicobacter-like bacilli are seen.
  • 2023-08-14 EGD
    • Reflux esophagitis LA Classification grade A
    • Suspect Barrett’s esophagus, EC junction, s/p biopsy(B)
    • Superficial gastritis, s/p biopsy(A)
    • Gastric subepithelial lesion, AW of high bpdy
  • 2023-07-31 CT - chest
    • Comparison was made with previous CT dated on 2023/04/26
      • Lungs: s/p post op change with staple lines in lt lung and Rt lower lower lung.
        • multiple pleural-based solid nodular abnormalities in left lung, and nodularity thickening at left interlobar fissure, stationary.
        • several small soft-tissues nodules at RLL.
      • Mediastinum and hila: small LNs in vsceral space
      • Vessels:
        • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Pleura: small Lt-sided effusion with loculation.
    • Impression:
      • lung and pleural metastases, stationary compared with CT on 2023/04/26
  • 2023-06-01 CXR
    • Few nodular opacity projecting in the left lung are suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Spondylosis and Scoliosis of the L-spine with convex to right side.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2023-05-05 All RAS + BRAF
    • ALL-RAS: Detected (KRAS codon 13 GGC>GAC, p.G13D)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-05-02 L-spine flex & ext
    • Presence of spondylolisthesis at L3/4, grade I.
  • 2023-05-02 Bone densitometry
    • Hip BMD performed by DXA revealed:
      • Hip, BMD is 0.574 gms/cm2, about 2.5 SD below the peak bone mass ( 68 %) and 0.0 SD at the mean of age-matched people ( 100 %).
      • IMP: osteoporosis
    • L-spines BMD (AP view) performed by DXA revealed:
      • AP L-spines, BMD of L1-4 0.742 gms/cm2, about 2.5 SD below the peak bone mass ( 73 %) and 0.2 SD above the mean of age-matched people ( 105 %).
      • IMP: osteoporosis
  • 2023-04-26 CT - chest
    • lung and pleural metastases, in progresion compared with CT on 2023/01/18.
  • 2023-04-17 Colonoscopy
    • No definite mucosal lesion was seen except diverticula at S-colon
  • 2023-04-13 CXR
    • Few nodular opacity projecting in the left lung are suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Spondylosis and Scoliosis of the L-spine with convex to right side.
  • 2023-01-18 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis and Scoliosis of the L-spine with convex to right side.
  • 2023-01-18 CT - abdomen
    • S/P LAR with autosuture retention over the rectum.
    • Prior CT identified two solid nodule in RLL and LLL of the lung are noted again, stationary.
  • 2023-01-18 CT - chest
    • lung and pleural metastases, stationary.
  • 2022-10-26 CT - chest
    • recurrent left lung and pleural metastases, stationary.
  • 2022-07-22 CT - chest
    • Left lower lobe meta. Stationary.
  • 2022-02-15 CT - chest
    • recurrent left lung and pleural metastases.
  • 2021-09-01 CT - chest
    • no new lung nodule.
  • 2021-05-06 CT - chest
    • s/p left upper lobe and left lower lobe op.
    • no evidence of recurrent tumor in the study.
  • 2020-12-30 Patho - lung wedge biopsy
    • pathologic diagnosis
      • Lung, left upper lobe (frozen section specimen), wedge — Metastatic colorectal adenocarcinoma
      • Lung, left lower lobe, wedge — Metastatic colorectal adenocarcinoma
      • Lymph nodes, LN 9, dissection — Negative for malignancy (0/3)
      • Parietal pleura, biopsy — Metastatic colorectal adenocarcinoma
    • microscopic examination
      • Tumor Focality: Multiple tumors over LUL, LLL, and parietal pleura
      • Histologic Type: Metastatic colorectal adenocarcinoma
      • Spread Through Air Spaces (STAS): Not identified
      • Visceral Pleura Invasion: Present
      • Lymphovascular Invasion: Present
      • Lymph nodes, LN 9: Negative for metastatic carcinoma (0/3)
      • IHC for tumor cells: CK7(-), CK20(+), and CDX2(+)
  • 2020-12-29 Frozen resection
    • Lung, LUL, frozen section — Adenocarcinoma, compatible with metastatic colorectal carcinoma
  • 2020-12-11 CT - chest
    • Left upper lobe and left lower lobe nodules. suspected lung mets.
    • Focal Pleural thickening. suspected pleural seeding.
  • 2020-12-01 CT - abdomen
    • Left basal lung nodules. Nature? Suggest chest CT
  • 2020-09-01 CT - abdomen
    • Post-op at the colon.
    • Right adrenal tumor, suggest follow up.
    • Uterine tumor, suspected myoma.
  • 2019-12-30 CT - abdomen
    • Rectal cancer s/p operation. No evidence of tumor recurrence.
  • 2018-08-13 CT - abdomen
    • Status post LAR with stable condition.
  • 2017-08-31 CT - abdomen
    • Rectal cancer s/p operation. No evidence of tumor recurrence.
  • 2017-03-18 CT - abdomen
    • Rectal CA, s/p operation. No evidence of tumor recurrence
  • 2013-end pathology
    • adenocarcinoma, metastatic (7/34)
    • pathology stage: pStage IIIC, pT3N2b(cMx),
    • IHC stain of EGFR: weak positive on 30% to 40% of the neoplastic glands.
  • 2013-11-29 CT - abdomen
    • rectal cancer with LNs & lung mets (T2N1M1a)

[MedRec]

  • 2023-07-26 SOAP Neurosurgery Huang GuoFeng
    • O
      • There is pain in the lower back or buttocks, which can extend to one or both sides of the lower limbs while walking.
      • There is intermittent limping (Neurogenic Claudication), and after walking for a few minutes or steps, there is increased numbness and weakness in the lower limbs.
      • There are also symptoms such as shooting pain in the calf and numbness in the feet, which require rest for some time to obtain relief.
      • The patient reports a decrease in sensation and severe numbness in the L5-S1 dermatome, as well as muscle weakness (rated 4-5) with no increase in deep tendon reflexes. Bladder and sphincter function are normal, and gait is slow. Hip joint and both lower limb pulses are normal. The root tension sign is positive, and the patient experiences worsening pain (rated 6 out of 10) that can reach 8 out of 10, making walking difficult. The pain is relieved when lying down but is exacerbated when standing up, preventing the patient from walking. The patient has been experiencing severe back pain and sciatica for a long time, and conservative treatment, including rehabilitation and medication, has been ineffective. Clinical instability is being ruled out, and SLRT is positive on the left side. Fabor test is negative, and deep tendon reflexes are decreased. The patient can walk on their toes and heels without issue.
    • Diagnosis
      • [M48.56XA] Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture
    • Prescription x3
      • U-Ca (calcitriol 0.25ug) 1# QD 84D
      • Evista (raloxifene 60mg) 1# QD 28D
  • 2021-01-12 SOAP Hemato-Oncology Zhang ShouYi
    • S: 68 y/o female. a pt of Rectal CA, pT3N2b (7/34) M0, stage IIIC, s/p Laparoscopic LAR on 12/24 13 by Dr Xiao GuangHong, s/p CCRT by Dr Huang JingMin & Post-CCRT adjuvant C/T wt sLV-5FU (2 days) Q2W x 12 finishing in Oct 2014, recurrence wt lung mets & pleura mets s/p lung metastasectomy in Dec 2020.
  • 2017-03-25 SOAP Hemato-Oncology Zhang ShouYi
    • S: 64 y/o female. a pt of Rectal CA, pT3N2b (7/34) M0, stage IIIC, s/p Laparoscopic LAR on 12/24 13 by Dr Xiao GuangHong, s/p CCRT by Dr Huang JingMin & Post-CCRT adjuvant C/T wt sLV-5FU (2 days) Q2W x 12 finishing in Oct 2014, was noted to have the CA by physical checkup without particular discomfort in Dec 2013.

[consultation]

  • 2023-06-05 Nephrology
    • Q
      • For hyponatremia & poor appetite
      • This 71-year-old woman, a patient of Rectal cancer, pT3N2b (7/34) M0, stage IIIC, s/p Laparoscopic LAR in 12 2013, s/p CCRT, adjuvant sLV-5FU Q2W x12 in 10 2014, recurrence with lung, pleura metastasis, s/p lung metastasectomy in 12 2020, s/p palliative FOLFIRI/Avastin x12 in 07 2021, recurrence with lung metastasis in 02 2022, s/p palliative mFOLFOX x12 in 01 2023, in progresion in 04 2023, s/p palliative FOLFIRI. She was admitted for C/T. She complained of general weakness, poor appetite post C/T and Na report from 136 -> 116 -> 111 mmol/L was noted. We need expertise to evaluate her condition thanks!
    • A
      • We visited the patient at the bedside and evaluated her condition. Her consciousness was clear, and not in respiratory distress. All four of her limbs were not edematous. The patient said she did not want to eat with nausea sensation since 2023-06-02, and she did not have vomiting or diarrhea. The caregiver observed that the patient speaked inherencetly recently.
      • Chemotherapy: FOLFIRI
      • Blood test showed severe hyponatremia.
        • 2023-06-05 Na (Sodium) 111 mmol/L
        • 2023-06-04 Urine osmolarity 542 mOsm/Kg
        • 2023-06-04 Na (Urine) 136 mmol/L
        • 2023-06-04 Blood Osmolality 241 mOsm/Kg
        • Cortisol, TSH, free T4 WNL
      • Our impressions are as follows:
        • Hypo-osmotic hypo/euvolemic hyponatremia, suspected to be SIADH related to irinotecan
        • Hypomagnesemia, hypokalemia, hypocalcemia, hypophosphatemia also identified
      • Our advices are as follows:
        • Check BUN, Cr, Uric acid
        • Record daily I/O and BW; - Restrict free water intake to 1000mL/day
        • Keep 3% NaCl 10ml/hr and monitor serum Na Q6H ~ Q8H; change in Na levels should not exceed 6-8 mEq/L within any 24-hour period
        • DC 0.298% IV fluid, adjusted to Constat-K 1# QID
        • Check serum K, Mg, P and urine K, Mg, P, Cr, urinalysis simultaneously on 2023-06-06
      • Please be assured that we will continue to follow up on this patient. Feel free to contact us should you require further assistance. Thank you.

[surgical operation]

  • 2020-12-29 VATS, LUL and LLL wedge + lymph node sampling
    • multiple scattered whitish to translucent nodules about 5mm~10mm on visceral and parietal pleura suspected rectal metastasis parietal biopsy, LLL wedge biopsy and lymph node sampling
    • a volcano like solid nodule about 1.5cm in diameter in LUL S1 segment after wedge biopasy
  • 2013-12-24 Laparoscopic LAR + Thoracoscopic wedge or Partial resection of the Lung

[radiotherapy]

  • early 2014

[chemoimmunotherapy] (not completed)

  • 2023-09-05 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 480mg NS 250mL 2hr + fluorouracil 2400mg/m2 2850mg 46hr (FOLFIRI Q2W, 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-15 - FOLFIRI

  • 2023-07-17 - FOLFIRI

  • 2023-07-03 - FOLFIRI

  • 2023-06-01 - FOLFIRI

  • 2022-03-08 ~ 2023-01-13 - FOLFOX

  • 2021-02-01 ~ 2021-07-27 - FOLFIRI plus bevacizumab

  • 2021-01-18 - FOLFIRI

  • 2014-04-03 ~ 2014-10-07 - PF, post CCRT adjuvant, 12 cycles

  • 2014-02-10 ~ 2014-03-13 - 5-Fu based

==========

2023-10-05

Vemlidy (tenofovir alafenamide 25mg) 1# QD prescribed by our gastroenterologist on 2023-09-30 is currently in use. No medication discrepancy was found.

Please note that both tumor markers CA-199 and CEA have started to show a slight upward trend after bottoming out in August. This may indicate a change in the balance of the treatment and the disease.

2023-09-22 CA-199 (NM) 1277.40 U/ml 2023-08-25 CA-199 (NM) 1125.26 U/ml 2023-08-18 CA-199 (NM) 743.66 U/ml 2023-08-01 CA-199 (NM) 931.32 U/ml 2023-07-18 CA-199 (NM) 1470.34 U/ml 2023-06-20 CA-199 (NM) 867.59 U/ml

2023-09-22 CEA (NM) 96.979 ng/ml 2023-08-25 CEA (NM) 87.270 ng/ml 2023-08-18 CEA (NM) 81.753 ng/ml 2023-08-01 CEA (NM) 61.346 ng/ml 2023-07-18 CEA (NM) 98.554 ng/ml 2023-06-20 CEA (NM) 66.050 ng/ml 2023-04-25 CEA (NM) 47.692 ng/ml 2023-01-18 CEA (NM) 5.127 ng/ml 2022-10-28 CEA (NM) 5.562 ng/ml

2023-09-06

No medication reconciliation issues were identified after reviewing the PharmaCloud database and hospital HIS5 records.

2023-07-18

After reviewing the PharmaCloud database and in-hospital HIS5 records, no medication reconciliation issues were found.

2022-04-20

  • This patient diagnosed with rectal cancer with LNs and lung mets in late 2013, recurrence monitored in late 2020, patient receives FOLFIRI (plus bevacizumab) from 2021-02-01 to 2021-07-27, following VATS, LUL and LLL on 2020-12-29, and recurrence detected again in early 2022. She is currently treated with FOLFOX since 2022-03-08.
  • Lab data reported on 2022-04-19 revealed that liver and kidney function, serum electrolytes, and blood cell counts were generally normal. The nursing note does not indicate any intolerances so far since this hospitalization.
  • Depending on the patient’s financial situation and there are no contraindications, targeted and/or immunotherapy treatments might also be considered.

701499491

231005

[MedRec]

  • 2023-10-03 SOAP Medical Emergency
    • S: (the following text seems to be from Sun Yat-Sen Cancer Center earlier CT)
      • CT Scan #A
      • Clinical History and Indications: metastatic neuroendocrine carcinoma of the pancreas with LNs of retroperitoneum, mediastinum, pleura and pericardial, with right 10th rib bone and liver metastasis, on palliative C/T.
      • Findings comparison CT: 2023/04
        • lung, airway: reticular opacities, right lower lung, no obvious change
        • lower neck, axilla: small lymph node(s), short axis <10mm
        • mediastinum, pulmonary hila: small lymph node(s), short axis <10mm
        • pleura, pericardium, chest wall: right pleural effusion; no pericardial effusion;
        • heart, great blood vessels: atherosclerosis;
        • hepatobiliary system: multiple metastasis in both lobes, size and number increase; dominant tumor 6cm right lobe S7, bigger; gallbladder wall thickening; minimal dilatation of bilateral intra-hepatic ducts;
        • mass lesion 77mm, replacing pancreatic body, bigger; atrophy of pancreatic tail;
        • enlarged lymph nodes, 39mm and 20mm, gastro-hepatic space, bigger;
        • spleen, adrenal glands: left adrenal gland metastasis, no obvious change
        • kidneys: no hydroneprhosis;
        • retroperitoneum: tumor involvement of upper retroperitoneum, tumor encasement of celiac trunk and SMA root, no obvious change; metastasis in left para-aortic space 42mm, no obvious change; tumor compression of left renal vein;
        • peritoneum, mesentery, GI tract: no evident ascites; small nodular lesion(s) in peritoneal cavity, no obvious change
        • pelvis: no enlarged lymph node; no evident mass lesion
        • bone: right chest wall mass lesiond <= 48mm with bony destruction of right ribs, more evident;
      • Impression and Suggestions
        • progression of liver metastasis;
        • progression of right chest wall metastasis;
        • bigger of tumor at pancreatic body;
        • bigger of gastro-hepatic space lymph nodes; no obvious change of retroperitoneum metastasis;
        • the overall picture suggests progressive disease
      • CT Scan #B
      • Clinical History and Indications Pancreatic carcinoma with multiple metastases, on palliative C/T.
        • Findings
          • Lymph nodes: a. in the mediastinum, less than 10 mm: — the node in the subcarinal region is smaller as compared with previous CT scan on 2023/01/31, probably metastasis. — other nodes are less than 10 mm and show no obvious change.
            • metastatic lymph nodes in the gastrohepatic ligament, up to 22 mm, larger.
            • in the para-aortic region, up to 15 mm, larger.
            • in the hepatic hilum, 12 mm. No obvious change.
          • Small right pleural effusion, stable.
          • Lung: minimal reticular opacities/atelectasis in right lower lobe. No obvious change.
          • Liver:
            • multiple metastasis with progression.
            • intrahepatic bile duct dilatation. No obvious change.
          • Pancreas: ill-defined soft tissue infiltration in the body, compatible with pancreatic cancer. No obvious change.
            • dilatation of the pancreatic duct, more obvious
            • tumor involves the left adrenal gland and encases the celiac artery, superior mesenteric artery, left renal vein.
          • Kidney:
            • suspicious a subcentimeter cyst in left kidney, stable.
            • subcentimeter stones in both kidneys. No hydronephrosis.
          • Spleen: no focal lesion.
          • Gallbladder: suspicious small stones.
          • Nodules in the right peritoneum and renal hilum, up to 10 mm, either stable or smaller, probably metastasis. (scan 7/80, 84)
          • Bone:
            • focal mixed density change in right 9th and 10th rib, probably metastasis, already noted on previous CT.
            • soft tissue around the right 10th rib, newly demonstrated, probably extraosseous tumor extension. (scan 7/63-73)
          • Back region: soft tissue defect in right lower back, at the level of right 9th and 11th ribs. Suggest clinical correlation.
        • Impression and Suggestions
          • Pancreatic carcinoma. No obvious change.
          • Metastatic lymph nodes in the gastrohepatic ligament and the para-aortic region, larger.
          • Hepatic metastasis with progression.
          • Peritoneal metastasis, either stable or smaller.
          • Suspicious bony metastasis in the ribs, already note d on previous CT.

==========

2023-10-05

This patient has been receiving treatment at the Koo Foundation Sun Yat-Sen Cancer Center in the past. The only prescription medication from that center that is still valid to date is Megest Oral Suspension (megestrol acetate). This drug is not currently included in the active medication list. If the patient continues to experience cachexia or poor appetite, it is advisable to reintroduce this medication.

700301189

231003

[exam findings]

  • 2023-10-03 CT - brain
    • Mild swelling of left parietal and occipital scalp.
  • 2023-10-02, -08-30, -08-02, -07-21, -07-12, -06-14, -06-01, -05-27 CXR
    • Bilateral Pleura effusion is noted.
    • There are multiple nodular opacities projecting in both lung that are c/w metastases after correlate with CT.
    • Spondylosis of the T-spine
    • Enlargement of cardiac silhouette.
  • 2023-06-26 CT - chest
    • PH: adenocarcinoma of low rectum s/p transanal local excision (2019/04/15), pT2NxM0, stage I, at least, G2, LVI(-), PNI(+), left margin involved (+), s/p radiotherapy & C/T
    • Chest and Abdominal CT with and without enhancement revealed:
      • Chest:
        • Nodular and cavitatory lesion at left lower lobe is found. In comparison with CT dated on 2023-03-21, the lesions decreased in size or became less compact
        • S/p port-A placement with its tip at left brachiocephalic vein.
        • Minimal bilateral pleural effusion with pleural thickening is found.
      • Visible abdomen:
        • Low density nodule at uncinate process of the pancreas is found measuring 1.2cm. Another mass like lesion at pncreatic tail measuring 2.7cm is noted. In comparison with CT dated on 2023-03-21, the lesion enlarged.
    • Imp:
      • Diffuse lung meta. In regression.
      • Bilateral pleural meta.
      • Pancreatic tail tumor and uncinate process nodule. In enlargmennt. Pancreatic cancer is favored.
  • 2023-03-28, -03-27, -03-24, -03-22 CXR
    • Pneumo-mediastinum is highly suspected.
    • Left Pleura effusion is noted.
    • Focal pneumothorax at right CP angle.
    • Subcutaneous emphysematous change over bilateral lower neck, bilateral axillary and right lateral chest wall.
    • There are multiple nodular opacities projecting in both lung that are c/w metastases after correlate with CT.
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
    • S/P pigtail catheter implantation at right CP angle with focal pneumothorax.
  • 2023-03-22 SONO - chest
    • Pleural effusion, moderate, right
    • Atelectasis, RLL
    • Organized pleurae, left
  • 2023-03-21 CT - chest
    • Comparison was made with previous CT dated on 2022/08/26
      • Lungs: multiple randomly distributed pulmonary nodules of varying sizes, consistent with metastatic lesions.
        • dependental partial relaxation atelectasis of RLL.
        • massive Rt and moderate Lt, bilateral pleural effusions, with parietal pleural thickening.
        • multiple subleural bulla lung cyst in bilateral apical lungs
      • Mediastinum and hila: no enlarged LN or mass.
      • Aorta: normal caliber of thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal-pelvic contents: hypodense lesions in pancreatic tail up to 19mm.
        • several small hepatic cysts.
        • unremarkable of the spleen, GB, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
        • no obvious bowel wall thickening of colon and rectum based on CT images.
        • extensive spondylosis and degenerative spinal canal and lateral recesses stenosis at L4-S1 levels.
    • Impression:
      • bilateral pulmonary metastases and exudative pleural effusion, in progression and new pancreatic tail tumors (metastases d/d primary cancer) as compared with previous CT study on 2022/08/26
  • 2023-03-21 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Septal infarct, age undetermined
  • 2022-09-23 Patho - lung transbronchial biopsy
    • Lung, right, CT-guide biopsy—adenocarcinoma, moderately differentiated, metastatic, consistent with colorectal origin
    • Sections show neoplastic cribriform glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal CK7(-), CK20(+), TTF-1(-), and CDX2(+). The results are consistent with metastatic colorectal adenocarcinoma.
  • 2022-08-26 CT - chest
    • Bilateral lung meta. Stable
    • Consolidation over left lower lobe, please monitor superimposed pneumonitis.
  • 2022-05-13 CT - chest
    • Multiple lung meta with necrotic or solid nodular appearance. In progression.
    • Small lymph nodes are found in the mediastinum.
  • 2022-04-06 CXR
    • Multiple nodules at RLL.
  • 2022-01-07 CT - abdomen
    • There is no evidence of wall thickening in the rectum. Please correlate with colonoscopy.
  • 2022-01-07 Colonoscopy
    • Previous surgical scar at low rectum was found. No recurrent.
  • 2020-12-04 CT - abdomen
    • There is no evidence of wall thickening in the rectum. Please correlate with colonoscopy.
  • 2020-12-04 Colonoscopy
    • No definite mucosal lesion was seen from rectum to cecum. Previous surgical scar at low rectum was seen without recurrent evidence
  • 2019-12-10 CT - abdomen
    • Clinical history: 73 y/o male patient with
      • 2019-04-08: He had been to KFSYSCC for second opinion, but they suggest him to receive surgery at our hospital, he refused APR, thus, transanal local excisin + CCRT is first choice
      • 2019-05-03: adenocarcinoma of low rectum s∕p transanal local excision (2019-04-15), pT2NxM0, stage I, at least, G2, LVI(-), PNI(+), left margin involved (+)
      • 2019-06-14: for CEA report (suggest CTC), s∕p 22th R∕T, refuse chemotherapy, anal pain, 2019-07-19: finished R/T, no discomfort, refuse C/T
      • 2019-11-01: no discomfort, for follow-up programs.
    • With and without contrast enhancement CT of abdomen - whole:
      • Small gallbladder stone.
      • Liver cysts, up to 0.8cm in left lobe.
      • Unremarkable change of the spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
    • Impression:
      • Clnical lower rectal cancer s/p, suggest follow up.
      • Small gallbladder stone.
      • Liver cysts.
  • 2019-04-16 CT - abdomen
    • There are few small gas bubbles in the perirectal space, near anal verge. please correlate with clinical condition.
    • Few tiny gallstones are suspected.
  • 2019-04-16 Surgical pathology Level IV
    • PATHOLOGIC DIAGNOSIS
      • Large intestine, rectum, transanal local excision —- Adenocarcinoma, moderately differentiated
      • Resection margins: involved, left
      • Lymph node, mesocolic, dissection —- Not received
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: pStage I, pT2Nx(if cM0)
    • MACROSCOPIC EXAMINATION
      • Operation procedure: transanal local excision
      • Specimen site: rectum
      • Specimen size: 2.8 x 1.7 x 1.4 cm
      • Tumor size: 1.5 x 1.0 cm
      • Tumor location: anterior: 0.3 cm; right: 0.4 cm; posterior: 0.6 cm; left: involved; deep: 0.8 cm
      • Depth of invasion grossly: muscularis propria
      • Mucosa elsewhere: congestion
      • Two separated tissue fragments measuring up to 2.0 x 0.7 x 0.5 cm are found.
      • All for section and labeled as: A1-2: cross section from right (green) to left (blue); A3: anterior; A4: posterior; A5: separated tissue fragments.
    • MICROSCOPIC EXAMINATION
      • Histology: adenocarcinoma; The immunohistochemical stains reveal CK(+) and CD56(-).
      • Histology Grade: moderately differentiated
      • Depth of invasion: muscularis propria
      • Angiolymphatic invasion: Not identified.
      • Perineural invasion: Present.
      • Discontinuous extramural tumor extension: Not identified.
      • Circumferential (radial) margin of rectum: Uninvolved, 8 mm from the margin,
      • Lymph node metastasis, mesocolic: not received
      • Lymph node metastasis, IMA / SMA: not received
      • Extranodal involvement: not received
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): pT2:Tumor invades the muscularis propria
        • Regional Lymph Nodes (pN): Nx
        • Distant Metastasis (pM): if cM0
      • Type of polyp in which invasive carcinoma arose: Tubulovillous adenoma.
      • Additional pathologic findings: S2019-3459: IHC stain— PMS2(+), EGFR(+), MSH-2(+), MSH-6(+), MLH-1(+)
      • TNM descriptors: unknown
      • Tumor regression grading S/P CCRT: patient not received
  • 2019-04-15 ECG
    • Normal sinus rhythm with sinus arrhythmia
    • ST abnormality, possible digitalis effect
    • Abnormal ECG
  • 2019-03-28 CT - abdomen
    • Imaging Report Form for Colorectal Carcinoma
      • TxN0Mx

[consultation]

  • 2023-03-27 Thoracic Surgery
    • Q
      • This is a 77 years old male with adenocarcinoma of low rectum s/p transanal local excision in 2019 with lungs metastases, stage IVa.
      • Complained about shortness of breath for 15+ days, exertional dyspnea. He came to ER on 2023/03/21, and was admitted on 2023/03/22.
      • Pig tail was inserted on 2023/03/22 for pleural effusion, output:1400 on 2023/03/22.
      • However, patient complained about exertional coughing/pain in the evenging, CXR showed focal pneumothorax. at 23:38 on 2023/03/22.
      • Symptom improved with rest. Educated about emptying air from the bag to the patient and caretaker.
      • Subcutaneuos emphesema was observed on 2023/03/24 over right lower neck and right axillary and right lateral chest wall.
      • After discussing with our VS, he suggested to put local compression over the pig tail insertion spot due to relatively asymptomatic manifestation.
      • Patient tolerated the situation well excpet exertional shortness of breath, until 2023/03/26 evening when he complained about enlarged area of subcutaneuos emphysema
      • LPS 18cm H2O was connected to pig tail on 2023/03/26, 22:57
      • His SpO2 remained 94-99%, stable TPR.
      • We would like to consult your expertise, thank you!
    • A1
      • S
        • This 77 y.o male was a case of Rectal Ca, Adenocarcinoma, post OP in 2019 with lung metastasis, stage IVa now. This time, he was admitted due to progressive dyspnea and bilateral pleural effusion noted on CXR on 2023-03-21. Chest echo + right pig-tail insertion for effusion drainage was done on 2023-03-22. Unfortunately, little subcutaneous emphysema and right focal pneumothorax was noted since 2023-03-24 by CXR. This condition not improvement after conservative treatment and LPS 18cm H2O. Follow up CXR on 2023-03-27 showed prograssive right subcutaneous emphysema and we were consulted for further treatment.
      • O
        • 2023-03-27 CXR: bilateral subcutaneous emphysema, pneumomediastinum, left CP angle blunting due to pleural effusion and right pig-tail in position.
      • Suggestion
        • keep right pig-tail drainage with LPS 15-20cm H2O, if necessary, may try two bottle drainage system
        • please consult Chest surgeon to evaluate his subcutaneous emphysema condition and the indication of surgical treatment or not
    • A2
      • may replace pigtail with chest tube. Bigger calibre would offer adequate chest drainage to release patient’s subcutaneous emphysema.

[SOAP]

  • 2022-08-19 Colorectal Surgery
    • A
      • adenocarcinoma of low rectum s/p transanal local excision (2019-04-15), pT2NxM0, stage I, at least, G2, LVI(-), PNI(+), left margin involved (+), s/p R/T
    • P
      • APR is refused, so arrange CCRT (R/T + UFUR by patient choice, BUT he refuse chemotherapy!)
      • F/U CEA + CXR (2022-07), CT (2022-12), colonoscopy (2022-12)
      • 2022-08-19 he did not receive CT-gioded biopsy for lung lesions (personal reason), re-check chest CT

[surgical operation]

  • 2019-04-15
    • Diagnosis: Adenocarcinoma of low rectum, cT1N0M0
    • PCS code: 74211B - Extensive excision of sacrococcygealrectal villous adenoma or malignacy
    • Finding
      • A 1.5cm tumor was identified at 3-5cm above anal verge of anterior aspect of low rectum.
      • Friable tumor pieces was pelling off after putting anal retractor.
      • Full-thickness local rectal excision was performed as possible to gain a safe margin.
      • Normal saline irrigation and hemostasis was done. Blood loss was about 10-20ml.
      • The wound was closed with 4/0 vicryl.
  • 2017-10-12
    • Diagnosis: back tumor
    • PCS code: 62011C - Excision of skin or subcutaneous tumor (Except face) - 2 to 4 cm
    • Finding: back tumor 3cm, x1
    • Procedure: Under LA, the tumor was excised. The wound was closed with 3-0 viryl and 4-0 Nylon.

[immunochemotherapy]

  • 2023-10-02 - Avastin + FOLFIRI
  • 2023-08-31 - Avastin + FOLFIRI
  • 2023-08-02 - Avastin + FOLFIRI
  • 2023-07-12 - Avastin + FOLFIRI
  • 2023-06-23 - Avastin + FOLFIRI
  • 2023-06-02 - Avastin + FOLFIRI
  • 2023-05-05 - FOLFIRI
  • 2023-04-07 - FOLFIRI

==========

2023-08-04

The recently refilled repeat prescription for Vemlidy (tenofovir alafenamide) on 2023-07-05 is being utilized without any reconciliation issues detected.

2023-03-29

On 2023-03-24, a Port-A was inserted for the patient who previously refused chemotherapy.

All the oral/inhaled medications in the active prescription are appropriate for his respiratory symptoms, including Sodicon (dextromethorphan), Butanyl (terbutaline), and Ipratran (ipratropium bromide).

700547380

231003

[exam findings]

  • 2023-09-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (75.9 - 14.9) / 75.9 = 80.34%
      • M-mode (Teichholz) = 80
    • Conclusion:
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Mild MR, TR and PR
      • No regional wall motion abnormalities
  • 2023-08-25 Nerve Conduction Velocity, NCV
    • Findings
      • Slowed NCVs in bilateral ulnar CMAPs above elbow.
      • Normal sensory NCV study in both arms.
    • Conclusion
      • This abnormal NCV study suggestd bilateral ulnar neuropathy acrossed elbow.
  • 2023-08-22 C-spine AP + Lat
    • mild anterior and posterior spur formation at the middle C-spine.
    • moderate decreased disc spaces in the C4/5 and C5/6 discs.
  • 2023-08-09 CT - brain
    • No definite intracranial abnormality.
  • 2023-07-26 CT - chest
    • Findings
      • Lungs: a part solid nodule, solid component < 5mm (6.4mm) at RLL, and 5mm granuloma at S9 of the same lobe. normal appearance of RUL, RML, and left lung.
      • Chest wall and visible lower neck: an enhancing tumor (28.3x28mm) at upper portion of the Rt breast, a 9.2mm lymph node at Rt axilla.
    • Impression:
      • Rt breast cancer (28.3x28mm) and a 9.2mm lymph node at Rt axilla.
      • RLL part solid nodule 6.4mm,possibly early ca d/d inflammation, suggest F/U low dose CT at 6-12 months later. RLL 5mm granuloma too.
  • 2023-07-17 Patho - breast biopsy (no need margin)
    • Breast, right, 12/2, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (+, 90%, strong intensity), PR (-, 0%, intensity), Her2/neu: negative(score=1+), Ki-67 (20%), E-cadherin (+).
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • 2023-07-17 Patho - lymphnode biopsy
    • Lymph node, right, axillary, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (+, 100%, strong intensity), PR (-, 0%, intensity), Her2/neu: negative(score=1+), Ki-67 (20%), E-cadherin (+).
    • Section shows fragments of lymph node tissue with irregular neoplastic ducts infiltration.

[MedRec]

  • 2023-09-05 ~ 2023-09-08 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Malignant neoplasm of unspecified site of right female breast
      • Right breast invasive carcinoma, cT1N1M0, stage IIA, no special type, NST. IHC stains: ER (+, 100%, strong intensity), PR (-, 0%, intensity), Her2/neu: negative (score = 1+), Ki-67 (20%), E-cadherin (+)
    • CC
      • for prepare chemotherapy.
    • Present illness
      • This 59 years old female had denied any underlying disease. According to the patient and family, the patient suffered from suspect L’t breast lesion form mammography on 2017/05/11. Due to sign and symptom exacerbation, the patient called at our OPD for help. Mammography and breast sono were done on 2017/07/12 showed regional microcalcifications in left breast, upper portion, probably benign finding-short interval follow-up suggested.
      • Sono showed Bil. fibroadenomas as described. Due to bilateral breast lump with calcification for several years, long-term follow up until 2022 loss follow up.
      • Last half year, feel discomftable, visted to our GS OPD follow up. Breast SONO was done on 2023/07/07 showed highly suspicious of malignancy, with sonographic positive axillary LAP, suggested core-needle biopsy was arranged on 2023/07/17.
      • Pathology showed Lymph node, right, axillary, core biopsy — Invasive carcinoma, no special type, NST. IHC stains: ER(+, 100%, strong intensity), PR(-, 0%, intensity), Her2/neu: negative(score=1+), Ki-67(20%), E-cadherin(+); Breast, right, 12/2, core biopsy — Invasive carcinoma, no special type, NST. IHC stains: ER (+, 90%, strong intensity), PR(-, 0%, intensity), Her2/neu: negative(score=1+), Ki-67(20%), E-cadherin(+).
      • Then, CT image was done on 2023/07/26 showed Rt breast cancer (28.3x28mm) and a 9.2mm lymph node at Rt axilla, RLL part solid nodule 6.4mm, possibly early ca d/d inflammation, suggest F/U low dose CT at 6-12 months later. RLL 5mm granuloma too.
      • Brain CT was survey on 2023/08/09 shoaed No definite intracranial abnormality. Diagnosis was right breast invasive carcinoma, cT1N1M0, stage IIA, no special type, NST. IHC stains: ER(+, 100%, strong intensity), PR(-, 0%, intensity), Her2/neu: negative(score=1+), Ki-67(20%), E-cadherin(+).
      • This tims, she was admitted for prepare chemotherapy.
    • Course of inpatient treatment
      • After admission, arrange 2D echo before chemotherapy with Epirubicin + Cyclophosphamide on 2023/09/06 showed LVEF:80%, Normal chamber size, Adequate LV and RV systolic function, Mild MR, TR and PR, No regional wall motion abnormalities. Then, she received chemotherapy with Epirubicin (90mg/m2) + Cyclophosphamide (600mg/m2) on 2023/09/06 smoothly. Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting. BP drop was noted, IVF for support. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2023/09/08 and OPD followed up later.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC

[chemotherapy]

  • 2023-10-02 - epirubicin 90mg/m2 120mg NS 100mL 30min + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-06 - epirubicin 90mg/m2 120mg NS 100mL 30min + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-03

[leukopenia]

2023-09-28 WBC 5.63 x10^3/uL 2023-09-21 WBC 1.66 x10^3/uL * 2023-09-13 WBC 4.32 x10^3/uL 2023-09-05 WBC 5.12 x10^3/uL

The leukopenia observed on 2023-09-21 at 1.66K/uL occurred approximately 2 weeks after her first administration of epirubicin and cyclophosphamide. Granocyte (lenograstim 250ug) was administered for 3 consecutive days beginning on 2023-09-21.

The second dose of epirubicin and cyclophosphamide was administered on 2023-10-02 and prophylactic G-CSF was considered and prescribed in advance for 2023-10-09 to 2023-10-11 during the double tenth consecutive holidays. Leukopenia is expected to be less severe this time.

700563554

231003

[lab data]

2023-09-13 HBV-DNA-PCR Target Not Detected IU/mL

2023-09-11 HBsAg Nonreactive
2023-09-11 HBsAg (Value) 0.49 S/CO
2023-09-11 Anti-HCV Nonreactive
2023-09-11 Anti-HCV Value 0.12 S/CO
2023-09-11 Anti-HBc Reactive
2023-09-11 Anti-HBc-Value 5.99 S/CO

[exam findings]

  • 2023-08-29 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS
      • Liver, S5 and S4b, S4b/5 resection — Metastatic neuroendocrine carcinoma
    • MACROSCOPIC EXAMINATION
      • Procedures: S4b/5 resection
      • Specimen Size: 12 x 8.0 x 4.8 cm and 185 gm
      • Tumor Focality: Multiple (number: 2)
      • Tumor Site: S5 and S4b
      • Tumor Size: 5.0 x 4.5 x 4.0 cm (S5) and 4.0 x 3.0 x 2.5 cm (S4b) respectively
      • Large vessel involvement: Not identified
      • Non-tumorous part: Not cirrhotic
      • Sections are taken and labeled as: A1-A2= S5 tumor, A3-A4= S4b tumor, A5= non-neoplastic liver
    • MICROSCOPIC EXAMINATION
      • Diagnosis: Metastatic neuroendocrine carcinoma
      • Histologic grade: High grade
      • Tumor growth pattern: Infiltrating
      • Tumor pseudocapsule: Absent
      • Tumor necrosis: Present
      • Parenchymal margin: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margins: 0.8 cm (S5) and 0.9 cm (S4b), respectively
      • Vascular invasion: Present
      • Perineural invasion: Not identified
      • Non-neoplastic liver parenchyma: Mild lymphocytic portal inflammation
      • Fatty Change: Present (5%)
  • 2023-08-14 PET
    • No previous study for comparison.
    • At least four focal lesions of increased FDG uptake in the right lobe of the liver, highly suspected metastatic tumors, suggesting biopsy for investigation.
    • Increased FDG uptake in the peritonium of middle lower abdomen, the nature is to be determined (inflammation or other nature ?), suggesting follow-up.
    • Increased FDG accumulation in bilateral kidneys and in the right ureter, probably physiological uptake of FDG.
    • Malignant neoplasm of gallbladder s/p treatment with highly suspected metastatic tumors in the liver, by this F-18 FDG PET scan.
  • 2023-07-19 CT - abdomen
    • Findings:
      • S/P cholecystectomy. There is a cystic lesion 3 cm in S5 of the liver that may be biloma S/P surgical resection.
      • There are two kissing poor enhancing mass 2.5 cm and 1.6 cm in S4/8 and a poor enhancing mass 3.5 x 2.2 cm in S4 of the liver.
        • Metastases are highly suspected.
    • Impression:
      • There is a cystic lesion 3 cm in S5 of the liver that may be biloma S/P surgical resection.
      • Three metastases 2.5 cm and 1.6 cm in S4/8 and 3.5 x 2.2 cm in S4 of the liver are highly suspected.
  • 2023-07-04 SONO - abdomen for follow-up
    • There is a hypoechoic lesion 2.53 x 1.85 cm in S5 of the liver that may be metastasis? Please correlate with contrast enhanced dynamic CT.
      • In addition, there is another suggestive cystic-like lesion with echogenic content 3.29 x 2.85 cm in S5 of the liver, near the gallbladder, that may be post-operative biloma?
    • S/P cholecystectomy.
  • 2023-03-30 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS:
      • Gallbladder, laparoscopic cholecystectomy— Neuroendocrine carcinoma, high-grade
      • Liver, S5, laparoscopic S5 rsection— Negative for malignancy
      • Cut-end, cystic duct— Free of tumor
      • Lymph node, LN8, regional LN dissection— Negative for malignancy ( 0 / 1 )
      • Lymph node, 12A, regional LN dissection— Negative for malignancy ( 0 / 5 )
      • Lymph node,12C regional LN dissection— Negative for malignancy ( soft tissue only )
      • Pathologic Staging (AJCC): pT2aN0 (if cM0); AJCC prognostic stage IIA
    • MACROSCOPIC EXAMINATION
      • Specimen Type — laparoscopic cholecystectomy+ laparoscopic S5 rsection
      • Specimen Size: Gallbladder: 7.5x 4x 3.5 cm; Liver: 11.5x 6x 4.5 cm
      • Tumor Size : 3.5x 2.8x 2.2 cm — Solitary
      • Liver Tissue — Non-cirrhotic
      • Sections are taken and labeled as: F2023-140: cut end of cystic duct, A1:right IHD cut end, A2:tumor with S5, A3-11:tumor, A12: non-tumor part, B: LN8, B:12A, C:12C
    • MICROSCOPIC EXAMINATION
      • Histologic Type — Neuroendocrine carcinoma
      • Histologic Grade — High grade
      • Gross tumor patterns: poorly defined and solid
      • Microscopic Tumor Extension — Tumor invades the perimuscular connective tissue on the peritoneal side, without involvement of the serosa (visceral peritoneum).
      • Margins (check all that apply)
        • cystic duct Margin—- free
      • Lymph-Vascular Invasion — Present
      • Perineural Invasion — Not identified
      • Regional Lymph Nodes
        • Lymph Node Examination (required only if the lymph nodes present in the specimen)
        • LN 8: 0 / 1 (Number involved / Number examined)
        • LN 12A: 0 / 5 (Number involved / Number examined)
        • LN 12A: negative for malignancy (soft tissue only)
      • Additional Pathologic Findings (select all that apply) — cholelithiasis, high grade dysplasia
      • Immunohistochemical stain reveals CD56(+), CK19(+), CK20(-), CK7(+), CA19-9(-).
  • 2023-03-17 CT - abdomen
    • Findings:
      • There is an irregular soft tissue mass at the gallbladder fundus, measuring 3.2 x 1.9 cm in size.
        • Adenocarcinoma of the gallbladder is highly suspected.
        • Please correlate with contrast-enhanced CT to evaluate if there is lymph node and peritoneum metastasis.
      • There is horse-shoe kidney.
    • IMP:
      • Adenocarcinoma of the gallbladder is highly suspected.
      • Please correlate with contrast-enhanced CT to evaluate if there is lymph node and peritoneum metastasis.

[MedRec]

  • 2023-03-28 ~ 2023-04-03 POMR General and Gastroenterological Surgery Wu Chaoqun
    • Discharge diagnosis
      • Gallbladder neuroendocrine carcinoma, high-grade pT2aN0(cM0) status post laparoscope cholecystectomy and S5 resection and lymph node dissection on 2023/03/29. ECOG:1
      • Gastro-esophageal reflux disease with esophagitis
      • Essential (primary) hypertension
      • Pure hypercholesterolemia
    • CC
      • Epigastric discomfort and dyspepsia for half a year.
    • Present illness
      • This is a 57 year old woman with the history of hypertension, hyperlipidemia, GERD and atrophic gastritis. This time, she was admittied due to epigastric discomfort and dyspepsia for half a year.
      • She had epigastric discomfort and dyspepsia in recent months. She denied of having nausea or vomiting sensations. Abdominal discomfort without pain. There was no fever, no tea color urine, or tarry stool. She went to LMD and was found to have a big gallbladder polyp (1.2 cm) with increased thickness of focal gallbladder wall on 2023/02/25. Thus, she came to our GI OPD on 2023/03/03 for further evaluation.
      • At GI OPD, her vital signs were stable. PE showed no icteric sclera and soft abdomen. Her blood test revealed overall no significant findings or abnormal results. Abdominal CT revealed an irregular soft tissue mass at the gallbladder fundus, measuring 3.2 x 1.9 cm in size. Adenocarcinoma of the gallbladder is highly suspected. Due to the above reasons, she was transferred to GS OPD then ward on 2023/03/28 for further treatment.
    • Course of inpatient treatment
      • After admission, preoperative survey was done and no contraindication was found against operation.
      • Laparoscopic cholecystectomy, parital S5 resection and lymph node dissection were performed on 2023/03/29. The operation went uneventfully and she was brought back to ward afterwards. After the operation, the patient complained about severe operation wound pain and improved after taking analgesics.
      • Tolerable oral diet and ambulation were noted after operation. Under stable condition, she was discharged today and OPD follow up was arranged.
    • Discharge prescription
      • BaoGan (silymarin 150mg) 1# TID
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
      • Celebrex (celecoxib 200mg) 1# PRNQD
      • ammoxicillin 250mg 2# TID

[surgical operation]

  • 2023-08-28
    • Surgery
      • S4b/5 liver resection
      • laparoscope exam
    • Finding
      • S5 : 5 x 4 x 3.5cm tumor
      • S4b : 4 x 3 x 2.5cm protruding tumor
      • no gossly peritoneal seeding
      • no ascite
      • no other tumor at liver
  • 2023-03-29
    • Surgery
      • Laparoscope S5 rsection
      • LC
      • regional LN dissection 8, 12
    • Finding
      • 4 x 3 x 1.5 cm fungating mass at GB dome anteriore wall to posterior wall
      • regional LN enlarge at station 12a

[chemotherapy]

  • 2023-09-11 - NS 1000mL 4hr (before CDDP) + furosemide 20mg (after NS) + cisplatin 70mg/m2 105mg NS 500mL 3hr D1 + NS 1000mL 4hr (after CDDP) + furosemide 20mg (after NS) + etoposide 100mg/m2 150mg NS 500mL 2hr D1-3
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-03

[drug identification]

Since the drug to be identified is an unpackaged tablet, its quality and expiration date cannot be confirmed, so the response is that the drug cannot be identified.

An in-hospital porter will be sent to deliver the tablets to the ward.

701060439

231003

[exam findings]

  • 2023-09-18 Tc-99m MDP bone scan
    • Increased activity in the skull base, maxilla, L2 -3 spines, bilateral sternoclavicular junctions and right scapula, the nature is to be determined, suggesting further investigation and follow-up with bone scan in 3 months.
    • Suspected benign lesions at bilateral shoulders, S-I joints, and hips.
  • 2023-09-16 CT - facial bone
    • One large protuding mass (3.4cm) arising from left-side of the nose, showing heterogeneous enhancement. Highly suspect malignancy. Suggest tissue proof.
    • No involvement of the nasal bone by this tumor.
  • 2023-09-15 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis with scoliosis of the T-spine with convex to right side

[MedRec]

  • 2023-09-14 SOAP Hemato-Oncology Gao WeiYao
    • O: She was found to have skin tumor during her stay at nursing home at Taichung (Nursing head 5A mother)
    • A: Nose skin tumor
  • 2023-09-14 SOAP Radiation Oncology Huang JingMin
    • S:
      • For radiotherapy due to squamous cell carcinoma of the nose skin.
      • PI: the patient suffered from squamous cell carcinoma of the nose skin. She was transferred from TaiZhong
    • O:
      • ECOG: 2
      • PE: neck and bil SCF: neg; nose: a huge tumor over left side nasal area. Sit on a wheelchair.
      • Pathology (SE22304418, 2023-08-09):
        • Skin, 3 o’clock, biopsy - involved by invasive carcinoma.
        • Skin, 6 o’clock, biopsy - severe dysplasia.
        • Skin, 9 o’clock, biopsy - involved by invasive carcinoma.
        • Skin, 12 o’clock, biopsy - involved by invasive carcinoma.
        • Skin, tumor body, biopsy - squamous cell carcinoma, moderately differentiated.
      • A: Squamous cell carcinoma, moderately differentiated of the left nasal area.
      • P: Radiotherapy is indicated for this patient with the following indicators: unresectable tumor over left nasal area
        • Goal: pallaition
        • Treatment target and volume: left nasal area and possible involved area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 6000cGy/30 fractions of the left nasal tumor bed area.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2023-09-20.
  • 2023-09-13 SOAP Plastic and Reconstructive Surgery Lu ChunDe
    • S: SCC, protrusion mass
    • O:
      • 8cm protrusion mass
      • radiotherapy first,
      • waiting for shrinkage of tumor, then considering surgery excision
  • 2017-07-13 SOAP Psychosomatic Medicine Li JiaFu
    • Diagnosis
      • Chronic fatigue syndrome [R53.82]
      • Generalized anxiety disorder [F41.1]
      • Major depressive disorder single episode, unspecified [F32.9]
      • Nonorganic sleep disorder, unspecified [F51.9]
      • Dementia in conditions classified elsewhere without behavioral disturbance [F02.80]
      • Senile dementia, uncomplicated [F03.90]

[consultation]

  • 2023-09-22 Gastroenterology
    • Q
      • The 79 y/o woman living in TaiChung nusring home, who is 5A HN’s mother. Newly diagnosis of SCC of nose, stage II. Due to she easy choking and can’t NG insertion, so we need your help for percutaneous endoscopy gastrostomy.
    • A
      • 79 years old female with SCC of nose, stage II and plan to CCRT. However, for PEG insertion, we are consulted.
      • O
        • conscious: E4VaM4
        • chest: smooth breath pattern, N/C: 3L
        • abdomen: soft and flat
        • Lab
          • 2023-09-21 S-GOT/AST 15 U/L
          • 2023-09-21 S-GPT/ALT 11 U/L
          • 2023-09-21 Creatinine 1.16 mg/dL
          • 2023-09-21 WBC 8.93 x10^3/uL
          • 2023-09-21 PLT 154 *10^3/uL
        • CT scan impression:
          • One large protuding mass (3.4cm) arising from left-side of the nose, showing heterogeneous enhancement. Highly suspect malignancy. Suggest tissue proof.
          • No involvement of the nasal bone by this tumor.
      • Impression
        • Dysphagia
        • SCC of nose, stage II
      • Suggestion
        • Complication of PEG was informed to family
          • Minor: Wound infection, Tube leakage to abdominal cavity (peritonitis), Stoma leakage, Inadvertent PEG removal, Tube blockage, Pneumoperitoneum, Gastric outlet obstruction, Peritonitis
          • Major: Aspiration pneumonia, Hemorrhage, Buried bumper syndrome, Perforation of bowel, Necrotizing fasciitis, Metastatic seeding
        • Plan for PEG insertion on 10/4.
        • Please also discuss gastrostomy with the general surgery
  • 2023-09-21 General and Gastroenterological Surgery
    • Q
      • The 79 y/o woman living in TaiChung nusring home. Newly diagnosis of SCC of nose, stage II. Due to she easy choking and can’t NG insertion, so we need your help for gastrostomy.
    • A
      • O:
        • vital signs: stable, no fever
        • abdomen: soft, ovoid, decrease bowel sound, no tenderness, no rebounding pain
        • lab data: see chart
      • A: SCC of nose, stage II.
      • P: Due to no operation room available and less general anesthesia and surgical risk, consult GI for percutaneous endoscopy gastrostomy is suggested.
  • 2023-09-15 Oral and Maxillofacial Surgery
    • Q
      • The 79 y/o woman living in TaiChung nusring home. This time, her left nose has mass and pathology showed squamous cell carcinoma, moderately differentiated of the left nasal area. Due to RT Director Huang suggested tooth extraction, so we need your help for management.
    • A
      • We are consulted for pre-RT dental evaluation.
      • O
        • General appearnce:ill looking
        • dementia was observed, uncooperative
      • intraoral examination:
        • multiple deep carious retained root of tooth 24, 25, 44 and 45 was noticed.
      • Plan:
        • Because the patient cannot cooperate, the tooth may not be extracted under local anesthesia.
        • It is recommended that cancer treatment be given priority. If the family considers tooth extraction before radiotherapy, another explanation will be arranged.

==========

2023-10-03

[tube feeding]

Concor 5mg — Please use the Simple Suspension Method (SSM) to place the tablet in warm drinking water and leave for 5-10 minutes, possibly stirring or gently shaking the container, until the tablet is dissolved, then can be passed through a feeding tube. This method involves dissolving tablets and capsules in warm water before suspending them for administration. This method could be used to administer Concor tablets through a feeding tube.

Const-K 750mg — The potassium content in fruits is relatively low, such as only about 2.2 mEq/inch or 0.9 mEq/cm in bananas. This means that consuming about two to three bananas is required to provide 40 mEq. Const-K is a type of extended-release tablet that contains 10 mEq/tab. One Const-K tablet provides less potassium than a single banana. If injectable potassium supplementation is not preferred, the tablet should be crushed into fine particles and taken with water.

701277889

231003

[exam findings]

  • 2023-04-24 Patho - breast mastectomy with regional lymph nodes
    • Diagnosis
      • Breast, left, partial mastectomy with frozen section (F2023-187) — invasive carcinoma, NST, no special type.
      • Margin: free
      • Lymph node, left, axillary sentinel, biopsy (S2023-187) — Free
      • pT2 pN0 (if cM0); anatomic stage: IIA, at least, pathology prgnostic stage group: IIA, at least.
      • IHC stains: (using block: F2023-187A5): ER (-), PR (-), Her2/neu: positive (score=3+), Ki-67: 90%, p53 (-).
    • Gross Description
      • Procedure- partial mastectomy:10.5 x 8 x 3 cm. Skin: 5.5 x 2.0 cm. No nipple..
      • Lymph node sampling (if lymph nodes are present in the specimen)- Sentinel lymph node(s)
      • Specimen laterality- left
      • Sections are taken and labeled as:
        • Tissue for frozen section: F2023-187FS: deep margin.
        • Tissue for formalin fixation: F2023-187: A1-4: 12, 3, 6, 9 o’clockmargins; A5-6: tumor; A7: skin. S2023- 7821: sentinel lymph node.
    • Microscopic Description
      • For Invasive Carcinoma
        • Histologic type: Invasive carcinoma, NST
        • Size of invasive carcinoma (mm): 27 mm
        • Histologic grade (Nottingham histologic score): grade II (score 6,7)
        • Extent of tumor (required only if the structures are present and involved)
        • Skin involvement: Absent
        • Chest wall invasion deeper than pectoralis muscle: no chest wall tissue.
      • For Ductal Carcinoma In Situ- no DCIS.
        • Tumor size (mm)- no DCIS.
        • Nuclear grade- no DCIS.
        • Architectural pattern- no DCIS.
        • Tumor necrosis- no DCIS.
      • Margins:
        • Negative, Closest margin (10 mm from deep margin)
      • Nodal status: Negative (sentinel)
        • No. examined: 1
        • No. macrometastases (> 2 mm): 0
        • No. micrometastases (> 0.2 ~ 2 mm and/or > 200 cells): 0
        • No. isolated tumor cells (<= 0.2 mm and <= 200 cells): 0
      • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)- no presurgical chemotherapy.
      • Immunohistochemical Study
        • IHC stains: (using block: F2023-187A5): ER (-), PR (-), Her2/neu: positive (score=3+), Ki-67: 90%, p53 (-).

[MedRec]

  • 2023-12-08 ~ 2023-12-09 POMR General and Gastroenterological Surgery Li ChaoShu
    • Discharge diagnosis
      • Left breast invasive carcinoma, pT2N0M0, stage IIA. ER (-), PR (-), Her2/neu: positive (3+), Ki-67: 90%. ECOG:0.
      • Post adjuvant chemotherapy with Ogivri (trastuzumab)
      • Carrier of viral hepatitis B
      • Agranulocytosis secondary to cancer chemotherapy
      • Dermatitis, unspecified
    • CC
      • adjuvant treatment for breast cancer
      • Two weeks after chemotherapy, multiple blisters and abscesses appeared on the soles of both feet.
    • Present illness
      • This 43-year-old female patient had Carrier of viral hepatitis B, but denied diabetes mellitus, hypertension, heart disease. She denied any TOCC histories in recent 3 months.
      • She noted a palpable mass at the left breast over 1 month. She came to Dianthus MFM Clinic for help. She accepted core needle biopsy and diagnosis of left breast cancer at Dianthus MFM Clinic. She didn’t return Dianthus MFM Clinic for the report. Thus, she came to our hospital for a second opinion. Breast sonography showed a lesion, left 1.5 o’/ 6 cm, size: 2.34 x1.36 cm, rule out malignancy suggesting biopsy.
      • She underwent of left partial mastectomy + sentinel lymph node dissection on 2023/04/24. The pathology showed invasive carcinoma, pT2N0M0, stage IIA. ER:(-), PR:(-), Her2/neu: positive (score=3+), Ki-67: 90%.
      • Tc-99m MDP whole body bone scan revealed no evidence of bone metastasis. Chest CT showed liver is intact. CEA:0.428 ng/ml、CA-153: 14.102U/ml on 2023/4/21. After well explain including pathology and the possible treatment modality were well explained to the patient.
      • She completed 8 courses adjuvant chemotherapy with Lipo dox + Endoxan for 4 cycles since 2023/05/19 then shift to Taxotere 75mg/m2 and Ogivri 8mg/m2 since 2023/08/18~2023/10/23. We refer to CGMH for R/T(proton) since 11/20.
      • Under the impression of left invasive carcinoma, pT2N0M0, stage IIA. This time, she was admitted to 6th target therapy with Ogivri (trastuzumab) 6mg/m2.
    • Course of inpatient treatment
      • After admission, 6th target therapy with Ogivri (trastuzumab) was given. No discomfort after chemotherapy.
      • Consult dermatology department for severe hand-foot syndrome who suggst 1. predinisolon 1 / Bid, 2. Zaditen (ketotifen) 1 / Bid, 3. Sinpharderm x 1 tube/bid, 4. Mycomb x 2 tubes/bid use.
      • Under the stable condition, she was discharged today and arrange next admission three weeks later.
    • Discharge prescription
      • Asthan (ketotifen 1mg) 1# BID
      • Compesolon (prednisolone 5mg) 1# BID
      • Sinpharderm Cream (urea) BID TOPI
      • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
  • 2023-04-23 ~ 2023-04-26 POMR General and Gastroenterological Surgery Li ChaoShu
    • Discharge diagnosis
      • Malignant neoplasm of unspecified site of left female breast
      • Left breast cancer, cT1aN0M0, stage IA status post left partial mastectomy+sentinel lymph node dissection on 2023-04-24; ECOG 0
      • Carrier of viral hepatitis B
    • CC
      • She noted a palpable mass at left breast over 1 month.
    • Present illness
      • This 48-year-old female patient denied any systemic disease. She denied a cancer history. She denied any TOCC histories in recent 3 months.
      • She noted a palpable mass at the left breast over 1 month. Then she came to Dianthus MFM Clinic OPD for help, Dianthus MFM Clinic diagnosis that she got left breast cancer. She came to our hospital for a second opinion. Breast sonography showed a lesion, left 1.5 o‘/ 6 cm, size: 2.34 x1.36 cm, r/o malignancy suggesting biopsy. She accepted Core needle biopsy at Dianthus MFM Clinic, but she doesn’t return Dianthus MFM Clinic for the report. She had no dizziness, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, or body weight loss. PE: symmetrical bilateral breasts. A hard, non-tender, movable mass and irregular margin at left breast around 2 x1.5 cm without discharge. The nipple was dimpling without exudative nor bloody discharge and no retraction. The right left skin had no cellulite change.
      • Under the impression of left breast invasive carcinoma, she was admitted for surgery of partial mastectomy + SLNB.
    • Course of inpatient treatment
      • This is a 48-year-old woman who underwent partial mastectomy + SLND today. During the surgery, IOUS was used to define the margins and location and partial mastectomy was done without complications. After admission, patient education with wound care was done. Due to her stable condition, she will be be discharged and followed up at our OPD.
    • Discharge prescription
      • MgO 250mg 1# TID
      • Antica syrup (orciprenaline, bromhexine, doxylamine) 10mL TID
      • Acetal (acetaminophen 500mg) 1# TID

[consultation]

  • 2023-12-08 Dermatology
    • Q
      • for skin rush over bilateral foot
      • Adjuvant chemotherapy with Lipo dox + Endoxan for 4 cycles then Taxotere 75mg/m2 for 4 cycles with ogivri injection were suggest.
      • Under impression of left breast invasive carcinoma, she was admitted for 6th adjuvant chemotherapy with ogivri.
      • This time, she complained of multiple broken skin wounds and pain on the soles of both feet. We need your help with treatment and management.
    • A
      • This patient suffered from multiple vesicles on bil soles for days.
      • Imp: dyshidrotic dermatitis
      • Suggestion:
        • predinisolon 1 / Bid
        • Zaditen 1 / Bid
        • Sinpharderm x 1 tube/bid
        • Mycomb x 2 tubes/bid

[surgical operation]

  • 2023-04-24
    • Operation
      • BCT + SLND   
      • IOUS     
    • Finding
      • IOUS: a tumor mass over left breast, 1 o’clock/3cm location, was encountered.
      • Clinical tumor status:
        • Tumor size: 2cm (cT1c)   - Gross skin invasion: No   - Gross pectoral fascia invasion: No   - Tumor location: right side, lateral upper quadrum (1’/3cm)   - Clinical T stage: cT1c (<3 cm)
      • Clinical nodal status:   - Axillary dissection: SLND using isotope detection   - Gross LNs: negative LAPs   - Clinical N stage: cN0(sn)
      • OP status:   - Procedures: BCT + SLND   - Pre-OP tissue prove: CNB   - Nerve preservation: not encountered   - Drainage: nil   - PostOP elastic bandage: Yes   - PostOP skin flap: No   - Closure of wound: two-layer, 3-0 Vicryl and 5-0 Nylon
      • Path of frozen section: free margins
      • Biobank: blood + normal tissue + tumor

[chemotherapy]

  • 2023-12-08 - trastuzumab 6mg/kg 400mg NS 250mL 90min (maintenance dose)

  • 2023-11-18 - trastuzumab 6mg/kg 400mg NS 250mL 90min (maintenance dose)

  • 2023-10-23 - docetaxel 75mg/m2 120mg NS 250mL 1hr + trastuzumab 6mg/kg 400mg NS 250mL 90min (maintenance dose)

    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL + filgrastin 150ug SC + glutathione 1500mg NS 200mL 20min
  • 2023-10-02 - docetaxel 75mg/m2 120mg NS 250mL 1hr + trastuzumab 6mg/kg 395mg NS 250mL 90min (maintenance dose)

    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL + filgrastim 150ug SC + glutathione 1500mg NS 200mL 20min
  • 2023-09-08 - docetaxel 75mg/m2 120mg NS 250mL 1hr + trastuzumab 6mg/kg 389mg NS 250mL 90min (maintenance dose)

    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL
  • 2023-08-18 - docetaxel 75mg/m2 120mg NS 250mL 1hr + trastuzumab 8mg/kg 514mg NS 250mL 90min (loading dose)

    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL
  • 2023-07-28 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr

    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL
  • 2023-06-30 - liposome doxorubicin 30mg/m2 49mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 986mg NS 500mL 1hr

    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL
  • 2023-06-09 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 990mg NS 500mL 1hr

    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL
  • 2023-05-19 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr

    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL

==========

2023-12-11

This patient has received six doses of Ogivri (trastuzumab) on the following dates: 2023-12-08, 2023-11-18, 2023-10-23, 2023-10-02, 2023-09-08, and 2023-08-18. The initial four doses were administered in combination with docetaxel. The patient reported skin symptoms approximately two weeks after the fifth dose of trastuzumab (2023-11-18), suggesting a possible link to trastuzumab.

Trastuzumab is known to potentially cause dermatologic adverse reactions, including skin rash (4% to 18%), acne vulgaris (2%), nail disease (2%), and pruritus (2%).

The discharged medications include those recommended by our dermatologist; it is advised to continue monitoring for changes in symptoms.

[glutathione - peripheral neuropathy]

Additionally, the pre-chemotherapy medications on 2023-10-02 and 2023-10-23 included glutathione. The 2020 ASCO systematic review of neuroprotectants for prevention of chemotherapy-induced peripheral neuropathy (CIPN) concluded that glutathione should not be offered for prevention of CIPN to patients receiving treatment with paclitaxel plus carboplatin, and that N-acetyl cysteine should not be offered to patients receiving potentially neurotoxic chemotherapy [1]. This position was also taken in the 2020 joint ESMO/EONS/EANO guidelines [2].

[1] Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325. [2] Systemic anticancer therapy-induced peripheral and central neurotoxicity: ESMO-EONS-EANO Clinical Practice Guidelines for diagnosis, prevention, treatment and follow-up. Ann Oncol 2020; 31:1306.

2023-10-03

[diarrhea]

Both docetaxel and trustuzumab have been reported to be associated with diarrhea (23% to 43% and severe diarrhea <= 6% for the former and 7% to 25% for the latter).

In the event of diarrhea, it is recommended that loperamide (2 mg/cap) be used with an initial 2# followed by 1# every 2 to 4 hours or after each loose stool; for diarrhea persisting > 24 hours, administer 1# every 2 hours (or 2# every 4 hours). Continue until 12 hours have passed without loose stools. Doses > 8# per day may not provide benefit; consider alternative therapy if diarrhea persists >= 48 hours.

[leukopenia]

2023-10-02 WBC 6.23 x10^3/uL 2023-09-14 WBC 1.56 x10^3/uL 2023-09-08 WBC 6.62 x10^3/uL 2023-09-01 WBC 14.67 x10^3/uL 2023-08-25 WBC 1.67 x10^3/uL 2023-08-18 WBC 5.34 x10^3/uL 2023-07-28 WBC 7.35 x10^3/uL 2023-06-30 WBC 6.00 x10^3/uL 2023-06-09 WBC 6.17 x10^3/uL 2023-05-26 WBC 7.59 x10^3/uL 2023-05-12 WBC 11.26 x10^3/uL 2023-04-18 WBC 8.85 x10^3/uL

Leukopenia was observed on 2023-09-14 and 2023-08-25, approximately 1 week after the administration of docetaxel + trastuzumab (on 2023-09-08 and 2023-08-18), prophylactic G-CSF might be considered.

[G-CSF administration timing]

G-CSF is usually started no earlier than 24 hours after administration of chemotherapy. Continuation until the absolute neutrophil count following the nadir exceeds 10,000/microL, as specified in the G-CSF package insert, is known to be safe and effective. However, a shorter duration that is sufficient to achieve clinically adequate neutrophil recovery is a reasonable alternative, considering issues of patient convenience and cost. G-CSF should not be given in the day or days prior to the next cycle of chemotherapy, or on the same day as chemotherapy or radiation therapy is administered. Ref:

  • Supportive therapies in the prevention of chemotherapy-induced febrile neutropenia and appropriate use of granulocyte colony-stimulating factors: a Delphi consensus statement. Support Care Cancer. 2022 Dec;30(12):9877-9888. doi: 10.1007/s00520-022-07430-7. Epub 2022 Nov 5. PMID: 36334157; PMCID: PMC9715510.
  • Pegfilgrastim on the Same Day Versus Next Day of Chemotherapy in Patients With Breast Cancer, Non-Small-Cell Lung Cancer, Ovarian Cancer, and Non-Hodgkin’s Lymphoma: Results of Four Multicenter, Double-Blind, Randomized Phase II Studies. J Oncol Pract. 2010 May;6(3):133-40. doi: 10.1200/JOP.091094. PMID: 20808556; PMCID: PMC2868638.

700201636

231002

[exam findings]

  • 2023-09-11, -09-10, -09-07, -09-04, -09-01, -08-14, -08-08, -08-07, -07-20, -07-18, -07-13, -07-12, -06-26, -06-19, -06-01, -05-29, -05-25, 05-22, -04-19 Body fluid cytology - ascites
    • Negative
  • 2023-05-22 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 10 dB HL; LE 21 dB HL
    • R’t WNL.
    • L’t normal to mild CHL.
  • 2023-04-20 Patho - soft tissue biopsy/simple excision (non lipoma)
    • PATHOLOGIC DIAGNOSIS
      • Lesser omentum, excision — Metastatic serous carcinoma
      • Soft tissue, abdominal wall #1 and #2, excision — Foreign body granuloma
      • Soft tissue, LUQ, excision — Foreign body granuloma
    • MACROSCOPIC EXAMINATION
      • The specimen is submitted in four parts. Part (1) consists of six pieces of gray-white and firm soft tissue, labeled “abdominal wall tumor #2”, measuring up to 3.0 x 2.5 x 0.5 cm. All for section as: A1-A4. Part (2) consists of a piece of soft tissue, received for frozen section, labeled “abdominal wall tumor #1”, measuring 5.5 x 2.9 x 0.5 cm. On section, an white and firm nodule is noted, measuring 2.5 x 1.0 x 0.4 cm. Representative parts are taken for section as: F2023-00178 and FSA1. Part (3) consists of a piece of pinkish white soft tissue, received for frozen section, labeled “lesser omentum tumor”, measuring 1.2 x 1.0 x 0.3 cm. All for section as: F2023-00178FSB-ink green. Part (4) consists of a piece of soft tissue, received for frozen section, labeled “LUQ tumor”, measuring 1.0 x 0.9 x 0.3 cm. All for section as: F2023-00178FSB without ink.
    • MICROSCOPIC EXAMINATION
      • The sections of “lesser omentum tumor” show a picture of metastatic serous carcinoma, composed of pleomorphic polygonal tumor cells, arranged in solid and papillary patterns. The sections of “abdominal wall tumor #1 and #2” and “LUQ tumor” show a picture of foreign body granuloma, composed of foreign material surrounded by histiocytes and foreign body type giant cells.
  • 2023-04-17 SONO - abdomen
    • mild fatty liver
    • fatty infiltration of pancreas
  • 2023-03-08 Gynecologic Ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2023-02-08 PET
    • The left subphrenic lesion shown on the previous abdomen CT reveals increased FDG uptake, highly suspected tumor seeding.
    • Increased FDG uptake in bilateral pulmonary hilar regions, probably reactive nodes.
    • Increased FDG uptake in bilateral palatine tonsils, probably chronic inflammation/infection process.
    • Increased FDG uptake in the lower abdomen and left pelvis, probably physiological uptake of FDG in the colon. However, tumor seeding should be excluded.
    • Left ovarian cancer s/p treatment with highly suspected tumor seeding in the left subphrenic region, by this F-18 FDG PET scan.
  • 2023-01-31 CT - abdomen
    • History and indication: ovary cancer with peritonal seeding
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. S/P Port-A infusion catheter insertion. A nodule at left subphrenic region.
      • A calcified spot (3.7cm) at S6 of liver.
    • IMP: S/P hysterectomy. A nodule at left subphrenic region r/o tumor seeding.
  • 2022-09-17 Gynecologic Ultrasonography
    • Bilateral adnexae: free
    • ATH
    • No obvious uterine or ovarian lesion
  • 2022-08-10 CT - abdomen
    • History: Ovarian CA. pT3bN0Mx; FIGO stage IIIB, s/p debulking surgery on 8/26 19 by Dr Zhen LunNa, s/p post-Op adjuvant C/T wt Taxol / carboplatin IV Q3W x 6 finishing in Jan 2020 & recurrence wt peritoneal seeding in Jan 2021, s/p debulking wt HIPEC on 3/24 21 by Dr Li ZhaoShu,
    • Impression: S/P hysterectomy. There is no evidence of tumor recurrence.
  • 2022-02-17 CT - abdomen
    • History and indication: ovary cancer with peritonal seeding
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. S/P Port-A infusion catheter insertion.
      • A calcified spot (3.7cm) at S6 of liver.
    • IMP: S/P hysterectomy. No evidence of tumor recurrence.
  • 2021-10-06 CT - abdomen
    • History and Indication: Recurrent Ovarian CA.
    • Impression:
      • S/P hysterectomy
      • Prior CT identified several soft tissue nodules (up to 0.8cm) in the omentum of left upper abdomen are not noted again, that is compatible with tumor seeding S/P C/T show complete response.
  • 2021-03-25 Patho - soft tissue biopsy/simple excision (non lipoma)
    • DIAGNOSIS:
      • Soft tissue , greater omentum, left, cytoreductive surgery — High-grade serous carcinoma, recurrent
      • Soft tissue , omentum, frozen biopsy — foreign body suture granuloma
      • Description: Microscopically, the sections show high grade serous carcinoma composed of irregular branching and highly cellular of neoplastic papillae and solid sheets of tumor cells with small papillary clusters spearated by hyaline fibrous stroma. Section FSA shows a foreign body suture granuloma.
      • Immunohistochemical stain reveals PAX8(+), CK7(+), CK20(-), WT-1(+).
  • 2021-02-23 SONO - abdomen
    • Diagnosis: ovarian cancer s/p OP
    • Suggestion: further laparoscopy and maybe CRS
  • 2021-02-06 Gynecologic Ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2021-01-30 CT - abdomen
    • Clinical history: 49 y/o female patient with Ovarian CA s/p Op & C/T.
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P hysterectomy and oophorectomy.
      • There are soft tissue nodules (up to 0.8cm) in mensentery of left upper abdomen
    • Impression:
      • S/P hysterectomy and oophorectomy.
      • Soft tissue nodules in LUQ, r/o peritoneal carcinomatosis.
  • 2020-08-12 Gynecologic Ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2020-08-01 CT - abdomen
    • S/P hysterectomy. No evidence of tumor recurrence.
  • 2020-04-08 Gynecologic Ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2020-02-15 CT - abdomen
    • S/P hysterectomy. No evidence of tumor recurrence.
  • 2019-12-25 Gynecologic Ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2019-08-27 Surgical Pathology Level VI
    • PATHOLOGIC DIAGNOSIS
      • Ovary, left, debulking surgery — High-grade serous carcinoma
        • Fallopian tube, left, ditto — Free from tumor invasion
      • Ovary, right, ditto — High-grade serous carcinoma
        • Fallopian tube, right, ditto — Free from tumor invasion
      • Cervix, uterus, ATH — Free of tumor invasion
        • Endometrium — Hyperplasia with nuclear atypia and free of tumor invasion
        • Myometrium — Free of tumor invasion
      • Omentum, omentectomy — High-grade serous carcinoma
      • Appendix, appendectomy — Involved by tumor in muscular wall
      • Soft tissue, “tumor”, excision — Carcinoma
      • Lymph nodes
        • Lymph node, R’t pelvic 1, dissection — Free of tumor metastasis (0/14)
        • Lymph node, R’t pelvic 2, ditto — Free of tumor metastasis (0/1)
        • Lymph node, L’t pelvic 3, ditto — Free of tumor metastasis (0/6)
        • Lymph node, L’t pelvic 4, ditto — Fat tissue only
      • AJCC Pathologic staging: pT3bN0Mx; FIGO stage IIIB at least
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: ATH, BSO, pelvic tumor excision, omentectomy, appendectomy, lymph node dissection
      • Specimen type: Uterus, bilateral adnexa, pelvic tumor, omentum, appendix & 4 bottles of lymph nodes
      • Specimen size:
        • R’t ovary: 2.2 x 1.4 x 1.3 cm
        • R’t fallopian tube: 4 x 0.7 x 0.6 cm
        • L’t ovary: 3.3 x 1.7 x 1.1 cm
        • L’t fallopian tube: 4 x 1.2 x 1.1 with paratubal cyst, 1.2 cm in diameter
        • Uterus: 9.1 x 6.2 x 5 cm in size and 125 gm in weight
        • Cervix: Nobothian cysts
        • Endometrium: thickness, 0.7 cm
        • Myometrium: No significant change
      • “Tumor” soft tissue: one small piece, 3.2 x 2.3 x 0.9 cm in size
      • Omentum: one piece, 17.5 x 6.3 x 3.3 cm in size
      • Appendix: 3.7 x 0.7 x 0.7 cm in size
      • Tumor site: bilateral ovary and peri-adnexal soft tissue
      • Tumor size: a few foci, up to 1.0 x 0.4 cm in dimension
      • Tumor appearance: Papillary and solid
      • Specimen integrity: Intact
      • Lymph nodes: R’t pelvic 1 (5 gm), R’t pelvic 2 (0.2 gm), L’t pelvic 3 (2 gm) and L’t pelvic 4 (0.2 gm)
      • Representative sections as: A1: R’t ovary, A2-A3: R’t F-tube, A4-A7: L’t ovary + F-tube, A8-A15: endometrium, myometrium, endocervix and cervix, A16: endometrium + myometrium, B1-B4: omentum, C: appendix, D: “tumor” soft tissue, E1-E2: R’t PLN1, F: R’t PLN2, G: L’t PLN3 and H: L’t PLN4
    • MICROSCOPIC EXAMINATION
      • Histologic type: High-grade serous carcinoma [IHC stains: CK7(+), WT-1(+), PAX-8(+), P53(+, 100%), ER(+)]
      • Histologic grade: High grade
      • Contralateral ovary involvement: Present
      • Tumor side ovarian surface involvement: Present
      • Contralateral ovary surface involvement: Present
      • Right tube involvement: Absent
      • Left tube involvement: Absent
      • In situ adenocarcinoma in right &/or left fallopian tube: Absent
      • Right adnexa soft tissue involvement: Present
      • Left adnexa soft tissue involvement: Present
      • Pelvic soft tissue involvement: Present (“tumor”)
      • Uterine serosa involvement: Absent
      • Omentum involvement: Present
      • Uterine Cervix involvement: Absent. chronic cervicitis with Nabothian cyst
      • Endometrium involvement: Absent. Hyperplasia with nuclear atypia
      • Myometrium involvement: Absent
      • Appendix: Involved by tumor
      • Lymph nodes metastasis: Free of tumor metastasis, total number: 0/21
  • 2019-08-10 Gynecologic Ultrasonography
    • Suspected RT ovarian mass

[chemotherapy]

  • 2023-09-28 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

    • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4
  • 2023-09-07 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)

    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-08-31 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

    • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4
  • 2023-08-11 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)

    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-08-04 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

    • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4
  • 2023-07-14 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)

    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-07-10 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

    • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4
  • 2023-06-23 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)

    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-06-16 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

    • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4
  • 2023-05-29 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)

    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-05-22 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

    • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4
  • 2023-04-19 - [liposome doxorubicin 30mg/m2 50mg D5W 100mL + carboplatin AUC 5 675mg NS 250mL] 90min IP (HIPEC)

  • 2022-07-25 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-07-01 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-06-10 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-05-17 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-04-21 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-03-31 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-03-11 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-02-16 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-01-26 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-01-05 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-12-15 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-11-24 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-10-04 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-09-10 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-08-18 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-07-29 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-07-02 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-05-31 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-04-27 - docetaxel 60mg/m2 95mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-03-23 - [liposome doxorubicin 30mg/m2 40mg D5W 100mL + carboplatin AUC 5 600mg NS 250mL] 90min IP (LipoDox dose reduced)

  • 2020-01-14 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr

    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + acetaminophen 500mg PO + granisetron 2mg + NS 250mL

==========

2023-10-02

Leukopenia was observed in mid-Sep with a nadir of 1.31K/uL, occurring after the administration of paclitaxel + cisplatin through IV on 2023-08-31, and paclitaxel through IP on 2023-09-07. Granocyte (lenograstim 250ug) has been administered for 3 consecutive days beginning on 2023-09-14, and no instances of leukopenia have been reported thus far.

2023-09-28 WBC 4.17 x10^3/uL
2023-09-21 WBC 7.00 x10^3/uL
2023-09-14 WBC 1.31 x10^3/uL ** 2023-09-10 WBC 1.96 x10^3/uL *
2023-09-07 WBC 3.70 x10^3/uL

2023-09-01

According to data from both PharmaCloud and HIS5, the patient has only been treated in the hemato-oncology department at our facility. Consequently, no issues with medication reconciliation have been found.

2023-08-07

Based on the records from the PharmaCloud and HIS5, the patient exclusively utilizes healthcare services at the hemato-oncology department in our hospital. As a result, no medication reconciliation discrepancies have been detected.

2023-07-11

According to the PharmaCloud database, the patient only receives medical services from our hospital. Therefore, there are no identified medication reconciliation issues.

2023-06-19

  • The PharmaCloud database reveals that all medical needs of this patient have been met at our hospital in the last three months. Consequently, no medication reconciliation issues have been identified.

  • The patient’s serum potassium level was slightly low at 3.3mmol/L as of 2023-06-16, and it has been trending downwards. It might be helpful to recommend that the patient consume more potassium-rich foods.

    • 2023-06-16 K(Potassium) 3.3 mmol/L
    • 2023-06-07 K(Potassium) 3.7 mmol/L
    • 2023-05-29 K(Potassium) 3.9 mmol/L

700998220

231002

[MedRec]

  • 2023-07-06 SOAP Gastroenterology Chen JiangLin
    • S
      • 49 y/o
      • 2023/07/06 partial response (hiccup)
      • 2023/06/15 belching, and acid reflux, bloating (+), long time.
      • PH: nephrotic symdrome
      • ABC(-)
    • O
      • 2023/06/15 GERDa
    • Prescription
      • Mopride (mosapride citrate 5mg) 1# BIDAC
      • Gaslan (dimethylpolysiloxane 40mg) 1# BID
      • Dexilant (dexlansoprazole 60mg) 1# QD
      • Flupine (fludiazepam 0.25mg) 1# BID
  • 2023-07-04 SOAP Hemato-Oncology He JingLiang
    • P: Chemotherapy Velcade (bortezomib 3.5 mg/vial) 2 mg SC ST
    • Prescription
      • Thado (thalidomide 50mg) 1# HS
      • Limeson (dexamethasone 4mg) 5# QD
      • Ulstop (famotidine 20mg) 1# BID
  • 2023-05-19 SOAP Hemato-Oncology Wan XiangLin
    • P
      • Apply for major disease and approved
      • Chemotherapy with VTD (C1W1 20230526)
  • 2023-03-30 SOAP Nephrology Peng QingXiu
    • A
      • Renal biopsy 2023-03-20
      • R/O IgA nephropathy with amyloidosis
    • P
      • DC carvedilol
      • DO workup for Monoclonal gammopathy.
  • 2023-03-19 ~ 2023-03-21 POMR Nephrology Peng QingXiu
    • Discharge diagnosis
      • Nephrotic syndrome with other morphologic changes, s/p renal biopsy
    • CC
      • Foamy urine(+) for 3 months and both leg edema ++
    • Present illness
      • This is a 49 y/o female with history of GERD. She denied systemic diseases, operation history, pregnancy, or allergic history. TOCC(-)
      • This time, she suffered from bilateral lower limbs edema for 7 months since 2022/08. Her edema relived while legs elevation, and exacerbated while waking or sitting. There was also foamy urine noted recently.
      • She denied leg pain, abnormal sensation of bilateral limbs, neck swelling, dysuria, urinary frequency or medication history.
      • Due to above condition, she had visited LMD and our CV and Nephrologic OPD.
      • Cervical ultrasound was done and revealed normal volume of thyroid in LMD. Mildly elevated D-dimer (1448.20 ng/mL(FEU)) and NT-proBNP (1237 pg/mL) were noted, excluding deep vein thrombosis (DVT) or heart failure (HF) induced bilateral legs edema.
      • Cardiac ultrasound on 3/10 showed LVEF 63% and impaired LV relaxation with restrictive physiology.
      • Normal value of C3, C4, IgG, IgM, and IgM indicated negative antoimmune kidney disease.
      • However, her albumin was low (2.7 on 3/11 -> 2.9 on 3/18) and high urine microalbumin (1268.88 mg/dL) was noted, despite normal eGFR (122.29).
      • Her ACR = microalbumin(mg/dL)/ urine creatinine(mg/dL) was within normal range 7.63 (<30).
      • Under the impression of bilateral lower limbs edema with high microalbuminuria and normal ACR ration, r/o nephrotic diseases, she was admitted for kidney biopsy and further survey.
    • Course of inpatient treatment
      • During the hospitalization, the hemograms, biochemistry testing. Renal biopsy was done, for urine analysis revelaed protein 4+. Post biopsy an examination.
      • Renal echo was performed on 2023/03/20. Showed pelvic heterogenous mass, r/o uterine myoma or pelvic mass. Suggestion: GYN OPD follow up. No hematura.
      • Under stable condition, she can be discharge on 2023/03/21. OPD follow up is arranged.   
    • Discharge prescription
      • Crestor (rosuvastatin 10mg) 1# QD
      • Uretropic (furosemide 40mg) 1# QD

[chemotherapy]

VTd regimen

==========

2023-10-02

[tube feeding]

The potassium content of fruits is relatively low (for example, about 2.2 mEq/inch or 0.9 mEq/cm in bananas), meaning that it would take about two to three bananas to provide 40 mEq. Const-K is an extended-release formulation containing 10 mEq/tab, which is less potassium than is found in one banana. If injectable potassium supplementation is not preferred, please crush the tablet into particles and administer it with water.

[diarrhea]

2023-09-02 Lab showed triglycerides (TG) 394 mg/dL and LDL-C 168mg/dL, Atozet (ezetimibe, atorvastatin) was initiated by our nephrologist. Due to recent diarrhea, Atozet is discontinued today. However, the possibility that Velcade (bortezomib) in VTd regimen (2023-05-26 started) may also be associated with diarrhea cannot be completely excluded.

By the way, a statin can be administered as an alternate day frequency with a similar efficacy and may have a lower incidence of side effects. Ref: Efficacy and Safety of Alternate-Day Versus Daily Dosing of Statins: a Systematic Review and Meta-Analysis. Cardiovasc Drugs Ther. 2017 Aug;31(4):419-431. doi: 10.1007/s10557-017-6743-0. PMID: 28741244.

701067842

231002

[exam findings]

  • 2023-09-26, -09-01, -08-31, -07-26, -07-25, -07-03, -06-13, -06-12 Body fluid cytology - ascites
    • Negative
  • 2023-07-21 CT - abdomen
    • Findings
      • S/P hysterectomy. There is a cystic lesion 4.2 x 2.8 cm in left anterior pelvis sidewall that is c/w lymphocele.
      • S/P Tenckhoff tube insertion from right lower abdominal wall and the tip located at the right lower perihepatic space.
      • Prior CT identified a cystic lesion 3.9 x 2.4 cm in left cardiac-phrenic angle is noted again, stationary.
    • Impression
      • S/P hysterectomy.
      • There is no evidence of tumor recurrence.
  • 2023-07-10 MRI - sella
    • No evidence of intracranial lesion.
  • 2023-05-25, -05-23 Body fluid cytology - ascites
    • Suspicious malignancy
  • 2023-04-21 Patho - uterus with or without SO non-neoplastic/prolapse
    • PATHOLOGIC DIAGNOSIS
      • Ovaries, bilateral, BSO — Clear cell carcinoma
      • Uterus, ATH — Parametrium involved by carcinoma
      • Cul-de sac, debulking — Involv ed by carcinoma
      • Omentum, infracolic omentectomy — Involved by carcinoma
      • Peritoneal mass, debulking — Involved by carcinoma
      • Lymph nodes, pelvic and para-aortic, bilateral, BPLND — Negative for malignancy (0/34)
      • AJCC 8 th edition, Pathology stage: pT3cN0; stage IIIC; FIGO stage IIIC
    • MACROSCOPIC EXAMINATION
      • Procedure: ATH + BSO + omentectomy + BPLND + para-aortic LN dissection + Cul-de sac and peritoneal tumor excision
      • Specimen Size:
        • Five pieces, up to 5.5 x 5.0 x 3.2 cm (Lt ovary, received for frozen section), four pieces up to 4.9 x 3.2 x 2.9 cm (Lt ovary), 3.5 x 0.6 cm (Lt tube), four pieces, up to 9.3 x 7.8 x 2.5 cm (Rt ovary), 4.0 x 0.6 cm (Rt tube), 7.1 x 6.0 x 3.8 cm and 95 gm (uterus), four pieces up to 1.8 x 1.5 x 0.5 cm (Cul-de sac), five pieces up to 3.6 x 0.8 x 0.4 cm (peritoneal mass), 28.5 x 8.8 x 1.5 cm (omentum)
      • Specimen Integrity
        • Right ovary: Capsule ruptured
        • Left ovary: Capsule ruptured
        • Right fallopian tube: Serosa intact
        • Left fallopian tube: Serosa intact
      • Tumor Site: Bilateral ovaries
      • Ovarian Surface Involvement: Present
      • Fallopian tube Surface Involvement: Absent
      • Tumor Size: Can not be assessed because of fragmented tumor tissue
      • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, left para-aortic and right para-aortic
      • Representative parts are taken for section and labeled as: F2023-00181FSA1, FSA2, A1-A6= left ovary. S2023-07635A= left iliac LNs, B= left obturator LNs, C= right iliac LNs, D= right obturator LNs, E= left para-aortic, F= right para-aortic LNs, G1-G2= left ovary, G3= left fallopian tube, H1-H3= right ovary, H4= right fallopian tube, I1= cervix, I2-I3= uterine corpus, I4-I6= parametrium, J= Cul-de sac, K1-K2= omentum, L= peritoneal mass.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Clear cell carcinoma
      • Histologic grade: High grade
      • Implants: Present
      • Other Tissue/Organ Involvement: Parametrial involvement
      • Peritoneal Fluid: Positive for malignant cells
      • Regional Lymph Nodes: All lymph nodes are negative for tumor cells
        • number of lymph node examined: 8 (left iliac), 7 (left obturator), 1 (right iliac), 5 (right obturator), 6 (left para-aortic) and 7 (right para-aortic)
        • number with metastases >10 mm: 0
        • number with metastases 10mm or less: 0
        • number with isolated tumor cells (<=0.2mm): 0
      • Cul-de sac: Involved by carcinoma
      • Peritoneal mass: Involved by carcinoma
      • Omentum: Involved by carcinoma
      • Pathologic Stage
        • Primary Tumor: pT3c (macroscopic peritoneal metastasis beyond the pelvis and > 2cm in size)
        • Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
        • Distant Metastasis: Not applicable
      • FIGO Stage: Stage IIIC
      • Lymphovascular invasion: Absent
      • Perineural invasion: Absent
      • Additional Pathologic Findings:
        • Cervix: Chronic cervicitis with Nabothian cysts and squamous metaplasia
        • Endometrium: Proliferative phase
        • Myometrium: Adenomyosis
        • Ovary, left: Endometrosis
        • Fallopian tube, right: Para-tubal cyst
      • IHC, tumor cells reveal: WT1(-), Napsin A(+), ER(-), and p53(no aberrant expression)
  • 2023-04-21 Body fluid cytology - ascites
    • 40 cc, pink, turbid — Malignancy
    • Smears show several clusters of atypical hyperchromatic and pelomorphic cells. Malignancy is favored. Please correlate with the clinical presentation.
  • 2023-04-20 Frozen Section
    • Ovary, left, frozen section — Malignant (carcinoma)
  • 2023-04-17 CT - abdomen
    • Abdominal CT with and without enhancement revealed:
      • Massive ascites is found.
      • Cystic change at bilateral ovaries measuring 11.7cm at right ovary and 5.4cm at left side is found. Some solid component is also found. Ovarian cancer is considered.
      • Tiny enhanced dots at mesentery is found. Mesenterric meta is favored.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • Normal heart size.
      • The lung fields are clear.
      • No pleural effusion is found.
    • Imp:
      • Bilateral ovarian cystic tumors with largest one at right side msm 11.7cm. Ovarian cancer is considered.
      • Peritoneal seeding is also found.
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-04-07 Gynecologic ultrasonography
    • R/O RT Ovarian mass: 109 x 85 (septum RI: 0.42)
    • Asites(+)
  • 2023-01-04 CT - abdomen
    • Indication
      • LMP: 2022-12-27, sex(+), dysmenorrhea sometimes, duration: 6 days
        • CA-125: 37.71
      • 20230104 sono: A cystic mass 7.3 x 5.4 cm in right adnexa with solid mural nodule 3.1 cm. R/O right ovarian mass.
        • Left ovarian cyst 2 cm.
      • 20230104 CA125, CEA, and CA199: normal
    • Findings:
      • There is a well-defined cystic lesion in right adnexa 7 cm in size (the largest dimension) with central solid mural nodule (2.6 cm in size).
        • The differential diagnosis include cystic adenoma and cystic adenocarcinoma.
      • There is a cystic lesion with wall thickening at left adnexa, measuring 4 x 2.4 cm in size.
    • Impression:
      • A cystic lesion with mural nodule at right adnexa, nature?
      • The differential diagnosis include cystic adenoma and cystic adenocarcinoma.
  • 2023-01-04 Gynecologic ultrasonography
    • R/O Lt Ovarian cyst
    • R/O RT Ovarian mass (septum RI: 0.63)

[consultation]

  • 2023-06-12 Dermatology
    • Q
      • A case of clear cell carcinoma of Bilateral ovarian, pT3cN0M0, stage IIIC; FIGO stage IIIC, status post debulking surgery on 2023/04/20
      • She was admitted for IP and IV chemotherapy with Taxol plus Carboplatin.However, she complained of skin rash over bilateral legs, we need your expertise for further management, thanks
    • A
      • This patient suffered from multiple erytheamtous papules on limbs for days.
      • Imp: Insect bite
      • Suggestion:
        • Dexamthson 1 / Qd
        • Ulex cream x5 tubes / bid
        • Zaditen 1 / Bid

[surgical operation]

  • 2023-04-20
    • Surgery
      • Diagnosis: Huge ovarian mass, bilateral
        • Frozen section: malignant, suspect carcinom
      • Operation:
        • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy (BY GENERAL SURGEON))   - Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, tense contact with bladder, peritoneum and bilateral adnexa due to the tumor burden. Multiple papillary mass was noted over anterior wall.
      • Adnexa:
        • LOV: huge ovarian mass about 10 X 10 X 8 cm in size, with heterogeneous and rough surface, partial rupture with hemorrhagic content
        • ROV: ovarian mass about 6 X 5 X 5 cm in size
        • Fallopian tube: tensely connected to the bowel and adjacent tissues due to adhesion
      • CDS: massive ascites
      • Ascites: light yellowish, at least 4000 mL
      • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(+)
      • Omentum: multiple hard, variable nodules noted; infracolic omentectomy was done by general surgeon.
      • Optimal debulking was achieved, Residual tumor:R0.
      • Estimated blood loss: 850 mL
      • Blood transfusion: LpRBC 2U
      • Complication: nil
  • 2023-04-20
    • Operation
      • Excision of intraabdominal tumor: pelvic peritoneum + omentectomy
      • Tenckhoff tube insertion
    • Finding
      • Several tumor seedins in pelvic peritoneum with massive ascites
      • Tenckhoff tube: over RLQ
    • Procedure
      • Under ETGA, GYN performed operation at first. Made omentectomy. Excised the seeding tumor in pelvic peritoneum. Inserted a Tenckhoff tube over RLQ. Finally, GYN commenced further operation.

[chemotherapy]

  • 2023-09-27 - paclitaxel 135mg/m2 215mg NS 250mL 3hr + carboplatin AUC 5 650mg NS 250mL 2hr + [paclitaxel 40mg/m2 64mg + cisplatin 30mg/m2 48mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-08-31 - paclitaxel 135mg/m2 215mg NS 250mL 3hr + carboplatin AUC 5 650mg NS 250mL 2hr + [paclitaxel 40mg/m2 64mg + cisplatin 30mg/m2 48mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-07-25 - paclitaxel 135mg/m2 215mg NS 250mL 3hr + carboplatin AUC 5 650mg NS 250mL 2hr + [paclitaxel 40mg/m2 63mg + cisplatin 30mg/m2 47mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-06-30 - paclitaxel 135mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 625mg NS 250mL 2hr + [paclitaxel 40mg/m2 65mg + cisplatin 30mg/m2 49mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-06-12 - paclitaxel 135mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 625mg NS 250mL 2hr + [paclitaxel 40mg/m2 65mg + cisplatin 30mg/m2 49mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-05-22 - paclitaxel 135mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 625mg NS 250mL 2hr + [paclitaxel 40mg/m2 65mg + cisplatin 30mg/m2 49mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr + NS 500mL 1hr (before chemotherapy) + NS 500mL 1hr (after chemotherapy)
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL

==========

2023-07-03

  • As per the PharmaCloud database and our in-house HIS5 records, our institution has been the sole provider of medical services to this patient over the past three months. In addition to our Hematology-Oncology department, the patient also attended appointments in our Metabolism and Endocrinology department on 2023-06-05 and our Obstetrics and Gynecology department on 2023-05-04. However, no prescriptions were issued by these two departments. All current medications were prescribed by our Hematology-Oncology department, with no medication reconciliation discrepancies detected.

701373808

231002

{why 2023-07-25 exemestane shifted to letrozole?}

[MedRec]

  • 2023-09-19 SOAP Hemato-Oncology Xia HeXiong
    • P: On 2023-09-19, because the tumor marker and size in progression, suggest admission for furrther evaluation and decide what CT regimen will be used. Admission for Heart Echo. CT scan.
    • Prescription
      • Stogamet (cimetidine 300mg) 1# BID
      • Xyzal (levocetirizine 5mg) 1# QD
      • Aromasin (exemestane 25mg) 1# QD [Steroidal AI]
      • Through (sennoside 12mg) 1# HS
      • Femara (letrozole 2.5mg) 1# QD [Non-steroidal AI]
      • Dulcolax (bisacodyl 5mg) 1# QN
      • Sinbaby Lotion (ZnO, diphenhydramine, dibucaine, etc) BID TOPI
      • Silverzine (silver sulfadiazine) BID EXT
  • 2023-07-25 SOAP Hemato-Oncology Xia HeXiong
    • P: Shift exemestaine (Steroidal AI) to letrozole (Non-steroidal AI) on 2023-07-25
    • Prescription x2
      • Stogamet (cimetidine 300mg) 1# BID
      • Xyzal (levocetirizine 5mg) 1# QD
      • Futisone Cream (fluticasone) BID EXT
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
      • Aromasin (exemestane 25mg) 1# QD [forgot to be DC]
      • Through (sennoside 12mg) 1# HS
      • MgO 250mg 1# TID
      • Femara (letrozole 2.5mg) 1# QD [newly added today]
      • Dulcolax (bisacodyl 5mg) 1# QN
      • Sinbaby Lotion (ZnO, diphenhydramine, dibucaine, etc) BID TOPI
      • Silverzine (silver sulfadiazine) BID EXT
  • 2023-05-30 SOAP Hemato-Oncology Xia HeXiong
    • A/P: On 2023-05-30, already mention
      • For dirty urine, need to change foley, need to do urine routine and culture
      • Antibiotics is for weeks. Patient should be back if urine is not clean and sent to ER
    • Prescription x2
      • Stogamet (cimetidine 300mg) 1# BID
      • Xyzal (levocetirizine 5mg) 1# QD
      • Futisone Cream (fluticasone) BID EXT
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
      • Aromasin (exemestane 25mg) 1# QD
      • Through (sennoside 12mg) 1# HS
      • MgO 250mg 1# TID
      • cephalexin 500mg 1# Q6H (14D, not repeated)
  • 2023-05-02 SOAP Hemato-Oncology Xia HeXiong
    • A/P: Only sister in law shows up on 2023-05-02.
      • Already mention
        • Disease extent: local left breast, bone and regional LN mets
        • Should consider C/T with Anti-HER2
        • If they do not take C/T and Anti-HER2 -> consider Hormonal therapy. But I would say Hormonal therapy (Aromasin, tamoxifen or Faslodex) will be less effect because Her2 (+). Moreover, visceral crisis (spinal cord compression).
        • Already mention the R/T to local primary -> will control for some time and will be to and from during R/T. (Patient is bed-ridden)
    • Prescription
      • Stogamet (cimetidine 300mg) 1# BID
      • Xyzal (levocetirizine 5mg) 1# QD
      • Futisone Cream (fluticasone) BID EXT
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
      • Aromasin (exemestane 25mg) 1# QD
      • Through (sennoside 12mg) 1# HS
      • MgO 250mg 1# TID
  • 2023-04-14 ~ 2023-04-18 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Left breast invasive carcinoma, no special type, ER+, PR-, HER2/Neu 3+, with multiple bone metastasis and Rt breast metastases, status post palliative radiotherapy
    • CC
      • Left breast newly emerged lump for 2 months  
    • Present illnesee
      • Neurosurgeon was consulted and surgery was not recommended. Palliative radiotherapy 30 Gy/ 10 fx was administered for spine metastasis.
      • Tamoxifen 1# po bid was given during admission and due to nodule regrowth at Left breast, under suspicion of no response of tamoxifen, letrozole 1# QD was given from 2023/01/07.
      • The patient had not receive any chemotherapy till now.
      • From 2023-02, the patient started to note newly emerged, progressively enlarging left breast lump. Furthermore, on 2023/04/13 she started to feel pain in her left breast lump, therefore she came to our hospital for 2nd opinion and was admitted for lung contrast CT for evaluation of metastatic lesion.
    • Course of inpatient treatment
      • After admission, lung contrast CT done on 4/15 showed Left breast cancer with left axillary, intramuscular and chest wall lymphadenopathy and bone meta.
      • Biopsy for left breast newly emerged lump was done on 4/17, with pathology report pending.
      • Bone scan to follow up for metastatic lesion was done on 4/18.
      • The family hesitated to receive chemotherapy for fear of deterioration of the patient’s performance status.
      • The patient has been informed that because of HER2/Neu 3+, she must be treated with herceptin and perjeta, and that because the disease has progressed, target plus chemotherapy must be used for control, but the patient currently only wants to use hormone therapy (letrozole). The patient has been told to invite all family members to participate in a family meeting, but the patient’s sister-in-law insists on hearing the explanation of the disease and going home to discuss it with her family members. In the end, the patient was still unwilling to undergo targeted and chemotherapy treatments, so she was discharged. And further discussion with the patient will be in the outpatient appointment.
  • 2023-03-31 SOAP Hemato-Oncology Gao WeiYao
    • P: encourage ER admission for her breakthrough neuropathic pain (spinal cord compression ??) (20230331)
    • Prescription
      • Switane (trihexyphenidyl 2mg) 1# BID
      • Through (sennoside 12mg) 2# HS
      • Winsumin (chlorpromazine 50mg) 2# BID
      • Stogamet (cimetidine 300mg) 1# BID
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Xyzal (levocetirizine 5mg) 1# QD
      • Futisone Cream (fluticasone) BID EXT
      • Femara (letrozole 2.5mg) 1# QD
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
  • 2022-04-25 ~ 2022-05-11 POMR Hemato-Oncology Zhang ShouYi
    • Discharge diagnosis
      • Malignant neoplasm of unspecified site of left female breast
      • Left side breast cancer with multiple bone metastasis S/P radiotherapy, Invasive carcinoma, no special type, NST. IHC stains: ER (+, 100%, strong intensity), PR(-, 0%), Her2/neu: positive (score=3+), Ki-67(40 %), p63 (-), E-cadherin (+), stromal tumor infiltrating lymphocytes: <5%.
    • CC
      • both lower legs weakness & parapleiga progression were also noted for 3-4 days.
    • Present illness
      • This 58-year-old female, a pt of suspected L breast CA with spine mets & cord compression with parapleiga since 4/22 22, s/p sent to Far Eastern H (FEMH) ER where image study done, T-spime MRI at FEMH showd spine mets & cord compression with parapleiga.
      • She suffered from initial presentation of L breast tumor for one years ago & paraplegia since 4/22 22. She came to our hemato-oncologic clinic on 4/25 22 for L breast tumor.
      • Owing to both lower legs weakness & parapleiga progression were also noted for 3-4 days.
      • Under the impression of suspected L breast CA with spine mets & cord compression with parapleiga. She was admitted for further survey.
    • Course of inpatient treatment
      • After admission, image study with breast sono (4/26 22) showed Left breast Size: 5.6x3.47 cm, Left breast tumor with left axillary lymph node, r/o malignancy suggest biopsy.
      • Sono-guided biopsy was done on 4/26 22 for left breast tumor.
      • The pathology (4/28 22) proved Invasive carcinoma, no special type, NST. IHC stains: ER (+, 100%, strong intensity), PR(-, 0%), Her2/neu: positive (score=3+), Ki-67(40 %), p63 (-), E-cadherin (+), stromal tumor infiltrating lymphocytes: <5%.
      • We consulted NS for operation evaluation and advisted to Surgical intervention will not be recommended for the patient.
      • Radiologist was consulted for radiotherapy evaluation and advisted to Plan to deliver 30 Gy/ 10 fx to the spine mets mentioned above. RT will start around 4/27 or 28. XRT started since 4/28 to 5/11 22 and intravenous Dexa 4mg qd was added.
      • The bone scan (4/28 22) showed Highly suspected cancer with bone mets in the skull, some T- and L-spine, and right acetabulum (the most prominent).
      • Tamoxifen 1# po bid was given since 5/3 22. She was discharged on 5/11 22 under stable condition and will follow-up at OPD.
  • 2022-04-25 SOAP Hemato-Oncology Zhang ShouYi
    • S: 58 y/o female, a pt of suspected L breast CA wt spine mets & cord compression wt parapleiga since 4/22 22, s/p sent to Far Eastern Memorial Hospital ER where image study done.

==========

2023-10-02

According to the PharmaCloud database, this patient just refilled a 28-day supply of Switane (trihexyphenidyl), Ativan (lorazepam), Winsumin (chlorpromazine), and Denosin (desloratadine) for her schizophrenia at the Bali Psychiatric Center of the Ministry of Health and Welfare on 2023-09-13. Except for lorazepam, all other medications are currently in use. If agitation, restlessness, or antipsychotic-induced akathisia continues to be observed, reintroduction of lorazepam may be considered.

700526788

231001

[exam findings]

  • 2023-10-03 ECG
    • Normal sinus rhythm
    • Septal infarct, age undetermined
    • T wave abnormality, consider inferior ischemia
    • T wave abnormality, consider anterolateral ischemia
  • 2023-09-09 SONO - abdomen
    • liver parenchymal disease, mild fatty liver
    • mild splenomegaly
    • gallbladder stones, sludge
    • mild gallbladder wall thickening
    • fatty infiltration of pancreas
  • 2023-08-08 SONO - nephrology
    • Bilateral chronic change with left small sized kidney.
    • Irregular bladder wall, cause?
  • 2023-08-02 ECG
    • Sinus tachycardia
    • T wave abnormality, consider inferior ischemia
    • Abnormal ECG
  • 2023-07-12 ECG
    • Sinus tachycardia with Premature atrial complexes
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-07-12 CTA - chest
    • A calcification (4mm) at right lung.
    • Left pleural effusion with adjacent lung collapse.
    • Fat stranding at right perirenal region.
    • Grade 4 fatty liver.
    • Gallbladder stone (3.2cm).
  • 2023-07-12 CT - brain
    • Brain atrophy.

[MedRec]

  • 2023-09-09 SOAP Gastroenterology Wang JiaQi
    • S
      • RUQ pain for 1-2 wks. fever (-)
      • vomiting this morning (+). poor appetite.
      • GB stones with cholecystopathy
    • O
      • PE: abdomen: soft and flat
      • PH: DM (+), HT (+)
      • US: liver parenchymal disease, mild fatty liver, mild splenomegaly, gallbladder stones, sludge, mild gallbladder wall thickening, fatty infiltration of pancreas (2023, 9/9)
    • Prescription
      • Acetal (acetaminophen 500mg) 1# TID
      • Mopride (mosapride citrate 5mg) 1# TID
      • Alusa (aldioxa 100mg) 1# TID
  • 2023-08-16 SOAP Infectious Disease Peng MingYe
    • A: Prolonged antibiotic for recurrent UTI, continue Ceficin for another 2 more weeks
    • P: Education and medications
    • Prescription
      • Ceficin (cefixime 100mg) 2# Q12H
  • 2023-08-03 POMR Infectious Disease Peng MingYe
    • Discharge diagnosis
      • Sepsis due to Escherichia coli [E. coli]
      • Bacteremia
      • urinary tract infection
      • Pneumonia, unspecified organism
      • Type 2 diabetes mellitus with unspecified complications
      • obesity
      • Calculus of gallbladder, 3.2 cm; ABD CT, 2023-07-12
      • Essential (primary) hypertension
    • CC
      • Fever since last night, Aug 01, with vomiting once with gastric juice.
      • No abdominal pain or diarhrea
    • Present illness
      • This 72-year-old female patient has underlying diseases of hypertension, diabetes mellitus, gall bladder stone. She was recently discharged from our Infection ward due to Escherichia coli UTI with sepsis on July 20, 2023. She has no allergies to food or drugs, no food allergy, no history of travel, occupation, contact or cluster recently.
      • This time, she suffered from recurrent fever since the night of Aug 01 and vomiting once with gastric juice noted. She denied abdomianl pain or diarrhea, no any URI symptoms. She was taken to our ED for hlep in the early morning of yesterday, Aug 02. At ED, fever 39.8C detected. The laboratory data showed normal whote cell count and CRP 1.4 only. Urinalysis showed typical UTI picture with bacteriuria and pyuria. The CXR showed increase of bilateral lung marking, the influenza and COVID tests all showed negative result. Under the impression of recurrent urinary tract infection, she was admitted to our INF ward for further management on Aug 03, 2023.
    • Course of inpatient treatment
      • After admission, empirical antibiotic Brosym was given for ifnection control. Urine and blood culture all showed Escherichia coli that E.coli urosepsis confirmed.
      • There is no more fever after admission and gradual improvement with more spiritful and oral intake. Lab data rechecked on 8/8 shwoed normal white count and much lower CRP level, 2.1. Renal echo wass done on Aug 8, whcih showed small left kidney size, no renal stone or hydronephrosi. CxR showed no infiltration on 8/7.
      • She is discharged on 2023/8/10 with oral Ceficin back home. OPD follow up is arranged.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H (if BT > 38)
      • Through (sennoside 12mg) 2# HS
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • Const-K (KCl 10mEq 750mg) 1# QD
      • Bisadyl supp (bisacodyl) 2# PRNQOD RECT (if no stool passage)
      • Ceficin (cefixime 100mg) 2# Q12H
  • 2023-07-12 POMR Infectious Diesease Hong BoBin
    • Discharge diagnosis
      • Sepsis due to Escherichia coli [E. coli]
      • Urinary tract infection, site not specified
      • Calculus of gallbladder, 3.2 cm; ABD CT, 2023-07-12
      • Metabolic syndrome
      • Hyperlipidemia, unspecified
      • Essential (primary) hypertension
      • Type 2 diabetes mellitus without complications
    • CC
      • Fever, chills, chest pain, and cough for three days, then consciousness loss with hyperglycemia one day.
    • Present illness
      • A 72-year-old female has past medical history of hypertension, diabetes mellitus, gall bladder stone, and Escherichia coli sepsis. She has no allergies to food or drugs, no food allergy, no history of travel, occupation, contact or cluster recently. Unknown of job.
      • She presented in the emergency department with the symptoms of fever, chills, chest pain, and cough for three days, then she was found consciousness loss last night, the finger sugar showed 383mg/dL by the emergency medical technician. The temperature 41.4°C, the pulse 128 beats per minute, the blood pressure 164/82 mmHg, the respiratory rate 22 breaths per minute, and the oxygen saturation 97%, regain consciousness E4V4M6. The physical examination showed pale conjunctiva, normal light reflex of bilateral pupils, bilateral symmetric expansion of chest, coarse sound, soft abdomen without tenderness, no pitting edema, muscle power: right side 3, left upper 4, and left lower 3.
      • A blood serum tests showed leukocytes with neutrophil predominant 61.6%, band 3.5%, hyperglycemia, elevated C-reactive protein and creatinine and creatine kinase and prothrombin time and d-dimer and troponin-I and lactic acid. Urinalysis showed pyuria. Chest x ray showed ground glass opacities in bilateral lungs. A computer tomography of the brain showed brain atrophy. A computed tomography angiography of the chest revealed left pleural effusion with adjacent lung collapse, no aortic dissection. Brosym was given. She was hospitalized on 2023-07-12.
    • Course of inpatient treatment
      • During the hospital stay, we use parenteral cefuroxime for empirical treatment of urosepsis. The foley catheter indwelling for monitor urine amount. The adequate fluid supplement. On critical condition. Insulin as sacle for hyperglycemia control.
      • Laboratory examination revealed improvemeent, but elevated CK noted. Sodium Bicarbonate was addition for urine alkalization. Blood culture yields Escherichia coli. We give de-escalation of antibiotics to cefazolin. Urine culture yields Escherichia coli.
      • Laboratory examinaiton revealed improvement, but anemia is noted. Blood transfusion with LPRBC one unit supplement for two days. Urinalysis showed no pyuria. Foley catheter was removal, urination voiding is smooth, residual urine showed 60 ml. No more fever occurs.
      • Glycemia under insulin control. She is discharged on July 20, 2023.
    • Discharge prescription
      • cephalexin 500mg 1# TID

==========

2023-10-04

The patient refilled the repeat prescription for Norvasc (amlodipine), Tulip (atorvastatin), Ankomin (metformin), and Ozempic Injection (semaglutide) on 2023-09-09. However, she is not currently taking these drugs. It is recommended that her serum glucose and blood pressure levels be monitored to determine if and when these medications should be reintroduced.

700372532

230928

[diagnosis] - 2023-03-15 admission note

  • Malignant neoplasm of rectum
  • Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema

[past history]

  • Type 2 diabetes mellitus and hyperlipidemia for 4-5 years under medications treatment.
  • Past operation: left middle finger post traumatic amputation 30+ years ago            

[allergy]

  • NKDA     

[family history]

  • Father died: AMI
  • Mother: diabetes
  • There is no family history of cancer, mental diseases or asthma

[exam findings]

  • 2023-07-10 Neurosonography
    • Mild atheromatous lesions in R subclavian artery, R CCA bifurcation, and L ICA.
    • Normal extracranial carotid, vertebral, and intracranial basal cerebral arterial flows.
  • 2023-06-20 CT - abdomen
    • History and indication: ca of colon
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P colon and liver operation. A patchy density (2.3cm) at RML. Recurrent metastases at right liver operative margin (much regression).
      • Some calcifications in prostate.
      • Tiny gallbladder stones.
      • Degeneration and spondylosis of L-S spine.
      • Atherosclerosis of aorta, iliac and coronary arteries.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P colon and liver operation. A patchy density (2.3cm) at RML. Recurrent metastases at right liver operative margin (much regression).
  • 2023-02-13 Microsonography
    • Clinical Diagnosis: IRC and ME os
    • Report: 207/482 um, IRC and ME os
  • 2023-02-09 CT - abdomen
    • History and indication: colon cancer with recurrent liver mets S/P op & C/T
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P colon and liver operation. Right pleural effusion with adjacent lung collapse. Recurrent metastases at right liver operative margin.
      • Some calcifications in prostate.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Degeneration and spondylosis of L-S spine.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac and coronary arteries.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P colon and liver operation. Right pleural effusion with adjacent lung collapse. Recurrent metastases at right liver operative margin.
  • 2022-12-27 Patho - pleural/pericardial biopsy
    • Diaphragm, right, partial resection — Adenocarcinoma, moderately differentiated, compatible with metastatic colonic adenocarcinoma of liver with diaphragm invasion
    • The sections show a picture of adenocarcinoma, moderately differentiated, composed of low columnar neoplastic cells arranged in tubular and cribriform patterns with dirty necrosis. The surgical margin is close to tumor. The finding is compatible with metastatic colonic adenocarcinoma of liver with diaphragm invasion.
  • 2022-12-27 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS
      • Liver, S7, S7 resection — Metastatic colonic adenocarcinoma
      • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
    • MACROSCOPIC EXAMINATION
      • Procedures: S7 resection
      • Specimen Size: 11 x 8.0 x 5.0 cm and 120 gm
      • Tumor Focality: Solitary
      • Tumor Site: S7
      • Tumor Size: 3.2 x 3.0 x 2.2 cm
      • Large vessel involvement: Not identified
      • Non-tumorous part: Not cirrhotic
      • Sections are taken and labeled as: A1-A2= tumor + margin, A3-A4= tumor + capsule
    • MICROSCOPIC EXAMINATION
      • Diagnosis: Metastatic colonic adenocarcinoma
      • Histologic grade: Moderately differentiated
      • Tumor growth pattern: Pushing
      • Tumor pseudocapsule: Present
      • Tumor necrosis: Moderate (15%)
      • Parenchymal margin: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margins: 1.5 cm from resection margin
      • Vascular invasion: Not identified
      • Perineural invasion: Not identified
      • Tumor regression grade: Grade 4 (residual cancer cells predominate over fibrosis)
      • Non-neoplastic liver parenchyma: Moderate lymphocytic portal inflammation and regeneration of hepatocytes
      • Fatty Change: Absent
  • 2022-12-26 ECG
    • Normal sinus rhythm
    • Left ventricular hypertrophy with repolarization abnormality
  • 2022-11-24 Whole body PET scan
    • A mild glucose hypermetabolic lesion in the segment 7 of the liver. Liver metastasis of low FDG uptake can not be ruled out. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in a focal area in the right iliac bone. The nature is to be determined. Please follow up other imaging modalities for further evaluation.
    • Mild glucose hypermetabolism in bilateral shoulders and hips. Inflammatory process may show this picture.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2022-11-14 CT - abdomen
    • Indication: Malignant neoplasm of rectum
    • Abdominal CT with and without enhancement revealed:
      • Hepatic tumor at right liver surface with marginal enhancement and central necrosis is found. Hepatic metastasis is considered. In comparison with CT dated on 2022-04-25, the lesion enlarged.
      • Hypervascular hepatic tumor at S5/6 of liver up to 0.8cm in largest dimension. Hemangioma is considered.
      • s/p RAR.
      • The spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
    • Imp: colon cancer s/p RAR with liver metastasis, in progression.
  • 2022-08-22 SONO - abdomen
    • Findings
      • Normal echogenicity of the liver.
      • Presence of gallbladder stones and polyps.
      • Patency of PV, HVs, IVC and aorta in hepatic portion.
    • Impression:
      • GB stones and polyps.
  • 2022-05-30 MRA - brain
    • Acute infarcts in right upper medulla oblongata. Intracranial artherosclerosis.
  • 2022-04-25 CT - abdomen
    • S/P colon and liver operation. No evidence of tumor recurrence.
  • 2022-01-27 SONO - abdomen
    • Gallbladder stones (up to 0.56cm).
  • 2021-11-01 CT - abdomen
    • S/P colon and liver operation. No evidence of tumor recurrence.
  • 2021-04-20 Patho - conjunctiva biopsy/pterygium
    • Labeled as “sclera od”, trabeculectomy od — fibrotic tissue
  • 2021-04-12 Patho - colorectal polyp
    • Intestine, large, cecum, 120 cm from anal verge, biopsy — tubular adenoma
  • 2021-04-09 CT - abdomen
    • Indication: rectal CA, pT3N2aM0, stage IIIB s/p CCRT from 2018-03 to 2018-05 and LAR wt protective ileostomy on 2018/06/07
      • 20180507 CT: hemangioma 0.8 cm in S5
      • 20190708 CT: hemangioma 0.8 cm in S5.
      • 20191230 CT: two metastases 0.7 cm in S7 and 1.3 cm in S6?
      • 20200204 MRI: two metastases in S7 and S6?
      • Metastases confirmed by pathology after resection
    • FINDINGS:
      • There are focal defect in S7 and S6 of the liver that are compatible with metastases S/P surgical enucleation.
        • There is no evidence of tumor recurrence.
      • S/P LAR with autosuture retention over the rectum.
      • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L5-S1.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, & both kidney.
        • There is no ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction. The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion in the mesentery and omentum.
    • IMP:
      • No evidence of tumor recurrence in the liver.
  • 2021-04-09 Colonoscopy
    • The scope reach the cecum under poor colon preparation.
    • Two small and sessile polyp was noted in the cecum size 0.7 cm. (120 cm from anal verge)
  • 2020-10-19 CT - abdomen
    • S/P colon and liver operation. No evidence of tumor recurrence.
  • 2020-02-25 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS:
      • Liver, S7 with partial S6, segmental hepatectomy — Metastatic colorectal adenocarcinoma
      • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
    • MACROSCOPIC EXAMINATION
      • Procedures: Segmental hepatectomy of S7 with partial S6
      • Specimen Size: 12.0 x 7.5 x 5.5 cm and 180 gm
      • Tumor Focality: Solitary
      • Tumor Site: S6
      • Tumor Size: 2.2 x 2.0 x 1.7 cm
      • Large vessel involvement: Not identified
      • Non-tumorous part: Not cirrhotic
      • Sections are taken and labeled as: A1-A4= tumor, A5- A6= non-neoplastic liver
    • MICROSCOPIC EXAMINATION
      • Diagnosis: Metastatic colorectal adenoarcinoma
      • Histologic grade: Moderately differentiated
      • Tumor growth pattern: Infiltrating
      • Tumor pseudocapsule:Absent
      • Tumor necrosis: Moderate (10%)
      • Parenchymal margin: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margins: 0.4 cm
      • Vascular invasion: Not identified
      • Perineural invasion: Not identified
      • Tumor regression grade: Grade 4 (residual cancer cells predominate over fibrosis)
      • Non-neoplastic liver parenchyma: Perivenular congestion, regeneration of hepatocytes, and mild lymphocytic and neutrophil portal inflammation
      • IHC: CK7(-), CK20(+) and CDX2(+)
  • 2020-02-24 MRI - liver, spleen
    • History and indication: R/I recurrence of liiverr mets.
    • IMP: Progressive enlargement of right liver tumors (S6-7, 1.0cm, 1.7cm), metastases shoulde be ruled out.
  • 2019-12-30 CT - abdomen
    • Rectal cancer s/p operation. Right liver hemangioma (8mm). Poor enhancing tumors (6mm, 9mm) in S6-7 of liver suspected metastases.
  • 2019-01-21 CT - abdomen
    • Status post LAR with autosuture at the rectum.
    • There is no evidence of tumor recurrence.
  • 2018-06-08 Surgical pathology Level VI
    • PATHOLOGIC DIAGNOSIS
      • Rectum, s/p CCRT, laparoscopic assisted LAR and protective colostomy —- Adenocarcinoma, moderately differentiated
      • Resection margins: free
      • Lymph node, mesocolic, s/p CCRT, dissection —- Metastatic adenocarcinoma (4/11) with extranodal extension (1/4).
      • Lymph node, IMA / SMA, dissection — N/A.
      • AJCC 8th edition Pathology stage: ypT2N2a (if cM0); ypStage: IIIB.
      • NOTE: cM might be the same or might be upgraded when additional clinical and image findings are available for evaluation.
    • MACROSCOPIC EXAMINATION
      • Operation procedure: s/p CCRT, laparoscopic assisted LAR and protective colostomy
      • Specimen site: rectum
      • Specimen size: 9 cm in length
      • Tumor size: 3 x 2 cm
      • Tumor location: 3 cm and 2 cm away from the two resection margins, respectively
      • Depth of invasion grossly: muscularis propria
      • Mucosa elsewhere: free
      • Tissue for sections: A1-4: tumor; A5-6: lymph nodes.
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: moderately differentiated
      • Depth of invasion: muscularis propria
      • Angiolymphatic invasion: Present.
      • Perineural invasion: Not identified.
      • Discontinuous extramural tumor extension: Not identified.
      • Circumferential (radial) margin of rectum: Uninvolved, 5 mm from the margin.
      • Lymph node metastasis, mesocolic: (4/11)
      • Lymph node metastasis,, IMA / SMA: N/A.
      • Extranodal involvement: Present.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT) ypT2: Tumor invades the muscularis propria
        • Regional Lymph Nodes (pN) ypN2a: Four to six regional lymph nodes are positive
        • Distant Metastasis (pM) (if cM0); ypStage: IIIB.
        • NOTE: cM might be the same or might be upgraded when additional clinical and image findings are available for evaluation.
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: None identified.
      • TNM descriptors: y (Post-treatment).
      • Tumor regression grading S/P CCRT:
        • Grade 3 (dominant fibrosis outgrowing of 50% of the tumor mass).
  • 2018-02-06 Surgical pathology Level IV
    • Clinical diagnosis:
    • Neoplasm of unspecified nature of digestive system;
    • Pathological diagnosis:
      • Rectum, 8 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • MICROSCOPIC DESCRIPTION:
      • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
      • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).

[MedRec]

  • 2023-08-28 SOAP Metabolism and Endocrinology Qiu QuanTai
    • Prescription x3
      • Toujeo (insulin glargine) 12 unit QDAC SC
      • Through (sennoside 12mg) 1# PRNHS
      • Crestor (rosuvastatin 10mg) 1# QD
      • Kludone (gliclazide 60mg) 1# BIDAC
      • Dibose (acarbose 100mg) 1# TIDAC
      • Olmetec (olmesartan medoxomil) 1# QD
      • Trulicity (dulaglutide) 1.5mg QW SC
      • Uretropic (furosemide 40mg) 0.5# PRNQD (hold if SBP < 100 mgHg)
      • Smecta (dioctahedral smectite 3mg) 1# TIDAC
  • 2023-08-28 SOAP Metabolism and Endocrinology Qiu QuanTai
    • A: 2023 ~ additional chemotherapy again (taking steroids will make the blood glucose as high as 3XX)

[consultation]

  • 2022-05-30 Neurology
    • Q
      • l’t arm weakness since this morning. unsteady sensation.
      • hx of DM, HTN.
    • A
      • S
        • This 58 y/o man with a Hx of DM, HTN, dyslipidemia, and rectal CA with liver mets, Dx in Jan 2018, s/p CCRT under regular OPD follow-up. He was in ADL independent status.
        • This time, he suffered from acute left side numbness at 2PM on 5/28 while driving with left neck pain. Left limbs weakness was noted on the next day morning on awakending. Due to persisted symptoms, he came to our ER. There was no vomiting, diplopia, choking, slrred speech, convulsion, headache, fever or recent head trauma.
      • O
        • NE
          • GCS: E4V5M6
          • VF: no hemianopia
          • light reflex: 3/3 -/+ (cata/cata (right eye glaucoma s/p OP
          • EOM: free
          • no nystagmus
          • no facial palsy
          • PPS: left face V-I,II,III hypoesthesia (equivocal
        • Muscle power:
          • RUE/LUE: 5/4
          • RLE/LLE: 5/4
        • PPS: left hypoesthesia
        • FNF & HKS: no dysmetria
        • gait: tilt to left
        • NIHSS 000 000 1010 01000 =3
        • Lab Bil 1.17, CEA 5.465
        • brain MRA: Acute infarcts in right upper medulla oblongata
      • Impression
        • Acute infarcts in right upper medulla oblongata
      • Suggestion
        • aspirin 100mg 1# ST and QD
        • clopidogrel 300mg ST and 75 mg QD
        • famotidine 1# ST and BID
        • N/S run 60 ml/hr
        • hold OPD anti-hypertensive medication and control BP < 220/120
        • admit to ward under Dr Xiao’s service
        • closely monitor neurological signs
  • 2020-09-10 Ophthalmology
    • Q
      • This 57-year-old man patient is a case of colon cancer with liver metastasis s/p operation. He was admitted for chemotherapy. This time, glaucoma with high intraocular pressure. Now, for follow-up. Thank you.
    • A
      • S: for f/u IOP
      • O
        • OPHx: DMR complicated with NVG s/p several IVILs ou and cryotherapy od and full PRP ou
        • recent IOP, od on 9/7 W1 up to 40 was noted –> diamox 1# qid + combigan + xalatan
        • PT: 10/12 mmHg
        • VAcNC: OD 20/200 OS 20/200
        • conj: not injected ou
        • K: cl ou
        • AC:deep/cell trace - 1+ od, deep /clear os
        • c/d: pale disc 0.6-7 od, 0.5 os
      • P:
        • tapper the diamox to 1# bid

[surgical operation]

  • 2022-12-26
    • Surgery
      • open S7 resection with rt diaphram partial resection and repair
    • Finding
      • S7 hepatic tumor 3.2 x 3.0 x 2.0 cm with direct invasion to diaphragm
  • 2020-07-27
    • Surgery: 0 IVI Lucentis    ou    
    • Finding: retinal edema    ou 
  • 2020-02-24
    • Surgery
      • S7 and partial S6 resection
      • laparoscope
    • Finding
      • AN illed define heteroechoic tumor at S7 1.7 cm and 1.5 cm tumor at S6
      • mild adhesion
  • 2019-08-16
    • Diagnosis: Exudative senile macular degeneration
    • PCS code: 86201B
  • 2019-07-05
    • Diagnosis: Proliferative diabetic retinopathy OU
    • PCS code: 86201B
  • 2019-05-24
    • Diagnosis: DME ou
    • PCS code: 86201B
  • 2019-04-19
    • Diagnosis: DME ou
    • PCS code: 86201B
  • 2018-11-22
    • Diagnosis: Rectal cancer s/p LAR and ileostomy
    • PCS code: 73020C
    • Findings: Loop-ileostomy was taken down and resection with re-anastomosis was achieved using GIA 75/4.8. The procedure was smooth.
  • 2018-06-07
    • Diagnosis: Adenocarcinoma of rectum, cT3N2M1 s/p CCRT
    • PCS code: 74205B
    • Finding
      • Rectal cancer s/p CCRT was noted at middle rectum.
      • The laparoscopy procedure was converted to open method due to difficult to apply endo-GIA instrument.
      • The anastomosis was then achieved using SDH-33. Cutting ends are intact and even. Air test is ok.
      • TISSEEL 2ml was used at anastomosis site.
      • Loop-ileostomy was done at LLQ abdomen. A drain in pelvos.
  • 2018-02-07
    • Diagnosis: Rectal Ca
    • PCS code: 47080B
    • Findings: We identify the cephaic vein & use cutdown method to insert the Echo Port 7 Fr cathter into it. We also use intra-operative EKG to check its position

[chemoimmunotherapy]

  • 2023-08-17 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5200mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg IVD + NS 250mL + aprepitant 125mg D1-3
  • 2023-07-31 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5100mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg IVD + NS 250mL + aprepitant 125mg D1-3
  • 2023-07-10 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5150mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 0.5mg IVD + NS 250mL
  • 2023-06-20 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5150mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-05-26 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5125mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-04-28 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5180mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-04-06 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5170mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-03-15 - irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 735mg NS 250mL 2hr + fluorouracil 2800mg/m2 5155mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-02-24 - irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 729mg NS 250mL 2hr + fluorouracil 2800mg/m2 5100mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-02-09 - irinotecan 160mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2020-09-10 - oxaliplatin 85mg/m2 146mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4810mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-08-27 - FOLFOX
  • 2020-08-13 - FOLFOX
  • 2020-07-30 - FOLFOX
  • 2020-07-16 - FOLFOX
  • 2020-07-02 - FOLFOX
  • 2020-06-18 - FOLFOX
  • 2020-05-28 - FOLFOX
  • 2020-05-14 - FOLFOX
  • 2020-04-30 - FOLFOX

==========

2023-09-28

The drugs prescribed by our endocrinologist have been added to the active medication list with no discrepancies found.

2023-08-18

A 28-day supply of Ulstop (famotidine), Bokey (aspirin), Saline (nicametate), and Vemlidy (tenofovir alafenamide) are refilled on 2023-08-05, all added to the active formulary with no reconciliation issues found.

2023-08-01

Our neurologist prescribed Ulstop (famotidine), Bokey (aspirin), Saline (nicametate citrate) on 2023-07-17, our ophthalmologist prescribed Xalatan (latanoprost), Azarga (brinzolamide, timolol), Alphagan (brimonidine) eye drops on 2023-07-31. These drugs are included in the active medication list without a reconciliation issue.

2023-07-11

[reconciliation]

The prescription of Alphagan (brimonidine tartrate), Azarga (brinzolamide), and Xalatan (latanoprost) eye drops were refilled at a local pharmacy on 2023-06-26, with a valid 28-day duration for his glaucoma diagnosis. However, these drugs are not currently included in the patient’s active medication list. Please check whether these medications are still required for the patient.

2023-06-21

  • This patient receives medical services exclusively at our hospital. In addition to hematology and oncology, the patient also sees metabolism and endocrinology for type 2 DM, hyperlipidemia, primary hypertension, constipation; ophthalmology for glaucoma; and neurology for previous stroke.
  • The patient received a refillable prescription from Metabolism and Endocrinology on 2023-06-05 for Toujeo (insulin glargine), Through (sennoside), Crestor (rosuvastatin), Kludon (gliclazide), Dobose (acarbose), Olmetec (olmesartan), and Trulicity (dulaglutide). From the ophthalmology department, the patient was prescribed Xalatan (latanoprost), Azarga (brinzolamide, timolol), and Alphagan (brimonidine) on 2023-05-08. The neurology department prescribed Ulstop (famotidine), Bokey (aspirin), and Saline (nicametate) on 2023-04-24.
  • All of these medications have been added to the current formulary, except for the eye drops from the ophthalmology department. Please remind the patient to continue using them to prevent his glaucoma from worsening.

2023-04-07

  • During this hospitalization, the patient received his first dose of Avastin (bevacizumab) as part of the FOLFIRI chemoimmunotherapy regimen. Although the patient had previously received 3 cycles of FOLFIRI, monitoring for bleeding and thrombosis may still be necessary as these symptoms may be related to the use of bevacizumab.
  • The preprandial FS glucose levels on 2023-04-06 and 2023-04-07 morning were 218 and 249, respectively. If the readings exceed 200 for more than two consecutive days, the insulin dose may need to be increased.

2023-03-16

  • The patient’s blood sugar level has been well controlled during his current hospitalization.
  • He has a history of acute infarcts in the right upper medulla oblongata and was found to have intracranial atherosclerosis on a brain MRA performed on 2022-05-30. On 2023-03-16 at 13:14, his SBP was measured to be 182mmHg. If the patient continues to have persistently high blood pressure, the addition of amlodipine may be considered.

700480867

230928

U-Vanco (vancomycin) was changed from 1000mg Q12H to 1500mg Q12H on 2023-09-24 because the trough was 4.9mg/dL on that day. Since the updated trough level is even lower today (2023-09-28) at 4.3mg/dL, it is recommended that the dose be increased to 2000mg Q12H (Cre 0.32mg/dL, eGFR 377).

701493707

230927

[exam findings]

  • 2023-08-19 Pure Tone Audiometry
    • PTA Reliability FAIR
    • Average RE 18 dB HL; LE 23 dB HL.
      • RE WNL.
      • LE normal to moderate SNHL.
  • 2023-08-17 Patho - esophageal biopsy
    • Labeled as “middle esophagus”, biopsy — squamous cell carcinoma.
    • Section shows squamous cell carcinoma.
  • 2023-08-16 Patho - esophageal biopsy
    • Esophagus, 25-30 cm below incisor, biopsy — squamous cell carcinoma
    • Microscopically, it shows squamous cell carcinoma consisting of non-keratinized epidermoid neoplastic nests in downward infitrating growth fasion. The tumor cells have eosinophilic cytoplasm, pleomorhic round nuclei and nuclear hyperchromasia.
    • Immunohistochemical stain reveals P40(+), P63(+), CK(+), CEA(-).
  • 2023-08-16 CT - chest
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
    • Findings
      • Lungs: normal appearance of bilateral lungs.
      • Mediastinum and hila: an enhancing submucosal mass (11mm thick, 30mm in length) at posterior wall of lower third of thoracic esopahgus, causing luminal narrowing and no adjacent structures invasion. a small periesophageal LN is foundmultiple small LNs in visceral space. the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
      • Heart: normal size of cardiac chambers.
      • Pleura: unremarkable.
      • Chest wall and visible lower neck: multiple discrete enlarged LNs at left supraclavicular fossa and posterior triangle of the lower neck.
      • Visible abdominal-pelvic contents:
        • an enlarged lymph node at retroperitoneum, behind the neck of thepancreas aand anterior diaphgramtic crura. several enlarged LNs at upper para-aortic region.
        • unremarkable of the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys.
        • bile ducts: No dilatation.
        • Mild atherosclerotic change of the abdominal aorta and bilateral common iliac arteries.
      • Visualized bones: unremarkable.
    • Impression: L/3 esophageal cancer T2N3Mx(E1)

[MedRec]

  • 2023-09-12 SOAP Dermatology Zhou WeiTing
    • S: severe itchy papules and plaques erupition over trunk after medication.
    • O:
        1. urticaria/angioedema type
        1. maculopapular type
        1. urticaria-purpura type
        1. erythema multiforme SJS/TEM
        1. fixed drug eruption or AGEP rapid onset type
        1. drug hypersensitivity syndrome as DRESS
        1. lichenoid chronic progressive type
      • Suspect related medication: chemotherapy.
    • Plan:
      • education about drug side effec and explain
      • strongly suggested OPD f/u
    • Prescription
      • Compesolon (prednisolone 5mg) 2# PRNQD
      • Asthan (ketotifen 1mg) 1# BID
      • Sinpharderm Cream (urea) QN TOPI
      • Topsym Cream (0.05% fluocinonide) BID EXT
  • 2023-09-07 SOAP Hemato-Oncology Xia HeXiong
    • Conclusion of Multidisciplinary Cancer Team Meeting, Meeting Date: 2023-08-22
      • L/3 Esophageal cancer SCC, cT2N3M0, stage IVA.
      • Initially, concurrent chemoradiotherapy (CCRT) will be administered, followed by an evaluation to determine whether surgery is feasible.
  • 2023-09-01 SOAP Radiation Oncology Wan YuNong
    • Plan to deliver 45 Gy/ 25 fx to the bil. SCFs, whole esopahgus, and adjacent lymphatic drainage area. Then boost the gross tumor and LAPs to 50.4 Gy/ 28 fx.
  • 2023-08-13 ~ 2023-08-30 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Middle third of thoracic esophagus squamous cell carcinoma with multiple enlarged lymph node, cT2N3M0, stage IVA
      • Eczema herpeticum
      • Essential (primary) hypertension
      • Hyperlipidemia, unspecified
      • Chronic viral hepatitis B without delta-agent, Anti-HBc: reactive
      • Insomnia
      • Intertrigo friction wound with tinea infestation
    • CC
      • PET showed L/3 esophageal tumor in 2023/08. The patient suffer from chocking easily for 2-3 years.
    • Present illness
      • This 56-year-old man, had past history of hypertension and hyperlipidemia under controlled.
      • According to his statement, he noticed a small nodule at his left neck about 2 years ago, the tumor keep existing and got bigger, so he went to pohai hospital for examination, where biopsy was done, and the result showed metastatic squamous cell carcinoma. Then he was done PET showed L/3 esophageal tumor in 2023/08. He had suffered from chocking easily for 2-3 years, without dysphagia or body weight loss or other discomfort.
      • There was no exacerbating factor and no relieving factor notes. Left neck mass had also been noted for 2-3 years. There was no vomiting, abdominal pain, abdominal bloating, diarrhea, epigastric pain, body weight loss, easy choking, dysphonia, hoarseness, chest pain, dyspnea, or hemoptysis. The patient denied trauma or esophageal injury history.
      • He visited our chest surgery out-patient department for cancer restaging and evaluation of surgical treatment. Physical examination showed clear breathing sound, regular heart beats, and soft abdomen with no tenderness. There was one mass with irregular margin over left neck with tenderness, not mobile, hard. Then he was admitted for cancer restaging under the impression of lower third esophageal cancer.
    • Course of inpatient treatment
      • After admission, he was done Brain MRI and abdominal echogram showed no metastasis, PES showed Esophageal tumor, 25-30 cm from incisor, M/3 of esophagus s/p Bx complicated with intra-luminal narrowing on 2023/08/15, chest CT showed L/3 esophageal cancer on 2023/08/16, EUS showed Esophageal tumor, probably submucosal lesion, middle esophagus, status post biopsy Para-esophageal lymphadenopathy, T3N3M0 on 2023/08/17. Arrange on Port-A catheter implantation on 2023/8/21.
      • Due to esophaheal cancer T3N3M0, consult Hematology Oncology and Radiology for arrange CCRT then tranferred to hematology oncology ward for future treatment on 2023/8/18. Before chemotherapy survey, PTA on 2023/08/19 showed Reliability FAIR, Average RE 18 dB HL; LE 23 dB HL, RE WNL, LE normal to moderate SNHL. 24hrs CCr. on 2023/08/19 showed 70.1mL/min.
      • Tramacet 37.5 & 325mg/tab 1# PO Q12H, Limadol 100mg/2mL/amp 50mg IVD PRNQ6H for pain control.
      • CT-simulation on 2023/08/22(+). Plan to deliver 45 Gy/ 25 fx to the bil. SCFs, whole esopahgus, and adjacent lymphatic drainage area. Then boost the gross tumor and LAPs to 50.4 Gy/ 28 fx. RT start on 2023/08/25.
      • He received radiochemotherapy with PF (Cisplatin 75mg/m2 D1, 5-Fu 1000mg D1-D4, (MgSO4 1amp and Lasix 1amp after Cisplatin)) from 2023/08/25~2023/08/29 smoothly. Adequate IVF was given.
      • For chemotherapy, Vemlidy 25 mg/tab 1# PO QD was given for Anti-HBc: reactive. Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting. Hypertension was treated with Sevikar F.C. 5 & 20mg/tab 1# PO QD. Hyperlipidemia with Zulitor F.C 4mg/tab 0.5# PO QN, Bokey 100mg/cap 1# PO QD. Insomnia with Alpraline 0.5mg/tab 1# PO PRNHS if insomnia. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/08/30 and OPD followed up later.
    • Discharge prescription
      • Zalain Cream (sertaconazole nitrate 2%) BID TOPI (over large area of peripheral annular lesions)
      • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) PRNBID TOPI (if itchy)
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Siliverzine (silver sulfadiazine) BID EXT (over maceration wound)
      • Through (sennoside 12mg) 2# HS
      • Alpraline (alprazolam 0.5mg) 1# PRNHS
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Limeson (dexamethasone 4mg) 1# QD
      • Stogamet (cimetidine 300mg) 1# QD
      • Zyprexa (olanzapine 5mg) 1# PRNHS

[consultation]

  • 2023-08-29 Dermatology Zhou WeiTing
    • Q
      • The patient is an 56-year-old male with a history of Middle third of thoracic esophagus squamous cell carcinoma with multiple enlarged lymph node, cT2N3M0, stage IVA
      • He presented with itch and skin rash at bilateral inguinal for few days, under Mycomb, no improving. We need your further evaluation and management.
    • A
      • The patient had sufferred from firctional excoriative wound with fuluremt dischagre and annular lesion with active borders on the gerion.
      • Under the impression of intertrigo fricitonal wound with tinea infestation.
      • The following sugeetion:
        • Sliverzine cream 1 tube topical bid use over maceration wound first.
        • Zalaine cream 1 tube topical bid use over large area of peripheral annular lesions.
          • If itchy or other symptoms, maintain Mycomb cream 1 tube topical PRN use over these lesions.
  • 2023-08-18 Radiation Oncology
    • Q (same as 2023-08-17 HemaOnco)
    • A
      • Biopsy at LuoDong BoAi H. showed metastatic squamous cell carcinoma.
      • If the pathology report showed submucosal SCC, neoadjuvant CCRT is indicated. CT-simulation will be arranged on 8/22.
      • Plan to deliver 45 Gy/ 25 fx to the bil. SCFs, whole esopahgus, and adjacent lymphatic drainage area.
      • Then boost the gross tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 8/24 or 25. Thank you very much.
  • 2023-08-17 Hemato-Oncology
    • Q
      • This 56-year-old man. He noticed a small nodule at his left neck about 2 years ago, biopsy showed metastatic squamous cell carcinoma. Then he was done PET showed L/3 esophageal tumor in 2023/08. He visited our CS OPD and admission for cancer staging.
      • He was done EUS on 8/17 showed Esophageal tumor, probably submucosal lesion, middle esophagus, Para-esophageal lymphadenopathy, T3N3M0.
      • We would like to consult for arrange CCRT. Thank you. Sincerely request your help to evaluate and manage this patient.
    • A
      • This 56 year old man is a case of nodal positive esophageal SCC. We are consulted for CCRT.
      • Please check Anti HBc, Anti HBs, HBsAg, Anti HCV, 24 urine CCr. Audiometry. We will discuss with patient about CCRT with PF and take over this case.
      • Please arrange port A insertion and book 11A ward.
  • 2023-08-14 Gastroenterology
    • Q
      • This 56-year-old male was admitted for further examination due to esopheal tumor was noted.
      • According to the patient, he noticed a small nodule at his left neck about 2 years ago, but he didn’t mild it. But the tumor keep existing, so he went to OPD for eamination, where biopsy was done, and the result showed metastatic squamous cell carcinoma. PET showed L/3 esophageal tumor in 2023/08. The patient stated that he had mild dysphagia and sometimes choking.
      • So, this time, he was admitted for esophageal tumor further exmination.
        • 8/14 WBBS
        • 8/15 09:00 chest CT + 12:40 Brain MRI
        • 8/16 09:30 CPET
        • 8/17 EUS + abdominal sona
      • We would like to consult for arrange EUS and abdominal sona on 8/17.
    • A
      • 56M
      • Phx: HTN under medication, Old CVA.
      • S+O:
        • Mild dysphagia and sometimes choking
        • Left neck palpable mass
        • The patient said he had EGD 2 years ago at other hospital.
        • Biopsy at left neck mass showed metastatic squamous cell carcinoma (other hospital)
      • A: Suspicious lower esophageal SCC
      • P:
        • Please arrange EGD before EUS examination
        • EUS for esophageal SCC staging already arrange on 8/17
        • Please prescribe J CROWS Lugols solution (self-paid TWD 1500) and bring it to the exam room.

[radiotherapy]

[chemotherapy]

  • 2023-09-26 - cisplatin 75mg/m2 100mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D2-4 (PF CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-25 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1800mg NS 500mL 24hr D2-4 (PF CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-09-27

[reconciliation]

The patient consistently refills his repeat prescription from LuoDong BoAi Hospital for Bokey (aspirin), Sevikar (amlodipine, olmesartan), and Livalo (pitavastatin). These drugs are currently being used with no discrepancies identified.

[dermatologic adverse reactions (5-FU)]

HIS5 records indicate that the patient visited our dermatologist on 2023-09-12 for suspected chemotherapy-related dermatopathy.

It has been reported that fluorouracil (administered initially on 2023-08-26 at a dose of 1800mg for 3 days) is associated with various dermatologic side effects, including alopecia, nail changes (including nail loss), dermatitis, hyperpigmentation (around veins), maculopapular rash (pruritic), palmar-plantar erythrodysesthesia, skin fissures, skin photosensitivity, Stevens-Johnson syndrome, toxic epidermal necrolysis, and xeroderma. Since the second dose was administered on 2023-09-27 at a lower dose of 1500mg for 3 days, it is advisable to monitor the patient closely for any recurrence of dermatopathy.

700603106

230926

[exam findings]

  • 2022-12-21 PET
    • Glucose hypermetabolic lesions in the right chest wall, compatilbe with recurrent breast tumor s/p operation.
    • Glucose hypermetabolic lesions in bilateral tonsils, probably chronic inflammation/infection process.
    • Increased FDG uptake in bilateral kidneys and left ureter, probably physiological uptake of FDG.
    • Right breast cancer with tumor recurrence s/p operation, no evidence of residual or metastatic tumor, by this F-18 FDG PET scan.
  • 2022-12-19 Patho - breast simple/partial mastectomy
    • Diagnosis
      • S2022-22806: Skin, right chest wall, resection margin, second wide excision —- Negative for malignancy
      • F2022-00612: Skin and foft tissue, right chest wall, wide excision —- invasive carcinoma of no special type, recurrent
    • Gross Description
      • S2022-22806: The specimen submitetd in formalin consists of a rim of skin and soft tissue measuring 5.2 x 0.9 x 0.8 cm. The width of the rim is 0.4 cm. All for section in 4 cassettes: A1: from 12 o’clock to 3 o’clock; A2: from 3 o’clock to 6 o’clock; A3: from 6 o’clock to 9 o’clock; A4: from 9 o’clock to 12 o’clock.
      • F2022-00612: The specimen submitetd in fresh consists of a piece of skin and soft tissue measuring 4.3 x 2.7 x 1.6 cm. On cutting, a gray, invasive tumor, measuring 3.0 x 2.2 x 1.5 cm is seen. The tumor is very close (< 0.1 cm) to deep and 6 o’clock resection margins and 0.1 cm away from the 12, 3, and 9 o’clock resectino margins. Representative sections are taken and labeled as: FsA1: through section from 12 o’clock (ink black) to 6 o’clock (ink orange) resection margin; FsA2: 3 o’clock resection margin; FsA3: 9 o’clock resection margin. After formalin fixation, additional sections are taken and labeled as: X1-2.
    • Microscopic Description
      • S2022-22806: Sections show skin and soft tissue without malignancy.
      • F2022-00612
        • For Invasive Carcinoma
          • Histologic type: Invasive carcinoma of no special type, recurrent
          • Size of invasive carcinoma (mm): 30 x 22 x 15 mm
          • Histologic grade (Nottingham histologic score): grade II (score 7)
            • Tubule formation: score 3
            • Nuclear pleomorphism: score 2
            • Mitotic count: score 2
          • Extent of tumor (required only if the structures are present and involved)
            • Skin involvement: Present (without ulceration)
            • Chest wall invasion deeper than pectoralis muscle: Invasion to superficial skeletal muscular tissue without deeper than pectoralis muscle
        • For Ductal Carcinoma In Situ: not applicable
        • Margins:
          • S2022-22806: Negative for malignancy
          • F2022-00612: The tumor is very close (< 0.1 cm) to deep and 6 o’clock resection margins and 0.1 cm away from the 12, 3, and 9 o’clock resectino margins.
        • Nodal status: not received
        • Treatment Effect: not applicable
        • Immunohistochemical Study
          • ER (Ab): Positive (90%, strong) (Internal control: positive)
          • PR (Ab): Positive (60%, moderate) (Internal control: positive)
          • Her-2/neu (Ab): Negative (1+)
          • Ki-67: 20%
  • 2022-12-18 CT - chest
    • Findings
      • S/P right breast operation. A soft tissue nodule (2.3cm) at right chest wall.
      • Some LNs at bil. neck.
      • A calcified spot (2.6mm) at right lung margin.
      • A hypodense nodule (0.9cm) at left hepatic lobe. Grade 4 fatty liver.
    • IMP:
      • A soft tissue nodule (2.3cm) at right chest wall.
  • 2019-04-23 Gynecologic ultrasonography
    • R/O RT ovarian cyst
    • Uterine myoma
  • 2018-10-23 MRI - breast
    • S/P right mastectomy.
    • Stipple enhancement in left breast, but no significant early enhancement. Suggest clinical correlation and follow up.
  • 2017-09-05 Gynecologic ultrasonography
    • Uterine myoma
    • EM: 3.6mm
  • 2017-03-07 Gynecologic ultrasonography
    • Uterine myoma

==========

2023-09-26

This patient has been consistently taking cyclin-dependent kinase inhibitor Verzenio (abemaciclib 150mg) 1# BIDCC and aromatase inhibitor Femara (letrozole 2.5mg) 1# QD for months.

Dyspnea, with a frequency ranging from 6% to 18%, has been associated with the use of letrozole. Abemaciclib, on the other hand, has been linked to interstitial lung disease (ILD) and/or pneumonitis, with the frequency not yet defined.

In the event that ILD is confirmed, the abemaciclib dosage should be adjusted as follows:

  • Grade 1 or 2: No abemaciclib dosage modification is required.

  • Persistent or recurrent grade 2 toxicity that does not resolve to baseline or grade 1 within 7 days (despite maximal supportive measures): Withhold abemaciclib until toxicity resolves to baseline or to ≤ grade 1 and then resume abemaciclib at the next lower dose.

  • Grade 3 or 4: Discontinue abemaciclib.

701038432

230926

[MedRec]

  • 2023-07-25 SOAP Cardiology Liu ZhiRen
    • Prescription x3
      • Meletin (mexiletine 100mg) 1# BID
  • 2023-05-02 SOAP Hemato-Oncology He JingLiang
    • A: Adenocarcinoma of S-colon with obstruction with multiple liver metastases, cT3N2M1a, stage IVa, status post T-loop colostomy on 2023/04/15
    • P: suggest palliative chemotherapy with FOLFIRI + target therapy with avastin x 12 cycles
  • 2023-04-15 POMR Colorectal Surgery Chen ZhuangWei
    • Discharge diagnosis
      • Sigmoid cancer obstruction with multiple liver metastases, cT3N2M1a, stage IVa, status post T-loop colostomy on 2023/04/15
      • Bilateral avascular necrosis
    • CC
      • abdominal fullness WITH OBSTIPATION for one week. Accompanied with nausea and poor appetite.
    • Present illness
      • This is a 74-year-old female without any underlying diseases. This time, she visited our emergency room due to abdominal fullness WITH OBSTIPATION for one week. Accompanied with nausea and poor appetite. SHE ALSO EXPERIENCED CHANGE IN BOWEL HABIT WITH DIFFICULT PASSAGE OF STOOL IN RECENT WEEKS. There was no fever, no chills, no chest pain, no tarry stool, no constipation, no diarrhea. She also denied body weight loss in the recent half year.
      • At our ER, her vital signs were BP:150/86; HR:91; BT:36.6; RR:18; Con’s:E4V5M6, SpO2:96%. PE showed soft and oviod abdomen with hypoactive bowel sound. Lab data showed hyponatremia, elevcated of CRP level and leukocytosis. KUB revealed ileus AND MARKED DILATED COLON. Abdomen CT showed long segmental wall thickening at sigmoid colon measuring 5.6cm in largest dimension, sigmoid colon cancer WITH OBSTRUCTION is considered. Several lymph nodes (n>8) are found around the main mass. The intestines are markedly dilated due to sigmoid colon obstruciton. Huge hepatic tumors are found at both lobes of liver up t 8.4cm in largest dimension. Liver meta is considered. Also, minimal ascites at subphrenic region and minimal right pleural effusion are found.
      • Under the impression of tumor of S-colon with obstruction and liver metastases, she was admitted for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, operation of T-loop colostomy under general anesthesia were performed on 2023/04/14. Op finding: marked colon and small bowel dilatation and bowel wall edema. The whole procedure was smooth. NPO and adequate IV fluid supplement. Antibiotic treatment with Sintrix was prescribed on 04/15~4/24. Early activity is encouraged. She had flatus and stool passage via ostomy. Her abdominal wound pain subsided. Oral intake program was adjusted and there was no abdominal discomfort after trying oral intake, IV fluid supplement was tapered and discontinued later.
      • She had passed stool with normal bowel movement. Oral intake with soft diet is tolerated well. Her abdominal wound pain had got much better. In stable condition, she was discharged on 2023/04/25 and will receive OPD follow up next week.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H

[surgical operation]

  • 2023-04-15 - Op Method: T-loop colostomy         
    • Finding:
      • Marked colon and small bowel dilatation and bowel wall edema.            - T-loop colostomy was carried out at RUQ abdomen. The whole procedure was smooth.    

[immunochemotherapy]

  • 2023-09-26 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-06 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-17 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-31 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-26 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-26 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-11 - bevacizumab 5mg/kg 200mg NS 100mL 1.5hr

  • 2023-05-09 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 500mL 45hr

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL

701186682

230926

[exam findings]

  • 2023-07-21 SONO - abdomen
    • Propable liver calcification, right
    • S/p cholecystectomy
    • Suspected fatty infiltration of pancreas
    • Small amount ascites
    • C/w ESRD
  • 2023-06-21 Joint soft tissue sonography
    • Finding: Ill-defined anechoic effusion with posterior enhancement and mild compressible just below the OP wound of the axilla site.
    • Impression And Suggestions: Right axilla post-OP wound effusion or serosanguineous mass accumulation.
  • 2023-05-31 Tc-99m MDP bone scan
    • A hot spot at a mid-T spine and increased activity at L2-4 spines, the nature is to be determined (post-traumatic reaction, early bone mets or other nature ?), suggesting further investigation and follow-up with bone scan in 3 months.
    • Suspected benign lesions in the maxilla, mandible, bilateral shoulders, elbows, S-I joints, knees, and feet.
  • 2023-05-31 Patho - breast mastectomy with regional lymph nodes
    • PATHOLOGIC DIAGNOSIS
      • Breast, right, partial mastectomy — Invasive carcinoma of no special type
      • Resection margin, breast, right, partial mastectomy — Free
      • Lymph nodes, sentinel and non sentinel, right axilla, lymphadenecomy — Negative for malignancy (0/8)
      • AJCC 8 th edition, Pathology stage: pT1cN0(cM0); Anatomic stage IA; Prognostic stage IA
    • MACROSCOPIC EXAMINATION
      • Breast Size: 10.5 x 6.0 x 3.5 cm
      • Skin Size: 5.0 x 1.0 cm
      • Nipple: Not included
      • Tumor Size: 1.8 x 1.4 x 1.2 cm
      • Resection Margin: Free, 2.4 cm from the deep margin
      • Lymph node: Sentinel (SLN1 and SLN2), and non-sentinel
      • Representative parts are taken for sections and labeled; A1= 12’ and 6’ margins, A2= 3’ and 9’ margins, A3-A4= skin + tumor, A5= tumor + base margin, B=SLN1, C= SLN2, D= non SLN.
    • MICROSCOPIC EXAMINATION
      • Histo
        • Histologic type: Invasive carcinoma of no special type
        • Size of invasive carcinoma: 1.8 x 1.4 x 1.2 cm
        • Histologic grade (Nottingham histologic score): Grade 2 (score= 6)
        • Skin involvement: Absent
        • Ductal carcinoma in situ: Present with intermediate nuclear grade; Extensive DCIS: Negative
      • Margins: Negative; Closest margin: >10 mm from closest lateral margins and 24 mm from deep margin
      • Nodal status: Negative (0/8)
        • number of lymph node examined: 3 (SLN1), 2 (SLN2), 3 (non SLN)
        • number with macrometastases (> 2mm): 0
        • number with micrometastases (> 0.2~2mm and/or > 200 cells): 0
        • number with isolated tumor cells (<= 0.2mm and <= 200 cells): 0
      • Treatment Effect: No presurgical neoadjuvant therapy received
      • Lymphovascular invasion: Presnt
      • Perineural invasion: Absent
    • IMMUNOHISTOCHEMICAL STUDY (S2023-09128)
      • ER (Ab): Positive (weak, 10%)
      • PR (Ab): Negative
      • HER-2/Neu (Ab): Negative (score= 1+)
      • Ki-67: 20%
  • 2023-05-30 Lymphoscintigraphy
    • Probably a sentinel lymph node at the right axillary region.
  • 2023-05-11 Patho - breast biopsy (no need margin)
    • Breast, right ( 2 / 3.5), core needle biopsy— Invasive carcinoma of no special type
    • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in ductal architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic activity.
    • Immunohistochemical study:
      • ER (Ab): Positive (weak, 10%)
      • PR (Ab): Negative
      • Her-2/neu (Ab): Negative (1+)
      • Ki-67 index: 20%
      • CK5/6: Negative
      • p63: Negative
  • 2023-05-08 Mammography (magnification)
    • BI-RADS category 4C, High suspicion for malignancy. Tissue diagnosis is suggested.
  • 2023-04-21 Cardiac Catheterization
    • Past Medical History
      • The patient has a history of DM for years with OHA control, HCVD with antiHTN and ESRD with PD since 2022-09.
    • Indication
      • The patient was referred with Refrcatory angina and Th-201 scan (++). The procedure was explained in detail to the patient and family. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
    • Approach
      • Percutaneous access was performed through the right radial artery
    • Catheters
      • Left coronary angiography was performed using 6Fr JL3.5 catheter and Right coronary angiography was performed using 6Fr JR4 catheter.
    • Procedure
      • The patient was taken to the cardiac catheterization laboratory in the TZU CHI Taipei Hospital. Heart institute and prepared in the usual sterile fashion. The contrast material used was Omnipaque 350 cc. The patient was treated with Heparin and NTG.
    • Finding Summary
      • Syntax Score = 2
      • Left Main : patent
      • Left Anterior Descending : heavy calcification at P- to M-LAD with mild atherosclerosis at P-LAD
      • Left Circumflex : patent
      • Right Coronary : about 50 % eccentric stenosis at M-RCA
    • In conclusion : CAD, SVD-RCA
    • Recommendation : Medical treatment
  • 2023-02-16 Myocardial perfusion SPECT with persantin
    • Probably mild to moderate myocardial ischemia at the apical anterolateral wall and posterior wall and mild myocardial ischemia at the septum and mid anterior wall.
  • 2023-02-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (119 - 29.3) / 119 = 75.38%
      • M-mode (Teichholz) = 75.4
    • Conclusion:
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • Calcified mitral annulus with mild MR, mild TR and PR
      • AV sclerosis with mild AR
      • No regional wall motion abnormalities

[MedRec]

  • 2023-07-27 SOAP Gastroenterology
    • Prescription x3
      • Vemlidy (tenofovir alafenamide 25mg) 1# QDCC
  • 2023-07-20 ~ 2023-07-21 POMR General and Gastroenterological Surgery
    • Discharge diagnosis
      • Right breast invasive carcinoma, pT1cN0M0 stage IA. ER : Positive (weak, 10%), PR: Negative, Her-2/neu : Negative (1+), Ki-67 index: 20%. ECOG:0.
      • End stage renal disease
      • Type 2 diabetes mellitus
      • Papillary thyroid carcinoma status post left thyroidectomy, pT1aNx pStage I status post radical lateral neck lymph node dissection and right thyroidectomy and re-implant of parathyroid gland on 2020/04/28
      • Hypo-osmolality and hyponatremia
      • Abnormal results of liver function studies
      • Anemia in chronic kidney disease
      • Hypoalbuminemia
      • Hyperbilirubinemia
    • CC
      • for 2nd adjuvant chemotherapy
    • Present illness
      • This 55-year-old post menopausal woman has
        • Hypertension
        • Type 2 Diabetes Mellitus
        • Chronic kidney disease stage 5 status post implantation of continuous ambulatory peritoneal dialysis catheter on 2022/08/01
        • Uterine myoma status post
        • Bilateral thyroid papillary carcinoma, pT1aN0M0, stage I
        • Coronary artery disease with medicine control
        • Gallbladder stones status post.
      • She denied any TOCC histories in recent 3 months.
      • She was diagnosed with right breast cancer then underwent of right partial mastectomy and sentinel lymph node biopsy on 2023/05/30. The finally pathlogy revealed invasive carcinoma, pT1N0M0 stage IA. IHC revealed ER (Ab): Positive, PR (Ab): Negative, HER-2/Neu (Ab): Negative, Ki-67: 20%. Tc-99m MDP whole body bone scan showed no obvious lesion for metastasis.
      • Under the impression of right breast cancer, pT1cN0M0 stage IA, she was admitted to our ward for 2nd adjuvant chemotherapy.
    • Course of inpatient treatment
      • After admission, 5-Fu 1047mg in Saline 100ml, Lipodox 55mg in Saline 250ml and Endoxan 800mg in saline 500ml were administered. There was no special complaint. Under the stable condition, she was discharged today and will be arranged next course adjuvent chemotherapy 3 weeks later.
    • Discharge prescription
      • Emend (aprepitant 125mg) 1# QD
      • Limeson (dexamethasone 4mg) 1# BID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Foliromin (ferrous sodium citrate 50mg) 1# BID
      • Through (sennoside 12mg) 2# PRNHS
      • Sinpharderm Cream (urea) BID TOPI
  • 2023-07-20 SOAP Cardiology
    • Prescription x3
      • Cardiolol (propranolol 10mg) 1# BID
      • Nirandil (nicorandil 5mg) 1# BID
      • Bokey (aspirin 100mg) 1# QD
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID

[consultation]

  • 2023-05-31 Nephrology
    • Q
      • This is a 55 years old female patient. She was under PD in our hospital. This time, she was admitted for surgery of partial mastectomy + SLNB on 2023/05/30. We need your consult for combine care. Thank you so much!!
    • A
      • We will arrange PD for the patient during the course of hospitalization.
      • If you need to remove more or less water, please feel free to contact us.
  • 2022-08-16 Urology
    • Q
      • For Tenckhoff catheter insertion.
      • This 54-year-old woman has history hypertenion under medical control for 20 years, diabetes mellitus under medical control for 20 years, chronic kidney disease, stage V, thyroid papillary carcinoma s/p left thyroidectomy and parathyroid hyerplasia s/p parathyroidecotomy of left side.
      • Due to progression renal function failure was noted (01/20, Cr: 4.68 mg/dl => 03/17, Cr: 7.32 mg/dl => 6/07, Cr:9.24 mg/dl => 7/05, Cr:9.71 => 8/16, Cr:14.66mg/dl ). Prepare Tenckhoff catheter insertion was suggested for prepare Peritoneal dialysis. After well explained his condition to the patient and his family, she was admitted for further management.
    • A
      • We will arrange PD tube insertion tomorrow, thank you!

[chemotherapy]

  • 2023-09-01 - fluorouracil 600mg/m2 1049mg NS 100mL 30min + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr (FAC Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-08-11 - fluorouracil 600mg/m2 1047mg NS 100mL 30min + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr (FAC Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-07-20 - fluorouracil 600mg/m2 1047mg NS 100mL 30min + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr (FAC Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-06-27 - fluorouracil 600mg/m2 1070mg NS 100mL 30min + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr (FAC Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

2023-09-26

[anemia]

The last dose of FAC regimen was administered on 2023-09-01 and blood transfusion was performed on the same day, after almost 4 weeks on 2023-09-25 HGB was still below 7g/dL. The recovery of hematopoietic capacity may not be able to catch up, if anemia becomes symptomatic or considered severe, additional blood transfusion might be needed.

2023-09-25 HGB 6.4 g/dL
2023-09-22 HGB 6.8 g/dL
2023-09-01 HGB 6.0 g/dL

[oral mucositis]

For oral mucositis, ASCO recommends using normal saline or salt and soda rinses, 2% viscous lidocaine swish and spit, modifying the diet, using 2% morphine mouthwash swish and spit, and administering systemic opiates based on increasing symptom burden. Ref: Management of Cancer Therapy-Associated Oral Mucositis. JCO Oncol Pract. 2020;16(3):103-109. doi:10.1200/JOP.19.00652

The patient may benefit from using Nincort Oral Gel (triamcinolone acetonide) as a means of relieving symptoms. Additionally, Comfflam Anti-inflammatory Spray (benzydamine 1.5 mg/mL) is available at this hospital and can be used as a rinse three to four times daily (depending on the severity of the mucositis).

2023-09-05

[anemia]

  • Recent HGB lab results
    • 2023-09-01 HGB 6.0 g/dL
    • 2023-08-26 HGB 6.0 g/dL
    • 2023-08-11 HGB 6.2 g/dL
    • 2023-07-31 HGB 5.8 g/dL
    • 2023-07-20 HGB 6.8 g/dL
    • 2023-07-04 HGB 7.2 g/dL
    • 2023-06-26 HGB 8.1 g/dL
  • The patient received blood transfusions on 2023-08-11 and 2023-09-01 due to low hemoglobin levels.

2023-08-15

[anemia]

  • Recent HGB lab results
    • 2023-08-11 HGB 6.2 g/dL
    • 2023-07-31 HGB 5.8 g/dL
    • 2023-07-20 HGB 6.8 g/dL
    • 2023-07-04 HGB 7.2 g/dL
    • 2023-06-26 HGB 8.1 g/dL
  • In the table above, the patient received FAC (lipo) on both 2023-07-20 and 2023-08-11. In addition, a blood transfusion was performed on 2023-08-11 (a previous transfusion was performed on 2023-05-30). Following the transfusion, the patient’s HGB (hemoglobin) level is expected to have increased.

[restaging]

On 2023-05-31, a bone scan indicated the need for further monitoring of an active spot in the mid-T spine and heightened activity in the L2-4 spines to ascertain potential bone metastasis. Furthermore, an abdominal sonography on 2023-07-21 showed a slight presence of ascites. If the disease is ultimately confirmed to have metastasized, restaging may be necessary.

2023-07-24

[anemia]

  • Recent HGB lab results

    • 2023-07-20 HGB 6.8 g/dL
    • 2023-07-04 HGB 7.2 g/dL
    • 2023-06-26 HGB 8.1 g/dL
    • 2023-06-20 HGB 8.0 g/dL
    • 2023-06-01 HGB 8.6 g/dL
  • This patient received two cycles of FAC (5FU + LipoDox + Endoxan) on 2023-06-27 and 2023-07-20. Prior to treatment, the hemoglobin (HGB) level remained above 8 g/dL, but after the first cycle, the level decreased to 7.2 g/dL and further decreased to 6.8 g/dL on the day of the second cycle administration.

  • Pegylated liposomal doxorubicin is known to be associated with anemia (grade 3: 5%, grade 4: <1%), and anemia is also common in patients receiving cyclophosphamide and/or fluorouracil.

  • As the patient has end-stage renal disease (ESRD) with impaired hematopoietic function, appropriate administration of epoetin alfa is required in addition to iron supplementation. In emergency situations or as needed, blood transfusion should still be considered to maintain hemoglobin levels.

700930475

230925

[MedRec]

  • 2023-09-15 SOAP Hemato-Oncology Gao WeiYao
    • A
      • Suspected metastatic malignant tumor of left neck
      • Recurrent squamous cell carcinoma of left buccal mucosa, pT4aN0M0, psatge IVa post of operation with close surgical margin (2023) status post CCRT and target therapy
      • S/P NG feeding (20230915)
    • P
      • symptom relief
      • patient has already signed the DNR
      • SUGGEST admission for chemotherapy and explained the risk of palliative chemotherapy.
  • 2022-11-10 ~ 2022-11-14 POMR Oral and Maxillofacial Surgery He ChengHan
    • Discharge diagnosis
      • Squamous cell carcinoma of left buccal mucosa, cT3N0M0 post of operation on 2022.
      • Squamous cell carcinoma of left face skin, cT1NxMx, ctsage I post of excision of the soft tissue tumor on the left chin area on 2022/11/11.
      • Squamous cell carcinoma of left buccal mucosa, pT1N0M0 post of operation on 2015.
      • Essential (primary) hypertension
      • Type 2 diabetes mellitus
      • Hyperlipidemia
    • CC
      • A firm mass of my left chin area for 3 months were noted .
    • Present illness
      • This 70 years-old male patient suffered from skin pigmentation of left face with local indurated mass on the left lower face and admitted to ward for surgery intervention.
      • According to his statement, he had was received series of treatment such as
          1. Squamous cell carcinoma of left buccal mucosa, pT1N0M0 s/p operation on 2015/08/31.
          1. Scar contracture of left buccal mucosa s/p operation on 2016/01/20, 2016/06/20 and 2016/08/31.
          1. Squamous cell carcinoma of left buccal mucosa, cT3N0M0 post of operation on 2022, with PNI invasion and close surgical margin.
      • He received post-op finished CCRT were also noted since 2022/03 ~ 2022/05. Then he is regular followed up to our O.S clinic.
      • This time, he found a firm skin skin around the left mouth angle for several mouths without infection sign or abnormal sensation. After discuss with himself and he was admitted to ward for further managemen.
    • Course of inpatient treatment
      • After admission, we had arrange operation and evaluation anesthesia was done. He received excision of the soft tissue tumor on the left chin area under GA on 2022/11/11. Postoperatively, empirical antibiotic agent with Cefa 1g q8h was prescribed. Intraoral and extraoral wound change dressing qd. Mouth gargling with Parmason solution q2h and cool high protein soft diet were educated. The frozen report showed SCC. We had well explained to patient the condition and choice of treatment options.
      • Because his general condition was acceptable after the this operation, he was discharged this morning and OPD follow up.
    • Discharge prescription
      • amoxicillin 250mg 2# Q8H
      • UFT (tegafur 100mg, uracil 224mg) 2# BID
  • 2017-03-02 SOAP Oral and Maxillofacial Surgery Xu BoZhi
    • Diagnosis
      • Malignant cheek mucosa neoplasm [C06.0]
  • 2017-01-31 SOAP Metabolism and Endocrinology Guo XiWen
    • Diagnosis
      • DM w/o mention of complication, IDDM Type, juvenile type, uncontrolled [E10.65]
      • Essential hypertension , malignant [I10]
      • Mixed hyperlipidemia [E78.2]
    • Prescription
      • Preterax (perindopril 2mg, indapamide 0.625mg) 1# BID
      • Januvia (sitagliptin 100mg) 1# QD
      • Uformin (metformin 500mg) 1# TIDCC
      • NovoNorm (repaglinide 1mg) 3# TIDAC

[chemotherapy]

  • 2023-06-28 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2023-06-21 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2023-06-08 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2023-05-31 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2023-05-19 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2023-05-12 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2023-05-05 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2023-04-28 - cetuximab 250mg/m2 400mg 2hr + cisplatin 28mg/m2 50mg NS 500mL 3hr (Erbitux + cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-04-19 - cetuximab 400mg/m2 700mg 2hr + cisplatin 40mg/m2 70mg NS 500mL 3hr (Erbitux + cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-08 - docetaxel 40mg/m2 70mg NS 150mL 1hr D1 + cisplatin 40mg/m2 70mg NS 250mL 3hr D1 + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr D2 + leucovorin 100mg/m2 170mg in 5-FU (TPF)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-11-30 - docetaxel 40mg/m2 70mg NS 150mL 1hr D1 + cisplatin 40mg/m2 70mg NS 250mL 3hr D1 + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr D2 + leucovorin 100mg/m2 170mg in 5-FU (TPF)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-05-04 - carboplatin AUC 2 150mg NS 300mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-04-25 - carboplatin AUC 2 150mg NS 300mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-04-19 - carboplatin AUC 2 150mg NS 300mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-04-13 - carboplatin AUC 2 150mg NS 300mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-03-28 - carboplatin AUC 2 150mg NS 300mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-03-18 - carboplatin AUC 2 150mg NS 300mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg

==========

701230006

230925

[MedRec]

  • 2023-08-24 SOAP Neurology Chen PeiYa
    • Prescription x3
      • Lixiana (edoxaban 30mg) 0.5# QD
      • Actein (acetylcysteine 600mg) 1# QD
      • Through (sennoside 12mg) 1# HS
      • Lanoxin (digoxin 0.25mg) 0.5# QD
      • Mesyrel (trazodone 50mg) 0.5# HS
  • 2023-07-28 SOAP Hemato-Oncology Gao WeiYao
    • S: The aged man was admitted for severe thrombocytopenia, but his family refused bone marrow exam during his hospitalization.
    • A:
      • Thrombocytopenia, unspecified
      • Heart failure, unspecified
      • Unspecified atrial fibrillation
  • 2023-07-23 ~ 2023-07-24 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Severe thrombocytopenia. nature to be determined.
      • Heart failure, unspecified
      • Unspecified atrial fibrillation
    • CC
      • generalized petechiae over 4 limbs for few days noticed
    • Present illness
      • This 94y/o male has past medical history of
        • Right MCA infarct s/p rt-PA
        • NSTEMI, Af with heart failure
      • This time, generalized petechiae over 4 limbs for few days noticed. Thus he was sent to ER for help. At ER, he denied trauma and any discomforts, except took medicine: edoxaben, cephalexin last week for toe infection, and chinese herbs for a while. Lab show WBC = 8.23 x10^3/uL; HGB = 12.0 g/dL; PLT = 2 x10^3/uL (5/2 PLT 159k). PT and aPTT is in normal range, thus r/o coagulation disorders. Under the impression of isolated thrombocytopenia, he is admitted for further survey.
    • Course of inpatient treatment
      • After admission, patient was arranged for LRP transfusion and repeating the complete blood count (CBC) and reviewing the peripheral blood smear, obtaining prior platelet counts if available, and assessing other hematologic abnormalities. We have consulted hospice care for families at the same time but there was no indication for hospice share care at current unless complication of thrombocytopenia in future. After explained the risk and benefit of bone marrow aspiration for families, they still refused for it and AAD was registered.
  • 2020-02-14 ~ 2020-03-23 POMR Neurology Chen PeiYa
    • Discharge diagnosis
      • Cerebral infarction, unspecified
      • Right middle cerebral artery territory large infarction post r-tpa (2020-02-14), with hemorrhagic transformation , follow by brain MRA on 2020-02-17
      • Modified ranking scale 4
      • Non-ST elevation (NSTEMI) myocardial infarction
      • Heart failure
      • Atrial fibrillation
      • Pneumonia
    • CC
      • Acute onset speechlessness and left limbs weakness for 1 day
    • Present illness
      • This 91-year-old male patiet denied of any past medical history. However, he fell down about half an year ago and poor gait was noted since then.
      • On 2/14 he was still normal around 7:00am. However, acute onset left limbs weakness was noted around 7:30am while he was in toilet. He was brought to ER.
      • For acute CVA call, neurologist was consulted. Initial NIHSS was 15 and right MCA infarction was impressed. For no contraindication of rt-PA therapy, IV TPA therapy was given at 10:00am. However, due to suspicious pulmonary edema and severe edema over bilateral legs were found, IAT was held due to high risk and possibilty of difficulty ET extubation. Initial EKG revealed AFIB RVR with unspecific TWI at lateral lead, and lab survey showed elevated trop-I (hs-Troponin I = 1600.6 ). CV doctor also consulted at ER and the impression and suggestion were NSTEMI with acute pulmonary edema and (AFIB, CHA2DS2-Vas = 4), follow-up cardiac enzymes and cardia echo, with gentle negative I/O therapy.
      • Hence he was admitted to neurology ICU for intensive monitor under impression of (1) Right MCA infarction s/p tPA therapy, (2) r/i NSTEMI with acute pulmonary edema, (3) Atrial fibrillations (CHA2DS2-Vas =4).
    • Course of inpatient treatment
      • During SICU stay, we closely monitored BP and gave adequate IV hydration to keep perfusion. Famotidine was used for stress ulcer prevention.
      • For NSTEMI, we followed once cardiac enzymes which showed improvement (Troponin I: 1600(ER)>1615), and clinically no chest discomfort were complained.
      • For Pulmonary edema and bilateral lower limbs pitting edema (3+~4+), we gave Lasix IV to keep I/O balance and added aldactin for hypokalemia.
      • Repeated brain CT on 2/15 showed no ICH and therefore we added aspirin. However, brain MRI on 2/17 disclosed right MCA large infarction with hemorrhagic transformation and thus Bokey was discontinued.
      • Digoxin #1 QD was given initially for AfRVR, and the dosage was tapered since 2/21 for bradyarrythmia. His spirit was rather lethargic since 2/17 but yet could still maintain GCS E3-4V4M6.
      • For hypoalbuminemia, we suggested transient self-paid albumin therapy (2/22~2/24) and the family agreed.
      • With relatively stablized condition, the patient was transfered to ward for further management on 2/24.
      • After transfer to ward, the patient was still presented with exertional dyspnea and positive I/O. We discussed with cardiologist for NSTEMI and associated heart failure management.
      • Busix was used to replace Lasix and Concor will be considered later if indicated.
      • With diuretics treatment, pulmonary edema was much improved and the patient could take off oxygen supplement.
      • For antiplatelet resumption, we repeated brain CT to follow up hemorrhagic transformation on 3/2 and then added back Plavix 1# QD for no hemorrhage noted.
      • For more stable condition, we used Lixiana 30 mg 1# QD since 3/13 for better stroke prevention.
      • Rehabilitation and acupuncture therapy were arranged.
      • However left hip pain at certain position was noted when doing rehabilitation activity and fell down history about 6 months ago was mentioned.
      • We did left hip plain film on 3/11 and found partial union of left femoral neck fracture. Orthopedist was consulted and suggested pain control and rehabilitation as usual CVA patient without indication for operation.
      • On 3/12 morning the patient complained chest tightness when rehabilitation, we arranged associated survey in case of heart ischemia but the results were normal.
      • In the afternoon we explained all the associated condition to the family and disccused about future discharge plan which would be PAC plan.
      • During the last week before discharge, we tried to taper diuretics and discussed with cardiologist to make sure heart condition. Follow-up laboratory survey and CXR showed fair results.
      • With stablized and improved condition, he was discharged on 2020/03/23 with oral medication and will be transferred to other hospital for intensive rehabilitation under PAC plan.

==========

2023-09-25

Mesyrel (trazodone) is the only oral medication on the list of active medications that can be fed by tube.

701486100

230921

[lab data]

2023-06-27 Anti-HBc Reactive
2023-06-27 Anti-HBc-Value 1.04 S/CO
2023-06-27 Anti-HCV Nonreactive
2023-06-27 Anti-HCV Value 0.10 S/CO
2023-06-27 Anti-HBs 229.48 mIU/mL
2023-06-27 HBsAg Nonreactive
2023-06-27 HBsAg (Value) 0.32 S/CO

[exam findings]

  • 2023-09-15 Bronchodilator Test
    • mild restrictive ventilatory impairment with small airway disease, FEV1/FVC = 76%, FVC = 62 -> 58%, FEV1 = 59 -> 52% , MMEF 44 -> 29%
  • 2023-09-08 CT - abdomen
    • History:
      • Beta-Thalassemia: IVS-2nt 654 (C to T), heterozygous
      • Hypertension. Thyroid ca post-thyroidectomy in 2017
      • Rectosigmoid colon cancer with para-aortic LAP cT3N2bM1a, stage IVA s/p LAR on 2020-03-31 at FuRen Univ Hospital, s/p FOLFIRI & A-FOLFOX
      • Right upper lobe lung adenocarcinoma pT1bN0M0, stage IA2
      • 20230522 CT: R/O multiple metastatic LNs in abdomen and pelvis.
      • 20230627 CT-guided biopsy: Metastatic adenocarcinoma, colon origin.
      • 20230721 CT: multiple metastatic LNs in abdomen and pelvis show progressive disease.
    • Findings: Comparison prior CT dated 2023/07/21.
      • Prior CT identified multiple metastatic nodes in para-aortic space, para-cava space, bilateral common iliac chain, bilateral external iliac chain, and bilateral internal iliac chain are noted again, decreasing in size.
        • It is c/w multiple metastatic nodes S/P C/T with partial response. please correlate with clinical condition.
      • S/P LAR with autosuture retention over the rectum.
      • S/P cholecystectomy.
      • There is a small poor enhancing lesion 6 mm in the spleen. Follow up is indicated.
      • There are several renal cysts on both kidney and the largest one measuring 1.2 cm in size at left middle pole.
    • Impression:
      • Multiple metastatic nodes S/P C/T show partial response.
  • 2023-07-21 CT - abdomen
    • Imp: Prior CT identified multiple metastatic nodes in para-aortic space, para-cava space, bilateral common iliac chain, bilateral external iliac chain, and bilateral internal iliac chain are noted again, increasing in size. please correlate with clinical condition.
  • 2023-06-27 Patho - lymph node region resection
    • Lymph node, plevis, left, CT-guide biopsy — Metastatic adenocarcinoma, in favor of colorectal origin
    • Microscopically, it shows lymphoid tissue with presence of nests of metastatic adenocarcinoma.
    • Immunohistochemical stain of CK20 is positive at tumor cells.
  • 2023-06-09 Gynecologic ultrasonography
    • R/O Bilateral Ovarian cyst
    • Uterine myoma

[MedRec]

  • 2023-07-17 SOAP Hemato-Oncology Xia HeXiong
    • S
      • << GS-US-570-6015 (IRB No: 11-FS-150) ICF Process >>
        • The subject has been provided the informed consent form (GS-US-570-6015_site 17413_Main ICF V6.1.1_02May2023_Chinese) and were fully explained the content of the informed consent form on 2023/07/14 by investigator and study Coordinator. The subject had enough time to ask all questions regarding the study. The subject brought the consent form back to consider whether to participate.
        • The subject understood the (GS-US-570-6015_site 17413_Main ICF V6.1.1_02May2023_Chinese) and signed on 2023/07/17. A copy of the signed informed consent form was provided to the subject.
        • GS-US-570-6015_Emergency Medical Support and Subject Card_v2.0_04May2022_ZH-TW has dispensed to subject on 2023/07/17 by PI/SC.
    • O
      • 2023.07.17
        • Subject No.: 17413101_initial: BLS
        • Ethnicity: Not Hispanic or Latino
        • Race: Asian
        • Country: TAIWAN
        • Never use alcohol
        • Never use tobacco
        • BH : 156.1 cm / BW : 71.9 Kg
        • Vital signs (assessed in a seated position after resting): 35.9’C/72/20 BP: 119/70 mmHg at 09:44 AM
        • Physical Examination:
          • Head, eyes, ears, nose and throat - Normal, specify
          • Cardiovascular - Normal, specify
          • Dermatological - Normal, specify
          • Musculoskeletal - Normal, specify
          • Respiratory - Normal, specify
          • Gastrointestinal - Intermittent diarrhea and abdominal distention
          • Neurological system - Normal, specify
        • ECOG Performance Status: 0
        • Childbearing Potential: NA, menopause around 52 years.
        • Collect 12-lead ECG at 09:41 AM
        • Collect central Hematology & Coagulation & Chemistry &
        • Endocrine function and basal cortisol & Hepatitis serology & HIV serology at 08:53 AM
        • Collect U/A at 09:50 AM
    • P
      • 2023.07.17
        • Anticipate to arrange the freshly cut unstained FFPE slides on 2023.07.17.
        • Arrange Neck & Chest & Abd & Pelvis CT on 2023.07.21.
      • Actein for prevention of contrast-induced nephropathy.
    • Prescription
      • Actein Effervescent (acetylcysteine 600mg) 1# BID 4D, use 2 days before CT from 2023-07-19 to 2023-07-22
  • 2023-07-12 SOAP Hemato-Oncology Xia HeXiong
    • S: CRC with multiple LNs mets s/p OP and C/T
    • O: 2023/06/27 HGB = 8.3 g/dL
    • P: Blood transfusion with pRBC
    • Prescription
      • Benamine (diphenhydramine 30mg/amp) ST IVD before blood transfusion
      • furosemide 20mg ST IVD after 2U pRBC
      • NS 500mL ST IVD for drug and blood transfusion
      • Hepac Lock Flush 100 USP units/mL 10mL ST IRRI
  • 2023-06-27 ~ 2023-06-28 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Rectosigmoid colon ca with para-aortic LAP CT3N2bM1a, stage IVA s/p LPS LAR on 2020-03-31, pT3N2bM1a, stage IVA (21/22), EGFR positive, KRAS: wild type, s/p FOLFIRI & A-FOLFOX 
      • Right upper lobe lung adenocarcinoma pT1bN0M0, stage IA2
      • Essential (primary) hypertension
      • Type 2 diabetes mellitus without complications
      • Chronic diarrhea
      • Chronic viral hepatitis B without delta-agent
    • CC
      • for CT guide biopsy of left plevis LNs
    • Present illness
      • The 64 years-old woman has past history of
        • Beta-Thalassemia: IVS-2nt 654 (C to T), heterozygous
        • Hypertension. Thyroid ca post-thyroidectomy in 2017
        • Rectosigmoid colon cancer with para-aortic LAP CT3N2bM1a, stage IVA s/p LPS LAR on 109-3-31, pT3N2bM1a, stage IVA (21/22), EGFR positive, KRAS: wild type (2020), s/p FOLFIRI & A-FOLFOX
        • Right upper lobe lung adenocarcinoma pT1bN0M0, stage IA2
      • In the beginning, she suffered from bloody stool for 1 years on 2020/03, visited to FuRen University Hospital, colonoscopy was done showed Rectosigmoid colon tumor, s/p biopsy showed tubulovillous adenocarcinoma with high grade dysplasia at least. Chest to pelvic CT was done on 2020/03/28 showed CRC cT3N26M1a (para-A LN) stage IVA, s/p laparoscopic LAR: mod-differentiated LN (21/22) pT3N2bMx on 2020/03/31. She received chemotherapy with FOLFIRI x 8 (no avastin ?) from 2020/04/22 ~ 08/20. 2020/11/10 CEA / Ca-199 4.45 / 14.4. CT guide biopsy was done on 2020/11/12 showed adenocarcinoma, CK7, TTF-1(+), (-)CK20 & CDX2, c/w primary lung adenocarcinoma.
      • Follow up bone scan on 2020/12/09 showed focal uptake in ant aspec of Lt 4th rib. Chest to abd CT was done on 2021/01/25 showed post OP change of RUL no liver mets. PET was done on 2021/03/15 showed PD in left lower neck & mediastinal, paraaortic to elvic LN, rTON2M1a. Bone scan was done on 2021/03/17 showed 1. No apparently interval changes in areas mentioned above, benign natures could be considered first. Follow up Colonoscopy on 2021/11/15 showed polyps, and the Pathology showed adenocarcinoma, Hyperplastic. CT image was folloe up on 2022/02/08 showed LAP in PD. Then, she received capecitabine, C1D1 on 2021/11/06 ~. Denied TOCC history in recent three months. Accroding to the CT image at Taipei Medical University Hospital on 2023/05, report showed progression of pelvis LNs was found. This time, she admitted to our ONC ward for CT guide biopsy of left pelvis LNs on 2023/06/27.

[consultation]

  • 2023-06-28 Diagnostic Radiology
    • Q
      • The patient is an 64-year-old female with a history of colon cancer s/p in 2020 (TMUH), HTN, DM, Lung adenocarcinoma s/p in 2021 (TMUH), Thyroid cancer s/p in 2016 (XiYuan Hospital), Lymphoma of the left neck.
      • For CT guide biopsy of pelvis LNs, we need your further evaluation and management. Thanks a lot!!!
    • A
      • Dear Dr.: According to the clinical condition and imaging findings, biopsy is indicated.

[immunochemotherapy]

  • 2023-09-12 - GS-1811 10mg 0.4mL D5W 99.6mL 1hr + zimberelimab 360mg 12mL D5W 238mL 1hr
    • acetaminophen 500mg PO (1hr before GS-1811)
  • 2023-08-22 - GS-1811 10mg 0.4mL D5W 99.6mL 1hr + zimberelimab 360mg 12mL D5W 238mL 1hr
    • acetaminophen 500mg PO (1hr before GS-1811)
  • 2023-08-01 - GS-1811 10mg 0.4mL D5W 99.6mL 1hr + zimberelimab 360mg 12mL D5W 238mL 1hr

==========

2023-09-21

The lab data indicate an elevated TSH, decreased T3, normal T4, and normal Thyroglobulin levels. This could potentially suggest a subclinical hypothyroidism. It’s noted that there are no records of hypothyroidism in this patient’s history in HIS5. Is there a connection to GS-1811?

2023-09-15 TSH (NM) 9.395 uIU/ml 2023-09-15 Free T4 (NM) 1.165 ng/dl 2023-09-15 T3 (NM) 66.083 ng/dl 2023-09-15 Thyroglobulin 0.322 ng/ml

2023-08-24 TSH (NM) 25.789 uIU/ml 2023-08-24 Free T4 (NM) 1.337 ng/dl 2023-08-24 T3 (NM) 87.021 ng/dl 2023-08-24 Thyroglobulin <0.3 ng/ml

2023-07-31

[prophylactic antiviral therapy prior to immunosuppressive agent use]

The patient’s hepatitis B serology results were as follows: HBsAg (-), anti-HBc (+), anti-HBs (+), indicating that she is immune due to natural infection but remains at risk for reactivation if exposed to immunosuppressive agents.

  • 2023-06-27 Anti-HBc Reactive
  • 2023-06-27 Anti-HBc-Value 1.04 S/CO
  • 2023-06-27 Anti-HBs 229.48 mIU/mL
  • 2023-06-27 HBsAg Nonreactive
  • 2023-06-27 HBsAg (Value) 0.32 S/CO

Given this information, if immunosuppressive agents are part of the treatment plan, it is recommended that prophylactic antiviral therapy be considered. Options include either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD. This preventive measure can help reduce the risk of possible reactivation of HBV infection due to the immunosuppressive effects of treatment.

701446179

230919

{triple negative breast cancer}

  • diagnosis
    • Invasive carcinoma of L breast, cT4bN3M1, stage IV, Dx in Aug 2022.
    • Chronic viral hepatitis B without delta-agent

[exam findings]

  • 2023-09-18 ECG
    • Sinus tachycardia
    • Inferior infarct, age undetermined
    • T wave abnormality, consider anterolateral ischemia
  • 2023-09-18 CXR
    • absence of Lt breast
    • extensive hazy areas of increased opacity over RUL and lower lung zone
    • Tortousity of thoracic aorta and calcified atherosclerotic change
    • Dilation of pulmonary trunk
  • 2023-07-13 CT - chest
    • Chest CT with and without IV contrast ehnancement shows:
      • Contracted soft tissue mass at left breast is found. In comparison with CT dated on 2023-01-03, the lesion is stationary.
      • Lymphadenopathy at left axillary and pectoralis muscle is found. In comparison with CT dated on 2023-01-03, the lesion is enlarged.
      • The lung fields are clear.
      • Some skin thickening is found.
      • No evidence of bilateral pleural effusion.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Imp:
      • Left breast cancer with left axillary lymphadenopathy. The primary tumor is stationary but the lymphadenopathy enlarged.
      • Bone meta. Suggest correlate with bone scan study
  • 2023-07-05 Tc-99m MDP bone scan
    • Increased activity in the body of the sternum, the nature is to be determined (bone mets, post-traumatic change, or other nature ?). Please correlate with other imaging modalities and follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the L3-4 spines, bilateral shoulders, hips and left knee.
  • 2023-07-05 SONO - breast
    • Diagnosis:
      • Left breast cancer with axillary LAP
      • Bil. fibroadenomas as described
    • BI-RADS: 6. known biopsy-proven malignancy
  • 2023-03-07 CT - brain
    • Imp: No brain nodule or metastasis. Mild Chronic left mastoiditis.
  • 2023-03-06 CXR (erect)
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2023-03-06 KUB
    • Spondylosis of the L-spine is noted.
  • 2023-02-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (62 - 19.1) / 62 = 69.19%
      • M-mode (Teichholz) = 69.2
    • Conclusion
      • Normal AV/MV, no AR/MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • Mild PR, no TR, normal IVC size
  • 2023-01-03 CT - chest
    • Findings
      • Lungs: subpleural ground-glass opacity and reticular opacities at LUL and both lower, may be post treatment change and combined dependent density at lower lobes. partial atelectasis of inferior lingular segment.
        • no abnormal nodule in the lungs
      • Mediastinum and hila:no enlarged LN
        • mild calcified plaques of the LAD and LCX coronary arteries.
      • Thoracic aorta: normal caliber, extensive atherosclerotic change mainly involving the ascending segment, aortic root, and aortic arch.
      • Central pulmonary arteries: dilated trunk (3.7cm in caliber) and right main artery.
      • Heart: normal in size of cardiac chambers.
      • Pleura: no nodule or effusion .
      • Chest wall and visible lower neck: soft-tissue defect with area of skin thickening and disappearance of the huge left breast tumor in regression, and further regression of metastatic lymphadenopathy at axillary region compared with CT on 2022/11/9.
      • Visible abdominal-pelvic contents: several tiny hepatic calcifications.
        • normal appearance of gallbladder. unremarkable of the spleen, both adrenal glands, pancreas, and both kidneys.
        • no enlarged lymph node.
        • Mild atherosclerotic change of the abdominal aorta.
      • Visualized bones: sclerotic change at xyphoid process and distal sternal body.
    • Impression:
      • left breast cancer with axillar LNs metastasis further regression compared with previous CT exam. on 2022/11/09
  • 2022-11-18 SONO - breast
    • findings
      • Parenchymal pattem
        • Loosely (inhomogeneously) sonodense
      • Focal sonographic lesion
        • already known left breast cancer with LAP metastasis, receviing chemotherapy now
        • right axillary LAP, distant metastasis of left breast cancer? or double primary breast cancer related?
        • multiple small FAs and cysts over right breast, less likely malignancy
    • diagnosis
      • Highly suspicious of malignancy, with sonographic negative axillary LNs
    • treatment
      • no need to biopsy
    • suggestion and plan
      • Regular OPD follow-up
      • BI-RADS - 6. Known Biopsy - Proven Malignancy
  • 2022-11-09 CT - chest
    • Indication: invasive carcinoma of left breast, ER(-) PR(-) Her-2/neu(-), Ki-67: 90%, T4bN3M1, stage IV
    • Findings:
      • Lungs: subpleural ground-glass opacity and reticular opacities at LUL and both lower, may be post treatment change and combined dependent density at lower lobes.
        • no abnormal nodule in the lungs
      • Mediastinum and hila: no enlarged LN
      • Vessels:
        • mild calcified plaques of the LAD and LCX coronary arteries.
        • Thoracic aorta: normal caliber, extensive atherosclerotic change mainly involving the ascending segment, aortic root, and aortic arch.
        • Central pulmonary arteries: dilated trunk (3.3cm in caliber) and right main artery.
        • Heart: normal in size of cardiac chambers.
      • Pleura: no nodule or effusion .
      • Chest wall and visible lower neck: soft-tissue defect with area of skin thickening and disappearance of the hugeleft breaar tumor and significant regression of metastatic lymphadenopathy at axillary region compared with CT on 8/15.
      • Visible abdominal-pelvic contents: several tiny hepatic calcifications.
        • normal appearance of gallbladder. unremarkable of the spleen, both adrenal glands, pancreas, and both kidneys.
        • no enlarged lymph node.
        • Mild atherosclerotic change of the abdominal aorta.
      • Visualized bones: sclerotic change at xyphoid process and distal sternal body.
    • Impression:
      • left breast cancer with good response to treatment compared with previous CT exam.
  • 2022-11-08 Whole body PET scan
    • Mild glucose hypermetabolism in a left axillary lymph node and a right axillary lymph node, compatible with metastatic lymph nodes s/p treatment change.
    • Mild glucose hypermetabolism in the left anterior chest wall, compatile with primary breast malignancy s/p treatment change.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2022-10-14 SONO - abdomen
    • dilated pelvis of left kidney
    • pancreas masked by gas
  • 2022-08-31 ECG
    • Low voltage QRS
    • Possible Inferior infarct , age undetermined
    • Nonspecific ST and T wave abnormality
  • 2022-08-31 CXR
    • Lung markings: increased density in the left middle lung field.
  • 2022-08-24 MRI - brain
    • no evidence of brain metastasis
    • high SI chnage on T2WI in the visible C-cord. Please correlate with C-spine MRI.
  • 2022-08-19 CXR
    • Atherosclerotic change of aortic arch
    • Patchy opacity projecting at left lower chest wall is noted that is c/w left breast cancer after correlate with CT.
  • 2022-08-16 Tc-99m MDP whole body bone scan
    • Decreased activity in the body of the sternum. Bone destruction may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the L3-4 spines. Degenerative change may show this picture.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and left knee, compatible with benign joint lesions.
  • 2022-08-15 CT - chest
    • left huge breast cancer T4bN3M1
  • 2022-08-11 Patho - breast biopsy
    • Breast, left, biopsy — Invasive carcinoma of no special type
    • Section shows skin and breast tissue with irregular neoplastic glands infiltration.
    • IHC:
      • GATA3 (+)
      • ER (Ab) (-)
      • PR (Ab) (-, <1%, moderate)
      • Her-2/neu (Ab): (-, 0)
      • Ki-67 90%
  • 2022-08-09 CXR
    • A mass at left breast.
    • Ground glass opacity in bilateral lower lungs.

[MedRec]

  • 2023-02-23 Multiple Team - Social Services
    • Referral Date: 2023-02-23
    • Referral Reason: Economic issues related to medical care, caregiving, daily necessities, etc.
    • Processing Status: Case opened
    • Family Situation: On 2023.02.23, a meeting was held with the patient, and their past case records were summarized as follows:
      • The patient is suffering from breast cancer and is regularly monitored by the Hematology-Oncology department at our hospital. On 2023.02.20, the patient complained of fever, shortness of breath, and burns on the buttocks and groin due to using an electric blanket, which led to her seeking treatment at the emergency room and being admitted to the hospital. During her hospitalization, her son periodically came to the hospital to accompany her.
      • The patient is 68 years old and has been married twice. Both husbands are deceased. She has one daughter from her first marriage and one son from her second marriage. The patient used to work at a health resort but had to stop working due to her health condition. She retired and receives a monthly pension of 5,000 TWD. She mentioned that she has very little savings left. The patient has national health insurance and critical illness insurance but no private medical insurance. Her household registration is in Taipei City, Zhongshan District.
      • The patient’s daughter, who is in her 40s, is married and unemployed due to her weakened physical condition. She relies on her son-in-law for support. The patient mentioned that due to her remarriage, she has had a distant relationship with her daughter for many years, with no contact. She also doesn’t have her daughter’s contact information. However, her daughter and son still maintain contact. Her son is 28 years old, unmarried, and childless. He works at a convenience store and earns around 22,000 TWD per month. Sometimes, due to taking leaves, his monthly income is approximately 10,000 TWD. The patient mentioned that her son was born prematurely, which may have led to lower intellectual and learning abilities. Currently, the patient and her son live together in a rented apartment in Yonghe District. It’s a 5th-floor apartment with no elevator, and the monthly rent is 20,000 TWD, shared between the patient and her son.
      • The patient’s nephew, 29 years old, was raised by the patient since childhood because her younger brother was unable to care for him. However, the nephew currently does not live with the patient, and their relationship is somewhat distant. Nevertheless, they still maintain contact. The nephew has had an unstable job history, and his financial situation is not good.
      • The patient mentioned that her parents and many of her siblings have passed away, leaving her with almost no other relatives to maintain contact with.
      • The patient stated that she and her son are paying off debts. After debt negotiations, they now need to pay 5,000 TWD per month. Additionally, the patient mentioned that her son was previously evicted from their residence, and at that time, they took out a loan for rent, which now requires monthly repayments of approximately 10,000 TWD, including interest.
    • Main Issue: Economic issues
    • Detailed Issues: Daily necessities, food, accommodation expenses, medical expenses
    • Disposition:
      • Donations of medical equipment or nutritional supplements from the hospital
      • Referral for economic assistance
      • Provision of economic assistance
    • Responder: Luo YuChuan
    • Response Date: 2023-02-23
    • Doctor’s Response:
      • 02/23 16:47 Zhang Shou-Yi Response: Noted, will continue to assess the patient’s economic situation
  • 2022-11-03 Multiple Team - Social Services
    • Referral Date: 2022-11-03
    • Referral Reason: Economic issues related to medical care, caregiving, daily necessities, etc.
    • Processing Status: Not opened
    • Reason for Not Opening: On 2022.11.03, a meeting was held with the patient, and their past case records were summarized as follows:
    • Family Situation:
      • The patient is 67 years old and has been married twice. Both husbands are deceased. She has one daughter from her first marriage and one son from her second marriage. The patient used to work at a health resort but had to stop working due to her health condition. She retired and receives a monthly pension of 5,000 TWD. She mentioned that she has very little savings left. The patient has national health insurance and critical illness insurance but no private medical insurance. Her household registration is in Taipei City, Zhongshan District.
      • The patient’s daughter, who is in her 40s, is married and unemployed due to her weakened physical condition. She relies on her son-in-law for support. The patient mentioned that due to her remarriage, she has had a distant relationship with her daughter for many years, with no contact. She also doesn’t have her daughter’s contact information. However, her daughter and son still maintain contact. Her son is 27 years old, unmarried, and childless. He works at a convenience store and earns over 9,000 TWD per month. The patient mentioned that her son was born prematurely, which may have led to lower intellectual and learning abilities. Currently, the patient and her son live together in a rented apartment in Yonghe District. It’s a 5th-floor apartment with no elevator, and the monthly rent is 20,000 TWD, shared between the patient and her son.
      • The patient’s nephew, 28 years old, was raised by the patient since childhood because her younger brother was unable to care for him. However, the nephew currently does not live with the patient, and their relationship is somewhat distant. Nevertheless, they still maintain contact. The nephew has had an unstable job history, and his financial situation is not good.
      • The patient mentioned that her parents and many of her siblings have passed away, leaving her with almost no other relatives to maintain contact with.
    • Assessment and Treatment:
      • A case was opened for the patient’s hospitalization in September 2022, and assistance from the Tzu Chi Foundation was arranged. The foundation provided one-time emergency assistance and is currently assessing long-term financial support. Volunteers from the foundation regularly visit the patient.
      • During this hospitalization, the patient mentioned that she can still take care of herself during the day, and her son comes to the hospital to accompany her in the evening. The Tzu Chi Foundation has been providing assistance and regular visits. Additionally, nutritional supplements were provided during this hospitalization.
      • The current referral provides the aforementioned treatment options. If there are additional social work assistance needs, please contact the social worker. Thank you.
    • Responder: Luo Yu-Chuan
    • Response Date: 2022-11-03
    • Doctor’s Response:
      • 11/04 08:11 Zhang Shou-Yi Response: Noted, will continue to follow up on the patient’s needs
  • 2022-09-01 Multiple Team - Social Services
    • Referral Date: 2022-09-01
    • Referral Reason: During hospitalization, the patient has no self-care ability, and family members are unable to come to the hospital to care for her.
    • Processing Status: Case opened
    • Family Situation: On 2022.09.01, a meeting was held with the patient, and the following family situation was obtained:
      • On 2022.02, the patient experienced left chest pain and discomfort but did not seek medical attention. She occasionally used pain relievers. On 2022.08.09, she sought treatment at the hospital’s emergency room due to severe pain and bleeding in her left breast. She was diagnosed, received her first round of chemotherapy, and was discharged on 2022.08.24. She was readmitted to the hospital on 2022.08.31 due to a lack of appetite and nausea since her previous discharge. During hospitalization, the patient stays alone in the hospital during the day, and her son comes to the hospital to accompany her in the evening.
      • The patient is 67 years old and has been married twice. Both husbands are deceased. She has one daughter from her first marriage and one son from her second marriage. The patient used to work at a health resort but had to stop working due to her health condition. She retired and receives a monthly pension of 5,000 TWD. She mentioned that she has very little savings left. The patient has national health insurance and critical illness insurance but no private medical insurance. Her household registration is in Taipei City, Zhongshan District.
      • The patient’s daughter, who is in her 40s, is married and unemployed due to her weakened physical condition. She relies on her son-in-law for support. The patient mentioned that her relationship with her daughter has been distant for the past five years, with no contact. She also doesn’t have her daughter’s contact information. However, her daughter and son still maintain contact. Her son is 26 years old, unmarried, and childless. He works at a convenience store and earns over 9,000 TWD per month. The patient mentioned that her son was born prematurely, which may have led to lower intellectual and learning abilities. Currently, the patient and her son live together in a rented apartment in Yonghe District. It’s a 5th-floor apartment with no elevator, and the monthly rent is 20,000 TWD, shared between the patient and her son.
      • The patient’s nephew, 27 years old, was raised by the patient since childhood because her younger brother was unable to care for him. However, the nephew currently does not live with the patient, and their relationship is somewhat distant.
      • The patient mentioned that her parents and many of her siblings have passed away, leaving her with almost no other relatives to maintain contact with.
    • Main Issue: Economic issues, Family support system is weak, Distant relationships
    • Detailed Issues: Daily necessities, food, accommodation expenses, hiring caregiver expenses
    • Disposition: None
    • Responder: Luo Yu-Chuan
    • Response Date: 2022-09-01
    • Doctor’s Response:
      • 09/02 09:04 Zhang Shou-Yi Response: Will proceed according to the recommendations

[chemotherapy]

  • 2023-09-12 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-09-05 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-08-22 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-08-15 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-08-01 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-07-28 - eribulin mesylate 1.4mg/m2 2mg NS 50mL 10min (Halaven QW)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-02-13 - cyclophosphamide 600mg/m2 950mg NS 500mL 1hr + epirubicin 60mg/m2 95mg NS 100mL 30min + fluorouracil 600mg/m2 950mg NS 100mL 30min (CEF75, next time Epicin returns to 75mg/m2)

docetaxel 75mg/m2 and carboplatin AUC 6, cycled every 21 days x 4-6 cycles, preoperative setting only - NCCN 2022-06-21

  • 2022-12-22 docetaxel 65mg/m2 100mg 1hr + carboplatin AUC 5 600mg 2hr (WBC 1230 1.27)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
  • 2022-12-01 docetaxel 65mg/m2 100mg 1hr + carboplatin AUC 5 600mg 2hr (WBC 1210 1.88)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
  • 2022-10-24 docetaxel 75mg/m2 110mg 1hr + carboplatin AUC 5 600mg 2hr (WBC 1102 0.80)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
  • 2022-10-03 docetaxel 75mg/m2 110mg 1hr + carboplatin AUC 5 600mg 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
  • 2022-09-12 docetaxel 75mg/m2 110mg 1hr + carboplatin AUC 5 600mg 2hr (WBC 0920 0.70)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
  • 2022-08-23 docetaxel 60mg/m2 90mg 1hr + carboplatin AUC 5 600mg 2hr (WBC 0830 0.68, 0831 0.74)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg
  • G-CSF
    • 2022-12-30 filgrastim 150ug SC (20221230 OPD)
    • 2022-12-26, -27 lenograstim 250ug SC (20221222 IPD)
    • 2022-12-10 lenograstim 250ug SC (20221210 OPD)
    • 2022-12-05, -06 lenograstim 250ug SC (20221201 IPD)
    • 2022-12-02, -03 lenograstim 250ug SC (20221201 IPD)
    • 2022-11-24 lenograstim 250ug SC (20221124 OPD)
    • 2022-11-02 filgrastim 150ug SC (20221102 OPD)
    • 2022-08-31 filgrastim 150ug SC (20220831 OPD, IPD)

[note]

PREOPERATIVE/ADJUVANT THERAPY REGIMENS - HER2-Negativeb (Breast Cancer NCCN Guidelines 20220621 Version 4.2022, BINV-L 1 OF 9, p55)

  • Preferred Regimens:
    • Dose-dense AC (doxorubicin/cyclophosphamide) followed by paclitaxel every 2 weeks
    • Dose-dense AC (doxorubicin/cyclophosphamide) followed by weekly paclitaxel
    • TC (docetaxel and cyclophosphamide)
    • Olaparib, if germline BRCA1/2 mutations
    • High-risk triple-negative breast cancer (TNBC): Preoperative pembrolizumab + carboplatin + paclitaxel, followed by preoperative pembrolizumab + cyclophosphamide + doxorubicin or epirubicin, followed by adjuvant pembrolizumab
    • TNBC and residual disease after preoperative therapy with taxane-, alkylator-, and anthracycline-based chemotherapy: Capecitabine
  • Useful in Certain Circumstances:
    • Dose-dense AC (doxorubicin/cyclophosphamide)
    • AC (doxorubicin/cyclophosphamide) every 3 weeks (category 2B)
    • CMF (cyclophosphamide/methotrexate/fluorouracil)
    • AC followed by weekly paclitaxel
    • Capecitabine (maintenance therapy for TNBC after adjuvant chemotherapy)
  • Other Recommended Regimens:
    • AC followed by docetaxel every 3 weeksc
    • EC (epirubicin/cyclophosphamide)
    • TAC (docetaxel/doxorubicin/cyclophosphamide)
    • Select patients with TNBC:
      • Paclitaxel + carboplating (various schedules)
      • Docetaxel + carboplating (preoperative setting only)

==========

2023-09-19

According to PharmaCloud records, the patient has only been seen at our hospital for the past three months. After reviewing the HIS5 records, no medication reconciliation issues were identified.

[Trodelvy (sacituzumab govitecan)]

Trodelvy (sacituzumab govitecan) has received approval from the TFDA and is prescribed for two specific indications:

  • It is used to treat adult patients with locally advanced or metastatic triple-negative breast cancer who have undergone at least two unsuccessful systemic treatments, with one of them being for advanced disease.
  • It is also suitable for the treatment of adult patients with unresectable locally advanced or metastatic hormone receptor-positive, human epidermal growth factor receptor 2-negative (IHC 0, IHC 1+, or IHC 2+/ISH–) breast cancer who have previously received a minimum of two systemic treatments for metastatic breast cancer.

However, it’s important to note that this medication is not currently covered by the NHI program. Therefore, it may pose a financial burden for patients who are economically disadvantaged.

2023-01-01

  • Several neutropenia events occurred around one week after the chemotherapy was administered.
    • 2022-12-30 WBC 1.27 *10^3/uL
    • 2022-12-10 WBC 1.88 *10^3/uL
    • 2022-11-02 WBC 0.80 *10^3/uL
    • 2022-09-20 WBC 0.70 *10^3/uL
    • 2022-08-31 WBC 0.74 *10^3/uL
    • 2022-08-30 WBC 0.68 *10^3/uL
  • There is no problem with treating neutropenia with G-CSF (granulocyte colony stimulating factor).

2022-12-23

  • The patient’s underlying condition of HBV carrier status is being managed with Baraclude (entecavir). Vital signs are stable and lab data showed no significant abnormalities.

2022-12-02

  • The CT on 2022-11-09 indicated that the left breast cancer responded to the regimen of [docetaxel + carboplatin].

2022-10-04

  • The use of olaparib may be an option in cases of germline mutations of BRCA1/2.
  • The NCCN breast cancer evidence blocks (2022-06-21 version 4.2022): The use of platinum agents in the adjuvant setting is not recommended. If platinum agents are included in an anthracycline based regimen, the optimal sequence of chemotherapy and choice of taxane agent is not established.

701485811

230919

[exam findings]

  • 2023-07-04 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 31 dB HL; LE 40 dB HL.
    • RE normal to moderate SNHL.
    • LE normal to moderately severe SNHL but have A-B gap at 4k Hz.
  • 2023-06-10 MRI - larynx
    • Imaging Report Form for Hypopharynx Carcinoma
      • Impression (Imaging stage) : T: T3(T_value) N: N3(N_value) M: M0(M_value) STAGE: IVB(Stage_value)
  • 2023-06-09 PET scan
    • Glucose hypermetabolism in the left hypopharynx, compatible with primary hypopharyngeal malignancy.
    • Glucose hypermetabolism in a focal area in the left neck level II to III regions, compatible with a metastatic lymph node.
    • Mild glucose hypermetabolism around bilateral hips. Post-operative change may show this picture.
    • Increased FDG uptake/accumulation in bilateral inguinal regions. The nature is to be determined (hernia? other nature?). Please correlate with other clinical findings for further evaluation.
  • 2023-06-08 Patho - larynx biopsy
    • Hypopharynx, left, biopsy — Squamous cell carcinoma, moderately differentiated
    • The sections a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and subtle stromal invasion. Keratin formation is evident.
  • 2023-06-08 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis, s/p CLO test
    • Gastric erosions, multiple
    • Duodenal shallow ulcers, bulb, SDA
  • 2023-06-08 SONO - abdomen
    • Suspected chronic liver parenchyma disease
    • Suspected fatty infiltration of pancreas
    • Suboptimal examination of liver,especially the subcostal view due to poor echo window
  • 2023-06-07 CXR
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2023-06-07 Nasopharyngoscopy
    • left hypopharyngeal tumor, s/p biopsy under flexible laryngoscope with working channel

[MedRec]

  • 2023-09-11 SOAP Oral and Maxillofacial Surgery He ChengHan
    • O - Panoramic findings:
      • Missing: 11, 14, 15, 16, 17, 18, 21, , 25, 26, 27, 28, 31, 32, 34, 35, 36, 37, 38, 41, 46, 47, 48
      • Impaction: nil
      • Crown and Bridge: nil
      • Caries: 24, 33, 41, 45
      • Residual root: 12, 22
      • Periodontal condition: chronic periodontitis
    • P
      • Take panoramic film for evaluation
      • Explain the findings
      • well inform the risk of radiation-related infection if not extract hopelss tooth (The patient and family members indicated understanding and chose not to extract the tooth.)
  • 2023-09-08 SOAP Radiation Oncology Wang YuNong
    • Plan: He will visit OS Dr. Ho next Mon. CT-simulation will be arranged 1 wk after the last teeth extraction (if indicated). Plan to deliver 50 Gy/ 25 fx to the bil. neck and hypopharynx. Then boost the hypopharyngeal tumor and LAPs to 70 Gy/ 35 fx. Need to arrange admission for CCRT.
  • 2023-08-15 SOAP Hemato-Oncology Xia HeXiong
    • P: On 2023-08-15, May consider CCRT with carboplatin. Wife would like to consider proton. After his condition is better, will start CCRT.
  • 2023-08-08 SOAP Hemato-Oncology Xia HeXiong
    • O
      • Cancer Treatment, Radiation/Targeted Therapy Side Effects Assessment (2023-08-08)
        • Physical Condition: G3: Bedridden for over 50% of the time while awake
          • Management of Physical Condition: Supportive therapy
        • Other: Grade 4 ammonia (NH3) elevation. Hepatic encephalopathy
          • Lab (suppl.)
            • 2023-07-10 Blood ammonia 26 umol/L
            • 2023-07-07 Blood ammonia 49 umol/L
            • 2023-07-06 Blood ammonia 418 umol/L
            • 2023-07-06 Blood ammonia 733 umol/L
  • 2023-06-13 SOAP Hemato-Oncology Xia HeXiong
    • A: left hypopharyngeal cancer, cT3N3bM0, stage IVb
    • P: explanation about induction chemotherapy +- CCRT or CCRT, op not recommended because left LAP attached on left ICA
      • After SDM (Induction C/T or CCRT), patient would like to take induction chemotherapy.

[chemotherapy]

  • 2023-07-04 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + carboplatin AUC 5 300mg NS 250mL 2hr D2 + fluorouracil 1000mg/m2 1700mg D5W 500mL 24hr D2-5 (TPF, Q3W)
    • dexamethasone 4mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg D2-4

==========

2023-07-05

[renal dose for carboplatin, metoclopramide and cimetidine]

2023-07-04 Cre 1.56mg/dL, eGFR 46.6, weight 75.9kg => CrCl 45mL/min. The patient has kidney impairment, which might necessitate dose adjustments for some medications in the active list:

  • Carboplatin (in TPF regimen): For patients with a CrCl between 10 and 50 mL/minute, it’s recommended to administer approximately 50% of the usual dose (Aronoff 2007).
  • Metoclopramide: For patients with a CrCl between 10 and 60 mL/minute, it’s recommended to administer approximately 50% of the usual total daily dose.
  • Cimetidine: For patients with a eGFR between 10 and 50 mL/minute, it’s recommended to administer 50% of the normal dose (Aronoff 2007).

Please review the dosages and clinical conditions accordingly to ensure safe and effective therapy for the patient.

700523579

230918

[exam findings]

  • 2023-09-11 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (177 - 135) / 177 = 23.73%
      • M-mode (Teichholz) = 24
    • Conclusion:
      • Dilated LA, LV, RA, RV and IVC; severely abnormal LV systolic function with global hypokinesia
      • Mild to moderate MR, mild TR and mild PR
      • Minimal pericardiac effusion
      • Preserved RV systolic function

==========

2023-09-19

According to the PharmaCloud database, this patient has received Glivec (imatinib) prescribed at Cardinal Tien Hospital for at least the last 3 months. BCR-ABL tyrosine kinase inhibitors, such as imatinib, dasatinib, nilotinib, bosutinib, ponatinib, and asciminib, have been associated with varying degrees of cardiovascular adverse reactions. Taking imatinib as an example, its incidence includes chest pain (7% to 11%), edema (11% to 86%; severe edema: 2% to 11%), peripheral edema (20% to 41%), cold extremity (≤1%), flushing, heart failure (≤1%), hypertension (4%), hypotension (≤1%), palpitations (5%), pericardial effusion (≤6%), Raynaud’s disease (≤1%), subdural hematoma (≤1%), syncope (≤1%), tachycardia (≤1%), and <1%: acute myocardial infarction, angina pectoris, atrial fibrillation, cardiac arrhythmia, left ventricular dysfunction (ref: UpToDate). The discontinuation of the drug is considered to be appropriate in this case (LVEF 24%).

2023-09-18

Imatinib has been associated with various cardiovascular side effects, including: chest pain (7% to 11%), edema (11% to 86%; severe edema: 2% to 11%), peripheral edema (20% to 41%), cold extremity (≤1%), flushing, heart failure (≤1%), hypertension (4%), hypotension (≤1%), palpitations (5%), pericardial effusion (≤6%), Raynaud’s disease (≤1%), subdural hematoma (≤1%), syncope (≤1%), tachycardia (≤1%) and <1%: acute myocardial infarction, angina pectoris, atrial fibrillation, cardiac arrhythmia, left ventricular dysfunction.

It’s important to note that other drugs in the same class as imatinib may also have cardiovascular adverse reactions.

  • Dasatinib: >10%: peripheral edema, cardiac conduction disturbance (7%; including cardiac arrhythmias [tachycardia, ventricular arrhythmia, ventricular tachycardia] and palpitations), cardiac disorder (≤4%; including cardiomyopathy, heart failure, left ventricular dysfunction, ischemic heart disease, reduced ejection fraction), chest pain, edema (1% to 4%), flushing, hypertension, pericardial effusion (1% to 4%), prolonged QT interval on ECG (≤1%) and <1%: Abnormal T waves on ECG, acute coronary syndrome, angina pectoris, cardiomegaly, coronary artery disease, deep vein thrombosis, embolism, hypotension, livedo reticularis, myocarditis, pericarditis, pleuropericarditis, prolongation P-R interval on ECG, pulmonary embolism, syncope, thrombophlebitis, thrombosis, troponin increased in blood specimen.

  • Nilotinib: hypertension (10% to 11%), occlusive arterial disease (9% to 15%; including limb stenosis), peripheral edema (9% to 15%), prolonged QT interval on ECG (children and adolescents: >30 msec from baseline: 28%; adults: >60 msec from baseline: 4%; adults: >500 msec: <1%), angina pectoris, cardiac arrhythmia (including AV block, atrial fibrillation, bradycardia, cardiac flutter, extrasystoles, and tachycardia), cerebral ischemia (1% to 3%), chest discomfort, chest pain, flushing, ischemic heart disease (5% to 9%), palpitations, pericardial effusion (≤2%), peripheral arterial disease (3% to 4%) and <1%: Acute myocardial infarction, arteriosclerosis, cardiac failure, cerebral infarction, coronary artery disease, coronary artery disease, facial edema, heart murmur, hypertensive crisis, intermittent claudication, ischemic stroke, syncope, transient ischemic attacks.

  • Bosutinib: chest pain (8% to 12%), edema (15% to 19%), hypertension (8% to 11%), coronary artery disease (3%), heart failure (2% to 5%), pericardial effusion, prolonged QT interval on ECG and <1%: Pericarditis.

  • Ponatinib: cardiac arrhythmia (17% to 25%; ventricular arrhythmia: 3%), edema (≤41%), heart failure (6% to 16%), hypertension (31% to 53%; severe hypertension: 3% to 13%), occlusive arterial disease (13% to 31%; including carotid, vertebral, and middle cerebral artery and renal artery stenosis), peripheral edema (17%), acute myocardial infarction (2%), atrial fibrillation (8%), bradycardia (≤1%; including leading to pacemaker implantation), cerebral infarction (grade 3/4: 2%), cerebrovascular occlusion (7%), coronary artery disease (grade 3/4: 2%), deep vein thrombosis (2%), pericardial effusion (4%), peripheral arterial disease (occlusive: grades 3/4: 3%), pulmonary embolism (2%), reduced ejection fraction (3%), syncope (2%), venous thromboembolism (4% to 10%) and <1%: atrial flutter, atrial tachycardia, complete atrioventricular block, hypertensive crisis, prolonged QT interval on ECG, retinal thrombosis, sinus bradycardia, sinus node dysfunction, subdural hematoma, superficial thrombophlebitis, supraventricular tachycardia, tachycardia, ventricular tachycardia.

  • Asciminib: hypertension (14%), increased serum creatine kinase (30%), cardiac arrhythmia (<10%), edema (<10%), heart failure (<10%), palpitations (<10%), prolonged QT interval on ECG (<10%)

700529576

230918

[diagnosis] - 2023-03-27 discharge note

  • Malignant neoplasm of extrahepatic bile duct
  • Urinary tract infection, site not specified

[past history]

  • Type 2 DM
  • Hypertension
  • Dyslipidemia

        

[allergy]

  • NKDA         

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-04-23 CXR

    • Boderline cardiomegaly
    • Tortuosity of the aorta with atherosclerotic change.
    • Increased lung markings over both lungs.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2023-04-18 SONO - abdomen

    • liver cyst, both lobe
    • post cholestectomy
    • post stenting to bilateral IHD
  • 2023-04-13 CXR

    • Ground glass opacity in bilateral lower lungs.
    • S/P operation with retention of surgical clips.
    • S/P CBD stenting.
  • 2023-04-11 CXR

    • Ground glass opacity in LLL.
  • 2023-03-24, -03-17 CXR

    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
  • 2023-03-21 CT - abdomen

    • History and indication: Klatskin tumor (Cancer that forms in the area where the left and right hepatic ducts join just outside the liver and form the common hepatic duct. Bile ducts carry bile from the liver and gallbladder to the small intestine. Klatskin tumor is a type of extrahepatic bile duct cancer. Also called perihilar bile duct cancer and perihilar cholangiocarcinoma. 2023-04-14 https://www.cancer.gov/publications/dictionaries/cancer-terms/def/klatskin-tumor)
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction. With and without-contrast CT of abdomen-pelvis revealed:
      • S/P CBD stenting. Dilatation of bil. IHD and distention of gallbladder.
      • Mild enlargement of left thyroid gland. Minimal ascites.
      • Mild bronchiectasis at LLL.
      • R/O right renal cyst (2.5cm).
      • Normal appearance of spleen, pancreas, adrenals.
      • Degeneration and spondylosis of L-S spine.
      • No enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • S/P Port-A infusion catheter insertion.
      • S/P foley catheter indwelling.
    • IMP:
      • S/P CBD stenting. Dilatation of bil. IHD and distention of gallbladder.
      • Mild bronchiectasis at LLL.
  • 2023-03-17 KUB

    • S/P plastic stent implantation in between the IHDs and duodenum
    • S/P Foley’s catheter insertion at the urinary bladder.
    • Fecal material store in the colon.
    • Spondylosis of the L-spine is noted.
  • 2023-03-15, -03-12 CXR

    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Widening of the upper mediastinum is noted, which may be innominate vessel or tumor. Please correlate with standing p-a view or CT.
  • 2023-02-12 ECG

    • Sinus tachycardia
    • Possible Left atrial enlargement
    • Left axis deviation
    • Abnormal ECG
  • 2023-01-09 Nasopharyngoscopy

    • via right nasal cavity: patent right nose, patent right E tube orifice, NPx seemed smooth
  • 2022-12-28 Cholangiography

    • Cholangiography via bil. PTCD catheters administration revealed:
      • Patency of the catheters. Mild migration of right PTCD catheter.
      • Obstruction of left proximal IHD.
      • Partial obstruction of right proximal IHD.
      • S/P operation with retention of surgical clips.
  • 2022-12-28 Endoscopic Retrograde CholangioPancreatography, ERCP

    • diagnosis:
      • Klatskin tumor, post bilateral PTCD, status post bilateral stricture balloon dilation and stenting to right anterior branch and right IHDs
      • Non-visualized GB
    • suggestion:
      • Please keep antibiotics treatment for high post ERCP cholangitis risk
  • 2022-12-26 Percutaneous Transhepatic Cholangio-Drainage, PTCD

  • 2022-12-23 Patho - gallbladder (benign lesion)

    • A: Gallbladder, cholecystectomy — chronic cholecystitis
    • B: Lymph node, group 12a, excision — negative for malignancy (0/1)
    • C: Lymph node, group 12c, excision — negative for malignancy (0/1)
    • F2022-00624 - Lymph node, zone 12 and 8, excision — Negative for malignancy (0/2)
  • 2022-12-12 Percutaneous Transhepatic Cholangio-Drainage, PTCD

  • 2022-12-12 SONO - abdomen

    • C/W hilar tumor with left IHD and right IHD branch (B6) dilation
    • Renal cysts, RK
    • Hepatic cysts, both lobe
  • 2022-12-11, -11-08 CXR

    • Atherosclerosis of the aorta.
    • Enlargement of right hilum.
  • 2022-11-11 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (77.3 - 24.4) / 77.3 = 68.43%
      • M-mode (Teichholz) = 68.4
      • 2D (M-simpson) = 64.4
    • Normal AV with mild AR
    • Normal MV with trivial MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, trivial TR, normal IVC size
  • 2022-11-22 Flow volume chart

    • mild obstructive ventilatory impairment
  • 2022-11-21 SONO - abdomen

    • C/W hilar tumor with left IHD and right IHD branch (B6) dilation
    • ERBD in situ (ERBD: Endoscopic Retrograde Biliary Drainage)
    • Renal cysts, RK
  • 2022-11-17 CT - abdomen

    • S/P CBD stenting.
    • Dilatation of bil. IHD and distention of gallbladder.
    • Mild bronchiectasis at LLL.
  • 2022-11-12 MRI - MR Cholangiography, MRCP

    • History and indication: Jaundice
    • IMP: In favor of Klatskin tumor with bil. proximal IHD invasion. Some LNs at hepatic hilar region.
  • 2022-11-11 Patho - liver biopsy needle/wedge

    • Bile duct, tip of cytoplogy brush, ERCP — Negative for malignancy
  • 2022-11-10 Endoscopic Retrograde CholangioPancreatography, ERCP

    • Diagnosis
      • Klastin tumor with obstructive jaundice, suspicious Bismuth-Corlette classification type I, s/p EPBD + brush cytology + ERBD (right IHD)
      • Duodenal ulcer, shallow, bulb
      • Duodenitis, bulb
    • Suggestion
      • On NPO except water tonight
      • f/u Hb, serum AST/ALT, T-bil, lipase on the next morning (11/11)
      • PPI Rx.
  • 2022-11-09 CT - abdomen

    • History and Indication: obstructive jaundice.
      • 20221108 CA199:811 U/mL (<35), CEA and AFP:normal.
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is a soft tissue mass in the trifurcation of both lobe IHDs and CHD, measuring 1.5 cm in size, causing IHDs dilatation and this mass directly attached the S4 liver.
        • Klatskin tumor (T2b) is highly suspected.
        • In addition, There are four enlarged nodes in the hepatoduodenal ligament (N2).
      • There are several enlarged nodes in gastrohepatic ligament, para-aortic space and para-cava space that may be non-regional lymph nodes metastases (M1).
      • There is linear calcification in the gallbladder fossa. please correlate with clinical condition.
      • There are several renal cysts on both kidney and the largest one measuring 2.4 cm in size at right upper pole.
      • Others
        • There is no focal abnormality in the pancreas, spleen & both kidney.
        • There is no ascites.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
      • IMP:
        • Klatskin tumor is highly suspected.
        • According to American Joint Committee on Cancer (AJCC) staging system,8th edition for perihilar CCC: T2b N2 M1, stage:IVB
  • 2021-04-13 Bone densitometry - hip

    • Hip BMD performed by DXA revealed:
    • Hip, BMD is 0.637 gms/cm2, about 1.9 SD below the peak bone mass (75 %) and 0.4 SD above the mean of age-matched people (108%).
    • IMP: osteopenia

[MedRec]

  • 2023-09-07 SOAP Orthopedics Li YiXuan
    • S
      • right hand contusion
      • Herpes zoster of right hand and palm
    • Prescription
      • Toricam (piroxicam) ASORDER TOPI
  • 2023-08-10 SOAP Dermatology Zhou WeiTing
    • S: painful eruption over right upper limb for days.
    • O:
      • Segmental papules, vesicles and crust formation with shooting tenderness over right upper limbs for days.
      • Impression: herpes zoster on the right C10 region.
    • Prescription
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# TID
      • Famvir (famciclovir 250mg) 1# TID
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNQID
      • Orolisin (chlorpheniramine 5mg, orotic acid 30mg, glycyrrhizic acid 50mg) 1# PRNQID
      • Silverzine (silver sulfadizaine) BID EXT
      • Xyzal (levocetirizine 5mg) 1# HS

[consultation]

  • 2023-01-09 Ear Nose Throat
    • Q
      • For left ear tinnitus
      • This 81 y/o female was a case of Klastin tumor with obstructive jaundice, T2bN2M1, stage:IVB, s/p ERBD on 2022/11/10. This time, she was admitted for further operation. However, TBI showed 15.21 was noted. Abdomen echo was performed which showed C/W hilar tumor with left IHD and right IHD branch (B6) dilation. Right side PTCD insertion was done smoothly on 2022/12/12. Operation was perfomred which revaled CHD tumor with direct bification and right portal vein invasion and severe fatty liver was noted, then no further operation is proceed due to high risk of hepatic failure. Due to persisted of TBI > 6, left side PTCD was inserted on 2022/12/26. In recent, she felt left ear tinnitus for 2 days. No other cold side were noted in recently. We need your help for further assessment for this patient. Thanks for your time!!
    • A
      • S:
        • Left tinnitus for 2 days, high frequency, especially when talking? Autophony?
        • hearing loss-, aural fullness-, dizziness-
        • NO-, Rhinorrhea+, Sneezing+
      • O:
        • Bil TM intact, EAC clean
        • Bil TM atrophic scar
        • Scope:
          • via right nasal cavity: patent right nose, patent right E tube orifice, NPx seemed smooth
          • the patient can’t tolerate the nasopharyngoscopy and refused further exam
        • Hearing exam:
        • Rinne test: Bil AC > BC
        • Weber: no lateralization
      • A:
        • Left tinnitus, cause?
        • DDx: patulous E tube
      • Plan:
        • may try kentamin if no contraindication
        • The patient refused further exam currently (PTA/typanometry or complete nasopharyngoscopy)
        • The patulous E tube may be improved by lying down or lower the head
        • Please arrange ENT OPD f/u
  • 2022-12-23 Radiation Oncology
    • A:
      • A: Klatskin tumor with bil. proximal IHD and portal vein invasion, s/p open cholecystectomy. LN 8,12, dissection.
      • P: Radiotherapy is indicated for this patient with the following indicators: unresectable Klatskin tumor
        • Goal: palliation
        • Treatment target and volume: Klatskin tumor and peripheral involved nodal lesions.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the Klatskin tumor and peripheral involved nodal lesions.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2023-01-19.

[surgical operation]

  • 2022-12-22
    • Surgery
      • open cholecystectomy
      • LN 8,12, dissection
    • Finding
      • CHD tumor with direct bification and right portal vein invasion
      • regional LN8 and 12 enlarge
      • severe fatty liver

[MedRec]

  • 2023-05-24 SOAP Hemato-Oncology
    • S: supportive treatment with oral UFT
    • Prescription
      • UFT (tegafur 100mg, uracil 224mg) 1# BID 7D
  • 2023-05-17 SOAP Hemato-Oncology
    • Plan
      • explain the clinical condition to patient’s daugther
      • suggest oral chemotherapy with UFUR
    • Prescription
      • UFT (tegafur 100mg, uracil 224mg) 1# BID 7D
  • 2023-01-30 SOAP Hemato-Oncology
    • explain to pt & her son about the indication & risk / benefit of palliative CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T

[radiotherapy]

  • 2023-01-19 ~ undergoing - 3960cGy/22 fractions (15 MV photon) of the Klatskin tumor and peripheral involved nodal lesions.

[chemotherapy]

  • 2023-05-17 ~ undergoing - UFT (tegafur 100mg, uracil 224mg) 1# BID

  • 2023-02-06 - fluorouracil 200mg/m2 300mg NS 500mL 24hr D1-5

    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-02-02 - fluorouracil 200mg/m2 300mg NS 500mL 24hr D1-2

    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL

[note]

Principles of Systemic Therapy — NCCN Clinical Practice Guidelines in Oncology - Biliary Tract Cancers - Version 2.2023 - May 10, 2023 - BIL-C

  • Neoadjuvant Therapy
    • Preferred Regimens
      • None
    • Other Recommended Regimens
      • FOLFOX
      • Capecitabine + oxaliplatin
      • Gemcitabine + capecitabine
      • Gemcitabine + cisplatin
      • Durvalumab + gemcitabine + cisplatin
      • Gemcitabine + cisplatin + albumin-bound paclitaxel (category 2B)
    • Useful in Certain Circumstances
      • None
  • Adjuvant Therapy
    • Preferred Regimens
      • Capecitabine (category 1)
    • Other Recommended Regimens
      • FOLFOX
      • Capecitabine + oxaliplatin
      • Gemcitabine + capecitabine
      • Gemcitabine + cisplatin
      • Capecitabine + cisplatin (category 3)
      • Single agents:
        • 5-fluorouracil
        • Gemcitabine
    • Useful in Certain Circumstances
      • None
  • Agents Used with Concurrent Radiation
    • 5-fluorouracil
    • Capecitabine
  • Primary Treatment for Unresectable and Metastatic Disease
    • Preferred Regimens
      • Durvalumab + gemcitabine + cisplatin (category 1)
    • Other Recommended Regimens
      • Gemcitabine + cisplatin (category 1)
      • FOLFOX
      • Capecitabine + oxaliplatin
      • Gemcitabine + albumin-bound paclitaxel
      • Gemcitabine + capecitabine
      • Gemcitabine + oxaliplatin
      • Gemcitabine + cisplatin + albumin-bound paclitaxel (category 2B)
      • Single agents:
        • 5-fluorouracil
        • Capecitabine
        • Gemcitabine
    • Useful in Certain Circumstances
      • Targeted therapy
        • For NTRK gene fusion-positive tumors:
          • Entrectinib
          • Larotrectinib
        • For MSI-H/dMMR tumors:
          • Pembrolizumab
        • For TMB-H tumors:
          • Nivolumab + ipilimumab (category 2B)
        • For RET gene fusion-positive tumors:
          • Pralsetinib (category 2B)
          • Selpercatinib for CCA (category 2B)
  • Subsequent-Line Therapy for Biliary Tract Cancers if Disease Progression
    • Preferred Regimens
      • FOLFOX
    • Other Recommended Regimens
      • FOLFIRI (category 2B)
      • Regorafenib (category 2B)
      • Liposomal irinotecan + fluorouracil + leucovorin (category 2B)
      • See also: Preferred and Other Recommended Regimens for Unresectable and Metastatic Disease above
    • Useful in Certain Circumstances
      • Nivolumab (category 2B)
      • Lenvatinib + pembrolizumab (category 2B)
      • Targeted therapy
        • For NTRK gene fusion-positive tumors:
          • Entrectinib
          • Larotrectinib
        • For MSI-H/dMMR tumors:
          • Pembrolizumab
          • Dostarlimab-gxly (category 2B)
        • For TMB-H tumors:
          • Nivolumab + ipilimumab
          • Pembrolizumab
        • For BRAF V600E-mutated tumors:
          • Dabrafenib + trametinib
        • For CCA with FGFR2 fusions or rearrangements:
          • Futibatinib
          • Pemigatinib
        • For CCA with IDH1 mutations
          • Ivosidenib (category 1)
        • For HER2-positive tumors:
          • Trastuzumabk + pertuzumab
        • For RET gene fusion-positive tumors:
          • Selpercatinib for CCA
          • Pralsetinib (category 2B)

Principles of Systemic Therapy — NCCN Clinical Practice Guidelines in Oncology - Hepatocellular Carcinoma - Version 1.2023 - March 10, 2023 - HCC-G

  • First-Line Systemic Therapy
    • Preferred Regimens
      • Atezolizumab + bevacizumab (Child-Pugh Class A only) (category 1)
      • Tremelimumab-actl + durvalumab (category 1)
    • Other Recommended Regimens
      • Sorafenib (Child-Pugh Class A [category 1] or B7)
      • Lenvatinib (Child-Pugh Class A only) (category 1)
      • Durvalumab (category 1)
      • Pembrolizumab (category 2B)
    • Useful in Certain Circumstances
      • Nivolumab (Child-Pugh Class B only)
      • Atezolizumab + bevacizumab (Child-Pugh Class B only)
      • For TMB-H tumors:
        • Nivolumab + ipilimumab (category 2B)
  • Subsequent-Line Systemic Therapy if Disease Progression
    • Options
      • Regorafenib (Child-Pugh Class A only) (category 1)
      • Cabozantinib (Child-Pugh Class A only) (category 1)
      • Lenvatinib (Child-Pugh Class A only)
      • Sorafenib (Child-Pugh Class A or B7)
    • Other Recommended Regimens
      • Nivolumab + ipilimumab (Child-Pugh Class A only)
      • Pembrolizumab (Child-Pugh Class A only)
    • Useful in Certain Circumstances
      • Ramucirumab (AFP >=400 ng/mL and Child-Pugh Class A only) (category 1)
      • Nivolumab (Child-Pugh Class B only)
      • For MSI-H/dMMR tumors -Dostarlimab-gxly (category 2B)
      • For RET gene fusion-positive tumors:
        • Selpercatinib (category 2B)
      • For TMB-H tumors:
        • Nivolumab + ipilimumab (category 2B)

==========

2023-09-18

According to the PharmaCloud data, this patient has only sought medical care at our hospital in the past three months. No discrepancies or problems were identified during the medication reconciliation process for this patient.

2023-05-29

  • The patient’s treatment was changed to UFT (a combination of Tegafur and Uracil) on 2023-05-17. There is limited data on the tolerability of UFT in older adults. However, in a study with a control group of 39 patients over 70 years of age who had undergone resection for colorectal cancer and received UFT alone, adverse events were rare and all were grade 2 or less (Reference: Cancer Biother Radiopharm. 2009;24(1):35-40). Given the patient’s advanced age, the chosen drug appears to be appropriate.

  • The drug UFT is approved in Taiwan and other countries, but is not approved by the FDA, Health Canada, or the European Medicines Agency (EMA), and is therefore not recommended by the NCCN guidelines. UFT consists of a 1:4 molar combination of tegafur (a prodrug of 5-FU) and uracil (which competitively inhibits the degradation of 5-FU, resulting in sustained plasma and intratumoral concentrations). As tegafur is a prodrug of 5-FU, which has already been used in this patient in concurrent chemoradiotherapy (CCRT), the efficacy of this approach should be continuously monitored as always.

2023-04-14

  • Amsulber (ampicillin, sulbactam) is used due to 2023-04-13 CRP 2.1mg/dL and CXR showed ground glass opacities in bilateral lower lungs.

  • Baogan (silymarin) is being used for the patient’s elevated AST and ALT.

2023-03-13

  • PharmaCloud database indicates that the medications prescribed within the last 3 months are currently being used properly with no reconciliation issues.

701059574

230918

[MedRec]

  • 2023-07-28 SOAP Gastroenterology Su WeiZhi
    • Prescription x2
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • Mopride (mosapride citrate 5mg) 1# TID
      • Algitab (alginic acid, MgCO3, Al(OH)3; 200mg) 1# TID
  • 2023-07-18 SOAP Metabolism and Endocrinology Hu YaHui
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Dyslipidemia ; other and unspecified hyperlipidemia [E78.5]
      • CRI; Unspecified disorder of kidney and ureter [N18.9]
      • Anemia, unspecified [D64.9]
      • Goiter, unspecified [E04.9]
      • Allergic rhinitis [J30.9]
    • Prescription
      • Allegra (fexofenadine 60mg) 1# QD
      • Crestor (rosuvastatin 10mg) 0.5# QW135
      • Ezetrol (ezetimibe 10mg) 1# QD
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
      • Trajenta (linagliptin 5mg) 1# QD
      • Ulstop (famotidine 20mg) 0.5# QD

==========

2023-09-18

Some of the medications prescribed by our gastroenterologist on 2023-07-28 and by our endocrinologist on 2023-07-18 do not appear in the active medication list. Please verify if these omitted medications are still necessary for the patient’s treatment.

701469284

230915

[exam findings]

  • 2023-02-10 MRI - nasopharynx
    • Indication: SCC of right buccal mucosa.
    • Past history: He is an oral cancer patient and has received operations in TSGH in 2011.
    • Neck MRI without/with Gadolinium-based contrast enhancement shows:
      • status post previous surgery with old intraoral flap at the right mandibular gingiva.
      • a large well-enhancing mass (largest diameter about 5.3cm) at right buccal region with direct invasion and destruction of right maxilla and right hard palate, with mass protruding medially into oral cavity. The fat plane between the tumor and inferior portion of medial/lateral pterygoid and temporalis muscles is blurred, with interstitial edema of the masticator space, tumor invasion to masticator space is suspected. T4b disease is favored.
      • slightly enlarged lymph nodes at right retropharyngeal space, bilateral level Ib and II, largest diameter about 1.7cm. N2c disease is suspected.
      • bilateral symmetric pharyngeal mucosa.
      • abnormal high signal change of left mandibular bone marrow with enhancement. However this lesion do not show hot spot in bone scan. Nature is to be determined.
    • Impression:
      • Advanced right buccal cancer, image staging favor AJCC T4bN2c.
      • Bone marrow signal change at left mandible, nature to be determined.
    • Oralcavity
      • Impression (Imaging stage) : T:4b N:2c M:0 STAGE:IVB
  • 2023-02-09, -02-06 CXR
    • Normal heart size. No mediastinal widening. No active lung lesion. Intact bony thorax. S/P Port-A. S/P CVP line from left? Surgical clips at right side of the neck.
  • 2023-02-08 Tc-99m MDP bone scan
    • Hot spots in the right aspect of the maxilla, the nature is to be determined (advanced oral cancer or other nature ?), suggesting PET scan for further evaluation.
    • Suspected benign lesions in some T- and L-spine, right sternoclvicular junction, bilateral shoulders, S-I joints, and knees.
  • 2023-02-07 SONO - abdomen
    • Possible small liver cyst, left lobe
  • 2023-02-06 ECG
    • Sinus bradycardia
    • Voltage criteria for left ventricular hypertrophy
    • ST elevation, consider early repolarization, pericarditis, or injury
  • 2023-01-27 Patho - gingival/oral mucosa biopsy
    • Labeled as “right maxillary gingiva”, biopsy — squamous cell carcinoma.
    • IHC stain: p16 (-).

[MedRec]

  • 2023-08-31 SOAP Oral and Maxillofacial Surgery Xia YiRang
    • O: 40% tumor shrinkage due to radiation therapy is noted. radiation-related painful mucositis is noted.
  • 2023-08-28 SOAP Oral and Maxillofacial Surgery He ChengHan
    • O: 20% tumor shrinkage due to radiation therapy is noted. radiation-related painful mucositis is noted.

[consultation]

  • 2023-05-26 Family Medicine
    • Q: This 52-year-old male suffered from an aggressive malignant tumor at his right maxillary gingiva, buccal and palate mucosa with bone destruction since few months ago. His SCC at the right buccal mucosa , maxillary gingiva, and palatal mucosa was classified as cT4bN2cM0, cStage IVB with terminal stage. We need your End-of-life co-care
    • A: 52-year-old male, Squamous cell carcinoma of right maxillary ginvia, buccal mucosa and platal mucosa with bone destruction, cT4bN2cM0, cstage IVB
      • This time suffer from disease progression, in process of induction chemotherapy
      • Consciousness E4V5M6, ECOG 2
      • We will arrange hospice combine care and follow up his condition
      • Indication: upper gum SCC (Major: Malignant neoplasm of upper gum)
      • Plan: Hospice combined care
  • 2023-05-23 Radiation Oncology
    • A: Squamous cell carcinoma of the right upper gingivobuccal mucosa and hard palate, AJCC stage cT4bN2cMo, s/p induction chemotherapy with progression.
    • P: Radiotherapy is indicated for this patient with the following indicators: stage cT4bN2cMo, s/p induction chemotherapy with progression
      • Goal: palliation
      • Treatment target and volume: the right upper gingivobuccal mucosa and hard palate tumor, peripheral involved, to bilateral neck.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5000cGy/25 fractions of the right upper gingivobuccal mucosa and hard palate tumor, peripheral involved, to bilateral neck, and 7000cGy/35 fractions of the right upper gingivobuccal mucosa and hard palate tumor and involved nodal lesions.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2023-5-31.
      • Please complete pre-RT dental evaluation and management.
  • 2023-02-10 Gastroenterology
    • Q
      • This 52 year old male suffered from an aggressive malignant tumor of right maxillary and mandibular gingiva, buccal mucosa and palate for a few months. SCC of right buccal mucosa, maxillary gingiva, and palatal mucosa which combined with bone destruction, cT4aN0M0. We will arrange induction chemotherapy with Taxotere, Cisplatin, 5-Fu for him.
      • However, his data showed HbsAg (-), Anti-HBc (-) , Anti-Hbs (+) and Anti-HCV (+). We need your further evaluation and suggestion. Thanks !!
    • A
      • The patient is not in the ward, and has no plans to return to the ward after being contacted. I’ve explained to him over the phone, and he has expressed understanding.
        • Blood Draw: DAA medication pre-examination items (no need to redraw if previously done).
          • ALT, AST, Albumin, BUN, Creatinine, Bil(D), Bil(T), HbsAg, a-Fetoprotein, HCV RNA PCR, CBC, PT
      • Well explained to the patient low incidnece of HCV reactivation during or after chemotherapy according to previous reports
      • GI OPD f/u for treatment and echo

[chemotherapy]

  • 2023-09-11 - cisplatin 36mg/m2 60mg NS 300mL 3hr + methotrexate 30mg/m2 50mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-09-04 - cisplatin 36mg/m2 60mg NS 300mL 3hr + methotrexate 30mg/m2 50mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-08-21 - cisplatin 36mg/m2 60mg NS 300mL 3hr + methotrexate 30mg/m2 50mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-06-13 - docetaxel 36mg/m2 60mg NS 100mL 1hr D1 + cisplatin 36mg/m2 50mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-05-24 - docetaxel 36mg/m2 50mg NS 100mL 1hr D1 + cisplatin 36mg/m2 50mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-05-17 - docetaxel 36mg/m2 60mg NS 100mL 1hr D1 + cisplatin 36mg/m2 60mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-04-28 - docetaxel 36mg/m2 60mg NS 100mL 1hr D1 + cisplatin 36mg/m2 60mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-04-21 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-04-06 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-03-13 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-03-06 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-20 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-13 - docetaxel 40mg/m2 60mg NS 100mL 1hr D1 + cisplatin 40mg/m2 60mg NS 300mL 3hr D1 + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-03-28 ~ 2023-04-04 UFT (tegafur 100mg + uracil 224mg) 2# BID

==========

2023-09-15

[oral mucositis]

Since 2023-06-13, the patient has been intermittently receiving radiotherapy. Regarding chemotherapy, after the last TPFL (docetaxel + cisplatin + 5-FU + LV) treatment on 2023-06-13, the patient transitioned to cisplatin + methotrexate starting from 2023-08-21. While oral mucositis could potentially be caused by chemotherapy, it’s important to note that the influence of radiotherapy cannot be entirely ruled out.

According to the recommendations in the article “Management of Cancer Therapy-Associated Oral Mucositis” (https://ascopubs.org/doi/full/10.1200/JOP.19.00652), management options for mucositis severity include bland rinses (normal saline or salt and soda), 2% viscous lidocaine swish and spit, gabapentin, 2% morphine mouthwash swish and spit, doxepin-containing mouthwashes, and systemic opiates, depending on the severity of mucositis.

2023-06-02

  • As the chemotherapy regimen has been ongoing since 2023-02-13, the patient’s WBC level remained within an acceptable range until April. However, a leukopenia event was observed following the most recent treatment cycle which began on 2023-05-24, as evident from the data on 2023-05-29. The patient was discharged on 2023-05-31, and it was noted in the discharge summary that “Filgrastim (G-CSF) 150mcg SC QD (self-paid) was prescribed for the prevention of neutropenia.” Nonetheless, the list of discharge prescriptions - loperamide, metoclopramide, zinc gluconate, and acetaminophen - does not include G-CSF. G-CSF is a reasonable medication in this context.
    • 2023-05-29 WBC 1.58 x10^3/uL
    • 2023-05-24 WBC 2.78 x10^3/uL
    • 2023-05-15 WBC 4.61 x10^3/uL
    • 2023-05-01 WBC 2.54 x10^3/uL
    • 2023-04-26 WBC 3.19 x10^3/uL
    • 2023-04-19 WBC 3.57 x10^3/uL
    • 2023-04-11 WBC 5.17 x10^3/uL
    • 2023-04-06 WBC 5.11 x10^3/uL
    • 2023-03-27 WBC 3.48 x10^3/uL
    • 2023-03-20 WBC 6.35 x10^3/uL
    • 2023-03-15 WBC 4.22 x10^3/uL
    • 2023-03-13 WBC 3.39 x10^3/uL
    • 2023-03-06 WBC 5.74 x10^3/uL
    • 2023-02-24 WBC 3.62 x10^3/uL
    • 2023-02-20 WBC 8.05 x10^3/uL
    • 2023-02-06 WBC 5.55 x10^3/uL
  • For non-hematological malignancy patients who have experienced leukopenia of less than 1000/uL, or an absolute neutrophil count (ANC) less than 500/uL following chemotherapy, national health insurance covers the use of filgrastim and lenograstim. However, the patient’s WBC count does not yet meet this criterion, hence the need for self-payment. Please confirm the prescription status of Filgrastim.

700731896

230912

  • diagnosis - 2022-12-02 admission note
    • Acute kidney failure, unspecified
    • Dyspnea, unspecified
    • Malignant neoplasm of cecum
    • Secondary malignant neoplasm of retroperitoneum and peritoneum
    • Secondary malignant neoplasm of liver and intrahepatic bile duct
    • Essential (primary) hypertension

[lab data]

2022-09-09 Anti-HBc Reactive
2022-09-09 Anti-HBc-Value 2.22 S/CO
2022-09-09 Anti-HBs 81.03 mIU/mL
2022-09-09 HBsAg (quantative) Nonreactive
2022-09-09 HBsAg Value (quantative) 0.00 IU/mL
2022-09-09 Anti-HCV Nonreactive
2022-09-09 Anti-HCV Value 0.11 S/CO

[exam finding]

  • 2023-08-21 CT - abdomen
    • History and indication: adenocarcinoma of cecum with total small bowel obstruction and carcinomatosis and liver metastases, stage IVC
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P ileostomy. Mild progression of cecal cancer, liver metastases and peritoneal carcinomatosis with ascites.
      • Bil. pleural effusions. Small liver cysts. Mild splenomegaly.
      • Atherosclerosis of aorta, iliac arteries.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P ileostomy. Mild progression of cecal cancer, liver metastases and peritoneal carcinomatosis with ascites. Bil. pleural effusions. Mild splenomegaly
  • 2023-08-17 MRI - brain
    • No brain nodule. No evident acute infarct.
  • 2023-07-25 SONO - abdomen
    • Indication: abdominal pain
    • Findings:
      • At least 4-5 hyperechoic lesions with faint acoustic shadows were noted at right lobe and possible S4. The largest one is about 1cm at S7.
      • Splenomegaly about 13.5cm.
      • Small to moderate amount ascites
      • Tiny echogenic lesions were noted on the peritoneum. (eg. liver surface)
    • Diagnosis:
      • Liver tumors
      • Splenomegaly
      • Ascites
      • c/w carcinomatosis
  • 2023-07-03, -06-20, -05-22, -05-14 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Spondylosis with scoliosis of the T-spine with convex to right side
  • 2023-06-20 KUB
    • Spondylosis of the L-spine is noted.
    • One segmental small bowel in LMQ abdomen shows mild dilatation.
    • Follow up is indicated. Otherwise, Please correlate with CT.
  • 2023-06-19 Tc-99m MDP bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, and hips.
  • 2023-05-25 CT - abdomen
    • History and indication: adenocarcinoma of cecum with total small bowel obstruction and carcinomatosis and liver metastases, stage IVC
    • IMP:
      • S/P ileostomy. Stable condition of cecal cancer, liver metastases and peritoneal carcinomatosis. Minimal ascites.
      • Minimal pleural effusion.
  • 2023-05-11 KUB
    • Degeneration of bony structures.
    • Stool retention in bowl.
  • 2023-04-12 KUB
    • Disk space narrowing with spurs formation at L3-L4, L4-L5, and L5-S1 levels due to spondylosis
    • mild dextroscoliosis of the L-spine
  • 2023-04-12 CXR
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch;. dilated ascending aorta
    • skin folds over Lt hemithorax otherwise clean lung fields based on plain image
    • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, T-spine.
    • Mild dextroscoliosis of the T-spine
  • 2023-04-12 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
  • 2023-02-06 CT - abdomen
    • S/P ileostomy. Mild regression of cecal cancer and liver metastases but mild progression of peritoneal carcinomatosis.
  • 2023-01-12 SONO - nephrology
    • Bilateral chronic change of both kidneys.
  • 2022-12-22 SONO - kidney
    • Normal echogenicity of the bil. kidneys.
    • Normal cortical thickness of the kidneys.
    • No evidence of urolithiasis.
    • No evidence of hydronephrosis.
  • 2022-12-02 CXR
    • Sinus tachycardia
    • T wave abnormality, consider lateral ischemia
    • Abnormal ECG
  • 2022-11-15 CXR
    • enlarged cardiac silhoutte may be prominent cardiophrenic angle mediastinal fat pad/ supine position
  • 2022-11-09 CXR
    • enlarged cardiac silhoutte may be prominent cardiophrenic angle mediastinal fat pad/ supine position
    • marginal spurs of multiple vertebral bodies of T-L spine due to spondylosis.
  • 2022-10-24 CXR
    • S/P nasogastric tube insertion
    • Enlargement of cardiac silhouette.
    • Spondylosis with scoliosis of the T-spine with convex to right side
  • 2022-10-17 CXR
    • appropriately positioned gastric tube
    • Port-A catheter inserted into SVC via left subclavian vein.
    • enlarged cardiac silhoutte may be due to dilated cardiac chambers and prominent cardiophrenic angle mediastinal fat pad/ supine position
    • Rt and Lt subpulmonary effusion?
  • 2022-10-14, -10-12, -10-10 CXR
    • enlarged cardiac silhoutte may be due to dilated cardiac chambers and prominent cardiophrenic angle mediastinal fat pad/ supine position
    • Rt and Lt subpulmonary effusion?
    • appropriately positioned gastric tube
  • 2022-10-07 CXR
    • Port-A catheter inserted into SVC via left subclavian vein.
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta. dilated ascending aorta
    • enlarged cardiac silhoutte may be due to dilated cardiac chambers (LVD) or LVH and prominent cardiophrenic angle mediastinal fat pad/ supine position?
    • Rt and Lt subpulmonary effusion?
    • appropriately positioned gastric tube
  • 2022-09-07 CT - abdomen, pelvis
    • Inidcation:
      • epigastric pain for one month,
      • abdominal fullness with crampying pain, intermittent
    • Findings:
      • There is ill-defined Eqivocal soft tissue mass-like lesion in the RLQ abdomen, near the cecal base, appendix, and ileocecal valve area, that may be adenocarcinoma. The differential diagnosis include metastasis.
        • In addition, this mass lesion causinig mechanical small bowel obstruction.
      • There is long segmental symmetrical mild wall thickening of the small intestine at the lower abdomen and upper pelvis causing marked dilatation of the proximal small bowel that may be tumor seeding or Crohn disease?
      • There is ascites, soft tissue lesions in the RLQ omentum and the mesentery that may be carcinomatosis. Please correlate with ascites cytology.
      • There is Eqivocal wall thickening of the sigmoid colon that may be primary adenocarcinoma or tumor seeding? Please correlate with colonoscopy.
      • There are three poor enhancing mass measuring 0.8 cm in S8 dome, 0.6 cm in S8, and 1.8 cm in S6 of the liver. Metastases are highly suspected.
      • The pancreas shows small size that is c/w senile atrophy.
      • Abdominal aorta shows atherosclerosis and ectasia 2.7 cm.
      • There is a enlarged node in pre-cava space measuring 2.2 x 1 cm that may be metastatic node.
      • There is no focal abnormality in the gallbladder, biliary system, spleen & both kidney. .
      • The IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
    • Impression:
      • Adencoarcinoma of the cecum or appendix causing high grade small bowel obstruction, carcinomatosis, and liver metastases is highly suspected.
      • The differential diagnosis include metastases, origin?
      • Please correlate with colonoscopy.
  • 2022-09-07 KUB
    • Presence of ileus.
    • Degeneration and spondylosis of L-S spine.
    • A calcified spot at left pelvic cavity.
  • 2022-09-07 CXR
    • Presence of ileus.
    • Interstitial pattern at bil. lower lungs.

[consultation]

  • 2023-05-18 Infectious Disease
    • Q
      • This 82-year-old man patient is a case of Lung cancer with lymph nodes and bone metastases, cT4N3M1b, stage IVA. This time, for Pneumonia, bilateral lung with Antibiotic with Tapimycin 4.5gm iv Q6H from 2023/04/26~. Cytomegaloviral disease with Valcyte F.C 450mg 2# po QD. Chronic obstructive pulmonary disease with Medason 40mg iv BID from 2023/04/27~, Symbicort Rapihaler 2 puff INHL BID and Spiriva Respimat 2 puff INHL QD. Pneumocystosis jirovecii pneumonia (2023/05/02 P.jiroveci DNA-Sp showed Positive) with Antibiotic with Sevatrim 400mg & 80mg 10ml IV Q8H from 2023/05/01~. O2 Mask 5L 31% use, SpO2:95%. Now, for evaluate antibiotic therapy. Thank you.
    • A
      • KP bacteremia on May 14, possible Port-A related.
      • Urine culture disclosed MRSH and Enterococcus faecalis mixed infections, with low colony count.
      • There is complete defervescence since yeterday morning under Brosym and Targocid use.
      • Change of antibiotic regimen should be not necessary.
      • Please keep Targocid for one week, and follow up urine culture 4-5 days later.
      • Port-A blood culture should be rechecekd tomorrow to see if there is sterile blood.
      • Brosym can be replaced by Cipro or Cravit on May 21 as sequential therapy.
  • 2022-10-13 Dermatology
    • Q
      • For skin rash
      • This 68-year-old male has past history of
        • hypertension
        • Adencarcinoma of the cecum with total small bowel obstruction and carcinomatosis, liver metastases, stage IVC status post Loop ileostomy on 2022/09/09~09/17.
      • Current problem: Due to skin rash around back, chest, abdomen and inguinal area, so we need your help for evaluation. Thanks!!
    • A
      • The patient had sufferred from diffuse fine reddish papules with minimal pruritus on the trunk, majorly on the compression sweat area.
      • several erythematous annular lesions with active borders over lower legs.
      • Under the impression of milaria over trunk and tinea pedis over foot and lower leg.
      • The following sugeetion:
        • for trunk, keep body position change and avoid too long compression, consider Sinbaby 1 bot topical PRN use for occlusion if pruritus development
        • for lower leg and foot, Exelderm 1 tube topical bid use on the lower leg and foot area.
  • 2022-10-13 Metabolism and Endocrinology
    • Q
      • For abnormal thyroid function (20221012 (nuclear medicine) Free T4: 1.81, TSH: 0.078, T3: 58.119), so we need your help for evaluation. Thanks!
    • A
      • S: For abnormal TFT
      • O:
        • TPR- 37.1/79/12; BP-147/88
        • free T4-1.810, T3-58.119, TSH-0.078
        • HbA1C-6.4
        • No sig. blood flow on bedside thyroid echo
      • A:
        • Favor sick euthyroidism or low T3 syndrome
        • Suspected DM
      • Suggestions:
        • It is unnecessary to medication for thyroid at this timing
        • Just to follow free T4, T3 and TSH after 1 week is fine
        • Any problem, please call me
  • 2022-10-12 Cardiology
    • Q
      • Lab 2022-10-12
        • Mg (Magnesium) 1.5 mg/dL
        • Na (Sodium) 138 mmol/L
        • K(Potassium) 4.0 mmol/L
      • Current problem: For short run VT with pulse around 8 sceonds, so we need your help for evaluation
    • A
      • O
        • BUN: 28
        • Cr: 0.66
        • Hb: 9.4
      • Suggestion:
        • Please add carvedilol (6.25mg) 0.5#bid-1#bid if no contraindication
        • Follow-up on call, Thanks.
  • 2022-10-07 Gastroenterology
    • Q
      • Lab 2022-09-09
        • Anti-HBc Reactive
        • Anti-HBc-Value 2.22 S/CO
        • Anti-HBs 81.03 mIU/mL
        • HBsAg Nonreactive
        • HBsAg Value 0.00 IU/mL
        • Anti-HCV Nonreactive
        • Anti-HCV Value 0.11 S/CO
      • Current problem: Due to chemotherapy will be conducted, we need your help for evaluation of prescription anti-Hepatitis B virus drug.
    • A
      • The patient has Adencoarcinoma of the cecum with total small bowel obstruction and carcinomatosis, liver metastases, stage IVC status post Loop ileostomy on 2022/09/09. This time, he was admitted for respiratory distress, AKI with hyperkalemia, start hemodialysis for oligouria, acidosis during this hospitalization. For planned chemotherapy, and his lab data: HBc(+), we are consulted for HBV therapy.
      • Lab
        • Anti-HBc Reactive
        • HBsAg Nonreactive
      • Impression
        • Resolved HBV infection
        • Acute kidney injury with metabolic acidosis, hyperkalemia, now under hemodialysis
        • Adencarcinoma of the cecum, plan for chemotherapy
      • Suggestion
        • Currently, chemotherapy has not been scheduled, and the NHI only covers HBV insurance covers drugs from one week before chemotherapy to half a year after chemotherapy; and the renal function is not stable, which will affect the dosage of anti-HBV drugs; please call the gastroenterology department to evaluate medicine if the date of chemotherapy has been determined.
  • 2022-10-04 Nephrology
    • A
      • Consult for AKI and renal function impairment
      • Lab data:
        • VBG PH: 7.372, PCo2: 31.5, HCO3: 17.9, BE: -7.6
        • WBC: 16.94, HbL: 17.4, Plt: 314
        • CK :436, CLMB: 37.9, TroponinI: 595.4
        • Na: 115, K: 6.6
        • BUN/ cre: 12/0.47(9/12)-> 139/7.83(9/29)-> 218/15.83(10/4)
        • CEA: 507.17,CA 199: 1052.27
        • U/O: decrease ( no foley)
        • GPT: 281, GOT: 93, T bil :1.52,albumin:5.1
        • BP:70/50mmHg, SOB
      • Impression:
        • Acute kidney injury stage 3 suspect prerenal, septic shock and dehydration
      • Suggestion:
        • Admit ICU
        • Correct metabolic acidosis with sodium bicarbonate 20ml per hr
        • Correct hyperkalemia with D50+ RI, kalimate
        • Correct hyponatremia with 3% NS
        • Suggest IV adequate Hydration
        • Explain family about Emergent CRRT
        • We will arrange RRT if family agree
        • Thank you for your consultation !
  • 2022-09-07 Colorectal Surgery
    • Q
      • epigastric pain for one month
      • panendoscopy at local clinic found DU
      • abdominal fullness with crampying pain, intermittent
      • deny abd op Hx
    • A
      • this patient told me that he got this problem abdout 2-3 months ago and start to feel abdomen distension about one wks ago
      • CT revealed that carcinomatosis was found
      • pt still passage of gas and stool now
      • there’s no need for emergency surgery now
      • thanks for your consultation

[chemoimmunotherapy]

  • 2023-08-23 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3 + atropine 1mg SC
  • 2023-08-09 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-21 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-02 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-18 - (Avastin + FOLFOX, Q2W)
  • 2023-03-29 - (Avastin + FOLFOX, Q2W)
  • 2023-03-16 - (Avastin + FOLFOX, Q2W)
  • 2023-02-15 - (FOLFOX, Q2W)
  • 2023-02-02 - (FOLFOX, Q2W)
  • 2023-01-16 - (FOLFOX, Q2W)
  • 2022-12-22 - (FOLFOX, Q2W)
  • 2022-11-25 - oxaliplatin 75mg/m2 135mg 2hr + leucovorin 300mg/m2 550mg 2hr + fluorouracil 300mg/m2 550mg 10min + fluorouracil 2400mg 4400mg 46hr (FOLFOX, Q2W)
  • 2022-11-07 - oxaliplatin 65mg/m2 120mg 2hr + leucovorin 300mg/m2 550mg 2hr + fluorouracil 300mg/m2 550mg 10min + fluorouracil 2400mg 4400mg 46hr (FOLFOX, Q2W)
  • 2022-10-24 - oxaliplatin 65mg/m2 120mg 2hr + leucovorin 300mg/m2 550mg 2hr + fluorouracil 300mg/m2 550mg 10min + fluorouracil 2400mg 4400mg 46hr (FOLFOX, Q2W)
  • 2022-10-11 - leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg 4500mg 46hr

==========

2023-07-04

[renal function follow-up]

Given the recent serum Cre and BUN records, it appears that the patient’s AKI status has been resolved for some time. Therefore, this might be marked as an inactive or resolved item in the medical problem list.

  • 2023-06-27 Creatinine 1.10 mg/dL
  • 2023-06-20 Creatinine 1.06 mg/dL
  • 2023-06-19 Creatinine 0.99 mg/dL
  • 2023-06-14 Creatinine 1.62 mg/dL
  • 2023-06-27 BUN 20 mg/dL
  • 2023-06-20 BUN 10 mg/dL
  • 2023-06-19 BUN 11 mg/dL
  • 2023-06-14 BUN 27 mg/dL

2022-12-05

  • On 2022-12-05, both serum creatinine and BUN were lower than on 2022-12-03 (Cre 3.63 -> 1.90 mg/dL; BUN 71 -> 48 mg/dL), which indicates that the patient’s kidney function has improved.
  • The administration of KCl in normal saline is used to treat hypokalemia (2.9 mmol/L 2022-12-05) as well as hyponatremia (127 mmol/L 2022-12-05).
  • In the past three days, the blood pressure has remained approximately 110/60 +- 10 mmHg; in the event that successive data points show BP lower than 100/60, Norvasc (amlodipine) could be held (while Carvedilol is continued for his 90 +-20 heart rate; 2022-10-12 short run VT with pulse around 8 sceonds).

2022-09-08

  • It is suspected that the patient has cecum or colon cancer and is undergoing a workup. There is no issue with the active prescription.

701001983

230912

[diagnosis] - 2023-03-20 admission note

  • Malignant neoplasm of gallbladder
  • Encounter for antineoplastic chemotherapy
  • Insomnia, unspecified
  • Unspecified viral hepatitis B without hepatic coma
  • Constipation, unspecified

[past history]

  • Left multiple lower neck LAP with cystic like change at level III, IV, Vb
  • Left thyroid tumor, small, favor benign.            

[allergy]

  • NKDA             

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-05-09, -04-10, -04-06 Abdomen - Standing (Diaphragm)
    • S/P plastic stent implantation from right lobe IHD to duodenum.
  • 2023-04-13 Patho - stomach biopsy
    • Stomach, body, biopsy — Non-atrophic chronic gastritis
    • The sections show gastric body mucosal tissue with congestion, edema, mild chronic inflammatory cell infiltration, no neutrophil infiltration, no intestinal metaplasia, no gastric atrophy, and no Helicobacter pylori colonization.
  • 2023-04-13 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis, lower esophagus, LA classification, grade A
    • Superfical gastritis, antrum
    • Gastric polyp, multiple, body, s/p biopsy
    • Post ERBD
  • 2023-04-12 CT - abdomen
    • History: 20230110 MRI: gallbladder cancer with cystic duct, CHD extension, LNs and liver metastases.
    • Findings:
      • Prior CT identified a mass lesion (3.8x7.5cm) in gallbladder is noted again, marked decreasing in size that is c/w gallbladder cancer S/P C/T with partial response.
      • Prior CT identified several metastatic LNs at hepatic hilar region are noted again, marked decreasing in size that is c/w metastatic LNs S/P C/T with partial response to near complete response.
      • Prior CT identified several metastases in both hepatic lobes are noted again, decreasing in size that is c/w liver metastases S/P C/T with partial response.
      • Prior CT identified a nodule (1.3cm) at right breast is noted again, stationary.
      • There is an ill-defined faint poor enhancing area in S4-8 of the liver, nature? Follow up is indicated.
      • S/P plastic stent implantation in between right lobe IHD and duodenum. However, mild dilatation of IHDs is still noted.
    • Impression:
      • Gallbladder cancer with liver and LNs metastases S/P C/T show partial response.
  • 2023-03-22 CT - brain
    • Indication: Gallbladder cancer with Common bile duct compression and multiple liver metastases, cT3N2M1, stage IV
    • IMP: no evidence of brain tumors.
  • 2023-03-20 CXR
    • Mild Scoliosis of the T-spine with convex to right side.
    • Atherosclerotic change of aortic arch
  • 2023-03-06 CXR
    • Scoliosis of the T-spine with convex to right side.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-01-16 Patho - lymphnode biopsy
    • Labeled as “subclavian lymph node, left”, biopsy — metastatic adenocarcinoma with neuroendocrine feature.
    • Section shows lymph node almost completely replaced by metastatic adenocarcinoma, demonstrating glands and short papillary structure.
    • IHC stains: CK7 (diffuse +), CK20 (-), TTF-1 (focal +), CK19 (diffuse +), PAX-8 (focal +), thyroglobulin (equivocal), Napsin-A (-), CD56 (focal +), synaptophysin (focal +). Extranodal extension is not present.
  • 2023-01-11 SONO - breast
    • A round right breast tumor (#2).
    • Enlarged left axillary lymph nodes, suspect lymphadenopathy.
    • BI-RADS category 4, Suspicious abnormality. Biopsy should be considered.
  • 2023-01-11 Endoscopic Retrograde CholangioPancreatography, ERCP
    • Diagnosis
      • Middle CBD stricture, s/p plastic stent placement (8.5 Fr. 9 cm )
      • Chronic cholangitis
      • Reflux esophagitis, Gr. A
    • Suggestion:
      • f/u amylase & lipase
  • 2023-01-10 MR Cholangiography, MRCP
    • History and indication: Acute cholecystitis
    • IMP: In favor of gallbladder cancer with cystic duct, CHD and CHD extension, LNs and liver metastases. Right breast tumor.
  • 2023-01-09 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Poorly differentiated carcinoma with marked neuroendocrine differentiation
    • The sections show a picture of sheets of poorly differentiated neoplastic cells with marked tumor necrosis, embedded in fibrous stroma. No definite glandular formation can be identified.
    • IHC shows: CK(+), CK7(+), CK20(-), CD56(+), and Synaptophysin(+). Either neuroendocrine carcinoma or mixed carcinoma with marked neuroendocrine differentiation should be considered.
  • 2023-01-08 CT - abdomen
    • Lobulated mass-like lesions within the gallbladder with heterogeneous enhancement. Suspected malignancy.
    • Several hypoperfusion nodular lesions over right hepatic lobe, may be metastatic lesions.
    • Dilated CBD and IHDs.
    • S/P hystorectomy.
    • Suspect confluent lobulated nodes over hepatic hilum.

[MedRec]

  • 2023-09-08 SOAP Ear Nose Throat
    • Prescription
      • Allegra (fexofenadine 60mg) 1# QD
      • Shitan (bromhexine 8mg) 1# BID
      • Anxokast (montelukasf 10mg) 1# HS
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD

[consultation]

  • 2023-01-17 Radiation Oncology
    • A
      • A: Poorly differentiated carcinoma with marked neuroendocrine differentiation of the gallbladder, with liver metastasis.
      • P: Radiotherapy is indicated for this patient with the following indicators: tumor with metastasis and pain
        • Goal: palliation
        • Treatment target and volume: gallbladder tumor, peripheral involved, to metastatic liver tumor
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the gallbladder tumor, peripheral involved, to metastatic liver tumor
        • The treatment planning of radiotherapy will be started at 0830, 2023-02-06.
  • 2023-01-12 Hemato-Oncology
    • Q
      • for chemotherapy
      • This is a 64 yesr old female patient. Under impressed of gallbladder cancer with liver metastases. We need your professional evaluation for this patient. Thank you so much!!
    • A
      • This 64 year old woman is a case of gall bladder cancer with liver metastasis (liver biopsy: Poorly differentiated carcinoma with marked neuroendocrine differentiation). We are consulted for chemotherapy.
      • Please arrange port A insertion and check HbsAg, Anti Hbc, Anti HCV. We will discuss with patient about further palliative chemotherapy (regimen such as cisplatin + etoposide). Please arrange our OPD after discharge.
  • 2023-01-12 Ophthalmology
    • Q
      • This time she felt headache due to high intraocular pressure at night. We need your help for professional assessment. Thank you so much!!
    • A
      • S
        • Left eyelid twitching and mild fullness
      • O
        • denied bv ou, headache occasionally
        • denied past hx
        • denied oph hx
        • nka
        • VAcNC od 20/70 os 20/70
        • IC 13/14mmHg
        • Pupil 3/3 +/+
        • Conj np ou
        • K clear ou
        • AC shallow / clear ou
        • Lens ns+++
      • A
        • no acute ocular problem at present
      • P
        • Inform the red flags, if worsen vision, come back asap
        • suggest oph opd f/u for prophylatic LI ou
        • opd f/u

[radiotherapy]

  • 2023-02-14 ~ 2023-03-30 - 1800cGy/10 fractions of the gallbladder tumor, peripheral involved, to metastatic liver tumor, and 4500cGy/25 fractions of the gallbladder tumor, peripheral involved area.

[chemotherapy]

  • 2023-07-20 - etoposide 70mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 70mg/m2 110mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-06-02 - etoposide 70mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 70mg/m2 110mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-05-09 - etoposide 75mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 80mg/m2 120mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-20 - etoposide 75mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 80mg/m2 115mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-02-10 - etoposide 75mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 80mg/m2 120mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-01-16 - etoposide 75mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 80mg/m2 120mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-03-21

  • High-grade neuroendocrine carcinomas (NEC) with poor differentiation tend to have a high likelihood of developing distant metastases and a concerning prognosis, even when they appear to be clinically localized. For the treatment of metastatic gastrointestinal and pancreatic NEC, it is often recommended to use a two-drug platinum-based regimen, usually consisting of cisplatin or carboplatin combined with etoposide.

  • The ideal treatment duration remains undetermined. Generally, the goal is to administer 4 to 6 cycles of therapy. However, if a patient continues to respond positively to the treatment and experiences minimal side effects, it may be suitable to extend chemotherapy until the maximum possible response is achieved. ref: UpToDate. https://www.uptodate.com/contents/high-grade-gastroenteropancreatic-neuroendocrine-neoplasms

  • Neuroendocrine tumors, metastatic carcinoma

  • The patient’s current etoposide and cisplatin regimen does not exceed the mentioned dosage, making it suitable and not necessitating any dosage adjustments.

701070729

230912

[MedRec]

  • 2023-07-18 ~ 2023-07-24 POMR Colorectal Surgery Chen ZhuangWei
    • Discharge diagnosis
      • A locally advanced adenocarcinoma at rectosigmoid colon with lumen obstruction, 20cm AAV, cT3N1M1 (liver metastasis), IVa status post Laparoscopic low anterior resection on 2023/07/20
      • ST elevation (STEMI) myocardial infarction involving right coronary artery
      • Hypertensive heart disease
      • Type 2 diabetes mellitus
      • Hyperlipidemia
    • CC
      • Lower abdominal pain, diarrhea and bloody stool noted for 1 month
    • Present illness
      • This 71-year-old male had history of
        • ST elevation myocardial infarction, triple vessels status post balloon angioplasty and drug-eluting stent for right coronary artery proximal segment on 2022/02/07
        • Diabete mellitus, type 2
        • Hyperlipidemia
      • According to his medical record, lab data such as stool occult blood test showed positive on 2022/02/21, however, anti-coagulation could not be stopped due to acute myocardial infaction. This time, he sufferred from lower abdominal pain, diarrhea and bloody stool noted for 1 month. He visited GI OPD for help and sigmoidoscopy on 2023/07/10 revealed rectosigmoid mucosal lesion with lumen obstruction, 20cm AAV. Pathology proved adenocarcinoma. Abdomen CT on 07/11 revealed Rectosigmoid malignancy with regional lymph nodes, poor enhancing liver tumors, suspect liver metastasis, cStage T3N1bM1a. Due to impending obstruction, he was admitted for laparoscopy anterior resection.
    • Course of inpatient treatment
      • After admission, pre-op assessment such as cardiac sonography and lung function test was arranged. Abdomen sonography was arranged for liver nodule suspect metastasis. Laparoscopic low anterior resection was performed smoothly on 2023/07/20. After operation, no specific complain except for mild wound pain was noted. Foley and Drainage was removed on 07/21 and 07/22, respectively. Flatus and stool passage was noted since 07/22 and try semi-liquid diet well. Wound was clean and no ozzing. Under relative stable condition, we arranged his discharge on 2023/07/24 and OPD follow up.
    • Discharge prescription
      • MgO 250mg 2# BID
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID

[surgical operation]

  • 2023-07-20
    • Op Method: Laparoscopic low anterior resection         
    • Finding:
      • A locally advanced tumor is located at rectosigmoid colon and focal tumor lesion grows through the bowel wall was seen. Several small white nodule lesions at colon surface and pelvia floor wall, one was sent for pathology.         - The tumor has caused bowel obstruction with much stool retention and bowel wall edema.         - The procedure of LAR was performed smoothly. Blood loss was about 20ml. Anastomosis was achieved using endo-GIA 60/green1+ 45/green1+ CDH-33+ TISSEEL 4ml. Some seromuscular silk sutures was put on posterior anastomosis site.  Air leak test is ok.         - A drain in pelvis    

[chemotherapy]

  • 2023-08-22 - irinotecan 180mg/m2 288mg D5W 250mL 90min + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4488mg NS 1000mL 46hr
    • dexamethasone 8mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + NS 250mL

==========

2023-09-12

[diarrhea]

The patient started FOLFIRI treatment on 2023-08-22 and experienced significant diarrhea, with seven or more bowel movements per day.

Irinotecan, a component of FOLFIRI, can lead to both early and late-stage diarrhea. For early-stage diarrhea, which may come with cholinergic symptoms, atropine can be effective. Although a 0.25mg dose of atropine was initially used, increasing the dose to 0.5mg during the next treatment could be considered (can be up to 1mg). Late-stage diarrhea requires immediate attention with loperamide, as it could be life-threatening.

In cases of diarrhea, maintain close monitoring of fluid and electrolyte levels, and provide necessary supplementation. If complications like ileus, fever, or severe neutropenia arise, antibiotics may be needed. In the event of severe diarrhea, consider interrupting the irinotecan treatment and adjusting the dosage for subsequent administrations.

Patients who are homozygous for the UGT1A128 or 6 alleles (28/28, 6/6), or compound heterozygous UGT1A128 and 6 alleles (6/28), may require a dose reduction in the starting irinotecan level. Any future adjustments should be tailored to individual tolerance levels.

For treating diarrhea induced by cancer therapy, the initial oral dose of loperamide is 4 mg, followed by 2 mg every 2 to 4 hours or after each instance of loose stool. If diarrhea continues for more than 24 hours, the dose should be 2 mg every 2 hours, or alternatively, 4 mg every 4 hours. Continue this regimen until 12 hours have elapsed without a loose bowel movement, as per guidelines from Andreyev 2014, Benson 2004, and Sharma 2005. It’s worth noting that daily doses exceeding 16 mg may not offer additional benefit, and alternative treatments should be considered if diarrhea persists for 48 hours or more.

[leukopenia]

Around the third week following the patient’s initial FOLFIRI treatment, leukopenia was detected. However, after administering a dose of G-CSF (filgrastim 150ug) on 2023-09-11, no further instances of leukopenia have been observed as of now.

2023-09-12 WBC 4.70 x10^3/uL
2023-09-11 WBC 1.58 x10^3/uL
2023-09-08 WBC 1.81 x10^3/uL
2023-09-05 WBC 1.95 x10^3/uL
2023-08-22 WBC 4.85 x10^3/uL

701192853

230912

[exam findings]

  • 2023-08-16 CXR
    • Linear densities at LLL.
  • 2023-07-27, -05-08 CXR
    • Peri-bronchial wall thickening of the left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-07-04 CT - abdomen
    • Stable condition of rectal cancer.
    • Bronchiectasis at bilateral basal lungs.
    • Grade 5 fatty liver.
    • Hyperplasia of left adrenal gland.
    • Renal cysts (up to 1.1cm).
    • Gallbladder stones (up to 1.2cm).
  • 2023-07-04 Sigmoidoscopy
    • rectal cancer s/p TNT, with total regression
  • 2023-06-27 MRI - pelvis
    • History and indication: Rectal cancer, cT3N2a M0, stage IIIB
    • IMP:
      • Stable condition of rectal cancer as compared with previous CT study (2023-04-13).
      • Bronchiectasis at bilateral basal lungs.
  • 2023-04-13 CT - abdomen
    • Much regression of rectal cancer.
    • Bronchiectasis at bilateral basal lungs.
    • Grade 5 fatty liver. Some calcifications at pancreas.
    • Hyperplasia of left adrenal gland.
    • Renal cysts (up to 1.1cm).
    • Gallbladder stones (up to 1.2cm).
  • 2023-03-28 Sigmoidoscopy
    • tumor shrinkage to smaller
    • 5cm above AV, TATAME if need OP
  • 2023-03-24 SONO - abdomen
    • Diagnosis:
      • Fatty liver, moderate
      • Suspected GB stones with cholecystopathy
      • Suboptimal examination of liver due to poor echo window caused by severe fatty infiltration
    • Suggestion:
      • GS OPD f/u
      • Follow liver function test and AFP
      • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
  • 2023-03-21 CXR
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-01-19 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
    • Gastric erosion, antrum
    • R/O gastric intestinal metaplasia with suspicious ulcer scar, prepyloric antrum, PW site
    • Duodenal ulcer, bulb
  • 2023-01-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (125 - 30) / 125 = 76.00%
      • M-mode (Teichholz) = 76
    • Conclusion:
      • Concentric LV hypertrophy with Gr I LV diastolic dysfunction.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis; mild MR; mild TR.
  • 2022-12-07 CT - abdomen
    • CC: intermittent bloody stool for times,
      • Constipation with excessive straining (-)
      • 20221206 colonoscopy: middle rectal cancer
    • Indication: CT staging
    • Findings:
      • There is asymmetrical wall thickening at right lateral aspect of the middle rectum, measuring 2.1 cm in wall thickness that is c/w adenocarcinoma (T3).
        • In addition, There are five enlarged node in the perirectal space (N2a).
      • There is mild fatty liver, grade 3.
      • There are stones (< 1.6 cm) and sludge in the gallbladder.
      • There is a homogeneous enhancing lesion measuring 1.6 cm in the pancreatic head that may be neuro-endocrine tumor. Please correlate with CA199, MRI, and EUS.
      • Bronchiectasis in RLL and LLL of the lung are suspected.
      • There are few small ovoid-shaped lymph nodes in paratracheal space that may be benign reactive nodes. Follow up is indicated.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIB(Stage_value)
  • 2022-12-07 Patho - colon biopsy (Y1)
    • DIAGNOSIS: Intestine, large, middle rectum, biopsy — adenocarcinoma
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.

[MedRec]

  • 2023-07-07 Colorectal Surgery Lv ZongRu
    • A. rectal adenocarcinoma, cT3N2M0
    • P. rectal cancer s/p TNT with total regression.
      • after discuss with patient, patient want follow sigmoidioscopy + CT ever 3 months and LAR if recurrence, refuse TAMIS first. (TAMIS: Transanal Minimally Invasive Surgery)

[chemotherapy]

  • 2023-09-11 FOLFOX

  • 2023-08-16 FOLFOX

  • 2023-07-28 FOLFOX

  • 2023-07-12 FOLFOX

  • 2023-06-26 FOLFOX

  • 2023-06-05 FOLFOX

  • 2023-05-08 FOLFOX

  • 2023-04-10 FOLFOX

  • 2023-03-21 FOLFOX

  • 2023-03-03 FOLFOX

  • 2023-02-16 FOLFOX

  • 2023-01-16 5-FU

  • 2023-01-09 5-FU

  • 2022-12-30 5-FU

  • 2022-12-28 5-FU

==========

2023-09-12

The medications in the repeat prescription provided by VGHTPE on 2023-08-09 were replenished on 2023-09-04 and are currently in use. No issues with medication reconciliation have been identified.

2023-08-17

This patient obtained a 28-day refill of aspirin, bisoprolol, fenofibrate, ezetimibe, amlodipine, and atorvastatin from VGHTPE on 2023-08-09. All these medications are actively being used, and there are no discrepancies identified.

2023-07-13

This patient refilled a prescription on 2023-07-03 that was issued by VGHTPE on 2023-05-10 for aspirin, bisoprolol, fenofibrate, ezetimibe, amlodipine and atorvastatin. These drugs are now on the active formulary with no reconciliation issues identified.

700021224

230906

[exam findings]

  • 2023-06-24 CT - abdomen
    • Indication: Combined hepatocellular and cholangiocarcinoma of the liver, s/p S2/3 hepatectomy (2021-08-18, NTUH), with left subhepatic region and retroperitoneum recurrence and lung metastasis, stage IV
    • With and without contrast enhancement CT of abdomen shows:
      • s/p left lobe hepatectomy. A cyst, 0.8cm, in S7 of liver.
      • Mild regression of nodules along celiac axis.
      • Regression of LUL nodule.
    • Impression
      • Hepatocellular and cholangiocarcinoma of liver, s/p operation
      • Lung metastsis, in regression
      • Retroperitoneal recurrence, mild in regression
  • 2023-03-01 CT - chest
    • Indication: HCC with lung mets
    • Comparison was made with previous CT dated on 2022/11/05
      • Lungs: significant regression of a subsegmwental opacity at lingula as compared with previous CT. no nodule and minimal dependent atelectasis at LLL.
      • Pleura: minimal Lt-sided effusion.
      • Visible abdominal-pelvic contents:
        • mild dilatation of CHD and CBD
        • regression of presumbed metastatic LAP at retroperitoneum, around the pancreatic head.
        • wall thickening at antral part of stomach?.
        • Lt renal cyst measuring 1.5cm. unremarkable of both adrenal glands. diffuse wall thickening of the U-bladder.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • Lingular nodule, significant in regression.
      • retroperitoneal LAP, in regression. chronic cystitis.
  • 2022-12-26 KUB
    • Spondylosis with scoliosis of the T-and L-spine with convex to right side.
    • Wedge deformity at left lateral aspect of T12 vertebral body is noted. Please correlate with clinical symptom and history.
    • S/P clips projecting at right lobe liver?
  • 2022-11-10 CXR
    • A nodular opacity projecting in the left middle lung is noted that may be metastasis suspected. Please correlate with CT.
    • Wedge deformity at left lateral aspect of T12 vertebral body is noted. Please correlate with clinical condition.
  • 2022-11-10 Patho - peritoneum biopsy
    • Lung, LUL, Ct-guide biopsy — poorly differentiated carcinoma, suggestive of metastatic hepatocellular carcinoma
    • Sections show sheets of pleomorphic tumor cells infiltrating in a fibrotic stroma with focal tumor necrosis.
    • The immunohistochemical stains reveal CK(focal +), CK7(focal +), CK20(-), a-fetoprotein(focal +), Hepatocyte(-), Arginase(-), TTF-1(-), p40(-), and CD56(-). The resitulin special stain reveals trabecular growth pattern. The results are suggestive of metastatic hepatocellular carcinoma. Please correlate with the clinical presentation.
  • 2022-11-07 PET
    • Glucose hypermetabolic lesions in the gastrohepatic space, left subhepatic region, and right subhepatic region, highly suspected recurrent tumor with celiac chain lymph nodes metastases, suggesting biopsy for further investigation.
    • Glucose hypermetabolic lesions in the left upper lung with pleura involvement, highly suspected another primary or secondary lung cancer. Please correlate with the findings of pathological examination.
    • Glucose hypermetabolic lesions in bilateral pulmonary hilar and mediastinal regions, the nature is to be determined (cancer with regional or distant lymph nodes mets, reactive nodes or other nature ?), suggesting biopsy for investigation.
    • Increased FDG accumulation in the colon, probably physiological uptake of FDG.
    • Malignant neoplasm of liver s/p treatment with tumor recurrence in the gastrohepatic space, left subhepatic and right subhepatic regions; another primary or secondary lung cancer in the left upper lung, by this F-18-FDG PET/CT scan.
  • 2022-11-05 CT - chest
    • History and indication: Malignant neoplasm of liver
    • With and without-contrast CT of chest revealed:
      • S/P liver and spleen operation. Soft tissue tumors (up to 4.4cm) at left subhepatic region and retroperitoneum. Right liver cyst (1.0cm).
      • A soft tissue nodule (2.3cm) at LUQ r/o accessory spleen.
      • A patchy density (2.7cm) at LUL. A tiny nodule (1.8cm) at LLL.
      • R/O left renal cyst (1.5cm).
    • IMP:
      • S/P liver and spleen operation. Soft tissue tumors (up to 4.4cm) at left subhepatic region and retroperitoneum.
      • A patchy density (2.7cm) at LUL. A tiny nodule (1.8cm) at LLL.
  • 2021-03-25 ENT Hearing Test
    • PTA:
      • Reliability FAIR
      • Average R’t 81 dB HL; L’t 91 dB HL
      • R’t moderately severe to profound mixed type HL.
      • L’t severe to profound mixed type HL.
      • (masking dilemma)
    • Tymp: R’t type A; L’t type C.
    • ART: Bil ipsi absent. (contra line malfunctioned, test not done)
    • Functional gain
      • RE: 10-35 dB.
      • LE: 20-45 dB.

[MedRec]

  • 2023-03-20 SOAP Hemato-Oncology
    • Owing to Leukopenia (WBC: 4890, seg:20, ANC:987) was notd and hold C/T on 3/20 23 .
  • 2022-11-24 ~ 2022-11-27 POMR Hemato-Oncology
    • Discharge diagnosis
      • Liver cell carcinoma
      • hepatocellular carcinoma, stage IVB
      • viral hepatitis B of anti-Hbc positive
    • Prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC 7D
      • Promeran (metoclopramide 3.84mg) 1# TIDAC 7D
  • 2022-11-21 SOAP Hemato-Oncology
    • S
      • explain to pt & his brother & sister about the indication & risk / benefit of palliative C/T wt FOLFOX4 plus Pembrolizumab (self paid) or Atezolizumab / Avastin ( self-paid).
      • Pt cannot afford expensive Atezo / Avastin, but accepted FOLFOX4 plus pembrolizumab (11/21 22).
      • will give FOLFOX4 plus Pembrolizumab IV Q2W x 4 then do chest CT for response evaluation (11/21 22).
      • Adm on 11/21 22 for #1 FOLFOX4 plus Pembrolizumab ( self-paid ) IV Q2W x 4.
  • 2022-11-08 SOAP Hemato-Oncology
    • A
      • combined hepatocellular & cholangiocarcinoma s/p Op x 2 in 2018 & 2021 at NTUH, was noted to have recurrence in retroperitoneal lesion & lung mets.

[consultation]

  • 2023-05-30 Dermatology
    • Q
      • for skin itchy, small bubble noted for one week.
      • This 69-year-old female, a pt of combined hepatocellular & cholangiocarcinoma s/p Op x 2 in 2018 & 2021 at NTUH, recurrence at lung mets & retroperitoneal LNs mets Dx in Nov 2022.
      • Today, he was admitted for #8 FOLFOX4 plus Pembrolizumab (self-paid) IV Q2W x 4 on 5/30 23. 
      • He complaints skin itchy, small bubble noted for one week, so we need your help for evaluation, thanks a lot!!
    • A
      • The patient had sufferred from dry scaling texture witherythematous papules on the trunk.
      • Under the impression of xerotic dermatitis. r/o follculitis development.
      • The following sugeetion:
        • First, use lotion broadly, then Mycomb cream 1 tube topical bid use for crust and itchy erythematous lesions.
        • consdier add Topysm cream 1 tube topical bid PRN use over residual itchy papules.

[chemoimmunotherapy]

  • 2023-09-05 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-01 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-13 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-21 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 310mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 620mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 935mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-30 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 315mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 630mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 945mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-24 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-29 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-27 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4; reduced Oxa hereafter)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-08 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 85mg/m2 130mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-05 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 85mg/m2 130mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-15 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 85mg/m2 130mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-24 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4; reduced Oxa)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-09-06

According to PharmaCloud, this patient has no records of visiting other healthcare facilities in the past three months. The repeat prescriptions for Baraclude (entecavir) and Harnalidge (tamsulosin), issued on 2023-08-10 by our hospital OPD, are currently on the active medication list and no reconciliation issues have been identified.

2023-05-31

  • Pembrolizumab is associated with a variety of dermatologic toxicities. These can include immune-mediated rashes, severe conditions like Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN; some cases can be fatal), exfoliative dermatitis, and bullous pemphigoid. Among the spectrum of immune-related adverse events (irAEs) linked to pembrolizumab, skin-related effects like skin rash, pruritus, and vitiligo are the most common and typically occur earliest. However, rarer rashes such as lichenoid eruption (e.g., lichenoid dermatitis), psoriasis flare (e.g., plaque), and bullous disorders including bullous pemphigoid, SJS, and TEN warrant special attention due to their severity and potential life-threatening consequences.
  • The exact mechanism underlying these skin-related side effects is not well-understood. It is thought to possibly involve the blockade of a common antigen present both on tumor cells and the dermo-epidermal junction, or other layers of the skin.
  • The onset of these dermatologic toxicities can vary, but they often appear within the first 3 to 4 weeks of therapy and may affect patients with any type of tumor. They have also been reported to occur later in the course of treatment. The median time to onset for Sjogren syndrome-like symptoms is 70 days. For most patients, dermatologic toxicity is the first irAE experienced.
  • Considering the first administration of pembrolizumab was on 2022-11-01, approximately six months ago, it would be worth considering whether the skin symptoms might have developed earlier in the treatment course. According to recent outpatient records, there have been no reports of skin-related adverse events. This might warrant further investigation.

[bedside visit]

  • I visited the patient around 14:00 on 2023-05-31, the patient was with his wife by his side. It is confirmed that the skin symptoms appeared about a week ago, limited to the back near the waist, with a few scattered spots of broken skin due to scratching, which showed signs of subsiding after the use of dermatological medication. The patient believes it is caused by rubbing too hard during a bath, while his wife suspects it was caused by contact with moldy wood shavings when he was sawing wood. It was suggested that the skin symptom had little to do with pembrolizumab.
  • In addition, a rash occurred during the 7th chemotherapy administration (started on 2023-04-24). It was treated with a reliever and by reducing the infusion rate. During this (8th) chemotherapy session, the infusion rate was reduced as soon as the patient felt itchy. No adverse skin reactions were observed during the visit, and the management was appropriate.

701170059

230906

[exam findings]

  • 2023-08-12 KUB and lateral views of lumbar spine:
    • S/P posterior instrumental fixation with TPS-rod fixation and posterolateral fusion and anterior fusion with cage at L2-S1 levels
    • No loosening of TPs
    • S/P decompressive laminectomy of L2-L5
  • 2023-08-08 SONO - nephrology
    • Bilateral chronic change of both kidneys.
    • Bilateral renal cysts.
    • Thickened bladder wall with irregular border, cause?.
  • 2023-08-07 CT - abdomen
    • Patchy consolidation over LLL. Increased infiltration over both lower lungs. May be active infection.
    • Left pleural effusion.
    • Markedly distended urinary bladder. Mild bilateral hydroureteronephrosis.
    • Bilateral perirenal fatty strandings.
    • S/P posterior instrumentation of L2-S1 vertebrae.
  • 2023-08-07 CT - brain
    • The brain shows age-related cortical atrophy, sulcal space widening, proportionate ventricular dilatation and white matter ischemic change including the periventricular, subcortical and subinsular regions. Old lacuna infarct over left internal capsule. There is no intracranial hemorrhage seen.
    • The posterior structures including the brain stem, cerebellum and CP angles look normal. However, the beam-hardening artifact over the skull base may hamper the film reading.
    • Please take notice that non-enhanced CT scan is limited in the detection of acute ischemic infarction (particularly within the first 6 hours), small vascular lesion, neoplasm, infectious/toxic/metabolic disease. Recommend correlate with clinical condition.
  • 2023-08-07 CXR
    • Cardiomegaly and tortuosity of the thoracic aorta.
    • Widening of the mediastinum.
    • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
    • Left pleural effusion.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2023-07-03, -06-29 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Interstitial and alveolar infiltrates involving predominantly the mid-and lower-lung fields, and pleura effusions are seen. Acute pulmonary edema is highly suspected.
  • 2023-06-24 ECG
    • Sinus rhythm with Premature atrial complexes
    • T wave abnormality, consider anterior ischemia
  • 2023-06-23 SONO - abdomen
    • Fatty liver, moderate
    • Parenchymal liver disease
    • cholecystopahty: improved.
    • Renal cyst, right
    • Renal stone, right
    • Ascites, moderate
  • 2023-06-23 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (113 - 44.1) / 113 = 60.97%
      • M-mode (Teichholz) = 61.0
    • Conclusion:
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Moderate MR, mild AR and TR
      • Dilated LA, IVC and aortic root; thick IVS and LVPW
      • Moderate pulmonary hypertension
      • Premature beats and suspected short-run atrial arrhythmia during the exam, HR 79-117bpm
  • 2023-06-16 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2023-06-16 SONO - abdomen
    • Diagnosis:
      • Fatty liver, moderate
      • suspicious, acute cholecystitis
      • Ascites, mild
      • Parenchymal renal disease, bilateral
      • Renal cyst, right
      • r/o, Renal stone, left
      • pancreatic tail masked by gas.
    • Suggestion:
      • consult GS surgeon.
  • 2020-03-20 MRI - L-spine
    • History
      • 20200318 Residual pain over sacrum.
      • 20200219 Numbness for 2 days. Residual pain.
      • 20200204 For SIJ RF
      • 20191218 Bilateral SIJ pain, VAS 7.
      • 20190403 SIJ pain improved 50%, acceptable. Still right L5 radicular pain and numbness.
      • 20190319 For IPM
      • 20190313 Pain relieved for one day. VAS 10.
      • 20190227 L-spine s/p PD + PI + PF x 4 time, last op one month ago. Bilateral buttock pain, VAS 9. CAD s/p stent. Plvix use. Numbness over right lateral leg.
    • Non-contrast MRI of lumbar spine, including sagittal T2W FSE, sagittal T1W, coronal STIR, axial T2W and axial T1W images (3 mm thickness in sagitta images and 4 mm thickness in the other images) reveals:
      • Scoliosis of L-spine.
      • S/P posterior decompression and TPSs at L2-3-4-5-S1.
      • General bulging disc, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis and bilateral mild neuroforaminal narrowing at L2-3-4-5-S1, esp right side at L2-3 (with midl retrolisthesis).
      • No intramedullary lesion.
      • Diffuse infiltrative T2-hyperintensity in the atrophic muscles of lower back, indicating myositis.
      • Several T2-hyperintence cysts in both kidneys, with the largest one about 15 mm.
  • 2019-03-13 KUB + L-spine Lat.
    • KUB and lateral views of lumbar spine show:
      • S/P posterior instrumental fixation with TPS-rod fixation and posterolateral fusion and anterior fusion with cage at L2-S1 levels
      • No loosening of TPs
      • S/P decompressive laminectomy of L2-L5

[MedRec]

  • 2023-07-06 MultiTeam - Oncology Psychology
    • Referral Date: 2023-06-28
    • Reason for Referral: Disease stress event: Psychophysiological stress reactions caused by physical illness or decisions about what kind of treatment to accept. Emotional distress: anxiety, fear, depression, anger; shyness, shock, etc. Social/interpersonal/communication difficulties: Conflicts or communication difficulties with family, colleagues, friends, medical staff, other patients.
    • Conclusion:
      • S
        • Visited on 2023/07/04, cared for by a caregiver, the patient was sleeping deeply. The patient’s wife mentioned that her husband would cough at night, couldn’t sleep well, had deep phlegm that couldn’t be suctioned out. The caregiver encouraged the patient to try coughing it out himself. The patient’s wife said that tying up his hands at night makes him even more unable to sleep. Once he falls asleep, it’s fine. The pain originally was only in the stomach, now it’s in the back and all over the body. When changing patches, he needs an extra half a shot for pain relief. Moreover, when he feels pain, it’s acute, very painful, not a gradual pain. If it’s a little pain, he wouldn’t say he needs an injection. When he was first admitted to the hospital, it was too painful, he even cursed himself and his daughter, because it was too painful and he was confused.
        • Now he’s more lucid, even jokes around with everyone, unlike the initial confusion. (Speaking softly) “Sometimes he says he’s in so much pain, it would be better to die”, now the doctor helps him relieve the pain, prescribed four kidney medications, thanks for the concern.
      • O
        • Prostate cancer (bone metastasis), colon cancer (post-surgery 2022-07) treated in another hospital, 2023/06/01-15 melena, discovered gastritis, internal hemorrhoids, abnormal liver function, thickened gallbladder wall at Taipei Mackay Hospital, transferred to our hospital for further treatment on 2023/06/16, 2023/06/28 confused consciousness, aggressive behavior, emotional and communication issues were referred by the NP, 2023/06/30 family meeting, 2023/07/03 occupational safety room, social worker concern.
      • I
        • Caring for the family’s care expectations.
      • AP
        • After care from multiple parties, the family expressed apology. They still have relatively strong opinions on care (suctioning, restraint, pain relief, etc.). It is recommended to communicate in a coordinate way and enhance prognostic awareness. Counselor Psychologist Huang XiaoFang
    • Reply by: Huang XiaoFang
    • Reply date: 2023-07-05 18:34
  • 2023-07-04 MultiTeam - Social Services
    • Referral Date: 2023-06-30
    • Reason for Referral: The patient and family members have emotional distress issues during hospitalization
    • Case Status: Not Open
    • Reason for not opening the case : 2023-07-03 Consultation with the patient’s wife:
    • Family situation:
      • The patient is 70 years old, married with three daughters.
      • The patient usually lives with his wife in Shulin District.
      • The eldest daughter is married and lives in Taipei, and sometimes can work remotely due to her job nature; the second daughter is unmarried, lives in Linkou District, runs her own business, and has flexible working hours; the youngest daughter is unmarried and lives in Neihu District.
    • Assessment and Treatment:
      • During the patient’s hospitalization, the caregiver and the patient’s wife were by his side to care for him. Due to the patient’s weakness, a conversation was held with his wife. Concerned about the patient’s condition during hospitalization, his wife expressed that the patient was in discomfort and sometimes confused when he was first admitted. The wife mentioned that last week, the patient had difficulty coughing up phlegm, the primary nurse suggested suctioning, but the patient didn’t want to be suctioned. The primary nurse then said, “If you don’t get the phlegm suctioned, (coughing like this) is expected.” The patient was displeased when he heard this, and his wife was also somewhat dissatisfied.
        • The wife stated that she asked the primary nurse whether it was the doctor’s recommendation to suction, but the primary nurse did not give a straightforward answer, which led to an argument that day. However, the team was informed and intervened, the wife said that it was mainly due to a misunderstanding in communication, and the patient was cursing people randomly due to his confusion at the time. The family has since apologized to the nursing staff, the wife stated that there were no issues with the care provided by the nursing staff afterwards, the patient is now more lucid, and there have been no more incidents of cursing people randomly. Therefore, there have been no issues with the care in recent days.
      • It was also understood during the consultation that there is a nurse caring for the patient during the hospitalization period. The patient’s wife, eldest daughter, and second daughter also take turns coming to the hospital to accompany him. Considering that the patient has out-of-pocket and other derivative expenses, the social worker was concerned about the family’s financial burden. The wife indicated that the family is financially secure and able to cover the additional expenses during hospitalization. The main issue currently is the patient’s back pain and other multiple sites of pain, sometimes the pain relief is not very effective, so the team is asked to pay attention to the patient’s pain.
      • The head nurse was informed of the above matters, and it was also learned from the head nurse and the primary nurse that the patient and his family’s attitudes have been more amicable recently, and there are currently no derivative issues with the care.
      • This referral provides the above treatment, and it is understood from the consultation that the patient and his family members currently have no derivative emotional distress issues, and the main concern is the patient’s pain, asking the team to pay attention. If there are further needs for social worker assistance in the future, they can be informed again, thank you.
    • Reply by: Luo Yuquan
    • Reply date: 2023-07-03

[consultation]

  • 2023-06-29 Dermatology
    • Q
      • This is a 70-year-old man with past history of:
        • Transverse colon cancer s/p laparoscopic left hemicolectomy on 2022/07/09 at MMH
        • Prostate cancer with multiple osseous metastases
        • CAD s/p PCI DES x2 at RP, under clopidogrel/Nicorandil
        • HFDEF (2022/04 LVEF:58%)
        • Adrenal insufficiency Hypoaldosteronism Hypotonic hyponatremia, r/o Al
        • Normocytic anemia, related to colon cancer
        • Hypertension Benign prostate hyperplasia.
      • Patient bedridden.
      • For skin itchy, we need your further evaluation and management.
    • A
      • The patient had sufferred from generalized itchy skin over trunk and limbs.
      • Under the impression of xerotic dermattiis
      • The following sugeetion:
        • CB strong 3 tube mix-up with Sinphraderm 1 tube. After evenly mixing with baby oil or lotion, apply it to the dry areas of the body.
        • consider Xyzal 1# HS po use and Orolsin 1#PRNTID po use for itchy control.
  • 2023-06-24 Rehabilitation
    • Q
      • For general weakness, rehabilitation plan, we need your further evaluation and management.
    • A
      • Due to deconditioning, we were consulted for bedside PT rehabilitation programs.
      • Assessment
        • Malignant neoplasm of prostate
      • Plan
        • His wife and the patient declined rehab training currently
  • 2023-06-23 Gastroenterology
    • Q
      • The patient is an 70-year-old male with a history of CHF, suspect IAI, T-colon cancer s/p laparoscopic left hemicolectomy on 2022/07/09 at MMH, Prostate cancer with multiple osseous metastases, CAD s/p stent x2, Adrenal insufficiency. He presented with intermittent bloody stool for 4 days sent to MMH.
      • For cholecystitis, liver function raised, we need your further evaluation and management.
    • A
      • 70M.
        • The clinical history and medical records were reviewed.
        • He was hospitalized 2023/6/1-6/16 with admission diagnosis of GI bleeding.
        • The definite etiology of bleeding was uncertain, but may be colon ulcer according to the endoscopy.
        • He received a protracted antibiotic treatment course in the hospitalization, including Flumarin plus metronidazole (6/5-6/10), ertapenem (6/10-6/14) and fluconazole (6/3-6/15).
        • He developed RUQ pain and tenderness with an acute cholestatic hepatitis in days before his transfer to our hospital.
      • S+O:
        • Drinking alcohol (-)
        • Raw food consumption (-)
        • Nausea (-), Vomiting (-)
        • Diarrhea (-)
        • Taking other medications not from this hospital (-)
      • PE: mild tenderness over RUQ region
      • Lab:
        • in MMH
          • 2023/06/02 AST 18 ALT 16 TBI 0.5
          • 2023/06/13 AST 405 ALT 391 ALP 451 GGT 1494 Lipae 33 TBI 2.0 DBI 1.7
          • 2023/06/15 AST 654 ALT 672 TBI 3.8 DBI 2.6
        • in TTCH
          • 2023/06/16 AST 237 ALT 441 ALP 430 GGT 1489 TBI 2.97 DBI 1.74; WBC 9.65 Seg 94.8% CRP 1.2 PCT 0.36

          • 2023/06/23 AST 68 ALT 127 ALP 239 GGT 993 TBI 5.64 DBI 3.43 PT 11.5 NH3 51

          • 2023/06/17 HBsAg-/AntiHBs+/AntiHCV-

          • 2023/06/23 TSH 0.053 (low), T3 0.67 (low) FT4 1.27; cortisol 17.74

        • in MMH
          • 2023/06/15 CT scan: marked edematous change of GB, but no evident gallstone or CBD stone, no biliary tract dilatation
        • in TTCH
          • 2023/06/16 Abd echo: moderate fatty liver, marked GB wall thickening with non-disteded GB, no biliary tract dilatation, mild ascites
          • 2023/06/23 Abd echo: moderate fatty liver, improved GB wall thickening, no biliary tract dilatation, moderate ascites
      • Impression:
        • Cholecystopathy or cholecystitis (non-calculous)
        • Acute cholestatic hepatitis or cholangitis, more likely to be intrahepatic cholestasis, but extrahepatic cause (such as microlithiasis of CBD) could not be ruled out
          • possible etiology of intrahepatic cholestas is included: atypical viral hepatitis, DILI (e.g. fluconazole or other antibiotic), sepsis, TPN, autoimmune liver disease (less likely)
        • Abnormal thryoid function, r/o sick euthyroid syndrome
      • Suggestion:
        • Treat acute disease per your expertise
        • No indication of biliary drainage since there was NO sign of biliary obstruction
        • Watch out for the hepatic decompensation for the progression of ascites and jaundice
        • May try empirical treament of Urso in dose of 1-2# TID
        • Consider EUS or MRCP to rule out microlithiasis of CBD
        • Screen viral hepatitis, such as HAV, EBV, CMV. May survey HEV (by CDC) if the other viral infeciton is excluded
        • Consider diagnostic paracentesis for the ascites
        • Avoid hepatic toxic agent and simplify medication if possible
        • Regularly follow up liver and biliary enzymes, bilirubin, PT
        • If the diagnosis remains inconclusive after these studies, consider to survey autoimmune profile, including: ANA. SMA, AMA, IgG4
        • Monitor liver function. If the above examinations and treatments do not yield results or improvements, please contact us.
  • 2023-06-23 Cardiology
    • Q
      • For HF history, liver function raised, R/O HF related, we need your further evaluation and management.
    • A1
      • 70 year-old male had the history of HF, CAD s/p stent(?), DM, T-colon cancer s/p left hemicolectomy at other hospital.
        • CXR 20230616 cardiomegaly
        • ECG 20230616 sinus tachycardia
      • O
        • LAB
          • 20230623 TSH 0.053, FT4 1.27 T3 0.67 cortisol 17.7 A1c6.3% chol 147 TG182 LDL99
          • Hb13.3 WBC8800 PLT112k ALT 441–201-127 Cre0.63 K2.8 albumin3.7 CRP4.8
        • Echocardiogram 20230623
          • Findings
            • AO(mm) = 38
            • LA(mm) = 47
            • IVS(mm) = 14.8-14.3
            • LVPW(mm) = 13.9-14.8
            • LVEDD(mm) = 49.1
            • LVESD(mm) = 33.0
            • TAPSE(mm) = 18.5
            • LVEF(%) =M-mode(Teichholz) = 61.0
            • TR: mild ; Max pressure gradient = 49 mmHg
            • Mitral E/A = 124 / 81.4 cm/s (E/A ratio = 1.52) ;
            • IVC size 21.4 mm with inspiratory collapse < 50%
          • Conclusion:
            • Adequate LV systolic function with no regional wall motion abnormality at resting state
            • Moderate MR, mild AR and TR
            • Dilated LA, IVC and aortic root; thick IVS and LVPW
            • Moderate pulmonary hypertension
            • Premature beats and suspected short-run atrial arrhythmia during the exam, HR 79-117bpm
      • liver echo-20230616
        • Fatty liver, moderate
        • suspicious, acute cholecystitis
        • Ascites, mild
        • Parenchymal renal disease, bilateral
        • Renal cyst, right
        • r/o, Renal stone, left
        • pancreatic tail masked by gas.
      • Impression
        • Moderate MR
        • suspected arrhythmia
        • abnormal liver biochemistry, related to fatty liver? congestive liver?
      • Suggestion
        • Holter ECG for atrial arrhythmia evaluation
        • resume medications as bisoprolol, valsartan, antiplatelet, OADs, furosemide and spironolactone
        • Monitor fluid status and titrate diiuretic dose, monitor potassium level
    • A2 2023-06-23 20:36:51
      • 6/23 NTproBNP 22334 A1c6.3%
      • Heart failure with preserved EF
    • A3 2023-07-11 14:22:49
      • lowest body weight on 7/1
      • more clear lung field by CXR of 7/3 than 6/29 and 7/10
      • Suggestion
        • may increase concor dose for HR control
        • may add digoxin 0.5# qd for HF
  • 2023-06-23 Infectious Disease
    • A
      • Consultation of Mepem antibiotic
        • There is no medical record about underlying disease and indication of Mepem antibiotic
        • Normal white count, negative serum PCT level, CRP level 4.9 on 2023-06-19, 4 days ago.
        • Patient has received one-week Flumarin for possible cholecystitis since 2023-06-16, the day of admission.
        • Higher bilirubin level noted today, that Flumarin is replaced by Mepem today.
        • Mepem seems not absolutely necessary at the present time.
      • Suggestion:
        • Recheck serum CRP level.
        • Use Brosym to replace Mepem.
  • 2023-06-21 Metabolism and Endocrinology
    • Q
      • The patient is an 70-year-old male with a history of CHF, suspect IAI, T-colon cancer s/p laparoscopic left hemicolectomy on 2022/07/09 at MMH, Prostate cancer with multiple osseous metastases, CAD s/p stent x2, Adrenal insufficiency. He presented with intermittent bloody stool for 4 days sent to MMH.
      • For Adrenal insufficiency history, we need your further evaluation and management.
    • A
      • This 70-year-old male, with past history of CHF, suspect IAI, T-colon cancer s/p laparoscopic left hemicolectomy on 2022/07/09 at MMH, Prostate cancer with multiple osseous metastases, CAD s/p stent x2, Adrenal insufficiency, was admitted due to bloody stool. We were consulted for adrenal insufficiency.
      • O:
        • Lab
          • 2023-06-19 S-GOT/AST 32 U/L
          • 2023-06-19 S-GPT/ALT 201 U/L
          • 2023-06-19 BUN 31 mg/dL
          • 2023-06-19 Creatinine 0.74 mg/dL
          • 2023-06-16 Na (Sodium) 141 mmol/L
          • 2023-06-16 K(Potassium) 3.8 mmol/L
        • SBP: 122-163
        • HR: 77-111
        • F/S: 377/239/284
      • A:
        • Adrenal insufficiency history
        • DM
      • Suggestions:
        • Keep Cortisone 1# BID at present
        • If vital signs unstable, IV hydrocortisone is indicate
        • Check ACTH/cortisol 8am, HbA1C, Cho, TG and LDL
        • After new data available, call me to interpret
  • 2023-06-17 Gastroenterology & General Surgery
    • Q
      • The patient is an 70-year-old male with a history of CHF, suspect IAI, T-colon cancer s/p laparoscopic left hemicolectomy on 2022/07/09 at MMH, Prostate cancer with multiple osseous metastases, CAD s/p stent*2, Adrenal insufficiency. He presented with intermittent bloody stool for 4 days sent to MMH.
      • 2023/06/10 CT showed
        • Compared with last CT on 2022/07/08, no CT evidence of local recurrence at previous operation region at colon loop & mild shrinkage of prostate gland and bilateral seminal vesicles
        • Neurogenic bladder
        • Suspicious for congestive heart failure; Please correlate with cardiac sonography findings.
      • 2023/06/16 Abdominal echo showed
        • Fatty liver, moderate
        • suspicious, acute cholecystitis
        • Ascites, mild
        • Parenchymal renal disease, bilateral
        • Renal cyst, right
        • r/o, Renal stone, left
        • pancreatic tail masked by gas.
      • above all, we need your further evaluation and management.
    • A
      • we were consulted for suspect cholecystitis and abnormal liver function test
      • lab data:
        • jaundice and AST/ALT improved (comparing the data on 6/15 and 6/16)
      • impression
        • abnormal LFT, suspect passing tiny CBD stones with cholangitis related
        • cholecystitis
      • suggest
        • keep flumarin use
        • try water today, may try clear liquid diet tomorrow
        • f/u lab data next w1

[treatment]

  • 2023-07-07 ~ undergoing - Xtandi (enzalutamide 40mg) 4# QDAC

  • 2023-07-10 - Zoladex Depot (goserelin 3.6mg) SC ST

  • 2023-05-09 - Firmagon (degarelix 80mg) at Taipei Mackey Hospital

  • 2023-04-11 - Firmagon (degarelix 80mg) at Taipei Mackey Hospital

  • 2023-05-09 - Xgeva (denosumab)

  • 2023-04-11 - Xgeva (denosumab)

==========

2023-09-06

[hyperbilirubinemia]

This patient’s blood bilirubin level has increased significantly since late August.

2023-09-04 Bilirubin total 25.09 mg/dL 2023-08-31 Bilirubin total 19.49 mg/dL 2023-08-29 Bilirubin total 19.02 mg/dL 2023-08-29 Bilirubin total 19.02 mg/dL 2023-08-28 Bilirubin total 18.30 mg/dL 2023-08-24 Bilirubin total 13.31 mg/dL 2023-08-21 Bilirubin total 10.81 mg/dL 2023-08-17 Bilirubin total 6.25 mg/dL 2023-08-14 Bilirubin total 3.61 mg/dL 2023-08-10 Bilirubin total 1.49 mg/dL 2023-08-08 Bilirubin total 1.03 mg/dL 2023-08-07 Bilirubin total 1.19 mg/dL

2023-09-04 Bilirubin direct 14.35 mg/dL 2023-08-31 Bilirubin direct 12.67 mg/dL 2023-08-29 Bilirubin direct 12.16 mg/dL 2023-08-29 Bilirubin direct 12.16 mg/dL 2023-08-28 Bilirubin direct 9.94 mg/dL 2023-08-24 Bilirubin direct 7.89 mg/dL 2023-08-21 Bilirubin direct 6.44 mg/dL 2023-08-17 Bilirubin direct 3.58 mg/dL 2023-08-14 Bilirubin direct 2.11 mg/dL 2023-08-10 Bilirubin direct 0.74 mg/dL 2023-08-08 Bilirubin direct 0.37 mg/dL

Upon reviewing all drugs on the active medication list, 3 drugs are found to be associated with liver-related adverse reactions:

  • Furosemide (frequency unspecified): Can cause hepatic encephalopathy, elevated liver enzymes, and intrahepatic cholestatic jaundice.
  • Fentanyl (occurring in 1% or more of patients): Associated with ascites, elevated serum alkaline phosphatase, increased serum aspartate aminotransferase, and jaundice.
  • Ceftriaxone (<= 6%): increased serum alanine aminotransferase, increased serum alkaline phosphatase, increased serum aspartate aminotransferase, increased serum bilirubin.

2023-08-08

[Brosym 1000mg Q12H for patients with CrCl < 15mL/min]

Patient: Male, 70 years old, weighing 52kg, with a creatinine level of 3.58mg/dL, resulting in a creatinine clearance (CrCl) of 14mL/min.

According to the Sanford Guide, the recommended maximum dose of sulbactam for patients with a CrCl < 15mL/min is 500mg every 12 hours. Therefore, the appropriate dose for this patient would be Brosym 1000mg every 12 hours.

2023-07-12

[to increase the dose of long-acting insulin]

Considering that fasting blood glucose levels from 2023-07-10 to 2023-07-12 are still on the high side, ranging around 200mg/dL to 300mg/dL, even with the current insulin regimen of Apidra (insulin glulisine) 3 units TIDAC and Tresiba (insulin degludec) 6 units HS for days, it is recommended to increase the dosage of Tresiba from 6 units to 7 units and continue monitoring blood glucose levels to determine if further adjustments are necessary.

[bilirubin level follow-up]

The patient’s bilirubin levels have remained stable over the past two weeks.

  • 2023-07-10 Bilirubin total 1.62 mg/dL
  • 2023-07-07 Bilirubin total 1.59 mg/dL
  • 2023-07-03 Bilirubin total 1.84 mg/dL
  • 2023-06-29 Bilirubin total 1.71 mg/dL
  • 2023-07-10 Bilirubin direct 0.53 mg/dL
  • 2023-07-07 Bilirubin direct 0.75 mg/dL
  • 2023-07-03 Bilirubin direct 0.67 mg/dL
  • 2023-06-29 Bilirubin direct 0.78 mg/dL

Upon reviewing the drugs in the patient’s active medication list, there is no clear evidence suggesting a need to adjust the dosages based on the current state of the patient’s liver function.

2023-07-10

[bedside visit]

I visited the patient around 09:15 on 2023-07-10. He was lying in bed with his eyes closed, and his wife and a caregiver were present in the room. The patient didn’t respond when I conversed with his wife and the caregiver.

The patient’s caregiver mentioned that the patient’s feet were cold, so she placed a warm water bag near his feet to try to provide warmth. The patient’s wife reported that the patient had begun to sweat profusely on his head the previous night (without night sweats from the body), had not slept all night, and had a poor appetite, eating only a small amount.

Upon asking about the patient’s pain, bowel movements, and breathing, the caregiver indicated that the patient’s stools were regular, but his urine output was reduced due to concerns about pulmonary edema and fluid retention leading to reduced fluid intake. The patient continues to experience occasional shortness of breath and expresses discomfort, but there has been no significant increase in the intensity or duration of pain.

[Zoladex (goserelin)]

There is no dosage adjustment necessary for Zoladex (goserelin) in kidney impairement and/or hepatic impairment patients.

NHI provides coverage for the use of Gn-RH analogs, such as goserelin, exclusively for conditions like prostate cancer, central precocious puberty, endometriosis, and breast cancer in pre-menopausal (or peri-menopausal) cases. This patient should meet the criteria for coverage.

2023-07-06

[bedside visit: breathing smoother]

I visited the patient on 2023-07-06 at approximately 10:30. The patient was in bed, using an oxygen mask with his eyes closed, and his wife and daughter were in the room with him. I noticed that the patient’s breathing did not seem rapid. I asked his wife and daughter about the patient’s condition, and his daughter replied that the patient’s breathing seemed smoother than it had been in the past few days and that there were no specific problems at the moment. When I asked if they had any questions about the medication or wanted to understand more, they indicated that they did not have any at this time.

[patient education: enzalutamide]

The patient agreed to use Xtandi (enzalutamide). I prepared an information sheet about enzalutamide, highlighting points the patient should be aware of, as well as potential side effects of the medication. At approximately 14:10 on 2023-07-06, I visited the patient, who was resting in the room with his daughter and caregiver. I gently woke the patient’s daughter and gave her the highlighted sheet. I also gave her the contact information for the pharmacy window and encouraged her to call if she had any questions about the medication.

2023-06-30

[Minutes of the Multidisciplinary Team Meeting and Patient Family Meeting]

Today, on 2023-06-30 at around 11:45, Dr. Hsia gathered the patient’s daughter and the patient’s wife’s brother, and explained the current status of the patient’s condition using medical images. Then, from 12:15 to 13:15, a multidisciplinary team meeting and family meeting was held in the ward conference room. The meeting was chaired by Dr. Hsia and included members such as the nurse practitioner, the head nurse of the ward, the charge nurse, the social worker, and myself as the pharmacist. The the patient’s family representatives included the patient’s daughter and the patient’s wife’s brother. Dr. Hsia first clarified several key observations and considerations about the patient’s current condition. I presented the rationale behind the selection of anti-androgen agents, taking into account the expected changes in liver function. In addition, each of the nursing professionals also expressed their own perspectives.

Going forward, the pharmacy will continue to collaborate with the entire team in the management of this patient.

[bedside visit]

I visited the patient around 13:15 on 2023-06-30. The patient was using an oxygen mask, and his wife was standing by his bed. I asked about the patient’s current condition, and his wife indicated that he still had difficulty breathing, but he no longer coughed up blood. Upon checking the patient’s feet, I did not find any signs of lower limb edema.

2023-06-29

[Rationale for the Selection of Anti-Androgen Agents in Patients with Potential Hepatic Impairment]

We currently have three anti-androgen medications in stock: Casodex (bicalutamide 50mg), Xtandi (enzalutamide 40mg), and Nubeqa (darolutamide 300mg), with the last one is a temporary purchase item and thus limited its use for certain patients.

Considering the patient’s normal AST and ALT levels along with elevated bilirubin (direct 0.78mg/dL, total 1.71mg/dL) as of 2023-05-29, the patient’s liver function should be taken into account when prescribing these drugs.

  • Bicalutamide:
    • For hepatic impairment at treatment initiation: No dosage adjustment is necessary for mild, moderate, or severe impairment. However, caution is advised for patients with moderate to severe impairment as clearance may be delayed in severe impairment (based on a limited number of patients).
    • For hepatic impairment during treatment: If ALT rises above twice the upper limit of normal or jaundice develops, the treatment should be discontinued immediately.
  • Enzalutamide:
    • For mild, moderate, or severe impairment (Child-Pugh class A, B, or C): No dosage adjustment necessary. Nevertheless, an increased drug half-life has been observed in patients with severe hepatic impairment.
  • Darolutamide:
    • For mild impairment (Child-Pugh class A): No dosage adjustment necessary.
    • For moderate impairment (Child-Pugh class B): The dose should be reduced to 300 mg twice daily.
    • For severe impairment (Child-Pugh class C): There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied).

In conclusion, enzalutamide appears to be least affected by liver function and could be a reasonable choice if the patient’s liver function is not expected to recover in the short term.

2023-06-19

  • The PharmaCloud database does not disclose any data for this patient, which could be due to the patient not having granting access.

  • In the past 3 years, there have been no records of outpatient or inpatient services for this patient at our hospital prior to this hospitalization. Consequently, no medication reconciliation issues have been detected.

  • Since the patient’s admission, fasting blood glucose levels have consistently ranged between 200 and 300 mg/dL, even with the administration of regular insulin 2 units PRNQ6H. To better manage these elevated blood sugar levels, it is advisable to increase the insulin dose to 3 units just before each meal. This approach trys to prevent blood glucose levels from exceeding 200 mg/dL. Continue to monitor blood glucose readings to assess the effectiveness of this adjustment and determine if further changes are needed.

  • The fasting serum glucose levels since this hospitalization were between 200 and 300 mg/dL even under regular insulin 2 units PRNQ6H. It is recommended to increase the dose to 3 unit right before each prandial to keep the blood sugar level at least not exceed 200mg/dL and keep monitoring the readings to decide if furthur adjustment necessary.

700208930

230905

[exam findings]

  • 2023-09-02 Ocular fundus color photography
    • BDR, Background Diabetic Retinopathy
  • 2023-08-05 MRI - pelvis
    • Indication: Endometrioid carcinoma, grade 2, of the uterine endometrium, AJCC Pathologic stage, pT2N0, cM0, stage II / FIGO stage II
    • Pelvic MRI with and without IV contrast enhancement shows:
      • s/p ATH and BSO
      • Cystic change at bilatral iliac fossa measuring 1.33cm at right side and 1.5cm at left side. Lymphocele is favored. In comparison with MRI dated on 2023-04-15, the lesion is stationary.
    • Imp:
      • s/p ATH and BSO.
      • Cystic change at bilatearal iliac fossa, stationary in size.
      • r/o lymphocele.
  • 2023-07-03 Gynecologic ultrasonography
    • ATH + BSO
    • IMP: No obvious uterine or ovarian lesion
  • 2023-04-15 MRI - pelvis
    • Clinical history: 44 y/o female patient with EM cancer.
    • Without contrast enhancement MRI: Pelvis
      • S/P hystercctomy.
      • Presence of gallbladder stones.
      • Mild ascites.
      • Disc space narrowing at L5-S1.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T: T0_(T_value) N:N0_(N_value) M:M0(M_value) STAGE:____(Stage_value)
    • Impression:
      • Clinical endometrial malignancy.
      • S/P hysterectomy.
      • GB stones.
  • 2023-04-13 Patho - uterus with or without SO non-neoplastic/prolapse
    • PATHOLOGIC DIAGNOSIS
      • Endometrium, uterus, frozen + LSC staging surgery — Endometrioid carcinoma, grade 2
      • Myometrium, uterus, ditto — Tumor invasion, less than half thickness
      • Cervix, uterus, ditto — Stromal invasion
      • Ovary, left, ditto — Free of tumor invasion, cystic follicles
        • Fallopian tube, left, ditto — Free of tumor invasion, paratubal cyst
      • Ovary, right, ditto — Free of tumor invasion
        • Fallopian tube, right, ditto — Free of tumor invasion
      • Lymph nodes
        • Lymph node, left iliac, dissection — Free of tumor metastasis (0/7)
        • Lymph node, left oburator, ditto — Free of tumor metastasis (0/5)
        • Lymph node, right iliac, ditto — Free of tumor metastasis (0/6)
        • Lymph node, right oburator, ditto — Free of tumor metastasis (0/4)
      • Parametrium, bilateral — Free of tumor invasion
      • AJCC Pathologic stage — pT1aN0, if cM0, stage IA / FIGO stage IA
      • Revised diagnosis: 8. AJCC Pathologic stage — pT2N0, if cM0, stage II / FIGO stage II
        • Reason for revision: cervical stromal invasion
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: frozen section + LSC staging surgery (TAH, BSO and BPLND)
      • Specimens include: uterus, bilateral ovaries and fallopian tubes and pelvic LNs
      • Specimen size:
        • uterus: 7.8 x 5.2 x 3.5 cm, 98 gm
        • right ovary: 3.5 x 2.1 x 1.6 cm
        • left ovary: 3.7 x 2.3 x 2.2 cm
        • right fallopian tube: 4.8 cm in length; 0.5 cm in diameter
        • left fallopian tube: 5.1 cm in length; 0.6 cm in diameter with one paratubal cyst 2.6 x 1.7 cm
      • Tumor site: endometrium
      • Tumor size: 4.8 x 4.1 cm, solid mass with many detached tumor fragments
      • The myometrium: up to 1.7 cm in thickness
      • The cervix : mucoid cysts
      • Adnexa (bilateral): left ovary and bilateral tubes are not invaded by tumor
      • Lymph nodes: left iliac LNs; left obturator LNs; right iliac LNs and right obturator LNs
      • Representative sections as follows: A: left iliac LNs; B: left obturator LNs; C: right iliac LNs; D: right obturator LNs, E1: R’t fallopian tube, E2: R’t ovary, E3: L’t fallopian tube, E4: L’t paratubal cyst, E5-E6: L’t ovary, E7: R’t parametrium, E8: L’t parametrium, E9-E13: mass, E14: cervix and E15: detached tumor fragments [Reference: F2023-00161 blood and some white tumor fragments measured up to 0.7 x 0.5 x 0.3 cm. All embedded as FSA1-FSA2]
    • MICROSCOPIC EXAMINATION
      • Histology type: Endometrioid carcinoma
      • Histology grade: Grade 2
      • Depth of invasion: less than half thickness of myometrium
      • Lymphovascular invasion: absent
      • The cervical stroma involvement: involved
      • Resection margins of the cervix: Free, 1.4 cm away from tumor
      • Additional pathologic findings: focal tumor necrosis
      • Lymph nodes: Free of tumor metastasis (0/22) in total number
      • Immunohistochemistry: P53(wild type), ER(+), PAX-8(+), P16(-) and vimentin(+) for tumor
      • Ascites cytology: negative
  • 2023-03-27 Gynecologic ultrasonography
    • R/O Mass ? Cx, 36 x 32 mm, RI: 0.44
  • 2023-03-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 23) / 79 = 70.89%
      • M-mode (Teichholz) = 70.4
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, grade 1 LV diastolic dysfunction
      • Mild MR, PR

[MedRec]

  • 2023-08-26 SOAP Metabolism and Endocrinology Laio YuHuang
    • Prescription
      • Linicor (niacin 500mg, lovastatin 20mg) 1# QD
      • Forxiga (dapagliflozin 10mg) 1# QD
      • Uformin (metformin 500mg) 1# QLCC
      • Glimet (glimepiride 2mg, metformin 500mg) 2# BIDCC
      • Lipanthyl (fenofibrate 160mg) 1# QD
      • Tresiba FlexTouch (insulin degludec) 10 unit HS SC
  • 2018-05-05 SOAP Metabolism and Endocrinology Laio YuHuang
    • Diagnosis
      • Type 2 diabetes mellitus without complications [E11.9]
      • Hyperlipidemia, unspecified [E78.5]
    • Prescription x3
      • Grumed (glimepiride 2mg) 0.5# QDCC
      • Uformin (metformin 500mg) 1# QLCC
      • Uformin (metformin 500mg) 2# BIDCC
      • Robestar (rosuvastatin 10mg) 1# QD
      • Januvia (sitagliptin phosphate 100mg) 1# QDCC
      • Lipanthyl (fenofibrate 160mg) 1# QD

[radiotherapy]

[chemotherapy]

  • 2023-09-05 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-08-05 - paclitaxel 165mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (lower paclitaxel)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-07-14 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-06-19 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-05-19 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-05-10 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2023-09-05

After reviewing the PharmaCloud and HIS5 records, no issues with medication reconciliation were identified. However, a blood glucose level of 263mg/dL recorded at 06:21 on 2023-09-05 suggests that glucose control may be suboptimal despite the use of multiple antidiabetic medications. Continuous monitoring of blood sugar levels is recommended to identify any developing trends.

[hypertriglyceridemia > 1000mg/dL]

During the months of June and July, there was a significant increase in triglyceride levels, leading to severe hypertriglyceridemia (exceeding 1000 mg/dL). Elevated triglycerides could interfere with an initial stage of the insulin signaling pathway, or conversely, insulin resistance might be contributing to the hypertriglyceridemia.

2023-08-26 Triglyceride (TG) 2209 mg/dL
2023-08-19 Triglyceride (TG) 1581 mg/dL
2023-08-05 Triglyceride (TG) 1183 mg/dL
2023-07-29 Triglyceride (TG) 2254 mg/dL
2023-07-22 Triglyceride (TG) 1814 mg/dL
2023-07-13 Triglyceride (TG) 2383 mg/dL
2023-07-08 Triglyceride (TG) 1802 mg/dL
2023-06-03 Triglyceride (TG) 597 mg/dL
2023-05-06 Triglyceride (TG) 491 mg/dL
2023-04-08 Triglyceride (TG) 495 mg/dL
2023-03-11 Triglyceride (TG) 409 mg/dL
2023-02-11 Triglyceride (TG) 318 mg/dL
2023-01-14 Triglyceride (TG) 309 mg/dL

Hypothyroidism is most often associated with hypercholesterolemia (2023-07-08 cholestrol total 355 mg/dL), but association with hypertriglyceridemia has also been described. Ref: Thyroid function and prevalent and incident metabolic syndrome in older adults: the Health, Ageing and Body Composition Study. Clin Endocrinol (Oxf). 2012;76(6):911-918. doi:10.1111/j.1365-2265.2011.04328.x

When the TG level is >1000 mg/dL, drugs used to lower TG have limited effectiveness. These agents work primarily by reducing hepatic TG synthesis and secretion as VLDL-TG and thus are relatively ineffective when TG level is severely elevated.

2023-06-20

  • Based on the PharmaCloud records, all recent medications have been prescribed by our hospital. This patient last visited our metabolism OPD on 2023-06-03 for her type 2 diabetes mellitus and hyperlipidemia. Our endocrinologist provided prescriptions for Linicor (niacin 500mg, lovastatin 20mg) 1# QD, Forxiga (dapagliflozin 10mg) 1# QD, Uformin (metformin 500mg) 1# QLCC, Glimet (glimepiride 2mg, metformin 500mg) BIDCC, Lipanthyl (fenofibrate 160mg) 1# QD and Tresiba Flex Touch (insulin degludec) 10 units HS. All these medications have been successfully incorporated into the active medication list, without any reconciliation issues identified.

[patient education]

  • At around 15:15 on 2023-06-20, I visited the patient, who was resting with her eyes closed. Her sister, who was sitting in a chair next to the bed, woke her up. I brought the patient information leaflets for paclitaxel and carboplatin, explaining the potential side effects of each drug one by one. I asked her to inform the medical team as soon as possible if any suspicious symptoms occur. The patient reported that she had previously told Dr. Wan about numbness in her fingertips after chemotherapy, and stated that this condition still persists at the time of this visit.

  • Although carboplatin has been linked to peripheral neuropathy in 4% to 6% of cases, the association is even stronger with paclitaxel, which is linked to peripheral neuropathy in 42% to 70% of cases (grades 3/4 <= 7%). Therefore, it’s more probable that the numbness in the patient’s fingertips is primarily due to paclitaxel.

  • The 2020 ASCO guidelines suggest that clinicians may consider offering duloxetine to patients with chemotherapy-induced peripheral neuropathy. Additionally, the 2020 joint ESMO/EONS/EANO guidelines recommend duloxetine for the treatment of neuropathic pain in this context. Reference: “Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325”.

  • We currently have Cymbalta (duloxetine 30mg/cap) in stock. For chemotherapy-induced peripheral neuropathy, the oral initial dose is 30 mg once daily for 1 week, then increased to 60 mg once daily. (ref: UpToDate)

700551627

230905

[exam findings]

  • 2023-08-11 All-RAS + BRAF gene mutation analysis
    • Tissue Block No: S2023-10045
    • RESULTS:
      • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-06-23 Pure Tone Audiometry, PTA
    • Reliabilty Fair
    • R’t : 31 dB HL, normal to moderate SNHL
    • L’t : 35 dB HL, mild to moderate SNHL.
  • 2023-06-05 Bladder Sonography
    • PVR: 26 mL
  • 2023-06-22 CXR
    • Interstitial pattern at LLL.
  • 2023-05-23 Patho - vaginal biopsy
    • Vagina, vaginectomy — Adenocarcinoma, recurrent
    • The secvtions show a picture of adenocarcinoma (tumor size: 0.3 x 0.3 cm), composed of low columnar to cuboidal neoplastic cells, arranged in glandular and papillary patterns, floating in mucin pool. The surgical margin is free of carcinoma. The distance of tumor from closest margin about 3 mm.
  • 2023-05-03 CT - chest
    • Indication: AIS of lung Vagina adenocarcinoma s/p OP and R/T. R/O recurrence
    • Comparison was made with previous CT dated on 2022
      • Lungs: surgical staple lines and coarse reticular and subsegmental opacities at both lower lobes, s/p wedge-resection.
        • a 11mm lung cyst at RLL too.
        • normal appearance of both upper lobes and RML.
      • Mediastinum and hila: no enlarged LN or mass.
        • the trachea and main bronchi are normallly identified without endobronchial lesion.
      • Vessels: normal appearance of thoracic aorta.
      • Central pulmonary arteries: dilated trunk (3.4cm in caliber)
      • Heart: normal in size of cardiac chambers.
      • Pleura: minimal effusion and thickening, both sides.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal contents: a poor enhancing nodule (1.5cm) at liver dome, S8, r/o a hemangioma
        • normal appearance of gall bladder. unremarkable of the spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
      • Visualized bones: compression fracture of L1 vertebral body
    • Impression:
      • post op change in both lower lobes of the lungs.
      • no new lung nodule (s). pulmonary hypertension, cause?
  • 2023-05-02 CT - abdomen
    • History and indication: Malignant neoplasm of vagina
    • IMP:
      • S/P hysterectomy. R/O recurrent tumor (2.3cm) at vaginal stump with urinary bladder invasion.
      • A poor enhancing nodule (1.5cm) at liver dome r/o hemangioma.
  • 2023-04-12 Pap Smear
    • Atypical glandular cells favor neoplasm
  • 2023-03-07 CT - abdomen
    • Clinical history: 53 y/o female patient with liver lesion and pathological report and follow up the deisease condition and report. LMP 8/3/20 HPV : + (type 18) pap : abnormal (2020). LEEP in 2016 NTUH, LSC LAVH+BSO (SlLS) on 20200907.
      • post laparotomy operation visit. for checking wound. Vaginal Ca s/p OP.
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P hysterectomy. There is rim enhanced lesion, 1.6cm in the vaginal stump, with urinary bladder involvement, r/o recurrent tumor.
      • Liver tumor, 1.5cm in S8, prior MRI study showed hemangioma. Suggest follow up.
      • Ventral herniation (lower abdomen).
    • Impression:
      • S/P hysterectomy. Rim enhanced lesion in the vaginal stump, with urinary bladder involvement, r/o recurrent tumor.
      • Liver tumor, r/o hemangioma.
      • Post-op at bilateral lower lungs.
  • 2023-01-09 CXR
    • Cardiomegaly is noted.
    • Some fibrotic change at left lower lobe is found.
    • Osteopenia of the bony structure is noted.
  • 2022-12-09 CT - abdomen
    • history: 52 y/o female patient with Vaginal cancer s/p OP
      • 20220914 lung nodule in RLL and LLL, favor metastases?
      • 20220921 Lung, RLL, VATS wedge: Non-necrotizing granulomatous inflammation
      • 20221116 Lung, LLL, VATS wedge: adenocarcinoma in situ.
    • Findings:
      • Prior CT identified two poor enhancing mass 1.5 cm in S8 and 0.4 cm in S5/6 of the liver are noted again, stationary that are c/w hemangiomas after correlate with prior MRI.
      • There are soft tissue lesion with curvelinear calcification in RLL and LLL of the lung that are c/w prior VATS procedure.
    • Impression:
      • Two hemangioma in S8 and S5/8 show stationary.
  • 2022-11-16 Patho - lung wedge biopsy
    • PATHOLOGIC DIAGNOSIS:
      • Lung, left, lower lobe, wedge resection —- Adenocarcinoma in situ
      • Lymph node, left, group No.9, lymphadenectomy —- Negative for malignancy (0/2) —- Non-necrotizing granulomatous inflammation
      • AJCC 8th edition pTNM Pathology stage: pTisN0
    • MACROSCOPIC EXAMINATION:
      • Specimen:
        • F2022-00544: Lung, size: 5.7 x 4.2 x 1.1 cm
        • S2022-20247: Lymph nodes, a bottle, group 9, maximal size: 0.5 x 0.2 cm
      • Tumor Site: Periphery
      • Tumor Size: Solitary: 0.2 x 0.2 x 0.2 cm
      • Gross tumor patterns: Well defined
      • A granuloma measuring 0.3 x 0.2 x 0.2 cm is seen.
      • Tissue for sections:
        • F2022-00544: Representative sections are taken and labeled as: FsA1: granuloma; FsA2: tumor, for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: resection margin; X2: lung; X3-4: lung, near tumor.
        • S2022-20247: All for section in a cassette.
    • Microscopic Description
      • Tumor Focality: Single tumor
      • Histologic Type (select all that apply): Adenocarcinoma in situ (AIS), nonmucinous; The immunohistochemical stain of TTF-1 is positive.
      • Histologic Grade: Not applicable
      • Spread Through Air Spaces (STAS): Not identified
      • Visceral Pleura Invasion: Not identified
      • Lymphovascular Invasion (select all that apply): Not identified
      • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
      • Margins (select all that apply): All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin (centimeters): 0.5 cm
        • Specify closest margin: wedge resection margin
      • Treatment Effect: No known presurgical therapy
      • Regional Lymph Nodes: group 9: 0/2
      • Extranodal Extension: Not identified
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): not applicable
          • Primary Tumor (pT): pTis (AIS): Adenocarcinoma in situ (AIS): adenocarcinoma with pure lepidic pattern, ≤3 cm in greatest dimension
          • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
          • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
      • Additional Pathologic Findings (select all that apply)
        • Non-necrotizing granulomatous is seen in the lung parenchyma and lymph nodes. The PAS and AFB special stains are negative.
  • 2022-11-01 Patho - cervix biopsy
    • Uterus, cervix, biopsy — high-grade glandular dysplasia
    • Microscopically,it shows high-grade glandular dysplasia characterized by papillary hyperplasia of atypical glands lined by high-grade atypical cells with nuclear hyperchromaisa and pleomorphism,coarse chromatin and occasional mitotic figures.
    • Immunohistochemical stain reveals ap16(+) and Ki-67 (+) at dysplastic cells.
  • 2022-09-22 Patho - lung wedge biopsy
    • PATHOLOGIC DIAGNOSIS:
      • Lung, right lower lobe, VATS wedge — Non-necrotizing granulomatous inflammation
      • Lymph node, LN 7, right, LND — Non-necrotizing granulomatous inflammation
    • MICROSCOPIC EXAMINATION:
      • The section of both “RLL nodule” and “LN7” show a picture of non-necrotizing granulomatous inflammation, composed of granulomas with aggregates of tightly clustered epitheloid histiocytes with giant cells. Necrosis is not present. Neither T.B. bacilli nor fungi can be identified in the acid fast and PAS stains.
  • 2022-08-10 Pap Smear
    • Atypical glandular cells favor neoplasm
  • 2022-05-16 CT - abdomen
    • S/P hysterectomy.
    • A poor enhancing nodule (1.5cm) at liver dome r/o hemangioma.
  • 2022-02-14 MRI - liver, spleen
    • R/O hemangiomas (up to 1.3cm) at S6-8 of liver. Right liver cyst (0.3cm).
  • 2022-01-04 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Moderate fatty change, compatible with non-alcoholic fatty liver disease (NAFLD)
    • The sections show liver tissue with mild portal inflammation, subtle piecemeal necrosis, mild lobular inflammation, few hepatic ballooning, a poorly formed granuloma, and moderate steatosis (50%). Periportal fibrosis and bridging fibrosis can be identified. There is no evidence of malignancy in the sections examined.
    • The grading and staging for NAFLD as follows:
      • Grading: Score = 4 (steatosis = 2/3, ballooning = 1/2, lobular inflammation = 1/3)
      • Staging: 3 (Bridging fibrosis)
  • 2021-12-28 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (65 - 17) / 65 = 73.85%
      • M-mode (Teichholz) = 73.8
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Concentric LVH, grade 1 LV diastolic dysfunction
      • Trivial MR, mild TR and PR
  • 2021-12-27 Cystography
    • The bladder capacity is about 200cc.
    • No evidence of contrast medium leakage.
  • 2021-12-21 Patho - vaginal biopsy
    • PATHOLOGIC DIAGNOSIS
      • Vagina, resection — Adenocarcinoma, HPV-associated
      • Pathologic Stage (AJCC 8th ed.): pT1aNx, stage IA if cMo; FIGO stage I
    • MICROSCOPIC EXAMINATION
      • Procedure: Vaginal resection
      • Tumor Site: Vagina, not otherwise specified
      • Tumor Size: 0.8 x 0.6 cm
      • Histologic Type: Adenocarcinoma, HPV-associated
      • Histologic Grade: G2, moderately differentiated
      • Tumor Extension: Involves muscular wall (pT1a)
      • Lymphovascular Invasion: Not identified
      • Margins: All margins negative for invasive carcinoma
        • Distance of closest margin at least 4 mm
      • Regional Lymph Nodes: No lymph nodes submitted (pNx)
      • Distant Metastasis: Not applicable
      • Additional Findings: Adenocarcinoma in situ
      • IHC: CK7(+), CK20(-), CDX2(focal+), and p16(+)

[MedRec]

  • 2023-06-21 ~ 2023-06-24 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Adenocarcinoma, HPV-associated, of the vgaina, pT1aNx, stage IA( if cMo); FIGO stage I status post Exision of vaginal lesion on 2021/12/20, recurrent tumor (2.3cm) at vaginal stump with urinary bladder invasion, s/p vaginal stump mass + partial vaginectomy on 2023/05/22, s/p chemotherapy with Paclitaxel plus carboplatin from 2023/06/23
      • Malignant neoplasm of vagina
      • Type 2 diabetes mellitus without complications
      • Chronic viral hepatitis B without delta-agent
    • CC
      • for prepare chemotherapy
    • Present illness
      • This is a 53-year-old, G6P2AA4 (C/S X 2) woman with underlying medical history of:
        • Cervix biopsy with report CIN3 and Condyloma at right vagina-s/p Loop electrosurgical excision procedure (LEEP) at NTUH on 2005.
        • s/p tracheletomy with report CIN2 recurrence and right side vgina biopsy report VAIN1 at NTUH on 2006.
        • Uterus, cervix, biopsy report LSIL at NTUH on 2009.
        • Recurrent abnormal findings of pap smear; HPV 18 (+) - Cervix biopsy with report: moderate glandular dysplasia, s/p Laparoscopic assisted vaginal hysterectomy + bilateral salpingo-oophorectomy on 2020/09/07 - 2021/10 Vaginal cuff smear: atypical glandular cells, favor neoplasm, s/p vaginal cuff biopsy: high grade glandular dysplasia, s/p Exision of vaginal lesion on 2021/12/20, with pathology report:(Cervical cancer), Adenocarcinoma, HPV-associated, pT1aNxcM0; FIGO stage I, s/p radiotherapy (2022/1/21~3/22); with recurrence.
        • Hemangiomas (up to 1.3cm) at S6-8 of liver.
        • Carcinoma in situ of lung over left lower lobe, s/p video-assisted thoracoscopic surgery left lower lobe lung wedge resection and lymph node sampling on 2022-11-16, under OPD followup.
        • Non necrotizing granulomas in the lungs, under OPD followup.
        • Type II diabetes mellitus, on oral hypoglycemic agent.
      • She has had regular follow-ups at Taipei Tzu Chi Hospital after LAVH + BSO since 2020, and for the above diseases. Abdomen + pelvis CT was performed as needed, in which liver dome and lund nodule were noticed and metastases of cervical cancer had been ruled out via examinations and pathology test. She reported no vaginal bleeding. Occasional vaginal discharge and palpitations were noted.
      • During the recent GYN OPD followup on 2023/03/24, elevated tumor marker CEA level (CEA = 5.23 ng/mL) was detected. Cystoscopy was performed for cancer surverys, and no urethra or bladder invasion was noted. Abdomen + pelvis CT was arranged on 2023/05/02 with impression of 1) S/P hysterectomy.R/O recurrent tumor (2.3cm) at vaginal stump with urinary bladder invasion; 2) A poor enhancing nodule (1.5cm) at liver dome r/o hemangioma. Under the impression of cervical cancer with recurrence, excision of vaginal stump mass + partial vaginectomy, which were performed on 2023/05/22. Severe adhesion between vagina and posterior bladder wall was noted during the operation and bladder ruptured intraoperatively during adhesiolysis, received bladder repair. This time, she was admitted for the prepare chemotherapy and further management.
    • Course of inpatient treatment
      • After admission, collect 24hrs CCr. on 2023/04/04 showed 66.4mL/min, and arranged audiometry on 2023/06/23 showed R’t : 31 dB HL, normal to moderate SNHL、L’t : 35 dB HL, mild to moderate SNHL. Dorison 5#(20mg) po and Cimetidine 1# po before chemotherapy with Taxol 12 hrs on 2023/06/22 at 23:00 and before chemotherapy with Taxol 6 hrs on 2023/06/23 at 05:00, she received chemotherapy with paclitaxel (175mg/m2, self paid) plus carboplatin (AUC:6, sflf paid) on 2023/06/23 (C1) smoothly. Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting. Type 2 diabetes mellitus was treated with Kludone MR 60mg/tab 1# PO QDAC and Forxiga 10mg/tab 1# PO QDAC control. For chemotherapy, Vemlidy 25 mg/tab 1# PO QD was given for Anti-HBc reactive. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2023/06/24 and OPD followed up later.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
  • 2023-05-20 ~ 2023-05-25 POMR Obstetrics and Gynecology Huang SiCheng
    • Course of inpatient treatment
      • She was arranged to admit for excision of vaginal stump mass + partial vaginectomy, which were performed on 20230522. Severe adhesion between vagina and posterior bladder wall was noted during the operation and bladder ruptured intraoperatively during adhesiolysis. We consulted urologist for bladder repair.The perforation lesion was repaired with 3-0 vicryl with watertight closure technique. There was no leak after normal saline leak test for 200 ml. Cystoscopy showed intact trigone and bilateral DBJ in situ. We were suggested to keep her foley 1 week after the operation for further observation. Her postoperative course was uneventful. Abdominal wound was clear without discharge and healing was well. Under patient’s requirement, she was discharged on 2023/05/25 with foley and double-J catheterization. Her OPD follow-up appointment is scheduled on 2023/05/30. Cystoscopy will be arranged then.
  • 2023-05-04 SOAP Obstetrics and Gynecology Huang SiCheng
    • Plan
      • 2022/11/08 ~ 2023/01/10 Aldara Cream (imiquimod 5% w/w)
      • 2023/04/27 1st Aldara
      • 2023/05/02 2nd Aldara
      • 2023/05/04 Pause the use of Aldara for now and supplement with female hormones.
  • 2021-12-30 SOAP Hemato-Oncology Xia HeXiong
    • Conclusion of Multidisciplinary Cancer Team Meeting, Meeting Date: 2021-12-30
      • Liver biopsy (2021/12/9 Abd CT: r/o liver meta)
      • Postoperative Radiotherapy.

[consultation]

  • 2023-05-21 Urology
    • A:
      • The cystoscopy on 05/03 showed tip of trigone being elevated.
      • The mucosa was healthy at that time but the tumor is very near trigone.

[surgical operation]

  • 2023-05-22 Cystorrhaphy + cystoscopic exam
    • Finding:
      • A 3 cm laceration wound at posterior wall, just near the previous vaginal wall
      • No N/S leak after 200 ml infusion to bladder
    • Procedure:
      • We took over from GYN doctor. Identify the perforation site of urinary bladder. Repair with 3-o vicryl with watertight closure technique. There was no leak after normal saline leak test for 200 ml. Cystoscopy showed intact trigone and bilateral DBJ in situ. The GYN doctor took over for the further surgery.
  • 2023-05-22 Excision of vaginal stump mass + partial vaginectomy
    • Finding:
      • Moderate adhesion of pelvic wall and sigmoid colon. Little ascites s/p washing cytology.
      • Vaginal lesion with papillary tissue at 9 ~12 oclock direction, 2x1cm, s/p excision
      • Severe adhesion between vagina and posterior bladder wall, bladder rupture intraoperatively, s/p repair by urologist.
      • Estimated blood loss: 300ml
      • Blood transfusion: nil
      • Complication: nil
    • Procedure:
      • Put patient on the lithotomy position.
      • Skin disinfection with betadine.
      • Supraumbilical midline vertical skin incision was done
      • Open the abdominal wall layer by layer.
      • Apply auto-retractor and pack up the intestine to expose the pelvic cavity.
      • Pelvic adhesiolysis was done.
      • Severe adhesion between vagina and posterior bladder wall, bladder rupture intraoperatively, s/p repair by urologist.
      • Excision of vaginal lesion and partial vaginectomy were performed smoothly to remove the lesion with safe margin.
      • Close the wound with 2-0 Vicryl.
      • Severe adhesion between vagina and posterior bladder wall, bladder rupture with a 3x2 cm hole intraoperatively, s/p repair by urologist.
      • Checking bleeding and hemostasis.
      • Two 15fr J-VAC were placed in the bilateral CDS
      • Reperitonealization and close the abdominal wall layer by layer.
      • Approximation of skin with 4-0 Vicryl.
  • 2023-05-22 cystoscopy examination and bilateral double J stenting   - Finding:
    • mass compression of bladder neck from external side
    • No gross tumor noted in bladder
    • Procedure:
      • Under endotracheal general general anesthesia, the patient was in lithotomy position. Disinfection and draping the operation field were done as usual methods. Cystoscopy was performed to examinate bladder and identify bil UO. After retrograde insertion of guidewire, 6 Fr 24 cm double-J catheters were inserted at each side.
      • A 14 Fr Foley catheter was indwelled. The patient stood the procedures 

[chemotherapy]

  • 2023-09-05- paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 6 540mg 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-10 - 2023-09-05- paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 6 540mg 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-18 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 6 540mg 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-21 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 6 540mg 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-08-11

[reconciliation]

A refill for a 28-day quantity of Omeprotect (omeprazole) and Dulcolax (bisacodyl) was recently completed on 2023-08-05, but these medications are currently not listed in the active medication records. Kindly assess whether these drugs are no longer required for the patient.

2023-07-19

[reconciliation]

On 2023-07-08, the patient just refilled a 28-day supply of Omeprotect (omeprazole) and Dulcolax (bisacodyl), and on 2023-07-10 refilled a 30-day supply of Anxoken (metformin), Kludone (gliclazide), and Forxiga (dapagliflozin). However, metformin is currently absent from the active medication list, and a serum glucose level of 341mg/dL was recorded on 2023-07-19 at 16:16. It is advisable to determine if the omission of metformin is deliberate or due to the scheduling of a CT scan.

701196950

230905

[exam findings]

  • 2023-09-04 CXR (erect)
    • Increased infiltration in both lungs
    • Bilateral pleural effusion
    • Borderline enlarged cardiac sihoutte

[consultation]

  • 2023-09-04 Urology
    • Q
      • RECENT DIAGNOSED LUNG AND RENAL TUMORS at TaoYuan Hospital
      • PH; EV bleeding + Hx
      • alcohol cirrhosis
    • A
      • Left RCC with right lung metastasis is impressed on 2023/08/10 film
      • He underwent renal tumor biopsy twice at TaoYuan Hospital (first time only found necrosis, second biopsy report may be shown on 2023/09/05)
      • Now ascites, pleural and pericardial effusion had rapid progress on 2023/08/21 film
      • He used to drink one bottle of sorghum liquor (GaoLiang Jiu) with severe liver cirrhosis
      • He was brought to ER for leg edema and dyspnea
      • I had limited experince on liver cirrhosis with pain control
      • His elder sister and daughter had understand the difficulty of treatment and multiple complication for severe liver cirrhosis

==========

2023-09-05

The patient monthly refills for his repeat prescription medications, which include famotidine, silymarin, vitamin B complex, and propranolol, with the last refill occurring on 2023-08-06. Please confirm whether these medications are no longer required for the patient’s current medical status.

700905127

230904

[MedRec]

  • 2023-05-02 ~ 2023-05-05 POMR Hemato-Oncology
    • Discharge diagnosis
      • LUL lung adenocarcinoma, cT3N3M1a stage IVA, with lung to lung and malignancy pleural effusion s/p TKI with Erlotinib from 2022/11/10~, progression
      • Anemia due to antineoplastic chemotherapy
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
      • Hypothyroidism, unspecified
      • Hyperlipidemia, unspecified
      • Cachexia
      • Insomnia, unspecified
      • Chronic kidney disease, stage 4 (severe)
    • CC
      • For bronchoscopy with biopsy.
    • Present illness
      • This 82-year-old woman is a case of LUL lung adenocarcinoma, cT3N3M1a stage IVA, with lung to lung and malignancy pleural effusion in 2022/09 (but no tissue prove of malignancy yet, pleural effusion smears suggeted metastatic pulmonary adenocarcinoma with immunohistochemical stain, but further biopsy results will need to be comfirmed).
      • Progressive dyspnea in 2022/10. Left pleural effusion with chest tapping on 2022/11/01 (1000c.c for drainage). (Drainage suspended on 11/4 due to excessive volune loss related to her morning dizziness suspected).
      • Chest echo on 2022/11/03 showed left massave pleural effusion with left pigtail tube drainge.
      • Brain MRI on 2022/11/03 showed mild general brain atrophy, cerebral small vessel disease and intracranial artherosclerosis.
      • Abdominal echo on 2022/11/04 showed suspected GB polyp, suspected fatty infiltration of pancreas, propable chronic renal paremchymal disorders, bil, suspected renal cysts,bil and suboptimal examination of liver due to poor echo window.
      • Pleural effusion cell block on 2022/11/04 and 2022/11/08 showed neutrophils, lymphocytes and reactive mesothelial cells. No aerobic culture or TB found in pleural effussion.
      • Chest/Abdominal CT on 2022/11/09 revealed ground-glass opacity 1.2 cm at RUL of the lung that may be primary lung cancer.
      • Due to highly lung cancer suspected, the self-paid TKI with Erlotinib (Tarceva) 150mg 1# QD from 2022/11/10.
      • Chest CT on 2023/03/27 showed LUL cancer stage IVA in progression. Dyspnea in 2023/04. Now, she was admitted to ward for bronchoscopy with biopsy.
    • Course of inpatient treatment
      • After admitted, Self pay TKI with Erlotinib(Tarceva) 150mg 1# QD.
      • Bronchoscopy with biopsy 2023/05/05.
      • Kentamin (B1 50mg & B6 50mg & B12 500mcg) 1# po TID.
      • Famotidine 0.5# po QD for GERD.
      • Type 2 diabetes mellitus with Check finger sugar and diet control.
      • Cancer cachexia with Megest 10ml po QD.
      • Insomnia with Xanax 1# po HS.
      • Anemia(Hb:8.6g/dL) with P-RBC 2u on 2023/05/02.
      • Patient tolerated the bronchoscopy with biopsy without dyspnea.
      • With the stable condition, she was discharged on 2023/05/05 and OPD followed up later.        
  • 2023-04-19 SOAP Hemato-Oncology
    • A/P: On 2023-04-19, already mention that admission for tissue biopsy (bronchoscopy), otherwise self pay osimertinib directly, or IV or oral C/T.
  • 2023-02-01 SOAP Hemato-Oncology
    • O
      • AE: Gr 1 Anorexia
      • AE: Gr 2 Anemia
  • 2022-12-28 SOAP Hemato-Oncology
    • A/P: Due to more amount of left pleural effusion on 2022-12-28, increase erlotinib from 1# QOD to 1# QD since 2022-12-28.
    • Prescription
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
      • Tarceva (erlotinib 150mg) 1# QD for QODAC use
      • Alpraline (alprazolam 0.5mg) 1# HS if insomnia
  • 2022-11-30 SOAP Hemato-Oncology
    • O
      • Cancer Multidisciplinary Team Meeting Conclusion, meeting date 20221108
        • NSCLC, stage IVA
        • TKI.
    • Prescription
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
      • Tarceva (erlotinib 150mg) 1# QOD for QODAC use
      • Alpraline (alprazolam 0.5mg) 1# HS if insomnia
  • 2022-11-01 ~ 2022-11-15 POMR Hemato-Oncology
    • Discharge diagnosis
      • Malignant neoplasm of upper lobe, left bronchus or lung
      • Pleural effusion in other conditions classified elsewhere
      • Secondary malignant neoplasm of right lung
      • Hyperlipidemia, unspecified
      • Hypothyroidism, unspecified
      • Essential (primary) hypertension
      • Type 2 diabetes mellitus without complications
    • CC: Dyspnea noted during activity

==========

2023-09-04

On 2023-08-05, the patient received a 30-day prescription for pioglitazone, linagliptin, pentoxifylline, amlodipine, irbesartan, and atorvastatin. Not all of these medications are currently on the list of active medications. Please check to see if any of these medications are no longer needed.

700588033

230901

[exam findings]

  • 2023-08-24 PET scan
    • Glucose hypermetabolism in a left supraclavicular lymph node, multiple bilateral paraaortic lymph nodes, bilateral common iliac lymph nodes and a left internal iliac lymph node, suggesting metastatic lymph nodes.
    • Mild glucose hypermetabolism in some focal areas in the right anterior lower pelvic cavity and right inguinal region. Metastatic lesions suhc as metastatic lymph nodes can not be ruled out. Please correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in the left anterior upper abdomen. The nature is to be determined (physiological FDG accumulation in the colon? other nature?). Please correlate with other imaging modalities for further evaluation.
  • 2023-08-18 CT - abdomen
    • Findings:
      • There are lobulated soft tissue lesions in right inguinal area and right common iliac chain, causing encasement of the adjacent artery and vein.
        • Metastatic nodes are highly suspected.
        • In addition, there are several newly developed enlarged nodes in para-aortic space and para-cava space that also c/w metastatic nodes.
      • There are multiple soft tissue lesions in the omentum at LUQ abdomen and left upper pelvis that are c/w tumor seeding (metastases).
      • S/P hysterectomy
    • IMP:
      • Metastatic nodes in right inguinal area, right common iliac chain, para-aortic space and para-cava space.
      • Multiple metastases in the omentum.
      • Detailed findings, please see description.
  • 2023-08-21, -03-16 Gynecologic ultrasonography
    • ATH + BSO
    • IMP: No obvious uterine or ovarian lesion
  • 2023-05-13 CT - abdomen
    • Indication: Right side ovarian (high-grade serous carcinoma), pT3cN1a, stage IIIC s/p debulking surgery, s/p chemotherapy with carboplatin + paclitaxel + Avastin
    • Imp: s/p ATH and BSO. No evidence of recurrent/residual tumor in the sudy.
  • 2023-04-06 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A (minimal)
      • Superficial gastritis
    • Suggestion:
      • Symptomatic treatment
  • 2023-01-16 CT - abdomen
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Abdominal CT with and without enhancement revealed:
      • s/p ATH.
      • The soft tissue mass at left pelvic sidewall is not visualized in the study. However,
      • Increased intestinal gas is found.
      • No evidence of free air is noted at the subphrenic region.
      • Non-specific bowel gas at abdominal cavity is found.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • Visible chest
      • Normal heart size.
      • The lung fields are clear.
      • No pleural effusion is found.
      • Suggest clinical correlation
    • Imp:
      • s/p ATH.
      • Dirty appearance of the pelvis mesetery is found. Suspected residual tumor activity.
  • 2023-01-06, 2022-12-09 CXR
    • A nodular opacity projecting in the right middle lung is suspected. Please correlate with CT.
  • 2023-01-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (88 - 32) / 88 = 63.64%
      • M-mode (Teichholz) = 63
    • Dilated LA
    • Adequate LV, RV systolic function with normal wall motion
    • LV hypertrophy, Impaired LV relaxation
  • 2022-11-09 Patho - soft tissue tumor, extensive resection
    • DIAGNOSIS:
      • A. Labeled as “01 left pelvic tumor”, debulking surgery/ excision — high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
      • B. Labeled as “02 omentum tumor”, debulking surgery/ excision — high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
      • C. Labeled as “03 para-rectal tumor (in CDS)”, debulking surgery/ excision — high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
      • D. Labeled as “04 right peritoneal tumor”, debulking surgery/ excision — high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
    • MICROSCOPIC DESCRIPTION:
      • A. Section shows high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
      • B. Section shows high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
      • C. Section shows high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
      • D. Section shows high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
  • 2022-11-09 Body fluid cytology
    • 35 cc brown turbid ascites
    • The smears show many hyperchromatic atypical epithelial cell clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
  • 2022-10-18 CT - abdomen
    • Clinical history: 45 y/o female patient with right side Ovarian (high-grade serous carcinoma) , pT3cN1a, stage IIIC s/p debulking surgery, s/p chemotherapy with Carboplatin + paclitaxel + Avastin (2021/10/01~2022/01/14 6 cycles).
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P hysterectomy.
      • Left obturator region hypodense lesion, 1.3cm, stationary.
      • Soft tissue lesion, 1.8cm in left pelvic cavity, anterior to left psoas muscle.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
      • Subpleural nodule in right lower lung, nature?
    • Impression:
      • S/P hysterectomy.
      • Stationary left pelvic cavity tumors.
      • Right lower lung subpleural nodule, nature?
  • 2022-10-17 Gynecologic ultrasonography
    • ATH + BSO
  • 2022-09-01 CT - abdomen
    • History and indication:
      • ROV cancer, stage IIIC s/p debulking surgeryeating and self voiding, defecation
    • IMP:
      • S/P hysterectomy.
      • A cystic lesion (1.1cm) at left pelvic cavity.
      • Grade 4 fatty liver.
  • 2022-08-12 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA grade A
    • Superficial gastritis
    • Gastric erosions, antrum
  • 2022-06-09 Gynecologic ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2022-04-19 CXR
    • A nodular opacity projecting in the right middle lung is suspected. Please correlate with CT.
  • 2022-03-11 CT - abdomen
    • History:
      • 20210821 G-I OPD refer. SONO: pelvic mass and Ascites, BW LOSS 7 KG/2-3 MO,
      • 20210821 ERCT: suspected ovarian cancer with massove ascites
      • 20210827 debulking surgery:ROV cancer, pT3cN1a, pstage IIIC
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.
    • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
    • Findings:
      • S/P hysterectomy
      • There is a cystic lesion measuring 3 cm in left pelvic sidewall that may be lymphocele? please correlate with clinical condition.
      • Others
        • There is no hyper-or hypodense lesion in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • IMP:
      • S/P hysterectomy.
      • Lynmphocele 3 cm in left pelvic sidewall is suspected. please correlate with clinical condition.
  • 2022-03-08 CT - chest
    • stationary of a well-defined RLL-S6 solid nodule (8 mm) as compared with previous CT study on 2021/12/06
  • 2021-12-16 Gynecologic ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2021-12-06 CT - chest
    • stationary of a well-defined RLL-S6 solid nodule (8 mm) and regression lobular/centriolobular ground-glass opacities in RUL-S2 as compared with previous CT study on 2021/09/25.
  • 2021-09-25 CT - chest
    • Right lower lobe nodule. In regression. Meta is not likely.
    • Right upper lobe ground glass nodules with bronchial distribution. suspected recent inflammation. Suggest closely follow up.
  • 2021-08-30 Patho - soft tissue tumor, extensive resection
    • PATHOLOGIC DIAGNOSIS
      • Ovarian mass, R’t, frozen + debulking surgery — High-grade serous carcinoma
      • Fallopian tube, R’t, ditto — Tumor present
      • Endometrium, uterus, debulking surgery — Free from tumor, proliferative phase
      • Myometrium, uterus, ditto — Tumor invasion and leiomyomas
      • Endoervix, uterus, ditto — Tumor present at serosa with myometrial invasion
      • Cervix, uterus, ditto — Free from tumor
      • Ovary. L’t, ditto — Tumor present
      • Fallopian tube, L’t, ditto — Tumor present at serosa area
      • Omentum ttissue, excision — Tumor present
      • Pelvic (in Douglous) mass, excision — Tumor present
      • R’t peritoneal mass, excision — Tumor present
      • Lymph node, R’t iliac, dissection — Tumor metastasis (1/6) without extracapsular extension (0/1)
      • Lymph node, R’t obturator, ditto — Free from tumor metastasis (0/3)
      • Lymph node, L’t iliac, ditto — Tumor metastasis (1/8) without extracapsular extension (0/1)
      • Lymph node, L’t obturator, ditto — Tumor metastasis (2/2) without extracapsular extension (0/2)
      • AJCC Pathologic staging: pT3cN1a, if cM0; stage IIIC
    • MICROSCOPIC EXAMINATION
      • Histologic type: high-grade serous carcinoma
      • Histologic grade: high grade
      • Contralateral ovary involvement: present
      • Tumor side ovarian surface involvement: present
      • Contralateral ovary involvement: present
      • Right tube involvement: present
      • Left tube involvement: present at serosal layer
      • In situ adenocarcinoma in right &/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: present
      • Left adnexa soft tissue involvement: present
      • Pelvic soft tissue involvement: present
      • Uterine serosa involvement: present
      • Omentum involvement: present
      • Uterine Cervix involvement: absent
      • Endocervix: tumor involved serosal and myometrial area, without endocervical glands invasion
      • Endometrium involvement: absent
      • Myometrium involvement: present at post endocervical region
      • Lymph nodes metastasis: tumor metastasis (4/19) without extracapsular extension (0/4) in total number
      • Immunohistochemistry: CK (+), WT-1 (+), PAX-8 (+), P53 (aberrant expression) and Napsin-A (-) for tumor
      • Ascites cytology: negative
  • 2021-08-21 CT - abdomen
    • suspected ovarian cancer with massove ascites
  • 2021-08-21 Gynecologic ultrasonography
    • Pelvic mass, suspected bilateral ovarian tumor, malignancy was highly suspected
  • 2021-08-21 SONO - abdomen
    • Diagnosis
      • Pelvic cystic tumor, huge
      • massive Ascites
    • Suggestion
      • GYN OPD visit

[consultation]

  • 2021-08-21 Obstetrics and Gynecology
    • A
      • S
        • This 44 y/o female suffered from abodminal fullness and poor appetite for one mth. She visited our GI OPD and was noted to have pelvic mass and ascites and was referred to ER.
        • BW LOSS 7 KG/2-3 MO,NO BLOODY STOOL
        • PH: NIL NKDA
      • O
        • P1, C/Sx1
        • LMP: 07/20+
        • MC: regular
        • PV: Discharge: mucoid, whitish, mild amount
        • VP: smooth, no motion tender
        • Adx and ut: unclear due to distend abdomen
        • Echo: pelvic mass, bil, malignancy was highly suspected
      • Imp
        • Ascites, cause to be determined
        • Pelvic mass, suspected ovarian cancer, origin to be determined
      • P
        • Please keep w/u other cause of ascites and origin of pelvic mass, eg. GI origin
        • Please contact us if other GYN lesion noted in the following study
        • Please also check CA 15-3 and gyneco-oncological OPD f/u for further management

[surgical operation]

  • 2022-11-08
    • Surgery: debulking surgery (left pelvic tumor + omentum tumor + pararectal tumor + right pelvic tumor excision) + enterolysis
  • 2021-08-27
    • Surgery: debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND + peritoneal tumor excision) + enterolysis

[chemoimmunotherapy]

  • 2023-08-31 - bevacizumab 800mg NS 250mL 1.5hr + topotecan 1.5mg/m2 2.5mg NS 80mL 30min D1-4
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg D1-4 + NS 250mL
  • 2023-08-01
  • 2023-07-05
  • 2023-06-06
  • 2023-05-12
  • 2023-04-07
  • 2023-03-06 - bevacizumab 800mg NS 250mL 1.5hr + liposome doxorubicin 30mg/m2 55mg D5W 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-06
  • 2023-01-06
  • 2022-12-09
  • 2022-10-17 - bevacizumab 15mg/kg 1200mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-09-20
  • 2022-08-30
  • 2022-08-11
  • 2022-07-21
  • 2022-06-27
  • 2022-06-07
  • 2022-05-12 - bevacizumab 15mg/kg 900mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-04-20
  • 2022-03-25
  • 2022-03-07
  • 2022-02-11
  • 2022-01-14 - bevacizumab 15mg/kg 900mg NS 250mL 1.5hr + paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 6 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2021-12-24
  • 2021-12-03
  • 2021-11-12
  • 2021-10-22
  • 2021-10-01 - no bevacizumab

==========

700021591

230831

[exam findings]

  • 2023-06-28 Tc-99m MDP bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, maxilla, mandible, some C-, T- and L-spine, right sternoclavicular junction, bilateral shoulders, elbows, and knees.
  • 2023-06-27 MRI - larynx
    • Impression (Imaging stage): T: T3(T_value) N: N1(N_value) M: M0(M_value) STAGE: ____(Stage_value)
  • 2023-06-27 SONO - abdomen
    • Liver cyst, right lobe
    • Gall stone
  • 2023-06-27 EGD
    • Reflux esophagitis LA Classification grade A
    • Hiatal hernia
    • Heterotopic gastric mucosa, upper esophagus
    • Superficial gastritis, s/p CLO test
    • Dudenal ulcer and ulcer scar, bulb
  • 2023-06-08 Patho - tonsil and/or adenoid
    • Labeled as “left tonsillar tumor”, excisional biopsy — poorly differentied squamous cell carcinoma.
    • Section shows poorly differentied squamous cell carcinoma. Margin (+).
    • IHC stains: EBER (-), p16 (+), HPV (-).
  • 2023-06-03 Nasopharyngoscopy
    • Finding: left odynophagia for months
    • Conclusion: left tonsillar tumor+, airway patent
  • 2023-02-01 Neurosonography
    • Mild atheromatous lesions in R CCA bifurcation and ICA.
    • Normal extracranial carotid, vertebral, and intracranial basal cerebral arterial flows except elevated flow velocity in R M1 (PS/ED= 124/42 cm/s)

[MedRec]

  • 2023-07-04 SOAP Hemato-Oncology He JingLiang
    • P: Tx: Bio-RT (erbitux weekly)
  • 2023-07-04 SOAP Ear Nose Throat Huang YunCheng
    • O: staging cT3N1M0, p16+, stage II suggest CCRT
  • 2023-07-04 SOAP Radiation Oncology Chang YouKang
    • A: IMP: Left tonsillar caner, PD SqCC, with left level II LAP metastasis, cT3N1M0, p16+, stage II.
    • Plan: CCRT to left ORX tumor and level II LAP for 7140cGy/34 fx is suggested for locoregional control. CT simulation on 7/04; possible treatment toxicity is told; diet education is given.
      • Refer to Medical Oncology for Bio-RT (weekly cetuximab).
  • 2023-07-01 SOAP Oral and Maxillofacial Surgery He ChengHan
    • Problem:
      • Squamous cell carcinoma of left tonsil
      • retained root of tooth 38 and 48
    • Plan:
      • explain the risk/benefit of dental extraction prior to radiotherapy
      • sign the informed consent
      • block anesthesia of bilateral mandible
      • complicated extraction of tooth 38 and 48
      • medication
      • teach him how to do home care
    • Prescription
      • Acetal (acetaminophen 500mg) 1# PRNTID
      • amoxicillin 250mg 2# Q8H
  • 2023-06-26 ~ 2023-06-28 POMR Ear Nose Throat Huang YunCheng
    • Discharge diagnosis
      • Malignant neoplasm of tonsil, unspecified
    • CC
      • left odynophagia noted for months
    • Present illness
      • This is a 79-year-old man with past history of prostate cancer status post operation
      • He had been suffered from left odynophagia for months. No dysphagia or hemoptysis was noticed. He was then brought to our OPD for help. Scope showed smooth nasopharynx with left tonsillar tumor. Excision of the tumor was done, and the pathology report prooved malignancy. Admission for further examination was suggested, and the patient agreed after thorough consideration. Therefore, under the impression of left tonsillar cancer, the patient was admitted for cancer work-up.        
    • Course of inpatient treatment
      • After admission, serial tests were arranged for tumor staging work up. Abdominal sonography showed right hepatic cyst. Upper GI pandescopy revealed no evidence of metastatic lesion. Consulted OS for dental evaluation was done, and tooth extraction will be arranged on this W6. Under relative stable condition, the patient was dishcarged with OPD follow up
    • Discharge prescription
      • cephalexin 500mg 1# Q6H
      • Acetal (acetaminophen 500mg) 1# Q6H
  • 2023-06-03 SOAP Ear Nose Throat Huang YunCheng
    • S: left odynophagia for months
    • O: NP scope: left tonsillar tumor, Np was smooth
    • Prescription
      • Comfflam Spray (benzydamine) 3 puff TID MOSP
  • 2021-01-11 SOAP Ear Nose Throat Huang YunCheng
    • S
      • lump in throat for long time, patient has strong gap reflex, hard to assess NP and larynx by mirror
      • cough and sorethroat for few days with purulent NR
    • O
      • Nasopharyngoscope findings: Smooth NP, Laryngx: mild edematous change of laryngeal mucosa
    • Prescription
      • Nasonex Aqueous Nasal Spray (mometasone) 2 puff QD
      • Actein Effervescent (acetylcysteine 600mg) 1# BID

[surgical operation]

[radiotherapy]

[immunochemotherapy]

  • 2023-07-21 - cetuximab 400mg/m2 400mg 2hr (CCRT)
    • acetaminophen 500mg PO
  • 2023-07-14 - cetuximab 400mg/m2 400mg 2hr (CCRT)
    • acetaminophen 500mg PO
  • 2023-07-07 - cetuximab 400mg/m2 400mg 2hr (CCRT)
    • acetaminophen 500mg PO

==========

2023-08-31

[vancomycin dosing for adults with normal kidney function]

Loading dose (for patients with known or suspected severe Staphylococcus aureus infection) 20 to 35 mg/kg (based on actual body weight, rounded to the nearest 250 mg increment; not to exceed 3000 mg). Within this range, we use a higher dose for critically ill patients; we use a lower dose for patients who are obese and/or are receiving vancomycin via continuous infusion. The patient’s weight is approximately 50 kg, which suggests a loading dose range of 1000mg to 1750mg. The administered dose of 1000mg on 2023-08-28 at 10:49 falls on the lower end of this range.

Initial maintenance dose and interval typically 15 to 20 mg/kg every 8 to 12 hours for most patients (based on actual body weight, rounded to the nearest 250 mg increment). The dosage of 20mg/kg every 12 hours is then being administered to this date currently.

Given the lower initial loading dose and the recently observed elevated trough level of 16.5 mg/L (2023-08-31 morning), a 20% reduction in the current dosage is recommended, which equates to administering 800mg Q12H.

700282560

230831

[diagnosis] - 2023-04-06 admission note

  • Acute promyelocytic leukemia, not having achieved remission
  • Gout, unspecified

[lab data]

2023-06-28 CMV IgM Nonreactive
2023-06-28 CMV IgM Value 0.04 Index
2023-06-28 FLT3/ITD Presence of mutation * 2023-06-28 NPM1 Undetectable
2023-06-28 PML-RARA 0.0000
2023-06-28 BCR/abl Undetectable
2023-06-28 CMV viral load assay Target not detecetedIU/mL

2023-04-22 CMV IgM Nonreactive
2023-04-22 CMV IgM Value 0.08 Index
2023-04-22 CMV_IgG Reactive
2023-04-22 CMV_IgG Value 49.0 AU/mL

2023-02-01 CMV viral load assay Target not detecetedIU/mL

2023-01-27 CMV_IgG Reactive
2023-01-27 CMV_IgG Value 22.8 AU/mL
2023-01-27 CMV IgM Nonreactive
2023-01-27 CMV IgM Value 0.12 Index

2023-01-20 BM chromosome analyz
- CYTOGENETICS LABORATORY REPORT - Chromosome Analysis: - Tissue Examined:Bone marrow - Staining Method:G-Banding - Colony number:NA - Bands level:350 - Chromosome Counts: - 45-()、46-(20)、47-()、Other-() Total-(20) - Karyotype:46,XY[20] - Interpretation: - Analysis of this bone marrow sample shows a male having 46,XY[20] karyotype. No chromosomal abnormality was detected. - Note: - ROUTINE BANDED LEVEL DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF RESOLUTIONS.

2023-01-17 FLT3-D835 Undetectable
2023-01-12 PML-RARA Presence of mutation *

2023-01-12 BCR/abl Undetectable
2023-01-12 FLT3/ITD Presence of mutation * 2023-01-12 NPM1 Undetectable

2023-01-10 CMV IgM Nonreactive
2023-01-10 CMV IgM Value 0.21 Index
2023-01-10 CMV_IgG Reactive
2023-01-10 CMV_IgG Value 11.8 AU/mL
2023-01-10 Anti-HBc Nonreactive
2023-01-10 Anti-HBc-Value 0.70 S/CO
2023-01-10 HBsAg Nonreactive
2023-01-10 HBsAg (Value) 0.33 S/CO
2023-01-10 Anti-HCV Nonreactive
2023-01-10 Anti-HCV Value 0.13 S/CO

[exam findings]

  • 2023-06-01 CXR
    • Increased lung markings on both lower lung are noted.
  • 2023-06-20 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Acute myeloid leukemia
    • Microscopically, it shows hypercellularity of marrow (approximately > 95%). Blasts are markedly increased in numbers (> 40%) and highlighted by CD34 and CD117.
    • Immunohisotchemical stain reveals CD138 (focal+, 1~2%), MPO (+), CD71 (focal+, sparse), CD61 (focal+, sparse), TdT (focal +).
  • 2023-04-07, -02-27, -02-21 Body fluid cytology - CSF
    • negative
  • 2023-02-02 SONO - abdomen
    • splenomegaly
    • accessory spleen
  • 2023-01-19 Patho - bone marrow biopsy
    • Bone marrow, iliac, s/p chemotherapy, biopsy — hypocellularity.
    • IHC stains: CD117: <1 %; CD34: <1 %; MPO: 45-50%, CD61: <5 %; CD71: 45-50 % (of the nucleated cells).
    • REFERENCE: S2023-00105: Bone marrow, biopsy — Compatible with acute myeloid leukemia
    • Section shows piece(s) of bone marrow with 10% cellularity and M:E ratio of approximately 1:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are reduced in number.
  • 2023-01-10 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (143 - 44) / 143 = 69.23%
      • M-mode (Teichholz) = 69
    • Conclusions
      • Dilated LV; normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated LA; normal LV diastolic function.
      • Normal RV systolic function.
      • Mild MR; mild TR; mild PR.
      • PICC catheter in right atrium.
  • 2023-01-03 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with acute myeloid leukemia
    • The sections show hypercellular marrow (90%). The marrow space is replaced by a population of medium to large-sized immature cells with oval nucleus and moderate amount cytoplasm. The CD71+ erythroid precursors are marked decreased. Increased CD34+ and/or CD117+ blasts, constitue 40% of marrow cells. Some of blasts are positive for MPO (50%). Scattered CD68+ cells (10%) can be found. The finding is compatible with acute myeloid leukemia. Suggest bone marrow smear evaluation and clinic correlation.
  • 2023-01-02 CT - abdomen
    • History and indication: Suspect perirectal abscess
    • IMP:
      • Wall thickening of rectum with adjacent fat stranding suspected malignancy.
      • Some LNs (up to 0.9cm) at paraaortic region.
      • Some calcifications at right adrenal gland.
      • Splenomegaly with focal low attenuation suspected infarct.
  • 2023-01-02 Anoscopy
    • Findings
      • Stool color: normal
      • Rectal mucosa: normal
      • Anal canal: abnormal
    • Impression
      • Bloody mucus in rectum
      • Rectal edema at left & right lateral, anterior wall

[consultation]

  • 2023-07-28 Colorectal Surgery
    • Q
      • The 37 y/o man has AML /p chemotherapy with neutropenic stage. Due to anal pain and swelling, so we need your help for management.
    • A
      • This is a 37- year old man with anal pain for days
      • DRE:
        • anal fissure over 6 and 12 o’clock region, swelling over anal region
        • no obvious abscess formation
      • A: perianal pain and anal fissure, R/I AML induced
      • P:
        • warm water sitz bath
        • alcos anal ointment topic use
        • pain control
        • control underlying disease
  • 2023-07-05 Denatal
    • Q
      • This 37 year old male is a case of Acute promylocytic leukemia status post induction chemotherapy with D3A7 on 2023/01/09, Consolidation chemotherapy with D3A7 plus weekly IT on 2023/02/20, transformation to Acute myeloid leukemia, FLT3/ITD mutation in 2023-06. FLAG was administered on 2023/06/21-27. However, a swelling mass was noted on left buccal. We need your expertise for further management, thanks
    • A
      • Patient complains of left lower facial pain.
      • Take panoramic radiography for examination.
      • #35 suspect dental caries with no symptoms.
      • Oral hygiene instructions with ultra-soft tooth brush.
      • Suggest follow up closely and visit dental OPD endodontic clinic if symptoms persist.
  • 2023-05-02 Dermatology
    • Q
      • for skin rash, redness and itchy around waist, and bilateral groins due to suspect allergy
      • This 36 y/o male patient is a case of acute promyelocytic leukemia post induction chemotherapy. Due to neutropenia fever, so gave antibitic with Cefepime, Targocid treatment since 2023/04/19, then he suffered from skin rash, rednessand itchy around waist, and bilateral groins due to suspect allergy.
      • We would like to consult your expertise, thank you!
    • A
      • The patient had sufferred from erythematous macules with hyperpigmentation change over trunk and axilla.
      • Under the impression of frictional eczema with secondary candidasis infestation.
      • The following suggetion:
        • keep regional body dry and clean.
        • Zalaine cream 1 tube topical QN use for large area of the pigmetation lesions and Mycomb cream 1 tube topical bid use over itchy lesions.
        • consider sinbaby lotion 1 bot topical PRN use for body occlussion/pruritus control.
  • 2023-03-15 Colorectal Surgery
    • Q
      • This is a 36 years old male with acute promylocytic leukemia and perineal abscess under chemotherapy
      • He suffered from intermittent perianal pain and swelling. High fever was noted and perianal pain progressed. He denied diarrhea or constipation. He visited our CRS outpatient department for help. Digital rectal examination showed no blood on the finger, nor palpable mass in the distance of finger length, nor palpable abscess cavity. Anoscopy showed normal color stool, normal rectal mucosa, while bloody mucus in rectum, rectal edema at left & right lateral, anterior wall were noted.
      • We would like to consult your expertise, thank you!
    • A
      • DRE: mild tendernes(+), no definite perianal abscess or fistula formation, mild hemorrhoids
      • A: Anal pain, R/O perianal infection
      • P:
        • Neomycin ointment bid use
        • Because no definite perianal abscess or fistula formation, surgical intervention is not necessary at present
        • CRS OPD follow-up
        • Please inform us if any problems
  • 2023-03-07 Infectious Disease
    • Q
      • Backline controlled antibiotics, consultation with an infectious disease specialist is required.
    • A
      • This is acse of AML with neutropenic fever.
      • Agree with your use of mepem and targocid.
      • Please adjust antibiotic according to culture results and clinical conditions.
  • 2023-01-28 Colorectal Surgery
    • Q
      • This 36 y/o male patient is a case of acute promyelocytic leukemia post induction chemotherapy with WBC tending to improve but still in severe neutropenic stage. We need your expertise for anal pain evaluation and recommendation, sincerely thanks.
    • A
      • I’ve visited this case.
      • PR: left lateral perianal superficial fistula tract and shallow ulcer, well drained  no abscess formation and no perianal infection sign
      • Suggestion
        • Treat underlying disease
        • Biomycin oint topical use
        • Pain control using NSAID or Paran (acetaminophen) if no contraindication
  • 2023-01-03 Hemato-Oncology
    • Q
      • For suspect acute leukemia,
      • This 36 year old man without underlying history was admitted with suspect perianal abscess.
      • Digital rectal examination showed no blood on the finger nor palpable mass in the distance of finger length. No palpable abscess cavity.
      • Anoscopy showed normal color stool, normal rectal mucosa, bloody mucus in rectum, rectal edema at left & right lateral, anterior wall.
      • Lab data showed
        • WBC (163720), Blast (66%), promyelocyte (3%), myelocyte (1%), metamyelocyte (1%)
        • Hb (9.4), PLT (26000), Cr (1.56), total bilirubin (2.6), AST (75), ALT(65)
        • Under the impression of suspect perianal abscess and suspect acute leukemia, he was admitted to our ward for further care.
    • A
      • Recommendation:
        • bone marrow with special stain, flowcytometer and chromosome study is indicated for this patient.
        • alkalinzation of urine with sodium bicarbonate to prevent tumor lysis syndrome
        • emperic antibiotics

[chemotherapy]

  • 2023-07-19 - fludarabine 30mg/m2 50mg NS 100mL 30min D1-6 + cytarabine 2000mg/m2 4200mg NS 500mL 4hr D1-5 (FLAG, Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-6
  • 2023-06-21 - fludarabine 30mg/m2 50mg NS 100mL 30min D1-6 + cytarabine 2000mg/m2 4200mg NS 500mL 4hr D1-5 (FLAG, Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-6
  • 2023-04-12 - [cytarabine 50mg + methotrexate 15mg + hydrocortisone 30mg] IT (intrathecal)
  • 2023-04-07 - daunorubicin 45mg/m2 90mg NS 100mL 30min D1-3 + cytarabine 2000mg/m2 4000mg NS 500mL 3hr Q12H D1-5 + [cytarabine 50mg + methotrexate 15mg + hydrocortisone 30mg] IT (intrathecal) D1
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-5
  • 2023-02-27 - [cytarabine 50mg + methotrexate 15mg + hydrocortisone 30mg] IT (intrathecal)
  • 2023-02-23 - daunorubicin 45mg/m2 80mg NS 100mL 30min D1-3 + cytarabine 200mg/m2 390mg NS 500mL 24hr D1-7
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3
  • 2023-02-21 - [cytarabine 50mg + methotrexate 12mg + hydrocortisone 30mg] IT (intrathecal)
  • 2023-01-09 - idarubicin 12mg/m2 24mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 200mg NS 500mL 24hr D1-7
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1

Granocyte (lenograstim 250ug) CGRAN01

  • 2023-03-03 ~ 2023-03-14
  • 2023-01-18 ~ 2023-01-31

G-CSF (filgrastim 150ug) CGCSF01

  • 2023-03-03 ~ 2023-03-14
  • 2023-01-18 ~ 2023-01-31

2023-01-13 - tretinoin 50mg

[note]

Rydapt (midostaurin) https://www.uptodate.com/contents/midostaurin-drug-information

  • Dosing - Adult - Acute myeloid leukemia (AML), FLT3-positive: Oral:
    • Induction: 50 mg twice daily on days 8 to 21 of each induction cycle (in combination with daunorubicin and cytarabine); administer a second induction cycle if there is definitive evidence of (clinically significant) residual leukemia.
    • Consolidation: 50 mg twice daily on days 8 to 21 of each 28-day consolidation cycle (in combination with high-dose cytarabine) for 4 consolidation cycles.
    • Maintenance (off- label): 50 mg twice daily on days 1 to 28 of each 28-day maintenance cycle for 12 cycles or until relapse, whichever occurs first.

Chemotherapy regimens for relapsed or refractory acute myeloid leukemia (AML) in adults — 2023-07-04 - https://www.uptodate.com/contents/image?imageKey=HEME%2F82823

  • Cytarabine plus daunorubicin
    • Common nonhematologic side effects seen in the majority of patients include stomatitis (mostly mild), alopecia, nausea and vomiting (10 percent severe), and diarrhea (mostly mild). Daunorubicin can be associated with an infusion reaction and cardiac arrhythmias; a flu-like syndrome and rash due to cytarabine may be seen during induction.
    • Re-induction with cytarabine plus daunorubicin will produce a complete remission in approximately 50 percent of patients with a first remission lasting longer than one year[1].
  • High-dose cytarabine (HiDAC)
    • The most common nonhematologic toxicities are nausea and vomiting, abnormal liver chemistries, diarrhea, conjunctivitis, rash, and cerebellar dysfunction. Toxicity is high in most patients over the age of 60 years.
    • HiDAC may be effective in 35 to 40 percent of patients resistant to conventional dose cytarabine regimens[2].
  • High-dose cytarabine plus mitoxantrone (HAM)
    • In addition to the side effects described for HiDAC above, nonhematologic toxicities include stomatitis, infections, and neutropenic fever. Infrequent transient, mild cardiac failure and tachyarrhythmias have also been reported.
    • If an anthracycline (eg, daunorubicin) was not used during initial induction, the combination of HiDAC plus the synthetic anthracycline analogue, mitoxantrone, may produce higher response rates than HiDAC alone[3].
  • High-dose cytarabine plus etoposide
    • In addition to the side effects described for HiDAC above, nonhematologic toxicities include hepatic toxicity, peripheral neuropathy, and anaphylactic-like reaction.
    • HiDAC plus etoposide results in similar response rates as HiDAC alone with a nonsignificant trend towards longer remission duration[4].
  • Mitoxantrone plus etoposide
    • Nonhematologic toxicities include stomatitis, nausea, infections, and neutropenic fever. Infrequent transient, mild cardiac failure and tachyarrhythmias have also been reported.
    • Mitoxantrone and etoposide given together for five days is a commonly used regimen to treat refractory or relapsed AML and has demonstrated complete response rates of approximately 40 percent[5].
  • Mitoxantrone, etoposide, cytarabine (MEC)
    • Side effects are similar to those described for mitoxantrone plus etoposide above, but also include hepatic dysfunction.
    • MEC demonstrates a trend towards higher complete response rates for patients <60 years old and those with unfavorable risk cytogenetics when compared with mitoxantrone plus etoposide alone[6].
  • Gemtuzumab ozogamicin (GO) as a single agent or plus cytarabine and mitoxantrone
    • Serious adverse reactions to GO include fatal anaphylaxis, hemorrhage, teratogenicity, and hepatic injury including sinusoidal obstruction syndrome (also known as hepatic veno-occlusive disease), plus side effects similar to mitoxantrone plus cytarabine, above.
    • GO as a single agent or in combination with mitoxantrone plus cytarabine can achieve complete remission in up to 25 to 35 percent[7].
  • Fludarabine, cytarabine, plus G-CSF (FLAG)
    • Studies including older adults have reported mild nonhematologic toxicity, most commonly with mucositis.
    • FLAG has reported complete remission rates of 45 to 55 percent in patients with primary refractory or relapsing AML[8].
  • Cladribine, cytarabine, G-CSF (CLAG)
    • Nonhematologic toxicity is generally mild to moderate (grade I/II) and includes fever/infection, mucositis, nausea and vomiting, diarrhea, and alopecia.
    • CLAG results in a complete remission in approximately 50 percent of patients, with a median duration of response of 16 weeks[9].
  • Cyclophosphamide plus high-dose etoposide
    • The most common non-hematologic toxicities include fever/infection, mucositis, hepatic toxicity, and hemorrhagic cystitis.
    • Approximately 42 percent of patients with resistant AML will achieve a complete remission[10].
  • Patients with resistant or relapsed AML should be encouraged to enroll on a clinical trial. While a number of chemotherapy regimens have been used for patients with resistant or relapsed disease, none results in acceptable long term remission rates. Many of these combinations are dose-intensive and cannot easily be applied in older patients. Since these regimens have not been directly compared, a choice is primarily based upon clinical experience and patient co-morbidities. A selection of these regimens is described above. Although response rates are presented for some of these regimens, an individual’s chance of responding to a particular regimen is influenced not only by prior exposure to chemotherapy but also by other patient- and leukemia-associated factors. In theory, the preferred regimen to treat relapsed AML would exclude agents at dose levels which the patient has been exposed to recently.

Cytarabine — 2023-04-12 - https://www.uptodate.com/contents/cytarabine-conventional-drug-information

  • Dosing: Adult - Note: Antiemetics may be recommended to prevent nausea and vomiting; IV doses >1,000 mg/m2 are associated with a moderate emetic potential. Consider hydration and antihyperuricemic therapy to prevent tumor lysis syndrome.
    • Acute lymphoblastic leukemia (off-label dosing):
      • Induction regimen, relapsed or refractory: IV: 3,000 mg/m2 over 3 hours daily for 5 days (in combination with idarubicin [day 3]).
      • Dose-intensive regimen: IV: 3,000 mg/m2 over 2 hours every 12 hours days 2 and 3 (4 doses/cycle) of even numbered cycles (in combination with methotrexate; alternates with Hyper-CVAD).
      • CALGB 8811 regimen:
        • Early-intensification phase: SUBQ: 75 mg/m2/dose days 1 to 4 and 8 to 11 (4-week cycle; repeat once).
        • Late-intensification phase: SUBQ: 75 mg/m2/dose days 29 to 32 and 36 to 39.
      • Linker protocol: Adults <50 years of age: IV: 300 mg/m2/day days 1, 4, 8, and 11 of even numbered consolidation cycles (in combination with teniposide).
      • CALGB 10403 regimen (as part of multi-agent, multicourse chemotherapy; refer to protocol for further details):
        • Adults <40 years of age:
          • Remission consolidation phase (course 2): IV, SUBQ: 75 mg/m2 on days 1 to 4, 8 to 11, 29 to 32, and 36 to 39.
          • Delayed intensification phase (course 4): IV, SUBQ: 75 mg/m2 on days 29 to 32 and 36 to 39.
    • Acute myeloid leukemia remission induction
      • Standard-dose; in combination with other chemotherapy agents): IV: 100 mg/m2/day continuous infusion for 7 days or 200 mg/m2/day continuous infusion (as 100 mg/m2 over 12 hours every 12 hours) for 7 days.
      • 7 + 3 regimens (a second induction course may be administered if needed; refer to specific references): IV: 100 mg/m2/day continuous infusion for 7 days (in combination with daunorubicin or idarubicin or mitoxantrone) or (Adults <60 years) 200 mg/m2/day continuous infusion for 7 days (in combination with daunorubicin).
      • Low-intensity therapy (off-label dosing):
        • Adults >=65 years of age: SUBQ: 20 mg/m2/day for 14 days out of every 28-day cycle for at least 4 cycles or 10 mg/m2 every 12 hours for 21 days; if complete response not achieved, may repeat a second course after 15 days.
        • Adults >=60 years of age (and ineligible for intensive chemotherapy): SUBQ : 20 mg/m2 once daily on days 1 to 10 every 28 days (in combination with venetoclax) until disease progression or unacceptable toxicity.
        • Adults >=55 years of age (and unsuitable for intensive therapy): SUBQ : 20 mg (flat dose) twice daily on days 1 to 10 every 28 days (in combination with glasdegib) until disease progression or unacceptable toxicity.
    • Acute myeloid leukemia consolidation (off-label use):
      • 5 + 2 regimens: IV: 100 mg/m2/day continuous infusion for 5 days (in combination with daunorubicin or idarubicin or mitoxantrone).
      • 5 + 2 + 5 regimen: IV: 100 mg/m2/day continuous infusion for 5 days (in combination with daunorubicin and etoposide).
      • Single-agent: Adults <=60 years of age: IV: 3,000 mg/m2 over 3 hours every 12 hours on days 1, 3, and 5 (total of 6 doses); repeat every 28 to 35 days for 4 courses.
    • Acute myeloid leukemia salvage treatment (off-label use):
      • CLAG regimen: IV: 2,000 mg/m2/day over 4 hours for 5 days (in combination with cladribine and G-CSF); may repeat once if needed.
      • CLAG-M regimen: IV: 2,000 mg/m2/day over 4 hours for 5 days (in combination with cladribine, G-CSF, and mitoxantrone); may repeat once if needed.
      • FLAG regimen: IV: 2,000 mg/m2/day over 4 hours for 5 days (in combination with fludarabine and G-CSF); may repeat once if needed.
      • GCLAC regimen: Adults 18 to 70 years:
        • Induction: IV: 2,000 mg/m2 over 2 hours once daily for 5 days (in combination with clofarabine and filgrastim; administer 4 hours after initiation of clofarabine); may repeat induction once if needed.
        • Consolidation: IV: 1,000 mg/m2 over 2 hours once daily for 5 days (in combination with clofarabine and filgrastim; administer 4 hours after initiation of clofarabine) for 1 or 2 cycles.
      • HiDAC (high-dose cytarabine) ± an anthracycline: IV: 3,000 mg/m2 over 1 hour every 12 hours for 6 days (total of 12 doses).
      • MEC regimen: IV: 1,000 mg/m2/day over 6 hours for 6 days (in combination with mitoxantrone and etoposide) or
        • Adults <60 years of age: IV: 500 mg/m2/day continuous infusion days 1, 2, and 3 and days 8, 9, and 10 (in combination with mitoxantrone and etoposide); may administer a second course if needed.
    • Acute promyelocytic leukemia induction (off-label dosing): IV: 200 mg/m2/day continuous infusion for 7 days beginning on day 3 of treatment (in combination with tretinoin and daunorubicin).
    • Acute promyelocytic leukemia consolidation (off-label use):
      • In combination with idarubicin and tretinoin: High-risk patients (WBC >=10,000/mm3): Adults <=60 years of age:
        • First consolidation course: IV: 1,000 mg/m2/day for 4 days.
        • Third consolidation course: IV: 150 mg/m2 every 8 hours for 4 days.
      • In combination with idarubicin, tretinoin, and thioguanine: High-risk patients (WBC >10,000/mm3): Adults <=61 years of age:
        • First consolidation course: IV: 1,000 mg/m2/day for 4 days.
        • Third consolidation course: IV: 150 mg/m2 every 8 hours for 5 days.
      • In combination with daunorubicin:
        • First consolidation course: IV: 200 mg/m2/day for 7 days.
        • Second consolidation course:
          • Age <=60 years and low risk (WBC <10,000/mm3): IV: 1,000 mg/m2 every 12 hours for 4 days (8 doses).
          • Age <50 years and high risk (WBC >=10,000/mm3): IV: 2,000 mg/m2 every 12 hours for 5 days (10 doses).
          • Age 50 to 60 years and high risk (WBC >=10,000/mm3): IV: 1,500 mg/m2 every 12 hours for 5 days (10 doses).
          • Age >60 years and high risk (WBC >=10,000/mm3): IV: 1,000 mg/m2 every 12 hours for 4 days (8 doses).
    • Chronic lymphocytic leukemia (off-label use): OFAR regimen: IV: 1,000 mg/m2/dose over 2 hours days 2 and 3 every 4 weeks for up to 6 cycles (in combination with oxaliplatin, fludarabine, and rituximab).
    • Hodgkin lymphoma, relapsed or refractory (off-label use):
      • DHAP regimen: IV: 2,000 mg/m2 over 3 hours every 12 hours day 2 (total of 2 doses/cycle) for 2 cycles (in combination with dexamethasone and cisplatin).
      • ESHAP regimen: IV: 2,000 mg/m2 day 5 (in combination with etoposide, methylprednisolone, and cisplatin) every 3 to 4 weeks for 3 or 6 cycles.
      • Mini-BEAM regimen: IV: 100 mg/m2 every 12 hours days 2 to 5 (total of 8 doses) every 4 to 6 weeks (in combination with carmustine, etoposide, and melphalan).
      • BEAM regimen (transplant preparative regimen): IV: 200 mg/m2 twice daily for 4 days beginning 5 days prior to transplant (in combination with carmustine, etoposide, and melphalan).
    • Non-Hodgkin lymphomas (off-label use):
      • BEAM regimen (transplant-preparative regimen): IV: 200 mg/m2 twice daily for 3 days beginning 4 days prior to transplant (in combination with carmustine, etoposide, and melphalan) or 100 mg/m2 over 1 hour every 12 hours for 4 days beginning 5 days prior to transplant (in combination with carmustine, etoposide, and melphalan).
      • Burkitt lymphoma:
        • CALGB 9251 regimen: Cycles 2, 4, and 6: IV: 150 mg/m2/day continuous infusion days 4 and 5.
        • CODOX-M/IVAC regimen:
          • Adults <=60 years of age: Cycles 2 and 4 (IVAC): IV: 2,000 mg/m2 every 12 hours days 1 and 2 (total of 4 doses/cycle) (IVAC is combination with ifosfamide, mesna, and etoposide; IVAC alternates with CODOX-M).
          • Adults <=65 years of age: Cycles 2 and 4 (IVAC): IV: 2,000 mg/m2 over 3 hours every 12 hours days 1 and 2 (total of 4 doses/cycle) (IVAC is combination with ifosfamide, mesna, and etoposide; IVAC alternates with CODOX-M).
          • Adults >65 years of age: Cycles 2 and 4 (IVAC): IV: 1,000 mg/m2 over 3 hours every 12 hours days 1 and 2 (total of 4 doses/cycle) (IVAC is combination with ifosfamide, mesna, and etoposide; IVAC alternates with CODOX-M).
        • Hyper-CVAD alternating with high-dose methotrexate/cytarabine regimen:
          • Adults <60 years of age: Cycles 2, 4, 6, and 8: IV: 3,000 mg/m2 every 12 hours days 2 and 3 (total of 4 doses/cycle) of a 21-day cycle (in combination with methotrexate and leucovorin), alternating with Hyper-CVAD administered on odd-numbered cycles (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) plus rituximab (in cycles 1 to 4) and CNS prophylaxis.
          • Adults >=60 years of age: Cycles 2, 4, 6, and 8: IV: 1,000 mg/m2 every 12 hours days 2 and 3 (total of 4 doses/cycle) of a 21-day cycle (in combination with methotrexate and leucovorin) alternating with Hyper-CVAD administered on odd-numbered cycles (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) with rituximab (in cycles 1 to 4) and CNS prophylaxis.
      • Mantle cell lymphoma:
        • R-DHAP regimen: Adults <=65 years of age: IV: 2,000 mg/m2 every 12 hours on day 2 (total of 2 doses/cycle) every 3 weeks (in combination with rituximab plus dexamethasone and cisplatin) for 4 cycles or 2,000 mg/m2 every 12 hours on day 2 (total of 2 doses/cycle; in combination with rituximab plus dexamethasone and cisplatin) alternating with R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) for 6 cycles (3 cycles each of R-CHOP and R-DHAP).
        • RBAC regimen: IV: 500 to 800 mg/m2 over 2 hours (starting 2 hours after bendamustine) on days 2 through 4 every 28 days for up to 6 cycles (in combination with rituximab and bendamustine).
        • Nordic regimen:
          • Adults <=60 years of age: IV: 3,000 mg/m2 over 3 hours every 12 hours for a total of 4 doses (in combination with rituximab) for 2 cycles alternating with Maxi-CHOP (dose-intensified CHOP) for 3 cycles (total of 5 cycles).
          • Adults >60 years of age: IV: 2,000 mg/m2 over 3 hours every 12 hours for a total of 4 doses (in combination with rituximab) for 2 cycles alternating with Maxi-CHOP for 3 cycles (total of 5 cycles).
        • Hyper-CVAD alternating with high-dose methotrexate/cytarabine regimen:
          • Adults <=60 years of age: Cycles 2, 4, 6, and 8: IV: 3,000 mg/m2 every 12 hours days 3 and 4 (total of 4 doses/cycle) of a 21-day cycle (in combination with methotrexate, leucovorin, and rituximab), alternating with Hyper-CVAD administered on odd-numbered cycles (cyclophosphamide, vincristine, doxorubicin, dexamethasone, and rituximab).
          • Adults >60 years of age: Cycles 2, 4, 6, and 8: IV: 1,000 mg/m2 every 12 hours days 3 and 4 (total of 4 doses/cycle) of a 21-day cycle (in combination with methotrexate, leucovorin, and rituximab) alternating with Hyper-CVAD administered on odd-numbered cycles (cyclophosphamide, vincristine, doxorubicin, dexamethasone, and rituximab).
      • Relapsed or refractory non-Hodgkin lymphomas:
        • DHAP regimen:
          • Adults <=70 years of age: IV: 2,000 mg/m2 over 3 hours every 12 hours day 2 (total of 2 doses/cycle) every 3 to 4 weeks for 6 to 10 cycles (in combination with dexamethasone and cisplatin).
          • Adults >70 years of age: IV: 1,000 mg/m2 over 3 hours every 12 hours day 2 (total of 2 doses/cycle) every 3 to 4 weeks for 6 to 10 cycles (in combination with dexamethasone and cisplatin).
        • ESHAP regimen: IV: 2,000 mg/m2 over 2 hours day 5 every 3 to 4 weeks for 6 to 8 cycles (in combination with etoposide, methylprednisolone, and cisplatin).
    • Primary CNS lymphoma (off-label use): IV: 2,000 mg/m2 over 1 hour every 12 hours days 2 and 3 (total of 4 doses) every 3 weeks (in combination with methotrexate and followed by whole brain irradiation) for a total of 4 courses or 3,000 mg/m2 (maximum dose of 6,000 mg) over 3 hours on days 1 and 2 every 4 weeks for 2 cycles (administer cytarabine after 5 to 7 cycles of the induction R-MPV regimen [rituximab, methotrexate, leucovorin, vincristine, and procarbazine] and whole brain radiation therapy) or 2,000 mg/m2 over 2 hours every 12 hours days 1 to 4 (total of 8 doses) as consolidation therapy (in combination with etoposide); cytarabine/etoposide is administered following remission induction with methotrexate, leucovorin, temozolomide, and rituximab.
    • Meningeal leukemia: Intrathecal therapy: Note: Optimal intrathecal chemotherapy dosing should be based on age rather than on body surface area (BSA); CSF volume correlates with age and not to BSA. Dosing provided in the manufacturer’s labeling is BSA-based.
    • Off-label uses or doses for intrathecal therapy:
      • CNS prophylaxis (ALL): Intrathecal: 100 mg weekly for 8 doses, then every 2 weeks for 8 doses, then monthly for 6 doses (high-risk patients) or 100 mg on day 7 or 8 with each chemotherapy cycle for 4 doses (low risk patients) or 16 doses (high-risk patients) or 70 mg on day 1 of remission induction cycle 1 (adults <40 years of age).
        • or as part of intrathecal triple therapy (TIT): Intrathecal: 40 mg days 0 and 14 during induction, days 1, 4, 8, and 11 during CNS therapy phase, every 18 weeks during intensification and maintenance phases.
      • CNS prophylaxis (APL, as part of TIT): Intrathecal: 50 mg per dose; administer 1 dose prior to consolidation and 2 doses during each of 2 consolidation phases (total of 5 doses).
      • CNS prophylaxis (Burkitt lymphoma; component of CODOX-M/IVAC regimen): Intrathecal: 70 mg on days 1 and 3 of cycles 1 and 3 (CODOX-M cycle).
      • CNS prophylaxis (Burkitt lymphoma; component of Hyper-CVAD alternating with cytarabine/methotrexate regimen): Intrathecal: 100 mg on day 7 of each 21-day treatment cycle.
      • CNS leukemia treatment (ALL, as part of TIT): Intrathecal: 40 mg twice weekly until CSF cleared.
      • CNS lymphoma treatment: Intrathecal: 50 mg twice a week for 4 weeks, then weekly for 4 to 8 weeks, then every other week for 4 weeks, then every 4 weeks for 4 doses.
      • CNS treatment (Burkitt lymphoma; component of CODOX-M/IVAC regimen): Intrathecal: 70 mg on days 1, 3, and 5 of cycles 1 and 3 (CODOX-M cycle) and 70 mg on days 7 and 9 of cycles 2 and 4 (IVAC cycle).
      • Leptomeningeal metastases treatment: Intrathecal: 25 to 100 mg twice weekly for 4 weeks, then once weekly for 4 weeks, then a maintenance regimen of once a month or 40 to 60 mg per dose.
    • Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance.

FLAG-IDA for acute myeloid leukemia — 2023-07-04 - https://aml-hub.com/medical-information/flag-ida-for-acute-myeloid-leukemia

FLAG-Ida for Acute Myeloid Leukaemia (AML) — 2023-07-04 - https://media.leukaemiacare.org.uk/wp-content/uploads/FLAG-Ida-for-Acute-Myeloid-Leukaemia-AML-Web-Version.pdf

FLAG (fludarabine + high-dose cytarabine + G-CSF): an effective and tolerable protocol for the treatment of ‘poor risk’ acute myeloid leukemias — https://pubmed.ncbi.nlm.nih.gov/7526088/

  • Twenty-eight patients with poor prognosis acute myeloid leukemia (AML) received therapy with two courses of fludarabine 30 mg/m2/day + ara-C 2 g/m2/day (days 1-5) and G-CSF 5 mg/kg/day (FLAG) (from day 0 to polymorphonuclear recovery).

==========

2023-08-31

[Posanol (posaconazole) initial dose may be insufficient]

For prophylactic treatment against invasive fungal infections, the package insert recommends administering Posanol (posaconazole) at a dose of 300 mg twice on the first day, followed by 300 mg daily thereafter.

Failing to administer the medication twice on the initial day could potentially compromise or delay its intended effects.

2023-08-01

[pancytopenia]

Rydapt (midostaurin 25 mg) 2# PO Q12H has been initiated since 2023-07-28. The package insert recommends taking the medication with food. Please ensure that the patient takes the medication with food Q12H.

The following adverse drug reactions and incidences are associated with midostaurin:

  • Hematologic and oncologic:
    • Anemia (60%; grade >=3: 38%)
    • Leukopenia (61%; grade >=3: 19%)
    • Lymphocytopenia (66%; grade >=3: 42%)
    • Neutropenia (49%; grade >=3: 22%)
    • Thrombocytopenia (50%; grade >=3: 27%)
  • Hepatic:
    • Hyperbilirubinemia (29%)
    • Increased gamma-glutamyl transferase (35%)
    • Increased serum alanine aminotransferase (31%)
    • Increased serum alkaline phosphatase (39%)
    • Increased serum aspartate aminotransferase (32%)

Since pancytopenia had already developed before this drug administration, it would be difficult to distinguish to what extent the subsequent pancytopenia would gradually be attributed to midostaurin (if any).

2023-07-27

[pancytopenia]

Both fludarabine and cytarabine, which are components of the FLAG regimen, are known to cause bone marrow suppression, especially fludarabine.

The patient received two cycles of the FLAG regimen, one on 2023-06-21 and the other on 2023-07-19. The first cycle resulted in a 5-day period (2023-06-28 to 2023-07-02) of WBC < 1K/uL, and the second cycle resulted in WBC < 1K/uL since 2023-07-24, which has not yet returned to levels above 1K/uL. Thrombocytopenia was previously mentioned in the pharmacist’s note. The HGB levels show a similar trend to the PLT levels. In addition, the patient has received several blood transfusions this year on different dates (2023-01-02, 2023-01-06, 2023-01-11, 2023-01-18, 2023-01-22, 2023-01-26, 2023-01-28, 2023-01-30, 2023-02-03, 2023-03-03, 2023-03-07, 2023-03-11, 2023-03-17, 2023-04-14, 2023-04-18, 2023-04-22, 2023-04-26, 2023-04-30, 2023-06-19, 2023-06-28, 2023-07-17, 2023-07-21, 2023-07-25) and also received G-CSF in the first quarter of this year.

2023-07-07

The FLAG regimen was initiated on 2023-06-21. However, the current thrombocytopenia event had started even before the regimen was administered. Visually estimating the platelet count before and after the FLAG administration, the values were approximately within the range of 50 +- 25 K/uL, and there was no clear downward trend. This is because the patient had received multiple transfusions to maintain PLT a certain level.

2023-07-06 PLT 55 x10^3/uL
2023-07-04 PLT 25 x10^3/uL
2023-07-02 PLT 48 x10^3/uL
2023-06-30 PLT 23 x10^3/uL
2023-06-28 PLT 62 x10^3/uL Blood Transfution
2023-06-26 PLT 37 x10^3/uL
2023-06-25 PLT 47 x10^3/uL
2023-06-24 PLT 73 x10^3/uL
2023-06-23 PLT 28 x10^3/uL Blood Transfution 2023-06-22 PLT 40 x10^3/uL
2023-06-21 PLT 54 x10^3/uL FLAG 2023-06-20 PLT 47 x10^3/uL
2023-06-19 PLT 19 x10^3/uL Blood Transfution 2023-06-08 PLT 70 x10^3/uL
2023-05-04 PLT 247 x10^3/uL
2023-05-02 PLT 176 x10^3/uL
2023-05-01 PLT 137 x10^3/uL Blood Transfution (2023-04-30)

The risk of bleeding generally increases with platelet counts below 40 to 50 K/uL, but there isn’t a strong linear correlation between platelet count and bleeding risk. If major or life-threatening bleeding occurs, platelet transfusions should be administered without delay.

2023-07-04

[FLT3 inhibitors]

  • Laboratory data from 2023-01-12 and 2023-06-28 indicated the presence of FLT3/ITD mutation.

  • There are two FDA approved FLT3 inhibitors for AML included in the National Health Insurance Medication Reimbursement Regulations, namely:

    • Midostaurin (such as Rydapt)
      • This is reserved for use in combination with standard induction and consolidation chemotherapy in adult patients newly diagnosed with FLT3 mutation positive AML.
      • Patients with acute promyelocytic leukemia (APL) must be excluded.
      • For first-time use during the standard induction period, pre-examination is not required, and it is limited to two courses. If complete remission is not achieved after two courses, further use is prohibited.
      • For continuous use, it must be approved after pre-examination. Applications must include the results and date of the FLT3 mutation positive test, the record of chemotherapy prescription, and the evaluation of treatment effect. Each renewal application is limited to two courses and must include the evaluation results from the previous treatment to confirm no disease progression. The total treatment courses are capped at six per patient.
      • If a patient undergoes hematopoietic stem cell transplantation, this drug will no longer be covered.
    • Gilteritinib (such as Xospata)
      • This is restricted to use in adult patients with FLT3-mutated relapsed or refractory acute myeloid leukemia (R/R AML) who are planning to undergo hematopoietic stem cell transplantation. It is limited to use before transplantation, with a maximum of six treatment courses per patient. Patients must have received at least one chemotherapy course including an anthracycline drug.
  • Currently, Rydapt is a temporarily procured drug at our hospital, and Xospata does not have a built drug code yet. If any of these two drugs is considered further use, a temporary procurement procedure must be carried out.

2023-04-19

[neutropenia follow-up]

  • The patient received daunorubicin for a 3-day course and cytarabine for a 5-day course at a dosage of 2000mg/m2 with 4000mg every 12 hours, on 2023-04-07. The patient’s WBC count dropped below 1000/uL beginning on 2023-04-14. As a result, lenograstim at 250ug and filgrastim at 150ug have been given daily from that date onwards. However, the patient’s WBC count has not yet returned to normal levels at this time.
    • 2023-04-18 WBC 0.10 x10^3/uL
    • 2023-04-16 WBC 0.15 x10^3/uL
    • 2023-04-14 WBC 0.56 x10^3/uL
    • 2023-04-12 WBC 1.51 x10^3/uL
  • The patient is in good spirits and has no chills. His diet and sleep are satisfactory, and his diarrhea symptoms have improved as of the morning of 2023-04-19.
  • Please remain vigilant for any signs of infection.

2023-04-12

[leukopenia]

  • On 2023-01-09, the patient started a regimen containing anthracycline and cytarabine (idarubicin for 3 days + cytarabine for 7 days), which led to more than 2 weeks of leucopenia with a WBC count of less than 1000/uL. More than 5 weeks later, on 2023-02-23, the second dose was shifted to daunorubicin for 3 days and cytarabine for 7 days. This time, the duration of WBC less than 1000/uL was approximately halved to 1 week. Although the patient was administered G-CSF (filgrastim 150ug) and Granocyte (lenograstim 250ug) on 2023-03-03, WBC count did not appear to increase soon after.

  • On 2023-04-07, the patient received daunorubicin for 3 days and cytarabine for 5 days at a more intensive dose of 2000mg/m2 amounting to 4000mg every 12 hours. After the administration, the WBC count has not dropped below 1000/uL and there has been a reduction in the severity of leukopenia to date.

  • WBC lab data

    • 2023-04-12 WBC 1.51 x10^3/uL
    • 2023-04-10 WBC 4.54 x10^3/uL
    • 2023-04-06 WBC 13.52 x10^3/uL
    • 2023-03-24 WBC 6.18 x10^3/uL
    • 2023-03-17 WBC 7.11 x10^3/uL
    • 2023-03-15 WBC 8.61 x10^3/uL
    • 2023-03-13 WBC 1.41 x10^3/uL
    • 2023-03-11 WBC 0.49 x10^3/uL
    • 2023-03-09 WBC 0.54 x10^3/uL
    • 2023-03-07 WBC 0.48 x10^3/uL
    • 2023-03-05 WBC 0.83 x10^3/uL
    • 2023-03-03 WBC 0.73 x10^3/uL
    • 2023-03-01 WBC 1.58 x10^3/uL
    • 2023-02-27 WBC 2.56 x10^3/uL
    • 2023-02-23 WBC 5.71 x10^3/uL
    • 2023-02-20 WBC 8.15 x10^3/uL
    • 2023-02-08 WBC 6.31 x10^3/uL
    • 2023-02-03 WBC 13.64 x10^3/uL
    • 2023-02-01 WBC 18.52 x10^3/uL
    • 2023-01-30 WBC 3.21 x10^3/uL
    • 2023-01-28 WBC 1.06 x10^3/uL
    • 2023-01-26 WBC 0.56 x10^3/uL
    • 2023-01-24 WBC 0.66 x10^3/uL
    • 2023-01-22 WBC 0.34 x10^3/uL
    • 2023-01-20 WBC 0.24 x10^3/uL
    • 2023-01-18 WBC 0.28 x10^3/uL
    • 2023-01-16 WBC 0.63 x10^3/uL
    • 2023-01-14 WBC 0.44 x10^3/uL
    • 2023-01-13 WBC 1.02 x10^3/uL
    • 2023-01-11 WBC 43.50 x10^3/uL
    • 2023-01-10 WBC 83.37 x10^3/uL
    • 2023-01-09 WBC 89.32 x10^3/uL
    • 2023-01-08 WBC 90.19 x10^3/uL
    • 2023-01-06 WBC 90.16 x10^3/uL
    • 2023-01-04 WBC 93.88 x10^3/uL
    • 2023-01-02 WBC 163.72 x10^3/uL

2023-01-13

  • There was neutropenia of grade 2 (2023-01-13 1.02K/uL) as well as suspected tumolysis syndrome (2023-01-11 P 7.3mg/dL, Ca 2.0mmol/L, uric acid 8.3mg/dL) in this patient. please consider whether G-CSF is necessary in the next few days.
  • Rolikan (sodium bicarbonate) has been prescribed since 2023-01-13. The role of urinary alkalinization with either acetazolamide and/or sodium bicarbonate is unclear and controversial. In the past, alkalinization to a urine pH of 6.5 to 7 or even higher was recommended to increase uric acid solubility, thereby diminishing the likelihood of uric acid precipitation in the tubules. However, this approach has fallen out of favor for the following reasons: 1. There are no data demonstrating the efficacy of this approach. In addition, the only available experimental study suggested that hydration with saline alone is as effective as alkalinization in minimizing uric acid precipitation.; 2. Alkalinization of the urine has the potential disadvantage of promoting calcium phosphate deposition in the kidney, heart, and other organs in patients who develop marked hyperphosphatemia once tumor breakdown begins. (ref: https://www.uptodate.com/contents/tumor-lysis-syndrome-prevention-and-treatment).
  • Febuxostat is administered to this patient currently. The level of uric acid has decreased to 3.8 mg/dL as of 2023-01-13.

700348601

230831

[lab data]

2023-07-27 LDH 150 U/L
2023-07-20 B2-Microglobulin 2197 ng/mL
2023-07-18 BM chromosome analysis - cytogenetics laboratory report

  • Chromosome Analysis:
    • Tissue Examined: Bone marrow
    • Staining Method: G-Banding
    • Colony number: NA
    • Bands level: 400
    • Chromosome Counts: 45-()、46-(20)、47-()、Other-() Total-(20)
    • Karyotype: 46,XY[20]
  • Interpretation:
    • Analysis of this bone marrow sample shows a male having 46,XY[20] karyotype. No chromosomal abnormality was detected.

2023-07-13 B2-Microglobulin 2254 ng/mL
2023-07-12 LDH 142 U/L

2023-06-21 Anti-HBc Reactive
2023-06-21 Anti-HBc-Value 4.63 S/CO
2023-06-21 Anti-HBs 297.01 mIU/mL
2023-06-21 HBsAg Nonreactive
2023-06-21 HBsAg (Value) 0.35 S/CO

[exam findings]

  • 2023-06-28 CXR
    • Spondylosis of the T-spine
    • Enlargement of cardiac silhouette.
  • 2023-06-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (81.3 - 17.3) / 81.3 = 78.72%
      • M-mode (Teichholz) = 78.7
    • Conclusion:
      • Normal AV with no AR
      • Normal MV with mild MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, normal IVC size
  • 2023-06-26 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy
    • Sections show 30-35 % cellularity. The M/E ratio is about 3/1 - 4/1. Megakaryocytes are found about 2-10/HPF. No increase of blasts is noted. There are no granulomas, nor foreign malignant cells.
    • The immunohistochemical stains of CD3 and CD20 show mixed lymphoid cells, and no aggregation of lymphoid cells.
  • 2023-06-26 Whole body PET scan
    • Increased FDG uptake in the stomach, compatible with the primary B-cell lymphoma of stomach.
    • Increased FDG uptake in the left axillary lymph nodes, probably reactive nodes.
    • Increased FDG accumulation in the left ureter and colon, probably physiological uptake of FDG.
    • B-cell lymphoma of stomach, stage I, by this F-18 FDG PET scan.
  • 2023-06-23 Patho - stomach biopsy
    • Stomach, low body to proximal antrum, biopsy — Diffuse large B cell lymphoma
    • Histology type: diffuse large B cell lymphoma characterized by dense lymphoid infiltration consists of large atypical lymphocytes
    • Immunohistochemistry: CD20(+, diffuse), CD3(-), CD10(-), CK(-), Bcl-6(+), Bcl-2(-), C-MYC (+, >30%), Cyclin-D1(-) and Ki-67(>90%) for tumor
  • 2023-06-23 CT - chest
    • Indication: B-cell lymphoma
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • The lung fields are clear.
        • Non-specific lymph nodes are found at paratracheal region is found.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Diffuse wall thickening at gastric body is found. Gastric lymphoma is compatible.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • IMp: Compatible with gastric lymphoma without chest nor mediastinal involvement.
  • 2023-06-23 EGD
    • Gastric tumor, Borrmann type III, low body to proximal antrum, s/p biopsy
    • Superficial gastritis
  • 2023-05-31 CT - abdomen gastric filling with water
    • Findings:
      • There is segmental wall thickening at the greater curvature side of the gastric body, measuring 2.2 cm in wall thickness.
        • Malignant lymphoma is highly suspected.
        • Please correlate with gastroscopy.
      • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidneys.
      • There is no evidence of ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
      • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Malignant lymphoma in the gastric body is highly suspected.
        • Please correlate with gastroscopy.

[MedRec]

  • 2023-07-19 SOAP Hemato-Oncology
    • P: Arrange admission for R-CHOP on 2023-07-19
  • 2023-07-07 SOAP Metabolism and Endocrinology
    • A/P
      • Educate complications: poor wound healing, hyperlipidemia, CAD/Stroke/DKD/retinopathy..
      • Diet and exercise control
      • Encourage SMBG
      • F/u OPH. QY and dentist Q6M
      • Check
        • TG/LDL/TCHO Q6M (2023/)
        • H1c, AC Q3M (2023/)
      • Medication:
        • metformin 2000, amayl BID -> metformin BID, amaryl BID, trajenta QD, 1M one touch
      • Educate hypoglycemia (in the event of hypoglycemia (below 70 mg/dL), drink a bottle of Yakult or YiMei’s small BaiJi fruit juice. Each serving contains approximately 10~15 grams of sugar. After 15~20 minutes, measure the blood sugar again, or consider having your main meal earlier.)
      • Goal:
        • SMBG: <65y/o/mutliple underlying - A1c 7.5-8.0%;AC 100-130mg/dl; PC 180mg/dl
        • BP <140/90mmHg, DKD < 130/80mmHg
        • Lipid: TCHO<160mg/dl, non-HDL<130mg/dl, HDL > 40(male), 50(female), TG< 150mg/dl
      • Side effects education
        • metformin: GI discomfort, renal function, Vit B12 deficiency
        • statin: hepatic dysfunction, myopathy, renal dose.
        • fibrate: gallstone, myopathy, GI upset, rash, pruritis
    • Prescription
      • Uformin (metformin 500mg) 2# BID
      • Trajenta (linagliptin 5mg) 1# QD
      • Amepiride (glimepiride 2mg) 1# BIDAC
  • 2023-06-21 ~ 2023-07-04 POMR Hemato-Oncology
    • Discharge diagnosis
      • Diffuse large B-cell lymphoma of gastric, stage I, Bcl-6(+), Bcl-2(-), C-MYC (+, >30%) and Ki-67(>90%) s/p chemotherapy with R-COP from 2023/06/27
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
      • Chronic viral hepatitis B without delta-agent
      • Anemia due to antineoplastic chemotherapy
      • Constipation, unspecified
    • CC
      • For examine and prepare chemotherapy.
    • Present illness
      • This 72-year-old man patient suffered from epigastric pain in 2023/02. No body weight loss, night sweat and fever. PES on 2023/05/13 at LMD showed middle body huge ulcer s/p biopsya and GRED, grad A, R/O advanced gastric cancer. Gastric pathology showed malignant B-cell lymphoma, Immunostains for CK(AE1/AE3), CD20 and CD3 are also performed. Abdominal CT on 2023/05/31 showed malignant lymphoma in the gastric body is highly suspected. Now, he was admitted for further treatment and prepare chemotherapy.
    • Course of inpatient treatment
      • After admitted, Check PES on 2023/06/23 showed gastric tumor, Borrmann type III, low body to proximal antrum, s/p biopsy and superficial gastritis. Stomach, low body to proximal antrum, biopsy showed diffuse large B cell lymphoma, Immunohistochemistry: CD20(+, diffuse), CD3(-), CD10(-), CK(-), Bcl-6(+), Bcl-2(-), C-MYC (+, >30%), Cyclin-D1(-) and Ki-67(>90%) for tumor.
      • Chest CT on 2023/06/23 showed compatible with gastric lymphoma without chest nor mediastinal involvement.
      • Bone marrow study on 2023/06/28 and pathology showed negative for malignancy.
      • Whole body PET scan on 2023/06/28 showed primary B-cell lymphoma of stomach with left axillary lymph nodes metastasis, B-cell lymphoma of stomach, stage.
      • Check 2D echo on 2023/06/27 showed M-mode (Teichholz) = 78.7, 1. Normal AV with no AR 2. Normal MV with mild MR 3. Concentric LVH 4. Preserved LV and RV systolic function 5. Mild PR, mild TR, normal IVC size.
      • Consilt GS on 2023/06/26 for Port-A catheter insertion on 2023/06/28.
      • Chemotherapy with COP (Cyclophosphamide 750mg/m2, Vincristine 1.4mg/m2, Prednisolone 60mg/m2)(C1) on 2023/06/29~2023/07/03. NS 1000ml IVF hydration. Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
      • Major Illness applied on 2023/07/03. Type 2 diabetes mellitus without complications with Diet control and check finger sugar, Glimepine 2mg 1# po BIDAC and Metformin 500mg 2# po BID. Essential (primary) hypertension with Norvasc 1# po QD and Aspirin 1# po QD. Chronic viral hepatitis B without delta-agent(2023/06/21 Anti-HBc showed Reactive) with Vemlidy 1# po QD. Anemia(Hb:7.5g/dL) with BT P-RBC 2u on 2023/07/03, 2023/07/04. Constipation with MgO 2# po TID, Sennoside 2# po HS and Bisadyl supp 1# RECT PRNQD. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/07/04 and OPD followed up later.
    • Discharge prescription
      • MgO 250mg 2# TID
      • Through (sennoside 12mg) 2# HS
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Bisadyl supp (bisacodyl 10mg) 1# PRNQD
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
  • 2023-06-06 SOAP Hemato-Oncology
    • O
      • 2023/05/31 CT: Abdomen gastric filling with water: Malignant lymphoma in the gastric body is highly suspected
    • P
      • Admission for EGD, Chest CT, PET-CT, bone marrow, lab HBV/HCV, LDH, UA. Port-A insertion.
  • 2023-05-30 SOAP General Surgery
    • S
      • epigastric pain for 3 months
      • BW: 75 kg
      • DM+ with 10 yrs
      • H/T with TX 10 yrs
    • O
      • UGI scope: middle body huge ulcer
      • path: malignant B cell lymphoma
      • arrange CT scan

[immunochemotherapy]

  • 2023-08-14 - rituximab 375mg/m2 680mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + doxorubicin 50mg/m2 75mg + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 50mg BID PO D1-5 (R-CHOP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-21 - rituximab 375mg/m2 680mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + doxorubicin 50mg/m2 75mg + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 50mg BID PO D1-5 (R-CHOP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-29 - cyclophosphamide 750mg/m2 1300mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 100mg QD PO D1-3 (COP Q3W)
    • dexamethasone 4mg + + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-09-01

[Dipeptiven dosage and administration]

(Dipeptiven ref: https://www.fresenius-kabi.com/nz/documents/Dipeptiven_Datasheet.pdf)

Solution for infusion after mixture with a compatible infusion solution. Solutions of mixtures with an osmolarity above 800 mosmol/L should be infused by the central venous route.

Dipeptiven is administered parallel with parenteral nutrition or enteral nutrition or a combination of both. Dosage depends on the severity of the catabolic state and on amino acids/protein requirement.

A maximum daily dosage of 2 g amino acids/or protein per kg bodyweight should not be exceeded in parenteral/enteral nutrition. The supply of alanine and glutamine via Dipeptiven should be taken into consideration in the calculation. The proportion of the amino acids supplied through Dipeptiven should not exceed approx. 30% of the total amino acids/protein supply.

  • Patients with total parenteral nutrition
    • The rate of infusion depends on that of the carrier solution and should not exceed 0.1 g amino acids/kg body weight per hour.
    • Dipeptiven should be mixed with a compatible amino acid carrier solution or an amino acid containing infusion regimen prior to administration.
  • Patients with total enteral nutrition
    • Dipeptiven is continuously infused over 20-24 hours per day. For peripheral venous infusion, dilute Dipeptiven to an osmolarity ≤ 800 mosmol/L (e.g. 100 mL Dipeptiven +100 ml saline).
  • Patients with combined enteral and parenteral nutrition
    • The full daily dosage of Dipeptiven should be administered with the parenteral nutrition, i.e. mixed with a compatible amino acid solution or an amino acid contained in infusion regimen prior to administration.

2023-08-31

[Selection of antiviral drugs for Hepatitis B]

This patient is undergoing dialysis, and the current administration methods for Hepatitis B medication available in our hospital for dialysis patients are:

  • Baraclude (entecavir 0.5mg)
    • Hemodialysis, intermittent (thrice weekly): Not significantly dialyzed (13%): Administer 10% of usual indication-specific dose daily. Alternatively, administer usual indication-specific dose every 7 days. When scheduled dose falls on a dialysis day, administer after hemodialysis.
    • Hepatic Impairment: No dosage adjustment necessary.
  • Vemlidy (tenofovir alafenamide 25mg)
    • Hemodialysis, intermittent (thrice weekly): No dosage adjustment necessary; when scheduled dose falls on a dialysis day, administer after dialysis.
    • Hepatic Impairment: Decompensated cirrhosis (Child-Pugh class B or C): Use is not recommended.
  • Viread (tenofovir disoproxil fumarate 300mg)
    • Hemodialysis, intermittent (thrice weekly): Tenofovir disoproxil fumarate: 300 mg following dialysis every 7 days; use with caution and close monitoring.
    • Hepatic Impairment: No dosage adjustment necessary.

Considering the patient’s bilirubin levels on 2023-08-30, with total bilirubin at 2.32mg/dL and direct bilirubin at 1.78mg/dL, the use of Baraclude 0.5mg QWAC may be an option.

2023-08-15

The patient renewed his prescription on 2023-08-03 for metformin, aspirin, bisoprolol, amlodipine, and atorvastatin. Comparing with the active medication list, statins are not listed. Lab results from 2023-08-04 indicated no hyperlipidemia. Thus, there are no identified issues with medication reconciliation.

2023-08-04 Cholesterol total 148 mg/dL
2023-08-04 Triglyceride (TG) 95 mg/dL
2023-08-04 LDL-C 95 mg/dL
2023-08-04 HDL-C 43 mg/dL

701181620

230831

[exam findings]

  • 2023-07-25 ECG
    • Sinus bradycardia
  • 2023-07-25 CXR
    • Atherosclerotic change of aortic arch
  • 2023-07-11 CT - abdomen
    • Clinical history: 64 y/o female patient with postoperative radiotherapy due to endometrium carcinoma.
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P hysterectomy and oophorectomy.
      • Cystic lesions, 2.9cm in left and 2.1cm in right pelvic cavity, r/o lymphocele.
    • Impression:
      • S/P hysterectomy and oophorectomy. Suggest follow up.
      • R/O lymphocele in the pelvic cavity.
  • 2023-06-05 Gynecologic ultrasonography
    • ATH + BSO
    • IMP: No obvious uterine or ovarian lesion
  • 2023-02-27 Patho - uterus (with or without SO) neoplastic
    • PATHOLOGIC DIAGNOSIS
      • Endometrium, uterus, 3D laparoscopic staging surgery — Endometrioid carcinoma, grade 2
      • Myometrium, uterus, ditto — Tumor invasion, more than half thickness
      • Cervix, uterus, ditto — Free of tumor invasion
      • Ovary, left, ditto — Free of tumor invasion
      • Fallopian tube, left, ditto — Free of tumor invasion, paratubal cysts
      • Ovary, right, ditto — Free of tumor invasion
      • Fallopian tube, right, ditto — Free of tumor invasion, paratubal cysts
      • Lymph node, L’t iliac, dissection — Free of tumor metastasis (0/3)
      • Lymph node, L’t oburator, ditto — Free of tumor metastasis (0/9)
      • Lymph node, R’t iliac, ditto — Free of tumor metastasis (0/2)
      • Lymph node, R’t oburator, ditto — Tumor metastasis (2/5)
      • Parametria, bilateral — Free of tumor invasion
      • Omentum, partial omentectomy — Free of tumor invasion
      • AJCC Pathologic stage — pT1bN1a, if cM0, stage IIIC1 (FIGO stage IIIC1)
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: 3D laparoscopic GYN cancer staging surgery
      • Specimens include: uterus, bilateral adnexa, partial omentum and pelvic lymph nodes
      • Specimen size:
        • uterus: 7.3 x 5.2 x 3.7 cm in size, 79 gm in weight
        • right ovary: 1.9 x 0.7 x 0.4 cm
        • left ovary: 2.3 x 1.0 x 0.7 cm
        • right fallopian tube: 5.7 cm in length, 0.5 cm in diameter
        • left fallopian tube: 4.5 cm in length, 0.5 cm in diameter
      • Tumor site: endometrium
      • Tumor size: 3.7 x 2.6 cm
      • The myometrium: tumor invasion more than half thicknes
      • The cervix: no remarkable change
      • Adnexa (bilateral): no remarkable change, bilateral paratubal cysts (L’t: 0.2 cm, R’t: 0.2 cm)
      • Omentum: two pieces, up to 7.8 x 4.8 x 1.7 cm, no remarkable change
      • Lymph nodes: left iliac LNs; left obturator LNs; right iliac LNs and right obturator LNs
      • Representative sections as A1: R’t F-tube, A2: R’t ovary, A3: L’t F-tube, A4-A10: tumor, A11-A12: cervix, A13: detached tumor fragments, X1: L’t ovary, X2: R’t parametrium, X3: L’t parametrium, B: omentum, C: L’t iliac LNs, D: L’t obturator LNs, E: R’t iliac LNs and F: R’t obturator LNs
    • MICROSCOPIC EXAMINATION
      • Histology type: Endometrioid carcinoma
      • Histology grade: Grade 2
      • Depth of invasion: More than half thickness of myometrium
      • Lymphovascular invasion: Present
      • The cervical stroma involvement: Absent
      • Resection margins of the cervix: Free, 2 cm away from tumor
      • Additional pathologic findings: secretory metaplasia, focal clear cell change, microabscesses
      • Lymph nodes: tumor metastasis (2/19) in total number without extracapsular extension (0/2)
      • Vaginal stump: free of tumor invasion
      • Perineural invasion: Present
      • Ascites: negative for malignancy
      • Immunohistochemistry: Napsin-A(+, scatter), PMS2(+), MLH1(+), MSH2(+) and MSH6(+) for tumor
  • 2023-02-15 MRI - pelvis
    • With and without contrast enhancement MRI: Pelvis
      • Diffuse soft tissue tumors in the uterine cavity, r/o endometrial malignancy, involvement of more than half myometrium.
      • Cysts in the uterine cervix, suggesting Nabothin cysts.
      • Incresed density in superior anterior aspect of urinary bladder.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T:T1b(T_value) N:N0(N_value) M:M0(M_value) STAGE: IB_(Stage_value)
    • Impression:
      • Diffuse soft tissue tumor in the uterine cavity, r/o endometrial malignancy, if proven endometrial malignancy cstage T1bN0M0.
      • Incresed density in superior anterior aspect of urinary bladder, nature?
  • 2023-02-13 Patho - endocervix curretage/biopsy Y1
    • Uterus, endocervical, ECC — adenocarcinoma, favor endometrial origin
    • Microscopically, section shows adenocarcinoma with complex atypical hyperplasia of atypical neoplastic glands with increased glandular complexity and glandular crowding with clear cytoplasm and nuclear enlargement, loss of polarity and prominent nuleoli with mitoses.
    • IHC stain — vimentin (+), p16(-)
  • 2023-02-13 Patho - endometrium curretage/biopsy Y1
    • Uterus, endometrium, EM sampling — endometrioid carcinoma, with clear cell carcinoma component
    • Microscopically, sections A and B show endometrioid carcinoma composed of proliferation of atypical neoplastic glands with papillary pattern and focal cribriform architecture. The tumor shows orund to oval hyperchromatic nuclei, increased N/C ratio, pleomorphsim, focal clear cytoplasm and mitoses.
    • IHC stain — p53: wild-type, ER: positive (moderate, 40%), Napsin A: posiitve
  • 2023-02-10 Gynecologic ultrasonography
    • EM: 25.3mm

[MedRec]

  • 2023-03-29 ~ 2023-03-31 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Endometrioid carcinoma, with clear cell carcinoma component, of the uterine endometrium, stage pT1bN1a,cM0, stage IIIC1 (FIGO stage IIIC1), s/p 3D laparoscopic GYN cancer staging surgery (on 2023-02-24).
    • CC
      • for chemotherapy
    • Present illness
      • Pathology showed endometrioid carcinoma,grade2. Port-A insertion on 2023/03/20.
      • Planning radiotherapy with 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions via IVRT to vaginal cuff mucosa surface.
      • This time, she was admitted for chemotherapy
    • Course of inpatient treatment
      • After admission, pre medication with Dexamethasone 20mg at 23:00 2023/03/29 and 05:00 2023/03/30. chemotherapy with C1 Taxol plus Carboplatin was administered on 2023/3/30.
      • Patient tolerated the chemotherapy.With the relatively stable condition, she was discharged on 2023/03/31 and will OPD follow up later
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Meitifen (diclofenac Na 75mg) 1# PRNQD
      • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC
  • 2023-02-22 ~ 2023-02-28 POMR Obstetrics and Gynecology Chen GuoHu
    • Discharge diagnosis
      • Endometrial cancer (endometrioid carcinoma, with clear cell carcinoma component), clinical stage Ib) C54.1
      • Female pelvic peritoneal adhesions
      • Laparoscopic staging on 2023-02-24
    • CC
      • Postmenopausal bleeding after COVID-19 vaccine (for 1 year)
    • Present illness
      • This 64 y/o woman, G1P1, NSD*1, menopaused at 48 y/o, menstral cycle irregular with a duration/interval of 5-7/28-30 days, had dysmenorrhea before.
      • She had no other underlying disease and denied any food or drug allergy, denied anticoagulants or hormone use. Mild postmenopausal bleeding was noted by THE patient HERSELF for one year and THE BLEEDING became severe in recent months. She had to wear the night sanitary pad in the morning and period panties at night. The blood clots could be found sometimes, with fresh red color.
      • There were mild abdominal pain with tenderness. HOWEVER, she denied nausea or vomiting, AND HAD no tarry/bloody stoool, no constipation, no unintention NOR body weight loss. She turned to our GYN OPD for help, and some examinationS were done. The pelvic examination showed smooth cervix and active bleeding after brush, VD watery old bloody.
      • The transvaginal sono on 2023.02.10 revealed EM 25.3mm, SO ECC + EM sampling were done and revealed endometrioid ADENOcarcinoma with clear cell component.
      • PELVIC MRI was also done and revealed diffuse soft tissue tumorS in the uterine cavity, r/o endometrial malignancy, if proven endometrial malignancy cstage T1bN0M0.
      • THE Tumor markerS WERE examinated and showd CA125 LEVEL WAS 108.5, CEA LEVEL WAS 1.76, AND SCC LEVEL WAS 0.4.
      • Under the impression of endometrioid ADENOcarcinoma, CLINICAL STAGE Ib, she was admitted on 2023.02.22 for further evaulation and THE sugery of laparoscopic gynecologic oncology staging surgery (LAVH + BSO + BPLND + partial omentectomy) and possible adhesiolysis will be performed on 2023.02.24.
    • Course of inpatient treatment
      • The patient was admitted on 2023-02-22 due to endometrial cancer (endometrioid carcinoma, with clear cell carcinoma component). GI panendoscopy was done on 2023-02-23. She underwent laparoscopic staging surgery (Laparoscope-assisted Vaginal Hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + partial omentectomy + washing cytology) and LSC dhesiolysis on 2023-02-24. The pathology was pending. Her postoperative course was uneventful. After flatus, her self voiding, eating and defecation were smooth. She was discharged on 2023-02-28. Her follow up appointment is scheduled on 2023-03-06.
    • Discharge prescription
      • MgO 250mg 1# QID
      • Actein (acetylcysteine 200mg) 1# TID
      • Sodicon (dextromethorphan 15mg) 1# TID
      • cephalexin 500mg 1# QID
      • Acetal (acetaminophen 500mg) 1# QID

[surgical operation]

  • 2023-02-24
    • Surgery
      • 3D laparoscopic GYN cancer staging surgery (laparoscopic hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymphonode dissection + partial omentectomy) + laparoscopic adhesiolysis
    • Finding
      • Uterus: 9x5x3 cm
      • endometrium: s/p D & C, lots of eroded tissues, due to residual EM cancer?
      • myomectrium - seemed involved by cancer cells ( > 1/2)
      • prev pathology report of endometrium (D & C): endometrioid adenocarcinoma
      • cervix - eroded, seemed involved by cancer cells
      • bil adnexa: normal-looking
      • bowels, omentum - seemed free of cancer invasion
      • Bilateral pelvic iliac and obturator LNs was removed
      • CDS: no ascites (washing cytology was sent) but pelvic adhesion was noted between ant peritoneum, pelic walls, and bowels s/p lysis
      • A 7mm JP drain was placed in CDS

[radiotherapy]

  • 2023-03-30 ~ 2023-05-18 - 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions via IVRT to vaginal cuff mucosa surface.

[chemotherapy]

  • 2023-07-26 - paclitaxel 175mg/m2 245mg NS 250mL 3hr + carboplatin AUC 5 465mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
  • 2023-06-29 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 465mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
  • 2023-05-31 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 465mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
  • 2023-04-25 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 465mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
  • 2023-03-30 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 465mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL

==========

2023-08-31

Based on PharmaCloud records, this patient has only received medical care at our hospital in the last three months, with no medication reconciliation issues identified.

從 PharmaCloud 紀錄來看,該名患者最近三個月只在本院就診,沒有發現 medication reconciliation issue.

700382066

230830

[lab data]

2023-08-14 CMV viral load assay Target not detecetedIU/mL

2023-08-09 CD45+Total leukocyte 329085 /uL
2023-08-09 %CD34+ 0.41 %
2023-08-09 CD34+ Count 1350 /uL

2023-08-09 CD45+Total leukocyte 25806 /uL
2023-08-09 %CD34+ 0.10 %
2023-08-09 CD34+ Count 26 /uL

2023-08-09 HPC Ratio 0.41 %
2023-08-09 HPC# 0.1050 10^3/ul

2023-08-08 CD45+Total leukocyte 367310 /uL
2023-08-08 %CD34+ 0.31 %
2023-08-08 CD34+ Count 1140.0 /uL

2023-08-08 RPR/VDRL Nonreactive
2023-08-08 HIV Ab-EIA Nonreactive
2023-08-08 Anti-HIV Value 0.07 S/CO

2023-08-08 Anti-HCV Nonreactive
2023-08-08 Anti-HCV Value 0.09 S/CO

2023-08-08 HBsAg Nonreactive
2023-08-08 HBsAg (Value) 0.27 S/CO

2023-08-08 CD45+Total leukocyte 22719 /uL
2023-08-08 %CD34+ 0.10 %
2023-08-08 CD34+ Count 24.0 /uL

2023-08-08 HPC Ratio 0.34 %
2023-08-08 HPC# 0.0820 10^3/ul

2023-07-18 IgG (blood) 732 mg/dL

2023-06-06 Free Light Chain κ/λ, (blood) ratio
2023-06-06 FKLC 9.6 mg/L
2023-06-06 FLLC 86.8 mg/L
2023-06-06 FK/FL ratio 0.11 ratio

2023-06-01 B2-Microglobulin 1862 ng/mL

2023-05-31 IgG (blood) 867 mg/dL

2023-05-23 CD45+Total leukocyte 216525 /uL
2023-05-23 %CD34+ 0.13 %
2023-05-23 CD34+ Count 285 /uL

2023-05-23 CD45+Total leukocyte 36136 /uL
2023-05-23 %CD34+ 0.02 %
2023-05-23 CD34+ Count 6 /uL

2023-05-23 HPC Ratio 0.04 %
2023-05-23 HPC# 0.018 10^3/ul

2023-05-22 CD45+Total leukocyte 243730 /uL
2023-05-22 %CD34+ 0.31 %
2023-05-22 CD34+ Count 760 /uL

2023-05-22 HPC Ratio 0.18 %
2023-05-22 HPC# 0.094 10^3/ul

2023-05-03 Free Light Chain κ/λ; (blood) ratio
2023-05-03 FKLC 11.2 mg/L
2023-05-03 FLLC 53.5 mg/L
2023-05-03 FK/FL ratio 0.21 ratio

2023-04-27 B2-Microglobulin 1275 ng/mL

2023-04-26 IgG (blood) 782 mg/dL

2023-04-11 CD45+Total leukocyte 246285 /uL
2023-04-11 %CD34+ 0.08 %
2023-04-11 CD34+ Count 200 /uL

2023-04-11 CD45+Total leukocyte 24252 /uL
2023-04-11 %CD34+ 0.01 %
2023-04-11 CD34+ Count 2 /uL

2023-04-11 HPC Ratio 0.15 %
2023-04-11 HPC# 0.036 10^3/ul

2023-04-10 CD45+Total leukocyte 191835 /uL
2023-04-10 %CD34+ 0.11 %
2023-04-10 CD34+ Count 205 /uL

2023-04-10 CD45+Total leukocyte 30658 /uL
2023-04-10 %CD34+ 0.02 %
2023-04-10 CD34+ Count 6 /uL

2023-04-10 HPC Ratio 0.21 %
2023-04-10 HPC# 0.062 10^3/ul

2023-03-31 Free Light Chain κ/λ; (blood) ratio
2023-03-31 FKLC 9.4 mg/L
2023-03-31 FLLC 55.1 mg/L
2023-03-31 FK/FL ratio 0.17 ratio

2023-03-25 B2-Microglobulin 1833 ng/mL

2023-03-24 IgG (blood) 621 mg/dL

2023-03-13 Free Light Chain κ/λ; (blood) ratio
2023-03-13 FKLC 9.6 mg/L
2023-03-13 FLLC 87.3 mg/L
2023-03-13 FK/FL ratio 0.11 ratio

2023-03-04 B2-Microglobulin 1701 ng/mL
2023-03-03 IgG (blood) 880 mg/dL

2023-02-23 Influenza A Ag Negative
2023-02-23 Influenza B Ag Negative

2023-02-08 Free Light Chain κ/λ; (blood) ratio
2023-02-08 FKLC 15.1 mg/L
2023-02-08 FLLC 231.25 mg/L
2023-02-08 FK/FL ratio 0.07 ratio

2023-02-04 B2-Microglobulin 2002 ng/mL

2023-02-03 IgG (blood) 757 mg/dL

2022-12-22 Free Light Chain κ/λ; (blood) ratio
2022-12-22 FKLC 13.4 mg/L
2022-12-22 FLLC 287.5 mg/L
2022-12-22 FK/FL ratio 0.05 ratio

2022-12-17 B2-Microglobulin 2642 ng/mL

2022-12-16 IgG (blood) 1463 mg/dL

2022-11-29 HBsAg Nonreactive
2022-11-29 HBsAg (Value) 0.41 S/CO
2022-11-29 Anti-HCV Nonreactive
2022-11-29 Anti-HCV Value 0.24 S/CO
2022-11-29 Anti-HBc Reactive
2022-11-29 Anti-HBc-Value 6.61 S/CO
2022-11-29 Anti-HBc IgM Nonreactive
2022-11-29 Anti-HBc IgM Value 0.09 S/CO
2022-11-29 Anti-HBs 9.54 mIU/mL

2022-11-24 CD2 NA
2022-11-24 CD3 61.7
2022-11-24 CD4 19.9
2022-11-24 CD5 75.6
2022-11-24 CD7 82.3
2022-11-24 CD8 52.2
2022-11-24 CD10 12.5
2022-11-24 CD11b NA
2022-11-24 CD13 NA
2022-11-24 CD14 3.9
2022-11-24 CD15 NA
2022-11-24 CD16 NA
2022-11-24 CD19 19.5
2022-11-24 CD19/kappa 7.27
2022-11-24 CD19/Lambda 9.4
2022-11-24 CD20 25.7
2022-11-24 CD23 18.9
2022-11-24 CD25 16.5
2022-11-24 CD33 NA
2022-11-24 CD34 6.9
2022-11-24 CD38 85.2
2022-11-24 CD56 29.1
2022-11-24 CD103 NA
2022-11-24 CD117 NA
2022-11-24 CD138 16.2
2022-11-24 FMC7 19.3
2022-11-24 HLA-DR NA
2022-11-24 MPO NA
2022-11-24 TdT NA
2022-11-23 BM chromosome analyz see attachment

  • Chromosome Analysis:
    • Tissue Examined: Bone marrow
    • Staining Method: G-Banding
    • Colony number: NA
    • Bands level: 350
    • Chromosome Counts: 45-(1)、46-(11)、47-()、Other-() Total-(12)
    • Karyotype: 46,XY[11]
    • Interpretation: Analysis of this bone marrow sample shows a male having 46,XY[11] karyotype. There was no significant clonal chromosomal abnormality detected. However, from 12 cells analyzed, one cell with 45,X,-Y was observed. No clinical significance can be ascribed to this single finding at the present time. Only 12 cells were available for chromosomal analysis due to low mitotic index.

2022-11-10 Free Light Chain κ/λ; (urine)
2022-11-10 Total Volume(24hr) 4500 mL
2022-11-10 FKLC 28.8 mg/L
2022-11-10 FLLC 6875 mg/L
2022-11-10 FK/FL ratio 0.004189

2022-11-08 IgD; <46.7 U/mL

2022-11-08 Free Light Chain κ/λ; (blood) ratio
2022-11-08 FKLC 14.0 mg/L
2022-11-08 FLLC 2725 mg/L
2022-11-08 FK/FL ratio 0.01 ratio

2022-11-07 Protein EP; (urine)
2022-11-07 Protein (Urine) 334 mg/dL
2022-11-07 Albumin(Urine) 4.8 %
2022-11-07 Alpha-1 0.9 %
2022-11-07 Alpha-2 1.1 %
2022-11-07 Beta 2.8 %
2022-11-07 Gamma 90.4 %
2022-11-07 A/G Ratio (Urine) 0.1

2022-11-05 Protein EP;
2022-11-05 Protein, total 8.8 g/dL
2022-11-05 Albumin 35.0 %
2022-11-05 Alpha-1 1.8 %
2022-11-05 Alpha-2 9.7 %
2022-11-05 Beta 8.6 %
2022-11-05 Gamma 44.9 %
2022-11-05 M-peak Positive
2022-11-05 A/G Ratio 0.50

2022-11-05 Protein, total 9.0 g/dL
2022-11-05 Albumin 35.3 %
2022-11-05 Alpha-1 2.4 %
2022-11-05 Alpha-2 9.5 %
2022-11-05 Beta 8.5 %
2022-11-05 Gamma 44.3 %
2022-11-05 M-peak Positive
2022-11-05 A/G Ratio 0.50
2022-11-05 IgG/A/M Kappa/Lambda IgG + Lambda chain
2022-11-05 IgE 13.4 IU/mL

2022-11-04 B2-Microglobulin 2800 ng/mL

2022-11-03 IgG (blood) 4374 mg/dL
2022-11-03 IgA 95 mg/dL
2022-11-03 IgM 34.0 mg/dL
2022-11-03 Total protein 9.4 g/dL

[MedRec]

  • 2023-08-23 SOAP Metabolism and Endocrinology Guo XiWen
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Mixed hyperlipidemia [E78.2]
      • Obesity, unspecified [E66.9]
    • Prescription
      • Zulitor (pitavastatin 4mg) 1# QOD
      • Uformin (metformin 500mg) 1# TID
      • Canaglu (canagliflozin 100mg) 1# QDAC
  • 2023-07-30 ~ 2023-08-10 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Multiple myeloma, IgG lambda type s/p posterior spinal fusion with instrumentation lumbar discectomy over thoracic 9-11 on 2022/11/07, Bone marrow, site unspecified, biopsy (11/7 22) revealed Plasma cell myeloma, immunohistochemical stain profiles: CD138(+, > 60%), lambda light chain(+), kappa light chain(-), CD20 (focal+, < 3%), CD34(-), MPO(focal+), CD71(focal+), CD117(focal+). S/P autologous stem cells collection on 4/10-4/11 23 & C1 C/T with Endoxan
      • Type 2 diabetes mellitus without complications
    • CC
      • for collect stem cells
    • Present illness
      • This 63-year-old man, a patient of multiple myeloma, IgG lambda type s/p posterior spinal fusion with instrumentation lumbar discectomy over thoracic 9-11 on 2022/11/07, suffered from bilateral flank pain for 6 days and he visited to our hema OPD for evaluation and survey.
      • Image study with abdominal CT (10/30 22) showed Osteolytic change of T10 r/o metastases. A patchy density (2.6cm) at left lingual lung. Bil. minimal pleural effusions. EGD (10/31 22) revealed duodenal ulcers. Chest CT (11/2 23) revealed old lung TB with tiny granulomas. no lung or medistinal tumor.favor metastatic lesion in spine and left ilium, origin?, d/d multiple myeloma and T-spine MRI (11/4 22) showed Multiple spinal metasases as described, esp T10 with paraspinal and intraspinal involvement and T10-spine, frozen section (11/7 22) proved no evidence of metastatic carcinoma. Bone marrow, site unspecified, biopsy (11/7 22) revealed Plasma cell myeloma,immunohistochemical stain profiles: CD138(+, > 60%), lambda light chain(+), kappa light chain(-), CD20 (focal+, < 3%), CD34(-), MPO(focal+), CD71(focal+), CD117(focal+).
      • Soft tissue, T10-spine, tumor excision (11/10 22) proved hematoma with lymphocytes, leukoyctes and plasma cells, Immunohistochemical stain reveals CD138(+ at plasma cells).
      • The laboratory showed tatal protine : 9.4g/dl, IgG: 4373mg/dl, B2-Microglobulin:2800ng/ml on 11/4 22 -> 2642ng/ml on 12/17 22 -> 2002ng/ml on 2/4 23 -> 1701 ng/ml on 3/4 23 -> 1833ng/ml on 3/25 23. IgG/A/K/M kappa/Lambda: Protein, total: 9.0 g/dL Albumin L 35.3 %, Alpha-1 2.4 %, Alpha-2 9.5 %, Beta L 8.5 %, Gamma H 44.3 %. The FKLL:15.1mg/L, FLLC: 231.25mg/L on 2/8 23, FKLL:9.6mg/L, FLLC: 87.3mg/L on 3/13 23.
      • He received posterior spinal fusion with instrumentation lumbar discectomy over thoracic 9-11 on 2022/11/07. He also received VTD C1W1 (20221128), C1W2 (20221205), C2W1 (20221216), C2W2 (20221223), C3W1 (20230106), C3W2 (20230113), C4W1 (20230203), C4W2 (20230210), C5W1 (20230303) and Xgeva (20230303).
      • Autologous stem cells collection after GCSF mobolization on account of multiple myeloma after VTD threatment with VGPR on 4/9 23. The HPC#: 0.062 10^3/ul, HPC Ratio: 0.21%, CD34+count: 6/ul, %CD34+: 6/ul, CD45+ total leukocyte: 30658/ul on 4/10 23 & HPC#: 0.036 10^3/ul, HPC Ratio: 0.15%, CD34+count: 2/ul, %CD34+: 0.01/ul, CD45+ total leukocyte: 24252/ul on 4/11 23.
      • Last time, he received chemotherapy with Endoxan 2000mg/m2 was given on 5/11 23.
      • Collect stem cell was done on 5/22-5/23 23.
      • CD34+ count: 760/UL, CD34+: 0.31%, CD45+ total leukocyte: 243730/uL on 5/22 23 CD34+ count: 285/UL, CD34+: 0.13%, CD45+total leukocyte: 216525/uL on 5/23 23. Double lumen was removed on 5/24 23.
      • This time, he was admitted for collect stem cell under Mozobil on 2023/07/30.
    • Course of inpatient treatment
      • After admission, echocardiography was done for prepare BMT later. D/L insetion was done, but failure. Portable was done, showed tracheal deviation to left side, but no pneumothorax. Re-on D/L over left inguinal area on 8/7. GCSF 750mcg sc qdac on 8/5-8/8. Mozobil 24mg at 10pm on 8/7-8/8. Collection stem cell at 9am on 8/8-8/9. Removed D/L smooth and no hematoma. Under the stable condition, he can be discharged on 2023/08/10.
      • PBSC:
        • CD34: 4.18kg x10^6
        • Total CD34: 311.05 x10^6
  • 2022-10-31 POMR Hemato-Oncology Wan XiangLin
    • Discharge diagnosis
      • Multiple myeloma, IgG lambda type
      • Suspect multiple myeloma with bone metastasis
      • Gastrointestinal hemorrhage, unspecified
      • Anemia, unspecified
      • Pleural effusion, not elsewhere classified
      • Type 2 diabetes mellitus without complications
      • Hyperlipidemia, unspecified
      • Constipation, unspecified
      • Hypermagnesemia
      • Enlarged prostate with lower urinary tract symptoms
    • CC
      • Due to bilateral flank pain since May, progression in July, and worse weakness unable to sit up and when changing position pain recently.
    • Present illness
      • This is a 63 y/o male with underlying diseae of DM and dyslipidemia. This time, he was admitted due to Bilateral flank pain for 6 days.
      • According to the patient, he had bilateral flank pain since May, progression in July, and worse weakness unable to sit up and when changing position pain recently. He had went to ER and neuro OPD and pain killer was given. However, the patient said no improvement. And the pain was progressed and radiated to epigastric region. He also stated tarry stool for one week. He denied fever, cough, rhinorrhea, dyspnea, chest pain, dysuria, incontinence. Due to above symptoms, he came to ER for help.
      • At ER, BP: 143/77; HR: 76; Temp: 36.5; RR: 16; Con’s: E4V5M6, SpO2: 97%. PE showed pale conjunctiva, epigastric tenderness. Lab showed Hb:7, CRP 8.57. Blood transfusion and PPI were given.
      • CT showed 1. Osteolytic change of T10 r/o metastases. 2. A patchy density (2.6cm) at left lingual lung. Bil. minimal pleural effusions.
      • Upper GI showed 1. Reflux esophagitis LA Classification grade A 2. Superficial gastritis, s/p CLO test 3. Duodenal shallow ulcers, bulb 4. Duodenal polyps, bulb.
      • Under impression of Upper GI bleeding with anemia, he was admitted to our ward for further treatment.
    • Course of inpatient treatment
      • After admission, Rivotril 0.5mg HS, Mefno 200mg TID for lower back pain, Tramacet 37.5 & 325mg/tab 1# PO Q6H, and Limadol 100mg/amp 1amp IVD PRNQ6H for pain control were prescribed. The patient tolerated soft diet since 2022/11/01, and oral PPI was prescribed.
      • We followed tumor markers on 2022/11/02, and CEA, CA199, SCC, PSA, CA125, AFP were within normal range. Chest CT on 2022/11/02 showed old lung TB and metastatic lesion in spine and left ilium, r/o multiple myeloma.
      • Lab data on 2022/11/02 revealed (Hb:9.9), (serum Ca: 2.2), (Serum IgG: 4374), (Serum IgA: 95), (Urine protein: 334mg/dl).
      • Skull PA on 2022/11/02 revealed multiple punch out lesions.
      • Pelvis AP view on 2022/11/02 revealed bony metastases in bilateral ilium and pubic bone.
      • Long Bones series performed on 2022/11/02 revealed osteolytic lesions in bilateral humerus.
      • Pathology report of bone marrow biopsy on 2022/11/03 revealed plasma cell myeloma.
      • Spine MRI on 2022/11/04 revealed multiple spinal metasases T6, T10-T12, L1-5, S1-3 verteral bodies, esp T10 with paraspinal and intraspinal involvement.
      • On 2022/11/07, posterior spinal fusion with instrumentation lumbar discectomy over thoracic 9-11 were performed, and he tolerated the surgery well. However, he suffered from dysuria after operation, so foley tube was re-inserted on 2022/11/09.
      • On 2022/11/10, we consult urology department for the dysuria, and they suggested UFR/PVR + TRUS and Urief 1# po QD.
      • On 2022/11/15, we had well explained further management plan including target therapy and stem cell implantaion to patient and his family 11/15.
      • We also consulted Radiation Oncology Department for T10 radiotherapy. The radiotherapy started on 2022-11-16.
      • Due to improving status, chemotherapy with Velcade 1.3 mg/m2 at D1, 4, 8, 11 and thalidomide 1# HS D1-21, dexamethasone 20mg BID started on 11/28, the patient tolerated the chemotherapy well.
      • Severe anemia with Hb:6.3 was noted, so we transfused LPRBC 2 units on 2022/11/28 and 2022/11/29 respectively. Foley was removed on 2022/11/30 and he had no urinary difficulty. Surgical staples were also removed after radiotherapy on 2022/12/01.
      • Under stable condition, he discharged on 2022/12/01 outpatient follow up and further treatment were also arranged.
    • Discharge prescription
      • Thado (thalidomide 50mg) 1# HS (2022-11-28 ~ 2022-12-18 D1-21)
      • Canaglu (canagliflozin 100mg) 1# QDAC
      • Mefno (mephenoxalone 200mg) 1# TID
      • Rivotril (clonazepam 0.5mg) 1# HS
      • Uformin (metformin 500mg) 1# TID
      • Urief (silodosin 8mg) 1# QD
      • Zulitor (pitavastatin 4mg) 1# QN
      • Wecoli (bethanechol 25mg) 1# TIDAC
      • Ulstop (famotidine 20mg) 1# BID
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
      • Lactul (lactulose 666mg/mL) 20mL PRNTID
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Limeson (dexamethasone 4mg) 5# BID (2022-12-01 18:00)
      • Through (sennoside 12mg) 2# HS
      • bisacodyl supp 10mg 2# PRNQD RECT
  • 2017-01-10 SOAP Metabolism and Endocrinology Guo XiWen
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Mixed hyperlipidemia [E78.2]
    • Prescription x3 Uformin (metformin 500mg) 1# TID

==========

2023-08-30

[family meeting minutes prior to ASCT]

On 2023-08-30 at 10:15 in the ward conference room, Dr. Gao chaired a family meeting with the patient and his relatives. Attendees included the patient himself, his wife, and his daughter, while his son joined via phone. Dr. Gao explained the treatment plan, the importance and potential risks of autologous stem cell transplantation as a treatment method, and allowed family members to ask questions freely during the meeting.

Overall, the family seemed supportive, and the patient indicated that he would be willing to use a nasogastric tube if necessary during the transplantation treatment. His daughter asked if mouthwash could alleviate symptoms of oral mucositis, to which Dr. Gao responded that mouthwash could help maintain oral cleanliness but couldn’t completely prevent or mitigate the condition, which is mainly caused by conditioning agents.

After the meeting, some casual conversation with the family revealed that the patient was a chef and had run his own business in the past. After retiring, he assisted with religious services in several temples. He is also a vegetarian and has no objections to the hospital’s food offerings.

[Evomela (melphalan) as conditioning regimen prior to HSCT for multiple myeloma]

The recommended dosing schedule is IV 100 mg/m2 daily for 2 days on day -3 and day -2 prior to autologous stem cell transplantation on day 0. Ref: Hari P, Aljitawi OS, Arce-Lara C, et al. A Phase IIb, Multicenter, Open-Label, Safety, and Efficacy Study of High-Dose, Propylene Glycol-Free Melphalan Hydrochloride for Injection (EVOMELA) for Myeloablative Conditioning in Multiple Myeloma Patients Undergoing Autologous Transplantation. Biol Blood Marrow Transplant. 2015;21(12):2100-2105. doi:10.1016/j.bbmt.2015.08.026

700557074

230830

[MedRec]

  • 2023-08-24 SOAP Hemato-Oncology He JingLiang
    • A:
      • Squamous cell carcinoma, moderately differentiated, of the urinary bladder, stage pT3aN0(cM0), stage IIIA, s/p Robotic-assisted pelvic organ preserving radical cystectomy with neobladder reconstruction.
      • Squamous cell carcinoma of the right kidney, stage pT4(cN1M0), stage IV, with para-aortic LNs metastases, s/p LPS right radical nephroureterectomy, and s/p radiotherapy.
    • Prescription
      • Through (sennoside 12mg) 1# HS
      • codeine phosphate 15mg 1# PRNQ12H
      • Roumin (prochlorperazine maleate 5mg) 1# TID
      • Limadol (tramadol 100mg) ST IM
      • OxyNorm (oxycodone 5mg) 1# PRNQ4H
      • Decan (dexamethasone 4mg) ST IM
      • Axcel Cream (acyclovir) TID TOPI
      • Limeson (dexamethasone 4mg) 1# QD
  • 2023-08-04 SOAP Cardiology
    • Diagnosis
      • Hypertensive heart disease without heart failure [I11.9]
      • Anxiety state,unspecified [F41.9]
      • Other insomnia [G47.00]
      • Mixed hyperlipidemia [E78.2]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Prescription
      • Uformin (metformin 500mg) 0.5# QD
      • Concor (bisoprolol 5mg) 1# QD
      • Pravafen (pravastatin 40mg, fenofibrate 160mg) 1# QD
      • Doxaben XL (doxazosin 4mg) 1# QD
      • Trajenta (linagliptin 5mg) 1# QD
  • 2022-02-20 ~ 2022-03-08 POMR Urology
    • Discharge diagnosis
      • Malignant neoplasm of bladder, status post robotic-assisted radical cystectomy with neobladder reconstruction, pT3N0M0
      • Bladder cancer, stage IIIA
    • CC
      • Pain after voiding. Hematuria.
    • Present illness
      • This is a 62-year-old female with underlying disease:
        • Type II Diabetes Mellitus under medication control for 7 years
        • Hypertension under medication control for 8 years
        • Hyperlipidemia under medication control for 7 years
      • She had Bladder cancer, SqCC and urinary tract infection. She felt pain after voiding and had hematuria. She came to OPD for help. At OPD hydronephrosis and urinary tract infection was diagnosed on 2021/12/09. Therefore, transurethral resection of bladder tumor was done on 2021/12/12. SqCC of bladder was diagnosed after biopsy. Therefore, admitted to Urology ward for Robot-Assisted Radical Cystectomy with neobladder on 2022/02/23.
  • 2021-12-12 ~ 2022-12-15 POMR Urology
    • Discharge diagnosis
      • Benign neoplasm of bladder status post transurethral resection of bladder tumor on 2021/12/13
      • Right hydronephrosis status post right  uretetroscopy on 2021/12/13
      • Urinary tract infection with Pseudomonas aeruginosa
    • CC
      • freqency, gross hematuria, lower abdominal pain for days.
    • Present illness
      • The 59-year-old woman had history of 1) Hypertension under medication control for years; 2) Right patellar lateral sublaxation s/p arthroascopic lateral release on 2009/06/10; 3) Right back mass excision on 2011/11.
      • According for this patient statement, freqency, gross hematuria, lower abdominal pain for days. She visited our urologic clinic for help where urinalysis showed WBC=50-59/HPF, RBC=20-29/HPF, OB=3+. Renal sonography revealed severe right hydronephrosis. Under the impression of right hydronephrosis, we advised the patient to receive right URS exam. After well explaining, the patient agreed. This time, she was admitted for further evaluation and management.
    • Course of inpatient treatment
      • After admission, transurethral resection of bladder tumor and right URS exam was performed on 2021/12/13. A large papillary tumor with hypervascularity was noted in right lateral wall of bladder with right ureteral orifice invasion was noted. Post-operatively, continuous irrigation of bladder with normal saline was given. Intravesical chemotherapy with Mitomycin was done. Slight urine color was noted and removed Foley tube done smoothly. With fair urination and stable condition, she was discharged today and follow up at urologic clinic.
  • 2017-03-10 SOAP Cardiology
    • Diagnosis
      • Hypertensive heart disease without heart failure [I11.9]
      • Anxiety state,unspecified [F41.9]
      • Other insomnia [G47.00]
      • Mixed hyperlipidemia [E78.2]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Prescription
      • Norvasc (amlodipine besylate 5mg) 1# QD
      • Eurodin (estazolam 2mg) 1# HS
      • Vytorin (ezetimibe 10mg, simvastatin 20mg) 0.5# HS
      • Concor (bisoprolol 5mg) 1# QD

[chemotherapy]

  • 2023-08-10 - gemcitabine 400mg/m2 600mg NS 100mL 30min + cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-07-28 - gemcitabine 400mg/m2 600mg NS 100mL 30min + cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-07-14 - gemcitabine 400mg/m2 400mg NS 100mL 30min + cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) (low Gemzar)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-06-16 - gemcitabine 400mg/m2 400mg NS 100mL 30min + cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) (low Gemzar)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-06-02 - gemcitabine 400mg/m2 400mg NS 100mL 30min + cisplatin 25mg/m2 40mg NS 500mL 3hr (low Gemzar)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-24 - gemcitabine 400mg/m2 400mg NS 100mL 30min + cisplatin 25mg/m2 40mg NS 500mL 3hr (low Gemzar)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-12-14 - mitomycin-C 30mg/m2 30mg BI 1hr

==========

2023-08-30

In the last three months, all medical records on PharmaCloud are from this hospital. Currently, no medication reconciliation issues have been identified.

700178859

230822

(not completed)

[MedRec]

  • 2023-05-08 ~ 2023-05-11 POMR General and Gastroenterological Surgery
    • Discharge diagnosis
      • Suspicious of right papillary thyroid carcinoma status post bilateral thyroidectomy, parathyroidectomy, right neck lymph node dissection on 2023/05/09
      • Adenocarcinoma of D-colon with multiple liver and lung metastases, cT4aN1bM1b, stage IVB status post Laparoscopic left hemicolectomy with partial hepatectomy and cholecystectomy on 2023/04/13, pT4aN0M1b, Stage IVB, status post Port-A implantation on 2023/05/09
    • CC
      • Glucose hypermetabolism at thyroid gland at whole body PET scan during evaluation of colon cancer was noted about 2 months ago
    • Present illness
      • This 59-year-old female had history of Adenocarcinoma of D-colon with multiple liver and lung metastases, pT4aN0cM1b, stage IVB status post Laparoscopic left hemicolectomy with partial hepatectomy and cholecystectomy on 2023/04/13.
      • After discharge from CRS ward, she was regular follow up at our GS and CRS OPD. According our multidisciplinary cancer conferrence, after colon surgery, she will receieve thyroid surgery, adjuvent chemotherapy and staged lung surgery. She denied any symptoms such as hoarseness, difficulty swallowing or pain at neck. Physical examination revealed some small firm nodules at right neck. Recently thyroid sonography on 2023/03/28 revealed 1. Heterogeneous right thyroid nodule, with calcifications, 1.6x1.2cm. 2. Tiny right thyroid nodules, 0.18x0.17cm, 0.24x0.17cm. 3. Left thyroid cyst, 0.83x0.49cm, Biopsy of right thyroid nodule revealed suspicious for papillary carcinoma. After discussion with patient, she will bilateral total thyroidectomy.
    • Course of inpatient treatment
      • After admission, pre-op preparation and anesthesia assessment was done. bilateral thyroidectomy, parathyroidectomy, right neck lymph node dissection and port-A implanatation were done smmothly on 2023/05/09. After operation, no specific complain except for mild wound pain was done. Follow up lab data revealed mild decreased serum calcium, so calcium supplement was given. Little ammount discharge from J-P drainage was noted. Under relative stable condition, we arranged her discharge on 2023/05/11 and OPD follow up.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Antica syrup (orciprenaline, bromhexine, doxylamine) 10mL TID
      • calcium carbonate 500mg 4# QID
      • Strocain (oxethazaine polymigel 5mg) 1# TIDAC
      • U-Ca (calcitriol 0.25ug) 1# TIDAC
  • 2023-04-11 ~ 2023-04-20 POMR Colorectal Surgery
    • Discharge diagnosis
      • Adenocarcinoma of D-colon with multiple liver and lung metastases, cT4aN1bM1b, stage IVB status post Laparoscopic left hemicolectomy with partial hepatectomy and cholecystectomy on 2023/04/13, pT4aN0M1b(0/20), G2, LVI(+), PNI(-), CRM(-), Stage IVB
      • Hypertension
      • Hyperlipidemia
      • Highly suspect right thyroid cancer
    • CC
      • diarrhea and bowel habit change since last year.
    • Present illness
      • This 59 y/o female patient with 1. D-colon cancer with liver and lung metastases 2. suspicious papillary carcinoma 3. Htn was quite well until she suffered from diarrhea and bowel habit change since last year. She visited our OPD for help and colonoscopy was done.
      • Colonoscopy showed a large circumferential tumor with near lumen obstruction was noted at sigmoid colon, s/p biopsy8. A 2cm advanced pedunculated polyp was noted at sigmoid colon (7-8cm below the tumor), s/p biopsy3. Pathology findings showed Adenocarcinoma, moderately differentiated in S-colon and villous adenoma 7 cm below the tumor.
      • Abdominal CT showed a segmental circumferential asymmetrical wall thickening at the sigmoid colon with irregular contour, measuring 6.5 cm in size(T4a). In addition, there are two enlarged nodes in the adjacent mesocolon (N1b). There is a poor enhancing mass 2.2 cm in S5 of the liver. Metastasis (M1a) is highly suspected.
      • In addition, there is a soft tissue nodule 1.1 cm in RML or RUL of the lung that may be lung metastasis (M1b).
      • This time, she admitted to our ward for preoperative preparation and surgical treatment. 
    • Course of inpatient treatment
      • After admission with ward routine and pre-op study were done. After well explain the risk of surgery including heart, lung complications and risk of leakage. Operation of Laparoscopic left hemicolectomy with partial hepatectomy and cholecystectomy under general anesthesia were performed on 112/04/13. NPO and adequate IV fluid supplement. Chewing cookies, toast, rice with gum was started at op day. Early activity is encouraged. The wound healing well and no erythema change. She had flatus passage and abdominal wound pain subsided. She started to take oral diet well and no abdominal discomfort after meal. He had passed stool with normal bowel movement. Oral intake with soft diet is tolerated well. His abdominal wound pain had got much better. Drain is clear ascites and removal of JP drain. In stable condition, he was discharged on 112/04/20 and will receive OPD follow up next week.
    • Discharge prescription
      • Meitifen (diclofenac 75mg) 1# BID
      • Urosin (atenolol 100mg) 1# QD
      • Ulstop (famotidine 20mg) 1# BID
      • MgO 250mg 2# BID
      • Through (sennoside 12mg) 1# HS
  • 2023-03-31 SOAP Colorectal Surgery
    • S
      • Vomiting and diarrhea during Chinese New Year >> relieved by fasting and rest
      • 2023-02-11: LLQ intermittent pain, soft loose stool; anemia was noted at LMD
      • 2023-03-13: referred from GI Dr for newly found a tumor of S-colon with impending obstruction, bloody stool and change in bowel habit for 1+ years
      • 2023-03-18: CT showed distal D-colon cancer with possible liver and lung metastases, arrange PET or more infomration
      • 2023-03-24: for PET report (Liver, lung metastases, and R/O thyroid tumor), can pass loose and liquid stool, no abdomen pain
      • 2023-03-31: Thyroid sono-biopsy showed suspicious papillary carcinoma, refer to GS, favor combined colon and hepatic surgery first followed by chemotherapy therapy + target therapy and lung and thyroid surgery
    • O
      • Conclusion of Cancer Multidisciplinary Team Meeting, Meeting Date: 2023-03-28
      • Referring to the General Surgery (GS) and Cardiothoracic Surgery (CS) Outpatient Department (OPD), the General Surgery team has scheduled a thyroid ultrasound with a possible biopsy. Depending on the results, a staged surgery plan is anticipated, which may also include chemotherapy.
    • A
      • D-colon cancer with liver and lung metastases
      • suspicious papillary carcinoma
    • P
      • admission (2023/04/11), albumin use, prepare colon, ERAS? inform GS, colectomy + partial hepatectomy (2023/04/13)

[immunochemotherapy]

  • 2023-08-22 - Avastin + FOLFIRI
  • 2023-08-02 - Avastin + FOLFIRI
  • 2023-07-04 - Avastin + FOLFIRI
  • 2023-05-31 - Avastin
  • 2023-05-29 - FOLFIRI

==========

2023-08-04

On 2023-07-09, the patient refilled her repeat prescription for atenolol and valsartan to manage her primary hypertension. This prescription was originally issued by JingMei Hospital on 2023-06-15. Both medications have been added to the active medication list, and there are no reconciliation issues detected.

700558953

230821

[MedRec]

  • 2021-02-08 SOAP Radiation Oncology Chang YouKang
    • A/P
      • PE, 2021-02-08: Op scar(+) over UOQ. No palpable LAPs over axilla or SCF.
      • Imp: Right breast cancer, Mucinous carcinoma, pT2N0(sn) cM0 s/p BCT & SNB on 2021/01/29.
      • Endocrine therapy: Femara since 2021/02/08.
      • Plan: Adjuvant R/T to Rt breast & scar for 5000cGy/25 fx & 6000cGy/30 fx is suggested. Possible toxicity (radiation dermatitis and pneumonitis) is told. CT simulation on 2021/03/02. Psychosocial support. Diet education.
  • 2021-01-21 SOAP General and Gastroenterological Surgery
    • S: s/p CNB (2021-1-13): mucinous carcinoma ==> advise adm for BCT + SLND
    • O:
      • 2021/01/14 PATHO - breast biopsy (no need margin)
        • Breast, right, sono-guided biopsy — Mucinous carcinoma, hypercellular type
        • IHC shows following features:
          • ER (Ab): Positive (> 95%, strong intensity)
          • PR (Ab): Positive (> 95%, strong intensity)
          • HER-2/Neu (Ab): Negative (score= 1)
          • Ki-67: 10%
      • A 3x2.5 cm sl firm mass in rt breast
        • Rt breast ca
        • cT2N0M0 stage 2A
  • 2021-01-12 SOAP General and Gastroenterological Surgery
    • S: breast sono: right breast tumor, r/o carcinoma, cT2N0 - BI-RADS 5
      • Chief complaint: A breast lump was noted recently with mastalgia
    • P: CNB

[surgical operation]

  • 2023-04-03
    • Operation
      • Excision of intraabdominal malignant tumor: omentectomy
      • Tenckhoff tube insertion
    • Finding
      • Tenckhoff tube: over RLQ
  • 2023-04-03
    • Surgery
      • Diagnosis: Right ovarian cancer
      • Surgery: Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy)
    • Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, tense contact with bladder
      • Adnexa:
        • LOV: grossly normal
        • ROV: 8cm tumor
        • Fallopian tube: bilateral grossly normal
      • CDS: invisible due to tumor mass occupied
      • Ascites: ascites (+), adhesion (+)
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • Omentum: grossly normal
      • Estimated blood loss: 150 mL
      • Blood transfusion: nil
      • Complication: nil
  • 2021-01-29
    • Surgery
      • Partial mastectomy and sentinel node(s) biopsy        
    • Finding
      • a 3x2.5x1.5 cm sl firm mass in rt breast    
      • SLN 0/2    
  • 2021-01-13
    • Operation
      • Breast tumor biopsy (63010C)
      • Intraoperative sonography (19002B)
    • Finding
      • IOUS: a breast tumor in right side, 8 o’clock / 4 cm location

[chemotherapy]

  • 2023-07-31 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr + [docetaxel 30mg/m2 45mg + cisplatin 30mg/m2 45mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-07-06 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr + [docetaxel 30mg/m2 45mg + cisplatin 30mg/m2 45mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-06-12 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-05-22 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-04-28 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 45mg + cisplatin 30mg/m2 50mg + gentamicin 45mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

701158972

230821

[immunochemotherapy]

  • 2023-08-07 - trastuzumab 6mg/kg 330mg NS 250mL 90min (Chang YaoRen)

  • 2023-07-19 - trastuzumab 6mg/kg 330mg NS 250mL 90min (Chang YaoRen)

  • 2023-07-05 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-06-28 - trastuzumab 6mg/kg 330mg NS 250mL 90min (Chang YaoRen)

  • 2023-06-21 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-06-14 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-06-07 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-06-07 - trastuzumab 6mg/kg 350mg NS 250mL 90min (Chang YaoRen)

  • 2023-02-10 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)

    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-01-27 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)

    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-01-12 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)

    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2022-12-29 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)

    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-07 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-11-16 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-10-26 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-10-05 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-09-14 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-08-24 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-08-03 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-07-13 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-06-22 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-05-25 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-05-04 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2023-04-13 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2023-03-23 - trastuzumab 6mg/kg 375mg NS 250mL 90min

  • 2022-03-02 - trastuzumab 6mg/kg 360mg NS 250mL 90min

  • 2022-02-09 - trastuzumab 6mg/kg 360mg NS 250mL 90min

  • 2022-01-19 - trastuzumab 6mg/kg 360mg NS 250mL 90min

  • 2021-12-29

  • 2021-12-08

  • 2021-11-17

  • 2021-10-27

  • 2021-10-06

  • 2021-09-15

  • 2021-08-25

  • 2021-08-04

  • 2021-07-14

  • 2021-06-23

  • 2021-06-02

  • 2021-05-05

  • 2021-04-14

  • 2021-03-24

  • 2021-03-03 - trastuzumab emtansine 230mg NS 250mL 1.5hr

    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2021-02-10 - trastuzumab emtansine 230mg NS 250mL 1.5hr

    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2021-01-11

  • 2020-12-21

  • 2020-11-30

  • 2020-11-09

  • 2020-10-19

  • 2020-09-28

  • 2020-09-07

  • 2020-08-17

  • 2020-07-27

  • 2020-07-06

  • 2020-06-22

  • 2020-06-15

  • 2020-06-03

  • 2020-05-27

  • 2020-05-13

  • 2020-05-06

  • 2020-04-22

  • 2020-04-15

  • 2020-04-01 - eribulin 1.4mg/m2 2.4mg NS 50mL 10min

    • betamethasone 8mg + diphenhydramine 30mg + NS 20mL
  • 2020-03-25 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + eribulin 1.4mg/m2 2.4mg NS 50mL 10min

    • betamethasone 8mg + NS 250mL
  • 2020-03-11 - eribulin 1.4mg/m2 2.4mg NS 50mL 10min

    • betamethasone 8mg + diphenhydramine 30mg + NS 20mL
  • 2020-03-04 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 1hr + eribulin 1.4mg/m2 2.4mg NS 50mL 10min

    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2020-02-10 - trastuzumab 600mg SC 5min

  • 2020-01-20 - trastuzumab 600mg SC 5min

==========

2023-08-21

[cachexia]

The patient has lost 10 kg in three months, from 63.2 kg on 2023-05-25 to 52.5 kg on 2023-08-11. To combat this significant weight loss, it’s important to improve the patient’s nutritional intake. In the absence of dysphagia, megestrol can be introduced as an appetite stimulant at a suggested dosage of 200 to 600 mg/day to counteract anorexia.

[oral mucotitis]

For oral mucotitis, the introduction of Nincort Oral Gel (triamcinolone) is recommended to relieve discomfort.

701493999

230821

[MedRec]

  • 2023-08-15 SOAP Family Medicine Ye JiaZe
    • S: previosu tx at CGMH, elevated Bil
    • P: arrange hospice ward
  • 2023-08-15 SOAP Hemato-Oncology He JingLiang
    • S: adenocarcinoma of pancreatic tail with liver mets
    • O: jaundice, T Bili 8.22
    • P: refer to hospice admission

==========

2023-08-21

The patient renewed a repeat prescription for insulin degludec, linagliptin, clopidogrel, doxazosin, bisoprolol, pitavastatin, levothyroxine, and ginkgo biloba extract on 2023-08-04. Some of these medications are not listed in the active medication list. Please verify if the unlisted medications are no longer required.

701494892

230821

[exam findings]

  • 2023-07-10 CT
    • PHx: left RCC S/P operation.
    • Findings: CT of chest, abdomen, and pelvis without and with IV contrast enhancement show - Comparison: CT on 2023-04-08.
      • Chest
        • No identified residual pulmonary embolism.
        • Multiple newly-developed nodules up to 0.8cm in bilateral lungs, in favor of lung metastasis
        • A fatty mass with calcified spot about 11.4x9.2x3.7cm at left upper back, in favor of lipoma.
        • Otherwise, the mediastinum is centered and of normal width. There is no lymphadenopathy and there are no perihilar masses. The heart has a normal configuration. Major intrathoracic vessels are unremarkable. No evidence of osteolytic or osteoblastic change of thoracic cage.
      • Abdomen
        • S/P left nephrectomy for RCC; no evidence of local tumor recurrence nor visible regional lymphadenopathy.
        • A newly-developed hypodense lesion with heterogeneous enhancement about 3.4x2.2cm at left adrenal gland, in favor of adrenal metastasis.
        • Faint hypodense lesions up to 2.2x1.8cm in bilateral liver lobes, in favor of liver metastasis.
        • Osteolytic lesion at left pubic inferior ramus, R/O bone metastasis.
        • Compression fracture of L2 vertebra.
        • Small right renal cysts.
        • Right inguinal hernia without bowel loop in the hernia sac.
        • Otherwise, the GB, spleen, pancreas are normal in size and position. The urinary system is not obstructed. The pelvic inlet appears normal, with normal configuration of the iliac wings and iliopsoas muscles.
    • IMPRESSION:
      • S/P left nephrectomy without local tumor recurrence nor visible regional lymphadenopathy.
      • Newly-developed left adrenal, liver, and bilateral lung metastasis as described above.
      • R/O bone metastasis at left pubic inferior ramus.
      • No identified residual pulmonary embolism.
      • A lipoma about 11.4x9.2x3.7cm at left upper back.

[MedRec]

  • 2023-08-18 SOAP Emergency
    • Impression: D41.00 Neoplasm of uncertain behavior of unspecified kidney

==========

2023-08-21

There are no medication reconciliation issues identified after reviewing the PharmaCloud database and HIS5 records.

700133802

230818

[exam findings]

  • 2023-07-14 KUB
    • Mild dilatation of small intestine at RLQ abdomen is highly suspected.
  • 2023-07-12 KUB
    • High grade mechanical small bowel obstruction is suspected. Please correlate with CT.
  • 2023-05-19 Cell block cytology
    • bilateral pleural effusion 50cc, brown, turbid — Atypia
    • Smears and cell block show lymphocytes, mesothelial cells, histiocytes and several atypical cells.
  • 2023-05-19 Pleural tapping
    • Special Procedure
      • echo-assisted Pleural tapping 16 #-needle Right side 1200 ml serosanguineous
      • echo-assisted Pleural tapping 16 #-needle Right side 1200 ml bloody
    • Echo diagnosis
      • left side small amount of pleural effusion
      • right side moderate amount of pleural effusion, 1200cc bloody fluid was aspirated for analysis.
  • 2023-05-18 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
    • Pleura effusion of right and left costal-phrenic angle
  • 2023-05-16 CXR
    • Bilateral pleural effusion.
    • Ground glass opacities in bil. lungs.
  • 2023-05-10 All-RAS + BRAF mutation
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-05-05 Cell block cytology
    • 35cc orange cloudy ascites — Positive for malignancy, compatible with colonic origin
    • The smears and cell block show lymphocytes, reactive mesothelial cells and scant atypical nest which immunocytochemistry shows CDX-2(+) and PAX-8(-). According to clinical information and cytomorphologic findings, it is compatible with metastatic adenocarcinoma with colonic origin. Clinical correlation is advised.
  • 2023-05-05 Acites tapping
    • Course: 18G needle was inserted at RLQ under echo guided insertion.
    • Findings: 1800 ml straw to orange color ascites was drained.
  • 2023-05-05 ECG
    • Sinus rhythm with Premature supraventricular complexes with aberrant conduction
    • Otherwise normal ECG
  • 2023-04-21 Gynecologic ultrasonography
    • Findingws
      • Uterus Position : AVF
        • Size: 96 * 28 mm
      • Endometrium:
        • Thickness: 10.1 mm, Fluid: with fluid
      • Adnexae:
        • ROV: Mass: 72 * 49 mm
        • LOV: Mass: 56 * 42 mm
      • CUL-DE-SAC: with fluid
    • IMP:
      • Ascites
      • R/O Bilateral Ovarian mass
  • 2023-04-20 SONO - chest
    • Special Procedure
      • echo-assisted Pleural tapping 16 #-needle Right side 1000 ml serosanguineous
    • Echo diagnosis
      • pleural effusion
    • Suggestion:
      • Send pleural effusion about cytology (cell block), biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
  • 2023-04-19 ECG
    • Sinus tachycardia
    • Minimal voltage criteria for LVH, may be normal variant
    • Borderline ECG
  • 2023-04-14 CT - abdomen
    • Indication: 20220130 CT: D-colon cancer with acute obstruction, pT3N2a cM0, stage IIIB
    • Findings:
      • There is massive ascites and multiple soft tissue masses in the perihepatic space parietal peritoneum and omentum that is c/w carcinomatosis. Please correlate with ascites cytology.
      • There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer.
      • There is mild left side hydroureteronephrosis and mild delayed contrast excretion of left kidney that is c/w obstructive uropathy.
        • The transition zone locates at left M3 ureter but nature?
        • Please correlate with retrograde pyelography.
      • There are bilateral Pleura effusion (more severe on right side).
    • Impression:
      • Carcinomatosis is noted. Please correlate with ascites cytology.
      • There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer. Please correlate with CEA and CA125.
  • 2023-04-11 Colonoscopy
    • Diagnosis: DS colon s/p OP with uncertain anastomosis region
    • Suggestion: follow CT to evaluation colon condition ( high risk before confirm anastomosis )
  • 2022-11-07 CT - abdomen
    • No evidence of recurrent/residual tumor in the study.
  • 2022-10-24 CT - brain
    • Clinical information: Cranial CT scans from the vertex to the mid-maxillary level were performed without i.v. contrast injection.
    • Impression:
      • The brain shows age-related cortical atrophy, sulcal space widening, proportionate ventricular dilatation and white matter ischemic change including the periventricular, subcortical and subinsular regions. Right frontal scalp swollen change. There is no intracranial hemorrhage seen.
      • The posterior structures including the brain stem, cerebellum and CP angles look normal. However, the beam-hardening artifact over the skull base may hamper the film reading.
      • Please take notice that non-enhanced CT scan is limited in the detection of acute ischemic infarction (particularly within the first 6 hours), small vascular lesion, neoplasm, infectious/toxic/metabolic disease. Recommend correlate with clinical condition.
  • 2022-07-23 CT - abdomen
    • s/p left hemicolectomy. No evidence of recurrent/residual tumor in the study.
  • 2022-04-07 CT - abdomen
    • S/P colon operation.
    • Some LNs (up to 1.3cm) at mediastinum.
    • Right minimal pleural effusion.
  • 2022-02-17 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Large intestine, descending-sigmoid colon, laparoscopic extensive left hemicolectomy —- Adenocarcinoma, moderately differentiated
      • Resection margins, proximal and distal: Free
      • Lymph node, mesocolic, dissection — Positive for adenocarcinoma (6/13)
      • T-colostomy, closure — Confirmed
      • AJCC 8th edition Pathology stage: pT3N2a(if cM0); AJCC stage IIIB
    • MACROSCOPIC EXAMINATION
      • Operation procedure: laparoscopic extensive left hemicolectomy
      • Specimen site: left descending-sigmoid colon
      • Specimen size: 22 cm in length
      • Tumor size: 4.5 cm
      • Tumor location: 3 cm away from the closest resection margin
      • Depth of invasion grossly: mesocolic soft tissue
      • Mucosa elsewhere: Not remarkable
      • Representative sections and labeled as: A1-8:tumor, A9-10:LNs, B:proximal end, C:distal end, D: T colostomy
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: moderately differentiated
      • Depth of invasion: mesocolic soft tissue
      • Angiolymphatic invasion: Present
      • Perineural invasion: Present.
      • Discontinuous extramural tumor extension: Not identified.
      • Circumferential (radial) margin of rectum: N/A / Serosal margin status of colon: Uninvolved
      • Lymph node metastasis, mesocolic: Positive (6 / 13)
      • Lymph node metastasis, IMA / SMA: N/A.
      • Extranodal involvement: Present.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT) - pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN) - pN2a: Four to six regional lymph nodes are positive
        • Distant Metastasis (pM) - N/A
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: None identified.
      • TNM descriptors: N/A.
      • Tumor regression grading S/P CCRT: N/A.
  • 2022-02-15 Colonoscopy
    • C/W colon cancer, with nearly total luminal obstruction, D-S junction
    • S/p T-colon colostomy
  • 2022-02-09 Patho - colon biopsy
    • Colon tumor, sigmoid, biopsy — High grade dysplasia at least
    • Microscopically, the sections show a picture of high grade dysplasia at least of colonic mucosal tissue characterized by atypical glands lined by high-grade dysplastic columnar cells, in tubular, fused glandular or cribriform arrangement without obvious desmoplasia due to limited specimen.
    • Immunohistochemistry of CDX2(+), PMS2(+), MLH1(+), MSH2(+) and MSH6(+) for dysplastic cell. According to clinical and radiologic findings, more advanced lesion (adenocarcinoma) should be suspect. Repeat biopsy is advised for further evaluation, if clinically indicated.
  • 2022-02-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (66.7 - 24.1) / 66.7 = 63.87%
      • M-mode(Teichholz) = 63.9
    • Conclusion:
      • Thickened AV with no AR
      • Normal MV with mild MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, normal IVC size
  • 2022-02-08 Spirometry
    • Mild restrictive ventilatory impairment
  • 2022-01-30 CT - abdomen
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:IIIB(Stage_value)
  • 2022-01-30 ECG
    • Sinus rhythm with Premature supraventricular complexes
    • Left ventricular hypertrophy with repolarization abnormality
    • Abnormal ECG

[consultation]

  • 2023-05-09 Hemato-Oncology
    • Q
      • 80 y/o female, a pt of D-colon colon, pT3N2a cM0, stage IIIB wt obstruction wt T loop colostomy s/p laparoscopic extensive L hemicolectomy and closure of T loop colostomy on 2/16 22 by Dr Lv ZongRu. After operation, she was referred to oncology for adjuvant chemotherapy with Oxalip 85mg/m2 + 5-Fu 2800mg/m2 since 2022/04/06 to 2022/10/06. She kept regular follow up at CRS outpatient department and hematology oncology outpatient department.
      • The patient complained about abdominal distention recent. Abdominocentesis for cell block examination on 2023-05-05.
      • The smears and cell block show lymphocytes, reactive mesothelial cells and scant atypical nest which immunocytochemistry shows CDX-2(+) and PAX-8(-). According to clinical information and cytomorphologic findings, it is compatible with metastatic adenocarcinoma with colonic origin.
      • We need your expertise for help her further management for  chemotherapy. Thanks for you help!
    • A
      • This 82-year-old female patient has past history of 1) Hypertension and hyperlipidemia under medical control for 10 years at NTUH. 2) HIVD s/p *2 times at TzuChi Hospital and NTUH 3) Descending-colon cancer, pT3N2acM0 stage IIIB with obstruction post T loop colostomy on 2022/01/30, post laparoscopic extensive left hemicolectomy + closure of T loop colostomy on 2022/03/16 with adjuvant with C/T since 2022/04/06 to 2022/10/06. 4) port-A implantation on 2022/03/28.
      • Follow up abdominal CT 2023-04-14 show 1. There is massive ascites and multiple soft tissue masses in the perihepatic space parietal peritoneum and omentum that is c/w carcinomatosis. 2. There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer.
      • Ascites cell block show: Positive for malignancy, compatible with colonic origin CDX-2(+)and PAX-8(-). We are consulted for further evaluation.
      • Please arrange exploratory laparotomy as your scheduled 5/10 for tissue and send All-RAS and RAF. Palliative chemotherapy is indicated. We will discuss with patient. Thanks for your consultation.
  • 2023-04-21 Obstetrics and Gynecology
    • Q
      • This 80-year-old female patient had past history of 1) D-colon colon, pT3N2a cM0, stage IIIB s/p laparoscopic extensive L-hemicolectomy and closure of T loop colostomy on 2022/02/16, adjuvant with C/T since 2022/04/06 to 2022/10/06. 2) Hypertension.
      • She suffered from initial presentation of constipation for a long time & abrupt onset of abd pain in Jan 2022. After operation. She kept regular follow up at our OPD. Refollow up abdomen CT showed bilateral pleural effusion. carcinomatosis is noted. There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer is noted.
      • We cnsultation CM. was suggest f/u chest echo and tapping 1000ml serosangumous pleural effusion at right side on 4/20. Cnsultation Hematologis who suggest we consult GYN for further evaluation. Get any tissue proof (colon cancer recurrent or newly diagnosis GYN cancer…).
      • Therefore, we needs your expert experience for further evaluation. Thaks a lot !!
    • A
      • This 80 y/o female with history of 1) D-colon colon, pT3N2a cM0, stage IIIB s/p laparoscopic extensive L-hemicolectomy and closure of T loop colostomy on 2022/02/16, adjuvant with C/T since 2022/04/06 to 2022/10/06. 2) Hypertension.
      • She was admitted for abd distention and dyspnea. followed up CT showed bilateral pleural effusion. carcinomatosis is noted. There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer is noted. we were consulted for cancer evaluation
      • Lab:
        • CEA 12.36ng/mL, CA 125 ?
        • Right pleura effusion cell block ??
        • TVUS and TAS:
          • Uterus: 96*28mm, EM 10.1mm + fluid
          • RT 72*49 mm
          • LT 56*42 mm
        • Ascites (+)
      • Impression:
        • Ascites
        • R/O Bilateral Ovarian mass, or colon cancer seeding (Krukenber tumor?)
      • Suggestion:
        • Consider CT guide biopsy for tissue proof
        • Consult oncologist for chemotherapy fist
        • Consider arrange tumor team meeding when tissue proof
  • 2023-04-21 Hemato-Oncology
    • Q
      • This 80-year-old female patient had past history of 1) D-colon colon, pT3N2a cM0, stage IIIB s/p laparoscopic extensive L-hemicolectomy and closure of T loop colostomy on 2022/02/16, adjuvant with C/T since 2022/04/06 to 2022/10/06. 2) Hypertension. She suffered from initial presentation of constipation for a long time & abrupt onset of abd pain in Jan 2022.
      • After operation. She kept regular follow up at our OPD. Refollow up abdomen CT showed carcinomatosis is noted. There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer is noted.
      • Due to abdomen CT showed pleural effusion, I consulted CM, and arranged a chest echo examination at 14:30 this afternoon.
      • We needs your expert experience for further evaluation and treatment. Thaks a lot !!
    • A
      • This 80 year old woman is a case of D-colon colon, pT3N2a cM0, stage IIIB s/p laparoscopic extensive L-hemicolectomy and closure of T loop colostomy on 2022/02/16, adjuvant with C/T since 2022/04/06 to 2022/10/06. For suspect carcinomatosis, we are consulted. Abdomen CT showed there are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer is noted.
      • Complete tumor marker. Arrange chest echo for right pleura effusion (send cell block). Consult GYN for further evaluation. Get any tissue proof (colon cancer recurrent or newly diagnosis GYN cancer…) Thanks for your consultation.
  • 2023-04-20 Chest Medicine
    • Q
      • This 80-year-old female patient had past history of 1) D-colon colon, pT3N2a cM0, stage IIIB s/p laparoscopic extensive L-hemicolectomy and closure of T loop colostomy on 2022/02/16, adjuvant with C/T since 2022/04/06 to 2022/10/06. 2) Hypertension. she suffered from initial presentation of constipation for a long time & abrupt onset of abd pain in Jan 2022.
      • After operation. She kept regular follow up at our OPD. Refollow up abdomen CT showed bilateral pleura effusion (more severe on right side) and carcinomatosis is noted.
      • We needs your expert experience for further evaluation and treatment (cytology). Thaks a lot !!
    • A
      • This 80 y.o female was a case of D-colon adenocarcinoma, pT3N2aM0, stage IIIb, post operation on 111-02-16 and C/T from 111-04 to 111-10. Now, because of Abdominal CT showed bilateral pleural effusion and carcinomatosis, we were consulted for further treatment.
      • Suggestion:
        • Please arrange Chest echo + pleural effusion drainage or pig-tail insertion for right massive pleural effusion (pleural effusion will submitted for cell block exam)
        • If Colon Ca with metastasis confirmed, please consult Hematologist for further treatment

[surgical operation]

  • 2022-02-16
    • Surgery
      • Laparoscopic extensive left hemicolectomy + closure of T loop colostomy
    • Finding
      • Tumor in DS colon with adhesion to left side lumbar region peritoneum.
      • LN in IMA root, removed
      • stenosis of rectum,
      • No 29 SDH for anastomosis for cancer
      • hand sew 2 layer for T colostomy
      • moderate stool in colon
      • Tissel 4ml for both 2 anastoomsis
      • No.15 Drain into pelvis
  • 2022-01-30
    • Surgery: T loop colostomy        
    • Finding: Dilation of colon 
  • 2017-05-10
    • Diagnosis: Lumbar stenosis, L3/4/5
    • PCS code: 83002C
    • Finding
      • Lumbar spondylosis with
        • Hypertrophic changes of ligamentum flavum and facet joints at L3/4 and L4/5 levels with dura compression and bilateral L4 and L5 roots compression. left side more severe.
        • No gross instability noted.

[immunochemotherapy]

  • 2023-08-02 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 165mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant D1-3 + NS 250mL
  • 2023-07-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 150mg D5W 250mL 90min + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant D1-3 + NS 250mL
  • 2023-06-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 165mg D5W 250mL 90min + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant D1-3 + NS 250mL
  • 2023-06-05 - irinotecan 120mg/m2 165mg D5W 250mL 90min + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant D1-3 + NS 250mL
  • 2023-05-19 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant D1-3 + NS 250mL
  • 2022-10-06 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4370mg NS 500mL 46hr (FOLFOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-09-21
  • 2022-09-08
  • 2022-08-25
  • 2022-08-10
  • 2022-07-22
  • 2022-07-07
  • 2022-06-22
  • 2022-06-06
  • 2022-05-09 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4190mg NS 500mL 46hr (FOLFOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-04-22 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4200mg NS 500mL 46hr (FOLFOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-04-06 - oxaliplatin 60mg/m2 90mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4200mg NS 500mL 46hr (FOLFOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-08-18

No medication reconciliation issues were identified after reviewing PharmaCloud and HIS5 records.

2023-08-04

The repeat prescription issued by NTUH was refilled on 2023-08-01 and includes Norvasc (amlodipine), Aprovel (irbesartan), Lipitor (atorvastatin), and Xanax (alprazolam). These medications are currently being used with no reconciliation issues identified.

2023-07-13

This patient visited NTUH on 2023-06-15 and was prescribed Norvasc (amlodipine), Aprovel (irbesartan), Lipitor (atorvastatin), Xanax (alprazolam) which were refilled at a local pharmacy on 2023-07-03. These drugs are now in the active medication list, no reconciliation issues found.

2023-06-28

Upon examining the PharmaCloud database, it appears that access to this patient’s information is currently unavailable, potentially due to lack of authorization. However, a review of the HIS5 medication records indicates that all valid prescriptions were provided by the Hemato-Oncology department. Hence, no medication reconciliation issues have been found.

700813390

230818

[exam findings]

  • 2023-08-17 Sigmoidoscopy
    • Low rectal cancer involving anal canal and anal sphincter

[MedRec]

  • 2023-08-14 SOAP Radiation Oncology Chang YouKang
    • S
      • PH: lung cancer stage Ia s/p OP in NTUH in 2018.
      • BPH s/p OP; C spine s/p OP > 10 yr.
      • No DM; no HTN.
      • Anal pain with some bleeding since 2023/05.
      • Anal fistula s/p admission and OP at HsinChu Mackay Hospital.
    • O
      • CT, 2023/08/11, HsinChu Mackay Hospital: 4-cm tumor over anal canal, small perirectal LAPs, no enlarged bilateral inquinal LAPs; cT3N1M0 at least. No lung, liver, distal LN metastasis.
      • CXR, 2023/08/08: blurred left CP angle.
      • DRE, 2023/08/14: anal canal induration and an ulcerative wound at right lateral to anterior.
      • 2023/08/10, CEA 1.77, CA199 7.77.
      • HsinChu Mackay Hospital Pathology, 2023/08/09 (S2306571): adenocarcinoma (goblet cell adenocarcinoma or signet ring cell ccarcioma with neuroendocrine differentiation)
    • Imp: Low rectal cancer (involving anal canal), cT3N1M0 at least; 83 Y/O.
    • Suggest CCRT then observation (prefered due to very old age), or local excision if good tumor response or APR.
      • RT dose: 5400cGy/30 fractions.
      • CT simulation on 8/17, 14:30.
      • Possible RT side effects are told; diet education.
  • 2023-08-14 SOAP Colorectal Surgery Xiao GuangHong
    • S
      • Anal fistula s/p admission and OP at HsinChu Mackay Hospital
      • Post-OP patho: adenocarcinoma
      • PH: lung cancer
    • O
      • CT: TxN0M0
      • DRE: anal canal induration and an ulcerative wound at right lateral to anterior
    • A
      • Suggest CCRT then evaluation of observation (prefered due to very old age) or APR
    • P
      • Arrange sigmoidoscopy for R/O colonic lesion

==========

2023-08-18

This patient received a repeat prescription on 2023-06-28 at NTUH HsinChu Branch and refilled it on 2023-07-20 at a local pharmacy for a 28-day supply of Sennapur (sennoside), Betmiga (mirabegron), Xanax (alprazolam), and Eurodin (estazolam). There is no mirabegron included in the active medication list, please confirm if the drug is no longer needed.

700367784

230816

[MedRec]

  • 2023-07-25 SOAP Dermatology
    • S: Heavy scaling over erythematous patchs on scalp, and eyelid and nasolabial fold with moderate itching
    • Prescription
      • Mycomb BID TOPI
      • Zalain External Gel Q3D EXT
      • Xyzal (levocetirizine 5mg) 1# HS
  • 2023-06-20 ~ 2023-06-21 POMR Hemato-Oncology
    • Course of inpatient treatmnet
      • After admission, he received chemotherapy with Gemcitabine + Nab-Paclitaxel (Gemcitabine 1000mg/m2, Nab-Paclitaxel 100mg/m2) on 2023/06/20 (C1D1) smoothly.
      • Hypertension was treated with Olmetec 20mg/tab # PO QD.
      • For chemotherapy, Vemlidy 25 mg/tab # PO QD was given for Hepatitis B carrier (Anti-HBc and HBsAg showed Reactive).
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/06/21 and OPD followed up later.
  • 2023-05-23 ~ 2023-05-24 POMR Gastroenterology
    • Discharge diagnosis
      • Pancreatic neuroendocrine tumor with liver metastasis with recurrent at S8, pT3N0M1a, stage IV status post exploratory adhesivelysis and Radiofrequency Ablation on 2023/03/09. ECOG:1; with liver metastasis with recurrent at S7 status post Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) on 2023/05/24
    • CC
      • for feasibility of EUS guided liver tumor ablation WITH ethanol
    • Present illness
      • This 61 year-old male has the history of
        • Hypertension
        • HBV carrier for 30 years,
        • pancreatic neuroendocrine tumor with liver metastasis status post distal partial pancreatectomy on 2011/09/14; s/p S1, S6, S7 segmentectomy and cholecystectomy on 2015/03/26; radiofrequency tumor ablation on 2015/10/16 & 2015/11/27 & 2016/01/22; s/p S8 partial hepatectomy on 2018/05/07; 4th radiofrequency tumor ablation using real-time virtual sonography on 2021/10/29; Pancreatic neuroendocrine tumor with liver metastasis with recurrent at S8, pT3N0M1a, stage IV status post exploratory adhesivelysis and Radiofrequency Ablation on 2023/03/09. ECOG:1
      • The follow up Liver CT (on 2023/04/22) reported S/P pancreatic operation, splenectomy and liver RFA. A small enhancing nodule (1.1cm) in S7 of liver r/o metastases. There was no fever, chills, nausea, vomiting, poor appetite, abdomen pain, bloody or tarry stool passage, tea color urine. he also denied TOCC history. Under the imprssion of Pancreatic neuroendocrine tumor with liver metastasis, he was admitted to GI ward for feasibility of EUS guided liver tumor ablation by ethanol.    
    • Course of inpatient treatment
      • After admission, we gave the preparation of EUS guided liver tumor ablation by ethanol. which was scheduled on 5/24 and reported EUS findings:Using EUS-UCT 260 showed a 21 mm mixed lesion at the seg 7 of  the left lobe of liver, which was closed to origin of the right hepatic vein.Management:CEH-EUS is performed with Sonozoid 0.6 cc injection and after 17 second, vascular hyperenhancement pattern with central hypoenhancement component is noticed. Ethanol injection cannot be performed due to interference by the right hepatic vein, inferior vena cava, and right atrium in the PATH of PUNCTURE ROUTE. Diagnosis:1. Metastatic hepatic tumor s/p CEH-EUS. Well informed above report, under stable condition, he was discahrged on 5/24 and will return to GS OPD later.
  • 2023-03-21 SOAP Hemato-Oncology Xia HeXiong
    • P: Intra-OP RFA on 2023-03-09, CT will be done 2023-04-22. If NED -> Apply sunitinib again.
  • 2023-03-08 ~ 2023-03-13 POMR General Surgery
    • Discharge diagnosis
      • Pancreatic neuroendocrine tumor with liver metastasis with recurrent at S8, pT3N0M1a, stage IV status post exploratory adhesivelysis and Radiofrequency Ablation on 2023/03/09. ECOG:1
      • Hypertension
      • Reflux esophagitis Los Angeles classification (LA) Classification grade C
      • Hepatitis B carrier
    • CC
      • Scheduled for radiofrequency ablation therapy.     
    • Present illness
      • This 61 year-old male patient has the histories of Hypertension for 10 years, Poliomyelitis for 40+ years, HBV carrier for 30 years, Reflux esophagitis and esophageal ulcer by panendoscopy on 2022/08/30 and pancreatic neuroendocrine tumor with liver metastasis status post distal partial pancreatectomy on 2011/09/14; s/p S1, S6, S7 segmentectomy and cholecystectomy on 2015/03/26; radiofrequency tumor ablation on 2015/10/16 & 2015/11/27 & 2016/01/22; s/p S8 partial hepatectomy on 2018/05/07; 4th radiofrequency tumor ablation using real-time virtual sonography on 2021/10/29. He is regularly followed up in our GI and hematology clinics. His SBP at home is around 120~130 mmHg.
      • This time, he was found at regular OPD followup that abdominal sono on 2022/12/14 showed a 1.5 cm faint tumor near IVC and two 2.3 and 2.8 cm hyperechoic mass at right ant segment. Abdominal CT on 2023/2/11 showed a 1.3cm recurrent tumor in liver dome, no enlarged lymph nodes in para-aortic and pelvic regions. Due to suspected recurrent liver metastasis of pancreatic neuroendocrine tumor, he was scheduled for further evaluation and treatment.     
    • Course of inpatient treatment
      • After admission, Pre-op evaluation was done. Performed exploratory adhesivelysis and radiofrequency ablation therapy (RFA) and repeated hepaectomy moderated adhesion of stomach and T-colon to liver on 112/02/23 due to a 2.7 x 2.5 x 2.5 cm hyperechoic tumor at S8. The postoperative course ran smoothly with intact neurovascular function. Pain control was maintained. The surgery wound mild oozing discharge, and wound education was performed. His condition remained stable, and the patient was discharged on 2023/03/13. OPD follow up will be arranged on 2023/03/21.       
    • Discharge prescription
      • BaiGan (silymarin) 1# TID
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# QID
      • MgO 250mg 1# TID
  • 2023-02-14 SOAP Hemato-Oncology Xia HeXiong
    • P
      • May refer back to Chief Wu for the possibility of surgical resection.
      • If RFA and OP is not feasible, may consider TACE.
  • 2022-12-20 SOAP Dermatology
    • S: multiple pruritic erytheamtous papule-vesicles on bil pale-soles for months, acute exacerbated.
    • Prescription
      • Topsym cream (fluocinonide) BID EXT
      • Sinpharderm Cream (urea) BID TOPI
      • Xyzal (levocetirine 5mg) 1# QN
  • 2022-11-22 SOAP Hemato-Oncology Xia HeXiong
    • P: Refer to GI Chief Wang on 2022-11-29 for the possible recurrence baed on CT report on 2022-11-19.
  • 2022-09-27 SOAP Dermatology
    • Prescription
      • Zalain cream (sertaconazole nitrate) BID TOPI
      • doxycycline 100mg 1# BID
      • Asthan (ketotifen 1mg) 1# BID *
  • 2022-09-17, -09-06, -08-30, -08-20, -08-13, -08-02 SOAP Dermatology
    • S
      • Heavy scaling over erythematous patchs on scalp, and eyelid and nasolabial fold with moderate itching
        • multiple painful erythematous papule-nodules on face, trunk and 4-limbs.
        • dyskeratotic nails on bil feet and hands for yrs, scaling(+), itching(+), local painful(+)
      • Erythematous patches on trunk and inguinal area for yrs, ringwarm(+)
      • T unguin was Dx and Tx at LMD for yrs
      • poor response to topical drugs
    • A: Buttock cellulitis (suggestive of funal dermatitis) and right foot
    • P: Conservative medications and antibiotics; topical ointment for skin care.
    • Prescription
      • Zalain cream (sertaconazole nitrate) BID TOPI
      • doxycycline 100mg 1# BID
      • Allegra (fexofenadine 60mg) 1# BID
  • 2022-08-02 SOAP Infectious Disease
    • S
      • Erythema swelling of buttock for 1-2 months (hot weather); much improvement after topical ointment and oral nemonoxacin x1 week.
      • History: pancreatic neoplasm status post target therapy.
    • O: Topical ointment with Mycomb and Zinc oxide ointment for symptomatic treatment.
    • A: Buttock cellulitis (suggestive of funal dermatitis) and right foot
    • P: Conservative medications and antibiotics; topical ointment for skin care.
    • Prescription
      • Mycomb BID TOPI
      • Zinc Oxide Oint BID TOPI
  • 2022-08-02 Hemato-Oncology Xia HeXiong
    • P
      • Due to Gr 1 H-F-S, refer to demratologist
      • Already suggest Hold sutent if deteriorated H-F-S even visiting Dermatologist on 2022-08-02
  • 2022-06-29 SOAP Infectious Disease
    • S: Pain over right post plantar, right lateral foot dermatitis. Underlying pancreas cancer
    • O: right lateral foot dermatitis
    • A: no need for antibiotic
    • P: topical Mycomba for skin dermatitis, right foot
    • Prescription
      • Mycomb BID TOPI
  • 2022-05-03 SOAP Infectious Disease
    • S: Erythema swelling of buttock for 4 weeks; much improvement after topical ointment and oral nemonoxacin x1 week.
      • History: pancreatic neoplasm status post target therapy.
    • O: Topical ZnO for skin care.
    • A: Buttock cellulitis
    • P: Conservative medications and antibiotics; topical ointment for skin care.
    • Prescription
      • zinc oxide oint BID TOPI
  • 2022-05-03 SOAP Hemato-Oncology Xia HeXiong
    • P: Sunitinib 3# QD (270 - 36 - 39 - 63 - 84 = 48)
    • Prescription
      • Sinpharderm Cream (urea) BID TOPI
      • Sutent (sunitinib 12.5mg) 3# QD
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
      • Actein (acetylcysteine 600mg) 1# BID
  • 2022-04-27 SOAP Infectious Disease
    • S: Erythema swelling of buttock for 3 weeks
    • A: Buttock cellulitis
    • P: Conservative medications and antibiotics
    • Prescription
      • Taigexyn (nemonoxacin 250mg) 2# QDAC
      • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
  • 2022-04-27 SOAP Hemato-Oncology Xia HeXiong
    • P: Due to suspect hepes vesicle over anal area, hold sutinib for 1 week until 2022-05-04
    • Prescription
      • Sinpharderm Cream (urea) BID TOPI
  • 2022-02-24 SOAP Hemato-Oncology Xia HeXiong
    • P: Sunitinib 3# QD (270 - 36 = 234)
    • Prescription
      • Sutent (sunitinib 12.5mg) 3# QD
      • Sinpharderm Cream (urea) BID TOPI
      • Actein (acetylcysteine 600mg) 1# BID
      • Nincort Oral Gel (triamcinolone) BID TOPI
  • 2022-02-08 SOAP Hemato-Oncology Xia HeXiong
    • P: Due to the failure of apply Sandostatin. Apply sunitinib
  • 2022-01-11 SOAP Radiation Oncology
    • P: RTC 6M. wait for Sandostadin approval due to recurrent liver mets.
  • 2021-12-07 SOAP Hemato-Oncology Xia HeXiong
    • P: Apply Sandostadin LAR or everlimus or sunitinib
  • 2017-03-14 SOAP General Surgery
    • S
      • Pancreatic NET with single liver mets
        • s/p RFA on 2015 10/16, 11/27
        • CT 1 m F/U showed viable tumor.
        • suggest op due to failed RFA (tumor below the heart)
      • pancreast tail tumor 2011-09
        • path: Pancreas, tail, distal partial pancreatectomy — Well differentiated endocrine tumor, uncertain behavior, with very close peripheral resection margin (<0.1cm).
          • Spleen, splenectomy — Negative for malignancy
          • Lymph node, peripancreatic, dissection — negative for malignancy (0/9)
          • Lymph node, splenic hilar, dissection — negative for malignancy(0/2)
      • arrange admission for op S7 and 6 resection
        • path: Liver, segment 1, 6, and 7, segmentectomy
          • Endocrine carcinoma from pancreas, metastatic
          • Chronic hepatitis B with focal bridging fibrosis and mild portal inflammation
            • Ishak modified HAI grading: necroinflammatory score: 3
            • Ishak modified staging: fibrosis score: 3 (Maximum 6)
            • Corresponding Metavir stage: fibrosis score: 2 (Maximum 4)
          • mild fatty change (10-20%)
    • Diagnosis
      • Secondary liver malignant neoplasm [C78.7]
      • Malignant pancreas neoplasm, part NOS [C25.9]
      • Neoplasm of unspecified nature of digestive system [D49.0]

701300692

230816

[MedRec]

  • 2023-08-01 ~ 2023-08-07 POMR Gastroenterology
    • Discharge diagnosis
      • Para-aortic lymphadenopathy susp lymphoma
      • GB wall thickening cause ?
      • Severe persistent asthma with (acute) exacerbation
      • Allergic rhinitis, unspecified
      • Irritable bowel syndrome without diarrhea
      • Gastro-esophageal reflux disease with esophagitis
    • CC
      • Diarrhea 5-6 times /days for 6 months
    • Present illness
      • This is a 44 year old female patient.She had an underlying disease of
        • asthma
        • allergic rhinitis
        • urticaria after covid viccination
      • Patient reported in recent half year, she sufferd from upper abdominal pain, exacerbated by coughing.And diarrhea 5-6 times /days for 6 months,she also reported about fever at night, and losing 10+ kilograms body weight acompanied with night sweating. Patient was regularly followed up chest, gastroenterology OPD at our hospital.
      • At 2023/07/11 US showed diffuse symmetrical edematous wall thickening of the gallbladder, suspect adenomyomatosis.
      • 2023/07/25 CT result shoed GB adenomyomamatosus and suspect lymphoma.Hepatomegaly and splenomegaly was noted.
      • She also complain about discomfortable after receiving the fourth dose of covid vaccine on 2023/01/13 and urticaria after covid viccination last year.
      • The LAB DATA showed higher total bilirubin 2.89mg/dL.
      • 2023/07/12 CT abdominal showed diffuse symmetrical edematous wall thickening of the gallbladder.
      • Under the impression of gallblader wall thinckening and enlargement of lymphnode, highly suspect adenomyomatosis and lymphoma, the patient was admitted to our ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission, we have arranged EUS for her which was revealed as
        • Hepatic hilum tumor, s/p CH-EUS & EUS/FNB (A)
        • Gallbladder wall thickening, s/p CH-EUS & EUS/FNB (B).
      • We have consulted GS for surgical evaluation and reply as waiting pathology report.
      • PET scan was arranged on 08/07. Under the stable condition, she was arranged discharge and OPD follow up.
  • 2023-03-08 SOAP Chest Medicine
    • S
      • post COVID
      • cough intermittent, without scanty sputum, sorethroat(-), chest tightness for weeks, dyspnea, rhinorrhea(-), nasal congestion(-), post nasal dripping(-), acid regurgitation, DOE(+), exercise limitation(+)
      • Past history: Allergic rhinitis, asthma
      • Family history of asthma
      • Smoking(-)
      • Allergic history(-)
      • Traveling history(-)
    • O
      • Throat: hyperemia
      • Tonsil: enlargement
      • Neck LAP:(-)
      • Breathing sound:course, wheezing(+), crackle(-)
      • HS: RHB
      • Abdomen: soft and flat
      • Pitting edema(-)
    • Prescription
      • Symbicort Rapihaler (budesonide, formoterol) 2# BID
      • Ulstrop (famotidine 20mg) 1# BID
      • Xyzal (levocetirizine 5mg) 1# HS
      • Actein (acetylcysteine 600mg) 1# BID
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
      • Cough Mixture (platycodon) 10mL HS
      • Acetal (acetaminophen 500mg) 1# TID
  • 2022-04-25 SOAP Rheumatology
    • S: 220425 impproved mild, mild elevated Eos, headache at night
    • Prescription
      • Allegra (fexofenadine 60mg) 1# TID
  • 2022-04-18 SOAP Rheumatology
    • S: 2022 0418 facial swelling, lip swelling off and on for half an yr, urticaria rash over turnk for 1 month
    • Prescription
      • Allegra (fexofenadine 60mg) 1# TID

701483618

230816

[MedRec]

  • 2023-07-18 ~ 2023-07-24 POMR Hemato-Oncology
    • Discharge diagnosis
      • Chronic viral hepatitis B without delta-agent
      • Rectal cancer, 4-cm from anal verge with right levator ani muscle invasion, cT4bN0M0, stage IIC.
      • Chronic viral hepatitis B without delta-agent
    • CC
      • for C1D1 chemoradiotherapy with FOLFOX
    • Present illness
      • This 48-year-old woman, a patinet of rectal cancer cT4bN0M0 stage IIC was diagnosed in July by Dr Xiao GuangHong, suffered from bowel habit change and tenesmus and bloody stool for 2-3 years ago and hemorrhoid during pregnancy was also noted. She visited to our CRS OPD for further evaluation and survey.
      • Image study with abdominal CT (2023/07/02) showed rectal cancer is highly suspected. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for rectal cancer: T4b N0 M0, stage: IIC . Colonfiberscopy (2023/07/08) showed rectal cancer s/p biopsy and pathology of Large intestine, rectum, from anal canal to 4 cm from anal verge, biopsy (2023/07/04) proved adenocarcinoma, moderately differentiated
      • Immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
      • The tumor marker showed CA-199 = 23.687; CEA = 3.627 and HBsAg(NM) = Positive on 2023/06/30.
      • Radiotherapy of 5040cGy/28 fx started since 2023/7/17 for rectal tumor.
      • Today, she was admitted for CCRT followed by C/T with FOLFOX (C1D1) on 2023/07/18.
    • Course of inpatient treatment
      • After admission, radiotherapy started since 2023-07-17 and chemoradiotherapy with 5FU (400mg/m2) plus Leucovorin (20mg/m2) was given on 7/19-7/21 & 7/24 23, smoothly without obvious side effect. She was discharged on 7/24 23 under stable condition and will follow-up at OPD.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
  • 2023-07-11 SOAP Hemato-Oncology
    • O
      • Now on CCRT followed by C/T with FOLFOX, CCRT C1D1 on 2023-07-18 or 19
    • P
      • Prescribe anti-HBV medication before CCRT
  • 2023-07-11 SOAP Radiation Oncology
    • O
      • Conclusion of Cancer Multidisciplinary Team Meeting, Meeting Date: 2023-07-11
        • CCRT (TNT) then evaluation the of sphincter preserving surgery or APR.
    • A/P
      • IMP: Rectal cancer, 4-cm from anal verge with right levator ani muscle invasion, cT4bN0M0, stage IIC.
      • Plan: Suggest pre-op CCRT (Favor TNT) then evaluation the possibility of sphincter preserving surgery or APR.
        • RT plan: 5040cGy/28 fx.
        • CT simulation on 7/11; possible treatment toxicity is told; diet education is given.
  • 2023-07-08 SOAP Colorectal Surgery
    • S
      • Newly diagnosed rectal cancer - cT4bN0M0 stage IIC
    • A/P
      • Suggest pre-op CCRT (Favor TNT) then evaluation the possibility of sphincter preserving surgery or APR
  • 2023-06-29 SOAP Colorectal Surgery
    • S
      • Newly diagnosed rectal cancer
      • Bowel habit change and tenesmus
      • Hemorrhoid during pregnancy
      • Mucoid bloody stool noted
      • F.H: Denied
    • O
      • One mass was noted in the rectum (from anal canal up to 4 cm from anal verge, right posterior lateral)
      • Management: Biopsy

[radiotherapy]

[chemotherapy]

700033032

230814

[lab data]

2023-05-19 Anti-HBs 1.62 mIU/mL
2023-05-19 Anti-HCV Nonreactive
2023-05-19 Anti-HCV Value 0.12 S/CO
2023-05-19 HBsAg Reactive
2023-05-19 HBsAg (Value) 3220.93 S/CO
2023-05-19 Anti-HBc Reactive
2023-05-19 Anti-HBc-Value 8.80 S/CO

[exam findings]

  • 2023-05-18 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 48 dB HL; LE 41 dB HL.
    • RE mild to severe SNHL.
    • LE mild to severe SNHL.
  • 2023-05-17 Tc-99m bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in bilateral clavicles, left scapula, some C-, T- and L-spine, and bilateral femoral shaft, M/3, in whole body bone survey.
    • IMPRESSION: Cancer with multiple bone metastases should be considered. Please correlate with the findings of PET scan.
  • 2023-05-16 MRI - brain
    • Indication: esophageal cancer survey
    • MRI of the brain in multiplanar projections, multisequences imaging acquisition without and with IV Gd-DTPA administration shows:
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • Imp:
      • No brain nodule or metastasis. Mild cortical brain atrophy.
  • 2023-05-15 Patho - esophageal biopsy
    • Esophagus, middle, biopsy— severe squamous dysplasia
    • Microscopically, it shows pieces of esophageal mucosal tissues with severe dysplasia of the squamous cellls.
  • 2023-05-15 PET scan
    • Glucose hypermetabolic lesions in the lower third of esophagus, compatible with the primary esophageal cancer.
    • Glucose hypermetabolism in bilateral mediastinal and bilateral pulmonary hilar lymph nodes, highly suspected cancer with regional and distant lymph nodes metastases.
    • Increased FDG uptake in the left upper and lower lungs, in the right lower lung, and in skeleton including bilateral clavicles, scapulae, several C-, T- and L-spine, sacrum, and femurs, highly suspected cancer with lung and bone metastases.
    • Lower third of esophageal cancer, cTxN2-3M1, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-05-15 SONO - abdomen
    • Findings
      • Liver
        • Heterogeneous echotexture. Smooth surface. Blunt liver edge.
        • Some cysts in bilateral lobes of liver, up to 1.08 cm
        • A 0.31 cm hyperechoic lesion with PAS in S7
      • Kidney
        • Cysts in both kidneys: 0.8 cm in RK, 0.59 cm in LK
      • Pancreas
        • Some parts of pancreas blocked by bowel gas, especially
    • Diagnosis
      • Parenchymal liver disease
      • Hepatic cysts
      • Hepatic calcified spot, S7
      • Renal cysts
      • Suspected pancreatic cystic lesion, body
  • 2023-05-15 Miniprobe Endoscopic Ultrasound
    • c/w, advanced esophageal cancer, lower esophagus, estimated stage, T3NxMx, with esophageal stenosis
    • Esophageal Lugol voiding area, 30cm below the incisor, s/p biopsy
  • 2023-05-10 CT - chest
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-05-09 Patho - esophageal biopsy
    • Diagnosis
      • Esophagus, 35-40 cm below incisor, biopsy — Squamous cell carcinoma, moderately differentiated
      • Esophagus, 33 cm below incisor, biopsy — Squamous cell carcinoma, moderately differentiated
      • Esophagus, 24 cm below incisor, biopsy — Hyperplastic polyp
  • 2023-05-06 ECG
    • Sinus tachycardia
    • Low voltage QRS of limb leads
    • Borderline ECG

[MedRec]

  • 2023-07-10 SOAP Radiation Oncology
    • A/P
      • RT dose: 5040cGy/28 fractions (6 MV photon) to L/3 tumor & LAPs, 2023/5/26 to 7/05.
      • Cisplatin/5FU: 5/22, 5/29, 6/06, 6/13, 6/27, 7/05.
      • RT Side effect evaluation, 7/10: Radiation dermatitis, grade 0; N/V, grade 1; esophagitis, grade 1; pneumonitis, grade 0.
      • Diagnosis: Esophageal cancer, L/3, squamous cell carcinoma, 33-40cm from incisor, with lumen obstruction (liquid diet now), cT3N0M1, with lung & bone metastasis; hypopharyngeal lesion; ECOG =1
      • s/p CCRT since 2023/5/26 to 7/05.
      • Plan: Diet education is given. BW monitoring. Psychological support. RTC 8/15. Watchout infection sign.
  • 2023-06-26 SOAP Radiation Oncology
    • Conclusion of Cancer Multidisciplinary Team Meeting, Meeting Date: 2023-05-23
      • cT3N2M1, stage IVB => CCRT

[consultation]

  • 2023-05-11 Thoracic surgery
    • Q
      • This is a 67 year old male with chief complaint of poor appetite, dysphagia. Due to above reason, the patient was admitted to our GI ward for further evaluation and management.
      • Panendoscopy on 2023/05/09 showed a lesion over hypopharynx, three lesions s/p biopsy over esophagus. Pathology of esophageal lesions revealed both specimen A (35-40 cm below incisor) and specimen B (33 cm below incisor) squamous cell carcinoma, moderately differentiated, and specimen C (24 cm below incisor) hyperplastic polyp. Chest CT on 2023/05/10 revealed L/3 esophageal cancer T3N0M0.
      • Now, we need your expertise for surgical intervention survey.
    • A
      • I will take over this case. Thanks for your consultation!!
  • 2023-05-11 Radiation Oncology
    • Q
      • This is a 67 year old male with chief complaint of poor appetite, dysphagia. Due to above reason, the patient was admitted to our GI ward for further evaluation and management.
      • Panendoscopy on 2023/05/09 showed a lesion over hypopharynx, three lesions s/p biopsy over esophagus. Pathology of esophageal lesions revealed both specimen A (35-40 cm below incisor) and specimen B (33 cm below incisor) squamous cell carcinoma, moderately differentiated, and specimen C (24 cm below incisor) hyperplastic polyp. Chest CT on 2023/05/10 revealed L/3 esophageal cancer T3N0M0.
      • Now, we need your expertise for CCRT survey.
    • A
      • Diagnosis: Esophageal cancer, L/3, squamous cell carcinoma, 33-40cm from incisor, with lumen obstruction (liquid diet now), cT3N0M0, (bone scan is pending); hypopharyngeal lesion; ECOG =1
      • Plan: Biopsy of hypopharyngeal lesion is suggested to R/O double primary cancer. Jejunostomy and Port A implantation is suggested for nutritional support and further chemotherapy. If only esophageal cancer is proved, pre-operative CCRT to esophageal tumor for 5040cGy/28 fx is suggested for tumor control. Possible radiation toxicity (radiation esophagitis and pneumonitis) is told. Diet education is given. CT simulation will be arranged next week after jejunostomy and Port A implantation are done.
  • 2023-05-11 Ear Nose and Throat
    • A1
      • The patent was absent during the visit.
      • According to the image of the EGD, the hypopharyngeal lesion was over posterior pharyngeal wall.
      • Biopsy under nasopharyngoscope is indicated.
      • VS Huang preferred biopsy at his OPD (e.g. next Monday PM). If the patient is already discharged by then, please arrange ENT OPD follow-up.
    • A2 (2023-05-16)
      • the hypopharyngeal lesion can’t be seen by nasopharyngoscopy exam
      • suggest biopsy under PES
  • 2023-05-11 Hemato-Oncology
    • A
      • This 67 year old man is a case of newly diagnosis lower third moderately differentiated esophagus squamous cell carcinoma, cT3N0M0, stage II. We are consulted for neoajuvant CCRT.
        • Please arrange EUS and PET scan for complete staging.
        • Consult chest surgeon for further evaluation (1. For esophagus cancer evaluation; 2. arrange port A insertion and consider jejunostomy if difficle oral intake due to dysphagia)
        • Consult radio-oncologist for further evaluation (CCRT)
        • For CCRT, we will give weekly cisplatin (25-30mg/m2 IVD 2hr) with 5FU (1000mg/m2 IVD 24hr). Please arrange 24 urine CCR and auditory test.

[radiotherapy]

[chemotherapy]

  • 2023-08-14 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
  • 2023-07-05 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
  • 2023-06-28 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
  • 2023-06-14 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
  • 2023-06-07 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
  • 2023-05-29 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
  • 2023-05-22 - cisplatin 25mg/m2 35mg NS 500mL 3hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL

==========

2023-08-14

No reconciliation issues found after reviewing PharmaCloud and HIS5 records.

2023-05-25

As of 2023-05-19, the patient has tested reactive for Anti-HBc. Baraclude (entecavir 0.5mg) 1# QDAC has been appropriately prescribed. The patient’s vital signs are currently stable and there are no issues with the active prescription.

700162322

230814

[exam findings]

  • 2023-07-18 Pure Tone Audiometry, PTA
    • Reliabilty Fair
    • R’t : 16 dB HL, normal to mild SNHL
    • L’t : 11 dB HL, WNL.
  • 2023-07-12 CXR
    • Tortous aorta with calcification is noted.
  • 2023-07-10 Tc-99m MDP bone scan
    • No strong evidnce of bone metastasis.
    • Suspected benign lesions in both rib cages, nasal bone, some C-, T- and L-spine, sacrum, bilateral shoulders, left elbow, hips, and knees.
  • 2023-07-08 MRI - brain
    • No evidence of brain metastasis.
  • 2023-07-07 PET
    • The FDG PET findings are compatible with esophageal cancer involving the EG junction with three regional lymph node metastases.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar regions and bilateral shoulders. Inflammatory process may show this picture.
    • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-07-06 Treadmill Exercise Test
    • Diagnosis: Esophageal ca
    • Exam for: Pre-op evaluation
    • Exam records:
      • Ergometer protocol: incrementa
      • Ergometer type: cycle ergometer,work rate:7 watt/min
      • Load time: 10.1 min
      • ΔVO2/ΔWR (Normal>8.6~10.3): 8.6
      • AT: 556 / 1182 = 47
    • Predict
      • MIP :104 -( 0.51 * 64 ) = 71.36
      • MEP :170 -( 0.53 * 64 ) = 136.08
      • Meas
        • MIP :96 / 71.36 )= 135
        • MEP :74 / 136.08 )= 54
      • Cause of stop:
        • CAT: 11341001 = 11
      • Rest BP: 110/70 mmHg
      • Max Exercise: 71 watts
      • Max BP: 179/65 mmHg
      • Max Borg: 5
      • Max leg fatigue: 10
      • Recovery 1st minute HR:104, BP:156/57 mmHg
      • Recovery 3rd minute BP:136/61 mmHg
      • Recovery 5th minute BP:107/61 mmHg
    • Conclustions
      • maximal exercise by RER>1.01
      • normal exercise capacity ( VO2 85%, WR 100%) ( normal value >85%)
      • spirometry: normal (FVC 88%, FEV1 85%)
      • respiratory muscle strength: low ( MIP 96%, MEP 54%)
      • No desaturation below 90%
      • low cardiac response during exercise
      • HR response during exercise: normal slope
      • work efficiency normal
      • anaerobic threshold normal
      • oxygen pulse normal
      • BP response: normal response during exercise
      • EKG: nonspecific findings
      • Health-related quality of life, CAT= 11, chest tightness 3, dyspnea 4
    • suggestion:
      • Treat underlying disease
      • For low cardiac response, suggest patient to intake adequate fluid for keeping adequate preload, suggest to survey cardiac function such as cardiac echo
      • For low respiratory muscle strength, do breathing exercise
  • 2023-07-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 23) / 93 = 75.27%
      • M-mode (Teichholz) = 75
    • Conclusion:
      • Normal LV filling pressure.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis; mild MR; mild to moderate TR; mild PR.
  • 2023-07-05 SONO - abdomen
    • Findings: A 4 cm hypoechoic mass near EC junction
    • Diagnosis: C/W esophageal tumor
  • 2023-07-04 CT - chest
    • Indication: lower 1/3 esophageal SCC
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Soft tissue mass at dilstal esophagus near EG junction measuring 4.1cm is found. Regional lymph nodes (n=4) are also noted.
        • Calcified coronary arteries is found.
    • Imp: Esophageal cancer at EG junction with regional lymphadenopathy.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-06-20 Patho - stomach biopsy
    • Stomach, cardia, biopsy —- Moderately differentiated squamous cell carcinoma
    • Microscopically, section shows moderately differentiated squamous cell carcinoma consisting of nests and sheets of tumor cells in infiltrative growth pattern, squamous differentiation and focal dyskeratosis.The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, nuclear pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
  • 2023-06-20 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
    • Gastric erosion, prepyloric antrum, LC
    • Gastric tumor, cardia R/O SET with ulcer or cancer, s/p biopsy(A)
    • Gastric polyps, body and fundus, s/p biopsy(B)
  • 2023-06-14 Esophagography
    • A polypoid lesion at lower esophagus.
  • 2022-07-28 Bone densitometry - Hip
    • Hip BMD performed by DXA revealed: Hip, BMD is 0.562 gms/cm2, about 2.6 SD below the peak bone mass (66%) and 0.5 SD below the mean of age-matched people (92%).
    • IMP: osteoporosis
  • 2020-03-25 Patho - esophageal biopsy “distal esophague near EG junction”, biopsy — low grade dysplasia.

[consultation]

  • 2023-07-11 Radiation Oncology
    • A
      • This 64-years-old female sufferred from dysphagia for 6 months. She can only eat semisolid or liquid diet. Thus she was brought to our Gastroenterology clinic on 2023/06/06. Upper Gastrointestinal endoscopy revelaed gastric tumor and Gastric polyps. Stomach biopsy was done and the pathology report showed moderately differentiated squamous cell carcinoma. The cancer staging revealed esophago-cardiac junction cancer, staging at least cT3N2M0.  
      • Neoadjuvant CCRT is indicated. CT-simulation will be arranged on 2023/07/17. Plan to deliver 45 Gy/ 25 fx to the esophagus and adjacent lymphatic drainage area. Then boost the EC junction tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 20230719 or 20. Thank you very much.

[radiotherapy]

[chemotherapy]

  • 2023-08-14 - cisplatin 75mg/m2 110mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 + fluorouracil 1000mg/m2 1500mg NS 500mL D1-4
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-20 - cisplatin 75mg/m2 110mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 + fluorouracil 1000mg/m2 1500mg NS 500mL D1-4
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-07-20

After reviewing the PharmaCloud database and in-hospital HIS5 records, no medication reconciliation issues were identified.

700301305

230814

[diagnosis] - 2023-03-22 discharge note

  • Peripheral T-cell lymphoma with right palatine tonsil, bilateral nasopharyngeal, cervical and axillary regions, bilateral SCF, ICF, bilateral pulmonary hilar regions and mediastinum , celiac chains, bilateral para-aortic space, common iliac chains, external and internal iliac chains, inguinal and thigh regions.
    • In addition,lower T- and L-spine involvement, Lugano stageIII, IPI Score:3, High-intermediate risk group
  • Paroxysmal atrial fibrillation
  • Hypertensive heart disease without heart failure
  • Chronic viral hepatitis B without delta-agent

[past history] - 2023-04-05 admission note

  • Hypertension for 10 years with regular medication control.
  • Denied history of DM        

[allergy]

  • NKDA         

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.  

[exam findings]

  • 2023-08-10 CT - chest
    • Indication: T cell lymphoma, bilateral para-aortic space, common iliac chains, external and internal iliac chains, inguinal and thigh regions, lower T- and L-spine involvement, Lugano stageIII, IPI Score:3, High-intermediate risk group
    • Findings
      • Lungs: no abnormal nodule or mass in the lungs.
        • dependent partail atelectasis over RLL.
      • Chest wall, visible neck, mediastinum and hila: extensive lymphadenopathy in the visceral space and anterior prevascular spaces of mediaastinum, cardiophrenic angles, bilateral axillary and supraclavicular regions.
        • mild calcified plaques of the LAD coronary artery.
      • Aorta: normal caliber, mild atherosclerotic change of descending thoracic aorta.
      • Heart: normal in size of cardiac chambers.
      • Pleura: moderate Rt and small Lt effusion, in progression.
      • Visible abdominal-pelvic contents: hyperplasia of left adrenal gland. distended gall bladder with a 5mm stone.
        • many bilateral renal cysts measuaring up to 4.8cm
        • multiple hepatic cysts measuaring up to 17mm
        • unremarkable of the spleen and pancreas,
        • extensive enlarged lymph nodes in retroperitoneum, mesentery root, and bilateral iliac chaind and inguinal regions. mild ascites.
      • Visualized bones:
        • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis. no lytic or blastic destruction.
      • Impression:
        • lymphoma extensive involving both sides of the diaphgram, in progression as compared with CT on 2023/04/05
  • 2023-08-09 KUB
    • Spondylosis of the L-spine is noted.
    • Gallstone is highly suspected.
  • 2023-08-08 ECG
    • Sinus tachycardia with Premature atrial complexes
    • Left atrial enlargement
  • 2023-08-01 Bronchodilator Test
    • Mild restrictive ventilatory impairment
    • Not significant bronchodilator reversibility
  • 2023-07-14 CXR
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Enlargement of cardiac silhouette.
  • 2023-06-27, -05-29, -05-15 CXR
    • Band-like opacity projecting at RLL of the lung.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Fibrosis projecting at bilateral middle lung is suspected.
  • 2023-05-03 24hr ECG
    • Sinus rhythm
    • Occasional isolated apcs
    • Rare apc couplets
    • A few episodes short run atrial tachycardia (longest: 4 beats)
    • A few isolated vpcs
    • No long pause
    • No significant tachyarrhythmia
  • 2023-04-25 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, antrum
    • Suggestion
      • PPI use
  • 2023-04-17 SONO - chest
    • Echo diagnosis
      • Bilateral pleural effusion, R>L
      • Post tapping at right side, about 520cc seroanguinous
      • Left side minimal pleural effusion
    • Suggestion
      • sent for anlysis and culture, and CXR follow up
  • 2023-04-05 CTA - chest
    • CTA of chest revealed:
      • Enlarged LNs at bil. neck, axillary regions, mediastinum, retroperitonum and mesentery.
      • A patchy density (1.7x6.0cm) at RML. Ground glass opacities at bil. lungs. Right pleural effusion.
      • Liver and renal cysts (up to 5.0cm).
      • Gallbladder stone (6mm).
    • IMP:
      • Enlarged LNs at bil. neck, axillary regions, mediastinum, retroperitonum and mesentery.
      • A patchy density (1.7x6.0cm) at RML. Ground glass opacities at bil. lungs. Right pleural effusion.
      • Gallbladder stone (6mm).
  • 2023-04-05 CXR
    • Ground glass opacities in bil. lungs.
  • 2023-04-03 Bladder Sonography
    • PVR 3.67 mL
  • 2023-04-03 Uroflowmetry
    • Q max: fair
    • flow pattern: obstructive
  • 2023-03-20 CXR
    • Right pleura effusion.
    • Partial atelectasis in RLL is suspected.
  • 2023-03-06 SONO - kidney, urology
    • bilateral renal cyst
  • 2023-03-06 Bladder Sonography
    • PVR 3.3 mL
  • 2023-02-23 CXR
    • Bilateral pleura effusion.
  • 2023-02-22 PET
    • Glucose-hypermetabolism in the right palatine tonsil and above-mentioned lymph node regions (Deauville score 5), highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
    • Glucose-hypermetabolism in some lower T- and L-spine (Deauville score 4), the nature is to be determined (DJD or lymphoma with involvement of bone marrow), suggesting further investigation.
    • T-cell lymphoma with involvement of lymph node regions on both sides of the diaphragm, stage III at least (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-02-21 CT - chest
    • Indication: T cell lymphoma, pending staging
    • MDCT (128-detector rows, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Lungs: no abnormal nodule or mass in the lungs.
        • dependent partail atelectasis over RLL.
      • Chest wall, visible neck, mediastinum and hila: extensive lymphadenopathy in the visceral space and anterior prevascular spaces of mediaastinum, cardiophrenic angles, bilateral axillary and supraclavicular regions.
        • mild calcified plaques of the LAD coronary artery.
      • Aorta: normal caliber, mild atherosclerotic change of descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: moderate Rt and small Lt effusion.
      • Visible abdominal-pelvic contents: hyperplasia of left adrenal gland. distended gall bladder with a 5mm stone.
        • many bilateral renal cysts measuaring up to 4.8cm
        • multiple hepatic cysts measuaring up to 17mm
        • unremarkable of the spleen and pancreas,
        • extensive enlarged lymph nodes in retroperitoneum, mesentery root, and bilateral inguinal regions. mild ascites.
        • Extensive atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
      • Visualized bones:
        • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis.
    • Impression:
      • T-cell lymphoma extensive involving both sides of the diaphgram.
  • 2023-02-21 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
    • IHC stains: CD117: <1%; CD34: <1 %; LCA: 10 %; CD3 and CD20: no predominant sub-population. (of the nucleated cells).
    • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • 2023-02-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (106 - 22) / 106 = 79.25%
      • M-mode (Teichholz) = 78
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Grade 1 LV diastolic dysfunction
      • Mild MR, TR
      • Pulmonary hypertension, RV hypertrophy
  • 2023-02-14 Patho - soft tissue biopsy/simple excision (non lipoma)
    • Lymph node, right neck, excision — Malignant T-cell lymphoma, consistent with peripheral T-cell lymphoma
    • Section show lymph nodes with diffusely infiltration of medium to large-sized lymphoid cells.
    • The immunohistochemical stains reveal CD3(+), CD20(-), CD4(+), CD8(-), CD10(-), BCL2(+), BCL6(-), Cyclin D1(-), CD30(-), ALK-1(-), CD56(-), Granzyme-B(-), TdT(-), CD21(-), and CK(-). The Ki-67 is about 60%. The results are consistent with peripheral T-cell lymphoma. Please correlate with the clinical presentation and image study.
  • 2023-02-07 CT - neck
    • Indication:
      • 2023/02/06 multiple painless neck swelling for 3-4 months (suspect lymphoma)
      • productive cough with mild sputum for 2 months
      • referred from endocrinologist, sonogram revealed multiple neck LAP
    • Pre- and post-contrast CT scans of the head and neck region from skull base to lower neck were performed on a spiral CT scanner and axial, coronal and sagittal images of a slice thickness of 3 mm were reconstructed and show:
      • Numerous enlarged lymph nodes, some with necrotic change, at bilateral levels I-V, supraclavicular fossas and axillary regions and also in superior mediastinum.
      • No abnormality at nasopharynx, oropharynx, hypopharynx and larynx.
      • Presence of right pleural effusion.
      • No skull base lesion, nor abnormality at visible intracranial regions.
    • IMP:
      • Bilateral cervical lymphadenopathies. R/O TB lymphadenitis. D/D: metasatses, lymphoma.
  • 2023-02-06 Nasopharyngoscopy
    • smooth NPx, OPx, HPx
    • fair inf. turbinate, L with clear mucus, NSD to L
  • 2023-01-30 SONO - thyroid
    • autoimmune thyroid disease
    • bilateral cervical lymph nodes
  • 2022-11-21 Clinical Dementia Rating
    • CDR score: 0.5
  • 2022-11-21 Mini-Mental State Examination
    • MMSE score: 24
  • 2021-11-22 Clinical Dementia Rating
    • CDR score: 0.5
  • 2021-11-22 Mini-Mental State Examination
    • MMSE score: 24

[MedRec]

  • 2023-03-06 SOAP Hemato-Oncology
    • Sick sinus syndrome
    • Bradycardia
  • 2023-02-20 SOAP Hemato-Oncology
    • Peripheral T cell lymphoma with bil neck enlargement, anr Rt pleural effusion
    • Hypertension
    • History of bradycardia treated by CV
    • Af under anticoagulation
    • Dementia

[consultation]

  • 2023-08-11 Radiation Oncology

    • A
      • A: Malignant T-cell lymphoma, consistent with peripheral T-cell lymphoma, Lugano stage III, s/p chemotherapy, with progression.
      • P: Radiotherapy is indicated for this patient with the following indicators: tonsil tumor with easy choking, and dyspnea.
        • Goal: palliation
        • Treatment target and volume: tonsil tumor, peripheral involved, to bilateral involved neck nodal lesions.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the tonsil tumor, peripheral involved, to bilateral involved neck nodal lesions.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2023-08-14.
  • 2023-08-11 Family Medicine

    • Q
      • The 86 y/o has peripheral T-cell lymphoma with right palatine tonsil, bilateral nasopharyngeal, cervical and axillary regions, bilateral SCF, ICF, bilateral pulmonary hilar regions and mediastinum, celiac chains, bilateral para-aortic space, common iliac chains, external and internal iliac chains, inguinal and thigh regions, lower T- and L-spine involvement, Lugano stageIII, IPI Score:3, High-intermediate risk group. Due to disease progress, family asks for hospice assessment. Thanks!
    • A
      • A 86 years old male, case of peripheral T-cell lymphoma.
      • He was admitted for pneumonia but status of lymphoma was in progression.
      • Cons: E4V5M6, ECOG:1-2
      • complained dyspnea and easy chocking
      • Patient could understand hospice and palliative care.
      • We will arrange combine care and follow his condition.
      • Consider hospice ward if agreed with palliative treatment.
  • 2023-08-11 Ear Nose Throat

    • Q
      • Due to dysphagia and easy choking, so he need your help use scope for NG insertion. Thanks!
    • A
      • Nasogastric tube was inserted smoothly under nasopharyngoscopy.
  • 2023-04-07 Infectious Disease

  • 2023-04-07 Chest Medicine

  • 2023-04-07 Cardiology

  • 2023-02-22 Vascular Surgery

    • A: insertion of port-A will be scheduled on 20230223.

[chemotherapy]

  • 2023-07-14 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + liposome doxorubicin 30mg/m2 54mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 50mg PO BID D1-5 (mCHOP, cyclophosphamide 10% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-06-16 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + liposome doxorubicin 30mg/m2 54mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 50mg PO BID D1-5 (mCHOP, cyclophosphamide 10% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-05-15 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + liposome doxorubicin 30mg/m2 54mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 50mg PO BID D1-5 (mCHOP, cyclophosphamide 10% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-20 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + liposome doxorubicin 30mg/m2 54mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 50mg PO BID D2-6 (mCHOP, cyclophosphamide 10% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-02-24 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + liposome doxorubicin 30mg/m2 54mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 50mg PO BID D1-5 (mCHOP, cyclophosphamide 10% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-08-14

[tube feeding: Detrusitol SR (tolterodine), Valcyte F.C (valganciclovir)]

  • Based on the information for Valcyte F.C (valganciclovir), the drug should not be crushed for tube feeding because animal data suggests that valganciclovir has the potential to be carcinogenic in humans. As this hospital does not have access to foscarnet or cidofovir, and ganciclovir shares a similar potential carcinogenic risk, it seems that continuing with Valcyte for tube feeding is the only option at this stage.

  • Detrusitol SR (tolterodine) is an extended-release capsule, and crushing it for tube feeding could compromise its prolonged-release properties. This could result in a more pronounced fluctuation in its concentration in the bloodstream, potentially affecting its therapeutic efficacy. All other in-hospital available drugs within the same class as tolterodine, such as Urotrol F.C (propiverine 15mg), Oxbu ER (oxybutynin 5mg), Vesicare F.C (solifenacin 5mg), and Betmiga (mirabegron 50mg), are designed as film-coated or extended-release. It might be beneficial to divide the dosage of Detrusitol into two administrations per day to stabilize the concentration in the bloodstream for tube feeding.

2023-06-16

  • The patient had an appointment at a local eye clinic in XinDian on 2023-06-06 for his left eye aqueous misdirection and was prescribed brimonidine tartrate and timolol maleate eye drops, which should last for a duration of 28 days. Although the prescription is not yet expired, these two eye drops are not reflected in the current active medication list. It is suggested to confirm if the related eye condition has been resolved.

2023-05-15

  • Patients undergoing treatment with immunosuppressive drugs are at an increased risk of developing Pneumocystis pneumonia (PCP). This risk is particularly heightened in patients who are receiving glucocorticoids in combination with cytotoxic agents such as cyclophosphamide, and in those receiving multiple chemotherapeutic agents, especially during periods of leukopenia. As a measure against PCP, the patient has been prescribed Morcasin (containing trimethoprim 80mg and sulfamethoxazole 400mg, also known as TMP-SMX). Given that the patient doesn’t show signs of renal insufficiency (based on 2023-05-15 lab data), there is no need for a dose adjustment.

  • Lab data reveals that the patient’s CMV viral load, which had peaked at 803 IU/mL on 2023-05-02, has now decreased to less than 35 IU/mL as of today, 2023-05-15. Valganciclovir, the active ingredient in Valcyte, is an oral prodrug that is rapidly converted into ganciclovir, a substance instrumental in the treatment and prevention of CMV infections in immunocompromised hosts. The marked decrease in CMV viral load suggests that the prescribed Valcyte is effectively managing the CMV infection.

    • 2023-05-15 CMV viral load assay <35 IU/mL
    • 2023-05-02 CMV viral load assay 803 IU/mL
    • 2023-04-24 CMV viral load assay 159 IU/mL
    • 2023-04-12 CMV viral load assay 141 IU/mL
  • As per the PharmaCloud records, all of the patient’s recent medications have been prescribed by our hospital, and no issues related to medication reconciliation have been identified.

2023-04-06

  • 2023-04-05 lab data showed elevated CRP, NT-proBNP, hs-Troponin I, D-dimer, as well as hyponatremia, leukopenia and anemia. Liver and kidney functions were normal. Cardiologist has been consulted.

    • 2023-04-05 CRP 8.35 mg/dL
    • 2023-04-05 NT-proBNP 581 pg/mL
    • 2023-04-05 hs-Troponin I 27.6 pg/mL
    • 2023-04-05 D-dimer 1228.12 ng/mL(FEU)
    • 2023-04-05 Na (Sodium) 127 mmol/L
    • 2023-04-05 WBC 2.84 x10^3/uL
    • 2023-04-05 HGB 10.3 g/dL
  • Pneumonia with exaggerated dyspnea and hypoxemia was observed on admission; planned chemotherapy is withheld until respiratory symptoms resolve. Brosym (cefoperazone + sulbactam) has been prescribed since the day the patient was admitted.

  • Rivaroxaban and amlodipine have been prescribed properly as self-carried items with no medication reconciliation issues.

701443315

230814

[exam findings]

  • 2023-08-11 ECG
    • Normal sinus rhythm
    • Prolonged QT
    • Abnormal ECG
  • 2023-07-24 MRI - nasopharynx
    • Indication: Right lower gum squamous cell carcinoma, grade I, cT3N2aM0, stage IVA s/p concurrent chemoradiotherapy to H&N tumors for 7140cGy/34 fractions, start and weekly chemotherapy with TP
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows - Comparison: 2023/04/29, 2022/09/22 HN MRI - prominent motion artifacts were found on most the images
      • Right low gum, bucco-gingival tumor mass, seems invading to mouth floor, seems stationary.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Necrotic right IB LAP, seems stationary.
      • Presence of soft tissue swelling over bil. neck, post CCRT change favored.
  • 2023-07-21 CT - chest
    • Indication:
      • Right upper lung adenocarcinoma, cT3N1M0, stage IIIA s/p weekly chemotherapy with TP (Carboplatin AUC:2 / Docetaxel 35mg/m2) from 2022/12/12 to 2023/02/06, progression for right upper lobe and left upper lobe tumor s/p chemotherapy with GP (Gemzar 800mg/m2, CDDP 60mg/m2) from 2023/05/02 ~
      • Right lower gum squamous cell carcinoma, grade I, cT3N2aM0, stage IVA s/p concurrent chemoradiotherapy to H&N tumors for 7140cGy/34 fractions, start from 2022/12/12 to 2023/2/13 and weekly chemotherapy with TP (Carboplatin AUC:2 / Docetaxel 35mg/m2) from 2022/12/12 to 2023/02/06
    • Chest and Abdominal CT with and without enhancement revealed:
      • Chest:
        • Mass like lesion at right upper lobe measuring 4.87cm and left upper lobe measuring 3.18cm are found. In comparison with CT dated on 2023-02-17, the right upper lobe mass decreased in size but the left upper lobe tumor progressed.
        • Another spiculated mass at right lower lobe measuring 3.67cm and 2.3cm in largest dimension are found. In progression.
        • Bronchiectatic change over right lower lobe and left lower lobe with tree in bud appearance at left lower lobe is found.
        • No evidence of bilateral pleural effusion.
        • Lymphadenopathy at both sides of the mediastinum.
      • Visible abdomen:
        • There is stone at dependent portion of GB. GB stone(s) are noted.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
    • Imp:
      • Right upper lobe mass, in regression.
      • Left upper lobe and right lower lobe mass like lesion. In progression. However, lung meta or recent inflammation should be differentiated.
      • Bilateral lower lung Bronchiectatic changes
  • 2023-06-14 CXR
    • Prior plain film identified Patchy opacity of the right upper lung zone is noted. again, decreasing in size. Please correlate with CT.
    • Linear infiltration over left upper lung zone and nodular opacity projecting at right lower lung is noted. please correlate with clinical condition.
    • Atherosclerotic change of aortic arch
    • Spondylosis with scoliosis of the T-spine with convex to right side
  • 2023-04-29 MRI - nasopharynx
    • Comparison: 2022/09/22 HN MRI
      • Right low gum, bucco-gingival tumor mass, seems invading to mouth floor.
      • Invasion of right anterior mandible bone, a 4A lesion?
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor, with mild regression.
      • Necrotic right left IB LAP, mild regressed size.
      • Presence of soft tissue swelling over bil. neck, post CCRT change favored.
  • 2023-02-17 CT - chest
    • History: This 71 years-old man has noted a 3x3 cm growing mass over right level I cervical lymph node since 2022/06. Dysphagia with solid food was also mentioned. The mass was fixed and solid, there was no tenderness, no redness or pus
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Spiculated mass at right upper lobe measuring 5.48cm in largest dimension is found. Another spiuclated lesion at left upper lobe measuring 2.97cm in largest dimension. In comparison with CT dated on 2022-09-24, the right upper lobe mass enlarged and left upper lobe mass is new.
        • No evidence of bilateral pleural effusion.
        • S/p port-A placement with its tip at Superior vena cava.
      • Visible abdomen:
        • There is stone at dependent portion of GB. GB stone(s) are noted.
        • The liver, spleen, pancreas,and adrenals are intact.
        • Left renal stone up to 0.4cm is found.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Right upper lobe and left upper lobe mass, in enlargement.
  • 2023-01-27 ALK IHC (EGFR positive needs self-paid)
    • S2022-16336: Negative
  • 2022-12-01 CXR
    • Patch density at RUL.
    • Presence of scoliosis of the lumbar spine.
    • A calcified spot at right neck.
  • 2022-11-24 PD-L1 IHC
    • Tumor cell (TC) staining assessment: >= 10% and < 50%
    • Percent of PD-L1 expression in tumor cells (TC): 10%
  • 2022-11-24 PD-L1 22C3
    • Tumor Proportion Score (TPS) assessment: >= 1% and < 50%
    • Tumor Proportion Score (TPS) : 10%
  • 2022-11-24 PD-L1 SP142
    • Result
      • Tumor cell (TC) staining assessment: TC category: TC >= 1% and < 5%
      • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2022-11-22 Pure tone audiometry
    • Reliability FAIR
    • Average RE 65 dB HL; LE 60 dB HL.
    • R’t moderate to severe MHL. (BC masking dilemma)
    • L’t mild to severe MHL.
      • Note: There are three kinds of hearing loss.
        • Conductive Hearing Loss (CHL) happens when there is a problem with the outer or middle ear that blocks sound from traveling to your inner ear. Often this is caused by wax build-up, fluid in the ears, a perforated eardrum, or damage to the bones in your ears.
        • Sensorineural Hearing Loss (SHL) happens when there is a problem in the inner ear that prevents sound from traveling to the cochlea or the auditory nerve. This can be caused by trauma, aging, disease, or being exposed to loud noise.
        • Mixed Hearing Loss (MHL) is a combination of both.
  • 2022-10-05, -10-03, -10-02, -09-29, -09-26, -09-20 CXR
    • One mass lesion over RUL.
    • Tortuosity of the aorta with atherosclerotic change.
    • Degenerative change of T-L spines with marginal osteophytes.
    • Scoliosis of the T-L spine.
  • 2022-10-05 Bronchodilator Test
    • moderate obstructive impairment; non-significant bronchodilator response.
  • 2022-10-04 Patho - bronchus biopsy
    • Lung, RUL, bronchoscopic biopsy — mild chronic inflammation
  • 2022-10-04 Bronchoscopy
    • Abnormal Endobronchial tumor over RUL
  • 2022-10-03 Tc-99m MDP whole body bone scan
    • Increased activity in the right aspect of mandible, the nature is to be determined (oral cancer with adjcent bone involvement, dental problem or other nature ?), suggesting investigation.
    • Suspected benign lesions in the maxilla, some T- and L-spine, bilateral shoulders, elbows, hips, femurs, and knees.
  • 2022-10-03 MRI - brain
    • Old insults in right frontal lobe. Cerebral small vessel disease. Mild general brain atrophy. A small enhancing nodule (5 mm) at left frontal base, may be due to confluent cortical veins. Suggest follow-up.
  • 2022-10-03 ROS1 FISH
    • ROS1 fluorescent-in-situ hybridization report - rearrangement of ROS1 gene is NOT detected. Patient with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
  • 2022-10-03 EGFR mutation
    • No mutation was detected at exon 18, 19, 20, 21 of EGFR gene in this specimen.
  • 2022-09-26 Patho - lung transbronchial biopsy
    • Lung, right, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show acinar glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.
  • 2022-09-24 CT - chest
    • Indication
      • 71 y/o man with RUL tumor for many years, stroke 5 years ago without hemiplegiaRight lower gum squamous cell carcinoma, grade I
    • Findings
      • Chest:
        • Mass like lesion at right upper lobe up to 6.9cm with attachement with interlobar fissure is found.
        • Some lymph nodes are found at right hilar region.
      • Visible abdomen:
        • Left renal stone is found.
    • Imp: Right upper lobe lung cancer with right hilar lymphadenopathy is favored.
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-09-23 Whole body PET scan
    • Glucose hypermetabolism in the right lower gum with possible invasion to adjcent mandible and mouth floor, compatible with primary malignancy involving these regions.
    • Glucose hypermetabolism in a right neck level I lymph node and a right neck level IV lymph node, compatible with metastatic lymph nodes.
    • Glucose hypermetabolism in a large focal area in the upper lobe of right lung. Primary lung malignancy should be wached out. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2022-09-22 MRI - nasopharynx
    • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-09-21 SONO - abdomen
    • Diagnosis
      • Parenchymal liver disease
      • Gallbladder stone and sludge
      • Gallbladder wall thicking, suspected cholecystopathy
      • suspected Calcified spot, right kidney
    • Suggestion
      • Regular ultrasound follow up
  • 2022-09-21 Panendoscopy
    • Diagnosis
      • Reflux esophagitis, LA B
      • Superficial gastritis and erosions, whole stomach, s/p CLO test
    • Suggestion
      • Please pursue CLO test
      • No evidence of esophageal lesion

[consultation]

  • 2022-10-06 Hemato-Oncology
    • Q
      • Consultation for evaluation and treatment advice for right lower gum squamous cell carcinoma, grade I
      • This 71 year-old man, has lung tumor and stroke 5 years ago with right eye nearly blindness. He denied any other systemic disease or surgical history. 3 months ago he noted a 3x3 cm growing mass over right level I cervical lymph node. Dysphagia with solid food was also mentioned. The mass was fixed and solid, there was no tenderness, no redness or pus secretion. Irregular palpable lesion over right lower gum was noticed. There was no bleeding or pus. The patient denied drooling, pain, choking, decreased appetite or body weight loss. Biopsy of right lower gum was done in 804 Hospital and showed squamous cell carcinoma, grade I, well differentiated. This time he is admitted for tumor survey.
      • MRI showed one 2.5x2.5 cm well-shaped homogenous nodule over right lower gum. There was no finding of metastasis or lymphadenopathy over opposite side of neck. PET will be done today.
      • Under the impression of right lower gum , our tentative plan will be either operation or CCRT. Therefore we need your advice for his further treatment. Thank you very much! We appreciate your help.
    • A
      • Impression:
        • Right lower gum, squamous cell carcinoma, grade I, well differentiated
        • Right upper lung mass
        • Stroke 5 years ago with right eye blindness
        • Superficial gastritis and erosion
      • Suggestion:
        • Pending PET data. May consider check EGFR
        • Arrange chest CT (+/-contrast) for right upper lung mass evaluation. And then CT guide biopsy if available
  • 2022-09-29 Infectious Disease
    • Q
      • This 71 year-old man, has lung tumor and stroke 5 years ago with right eye nearly blindness. He denied any other systemic disease or surgical history. 3 months ago he noted a 3x3 cm growing mass over right level I cervical lymph node. Dysphagia with solid food was also mentioned. The patient came to our ENT OPD for help, after examination, right lower gum cancer was impressed. He was admitted for cancer work up. After a series of examination right lower gum, squamous cell carcinoma, grade I was diagnosed.
      • Since his left lung nodule persist for a logn time, radio-oncologist suggest for further lung CT and CT guide biopsy for rule out malignancy.
      • The patient underwent lung CT on 20220924 which revealed right upper lung cancer, cT3N1M0. We arrange CT guide biopsy on 20220926. After CT guide biopsy, room air SPO2:88~90%. We recheck CXR today showed right lung pneumothorax. Right chest pig-tail was placed on 20220926.
      • According to his serum lab data revealed RPR/VDRL: reactive 1:2. We request your consultation for further treatment.
    • A
      • The Lab data discloses the information, I suggest my opinions as follows:
        • RPR (1:2x) with negative TPHA: false positive for syphilis.
        • RPR (1:2x) with elevated TPHA, not exceeding 1:320, follow-up (RPR and TPHA) 1 month apart; pre-emptive treatment with single dose Retarpen 2.4 MU IM may be considered.
        • RPR (1:2x) with TPHA exceeding exceeding 1:320, follow-up 3 months apart.
      • Suggestion: Check TPHA
  • 2022-09-23 Radiation Oncology
    • A
      • Impression: Rt right lower gum cancer with Rt level I LAP metastasis, WD SqCC, cT2N2M0 at least, with synchronous lung cancer, RUL; ECOG =1.
      • Plan: Chest CT and CT-guided biopsy of RUL tumor for staging and tissue proof of RUL tumor. I will follow up him with his son next Tuesday after reports of MRI and PET scan, and clinical staging are available.
  • 2022-09-23 Oral and Maxillofacial Surgery
    • Q
      • MRI showed one 2.5x2.5 cm well-shaped homogenous nodule over right lower gum. There was no finding of metastasis or lymphadenopathy over opposite side of neck. PET will be done today.
      • Under the impression of right lower gum, our tentative plan will be either operation or CCRT. Therefore we need your expertise to evaluate the condition of his teeth before radiotherapy. Thank you very much! We appreciate your help.
    • A
      • this 71-year-old man came for dental evaluation before radiotherapy.
      • O:
        • Residual root of tooth #17, #46
        • Severe peridontitis of tooth #18, #24, #41, #44, #45
        • Poor oral hygiene is noted.
      • A:
        • Residual root of tooth #17, #46
        • Severe peridontitis of tooth #18, #24, #41, #44, #45
      • P:
        • take panoramic X-ray film to check
        • explain the findings and treatment plan to the patient
        • suggest extraction of tooth #17, 18, #24, #41, #44, #45, #46
        • tooth extraction would be arranged on 2022/09/26 and 2022/09/29
        • please prescribe Amoxicillin 250mg 2# PO Q8H 2 days before tooth extraction

[chemoimmunotherapy]

  • 2023-07-25 - gemcitabine 800mg/m2 1000mg NS 100mL 30min D1 + cisplatin 60mg/m2 80mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) (gencitabine + cisplatin, Q3W, NSCLC)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-05 - gemcitabine 800mg/m2 1000mg NS 100mL 30min D1 + cisplatin 60mg/m2 80mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) (gencitabine + cisplatin, Q3W, NSCLC)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-07 - gemcitabine 800mg/m2 1000mg NS 100mL 30min
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-05-31 - gemcitabine 800mg/m2 1000mg NS 100mL 30min D1 + cisplatin 60mg/m2 80mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) (gencitabine + cisplatin, Q3W, NSCLC)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-10 - gemcitabine 800mg/m2 1000mg NS 100mL 30min
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-05-02 - gemcitabine 800mg/m2 1000mg NS 100mL 30min
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-02-06 - docetaxel 25mg/m2 35mg D5W 100mL 1hr + carboplatin AUC2 110mg NS 500mL 2hr
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-06 - docetaxel 25mg/m2 35mg D5W 100mL 1hr + carboplatin AUC2 110mg NS 500mL 2hr
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-14 - docetaxel 25mg/m2 40mg D5W 100mL 1hr + carboplatin AUC2 120mg NS 500mL 2hr
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-04 - docetaxel 25mg/m2 35mg D5W 100mL 1hr + carboplatin AUC2 120mg NS 500mL 2hr
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-28 - docetaxel 25mg/m2 35mg D5W 100mL 1hr + carboplatin AUC2 120mg NS 500mL 2hr
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-21 - docetaxel 25mg/m2 35mg D5W 100mL 1hr + carboplatin AUC2 120mg NS 500mL 2hr
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-12 - carboplatin AUC 2 120mg NS 500mL 2hr D1 + docetaxel 25mg/m2 35mg D5W 100mL 1hr D2 (reverse sequence?)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + palonosetron 250ug D1 + NS 250mL D1-2 + aprepitant 125mg PO D1-3

==========

2023-08-14

  • According to the PharmaCloud database, the patient only visited our hemato-oncology and radiation oncology departments in the last 3 months, no reconciliation issues were identified.

2022-12-13

  • The patient admitted to receive carboplatin/docetaxel treatment for the first time to treat his right lower gum squamous cell carcinoma.
  • In the lab results of 2022-12-12, no extreme abnormalities were observed.
  • In previous lab analyses of lung adenocarcinoma, EGFR mutation or ROS1 rearrangement was not detected, and PD-L1 TPS and TC were 10%. (no ALK results available yet)
  • Patients with NSCLC who are positive for PD-L1 and negative for actionable molecular biomarkers might benefit from atezolizumab treatment. The NHI covers atezolizumab under certain conditions.
  • Except for a higher SBP of 156mmHg (2022-12-12 20:30), all vital signs were stable. There is no issue with the active prescription.

700515575

230811

[exam findings]

  • 2023-08-04 CT - chest
    • Indication: Malignant neoplasm of liver, primary, unspecified as to type
    • Findings:
      • Low density lesions are found at both lobes of thyroid measuring 2.8cm in largest dimension.
      • Enlarged lymph nodes are found at hepatic hilar region. In comparison with CT dated on 2023-06-23, these lymph nodes enlarged slightly.
      • s/p op. over S4/5 of liver.
      • Bilateral renal cysts up to 5.2cm is found.
    • Imp:
      • Hepatic hilar lymphadenopathy, slightly enlarged.
      • No evidence of pulmonary meta.
      • Thyroid nodules. Suggest sonography.
  • 2023-07-20 Patho - liver biopsy needle/wedge
    • Lymph node, hepatoduodenal ligament, EUS-guided FNA/B — Metastatic poorly differentiated carcinoma
    • The sections show a picture of metastatic poorly differentiated carcinoma, composed of nests of pleomorphic polygonal neoplastic cells, arranged in solid pattern with moderate inflammatory cell infiltrate, embedded in fibrous stroma.
    • IHC, tumor cells reveal: CK7(-), CK20(-), Hepa-1(-) and Arginase-1(-). Neither hepatocytic nor cholangiocytic differentiation can be found.
  • 2023-06-23 CT - abdomen
    • Hx
      • 20221018 CT: liver tumor 7cm in S4 shows contrast enhancement in arterial phase and contrast washout at late phase, r/o HCC.
      • 20221121 Liver, S4-5, segmentectomy: HCC, pT2Nx; Stage II at least
    • Findings:
      • S/P S4-5 segmentectomy of the liver and cholecystectomy.
        • Biloma 2.5 x 2 cm in S5 liver bed is noted.
      • There are several enlarged nodes in the hepatoduodenal ligament and the largest one measuring 4.5 x 3 cm in size.
        • Metastatic nodes are highly suspected.
        • The differential diagnosis includes reactive nodes and lymphoma.
        • please correlate with clinical condition and PET scan.
        • In addition, there is one enlarged node 1.4 x 0.8 cm in left para-aortic space.
      • There are several renal cysts on both kidney and the largest one measuring 5.7 cm in size at left lower pole.
      • Abdominal aorta shows atherosclerosis and aneurysm 3.8 cm.
      • S/P hysterectomy
      • There is a diverticulum measuring 4 cm in the medial aspect of duodenum 2nd portion, near the ampulla of Vater area. Please correlate with clinical condition.
      • Hyperplasia of left adrenal gland is noted.
      • There is mild irregular contour of the left lobe liver that may be early cirrhosis.
    • Impression:
      • There are several enlarged nodes in the hepatoduodenal ligament and the largest one measuring 4.5 x 3 cm in size.
      • Metastatic nodes are highly suspected.
      • The differential diagnosis includes reactive nodes and lymphoma.
      • please correlate with clinical condition and PET scan.
  • 2022-11-21 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS:
      • Liver, S4-5, laparoscopic segmentectomy — Hepatocellular carcinoma
      • Pathologic Staging: pT2Nx; Stage II at least
    • MACROSCOPIC EXAMINATION
      • Specimen Type: S4-5 laparoscopic segmentectomy
      • Specimen Size: 10.2 x 8.1 x 4.0 cm; Weight: 162.5 gm
      • Focality: Solitary, well-defined, yellow and tan mass, 1.4 cm away from the nearest resection margin
      • Tumor Size: 7.0 x 6.0 x 3.5 cm
      • Satellite nodules: None
      • Tumor necrosis: Present
      • Venous (Large Vessel) Invasion: Absent
      • Non-tumor Liver Tissue: Cirrhotic
      • Representative parts are taken for section and labeled as: A1= tumor + margin, A2-A4= tumor, A5= non-tumor
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Hepatocellular carcinoma, mixed trabecular and pseudoglandular patterns
      • Histologic Grade: Poorly differentiated (G3)
      • Tumor Growth Pattern: Mass-forming
      • Tumor Necrosis: Present (<10%)
      • Tumor Extension: Tumor confined to hepatic parenchyma
      • Large Vessel Invasion: Not identified
      • Small Vessel Invasion: Present
      • Perineural Invasion: Not identified
      • Margins
        • Parenchymal Margin: Free, 1.6 cm from closest margin
        • Hepatic Capsule: Involved by invasive carcinoma
      • Pathologic Staging (pTNM): Stage II at least (pT2Nx)
      • Additional Pathologic Findings: Marked intratumoral neutrophils and chronic inflammatory cells infiltration
      • Hepatitis (specify type): Non-B and non-C
      • Ishak Modified HAI Grading: Score=4 (interphase hepatitis=1/4, confluent necrosis=0/6, focal necrosis=1/4, portal inflammation=2/4) (Corresponding Metavir A1, mild activity)
      • Ishak Staging: F6 (Corresponding Metavir F4, cirrhosis)
      • Fatty change: Minimal (1%)
      • IHC: CK7(+ for pseudoglandular component), CK20(-), Hepa-1(+), Arginase-1(+)
  • 2022-10-25 Bronchodilator Test
    • mild restrictive impairment; non-significant bronchodilator response
  • 2022-10-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (111 - 29) / 111 = 73.87%
      • M-mode (Teichholz) = 74
  • 2022-10-18 CT - abdomen
    • Clinical history: 83 y/o female patient with RUQ for 2 weeks, symptoms improving now, No fever. aggravated when breath?.
    • With and without contrast enhancement CT: ABD — liver, spleen, biliary duct, pancreas
      • There is liver tumor, 7cm in S4 with mild enhancement and some washout at late phase, with abdominal wall abutting, r/o atypical HCC, cholangiocarcinoma or mixed type.
      • Bilateral renal cysts, up to 4.7cm.
      • Presence of duodenal diverticulum.
      • Aneurysmal dilatation of abdominal aorta.
      • Bulging contour at left adrenal gland, r/o adrenal hyperplasia.
    • Impression:
      • Liver tumor (S4) with abdominal wall abutting, r/o atypical HCC, cholangiocarcinoma or mixed type.
      • Bilateral renal cysts.
      • Duodenal diverticulum.
      • Aneurysmal dilatation of abdominal aorta.
      • R/O left adrenal hyperplasia.
    • Post-OP:
      • Liver, S4-5, laparoscopic segmentectomy — Hepatocellular carcinoma, Pathologic Staging: pT2Nx; Stage II at least
    • Imaging Report Form for Hepatocellular Carcinoma
      • Impression (Imaging stage) : T:T1b(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)

[MedRec]

  • 2023-08-10 SOAP Radiation Oncology

    • O: RT (2023-08-09 ~): at 360cGy/2 fractions of the metastatic poorly differentiated carcinoma nodes in the hepatoduodenal ligament and partaaortic space.
  • 2023-08-02 SOAP Hemato-Oncology Xia HeXiong

    • P: Port-A and admission for CCRT with CDDP or 5-FU
  • 2023-07-27 SOAP Hemato-Oncology Gao WeiYao

    • O
      • 2023/07/20 PATHO - Liver biopsy needle/wedge
        • IHC, tumor cells reveal: CK7(-), CK20(-), Hepa-1(-) and Arginase-1(-). Neither hepatocytic nor cholangiocytic differentiation can be found.
    • P
      • Recommend to be checked with PET for searching with possible primary origin.
  • 2023-07-27 SOAP Radiation Oncology

    • O
      • Cytology (N2023-02815, 2023-07-21): EUS guide NA/B of liver: posiitve for malignancy; see description. The differential diagnoses include but not limited to cholangiocarcinoma or hepatocellular carcinoma with the former favored.
      • Pathology (S2023-14355, 2023-07-24): Lymph node, hepatoduodenal ligament, EUS-guided FNA/B — Metastatic poorly differentiated carcinoma.
    • A:
      • Hepatocellular carcinoma of the liver, stage pT2Nx (Stage II at least), s/p laparotomy S4-5 partial resection & cholecystectomy, with metastatic poorly differentiated carcinoma nodes in the hepatoduodenal ligament and partaaortic space.
    • P:
      • Radiotherapy is indicated for this patient with the following indicators: metastatic poorly differentiated carcinoma nodes in the hepatoduodenal ligament and partaaortic space.
      • Goal: palliation
      • Treatment target and volume: metastatic poorly differentiated carcinoma nodes in the hepatoduodenal ligament and partaaortic space
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the metastatic poorly differentiated carcinoma nodes in the hepatoduodenal ligament and partaaortic space.
      • The treatment planning of radiotherapy will be started at 1030, 2023-08-01.
  • 2023-07-19 ~ 2023-07-20 POMR Gastroenterology

    • Discharge diagnosis
      • Hepatocellular carcinoma, s/p partial resection and cholecystectomy in 2022/11, r/o hepatoduodenal ligment LN metastases, s/p endoscopic ultrasound biopsy on 2023/07/20
    • CC
      • For scheduled endoscopic ultrasound and fine needle biopsy for lymph nodes enlargement
    • Present illness
      • This 85 y/o female patient had the following underlying diseases,
        • Type 2 diabetes mellitus,
        • Hypertension and
        • Hepatocellular carcinoma,s/p S4/5 partial resection, PT2Nx stage II and cholecystectomy on 2022/11/21
      • She was regular followed up at our GI OPD follow-up. The 2023/06/21 CT showed several enlarged nodes in the hepatoduodenal ligament and the largest one measuring 4.5 x 3 cm in size and one enlarged node 1.4 x 0.8 cm in left para-aortic space. Metastatic nodes are highly suspected. She denied body weight loss or poor appetite or abdominal discomfort. The aFP level was not elevated (3.3).
      • Under suspicious hepatocellular carcinoma lymph node metastases, she was admitted for endoscopic ultrasound and fine needle biopsy for lymph nodes enlargement.
    • Course of inpatient treatment
      • She was admitted for EUS + biopsy for suspicious HCC lymph nodes metastases. The EUS + biopsy was performed on 7/20 and showed Multipe hypoechoic lesions with hypoechoic component noted at hilum near the pancrea; Largest one was about 35 mm.
      • Mild ascites was noted. s/p lymph node biopsy.
      • The pathology report was pending.
      • There was no obvious abdominal pain after the procedure, she then was arranged todischarge on 7/20 and GI/GS OPD follow-up.
  • 2023-07-04 SOAP Hemato-Oncology Gao WeiYao

    • S: For evaluation due to several enlarged nodes in the hepatoduodenal ligament and partaaortic space with NORMAL AFP
  • 2023-07-04 SOAP Radiation Oncology

    • S: For evaluation due to several enlarged nodes in the hepatoduodenal ligament and partaaortic space.
      • PI: Hepatocellular carcinoma of the liver, stage pT2Nx (Stage II at least), s/p laparotomy S4-5 partial resection & cholecystectomy (on 2022-11-21), with suspicious metastatic nodes in the hepatoduodenal ligament and partaaortic space.
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (quit); Betel nut (-).
      • Personal Hx: DM (+); HTN (+)
      • Allergy (+)
      • Previous RT Hx: (-)
    • O:
      • O: ECOG: 0
      • PE: neck and bil SCF: neg.
      • Operation (2022-11-21): Laparotomy S4-5 partial resection & cholecystectomy
      • Pathology (S2022-20594, 2022-11-23):
        • Liver, S4-5, laparoscopic segmentectomy — Hepatocellular carcinoma.
        • Pathologic Staging: pT2Nx; Stage II at least
      • Abd sono (2023-3-24):
        • S/P surgical resection of S4 liver.
        • S/P cholecystectomy.
        • There is a hypoechoic lesion 3.55 x 2.87 cm in the peripancreatic neck area that may be enlarged node.
        • Abdominal aortic aneurysm 3.4 x 3.7 cm (width x depth).
        • Several renal cysts on both kidneys.
        • Otherwise, no significant abnormal finding is noted.
      • CT scan of abdomen (2023-6-23):
        • There are several enlarged nodes in the hepatoduodenal ligament and the largest one measuring 4.5 x 3 cm in size. Metastatic nodes are highly suspected. The differential diagnosis includes reactive nodes and lymphoma. please correlate with clinical condition and PET scan.
      • Lab data
        • 2023/06/23 AFP = 3.3 ng/mL;
    • A:
      • Hepatocellular carcinoma of the liver, stage pT2Nx (Stage II at least), s/p laparotomy S4-5 partial resection & cholecystectomy, with suspicious metastatic nodes in the hepatoduodenal ligament and partaaortic space.
    • P:
      • Refer to medical oncology for further evaluation the nature of suspicious nodal lesions.
      • RTC: 2 weeks.
  • 2023-06-21 SOAP Cardiology

    • Prescription
      • Algitab (alginic acid, MgCO3, Al(OH)3; 200mg) 1# PRNQD
      • Eurodin (estazolam 2mg) 1# HS
      • Concor (bisoprolol 5mg) 0.5# QD
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
  • 2023-06-20 SOAP Metabolism and Endocrinology

    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertention, unspecified [I10]
      • Heart failure,unspecified [I50.9],
    • Prescription x2
      • Tulip (atorvastatin 20mg) 0.5# QD
      • Glimet (glimepiride 2mg, metformin 500mg) 0.5# QD
      • Dibose (acarbose 100mg) 1# QD
      • Trajenta (linagliptin 5mg) 1# QD

[consultation]

  • 2023-08-10 Psychosomatic Medicine
    • Q
      • Cancer inpatients with suicidal thoughts score >= 2.
    • A
      • Psychiatric impression:
        • Adjustment disorder, with depressive and anxious mood.
      • Clinical course:
        • This is a 84 y/o female who lives with her family. She was admitted today for preparing chemotherapy for hepatocellular carcinoma of the liver, stage pT2Nx (Stage II at least).
        • According to the patient, she has right upper abdominal discomfort about 2 months ago, and after a serial of examination, hepatocellular carcinoma of the liver, stage pT2Nx (Stage II at least) was impressed, and she is receiving treatment now, underwent radiotherapy and now preparing for chemotherapy. She also mentioned about stressfulness feeling and worry about her husband because he suffered from COVID infection, worrisome behaviors, and fell down in recent 1 month.
        • In recent 1 month, she has dysphoric mood, less happy feeling , decrease appetite, sometimes insomia (difficulty falling asleep, shallow sleep), intermittent death thoughs (The patient mentioned that about a month ago, when her husband was less stable, she would think about leaving and giving up. Currently, her husband’s condition has improved, and she doesn’t have those thoughts of wanting to die as much. However, she still feels distressed due to dealing with health issues like the tumor.)
        • MSE: kempt, sitting at her bedside, concious clear, frowning, worry, low mood, polite and social smile, fluent speech, appropriate tone and volume
      • Suggestion:
        • Acute intervention, supportive psychotherapy
        • Suggest Mirtazapine (30mg) 0.5# HS with Eurodin (2mg) 0.5-1# HSPRN if insomnia

[radiotherapy]

[chemotherapy]

==========

2023-08-11

[reconciliation]

A repeat prescription was issued by our cardiologist on 2023-06-21 and was refilled on 2023-08-06 for Algitab (alginic acid, MgCO3, Al(OH)3), Eurodin (estazolam), Concor (bisoprolol), and Sevikar (amlodipine 5mg, olmesartan 20mg). All of these refilled drugs, except for Algitab, have been included in the formulary. Please confirm whether Algitab is still necessary for the patient.

[FDG-PET/CT in detecting cancers with unknown primary site depends on histological subtype]

On 2023-07-20, the pathologic analysis results of the liver biopsy needle/wedge did not reveal any evidence of hepatocytic or cholangiocytic differentiation based on ICH staining. Therefore, the primary origin of the condition remains unidentified. An article titled “The usefulness of FDG-PET/CT in detecting and managing cancers with unknown primary site depends on histological subtype. Sci Rep. 2021;11(1):17732. Published 2021 Sep 6” highlighted the following key points:

  • The study evaluated the usefulness of FDG-PET/CT for detecting primary tumors and guiding treatment in 64 patients with cancers of unknown primary site (CUP).
  • PET/CT detected the primary tumor in 44% of patients overall. Detection rate was lower for squamous cell carcinoma (SCC) at 10% vs 50% for non-SCC tumors.
  • PET/CT detection did not differ by age, SUVmax, or sites of metastases between groups. However, SCC patients had fewer metastatic lesions than non-SCC.

In light of this, the use of PET could be an optional tool to help identify the origin of the biopsy liver lesion.

701081046

230811

[diagnosis] - 2023-05-02 admission note

  • Diffuse large B-cell lymphoma, stage II, IPI score: 2 s/p R-miCHOP from 2023/03/31
  • Type 2 diabetes mellitus with other specified complication
  • Chronic viral hepatitis B without delta-agent
  • Hyperlipidemia, unspecified
  • Cerebral atherosclerosis
  • Hypothyroidism, unspecified
  • Essential (primary) hypertension

[past history]

Medical history: - Hypertension under Losa & hydro control for more than ten years - Type 2 diabetes mellitus under Dibose and Trajenta contro for two months - Hypothyrodism without medical control for over three years. - Hyperlipidemia with Zulitor F.C 4mg 0.5# po QD - Cerebral atherosclerosis with Plavix F.C 75mg 1# po QD

Surgical history: - Left knee osteoarthritis status post left total knee replacement on 2016. - Gastric perforation status post Billroth II for many years.

[allergy]

  • NKDA         

[family history]

  • There is no family history of cancer, diabetes, hypertension, mental diseases or asthma.

[exam findings]

  • 2023-06-05 Nasopharyngoscopy
    • smooth nasopharynx, oropharynx and hypopharynx.
  • 2023-03-31 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2023-03-30 KUB
    • Fecal material store in the colon.
    • Spondylosis of the L-spine is noted.
  • 2023-03-29 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • The trachea shows right lateral deviation in thoracic inlet level that may be intrathoracic goiter. Please correlate with clinical condition or CT.
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-03-29 PET
    • Glucose hypermetabolism lesions in the left thyroid bed (Deauville score 5), compatible with diffuse large B-cell lymphoma.
    • Glucose hypermetabolism lesions in the left neck, SCF, and ICF lymph nodes (Deauville score 5), in the right neck and SCF, and right mediastinal lymph nodes (Deauville score 5), highly suspected lymphoma with involvement of lymph node regions on the same side of the diaphragm.
    • Increased FDG uptake in bilateral pulmonary hilar lymph nodes (Deauville score 3), probably reactive nodes.
    • Diffuse large B-cell lymphoma, stage II (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2023-03-28 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
    • Section shows piece(s) of bone marrow with 30% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
    • IHC stains: CD3: <2%; CD20: <2 %. (of the nucleated cells).
  • 2023-03-28 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (87 - 25) / 87 = 71.26%
      • M-mode (Teichholz) = 71
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Grade 1 LV diastolic dysfunction
      • Trivial MR, TR
  • 2023-03-17 Patho - thyroid total/lobe
    • PATHOLOGIC DIAGNOSIS
      • Lymph node, VI, excision — Compatible with diffuse large B-cell lymphoma with a T-cell/histiocyte rich pattern
      • Thyroid, left, subtotal thyroidectomy — Compatible with diffuse large B-cell lymphoma with a T-cell/histiocyte rich pattern and Hashimoto thyroiditis
    • MACROSCOPIC EXAMINATION
      • The specimen submitted in three parts. Part (1) consists of a piece of tan-gray and firm soft tissue, labeled LN VI, measuring 2.0 x 1.5 x 0.8 cm. All for section as: “A”. (2) a piece of tan-gray and firm soft tissue, labeled left thyroid, measuring 3.5 x 2.5 x 1.4 cm. All for section in two cassettes as: B1-B2. (3) a piece of pink-white and firm tissue, received for frozen section, measuring 1.0 x 0.9 x 0.4 cm. All for paraffin section as: F2023-00108.
    • MICROSCOPIC EXAMINATION
      • The sections of all three parts show following features:
        • Specimen: Left thyroid and lymph node VI
        • Procedure: Excision and subtotal thyroidectomy
        • Tumor site: Thyroid and lymph node
        • Histologic type: Compatible with diffuse large B-cell lymphoma with a T-cell/histiocyte rich B-cell lymphoma pattern, composed of mixed proliferation of small lymphocytes, histiocytes, and scattered large transformed atypical cells and Hodgkin/Reed-Sternberg-like cells. Focal geographic necrosis is present. The thryoid tissue also shows Hashimoto thyroiditis with fibrosis. IHC, anaplastic carcinoma is unlikely.
        • Immunophenotyping for large transformed atypical cells and Hodgkin/Reed-Sternberg-like cells: CK(-), CAM5.2(-), PAX8(-), TTF1(-), CD3(+ background small lymphoid cells), CD20(+), PAX5(few cells +), CD68(abudant background histiocytes+), CD15(-), CD30(+), Ki67= 40%
  • 2023-03-17 Frozen Section - thyroid
    • Thyroid, left, frozen section — The sections show necrosis, sclerosis, and scattered large atypical cells with inflammatory background. The finding favor lymphoma, and Hodgkin lymphoma should be considered
  • 2023-03-16 CXR
    • Cardiomegaly and tortuosity of the thoracic aorta.
    • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
    • Degenerative joint disease of T-spine with marginal osteophytes.
    • Right-side deviation of the trachea.
  • 2023-03-09 CT - chest
    • Indication: Hodgkin lymphoma of neck. Please perfrom from neck, chest to Abd/Pelvis. Thanks.
    • Chest and Abdominal CT with and without enhancement revealed:
      • Chest:
        • Huge left thyroid mass up to 5.89cm in largest dimension is found with tracheal deviation to right side is found.
        • Small lymph nodes are found at bilateral paratracheal region.
        • Calcified coronary arteries is found.
        • No evidence of bilateral pleural effusion.
        • Increased pulmonary vasculature is found.
      • Visible abdomen:
        • Dilated CBD with soft tissue nodule at distal CBD is suspected. suggest MRCP.
        • Infrarenal aortic aneurysm with mural thrombosis is found up to 2.8cm in largest dimension.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • The GB is well distended without soft tissue lesion
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Huge left thyroid mass up to 5.89cm with tracheal deviation.
      • Distal CBD nodule. Nature? Suggest MRCP
  • 2023-02-20 Patho - lymphnode biopsy
    • Lymph node, left neck, core needle biopsy — Scatter atypical large B cells, suspicious for Hodgkin lymphoma
    • Microscopically, the sections shows a picture of scatter atypical large B cells with prominent nucleoli surrounded by small lymphocytes and has background of reactive CD4(+) T cells in focal area.
    • Immunohistochemistry shows CD15(-), CD30(+), CD3(-), CD20(+, focal), Bcl-6(+, scatter), PAX-5(+, scatter), CD4(+, reactive T cell), CK(-) and TTF-1(-) for atypical lymphoid cells. According to above histopathologic findings, it is suspicious for Hodgkin lymphoma due to limited specimen. More adequate specimen is need for further evaluation.
  • 2023-02-07 CT - neck
    • Indication: left neck swelling for months
    • Pre- and post-contrast CT scans of the head and neck region from skull base to lower neck were performed on a spiral CT scanner and axial, coronal and sagittal images of a slice thickness of 3 mm were reconstructed and show:
      • A huge hypodense mass with heterogenous enhancement involving left thyroid lobe, about 94 mm x 58 mm x 59 mm, causing mass effect on surrounding structures (esophagus, trachea, great vessels and msucles) and protruding to superior mediastinum.
      • No enlarged lymph noe.
      • Calcification foci and non-enhacning artheroma along major arteries at neck, indicating artherosclerosis.
      • No abnormality at nasopharynx, oropharynx, hypopharynx and larynx.
      • Post-oepration change at both lens.
    • IMP; Left thyroid tumor (94 mm, 58 mm x 59 mm). Malignancy should be first considered until proved otherwise.
  • 2023-02-01 Nasopharyngoscopy
    • smooth NPx, oropharynx, hypopharynx
    • laryngeal edema with mild narrowed airway
  • 2022-11-02 Flow Volume Loop
    • mild restrictive impairment
  • 2022-09-23 Hearing Test
    • Tymp RE Type C, LE type A
    • ART reduced and absent
    • PTA:
      • Reliability FAIR
      • Average RE 59 dB HL, LE 65 dB HL
      • RE moderate to profound SNHL
      • LE mild to profound SNHL
  • 2022-08-26 Hearing Test
    • Reliabilty Fair
    • PTA
      • R’t : 53 dB HL
      • L’t : 60 dB HL
      • Bil moderate to severe SNHL
    • Tymp
      • R’t : Type C
      • L’t : Type A
    • ART
      • Bil absent.
  • 2022-07-29 Hearing Test
    • Reliabilty Fair
    • PTA
      • R’t : 54 dB HL
      • L’t : 61 dB HL
      • Bil moderate to severe SNHL.
  • 2022-07-05 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (73 - 16) / 73 = 78.08%
      • M-mode (Teichholz) = 78
    • Conclusion:
      • Septal hypertrophy with Gr II LV diastolic dysfunction and impaired RV relaxation; severely dilated LA.
      • Normal LV and RV systolic function.
      • Prominent mitral annulus calcification with trivial MR; mild aortic valve sclerosis.
      • Dilated proximal ascending aorta (36mm); mild aortic root calcification.
  • 2022-07-07 Neurosonology
    • Moderate to severe atheromatous lesions in right BIF with diameter reduction in 54.5%, area reduction in 48.7%.
      • Moderate atheromatous lesions in left ICA with diameter reduction in 43.6%. Mild to moderate atheromatous lesions
      • in right ICA, left BIF, left distal CCA and left mid CCA.
    • Normal PSV in bilateral ICA and CCA. Normal ICA/CCA PS ratio bilaterally
    • Adequate total VA flow (150) may suggest no evidence of VBI
  • 2022-07-01 ENT Hearing Test
    • Tymp bil type A
    • ART bil absent
    • PTA:
      • Reliability FAIR
      • Average RE 60 dB HL, LE 64 dB HL
      • bil moderate to severe SNHL
  • 2022-06-21 MRA - brain
    • The MRA study shows moderate to severe arteriosclerosis of the neck and intracranial vessels with irregular outline and mild multiple focal stenoses but without complete occlusion.
    • Imp:
      • Right frontal-temporal brain contusions.
      • Bilateral convexity SDHs
      • Brain atrophy
      • Diffuse arteriosclerosis.
  • 2022-06-20 CXR
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • mild enlarged cardiac silhoutte due to prominent pericardial fat/ prominent cardiophrenic angle mediastinal fat pad
    • Coronary arterial calcification (left anterior descending artery) indicating CAD
    • Clean lung fields based on plain image
    • Displacement of the tracheal axis to right at thoracic inlet due to enlarged thyroid gland
  • 2022-06-14 CTA - chest
    • favor small airways disease.
    • extensive 3V-CAD and thyroid goiter

[consultation]

  • 2023-03-28 General and Digestive Surgery
    • Q
      • This 88 year-old woman had history of hypertension, type 2 diabetes mellitus, and hypothyrodism under medical control for over ten years.
      • Her operation history of
        • Left knee osteoarthritis status post left total knee replacement on 2016.2
        • Gastric perforation status post Billroth II for many years.
      • According to herself and medical record, she had a mass at left neck for more than 3 years ago. She felt tumor enlarging, worsen with pain and mild shortness of breath for days. She went to LMD for help, the symptoms not improved after LMD treatment. She came ENT OPD for further evaluation. At physical examination, a huge mass over left lower neck about 5x5 cm, non-movable and non-tender. Neck sonography showd a huge mass at left thyroid with trachea deviation to right side. FNA pathology showed negative. Neck CT showed left thyroid tumor about 94 mm x 58 mm x 59 mm. Malignancy should be first considered. Sono-guide biopsy of enlarged lymph nodes and left thyroid tumor, which pathology releaed unsatisfactory-thyroid, suspicious for Hodgkin lymphoma-lymph nodes. Thus, left subtotal thyroidectomy and excision of central neck LAP was performed, and pathologic report of Lymph node at VI which was compatible with diffuse large B-cell lymphoma with a T-cell/histiocyte rich pattern.
      • We strongly nned your experise for port-A insertion for chemotherapy. Thnak you very much.
    • A
      • we will arrange op tomorrow

[MedRec]

  • 2023-04-12 SOAP Hemato-Oncology
    • Multidisciplinary Cancer Team Meeting Conclusion (2023-04-03)
      • Diffuse large B-cell lymphoma stage Ⅱ
      • IPI
      • Tx: R-miniCHOP (old age).
    • Now on R-miniCHOP, C1D1 on 2023-03-31
      • AE: Gr 3 Leukopenia
  • 2023-03-21 SOAP Hemato-Oncology
    • P: Arrange admission for BM Study, PET, Heart Echo, Port-A, then C/T
  • 2023-03-08 SOAP Metabolism & Endocrinology
    • A: Theoretically, lymphoma and a thyroid mass are two distinct issues. It’s suggested that the lymphoma be treated first, then reassess whether thyroid surgery is necessary. In the event it is a thyroid lymphoma, chemotherapy and/or radiotherapy could also potentially shrink the mass.
  • 2022-08-11 SOAP Chest Medicine
    • PHx: small airway disease, COVID, HTN
    • Diagnosis
      • Mild intermittent asthma, uncomplicated
      • Post COVID-19 condition,unspecified
      • Dizziness and giddiness
      • Essential (primary) hypertension
      • history of Hypothyroidism
  • 2022-07-01 SOAP Cardiology
    • Prescription
      • Concor (bisoprolol 5mg) 0.5# QD 28D
      • Coxine (isosorbide-5-mononitrate 20mg) 0.5# BID 28D
  • 2022-07-01 SOAP Cardiology
    • S: refer from chest OPD; systolic murumur at aortic area; CTA: 3V CAD; formerly followed up at chest OPD

[chemoimmunotherapy]

  • 2023-05-02 - rituximab 375mg/m2 540mg NS 500mL 12hr + cyclophosphamide 400mg/m2 550mg NS 250mL 30min + vincristine 1mg NS 50mL 10min + doxorubicin 25mg/m2 35mg NS 50mL 24hr + prednisolone 40mg/m2 60mg D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + acetaminophen 500mg PO + aprepitant 125mg PO D1-3
  • 2023-03-31 - rituximab 375mg/m2 540mg NS 500mL 12hr + cyclophosphamide 400mg/m2 550mg NS 250mL 30min + vincristine 1mg NS 50mL 10min + doxorubicin 25mg/m2 35mg NS 50mL 24hr + prednisolone 40mg/m2 60mg D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + acetaminophen 500mg PO + aprepitant 125mg PO D1-3

Revised Edition of Hematologic Oncology Chemotherapy Drug Prescription (in hospital regimen collection, version 2022-07-04)

  • Non-Hodgkin’s lymphoma (NHL) - First-Line for Diffuse large B-cell lymphoma - R-CHOP
    • Rituximab 375 mg/m2 IV - Several schedules, e.g. on day 1 of each cycle of CHOP chemotherapy, or given on day 3 of each cycle of therapy, or 7+3 days before cycle 1 and cycle 2 days before cycles 3, 5 and 7.
    • Cyclophosphamide 750 mg/m2 IV D1
    • Doxrubicin 50 mg/m2 IV D1
    • Vincristine 1.4 mg/m2 (max. 2mg) IV D1
    • Prednisone 60 mg/m2 PO D1-5
    • To be repeated every 3 weeks, 6-8 cycles
    • References: Br.J Cacer 1995;71:326-330

Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP21) for non-Hodgkin lymphoma 2023-06-06 https://www.uptodate.com/contents/image?imageKey=ONC%2F63586&topicKey=HEME%2F4729

  • Cycle length: 21 days.

  • Regimen

    • Rituximab
      • 375 mg/m2 IV
      • Dilute in NS or D5W to a final concentration of 1 to 4 mg/mL. Initial infusion: Start at 50 mg/hour; escalate in 50 mg/hour increments every 30 minutes to a maximum of 400 mg/hour, as tolerated. For subsequent infusions, administer 20% of the total dose over the first 30 minutes and the remaining 80% over 60 minutes, as tolerated. The 90-minute infusion schedule should NOT be used in patients who have clinically significant cardiovascular disease or have a circulating lymphocyte count ≥5000/microL.
      • Day 1
    • Cyclophosphamide
      • 750 mg/m2 IV
      • Dilute in 250 mL NS or D5W and administer over 30 minutes.
      • Day 1
    • Doxorubicin
      • 50 mg/m2 IV
      • Dilute in 50 mL NS or D5W and administer over three to five minutes.
      • Day 1
    • Vincristine
      • 1.4 mg/m2 IV (max dose 2 mg)
      • Dilute in 50 mL NS or D5W and administer over 15 to 20 minutes.
      • Day 1
    • Prednisone
      • 100 mg orally
      • Administer 30 minutes prior to chemotherapy on day 1, then every 24 hours on days 2 to 5.
      • Days 1 to 5
  • Pretreatment considerations:

    • Hydration
      • Patients receiving cyclophosphamide should maintain adequate oral hydration (2 to 3 L/day) and void frequently to reduce risk of hemorrhagic cystitis.
    • Emesis risk
      • MODERATE (30 to 90% risk of emesis).
    • Prophylaxis for infusion reactions
      • Premedicate with acetaminophen and diphenhydramine, with or without an H2 blocker, 30 minutes prior to at least the first and second infusions of rituximab.
    • Vesicant/irritant properties
      • Doxorubicin and vincristine are vesicants; avoid extravasation.
    • Infection prophylaxis
      • The risk of febrile neutropenia with this regimen is 10 to 20%; primary prophylaxis with hematopoietic growth factors should be considered on an individual basis, particularly for high-risk patients such as those with preexisting neutropenia, advanced disease, poor performance status, or patients age 65 years or older.
    • Dose adjustment for baseline liver or renal dysfunction
      • Adjustment of initial cyclophosphamide, doxorubicin, and vincristine doses may be needed for preexisting liver dysfunction. In addition, dose adjustment of cyclophosphamide may be required for renal dysfunction.
    • Hepatitis screening
      • Patients should be screened for hepatitis B and C virus prior to starting rituximab, and if positive, considered for antiviral prophylaxis.
    • Cardiac screening
      • LVEF should be evaluated prior to initiation of therapy. Dose alterations should be considered for LVEF <50%, and doxorubicin therapy is contraindicated in patients with LVEF <30% at initiation. Infusion times and schedule may be adjusted to decrease the risk of cardiotoxicity in individuals at high risk for its development.
    • Neurotoxicity
      • Vincristine may cause constipation, and in severe cases, paralytic ileus. A routine prophylactic regimen against constipation is recommended in all patients receiving vincristine.
  • Monitoring parameters:

    • CBC with differential and platelet count weekly during treatment.
    • Assess basic metabolic panel (creatinine and electrolytes) and liver function prior to each subsequent treatment cycle.
    • LVEF should be evaluated periodically based on LVEF at initiation of therapy and cumulative dose of doxorubicin.
    • Carriers of hepatitis B or C should be monitored for clinical and laboratory signs of active infection during and following completion of therapy. Rituximab should be discontinued if reactivation occurs.
  • Suggested dose modifications for toxicity:

    • Myelotoxicity
      • Treatment should be delayed until ANC is >1500/microL and platelet count is >100,000/microL. If a patient develops grade 4 (ANC <500/microL) neutropenia or febrile neutropenia with any cycle, G-CSF support is added to the regimen for subsequent cycles. If grade 4 neutropenia or febrile neutropenia occurs despite G-CSF support, or if the patient develops grade 3 (25,000 to 50,000/microL) or 4 (<25,000/microL) thrombocytopenia with any cycle, the doses of cyclophosphamide and doxorubicin should be decreased by 50% for subsequent cycles.
    • Neuropathy
      • Dose adjustment of vincristine may be necessary if the severity of neuropathy persists or worsens. No specific guidelines are available for dose adjustments.

Older patients with DLBCL generally have a worse prognosis compared to younger patients due, in part, to more comorbid conditions and lower treatment tolerance. 2023-06-06 https://www.uptodate.com/contents/initial-treatment-of-advanced-stage-diffuse-large-b-cell-lymphoma

  • For patients >80 years with adequate heart, kidney, and liver function and for patients 60 to 80 years with modest impairments, we generally treat with R-mini-CHOP to reduce adverse effects (AE) associated with more intensive regimens.
    • Pretreatment evaluation
      • For older patients, a comprehensive geriatric assessment can aid assessment of comorbid conditions and functional status and facilitate formulation of an appropriate, individualized treatment plan. Special considerations for the use of chemotherapy in older patients are discussed separately.
    • Treatment
      • Our preferred approach for older adults who are unable to tolerate standard doses of R-CHOP-21 is treatment with
        • R-mini-CHOP (rituximab 375 mg/m2, cyclophosphamide 400 mg/m2, doxorubicin 25 mg/m2, vincristine 1 mg on day 1 of each cycle, 40 mg/m2 prednisone on days 1 to 5).
      • A pre-treatment phase of a systemic steroid, with or without rituximab, may improve the patient’s performance status (PS) and facilitate treatment with R-mini-CHOP.
      • Frail patients who require symptom palliation but cannot tolerate R-mini-CHOP may benefit from a systemic steroid (with or without rituximab) or single chemotherapeutic agents.

==========

2023-08-11

Our endocrinologist wrote a repeat prescription for Zulitor (pitavastatin), Trajenta (linagliptin 5mg) and Dibose (acarbose 100mg) on 2023-08-02 and the drugs are included in the formulary with no reconciliation issue identified.

2023-06-30

On 2023-06-08, our neurologist issued a refillable prescription for Plavix (clopidogrel) and diphenidol, and on 2023-06-23, our otolaryngologist prescribed Strocain (oxethazaine polymigel), Acetal (acetaminophen), and cephalexin. Apart from diphenidol, which is no longer necessary due to the resolution of vertigo, all other validly prescribed drugs mentioned have been incorporated into the active medication list without any reconciliation issues.

2023-06-06

  • This patient visited local medical doctor on 2023-05-26, 2023-05-28, 2023-05-29, 2023-05-30, 2023-06-01, 2023-06-04 for her myositis, functional dyspepsia, acute upper respiratory infection, and prescribed acetaminophen, diazepam, loratadine and opium derivatives. for each a short 3-day valid prescription. These symptoms are generally covered in current medical problem list and managed with corresponding same or similar therapeutic class medications. No medication reconciliation issues identified.

  • Given that this patient has been diagnosed with myositis and dyspepsia that have persisted for months according to the PharmaCloud database, it’s plausible that these could be indicative of statin-induced muscle side effects. Clinical experience suggests that a change in dosing frequency, such as alternate day dosing, may improve statin tolerability in patients experiencing adverse effects such as myalgia. This strategy is particularly beneficial for patients who cannot tolerate daily statin therapy. In addition, alternate-day statin therapy is also considered a cost-effective method to improve drug utilization (Ref: Efficacy and Safety of Alternate-Day Versus Daily Dosing of Statins: a Systematic Review and Meta-Analysis. Cardiovasc Drugs Ther. 2017;31(4):419-431). Considering the information from these studies and the fact that the laboratory data indicate an improvement in the patient’s hyperlipidemia, it is recommended that the administration of Zulitor be changed from 0.5# QD to 0.5# QOD.

    • 2023-05-16 LDL-C 102 mg/dL
    • 2023-04-25 LDL-C 135 mg/dL
    • 2023-01-04 LDL-C 167 mg/dL
    • 2023-04-25 Cholesterol total 217 mg/dL
    • 2023-01-04 Cholesterol total 239 mg/dL

2023-05-03

  • Due to the patient’s advanced age, R-miniCHOP (a dose-reduced version of R-CHOP with reduced amounts of cyclophosphamide and vincristine) was selected as treatment starting on 2023-03-31. One episode of leukopenia was observed (1.56K/uL on 2023-04-12) and was alleviated with two consecutive days of Granocyte (lenograstim) administration. Please monitor for recurrence of leukopenia after this 2nd dose of R-miniCHOP.

  • Beta-2 microglobulin (b2M) is a major histocompatibility complex (MHC) class I molecule found on the surface of nearly all nucleated cells in the body. Cells with a high turnover rate, such as immune cells and cancer cells, tend to produce and express higher levels of b2M on their surface. In non-Hodgkin’s lymphoma, cancer cells may also have elevated levels of b2M. The elevated levels of b2M observed around the trough of leukopenia may indicate the destruction of cancerous B cells.

    • 2023-04-26 B2-Microglobulin 2899 ng/mL
    • 2023-04-13 B2-Microglobulin 4166 ng/mL
    • 2023-03-28 B2-Microglobulin 2946 ng/mL
    • 2023-03-08 B2-Microglobulin 2438 ng/mL
  • Lab data showed that levels above the ULN are associated with type 2 diabetes and hyperlipidemia. Dibose (acarbose), Trajenta (linagliptin) and Zulitor (pitavastatin) are currently appropriately prescribed.

    • 2023-04-25 HbA1c 7.6 %
    • 2023-04-25 Glucose(AC) 127 mg/dL
    • 2023-04-25 Cholesterol total 217 mg/dL
    • 2023-04-25 LDL-C 135 mg/dL
    • 2023-04-25 Triglyceride (TG) 172 mg/dL
  • The patient’s cerebral atherosclerosis is treated with Plavix (clopidogrel) and her hepatitis B is treated with Baraclude (entecavir) without an issue.

  • Hypothyroidism is listed as a diagnosis for the patient, but there is no corresponding medication prescribed currently. The serum free T4 level on 2023-03-17 was 0.57 ng/dL, which is slightly below the normal range. It is recommended to reevaluate the patient’s condition and consider prescribing appropriate medication, such as levothyroxine, if necessary to manage her hypothyroidism.

2023-03-27

[drug identification]

The three requested drugs have been identified as follows:

  • Sodicon: contains dextromethorphan 15mg
  • Losa & Hydro: contains losartan 50mg and hydrochlorothiazide 12.5mg
  • Acetal: contains acetaminophen 500mg

An in-hospital porter will be sent to deliver these medications to the patient’s ward.

700048952

230810

[exam findings]

  • 2019-08-16 Colon fiberscopy
    • A sessile 0.8cm polyp at proximal T-colon and biopsy removal was done. Previous rectal cancer (10cm AAV) s/p CCRT was seen.
  • 2019-07-03 CTA - pelvis
    • CT on 2018/12/21: cT3N2M1, paraaortic LN (+) potentially resectable
    • Findings Comparison: prior CT dated 2019/03/28.
      • Prior CT identified enhanceing focal wall thickening in the rectum about 1.2 cm in wall thickness is noted again, decreasing in size to 1 cm in the current CT that is c/w rectal cancer S/P C/T with partial response.
      • Prior CT identified enlarged node 0.88 cm in left common iliac chain is noted again, stable in size.
        • It is compatible with metastatic node S/P C/T with partial response.
      • There are several renal cysts on both kidney and the largest one is measured about 3.1 cm in size at the right upper pole.
      • A small hepatic cyst 4 mm in S2/3 shows stable in size.
      • A gallstone 7 mm also shows stable in size.
    • Impression:
      • Rectal cancer and metastatic node in left common iliac chain S/P C/T show partial response. please correlate with clinical condition.
  • 2019-03-28 Sigmoidfiberscopy
    • Rectal cancer at 80 cm from AV s/p CCRT with significant tumor regression
  • 2019-03-28 CT - abdomen
    • Much regression of rectal cancer. Decreased size of non-regional LNs.
    • Renal cysts (up to 2.8cm).
    • Gall stone (7mm).
  • 2018-12-26 MRI - pelvis
    • History and indication: Rectal cancer
    • With and without contrast MRI of upper abdomen revealed:
      • Wall thickening of rectum (1.6cm in thickness) with regional and non-regional LAP.
      • Renal cysts (up to 3.2cm).
    • Impression:
      • Rectal cancer with LNs metastases.
  • 2018-12-21 CT - abdomen
    • Clinical history: 59 y/o male patient with newly diagnosed rectal cancer at 8 cm from AV.
    • With and without contrast enhancement CT, ABD — Liver, Spleen, Biliary duct:
      • Thickening wall at rectum, r/o rectal malignancy.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
    • Impression:
      • Rectal cancer with perirectal involvement and lymph nodes in pelvic cavity and paraaortic region, cstage T3N2M1.
      • GB stone.
      • Renal cysts.
  • 2012-12-14 SONO - hepatobiliary
    • Sonography of hepatobiliary system revealed:
      • Increased echogenicity of the liver. A hypoechoic nodule (1.12x1.50cm) at S5 of liver.
      • Gallbladder stone (0.87cm).
      • Patency of PV, HVs, IVC and aorta in hepatic portion.
      • Normal appearance of spleen.
      • No evidence of pleural effusion.
      • Right renal cyst (2.34x2.69cm). Left renal cyst (1.08x1.17cm).
    • IMP:
      • Mild fatty liver. A hypoechoic nodule (1.12x1.50cm) at S5 of liver.
      • Gallbladder stone (0.87cm). Bil. renal cysts.
  • 2018-12-04 Surgical pathology Level IV
    • Rectum, 8 cm above anal verge, biopsy — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).

[MedRec]

  • 2023-07-10 SOAP Colorectal Surgery

  • 2020-06-16 SOAP Metabolism and Endocrinology

    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension , malignant [I10]
      • Gouty arthropathy [M10.00]
      • Mixed hyperlipidemia [E78.2]
      • Obesity, unspecified [E66.09]
      • Malignant neoplasm of rectum [C20] *
    • Prescription
      • repaglinide 1mg 2# TIDAC15
      • Blopress (candesartan 8mg) 1# QD
      • Dibose (acarbose 100mg) 1# TIDAC
      • Tresiba FlexTouch (insulin degludec) 56 unit QN SC
      • Victoza (liraglutide) 1.8mg QDAC SC
      • Zulitor (pitavastatin 4mg) 1# QN
  • 2018-12-04 SOAP Colorectal Surgery

    • S
      • A case of newly diagnosed rectal cancer at 8 cm from AV
  • 2018-11-05 SOAP Colorectal Surgery

    • S
      • The patient received physical check up and was positive for FOBT.
      • Family hx of colon cancer (-)
      • Systemic disease/ Past history: Type 2 DM since 2007, HCVD
      • Op history: back lipoma s/p op
      • FOBT(+) noted on routine health exam / colon cancer screening
      • Small caliber stool
      • Anal discomfort and bloody stool
      • Ocupation: Driver
      • Anal fresh bleeding off and on and noted again these days
  • 2017-03-06 SOAP Metabolism and Endocrinology

    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension , malignant [I10]
      • Gouty arthropathy [M10.00]
      • Mixed hyperlipidemia [E78.2]
      • Obesity, unspecified [E66.09]
    • Prescription
      • Levemir FlexPen (insulin detemir) 24 unit HS SC
      • Victoza (liraglutide) 1.8mg QDAC SC
      • NovoNorm (repaglinide 1mg) 2# TIDAC
      • Preterax (perindopril 2mg, indapamide 0.625mg) 1# BIDAC
      • Uformin (metformin 500mg) 1# TIDCC

[chemotherapy]

  • 2020-05-20 - irinotecan 150mg/m2 270mg D5W 100mL 2hr
    • dexamethasone 6mg + granisetron 3mg + NS 500mL + atropine 0.3mg
  • 2020-05-06 - oxaliplatin 85mg/m2 150mg D5W 150mL 2hr
    • dexamethasone 6mg + granisetron 3mg + NS 250mL
  • 2020-04-17 - oxaliplatin 85mg/m2 150mg D5W 150mL 2hr
    • dexamethasone 6mg + granisetron 3mg + NS 250mL

==========

2023-08-10

On 2023-08-01, this patient obtained a 28-day supply of metformin, repaglinide, bisoprolol, olmesartan, and pitavastatin from Cheng Hsin General Hospital. It is noted that GLP-1 agonist (such as semaglutide) and HMG-CoA reductase inhibitor (like pitavastatin) are not currently listed in the active medication profile. It is advisable to closely observe the patient’s blood lipid and blood sugar levels to determine whether these medications or similar drugs within the same therapeutic class are necessary for his ongoing treatment.

701177392

230810

[lab data]

2023-08-10 Anti-β2-glycoprotein-I Ab 0.6 U/mL
2023-08-10 Anti-cardiolopin IgG 0.7 GPL-U/mL
2023-08-10 Anti-cardiolipin IgM 1.3 MPL-U/mL

2023-08-08 CEA (NM) 89.031 ng/ml

2023-08-07 HBsAg Nonreactive
2023-08-07 HBsAg (Value) 0.36 S/CO
2023-08-07 Anti-HBc Reactive
2023-08-07 Anti-HBc-Value 6.47 S/CO
2023-08-07 Anti-HCV Nonreactive
2023-08-07 Anti-HCV Value 0.09 S/CO

2023-08-07 CEA 96.78 ng/mL
2023-08-07 CA199 29.24 U/mL

2023-08-07 D-dimer > 10000.00 ng/mL(FEU)
2023-08-07 PT 11.1 sec
2023-08-07 INR 1.08
2023-08-07 APTT 25.7 sec
2023-08-07 Fibrinogen(quantita) 364.4 mg/dL

2023-08-04 Alkaline phosphatase 931 U/L

[exam findings]

  • 2023-08-09 T- and L-spine AP + Lat.
    • Osteolytic lesion in L3 and L4 vertebral body is noted that may be bony metastasis. Please correlate with CT.
  • 2023-08-09 Pelvis & Bilat. Hip Lat
    • An ill-defined osteopenic defect in right ilium is highly suspected.
  • 2023-08-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (81 - 26) / 81 = 67.90%
      • M-mode (Teichholz) = 68
    • Conclusion:
      • Normal LV filling pressure; impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis; trivial tricuspid regurgitation.
      • Possible mild pulmonary hypertension (the estimated systolic PA pressure 43 mmHg).
  • 2023-08-09 Venous Ultrasound
    • Doppler study: (N = Normal, A = Abnormal, T = Thrombus)
    • Spontaneous signal:
      • Right:
        • CFV: N
        • SFV: N
        • PV: T
        • PTV: N
        • SV: N
      • Left:
        • CFV: N
        • SFV: N
        • PV: T
        • PTV: N
        • SV: N
    • Respiratory changes:
      • Right:
        • CFV: N
        • SFV: N
        • PV: T
        • PTV: N
        • SV: N
      • Left:
        • CFV: N
        • SFV: N
        • PV: T
        • PTV: N
        • SV: N
    • Cough response:
      • Right:
        • CFV: N
        • SFV: N
        • PV: T
        • PTV: N
        • SV: N
      • Left:
        • CFV: N
        • SFV: N
        • PV: T
        • PTV: N
        • SV: N
    • Compression study:
      • Right:
        • CFV: N
        • SFV: N
        • PV: T
        • PTV: N
        • SV: N
      • Left:
        • CFV: N
        • SFV: N
        • PV: T
        • PTV: N
        • SV: N
    • Report: Thrombus at R’t, L’t PV
      • Varicose vein : None
      • Right side:
        • SVC: 13.9 mmHg ; 15.5 mmHg ;
        • MVO/SVC: 85 % ; 79 % ;
        • Average MVO/SVC: 82.00 %
      • Left side:
        • SVC: 12.3 mmHg ; 17.0 mmHg ;
        • MVO/SVC: 92 % ; 76 % ;
        • Average MVO/SVC: 84.00 %
    • Conclusion:
      • Subacute DVT, thrombus involved both popliteal vein with total occlusion
  • 2023-08-08 Tc-99m MDP bone scan
    • The scintigraphic findings suggest multiple bone metastases.
  • 2023-08-08 Patho - lymphnode biopsy
    • Lymph node, axillary, right, sono-guided biopsy — Metastatic adenocarcinoma, lung origin
    • The sections show a picture of metastatic pulmonary adenocarcinoma, poorly differentiated, composed of lymphoid tissue with nests, cords, and signle large polygonal neoplastic cells with abundant eosiophilic cytoplasm, arranged in solid, papillary and subtle acinar patterns.
    • IHC - the tumor cells show: TTF1(+), GATA3(-), and PAX8(-).
  • 2023-08-05 CT - chest
    • MRI at Cardinal Catholic: suspected tumors over spine with elevated alkaline phosphatase and CEA. Significant weight loss was noted.
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lymphadenopathy at right axillary, both sides of the mediastinum and
        • Cystic lesion at right upper lobe measuring 1.98cm in largest dimension. Cystic lung cancer is highly suspected.
        • Right and left pulmonary embolism is found. Suggest urgent treatment.
        • No evidence of bilateral pleural effusion.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • No evidence of abnormal soft tissue mass at pelvic cavity.
        • No definite inguinal or pelvic sidewall LAP
        • Non-specific bowel gas at abdominal cavity is found.
    • Imp:
      • Right upper lobe cystic tumor. 1.98cm, r/o cystic lung cancer with bone meta, right axillary and mediastinal lymphadenopathy.
      • Bilateral pulmonary embolism. Suggest further, urgent treatment.
    • Imaging Report Form for Lung Carcinom
      • Impression (Imaging stage): T:T1(T_value) N:N3(N_value) M:M1(M_value) STAGE:____(Stage_value)

[MedRec]

  • 2023-08-04 SOAP Hemato-Oncology Gao WeiYao
    • S: She experienced back pain since this March 2023 and she visited Cardinal Catholic hospital ortho and later she was transferred hematologic oncologic divsion at the same hospital.
    • A: BW 59, significant weight loss 11 kg within one month
      • MRI from other hospital revealed suspected spine tumor which might be related to her back pain.

700329331

230809

[lab data]

2023-07-26 Anti-HBc Reactive
2023-07-26 Anti-HBc-Value 6.35 S/CO
2023-07-26 Anti-HBs 7.41 mIU/mL
2023-07-26 Anti-HCV Nonreactive
2023-07-26 Anti-HCV Value 0.23 S/CO
2023-07-26 HBsAg Nonreactive
2023-07-26 HBsAg (Value) 0.26 S/CO

[exam findings]

  • 2023-08-04 MRI - pelvis
    • CC: Bloody stools for 2-3 months. BW loss 6-7 Kg/half year
      • 20230705 colonoscopy: One hemi-circular tumor with ulceration and friability was noted at 10cm AAV, and the scope was unable to pass the lumen. Biopsy was done. pathology: adenocarcinoma.
      • 20230718 CT: rectal cancer with suspicious uterus invasion
    • Indication: Rectal cancer, MRI to R/O uterus invasion.
    • Findings:
      • There is segmental circumferential wall thickening at the upper rectum, measuring 5.5 cm in size, with suggestive intussusception from the sigmoid colon invagination into the rectum that is c/w Adenocarcinoma (T3).
        • In addition, the fat plane between the rectal cancer and uterine cervix area is still clear.
        • Rectal cancer with uterine cervix invasion is less likely.
      • There are seven enlarged nodes in the perirectal space and sigmoid mesocolon that are c/w metastatic nodes (N2b).
      • There are few cystic lesions in the uterine cervix area, the largest one 1 cm, that are c/w Nabothian cysts.
      • There are two hypodense nodule 1.4 cm and 0.7 cm in the uterine myometrium on T2WI that are c/w myoma.
      • There is no cystic lesion in left adnexa.
    • IMP:
      • Rectal cancer is noted.
      • According to American Joint Committee on Cancer (AJCC) staging system,8th edition for colon cancer: T3 N2b M0, stage: IIIC
  • 2023-07-18 CT - abdomen
    • With and without contrast enhancement CT of abdomen–whole:
      • Thickening wall at rectosigmoid colon, r/o colon malignancy.
      • Presence of pericolonic lymph nodes, r/o lymph nodes metastasis.
      • Cystic lesion, 1.5cm in left adnexa, r/o left ovarian cyst.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2a(N_value) M:M0(M_value) STAGE: IIIB_(Stage_value)
    • Impression:
      • Rectosigmoid cancer with regional lymph nodes, cstage T3N2M0.
      • R/O left ovarian cyst.
  • 2023-07-06 Patho - colon biopsy
    • Colorectum, rectum 10 cm above anal verge, biopsy — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).

[MedRec]

  • 2023-07-25 SOAP Radiation Oncology
    • RT planning: 5040cGy/28 fx (pre-operative) to rectosigmoid cancer and LAPs. CT simulation on 8/01 13:30. Possible GI/GU toxicity and menopause are told to her and her husband. Diet education (BW loss 6-7 kg in half yr).
  • 2023-07-25 SOAP Hemato-Oncology
    • P
      • Simulation on 2023-08-01
      • Admission for 5-FU/LV
  • 2023-07-22 SOAP Colorectal Surgery
    • S
      • A case of newly diagnosed rectal cancer
      • Poor appetite
      • BWloss 6-7 Kg in half year
    • A/P
      • Suggest TNT then OP
  • 2023-07-17 SOAP Gastroenterology
    • O: 2023/07/06 PATHO-Colon biopsy - Colorectum, rectum 10 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1
  • 2017-03-02 SOAP Cardiology
    • Diagnosis
      • Pure hypercholesterolemia [E78.0]
      • Essential (primary) hypertension [I10]
    • Prescription
      • Hyzaar (losartan 100mg, hydrochlorothiazide 12.5mg) 0.5# QD
      • Norvasc (amlodipine 5mg) 1# QD
      • Tulip (atorvastatin 20mg) 0.5# QD

701101946

230809

[lab data]

2023-07-22 Anti-HBc Reactive
2023-07-22 Anti-HBc-Value 4.23 S/CO
2023-07-22 Anti-HCV Nonreactive
2023-07-22 Anti-HCV Value 0.13 S/CO
2023-07-22 Anti-HBs 5.84 mIU/mL
2023-07-22 HBsAg Nonreactive
2023-07-22 HBsAg (Value) 0.49 S/CO

[exam findings]

  • 2023-08-07 CXR
    • RUL lobar consolidation with occuded lobar bronchus and involving the hilum
    • there is pulmonary fibrosis at lower lung and LUL
    • moderate enlarged cardiac silhoutte due prominent cardiophrenic angle mediastinal fat pad / supine position
    • Port-A catheter inserted into RA via left subclavian vein.
  • 2023-07-28 PET
    • Glucose hypermetabolism in a focal area in the upper lobe of right lung with invasion to the right pulmonary hilar region and adjacent right aspect of the mediastinumm, compatible with metastatic neuroendocrine carcinoma involving these regions.
    • Mild glucose hypermetabolism in the left shoulder. Inflammatory process may show this picture.
    • Mild glucose hypermetabolism in some focal areas in the mandible. Dental problem is more likely.
    • Increased FDG accumulation in the colon, both kidneys and bilateral ureter. Physiological FDG accumulation may show this picture. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2023-07-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (103 - 42.2) / 103 = 59.03%
      • M-mode(Teichholz) = 59
    • Conclusion:
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • AV sclerosis with mild AR, mild MR, TR and PR
      • No regional wall motion abnormalities
      • One nodule lesion with diamter about 1.27x1.1 cm at RA cavity
  • 2023-07-27 BronchoDilator Test
    • Diagnosis: Lung cancer
    • Conclusion: POOR PERFORMANCE
      • mild obstructive ventilatory impairment without significant reversibility, combine restrictive
  • 2023-07-26 24hr ECG
    • Baseline was sinus rhythm
    • A few isolated VPCs / VPC couplet
    • A few isolated APCs / APC couplets (with some blocked APC)
    • 9 episodes of short-run At, max 4 beats
    • No long pause
  • 2023-07-26 Tc-99m MDP bone scan
    • Two hot spots at the lower T- and upper L-spine, the nature is to be determined (severe DJD, post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, mandible, some upper T-spine, sacrum, right sternoclavicular junction, bilateral shoulders, left elbow, S-I joints, hips, and left knee.
  • 2023-07-26 Neurosonology
    • Mild (to moderate) atheromatous lesions in R middle to distal CCA and L ICA; mild atheromatous lesions in L middle CCA to CCA bifurcation, R CCA bifurcation and R ICA
    • Smaller caliber with decreased flow in R cervical VA, possible R VA hypoplasia.
    • Normal extracranial carotid and L vertebral arterial flows.
  • 2023-07-25 MRI - brain
    • Multifocal areas of acute ischemic cortical infarct over both frontal, parietal & occipital lobes and left temporal lobe. Also multiple embolic infarcts over both corona radiata.
    • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
    • No evidence of brain metastasis.
  • 2023-07-24 Patho - pleural/pericardial biopsy
    • Lung, right, CT-guide biopsy — metastatic neuroendocrine carcinoma
    • Sections show nests of pleomorphic tumor cells infiltrating in a fibrotic stroma with focal tumor necrosis.
    • The immunohistochemical stains reveal CK7(focal +) , CK20(-), Synaptophysin(focal +), TTF-1(-), Napsin A(-), and p40(-). The results are consistent with metastatic neuroendocrine carcinoma.
  • 2021-07-16 CT - abdomen
    • S/P total gastrectomy and partial resection of S7 of the liver. There is no evidence of tumor recurrence.
  • 2017-11-01 Surgical pathology level VI
    • PATHOLOGIC DIAGNOSIS
      • Stomach, cardia, radical total gastrectomy with frozen section for margin (S2017-17868) —- Neuroendocrine carcinoma, grade 3.
        • IHC stains: synaptophysin (+), chromogranin A (-), NSE (-), S-100 protein (-), CD56 (-), Ki-67: 80%. (on S17-17911A4)
      • Margin: free
      • Lymph node, LN1-2-3, LN4, LN5-6, LN7-8-9, LN 10-11, LN12, D2 dissection — Metastatic neuroendocrine carcinoma (2/27 = serosal surface LN: (1/2), LN 1-2-3: (1/9), LN4: (0/1), LN5-6: (0/1), LN 7-8-9: (0/11), LN 10-11: (0/2), LN12: (0/1).
      • Pathology stage: pT3N1 (cMx); pStage: IIB.
        • IHC stain: (S17-17753 biopsy specimen): Her2/neu: (-).
    • MACROSCOPIC EXAMINATION
      • Specimen type: radical total gastrectomy with frozen section for margin
      • Specimen size: Greater curvature: 20 cm, Lesser curvature: 15 cm
      • Number of lesions: 1
      • Tumor site: cardial region, greater curvature side
      • Tumor size: 6 x 6 cm.
      • Tumor configuration: For advanced cancer (Borrmann’s classification)
        • Type III ulcerated and infiltrating.
      • Tissue for sections: S2017-17898FS: Esophageal end margin; S2017-17911A1: distal margin; A2-5: tumor with serosal surface; B: omentum; C1-3: LN1-2-3, D: LN4, E1-2: LN5-6, F1-2: LN7-8-9, G1-2: LN 10-11, H: LN12.
    • MICROSCOPIC EXAMINATION
      • Histologic type: Neuroendocrine carcinoma
      • Histologic grade: Grade 3
      • Depth of tumor invasion: serosal adipose tissue.
      • Lymph node
        • Lymph node as designated NO. positive / NO. total
        • 2/27 = serosal surface LN: (1/2), LN 1-2-3: (1/9), LN4: (0/1), LN5-6: (0/1), LN 7-8-9: (0/11), LN 10-11: (0/2), LN12: (0/1).
      • Pathology Staging: pT3N1 (cMx); pStage: IIB.
        • Tumor invasion: T3 Tumor penetrates subserosal connective tissue without invasion of visceral
        • Lymph node status: N1 Metastasis in 1 to 2 regional lymph nodes
      • Margins
        • Proximal Margin: Free, 5 mm from the margin
        • Distal Margin: Free, 9.5 cm from the margin
        • Circumferential (Adventitial) Margin: Free, 0.2 cm from the margin
      • Additional pathologic findings:
        • Mitotic count: 10 mitoses/10HPFs. Ki-67: 80%.
        • IHC stains: synaptophysin (+), chromogranin A (-), NSE (-), S-100 protein (-), CD56 (-), (on S17-17911A4)
  • 2017-10-30 Surgical pathology level IV
    • Stomach, fundus, biopsy — Adenocarcinoma.
    • Section shows fragments of gastric tissue infiltrated by irregular glands.
    • IHC stain of cytokeratin (CK) highlights irregular neoplastic glands. Her2/neu: (-).

[MedRec]

  • 2023-07-21 SOAP Gastroenterology Zhao YouCheng
    • Diagnosis: Gastric cacner [C16.9]
    • Prescription x3
      • Nexium (esomeprazole 40mg) 1# QN
      • B-Red (hydroxocobalamin 1mg) 1# ST IM
      • Foliromin (ferrous sodium citrate 50mg) 1# QD
      • Allegra (fexofenadine 60mg) 1# QN
      • Stogamet (cimetidine 300mg) 1# QN
  • 2018-08-30 SOAP Rheumatology
    • Diagnosis
      • Gouty arthropathy [M10.00]
      • Malignant neoplasm of stomach, unspecified [C16.9]
    • Prescription x2
      • Feburic (febuxostat 80mg) 1# QD
      • Paran (acetaminophen 500mg) 1# PRNBID
      • Compesolon (prednisolone 5mg) 1# PRNBID
      • colchichine 0.5mg 1# QD
  • 2017-12-18 SOAP Rheumatology
    • Diagnosis
      • Gouty arthropathy [M10.00]
      • Malignant neoplasm of stomach, unspecified [C16.9]
    • Prescription x2
      • Mopik (meloxicam 7.5mg) 1# PRNQD
      • Euricon (benzbromarone 50mg) 1# QD
  • 2017-11-20 SOAP Hemato-Oncology Gao WeiYao
    • Diagnosis
      • Malignant neoplasm of stomach, unspecified [C16.9]
      • Drug-induced gout, right ankle and foot [M10.271]
      • Iron deficiency anemia, unspecified [D50.9]
      • Acute nasopharyngitis [common cold] [J00]
    • Prescription
      • Foliromin (sodium ferrous citrate 50mg) 1# BID
  • 2017-10-27 SOAP Gastroenterology Zhao YouCheng
    • Diagnosis: Gastric cacner [C16.9]

[consultation]

  • 2023-08-04 Hemato-Oncology
    • A
      • This 79 year old man is a case of Gastric cancer, neuroendocrine carcinoma, grade 3, pT3N1 cM0 s/p radical total gastrectomy on 2017/10/31 with liver metastasis s/p S7 segmental hepatectomy on 2018/4/12 s/p C/T with EP, shift to carboplatin plus irinotecan regimen since 2018/05/14 with RUL metastasis; ECOG = 2. We are consulted for further treatment.
      • We will take over this case. Please book 11A (fisrt) or 10B. Thanks for your consultation.
  • 2023-07-31 Radiation Oncology
    • A
      • Diagnosis: Gastric cancer, neuroendocrine carcinoma, grade 3, pT3N1 cM0 s/p radical total gastrectomy on 2017/10/31 with liver metastasis s/p S7 segmental hepatectomy on 2018/4/12 s/p C/T with EP, shift to carboplatin plus irinotecan regimen since 2018/05/14 with RUL metastasis; ECOG =2.
      • Plan: Palliative RT to RUL tumor for 4900cGy/14 fx is suggested for tumor control. CT simulation is arranged on July 31 15:30. Possible toxicity is told; diet education is given. Treatment will be started 2-3 days later.
  • 2023-07-26 Neurology
    • Q
      • For brain MRI showed Multifocal areas of acute ischemic cortical infarct over both frontal, parietal & occipital lobes and left temporal lobe. Also multiple embolic infarcts over both corona radiata.
      • This is 79 years-old male has had history of gouty. And he was diagnosed with gastric neuroendocrine carcinoma s/p radical total gastrectomy on 2017/10/31. The surgery pathology reports Neuroendocrine carcinoma, grade 3, pT3N1(2/27)(cMx); pStage: IIB, Free Margin, 9.5cm, KI-67: 80%.
      • This time, Cough for days, Fall down on 2023-07-16. COVID-19 virus infection on 2023-07-17. Had a CT scan done in Kinmen, suspected lung cancer, further examination recommended (case details available in the cloud). Poor appetite and Body weight loss (don’t remember how many kilograms) were noted. He came to our GI OPD refer to CM OPD, CXR and CT showed right upper lung collapse and tumor obstruction.
      • Admission from ER. At ER, Vital sign: TPR: 36.3/63/18, BP: 119/56mmHg, Conscious clear, GCS: E4V5M6, SpO2: 97%, Laboratory: Covid-19 PCR: Not Detected, No leukocytosis. D-dimer: 838.28 ng/mL(FEU).
      • Under the impression of right upper lung collapse and tumor obstruction, suspect lung cancer, he was admitted for lung cancer survey.
    • A
      • According to the patient and his wife’s statement, he denied focal weakness, slurred speech, easy choking, blurred vision or other symptoms except generalized weakness.
      • NE E4V5M6 relatively cachexia
        • CNs: intact
        • MP symmetric and weak MP 3
        • sensation: intact for touch
        • FNF/HNS: no dysmetria
      • brain MRI on 7/25: Multifocal areas of acute ischemic cortical infarct over both frontal, parietal & occipital lobes and left temporal lobe. Also multiple embolic infarcts over both corona radiata.
      • impression: embolic stroke, suspect cardiogenic etiology, r/o Trousseau syndrome
      • suggestion:
        • please do heart echography, 24H holter EKG and CPA/TCD for embolic stroke survey; be cautious of infectious endocarditis
        • use DOAC if no contraindication and Af or Trousseau syndrome was confirmed
        • neurology OPD follow-up after discharge if indicated.
      • Contact me if any questions and thank you for consultation.

[surgical operation]

  • 2018-04-12
    • Diagnosis: Gastric neuroendocrine tumor, pstage IIB with liver metastasis, S7
    • PCS code: 75003B
    • Finding
      • A 2.5x1.5 cm tumor over S7 noted from intra-op Sono. No daughter nodule. no vein thrombosis.
      • Two nodules over R`t abdominal wall peritoneum and biopsy was done.
      • Severe peritoneal adhesion due to previous total gastrectomy & D2 LN dissection. We lysis all of them with electrocautery.
  • 2017-10-31
    • Diagnosis: Gastric cardial Ca, cT2N0M0
    • PCS code: 72032A
    • Finding
      • 7x7 cm gatric tumor over gastric cardial region, greater curvature side with suspect serosal invasion
      • Preigastric lymph nodes (area 3, 7, 8, 9, 10, 11, & 12) enlargement were noted and D2 lymph node dissection was done.
      • Proximal cutting end about 2 cm and frozen section was free
      • Blood loss about 300 ml

==========

2023-08-09

[prophylactic antiviral therapy prior to immunosuppressive agent use]

The patient’s hepatitis B serology results indicate that he is immune due to natural infection, with negative HBsAg, positive anti-HBc, and positive anti-HBs. However, he remains vulnerable to reactivation if exposed to immunosuppressive agents.

Given this situation, if the treatment plan involves immunosuppressive agents, it is advisable to consider prophylactic antiviral therapy. Possible options include prescribing either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD. This preventive approach can effectively lower the risk of potential HBV reactivation induced by the immunosuppressive effects of the treatment.

ref: Pharmacy FAQ - Hepatitis B reactivation and screening. http://www.bccancer.bc.ca/pharmacy-site/Documents/Pharmacy%20FAQs/Pharmacy-FAQ-Hepatitis-B.pdf

701016342

230808

[MedRec]

  • 2023-08-07 DutyNote
    • Problem List
      • left breast invasive ductal carcinoma cT2N1 stage IIB at least
      • left multiple rib fructure and hemothorax status oist left video-assisted thoracoscopic surgery evacuation of hematoma on 112/7/3
      • acute to subacute multiple embolic storke over bilateral frontal parietal, temproal and left occipital lobe suspect related to tumor embolic.
      • type 2 diabetes mellitus
      • hypertension
    • Course of treatment
      • This 71-year-old female, a patient had history of hypertension & stroke of left pontine/right caudate infracts in 2013. This time, fall down was noted for 1-2 weeks and visited to WanFang hospital for evaluation and CXR showed rib fructure. Owing to sudden onest of dyspnea and chest discoomfort was developed and came to WanFang hospital ER again and left multiple rib fructure and hemothorax status oist left video-assisted thoracoscopic surgery evacuation of hematoma on 2023/07/03. suspected aphasia was noted on 2023/07/08 and brain CT showed acute to subacute multiple embolic storke over bilateral frontal parietal, temproal and left occipital lobe suspect related to tumor embolic. Elevated CEA &CA-199 level was noted during storke survey thrtrgore vaginal ultrasound was done and no specific finding was noted.
      • Breast sono revealed highly suspected breast cancer at left 2.5 with left axillary lymphadenopathy. Breast biopsy proved microscopically incasive ductal carcinoma with ER (+) , PgR(+) , Her2: negative (1+) and Ki-67 with 5-10%positive nuclei. Owing to disease progression noted and for further treatment by her family and she was transferred to our hospital on 2023/08/07.
  • 2023-11-20 ~ 2013-11-29 Discharge Note
    • CC
      • Right limbs weakness for about 2 days
    • Present illness
      • This 63 y/o female patient is a case of right OA knee and patella fracture s/p op. Before this episode, she could walk with a regular cane but with right leg weakness. This time, she seemed to suffer from right side limbs weakness for about 2 days. She became unable to walk this morning and was brought to our ER for help. Neurological examination revealed right central facial palsy, mild dysarthria and right muscle power UE = 4+; LE = 4+. Brain CT was performed and no ICH. Under the impression of left hemisphere ischemic stroke, she was advised to admission for further evaluate and management.
    • Course of inpatient treatment
      • After admission, adequated hydration and antiplatlet were given. TCD/CCD was done and showed minimal atherosclerosis in bilateral CCA and right BIF; mild atheromatous lesions in left proximal CCA. Brain MRA was done and revealed an acute infarct in left pons. An old infarct in right caudate nuscleus. Cardiac echo was done and showed mild MR and TR; trivial AR. Rehab. dept was consulted and rehab. program was started smoothly. General skin itching but no rash was found, so we check autoimmune profile and showed normal. So CTM and sinbaby was given. Bilateral leg pain was controlled by Scanol. Under stable condition, she was discharged and OPD follow up was arranged.

==========

2023-08-08

Concor (bisoprolol) and Nexium (esomeprazole) should be prepared by the simple suspension method before tube feeding.

The simple suspension method refers to the process of placing tablets and capsules in warm water for a period of time and gently shaking them to promote disintegration and suspension of the medication, rather than grinding them into powder for tube feeding.

701280715

230807

{rectal cancer with LNs, lung, sacrum, sacroiliac joints mets, stage IV}

[lab data]

2023-07-19 HBsAg (NM) Negative
2023-07-19 HBsAg Value (NM) 0.420
2023-07-19 Anti-HBs (NM) Negative
2023-07-19 Anti-HBs value (NM) <2.000 mIU/mL
2023-07-19 Anti-HBc (NM) Negative
2023-07-19 Anti-HBc Value (NM) 2.190

2021-06-02 KRAS 12/13 Sample No S2021-6919
2021-06-02 KRAS 12/13 mutation detected
2021-06-02 NRAS/KRAS Sample No S2021-6919
2021-06-02 NRAS/KRAS mutation Not detected

2021-05-14 HBsAg Nonreactive
2021-05-14 HBsAg (Value) 0.34 S/CO
2021-05-14 Anti-HBc Nonreactive
2021-05-14 Anti-HBc-Value 0.44 S/CO
2021-05-14 Anti-HCV Nonreactive
2021-05-14 Anti-HCV Value 0.06 S/CO

[exam finding]

  • 2023-07-19 CT - chest
    • Impression: rectal cancer with lung metastases, sligthly in regression as compared with CT on 2023/2/7
  • 2023-06-21 MRI - L-spine
    • Indication: Pain over sacral region and bil SI joint area for 2 yrs
    • Without- and with-contrast MRI of lumbar spine, including sagittal T2W FSE, sagittal T1W, coronal STIR, axial T2W and axial T1W images (3 mm thickness for sagittal images and 4 mm thickness for the others) reveals:
      • Wedge-shaped deformity, fracture lines, T1-hypointensity, mottled T2-hyperintensity and heterogeneous enhancement involving L4 vertebral body, associating with left paraspinal soft tissue mass (mainly T1-hypointensity, mild T2-hyperintensity and faint peripheral enhancement). D/D: compression fracture with spondylitis and left paraspinal abscess, metastases (less likely).
      • Mild general bulging disc at L1-2-3-4-5-S1.
      • No intramedullary lesion.
    • IMP: L4 vertebral body facture with left paraspinal lesion. D/D: compression fracture with spondylitis/left paraspinal abscess; metastases (less likely).
  • 2023-06-13 L-spine AP + Lat. (including sacrum)
    • Compression fracture of L4 vertebral body.
    • S/P metalic stent in the rectum.
  • 2023-05-15 CT - abdomen
    • Imp:
      • Rectal cancer s/p stent placement. Stable in the local region.
      • Lymphadenopathy at right pelvic side wall. Stationary.
      • Bilateral lung meta. In regression.
      • Compression fracture. L4.
  • 2023-02-07 CT - chest
    • Impression: rectal cancer with pelvic LNs metastasis and lung metastases, in progression as compared with CT on 2022/12/07
  • 2022-12-07 CT - chest
    • Impression: rectal cancer with pelvic LNs metastasis and stationary of lung metastases as compared with CT on 2022/08/30
  • 2022-11-28 Tc-99m MDP bone scan
    • Increased activity at bilaterl S-I joints comes to more evident and some new lesions of increased activity in some T-spine are noted compred with the previous study on 2022-04-28; the nature is to be determined (severe DJD, bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
    • Suspected benign lesions in bilateral rib cages, some L-spine, bilateral sternoclavicular junctions, shoulders, and hips.
  • 2022-10-05 CT - abdomen
    • Impression:
      • Rectal cancer with bowel obstruction.
      • Lymph nodes metastasis and multiple lung metastasis.
  • 2022-10-05 Sigmoidoscopy
    • Findings:
      • Colonoscopy and Seld-expandable metalic stent (SEMS. 12cm, uncovered stent) was inserted smoothly
      • Stool passage was noted immediately after stent placement
    • Diagnosis:
      • Rectal cancer obstruction s/p SEMS
    • Suggestion:
      • Elective colectomy
    • Complication:
      • No immediate complication
  • 2022-08-30 CT - chest
    • Impression: rectal cancer with progressive lung metastases compared with CT on 2022/05/28
  • 2022-07-10 CXR
    • There are few nodular opacity projecting in both lung that are c/w metastases.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2022-05-28 CT - abdomen, pelvis
    • Findings
      • Mild progression of rectal cancer with LNs and lung metastases.
      • Right renal cyst (1.4cm).
    • IMP:
      • Mild progression of rectal cancer with LNs and lung metastases.
  • 2022-04-28 Tc-99m MDP whole body bone scan
    • Mildly increased activity in some L-spines. Degenerative change may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Probably benign joint lesions in bilateral sternoclavicular junctions, shoulders, hips, and knees.
  • 2022-03-08 Chest PA erect view
    • There are few nodular opacity projecting in both lung that are c/w metastases.
  • 2022-02-21 CT - abdomen, pelvis
    • Mild progression of rectal cancer with LNs and lung metastases.
  • 2021-12-21 Chest PA erect view
    • There are few nodular opacity projecting in both lung that are c/w metastases.
  • 2021-11-18 CT - abdomen, pelvis
    • Mild regression of rectal cancer with LNs and lung metastases.
  • 2021-08-10 CT - abdomen, pelvis
    • Rectal malignancy with lymph nodes and lung metastasis, regression.
  • 2021-05-06 Chest PA eract view
    • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
  • 2021-05-05 Tc-99m MDP whole body bone scan
    • Markedly increased tracer uptake in the sacrum and bilateral S-I joints, the nature is to be determined, suggesting further investigation and follow-up with bone scan in 3 months for further evaluation.
    • Probably benign lesions in both rib cages, bilateral sternoclavicular junctions, shoulders, hips, and knees.
  • 2021-05-03 Patho - colon biopsy
    • Rectum, 5 cm above anal verge, biopsy — Adenocarcinoma.
    • IHC: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • 2021-05-03 CT - abdomen, pelvis
    • Impression (Imaging stage): T4aN2bM1a, stage IVA
  • 2021-05-03 Chest PA erect view
    • Multiple nodules at bil. lungs.
  • 2021-05-03 Colonoscopy
    • Diagnosis: Rectal ulcerative lesion, s/p biopsy, suspected malignancy.
    • Suggestion: F/U pathology report; suggest admission for more evaluation and management.

[MedRec]

  • 2023-06-30 SOAP Neurology
    • Prescription
      • Arcoxia (etoricoxib 60mg) 1# PRNQD
      • Neurontin (gabapentin 100mg) 1# PRNBID

[chemoimmunotherapy]

  • 2023-08-07 - irinotecan 180mg/m2 175mg D5W 250mL 90min + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2800mg/m2 4535mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-07-24 - irinotecan 180mg/m2 175mg D5W 250mL 90min + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2800mg/m2 4535mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-07-10 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-06-26 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-06-13 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-05-30 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-05-12 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-04-21 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-04-03 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-03-09 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-02-21 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2022-09-19 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-09-01 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-08-14 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-08-01 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

  • 2022-07-11 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

  • 2022-06-27 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 157mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

  • 2022-06-06 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 336mg 1.5hr + leucovorin 400mg/m2 748mg 2hr + fluorouracil 2800mg/m2 5235mg 46hr

  • 2022-05-19 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 330mg 1.5hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5190mg 46hr

  • 2022-04-29 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 330mg 1.5hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5190mg 46hr

  • 2022-04-15 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 330mg 1.5hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 2800mg/m2 5130mg 46hr

  • 2022-03-23 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 347mg 1.5hr + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr

  • 2022-03-09 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 347mg 1.5hr + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr

  • 2022-02-22 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 348mg 1.5hr + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr

  • 2022-02-08 - irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr

  • 2022-01-18 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr

  • 2022-01-04 - bevacizumab 5mg/kg 380mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr

  • 2021-06-29 ~ 2022-01-18 - FOLFIRI + bevacizumab

  • 2021-05-13 ~ 2021-06-11 - FOLFIRI

==========

2023-08-07

[anemia]

Since 2023-02, the patient has been receiving FOLFIRI regimen. On 2023-08-06, there was an episode of grade 3 anemia (HGB < 8 g/dL) (another grade 3 anemia was recorded on 2023-04-03 with a HGB level of 7.6g/dL). To address the anemia, blood transfusions were administered on 2023-03-14, 2023-04-03, 2023-05-12, and 2023-08-06.

Starting from 2023-04-03, the dose of Irinotecan was reduced to 60% (300mg -> 180mg -> 175mg).

2023-07-25

According to the PharmaCloud database, this patient has only received his medical needs from our hospital in the past 3 months, no medication reconciliation issues identified.

2022-06-07

  • This is a stage IV rectal cancer patient with a LN and lung mets (EGFR+, pMMR, mutated KRAS codon 12/13) who is currently being treated with FOLFIRI plus ramucirumab.
  • The presence of KRAS mutations have been identified as predictors of resistance to anti-EGFR therapy in patients with mCRC. PFS was significantly improved with ramucirumab (currently used) compared to placebo in the RAS mutation subgroup (P=0.021) ( https://pubmed.ncbi.nlm.nih.gov/30339194/ )
  • The imaging studies revealed regression (2021-11-18 CT) followed by mild progression (2022-02-21 CT, 2022-04-28 bone scan, 2022-05-28 CT) with CEA (2022-05-10 7.474 ng/mL) and CA199 (2022-05-10 38.630 U/ml) remaining elevated.
  • As the effect of the current treatment is still being observed, [trifluridine + tipiracil] might be an option if the results do not meet expectations (the drug is covered by national health insurance).
  • The patient had primary hypertension and his BP readings have been around 150/100 since this hospital stay under Sevikar (amlodipine 5mg plus olmesartan 20mg) 1# PO QD. If the high pressure does not go down and becomes symptomatic, then increasing the dose of Sevikar could be an option. (Maximum daily dose: amlodipine 10 mg, olmesartan 40 mg).

2022-04-18

  • This is a patient with stage IV rectal cancer with a LN and lung metastasis being treated with FOLFIRI since 2021-05-13.
  • Earlier tests indicated that EGFR(+), MMR-proficient, and mutated KRAS codon 12/13.
  • CT images revealed first regression (2021-11-18) and then progression (2022-02-21). Bevacizumab was added from 2021-06-29 to 2022-01-18, then ramucirumab was added from 20202-22-22.
  • Lab readings were generally normal (2022-04-15), however CEA (2022-04-01) and CA199 (2022-04-08) remained elevated.
  • Current updated treatment effect is still being observed, and if the results are not as expected, then [trifluridine + tipiracil] might be an option (the drug is covered by national health insurance).
  • Besides analgesics, non-pharmacological interventions that can control pain over a longer period of time might also be considered. The following interventions are available to treat metastatic bone cancer pain (not exhaustive, reference: https://pubmed.ncbi.nlm.nih.gov/31140913/):
    • Epidural and selective nerve root block
    • Radiofrequency ablation and cryoablation
    • Vertebral augmentation
    • Intrathecal drug delivery
    • Spinal cord stimulation
    • Dorsal root ganglion stimulation

700573987

230804

[exam findings]

  • 2023-06-20 CXR
    • Solitary pulmonary nodule at right lung.
    • Presence of radiopaque gallbladder stones.
  • 2023-06-13 SONO - abdomen
    • GB stone, multiple
  • 2023-05-24 Patho - lymph node region resction
    • DIAGNOSIS:
      • Lymph node, level II, right, modified radical neck dissection — Positive for moderately differentiated squamous cell carcinoma ( 1 / 7 )
      • Lymph node, level Ia, midline, modified radical neck dissection — Negative for malignancy ( 0 / 2 )
      • Lymph node, level Ib, right, modified radical neck dissection — Negative for malignancy ( 0 / 4 )
      • Lymph node, level III, right, modified radical neck dissection — Positive for moderately differentiated squamous cell carcinoma. ( 1 / 5 )
      • Lymph node, level IV, right, modified radical neck dissection — Positive for moderately differentiated squamous cell carcinoma. ( 1 / 9 )
      • Lymph node, level Va, right, modified radical neck dissection — Negative for malignancy ( 0 / 1 )
      • Lymph node, level Vb, right, modified radical neck dissection — Negative for malignancy ( 0 / 3 )
      • Salivary gland, submandibular, right, modified radical neck dissection — Negative for malignancy
      • Skin, neck,level II, right, modified radical neck dissection — Negative for malignancy
    • MICROSCOPIC EXAMINATION
      • Neck Lymph Nodes: Positive for moderately differentiated squamous cell carcinoma (see above)
        • Size (greatest dimension) of the largest positive lymph node: 5 cm
        • Extranodal extension: Absent
      • Submandibular gland, right: Negative for malignancy
      • Skin, level II, right neck: Negative for malignancy
  • 2023-04-28 Patho - tonsil and/or adenoid
    • DIAGNOSIS:
      • Nasopharyngeal lesion, right, biopsy— Lymphoid hyperplasia
      • Nasopharyngeal lesion, left, biopsy— Lymphoid hyperplasia
      • Tongue base, right, laryngomicrosurgery — Lymphoid hyperplasia
      • Tonsil, right, tonsillectomy— Lymphoid hyperplasia
    • Microscopically, sections A, B, C and D shows bland tissues with lymphoid hyperplasia. There are no evidence of malignancy.
    • Immunohistochemical stain reveals CK (-).
  • 2023-04-19 PET scan
    • Increased FDG uptake in the right oropharynx, highly suspected the primary oral malignancy, suggesting biopsy for investigation.
    • Increased FDG uptake in lymph nodes of the right neck region, compatible with metastatic lymph nodes.
    • Mildly increased FDG uptake in 2 lesions in the right lower lung, the nature is to be determined (chronic inflammation process, benign/malignant neoplasm, or other nature ?), suggesting further investigation and follow-up.
    • Increased FDG uptake in bilateral pulmonary hilar regions, probably physiological uptake of FDG.
    • Right oropharyngeal cancer, cTxN1M0, by this F-18 FDG PET scan.
  • 2023-04-12 Patho - lymphonode biopsy
    • Lymph node, neck, right, excision — Non-keratinizing squamous cell carcinoma, metastatic
    • The sections show a picture of metastatic non-keratinizing squamous cell carcinoma, poorly differentiated, composed of lymphoid tissue with nests of large neoplastic cells with oval nuclei, arranged in solid pattern. Keratin formation is absent.
    • IHC, tumor cells reveal: CK7(-), CK20(-), p40(+) and p16(-).
    • EBER in situ hybridization — Negative
  • 2023-04-06 CT - neck
    • Indication: the R’t neck mass get enlarged progressively in recent 6 months
    • Finding:
      • Enlarged lymph nodes at right level II (46 mm) and level III (15 mm), both with heterogeneous enhancement. Mass effect on right submandibular gland and internal jugular vein also noted.
      • Calcification along aortic arch.
    • IMP:
      • Enlarged lymph nodes at right level II and III.
      • D/D: lymphoma, reactive lympadenitis.
  • 2023-02-07 CT - abdomen
    • A nodule (1.9cm) at RLL.
    • Gallbladder and distal CBD stones (2-4mm).
    • Colonic diverticula.
  • 2022-08-02 CT - chest
    • Finding: a dense calcified nodule (13mm) and adjacent 3mm calcification at superior segment and a lobulated soft-tisue nodule with two tiny eccentric calcification (18mm) with surrounding interlobular septal thickening at posterobasal segment of RLL. Multiple subleural bullae in bilateral apical lungs
    • Impression:
      • two granulomas up to 13mm and a calcified nodule (18mm) in RLL of lung, stationary as compared with CT on 2016/07/05.
      • multiple subleural bullae in bilateral apical lungs
  • 2020-08-06 CT - brain
    • Mild cortical brain atrophy.
  • 2018-02-23 CT - brain
    • No intracranial abnormality
  • 2017-08-05 SNCV, MNCV
    • Comments
      • Normal motor and sensory conduction studies of the arms and legs.
      • Normal F-wave latencies followed all sampling nerve stimulations.
      • Normal H-reflex study in both legs..
    • Conclusion
      • This is a normal NCV study.

[surgical operation]

  • 2023-05-24
    • Surgery
      • Modified radical neck dissection, right
    • Finding
      • Enlarged indurated lymphadenopathy over right level II, III
      • Right SCM (upper part partially removed with level II LN), IJV, SAN preserved
  • 2023-04-27
    • Surgery
      • Nasopharyngeal biopsy, bilateral    
      • Laryngomicrosurgery        
      • Right tonsillectomy        
    • Finding
      • Granular surface over upper pole of right tonsils  
  • 2023-04-12
    • Surgery
      • Excision        
    • Finding
      • A 4 cm hard tumor over R’t lateral neck and we excise part of it for biopsy

[MedRec]

  • 2023-05-04 SOAP Hemato-Oncology Gao WeiYiao
    • P: ENT Dr Hwang will perfomed to receive operation first followed by CCRT
  • 2023-05-04 SOAP Ear Nose Throat Huang TongCuan
    • A/P
      • right neck metastatic SCC
      • s/p Right tonsillectomy, biopsy of right base lesion and bi nasopharynx on 2023/04/27, no primary lesion found
      • cTxN2aM0 >>> explanation about treatment option:
        • Op + post-op RT or CCRT
        • CCRT
  • 2023-04-25 SOAP Ear Nose Throat Huang TongCuan
    • A/P: right neck metastatic cancer >>> arrange admission for endoscope exam + biopsy (NP, tongue base) + tonsillectomy
  • 2017-08-01 SOAP Neurology
    • S
      • P’t suffered from bilateral hands and feet numbness for 2~3 months. Left side dominent, worse when sit.
    • O
      • E4V5M6
      • Normal cranial nerve sign
      • MP: Full
      • Sensation: distal hyperalgesia
      • DTR: bilateral ankle +
    • A
      • Polyneuropathy [G62.9]
    • Prescription
      • Euclidan (nicametate citrate 50mg) 1# BID

[radiotherapy]

[chemotherapy]

  • 2023-07-25 - NS 500mL 1hr (pre-cisplatin) + cisplatin 35mg/m2 50mg NS 500mL 1.5hr + NS 500mL 1hr (post-cisplatin) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL
  • 2023-07-18 - NS 500mL 1hr (pre-cisplatin) + cisplatin 35mg/m2 50mg NS 500mL 1.5hr + NS 500mL 1hr (post-cisplatin) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL
  • 2023-07-07 - NS 500mL 1hr (pre-cisplatin) + cisplatin 35mg/m2 50mg NS 500mL 1.5hr + NS 500mL 1hr (post-cisplatin) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL
  • 2023-06-30 - NS 500mL 1hr (pre-cisplatin) + cisplatin 35mg/m2 50mg NS 500mL 1.5hr + NS 500mL 1hr (post-cisplatin) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL

==========

2023-08-04

The package insert for Dicetel (pinaverium bromide) advises against oral ingestion or chewing. It is recommended to swallow the medication with a large glass of water during meals to prevent contact with the esophageal mucosa (risk of esophageal injury) and not be taken while lying down or before bedtime. This indicates that tube feeding is not recommended.

700902773

230804

[MedRec]

  • 2023-07-03 Metabolism and Endocrinology
    • Prescription x3
      • Eltroxin (levothyroxine 50ug) 2# QDAC
  • 2023-06-26 Orthopedics
    • Prescription x3
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# BID
      • Neurontin (gabapentin 100mg) 1# HS
      • Toricam (piroxicam) ASORDER TOPI
  • 2023-05-25 Cardiology
    • Diagnosis
      • Atrial fibrillation [I48.0]
      • Sick sinus syndrome [I49.5]
      • Presence of cardiac pacemaker [Z95.0]
      • Conduction disorder, unspecified [I45.9]
      • Chronic renal failure [N18.6]
      • Unspecified hypothyrodism [E03.9]
      • Anemia, unspecified [D64.9]
    • Prescription x3
      • Cordarone (amiodarone 200mg) 0.5# QD
      • Ulstop (famotidine 20mg) 1# QD
      • midorine 2.5mg 2# PRNTID
  • 2022-07-31 ~ 2022-08-04 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Urothelial carcinoma, low grade, papillary type, of the right renal pelvis, s/p NU, cystectomy, hysterectomy, urethrectomy, with local recurrence (vaginal metastases) .
      • End stage renal disease under hemodialysis on QW 246 (clinic)
      • Paroxysmal atrial fibrillation
      • Sick sinus syndrome
      • Presence of cardiac pacemaker
      • Hypothyroidism, unspecified
    • CC
      • for CCRT
    • Present illness
      • The 73-year-old woman has histories of
        • ESRD on regular hemodialysis QW246 since 2016.
        • Thyroid goiter s/p partial thyroidectomy under Thyroxin control for 20+ years.
        • Left ureteral urothelial carcinoma, high grade, pT2N0cM0, status post anterior pelvic exenteration and left nephroureterectomy on 2016/08/31
        • Bladder urothelial carcinoma, high grade, pT1N0cM0, status post radical cystectomy on 2016/08/31
        • Urothelial carcinoma over the right renal pelvis, left upper ureter, bladder and urethra s/p bilateral neprhectomy, cystectomy, abdominal total hysterectomy with bilateral salpingo-oophorectomy and urethrectomy on 2014/11/05
        • Sick sinus syndrome pacemaker implantation on 2017/4/19
      • In 2022/06 she had suffered from bloody stool. She had visited CRS OPD and colonoscopy showed extra-rectal tumor with external compression. She was referred to GYN OPD. DRE test found extra-rectal large solid tumor at anterior. PV exam found ulcerative mass at posterior vaginal wall. Malignancy was highly suspected. GYN echo showed one 48x39mm mass. Cervical biopsy was done and showed malignancy with urothelial origin. Urothelial cell carcinoma with vaginal metastasis was diagnosed.
      • Under the impression of urothelial cell carcinoma with vaginal metastasis, radiotherapy was suggested. The patient agreed to undergo the therapy. Therefore she was admitted on 2022/7/31 for further evaluation and radiotherapy localization was scheduled on 2022/8/3.
    • Course of inpatient treatment
      • After admission, she received LPRBC 2u and EPO for anemia. Nephro was consulted and arranged HD qw 246. Chemotherapy as C1 Gemzar (200mg/m2) during RT- RT positioning on 2022/8/4. Under the stable condition, she can be discharged on 2022/08/04. OPD follow up is arranged.

[chemotherapy]

  • 2022-09-14 - gemcitabine 200mg/m2 280mg NS 100mL (after hemodialysis) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-31 - gemcitabine 200mg/m2 280mg NS 100mL (after hemodialysis) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-12 - gemcitabine 200mg/m2 282mg NS 100mL (after hemodialysis) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-02 - gemcitabine 200mg/m2 282mg NS 100mL (after hemodialysis) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

==========

2023-08-04

All repeat prescriptions from our endocrinologist, orthopedist, and cardiologist were added to the active medication list, with the exception of midorine. During this hospitalization, there is no evidence of symptomatic orthostatic hypotension in the HIS5 records, so no reconciliation issues were identified.

701073389

230804

[diagnosis] - 20230114 discharge note

  • Pancreatic head cancer, stage III, with common bile duct obstructive jaundice, status post Endoscopic Retrograde Biliary Drainage revision
  • Duodenal ulcer compared with tumor invasion
  • Hypokalemia
  • Chronic viral hepatitis B without delta-agent
  • Type 2 diabetes mellitus without complications
  • Inferior wall myocardial infarction with cardiogenic shock, status post Percutaneous transluminal coronary angioplasty with stent on 2012/05/25

[past history]

  • HBeAg(-) HBV carrier
  • Inferior wall myocardial infarction with cardiogenic shock, post primary PCI & stent for RCA on 2012/05/25
  • DM    
  • Pancreatic head cancer with obstructive jaundice and duodenal invasion, status post Contrast harmonic echo-endoscopic ultrasound guided fine needle biopsy, stage III.

[exam findings]

  • 2023-06-24 CT - abdomen
    • Pancreatic head cancer (3.7*2.7cm), in regression
    • s/p biliary stents
    • Liver hypodensity; DDx: fatty liver, hepatitis
  • 2023-05-04 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • No bloody material nor coffee ground material during this examination
      • Gastric mucosa swelling, antrum, PW site
      • C/W pancreatic cancer with duodenal involving
      • Duodenal orifices, ampulla and periampulla, need to r/o pancreatic cancer involving duodenal causing perforation
      • Duodenal plastic stent inplace
      • Superficial gastritis
      • Deformed antrum
    • Suggestion
      • PPI use
  • 2023-04-29 Embolization (TAE) - abdomen
    • Embolization of gastroduodenal artery via right femoral artery puncture revealed:
      • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
      • No definite active bleeding during the celiac axis and SMA injections.
      • Prevention emobilization of gastroduodenal artery was periformed with 2 coils. Nearly total obliteration of gastroduodenal artery after embolization.
      • No procedure related complication.
    • Impression
      • c/w TAE of gastroduodenal artery
      • A Fr.5 sheath was placed in right common femoral artery. Please remove it in 3 days.
  • 2023-04-29 Esophagogastroduodenoscopy, EGD
    • Duodenum
      • One 3mm clean base ulcer with pigmentation was found at SDA. Active oozing, suspect the previous ulcer(2022/12/15), near the major papilla was noted, due to unable to tolerate, hemostasis is not done.
    • Diagnosis
      • Incomplete study due to much blood and intolerace
      • Duodenal oozing lesion, suspicious previous ulcer, 2nd portion
      • Duodenal ulcer, Forrest classification IIc, SDA, AW
    • Suggestion
      • Arrange TAE for hemostasis
      • Admission to ICU and then repeat EGD in the future
      • High dose PPI and NPO
  • 2023-03-13 CT - abdomen
    • Indication: Pancreatic head cancer, stage III, with common bile duct obstructive jaundice, status post Endoscopic Retrograde Biliary Drainage revision
    • Abdominal CT with and without enhancement revealed:
      • Cystic lesion at pancreatic head measuring 5.7cm in largest dimension obliterating CBD and causing dilated biliary tree is found. In comparison with CT dated on 2022-11-30, the tumor size is stationary.
      • Marked fatty liver is found.
      • s/p biliary tree stent placement.
      • The GB is well distended without soft tissue lesion
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
      • The urinary bladder is well distended without soft tissue lesion.
      • Scoliotic alignment of the thoracolumbar spine is noted.
    • Imp:
      • Cystic lesion at pancreatic head measuring 5.7cm in largest dimension obliterating CBD and causing dilated biliary tree is found. In comparison with CT dated on 2022-11-30, the tumor size is stationary.
  • 2023-03-09 CXR
    • Atherosclerotic change of aortic arch
    • Scoliosis of the T-spine with convex to right side.
  • 2023-01-12 Endoscopic Retrograde CholangioPancreatography, ERCP
    • Indication
      • pancreatic head cancer post ERBD, malfunction of ERBD
    • Diagnosis
      • Pancreatic head cancer with CBD obstructive jaundice, post ERBD revision
      • Duodenal ulcer, c/w, tumor invasion.
    • Suggestion
      • On diet tonight
      • f/u Hb, serum AST/ALT, T-bil, lipase on the next morning
  • 2023-01-11 Abdomen - standing (diaphragm)
    • S/P CBD stenting.
  • 2023-01-11, 2022-12-26 CXR
    • Presence of scoliosis of the T-L spine.
  • 2022-12-30 Whole body PET scan
    • There was inhomogenously increased FDG uptake in the region about the pancreatic head (SUVmax early: 7.43, delay: 6.38) and there was increased FDG uptake in the left shoulder joint (SUVmax early: 8.51, delay: 5.94). Besides, there was increased FDG accumulation in the colon, both kidneys and right ureter.
    • IMPRESSION:
      • Inhomogenously increased FDG uptake in the region about the pancreatic head, compatible with primary pancreatic malignancy. Please correlate with other clinical findings for further evaluation.
      • Glucose hypermetabolism in the left shoulder joint, compatible with active arthritis.
      • Increased FDG accumulation in the colon, both kidneys and right ureter. Physiological FDG accumulation is more likely.
      • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2022-12-23 SONO - abdomen
    • Liver tumor, S6 and S7, suspicious Liver hemangioma
    • Fatty liver, mild
    • post ERBD.
    • Dilated left IHD.
  • 2022-12-16 T-tube cholangiography
    • Cholangiography via PTCD catheter administration revealed:
      • Patency of the catheter.
      • Poor drainage function of CBD stent.
  • 2022-12-16 Patho - duodenum biopsy
    • Labeled as “duodenum, major papilla (A)”, biopsy — adenocarcinoma.
      • IHC stains: CA19-9 (+), CK19 (+), CK7 (+), CK 20 (focal +), Ki-67 (60-70%)
    • Labeled as “duodenum, postbulb (B)”, biopsy — adenocarcinoma.
      • IHC stains: CA19-9 (+), CK19 (+), CK7 (+), CK 20 (focal +), Ki-67 (60-70%)
  • 2022-12-16 Patho - pancreas biopsy
    • Labeled as “Pancreas”, EUS biopsy — adenocarcinoma.
      • IHC stains: CA19-9 (+), CK19 (+), CK7 (+), CK 20 (focal +), Ki-67 (60-70%)
  • 2022-12-15 Endoscopic Retrograde CholangioPancreatography, ERCP
    • Indication
      • pancreatic head cancer with obstructive jaundice
    • Diagnosis
      • pancreatic head cancer with obstructive jaundice, s/p EST, CBD dilatation + ERBD
      • duodenal ulcer, suspicious tumor invasion, s/p biopsy(A) at major papilla, biopsy(B) at postbulb
      • post PTCD
    • Suggestion
      • On NPO except water tonight
      • f/u Hb, serum AST/ALT, T-bil, lipase on the next morning
      • PPI Rx
  • 2022-12-15 Endoscopic Ultrasonography, EUSDiagnosis:
    • Diagnosis: Pancreatic head cancer with obstructive jaundice and duodenal invasion, s/p CHE-EUS-FNB
    • Suggestion: pursue pathology.
  • 2022-12-13 MRI - pancreas
    • Pancreatic head tumor (5.4cm).
    • S/P PTCD. Some nodules in liver.
    • Bil. pleural effusion with adjacent lung collapse.
  • 2022-12-12 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (138 - 48) / 138 = 65.22%
      • M-mode (Teichholz) = 65
    • Borderline dilated LA and LV; Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
  • 2022-12-08 Visceral Angiography 2 vessels
    • DSA of celiac trunk, SMA and common hepatic artery via right common femoral artery puncture revealed:
      • S/P PTCD.
      • Liver cirrhosis.
      • Patency of hepatic arteryies and portal vein. No evidence of active bleeding.
      • No procedure-related complication during the whole procedure.
    • IMP: No evidence of active bleeding.
  • 2022-12-08 Percutaneous Transhepatic Cholangial Drainage, PTCD (drainage)
    • Dilatation of the biliary tree (by CT images).
    • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree smoothly.
    • No procedure-related complication during the whole procedure.
  • 2022-11-30 CT - abdomen
    • Findings:
      • There is a well-defined hypodense mass at the pancreatic head, measuring 6 cm in size (the largest dimension), causing dilatation of bile ducts and pancreatic duct. During contrast-enhanced dynamic study, this mass shows poor enhancement in arterial phase and portal venous phase images, and mild enhancement in delayed phase images.
        • Adenocarcinoma of the pancreatic head is highly suspected.
        • The differential diagnosis include acinar cell carcinoma.
        • In addition, There is loss of normal fat plane between the pancreatic head mass and superior mesenteric vein that may be tumor direct invasion superior mesenteric vein (T4).
      • There are several ill-defined mild enhancing lesions in both hepatic lobes at arterial phase images. However, all lesions are not identified (isodensity) in portal venous phase and delayed phase images. The largest one 2.4 x 1.2 cm in S7 of the liver.
        • Pseudolesions (flow artifacts) are highly suspected.
        • The differential diagnosis include metastases.
        • Please correlate with sonography and MRI.
      • A renal cyst measuring 1 cm in left middle pole is noted.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T4 (T_value) N:N0 (N_value) M:M0 (M_value) STAGE:III(Stage_value)
  • 2021-05-11, -02-23 CXR
    • There is scoliosis of the T-spine with convex to right side.
    • Atherosclerotic change of aortic arch
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura thickening or effusion?
  • 2020-03-04 Treadmill exercise test (BRUCE protocol)
    • The patient exercised according to the BRUCE for 08:00 min:s, achieving a work level of max METS: 10.1. The resting heart rate of 96 bpm rose to a maximal heart rate of 169 bpm. This value represents 107 % of the maximal, age-predicted heart rate. The resting blood pressure of 145/71 mmHg, rose to a maximum blood pressure of 201/61 mmHg. The exercise test was stopped due to Target heart rate maximal, Dyspnea, Fatigue.
    • Conclusion:
      • Resting ECG: normal
      • Arrhythmia: Nil
      • No significant ST-T change during exercise and recovery phases.
    • Impressions
      • Negative for myocardial ischemia
  • 2022-12-12 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 35) / 93 = 62.37%
      • M-mode (Teichholz) = 63
    • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Subendocardial scarring of inferior and inferoseptum with preserved wall motion and normal LV systolic function.
    • Normal RV systolic function.
    • Mild AV sclerosis; trivial MR.
    • Sinus tachycardia.
  • 2017-01-07 SONO - Nephrology
    • Finding:
      • Size Shape
        • R’t :10.69 cm, smooth
        • L’t :10.87 cm, smooth
      • Cortex
        • R’t :Echogenicity: normal; Thickness: normal
        • L’t :Echogenicity: normal; Thickness: normal
      • Pyramid:
        • R’t : visible
        • L’t : visible
      • Sinus
        • Not Dilated
      • Cyst
        • None
      • Stone
        • None
      • Mass
        • None
    • Interpretation:
      • No signficant abnormality from echography for both kidneys.

[consultation]

  • 2022-12-20 Radiation Oncology
    • Diagnosis: Pancreatic head cancer, adenocarcinoma, cT4N1M0 at least, with obstructive jaundice on 2022/12/08, s/p ERCP + ERBD / EUS-FNB on 2022/12/15; severe BW loss; ECOG =1.
    • Plan: Pre-operative CCRT to pancreatic head tumor & regional LAPs for 5040cGy/28 fx is suggested for locoregional tumor control. Possible treatment toxicity is told. CT simulation is arranged on 2022/12/21. Psychological support & diet education is given to him and his daughter. Please consult dietician for diet education, medical oncologist for systemic chemotherapy and surgeon for PortA implantation.

[MedRec]

  • 2023-07-25 SOAP General and Gastroenterological Surgery
    • Prescription x3
      • Protase (pancrelipase 280mg) 1# TIDCC
  • 2023-06-06 SOAP Cardiology
    • Prescription x3
      • Plavix (clopidogrel 75mg) 1# QD
      • carvedilol 6.25mg 1# BID
      • Cabudan (captopril 25mg) 1# QD
      • Alpraline (alprazolam 0.5mg) 1# HS
  • 2023-05-17 SOAP Gastroenterology
    • Prescription x3
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Genurso (ursodeoxycholic acid 100mg) 1# BID
      • BaoGan (silymarin 150mg) 1# TID
      • Dexilant (dexlansoprazole 60mg) 1# QD
  • 2023-01-03 SOAP Hemato-Oncology
    • O:
      • Cancer Multidisciplinary Team Meeting Conclusion, meeting date: 20230103
        • Neoadjuvant C/T -> OP.
    • S
      • will give pre-Op neoadjuvant C/T wt FOLFIRINOX IV Q2W x 12.
      • RTC 1 wk later on 20230109 for LFT & arrange adm for #1 pre-Op neoadjuvant C/T wt FOLFIRINOX IV Q2W x 12.

[radiotherapy]

  • 2023-01-27 ~ 2023-02-20 - 5040cGy/28 fractions (15 MV photon) to pancreatic tumor/LAPs

[chemotherapy]

  • 2023-08-02

  • 2023-07-11

  • 2023-06-23 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg NS 500mL 2hr + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 2800mg 3500mg NS 500mL 46hr (FOLFIRINOX, Iri 90%, 5FU 80%)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-05-31 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg NS 500mL 2hr + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 2800mg 4320mg NS 500mL 46hr (FOLFIRINOX)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-04-07 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 235mg NS 500mL 2hr + leucovorin 400mg/m2 625mg NS 500mL 2hr + fluorouracil 2800mg 4375mg NS 500mL 46hr (FOLFIRINOX)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-03-09 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 235mg NS 500mL 2hr + leucovorin 400mg/m2 625mg NS 500mL 2hr + fluorouracil 2800mg 4385mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-02-13 - fluorouracil 225mg/m2 340mg NS 500mL 24hr D1-5 (CCRT)

    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-02-06 - fluorouracil 225mg/m2 340mg NS 500mL 24hr D1-5 (CCRT)

    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL

==========

2023-08-04

All repeat prescriptions issued by our gastroenterologist on 2023-05-17, cardiologist on 2023-06-06, and general surgeon on 2023-07-25 have been consistently refilled. These medications have been added to the active medication list, and no reconciliation issues have been identified.

2023-06-26

  • Based on the PharmaCloud database, it appears that our hospital has been exclusively providing all necessary medical services and medications for this patient in the past few months. As such, we’ve found no issues regarding medication reconciliation.

2023-03-10

  • The 2023-03-09 lab results indicate elevated levels of AST, ALT, direct bilirubin readings, and hypoalbuminemia. Plasbumin (human albumin) and BaoGan (silymarin) have been prescribed properly.
  • As this is the patient’s first time receiving FOLFIRINOX, he is are undergoing a modified regimen, which involves a lower dose of oxaliplatin (reduced from 85mg/m2 to 70mg/m2) and irinotecan (reduced from 180mg/m2 to 150mg/m2), and the 5-FU bolus dose is skipped, with the same dose added to the 5-FU infusion.
  • The active prescription does not appear to be an issue.

2023-02-09

  • Cancer Multispecialty Team Meeting on 2023-01-03 concluded: Neoadjuvant C/T (CCRT) then op. For the time being, the patient is receiving CCRT.
  • There has been a weight loss of 3kg in the past month for the patient (54.4kg 2022-12-07 -> 51kg 2023-02-07). The addition of some appetizers, such as megestrol, might be beneficial.
  • The patient has a history of DM. As all data points of fasting blood sugar level during this hospital stay exceeded 110 mg/dL, metformin 500mg BID could be added, since the patient’s renal function appears to be in good working order.
  • Other underlying conditions caused by HBV and cardiovascular disease are managed with corresponding medications appropriately.

701168936

230804

[MedRec]

  • 2023-07-11 ~ 2023-08-02 POMR Family Medicine
    • Discharge diagnosis
      • hepatocellular carcinoma, cT4N0M1 with multiple metastases on both lungs status post C1 selfpaid of Avastin plus Tecentriq on 2023/6/27
      • Type 2 diabetes mellitus without complications
    • CC
      • dyspnea with chest pain for two days.
    • Present illness
      • This 74 year old female has history of 1) Diabetes Mellitus 2) hepatocellular carcinoma, cT4N0M1 with multiple metastases on both lungs status post C1 selfpaid of Avastin plus Tecentriq on 2023/6/27
      • This time she had suffered from dyspnea with chest pain for two days.Therefore,she was brought to our ER for help. There were no fever,no abdominal pain or tarry stool. At ER, her vital sign was BP:181/104mmHg;HR:114bpm; BT:37.4 ℃; RR:28 bpm; SpO2:86%. Physical examination showed pitting edema 4+. Laboratory test revealed leukocytosis(WBC 10.1k/ul),elevated CRP level(14.4 mg/dL),hypoalbuminemia(2.9 g/dL ),hyperbililubinemia(2.25 mg/dL),hyponatriemia(122 mmol/L).Chest film disclosed Nodular lesions in both lung fields,lung metastasis.Empiric antibiotics with Brosym was prescribed.
      • Under the impression of hepatocellular carcinoma, cT4N0M1 with multiple metastases on both lungs status post C1 selfpaid of Avastin plus Tecentriq on 2023/6/27 with acute respiratory failure, she was admitted to our ward for further management
    • Course of inpatient treatment
      • After admission, selfpaid of Albumin 100mg QD with diuretic was prescribed from 7/12-. Methyprednisolone 40mg Q12H IVD for dyspnea relief. Empiric antibiotics with Brosym 4g Q12H from 7/11, blood culture was negative. Patient refused the NG tube insertion. Followed chest film on 7/13 disclosed multiple nodular opacity projecting in both lung that are c/w metastases. Desaturation was noted during Bipap used. Hospice was also consulted and DNR had signed after we explained the current condition, but not all of family agree hospice care and some families hesitated to continue active treatment. Thus, respiratory failure was noted under RT weaning as NRM or V-M, Finally, all family members agreed transfer to hospice ward on 2023/8/2.
      • After transferred to hospice ward, the patient showed drowsy consciousness with nearly air-huger breathing pattern, and we had informed the family on the patient’s clinical condition. The family had agreed on discontinuing IV fluid and adding PRN Morphine for the patient’s dyspnea. The patient’s condition continued downhill, and she expired at 17:46 on 2023-08-02.
  • 2023-06-20 ~ 2023-06-30 POMR Hemato-Oncology
    • Discharge diagnosis
      • Malignant neoplasm of liver, primary, unspecified as to type, AFP positive hepatocellular carcinoma, stage IV
      • Secondary malignant neoplasm of unspecified lung. multiple lung metastases from AFP positive hepatocellular carcinoma
      • Type 2 diabetes mellitus without complications
    • CC
      • for CT guide biopsy
    • Present illness
      • This 74 y/o with underlying disease of type 2 DM was admitted for CT guide biopsy.
      • She was found to have multiple lung tumor with elevated AFP 1210 via CT at local clinic. She had Falling down injury over Rt shoulder. She had mild dyspnea after walking. Leg edema 2+ was noted. Lab data showed 2023/06/12 S-GOT/AST = 91 U/L; Bilirubin direct = 0.30 mg/dL; HGB = 9.4 g/dL.
      • Under the impression of multiple lung tumor with elevated AFP 1210 via CT, she was admitted to our ward for further treatment adn evaluation.
    • Course of inpatient treatment
      • After admission, CT-guide biopsy was done and revealed Consistent with metastatic hepatocellular carcinoma. ABD contrast CT showed HCC, cT4N0M1 with multiple metastases on both lungs. Pitting edema was noted, laxis 1# QD (06/23-27) was given > 1# BID (06/27- ). Heart echo was arranged. Heart echo: Preserved LV and RV systolic function. She started avastin (06/27)+ tecentriq (06/27).
      • On 06/28, we DC forxiga and pioglitazone on 06/28 for pitting edema.
      • Under stable condition, she was discharged with OPD follow up.
    • Discharge prescription
      • Apidra (insulin glulisine) 3 unit TIDAC
      • Tresiba FlexTouch (insulin degludec) 6 unit HS
      • Allegra (fexofenadine 60mg) 1# BID
      • Diovan (valsartan 160mg) 0.5# QD
      • Foliromin (ferrous sodium citrate 50mg) 1# QD
      • Januvia (sitagliptin 100mg) 1# QD
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H if pain
      • Ulstop (famotidine 20mg) 1# BID
      • Uretropic (furosemide 40mg) 0.5# QD hold if SBP < 120

700128348

230802

[diagnosis]

  • Malignant neoplasm of endometrium

[past history]

  • Localized swelling, mass and lump, neck, pathology: metastatic endometrioid carcinoma,status post left selective neck dissection and left axillary mass excision on 2022/12/27
  • Endometrial adenocarcinoma, Grade 2, stage pT1aN0M0, FIGO stage: IA, status post staging surgery on 2019-12-25 and postoperative radiotherapy, status post
  • Gastric adenocacinoma, pT3N0M0, status post total gastrectomy with Roux-en-Y gastrojejunostomy in 2016/07 chemotherapy and immunotherapy at Far Eastern Memorial Hospital
  • Insomnia
  • Lumbar spine stenosis status post vertebroplasty

[allergy]

  • NKDA     

[family history]

  • There is no family history of cancer, diabetes, hypertension, mental diseases or asthma.

[exam findings]

  • 2023-02-24 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Compression fracture of L1 S/P vertebroplasty T12, L1, and L2.
  • 2023-01-12 Gynecologic ultrasonography
    • Bilateral adnexae:free
    • ATH
    • IMP: No obvious uterine or ovarian lesion
  • 2022-12-27 Patho - lymph node region resection
    • Diagnosis:
      • Lymph node, level II & amp level, left selective neck dissection— metastatic endometrioid carcinoma ( 2 / 2 )
      • Lymph node, level Vb LAPs, left selective neck dissection— metastatic endometrioid carcinoma ( 1 / 1 )
      • Lymph node, supraclavicular fossa, left selective neck dissection— metastatic endometrioid carcinoma ( 1 / 2 )
      • Lymph node, axillary LAPs, excision— metastatic endometrioid carcinoma ( 1 / 5 )
      • AJCC 8th edition pathology stage: pM1; FGO stage IVB, C:supraclavicular fossa, D1-4:
    • Gross description:
      • The specimen submitted consists of 1 tissue fragment measuring 1.5x 1.3x 1 cm in size, fixed in formalin. Grossly, it is brownish and elastic.
      • The specimen submitted consists of 1 tissue fragment measuring 3.5x 2.5x 2cm in size, fixed in formalin. Grossly, it is brownish and elastic.
      • The specimen submitted consists of 1 tissue fragment measuring 1.5x 1x 1cm in size, fixed in formalin. Grossly, it is brownish and elastic.
      • The specimen submitted consists of 1 tissue fragment measuring 3.3x 2.5x 2cm in size, fixed in formalin. Grossly, it is brownish and elastic.
      • Sections are taken and labeled as: A:level II & amp level, B1-4:Vb LAPs, C:supraclavicular fossa, D1-4: axillary LAPs
    • Microscopic Description:
      • Lymph Nodes:
        • Level II & amp level: metastatic endometrioid carcinoma ( 2 / 2 )
        • Level Vb LAPs, left: metastatic endometrioid carcinoma ( 1 / 1 )
        • Supraclavicular fossa, left metastatic endometrioid carcinoma ( 1 / 2 )
        • Axillary LAPs, left — metastatic endometrioid carcinoma ( 1 / 5 )
      • Ancillary Studies: IHC stain — ER(+), vimentin (+), CD56(-), CDX-2(-), CK20(-).
  • 2022-12-23 Whole body PET scan
    • Prominent glucose hypermetabolism in a left neck level II lymph node, a left neck level V lymph node, a left supraclavicular lymph node, a left infraclavicular lymph node and some left axillary lymph nodes. Multiple metastatic lymph nodes may show this picture.
    • Mild to moderate glucose hypermetabolism in some mediastinal lymph nodes and bilateral pulmonary hilar lymph nodes. Inflammatory process is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Increased FDG accumulation in the colon, bilateral kidneys and ureters. Physiological FDG accumulation may show this picture.
  • 2022-12-13 CT - neck
    • One micro-lobulated mass lesion (2.8cm) over left supraclavicular fossa. Suggest tissue proof to rule out malignant node.
    • Another round node (7mm) over left level V of neck. Highly suspect malignant node.
  • 2022-11-16 CT (Far Eastern Memorial Hospital)
    • Imp: bil lung tiny nodules, suspect peritoneal seeding
    • compared to previous 2022-07-29
      • Status post operation for endometrial cancer
      • Status post total gastrectomy with Roux-en-Y gastrojejunostomy for gastric adenocarcinoma (pathology: pT3N0). No obvious local recurrence
      • Status post left neck metastatic mass excision
      • Enlarged soft tissue mass at left axilla and left neck base, in favor of metastasis, decreased in size
      • Multiple tiny nodules in bilateral lungs, in favor of lung metastasis s/p treatment, decreased in number & size
      • Mild enlarged heart size
      • compatible with liver metastasis s/p treatment, with residual one in left hepatic lobe, decreased in number & size
      • Prominent right renal pelvis- Status post splenectomy
      • Unremarkable gall bladder, pancreas and adrenal glands
      • Mild mesentery fat stranding and suspected mesenteric nodule, peritoneal seeding can not be excluded, no significant interval change - Small lymph nodes at abdominal paraaortic region
      • Mild ascites in the pelvis
      • Status post vertebroplasty at T12
  • 2020-12-02 CT - abdomen
    • History and Indication:
      • 2019-12-23 CT: Hydrometra with mural soft tissue nodule. R/O Endometrial cancer
      • 2019-12-25 Uterus endometrioid adenocarcinoma, Grade 2, pT1aNO, FIGO stage: IA
    • Findings:
      • S/P hysterectomy
      • S/P vertebroplasty of T12, L1, and L2 vertebral body.
      • S/P total gastrectomy and splenectomy.
      • There are several hepatic cysts in both lobes and the largest one is measured about 2.3 x 1.6 cm in size at S6.
      • Hyperplasia of left adrenal gland is noted.
    • Impression:
      • S/P hysterectomy.
      • There is no evidence of tumor recurrence.
  • 2020-12-01 Patho - vaginal biopsy
    • Labeled as “vaginal stump”, biopsy — adenocarcinoma.
    • Section shows adenocarcinoma with papillary like structure, morphologically similar to focal areas of previous tumor (S2019-22417).
    • IHC stains: vimentin (+), WT-1 (-), p16 (+), ER: (+, strong intensity 100%), PR (+ intermedoate, intensity 70%),compatible with endometrial origin. CK20 (-): dis-favor gastrointestinal origin.
  • 2019-12-25 Surgical pathology Level VI
    • Clinical diagnosis: Postmenopausal bleeding;
    • PATHOLOGIC DIAGNOSIS:
      • Uterus, endometrium, staging surgery — endometrioid adenocarcinoma, Grade 2 — pTNM: pT1aNO , FIGO stage: IA
      • Uterus, myometrium, staging surgery — involved by endometrioid adenocarcinoma (< 1/2 thickness) — adenomyosis
      • Uterus, cervix, staging surgery — negative for malignancy — free of lower cervical margin
      • Fallopian tube, right, staging surgery — negative for malignancy
      • Fallopian tube, left, staging surgery — negative for malignancy
      • Ovary, right, staging surgery — negative for malignancy
      • Ovary, left, staging surgery — negative for malignancy
      • Lymph node, left external iliac, dissection — negative for malignancy ( 0 / 4 )
      • Lymph node, left obturator, dissection — negative for malignancy ( 0 / 2 )
      • Lymph node, right external iliac, dissection — negative for malignancy ( 0 / 4 )
      • Lymph node, right obturator, dissection — negative for malignancy ( 0 / 3 )
      • Lymph node, left para-aortic, dissection — negative for malignancy ( 0 / 2 )
      • Lymph node, right para-aortic, dissection — negative for malignancy ( 0 / 7 )
      • Pathology stage:pTNM: pT1aNO, FIGO stage: IA
    • MICROSCOPIC EXAMINATION
      • Histology type: endometrioid adenocarcinoma
      • Histology grade: grade 2
      • Depth of invasion: Tumor invades less than one-half of myometrium (2 mm)
      • Lymphovascular invasion: absent
      • The cervical stroma involvement: absent
      • Resection margins of the cervix (or vagina): free (3.5 cm)
      • Additional pathologic findings:
        • Endometrial hyperplasia: present
        • (squamous) metaplasia: absent
        • adenomyosis: present
      • Bilateral adnexa: free of tumor
      • Lymph node metastasis
        • Group as specified No. Positive / No. Total
        • Left iliac ( 0 / 4 )
        • Left obturator ( 0 / 2 )
        • Right iliac ( 0 / 4 )
        • Right obturator ( 0 / 3 )
        • Left para-aortic ( 0 / 2 )
        • Right para-aortic ( 0 / 7 )
      • Immunohistochemical stain reveals CK7(+), PAX-5(-), CDX-2(-), vimentin(focal+), CK20(-).
  • 2019-12-16 Gynecologic ultrasonography
    • IMP: Suspected endometrial hyperplasia (with Papillar)

[MedRec]

  • 2022-12-30 MultiTeam - Social Services Referral
    • Referral Date: 2022-12-26
    • Reason for Referral: Others - Inpatient with a brief health scale score ≥ 10 points
    • Handling Status: Not opened for case management
    • Reason for Not Opening: Referral Reason: BSRS=10
      • The patient lives with her husband, who is the primary caregiver. They have three daughters and one son, all of whom are married. The family support system is still good, and there is sufficient financial support.
      • The patient was admitted for tumor resection surgery and experienced preoperative anxiety and difficulty falling asleep.
      • On 2022/12/27, a postoperative reassessment was conducted, and the BSRS score was 0.
      • If there are any further needs during the course of treatment, please do not hesitate to contact the social worker. Thank you!
    • Responder: Wu FangQian
    • Response Date: 2022-12-30
  • 2022-12-29 MultiTeam - Psychological Oncology Referral
    • Referral Date: 2022-12-26
    • Reason for Referral: Others - Cancer inpatient with a brief health scale score ≥ 10 points
    • Conclusion:
      • (Summary) Visited on 12/28 with the patient’s husband accompanying. The patient expressed feeling anxious before the surgery, but now that the surgery is done, she feels settled. Before being hospitalized, she was still busy preparing Christmas gifts and had a total of twenty to thirty people, including her grandchildren. They played a game of picking gifts from a grid to find out what they got. Since childhood, she has been putting candy in stockings for the children, and they used to run a grocery store, making Christmas lively every year. She was admitted to the hospital the day after Christmas but didn’t let her son and daughter know in order not to worry them. Her son is in the engineering field, and she didn’t want to distract him. This hospitalization has been manageable because her husband is here, and they even brought the tea set from home to have afternoon tea together every day. “Being in her seventies, she is content and takes things lightly.”
      • (Objective) 7 years ago, she had gastric cancer surgery. In 2019 Dec, she had stage IA endometrial cancer, followed by IVRT post-surgery. In 2020 Dec, there was a recurrence, and she received treatment at another hospital. She has had a lump in her left neck and armpit for nearly a year, and recent biopsies confirmed malignancy. She underwent surgery on 12/27. Her BSRS score is 10 (moderate), and she has been intermittently visiting the Psychiatry Department since 2017 for panic disorder and mild depression.
      • (Intervention) Focus on post-surgery emotional status and family support.
      • (Action Plan) All presented aspects are positive, focusing on post-surgery and holiday matters. There was no mention of psychiatric symptoms or family conflicts. Continue monitoring based on the BSRS score. Counseling Psychologist Huang XiaoFang
    • Responder: Huang XiaoFang
    • Response Date: 2022-12-28 17:21
  • 2017-01-17 SOAP Psychosomatic Medicine
    • S
      • come alone.
      • easily affect by noise. anxiety, rumination were told. education to use ear plug.
      • Whenever the patient’s husband coughs loudly at night, she becomes anxious and experiences chest tightness. It is advised to teach the patient to use earplugs.
      • Without taking medication, the patient easily becomes irritable and starts verbally abusing others.
      • The patient is constantly worried about the heavy dosage of her medications. She is afraid to take sleeping pills and keeps asking when she can stop taking the medications.
    • O
      • CGI: 3
      • Reeducative individual psychotherapy for drug information and compliance:
      • The patient has intermittent poor complaince because of overworring about drug adverse effect and addiction possibility. We educate the patient to understand the mechanism of drug effect and possible side effets. Also, we ensure that the medications are not addictive if taking it regularly everyday.
    • Diagnosis
      • Neurotic depression [F34.1]
      • Panic disorder [F41.0]
      • Nonorganic sleep disorder,unspecified [F51.9]
    • Prescription x3
      • Seroxat (paroxetine 12.5mg) 1# HS
      • Seroxat (paroxetine 12.5mg) 1# PRNHS
      • Eurodin (estazolam 2mg) 0.5# PRNHS

[consultation]

  • 2023-02-23 General and Digestive Surgery
    • Q: this is a 71-year-old female with history of Endometrioid adenocarcinoma, Grade 2, of the uterine endometrium, stage pT1aN0(cM0) , FIGO stage: IA, s/p staging surgery (BSO + omentectomy + ATH + retroperitoneal lymphadenectomy), and s/p radiotherapy, with vaginal stump recurrence (2020-12), with multiple lymph nodes metastases, s/p operation (Selective neck dissection, left. Excision of left axillary conflulent LNs, left, 2022-12-27 ). The patient said ever received immunotherapy at Far Eastern Memorial Hospital. She was admitted for chemotherapy, so port-A is suggested.
    • A: we will arrange port-A implantation tomorrow

[surgical operation]

  • 2022-12-27
    • Surgery
      • Selective neck dissection, left
      • Excision of left axillary conflulent LNs, left
    • Finding
      • Endometrial adenoca s/p OP in 2019 and RT
      • Gastric adenoca s/p total gastrectomy with Roux-en-Y gastrojejunostomy (pT3N0) later at Far Eastern Memorial Hospital
    • LN metastasis was suspected and told by GYN but Rx poor (chemotherapy and immunotherapy) Immunotherapy (NT 11W*4 times) at Far Eastern Memorial Hospital in vain (origin from which ca? no definite pathologic report)

[radiotherapy]

  • 2023-02-22 ~ undergoing - 4000cGy/20 fractions of the left neck to left axilla area.
  • 2020-01-30 ~ 2020-02-20 - 2800cGy/7 fractions via IVRT to vaginal cuff mucosa surface.

[chemoimmunotherapy]

  • 2023-08-01 - paclitaxel 175mg/m2 200mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
  • 2023-05-30 - paclitaxel 175mg/m2 235mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 650mg NS 250mL 1.5hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
  • 2023-03-23 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 650mg NS 250mL 1.5hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
  • 2023-02-24 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr + bevacizumab 15mg/kg 650mg NS 250mL 1.5hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL

==========

2023-08-02

This patient refilled Eurodin (estazolam) and Lexapro (escitalopram) on 2023-07-10 issued by our psychosomatic medicine department and these drugs have been included in the active medication list without a reconciliation issue found.

2023-03-24

  • Laboratory results from 2023-03-24 showed that the patient’s liver and kidney function, albumin and electrolyte levels were grossly normal, with the exception of slightly lower blood cell counts. However, the levels are still within an acceptable range to continue chemotherapy.
  • The patient was not found to need to reconcile her medications.

700610703

230801

==========

2023-08-01

[fluconazole dosing for HD patients]

For patients undergoing intermittent (thrice weekly) hemodialysis, whether intravenous or oral fluconazole is used, the dosing should be administered three times a week after each dialysis session. No dosage adjustment is required for indication-specific loading/initial or maintenance doses recommended in the adult dosing section. However, it is important to administer maintenance doses only three times per week on dialysis days after the dialysis session.

701453309

230801

[lab data]

  • 2023-01-27 HBsAg(nuclear medicine) Negative
  • 2023-01-27 HBsAg Value(nuclear medicine) 0.395
  • 2022-10-07 Anti-HBc Reactive
  • 2022-10-07 Anti-HBc-Value 4.33 S/CO
  • 2022-10-07 Anti-HBs 66.52 mIU/mL
  • 2022-10-07 HBsAg(quantitative) Nonreactive
  • 2022-10-07 HBsAg Value(quantitative) 0.00 IU/mL
  • 2022-10-07 Anti-HCV Nonreactive
  • 2022-10-07 Anti-HCV Value 0.09 S/CO
  • 2022-10-04 HBsAg(nuclear medicine) Negative
  • 2022-10-04 HBsAg Value(nuclear medicine) 0.415

[exam findings]

  • 2023-05-05 CT - abdomen
    • History: Bloody stool passage
      • 20220929 Low rectal cancer at right lateral from dentate line up to 4 cm above dentate line, T3N1aM1a, STAGE: IVA s/p chemoradiotherapy from 2022/10/17 to 2022/11/23
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
    • Findings: Comparison: prior CT dated 2022/09/30.
      • Prior CT identified two metastatic nodes in right internal iliac chain are noted again, stationary.
        • Prior CT identified one metastatic node in left posterior perirectal space is noted again, marked decreasing in size.
      • Prior CT identified wall thickening at right lateral aspect of the rectum is noted again, stationary.
      • Multiple gallstones are noted.
      • S/P hysterectomy.
    • IMP:
      • Prior CT identified two metastatic nodes in right internal iliac chain are noted again, stationary.
      • Prior CT identified one metastatic node in left posterior perirectal space is noted again, marked decreasing in size.
  • 2023-02-02 Colonoscopy
    • Rectal cancer s/p CCRT
    • Significant tumor regression
  • 2023-02-02 MRI - pelvis
    • Indication: Adenocarcinoma of low rectal with right interal iliac LNs metastasis, cT3N1aM1a, stage IVA s/p chemoradiotherapy from 2022/10/17 to 2022/11/23 (R/T from 2022/10/17 to 2022/11/23 to the pelvis for 45 Gy/ 25 fr, The rectal tumor and LAPs for 48.6 Gy/ 27 fr)
    • Findings: Comparison: prior CT dated 2022/09/30.
      • Prior CT identified two metastatic nodes in right interal iliac chain and one metastatic node in left posterior perirectal space are noted again, stationary.
      • Prior CT identified wall thickening at right lateral aspect of the rectum is noted again, stationary.
  • 2023-01-26 CT - abdomen
    • History and indication: low rectal cancer
    • IMP: Mild regression of rectal cancer and metastatic LAP.
  • 2023-01-26 CXR
    • Clear both lung field.
  • 2022-10-14 CXR
    • Solitary pulmonary nodule at RLL.
  • 2022-09-30 CT - abdomen
    • History: Bloody stool passage
      • 20220929 Low rectal cancer at right lateral from dentate line up to 4 cm above dentate line
    • Findings:
      • There is wall thickening at right lateral aspect of the low rectum, measuring 1.5 cm in wall thickness that is c/w adenocarcinoma (T3).
        • In addition, There is a lymph node measuring 1 cm in left lateral posterior aspect of the perirectal space that is c/w metastatic node (N1a).
        • There are two enlarged nodes 0.7 cm and 1.1 cm in right interal iliac chain that may be non-regional nodal metastases (M1a).
        • Please correlate with MRI.
      • Multiple gallstones are noted.
      • S/P hysterectomy.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N1a (N_value) M:M1a (M_value) STAGE:IVA(Stage_value)
  • 2022-09-30 Patho - colorectal polyp
    • Low rectal tumor, biopsy — Adenocarcinoma
    • Microscopically, the sections show a picture of adenocarcinoma characterized by cribriform or glandular tumor cell infiltrate with desmoplasia and focal necrosis.
    • Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor cells.
  • 2022-09-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (85.8 - 22.1) / 85.8 = 74.24%
      • M-mode (Teichholz) = 74
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Mild to moderate MR, mild TR and PR , trivial AR
    • No regional wall motion abnormalities

[MedRec]

  • 2023-04-06 SOAP Colorectal Surgery
    • A
      • The patient request NO surgery and keep follow up due to very old age
  • 2023-02-09 SOAP Colorectal Surgery
    • A
      • RT finished on 2022-11-23
      • Much regression of the tumor and suggest keep chemotherapy for disease control
      • Althogh the tumor is smaller but still fixed with the sphincter, Surgery may assosciated with a permanent colostomy, palliative CCRT and observation is another good choice for this patient.
  • 2023-01-19 SOAP Hemato-Oncology
    • Re-evaluation by 2023-01-26, OP in 2023-02
  • 2022-12-08 SOAP Hemato-Oncology
    • A/P: Consider FOLFOX (Minor) or biweekly HDFL (Major)
  • 2022-11-04 SOAP Radiation Oncology
    • Suggest CCRT then re-evaluation the cancer
    • Refer to GS for Port-A insertion
    • Arrange admission for CCRT with 5-FU on 2022-10-17
    • Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx.
  • 2022-10-06 SOAP Hemato-Oncology
    • A/P
      • Suggest CCRT then re-evaluation the cancer
        • Refer to GS for Port-A insertion
        • Arrange admission for CCRT with 5-FU on 2022-10-17

[chemoimmunotherapy]

  • 2023-07-31 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-28 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-31 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-05 - (FOLFOX)
  • 2023-04-14 - (FOLFOX)
  • 2023-03-20 - (FOLFOX)
  • 2023-03-01 - (FOLFOX)
  • 2023-01-30 - oxaliplatin 75mg/m2 115mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg/m2 3500mg 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3
  • 2022-12-30 - oxaliplatin 75mg/m2 115mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg/m2 3500mg 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3
  • 2022-12-15 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg/m2 3500mg 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3
  • 2022-11-11 - fluorouracil 225mg/m2 340mg 10min D1-D5 (CCRT)
    • dexamethasone 4mg D1-5
  • 2022-10-20 - fluorouracil 225mg/m2 340mg 10min D1-D5 (CCRT)
    • dexamethasone 4mg D1-5

==========

2023-08-01

The patient recently renewed her repeat prescription for Diovan (valsartan) to manage her primary hypertension at a local pharmacy on 2023-07-19. This medication is currently listed in the active formulary, and no reconciliation issues have been identified.

The most recent medical image was scaned on 2023-05-05 (abdomen CT). An update may be beneficial to reassess the current disease status.

2023-06-29

  • The patient regularly refills her prescription for Diovan (valsartan) for primary hypertension at a local pharmacy. This medication was accurately added to the active formulary and no reconciliation issues were identified.
  • It’s worth noting that the patient had prescriptions filled for respiratory medications for COVID-19, acute nasopharyngitis, and acute bronchitis on 2023-06-06, 2023-06-15, and 2023-06-21, respectively. These prescriptions were for short-term use and are no longer valid. Please continue to monitor for persistent respiratory symptoms.

2023-06-01

  • The patient consistently renews her Diovan (valsartan) prescription for her primary hypertension at a neighborhood pharmacy. This medication has been correctly added to the active medication list and there were no conflicts discovered during the medication reconciliation procedure.

2023-01-31

  • CT 2023-01-26 showed partial response.
  • The HBsAg retest result for 2023-01-27 was still negative after a period of approximately three months.

2022-11-14

  • Since late Sep 2022, all four serum bilirubin data points (direct and total) have exceeded the upper limit of normal range, and there were multiple gallstones being found on CT in September 2022. When there is no longer a concern about diarrhea, Dicetel (pinaverium bromide 100mg 1# BID) may provide relief from symptoms associated with functional disorders of the biliary tract.
  • The patient has one bowel movement a day, blood pressure within acceptable ranges, and the underlying conditions remain stable.
  • The active prescription is not subject to any issues.

700308626

230731

[exam findings]

  • 2023-07-29 CT - abdomen
    • Clinical history: 59 y/o female patient with RLQ (VAS 4-7). Hx of samll intestine GIST with liver and spleen metastasis.
    • With and without contrast enhancement CT of abdomen–whole:
      • Mutiple low density liver tumors in both lobes of liver(up to 2.5cm), r/o liver metastasis.
      • Multiple soft tissue tumors (up to 11.4cm) in right subphrenic region and right lower abdomen, r/o metastasis.
      • R/O tumor invasion of right kidney.
      • Unremarkable change of the spleen, pancreas and left kidney.
      • No enlarged lymph node in the paraaortic region.
      • Presence of ascites.
    • Impression:
      • Clnical history of small bowel GIST.
      • Liver metastasis, multiple peritoneal metastasis (mainly in right) and ascites, with invasion of right kidney.
  • 2019-01-30 SONO - abdomen
    • CC: right upper to middle abdominal pain
    • Findings
      • Liver: The liver parenchyma is homogenous. A heterogenous mixed echoic lesion with hypoechoic rim: size 4.7cm, at right lobe: metastatic tumor or primary liver tumor both considered.
      • Gallbladder and bile ducts: some gallstones: size up to 0.6-0.7cm
      • Others: a mixed echoic lesion in right abdomen, adjacent to right kidney and liver, size about 6.3cm
    • Diagnosis
      • liver tumor: cause to be considered
      • gallstones
      • suspect intra-abdominal tumor or focal inflammation in right abdomen
    • Suggestion
      • suggest admission for treatment and emergent CT scan: but patient hesitated: she requested for the second opinion at TMUH, suggest go to ER of TMUH, suggest her go to ER directly because of acute abdominal pain
  • 2018-09-19 Mammography
    • Screening Digital mammography of both breasts with MLO and CC views:
    • Old mammographic study: 2012-7-17 (BIRADS 0)
      • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
      • There are benign calcifications in bilateral breasts.
      • Bilateral axillary lymph nodes.
    • Impression: Dense breast.
      • Benign calcifications in bilateral breasts.
    • BI-RADS: Category 2

[MedRec]

  • 2023-07-18 SOAP Hemato-Oncology Xia HeXiong
    • S
      • Hx of Jejunal GIST s/p LPS excision of intestial tumor and resection of inerinal tumor on 2015-02-10, pT3N0M0, Stage II
        • s/p imatinib from 2015-03 to 2019-03
        • s/p liver mets -> RFA x 4 on 2020-04-21
        • s/p intra-abdominal recurrence GIST, LPS tumor eccision on 2020-05-12
        • s/p LIver mets and LPS S6/7 hepatectomy and peritoneal nodule resection on 2021-05-28
        • s/p liver and peritoneal mets, then sunitinib 3# from 2023-03-27 to 2023-07-14
    • O
      • CT in 2023-07: Disease in progression
      • s/p imatinib and sunitinib -> PD
    • P
      • Apply regorafenib
  • 2019-01-30 SOAP Gastroenterology
    • S
      • RUQ to RMQ pain for 3-4 days
      • dull pain with fullness sensation. without vomiting.
      • nausea (-)
      • fever yesterday, the day before yesterday
      • explained high CRP: we’ve suggested admission for thorough exam, IV antibiotic, close observation.
      • patient denied pregnancy
      • constipation sometimes. denied tarry/bloody stool; denied dysuria
      • we’ve informed the patient and family: if symptoms recur or aggravate: should back to OPD or ER immediately
      • suggest admission for treatment and emergent CT scan but patient and her family hesitated: they requested to go to TMUH. Direct referral to the Emergency Department has been recommended.
    • O
      • history of small bowel GIST post surgery in TMUH. Last follow-up (TMUH) 6 months ago
      • abd echo on 1/30 PM
      • PE abd soft tenderness at RUQ to RMQ area. no muscle guarding; no rebound pain.
    • Diagnosis
      • right upper quadrant pain [R10.11]
      • small bowel GIST post surgery [C17.9]

==========

2023-07-31

[medication reconciliation]

The patient was prescribed famotidine, cyanocobalamin, and betamethasone on 2023-07-28 for a 7-day duration at JingMei Hospital to address her malignant neoplasm of the small intestine. However, these medications are currently not included in the active medication list. It is advised to review whether they are still necessary for the patient’s current condition.

700357530

230731

[exam findings]

  • 2023-06-10 Bladder sonography
    • PVR: 44.2 ml
  • 2023-06-10 Urology SONO - kidney
    • CC:
      • Bladder lymphoma s/p TUR-BT, pathology proven lymphoma
      • repeat TUR-BT revealed bladder lymphoma,
      • Under C/T for lymphoma
    • Diagnosis:
      • Grossly normal, bilateral kidneys
  • 2023-05-30 CT - abdomen
    • Clinical history: 81 y/o male patient with Triple diffuse arge B cell lymphoma with urinary bladder wall,gastric wall, distal descending colon, and sigmoid colon, left upper neck, bilateral pulmonary hila, and right lower paratracheal area, involvement, Lugano stage I.
    • With and without contrast enhancement CT of abdomen - whole:
      • Liver cysts, up to 5.5cm in S2 liver.
      • Aneurysmal dilatation of distal abdominal aorta.
    • Impression:
      • Clinical urinary bladder diffuse arge B cell lymphoma. Suggest follow up.
      • Liver cysts.
      • Aneurysmal dilatation of distal abdominal aorta.
  • 2023-05-01, -04-06, -02-15 CXR
    • Enlargement of cardiac silhouette.
  • 2023-03-18 Bladder sonography
    • PVR: 32.3 ml
  • 2023-02-17 Patho - colorectal polyp
    • Colorectum, cecum, s/p cold snare polypectomy (A) — Hyperplastic polyp
    • Colorectum, transverse colon, 55cm AAV, s/p cold snare polypectomy (B) — Hyperplastic polyp
    • Colorectum, transverse colon, 50cm AAV s/p cold snare polypectomy (C) — Tubular adenoma with low grade dysplasia
    • Colorectum, descending colon, s/p biopsy removal (D) — Tubular adenoma with low grade dysplasia
  • 2023-02-17 Patho - stomach biopsy
    • Stomach, angle, s/p biopsy (A) — Chronic gastritis with intestinal metaplasia, H pylori NOT present
    • Stomach, GC site of middle body, s/p biopsy (B) — Ulcer, H pylori and candida present
  • 2023-02-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (101 - 27) / 101 = 73.27%
      • LVEF(%) = 73
      • M-mode (Teichholz) = 73
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated LA; LV diastolic dysfunction Gr 2.
      • Normal RV systolic function.
      • Mild AR; mild MR; mild TR; mild PR.
  • 2023-02-13 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — No evidence of lymphoma involvement
    • The sections show normocellular marrow (25%). M/E ratio = 3:1. The myeloid cells show good maturation. The megakaryocytes are normal in number and morphology. No lymphoid aggregates can be found. No increased blasts in CD34 and CD117 immunostains. Scattered CD3+ small T lymphocytes, and CD20+ and/or CD79a+ small B-cells in interstitium can be identified. There is no evidence of large B-cell lymphoma involvement in the sections examined. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2023-02-11 Bladder sonography
    • PVR: 83.2 ml
  • 2023-02-07 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
  • 2022-08-04 CT - abdomen
    • History and indication: Bladder cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P foley catheter indwelling. Collapse of urinary bladder with wall thickening. Fat stranding with some air in periventricular region r/o rupture. Several LNs at pelvic cavity.
      • Some tiny nodules at bil. lungs r/o metastases.
      • Liver cysts (up to 5.1cm).
      • Mild dilatation of infrarenal abdominal aorta (3.7cm).
      • Atherosclerosis of aorta, iliac arteries.
    • Imaging Report Form for Urinary Bladder Carcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N2(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
  • 2022-08-03 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
      • Tumor type: Mixed high grade urothelial carcinoma and diffuse large B cell lymhpoma
      • Tumor location: urinary bladder
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark ULTRA
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: [V]Pass, [ ]Fail
      • Adequate tumor cells present (>=50 viable tumor cells): [V] Yes, [ ] No
    • Result:
      • Tumor cell (TC) staining assessment:
        • TC category:TC < 1%
        • Percentage of PD-L1 expressing tumor cells (%TC): <1%
      • Tumor-infiltrating immune cell (IC) staining assessment:
        • IC category: IC >=1% and <5%
        • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): <5%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2022-08-03 PD-L1 IHC
    • PD-L1 Immunostaining Result
      • Tissue blocks/unstained slides received labeled as: S2022-12650A1
      • Testing assay: 28-8 pharmDx Assay (Agilent/Dako)
      • Control slide result: [V]Pass
      • Adequate tumor cells present (>= 100 viable tumor cells): [V]Pass
    • Result:
      • Tumor cell (TC) staining assessment: TC < 1%
      • Percent of PD-L1 expression in tumor cells (TC): 0%
  • 2022-08-03 PD-L1 22C3
    • PD-L1 Immunostaining Result
      • Tissue blocks/unstained slides received labeled as: S2022-12650A1
      • Testing assay: 22C3 pharmDx Assay (Agilent/Dako)
      • Control slide result: [V]Pass
      • Adequate tumor cells present (>= 100 viable tumor cells): [V]Pass
    • Result:
      • Combined Positive Score (CPS) assessment: CPS >= 10
      • Combined Positive Score (CPS): 15
  • 2022-08-03 Patho - urinary bladder TUR
    • PATHOLOGIC DIAGNOSIS
      • Tumor, urianry bladder, TURBT — Mixed invasive papillary urothelial carcinoma, high-grade and diffuse large B cell lymphoma
      • Muscularis propria — Free of tumor invasion
    • MICROSCOPIC EXAMINATION
      • Histologic type: Mixed invasive papillary urothelial carcinoma and diffuse large B cell lymphoma
      • Histologic grade: High grade
      • Tumor configuration: Papillary
      • Muscularis propria: Present and free
      • Lymphovascular invasion: Not identified
      • Microscopic tumor extension: Tumor invades subepithelial connective tissue
      • Immunohistochemistry:
        • Urothelial carcinoma: CK7(+), CK20(+, scatter), GATA-3(+), CD3(-) and CD20(-)
        • Malignant lymphoma: CD20(+), CD3(-), CD10(-), CD30(-), Bcl-2(+), Bcl-6(+), C-MYC(+, 60-70%), MUM-1(+) and Ki-97:>90%
  • 2022-08-02 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
  • 2022-08-02 CXR
    • Incrased density in right lower lung, suggest chest CT for further study.
    • Plate atelectasis in left lower lung.
  • 2022-07-07 Transrectal Ultrasound of Prostate - TRUS-P
    • CC
      • 2022/07/07 recurred hematuria with blood clot
      • 2022/06/16 keep Tx
      • 2022/03/24 nocturia (several times at learly beginning and improved after SLEEP PILLS)
      • 2021/12/30 for report and improved hematuria now
      • 2021/12/20 gross hematuria with blood and visited ER
      • 2021/12/02 urinary burning sensation
      • low abd discomfort on foley at ER, no AUR?
      • hematuria now
      • nocturia 4-5 with voiding difficulty for a while
      • BPH on med at Cathay H and Sutien for 1 year
      • BIH s/p op 10 years ago here
    • Diagnosis:
      • Benign prostatic hyperplasia

[consultation]

  • 2021-11-17 Urology
    • Q
      • for acute urine retension with hematuria
      • He was admitted due to # CAD s/p Robotic CABG x1 on 2021/11/12. Suddent AUR s/p foley insertion. We need your help for further care.
      • Hx of enlarged prostate with lower urinary tract symptoms status post transurethral resection of the prostate on 2020/07/29
    • A
      • This 80yo male received CABG on 2021-11-12.
        • Aspirin +
        • AUR was noted this morning and a 18 Fr. 2-way Foley was inserted.
        • Gross hematuria was noted after Foley. Blood clots (+)
        • active ozzing now (+), manual irrigation: some littile blodd clots
      • Plan:
        • continuous irrigation
        • if Foley obstructed, then consider manual irrigation and 22 Fr. 3-way Foley
  • 2021-10-24 Cardiology
    • Q
      • Suspected cardiac chest pain/chest discomfort with cold sweats
        • noted since 9AM today, lasting for around half an hour
        • feeling better now
        • chronic cough also noted
        • no fever
        • deny chest/abdomen/back pain
        • 2021/09/23 2nd dose Moderna
      • PH: HTN; BPH s/p op ; chronic insomnia
      • NKA
    • A
      • SUFFERED from PSVT a few months before.
        • This time, came for different symptom and chest tightnes spontaneous resolved
        • At ER, his ECG showed sinus rhythm and gradual trop-I elevation noted.
        • Bedside echo: normal LV wall motion
      • Suggestion:
        • could be and not excluded NSTEMI
        • recommended empirical DAPT (Aspirin / Plavix) and Q8H trop-I follow up

[immunochemotherapy]

  • 2023-07-03 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
    • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-05-29 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
    • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-05-02 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
    • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-04-06 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
    • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-03-13 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
    • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-02-20 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
    • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2022-08-04 - mitomycin-C 30mg/m2 30mg BI 1hr

==========

2023-07-31

On 2023-06-10, our urologist wrote a 3-time refill prescription (valid for 84 days) for Harnalidge (tamsulosin) and Betmiga (mirabegron). Additionally, on 2023-06-12, our cardiac surgeon issued a 3-time repeat prescription (also valid for 84 days) for Blopress (candesartan), Bokey (aspirin), Concor (bisoprolol), Eurodin (estazolam), and Crestor (rosuvastatin). These medications have been included in the active medication list, and no reconciliation issues have been identified.

2023-07-03

In accordance with the PharmaCloud database, this patient has only been a patient of our hospital for the last 3 months. In addition to our hemato-oncology department, our urologist prescribed Harnalidge (tamsulosin) and Betmiga (mirabegron) on 2023-06-10. In addition, our cardiac surgeon prescribed Blopress (candesartan), Bokey (aspirin), Concor (bisoprolol), Eurodin (estazolam), and Crestor (rosuvastatin) on 2023-06-12. These medications have been accurately added to the list of active medications and no discrepancies have been identified in the reconciliation.

700061972

230728

[exam findings]

  • 2023-07-17 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Abnormal ECG
  • 2023-06-23 Patho - oral cancer (wide excision + lymph node)
    • PATHOLOGIC DIAGNOSIS
      • Tumor, left tongue, wide excision — Squamous cell carcinoma
      • Resection margins — Free of tumor invasion
        • Deep margin, left, frozen section (F2023-00293) — Free of tumor invasion
      • Lymph nodes
        • Lymph node, bilateral level Ia, dissection — Free of tumor metastasis (0/6)
        • Lymph node, left level Ib, ditto — Free of tumor metastasis (0/1)
        • Lymph node, left level III, ditto — Free of tumor metastasis (0/3)
        • Lymph node, left level IIa+III, ditto — Free of tumor metastasis (0/3)
      • Salivary gland, left level Ib — Free of tumor invasion
      • AJCC Pathologic staging — pT3N0, if cM0, stage III
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure(s): wide excision
      • Specimen Type:
        • Main location: tongue
        • Other part(s) included: N/A
        • Lymph node dissection: Yes
      • Specimen Integrity: Intact
      • Specimen Size: 5 x 3.9 x 2.3 cm
      • Tumor Site: left tongue
      • Tumor Focality: solitary
      • Tumor Size: 2.2 x 2.1 cm
        • Tumor thickness: 1.3 cm
      • Mucosal Surface: elevated tumor
      • Gross Tumor Extension (specify) : 1.3 cm in depth
      • Salivary gland at level Ib: 3.7 x 2.8 x 1.7 cm
      • Representative sections as follows: A: bilateral level Ia LN, B1: left level Ib LN, B2: salivary gland at level Ib, C:left level III LN, D: left level IIa+III LN, E1, E3 and E5: tumor + anterior margin + base, E2, E4 and E6: tumor + posterior margin, E7: tumor + medial margin, E8:-E10: tumor + lateral margin [Reference: Frozen section: F2023-00293FS left deep margin, one small piece of muscle tissue measured 1.1 x 0.9 x 0.3 cm in size]
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Squamous cell carcinoma
      • Histologic Grade: G2, moderately differentiated
      • Microscopic Tumor Extension: 1.3 cm in depth
      • Margins: Free, 0.6 cm from base, 0.7 cm from anterior, 2.0 cm from posterior, 0.5 cm from medial and 0.4 cm from lateral margin
      • Lymph-Vascular Space Invasion: Not identified
      • Perineural Invasion: Present
      • Neck Lymph Nodes: free of tumor metastasis (0/13) in total number
  • 2023-06-21 ECG
    • Sinus rhythm with 1st degree A-V block
    • Inferior infarct, age undetermined
    • Poor wave progression
    • Abnormal ECG
  • 2023-06-12 Nasopharyngoscopy
    • smooth NPx, OPx, HPx
    • fair inf. turbinate, with clear mucus
    • 3 cm protruding mass with ulcer over left posterior tongue, with suture
  • 2023-05-26 Tc-99m MDP bone scan
    • Mildly increased activity in the middle C-spine and lower L-spines. Degenerative change may show this picture.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture. Please correlate with other clinical findings for further evaluation.
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips, right knee and right foot, compatible with benign joint lesions.
  • 2023-05-24 Patho - tongue biopsy
    • Labeled as “left dorsal tongue”, incisional biopsy — squamous cell carcinoma.
    • IHC stain: p16 (-).
  • 2023-05-23 MRI - nasopharynx
    • Findings: Left dorsal ventral tongue tumor mass, extending to right, up to 31mm, seems with extrinsic muscle invasion (likely the styloglossus).
    • IMP: Left tongue CA, T4aN0M0 stage IVA.
    • Oralcavity - Impression (Imaging stage) : T:4A N:0 M:0 STAGE:IVA

[MedRec]

  • 2023-06-21 ~ 2023-07-11 POMR Ear Nose Throat
    • Course of inpatient treatment
      • ENT ward 6/21-23
        • After admission, pre-operative evaluation was done. We also consulted plastic surgeon for free flap reconstruction. Operation was perforemed on 6/23, and he was tranferred to intensive care unit after operation.
      • ICU 6/23-24
        • During SICU, under Pain control with Fentanyl titration, Tracheostoym with ventilator support. After when patient conscious recover to clear, try weaning ventilator to T-mask use it well. Today, try on EN feeding with NG diet 1000 kcal/day, due to stable hemodynamic condition and pulmonary condition, we arrange transfer this patietn to ENT ward for care.
      • ENT ward 6/24-7/11
        • We removed foley catheter and femoral CVC smoothly on 6/27, and shifted antibiotics from Cefmetazole IVD to Cefaclor PO from 6/30. We removed JP drain and shifted tracheostomy from low pressure to shiley on 7/03, and removed suture over left neck surgical wound on 7/04. Under stable condition, he will be discharged on 7/10, and outpatient depatment following up will be arranged then.
    • Discharge prescription
      • Biomycin Ointment (neomycin, tyrothricin) QD TOPI
      • Parmason Gargle Solution (chlorhexidine) TID GAR
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
      • Through (sennoside 12mg) 2# HS
      • MgO 250mg 1# Q6H
      • Cero (cefaclor monohydrate 250mg) 2# Q8H
  • 2023-05-22 ~ 2023-05-27 POMR Oral and Maxillofacial Surgery
    • Discharge diagnosis
      • squamous cell carcinoma of the left posterior tongue (near lingual tonsil) (cT4aN0M0, MRI images)
      • infection of the tongue
      • Old cerebrovascular accident with left hemiparesis
      • Parkinson’s disease
      • Hypertensive heart disease without heart failure
      • Enlarged prostate with lower urinary tract symptoms
      • Paroxysmal atrial fibrillation
      • Primary insomnia
      • Unspecified kidney failure
      • Parenchymal liver disease
      • Splenomegaly
      • Gout, unspecified
    • CC
      • I had A painful red lump at my left tongue for few weeks.
    • Present illness
      • According to his statement, this 56-year-old male patient had history of the left tongue cancer after operation and oral chemotherapy for 20+ years in ShinKong Hospital. He did not go to ShinKong Hospital for regular opd follow-up. lately, he noted a mass lesion at his left tongue for few weeks. He visited to our Oral and Maxillofacial Surgery clinic on 2023/05/16, where an ulcerative, red malignant lesion at the left posterior tongue (near lingual tonsil) was noted. His panoramic film showed no bone destruction by tumor but periodontal bone loss. Because a malignancy tongue lesion was highly suspected, we had to do a biopsy for him. Unfortunately, trismus and posterior location of this malignant lesion were noted. After we explained his treatment plans to the patinet, he was admitted for tumor survey and further surgical management.
    • Course of inpatient treatment
      • During the hospitalized time, he underwent nasopharynx MRI examinaton on 05/23, which shows tumor size over 4cm with DOI over 10mm. No regional nodal metastasis was noted. Then the biopsy of left tongue under general anesthesia was performed on 2023/05/24. Empirical antibiotic agent with cefazolin were prescribed. Along with algesic agent for surgical wound pain control. Mouth care and mouth gargling with Parmason solution Q3H and PRN was educated.
      • Because his general condition was acceptable after the operation. After his abdomen sona on 05/25 and whole body bone scan on 05/26 were done and showed no tumor metastasis. He was discharged on 2023/05/26.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ4H
  • 2023-05-18 SOAP Urology
    • Diagnosis
      • Enlarged prostate with lower urinary tract symptoms [N40.1]
    • Prescription
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Doxaben XL (doxazosin 4mg) 1# QD
      • Betmiga (mirabegron 50mg) 1# QD
    • ChatGPT
      • Doxazosin and Mirabegron can be coadministered in the management of urinary symptoms, particularly in the context of conditions like benign prostatic hyperplasia (BPH) and overactive bladder (OAB).
      • Doxazosin is an alpha-1 adrenergic receptor blocker used to relax the smooth muscles of the prostate and bladder neck, which can improve urine flow and decrease symptoms of BPH. It can also be used in hypertension as it relaxes blood vessels.
      • Mirabegron is a beta-3 adrenergic receptor agonist used to treat overactive bladder (OAB) symptoms. It works by relaxing the detrusor muscle during the storage phase of the bladder fill-void cycle, leading to increased bladder capacity.
  • 2019-07-25 SOAP Urology
    • Prescription
      • Doxaben XL (doxazosin 4mg) 1# QD
  • 2019-06-17 SOAP Urology
    • Diagnosis
      • Enlarged prostate with lower urinary tract symptoms [N40.1]
    • Prescription
      • Harnalidge (tamsulosin 0.4mg) 1# HS
  • 2019-05-25 SOAP Orthopedics
    • Prescription x3
      • Arcoxia (etoricoxib 60mg) 1# QD
  • 2019-04-22 SOAP Orthopedics
    • S: left toe pain during walking
    • O: mild swelling and ecchymosis, imflammatory sign+
    • Prescription
      • Celebrex (celecoxib 200mg) 1# QD
      • colchicine 0.5mg 1# QD
  • 2017-10-24 SOAP Neurology
    • Diagnosis
      • Nontraumatic intracerebral hemorrhage in hemisphere, subcortical [I61.0]
      • Parkinsonism [G21.4]
    • Prescription x3
      • Madopar (levodopa, benserazide; 250mg) 0.5# QID
  • 2017-01-18 SOAP Cardiology
    • Diagnosis
      • HCVD, unspecified, without CHF [I11.9]
      • Unspecified late effect of cerebrovascular disease [I69.90]
      • Peristent disorder of initiating or maintaining sleep [F51.01]
      • Gout, unspecified [M10.9]
      • Mixed hyperlipidemia [E78.2]
    • Prescription x3
      • Modipanol (flunitrazepam 1mg) 1# HS
      • Ancogen (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNBID
      • Through (sennosides 12mg) 2# HS
      • Bokey (aspirin 100mg) 1# QD
      • Pitator (pitavastatin 2mg) 1# QN
      • Blopress (candesartan 8mg) 1# QD
      • Euricon (benzbromarone 50mg) 1# QD
      • Adalatoros (nifedipine 30mg) 1# QD

[consultation]

  • 2023-07-07 Oral and Maxillofacial Surgery
    • A
      • we are consulted prior to postoperative radiotherapy
      • poorly-fitted bridge of right lower tooth was pulled out along with previous cancer ablation surgery.
      • the rest of the dentition was in acceptable condition

[surgical operation]

  • 2023-06-23
    • Surgery
      • resurface of mucosal defect of left oral base with tongue flap
    • Finding
      • missing at least left 3/5 of the tongue and most of its inner muscles
      • 9cm X 5cm mucosal defect over left oral base and tongue base
      • Although free flap was palnned, the tongue flap was thought to be OK to fill the intra-oral defect; so the remaining part of the tongue after cancer ablasion was used to form a flap.
      • a 10F JP drain was placed over left-anterior neck fro post operative drainage
    • Procedure
      • after cancer ablasion, re-drape the patient
      • design, elevation, and transposition of the flap
      • suture inset of the flap
      • placement of the JP drain
      • closure and dressing of the wound of the neck
  • 2023-06-23
    • Surgery
      • Composite resection of oral cancer, left
      • Glossectomy, near-total
      • Selective neck dissection, left (level Ia, Ib, IIa, III)
      • Tracheotomy
    • Finding
      • MRI = tongue cancer, left, cT4aN0
      • floor-of-mouth in communication with neck, left posterolateral (mylohoid and digastric muscle were meticulously preserved since no gross invasion of cancer could be identified)
      • left lingual nerve, CN 12, sacrifice
      • left lingual artery ligated
      • right lingual artery ligated
      • frozen section (deep margin)= free from tumor
      • carotid bifurcation, IJV, superior thyroid artery exposed after dissection
      • enlarged LN over L level IIa
      • poor oral hygiene with caries (foul smell), yet all the teeth were not loose
  • 2023-05-24
    • Surgery
      • Soft tissue biopsy (92067C * 1)
      • Complicated tooth extraction of #47 (92014C * 1)
      • Removal of casting crown of #45 (90007C * 1)
    • Finding
      • An ulcerative malignant-like lesion on the left posterior tongue
      • Underbridge deep caries of #47

==========

2023-07-28

[reconciliation]

Our hospital is the only medical provider for this patient according to the PharmaCloud database, no medication reconciliation issues identified.

[tube feeding]

Betmiga (mirabegron) is a long acting formulation, it is not recommended to crush or halve for tube feeding. As the effect of mirabegron 50mg is approximately equivalent to that of propiverine 30mg, it is recommended to switch to Urotrol (propiverine 15mg), 1# BID for tube feeding. Doxaben XL (doxazosin) is a sustained-release formulation. It is suggested to consider switching to Urief (silodosin) as an alternative to Doxaben.

700062834

230728

[diagnosis] - 2023-04-06 admission note

  • Double hit, diffuse large B cell lymphoma, non-germinal center type with right oropharynx involving and mediastinal lymphadenopathy, stage II, Lugano stage II, IPI score:2 s/p chemotherapy with R-CHOP from 2023/03/17
  • Insomnia, unspecified
  • Chronic viral hepatitis B without delta-agent
  • Hypothyroidism, unspecified

[past history]

  • Hypothyroidism history without drug control
  • DM(-), HTN(-)   

[allergy]

  • NKDA     

[family history]

There is no family history of cancer, diabetes, hypertension, mental diseases or asthma.

[exam findings]

  • 2023-07-06 CT - chest
    • Indication: Double hit, diffuse large B cell lymphoma, non-germinal center type with right oropharynx involving and mediastinal lymphadenopathy, stage II, Lugano stage II, IPI score:2 s/p chemotherapy with R-CHOP from 2023/03/17~
    • Chest CT with and without IV contrast ehnancement shows:
      • Lower neck :
        • Regression of the lymphadenopathy at right neck is found.
        • Patent airway is found.
      • Chest:
        • Small lymph nodes are found at paratracheal region. In comparison with CT dated on 2023-03-10, the lesions are stationary.
        • The lung fields are clear.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • No evidence of abnormal soft tissue mass at pelvic cavity.
        • No definite inguinal or pelvic sidewall LAP
        • Non-specific bowel gas at abdominal cavity is found.
    • Imp:
      • Marked regression of right neck lymphadenopathy.
      • No residual lymphadenopathy at right neck is found.
      • Small lymph nodes at mediastinum. Stable.
  • 2023-03-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (110 - 32) / 110 = 70.91%
      • M-mode (Teichholz) = 71
    • Conclusion:
      • Normal LV filling pressure.
      • Normal LV and RV systolic function
      • Mild aortic valve sclerosis; trivial MR
  • 2023-03-15 CXR
    • Spondylosis of the T-spine
  • 2023-03-14 PET scan
    • The FDG PET findings are compatible with lymphoma involving the right nasopharynx, soft palate, right oropharynx and in a large confluent area with some small adjacent focal areas in the right parotid region and right neck level II to V regions.
    • Mildly increased FDG uptake in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-03-10 CT - chest
    • oropharyngeal lymphoma, for cancer work up
    • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Visible neck
        • Huge necrotic soft tissue mass at right neck with extension into oral cavity measuring 10.3cm is found.
      • Chest:
        • Mild centrilobular Emphysematous change over both lungs is found.
        • Lymphadenopathy at bilateral paratracheal and AP window is found.
          • ChatGPT: AP window in CXR stands for “anterior-posterior window”, which is an area seen on the front to back view of a chest X-ray. It refers to the space between the aortic arch and the left pulmonary artery, which can be obscured by structures such as the trachea or mediastinal lymph nodes. Abnormalities in the AP window can indicate the presence of tumors, enlarged lymph nodes or other pathologies.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • No evidence of abnormal soft tissue mass at pelvic cavity.
        • No definite inguinal or pelvic sidewall LAP
        • Suggest clinical correlation
    • Imp:
      • Extensive right neck mass with mediastinal lymphadenopathy.
      • Mild COPD.
  • 2023-03-09 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
    • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
    • IHC stains: CD3 <5% and CD20: <5% and no predoimnant subpopulation. (of the nucleated cells).
  • 2023-03-09 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-03-01 Patho - nasopharyngeal/oropharyngeal biopsy
    • Labeled as “right oropharynx”, biopsy — B cell lymphoma.
    • Section shows soft tissue with diffuse infiltration of paternless round blue neoplastic cells.
    • IHC stains: CK (-), CD3 and CD20: a predominant B cell sub-population. Bcl-2 (+), bcl-6 (+, >30%), MUM-1 (+, >30%), c-myc (-), CD10(-), Ki-67: 90%, cyclin-D1 (-), CD23 (-), a pattern of diffuse large B cell lymphoma, non-germinal center type.
  • 2023-02-27 Nasopharyngoscopy
    • Findings
      • smooth NPx; boggy inf. turbinate with clear mucus
      • smooth bulging over right lateral pharyngeal wall; granular tumor at right soft palate, right anterior and posterior
      • pillar, right tonsillar fossa; biopsy from right tonsilar fossa done; right RMT smooth bulging
    • Diagnosis/Conclusion
      • right oropharyngeal tumor, favor malignancy, biopsy done

[consultation]

  • 2023-03-10 Hemato-Oncology
    • Q
      • for transferred for lymphoma evaluation
      • This is a 57-year-old man with past history of hypothyroidism.
      • This time, he was admitted to our ward for right neck mass and right oropharyngeal tumor. Pathology report for oropharyngeal lesion revealed B cell lymphoma. We need your expertise for further examination suggestion and possible taking over.
    • A
      • This 57 year old man is a case of B cell lymphoma, pending IHC stain. Initial presentation was progressive painless right neck mass for 2 months, accompanying with right side otalgia and lumping throat. He has underline of hypothyroidism under levothyroxine treatment. We are consulted for lymphoma treatment.
      • Please arrange PET CT scan, CT scan of neck extending chest, abdomen to pelvis and bone marrow for complete staging. Transfer to 11A on Dr Xia service.

[chemoimmunotherapy]

  • 2023-07-27 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3
  • 2023-07-07 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3
  • 2023-06-09 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3
  • 2023-05-08 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3
  • 2023-04-07 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3
  • 2023-03-17 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3

==========

2023-07-28

Based on the PharmaCloud database, we see that the patient has only visited our hemato-oncology department in the last 3 months. As a result, no medication reconciliation issues are identified for this admission.

2023-06-09

  • A leucopenia episode occurred on 2023-05-18, just ten days following the initiation of the 3rd cycle of the R-CHOP regimen on 2023-05-08. The patient was treated with Granocyte (lenograstim 250ug) for 3 consecutive days starting on 2023-05-18. Since then, no further instances of leucopenia have been detected.
    • 2023-06-09 WBC 5.23 x10^3/uL
    • 2023-05-25 WBC 7.25 x10^3/uL
    • 2023-05-18 WBC 1.33 x10^3/uL
    • 2023-05-08 WBC 5.66 x10^3/uL
    • 2023-04-25 WBC 9.45 x10^3/uL
    • 2023-04-20 WBC 5.48 x10^3/uL
  • The risk of febrile neutropenia with R-CHOP regimen is 10 to 20%; primary prophylaxis with hematopoietic growth factors might be considered on an individual basis, particularly for high-risk patients such as those with preexisting neutropenia, advanced disease, poor performance status, or patients age 65 years or older.

2023-04-10

  • Leucopenia was observed on 2023-03-28, the 11th day since the start of the first R-CHOP regimen on 2023-03-17. Granocyte (lenograstim) was administered for 3 consecutive days starting on the observed day. The patient’s WBC count should be closely monitored 1 to 2 weeks after the start of the second dose, which was administered on 2023-04-07.
    • 2023-04-06 WBC 12.36 x10^3/uL
    • 2023-03-28 WBC 1.09 x10^3/uL
    • 2023-03-20 WBC 7.21 x10^3/uL
    • 2023-03-18 WBC 6.23 x10^3/uL
    • 2023-03-16 WBC 9.96 x10^3/uL
    • 2023-03-13 WBC 10.03 x10^3/uL
    • 2023-03-08 WBC 10.82 x10^3/uL
  • Rapid weight loss
    • The patient has recently experienced rapid weight loss, from 50.6 kg on 2023-03-09 to 46.3 kg on 2023-04-06. To address this issue, it is recommended that the patient’s nutritional intake be increased. If there is no dysphagia, megestrol can be used as an appetite stimulant at a dose of 200 to 600 mg/day to alleviate anorexia.
  • Constipation
    • Based on the TPR panel indicating no bowel movement for three consecutive days (2023-04-06 to 2023-04-08), it is recommended to rule out the possibility of ileus.
    • For functional constipation or fecal impaction
      • Suppositories:
        • For treatment of defecatory dysfunction, we favor an initial trial of suppositories (glycerin or bisacodyl) since suppositories can be effective in liquifying stool and thereby overcoming obstructive defecation.
      • Disimpaction:
        • Patients with a fecal impaction (a solid immobile bulk of stool in the rectum) should initially be disimpacted starting with manual fragmentation if necessary. After this is accomplished, an enema with mineral oil will help to soften the stool and provide lubrication.
        • If disimpaction is unsuccessful or only partially successful, we may order a water-soluble contrast enema (Gastrografin or Hypaque) administered under fluoroscopy to assure absence of any obstruction and to eliminate more proximal impactions. Occasionally, fractionation of impacted stool beyond the reach of the finger must be accomplished using flexible or rigid sigmoidoscopy with instrumentation. The colon must then be thoroughly evacuated. This can be accomplished with daily warm water enemas for up to three days, or by drinking a balanced electrolyte solution containing polyethylene glycol (PEG) until cleansing is complete.

700601390

230728

[exam findings]

  • 2023-05-19 CT - abdomen
    • 20230313 ATH + BSO + omentectomy + BPLND + vaginectomy.
      • PATHOLOGIC DIAGNOSIS
        • Ovary, left: Endometroid carcinoma, FIGO grade 3
        • Endometrium, uterus: Endometroid carcinoma, FIGO grade 2
        • Lymph nodes, pelvic and para-aortic: Negative for malignancy (0/78)
        • Pathology stage: pT1c2N0; stage IC (ovary); and stage IA (endometrium)
    • Findings:
      • There are three kissing cystic lesions in left lateral pelvis and one cystic lesion in right lateral pelvis that may be lymphocele.
      • There is mild fatty stranding of the mesentery at the pelvis.
      • S/P hysterectomy
      • S/P catheter insertion from right upper pelvic wall and the tip located at the dependent portion of the lower pelvis for HIPAC. please correlate with clinical history.
    • Impression:
      • There are three kissing cystic lesions in left lateral pelvis and one cystic lesion in right lateral pelvis that may be lymphocele.
      • There is mild fatty stranding of the mesentery at the pelvis.
      • Follow up is indicated.
  • 2023-03-14 Patho - uterus (with or without SO) neoplastic
    • PATHOLOGIC DIAGNOSIS
      • Ovary, left, staging surgery — Endometroid carcinoma, FIGO grade 3
      • Endometrium, uterus, staging surgery — Endometroid carcinoma, FIGO grade 2
      • Lymph nodes, pelvic and para-aortic, bilateral, BPLND — Negative for malignancy (0/78)
      • AJCC 8 th edition, Pathology stage: pT1c2N0; stage IC (ovary); and stage IA (endometrium)
    • MACROSCOPIC EXAMINATION
      • Procedure: ATH + BSO + infracolic omentectomy + BPLND + para-aortic LN dissection + vaginectomy
      • Specimen Size: 7.5 x 4.6 x 2.4 cm (Lt ovary, received for frozen section), 5.5 x 0.6 cm (Lt tube), 3.2 x 2.5 x 2.2 cm (Rt ovary), 6.0 x 0.9 cm (Rt tube), 12.0 x 8.0 x 5.0 cm (uterus), 6.0 x 4.0 x 3.0 cm (vagina), 28 x 12 x 3.0 cm (omentum)
      • Specimen Integrity
        • Right ovary: Capsule intact
        • Left ovary: Capsule not intact
        • Right fallopian tube: Serosa intact
        • Left fallopian tube: Serosa intact
      • Tumor Site: Left ovary and endometrium
      • Ovarian Surface Involvement: Present
      • Fallopian tube Surface Involvement: Absent
      • Tumor Size: 7.5 x 4.6 x 2.4 cm (Lt ovary), diffuse thickening, up to 0.9 cm in thickness (endometrium)
      • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, right para-aortic and left para-aortic
      • Representative parts are taken for section and labeled as: F2023-00098FS and A2-A5= left ovary, A1= left fallopian tube. S2023-04575 A= left iliac LNs, B1-B2= left obturator LNs, C= right iliac LNs, D= right obturator LNs, E= left para-aortic, F= right para-aortic LNs, G1-G6= cervix, G7-G12= endocervix, G12-G27= uterine endometrium, G20= corpus, G29= right ovary, G30= right fallopian tube, H1-H4= vagina, I1-I2= omentum.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Synchronous endometroid carcinoma of ovary and endometrium
      • Histologic grade: Grade 3 (ovary) and grade 2 (endometrium)
      • Implants: Not identified
      • Other Tissue/Organ Involvement: Not identified
      • Peritoneal Fluid: Negative
      • Regional Lymph Nodes: All lymph nodes negative for tumor cells (0/78)
      • Pathologic Stage
        • Primary Tumor: pT1c2 (ovary, tumor ruptured) and pT1a (endometrium, tumor limit to endometrium)
        • Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
        • Distant Metastasis: Not applicable
      • FIGO Stage: Stage IC (ovary) and Stage IA (endometrium)
      • Lymphovascular invasion: Absent
      • Perineural invasion: Absent
      • Additional Pathologic Findings:
        • Cervix: Chronic cervicitis with Nabothian cysts and squamous metaplasia
        • Endometrium: Endometroid carcinoma
        • Myometrium: Leiomyoma
        • Ovary, right: Compatible with steroid cell tumor NOS (1.0 x 0.5 cm)
        • Fallopian tubes, bilateral: No remarkable change
        • Vagina: Chronic vaginitis
        • Omentum: No remarkable chang
      • IHC for ovarian tumor: ER(+), PR(+), WT1(-), Napsin A(-), p53 (aberrant exprssion)
  • 2023-03-13 Patho - stomach biopsy
    • Stomach, GC/AW site of low body (A), biopsy — Hyperplastic polyp
    • Labeled as “esophagus, 30cm below the insicor”, s/p biopsy(B) — papilloma
  • 2023-03-09 MRI - pelvis
    • Clinical history: 41 y/o female patient with Uterus, cervix, polypectomy — Adenocarcinoma.
    • With and without contrast enhancement MRI: Pelvis
      • There is cystic tumor, 6cm in left adnexa, with internal soft tissue, r/o left ovarian malignancy.
      • Diffuse endometrial thickening, hyperplasia or malignancy?
      • Focal tubular lesion in the endocervical region, protrusion from uterine body.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • Presence of ascites.
      • Nodularity at peritoneum, r/o carcinomatosis.
    • Impression:
      • Left ovarian cystic tumor, r/o ovarian malignancy.
      • Nodularity at peritoneum, r/o carcinomatosis.
      • Diffuse endometrial thickening, hyperplasia or malignancy, suggest further study.
      • Focal tubular lesion in the endocervical region, protrusion from uterine body. Nature?
      • Ascites.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T: T1a_(T_value) N: N0(N_value) M:M0(M_value) STAGE:IA__(Stage_value)
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T1c(T_value) N:N0(N_value) M:M0(M_value) STAGE: Ic____(Stage_value)
  • 2023-03-08 PET
    • Increased FDG uptake in the left ovary, highly suspected the primary ovarian cancer, suggesting biopsy for further investigation.
    • Increased FDG uptake in the uterus, compatible with the pathological findings of adenocarcinoma of uterus.
    • Increased FDG uptake in the in the posterior wall of upper hypopharynx, probably chronic inflammation process or other nature. Please also correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    • Left ovarian cancer, cTxN0M0, by this F-18 FDG PET scan.
  • 2023-03-06 CT - abdomen
    • Clinical history: 41 y/o female patient with Polyp of cervix uteri
    • With and without contrast enhancement CT of abdomen - whole:
      • There is cystic tumor, 5.7cm in left adnexa, with internal hyperdensity and septum, r/o left ovarian malignancy. DDx: endometrioma.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • Presence of ascites. Mild nodularity and loculated ascites in left upper abdomen. Reative or carcinomatosis?
    • If proven ovarian malignancy:
      • Imaging Report Form for Ovarian Carcinoma
        • Impression (Imaging stage): T:T1c(T_value) N:N0(N_value) M:M0(M_value) STAGE: Ic (Stage_value)
  • 2023-03-02 Patho - cervix/endometrial polyp
    • Uterus, cervix, polypectomy — Adenocarcinoma
      • NOTE: Please check endometrium or ovary for the possibility of tumor origin.
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with invasive growth pattern and areas of necrosis. The tumor cells display hyperchromatic nuclei, pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • Immunohistochemical stain reveals vimentin (+), p53: abberrant-type (strong diffuse positive, 90%), ER: positive (moderate, 90%), P40(-), p16 ( patchy strong focal+, 30%).
  • 2023-03-01 Gynecologic ultrasonography
    • Cul-De-Sac: with fluid
    • LT: fluid
    • IMP: Suspected Lt Ovarian mass (47 x 32 mm)

[SOAP]

  • 2023-03-28 Hemato-Oncology
    • Arrange admission for 24 hours CCr, audiometry, Chest CT, then IP C/T and systemic C/T

[surgical operation]

  • 2023-03-13
    • Operation
      • Excision of intraabdominal malignant tumor, omentectomy
      • Tenckhoff tube insertion
    • Finding
      • Moderate ascites with positive cytology
      • Tenckhoff tube: over RLQ
  • 2023-03-13
    • Surgery
      • Diagnosis:
        • Left ovarian tumor, r/o malignancy.
        • Pelvis MRI on 2023/03/09 showed:
          • Left ovarian cystic tumor, r/o ovarian malignancy.
          • Nodularity at peritoneum, r/o carcinomatosis.
          • Diffuse endometrial thickening, hyperplasia or malignancy, suggest further study..
          • Focal tubular lesion in the endocervical region, protrusion from uterine body.
          • Ascites.
    • Operation:
      • Debulking surgery (ATH + BSO + BPLND + paraaortic lymphadectomy + infracolic omentectomy + vaginectomy)
    • Frozen:
      • Left ovary with malignancy.
    • Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size,
      • Adnexa:
        • LOV: 6x5x3 cm , capsule not intact with mass protruding out
        • ROV: 3x2x2 cm , capsule intact , smooth surface.
        • Fallopian tube: bilateral grossly normal
      • CDS: ascites+
      • Ascites: yellowish and clear , about 550 ml
      • Bilateral pelvic and paraaortic lymph nodes: normal(+), enlarged(+), indurated(-)
      • Omentum: grossly normal, no variablesized nodules, infracolic omentectomy was done by GS surgeon.
      • Liver: grossly normal & smooth
        • Subdiaphragmatic surface: miliary tumorseeding(-).
      • Appendix: grosslt normal.
      • After the operation, Optimal debulking surgery was achieved.
      • Residue tumor: R0
      • Estimated blood loss: 200 ml
      • Blood transfusion: nil
      • Complication: nil

[chemotherapy]

  • 2023-07-27 - paclitaxel 175mg/m2 240mg D5W 250mL 3hr + cisplatin 75mg/m2 110mg NS 500mL 24hr + NS 1000mL 24hr (Y-sited cisplatin)
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-07 - paclitaxel 175mg/m2 240mg D5W 250mL 3hr + cisplatin 75mg/m2 110mg NS 500mL 24hr + NS 1000mL 24hr (Y-sited cisplatin)
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-13 - paclitaxel 175mg/m2 240mg D5W 250mL 3hr + cisplatin 75mg/m2 110mg NS 500mL 24hr + NS 1000mL 24hr (Y-sited cisplatin)
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-25 - paclitaxel 135mg/m2 200mg NS 250mL 24hr D1 + cisplatin 75mg/m2 110mg NS 500mL IP 1hr D2
    • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + aprepitant 125mg PO + NS 250mL] D2
  • 2023-04-11 - paclitaxel 60mg/m2 90mg NS 250mL 1hr (previous D8)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
  • 2023-04-05 - paclitaxel 135mg/m2 200mg NS 250mL 24hr D1 + cisplatin 75mg/m2 110mg NS 500mL IP 1hr D2
    • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + aprepitant 125mg PO + NS 250mL] D2

==========

2023-07-28

Based on the PharmaCloud database, we see that the patient has only visited our hospital. No medication reconciliation issues are identified for this admission after reviewing HIS5 records..

On 2023-07-26, the serum magnesium level was measured at 1.5mg/dL, indicating a low value. As a result, it is advised to add magnesium supplementation for the patient.

2023-04-06

  • This patient, who is a nurse on our staff, was diagnosed with endometroid carcinoma pathology stage pT1c2N0 stage IC (ovary) and stage IA (endometrium). She underwent surgical operation ATH + BSO + infracolic omentectomy + BPLND + para-aortic LN dissection + vaginectomy on 2023-03-13. Currently, she has been admitted for her first cycle of chemotherapy, which includes paclitaxel 135mg/m2 200mg IV on day 1 (yesterday) and cisplatin 75mg/m2 110mg IP on day 2 (today).
  • As of the latest lab data on 2023-04-04, her values are grossly normal except for elevated D-dimer (3137ng/mL FEU) and U-Cr 24hr (1185mg/kg/24hr), which do not contraindicate the planned chemotherapy.
  • To date, there have been no apparent side effects from the patient’s chemotherapy according to the nursing notes.

700415083

230727

[exam findings]

  • 2023-07-04 SONO - abdomen
    • Findings
      • Liver: Fine echotexture. Several hyperechoic lesions up to 9.6 cm in GB. A 1.2 cm anechoic lesion at S8
      • Portal vein: Echogenic lesion in right portal vein.
      • Pancreas: Part of head and part of tail masked
      • Others: Bilateral plerual effusion was noted
    • Diagnosis:
      • Hepatoma with right portal vein thrombosis
      • Pleural effusion, bilateral
  • 2023-07-02 CT - abdomen
    • Indication: Epigatric pain and back pain since yesterday. Mild cold sweating. No N/V, no tarry stool, no fever, no cough, no sputum, no SOB, no chest pain, no dysuria
    • With and without contrast enhancement CT of abdomen shows:
      • Multiple HCCs, s/p TACE. Uneven surface and left lobe hypertrophy of liver, suggestive of liver cirrhosis. Patent portal vein.
      • Swelling of pancreas with fluid density in retroperitoneum.
    • Impression
      • HCCs, s/p TACE
      • Suspect acute pancreatitis, grade D. Suggest clinical correlation.
  • 2023-07-02 ER SONO
    • fluid collection in abdomen: mild over spleno-renal fossa
    • heterogenous mass over bilateral lobe of liver
  • 2023-06-30 CT - abdomen
    • history: Right HCC, cT4N0M0 stage IIIB, post TACE on 2023/03/21 and 1st immunotherapy and Target therapy (Tecentriq + Avastin) on 2023/03/23.
    • Findings:
      • There are multiple poor enhancing masses on both hepatic lobes at portal venous phase images that are c/w multiple HCCs.
      • There are multiple hyperdense lesions in both hepatic lobes that are c/w HCCs S/P TACE with lipiodol retention.
      • There is filling defect at right superior portal vein that is c/w tumor thrombosis.
      • There is mild ascites.
    • Impression:
      • Multiple HCCs on both hepatic lobes show stable disease.
      • Tumor thrombosis in right superior segment portal vein.
  • 2023-06-13 Embolization (TAE) - abdomen for tumor
    • TACE of RIGHT HCCs via right common femoral artery puncture using Seldinger technique revealed:
      • Presence of liver cirrhosis.
      • Hypervascular tumors at both hepatic lobes with multifeeders. TACE was performed using 10mg adriblastina plus 10 cc lipiodol. Decreased the blood flow of the feeding arteries using some gelfoam pieces also performed.
    • IMP: Bil. HCCs s/p right TACE.
  • 2023-05-22 Embolization (TAE) - abdomen for tumor
    • TACE of left HCCs via right common femoral artery puncture using Seldinger technique revealed:
      • Presence of liver cirrhosis.
      • Hypervascular tumors at bil. hepatic lobes with multifeeders. TACE of left HCCs was performed using 10mg adriblastina plus 7 cc lipiodol via microcatheter. Decreased the blood flow of the feeding arteries using some gelfoam pieces also performed.
    • IMP: Bil. HCCs s/p left TACE.
  • 2023-05-17 CT - abdomen
    • CC: LUQ pain and fever up to 38’C since last night
    • Past history:
      • right HCC, cT4N0M0 stage IIIB, post Transcatheter arterial chemoembolization on 2023/03/21 and 1st immunotherapy and Target therapy with Tecentriq + Avastin on 2023/03/23.
      • hepatitis B carrier with regular medication control with Entecavir since 2023/03/23.
    • Findings:
      • There are multiple poor enhancing masses on both hepatic lobes at portal venous phase images that are c/w multiple HCCs.
      • There are hyperdense lesions in the superior segment of right lobe liver that are c/w HCCs S/P TACE with lipiodol retention.
      • There is filling defect at right superior portal vein that is c/w tumor thrombosis.
      • There is mild ascites.
    • Impression:
      • Multiple HCCs on both hepatic lobes.
      • Tumor thrombosis in right superior segment portal vein.
  • 2023-03-23 Tc-99m MDP bone scan
    • Increased activity in the right aspect of mandible. Dental problem may show this picture. Please correlate with other clinical findings for further evaluation.
    • Some faint hot spots in the right rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, right elbow, bilateral hips and knees, compatible with benign joint lesions.
  • 2023-03-23 Esophagogastroduodenoscopy, EGD
    • Gastric ulcers and erosions, antrum, s/p biopsy
    • Shallow duodenal ulcers, bulb
    • Superficial gastritis
  • 2023-03-21 Embolization (TAE) - abdomen for tumor
    • TACE of RIGHT HCCs via right common femoral artery puncture using Seldinger technique revealed:
      • Presence of liver cirrhosis.
      • The RH-catheter was inserted into distal branch of right hepatic artery.
      • Hypervascular tumors at both hepatic lobes (up to 10.6cm) with multifeeders. TACE was performed using 10mg adriblastina plus 10 cc lipiodol. Decreased the blood flow of the feeding arteries using some gelfoam pieces also performed.
    • IMP: Bil. HCCs s/p right TACE.

[MedRec]

  • 2023-07-20 SOAP Dermatology
    • S
      • severe itchy papules and plaques erupition over trunk after medication.
      • HBV carrier.
      • compesolon 0.5# initally up to 2# QD
    • O
      • urticaria/angioedema type
      • maculopapular type
      • urticaria-purpura type
      • erythema multiforme SJS/TEM
      • fixed drug eruption or AGEP rapid onset type
      • drug hypersensitivity syndrome as DRESS
      • lichenoid chronic progressive type
      • Suspect related medication: mopride. morbilliform drug eruption.
    • Plan:
      • education about drug side effec and explain
      • Strongly suggested OPD f/u
    • Prescription
      • Compesolon (prednisolone 5mg) 2# QD
      • Xyzal (levocetirizine 5mg) 1# BID
      • Asthan (ketotifen 1mg) 1# BID
      • Pilan (cyproheptadine 4mg) 1# HS
      • Topsym Cream (fluocinonide 0.05%) BID EXT
  • 2023-03-20 ~ 2023-03-25 POMR General and Gastroenterological Surgery
    • Discharge diagnosis
      • Hepatocellular carcinoma, cT4N0M0 stage IIIB, status post Transcatheter arterial chemoembolization on 2023/03/21; 1st immunotherapy and Target therapy with Tecentriq + Avastin on 2023/03/23. BCLC:B, ECOG:0
      • Carrier of viral hepatitis B
      • Gastric ulcer
      • Duodenal ulcer
    • CC
      • RUQ pain after chest contussion during work for 2 weeks since 1 month ago
    • Present illness
      • This 40 y/o male with past history of hepatitis B carrier without regular control. This time, he sufferred from RUQ pain after chest contussion during work for 2 weeks. The pain with aggravated if deep breathing, hiccup. He ever visited to CM OPD on 2023/02/14 for follow up and CXR with no evidence of rib fracture. Analgesic agent was given but in vain. However, sever right upper quadrant pain was noted on 2023/03/17 then he visited to ChangGung hospital for help. Abdomen CT was performed and showed multiple liver tumors at both lobes, the largest one > 10.2 cm in S7/8 encasing the right hepatic vein, firstly consider HCC (T4N0), DDx: liver metastasis from other primary cancer. Admission was sugested but patient refused. Due to persised of RUQ pain, he came to our ER for help. Pain control was given, GS was consuted who suggested TACE first. Under impressed of HCC, he was admitted to our ward for TACE management.
    • Course of inpatient treatment
      • After admission, we consulted Diagnostic Radiology for arranging TACE. The procedure was performed on 2023/03/21 uneventfully. He tolerated the treatment well. After bedrest for 8 hours, no significant oozing was found over TACE wound. He also decided to received immunotherapy+target therapy with tecentriq + Avastin after well discussion on 2023/03/23. The medication was applied and no significant discomfort was complained of. UGI scope was also performed before immunoteherapy which showed gastric and duodenal ulcer. We keep PPI with nexium treatment for GU. On the other side, HBV DNA showed 1090IU/mL, then Baraclude (self-pay) for HBV control since 2023/03/23. Under a relative stable condition, he was discharged and OPD will be arranged.
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Nexiuum (esomeprazole 40mg) 1# QDAC
      • Celebrex (celecoxib 200mg) 1# Q12H
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
      • Smecta (dioctahedral simeclite 3mg) 1# PRNTIDAC
      • loperamide 2mg 1# PRNQ12H
      • Naproxen (naproxen 250mg) 1# PRNQ12H
  • 2023-02-21 SOAP Chest Medicine
    • S/O: chest contussion during work for 2 weeks, aggravated if deep breathing, hiccup, no dyspnea, no cough,
    • A/P: s/s Tx, arrange CXR
    • Prescription
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • Keto (ketorolac 10mg) 1# Q6H
      • Algitab (alginic acid, MgCO3, Al(OH)3; 200mg) 1# Q6H

[immunochemotherapy]

  • 2023-06-14 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 500mg NS 100mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-05-23 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 500mg NS 100mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-04-21 - nivolumab 3mg/kg 160mg NS 100mL 1hr
    • none
  • 2023-03-23 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 500mg NS 100mL 1hr
    • none

==========

2023-07-27

[reconciliation]

Our dermatologist prescribed a 7-day course of Compesolon (prednisolone), Xyzal (levocetirizine), Asthan (ketotifen), Pilan (cyproheptadine), and Topsym Cream (fluocinonide) for the patient’s severe itchy papules and plaques eruption over the trunk on 2023-07-20. However, these drugs are not currently included in the list of active medications. It is advisable to check whether the skin symptoms have improved before continuing or adjusting the treatment plan.

701251392

230727

[lab data]

2023-07-19 HSV 1 IgM Negative NTU
2023-07-19 HSV 1 IgM Value 1.52 NTU
2023-07-19 HSV 2 IgM Negative NTU
2023-07-19 HSV 2 IgM Value 1.37 NTU
2023-07-19 HLA A-high 11:01
2023-07-19 HLA A-high 33:03
2023-07-19 HLA B-high 38:02
2023-07-19 HLA B-high 39:01
2023-07-19 HLA C-high 07:02
2023-07-19 HLA C-high -

2023-07-19 HLA DRB1-high rsolution 2023-07-19 HLA DQ-high 03:03
2023-07-19 HLA DQ-high 05:02

2023-07-19 HLA DRB1-high rsolution 2023-07-19 HLA DR-high 09:01
2023-07-19 HLA DR-high 14:54

[exam findings]

  • 2023-06-23 SONO - abdomen
    • Liver cyst, S6
    • Gallbladder adenomyomatosis
    • Gall stones
    • Renal stone, left kidney
    • Renal cyst, left kidney
  • 2023-05-26 Patho - spleen
    • Spleen, laparoscopic splenectomy — N/K T cell lymphoma.
    • Sections show multiple pieces of splenic tissue with prominent white pulps and markedly dilated congested sinuses.
    • IHC stains: CD3 > CD20; CD4 > CD8; CD56 (+).
  • 2023-05-25 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — residual N/K T cell lymphoma.
    • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There are rare minute lymphoid aggregates (< 1mm in sizes).
    • IHC stains: CD3 > CD20; CD4 > CD8; CD56 (+).
  • 2023-05-23 PET
    • Glucose hypermetabolism in two focal areas in the spleen. The nature is to be determined (lymphoma? other nature?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the right anterior upper chest wall and bilateral pulmonary hilar regions. Inflammatory process is more likely.
    • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-05-17 CT - abdomen
    • CC: intermittent fever for 3 days, general malaise, mild dysuria, no cough, no SOB
    • History: Mature T/NK-cell lymphomas
    • Findings:
      • There is splenomegaly and the greatest cranial-caudal dimension measuring about 13 cm in size.
      • A hepatic cyst 1 cm in S5/6 is suspected. Please correlate with sonography.
      • The gallbladder shows small contracted with diffuse symmetrical mild wall thickening that may be adenomyomatosis?
        • In addition, three gallstones in the neck are noted.
      • Two renal stone 1 cm and 0.8 cm in left lower pole are noted.
      • There is nodular osteopenic defect in left lateral aspect of L3 vertebral body with fat density. Lipoma is highly suspected. please correlate with clinical condition and MRI.
      • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5. There is end plate sclerotic change of L3-4.
      • Transitional vertebra of L5-S1, left side.
    • Impression:
      • Splenomegaly is noted. please correlate with clinical condition.
      • Lipoma in left lateral aspect of L3 vertebral body is suspected. please correlate with clinical condition and MRI.
  • 2023-05-03, 2022-11-07 MRI - nasopharynx
    • IMP: No neck LAP, stationary.
  • 2022-03-08 MRI - nasopharynx
    • Swollen change of hypopharyngeal space with mucosal thickening.
    • The bilateral parotid and submandibular glands enhance as before. It is consistent with post-radiation inflammation.
  • 2021-11-16 MRI - nasopharynx
    • History of NK lymphoma of nasopharynx
    • IMP: small LNs in bil. level I-II spaces, stationary.
  • 2021-07-02 MRI - nasopharynx
    • Indication: History of nasal NK T cell lymphoma, post chemotherapy and RT. For evaluate tumor status.
    • Impression:
      • Edematous change of bilateral aryepiglottic folds.
      • Regression of the Waldeyer’s ring masses.
      • No enlarged cervical lymphadenopathy.
  • 2021-03-29 CT - neck
    • History of NK-T cell lymphoma over oropharynx with mediastinal LN metastases. Follow up lymphoma status
    • IMP: no neck LAP
  • 2021-02-18 Neck Soft Tissue
    • Disc space narrowing with marginal osteophyte formation of C3-4 and C4-5.
  • 2020-12-24 CT - chest
    • Imp:
      • Regression of mediastinal lymphadenopathy
      • Consolidation over B6 of left lower lobe, previous infection
      • Gallstones and GB polyp(?) Suggest correlate with sonography.
  • 2020-10-02 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (71.7 - 16.6) / 71.7 = 76.85%
      • M-mode (Teichholz) = 76.8
    • Conclusion:
      • Concentric LVH.
      • Normal RV & LV systolic function. No regional wall motion abnormalities.
      • Impaired LV relaxation.
      • Aortic valve sclerosis, with mild aortic regurgitation.
      • Mild mitral regurgitation.
      • Mild tricuspid regurgitation.
      • Mild pulmonic regurgitation.
      • Small pericardial effusion.
  • 2020-09-24 CT - chest
    • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
    • Small lymph nodes are found at bilateral pulmonary hilar and paratracheal region is found.
    • There is bilateral minimal pleural effusion.
    • Diffuse interstitial change at both lungs is found.
    • Splenomegaly is found.
    • There is stone at dependent portion of GB. GB stone(s) are noted. The GB wall is not thickening
  • 2020-09-22 CXR
    • Tortuosity of thoracic aorta with Atherosclerotic change of aortic arch and Cardiomegaly
    • Spondylosis with scoliosis of the T-spine with convex to right side
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process. The differential diagnosis include pulmonary edema?
  • 2020-09-22 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy
    • Sections show 30-40 % cellularity. The M/E ratio is about 3/1 - 4/1. Megakaryocytes are found about 2-9/HPF. No increase of blasts is noted. There are no granulomas, nor foreign malignant cells. The immunohistochemical stains of CD3, CD20, and CD56 show no infiltrative lymphoma.
  • 2020-09-21 PET
    • Glucose hypermetabolism in nasopharyngeal wall, Waldeyer’s ring, and right piriform sinus, and bilateral cervical lymph nodes, compatible with lymphoma involving lymphatic sites on the same side of diaphragm with extralymphatic extension.
    • Some glucose-hypermetabolic lesions of ground-glass opacity in upper lobe of left lung and middle lobe of right lung, pulmonary infection/inflammation may show such a picture but malignancy cannot be excluded. Please keep follow up with imaging modalities and, if feasible, correlate with histopathological studies for further evaluation.
    • Lymphoma, c-stage IIE (Lugano classification), by this F-18-FDG PET/CT scan.
  • 2020-09-14 Patho - nasopharyngeal/oropharyngeal biopsy
    • Labeled as “Post. oropharyngeal wall grnulation tissue, r/o killer cell lymphoma?”, biopsy — Lymphoma.
    • Section shows bland squamous mucosa lined tissue with marked necrotic and diffusely infiltration of atypical round blue cells.
    • IHC stains: CD56 (strong +), CD3 and CD20: equivocal; CD4 and CD8 : more CD4 than CD8. CK (equivocal, probalby background). Features compatible with N/K T cell lymphoma.
  • 2020-09-04 CT - neck
    • IMP: Lesions at right nasopharynx, left palatine tonsil and right pyriform sinus with bilateral lymph nodes. D/D: multiple malignancies, infectious processes.

[MedRec]

  • 2023-06-18 ~ 2023-07-01 POMR Hemato-Oncology
    • Discharge diagnosis
      • Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites stage IV post chemotherapy with relapse over spleen and bone marrow post splenectomy
      • Urinary tract infection, site not specified
    • CC
      • fever and weakness since 2 days ago.
    • Present illness
      • This 64 year old female who denied any systemic disease. Neck CT on 2020/09/03 revealed lesions at right nasopharynx, left palatine tonsil and right pyriform sinus with bilateral lymph nodes. Nasopharyngoscopy local biopsy was done on 2020/09/14, the pathological report proved N/K T cell lymphoma. PET was performed on 2020/09/21 which revealed 1. Glucose hypermetabolism in nasopharyngeal wall, Waldeyer’s ring, and right piriform sinus, and bilateral cervical lymph nodes, compatible with lymphoma involving lymphatic sites on the same side of diaphragm with extralymphatic extension. 2. Some glucose-hypermetabolic lesions of ground-glass opacity in upper lobe of left lung and middle lobe of right lung, pulmonary infection/inflammation may show such a picture but malignancy cannot be excluded. Please keep follow up with imaging modalities and, if feasible, correlate with histopathological studies for further evaluation. 3. Lymphoma, c-stage IIE (Lugano classification). Bone marrow done on 2020-09-21 which revealed Negative for malignancy. Port-A insertion was done on 20200922. CT of chest on 20200924 which revealed small lymph nodes are found in the mediastinum. Diffuse interstitial change at both lungs. Gallstones. Bronchoscopy was performed on 20200925 for distal airway sampling to r/o TB, lymphoma with lung involvement, PJP infection, aspergillosus or other pathogen, PFT test to evaluate small airway dysfunction. RT was started from 2020/10/02 at 1000cGy/5 fractions (6MV photon) of the pharyngeal tumor, peripheral, to bilateral neck nodal area. PJP DNA was reported positive on 2020/10/05, thus Infection was consulted. They suggest Baktar 2# Q8H for PJP infection control and augmented with Cravit 750mg IV QD for two week.
      • Under the diagnosis of Right oropharyngeal N/K T cell lymphoma, stage IIE
      • Chemotherapy as weekly Cisplatin (30) x 3 weeks, then followed by VIPD x3 (every 3 weeks)
      • She received CCRT with Cisplatin since 2020/09 - 2020/11.
      • C1 VIPD on 2020/11/27 to C4 VIPD on 2021/02/18.
      • Followed MRI was performed on 2023/05/03 and report showed no neck LAP.
      • Bone marrow was done for pancytopenia on 2023/05/25.
      • Bone marrow pathoolgy (2023/05/25) showed residual N/K T cell lymphoma. IHC stains: CD3 > CD20; CD4 > CD8; CD56 (+).
      • PET showed glucose hypermetabolism in two focal areas in the spleen. GS was consulted for pancytopenia and splenomegaly surgical intervention assessment.
      • Spleen, laparoscopic splenectomy pahtology (2023/05/26) showed: N/K T cell lymphoma. IHC stains: CD3 > CD20; CD4 > CD8; CD56 (+).
      • Due to impression of splenic lesions and splenomegaly with progressed pancytopenia and leukopenia. She received Pneumococcal Vaccine 13 and GCF on 2023/05/25. She received laparoscopic splenectomy on 2023/05/26, and was transferred to GS service care on 2023/05/26.
      • 2023-05-17 ABD CT: Two renal stone 1 cm and 0.8 cm in left lower pole are noted.
      • This time, she has fever with chills and limbs soreness for 2 days, so she was brought to our ED for help pn 2023/06/18 afternoon. She denied abdominal pain or dysuria condition, but sometimes has dry cough. At ED, the lab data showed normal WBC, CRP just 2. No evidence of UTI or pneumonia. Under the impression of fever suspect virus or tumor related, so she was admitted.
    • Course of inpatient treatment
      • After admission, antibiotic was given. Tapimycin (06/18- ) > Sintrix (06/19- ) > Doripemem (06/21- ). Sintrix changed to doripenem was based on U/C. N/S: 500 BID + nako no.5 500 QD were given for hydration. Panadol was given for fever control.
      • Lab data showed WBC: 6.9 (06/18) > 4.4 (06/23), CRP: 2.2 > 1.9 (06/23). Abd echo: no hydronephrosis, Hyperechoic lesion was noted in the left kidney Size 0.9 cm. Blood culture showed no growth on 06/24.
      • On 06/26, U/A showed WBC: 0 (06/26), RBC: 0 (06/26).
      • On 06/27, fever up to 37.8c. WBC showed 6.9 (06/18) > 4.4 (06/23) > 5k (06/27). PCT showed 0.07.
      • We changed to brosym on 06/28. Urine culture on 06/26 showed no growth.
      • Under stable condtion, she was discharged with OPD follow up.
    • Prescription
      • Cinolone (ciprofloxacin 250mg) 2# BIDAC
      • Acetal (acetaminophen 500mg) 1# Q6H
      • Eurodin (estazolam 2mg) 0.5# HS
      • Axcel (acyclovir) QD TOPI for buttock herpes zoster

[chemotherapy]

  • 2023-07-19 - L-asparaginase 6000unit/m2 9540unit IM 1min

  • 2023-07-10 - methotrexate 4600mg NS 250mL 24hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2021-02-18

  • 2021-01-14

  • 2020-12-21

  • 2020-11-27

  • 2020-11-13

  • 2020-10-06

  • 2020-09-29

==========

2023-07-31

[deterioration in liver function; acetaminophen, Stronger Neo Minophagen C Injection]

In recent days, the patient has shown a significant increase in bilirubin and liver enzymes. After reviewing the drugs listed in the active medication, entecavir, furosemide, and acetaminophen are found to be associated with these symptoms according to the medication database. Since the VAS (visual analogue scale) has been recorded as 0 since 2023-07-29, it might be worth considering discontinuing acetaminophen. Additionally, please note that the Stronger Neo Minophagen C Injection will expire by the morning of 2023-08-01. If it is still required, please extend its use accordingly.

2023-07-31 Bilirubin total 14.51 mg/dL ** 2023-07-27 Bilirubin total 2.44 mg/dL *
2023-07-26 Bilirubin total 1.02 mg/dL
2023-07-24 Bilirubin total 0.70 mg/dL
2023-07-21 Bilirubin total 0.49 mg/dL
2023-07-19 Bilirubin total 0.51 mg/dL
2023-07-17 Bilirubin total 0.52 mg/dL
2023-07-15 Bilirubin total 0.59 mg/dL
2023-07-14 Bilirubin total 0.68 mg/dL
2023-06-27 Bilirubin total 0.31 mg/dL

2023-07-31 S-GPT/ALT 655 U/L 2023-07-27 S-GPT/ALT 309 U/L 2023-07-26 S-GPT/ALT 219 U/L 2023-07-24 S-GPT/ALT 161 U/L 2023-07-21 S-GPT/ALT 180 U/L 2023-07-19 S-GPT/ALT 162 U/L 2023-07-17 S-GPT/ALT 278 U/L 2023-07-15 S-GPT/ALT 541 U/L 2023-07-14 S-GPT/ALT 638 U/L 2023-07-13 S-GPT/ALT 412 U/L 2023-07-09 S-GPT/ALT 137 U/L 2023-06-27 S-GPT/ALT 63 U/L 2023-06-23 S-GPT/ALT 62 U/L 2023-06-18 S-GPT/ALT 46 U/L 2023-06-05 S-GPT/ALT 31 U/L 2023-06-03 S-GPT/ALT 26 U/L

2023-07-27

[No specific preparation is described for Stronger Neo-Minophagen C Injection]

to primary nurse: After checking the Micromedex database, there is no available data on the compatibility of glycyrrhizinate monoammonium, the main ingredient in Stronger Neo-Minophagen C Injection. Additionally, the package insert for this medication does not provide specific instructions regarding the preparation prior to injection administration.

2023-07-19

[teicoplanin 600mg from Q3D to QOD]

2023-07-19 Cre 1.47mg/dL, 57.5kg => CrCl 35mL/min. According to the Sanford Guide, teicoplanin in patients with CrCl 30 to 80, for complicated skin/soft tissue, pneumonia, complicated UTI: 6mg/kg QOD and for bone and joint infections, endocarditis: 12mg/kg QOD. It is recommended to increase the frequency from Q3D to QOD.

[leukopenia]

An episode of leukopenia was observed on 2023-07-19, 9 days after administration of 4600 mg MTX on 2023-07-10. The label for MTX includes a boxed warning regarding potential bone marrow, liver, lung, skin, and kidney toxicity, and patients should be monitored closely for such effects. Given the timing and characteristics of MTX, it cannot be ruled out that the leukopenia episode was due to MTX.

  • 2023-07-19 WBC 1.47 x10^3/uL
  • 2023-07-17 WBC 4.58 x10^3/uL
  • 2023-07-15 WBC 11.08 x10^3/uL
  • 2023-07-14 WBC 14.72 x10^3/uL
  • 2023-07-13 WBC 16.11 x10^3/uL
  • 2023-07-09 WBC 11.29 x10^3/uL

According to NHI reimbursement guidelines, short-acting G-CSF (e.g., filgrastim, lenograstim) may be used for patients with hematologic malignancies receiving intravenous chemotherapy, provided the patient meets this condition.

2023-07-14

[MTX level follow-up. Leucovorin might begin 24 hr after the start of MTX]

Methotrexate 4600mg was administered on 2023-07-10, and leucovorin 150mg Q3H has been started since 2023-07-13. Follow-up methotrexate level has shown significant decrease and is now less than 10 umol/L.

  • 2023-07-14 Methotrexate 9.927 umol/L
  • 2023-07-13 Methotrexate 39.609 umol/L
  • 2023-07-13 Methotrexate 65.124 umol/L

It is recommended that rescue treatment following high-dose methotrexate starts with an initial dosage of around 15 mg (~10 mg/m2). This should begin 24 hours after the start of the methotrexate infusion and the treatment should continue Q6H for doses, until the MTX level drops below 0.05 micromolar.

The patient is adequately hydrated with normal saline and the urine is alkalinized with Rolikan (sodium bicarbonate).

[bedside visit]

I visited the patient at around 16:00 today. She mentioned that her throat was a bit sore, which could be due to mucositis. The addition of Nincort Oral Gel (triamcinolone acetonide) might help in relieving her symptoms.

[Covorin demand confirmation]

Today, during the UD (Unit Dose) vehicle preparing, it was discovered that the demand for Covorin (leucovorin 50mg) is 72 amps. At 13:25, I made a call to Dr. Wang QiQi to confirm the chief resident physician’s decision on the medication quantity.

701432045

230727

[diagnosis] - 2023-03-13 admission note

  • Malignant neoplasm of stomach, unspecified
  • Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
  • Type 2 diabetes mellitus without complications
  • Thyrotoxicosis, unspecified without thyrotoxic crisis or storm
  • Insomnia, unspecified

[past history]

  • The patient had type 2 diabetes mellitus and thyrotoxicosis under medicatiosn control.
  • history of operation: nil
  • Denied recent traveling history
  • Blood transfusion history: NIL
  • Regular medications:
    • Amepiride 2mg/tab (Glimepiride) 0.5 tab QDAC
    • Cardiolol 10mg/tab (Propranolol) 1 tab TID
    • Methimazole 5 mg/tab (Methimazole) 1 tab TID
    • Uformin 500mg/tab (Metformin) 1 tab BIDCC             

[family history]

  • Mother: type 2 diabetes hypertension
  • Sisiters: breast cancer and skin cancer

[lab data]

  • 2022-08-11 TSH receptor Ab 40 %
  • 2022-08-11 Free T4 (nuclear medicine) 1.926 ng/dl
  • 2022-08-11 TSH (nuclear medicine) <0.04 uIU/ml
  • 2022-07-08 RPR/VDRL Nonreactive
  • 2022-07-08 T3 3.85 ng/mL
  • 2022-07-08 TSH <0.005 uIU/mL
  • 2022-07-08 Free-T4 4.60 ng/dL
  • 2022-07-08 Free PSA 0.655 ng/mL
  • 2022-07-08 free PSA/PSA 45.631 %
  • 2022-07-08 Anti-HAV IgG Nonreactive
  • 2022-07-08 Anti-HAV IgG Value 0.20 S/CO
  • 2022-07-08 Anti-HBc Reactive
  • 2022-07-08 Anti-HBc-Value 7.80 S/CO
  • 2022-07-08 Anti-HBs 0.99 mIU/mL
  • 2022-07-08 HBsAg Reactive
  • 2022-07-08 HBsAg (Value) 4.68 S/CO
  • 2022-07-08 HIV Ab-EIA Nonreactive
  • 2022-07-08 Anti-HIV Value 0.09 S/CO
  • 2022-07-08 Anti-HCV Nonreactive
  • 2022-07-08 Anti-HCV Value 0.31 S/CO
  • 2022-07-08 HbA1c 8.4 %

[exam findings]

  • 2023-05-12 CT - abdomen
    • History: gastric cancer, pT4aN2 (4/40), cM0, stage IIIA, s/p subtotal gastrectomy & HIPEC
    • Findings: Comparison prior CT dated 2021/09/23. There is no significant interval change.
      • Prior CT identified four metastases on both hepatic lobes are noted again, mild increasing in size that is c/w liver metastases S/P C/T with stable disease.
        • A hepatic cyst measuring 0.9 cm in S2/3 is noted.
      • There are few enlarged nodes in hepatoduodenal ligament and celiac trunk area. Metastatic nodes are highly suspected.
      • S/P subtotal gastrectomy and S/P cholecystectomy.
      • Prior CT identified focal cystic lesion 3.6 cm (the largest dimension) in between the residual stomach and pancreatic tail is noted again, mild decreasing in size to 3.2 cm.
    • Impression:
      • Four metastases on both hepatic lobe S/P C/T show stable disease.
      • There are few enlarged nodes in hepatoduodenal ligament and celiac trunk area. Metastatic nodes are highly suspected.
  • 2023-02-25 CT - chest
    • Indication: gastric cancer, pT4aN2 (4/40), cM0, stage IIIA, s/p subtotal gastrectomy & HIPEC
    • IMP
      • No evidence of pulmonary meta in the study.
      • s/p nearly total gastrectomy.
      • Loculated fluid like accumulation anterior to the pancreatic tail is found measuring 3.5cm in largest dimension. Meta? Post op. change?
  • 2023-02-24 CT - abdomen
    • History: gastric cancer, pT4aN2 (4/40), cM0, stage IIIA, s/p subtotal gastrectomy & HIPEC
    • Findings:
      • There are four well-defined poor enhancing lesions 1.7 cm in S2, 0.8 cm in S8 (near IVC), 0.4 cm in S5, and 1 cm in S6 of the liver that may be metastases. Please correlate with MRI.
      • A hepatic cyst measuring 0.9 cm in S2/3 is noted.
      • S/P subtotal gastrectomy
      • There is focal cystic lesion 3.6 cm (the largest dimension) in between the residual stomach and pancreatic tail that may be focal seroma or abscess?
    • Impression:
      • Four metastases on both hepatic lobes are highly suspected.
  • 2022-09-27 Tc-99m MDP whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed some hot or faint hot spots in the anterior aspect of bilateral rib cages and increased activity in the lower L-spines, left humeral shaft, bilateral shoulders, left sternoclavicular junction and bilateral hips in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Some hot or faint hot spots in the anterior aspect of bilateral rib cages and mildly increased activity in the left humeral shaft. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, left sternoclavicular junction and bilateral hips, compatible with benign joint lesions.
  • 2022-08-12 Patho - stomach subtotal/total (tumor)
    • PATHOLOGIC DIAGNOSIS
      • Stomach, subtotal gastrectomy — Adenocarcinoma
      • Margin, frozen section — Free of tumor invasion
      • Margins, subtotal gastrectomy — Free of tumor invasion
      • Lymph nodes, LN 1, ditto — Free of tumor metastasis (0/3)
      • Lymph nodes, LN 3, ditto — Tumor metastasis (3/9) with extracapsular extension (3/3)
      • Lymph nodes, LN 4, ditto — Free of tumor metastasis (0/11)
      • Lymph nodes, LN 5, ditto — Free of tumor metastasis (0/1)
      • Lymph nodes, LN 6, ditto — Fat tissue only
      • Lymph nodes, LN 12c, ditto — Free of tumor metastasis (0/1)
      • Lymph nodes, LN 14, ditto — Free of tumor metastasis (0/8)
      • Lymph nodes, LN 7,8,9,11p,12a, ditto — Tumor metastasis (1/7) with extracapsular extension (0/1)
      • Omentum, omentectomy — Free of tumor invasion
      • Gallbladder, cholecystectomy — Free, chronic cholecystitis
      • AJCC Pathologic staging — pT4aN2, if cM0, stage IIIA
    • MACROSCOPIC EXAMINATION
      • Specimen type: Stomach, lymph nodes, gallbladder and omentum
      • Specimen size: (a) Stomach: GC: 20.5 cm; LC: 6.8 cm, (b) Omentum: 35 x 19 x 4 cm
      • Number of lesions: Solitary
      • Tumor site: angle
      • Tumor size: 3.6 cm
      • Tumor configuration: ulcerative mass
      • Gallbladder: 5.6 x 3.3 x 1.6 cm
      • Representative sections as follows: A: LN 1, B1-B3: LN 3, C: LN 4, D: LN 5, E: LN 6, F: LN 12c, G1-G2: LN 14, H1-H2: LN 7,8,9,11p,12a, I1-I2: bilateral resection margins, I3-I8: tumor + serosa, I9: non-tumor stomach, J1-J2: omentum, K: gallbladder [Reference: F2022-00375 FS: cutting end, one small piece measured 9.7 x 0.5 cm with staples]
    • MICROSCOPIC EXAMINATION
      • Histologic type: Adenocarcinoma
      • Histologic grade: Grade 3, poorly differentiated
      • Depth of tumor invasion: serosa layer
      • Lymph nodes: Tumor metastasis (4/40) with extracapsular extension (3/4) in total number
      • Omentum: free of tumor invasion
      • AJCC Pathologic Staging: pT4aN2, stage IIIA
      • Bilateral Margins: Free, 2.8 and 3.6 cm away from bilateral margins
      • Additional pathologic findings: focal tumor necrosis, focal micropapillary pattern and mild intestinal metaplasia
      • Perineural invasion: Present
      • Lymphovascular space invasion: Present
      • Immunohistochemical stains: CK(+) and HER2(equivocal, Dako score 2+)
      • Gallbladder: chronic cholecystitis with one reactive lymph node. No stone
  • 2022-08-09 CT - abdomen
    • History and indication: gastric cancer
    • Findings
      • A tumor (3.6cm) at gastric body, LC, with reginal LAP.
      • Left liver cyst (0.9cm).
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • No abnormal density at bilateral basal lungs.
    • IMP: Gastric body cancer (3.6cm, LC) with regional LAP.
  • 2022-08-08 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Borderline ECG
  • 2022-08-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (132 - 41) / 132 = 68.94%
      • M-mode (Teichholz) = 69
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis
  • 2022-07-21 Thyroid Ultrasound
    • Autoimmune thyroid disease
  • 2022-07-19 CT - abdomen
    • Clinical history: 56 y/o male patient with An big A2 ulcer was noted at angle. Biopsy x4 was done. DIAGNOSIS: Stomach, antgle, biopsy — Adenocarcinoma.
    • Findings
      • Thickening wall at gastric body, c/w gastric malignancy.
      • There are enlarged lymph nodes in perigastric region, could be due to metastatic lymph nodes.
      • Suspected liver cyst, 0.9cm in S2.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
      • Bilateral lower lung cysts.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE: III (Stage_value)
  • 2022-07-08 Patho - colorectal polyp
    • Colon, 10 cm above anal verge, cold snare polypectomy (B) — Hyperplastic polyp
    • Section shows fragment(s) of polypoid colonic mucosal tissue with crowded benign hyperplastic mucinous glands.
  • 2022-07-08 Patho - colorectal polyp
    • Colon, 25 cm above anal verge, polypectomy (A) — Tubular adenoma with low grade dysplasia
    • Section shows fragment(s) of polypoid colonic mucosal tissue with proliferative tubular mucinous glands lined by cells containing hyperchromatic, elongated nuclei with low grade dysplasia.
  • 2022-07-08 Patho - stomach biopsy
    • Stomach, antgle, biopsy — Adenocarcinoma.
    • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands.
  • 2022-07-08 CT - chest
    • Low dose spiral CT of the chest without contrast enhancement for screening of lung tumor showed:
      • Lungs:Pneumatocele at both lungs up to 1.75cm in largest dimension.
      • Unremarkable in the mediastinum and hilars.
      • Unremarkable of the pleura.
      • Unremarkable of the chest wall.
      • Unremarkable of the supraclavicular fossa.
      • Visible bones: Unremarkable.
      • Calcified coronary arteries is found.
      • Enlarged lymph nodes are found at gastric pericardial region. r/o gastric tumor related.
    • IMP:
      • No definite nodular lesion at both lungs.
      • Calcified coronary arteries is found.
      • Perigastric lymphadenopathy, suspected gastric tumor related.
  • 2022-07-08 Panendoscopy
    • Superficial gastritis, antrum s/p CLO test
    • GU, large, angle s/p biopsy suspected malignancy

[consultation]

  • 2022-12-13 Dermatology
    • Q
      • for skin itchy, skin rash at back and upper limbs after chemotherapy.
      • This 56-year-old male, a pt of gastric CA, pT4aN2 (4/40), cM0, stage IIIA, s/p subtotal gastrectomy & HIPEC on 20220812 by Dr Wu, suffered from initial presentation of progressive weight loss of 80kg to 65kg in 3 months & CEG in July 2022 showed a big A2 ulcer at angle. Biopsy proved CA.
      • Today, he was admitted for #2 post-Op adjuvant C/T with mFOLFOX IV Q2W x 12 on 20221213. He complatins skin itchy, skin rash at back and upper limbs after chemotherapy, so we need your help, thanks a lot!!
    • A
      • The patient had sufferred from cancer s/p chemotherapy. diffuse ithcy red papules with keratosis and fine pusutles was noted.
      • Under the impression of xerotic dermatitis and lichen pilaris et secondary inflammation episode.
      • The following sugeetion:
        • for itchy reddish papules and fine pustules lesion, Mycomb cream 2 tube topical PRN bid use.
        • for follculiar kertosis and xerosis, Sinphraderm cream 1 tube topical QN use.
  • 2022-08-19 Radiation Oncology
    • Q
      • For CCRT
      • This 56-year-old male is a case of type 2 diabetes mellitus and thyrotoxicosis under medicatiosn control. According for his statement, he noted of weight loss for 20 kg and mild poor appetite in 2 months. Then he came to our hospital for health examination on 2022/07/08. UGI scope was showed erythmatus change of gastric mucosa was found at antrum. An big A2 ulcer was noted at angle. Biopsy was done. Final pathology showed adenocarcinoma. Abdomen CT also revealed gastric malignancy with lymph nodes metastasis, cstage T3N2M0. On the same health examination, type 2 diabetes mellitus and thyrotoxicosis was also noted. So medications was keep control first. Due to gastric cancer, he referred to GS OPD for further management. Tumor marker of CEA:2.095 ng/ml; CA-199:173.175 U/ml on 20220711. After diabetes and thyrotoxicosis under medications control, his body wight was improved and stable in 65kg. He denied fever, chills dizzness, poor appetite, nausea, vomiting, or tarry stool passage in recently.
      • This time, he was admitted to our ward for further evaluate and management. He underwent subtotal gastrectomy + HIPEC on 20220811. Post operative course smoothly, fair oral intake. The pathology showed adenocarcinoma, pT4aN2M0, stage IIIA. We need your expertise for further radiotherapy evaluation. Thanks for your times.
    • A
      • A: Adenocarcinoma of the stomach, AJCC Pathologic staging — pT4aN2(cM0), stage IIIA, s/p distal subtotal gastrectomy with D2 LN dissection. HIPEC with Oxaliplatinum, laparoscope staging, and small bowel serosa repair; laparoscope.
      • P: Postoperative CCRT is indicated for this patient with the following indicators: stage pT4aN2(cM0).
        • Goal: curative
        • Treatment target and volume: gastric to regional lymphatic area
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the gastric to regional lymphatic area
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his girl friend. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-09-15.

[MedRec]

  • 2023-03-08 SOAP Hemato-Oncology
    • O: 2023/02/24 CT ABD: Four metastases on both hepatic lobes are highly suspected.
    • P: Suggest to change regimens to Doctaxel + 5-FU and pembo (100 mg) q2w
  • 2022-09-06 SOAP Hemato-Oncology
    • S: Will give post-Op adjuvant C/T wt mFOLFOX IV Q2W x 6 then post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T then post-Op adjuvant C/T wt mFOLFOX IV Q2W x 6.

[surgical operation]

  • 2022-08-20
    • Surgery
      • small bowel serosa repair
      • laparoscope
    • Finding
      • small bowel serosa tear with bleeding+
      • intraabd blood 450cc
      • left inguinal hernia indirect type
  • 2022-08-11
    • Surgery
      • distal subtotal gastrectomy with D2 LN dissection
      • HIPEC with Oxaliplatinum 300 mg for 60 mins at 42 C
      • laparoscope staging
    • Finding
      • laparoscope staging: distal gastric tumor with serosa involve
      • no peritoneal seeding
      • obvious LN at lesser curvature

[radiotherapy]

  • 2022-09-28 ~ 2022-11-02 - 4500cGy/25 fractions of the gastric to regional lymphatic area.

[chemoimmunotherapy]

  • 2023-07-26 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 65mg NS 200mL 4hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 1000mg/m2 1640mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 65mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-06-30 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 65mg NS 200mL 4hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 400mg/m2 670mg NS 100mL 10min + fluorouracil 1000mg/m2 1650mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 65mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-06-06 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 65mg NS 200mL 4hr + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 400mg/m2 675mg NS 100mL 10min + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-05-08 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 60mg NS 200mL 4hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 400mg/m2 690mg NS 100mL 10min + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr Wan XiangLin)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-04-06 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 60mg NS 200mL 4hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 400mg/m2 680mg NS 100mL 10min + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr Wan XiangLin)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-03-13 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 60mg NS 200mL 4hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 400mg/m2 690mg NS 100mL 10min + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr Wan XiangLin)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-02-22 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 685mg NS 250mL 2hr + fluorouracil 2800mg/m2 4825mg NS 500mL 46hr (adjuvant FOLFOX, Dr. Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-30 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 2800mg/m2 4750mg NS 500mL 46hr (adjuvant FOLFOX, Dr. Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-29 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (adjuvant FOLFOX, Dr. Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-13 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4720mg NS 500mL 46hr (adjuvant FOLFOX, Dr. Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-24 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr (adjuvant FOLFOX, Dr. Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-31 - fluorouracil 225mg/m2 360mg NS 500mL 24hr D1-D3 (adjuvant CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-10-24 - fluorouracil 225mg/m2 360mg NS 500mL 24hr D1-D5 (adjuvant CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-10-17 - fluorouracil 225mg/m2 360mg NS 500mL 24hr D1-D5 (adjuvant CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-10-14 - fluorouracil 225mg/m2 360mg NS 500mL 24hr (adjuvant CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-08-11 - oxaliplatin 300mg/m2 525mg IP 1hr (HIPEC)

[note]

Chemotherapy regimens for advanced esophagogastric cancer: Docetaxel, cisplatin, and fluorouracil (DCF) 2023-07-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F73324

  • Cycle length: 21 days.
  • Drug
    • Docetaxel
      • 75 mg/m2 IV
      • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
      • Day 1
    • Cisplatin
      • 75 mg/m2 IV
      • Dilute in 250 mL NS and administer over 60 minutes. Do not administer with aluminum needles or IV sets.
      • Day 1
    • Fluorouracil (FU)
      • 750 mg/m2 per day IV
      • Dilute in 500 to 1000 mL D5W and administer as a continuous infusion over 24 hours. For use in an ambulatory infusion pump. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose can be diluted in 100 to 150 mL NS.
      • Days 1 through 5

Chemotherapy regimens for locally advanced, potentially resectable gastric or gastro-esophageal junction adenocarcinoma: Perioperative docetaxel, oxaliplatin, fluorouracil, and leucovorin (FLOT4) 2023-03-14 https://www.uptodate.com/contents/image?imageKey=ONC%2F120512

  • Cycle length: 14 days.
  • Duration of therapy: In the original trial, preoperative FLOT was given every 14 days for 4 cycles. Following surgery, postoperative FLOT was given every 14 days for 4 cycles.
  • Drug
    • Docetaxel
      • 50 mg/m2 IV
      • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
      • Day 1
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (oxaliplatin and leucovorin can be administered concurrently in separate bags using a Y-connector).
      • Day 1
    • Leucovorin
      • 200 mg/m2 IV
      • Dilute in 250 mL D5W and administer over two hours concurrent with oxaliplatin.
      • Day 1
    • Fluorouracil (FU)
      • 2600 mg/m2 IV
      • Dilute in 500 to 1000 mL D5W and administer over 24 hours (begin immediately after completion of leucovorin infusion). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose can be diluted in 100 to 150 mL NS or D5W.
      • Day 1

ref: Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet. 2019;393(10184):1948-1957. doi:10.1016/S0140-6736(18)32557-1

==========

2023-07-27

This patient receives all medical care exclusively at our hospital and has appointments with both the hematology-oncology and endocrinology and metabolism departments. Medications prescribed by the endocrinology and metabolism department, including Cardiolol (propranolol), Galvus Met (vildagliptin, metformin), and methimazole, were correctly documented on the active medication list. As a result, no medication reconciliation issues were identified.

2023-07-03

  • This patient is treated exclusively at our hospital and has appointments with both the Hematology-oncology and Endocrinology and Metabolism departments. The medications prescribed by the endocrinology and metabolism department, which include Cardiolol (propranolol), Galvus Met (vildagliptin, metformin), and methimazole, were all accurately entered into the active medication list. As a result, no discrepancies were found during the medication reconciliation process.

2023-06-07

  • This patient is treated only at our hospital. In addition to visits to the hematology-oncology service, he also visits the endocrinology and metabolism service. Medications prescribed by the latter department, including Cardiolol (propranolol), Galvus Met (vildagliptin, metformin), and methimazole, are all appropriately included in the active medication list, with no medication reconciliation issues identified.

2023-05-09

  • Given that the most recent CT scan was conducted in February 2023 and three months have since elapsed, it may be prudent to schedule a new CT scan to obtain updated imaging.
  • The patient’s fasting blood glucose levels during this hospital stay were recorded approximately 150mg/dL. Including Dibose (acarbose 100mg/tab) 1# TIDCC could potentially improve glucose regulation.

2023-03-14

  • CT scans conducted in late Feb indicated the possible presence of metastases in the liver as well as loculated fluid-like accumulation near the pancreatic tail. As a result, the FOLFOX regimen was replaced by a new treatment regimen consisting of pembrolizumab, docetaxel, leucovorin, fluorouracil, and cisplatin. This new regimen was first administered during the patient’s current hospital stay.
  • The patient’s vital signs in the TPR panel have remained stable, and the lab data from 2023-03-14 showed grossly normal results. The patient’s underlying conditions of hyperglycemia and thyrotoxicosis are being managed with corresponding medications, and hydroxocobalamin is being administered to prevent vitamin B12 deficiency after gastrectomy. No medication reconciliation issues were found.

2022-12-14

  • The IHC HER2 result was equivocal (Dako score 2+), and there was no HER2 FISH or PD-L1 result available yet. Trastuzumab or its biosimilar should be added to first-line chemotherapy for HER2 overexpression positive adenocarcinoma.
  • The underlying conditions are treated with corresponding medications without an issue.

700145771

230726

[lab data]

2023-07-18 CA-199 (NM) 52.608 U/ml
2023-07-04 CA-199 (NM) 38.491 U/ml
2023-06-09 CA-199 (NM) 39.33 U/ml
2022-05-26 CA-199 53.04 U/mL

2023-06-09 HBsAg (NM) Negative
2023-06-09 HBsAg Value (NM) 0.373
2023-06-09 Anti-HCV (NM) Negative
2023-06-09 Anti-HCV Value (NM) 0.042
2023-06-09 Anti-HBc (NM) Positive
2023-06-09 Anti-HBc Value (NM) 0.009
2023-06-09 Anti-HBs (NM) Negative
2023-06-09 Anti-HBs value (NM) 4.06 mIU/mL

2022-05-26 HBsAg Nonreactive
2022-05-26 HBsAg (Value) 0.63 S/CO
2022-05-26 Anti-HCV Nonreactive
2022-05-26 Anti-HCV Value 0.08 S/CO

[exam findings]

  • 2023-07-11 CT - abdomen
    • Clinical history: 85 y/o female patient with cholangiocarcinoma post CCRT (xeloda) at ShinKuan hospital and received CCRT there. But progression was noted 3 months after CCRT.
    • With and without contrast enhancement CT of abdomen - whole:
      • Focal IHD dilatation in left lateral segment of liver.
      • Ill-defined low density lesion, 5.2cm in S2 liver with adjacent vascular compression, r/o cholangiocarcinoma with progression.
      • Enlarged lymph nodes in upper abdomen, r/o metastatic lymph node.
      • Small liver cyst, 4.2cm in S6.
      • Outpouching lesions in the sigmoid colon, suggesting sigmoid colon diverticula.
      • Left renal cyst, 0.9cm.
      • L1 and L2 compression fractures.
    • Impression:
      • Cholangiocarcionoma with IHD dilatations and lymph nodes metastasis. Progression.
      • Sigmoid colon diverticula.
      • Liver and left renal cysts.
      • L1 and L2 compression fractures.
  • 2023-06-16 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2023-06-16 ECG
    • Normal sinus rhythm
    • T wave abnormality, consider lateral ischemia
    • Abnormal ECG
  • 2023-04-17 Microsonography
    • clinical diagnosis: end stage glaucoma ou
    • Report: OCT-D x/72, x/2.14, x/0.86
      • CRT: 209/286 um, high myopia change ou
  • 2022-12-13 L-spine AP + Lat. (including sacrum)
    • L1, L2, L3 compression fracture.
    • Grade 1 spondylolisthesis at L5-S1 level.
    • Degenerative change of the spine with marginal spur formation.
    • Osteopenia of visible bones.
  • 2022-11-14 Hip BMD performed by DXA
    • Finding: Left hip, BMD is 0.477 gms/cm2, about 3.4 SD below the peak bone mass (56%) and 0.2 SD below the mean of age-matched people (97%).
    • Impression: Osteoporosis
  • 2022-05-26 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
    • ST & T wave abnormality, consider lateral ischemia
    • Prolonged QT
  • 2022-05-25 CT - abdomen
    • Clinical history: 84 y/o female patient with low back pain, lower abdominal distension, dysuria, bilateral lower limb edema.
    • With and without contrast enhancement CT of abdomen - whole:
      • Focal IHD dilatation in left lateral segment of liver.
      • Ill-defined low density lesion, 5cm in S2 liver, r/o cholangiocarcinoma.
      • Small liver cyst, 4.2cm in S6.
      • Outpouching lesions in the sigmoid colon, suggesting sigmoid colon diverticula.
      • Left renal cyst, 0.9cm.
      • Right pleural effusion with basal lung collapse.
      • L1 and L3 compression fractures.
      • Gr I spondylolisthesis at L5-S1.
    • Impression:
      • Left lobe liver tumor with focal IHD dilatation in left lateral segment of liver. R/O cholangiocarcinoma, suggest further study.
      • Sigmoid colon diverticula.
      • Liver and left renal cysts.
      • Right pleural effusion with basal lung collapse.
      • L1 and L3 compression fractures. Gr I spondylolisthesis at L5-S1.
  • 2022-05-25 CXR
    • Mild bunting of costophrenic angle, both sides.
    • Cardiomegaly.
    • Intimal calcification of thoracic aorta.
    • L1 compression fraccture.
    • Narrowing of right shoulder joint.
  • 2022-05-25 KUB
    • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
    • Non-specific bowel gas pattern.
    • Clear margin of bilateral psoas muscles.
    • Lumbar spondylosis.
    • L2 and L4 compression fractures.
    • Osteoporosis of the bones.

[MedRec]

  • 2023-07-26 POMR ProgressNote
    • The patient requested to self-administer her own medication, adjusting it based on her daily condition. She expressed doubts about receiving medications from nurses. The nurse practitioner informed her about the safety of administering medication through the nursing team, but the patient was unable to accept it. Therefore, the patient’s outpatient medication was canceled.
  • 2023-06-23 SOAP Hemato-Oncology
    • A: She requested self-paid Xeloda as before duringt her preparation for vertioplasty by ortho doctors
    • Prescription
      • Xeloda (capecitabine 500mg) 2# BID
  • 2023-06-20 SOAP Hemato-Oncology
    • A: She preferred to be treated for her back first and hold the chemotherapy according to her decision.
  • 2023-06-16 ~ 2023-06-16 POMR Hemato-Oncology
    • Discharge diagnosis
      • cholangiocarcinoma post CCRT (xeloda) at ShinKuan hospital
    • CC
      • for port-A insertion and further treatment
    • Present illness
      • This 84 years old female with history of
        • HTN
        • Chronic ischemic heart disease
        • Cerebral artherosclerosis
        • cholangiocarcinoma post CCRT (Xeloda) at ShinKuan hospital
        • COVID-19 test (+). Confirmed on 2022-05-17, and discharged on 2022-05-20.
      • According to her daughter, CT at ShinKuan hospital told progression. This time,she was admitted for port-A insertion and further treatment.
    • Course of inpatient treatment
      • After admission, labortaory test revealed fair CBC level. plan to receive port-A insertion on 2023-06-21 but patient requsted for against medical advice discharge due to the next bed had influenza-A on 2023/06/16. OPD follow up was arranged
  • 2023-06-02 SOAP Hemato-Oncology Gao WeiYao
    • S: A documented cholangiocarcinoma post CCRT (Xeloda) at ShinKuan hospital and received CCRT there. But progression was noted 3 months after CCRT.
    • P: Ask her and her daughter to bring back the patho report and CT imaging.
  • 2022-12-13 SOAP Orthopedics
    • A
      • spinal orthosis
      • prolia 1st dose since 2022/12/13
      • warm packing
      • add density
    • Prescription
      • Arcoxia (etoricoxib 60mg) 1# QD
      • Prolia (denosumab 60mg) SC
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# BID
  • 2022-05-25 ~ 2022-06-04 POMR Gastroenterology
    • Discharge diagnosis
      • COVID-19, virus identified
      • Urinary tract infection (Urine culture grew PDR-Chryseobacter indologene)
      • Left lobe liver tumor with focal intrahepatic bile duct dilatation in left lateral segment of liver. Rule out cholangiocarcinoma
      • Sigmoid colon diverticula
      • Right pleural effusion with basal lung collapse
      • Edema, unspecified
      • Hypo-osmolality and hyponatremia
      • Hypokalemia
      • Lumbar spondylosis
      • Lumbar 2 and Lumbar 4 compression fractures
      • Liver cysts
      • Left renal cysts
      • Chronic ischemic heart disease, unspecified
    • CC
      • abdomen distension and pitting edema for few days
    • Present illness
      • This 84 years old female with history of
        • HTN
        • Chronic ischemic heart disease
        • Cerebral artherosclerosis
      • She just discharged from our Hospital, due to COVID-19 test(+). Confirmed on 2022-05-17, and discharged on 2022-05-20.
      • This time, she was suffered from abdomen distension and pitting edema for few days, the s/s was progressive. She was sent to our ER for help. At MER, physical examination revealed acute on chronic ill-looking, the CXR showed Mild bunting of costophrenic angle, both sides, Cardiomegaly. Abd CT was performed and revealed Left lobe liver tumor with focal IHD dilatation in left lateral segment of liver, R/O cholangiocarcinoma, suggest further study. Lab data revealed elevated CRP 9.90mg/dL. Under the impression of Left lobe liver tumor R/O cholangiocarcinoma. She was admitted to our ward for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, adquat IV fluid support, IV Lasix empirical antibtioic were both given. We Well informed current condition of liver tumor R/O cholangiocarcinoma to herself and her son and suggested tissue proof later. They understand and wait for their answer. Nephrologist was consulted for hyponatremia. WE Checked HBsAg, anti-HCV, AFP, CEA, Ca19-9, ALP and rGT st and arrange abdomen echo. However, her SARS-CoV-2 RT-PCR reported Positive today and after we contact our infection control unit, suggested COVID-19 ward for isolation and for further management.
      • After isolation ward, keep current treatment and antibiotic with Brosym 4gm ivd (20220526~20220601) was perscribed. Diuretics with lasix was given for lower limbs edema. Intravenous infusion with 3% NaCL was given for one day for hyponatremia, then shift 0.9% NaCL 500ml/day. Follow-UP lab, revealed hypokalemia, Radi-K po was given (20220530 - 20220604). Due to COVID-19 CT value > 30, she was transfer to GI ward for further management. After transferring to ordinary ward, we kept the medical treatment. WE SUGGESTED LIVER BIOPSY AND DUPLEX STUDY FOR HER LEFT LEG EDEMA. FAMILY WISH EARLY DISCHARGE. Under stable condition, she was discharged on 2022/06/04 and GI OPD follow-up was arranged later.
    • Discharge prescription
      • Through (sennoside 12mg) 2# HS
      • Uretropic (furosemide 40mg) 0.5# QD
      • Alpraline (alprazolam 0.5mg) 1# HS
  • 2017-07-18 SOAP Ophthalmology
    • Diagnosis
      • Tear film insufficiency, unspecified [H04.123]
      • Lens replaced by other means [Z96.1]
      • Exotropia, unspecified [H50.10]
    • Prescription x3
      • Vidisic Gel (carbomer) QID OU
      • tetracycline BID OD
      • Sinomin (sulfamethoxazole) QID OU
  • 2017-03-09 SOAP Neurology
    • Diagnosis
      • Chronic ischemic heart disease, unspecified [I25.9]
      • Cerebral atherosclerosis [I67.2]
      • Arteriosclerotic dementia, uncomplicated [F01.50]
      • Displacement of lumbar intervertebral disc without myelopathy [M51.27]
    • Prescription x3
      • Alpraline (alprazolam 0.5mg) 1# HS
      • Syntam (piracetam 1200mg) 1# BID
      • Schnin (ginkgo biloba 9.6mg) 1# BID
      • Rivotril (clonazepam 0.5mg) 1# HS

[consultation]

  • 2022-05-26 Nephrology
    • Q
      • This 84 y/o female with history of 1) HTN 2) Chronic ischemic heart disease, just discharge from our Hospital, due to COVID-19 test(+). This time, she was suffered from low back pain and pitting edema for few days, the s/s was progressive. She was sent to our ER for help. At MER, physical examination revealed acute on chronic ill-looking, the CXR showed Mild bunting of costophrenic angle, both sides, Cardiomegaly. Abd CT was performed and revealed Left lobe liver tumor with focal IHD dilatation in left lateral segment of liver. R/O cholangiocarcinoma, suggest further study. Lab data revealed elevated CRP 9.90mg/dL. Under the impression of Left lobe liver tumor with focal IHD dilatation in left lateral segment of liver, R/O cholangiocarcinoma. She was admitted to our ward for further evaluation and treatment.
      • we need your expertis for hyponatremia
    • A
      • Consult for hyponatremia
      • Lab data :
        • WBC: 10.83, Hb: 14.8,Plt: 155
        • Na: 131(5/17) -> 123, K: 3.3, CRP: 9.9, NTproBNP: 446
        • BUN: 19, cre: 0.57
        • Lipase: 45, T bil: 0.79, albumin: 3.6, gucose: 108
        • HBV (-), HCV (-), ALKP: 75 ,r GT: 68
        • AFP: 4.0, CEA: 3.3, CA199: 53.04
        • U/A: light yellow, clear, SG: 1.008, PH: 7.0, Nit: -, glu: -, pro: -, OB: -, RBC: 3-5, WBC: 0-5, Cast: 0, bacteria :-
        • CXR: cardiomegaly and bilateral costophrenic angle bunting and slight pulmonaty congestion
        • KUB: L2-L4 compression fracture
        • CT abdomen: Left lobe liver tumor with focal IHD dilatation in left lateral segment of liver. R/O cholangiocarcinoma
        • PE: EDEMA 2-3+
        • Current medication : lasix 20mg IV QD
      • Impression:
        • Hyponatremia cause to be determined
      • Suggestion :
        • Check plasma osmolality, urine osmolarity, Ur Na, Ur K, Ur cre, Ur Cl, Fe uric acid
        • Check lipid profile, total protein
        • Check thyroid function and ACTH, cortisol
        • Please arrange cardiac echo to rule out heart failure
        • Follow up Na, K,
        • Thank you very much for your consultation.

==========

2023-07-26

[medication reconciliation]

This patient just refilled Betmiga (mirabegron) on 2023-07-10 for her urinary incontinence for a 28-day valid duration at Far Eastern Hospital, this drug is not included in the active medication list, please confirm if this drug is not necessary for the patient’s current condition.

[poor medication compliance, non-adherence to medication regimen]

The 2023-07-26 progress note states, “The patient requested to self-administer her medications, adjusting them based on her daily condition. She expressed concern about receiving medications from nurses. The nurse practitioner educated her about the safety of medication administration by the nursing team, but the patient was unable to accept it. As a result, the patient’s outpatient medication was discontinued”.

On 2023-07-26, I visited the patient and her caregiver at approximately 11:00 am to address the concerns raised in the progress note regarding the patient’s medication compliance.

The patient said she is a member of TzuChi and was diagnosed with suspected cholangiocarcinoma in 2022-05 and subsequently treated at ShinKong Hospital. During the visit, I found that the patient tends to be selective in taking prescribed medications, believing that certain medications are more effective and should be taken more, while she perceives little efficacy from other prescribed medications. In addition, the patient mentioned that she does not always take her prescribed painkiller.

I have tried to help the patient understand the importance of adhering to the prescribed medication regimen. However, it appears that the patient still holds strong personal beliefs regarding medication, which may lead to inaccurate assessments of treatment effectiveness.

Regarding the issue of low sodium levels, I advised the patient to increase her salt intake, the patient attributed this to the caregiver’s cooking, as she felt that the meals were not seasoned enough. However, upon further discussion with the nurses, the caregiver mentioned that she already added an adequate amount of salt to the meals.

700185130

230725

{not completed}

[exam findings]

  • 2023-07-05 CT - abdomen
    • History:
      • Pancreatic cancer with tumor necrosis, portal vein thrombosis, invasion to left kidney, T4NxM1, stage IV, status post transabdominal pancreatic biopsy on 2023/04/11 s/p EP from 2023/04/27
      • 20230411 US-guided biopsy: Neuroendocrine carcinoma, large cell type
    • Findings:
      • Prior CT identified a large heterogeneous poor enhancing tumor with central tumor necrosis (10.0cm in the largest dimension) at the pancreatic body and tail is noted again, stationary that is c/w neuro-endocrine carcinoma of the pancreas S/P C/T with stable disease.
        • Prior CT identified tumor thrombosis in the trifurcation of the splenic vein, superior mesenteric vein, and portal vein is noted again, stationary.
        • In addition, there is small size of the splenic artery and non-visualization of the splenic vein that is c/w tumor encasement.
      • There is splenomegaly (the greatest cranial-caudal dimension measuring 13 cm in size).
      • There is ascites in the pelvis.
    • Impression:
      • Neuro-endocrine carcinoma of the pancreatic body and tail S/P C/T shows stable disease.
  • 2023-07-02 CT - brain
    • Indication: con’s change
    • Impression: No definite abnormality in this study
  • 2023-07-01 ECG
    • Sinus bradycardia
    • Lateral infarct, age undetermined
  • 2023-06-13 ECG
    • Sinus rhythm with short PR
  • 2023-06-09 All-RAS + BRAF mutation
    • Tissue Block No: S2023-06855
    • RESULTS:
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-04-26 ENT Hearing Test
    • Reliabilty Fair
    • PTA
    • R’t : >120 dB HL, profound HL
    • L’t : 93 dB HL, severe to profound SNHL.
  • 2023-04-12 Patho - pancreas biopsy
    • Pancreas, sono-guided biopsy — Neuroendocrine carcinoma, large cell type
    • The sections show neuroendocrine carcinoma, large cell type, composed of large pleomorphic neoplastic cells with moderate amount eosinophilic cytoplasm, arranged in solid pattern. Tumor necrosis is present.
    • IHC, tumor cells reveal: CK(+), CK7(+), CD56(focal +), Synaptophysin(+), Trypsin(-/+) and Ki67=70%.
  • 2023-04-11 Sono-guided pancreatic tumor biopsy
    • Findings: A large heterogeneous isoechoic tumor with anechoic component at pancreatic neck and body.
  • 2023-04-08 MRI - pancreas
    • History and indication: abdominal pain
    • With and without contrast MRI of abdomen with MRCP reconstruction revealed:
      • A large poor enhancing tumor (8.8x10.0cm) at LUQ with splenic artery, vein, stomach, left adrenal, adjacent bowel and spleen invasion. Proximal portal vein thrombosis with collateral circulation.
      • Normal appearance of liver and kidneys.
      • No ascites, nor enlarged lymph node.
      • No abnormal signal intensity in bilateral basal lungs.
    • IMP:
      • In favor of pancreatic tumor as described.
  • 2023-04-07 SONO - abdomen
    • Diagnosis
      • Pancreatic tumor, with tumor necrosis, PVT, invasion to left kidney.
      • Splenomegaly, mild
    • Suggestion
      • consider trans-abdominal biopsy.
  • 2023-03-25 CT - abdomen
    • History and indication: Hematochezia / Melena
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A large poor enhancing tumor (8.1x10.0cm) at LUQ r/o pancreatic tumor. Splenic artery and vein invasion and proximal portal vein thrombosis with collateral circulation was noted. Stomach, left adrenal, adjacent bowel and spleen invasion should be ruled out.
      • Small amout ascites. Some LNs at upper abdomen.
    • IMP:
      • Suspected pancreatic tumor with splenic artery/ vein/ portal vein/ stomach/ left adrenal gland/ adjacent bowel loop and splenic invasion.

[consultation]

  • 2023-06-09 Obstetrics and Gynecology
    • Q
      • This is a 43-year-old female with history of Pancreatic cancer with tumor necrosis, portal vein thrombosis, invasion to left kidney, T4NxM1, stage IV, status post transabdominal pancreatic biopsy on 2023/04/11, s/p Etoposide plus Cisplatin form 2023/04/27, this time, she was admitted for chemotherapy.  
      • For menstrual pain was noted, we need your consultation for evaluation. Thanks a lot!!!
    • A
      • We consulted for menstrual pain
      • OBGYN:
        • P2 (NSD*2)
        • LMP 06/06
      • Lab:
        • WBC 3660, Hb 10.7, PLT 178000, BCS WNL
        • CEA 2.09, CA199 9.14, CA125 49.3
      • PV:
        • moderate amount of red discharge
        • no lifting pain
        • smooth cervix
      • TVUS and TAS:
        • Uterus 108*40mm, EM 14.8mm
        • ROV 2418mm, LOV 2317mm
        • ascites+
      • Impression:
        • EM 14.8mm
      • Suggestion:
        • current no GYN lesion noted
        • NSAID for pain control
        • GYN OPD f/u for menstrual cycle
  • 2023-04-13 Hemato-Oncology
    • A -This 43 year old woman is a case of pancreatic tumor with splenic artery/ vein/ portal vein/ stomach/ left adrenal gland/ adjacent bowel loop and splenic invasion s/p Transabdominal pancreatic biopsy was done on 20230411. We are consulted for further evaluation.
      • May check LDH, HBsAg, Anti-HBc, Anti-HBs, Anti-HCV. Pending pathology result. Arrange our OPD after discharge.
  • 2023-04-12 General and Gastroenterological Surgery
    • Q
      • This 43 years old woman denied any systmic underlying disease, hearing-impaired person.
      • This time, she has abdominal pain since 2023-03-15 (thought it was menstrual pain) but pain sensation no improve so she came to our ED for hlep on 2023-03-19, ecchymosis around the navel was also noted, suggest abdominal CT examination but reufsed and AAD. Still intermittent abdominal pain and mass lesion over left abdominal, back stool passage for one weeks, so she came to ED and arrange PES was done on 2023-03-24, report showed Gastric huge mass lesion, upper body, suspect external compression, no ulcer or active bleeding noted. The Abdominal CT was done on 2023-03-25 and revealeding R/O pancreatic tumor with splenic artery/ vein/ portal vein/ stomach/ left adrenal gland/ adjacent bowel loop and splenic invasion. There was no fever, productive cough, abdominal pain is intermittent, The tarry stool was improved after medication, but syncope while riding a motorcycle yesterday. TOCC history was unremarkable. Thus, she was admitted to our GI ward for MRCP examination on 2023-04-05.
      • Pancreatic MRI plus MRCP was performed on 2023/04/08 and reported A large poor enhancing tumor (8.8x10.0cm) at LUQ with splenic artery, vein, stomach, left adrenal, adjacent bowel and spleen invasion. Proximal portal vein thrombosis with collateral circulation.Transabdominal pancreatic biopsy was done on 2023-04-11 ,the pathology was pending. We will need your surgical evaluation, thank you
    • A
      • Please pending pathology report
      • Poor operation due to r/o pertoneal seeding and proximal portal vein thrombosis was noted.

[MedRec]

  • 2023-07-03 Multi-disciplinary Team Recommendations - Social Services
    • Referral Date: 2023-07-03
    • Reason for Referral: The patient lacks self-care ability during hospitalization, and family members are unable to come to the hospital to take care of her.
    • Status: Case opened
    • Family Situation: According to past service records and the visit to the patient on 2023-06-30, and after having a conversation with the patient, the following family situation was obtained:
      • The patient is 43 years old, unmarried, and has a hearing impairment. She works as an administrative assistant with a monthly income of 24,000 NTD. She used to live with her two children on the 8th floor with an elevator in a rented apartment, with a monthly rent of 29,000 NTD. Since June 2023, she has moved in to live with her mother, and her two children are taken care of by her eldest younger sister.
      • The patient has had two intimate relationships, and each relationship has resulted in one son. The elder son is in the fourth grade of Muzha Elementary School, and the younger son is in the middle class of Renmei Kindergarten. According to the patient’s aunt, the elder son maintains contact with his biological father, while the younger son has no contact with his biological father, and both sons have not undergone paternity acknowledgment.
      • The patient’s mother is 64 years old and works in a fruit shop. She has been married twice and has three daughters and one son (female, female, female, male). The patient is the eldest daughter, and her father has passed away. Her two younger sisters are married, and her brother lives abroad. According to the patient’s aunt, due to past family issues, the relationship between the patient and her mother and siblings is somewhat distant. The patient was raised by her maternal grandmother since childhood and is closer to her aunt, who is of a similar age, and thus trusts her aunt more.
      • The patient was diagnosed with malignant sebaceous gland tumor around 2017 years ago and received treatment at the Postal Hospital. After completing the treatment, the patient did not continue to follow up with regular visits.
      • The patient is classified as a fourth-class low-income household in Taipei City and holds a second-class severe disability certificate due to her hearing impairment. She receives a total of 17,576 NTD in disability and low-income living allowances each month.
      • Contact persons: Patient’s mother (Deng XiuZhu), patient’s aunt (Deng YuZhu).
    • Main Problem: Economic issue
    • Problem Details: Issue with hiring caregiver costs
    • Disposition: Referral for economic assistance
    • Responder: Liu SiLing
    • Reply Date: 2023-07-03
    • Physician Response:
      • 2023/07/04 10:48 Dr. Xia Hexiong: Will follow the recommendations, the family relationship in this case is very complicated. The patient’s children are taken care of by her younger sister, but the patient has a poor relationship with her sisters. The patient interacts more with her aunt. The patient now lives with her mother, but during the conversation with her aunt regarding the patient’s condition, it was discovered that even the relationship between the aunt and the patient’s mother is not good. The attending physician hopes to have a complete discussion and explanation of the patient’s condition with all the family members concerned about the patient. A family meeting is scheduled to be held on Friday, 2023/07/07. The aunt has left the mother’s phone number, and the hospital is expected to contact the mother directly. Attempts were made to contact the mother on 2023/07/03 and 2023/07/04, but the calls were not answered.
  • 2023-07-02 Multi-disciplinary Team Recommendations - Psychological Oncology
    • Referral Date: 2023-07-02
    • Reason for Referral: Stressful illness event: Psychological response due to physical illness or decision-making regarding treatment options; Emotional distress: Anxiety, fear, depression, anger; shyness, shock, and other emotional categories.
    • Conclusion: (Social) Visit on 7/4, the patient was using a smartphone and responded with gestures that the treatment has not started yet. The first two treatments were okay, and they have been doing well at home and with their eating. Thank you for the concern. (Objective) Diagnosed with pancreatic cancer and renal metastasis on 12/3, previously visited on 4/27 (emotional distress, chronic stress; hearing impairment; unmarried, two children); admitted for the third round of chemotherapy on 6/30, nursing consultation on 7/2 reported psychological stress response. (Intervention) Providing support for the treatment burden of the patient. (Action Plan) The patient remains unwilling to talk; it is advised to consider prognosis, physical condition, family support, and financial burden, and continue discussing the treatment direction with the family. Counseling Psychologist Huang Xiaofang 65628
    • Responder: Huang XiaoFang
    • Reply Date: 2023-07-05 17:42
    • Physician Response:
      • 2023/07/06 07:49 Dr. Xia Hexiong: Will follow the recommendations and continue to monitor and observe the patient’s condition. Will also arrange a family meeting to help the patient and family better understand the current situation. Thank you for the team’s response.
  • 2023-06-30 Multi-disciplinary Team Recommendations - Social Services
    • Referral Date: 2023-06-30
    • Reason for Referral: Other: Low-income household
    • Status: Not opened
    • Reason for Not Opening: The social services department has dealt with the case previously and is still in the process.
    • Family Situation: The same as previously mentioned.
    • Social Worker Evaluation and Handling:
      • The patient is undergoing routine chemotherapy during this hospitalization. As a low-income individual, she is exempt from hospitalization fees and has not used any self-paid items. The patient can take care of herself during hospitalization, so there are no economic and care issues assessed.
      • The social worker has provided the above handling, and there are no further derivative problems at this time. If there are any other needs, please refer again. Thank you.
    • Responder: Liu Si-ling
    • Reply Date: 2023-06-30
    • Physician Response:
      • 2023/07/03 08:00 Dr. Xia Hexiong: Will follow the recommendations and continue to monitor and observe the patient’s condition. Will also arrange a family meeting to help the patient and family better understand the current situation. Thank you for the team’s response.
  • 2023-04-19 SOAP Hemato-Oncology
    • Assessment and Plan
      • pancrease neuroendocrine carcinoma, large cell type
      • transfer to ER due to anemia with dizzines (blood transfusion and admission)
      • admiited for port A insertion, check 24 urine CCR, audiometry and then C/T with EP
        • etoposide + carboplatin (hearing impairment)

[chemotherapy]

  • 2023-06-30 - etoposide 100mg/m2 120mg NS 500mL 1hr D1-3 + cisplatin 25mg/m2 30mg NS 500mL D1-3
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-06-07 - etoposide 100mg/m2 130mg NS 500mL 1hr D1-3 + cisplatin 25mg/m2 35mg NS 500mL D1-3
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-04-27 - etoposide 100mg/m2 130mg NS 500mL 1hr D1-3 + cisplatin 25mg/m2 35mg NS 500mL D1-3
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

==========

2023-07-25

Episodes of anemia were evident according to the most recent lab results.

  • 2023-07-24 HGB 9.1 g/dL
  • 2023-07-19 HGB 6.4 g/dL **
  • 2023-07-10 HGB 10.4 g/dL
  • 2023-07-07 HGB 8.7 g/dL *
  • 2023-07-05 HGB 10.9 g/dL
  • 2023-07-03 HGB 10.8 g/dL
  • 2023-07-01 HGB 9.0 g/dL
  • 2023-06-30 HGB 9.1 g/dL

The most recent chemotherapy administration was initiated on 2023-06-30. Additionally, the patient experienced several GI tumor bleeding events since 2023-03 and received blood transfusions on the following dates: 2023-03-24, 2023-03-25, 2023-04-05, 2023-04-12, 2023-04-19, 2023-04-23, 2023-06-30, 2023-07-07, 2023-07-19, and 2023-07-24. Considering that both tumor bleeding and blood transfusions can affect HGB levels, it is difficult to conclusively attribute anemia solely to chemotherapy, and the potential impact of chemotherapy cannot be completely ruled out.

2023-07-10

Studies indicate that patients with gastroenteropancreatic neuroendocrine carcinoma who receive cisplatin/etoposide treatment can have an Objective Response Rate (ORR) ranging from 14% to 67%, as stated in “Systemic Treatment of Gastroenteropancreatic Neuroendocrine Carcinoma. Curr. Treat. Options in Oncol. 22, 68 (2021).”

The CT scan on 2023-07-05 demonstrated stable disease for the neuroendocrine carcinoma of the pancreatic body and tail, following 3 cycles of the cisplatin/etoposide regimen. This might suggest that the disease could be developing some degree of resistance to the treatment.

2023-07-03

After reviewing the PharmaCloud database and in-hospital HIS5 records, no medication reconciliation issues were identified.

2023-06-08

The patient sought treatment for unspecified dermatitis at Huang ZhenXian Dermatology Clinic on 2023-05-08 and was prescribed tranexamic acid, betamethasone, prednisolone, and loratadine for a short duration of 3 days. Currently, no dermatitis-related symptoms are observed in the admission note or the active medical problem list. Therefore, no medication reconciliation issues are identified.

700337848

230725

[exam findings]

  • 2023-06-26 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2023-06-05 Patho - colon biopsy
    • Large intestine, rectum, 6-7 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2023-06-05 Colonoscopy
    • An ulcerative tumor lesion is located at rectum (6-7cm AAV) with obstruction.
  • 2023-06-02 MRI - pelvis
    • Indicaiton
      • 20230528 CC: bloody stool on and off for months
      • 20230530 colonoscopy: circumferential rectal tumor with lumen narrowing, scope cannot pass through since 10cm, 1st fold of rectum.
      • 20230601 CT: upper rectal cancer & obstruction, T4bN2aM0, STAGE: IIIC
    • Findings
      • There is a lobulated soft tissue mass in the upper rectum, measuring 8 cm (the largest dimension), showing hypointensity on T1WI and mild hyperintensity on both T2WI and DWI. During dynamic study, this tumor shows poor enhancement that is c/w adenocarcinoma of the upper rectum.
        • In addition, there is fat plane obliteration between this rectal mass and the urinary bladder and prostate that may be urinary bladder and prostate invasion (T4b).
        • There is fat plane obliteration between this rectal mass and the mesorectal fascia that is c/w mesorectal fascia invasion.
      • There are four enlarged nodes in the perirectal space that are c/w metastatic nodes (N2a).
      • There are enlarged nodes in right and left inguinal area that may be non-regional metastatic nodes (M1a).
        • Please correlate with PET scan.
      • There is a vesical stone 1 cm.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression ( Imaging stage ): T:T4b(T_value) N:N2a(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
  • 2023-06-01 CT - abdomen
    • History and indication:
      • rectal cancer with obstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of rectum with adjacent fat, prostate, seminal vesicles invasion and regional LAP.
      • Bil. pleural effusions.
      • A stone (1.0cm) in urinary bladder. Left renal staghorn stone. Renal cysts (up to 1.8cm).
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression ( Imaging stage ): T:T4b(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2023-06-01 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (122 - 73) / 122 = 40.16%
      • M-mode (Teichholz) = 40
    • Conclusion:
      • Dilated LA
      • Impaired LV systolic function, generalized hypokinesis
      • LV hypertrophy, Impaired LV relaxation
      • Mild MR, TR, AR, PR
  • 2023-06-01 Flow Volume Loop
    • Normal spirometry
  • 2023-05-31 KUB
    • Radiopaque spot(s) at left renal region r/o renal stone(s).
    • Presence of ileus.
    • A calcification at right pelvic cavity.
  • 2023-05-30 Sigmoidoscopy
    • Finding: circumferential rectal tumor with lumen narrowing, scope can not pass through since 10cm, 1st fold of rectum.
    • Diagnosis: Highly suspect rectal cancer with osbtruction, due to PLVIX only 3 days stopping, no biopsy
    • Suggestion:
      • repeat sigmoidoscopy with biopsy after plavix 6~7 days
      • T colostomy or stenting for rectal cancer obstruction
      • A + P and Chest CT, CEA.
  • 2023-05-29 SONO - abdomen
    • Hepatic calcification, right lobe
    • Parenchymal renal disease
    • Renal cyst, RK
    • Renal stone, LK
  • 2023-05-29 Esophagogastroduodenoscopy, EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A
      • Hiatal hernia
      • Gastric polypoid lesion, prepyloric antrum, LC, s/p biopsy
      • Gastric erosions, pylorus
      • Duodenal ulcer scar with pseudodiverticulum, bulb
    • Suggestion:
      • Pursue pathology report
      • PPI therapy
  • 2023-05-27 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
    • Left axis deviation
    • Moderate voltage criteria for LVH, may be normal variant
    • Inferior infarct, age undetermined
    • Abnormal ECG
  • 2023-05-27 CXR
    • Cardiomegaly and tortuosity of the thoracic aorta.
    • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2023-05-27 ECG
    • Sinus rhythm with frequent Premature ventricular complexes
    • Left axis deviation
    • Voltage criteria for left ventricular hypertrophy
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG

[MedRec]

  • 2023-07-10 SOAP Radiation Oncology
    • A/P
      • RT dose: 2700cGy/15 fractions (15 MV photon) to rectal tumor and lymphatics, 2023/6/16 to 7/07.
        • 5FU: 6/25-30.
      • RT Side effect evaluation, 7/07: Radiation dermatitis, grade 0; N/V, grade 0; enteritis, grade 0; cystitis, grade 0; proctitis, grade 0.
  • 2023-07-04 SOAP Dermatology
    • S
      • multiple painful erythematous papule-nodules on face,trunk and 4-limbs
      • multiple erythematous scars and keloids on scalp for months, progressive enlarged recently, itching(+), keloid (+)
    • O
      • Imp: acne on face and trunk for months, multiple pustule (+),inflammation(+), painful(+)
    • P
      • education about drug side effec and explain
      • strongly suggested OPD f/u
    • Prescription
      • triamcinolone suspended 10mg ST IS
      • fusidic acid BID EXT
      • doxycycline 100mg 1# BID PO

[consulation]

  • 2023-07-11 Cardiology
    • Q
      • The patient is an 76-year-old male with a history of
        • Hypertension for 20+ years with medication control,
        • Coronary artery disease for 10+ years s/p stent x6 (last one in early of 2023),
        • Type II diabetes mellitus for 10+ years with medication control,
        • Rectal cancer with impending obstruction s/p loop colostomy on 2023/06/02 with perirectal and bilateral inquinal LAP metastasis, stage cT4bN2aM1a, stage IVA
      • He presented with Coronary artery disease for 10+ years s/p stent x6 (last one in early of 2023) and Hypertension for 20+ years with medication control Hx, for CV drug adujst, we need your further evaluation and management.
    • A
      • He is admitted for evaluation of chemotherapy and we are consulted for CV meds adjust
        • ECG shows sinus rhythm with PVCs, LAD
        • CXR shows cardiomegaly
        • echocardiography shows dilated LA, LVH, global LV hypokinesis with impaired LV systolic function
      • CV meds with plavix 1 # qd, concor 2.5 mg qd, diovan 40 mg qd forxiga 1 # qd
      • suggest
        • to keep present CV meds
        • monitor I/O and BW
        • to avoid overhydration

[radiotherapy]

[chemotherapy]

  • 2023-07-14 - [fluorouracil 400mg/m2 650mg NS 100mL 10min + leucovorin 20mg/m2 30mg NS 100mL 10min] D1,4-7 (for CCRT, QW)
  • 2023-06-26 - [fluorouracil 400mg/m2 650mg NS 100mL 10min + leucovorin 20mg/m2 30mg NS 100mL 10min] D1-5 (for CCRT, QW)

==========

2023-07-25

[tube feeding - Concor]

According to the manufacturer’s instructions for Concor (bisoprolol 5 mg tablets), it should be swallowed with a drink of water and not chewed. However, if the patient is receiving tube feeding, the Simple Suspension Method (SSM) can be used. This method involves dissolving the tablets in warm water for 5-10 minutes and then passing the solution through a feeding tube for administration. The Simple Suspension Method may be appropriate for administration of Concor tablets through a feeding tube.

[renal dosing Tapimycin from Q6H to Q8H]

Kidney function appears to be deteriorating in this patient. 2023-07-25 CrCl 27 mL/min.

  • 2023-07-25 Creatinine 2.00 mg/dL
  • 2023-07-14 Creatinine 1.50 mg/dL
  • 2023-07-25 eGFR 34.70
  • 2023-07-14 eGFR 48.36
  • 2023-07-25 BUN 38 mg/dL
  • 2023-07-14 BUN 22 mg/dL

When using Tapimycin (piperacillin 4g, tazobactam 0.5g) in patients with a CrCl between 20 and 40, if the intended dose is 4.5g Q6H infused over 30 minutes, then the recommended doses are either 4.5g Q8H or 3.375g Q6H, with the former being preferred.

A dose of 4 mg once daily is recommended when using Urief (silodosin 8 mg) in patients with a CrCl between 30 and 50.

[leukopenia and thrombocytopenia]

Bicytopenia (leukopenia and thrombocytopenia) is evident based on recent lab results after consecutive 5-day fluorouracil administration (for CCRT), which started on 2023-06-26 and 2023-07-14.

  • 2023-07-25 WBC 0.16 x10^3/uL

  • 2023-07-14 WBC 2.82 x10^3/uL

  • 2023-07-05 WBC 6.47 x10^3/uL

  • 2023-06-26 WBC 8.28 x10^3/uL

  • 2023-06-13 WBC 9.43 x10^3/uL

  • 2023-07-25 HGB 9.0 g/dL

  • 2023-07-14 HGB 9.1 g/dL

  • 2023-07-05 HGB 9.5 g/dL

  • 2023-06-26 HGB 8.3 g/dL

  • 2023-06-13 HGB 10.0 g/dL

  • 2023-07-25 PLT 80 *10^3/uL

  • 2023-07-14 PLT 301 *10^3/uL

  • 2023-07-05 PLT 299 *10^3/uL

  • 2023-06-26 PLT 340 *10^3/uL

  • 2023-06-13 PLT 459 *10^3/uL

Blood transfusions are performed on 2023-05-27, 2023-06-01, 2023-06-26, 2023-07-14, 2023-07-25 and Granocyte (lenograstim 250ug) is to be administered since 2023-07-25 for consecutive 6 days. No issue with the use of G-CSF.

2023-07-18

[ARBs Equivalent Dose Conversion]

This patient is currently self-administering Diovan (valsartan 40mg) once daily and the supply is almost exhausted. Upon checking, our hospital only carries a 160mg dosage, which is inconvenient to divide into quarters. However, Olmetec (olmesartan 20mg) or Blopress (candesartan 8mg) is an option, as it belongs to the class of angiotensin II receptor blockers (ARBs) just like valsartan. Considering that approximately 40 mg of valsartan is equivalent to 10 mg of olmesartan or 4 mg of candesartan, it may be advisable to prescribe Olmetec at a dose of 0.5 tablets or Blopress at a dose of 0.5 tablets per day as a suitable alternative.

2023-07-11

Our dermatologist prescribed fusidic acid and doxycycline on 2023-07-04 and these drugs are integrated into the active medication list without reconciliation issues found

2023-06-29

[to replace Forxiga with Jardiance]

  • Based on the HIS5 database records, the patient’s eGFR has remained within a range of approximately 40 to 50 mL/min/1.73 m2 for the past 30 days. 2023-06-26 eGFR 43, Cre 1.64mg/dL, age 75 male => CrCl 34mL/min.
  • Considering the patient’s type 2 DM and an eGFR below 45, the package insert advises against the use of dapagliflozin. However, empagliflozin can still be used for patients with an eGFR greater than or equal to 30. Therefore, it would be beneficial to switch from Forxiga (dapagliflozin 10mg) 1# QDAC to Jardiance (empagliflozin 10mg) 1# QD.

[patient education: 5-FU]

  • I visited the patient on 2023-06-29 at 13:30. The patient was lying in bed while his wife sat on the bench next to the bed. I brought an information sheet about fluorouracil and explained to both of them the precautions and possible side effects of the drug. I emphasized that because of the potential impact on his immune system, he should avoid raw foods and practice good food preparation hygiene. Since the patient’s renal function is relatively poor, I also reminded him to maintain adequate hydration.
  • During my visit, the patient seemed somewhat frail, even though he was capable of communicating without any difficulties. He seemed to lack energy and spirit. At the time of the visit, the patient did not express any specific concerns or complaints.

2023-06-26

[reconciliation]

  • The patient has had multiple medical appointments at different hospitals over the past few weeks. On 2023-05-23, the patient was seen at JingMei Hospital for hemorrhoids. Additional visits to JingMei Hospital include a visit on 2023-05-08 for contact dermatitis, and another one on 2023-05-01 for tinea corporis.
  • The patient also visited WanFang Hospital for various conditions. On 2023-04-30, he was treated for pneumonia; on 2023-04-29, for a gastric ulcer; and on 2023-04-24, for anemia.
  • The prescriptions from these visits seem to be mostly short-term, with the exception of a 28-day prescription for lansoprazole 30mg QDAC, which could possibly be refilled. Currently, this medication is included in the patient’s active medication list, therefore no reconciliation issues have been identified.

700787697

230725

[MedRec]

  • 2023-07-24 DutyNote Hemato-Oncology
    • The 82 y/o pateint 1) Hypertension, heart disease under control; 2) Diabetes mellitus, type 2 under control; 3) right renal stone; 4) L spine HIVD s/p op had admitted to our ward due to leukocytosis (WBC > 16K) at ER on 7/8. In order to rule out the possibility of multiple myeloma, the patient was admitted to our ward for bone marrow survey and further management. According to himself, he denied fever, chillness, dizziness, or other discomfort but bilateral leg edema with tenderness and slightly short of breathe but with fair saturation under nasal cannula 3L/min given.
  • 2023-06-13 SOAP Ophthalmology
    • Prescription (multiple)
      • Combigan Eye Drops (brimonidine 2mg, timolol 5mg) 1# Q12H OS
      • Vidisic Gel (carbomer 10gm) QID OU
      • Tears Naturale (hydroxypropyl methylcellulose 3mg, dextran 70) QID OU
  • 2023-06-06 SOAP Neurology
    • Prescription (multiple)
      • dipydidamole 25mg 1# BID
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNQD
      • Rivotril (clonazepam 0.5mg) 0.5# PRNHS
      • Neurontin (gabapentin 100mg) 1# PRNHS
  • 2023-05-03 SOAP Metabolism and Endocrinology
    • Prescription (multiple)
      • NovoRapid (insulin aspart, recombinant) 15unit TIDAC
      • Toujeo (insulin glargine) 15unit HS
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
      • Lipanthyl Supra (fenofibrate 160mg) 1# QW1357
      • Through (sennoside 12mg) 2# HS
      • Tulip (atorvastatin 20mg) 1# QD
  • 2023-04-06 SOAP Cardiology
    • Prescription (multiple)
      • Norvasc (amlodipine 5mg) 1# BID
      • Syntrend (carvedilol 25mg) 0.5# BID
      • Meletin (mexiletine 100mg) 1# BID
      • Ulstop (famotidine 20mg) 1# QD
      • Plavix (clopidogrel 75mg) 1# QOD
      • Urief (silodosin 8mg) 1# QD

==========

2023-07-25

This patient has been regularly visiting multiple departments at our hospital and receiving several repeat prescriptions.

Cardiology prescribed the following medications: - Norvasc (amlodipine) - Syntrend (carvedilol) - Meletin (mexiletine) - Ulstop (famotidine) - Plavix (clopidogrel) - Urief (silodosin)

Endocrinology prescribed the following medications: - NovoRapid (recombinant insulin aspart) - Toujeo (insulin glargine) - Kentamin (vitamin B1, B6, B12) - Lipanthyl (fenofibrate) - Through (sennoside) - Tulip (atorvastatin)

Neurology prescribed the following medications: - Dipydidamole - Sketa (acetaminophen, chlorzoxazone) - Rivotril (clonazepam) - Neurontin (gabapentin)

Ophthalmology prescribed the following eye medications: - Combigan Eye Drops (brimonidine, timolol) - Vidisic Gel (carbomer) - Tears Naturale (hydroxypropyl methylcellulose, dextran 70)

All the oral drugs have been included in the active medication list, except for the eye medications. Please check if the patient still needs these eye medications.

700385796

230724

[exam findings]

  • 2023-07-15 MRI - brain
    • Indication: Esophageal cancer with regional lymph nodes are favored.
    • IMP: no evidence of brain metastasis.
  • 2023-07-14 SONO - abdomen
    • Suspected liver cyst,left
    • Suspected GB polyps
  • 2023-07-13 PET
    • A glucose hypermetabolic lesion involving the middle portion of the esophagus, compatible with primary esophageal malignancy.
    • Glucose hypermetabolism in two upper left paratracheal lymph nodes. Metastatic lymph nodes may show this picture.
    • A glucose hypermetabolic lesion in the posterior aspect of right acetabulum. The nature is to be determined. Please correlate with other imaging modalities such as MRI to rule out the possibility of bone metastasis.
    • Mild glucose hypermetabolism in a focal area in the anterior aspect of right 4th rib, possibly more benign in nature. However, please follow up bone scan for further evaluation.
  • 2023-07-13 Pure Tone Audiometry
    • Reliability FAIR
    • Average RE 33 dB HL; LE 34 dB HL.
    • Bil normal to moderately severe SNHL.
  • 2023-07-12 Treadmill Exercise Test
    • Conclusion
      • maximal exercise by RER>1.10
      • low exercise capacity ( VO2 48%, WR 65%) ( normal value >85%)
      • spirometry: normal (FVC 101%, FEV1 98%)
      • respiratory muscle strength: low ( MIP 59%, MEP 51%)
      • Breathing reserve normal
      • desaturation below 90%: nil
      • cardiac response during exercise normal
      • HR response during exercise: normal slope
      • work efficiency low
      • anaerobic threshold low
      • oxygen pulse low
      • BP response: normal
      • EKG: nonspecific findings
      • Health-related quality of life, CAT= 8, poor sleep 3
    • Impression:
      • low exercise capacity
      • low respiratory muscle strength
    • suggestion:
      • Treat underlying disease
      • Exercise training for low exercise capacity
      • Breathing exercise
      • low work efficiency, low AT, low O2p but normal cardiac response, suggest to arrange lower limbs doppler to survey PAOD
  • 2023-07-10 Tc-99m MDP bone scan
    • Two hot spots in the ant. aspect of the left 5th rib, and the right 4th rib, respectively, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
    • Suspected benign lesions in the maxilla, some C-, T- and L-spine, bilateral shoulders, S-I joints, and hips.
  • 2023-07-03 CT - chest
    • Indication: EGD today: favor esophageal cancer. s/p biopsy. arranged chest CT scan. refer to CS OPD on 2023-07-06 for further management.
    • Findings
      • Soft tissue mass at middle third esophagus up to 4.32cm is found.
      • Lymphadenopathy at paratracheal region is found.
      • Minimal tree in bud appearance at both lungs are found. Previous aspiration is suspected.
    • Imp: Esophageal cancer with regional lymph nodes are favored.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-06-30 Patho - esophageal biopsy
    • Esophagus, 25-30 cm below incisor, biopsy — Poorly differentiated squamous cell carcinoma
    • Microscopically, it shows poorly differentiated squamous cell carcinoma composed of a proliferation of non-keratinizing squamous tumor cells with invasive growth pattern, arranged in solid architecture and foci of c debris. The tumor shows nuclear hyperchromasia, pleomorphism and mitotic activity.
    • Immunohistochemical stain reveals P40(+), p63(+), CD56(focal +, 5%), CEA(-) and CDX-2(-).
  • 2023-06-30 Esophagogastroduodenoscopy, EGD
    • Highly suspected advanced esophageal malignancy, M/3
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis

[chemotherapy]

  • 2023-07-21 - cisplatin 30mg/2 47mg NS 500mL + fluorouracil 1000mg/m2 1580mg NS 500mL 24hr (PF CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

701475030

230724

[exam findings]

  • 2023-03-30 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Hepatocellular carcinoma, moderately differentiated
    • The sections show a picture of hepatocellular carcinoma, moderately differentiated, composed of nests of polygonal neoplastic hepatocytes with moderate amount basophilic cytoplasm, arranged in trabecular pattern.
  • 2023-03-28 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, mandible, middle C-spine, L4, bilateral shoulders and hips in whole body survey.
    • IMPRESSION:
      • Increased activity in the middle C-spine. Bone metastasis should be watched out. Please correlate with other imaging modalities for further evaluation.
      • Increased activity in the maxilla and mandible. Dental problem may show this picture.
      • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
  • 2023-03-28 CT - abdomen
    • CC: left arm weakness for 3 weeks
      • 20230325 MRI: a heterogeneous enhancing tumor, about 35mm, along the left cervical VA from the level of the C3 to C4 vertebral body. Tumor encasement of the left cervical CA was noted. Tumor invasion to the C4 vertebral body and left prevertebral muscles was noted.
      • 20230325 AFP:70867 ng/mL (< 9). CEA, CA199, CA125, PSA, & SCC: normal Indication: R/O metastasis
    • Findings:
      • There are several kissing masses on right lobe of the liver, measuring 10 cm in size (the largest dimension), and showing contrast washout in delayed phase images.
        • HCCs on right lobe of the liver (T3) are highly suspected.
        • In addition, right superior segment portal vein is not visualized that is c/w tumor compression.
        • In addition, there is no enlarged node in the hepatic hilum (N0).
      • There is osteolytic lesion in left lateral aspect of C4 vertebral body and left transverse process that is c/w bony metastasis (M1).
      • There is no focal lesion in both lung and mediastinum.
    • Imaging Report Form for Hepatocellular Carcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N0(N_value) M:M1(M_value) STAGE:IVB(Stage_value)
  • 2023-03-25 MRI - C-spine
    • Indication: cervical 4-5 and 5-6 herniated interverteb disc disease, r/o tumor formation need enhancement for exclusion.
    • Without-contrast multiplanar spine MRI (including sagittal and axial T1WI, sagittal and axial T2WI and coronal STIR images) revealed
      • normal bone alignment of the spine
      • a heterogeneous enhancing tumor, about 35mm, along the left cervical VA from the level of the C3 to C4 vertebral body. Tumor encaenment of the left cervical CA was noted. Tumor invasion to the C4 vertebral body and left prevertebral muscles was noted. Signal-void curvilinear structures in the lesion was noted.
      • unremarkable change in the visible cord.
      • degenerative change at the middle and lower C-spine disc spaces. Herniated disc in the C4/5 disc cuased moderate anterior indentation on the right C405 cord.
      • unremarkable change in the bone marrow signal intensity.
    • IMP:
      • a tumor in the left paravertebral and perivertebral spaces along the left VA at the levels of the C3 and C4 vertebral bodies.
      • herniated disc in the C4/5.

[chemoimmunotherapy]

  • 2023-05-09 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 15mg/kg 900mg NS 100mL 90min
    • diphenhydramine 30mg + NS 250mL

atezolizumab 2023-05-15 https://www.uptodate.com/contents/atezolizumab-drug-information

  • Brand Names: Tecentriq

  • Pharmacologic Category

    • Antineoplastic Agent, Anti-PD-L1 Monoclonal Antibody; Antineoplastic Agent, Immune Checkpoint Inhibitor; Antineoplastic Agent, Monoclonal Antibody
  • Dosing: Adult

    • Note: Per the manufacturer’s labeling, atezolizumab may be dosed at 840 mg IV once every 2 weeks or 1,200 mg IV once every 3 weeks or 1,680 mg IV once every 4 weeks. Indication, combination, and/or trial-specific dosing is listed below; refer to protocols for further information.
    • Alveolar soft part sarcoma, unresectable or metastatic
      • IV: 1,200 mg once every 3 weeks (as a single agent); continue until disease progression or unacceptable toxicity.
    • Hepatocellular carcinoma, unresectable or metastatic
      • IV: 1,200 mg once every 3 weeks (in combination with bevacizumab); continue until disease progression or unacceptable toxicity; may continue beyond disease progression if clinical benefit demonstrated
        • If bevacizumab is discontinued due to unacceptable toxicity, may continue atezolizumab monotherapy (at any of the approved doses/intervals) until disease progression or unacceptable toxicity.
    • Melanoma, unresectable or metastatic (BRAF V600 mutation-positive)
      • IV: 840 mg once every 2 weeks (in combination with cobimetinib and vemurafenib); continue until disease progression or unacceptable toxicity; prior to initiating atezolizumab, patients should receive a 28-day treatment cycle of cobimetinib and vemurafenib. Refer to protocol for further information.
    • Non–small cell lung cancer, adjuvant treatment:
      • IV: 1,200 mg once every 3 weeks (as a single agent; after up to 4 cycles of adjuvant platinum-based chemotherapy); continue atezolizumab for up to 1 year, unless disease recurrence or unacceptable toxicity occurs.
        • Note: Select patients for atezolizumab therapy based on the programmed death-ligand 1 (PD-L1) expression on tumor cells.
    • Non–small cell lung cancer (NSCLC), metastatic:
      • Single-agent atezolizumab:
        • First-line treatment NSCLC: IV: 1,200 mg once every 3 weeks; continue until disease progression or unacceptable toxicity.
          • Note: Select patients for atezolizumab therapy based on the PD-L1 expression on tumor cells or on tumor-infiltrating immune cells.
        • Previously treated NSCLC: IV: 1,200 mg once every 3 weeks; continue until disease progression or unacceptable toxicity.
      • Combination therapy:
    • First-line treatment, nonsquamous NSCLC:
      • IV: 1,200 mg on day 1 every 3 weeks (in combination with bevacizumab, paclitaxel, and carboplatin) for 4 to 6 cycles, followed by atezolizumab 1,200 mg on day 1 (followed by bevacizumab) every 3 weeks until disease progression or unacceptable toxicity; if bevacizumab is discontinued after the 4 to 6 cycles of combination chemotherapy, atezolizumab may be continued as a single agent (at any of the approved doses/intervals) until disease progression or unacceptable toxicity.
      • IV: 1,200 mg on day 1 every 3 weeks (in combination with paclitaxel [protein bound] and carboplatin) for 4 to 6 cycles; after the 4 to 6 cycles of induction combination chemotherapy, atezolizumab may be continued as a single agent (at any of the approved doses/intervals) until disease progression or unacceptable toxicity.
    • Small cell lung cancer (extensive stage), first-line treatment:
      • IV: 1,200 mg once every 3 weeks (in combination with carboplatin and etoposide for 4 cycles), followed by maintenance therapy of single-agent atezolizumab (at any of the approved doses/intervals) until disease progression or unacceptable toxicity.
    • Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

==========

2023-07-24

[De-escalation of Cefepime]

Based on in-hospital stock, the only available third-generation oral cephalosporin is Ceficin (cefixime 100mg) at a recommended dosing frequency of 2# Q12H. As the patient’s laboratory data on 2023-07-24 showed normal values for creatinine and blood urea nitrogen (BUN), there is no need to adjust the dosage of Ceficin.

2023-05-15

  • This is the patient’s first dose of the immune checkpoint inhibitor atezolizumab during this hospiatalization. While this therapy is designed to boost the immune response against cancer cells, it can sometimes cause the immune system to attack normal organs and tissues in the body. These side effects are commonly referred to as immune-related adverse events (irAEs).
  • It’s important to closely monitor the patient for potential irAEs such as dermatologic symptoms (e.g., rash), endocrine and metabolic symptoms (e.g., hypothyroidism), and gastrointestinal symptoms (e.g., constipation, diarrhea, nausea, decreased appetite). Prompt recognition and treatment of these irAEs may help reduce their severity and prevent serious complications.
  • Atezolizumab is currently being administered in combination with bevacizumab. It is supposed to continue this combination until there is evidence of disease progression or the occurrence of unacceptable toxicity. If the patient continues to demonstrate clinical benefit, treatment may persist even beyond disease progression.
  • In case bevacizumab has to be discontinued due to severe side effects, atezolizumab monotherapy can be maintained until the disease progresses or until there are intolerable side effects.

701468195

230720

[diagnosis] - 2023-04-12 admission note

  • Nasopahryngeal Non-keratinizing carcinoma, undifferentiated, with bilateral neck LAPs metastasis, T4N3M1, stage IVB
  • Chronic viral hepatitis B without delta-agent
  • Constipation, unspecified
  • Cachexia

[past history]

  • DM(-), HTN(-)    

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, diabetes, hypertension, mental diseases or asthma.

[exam findings]

  • 2023-05-26 CT - neck
    • With and Without contrast Neck CT showed
      • an extensive tumors in the nasopharynx with invasion to the posterior cranial fossa, upper C-spine spinal canal, bilateral parapharyngeal space, bilateral prevertebral fascia and left perevertebral space.
      • multiple enlarged heterogeneous enhancing lymph nodes in the bilateral neck, esp. left neck.
      • The major salivary glands were unremarkable.
      • skull bone invasion and bone metastasis at the upper C-spine and upper T-spine.
    • IMP: extensive tumors in the upper neck with LAP and bone metastasis. As compared with previous study on 20230131, the sizes were mildly decreased.
  • 2023-02-04 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 60 dB HL, LE 44 dB HL
    • R’t moderate to profound mixed type HL
    • L’t mild to severe HL.
    • (BC masking dilemma) ChatGPT: “BC masking dilemma” refers to a situation that can occur during pure tone audiometry when a sound presented to one ear through bone conduction (BC) also stimulates the opposite ear, making it difficult to determine the true threshold of the stimulated ear.
  • 2023-02-01 bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed hot spots in the right frontal region of the skull, some C- and upper T-spine, faint hot spots in both rib cages, and increased activity in the maxilla, sternum, some L-spine, bilateral shoulders, elbows, S-I joints, hips, and feet, in whole body survey.
    • IMPRESSION:
      • Hot spots in some C- and upper T-spine, faint hot spots in both rib cages, and increased activity in the sternum, malignancy with bone mets may be considered, suggesting further investigation and follow-up with bone scan in 3 months.
      • A hot spot in the the right frontal region of the skull, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
      • Suspected benign lesions in the maxilla, some L-spine, bilateral shoulders, elbows, S-I joints, hips, and feet.
  • 2023-01-31 MRI - nasopharynx
    • Indication: nasopharyngeal cancer, for cancer workup
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • Large nasopharynx tumor, bilateral, up to 11 cm, with skull base invasion, extension to bil. parapharyngeal spaces, encasing bil. carotid arteries.
      • Invasion of right Foramen of Ovale, but No definte intracranial invasion.
      • Invasion of right parotid gland (T4).
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Multiple bil. neck LAPs, especially at left, below the low border of cricoid cartilage.
      • Destructions of left T1 boy and right T3 body were noted.
    • IMP: NPC, bilateral neck LAPs, T4N3M1, stage IVB
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:1(M_value) STAGE:IVB (Stage_value)
  • 2023-01-31 SONO - abdomen
    • Diagnosis: negative
  • 2023-01-16 Patho - nasopharyngeal / oropharyngeal biopsy
    • Nasopahrynx, left, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B);
    • IHC stain: CK (+).
  • 2023-01-16 Nasopharyngoscopy
    • NP tumor(+), suspected NPC

[MedRec]

  • 2023-02-07 SOAP Radiation Oncology
    • Diagnosis: Nasopharyngeal carcinoma, non-keratinizing carcinoma, undifferentiated, with extensive LN metastasis and bone metastasis, cT4N3M1, stage IVB; BW loss of 15 kg in 6 months; ECOG =1.
    • He requests CCRT first.
    • Plan: CCRT to NPX tumor and LAPs, C spine metastasis for 7140cGy/34 fx may also be considered.
  • 2023-02-07 SOAP Hemato-Oncology
    • Arrange weekly CDDP for CCRT then followed by palliative PF
    • C/T will be given next week
    • RTC on 2023-02-16 for 2023-02-17 C/T

[consultation]

  • 2023-05-29 Thoracic Surgery
    • Q
      • This 47-year-old man patient had Nasopahryngeal Non-keratinizing carcinoma, undifferentiated, with bilateral neck LAPs metastasis, T4N3M1, stage IVB s/p chemotherapy with TPF (Taxotere 60mg/m2, CDDP 75mg/m2, 5FU 1000mg/m2x4days) from 2023/02/17.
      • This time, he suffered from poor appetite, easy choking for one weeks.
      • For unable to eat, hope ostomy implantation for intake, we need your further evaluation and management.
      • Thanks a lot!!!
    • A
      • I will arrange interview with his family and himself at my OPD. I will explain risk factor of jejunostomy and maybe tracheostomy if ETT (endotracheal tube) can not be weaning. I will arrange operation this week. Thanks for your consultation!!
  • 2023-02-11 Hemato-Oncology
    • A
      • For metastasis NPC, systemic therapy is indicated. Consider cisplatin-based regimens (Gemcitabine plus cisplatin may considered a preferred front-line option). Please arrange port A insertion.
      • Check EBV DNA, 24 urine CCR, HbsAg, Anti Hbc, Anti HCV, auditory test. Thanks for your consultation.
  • 2023-02-02 Radiation Oncology
    • Q
      • For CCRT for NPC, T4N3M1, stage IVB
      • This is a 47-year-old man with no known underlying disease. This time, he was admitted to our ward for nasopharyngeal carcinoma work-up. Nasopharynx MRI arranged and showed NPC, bilateral neck LAPs, T4N3M1, stage IVB. Abd echo showed negative. Bone scan was done, and pending result. Concurrent chemoradiotherapy will be arranged after staging. We need your expertise for CCRT evaluation. Thanks a lot!
    • A
      • Subjective:
        • History: This is a 47-year-old man with no known underlying disease. He has suffered from painful left neck mass for 3 months. BW loss of 15 kg in 6 months, nasal obstruction, left hearing impairment, mild dysphagia and mild dyspnea during meal was noticed. He denied epistaxis, diplopia, otalgia, blurred vision or facial numbness. Therefore, the patient came to our OPD for help. Physical exam showed a 75 cm hard mass over left neck level II-III region and a 32 cm firm mass over right level V region. Fiberscopic exam showed nasopharyngeal tumor. Nasopharynx MRI showed NPC, bilateral neck LAPs, T4N3M1, stage IVB with bone metastasis. Abdomen echo showed negative. Bone scan showed multiple spines, ribs, pelvic bone metastasis (pending formal report).
          • Previous RT: denied.
          • Other disease: denied.
          • Family history: denied.
        • Habit: Alcohol: quitted; Smoking: 1 PPD for 20 yr, just quitted.; betel nut: quitted.
        • Single. Caregiver: his mother. Job: car wire. Mild economic stress.
        • Language: Mandarin. Taiwanese.
        • Religion: Buddism.
      • Objective:
        • General Condition-ECOG: 1.
        • PE, 2023/02/02: Extensive LAPs over left and right neck, left SCF.
        • Pathology:
          • Nasopharyngeal Biopsy, 2023/01/16: Nasopahrynx, left, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B); IHC stain: CK (+).
          • left neck mass biopsy, 2023/01/16: Malignancy.
        • Images:
          • Nasopharynx MRI, 2023/01/31: Large nasopharynx tumor, bilateral, up to 11 cm, with skull base invasion, extension to bil. parapharyngeal spaces, encasing bil. carotid arteries. Invasion of right Foramen of Ovale, but No definite intracranial invasion. Invasion of right parotid gland (T4). Multiple bil. neck LAPs, especially at left, below the low border of cricoid cartilage. Destructions of left T1 bony and right T3 body, spinous process of C5-6 were noted. IMP: NPC, bilateral neck LAPs, T4N3M1, stage IVB
          • Bone scan, 2023/02/01: multiple spines, ribs, pelvic bone metastasis (report pending).
          • CXR, liver echo, 2023/01: negative for metastasis.
          • EBV DNA titer: pending.
      • Diagnosis: Nasopharyngeal carcinoma, non-keratinizing carcinoma, undifferentiated, with extensive LN metastasis and bone metastasis, cT4N3M1, stage IVB; BW loss of 15 kg in 6 months; ECOG =1.
      • Plan: Systemic chemotherapy with standard regimen is suggested for systemic control. CCRT to NPX tumor and LAPs, C spine metastasis for 7140cGy/34 fx may also be considered. Possible treatment toxicity of chemotherapy and radiotherapy is told. Diet education is given but nutrition consultation is also recommended.
  • 2023-01-30 Oral and Maxillofacial Surgery
    • Q
      • This is a 47-year-old man with no known underlying disease. This time, he was admitted to our ward for nasopharyngeal carcinoma cancer workup. Concurrent chemoradiotherapy will be arranged after staging. We need yout expertise for dental evaluation bfore radiotherapy. Thanks a lot!
    • A
      • This is a 47-year-old man suffering from nasopharyngeal carcinoma and is scheduled for further CCRT treatment. This time, we were consulted for dental evaluation before radiotherapy.
      • S: No specific discomfort over full mouth
      • O:
        • Panoramic findings:
          • Missing: Nil
          • Impaction: 48
          • Caries: Nil
          • Crown and bridges: Nil
        • Periodontal condition: Full mouth chronic periodontitis
        • Trismus due to large tumor compression over left neck was noted.
        • No specific intraoral lesion
      • P:
        • Explained the findings to the patient and his family.
        • Suggest keep good oral hygiene
        • No tooth extraction or treatment is needed at this moment. Suggest OPD follow up every 6 months

[surgical operation]

  • 2023-05-30
    • Surgery
      • Feeding jejunostomy + tracheostomy
    • Finding
      • 18 Fr. silicon Foley catheter as feeding jejunostomy.
      • 8.0 mm tracheostomy tube.

[chemotherapy]

  • 2023-04-12 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 75mg/m2 115mg NS 500mL 24hr D1 (with 5-FU) + [furosemide 20mg NS 30mL (30min after cisplatin) + MgSO4 10% 20mL NS 100mL (1hr after cisplatin)] D2 + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (TPF)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-14 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 75mg/m2 115mg NS 500mL 24hr D1 (with 5-FU) + [furosemide 20mg NS 30mL (30min after cisplatin) + MgSO4 10% 20mL NS 100mL (1hr after cisplatin)] D2 + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (TPF)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-17 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 75mg/m2 115mg NS 500mL 24hr D1 (with 5-FU) + [furosemide 20mg NS 30mL (30min after cisplatin) + MgSO4 10% 20mL NS 100mL (1hr after cisplatin)] D2 + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (TPF)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

[note]

TPF regimens for Neoadjuvant Chemotherapy (in-hospital Chemotherapy Regimens for Head and Neck Cancer: Collection as of 2022-02-11) - see No.701240721, with docetaxel 40mg/m2 and cisplatin 40mg/m2

Docetaxel, cisplatin and fluorouracil induction chemotherapy followed by chemoradiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX324) 2023-04-13 https://www.uptodate.com/contents/image?imageKey=ONC%2F65438

  • Cycle length: Every 21 days for three cycles.

  • Regimen

    • Docetaxel
      • 75 mg/m2 IV
      • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
      • Day 1
    • Cisplatin
      • 100 mg/m2 IV
      • Dilute in 250 mL NS and administer over 30 minutes to three hours. Do not administer with aluminum needles or IV sets.
      • Day 1
    • Fluorouracil (FU)
      • 1000 mg/m2/day IV
      • Dilute in 500 to 1000 mL D5W or NS and administer as a continuous infusion over 24 hours.
      • Days 1 through 4

In search for optimal induction chemotherapy for advanced nasopharyngeal cancer: Standard dosing of Docetaxel, Platinum, and 5-Fluorouracil (TPF) followed by chemoradiation. Published: 2023-02-02. https://doi.org/10.1371/journal.pone.0276651

  • induction standard dose T (75 mg/m2) P (75 mg/m2) F (750 mg/m2 IVCI x 5days) x 3 followed by weekly cisplatin (40 mg/m2) or carboplatin (AUC 1.5) x 6 concurrent with radiation therapy of 70 Gy over 6.5 to 7 weeks.
  • The 2-year progression free survival (PFS) rate for the M0 cohort was 90% (95% CI: 77.8%-100%), and was sustained at 5 years. The 2-year PFS rate for the M1 cohort was 66.7% (95% CI: 37.9%-00%). The 2-year overall survival (OS) rates for the M0 and M1 cohorts were 100% and 83.3% (95% CI: 58.3%-100%), respectively. At five years, OS was 94.4% for the M0 cohort.
  • Conclusion: Administration of standard-dose TPF as induction chemotherapy in this NPC patient population is both feasible and effective when coupled with definitive concurrent chemoradiation.

==========

2023-07-20

[duplicated H2RA]

The concomitant use of histamine H2-receptor antagonists such as Stogamet (cimetidine 300mg) and Ulstop (famotidine 20mg) is generally not recommended. Both drugs work by reducing the production of stomach acid, and using them together may increase the risk of side effects. It is advisable to evaluate the need to use these two drugs together to ensure drug safety.

2023-03-15

  • On 2023-02-25, a leukopenia event was observed in the patient with a WBC level of 2.88K/uL. This occurred approximately 1 week after the patient’s first TPF treatment, and will need to be closely monitored.
  • No medication reconciliation issues have been identified for the patient.

700132489

230717

[diagnosis] - 2023-04-06 admission note

  • Malignant neoplasm of unspecified site of unspecified female breast

  • 2023-03-17 discharged note

    • Malignant neoplasm of unspecified site of unspecified female breast
    • Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
    • Insomnia, unspecified
    • Left breast cancer, 11/2.5 cm s/p SM + SLNB in 2018/07, ER(95%) PR(60%) Her2/neu(+) Ki-67: 60%, with left lower lobe lung metastasis, and bone metastasis - post anastrozole since 2022/03/23, shifted to Kisquali (ribociclib) on 2022/04/20, added Anazo on 2022/04/27, with multiple bilateral lung metastases with pleural involvements, multiple liver metastases, and multiple bony metastases according to the Positron Emission Tomography and computed tomography on 2023/03

[past history] - 2023-03-15 admission note

  • old CVA (20100402)
  • chronic left leg DVT (2017601)
  • HTN,
  • HCVD,
  • GERD,
  • hyperlipidemia,
  • cataract, insomnia,
  • left metastatic breast carcinoma /p operation and post treated at Taipei Medical University Hospital.

  [allergy]

  • NKDA

[family history]

  • Unknown of DM, CVA, cancer or CAD in her family

[exam findings]

  • 2023-07-06 SONO - abdomen
    • Hepatic tumors R/O metastasis
    • Focal fatty liver, mild
    • Prob. Parenchymal liver disease
    • Cholecystopathy
    • Rt renal cyst
    • Minimal ascites
  • 2023-07-05, 2023-06-21 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • There are several nodular opacity projecting in both lower lung that are c/w metastases after correlate with CT.
  • 2023-07-05, -06-28 KUB
    • Osteoblastic change of right sacrum is highly suspected. Please correlate with CT.
  • 2023-05-31 CT - chest
    • Indication: Breast cancer with lung and liver mets
    • Comparison was made with CT on 2023/02/25
      • Lungs: multiple nodules of variable sizes in both lungs upper to 22mm at LLL due to metastases.
      • Vessels: mild calcified plaques of the LAD coronary artery.
      • Thoracic aorta: dilated ascending aorta (4.3cm). mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Heart: dilated LA, conventric LVH, mild calcified aortic valves
      • Chest wall and visible lower neck: s/p Rt MRM.
      • Visible abdominal-pelvic contents: diffuse heterogeneous enhancement of Lt hepatic lobe, in regression.
      • Extensive atherosclerotic change of the abdominal aorta and bilateral iliac arteries.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • IMP: breast ca with progression of lung metastasis and regression of hepatic metastasis compared with CT on 2023/02/25
  • 2023-04-07 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Patchy opacity projecting at right upper lung zone was suspected.
    • Please correlate with CT.
  • 2023-03-23 MRI - brain
    • Findings:
      • Mild periventricular small vessel disease. NO acute ischemic infarct.
      • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
      • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
      • Left mastoiditis.
    • Impression:
      • Aging brain appearance.
  • 2023-03-16 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (114 - 25) / 114 = 78.07%
      • M-mode (Teichholz) = 78
    • Dilated LA
    • Adequate LV, RV systolic function with normal wall motion
    • LV hypertrophy, Impaired LV relaxation
    • Mild AR
  • 2023-02-25 CT - abdomen
    • History and indication: left abdominal pain
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Poor enhancement of left hepatic lobe r/o malignancy. Poor enhancing nodules at S1 and right hepatic lobe.
      • Multiple nodules at bil. lungs.
      • Renal cysts (up to 1.8cm).
      • Normal appearance of spleen, pancreas, adrenals.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • Suspected liver malignancy with lung metastases.
  • 2023-02-25 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-02-22 Nasopharyngoscopy
    • erosion on bil nasal septum, smooth NPx, OPx, a cyst over R AE fold
  • 2022-12-30 CT (Taipei Medical University Hospital)
    • Findings
      • Progressive change of the metastatic nodules at both lung fields, the largest one is 2.1 cm at superior segment of LLL.
      • Still mild radiation pneumonitis at anterior portion of the left lung, stationary.
      • No significant pleural effusion.
      • Calcifications of the aorta and coronary arteries are present.
      • S/P left mastectomy
      • No evidence of local recurrence or axillary lymphadenopathy is noted.
      • There is no evidence of masses in the anterior, middle and posterior compartment.
      • No significant enlarged lymphadenopathy is noted in the mediastinum.
      • Newly developed hypodensity lesions at left lobe liver, suggest MRI for further evaluation.
      • No significant bone destruction is noted.
    • IMPRESSION:
      • Progressive change of the metastatic nodules at both lung fields, the largest one is 2.1 cm at superior segment of LLL.
      • Still mild radiation pneumonitis at anterior portion of the left lung, stationary.
      • S/P left mastectomy without local recurrence or axillary lymphadenopathy is noted.
      • Newly developed hypodensity lesions at left lobe liver, suggest MRI for further evaluation
  • 2022-12-02 24hr portable ECG
    • Sinus rhythm
    • Occasional isolated apcs
    • Rare apc couplets
    • A few isolated vpcs
    • A few episodes of 2:1 sinoatrial exit block, longest R-R interval 2.26 secs at 04:44
    • No significant tachyarrhythmia
  • 2022-12-02 ECG
    • Normal sinus rhythm
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2022-12-02 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (110 - 33) / 110 = 70%
      • M-mode (Teichholz) = 70
    • Concentric LV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Aortic valve sclerosis with trivial AR; mild posterior mitral annulus calcification.
    • Prominent aortic root calcification with protruding atheroma (8.8 mm of thickness); dilated proximal ascending aorta (38 mm).
  • 2020-09-03 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2019-11-19 CT - chest
    • no mediastinal mass or enlarged LN. (Lateral bulge in right superior mediastinum due to tortousity of innominate artery on chest radiograph).
    • dilated ascending aorta (4.5cm in diameter).
    • 4mm LLL nodule and old granulomas in hilum and mediastinum.
  • 2019-10-17 Upper GI panendoscopy
    • Reflux esophagitis, LA classification grade A  - Chronic superficial gastritis, whole stomach  - Gastric erosions  - s/p CLO
  • 2019-03-29 C-spine AP + Lat
    • Radiograph of the cervicaloorphic degeneration of C-spine. Decreased disc space at C5-6-7.
  • 2019-03-11 SONO - abdomen
    • suspect liver parenchyma disease/ incomplete exam of liver
  • 2019-03-11 Carotid PhonoAngiograph, CPA
    • mild atheroma on right ICA, moderate atheroma on right carotid bifurcation with diameter reduction of 42%, mild atheroma on left ICA, moderate atheroma on left carotid bifurcation with diameter reduction of 49%
    • normal flow and flow velocities on bil. extracranial carotid and vertebral arteries
  • 2018-11-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (143 - 51) / 143 = 64.34%
      • M-mode (Teichholz) = 64
    • Septal and RV hypertrophy with Gr II LV diastolic dysfunction and impaired RV relaxation.
    • Dilated LV with normal LV and RV systolic function.
    • Mild AV sclerosis and posterior mitral annulus calcification with mild AR; trivial MR; mild TR.
    • Dilated proximal ascending aorta (38mm) with mild calcification; protruding non-mobile atheroma (18 mm x 7mm) at sinotubular junction.

[chemotherapy]

  • 2023-05-17 - Enhertu (trastuzumab deruxtecan) 5.4mg/kg 200mg D5W 100mL 90min
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-2
  • 2023-04-27 - Enhertu (trastuzumab deruxtecan) 5.4mg/kg 200mg D5W 100mL 90min
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-2
  • 2023-04-07 - Enhertu (trastuzumab deruxtecan) 5.4mg/kg 200mg D5W 100mL 90min
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-2
  • 2023-03-16 - Enhertu (trastuzumab deruxtecan) 5.4mg/kg 200mg D5W 100mL 90min
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-2

==========

2023-07-17

According to the PharmaCloud database, it appears that the patient has only been receiving medical care at our hospital for the past three months. No medication reconciliation issues were identified during her current admission.

2023-07-14

Recently, a noticeable increase in ALT, AST and bilirubin levels can be seen based on the weekly lab data.

2023-07-12 S-GPT/ALT 119 U/L
2023-07-05 S-GPT/ALT 129 U/L
2023-06-28 S-GPT/ALT 132 U/L
2023-06-21 S-GPT/ALT 145 U/L
2023-06-14 S-GPT/ALT 112 U/L
2023-06-07 S-GPT/ALT 53 U/L
2023-07-12 S-GOT/AST 431 U/L
2023-07-05 S-GOT/AST 279 U/L
2023-06-28 S-GOT/AST 180 U/L
2023-06-21 S-GOT/AST 169 U/L
2023-06-14 S-GOT/AST 115 U/L
2023-06-07 S-GOT/AST 66 U/L
2023-07-12 Bilirubin total 2.73 mg/dL
2023-07-05 Bilirubin total 1.90 mg/dL
2023-06-28 Bilirubin total 1.00 mg/dL
2023-06-21 Bilirubin total 0.56 mg/dL
2023-06-14 Bilirubin total 0.40 mg/dL
2023-06-07 Bilirubin total 0.34 mg/dL

Per UpToDate, Enhertu (trastuzumab deruxtecan) is linked to a raised serum alanine aminotransferase (34% to 53%), elevated serum alkaline phosphatase (22% to 54%), increased serum aspartate aminotransferase (35% to 67%), and elevated serum bilirubin (16% to 24%).

According to the Enhertu label, there are limited data available for patients with moderate hepatic impairment, and none for patients with severe hepatic impairment. Given that metabolism and biliary excretion are the primary elimination routes for the topoisomerase I inhibitor component (DXd) in Enhertu, caution should be exercised when administering Enhertu to patients with moderate or severe hepatic impairment. The package insert does not provide dose adjustment guidelines based on LFT readings. It might be suggested to temporarily withhold the drug until the drug is ruled out as the cause of deterioration of liver function.

2023-04-07

  • Based on the patient’s medical history and current condition, it is recommended that Xarelto (rivaroxaban) be resumed after Port-A catheter placement.

2023-03-16

  • According to the recommended dosage guidelines, for patients with unresectable or metastatic breast cancer, regardless of HER2-low or HER2-positive status, Enhertu (trastuzumab deruxtecan) should be administered at a dose of 5.4 mg/kg once every three weeks until disease progression or unacceptable toxicity. Based on the patient’s body weight of 57.5kg recorded on 2023-03-15, the appropriate dosage of Enhertu would be 310mg. However, considering the patient’s advanced age and the fact that this is her first time receiving this drug, a reduced dosage of 200mg has been used.
  • Interstitial lung disease (ILD) and pneumonitis, including fatal cases, have been reported with fam-trastuzumab deruxtecan. Please monitor for and promptly investigate signs and symptoms including cough, dyspnea, fever, and other new or worsening respiratory symptoms.

700887181

230717

[diagnosis] - 20230103 admission note

  • Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
  • Non-follicular (diffuse) lymphoma, unspecified, extranodal and solid organ sites
  • Cardiac arrhythmia, unspecified

[present illness] - 20230103 admission note

  • This 75 y/o man is a case of HTN, CKD stage3, urothelial carcinoma, high-grade s/p TURBT on 2009-01-21, 2010-10-01 and 2011-01-20. (TURBT, transurethral resection of bladder tumor)
  • He was diagnosed with diffuse large B-cell lymphoma in 201706, stage IV with bone, bone marow involvement. He received chemotherapy with R-DA-EPOCH on 201706 ~ 201710. R-CHOP on 2018/10/17 and 2018/11/29. R-ICE (Mabthera + Etoposide + Ifosfamide) on 2018/12/26 ~ 2019/06/13. He received stem cell collection on 2019/03/05 ~ 07 but inadequate cell number was collected for auto PBSCT.

[past history]

  • Diffuse large B-cell lymphoma, stage IV with bone, bone marow involvement, diagnosed on 201706 s/p chemotherapy
  • HTN
  • CKD stage3
  • urothelial carcinoma, high-grade s/p TURBT
  • Appendicitis s/p appendectomy

[Allergy]

  • NKDA

[family history]

  • Father - prostate cancer

[lab data]

  • 2022-12-05 Anti-HCV Nonreactive
  • 2022-12-05 Anti-HCV Value 0.06 S/CO
  • 2022-12-05 Anti-HBc Reactive
  • 2022-12-05 Anti-HBc-Value 2.18 S/CO
  • 2022-12-05 HBsAg Nonreactive
  • 2022-12-05 HBsAg (Value) 0.41 S/CO
  • 2022-12-05 Anti-HBs 8.79 mIU/mL

[exam findings]

  • 2023-05-12, -05-10, -05-03 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • S/P autosuture projecting at left middle lung.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura thickening or effusion ?
    • Compression fracture of T12 vertebral body?
    • Spondylosis with scoliosis of the T-spine with convex to right side.
  • 2023-03-28 PET scan
    • In comparison with the previous study on 2022-11-07, the previous lesion in the lymph node in the left posterior lower neck region and the glucose hypermetabolism in the bone marrow of the skeleton are a little more evident. Lymphoma in a little more progression should be watched out. However, other glucose hypermetabolism in the left SCF and right axillary lymph nodes, bilateral pulmonary hilar lymph nodes, mediastinal lymph nodes, bilateral lungs, left lower lung pleua and left rib cage is a little less evident.
    • Increased FDG uptake in the right tonsil. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
  • 2023-03-09 CT - neck
    • Indication: relapsed DLBCL, Lugano stage IV
    • Head and Neck CT without IV contrast administration shows (comparison: 2022/11/23 Chest CT with and without contrast)
      • Residual enlarged LNs in left low posterior neck, the supraclavicular fossa.
      • Multiple Small bil. neck LNs also were noted.
      • No obvious nasopharynx, oropharynx, hypopharynx or larynx mass.
    • Chest, abdomen and pelvis (noncontrast):
      • An ill-defined nodule in left anterior part of LUL, another smaller one in low posterior part, nature?
      • No evident abnormal enlarged lymph node in the mediastinum, paraaortic spaces or iliac region.
      • Gallstones were noted incidentally.
      • BPH with bladder tumor?
      • Multi-focal osteoblastic change of TL-spine also were found.
  • 2022-12-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 30) / 80 = 62.50%
      • M-mode (Teichholz) = 62
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • Preserved RV systolic function
  • 2022-12-05, 2022-11-21, 2021-12-21, 2020-08-17, 2019-03-01 ECG
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2022-11-25 Patho - lymphnode biopsy
    • Lymph node, neck, left, biopsy — Diffuse large B-cell lymphoma and see comment
    • The sections show a picture of diffuse large B-cell lymphoma with following features:
      • Specimen: Lymph node, neck, left
      • Procedure: Biopsy
      • Tumor site: Left neck
      • Histologic type: Diffuse large B-cell lymphoma
      • Immunophenotyping: CD3(-), CD20(+), PAX5(+), BCL6(+), CD10(+), and MUM1(-)
      • Comment: The findings favor germinal center B-cell subtype
  • 2022-11-25 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Hypocellular marrow without evidence of lymphoma involvement
    • The sections show hypocellular marrow (5%). Small amount of hematopoietic cells and focal hemosiderin deposition can be found. There is no evidence of lymphoma involvement in CD3, CD20, CD10, PAX5 and BCL6 immunostains.
  • 2022-11-23 CT - chest
    • Comparison was made with prior CT dated on 2021/10/30
      • Lungs:
        • a 17mm spiculated nodule at S3 with pleural tail at LUL. a nodular opacit at S6 and a long coarse reticular opacity in LLL. as compared with previous CT study.
      • Mediastinum and hila: large soft-tissue mass along the left anterior prevascular space and A-P window. small LNs in other locations of visceral space.
      • Vessels:
        • Thoracic aorta: normal in caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal in caliber.
        • Heart: normal in size of cardiac chambers.
      • Pleura: small Lt pleural effusion.
      • Chest wall and lower neck: multiple small LNs and a 17mm LAP in left lower posterior triangle of neck. small LNs in bilateral submandibular spaces.
      • Visible abdominal-pelvic contents: splenomegaly mutliple small areas of low attenuations. enlarged prostate.
        • a small Lt renal cyst (30mm) and small-sized of Rt kidney. many gall bladder stones. no enlarged lymph node.
        • unremarkable of the liver, adrenal glands, and pancreas.
      • Visualized bones: blastic change in many vertebrae and sternum, and marked compression fracture of L1 vertebral body.
    • Impression:
      • Diffuse large B-cell lymphoma s/p treatment with residual nodular lesions and fibrotic scar or linear atelectasis in lungs, and bony involvment, stationary, and visible newly splenic involvement and mediastinal and left LAP, compared with CT 2021/10/30.
  • 2022-11-07 Whole body PET scan
    • In comparison with the previous study on 2022-01-03, most of above-mentioned lymph node regions and bilateral lungs of glucose hypermetabolism come to more evident.
    • In addition, there are several new lesions of increased FDG uptake in a lymph node in the left post. lower neck region, left ICF, right axillary region, bilateral mediastinal space, left lower lung pleua, and several upper T-spine.
    • Diffuse large B-cell lymphoma s/p treatment with tumor recurrence in multiple lymph node regions on the same side of the diaphragm and involvement of bilateral lungs, left lower lung pleura, left rib cage, and several upper T-spine, rc-stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2022-10-26 MRI - L-spine
    • Indication:
      • DLBL, double hit (CT-guided biopsy from rt kidney), involving rt kidney, paraortic LNs, multiple bone. follow up
      • bladder CA
    • IMP:
      • herniated discs in the L1/2, L2/3, L3/4 and L4/5 discs
      • subacute compression fractures at L2 and L4 vertebral bodies
  • 2022-10-26 Cystoscopy
    • Clinical History: bladder cancer s/p TUR-BT on 20110119
    • PH:
      • bladder cancer s/p TUR-BT on 20090121 and on 20100930, s/p intravesical C/T with Cistplatin, Adriamycin
      • Hypertension
      • s/p appendectomy.
    • Comment / Suggestion:
      • BPH, No tumor recurrent
  • 2022-09-21 Tc-99m MDP whole body bone scan
    • Two new lesions of increased tracer uptake at the L4 spine and post. aspect of the left 6th rib, respectively compared with the previous study on 2021-11-22, the nature is to be determined (post-traumatic change or others ?), suggesting follow-up with bone scan in 3 months for further investigation.
    • Suspected benign lesions in the left high frontal region of skull, maxilla, mandible, L1-2 spines, bilateral shoulders, right S-I joint, hips, and left knee.
  • 2022-01-03 Whole body PET scan
    • In comparison with the previous study on 2020-05-18, glucose hypermetabolism lesions in bilateral pulmonary hilar lymph nodes and bilateral mediastinal lymph nodes come to more evident, reactive change in response to locoregional inflammation, however, may show such a picture. Please correlate with clinical findings and keep follow up to exclude the possibility of malignancy involvement.
    • Glucose hypermetabolism lesions in bilateral lungs show no significant chnage, probably inflammation process.
    • Glucose hypermetabolism lesions in the left 4th and 5th ribs become more evident also, post-traumatic change or lymphoma with involvement of bone marrow may show such a picture, suggesting biopsy for investigation.
    • Glucose hypermetabolism lesions in the right inguinal lymph nodes, probably reactive nodes.
    • No abnormally increased FDG uptake is evidently delineated elsewhere.
  • 2021-12-07 MRI - L-spine
    • Diffuse spinal metastases with mild ventral dural sac compression. Mild to moderate spinal canal stenoses.
  • 2021-11-22 Tc-99m MDP whole body bone scan
    • A new lesion of increased tracer uptake at the L2 spine compared with the previous study on 2020-05-27, the nature is to be determined (post-traumatic change, new bone mets or others ?), suggesting follow-up with bone scan in 3 months for further investigation.
    • Suspected benign lesions in the left high frontal region of skull, maxilla, mandible, bilateral shoulders, right S-I joint, hips, and left knee.
  • 2021-10-30 CT - chest
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Nodular lesions at both lungs up to 1.4cm at left upper lobe is found. In comparison with CT dated on 2021-07-02, the lesions are stationary.
        • No evidence of bilateral pleural effusion.
        • S/p port-A placement with its tip at Superior vena cava.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Visible abdomen:
        • There is stone at dependent portion of GB. GB stone(s) are noted.
        • The liver, spleen, pancreas, and adrenals are intact.
        • Atrophy of both kidneys are found.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Stationary nodular lesions at both lungs.
      • Bilateral renal atrophy.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
  • 2021-07-02 CT - abdomen
    • Comparison: prior CT dated 2021/01/30.
      • Bilateral lung nodules (more at left side), staionary.
        • Fibrotic infiltrates in bilateral upper lung.
      • The spleen shows prominence in size (the greatest anterior-posterior dimention measuring about 12.2 cm in length).
      • A renal cyst measuring 2.6 cm in left upper pole is noted.
        • Atrophy of right kidney is noted that is c/w chronic renal disease.
      • There are two gallstones (< 1 cm).
      • Prior CT identified multiple osteoblastic bony metastases in the spine and pelvic bone are not noted. please correlate with clinical condition.
        • Compression fracture of L1 vertebral body. Spondylosis with scoliosis of the L-spine with convex to left side. Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L5-S1.
    • Impression:
      • Bilateral lung nodules (more at left side), staionary.
  • 2021-01-30 CT - abdomen
    • Gallbladder stones.
    • Suspected left renal cyst, 2.7cm.
    • Relative atrophy of right kidney.
    • Enlarged prostate gland.
    • Persistent bilateral lung nodules.
    • Tree-in-bud infiltrates in right lower lung, could be due to inflammation.
  • 2020-09-11 Uroflowmetry
    • Q max: low
  • 2020-08-17 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (99.8 - 33.3) / 99.8 = 66.63%
      • M-mode (Teichholz) = 66.6
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Trivial tricuspid regurgitation
    • LV hypertrophy
    • Impaired LV relaxation
  • 2020-06-17 bladder sonography
    • PVR 9.84 mL
  • 2020-05-27 Tc-99m MDP whole body bone scan
    • All lesions are old and show stationary or less evident radioactivity compared with the previous study on 2019-08-14, indicating response to current therapy.
    • Suspected DJD at shoulders, and left knee.
  • 2020-05-20 Uroflowmetry
    • Q max: low
    • flow pattern: obstructive
  • 2020-05-18 PET
    • A mildly glucose-hypermetabolic nodule in upper lobe of left lung that had been stationary comparing with the previous study on 2019/03/20 and several previous CT scans of chest, an inflammatory lesion is likely. Please correlate with other imaging modalities and clinical findings and keep follow up for further evaluation.
    • Mild to moderate glucose hypermetabolism in bilateral pulmonary hilar lymph nodes and some mediastinal lymph nodes, reactive change in response to locoregional inflammation may show such a picture. Please correlate with clinical findings and keep follow up to exclude the possibility of malignancy involvement.
    • In comparison with the previous study, there were newly developed, mildly to moderately glucose-hypermetabolic lesions in posterior aspect of the left 4th and 5th ribs. Post-traumatic inflammatory changes are likely but possibility of malignancy involvement cannot be totally excluded. Please correlate with clinical findings and keep follow up for further evaluation.
    • Probably reactive change resulting from locoregional inflammation in right inguinal lymph nodes.
    • Probably post-traumatic inflammatory change in right femoral head.
    • Probably an inflammatory lesion in skin overlying right sacral region.
  • 2018-09-26 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (83 - 23) / 83 = 72.29%
      • M-mode (Teichholz) = 72
    • Normal chamber size
    • Concentric LV hypertrophy
    • Adequate LV and RV performance
    • Possibly impaired LV relaxation
    • Mild MR, TR and PR
    • AV sclerosis with trivial AR
    • No regional wall motion abnormalities
  • 2018-09-22 CT - abdomen
    • History and indication: AKI suspected obstrucitve uropathy
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • Non-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of urinary bladder.
      • A nodule (2.9cm) in left kidney r/o cyst. Right hydronephrosis. Left hydronephrosis and hydroureter. Some LNs at retroperitoneum and bil. pelvic cavity.
      • Tiny gall stones (2-4mm).
      • Normal appearance of liver, spleen, pancreas, adrenals.
      • Compression fracture of L1. Multiple bony metastases.
    • Impression:
      • Wall thickening of urinary bladder.
      • Right hydronephrosis. Left hydronephrosis and hydroureter. Some LNs at retroperitoneum and bil. pelvic cavity.
      • Multiple bony metastases.
      • Tiny gall stones (2-4mm).
  • 2018-09-05 MRI - T-spine
    • benign subacute compression fracture in the L1 vertebral body
    • focal heterogeneous enhancement in the T12 and T9 vertebral bodies. Nature?
  • 2018-08-16 CT - abdomen
    • Multiple bony metastases. Much regression of LAP. Suspected right renal metastases (2.0cm).
  • 2018-05-07 Tc-99m MDP whole body bone scan
    • The old lesions in the skull, multiple C-, T- and L-spine, sternum, left scapula, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, bilateral S-I joints and left femur show less prominent compared with the previous study on 2018/01/05, indicating response to current therapy.
    • However, a new focal lesion in the mandible is noted, and the nature is to be determined (anti-tumor drug-related, dental problem or ther nature ?), suggesting further investigation.
  • 2018-05-07 Surgical pathology Level IV
    • pathologic diagnosis
      • Kidney, right, CT guided needle biopsy —– Diffuse large B cell lymphoma
    • macroscopic description
      • Operation procedure: CT guided needle biopsy
      • Topology: Kidney, right
      • Specimen size and number: 2 cores, the longer one, 0.7 x 0.1 x 0.1 cm.
    • microscopic examination
      • 1.Histology type: B-cell neoplasms: Diffuse large B-cell lymphoma
      • Immunohistochemical stain profiles: IHC stain: CD3 (focal+), CD20 (diffuse +), B cell predominance. bcl-2 (+), bcl-6 (+), CD10 (equivocal), CK (-).
      • REFERENCE: C-myc(+, >90%) (S2017-8170) supporting double hit type.
  • 2018-04-30 CT - abdomen
    • Multiple bony metastases. Multiple enlarged LNs (0.5-3.5cm) at paraarotic region. Suspected right renal metastases (6.6cm).
  • 2018-01-05 Tc-99m MDP whole body bone scan
    • The scintigraphic findings suggest that multiple bone metastases. In comparison with the previous study on 20170323, some of the previous bone lesions in the sacrum and bilateral S-I joints are less evident. However, more bone lesions in the skull, some C- and T-spines, sternum, some ribs, left pubic bone and left femur are more prominent. Please correlate with other clinical findings for further evaluation.
  • 2017-12-25 CT - abdomen
    • Multiple bony metastases. A tiny nodule (5mm) at LLL. Gall stones (5-6mm).
    • Enlargement of prostate.
  • 2017-11-14 PET
    • In comparison with the previous study on 2017/04/26, the glucose hypermetabolism in right axillary lymph node is much less evident and no prominent FDG uptake is noted in other previous lymph node lesions.
    • The previous multiple FDG avid bone lesions are either less evident or disappeared.
  • 2017-08-18 CT - abdomen
    • Malignancy lymphoma s/p treatment with regression of paraaortic lymph nodes.
    • Multiple bone metastsis.
    • GB stones.
    • Enlarged prostate gland.
  • 2017-05-26 Surgical pathology Level IV
    • Indication: Malignant bladder neoplasm, part unspecified
    • Soft tissue, left neck, excision — Malignant B cell lymphoma, consistent with diffuse large B cell lymphoma
    • Microscopically, the sections show a picture of histiocytes-rich malignant B cell lymphoma consists of some large atypical lymphoid cells.
    • The Immunohistocehmcial study reveals CD3(-), CD20(+), CD10(+), Bcl-2 (+), C-myc(+, >90%), Bcl-6(+, focal), CD30(-), CD68(-) and CK(-).
    • According to the histopathologic findings, it is consistent with diffuse large B cell lymphoma, centroblastic type, and histiocyte-rich variant maybe considered.
  • 2017-04-26 PET
    • Glucose hypermetabolic lesions in multiple sites throughout the axial skeleton, bilateral humeri, and bilateral femurs, suggesting multiple lesions of osseous metastasis. In comparison with the skeletal scintigraphy performed on 2017/03/23, the distribution of metastatic lesions in bones had extended to include the skull, both humeri, and both femurs. The finding suggested progression, and hence a very limited response to the previous treatment, of the malignancy. However, flair-up phenomenon sometimes occurs when PET/CT scan is performed too close to the last session of radiation therapy. It is suggested that PET/CT scan be arranged at least 6 weeks after the completion of radiation therapy.
    • Glucose hypermetabolic lymph nodes in bilateral inguinal regions, the right axillary region, bilateral infraclavicular and supraclavicular regions, and the left lower cervical region, suggesting metastases to both regional and distant lymph nodes.
    • Uroepithelial carcinoma of uncertain primary site, with multiple lesions of regional lymph node metastasis, distant lymph node metastasis, and bone metastasis, by this F-18-FDG PET/CT scan.
  • 2017-03-31 CT - abdomen
    • Diffuse lymph nodes metastasis (paraaortic and pelvic cavity) and bone metastasis, bladder malignancy? Suggest PSA data correlation for possibility prostate malignancy.
    • Enlarged prostate gland.
    • Suspected liver cysts.
  • 2017-03-23 Tc-99m MDP whole body bone scan
    • The scintigraphic findings suggest that multiple bone metastases should be considered. Please correlate with other clinical findings for further evaluation.
  • 2017-03-15 MRI - L-spine
    • herniated discs in the L3/4 and L4/5 discs
    • tumors in the visible L-spine and T-spine, and pelvic bones
    • mild spondylolisthesis at L3-4

[MedRec]

[consultation]

  • 2023-05-11 Infectious Disease
    • Q
      • The 76 y/o woman has relapse double hit diffuse large B-cell lymphoma with bone marow, right kidney, paraortic LNs and multiple bone involvement, Lugano stage IV will do the stem cell collaction.
      • Due to fever, we gave Tapimycin treatment, but watery diarrhea noted this morning, so we escalated to Doripenam treatment. Thanks!
    • A
      • WBC: 520, Fever: +
      • Agree with your use of Finibax.
      • Please collect B/C.
      • Protective isolation.
  • 2021-12-21 Radiation Oncology
    • Q
      • The 74-year-old man patient had history of 1) Hypertension, Chronic renal injury 2) Urothelial carcinoma, high-grade on 2011-01-24. 3) Diffuse large B-cell lymphoma, stage IV with bone, bone marow involvement since 2017. Bone scan on 2021-11-22 showed a new lesion of increased tracer uptake at the L2.
      • This time, he has flank soreness progress and numbness of both leg for 1 month. L-spine MRI on 2021-12-07 revealed diffuse spinal metastases with mild ventral dural sac compression, mild to moderate spinal canal stenoses. We need your help for tissue proof. Thanks!
    • A
      • MRI show multiple thoracic and lumbar spinal metastases.
      • Biopsy can be done at L2, for further confirmation.

[chemoimmunotherapy]

  • 2023-06-30 - busulfan 3.2mg/kg 190mg NS 400mL 3hr D1-3 + etoposide 400mg/m2 500mg NS 30mL 6hr D3-4 + cyclophosphamide 50mg/kg 2900mg NS 500mL 4hr D5-6 (BuCyE)
    • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + palonosetron 250ug D1 + granisetron 2mg D3-6 + aprepitant 125mg D5-7 + NS 250mL D1-6
  • 2023-05-03 - etoposide 500mg/m2 600mg NS 30mL 2hr (20% off due to impaired renal function)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-29 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
  • 2023-03-07 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
  • 2023-02-10 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
  • 2023-01-17 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
  • 2023-01-03 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
  • 2022-12-21 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
  • 2022-12-07 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D1 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D1 (R-GemOx)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg + granisetron 2mg

Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in medically-fit patients - 20230104 https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients

  • R-GemOx (Rituximab, gemcitabine, oxaliplatin)
    • Administration - R-GemOx includes rituximab (375 mg/m2 on day -1), gemcitabine (1000 mg/m2 on day 2), and oxaliplatin (100 mg/m2 on day 2).
    • Adverse effects - Severe hematologic toxicity occurs in half of patients and neuropathy can occur.
    • Outcomes - R-GemOx is associated with ORR in up to half of patients and CR in up to one-third of patients with r/r DLBCL.
      • Oxaliplatin has not been approved by the US Food and Drug Administration (FDA) for treatment of r/r DLBCL.

==========

2023-07-17

2023-07-16 (D9) WBC level has risen to 1.64K/uL, the recovery is obvious and the CMV viral load test showed that no virus was detected on 2017-07-17 (today). So far so good.

  • 2023-07-16 WBC 1.64 x10^3/uL D9
  • 2023-07-14 WBC 0.06 x10^3/uL D7
  • 2023-07-13 WBC 0.03 x10^3/uL D6
  • 2023-07-11 WBC 0.03 x10^3/uL D4
  • 2023-07-09 WBC 0.07 x10^3/uL D2
  • 2023-07-07 WBC 0.71 x10^3/uL D0
  • 2023-07-05 WBC 3.07 x10^3/uL
  • 2023-07-03 WBC 3.46 x10^3/uL
  • 2023-06-25 WBC 5.39 x10^3/uL

After the transplant, the patient’s kidney function levels fluctuate up and down around the upper limits of the normal range. A slight elevation in serum Cre is observed on 2023-07-13 and is to be followed.

  • 2023-07-13 Creatinine 1.39 mg/dL D6
  • 2023-07-11 Creatinine 1.21 mg/dL D4
  • 2023-07-09 Creatinine 1.22 mg/dL D2

The LFT results showed a monotonic increase in bilirubin levels after the transplant, as the enzyme levels started to fall, it might be sufficient to observe for a short time, if bilirubin still remains high, then action might need to be taken. Mycamine (micafungin) is associated with hyperbilirubinemia (UpToDate: <15%).

  • 2023-07-13 Bilirubin total 2.51 mg/dL
  • 2023-07-11 Bilirubin total 1.74 mg/dL
  • 2023-07-09 Bilirubin total 1.34 mg/dL
  • 2023-07-03 Bilirubin total 0.63 mg/dL
  • 2023-07-13 Bilirubin direct 1.63 mg/dL
  • 2023-07-11 Bilirubin direct 0.81 mg/dL
  • 2023-07-09 Bilirubin direct 0.43 mg/dL
  • 2023-07-03 Bilirubin direct 0.16 mg/dL
  • 2023-07-13 S-GPT/ALT 43 U/L
  • 2023-07-11 S-GPT/ALT 114 U/L
  • 2023-07-09 S-GPT/ALT 174 U/L
  • 2023-07-03 S-GPT/ALT 71 U/L
  • 2023-07-13 S-GOT/AST 14 U/L
  • 2023-07-11 S-GOT/AST 38 U/L
  • 2023-07-09 S-GOT/AST 101 U/L
  • 2023-07-03 S-GOT/AST 43 U/L

2023-07-10

[liver function]

It seems that the patient’s liver function has declined, as indicated by increased levels of ALT, AST, and bilirubin.

  • 2023-07-09 S-GPT/ALT 174 U/L

  • 2023-07-03 S-GPT/ALT 71 U/L

  • 2023-06-25 S-GPT/ALT 50 U/L

  • 2023-06-09 S-GPT/ALT 38 U/L

  • 2023-06-02 S-GPT/ALT 29 U/L

  • 2023-05-25 S-GPT/ALT 27 U/L

  • 2023-07-09 S-GOT/AST 101 U/L

  • 2023-07-03 S-GOT/AST 43 U/L

  • 2023-06-25 S-GOT/AST 40 U/L

  • 2023-06-09 S-GOT/AST 29 U/L

  • 2023-06-02 S-GOT/AST 22 U/L

  • 2023-07-09 Bilirubin direct 0.43 mg/dL

  • 2023-07-03 Bilirubin direct 0.16 mg/dL

  • 2023-06-25 Bilirubin direct 0.13 mg/dL

  • 2023-07-09 Bilirubin total 1.34 mg/dL

  • 2023-07-03 Bilirubin total 0.63 mg/dL

There are several drugs on the patient’s active list that could potentially contribute to the decline in liver function. These include:

  • Tenofovir Alafenamide: This drug may cause an increase in serum alanine aminotransferase (grades 3/4: 8%) and serum aspartate aminotransferase (grades 3/4: 3%), impacting liver function.
  • Fluconazole: Possible liver-related side effects include cholestatic hepatitis, hepatic failure, mixed hepatitis, hepatocellular hepatitis, hepatotoxicity, and increased serum transaminases.
  • Benazepril: This medication may cause cholestatic hepatitis, increase liver enzymes, and increase serum bilirubin levels, which can affect liver function.
  • Bisoprolol: Possible (< 1%) liver-related side effects of this medication include increased serum alanine aminotransferase and increased serum aspartate aminotransferase.

Given that another anti-HBV drug Baraclude (entecavir) can also lead to increased serum alanine aminotransferase levels (>5 x ULN: 11% to 12%; >10 x ULN and >2 x baseline: 2%), substituting tenofovir alafenamide with entecavir is not advised at present time. Similarly, another antifungal medication micafungin can lead to an increased serum alkaline phosphatase level (3% to 6%).

Considering the recent dosage increase of BaoGan (silymarin) on 2023-07-09 from 1# TID to 2# TID, rechecking the liver function tests in 2 days could be a practical strategy.

[renal function]

Aside from a slightly elevated BUN, decreasing serum creatinine and increasing eGFR suggest an improvement in the patient’s renal function. The CrCl has increased to 44 mL/min.

  • 2023-07-09 Creatinine 1.22 mg/dL

  • 2023-07-03 Creatinine 1.40 mg/dL

  • 2023-06-25 Creatinine 1.76 mg/dL

  • 2023-07-09 eGFR 61.38

  • 2023-07-03 eGFR 52.37

  • 2023-06-25 eGFR 40.21

  • 2023-07-09 BUN 26 mg/dL

  • 2023-07-03 BUN 28 mg/dL

  • 2023-06-25 BUN 25 mg/dL

If the CrCl remains above 50 mL/min stably for several days and no further decline is expected, the dose of levofloxacin could optionally be increased to 750mg daily. In addition, the fluconazole dose could optionally be increased to 2# QD once it has been determined that it is not the cause of the deterioration in liver function.

2023-07-07

[myeloablative conditioning regimen effect follow-up]

The BuCyE regimen was initiated on 2023-06-30, and there is a notable reduction in WBC, HGB, and PLT levels, which indicates that the regimen is taking effect.

  • 2023-07-07 WBC 0.71 x10^3/uL

  • 2023-07-05 WBC 3.07 x10^3/uL

  • 2023-07-03 WBC 3.46 x10^3/uL

  • 2023-06-25 WBC 5.39 x10^3/uL

  • 2023-07-07 HGB 9.3 g/dL

  • 2023-07-05 HGB 11.6 g/dL

  • 2023-07-03 HGB 12.1 g/dL

  • 2023-07-07 PLT 33 x10^3/uL

  • 2023-07-05 PLT 67 x10^3/uL

  • 2023-07-03 PLT 80 x10^3/uL

2023-07-06

[renal function follow-up]

  • Recent lab results show a decrease in serum Cre and an increase in eGFR, which suggests that kidney function seems to be improving. However, the simultaneous slight increase in BUN has resulted in a BUN-to-creatinine ratio of exactly 20. If the BUN-to-creatinine ratio continues to increase, it might indicate increased BUN reabsorption. This could potentially suggest dehydration or hypoperfusion.
    • 2023-07-03 Creatinine 1.40 mg/dL
    • 2023-06-25 Creatinine 1.76 mg/dL
    • 2023-07-03 eGFR 52.37
    • 2023-06-25 eGFR 40.21
    • 2023-07-03 BUN 28 mg/dL
    • 2023-06-25 BUN 25 mg/dL

[dosage reviewed for current renal function level]

  • Flu-D (fluconazole 150mg) 1# QD has been prescribed. The recommended dose for prophylaxis against candidiasis in patients with hematologic malignancy or hematopoietic cell transplant (HCT) recipients who do not require mold-active prophylaxis is 400 mg orally once daily, with the duration being at least until resolution of neutropenia. However, given that this patient has kidney impairment with a CrCl of 38mL/min (as of 2023-07-03), a reduction of dose by 50% has been recommended. For the time being, no adjustment is necessary, nor is it needed for the current prescription of Cravit (levofloxacin 500mg) 1.5# QOD.
  • No other drugs in the active medication list require dose adjustments either.

2023-06-28

[pharmacist shift handover to chemotherapy preparation room]

Stem Cell Infustion Date D0: 2023-07-07 (tentative)

Drug - Dose - Infusion - Frequency - Duration - Date busulfan - 3.2mg/kg - 3hr - QD - D-7 ~ D-5 - 2023-06-30 ~ 2023-07-02 etoposide - 400mg/m2 - 6hr - QD - D-5 ~ D-4 - 2023-07-02 ~ 2023-07-03 cyclophosphamide - 50mg/m2 - 4hr - QD - D-3 ~ D-2 - 2023-07-04 ~ 2023-07-05

2023-06-27

[Recommended Dose Adjustments for the BuCyE Conditioning Regimen and Associated Premedication]

  • 2023-06-25 serum Cre 1.76mg/dL, age 76 => CrCl 30mL/min; height 162cm, weight 60kg => BMI 22.9kg/m2, BSA 1.64m2; 2023-06-25 S-GPT/ALT 50U/L, S-GOT/AST 40U/L, DBI/TBI 18.31%.

  • For BuCyE conditioning regimen, dose adjustment recommendation for the scheduled ASCT in this impaired renal function patient

    • busulfan
      • no dosage adjustments provided in the manufacturer’s labeling
    • cyclophosphamide
      • CrCl ≥30 mL/minute: No dosage adjustment necessary.
      • CrCl 10 to 29 mL/minute: administer 75% of normal dose.
      • As the patient’s current CrCl is at the borderline of 30, it is recommended to start with 100% dose, while providing adequate hydration, and closely monitor kidney function to determine the direction of dose adjustment in the future.
      • mesna: there are no dosage adjustments provided in the manufacturer’s labeling (has not been studied).
    • etoposide
      • CrCl 15 to 50 mL/minute: administer 75% of normal dose.
  • For premedication

    • phenytoin
      • primarily metabolized by the liver to inactive metabolites with <5% of active drug excreted unchanged in the urine
      • no dosage adjustment necessary for any degree of kidney dysfunction
    • fluconazole
      • CrCl <= 50 mL/minute: reduce dose by 50%.
    • levofloxacin
      • CrCl 20 to <50: if usual recommended dose is 500 mg every 24 hours, 500 mg initial dose, then 250 mg every 24 hours
    • palonosetron
      • no dosage adjustment is necessary.
    • granisetron
      • no dosage adjustment necessary
    • betamethasone
      • no dosage adjustments provided in the manufacturer’s labeling
    • mannitol
      • contraindicated in severe renal impairment. Use caution in patients with underlying renal disease.

[Preparation and Administration of Mesna]

  • Mesna can be prepared in either 0.9% normal saline (NS) or 5% dextrose in water (D5W).
  • Given that the patient’s weight is 60kg, the planned dose of mesna is 12mg/kg. This translates to a total of 720mg of mesna to be dissolved in at least 50mL of the above-mentioned solvents, ensuring that the final concentration does not exceed 20mg/mL.
  • For best administration results, it is advised that the injection be given over a duration of at least 30 minutes.

2023-06-26

  • According to the PharmaCloud database, our hospital has been the sole provider for all the patient’s medical and pharmaceutical needs in recent months. Alongside treatment from the Hematology-Oncology department, the patient has received refills for Avodart (dutasteride) and Harnalidge (tamsulosin) from our urologist on 2023-06-12 and Concor (bisoprolol) and Amtrel (amlodipine, benazepril) from our cardiologist on 2023-06-06. These medications are included in the patient’s current active medication list. Consequently, there are no medication reconciliation issues identified.
  • Based on serum creatinine levels, the patient’s renal function, as indicated by eGFR, has remained relatively stable over the past three years (eGFR between 40 and 50, most recent eGFR on 2023-06-25 was 40.21). This suggests that there is no significant long-term deterioration in renal function or drug-induced impairment. It’s recommended that the patient’s renal function continue to be monitored regularly, especially when new drugs with potential nephrotoxicity are added to the treatment plan. At this time, there is no need for renal function adjustments to current active medications.

2023-01-27

  • Anti-HBc tested reactive in the lab on 2022-12-05; Vemlidy (tenofovir alafenamide) is administered appropriately.
  • Additionally, Brosym (cefoperazone + sulbactam) was prescribed for the patient’s febrile neutropenia without an issue. ref: Efficacy and safety of cefoperazone-sulbactam in empiric therapy for febrile neutropenia: A systemic review and meta-analysis. Medicine (Baltimore). 2020;99(8):e19321. doi:10.1097/MD.0000000000019321
  • As far as the active prescription is concerned, there is no problem.

2023-01-18

  • The patient’s serum creatinine has shown a slow upward trend during the past month. R-GemOx, the regimen initiated since 2022-12-07, contains gemcitabine and oxaliplatin, which may cause this. Please continue to follow up as usual.
    • 2023-01-17 Creatinine 1.81 mg/dL
    • 2023-01-12 Creatinine 1.60 mg/dL
    • 2022-12-30 Creatinine 1.63 mg/dL
    • 2022-12-21 Creatinine 1.63 mg/dL
    • 2022-12-15 Creatinine 1.62 mg/dL
    • 2022-12-07 Creatinine 1.57 mg/dL
  • There is a history of hypertension in the patient. During this hospitalization, the patient’s blood pressure appears to be well controlled according to the records of the vital sign panel.

701307426

230717

[past history]

  • Nontuberculosis mycobacteria under Tx since 2021-09.
    • 2021-08-27 ~ 2022-03-10 - AKuriT-4 for TB

[lab data]

2023-06-28 HIV Ab-EIA Nonreactive
2023-06-28 Anti-HIV Value 0.09 S/CO
2023-06-26 MTBC PCR DETECTED CFU/ml
2023-06-26 MTBC PCR Value 10000 - 100000 CFU/ml

[exam findings]

  • 2023-07-15 CXR
    • Ground glass opacities in bil. lungs.
  • 2023-06-21 Patho - esophageal biopsy
    • Low esophagus, near stent proximal end, biopsy — Ulcer with atypical cells, favor reactive atypia
  • 2023-06-21 Esophagogastroduodenoscopy, EGD
    • Esophageal fully-covered metallic stent at lower esophagus, across ECJ, without obvious tumor ingrowth
    • Esophageal lesion, near stent proximal end, r/o granulation tissue, s/p biopsy
    • Superficial gastritis, antrum
  • 2023-06-17 CT - chest
    • Indication: Esophageal cancer for follow up
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Cystic Bronchiectatic change over right upper lobe and left upper lobe and tree in bud appearance at both lower lobes is found.
        • Left Pneumothorax without mediastinal shifting is noted.
        • s/p espohageal stent placement from middle to lower third esophagus. In comparison with CT dated on 2023-03-27, the condition is stationary.
        • Faint aveolar opacity over right lower lobe is found.
        • No evidence of bilateral pleural effusion.
        • S/p port-A placement with its tip at Superior vena cava.
        • Small lymph nodes are found at both sides of the mediatinum. In enlargement.
      • Visible abdomen:
        • S/P jejunaltube placement from LUQ.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • Increased intestinal gas is found.
        • The urinary bladder is well distended without soft tissue lesion.
        • There is no evidence of destructive bone lesion.
    • Imp:
      • Esophageal cancer s/p stenting with stationary esophageal condition but the mediastinal lymph nodes enlarged. Infected lymph nodes or metastatic lymph nodes should be further determined.
      • Bronchiectatic change and bronchiolitis at both lungs. The bronchiolitis progressed, probably due to repeated aspiration.
  • 2023-05-31, -05-03, -04-24, -04-17, -04-10 CXR
    • S/P port-A implantation.
    • S/P esophageal stenting
    • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
    • Linear infiltration over both lower lung zone is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
    • Enlargement of cardiac silhouette.
  • 2023-04-11 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Hiatal hernia
      • Reflux esophagitis,Gr A
      • C/w Esophageal malignant stricture,lower esophagus s/p SEMS
      • Superficial gastritis,antrum
      • Incomplete EGD examination
    • Suggestion
      • Medication and OPD f/u
      • EGD may be planned for Esophageal malignant stricture and Poor distension of stomach f/u later
  • 2023-04-06 ECG
    • Sinus tachycardia
    • Right atrial enlargement
    • Right bundle branch block
    • Rightward axis
    • Abnormal ECG
  • 2023-03-27 CT - chest
    • Indication: Esophageal cancer for F/U.
    • Comparison was made with previous CT dated on 2022/01/20
      • Lungs: abnormal consolidative opacities with reticular and nodular opacities, cavitary lesions of varying sizes, and bronchiectasis, at both upper lobes and patchy consolidations and reticular opacities at RLL, stationary as compared with previous CT 2022/12/09
      • Mediastinum and hila: s/p esophageal stenting from m/3 to L/3 with increased soft-tissue density in periesophageal fat space. enlarged LNs at Rt precarinal and A-P window regions. small pericardial effusion.
      • Pleura: small Rt pleural effusion.
      • Chest wall and visible lower neck: unremarkable..
      • Visible abdominal-pelvic contents: normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. s/p jejunostomy
      • Visualized bones: unremarkable.
    • Impression
      • esophageal cancer with regional LNs metastases, post stenting from m/3 to L/3, with periesophageal fat space inflammation.
      • RLL pneumonia or treatment related pneumonitis and both upper lobes TB, stable.
  • 2023-01-06 CXR
    • S/P esophageal stenting
    • S/P port-A implantation.
    • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
    • Linear infiltration over right lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2022-12-19 ECG
    • Right bundle branch block
    • indeterminated axis
  • 2022-12-19 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal malignant stricture s/p SEMS
      • Reflux esophagitis LA Classification grade A
    • Suggestion
      • NPO for 12 hours and start liquid food coming morning.
  • 2022-12-09 CT - chest
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Cavitatory lesions at bilateral upper lobes and some irregular patches at right lower lobe is found. In comparison with CT dated on 2022-08-18, the lesions incresaed in size and numbers mostly at right lower lobe. Either progressoin of the meta or some new aspiration pneumonitis should be D.D.
        • Wall thickening at lower third esophagus and EG junction is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • s/p jejunostomy.
        • Minimal ascites is found.
    • IMp: Lower third esophageal cancer with bilateral lung meta. Increased nodularities at right lower lobe, either new meta or aspiration pneumonia should be D.D.
  • 2022-11-30 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • C/W esophageal cancer, s/p CCRT, with scarring (32~36cm below incisor) and luminal stricture (36cm below incisor)
      • Incomplete study due to esophageal stricture
  • 2022-11-04 Esophagography
    • Esophagraphy shows
      • Water soluble contrast medium was delivered from oral cavity.
      • Up to 90% stenosis at lower third esophagus is found. The contrast medium could only pass the narrowing lumen slowly.
      • The EG junction is intact.
    • Imp: Compatible with esophageal cancer at lower third with almost complete stenosis.
  • 2022-08-18 CT - chest
    • Findings
      • Cavitatory lesions are found at bilateral upper lobes with solid nodularity. Metastatic leion is favored but aspiration is also possible (Less likely due to lobar consideration). In comparison with CT dated on 2022-05-10 and 2021-08-27, the lesions regressed partially.
      • Diffuse wall thickening from upper third esophagus into lower third. Esophageal cancer mixed with esophatitis is favored.
      • The pleural tagging at right lower lobe is still visualized.
    • Imp
      • Long segmental esophageal cancer with bilateal lung and right pleural mets, in regression.
  • 2022-08-02 Patho - esophageal biopsy
    • Low esophagus, biopsy — Chronic inflammation with reactive atypia
    • Microscopically, the sections show a picture of chronic inflammation with some inflammatory cells infiltration, scant necrotic debris, focal crush artifact and focal mild enlarged nuclei of squamous epithelium, favor reactive atypia, Follow up.
  • 2022-08-02 Esophagogastroduodenoscopy, EGD
    • Findings
      • Esophagus: A stricture was noted at 35 cm. The scope cannot advance over the lesion. Biopsy was done.
      • Stomach: Not check
      • Duodenum: Not check
    • Diagnosis
      • Esophageal stricture, low esophagus s/p biopsy
      • Incomplete study
  • 2022-05-10 CT - lung/mediastinum/pleura
    • Finding
      • Lungs:
        • abnormal consolidative opacities with reticular and nodular opacities, cavitary lesions of varying sizes, and bronchiectasis, at both upper lobes. in regression as compared with previous CT exam.
      • Mediastinum and hila:
        • significant regression of a Long segmental circumferential wall thickening of the middle to lower third of the thoracic esophagus, with decreased luminal narrowing as compared with previous CT exam.
        • no enlarged LN.
      • Aorta: normal appearance of thoracic aorta and central pulmonary arteries: normal in caliber. Heart: normal in size of cardiac chambers.
      • Pleura: regression of Rt lower pleural metastasis with effusion as compared with previous CT exam.
      • Chest wall and visible lower neck: unremarkable..
      • Visible abdominal-pelvic contents:
        • normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
        • no enlarged lymph node. s/p jejunostomy
      • Visualized bones: unremarkable.
    • Impression:
      • esophageal cancer with pleural and regional LNs metastases, post treatment, with significant regression of as compared with previous CT exam.
  • 2022-02-10 Patho - esophageal biopsy
    • Esophagus, 30cm below incisors, biopsy — squamous cell carcinoma, moderately differentiated, at least.
    • The grade of tumor differentiation might be the same or might be upgraded when the entire tumor is resected for further pathological evaluation.
  • 2022-01-20 Patho - esophageal biopsy
    • Labeled as ‘Esophagus, 30cm below incisors’, biopsy — squamous cell carcinoma.
    • IHC stain: p16(-).
  • 2022-01-20 CT - lung/mediastinum/pleura
    • Esophageal cancer with lung mets.
    • Previous tubercuosis at bilateral apical lungs.
  • 2022-01-20 Miniprobe endoscopic ultrasound
    • Advanced esophageal squamous cell carcinoma, at least T3N2Mx
  • 2022-01-19 Whole body PET scan
    • A glucose hypermetabolic lesion in the middle to lower third esophagus, compatible with the primary esophageal cancer.
    • A glucose hypermetabolism in the gastrohepatic lymph node, reactive node or cancer with regional lymph node metastasis may show this picture, suggesting biopsy for further investigation.
    • Increased FDG uptake in the left pulmonary hilar region, left upper lung, left lower lung, and right upper lung, TB or cancer with both lungs metastases may show this picture.
    • Glucose hypermetabolic lesions in the right lower lung pleura, cancer with pleura metastases should be considered, suggesting biopsy for further investigation also.
    • Esophageal cancer, cT4aN0-1M0-1, c-stage III at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2022-01-18 Tc-99m MDP whole body bone scan
    • Increased activity in the lower C-spine. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
  • 2022-01-07 Esophagogastroduodenoscopy, EGD
    • One lumen occupied mass lesion with friability was noted at 30cm below incisors. The scope cannot advance over the lesion.
    • Highly suspected esophageal cancer.
  • 2021-08-27 CT - lung/mediastinum/pleura
    • Cavitatory lesion at left apical lung about 5.58cm and traction fibrotic mass at right upper lobe are found. Smaller nodules mixed with fibrotic change is found at bilateral upper lobes. Tuberculosis is more favored.

[MedRec]

  • 2023-04-06 ~ 2023-04-29 POMR Hemato-Oncology
    • Discharge diagnosis
      • Esophageal cancer, MD squamous cell carcinoma with paraesophageal LAPs, lung, pleural metastasis, cT3N2M1, stage IV, jejunostomy and left Port-A implantation on 2022/01/21 and concurrent chemoradiotherapy and Chemotherapy with PF4 (CDDP 75mg/m2, 5FU 1000mg/m2 x 4 days) from 2022/02/01, regression, s/p Immunity therapy with Q2W OPDIVO (Nivolumab, 3mg/kg) from 2023/01/10.
      • Pneumonia, bilateral lung with 2023/04/17 sputum/C showed Pseudomonas aeruginosa
      • Acute kidney failure, unspecified
      • Chronic obstructive pulmonary disease, unspecified
      • Hypomagnesemia
      • Anemia due to antineoplastic chemotherapy
      • Gastro-esophageal reflux disease with esophagitis
    • CC: Severe cough for 3 days.

[consultation]

  • 2022-01-21 hematology & oncology
    • A
      • O
        • CT show Esophageal cancer with lung meta.
        • Previous tubercuosis at bilateral apical lungs.
      • Impression:
        • Advanced esophageal middle third squamous cell carcinoma with lung meta, cT3N2M1
        • History of nontuberculosis mycobacteria under RINA
        • COPD
      • Suggestion
        • advanced or metastasis disease, systemic therapy is indicated. Ex: FLuorouracil (or capecitabine) with cisplatin (or oxaliplatin), or clinical trial
        • please check anti Hbc for HBV evaluation
  • 2022-01-20 radiation oncology
    • A
      • Diagnosis: Esophageal cancer, L/3, MD SqCC with paraesophageal LAPs, lung, pleural metastasis, cT3N2M1, jejunostomy and left Port-A implantation (scheduled on 2022/01/21); nontuberculosis mycobacteria (NTM) under treatment; ECOG: 1.
      • Plan: Clinical trial may be considered if he fits the inclusion criteria. RT to esophageal tumor & LAPs for 5040cGy/28 fx is suggested for tumor control.

[surgical operation]

  • 2022-01-25
    • Surgery
      • Bowel decompression and revision of jejunostomy
    • Finding
      • Detached peritonization of jejunum over superior direction with exposure of jejunostomy tube.
      • Mild edematous and dilated proximal jejunum without ischemia.
      • Total 4000ml of gastric juice drained by upper gastrointestinal endoscope.
      • Failure of nasogastric tube insertion.
      • Estimated blood loss: 20ml.
  • 2022-01-21
    • Surgery
      • mini-laparoscopic feeding jejunostomy + port-A insertion
    • Finding
      • 8 Fr. port-A via left cephalic vein
      • 18 Fr. foley with balloon removal as jejunostomy tube
      • patent tube function during intra-operative feeding test

[radiotherapy]

  • Plan: RT to lung metastasis for 4900cGy/14 fractions is suggested for tumor control. Diet education. RTC 9/15. (RTC = return to clinic)
  • 2022-07-28 ~ 2022-08-15 - 4550cGy/13 fractions (6 MV photon) to RLL pleural tumors.
  • 2022-04-13 ~ 2022-04-25 - 3150cGy/9 fractions (6 MV photon) to RML/RLL tumors (n=3)
  • 2022-02-04 ~ 2022-03-16 - 5040cGy/28 fractions (15 MV photon) to esophageal tumor & LAPs

[chemotherapy]

  • 2023-05-17 - fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4
    • dexamethasone 4mg + NS 250mL
  • 2023-03-30 - carboplatin AUC 5 300mg NS 500mL 2hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF, Q4W. in fact, there is no cisplatin this time)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-03-29 - nivolumab 3mg/kg 200mg NS 100mL 1hr (Opdivo Q2W)
    • diphenhydramine 30mg + NS 250mL
  • 2023-02-23 - carboplatin AUC 5 300mg NS 500mL 2hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF, Q4W. in fact, there is no cisplatin this time)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-02-22 - nivolumab 3mg/kg 200mg NS 100mL 1hr (Opdivo Q2W)
    • diphenhydramine 30mg + NS 250mL
  • 2023-02-03 - nivolumab 3mg/kg 200mg NS 100mL 1hr (Opdivo Q2W)
    • diphenhydramine 30mg + NS 250mL
  • 2023-01-11 - cisplatin 75mg/m2 110mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF, Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-01-10 - nivolumab 3mg/kg 200mg NS 100mL 1hr (Opdivo Q2W)
    • diphenhydramine 30mg + NS 250mL
  • 2022-12-12 - cisplatin 75mg/m2 110mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF, Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-11-08 - cisplatin 75mg/m2 110mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF, Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-10-06 - cisplatin 75mg/m2 110mg NS 500mL 24hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF, Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-09-08 - cisplatin 75mg/m2 110mg NS 500mL 24hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF, Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-08-18 - cisplatin 75mg/m2 105mg 24hr D1 + fluorouracil 1000mg/m2 1450mg 24hr D1-4 (PF4)
  • 2022-07-01 - cisplatin 75mg/m2 105mg 24hr D1 + fluorouracil 1000mg/m2 1420mg 24hr D1-4 (PF4)
  • 2022-06-08 - cisplatin 75mg/m2 110mg 24hr D1 + fluorouracil 1000mg/m2 1460mg 24hr D1-4 (PF4)
  • 2022-05-10 - cisplatin 75mg/m2 110mg 24hr D1 + fluorouracil 1000mg/m2 1460mg 24hr D1-4 (PF4)
  • 2022-04-11 - cisplatin 75mg/m2 110mg 24hr D1 + fluorouracil 1000mg/m2 1490mg 24hr D1-4 (PF4)
  • 2022-03-14 - cisplatin 75mg/m2 110mg 24hr D1 + fluorouracil 1000mg/m2 1490mg 24hr D1-4 (PF4)
  • 2022-02-11 - cisplatin 75mg/m2 120mg 24hr D1 + fluorouracil 1000mg/m2 1600mg 24hr D1-4 (PF4)

==========

2023-07-17

[tube feeding]

For patients on tube feeding, Dexilant (dexlansoprazole 60mg/cap) can be administered by breaking the capsule open and pouring the small granules into an appropriate amount of drinking water. After mixing well, this prepared solution can be administered through the feeding tube. Note that these granules should not be crushed or chewed, and the prepared solution should be used immediately after it’s prepared.

[reconciliation]

According to the PharmaCloud database, it appears that the patient has only been receiving medical care at our hospital for the past three months. No discrepancies or issues were identified during the medication reconciliation process for this patient during his current admission.

[assessment]

It appears that the patient’s renal function deteriorated last weekend. 2023-07-15 CXR showed ground-glass opacities in both lungs. CRP 13.8 mg/dL. There is a high incidence of AKI in patients hospitalized for CAP. It is advisable to be alert for the prevention and early detection of AKI in CAP patients. ref: Incidence and Risk Factors of Acute Kidney Injury in Patients Hospitalized with Pneumonia: A Prospective Observational Study. Med J Islam Repub Iran. 2021;35:150. Published 2021 Nov 10. doi:10.47176/mjiri.35.150

  • 2023-07-15 Creatinine 1.76 mg/dL

  • 2023-07-06 Creatinine 1.08 mg/dL

  • 2023-07-03 Creatinine 1.05 mg/dL

  • 2023-07-15 eGFR 43.10

  • 2023-07-06 eGFR 75.73

  • 2023-07-03 eGFR 78.23

The current dosage of Tapimycin (peperacillin 4g, tazobactam 0.5g) at 4.5g Q8H is still within a reasonable range, considering the patient’s current renal function.

2023-06-16

  • In patients who are on tube feeding, Dexilant (dexlansoprazole 60mg/cap) can be administered by breaking open the capsule and pouring the tiny granules into an appropriate amount of drinking water. After mixing well, this prepared solution can be delivered via the feeding tube. Do bear in mind that these granules shouldn’t be crushed or chewed, and the prepared solution must be used right after its preparation.

  • From 2023-03-28 to 2023-06-16, the patient has experienced significant weight loss, dropping from 53.1kg to 41.6kg. This indicates a loss of over 10kg within a span of approximately 2.5 months. A consultation with a dietitian took place on 2023-05-19. However, cachexia remains a current health issue for this patient. The patient is currently on tube feeding and is also taking the progesterone analogue megestrol without an issue. Glucocorticoids could potentially improve the patient’s appetite to a similar extent as the progesterone analogues. However, considering the potential for toxicities and decreased effectiveness with prolonged use, the application of glucocorticoids as an appetite stimulant is typically reserved for individuals with an estimated life expectancy ranging from a few weeks to a couple of months. Consequently, the use of glucocorticoids is not advised at this time.

  • The patient’s renal function markers continue to be elevated, so hydration has been administered (NS 500mL Q8H currently). The TPR panel reveals that the patient was experiencing tachycardia (122/min), tachypnea (21/min), and potentially inadequate SpO2 (92%), alongside a relatively low blood pressure reading (81/52 mmHg). Close monitoring is necessary in this case.

    • 2023-06-16 Creatinine 1.44 mg/dL
    • 2023-05-31 Creatinine 1.45 mg/dL
    • 2023-05-16 Creatinine 1.58 mg/dL
    • 2023-05-03 Creatinine 1.82 mg/dL
    • 2023-06-16 BUN 42 mg/dL
    • 2023-05-31 BUN 35 mg/dL
    • 2023-05-16 BUN 33 mg/dL
    • 2023-05-03 BUN 17 mg/dL

2023-05-17

  • For tube feeding, Dexilant (dexlansoprazole 60 mg/cap) may be administered by opening the capsule and emptying the small granules into adequate drinking water to complete the preparation.

2022-09-12

  • The current regimen is still effective, as evidenced by recent CT scans on (2022-08-27, 2022-08-18, 2022-05-10) showing partially regression, however this does not square with the elevated SCC and CEA levels on 2022-09-09.
  • There is a low body mass index (BMI) of 16 in the patient (based on a height of 167 cm and weight of 45 kg on 2022-09-08), suggesting an increase in food intake is necessary.
  • Patients with malnutrition (~low body mass index), cirrhosis, diarrhea, or long-term diuretic use are more likely to suffer from hypomagnesemia (1.6mg/dL 2022-09-08). Magnesium supplements might be beneficial.
  • There is a gradual decrease in HGB levels (12.7 g/dL 2021-08-27 to 8.3 g/dL 2022-09-08), which should be noted and monitored regularly to determine if an intervention is necessary.

2022-06-09

  • Current regimen is effective. CT (2022-05-10) showed esophageal cancer with pleural and regional LNs metastases, post treatment, with significant regression of as compared with previous CT on 2022-01-20.
  • Lab data on 2022-06-07 indicated low K (3.1 mmol/L) and low Mg (1.7 mg/dL) have been treated with Radi-K (potassium gluconate) tablets and magnesium sulfate injections.
  • As the patient has a low BMI of 15 (based on BH 165 cm and BW 43.3 kg, 2022-06-08), an increase in food intake may be beneficial.
  • Trend of HGB is decreasing gradually (12.7 g/dL 2021-08-27 -> 9.5 g/dL 2022-06-07) which should be noted and regularly observed.
  • All the oral drugs in active prescription can be administered with nasogastric tube.
  • No issue with current medication.

2022-04-12

  • An economically not advantaged divorced man living with his school-age daughters has recently learned that he has an advanced esophageal squamous cell carcinoma and is undergoing 5-Fu + cisplatin since early February 2022.
  • According to the most recent lab results reported on 2022-04-07, liver and kidney function were normal and there were no obvious abnormalities with CBC and WBC readings.
  • Trastuzumab might be added to first-line chemotherapy for HER2 overexpression positive adenocarcinoma (HER2 testing result not found yet).
  • Oxaliplatin is generally preferred over cisplatin due to lower toxicity.

2022-04-11

[tube feeding]

  • Broen-C (bromelain, L-cysteine) enteric coated tablets should not be ground for tube feeding, acetylcysteine is available to act as an alternative.

701463845

230717

[exam findings]

  • 2023-04-29 CT - brain
    • Indication: Traumatic SAH.
    • Without-contrast CT of brain shows:
      • SAH in bilateral frontal and temporal regions, in regression.
      • Prominent sulci, fissures, and cisterns. Dilatation of the ventricles.
      • No midline shift.
      • Left occipital skull linear fracture.
      • Left occipital scalp swelling.
    • Impression
      • Traumatic SAH, in regression
  • 2023-04-26 CTA - brain (head, neck)
    • With and without-contrast axial brain CT revealed:
      • Bil. SAH. Swelling of left parietal and occipital scalp.
      • No midline shift.
      • Intact bony structures.
      • Widening of cortical sulci and dilatation of ventricles.
      • No abnormal intracranial enhancement.
    • IMP:
      • Bil. SAH. Swelling of left parietal and occipital scalp.
  • 2023-04-26 CT - brain
    • Non-contrast brain CT revealed:
      • Bil. SAH. Swelling of left parietal and occipital scalp.
      • No midline shift.
      • Degeneration and spondylosis of C-spine.
      • Widening of cortical sulci and dilatation of ventricles.
    • IMP:
      • Bil. SAH. Swelling of left parietal and occipital scalp.
  • 2023-04-26 Sacrum & Coccyx
    • Minimal fracture of coccyx.
    • S/P left side double J catheter insertion.
  • 2023-04-21 PET scan
    • A glucose hypermetabolic lesion in the upper lobe of right lung. A metastatic lesion should be watched out.
    • Mild glucose hypermetabolism in a focal area in the lower lobe of right lung. Post-operative inflammation is more likely. However, please correlate with other clinical findings for further evaluation and to rule out the possibility of recurrent tumor of low FDG uptake.
    • Glucose hypermetabolism in a focal area in the midline anterior lower abdominal wall. The nature is to be determined (post-operative inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
    • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
  • 2023-04-08 CT - abdomen
    • Clinical history: 70 y/o female patient with alignant neoplasm of sigmoid colon sigmoid cancer s/p OP and C/T
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P double J catheter drainage, left side. Relative atrophy of left kidney.
      • Bilateral renal cysts, up to 3cm in right kidney.
      • Cystic lesion, 0.8cm in pancreatic body.
      • Soft tissue, 1.3cm in RLL around prior surgical clips. Recurrent tumor?
    • Impression:
      • Post-op at the colon.
      • S/P double J catheter in left kidney, relative atrophy of left kidney.
      • Bilateral renal cysts.
      • Pancreatic body cystic nodule, 0.8cm, suggest follow up.
      • Soft tissue, 1.3cm in RLL around prior surgical clips. Recurrent tumor?
  • 2023-01-16 Tc-99m MDP bone scan
    • A hot spot in the lateral aspect of the right 10th rib, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, some C-, T- and L-spine, bilateral sternoclavicular junction, shoulders, S-I joints, and hips.
  • 2023-01-13, -01-12 CXR
    • Spondylosis with scoliosis of the T-spine with convex to right side
    • Borderline cardiomegaly
  • 2022-12-21 All-RAS + BRAF
    • Cell block No: S2022-22267 A4
    • RESULTS:
      • All-RAS: There was no variant detect in the KRAS/NRAS gene.
      • BRAF: There was no variant detect in the BRAF gene.
  • 2022-12-13 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, sigmoid colon, sigmoid colectomy —- Adenocarcinoma, moderately differentiated
      • Resection margins: free
      • Lymph node, mesocolic, dissection —- Negative for malignacny (0/40)
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: pStage IIA, pT3N0(if cM0)
    • Gross Description:
      • Operation procedure: sigmoid colectomy
      • Specimen site: sigmoid colon
      • Specimen size: 10.7 cm in length
      • Tumor size: 5.2 x 4.1 x 1.5 cm
      • Tumor location: 4.5 cm and 2.1 cm away from the two resection margins, respectively
      • Depth of invasion grossly: mesocolic soft tissue
      • Mucosa elsewhere: congestion
      • Macroscopic Tumor Perforation: Not identified
      • Sections are taken and labeled as: A1: colon, non-tumor; A2-5: tumor; A6-12: lymph node, mesocolic; B: proximal cutend; C: distal cutend.
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma with marked acute suppurative inflammation
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Uninvolved; Distance of tumor from margin: 5 mm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Not identified
      • Tumor Budding: Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: tubulovillous adenoma
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes: 0/40
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): not applicable
          • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
          • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
          • Distant Metastasis (pM): if cM0
      • Additional Pathologic Findings (select all that apply):
        • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2022-12-13 Patho - lung wedge biopsy
    • PATHOLOGIC DIAGNOSIS:
      • Lung, right, lower lobe, wedge resection —- Atypical carcinoid tumor
      • Lymph node, right, group No.9, lymphadenectomy —- Negative for malignancy (0/3)
      • AJCC 8th edition pTNM Pathology stage: pStage IA1, pT1aN0(if cM0)
    • MACROSCOPIC EXAMINATION:
      • Specimen:
        • Lung, size: 5.5 x 3.0 x 1.2 cm; 8g
        • Lymph nodes, a bottle, group 9; maximal size: 0.2 x 0.1 x 0.1 cm
      • Tumor Site: Periphery
      • Tumor Size: Solitary: 1.0 x 0.9 x 0.8 cm
      • Gross tumor patterns: poorly defined, Pleural retraction
      • Tissue for sections: A1: resection margin; A2 and A4: lung, non-tumor; A3: tumor; B: lymph node, group 9.
    • Microscopic Description
      • Tumor Focality: Single tumor
      • Histologic Type (select all that apply): Atypical carcinoid tumor; The immunohistochemical stains reveal CK(+), TTF-1(+), CD56(+), and Synaptophysin(+). The Ki-67 is about 4%. The Congo red special stain is negative.
      • Histologic Grade: G1: Well differentiated
      • Spread Through Air Spaces (STAS): Not identified
      • Visceral Pleura Invasion: Not identified
      • Lymphovascular Invasion (select all that apply): Not identified
      • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
      • Margins (select all that apply): All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin (centimeters): 1.2 cm
        • Specify closest margin: resection margin
      • Treatment Effect: No known presurgical therapy
      • Regional Lymph Nodes: group 9: 0/3
      • Extranodal Extension: Not identified
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): not applicable
          • Primary Tumor (pT): pT1a: Tumor ≤1 cm or less in greatest dimension;
          • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
          • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
      • Additional Pathologic Findings (select all that apply): None identified
  • 2022-12-09 CT - abdomen
    • History: 20221208 colonoscopy: Colon cancer at 30 cm from AV with nearly total obstruction, biopsy was done. Tattooing was performed.
    • Indication: sigmoid colon cancer, CT staging
    • Findings:
      • There is segmental asymmetrical wall thickening of the sigmoid colon with medial exophytic growing, measuring 7 cm in length that is c/w adenocarcinoma.
        • The left side obliterated umbilical artery shows increasing thickness that may be tumor invasion? (T4b).
        • In addition, The fat plane between sigmoid tumor and left fallopian tube shows obliteration that also may be tumor invasion.
      • There are at least 10 enlarged nodes in the adjacent mesocolon that are c/w metastatic nodes (N2b).
      • There is a soft tissue nodule in RLL of the lung, measuring 0.8 cm in size at lung window setting.
        • Lung metastasis (M1a) is highly suspected.
      • There is a cystic lesion 1 cm in the pancreatic body.
        • Simple cyst or macrocystic adenoma is highly suspected.
      • There are several renal cysts on both kidney and the largest one measuring 3.3 cm in size at right middle pole.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b (T_value) N:N2b (N_value) M:M1a (M_value) STAGE:IVA(Stage_value)
  • 2022-12-09 Flow Volume Loop Chart
    • Mild restrictive ventilatory impairment
  • 2022-12-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (118 - 33) / 118 = 72.03%
      • M-mode (Teichholz) = 72
    • Conclusion:.
      • Normal chamber size
      • Thickening of IVS and LVPW
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • Calcified mitral annulus with mild MR, mild TR and PR
      • No regional wall motion abnormalities

[MedRec]

  • 2023-04-26 ~ 2023-04-29 POMR Neurosurgery

    • Discharge diagnosis
      • Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, initial encounter
      • Unspecified fracture of skull, initial encounter for closed fracture
      • Essential (primary) hypertension
      • Type 2 diabetes mellitus without complications
      • Malignant neoplasm of sigmoid colon
      • Malignant neoplasm of lower lobe, right bronchus or lung
    • CC
      • collapse, fall down then head injury on 2023/04/25 23:30
    • Present illness
      • This is 70 years old female who sufferred from collapse, fall down then head injury on 2023/04/25 23:30. She was brought to our emergency room for help. At emergency room, dizziness and right lower limbs weakness were noted. Swelling of left parietal and occipital scalp. Follow brain CT showed bilateral traumatic subarachnoid hemorrhage. Swelling of left parietal and occipital scalp. Follow brain computed tomography angiography showed non-specific.
      • Anticonvulsants with keppra use for seizure prevent, hemostatic agent with transamin 1000mg q8h and famotidine 20mg q12h IVD for stress ulcer prevention were given. After neurosurgeon consulted who suggested arrange admission and monitor neurological condition.
    • Course of inpatient treatment
      • After admission, anticonvulsants with keppra use for seizure prevent. Analgesic agents with acetaminophen 1tab qid for pain control. Hemostatic agent with transamin 1000mg q8h. Local ice packing of occipital lobe. Repeat brain CT showed traumatic subarachnoid hemorrhage was in regression. Under her stable condition, she was discharged and outpatient follow-up was mandatory.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ12H
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD
      • Keppra (levetiracetam 500mg) 1# BID
      • Neurontin (gabapentin 100mg) 1# HS
      • Norvasc (amlodipine 5mg) 1# BID
      • Trynol (amitriptyline 25mg) 1# QN
      • Tulip (atorvastatin 20mg) 1# QN
      • Canaglu (canagliflozin 100mg) 1# QDAC
      • Relinide (repaglinide 1mg) 1# TIDAC15
      • Trajenta (linagliptin 5mg) 1# QD
      • Uformin (metformin 500mg) 1# TIDCC
  • 2023-04-18 SOAP Hemato-Oncology

    • P: Arrange Lung/Abd/Pelvis CT Q3M, next on 2023-07-03.
  • 2023-04-11 ~ 2023-04-14 POMR Metabolism and Endocrinology (not completed)

  • 2023-02-15 SOAP Hemato-Oncology

    • Multi-disciplinary Oncology Team Meeting Conclusion, Meeting Date: 2022-12-27
      • High risk stage II, post-op Adjuvant Chemotherapy。
  • 2022-12-20 SOAP Hemato-Oncology

    • A/P
      • Lab: HBV, HCV, Tumor markers (CEA, CA199)
      • Admission for Lab tests (CBC/DC, biocemistry), Port-A insertion by Chief Hsieh, and C/T with FOLFOX on 2023-01-10
      • Treatment: FOLFOX x 12 courses

[surgical operation]

  • 2022-12-12
    • Surgery
      • 3D VATS RLL wedge + LN dissection.
    • Finding
      • One nodular lesion was noted over RLL, size about 0.6cm in diameter.
      • One 20 Fr. straight chest tube was inserted via right 7th ICS.
  • 2022-12-12
    • Surgery
      • Sigmoid colectomy        
    • Finding
      • Sigmoid cancer about 7x6x5 cm , nearly total obstruction with left side abdominal wall, peritoneum involved, Mesentaric lymph nodes enlargement also noted
    • Procedure
      • Patient was placed in the modified lithotomy position.
      • The abdomen was prepared and draped in the standard fashion to provide wide exposure.
      • The patient was placed in a steep Trendelenburg position, the surgeon stands on the left side of the patient.
      • Midline incision was made. Dissection and division begin from the left lateral attachment of the sigmoid and identification of left ureter.
      • After the inferior mesenteric vessels have been divided and ligated, the mesenteric vessels & marginal artery were ligated . Left colon is transected using linear stapler.
      • The dissection moves first to the right and then to the left of the rectum, the rectosigmoid is pulled up and rectal washing was done using the B-I solution . Rectosigmoid was transected by TA-linear stapler. Then the specimen was removed.
      • End-to-end anastomosis using double stapled method , air tight was tested and anastomosis was rechecked using rigid proctoscope; Tissel 4ml apply on the anastomosis.
      • Check bleeders and clean the abdominal cavity using warm saline
      • Close the wound in layers
  • 2022-12-12
    • Surgery
      • Left DBJ insertion     
    • Finding
      • smooth bladder mucosa
      • bilateral U/O (+)

[chemotherapy]

  • 2023-07-03 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-05-23 - FOLFOX @ Thailand

  • 2023-05-09 - FOLFOX @ Thailand

  • 2023-04-25 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-03-28 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-03-14 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-03-01 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-02-15 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-30 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-16 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-07-17

[reconciliation]

  • The patient is not from the local area, so no records are available in the PharmaCloud database.

  • On 2023-05-03, our endocrinologist prescribed Canaglu (canagliflozin), Trajenta (linagliptin), Uformin (metformin), and Kludone (gliclazide). On the same day, our neurosurgeon prescribed Keppra (levetiracetam), Neurontin (gabapentin), Norvasc (amlodipine), and Tulip (atorvastatin). These prescriptions, which are valid for 70 days, were added to the patient’s current medication list with no discrepancies identified during medication reconciliation.

[assessment]

A recent lab reading taken on 2023-07-11 revealed a significantly elevated serum glucose level of 253mg/dL, despite the administration of four antiglucemic agents - Canaglu (canagliflozin), Trajenta (linagliptin), Uformin (metformin), and Kludone (gliclazide). It would be advisable to ensure regular monitoring of the patient’s blood sugar levels, and these readings should be displayed in the TPR panel.

2023-07-03

[reconciliation]

  • The patient is a non-native individual, therefore no records are accessible from the PharmaCloud database.
  • On 2023-05-03, our endocrinologist prescribed Canaglu (canagliflozin 100mg) 1# QDAC, Trajenta (linagliptin 5mg) 1# QD, Uformin (metformin 500mg) 1# TIDCC, Kludone (gliclazide 60mg) 1# BID. On the same day, our neurosurgeon prescribed Keppra (levetiracetam 500mg) 1# BID, Neurontin (gabapentin 100mg) 1# HS, Norvasc (amlodipine 5mg) 1# BID, Tulip (atorvastatin 20mg) 1# QN. These prescriptions, valid for 70 days, were added to the patient’s active medication list with no reconciliation discrepancies noted.

[bedside visit, patient education]

  • I visited the patient at about 15:00 on 2023-07-03. Two of the patient’s relatives (?) were also present in the room - a man lying on the bench by the window and a woman sitting on a chair. I asked the patient how she was feeling today, and she replied that she was generally well and didn’t have any particular complaints. During my visit, I observed that the patient was in a fairly good state of mind and did not appear to be too tired to respond.
  • As the patient has already received several doses of the FOLFOX regimen, including the continuation of the same treatment when she returned to Thailand in May 2023, she was not entirely unfamiliar with this regimen. I provided her with information sheets on the use of oxaliplatin and fluorouracil, highlighting the key points for her to be aware of, and also left the contact details of the pharmacology department’s drug counseling service for her to use if needed.

701469090

230717

[exam findings]

  • 2023-06-29 Patho - bone marrow biopsy
    • Bone marrow, clinical history of leukemia s/p chemotherapy, iliac, biopsy — acute myelogenous leukemia.
    • Section shows piece(s) of bone marrow with 80% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with many immature leukocytes. Megakaryocytes are adequate in number.
    • IHC stains: CD117: 10-15%; CD34: 5-10 %; MPO: 80%, CD61: 5 %; CD71: 10% (of the nucleated cells).
  • 2023-05-04 Abdomen - standing (diaphragm)
    • Spondylosis with scoliosis of the L-spine with convex to right side
  • 2023-02-20 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Acute myeloid leukemia (AML)
    • The sections show hypocellular marrow (10%). Focal reduced fat cells with accumulation of extracellular gelatinous substances, decrease in trilinage hematopoietic cells including megakaryocyts, CD71+ erythroid precursors and MPO+ myeloid cells, scattered CD138+ mature plasma cells, fibroblastic proliferation, vascular dilatation, and stromal edematous change are present. Residual CD34-/CD117+ blasts, account for 20% of nuclear cells can be found. Suggest bone marrow smear evaluation and clinic correlation.
  • 2023-02-20 KUB
    • Spondylosis with scoliosis of the L-spine with convex to right side
    • Non-specific bowel gas pattern in the middle abdomen is noted. please correlate with clinical condition. Follow up is indicated.
    • Ascites is highly suspected. Please correlate with sonography.
  • 2023-02-08 Abdomen - standing (diaphragm)
    • Spondylosis with scoliosis of the T-spine with convex to right side
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon at left lateral aspect of L3-4.
    • Disk space narrowing and Marginal osteophyte formation of L5-S1.
  • 2023-01-30 Patho - bone marrow biopsy
    • Bone marrow, biopsy — acute myeloid leukemia (AML)
    • NOTE: Correlation of peripheral blood, bone marrow smear, flow cytometry, molecular genetic study and clinical feature is recommended.
    • Microscopically, it shows hypercellularity (90%) with proliferation of myeloblasts hightlighted by CD117 (> 90%).
    • Immunohisotchemical stain reveals CD34(-), CD20 (focal+), CD138 (-), MPO(+), CD71(focal+), TdT(-).

[consultation]

  • 2023-02-25 Infectious Disease
    • Q
      • The 59 y/o woman has APL post chemotherapy least 2023/02/12. Due to intermittent fever without bacteremia from culture, so we need your help for management. Thanks
    • A
      • intermittent fever still noted despite Mepem, vancomycin, and Mycamine use.
      • No significant culture report available.
      • CxR clear lungs that urinalysis showed mild bacteriuria without pyuria.
      • There are diffuse skin lesions over trunk and lower limbs, etiology uncertain, which should be related to fever.
      • Suggestion:
        • check HSV and VZV viral load
        • check CMV viral load
        • continue the present antibiotic regimen
        • empirical iv steroid can be tried.
  • 2023-02-23 Dermatology
    • Q
      • for suspect Herpes Zoster at bilateral waist, and skin rash at bilateral groin, the painful, skin rash at perineum
      • The 59 y/o woman dosen’t have any history.
      • This time, she sufferes from hand, back ecchymosis and both leg petechia, so she sent to Cardinal Tien Hospital. LRP transfusion for thrombocytopenia 16000/uL on 2023/01/20. Due to elevated blast and suspect leukemia, so she transfered to our ED for help. Her BW loss 5 kg around 1 year. Got fatigue noted after postive of COVID (2022-09). At ED, the lab data showed WBC 8170/uL, Hb 10.0 g/dL, PL 44 *10^3/uL, Blast 58%. Under the impression of APL, so she was admitted.
      • chemotherapy with (3+7) Idarubicin/Cytarabine on 2023/02/06 ~ 2023/02/12
      • This time, suspect Herpes Zoster at bilateral waist, and skin rash at bilateral groin, the painful, skin rash at perineum , so we need your help, thanks a lot!!
    • A
      • The patient had sufferred from diffuse non-blanchable erythema lesions over trunk and lower legs.
      • Under the impression of thrombopenia purpura with fine vesicle/bullae formation r/o allergic purpura.
      • The following sugeetion:
        • exclude herpes zoster infection episode currently.
        • correct patient underlying state as your experist.
          • for fine vesicle or bullae, Betason-N onit 2 tube topical bid use.
          • for itchy skin lesions, Mycomb cream 1 tube topical bid use.
        • enhance skin mositurization, Sinphraderm cream 1 tube QN use over fine scales/xerotic area after body clean.

[chemotherapy]

  • 2023-06-05 - cytarabine 1500mg/m2 2400mg NS 500mL 3hr Q12H D1-3 (HD Ara-C, Q4W)
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D1-3 + NS 250mL D1-3
  • 2023-04-28 - cytarabine 1500mg/m2 2400mg NS 500mL 3hr Q12H D1-3 (HD Ara-C, Q4W)
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D1-3 + NS 250mL D1-3
  • 2023-03-23 - cytarabine 1500mg/m2 2400mg NS 500mL 3hr Q12H D1-3 (HD Ara-C, Q4W)
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D1-3 + NS 250mL D1-3
  • 2023-02-06 - idarubicin 10mg/m2 16mg NS 100mL D1-3 + cytarabine 100mg/m2 165mg NS 500mL D1-7 (3+7 idarubicin/cytarabine, Q4W)
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + palonosetron 250ug D1 + granisetron 2mg D2-3 + NS 250mL D1-3

G-CSF (filgrastim) 150ug

  • 2023-03-27 ~ 2023-04-05 (prior C/T on 2023-03-23)
  • 2023-02-15 ~ 2023-03-02 (prior C/T on 2023-02-06)

WBC

  • 2023-05-02 WBC 2.79 x10^3/uL
  • 2023-04-28 WBC 3.57 x10^3/uL 2023-04-28 C/T
  • 2023-04-19 WBC 4.14 x10^3/uL
  • 2023-04-10 WBC 2.54 x10^3/uL
  • 2023-04-08 WBC 4.58 x10^3/uL
  • 2023-04-06 WBC 13.57 x10^3/uL
  • 2023-04-04 WBC 0.85 x10^3/uL
  • 2023-04-02 WBC 0.21 x10^3/uL
  • 2023-03-31 WBC 0.56 x10^3/uL
  • 2023-03-29 WBC 7.65 x10^3/uL
  • 2023-03-27 WBC 2.22 x10^3/uL
  • 2023-03-25 WBC 3.79 x10^3/uL 2023-03-23 C/T
  • 2023-03-22 WBC 3.84 x10^3/uL
  • 2023-03-15 WBC 4.14 x10^3/uL
  • 2023-03-08 WBC 1.35 x10^3/uL
  • 2023-03-06 WBC 1.76 x10^3/uL
  • 2023-03-04 WBC 2.72 x10^3/uL
  • 2023-03-02 WBC 3.18 x10^3/uL
  • 2023-02-28 WBC 0.91 x10^3/uL
  • 2023-02-26 WBC 0.29 x10^3/uL
  • 2023-02-24 WBC 0.23 x10^3/uL
  • 2023-02-22 WBC 0.21 x10^3/uL
  • 2023-02-20 WBC 0.26 x10^3/uL
  • 2023-02-18 WBC 0.26 x10^3/uL
  • 2023-02-16 WBC 0.25 x10^3/uL
  • 2023-02-14 WBC 0.19 x10^3/uL
  • 2023-02-12 WBC 0.24 x10^3/uL
  • 2023-02-10 WBC 0.53 x10^3/uL
  • 2023-02-08 WBC 1.44 x10^3/uL
  • 2023-02-06 WBC 8.30 x10^3/uL 2023-02-06 C/T
  • 2023-02-04 WBC 7.75 x10^3/uL
  • 2023-02-03 WBC 7.53 x10^3/uL
  • 2023-02-01 WBC 8.69 x10^3/uL
  • 2023-01-30 WBC 11.71 x10^3/uL
  • 2023-01-30 WBC 10.55 x10^3/uL
  • 2023-01-28 WBC 7.74 x10^3/uL
  • 2023-01-26 WBC 6.40 x10^3/uL
  • 2023-01-25 WBC 8.17 x10^3/uL

==========

2023-07-17

After reviewing the PharmaCloud database, no reconciliation issues were found.

[exploring CNS involvement]

An increased level of LDH is more common seen in patients with AML involving the CNS. Given that this patient was admitted with symptoms of dizziness and tinnitus, it could be worthwhile to conduct further investigations.

  • 2023-07-17 LDH 20297 U/L
  • 2023-07-03 LDH 7732 U/L
  • 2023-06-04 LDH 936 U/L
  • 2023-05-31 LDH 467 U/L
  • 2023-04-19 LDH 112 U/L
  • 2023-04-06 LDH 131 U/L
  • 2023-04-02 LDH 77 U/L

2023-05-02

  • The patient experienced 2 episodes of grade 4 neutropenia each time after chemotherapy treatments and showed improvement with more than 1 week of G-CSF use.
  • As the patient received her 3rd treatment during this hospitalization, it is suggested that the use of prophylactic G-CSF be considered to prevent recurrence of severe neutropenia.

2023-03-29

  • The patient’s WBC count, which had been low, has returned to a normal range after receiving filgrastim (G-CSF) (planned for 10 days) since 2023-03-28. The patient’s oral thrush has also improved.
    • 2023-03-29 WBC 7.65 x10^3/uL
    • 2023-03-27 WBC 2.22 x10^3/uL
    • 2023-03-25 WBC 3.79 x10^3/uL
  • It appears that the patient may be more susceptible to leukopenia when receiving the “HD Ara-C” regimen compared to the “3+7 Idarubicin/Cytarabine” regimen based on the WBC levels observed during these limited treatments.

700979859

230714

[exam findings]

  • 2023-06-09 Nasopharyngoscopy
    • smooth nasopharynx, oropharynx and hypopharynx; fair vocal cord movement.
  • 2023-04-27 Aspiration - thyroid
    • Indication: PET - Increased FDG uptake in a focal area in the right lobe of the thyroid gland, another primay thyroid cancer is highly suspected,
    • PATHOLOGIC DIAGNOSIS: Atypia, favor lymphocytic thyroiditis
    • MICROSCOPIC EXAMINATION: Two wet smears show colloid, dispersed lymphocytes, neutrophils and some atypical oncocytic follicular cells with mild to moderate anisonucleosis, lymphocytic thyroiditis maybe first considered. Clinical and laboratory correlation is needed. Follow up
  • 2023-04-18 Patho - esophagus subtotal/total resection
    • Diagnosis
      • Esophagus, lower third, VATS esophagectomy —- Squamous cell carcinoma, moderately differentiated, s/p CCRT
      • Stomach, cardia, partial gastrectomy —- Squamous cell carcinoma, moderately differentiated, by direct invasion —- Gastrointestinal stromal tumor (GIST)
      • Azygos vein, right, excision —- Negative for malignancy
      • Resection margin: Negative for malignancy; proximal cutend of esophagus: Negative for malignancy
      • Lymph node, upper paraesophageal, specimen 1, dissection —- Negative for malignancy (0/1)
      • Lymph node, middle paraesophageal, specimen 1, dissection —- Negative for malignancy (0/4)
      • Lymph node, lower paraesophageal, specimen 1, dissection —- Negative for malignancy (0/0)
      • Lymph node, peri-gastric, specimen 1, dissection — Squamous cell carcinoma, metastatic (1/9)
      • Lymph node, right, group 2+4, dissection —- Negative for malignancy (0/14)
      • Lymph node, right, group 7, dissection —- Negative for malignancy (0/5)
      • Lymph node, right, group 11, dissection —- Negative for malignancy (0/1)
      • AJCC 8 th edition pT N M Pathology stage:
        • Esophagus: ypStage IIIB, ypT3N1(if cM0)
        • Stomach GIST: pStage IA, pT1N0(if cM0)
    • Gross Description:
      • Procedure: VATS esophagectomy and gastric tube reconstruction; Size: Esophagus: 12.5 cm in length with a portion of gastric tissue measuring 4.7 cm in length. Azygos vein: 1.1 x 0.5 x 0.5 cm
      • Tumor Site: Distal esophagus (low thoracic esophagus) with involving esophagogastric junction (EGJ)
      • Relationship of Tumor to Esophagogastric Junction: Tumor midpoint lies in the distal esophagus and tumor involves the esophagogastric junction
      • Tumor Size: 3.5 x 1.5 cm
      • A calcified nodule, measuring 1.0 x 0.5 x 0.5 cm, is seen in the gastric wall and 0.6 cm away from the distal gastric resection margin.
      • Sections are taken and labeled as: A1-2: Distal gastric resection margin; A3: esophagus; A4: stomach tumor; A5: EG junction; A6-9: tumor; A10: lymph node, upper paraesophageal; A11: lymph node, middle paraesophageal; A12: lymph node, lower paraesophageal; A13-14: lymph node, perigastric; B1-2: lymph node, right group 2+4; C: lymph node, right group 7; D: lymph node, right group 11; E: azygos vein; F: proximal cutend of esophagus.
    • Microscopic Description:
      • Histologic Type: Squamous cell carcinoma, s/p CCRT; The immunohistochemical stains reveal CK(+) and p40(+).
      • Histologic Grade: G1: Well differentiated
      • Tumor Extension: Tumor invades adventitia
      • Margins: All margins are uninvolved by invasive carcinoma, dysplasia, and intestinal metaplasia
        • Distance of invasive carcinoma from closest margin (millimeters or centimeters): 1 mm ; Specify closest margin: adventitia resection margin
        • Proximal resection margin: 6.0 cm
        • Distal resection margin: 5.0 cm
      • Treatment Effect : Present, Single cells or rare small groups of cancer cells (near complete response, score 1)
      • Lymphovascular Invasion: Not identified
      • Perineural Invasion: Not identified
      • Regional Lymph Nodes: please see diagnosis
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors: y (posttreatment)
          • Primary Tumor (pT): pT3: Tumor invades adventitia
          • Regional Lymph Nodes (pN): pN1: Metastasis in one or two regional lymph nodes
          • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
      • Additional Pathologic Findings: A gastrointestinal stromal tumor is seen and very close (< 0.1 cm) to serosal surface. The immunohistochemical stains reveal CD34(+), CD117(+), and DOG-1(+). The mitotic rate < 5/5 mm (square).
  • 2023-04-14 Treadmill Exercise Test
    • Diagnosis
      • Squamous cell carcinoma of lower third of esophagus, cT3N1M0 stage III
      • Hypertension
      • Carrier of viral hepatitis B
    • Exam Object: Pre-op evaluation
    • Exam Record:
      • Ergometer protocol: incrementa
      • Ergometer type: cycle ergometer, work rate: 15 watt/min
      • Load time: 6.9 min
        • ΔVO2/ΔWR (Normal > 8.6 ~ 10.3): 5.9
        • AT: 628/1830 = 34
      • Predict
        • MIP :143 -( 0.55 * 59 ) = 110.55
        • MEP :268 -( 1.03 * 59 ) = 207.23
      • Meas
        • MIP :125 / 110.55 ) = 113
        • MEP :148 / 207.23 ) = 71
      • Cause of stop:
        • Rest BP: 120/79 mmHg
        • Max BP: 222/99 mmHg
      • Max Exercise: 104 watts
      • Dyspnea: 3-4 points
      • leg fatigue: 7-8 points
      • CAT: 11000121 = 6
    • Conclusion
      • low exercise capacity (VO2 55% <85%, WR 80%)
      • small airway disease with significant reveresibility (FVC 101%, FEV1 83%, MMEF 46 -> 63)
      • normal inspiratory muscle strength (MIP 113%, MEP 71%)
      • No SpO2 desaturation < 90% during exercise
      • normal stroke volume response during exercise
      • maximal HR 74% (<85%) but normal response slope
      • work efficiency low
      • anaerobic threshold low
      • oxygen pulse low
      • high BP response, BP 120/79 -> 222/99
      • EKG: no specific findings
      • Health-related quality of life, CAT = 6, OK
    • Impression:
      • deconditioning with low exercise capacity
      • small airway disease with significant reveresibility (MMEF 46->63)
      • HTN during exercise
    • suggestions:
      • treat underlying condition
      • give bronchodilator for small airway diseases
      • control BP
      • suggest home or hospital based exercise training after operation
  • 2023-04-13 MRI - brain
    • No evidence of intracranial lesion.
  • 2023-04-12 PET
    • Compared with the previous study on 2022-12-27, the glucose hypermetabolic lesion involving the lower portion of the esophagus and adjacent EG junction is old and comes to less evident, and the glucose hypermetabolic lesion in adjacent paracardial area disappears, indicating cancer with respopsne to current therapy.
    • Glucose hypermetabolism in a nodular lesion in the left upper lung, the nature is to be determined (inflammation process, metastasis or other nature ?), suggesting further investigation.
    • Mild glucose hypermetabolism in the right mediastinal space and bilateral pulmonary hilar regions, probably reactive nodes.
    • Increased FDG uptake in a focal area in the right lobe of the thyroid gland, another primay thyroid cancer is highly suspected, suggesting biopsy for investigation.
    • No prominent abnormal focal FDG uptake is noted elsewhere.
  • 2023-04-11 Tc-99m MDP bone scan
    • In comparison with the previous study on 2022/12/29, no prominent change is noted in the lesions in some T- and L-spines. Degenerative change may show this picture.
    • No prominent change is noted in the faint hot spots in the sternum and bilateral rib cages, possibly more benign in nature.
    • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2023-04-11 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (82.6 - 20.0) / 82.6 = 75.79%
      • M-mode (Teichholz) = 73.7
    • Conclusion:
      • Normal AV with no AR
      • Normal MV with trivial MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • No PR, mild TR, normal IVC size
  • 2023-03-07 CT - chest
    • Indication: esophagus cancer, cT3N1M0, stage III
    • Comparison was made with previous CT dated on 2022/12/26
      • Lungs: no abnormal nodule in the lungs,
        • moderate centrilobular emphysema at both upper lobes. and subpleural paraseptal emphysema
        • minimal subpleural fibrosis at LLL and RLL,
      • Mediastinum and hila: no enlarged LN or abnormal enhancing LN.
        • lymphadenopathy in stations
        • interval significant decrease in size of L/3 esophageal tumor with visible luminal wide as compared with CT on 2022/12/26
        • (residual circumferential wall thickness is 11.4mm).
      • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • s/p percutaneous gastrostomy.
      • Mild atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • L/3 esophageal cancer s/p C/T with partial response.
  • 2023-03-06 Abdomen - standing (diaphragm)
    • S/P ileostomy
    • S/P posterior instrumentation fixation from L5 to S1.
  • 2023-02-06 KUB
    • S/P posterior instrumentation fixation from L5 to S1.
    • Fecal material store in the colon.
    • S/P Foley’s catheter projecting at left abdomen?
  • 2023-01-10 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (100 - 23) / 100 = 77.00%
      • M-mode (Teichholz) = 77
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
  • 2022-12-30 MRI - brain
    • No evidence of intracranial lesion.
  • 2022-12-29 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in the sternum and bilateral rib cages and increased activity in some T- and L-spines, bilateral shoulders, sternoclavicular junctions and hips in whole body survey.
    • IMPRESSION:
      • Increased activity in some T- and L-spines. Degenerative change is more likely.
      • Some faint hot spots in the sternum and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2022-12-28 Miniprobe Endoscopic Ultrasound
    • EUS findings
      • Using EUS-DP- 25R, EUS showed a mucosal lesion invading into the adventitia of esophageal wall at the lesion site.
      • At least 2 lymph nodes were noted. The biggest lymph node was noted with size about 4.6 mm.
    • Diagnosis
      • Esophageal cancer, at least cT3N1, 40cm below incisor. s/p chromoendoscopy
  • 2022-12-28 SONO - abdomen
    • Finding
      • Mass-like lesion in lower esophagus just above EG junction, suspected to be circumferential wall thickening up to 2.33 cm, compatible with lower esophageal tumor
    • Diagnosis
      • Probable lower esophageal tumor
    • Suggestion
      • Correlate with CT scan and endoscopy
  • 2022-12-27 Whole body PET scan
    • There was increased FDG uptake in the lower portion of the esophagus and adjacent EG junction (SUVmax early: 11.59, delay: 18.82), in a focal area in adjacent paracardial area (SUVmax early: 6.52, delay: 10.97) and bilateral pulmonary hilar regions (SUVmax early: 3.23, delay: 5.50). Besides, there was increased FDG accumulation in both kidneys and bilateral ureters.
    • IMPRESSION:
      • A glucose hypermetabolic lesion involving the lower portion of the esophagus and adjacent EG junction, compatible with primary esophageal malignancy.
      • Glucose hypermetabolism in a focal area in adjacent paracardial area. A metastatic lymph node should be considered.
      • Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammation may show this picture.
      • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
      • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2022-12-27 Flow volume chart
    • Suspected small airway obstruction
  • 2022-12-26 CT - chest
    • Findings: segmental wall thickening in the lower esophagus.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:3(T_value) N:0(N_value) M:0(M_value) STAGE:IIA(Stage_value)
  • 2022-12-19 Patho - esophageal biopsy
    • DIAGNOSIS:
      • Esophagus, lower, from EG junction to 35 cm below incisor, biopsy — Squamous cell carcinoma, moderately differentiated
    • MICROSCOPIC DESCRIPTION:
      • Section shows pieces of squamous mucosa with infiltration of nests of neoplastic squamous cells. The immunohistochemical stain of p40 is positive.
  • 2022-12-19 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Advanced Esophageal cancer, lower esophagus, with luminal narrowing, s/p biopsy
      • Reflux esophagitis LA Classification grade A
      • Hiatal hernia
      • Superficial gastritis, antrum and body.
    • Suggestion
      • keep PPI
      • arrange magnified endoscopy/miniprobe EUS, chest/neck CT for cancer stage.
  • 2018-10-15 SONO - abdomen
    • Probable parenchymal liver disease
    • Status post cholecystectomy
  • 2018-06-09 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Hiatal hernia with Reflux esophagitis, Gr D   - Propable Distal esophageal diverticulum   - Superficial gastritis, antrum   - Duodenitis, bulb
    • Suggestion
      • Medication and OPD f/u   - Repeated EGD was suggested for GERD F/u 3 months later
  • 2018-06-08 CT - abdomen
    • Long segmental wall edema of colon.
    • Focal dilatation of lower esophagus.
  • 2018-01-05 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (122 - 38) / 122 = 68.85%
      • M-mode (Teichholz) = 69
    • Conclusion
      • Mild septal and RV hypertrophy with Gr I LV diastolic dysfunction.
      • Normal LV and RV systolic function.
      • AV sclerosis and mild aortic root calcification.
      • Trivial MR.

[consultation]

  • 2022-12-28 Hemato-Oncology
    • A
      • This 58 year old man is a case of lower esophagus squamouse cell carcinoma (inital presentation was postmeal vomiting since 2 weeks ago with acid regurgitation and heartburn sensation). We are consulted for further evaluation.
      • Arrange PET CT scan for staging. If no evidence of M1 unresectable disease, arrange Endoscopic ultrasound (EUS) and consult chest surgeon for possible of resection.
      • If unresectable advance esophagus cancer, CCRT is suggest. -> Arrange port A insertion, For nearing total obstruction esophagus cancer, before CCRT, please arrange jejunostomy for nutrition support.
      • PPN is suggested
  • 2022-12-27 Radiation Oncology
    • Diagnosis:
      • Esophageal cancer, MD squamous cell carcinoma, cT3N1M0 at least, with LAP metastasis over EG junction & lumen obstruction (liquid diet only); ECOG =1. PortA implantation and feeding ileostomy is scheduled on 2023/01/02.
    • Plan: EUS for staging if feasible. Preoperative CCRT to esophageal tumor, EG junction LAP & regional lymphatics for 5040cGy/28 fx is suggested for locoregional tumor control. Possible treatment toxicity (radiation esophagitis and pneumonitis) is told. CT simulation is arranged on 2023/01/03 14:30 after PortA implantation and feeding ileostomy is done. Psychological support & diet education is given to him.

[chemotherapy]

  • 2023-07-14 - NS 500mL 2hr (before cisplatin) + cisplatin 60mg/m2 100mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (PF4, CDDP 80%, 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-06-12 - NS 500mL 2hr (before cisplatin) + cisplatin 60mg/m2 100mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (PF4, CDDP 80%, 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-06 - NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 125mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1670mg NS 500mL 24hr D1-4 (PF4)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-02-03 - NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 125mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1640mg NS 500mL 24hr D1-4 (PF4)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-01-09 - NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 125mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF4)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-03-06

  • The patient’s renal function is showing a gradual decline and requires close monitoring.
    • 2023-03-06 BUN 29 mg/dL
    • 2023-02-15 BUN 28 mg/dL
    • 2023-02-06 BUN 17 mg/dL
    • 2023-02-02 BUN 22 mg/dL
    • 2023-01-09 BUN 15 mg/dL
    • 2023-03-06 Creatinine 0.98 mg/dL
    • 2023-02-15 Creatinine 0.97 mg/dL
    • 2023-02-06 Creatinine 0.85 mg/dL
    • 2023-02-02 Creatinine 0.81 mg/dL
    • 2023-01-09 Creatinine 0.68 mg/dL
  • Cisplatin can cause severe renal toxicity, including acute renal failure. Severe renal toxicities are dose-related and cumulative. Adequate hydration has been considered, specifically, NS 500mL is given both before and after the cisplatin infusion, which is administered in NS 500mL as well. However, if there is continued acceleration of the decline in kidney function, dose reduction or alternative treatment options should also be considered for this patient.

700385067

230713

  • diagnosis - 2022-10-19 discharge note
    • Malignant neoplasm of mediastinum, part unspecified
    • Germ cell tumor of left mediastinal invasion, stage IV s/p chemotherapy with BEP (Bleomycin 30unit on D2.9.16/ Etoposide 80mg/m2、Cisplatin 15mg/m2 on D1-5 Q3W) since 2022/09/20
    • Unspecified viral hepatitis B without hepatic coma
  • lab data
    • 2022-09-17 Urine-Creatinine 142.38 mg/dL
    • 2022-09-17 U-Cr (24hr) 2135.7 mg/kg/24 hr
    • 2022-09-17 HBsAg Reactive
    • 2022-09-17 HBsAg (Value) 3335.07 S/CO
    • 2022-09-17 Anti-HBc Reactive
    • 2022-09-17 Anti-HBc-Value 7.18 S/CO
    • 2022-09-17 Anti-HCV Nonreactive
    • 2022-09-17 Anti-HCV Value 0.11 S/CO
    • 2022-09-16 beta-HCG 20.2 mIU/mL
    • 2022-09-16 AFP 1.6 ng/mL
    • 2022-09-15 LDH 397 U/L
    • 2022-09-15 AFP (nuclear medicine) 3.617 ng/ml
    • 2022-09-15 CEA (nuclear medicine) 12.729 ng/ml
    • 2022-09-15 SCC (nuclear medicine) 1.61 ng/mL
    • 2022-09-15 CA-199 (nuclear medicine) 23.149 U/ml
    • 2022-09-15 CA-125 (nuclear medicine) 24.131 U/ml
    • 2022-09-15 CyFra 21-1 (nuclear medicine) 14.0 ng/mL

[exam findings]

  • 2023-06-07, -05-19, -05-03, -04-30 CXR
    • Prior plain chest film identified left superior mediastinal widening and enlarged Lt hilum is noted again, stable in size that is c/w Germ cell tumor S/P C/T with stable disease.
  • 2023-04-18 CXR
    • Prior plain chest film identified left superior mediastinal widening and enlarged Lt hilum is noted again, marked decreasing in size that is c/w Germ cell tumor S/P C/T with partial response.
  • 2023-03-27, -03-20, -03-10 CXR
    • There is left superior mediastinal widening and enlarged Lt hilum that is c/w Germ cell tumor after correlate with CT and pathology.
  • 2023-02-18 CT - chest
    • Indication: germ cell tumor of left mediastinal progress and severe cough noted
    • Chest CT with and without IV contrast ehnancement shows:
      • Minimal interstitial change at bilateral peripheral lung fields is found.
      • Huge soft tissue mass with central necrotic part at superior mediastinum encasing great vasculature is found measuring 8.4cm in largest dimension. In comparison with CT dated on 2022-12-13, the lesion is stationary.
      • Calcified coronary arteries is found.
    • Imp:
      • Mediastinal mass, compatible with germ cell tumor. Stationary.
      • Interstitial change at both lungs. Either treatment effect or idiopathic pullmonary fibrosis should be considered. Suggest follow up.
  • 2022-12-13 CT - abdomen
    • History and indication: Germ cell tumor of left mediastinal invasion
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Mild regression of germ cell tumors with mediastinnal invasion. S/P Port-A infusion catheter insertion. A thrombus at SVC. Some LNs at bil. neck and mediastinum.
      • Liver cysts (up to 1.0cm).
    • IMP:
      • Mild regression of germ cell tumors with mediastinnal invasion. S/P Port-A infusion catheter insertion. A thrombus at SVC. Some LNs at bil. neck and mediastinum.
  • 2022-11-30 CXR
    • There is left superior mediastinal widening and enlarged Lt hilum that is c/w Germ cell tumor after correlate with CT and pathology.
  • 2022-11-15, -11-01, -10-19, -10-05, -09-27 CXR
    • There is marked superior mediastinal widening (Lt greater than Rt), and enlarged Lt hilum that is c/w Germ cell tumor after correlate with CT and pathology.
  • 2022-10-26 MRI - brain
    • Findings
      • mild dialted intraventricular and extraventricular CSF spaces
      • some white matter gliosis int he bilateral frontal brain parenchyma
      • unremarkable change in the skull base
      • no abnormal brain parenchymal enhancement
    • IMP:
      • no evidence of brain metastasis.
  • 2022-09-19 CXR
    • marked superior mediastinal widening (Lt greater than Rt), displacing the trachea to Rt, and prominent soft-tissue over Lt supraclavicular fossa and enlarged Lt hilum, due to extensive lymphadenopathy or tumor and lymphadenopathy
    • Normal heart size
    • no pneumothorax or pleural effusion
  • 2022-09-19 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 43 dB HL; LE 39 dB HL.
    • R’t mild to moderately severe MHL.
    • L’t mild to moderate MHL.
  • 2022-09-16 CT - abdomen
    • History: Mediastinal mass, pathology: germ cell tumor
    • Indication: for cancer survey
    • Findings:
      • Prior CT identified a heterogeneous soft tissue mass at left upper anterior mediastinum, measuring 10 cm in the largest dimension, with encasement of left subclavian artery and aortic arch, causing mild right lateral deviation of the trachea and esophagus, and multiple enlarged nodes in left lower neck, paratracheal space, and left hilum are noted again, stationary.
        • Germ cell tumor is highly suspected.
      • There are several hepatic cysts in both lobes and the largest one 0.9 cm in size at S5.
    • Impression:
      • Germ cell tumor of left upper anterior mediastinum is highly suspected.
  • 2022-09-16 Pulmonary function test
    • normal standard spirometry
    • negative BDT (bronchial dilation test)
    • normal DLCO (diffusion capacity of carbon monoxide)
  • 2022-09-14 Bronchoscopy
    • no endotracheal or endobronchial lesion
  • 2022-09-12 Patho - lung transbronchial biopsy
    • Mediastinum, CT-guide biopsy — in favor of germ cell tumor
    • Sections show nests of large pleomorphic tumor cells infiltrating in fibrous stroma with tumor necrosis.
    • The immunohistochemical stains reveal CK(+), SALL4(focal +), beta-hCG(focal +), CK7(-), CK20(-), CK5/6(-), TTF-1(-), Napsin A(-), p40(-), GATA3(focal +), PSA(-), CDX2(+), CD117(-), and CD56(-). According to the results, germ cell tumor (embryonal carcinoma or choriocarcinoma) is favored. Thymic tumor, lung cancer, mesothelioma, or lymphoma is less likely. Please correlate with the clinical presentation and image study.
  • 2022-08-31 CT at ShuangHo Hospital
    • Findings: A 7.6 cm mass at LUL with mediastinal invasion causing confluence of lymph nodes in the paratracheal, prevascular, subcarinal and left hilar regions. Encasement of left subclavian artery and displacing trachea, esophagus and left CCA noted.
    • DDX: bronchogenic carcinoma, thymic carcinoma or other malignancy. Advise further work-up.
  • 2022-08-31 Aspiration Cytology - lymph node
    • Clinical diagnosis: Paralysis of vocal cords and larynx, unspecified
      • Hoarseness for a month.
      • Previous URI(+)
      • Choking(+)
    • Cytological diagnosis
      • Left level IV mass: Positive for malignancy
    • Four wet smears show lymphocytes, neutrophils and some hyperchromatic atypical epithelial clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
  • 2022-08-31 SONO - neck
    • Findings
      • Multiple LNs in bilateral neck, with size up to 1.42 cm in length at right and 2.37cm at left.
      • No abnormal fluid collection.
    • Imp: Multiple bilateral neck LNs.
  • 2022-08-30 SONO - head and neck soft tissue
    • cervical lymph node: 1.34*3.0cm LAP at left supraclavicular fossa
  • 2022-08-03 SONO - abdomen
    • Diagnosis
      • GB polyp, large R/O focal wall thickening
      • Parenchymal liver disease
    • Suggestion
      • Keep regular follow up

[MedRec]

  • 2023-04-18 ~ 2023-05-05 POMR Hemato-Oncology
    • Discharge diagnosis
      • Germ cell tumor of left mediastinal invasion, stage IV s/p chemotherapy with BEP (Bleomycin 30unit on D2.9.16/ Etoposide 80mg/m2 and Cisplatin 15mg/m2 on D1-5 Q3W) from 2022/09/20 to 2023/01/04
      • Neutropenia due to infection post chemotherapy blood culture: no growth for 5 days aerobically & anaerobically
      • Hypokalemia
      • Hypomagnesemia
      • Anemia due to antineoplastic chemotherapy
    • Chief Complaints
      • for C2 chemotherapy with TIP & autologout stem cell collection
    • Present illness
      • Port-A implantation on 2023/03/10.
      • C1 chemotherapy with TIP was given on 3/21-3/25 23 and autologous hematopoietic cell transplantation was performed on 4/3 23.
      • Today, he was admitted for C2 chemotherapy with TIP & autologous hematopoietic cell transplantation on 4/18 23.
    • Course of inpatient treatment
      • After admission, chemotherapy with TIP (Taxol 250mg/m2, self-paid D1 4/19 ) & Mesna (300mg/m2, IVD 15mins, after Ifosfamide at 0, 4, 8 hour on 4/20-4/23), Ifosfamide 1500mg/m2 (D2-D5 4/20-4/23), Cisplatin (25mg/m2, D2-D5 4/20-4/23) were given, smoothly without obvious side effect. Lenograstim started since 4/25 23 was added. He complained of watery diarrhea and Imodium was given for symptom relief. Will arrange autologout stem cell collection on 5/4-5/5 23. Lenograstim 250mcg & G-CSF 150mcg sc qd was given for post C/T. He complained of watery diarrhea post C/T and Imodium 1# po prnq6h was added.
      • Fever with chills was developed on 4/27 23 afternoon and septic work-up was performed and antibiotic with Cefim 2000mg ivd q8h was given for neutropenia fever. The blood culture report showed No growth for 5 days aerobically & anaerobically. Blood transfusion with LPRBC 2U was given on 5/2 23. Double lumen was inserted on 5/3 23 and autologous stem cell collection on 5/3-5/4 23 and CD34+: 0.01% & CD34 + count (5/3 23): 25/uL, CD34+: 0.02% & CD34 + count (5/4 23): 60/uL were noted. Intravenous KCL 10cc & MgSO4 1amp was given for hypokalemia & hypomagnesemia. Double lumen was removed on 5/5 23 and he was discharged on 5/5 23 with stable condition and will follow-up at OPD.
  • 2023-03-09 ~ 2023-04-03 POMR Hemato-Oncology
    • Discharge diagnosis
      • Malignant neoplasm of mediastinum, part unspecified
      • Germ cell tumor with left medistainal invastion, stage IV, S/P BEP chemotherapy with refractory, S/P TIP chemotherapy and autologous stem cell collection
      • Germ cell tumor of left mediastinal invasion, stage IV s/p chemotherapy with BEP (Bleomycin 30unit on D2.9.16/ Etoposide 80mg/m2 and Cisplatin 15mg/m2 on D1-5 Q3W) from 2022/09/20 to 2023/01/04
    • Present illness
      • This 53 year-old man suffered from hoarsness in 2022/08. He went to local clinic first and they suggested hospital follow up. He then went Shuang Ho Hospital for help. According to CT report from Shaung Ho, there is a 7.6 cm mass at LUL with mediastinal invasion and encasement of left subclavian artery and displacing trachea, esophagus and left CCA noted. Differential diagnosis included bronchogenic carcinoma, thymic carcinoma or other malignancy.
      • He then came to our otorhinolaryngology clinic for further evaluation. Nasopharyngoscopy on 2022/08/30 showed smooth nasopharynx, oropharynx, hypopharynx and left vocal cord palsy. Neck sonography revealed left supraclavicular lymphadenopathy. Moreover, sono-guide fine needle aspiration revealed metastatic malignancy. He was reffered to our chest surgery clinic for further management.
      • After admission, CT-guide biopsy of left mediastinal mass on 2022/09/12 showed left mediastital mass revealed germ cell tumor, embryonal carcnimoa or choriocarcinoma is favored. Upper GI endoscopy on 2022/09/13 revealed reflux esophagitis. Bronchoscopy on 2022/09/14 showed no endotracheal or endobronchial lesion. Abdominal/Pelvic CT on 2022/09/16 showed germ cell tumor of left upper anterior mediastinum is highly suspected.
      • For pre-chemotherapy evaluation, pulmonary function test (FRC + DLCO) on 2022/09/16 normal standard spirometry, 24 urine CCR on 2022/09/17 showed 178.7 ml/min / urine 1500 ml/day, pure-tone audiometry test on 2022/09/19 showed R’t mild to moderately severe MHL, L’t mild to moderate MHL. Port-A insertion on 2022/09/19.
      • Chemotherapy with BEP (Bleomycin 30unit on D2.9.16/ Etoposide 80mg/m2 and Cisplatin 15mg/m2 on D1-5 Q3W) from 2022/09/202022/09/25(C1D1D5), 2022/09/28(C1D9), 2022/10/202022/10/25(C2D1D5), 2022/10/28(C2D9), 2022/11/01(C2D16), 2022/11/152022/11/20(C3D1D5), 2022/11/22(C3D9), 2022/12/062022/12/11(C4D1D5), 2022/12/14(C4D9), 2022/12/17-2023/01/01(C5D1~D5), 2023/01/04(C5D9).
      • CXR on 2022/09/27 showed mediastinal widening (left greater than right) improving, and enlarged left hilum. Brain MRI on 2022/10/26 showed no evidence of brain metastasis. CXR on 2022/11/15 showed mediastinal widening (left greater than right) mild improving. Abdominal CT on 2022/12/13 showed mild regression of germ cell tumors with mediastinnal invasion, a thrombus at SVC and some lymph nodes at bil. neck and mediastinum.  
      • He had COVID-19 infection on 2023/02, but he denied cough, sputum or fatigue. But, before C6D1 chemotherapy, he has fever with chills suddenly, so we hold chemo and check blood studies. R’t Port-A was removed by CS for yield Pseudomonas spp on 2023/02/10. Fever also noted durine Cefepime, consider tumor fever related. He received Chest CT showed mediastinal mass, compatible with germ cell tumor stationary and interstitial change at both lungs on 2023/02/18, but image showed mediastinal mass got bigger and due to a 1cm x 1cm LN over left suparclavicle, so we thick the disease in progress. After well infection control, discharged on 2023/02/22.
      • This time, he had mild fever at home (highest to 37.6’C), and he had mild cough without sputum, no fever, mild dysphagia was noted. He was admitted for port-A implantation and receive new regimen chemotherapy.
    • Course of inpatient treatment
      • After admission, consult CS for Port-A implantation on 2023/03/10, funtion well. Pain control with Tramacet 37.5 & 325mg/tab 1# PO Q12H. He was transfered to Dr. Wan service for autologous hematopoietic cell transplantation (autoHCT). Palitaxel on (2023/03/21) -> Ifosfamide, cisplatin (2023/03/22-2023/03/25). G-CSF 150mcg, granocyte 500mcg (2023/03/27-). We would keep on monitoring his clinical manifestation and provide necessary treatments.
      • On 2023/04/03, we placed a double lumen catheter for stem cell collection. After one day with 18 liters of peripheral blood circulation through the cell separater and CD34+ cell collection. Total 1.99 x 10 ^6/kg of CD 34+ cells were collected. Removal of the double lumen catheter and disharged at today. The next chemotherapy and then stem cell collection will be scheduled at April 11.

[consultation]

  • 2022-12-08 Dermatology
    • Q
      • This 53-year-old man patient is a case of Germ cell tumor of left mediastinal invasion, stage IV s/p chemotherapy with BEP (Bleomycin 30unit on D2.9.16/ Etoposide 80mg/m2、Cisplatin 15mg/m2 on D1-5 Q3W) from 2022/09/20~. He was admitted for chemotherapy with BCP(C4). this time, for left upper arm redness rash without itch, R/O hemangioma. Now, for evaluate left upper arm redness rash therapy. Thank you.
    • A
      • The patient had sufferred from germ cell tumor under chemotherapy. region telangetasia with vascular dialation was noted over left upper limb.
      • Besides, no regional swelling or tenderness was noted.
      • Under the impression of peripheral vsaculopathy, be aware of progressive vasculitis, favor IV form medication-related.
      • The following suggestion:
        • notify IV form electrolyte infusion rate, decrease osmotic imbalance as possible.
        • Due to no obvious clinical symptom, further regional skin care and moisturization with Sinphraderm cream 1 tube topical bid use.
  • 2022-09-26 Hemato-Oncology
    • Q
      • This 53-year-old man was admitted under impression of LUL mediastinal mass.
      • CT-guide biopsy was done and pathology revealed germ-cell tumor (embryonal carcinoma or choriocarcinoma is favored)
        • LDH 397
        • AFP 3.617
        • CEA 12.7
        • CA 199 23.1
        • CA 125 24.1
        • CyFra 14
      • We need your expertise for this patient’s further management
    • A
      • Impression:
        • LUL mediastinal mass s/p CT guide biopsy, pathology show germ cell tumor (embryonal carcinoma or choriocarcinoma is favored) LDH 397, AFP 3.617-B HCG: pending.
      • Suggestion:
        • For germ cell tumor cancer work up, please arrange abdominal/pelvic CT and Pending B-HCG level
        • Prepare cancer treatment, please arrange pulmonary function test (FRC + DLCO), 24 urine CCR, Pure-tone audiometry test, HbsAg, Anti Hbc, Anti HCV
        • On port-A if patient agree further systemic chemotherapy. We wound like to take over this case, if you agree.
        • Thanks for your consultation. If there is any problem, please feel free to let us known

[chemoimmunotherapy]

  • 2023-06-07 - paclitaxel 250mg/m2 420mg NS 500mL 24hr D1 + [ifosfamide 1500mg/m2 2600mg NS 500mL + mesna 300mg/m2 510mg NS 250mL 15min (x3 at 0, 4, 8 hr after ifosfamide) + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 250mL 1hr + NS 500mL 2hr (after cisplatin)] D2-5 (for PBHSC harvest)
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL] D1-5 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3
  • 2023-04-19 - paclitaxel 250mg/m2 430mg NS 500mL 24hr D1 + [ifosfamide 1500mg/m2 2600mg NS 500mL ………………………………………………………………. + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 250mL 1hr + NS 500mL 2hr (after cisplatin)] D2-5 (for PBHSC harvest)
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL + palonosetron 250ug] D1-5
  • 2023-03-20 - paclitaxel 250mg/m2 420mg NS 500mL 24hr D1 + [ifosfamide 1500mg/m2 2580mg NS 500mL ………………………………………………………………. + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 250mL 1hr + NS 500mL 2hr (after cisplatin)] D2-5 (for PBHSC harvest)
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL + palonosetron 250ug] D1-5
  • 2023-02-07 - etoposide 80mg/m2 140mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 27mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16
    • [dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-5 + famotidine 20mg D1
  • 2023-01-04 - bleomycin 30mg NS 100mL 10min D2,9,16
    • dexamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2022-12-27 - etoposide 80mg/m2 135mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 25mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16
    • dexamethasone 8mg ST D1 & 8mg QD D2-5 + diphenhydramine 30mg ST & 30mg QD D2-5 + palonosetron 250ug D1 + aprepitant 125mg ST D1 & 125mg QD D2-3
  • 2022-12-13 - bleomycin 30mg NS 100mL 10min D2,9,16 (G-CSF 1222, 1223)
    • dexamethasone 8mg + diphenhydramine 30mg
  • 2022-12-06 - etoposide 80mg/m2 135mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 25mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16
  • 2022-11-22 - bleomycin 30mg NS 100mL 10min D2,9,16 (G-CSF 1130, 1201, 1202)
  • 2022-11-15 - etoposide 80mg/m2 135mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 25mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16
  • 2022-11-01 - bleomycin 30mg NS 100mL 10min D2,9,16 (G-CSF 1101, 1108, 1110)
  • 2022-10-28 - bleomycin 30mg NS 100mL 10min D2,9,16
  • 2022-10-19 - etoposide 80mg/m2 135mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 25mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16
  • 2022-09-28 - bleomycin 30mg NS 100mL 10min D2,9,16 (G-CSF 1105, 1106, 1107)
  • 2022-09-20 - etoposide 80mg/m2 135mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 25mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16

Granocyte (lenograstim) 250mg SC

  • 2022-12-22, -23 (20221221 OpdRx)
  • 2022-12-01, -02 (20221130 OpdRx)
  • 2022-11-30 (20221115 IpdRx)
  • 2022-11-08, -10 (20221101 OpdRx)
  • 2022-11-01 (20221019 IpdRx)
  • 2022-10-05, -06, -07 (20221005 OpdRx)

lab WBC

  • 2022-12-27 WBC 9.45 *10^3/uL BEP 1227
  • 2022-12-21 WBC 2.00 *10^3/uL G-CSF 1222, 1213
  • 2022-12-13 WBC 2.66 *10^3/uL bleomycin 1213
  • 2022-12-06 WBC 6.11 *10^3/uL BEP 1206
  • 2022-11-30 WBC 1.73 *10^3/uL G-CSF 1130, 1201, 1202
  • 2022-11-23 WBC 3.52 *10^3/uL bleomycin 1122
  • 2022-11-15 WBC 5.84 *10^3/uL BEP 1115
  • 2022-11-01 WBC 2.38 *10^3/uL G-CSF 1108, 1110
  • 2022-10-28 WBC 3.01 *10^3/uL G-CSF 1101; bleomycin 1028
  • 2022-10-19 WBC 6.04 *10^3/uL BEP 1019
  • 2022-10-12 WBC 6.84 *10^3/uL
  • 2022-10-05 WBC 1.17 *10^3/uL G-CSF 1105, 1106, 1107
  • 2022-09-26 WBC 11.36 *10^3/uL bleomycin 0928
  • 2022-09-20 WBC 5.46 *10^3/uL BEP 0920
  • 2022-09-12 WBC 4.52 *10^3/uL

[note]

==========

2023-07-13

  • Over the last three months, this patient has solely been utilizing our hospital’s outpatient and inpatient hemato-oncology services. There have been no issues identified regarding medication reconciliation.

2023-06-08

  • Based on the PharmaCloud database, this patient has exclusively been visiting our hospital for outpatient and inpatient hemato-oncology services over the past three months. No medication reconciliation issues have been identified.

2022-12-28

  • CT on 2022-12-13 showed mild regression of germ cell tumors with mediastinal invasion, suggesting that the current BEP regimen is effective in inhibiting tumor progression. CS opinioned on 2022-12-22 that the tumor was not suitable for surgical removal due to the fact that it encased large vessels over the mediastinum.
  • In accordance with the appropriate G-CSF administration timing, there have been no WBC events less than 2K/uL since December 2022.
  • Although magnesium supplements were administered, lab results showed a slow decline in serum magnesium levels (now slight below LLN).
    • 2022-12-27 Mg (Magnesium) 1.8 mg/dL
    • 2022-12-21 Mg (Magnesium) 1.8 mg/dL
    • 2022-12-13 Mg (Magnesium) 1.6 mg/dL
    • 2022-12-06 Mg (Magnesium) 1.7 mg/dL
    • 2022-11-30 Mg (Magnesium) 1.6 mg/dL
    • 2022-11-23 Mg (Magnesium) 1.7 mg/dL
    • 2022-11-15 Mg (Magnesium) 1.9 mg/dL
    • 2022-10-28 Mg (Magnesium) 1.8 mg/dL
    • 2022-09-26 Mg (Magnesium) 1.9 mg/dL
    • 2022-09-20 Mg (Magnesium) 2.0 mg/dL
  • Magnesium losses from both the upper and lower gastrointestinal tract can induce hypomagnesemia. In general, magnesium depletion is more commonly due to diarrhea than to vomiting. As there have been no recent diarrhea or vomiting-related events recorded, these may be less likely to be to blame.
  • Hypomagnesemia due to urinary magnesium wasting occurs in over one-half of cases of cisplatin-induced nephrotoxicity and can be severe. It is dose related and can occur without the presence of concomitant AKI. In patients who receive cisplatin for several months, urinary magnesium wasting may persist even after discontinuation of cisplatin therapy. In addition to its direct clinical manifestations, hypomagnesemia may exacerbate cisplatin toxicity. As always, regular monitoring is essential.
  • There is no problem with the active prescription.

2022-12-07

  • It appears that the approximate cycled trough WBC count occured around one week after the administration of single bleomycin agent, the G-CSF administration might follow this pattern.

    • 2022-12-06 WBC 6.11 *10^3/uL BEP 1206
    • 2022-11-30 WBC 1.73 *10^3/uL G-CSF 1130, 1201, 1202
    • 2022-11-23 WBC 3.52 *10^3/uL bleomycin 1122
    • 2022-11-15 WBC 5.84 *10^3/uL BEP 1115
    • 2022-11-01 WBC 2.38 *10^3/uL G-CSF 1108, 1110
    • 2022-10-28 WBC 3.01 *10^3/uL G-CSF 1101; bleomycin 1028
    • 2022-10-19 WBC 6.04 *10^3/uL BEP 1019
    • 2022-10-12 WBC 6.84 *10^3/uL
    • 2022-10-05 WBC 1.17 *10^3/uL G-CSF 1105, 1106, 1107
    • 2022-09-26 WBC 11.36 *10^3/uL bleomycin 0928
    • 2022-09-20 WBC 5.46 *10^3/uL BEP 0920
    • 2022-09-12 WBC 4.52 *10^3/uL
  • The AFP/beta-HCG/LDH tests might be conducted again in December 2022 to make the monitor frequency not fall below two months. (There were still superior mediastinal widening and an enlarged Lt hilum on the CXR of 2022-11-30)

  • Pulmonary fibrosis is the most severe toxicity associated with bleomycin. The most frequent presentation is pneumonitis occasionally progressing to pulmonary fibrosis. Its occurrence is higher in elderly patients and in those receiving more than 400mg total dose, but pulmonary toxicity has been observed in young patients and those treated with low doses.

    • 2022-09-16 pulmonary function test showed the patient with normal standard spirometry, negative BDT, normal DLCO.
    • As of 2022-12-07, there has been 240mg (30mg x 8) of cumulative exposure to bleomycin.
    • Please monitor for signs of lung deterioration on a regular basis.

2022-11-16

  • Lab data from selected tumor markers revealed that each marker had a different trend without an overall trend.
    • 2022-11-01 AFP 16.6 ng/mL
    • 2022-09-16 AFP 1.6 ng/mL
    • 2022-07-05 AFP 1.4 ng/mL
    • 2022-11-01 beta-HCG 5.8 mIU/mL
    • 2022-09-16 beta-HCG 20.2 mIU/mL
    • 2022-10-19 LDH 377 U/L
    • 2022-10-12 LDH 349 U/L
    • 2022-09-26 LDH 253 U/L
    • 2022-09-15 LDH 397 U/L
  • The WBC is boosted with lenograstim when neutropenia is observed following the BEP regimen.
  • Chronic hepatitis B is treated appropriately with Baraclude (entecavir) 0.5mg QDAC.
  • The active prescription is not subject to any issues.

2022-10-20

  • The primary chemotherapy regimen for germ cell tumors could be BEP, which consists of the following components (NCCN).

    • Etoposide 100 mg/m2 IV on Days 1-5
    • Cisplatin 20 mg/m2 IV on Days 1-5
    • Bleomycin 30 units IV weekly on Days 1, 8, and 15 or Days 2, 9, and 16
    • Repeat every 21 days
  • AST, ALT, Cre, and eGFR (2022-10-19) did not exhibit abnormalities, therefore no dose adjustment would be required for the BEP regimen based on pharmacokinetics.

  • The dose used is slightly lower than that recommended by the NCCN (currently: 80mg/m2 of etoposide, 15mg/m2 of cisplatin. NCCN: 100mg/m2, 20mg/m2). Given that the patient’s performance status scale is ECOG 0, it might be an option to upgrade the dose to meet the guideline to obtain more expected effects if no other considerations exist.

700014611

230712

(not completed)

[exam findings]

[chemotherapy]

==========

2023-07-12

[reconciliation]

This patient intermittently visits a local ophthalmology clinic due to symptoms in his left eye. His most recent visit was on 2023-06-30, and the prescription given, which was valid for 3 days, has now expired. Please decide whether to refer him to our hospital’s ophthalmology department based on his current clinical condition.

700536529

230712

[MedRec]

  • 2023-07-10 MultiTeam - Palliative Care
    • Multidisciplinary Team Suggestions
    • Consultation date: 2023-07-10
    • Response: Together with Dr. Chen from the Department of Family Medicine, the co-care nurse visited the patient, who is in fair spirits and reports no discomfort. The foreign caregiver was taking care of the patient at the bedside. The patient is expected to be discharged tomorrow. The co-care nurse called the patient’s eldest son (0933221580) and introduced the concept of palliative care. The eldest son expressed the wish to discuss palliative care face-to-face with his siblings. He would contact the co-care nurse when he arrives at the hospital tomorrow morning, and left the co-care nurse’s contact number for future follow-ups. In the afternoon, the eldest son called to arrange a face-to-face meeting at 16:30 today. The co-care nurse explained the concept of palliative care (palliative care ward, co-care palliative, home palliative care) to the eldest son, the patient’s daughter, and the patient’s son-in-law. The eldest son agreed to direct the patient’s care towards palliative care, hoping that the patient can be comfortable and not suffer. The patient is aware of his cancer diagnosis and has previously stated that he does not want resuscitation. The co-care nurse introduced the concept of Advance Care Planning (ACP) for palliative care and suggested that they complete the ACP.
    • Conclusion and Suggestions: Palliative co-care, Follow-up on the Advance Care Planning for Palliative Care.
    • Responder: Chen Hui
    • Reply date: 2023-07-10 17:42

==========

2022-01-18

  • Recent lab data

    • 2022-01-18 serum glucose 191mg/dL
    • 2022-01-17 serum glucose 164mg/dL
    • 2022-01-11 serum glucose 154mg/dL
    • 2021-11-10 ascites glucose 150mg/dL
  • Elevated serum glucose. This patient has type 2 DM and CVD, SGLT2i might be a choice to protect heart while lowering blood sugar.

  • SGLT2i such as empagliflozin, dapagliflozin, canagliflozin are available in stock could be prescirbed if UTI is unlikely.

700960001

230712

{not completed}

[diagnosis] - 2023-05-08 admission note

  • Serous carcinoma, high grade of left ovary, pTIc1pN0(if cM0); FIGO stage:IC, s/p Debulking sugery on 2021/06/30, IHC stains: ER(-), PR(-) s/p chemotherapy with Taxol(175mg/m2)/Carboplatin(AUC:5) from 2021/07/23 to 2021/11/11 (for 6 cycles) with liver metastasis s/p chemotherapy with Taxol(175mg/m2)/Carboplatin(AUC:5) from 2023/03/14.
  • Chronic viral hepatitis B without delta-agent
  • Encounter for antineoplastic chemotherapy

[exam findings]

  • 2023-03-10 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Compatible with metastatic ovarian serous carcinoma
    • The sections show a picture compatible with metastastic serous carcinoma of ovary, composed of nests large pleomorphic neoplastic cells arranged in solid and subtle papillary pattern in fibrous stroma.
    • IHC shows: PAX8(+) and WT1(-).
  • 2023-03-02 CT - abdomen
    • Findings
      • S/P hysterectomy. Right ovary cyst (3.0cm).
      • Poor enhancing tumors (up to 3.3cm) at left hepatic lobe.
      • A tiny nodule (3mm) at left lung.
    • IMP
      • S/P hysterectomy. Poor enhancing tumors (up to 3.3cm) at left hepatic lobe r/o metastases.
      • A tiny nodule (3mm) at left lung.
  • 2022-12-01 CT - abdomen
    • S/P hysterectomy.
    • A tiny nodule (3mm) at left lung.
  • 2022-09-06 CT - abdomen
    • S/P hysterectomy.
    • A tiny nodule (2mm) at LUL.
  • 2022-06-08 CT - abdomen
    • S/P hysterectomy.
    • There is no evidence of tumor recurrence.
  • 2022-03-12 CT - chest
    • Left upper lobe tiny subpleural nodule. Stable.
  • 2022-03-02 CT - abdomen
    • There is a small soft tissue nodule 4 mm in LLL of the lung. Follow up chest CT 6 months later is indicated.
    • S/P hysterectomy. There is no evidence of tumor recurrence.
  • 2021-11-30 CT - abdomen
    • S/P hysterectomy and oophorectomy.
    • Focal fatty density in right subhepatic region, suggest follow up.
  • 2021-10-08 Gynecologic ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2021-07-21 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 15 dB HL; LE 16 dB HL.
    • Bil normal to mild SNHL.
  • 2021-06-30 Patho - uterus (with or without SO) neoplastic
    • Diagnosis:
      • Ovary, left, oophorectomy with frozen section (F2021-248) — Serous carcinoma, high grade.
        • IHC stains: ER: (-), PR (-), WT-1 (+), PAX8 (+), Napsin-A (-), p53 (+).
      • Fallopian tube, left, salpingectomy (F2021-248) — Free
      • Omentume, omentectomy —- Free
      • Lymph node, bilateral pelvic and right para-aortic, dissection — Free
      • pTIc1 pN0 (if cM0); FIGO stage:IC1.
        • NOTE: According to AJCC staging manual 2017 8th edition page 10. “Pathologist should not report any M category unless appropriate for the specimen evaluated.” … “Only the managing physician can assign cM0 after taking into account physical examination, image, and other information”. However, the pathologyists are ordered by this hospital adminstration (including the chiefs of cancer committee, hemato-oncology and radiation oncology) to assign the “cM” category although pathologists are not in the position of doing so.
    • Gross description:
      • Procedure (select all that apply)- Debulking surgery (Left salpingo-oophorectomy + infracolic omentectomy + pelvic lymph node dissection)
      • Specimen Integrity
        • Specimen Integrity of Right Ovary- not received
        • Specimen Integrity of Left Ovary- intra-operative rupture
        • Specimen Integrity of Right Fallopian Tube – not received
        • Specimen Integrity of Left Fallopian Tube- free
      • Tumor Site: Left ovary
      • Ovarian Surface Involvement (required only if applicable): Present (Left)
      • Fallopian Tube Surface Involvement (required only if applicable): Absent
      • Tumor Size-Greatest dimension (centimeters): Ovary: 16 x 12 x 9 cm, solid part: 6.5 x 4 x 4 cm.
        • Sections are taken and labeled as:
        • Tissue for frozen sections: F2021-248FSA1-2: left ovarian tumor.
        • Tissue for formalin fixation: F2021-248A1-5: left ovarian tumor;
        • S2021-8661A: left iliac LN; B: left obturator LN; C: right iliac LN; D: right obturator LN; E: right para-aortic LN; F: omentum.
    • Microscopic Description:
      • Histologic Type: Serous carcinoma
      • Histologic Grade - high grade
      • Implants- Not identified
      • Other Tissue/ Organ Involvement (select all that apply): Not identified
      • Largest Extrapelvic Peritoneal Focus (required only if applicable): not apllicable
      • Peritoneal/Ascitic Fluid - Negative for malignancy (normal/benign)
      • Regional Lymph Nodes: negative for metastasis: 0/22 (0/ total No. of nodes) = left iliac LN (0/1); left obturator LN (0/2); right iliac LN (0/7); right obturator LN (0/3); right para-aortic LN (0/9)
      • Additional Pathologic Findings - None identified
      • Comment(s): IHC stains: ER: (-), PR (-), WT-1 (+), PAX8 (+), Napsin-A (-), p53 (+).
  • 2021-06-19 CT - abdomen
    • Indication: Suspect pelvis mass: 160x116mm
    • Abdominal CT with and without enhancement revealed:
      • Cystic lesion at pelvis up to 15.6cm in largest dimension is found. Some solid part is found. Ovarian cancer is considered. The left ureter is obliterated with left hydronephrosis and hydroureter.
    • Imp: Left ovarian cancer without ascites formation.
    • Imaging Report Form for Ovarian Carcinoma
    • Impression (Imaging stage): T:____(T_value) N:____(N_value) M:____(M_value) STAGE:____(Stage_value)
  • 2021-06-18 Gynecologic ultrasonography
    • Suspect pelvis mass: 160x116mm
  • 2020-07-29 CT - abdomen
    • History and Indication: 2020/07/28 sona: Total hysterectomy ATH, ROV Mass:59 x 31 mm; IMP: R/O Rt ovarian mass(no blood flow)
    • FINDINGS:
      • S/P hysterectomy
      • There is a cystic lesion with septum formation and mural nodule measuring 4.7 x 2.9 cm in right adnexa.
      • There are three kissing mixed solid and cystic lesion in left adnexa.
      • S/P double J catheter insertion, right side urinary tract.
      • A renal cyst measuring 0.7 cm in right middle pole is noted.
    • IMP:
      • Cystic mass lesion in bilateral adnexal area are noted. please correlate with clinical condition and MRI to rule out endometrioma or cystic tumor.
  • 2017-03-27 Surgical pathology Level V
    • A. Cervix, uterus, complicated total hysterectomy — Chronic cervicitis, Nabothian cysts
      • Endometrium, uterus, ditto — Proliferative phase
      • Myometrium, uterus, ditto — Adenomyosis
    • B. Ovarian cyst, left, salpingo-oophorocystectomy — Endometriosis
    • C. Ovarian cyst, right, salpingo-oophorocystectomy — Endometriosis
  • 2017-03-14 Gynecologic ultrasonography
    • Adenomyosis
    • R/O Bilateral endometrioma

[consultation]

  • 2021-07-07 Hemato-Oncology
    • Q
      • For post-op chemotherapy
      • This 46 y/o female, she was arranged to admit for Debulking surgery on 20210630.
      • The pathology report: Ovary, left, oophorectomy with frozen section —- Serous carcinoma, high grade. IHC stains: ER: (-), PR (-), WT-1 (+), PAX8 (+), Napsin-A (-), p53 (+). pTIc1 pN0 (if cM0); FIGO stage: IC1.
      • We need your expertise for help her further management for post-op chemotherapy. Thanks for you help!
    • A
      • Patient examined and Chart reviewed. A case of ovarian serous carcinoma, high grade, pathological Stage IC1 is noted. I am consulted for further management.
      • My suggestions would be:
        • Adjuvant CCRT with weekly cisplatin is indicated.
        • Please arrange Port-A insertion (Done)
        • Please arrange family meeting, regarding the issue of adjuvant treatment and genetic test.
        • Thanks for your consultation. Please let me know if any problem.

[surgical operation]

  • 2022-09-22
    • Surgery: Internal hemorrhoids rubber band ligation        
    • Finding: Enlarged internal hemorrhoids with congestion at 3 o’clock  
  • 2022-09-01
    • Surgery: Internal hemorrhoids rubber band ligation        
    • Finding: Enlarged internal hemorrhoids with congestion at 7 o’clock  
  • 2021-07-06
    • Operation
      • Port-A (47080B)
      • Fluoroscopy (32026C) 
  • 2021-06-30
    • Surgery
      • Bilateral DBJ catheter insertion
    • Finding
      • External compression at posterior wall of urinary bladder
      • Left lower ureteral angulation
      • Bilateral 6Fr. 24cm DBJ inserted
  • 2021-06-30
    • Surgery
      • Diagnosis: Left ovarian tumor r/o malignancy s/p debulking surgery.
      • Operation: Debulking surgery (LSO + infracolic omentectomy + pelvic lymphnode dissection)   - Finding
      • Left ovarian tumor, r/o malignancy.
      • Ovarian cancer, stage , pT1aN0M0(type)
      • Frozen: adenocarcinoma
      • Supraumbilical midline vertical skin incision
      • Uterus:s/p ATH
      • Adnexa:
        • LOV: cystic lesion, 16x12cm, capsule intact, smooth surface. intra-op rupture(+)
        • ROV: not seen.
      • CDS: invisible due to tumor mass occupied
      • Ascites: minimal, washing cytology was done.
      • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(+)
      • Omentum: infracolic omentectomy was done.
      • Liver: grossly normal & smooth
      • After the operation, optimal debulking surgery was achieved.
      • Residue tumor: <2cm.
      • Estimated blood loss: 500ml
      • Blood transfusion: nil
      • Complication: nil  
  • 2020-07-22
    • Surgery: Right ureterorenoscopic exam & double-J stenting  + retrograde pyelography       
    • Finding
      • Right upper ureter kinking was noted and confirmed by retrograde pyelography       
      • 6Fr 24 cm DBJ was placed
  • 2017-03-27
    • Cystoscopy + retrograded ureteral catheterization
  • 2017-03-27
    • Uterus: Avfl, hypertrophic and disfigured due to adenomyosis
    • RAD: enlarged with chocolate like content with severe adhesion to uterus, rectum, and LAD. cannot totally remove chocolate cyst due to severe adhesion.
    • LAD: enlarged with chocolate like content with severe adhesion to uterus, sigmoid colon, and RAD.
    • CDS: obliteration due to severe endometriosis.
    • Estimated blood loss: 900ml
    • Blood transfusion: pRBC2u
    • Complication: nil

[chemoimmunotherapy]

  • 2023-06-02 - bevacizumab 15mg/kg 900mg NS 250mL 90min + paclitaxel 175mg/m2 300mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr (Avastin init)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1
  • 2023-05-08 - paclitaxel 175mg/m2 300mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-07 - paclitaxel 175mg/m2 300mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-13 - paclitaxel 175mg/m2 300mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-11-10 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-10-21 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-09-27 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-09-06 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + carboplatin AUC 5 500mg NS 300mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-08-12 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + cisplatin 75mg/m2 120mg NS 500mL 24hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-07-23 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 120mg NS 500mL 24hr + NS 250mL 1hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 750mL

==========

2023-07-12

According to the PharmaCloud database, this patient only receives medical services at our hospital. Cross-referencing this with HIS5 records, there were no active prescriptions issued by other departments. Consequently, no medication reconciliation issues were identified.

2023-05-09

Granocyte (lenograstim) is pre-prescribed for 2 to 3 consecutive days, a few days after each chemotherapy session, as a prophylactic measure against leukopenia. Since mid-Nov 2021, the patient’s WBC count has remained consistently above 3K/uL.

701462990

230712

[chemotherapy]

  • 2023-07-10 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-20 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-26 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 15mg/kg 900mg NS 100mL 90min
    • diphenhydramine 30mg + NS 250mL
  • 2023-04-28 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 15mg/kg 900mg NS 100mL 90min
    • diphenhydramine 30mg + NS 250mL
  • 2023-04-03 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 15mg/kg 900mg NS 100mL 90min
    • diphenhydramine 30mg + NS 250mL

701486110

230712

[exam findings]

  • 2023-06-14 CT - chest
    • Indication: One mass was noted in the rectum (12 cm from anal verge) with partial obstruction, for cancer staging
    • Chest CT without IV contrast ehnancement shows:
      • Perifissural nodule at right middle lobe measuring 0.36cm is found. Old insult is more favored.
      • Calcified coronary arteries is found.
    • Imp: Right middle lobe perissural nodule. 0.36cm
  • 2023-06-13 Patho - colon biopsy
    • Colorectum, rectum, 12 cm above anal verge, biopsy — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-06-08 CT - abdomen
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of R-S junction of colon with adjacent fat stranding and fluid collection. Some LNs at pelvic cavity.
      • Tiny liver and renal cysts.
      • Atherosclerosis of aorta, iliac arteries.
      • A nodule (3mm) at RML, nature ?
    • Addendum Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)

[consultation]

  • 2023-06-15 Radiation Oncology
    • A
      • Preoperative CCRT first followed by surgical treatment was suggested. CT-simulation will be arranged on 2023/06/20. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 2023/06/26. Thank you very much.
  • 2023-06-15 Hemato-Oncology
    • Q
      • For neoadjuvant CCRT
      • This 51-year-old male got intermittent right lower abdominal pain, bloody stool for two months and got worse in recent days. Thus, he vistit our CRS OPD then referred to our ER on 2023/06/08. Lab data revealed leukocutosis and CRP level 10.9. Abdominal CT showed wall thickening of R-S junction of colon with adjacent fat stranding and fluid collection, along with some lymph nodes at pelvic cavity. Uner the diagnosis of diverticulitis of R-S colon, the patient was admitted for further evaluation. After admission, NPO with adequate fluid supplement and empirical antibiotic treatment with Brosym were prescribed. After medical treatment, his abdominal pain improved much. Sigmoidoscopy was arranged and revealed one mass was noted in the rectum (12 cm from anal verge) with partial obstruction. Biopsy was done and pathology proved adenocarcinoma. Chest CT showed right middle lobe perissural nodule. 0.36cm.
      • After fully explained of the condition, preoperative CCRT first followed by surgical treatment was suggested. We needs your expert experience for evaluation of CCRT. Thanks a lot !!
    • A
      • Dear doctor: This 51 year old man is a case of newly diagnosis rectal cancer, cT4aN2b , stage IIIc. We are consulted for total neoajuvant chemotherapy.
      • We will discuss with patient about total neoajuvant chemotherapy (CCRT followed by systemic chemotherapy 12-16 week) and then restaging for operation.
      • Please arrange port A insertion. Please check HBsAg, Anti HBc, AntiHBs, Anti HCV. Transfer to 11A or 10B on Dr

[radiotherapy]

[chemotherapy]

  • 2023-06-26 - [leucovorin 20mg/m2 30mg NS 250mL 10min + fluorouracil 400mg/m2 630mg NS 100mL 10min] D1-5 (CCRT)

==========

2023-07-12

The patient previously visited WanFang Hospital on 2023-06-02 for treatment of hemorrhoids and was given a 14-day supply of medication, which has now expired. As the patient did not report any problems related to his hemorrhoids at the time of his current admission, no concerns were identified during the medication reconciliation process.

2023-06-20

Continuing from the previous pharmacist note, confirm that Baraclude (entecavir 0.5 mg) 1# QDAC has been prescribed. There are no other medication-related problems at this time.

2023-06-16

Lab 2023-06-16 Anti-HBc positive. If immunosuppressive chemotherapy is to be used, it is advisable to use either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD as a precaution, at least during the course of chemotherapy. This would help protect against the potential reactivation of HBV infection by chemotherapy.

700067411

230711

[exam findings]

  • 2023-06-15 KUB
    • Radiopaque spots are noted at both renal region. Bilateral renal stones are considered.
    • There is no evidence of destructive bone lesion.
  • 2023-05-15 Uroflowmetry
    • Q max : fair
    • flow pattern : obstructive
  • 2023-05-15 Bladder sonography
    • PVR: 24 mL
  • 2023-05-06 CT - abdomen
    • Clinical history: 63 y/o male patient with peri-unbilical pain since 2 hours ago, nausea, no vomtiing. loose stool.
    • WITHOUT contrast enhancement CT of abdomen–whole:
      • Gallbladder stone with wall edema of gallbladder, r/o cholecystitis.
      • Bilateral renal stones.
      • Dilatation of right pelvicaliceal system with right upper ureteral wall thickening, may consider URS study.
    • Impression:
      • GB stones with gallbladder wall edema, r/o cholecystitis.
      • Bilateral renal stones.
      • Right hydronephrosis with upper ureteral wall thickening, suggest URS study.
  • 2023-05-06 CXR
    • Presence of ileus.
    • Presence of bil. renal stones.
  • 2023-05-06 KUB
    • Presence of bil. renal stones.
    • Intact bony structure(s).
  • 2023-02-10 Patho - salivary gland biopsy
    • Labeled as “right parotid”, needle biopsy — poorly differentiated carcinoma.
    • Section shows nests of round blue cells with abundant infiltration of lymphoid cells.
    • IHC stain of CK highlight irregular nests of CK (+) sheets which is also focal P40 (+), morphologically is similar to nasopharyngeal carcinoma.
  • 2023-02-09 PET
    • Glucose hypermetabolism involving the nasopharynx, compatible with primary nasopharyngeal malignancy.
    • Glucose hypermetabolism in bilateral retropharyngeal lymph nodes and in multiple neck lymph nodes in bilateral parotid areas, bilateral neck level II to III regions and left neck level IV region, suggesting metastatic lymph nodes.
    • Increased FDG accumulation in both kidneys and urethra. Physiological FDG accumulation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-02-08 ENT Hearing Test
    • Tymp:
      • RE type B; LE type Ad.
    • ART:
      • Bil absent.
    • PTA
      • Reliability FAIR
      • Average RE 73 dB HL; LE 36 dB HL.
      • RE normal to moderate SNHL.
      • LE moderate to profound mixed type HL.
  • 2023-02-07 MRI - nasopharynx
    • Indication: nasopharyngeal ccancer, for cancer work up
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • A right nasopharynx tumor, up to 3.7 cm, no obvious parapharyngeal or skull base invasion.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Multiple bilateral retropharyngeal and neck LAPs, with central necrosis, below the low border of cricoid cartilage at left.
      • Decreased right mastoid air cells pneumotization indicating chronic mastoiditis.
    • IMP: Right NPC with bil. neck LAPs. T1N3Mx stage IVA.
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:T1(T_value) N:N3(N_value) M:M0(M_value) STAGE:IVA (Stage_value)
  • 2023-02-06 ECG
    • Sinus rhythm with Premature supraventricular complexes
  • 2023-02-06 CXR
    • Borderline heart size. No mediastinal widening. Enlargement of right hilar region?
    • No active lung lesion. Intact bony thorax.
  • 2023-02-02 SONO - abdomen
    • Fatty liver, mild
    • Suspected GB stone
    • Suspected chronic renal parenchymal disorders, bil
    • Suspected renal cysts, bil
    • Suspected renal stones, bil
    • Pancreas not shown
    • Suboptimal examination of liver due to poor echo window
  • 2023-01-18 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopharynx, biopsy — Nasopharyngeal carcinoma, non-keratinizing and undifferentiated
    • Microscopically, section shows nasopharyngeal carcinoma characterized by diffuse sheets of non-keratinizing invasive carcinoma closely infiltrated by prominent lymphoplasmacytic cells. The tumor shows nclear hyperchromasia, high N/C ratio and mitotic figures.
    • Immunohistochemical stain reveals CK(+) for tumor cells.
  • 2023-01-18 Nasopharyngoscopy
    • Findings
      • smooth oropharynx, hypopharynx
      • yellowish mucopus over nasopharyngeal granular tumor
      • s/p submucosla turbinectomy,bil
    • Diagnosis, conclusion
      • Nasopharyngeal tumor, occupying bil choanae s/p biopsy

[consultation]

  • 2023-02-10 Radiation Oncology
    • A
      • Diagnosis: Nasopharyngeal cancer, nasopharyngeal carcinoma, non-keratinizing and undifferentiated, cT1N3M0, with bilateral neck and retropharyngeal LAP metastasis; 2.2-cm Rt parotid tumor s/p biopsy on 2023/2/10; ECOG =1.
      • Plan: After teeth treatment, CCRT to NPX tumor & LAPs (and parotid tumor) for 7140cGy/34 fx is suggested for tumor control. CT simulation will be arranged after teeth extraction. Possible treatment toxicity of radiotherapy (radiation dermatitis, mucositis, pharyngitis & esophagitis) is told.
  • 2023-02-08 Oral and Maxillofacial Surgery
    • Q
      • This is a 63 y/o male with history of HBV carrier
      • This time, he was admitted to our ward for Nasopharyngeal cancer survey. Under the impression of NPC, T1N3Mx, stage IVA, CCRT is indicated. We need your expertise on dental evaluation before radiotherapy.
    • A
      • This is a 63 y/o male with history of HBV carrier. This time, he was admitted due to nasopharynx carcinoma, cT1N3Mx, stage IVA and was scheduled for further CCRT. We were consulted for pre-RT dental evaluation.
      • O:
        • Panoramic findings:
          • Missing: 18,17,16,11,21,22,28,38-34,32-48
          • Impaction: Nil
          • Caries: 14,13,23,26,27
          • Crown and bridges: nil
          • Periodontal condition: Severe periodontitis
        • Full mouth severe periodontitis with advanced periodontal bone destruction was noted.
        • Multiple deep caries and residual roots was noted.
        • Poor oral hygiene.
      • P:
        • Explained the findings and treatment plan to the patient
        • Suggest extraction of all teeth including 15,14,13,12,23,24,25,26,27,33
        • Patient needed to consider.
        • If the patient needs a tooth extraction, please contact Dr. Xia’s clinic assistant to arrange the extraction time and prescribe prophylactic antibiotics. Thank you.

[chemotherapy]

  • 2023-07-10 - cisplatin 75mg/m2 100mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF Q4W, 5-FU 800mg/m2)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-07 - cisplatin 75mg/m2 100mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF Q4W, 5-FU 800mg/m2)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-11 - cisplatin 40mg/m2 70mg NS 500mL (Y-sited with NS 500mL) (CDDP QW)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-27
  • 2023-04-13
  • 2023-04-06
  • 2023-03-30
  • 2023-03-23
  • 2023-03-16
  • 2023-03-09
  • 2023-03-02

==========

2023-07-11

This patient just refilled a prescription for Harnalidge (tamsulosin) on 2023-07-06 for his benign prostatic hyperplasia with lower urinary tract symptoms. This drug has been included in the active medication list with no reconciliation issues identified.

700370136

230711

[exam findings]

  • 2023-05-24 Nasopharyngoscopy
    • Findings
      • Nose: no tumor lesion
      • Nasopharynx: smooth
      • Oropharynx: no tumor lesion, mucosa erythema
      • Larynx: left vocal fixation
      • Hypopharynx: left hypopharygeal tumor with left vocal fixation, some ulcer
      • airway patent
    • Diagnosis/Conclusion:
      • Left hypopharynx SqCC, T4aN2bM0. Stage IVA under induction C/T
      • Gr II mucositis
  • 2023-05-16 ENT hearing test
    • PTA
    • Reliability FAIR
    • Average RE 23 dB HL; LE 33 dB HL.
      • RE normal to moderate SNHL
      • LE normal to moderately severe SNHL
  • 2023-05-03 Nasopharyngoscopy
    • Findings
      • Nose: no tumor lesion,
      • Nasopharynx: smooth
      • Oropharynx: no tumor lesion
      • Larynx: no tumor lesion, bilateral vocal movement: left vocal cord fixation
      • Airway patent currently
      • Hypopharynx: left hypopharyngeal tumor
    • Diagnosis/Conclusion
      • hypopharyngeal SqCC cT4aN2bM0
      • Airway patent currently
  • 2023-04-28 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, mandible, upper C-spine, some L-spines, bilateral shoulders, hips, knees and feet in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the upper C-spine and some L-spines. Degenerative change may show this picture.
      • Increased activity in the maxilla and mandible. Dental problem may show this picture.
      • Increased activity in bilateral shoulders, hips, knees and feet, compatible with benign joint lesions.
      • No definite evidence of bone metastasis.
  • 2023-04-28 SONO - abdomen
    • Liver calcification, S5/8
    • Gallbladder polyp
  • 2023-04-28 Patho - larynx biopsy
    • Labeled as “left hypopharyngeal tumor”, biopsy — squamous cell carcinoma.
    • Section shows squamous cell carcinoma.
    • IHC stain: p16 (-).
  • 2023-04-17 ECG
    • Right bundle branch block
    • Inferior infarct, age undetermined
  • 2023-04-10 CT - neck
    • Head and Neck CT with and without IV contrast administration shows:
      • A left hypopharynx tumor mass, up to 38 mm in length, with thyroid cartilage invasion.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Multiple enlarged necrotic left neck LNs.
    • IMP: Left hypopharynx CA, T4AN2BMX, Stage IVA.
    • Imaging Report Form for Hypopharynx Carcinoma
      • Impression (Imaging stage) : T: 4A(T_value) N: N2B(N_value) M: M0(M_value) STAGE: IVA (Stage_value)
  • 2023-04-06 Nasopharyngoscopy
    • left hypopharyngeal tumor with left vocal fixation, suspect malignancy
  • 2018-02-05 Bladder sonography
    • bladder volume: 27.1 CC
  • 2018-01-15 Post Void Residual, PVR
    • acceptable PVR: 15.99 CC
  • 2017-09-28 Pure Tone Audiometry, PTA
    • R’t mild SNHL
    • L’t mild to moderately severe MHL

[MedRec]

  • 2023-05-04 SOAP Hemato-Oncology
    • A/P
      • Already discussion with patient regarding the options:
        • OP -> first option
        • Induction C/T -> OP
        • CCRT -> OP
      • After discussion with patient favor neoadjuvant chemtoehrapy
      • Admission for 24 hours CCr, audiometry, TPF
  • 2023-05-03 SOAP Ear Nose and Throat
    • S
      • patient asked for organ preservation
      • refer to oncologist for induction CCRT
    • O
      • finish staging.
      • left hypopharynx SqCC, T4aN2bM0.
  • 2023-01-12 SOAP Metabolism and Endocrinology
    • O
      • 2023/01/03 Cholesterol total = 245 mg/dL;
      • 2023/01/03 LDL-C = 147 mg/dL;
      • 2023/01/03 Triglyceride (TG) = 217 mg/dL;
    • A/P
      • reinforce compliance to medication
      • reinforce diet control
      • SMBP (self-measured blood pressure monitoring)
      • 3m
    • Diagnosis
      • Nontoxic goiter, unspecified E04.9
      • Hyperlipidemia, unspecified E78.5
      • Essential (primary) hypertension I10
      • Impaired fasting glucose R73.01
    • Prescription
      • Crestor (rosuvastatin 10mg) 1# QD
      • Diovan (valsartan 160mg) 0.5# QD
      • Suwell (aluminum hydroxide 200mg, magnesium hydroxide 200mg, simethicone 25mg) 1# QD
      • Norvasc (amlodipine 5mg) 2# QD
      • Lipanthyl (fenofibrate 160mg) 1# QD

[chemotherapy]

  • 2023-07-10 - docetaxel 75mg/m2 140mg NS 250mL 1hr D1 + cisplatin 75mg/m2 150mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) D3 + furosemide 20mg NS 30mL 10min (after CDDP) D3 + 1000mg/m2 2000mg NS 500mL D2-5
    • dexamethasone 4mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg D2-4
  • 2023-06-12 - docetaxel 75mg/m2 140mg NS 250mL 1hr D1 + cisplatin 75mg/m2 150mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) D3 + furosemide 20mg NS 30mL 10min (after CDDP) D3 + 1000mg/m2 2000mg NS 500mL D2-5
    • dexamethasone 4mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg D2-4
  • 2023-05-17 - docetaxel 75mg/m2 140mg NS 250mL 1hr D1 + cisplatin 75mg/m2 150mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) D3 + furosemide 20mg NS 30mL 10min (after CDDP) D3 + 1000mg/m2 2000mg NS 500mL D2-5
    • dexamethasone 4mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg D2-4

==========

2023-07-11

Our otorhinolaryngologist prescribed a regimen on 2023-07-05 that included Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), Shitan (bromhexine), Acetal (acetaminophen), Ulstop (famotidine), and Nincort Oral Gel (triamcinolone). Additionally, our endocrinologist provided prescriptions for Crestor (rosuvastatin), Diovan (valsartan), Suwell (aluminum hydroxide, magnesium hydroxide, simethicone), Bokey (aspirin), Norvasc (amlodipine), and Lipanthyl (fenofibrate) on 2023-06-29. All these medications are currently present on the patient’s active medication list, with no detected issues relating to medication reconciliation.

2023-06-13

  • Our otorhinolaryngologist issued a prescription on 2023-06-07, which included Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), Broen-C (bromelain, L-cysteine), Tramacet (tramadol, acetaminophen), and Nincort Oral Gel (triamcinolone) to address the patient’s ENT symptoms. The prescription was given a 14-day duration and is currently still valid. However, none of these drugs appear on the active medication list. Please verify if the related symptoms have resolved, which would explain the absence of these medications from the active list. Thank you!

  • Laboratory data show that the patient experienced an episode of leukopenia with a WBC count of 2.39K/uL on 2023-05-24, one week after starting his 1st dose of the current treatment regimen on 2023-05-17. Granocyte (lenograstim 250ug) was administered for 3 consecutive days (from 2023-05-24 to 2023-05-26) to increase the WBC count. The 2nd administration of the regimen began on 2023-06-12, maintaining the same dose level as the first cycle. Therefore, a similar incidence of leukopenia might be expected and prophylactic use of G-CSF may be considered to mitigate this potential risk.

    • 2023-06-12 WBC 7.44 x10^3/uL
    • 2023-06-01 WBC 7.14 x10^3/uL
    • 2023-05-24 WBC 2.39 x10^3/uL
    • 2023-05-16 WBC 6.75 x10^3/uL
    • 2023-05-04 WBC 7.63 x10^3/uL
    • 2023-04-17 WBC 7.96 x10^3/uL

700370264

230711

{Recurrent hepatocellular carcinoma with lung metastasis, rycT3N0M1, stage IVB}

[diagnosis] - 2022-11-19 admission note

  • Encounter for antineoplastic chemotherapy
  • Liver cell carcinoma
  • Secondary malignant neoplasm of unspecified lung
  • Malignant neoplasm of pancreas, unspecified
  • Encounter for antineoplastic immunotherapy
  • Mild intermittent asthma, uncomplicated

[past history] - 2022-11-19 admission note

  • Chronic hepatitis
  • Frequent acute pancreatitis episodes in 2006, 2007, 2008, 2014/03/05 and 2014/09/30,
  • Pancreatic intraductal papillary mucinous carcinoma, invasive pStage (pT1N0M0) s/p PPPD in 2014
  • HCC s/p S8 segmentectomy on 2016/06/30, pT2Nx(cMx), stage II.
  • Post S8 segmentectomy with liver abscesss/p pig-tail drainage on 2016/07/12, discharged on 2016/07/20.
  • Hepatocellular carcinoma, recurrent (S2-3 and S7) rpT3bNx(cMx) stage IIIb s/p S2-3 hepatectomy and S7 partial hepatectomy on 2016/10/03. Keep Target therapy (Nexavar) side effect management since 2016/10/23-10/26. Post operation, liver abscess again s/p pig-tail insertion on 2016/11/02.
  • Recurrent hepatocellular carcinoma, s/p TACE on 2017/08/08 and 2020/09/29, s/p S7 partial hepatectomy, adhesivelysis with bowel repair, and diaphragm resection with repair by chest surgeon on 2020/11/16; recurrent HCC s/p TACE on 2021/09/14, 2021/12/30, 2022/03/23 and immunotherapy with Nivolumab on 2021/09/08, 2021/10/08, 2021/12/07, 2021/12/31, 2022/01/24, 2022/03/23.     

[exam findings]

  • 2023-05-29 CT - abdomen
    • History and indication: Recurrent hepatocellular carcinoma with lung metastasis
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P liver operation and TACE. Liver cirrhosis with portal hypertension and splenomegaly. A nodule (9.4mm) at RUL.
      • Some fluid collection in right subphrenic region.
      • Old fracture of right rib. R/O an osteolytic lesion at T11.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P liver operation and TACE. Liver cirrhosis with portal hypertension and splenomegaly. A nodule (9.4mm) at RUL.
      • R/O an osteolytic lesion at T11.
  • 2023-05-25 ECG
    • Normal sinus rhythm
    • Right bundle branch block
  • 2023-05-08, -04-07, -03-20, -03-13, -03-01 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Peri-bronchial wall thickening of the right lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2023-03-13 SONO - chest
    • No pleural effusion but right pleural thickening.
  • 2023-03-11 CT - abdomen
    • Clinical history: 58 y/o male patient with fever and chills, SOB.
    • With and without contrast enhancement CT of abdomen
      • Focal loculated fluid (4x1.8cm) in right subphirenic region.
      • Segmental wall edema of S-colon.
      • Uneven surface of liver parenchyma, suggesting liver cirrhosis.
      • Post-op at the liver and pancrease.
      • Presence of splenomegaly.
      • No enlarged lymph node in the paraaortic region.
      • Consolidation in right lower lung and pleural effusion.
      • Bilateral lung nodules, stationary.
    • Impression:
      • Focal loculated fluidin right subphirenic region. Stationary as compare with CT study on 2023-02-10.
      • Post-op at the liver.
      • Liver cirrhosis and splenomegaly.
      • Segmental wall edema of S-colon.
      • Consolidation in RLL. Bilateral lung metastasis, stationary.
  • 2023-03-11 ECG
    • Sinus tachycardia
    • Right bundle branch block
  • 2023-03-09 Bladder Sonography
    • PVR 7.94mL
  • 2023-03-09 Uroflowmetry
    • Q max: fair
    • flow pattern: obstructive
  • 2023-03-03 Abdomen - standing (diaphragm)
    • Fecal material store in the colon.
    • splenomegaly.
    • Left hemi-diaphragm elevation is noted, which may be due to eventration or splenomegaly.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2023-02-25 Uroflowmetry
    • Q max: low
    • flow pattern: obstructive
  • 2023-02-25 Bladder sonography
    • PVR 21 mL
  • 2023-02-10 CT - chest
    • Indication: Liver cell carcinoma
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Consolidation over right lower lobe is found.
        • Nodular lesion at right upper lobe and left upper lobe is found. In comparison with CT dated on 2022-11-23, the lesions are regressed slightly.
        • Some lymph nodes are found at paratracheal and subcarina region.
        • Mild bilateral pleural effusion is found.
      • Visible abdomen:
        • Splenomegaly and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
        • s/p partial pancreatectomy.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • The portal vein and IVC are patent.
        • No evidence of abnormal soft tissue mass at pelvic cavity.
        • No definite inguinal or pelvic sidewall LAP
        • Minimal ascites is found.
    • IMp:
      • Liver cirrhosis with splenomegaly
      • Bilateral lung meta. In regression.
      • mediastinal lymphadenopathy. Stable.
  • 2023-02-08 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-01-03 Bronchodilator Test
    • FEV1/FVC= 87%, FVC 51%, FEV1 56%
  • 2022-12-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (62 - 11) / 62 = 82.26%
      • M-mode (Teichholz) = 83
    • Normal LV filling pressure and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Trivial TR.
  • 2022-11-23 CT - chest
    • HCC with lung mets dyspnea
    • multiple lung metastases, seem stationary, and newly extensive lung infecion with hyperplastic mediastinal LAP r/o metastatic LAP as compared with CT on 2022/09/14
  • 2022-11-22 SONO - abdomen
    • Chronic liver parenchymal disease
    • Hepatic tumor, rule out hemangioma
    • Post left lobectomy of liver
    • Post choleystectomy
    • Fluid collection, right subphrenic region
    • Splenomeglay, mild
  • 2022-11-19 KUB
    • S/P clips projecting at right lobe liver.
    • S/P metalic autosuture at left middle abdomen.
    • Fecal material store in the colon.
  • 2022-09-14 CT - chest
    • multiple lung metastases, with significant in regression as compared with CT on 2022/06/15 s/p C/T.
  • 2022-06-15 CT - abdomen, pelvis
    • Findings:
      • Prior CT identified mutiple HCCs (> 10 lesions) in right hepatic lobe S/P TACE and Nivolumab are noted again, decreasing in size that are c/w HCCs S/P TACE and Nivolumab with partial response.
      • Prior CT identified multiple lung metastases are noted again, decreasing in size that is c/w lung metastases S/P Nivolumab with partial response.
      • S/P surgical enucleation of S7 HCC.
        • S/P cholecystectomy, Whipple operation, and left lateral segmentectomy and partial resection of S4/7/8 of the liver.
      • There is a osteolytic lesion in T11 vertebral body that may be bony metastasis.
      • There is no focal abnormality in the biliary system, spleen & both kidney.
      • There is no ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
      • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Multiple HCCs in right hepatic lobe S/P TACE and Nivolumab show partial response.
      • Multiple lung metastases S/P Nivolumab show partial response.
      • Bony metastasis in T11 vertebral body is suspected. Please correlate with bone scan.
  • 2022-05-18 CXR
    • S/P Port-A infusion catheter insertion.
    • Multiple nodules at bil. lungs.
    • HCCs s/p TACE.
  • 2022-05-06 CT - liver, spleen, biliary duct, pancreas
    • Three recurrent HCCs in right hepatic lobe show stable in size. However, Several newly-developed recurrent HCCs in the right lobe liver are noted.
    • Multiple lung metastases show mild increasing in size.
  • 2022-03-11 CT - liver, spleen, biliary duct, pancreas
    • Three recurrent HCCs in right hepatic lobe show mild increasing in size.
    • Multiple lung metastases show stable disease.
  • 2021-12-29 CT - liver, spleen, biliary duct, pancreas
    • Three recurrent HCCs in right hepatic lobe are noted.
    • Multiple lung metastases show progressive disease.
  • 2021-09-01 CT - liver, spleen, biliary duct, pancreas
    • Two recurrent HCCs 1.4 x 1.1 cm and 1.4 x 1.2 cm in right hepatic lobe are highly suspected.
    • Multiple lung metastases are highly suspected.
  • 2021-06-01 SONO - abdomen
    • S/P surgical enucleation of S7, left lateral segmentectomy and partial resection of S4/7/8 of the liver.
    • S/P cholecystectomy and Whipple operation.
  • 2021-02-19 CT - liver, spleen, biliary duct, pancreas
    • S/P surgical enucleation of S7 HCC.
    • There is no evidence of tumor recurrence.
  • 2020-11-17 Patho - liver partial resection
    • pathologic diagnosis
      • Liver, segment 7, partial hepatectomy — Hepatocellular carcinoma
      • Pathologic Staging (AJCC) — rypT4 (if cN0 and cM0), stage IIIB
      • R’t diaphragm, frozen section (F2020-00457) — Tumor invasion
    • microscopic examination
      • Histologic Type: Hepatocellular carcinoma
      • Histologic Grade: G3, poorly differentiated
      • Cytological grade: III
      • Tumor necrosis: Present
      • Inflammatory cell infiltration: Mild
      • Tumor capsule: incomplete with capsular invasion
      • Satellite nodule: present
      • Venous (Large Vessel) Invasion: Absent
      • Portal Vein Thrombosis: (-), Capsular vein invasion: (-)
      • Perineural Invasion: Absent
      • Bile duct Invasion: Absent
      • Pathologic Staging (pTNM): Stage IIIB (pT4)
      • Margins
        • Parenchymal Margin: Free, 0.8 cm from closest margin
        • Hepatic capsule: involved by invasive carcinoma
      • Additional Pathologic Findings: clear cell change and fibrosis
      • Hepatitis (specify type): unknown (by medical record)
      • Ishak modified HAI grading: Necroinflammatory Scores 2
      • Ishak staging: 3 (occasional bridging)
      • Fatty change: focal and mild
      • Immunohistochemistry (F2020-00457): Arginase(+, focal), hepa-1(+, scant) for tumor cells
  • 2020-11-16 Frozen resction
    • Diaphragm, right, frozen section — Tumor invasion
    • Margins — Tumor present at muscle side, other margins are free
  • 2020-10-27 MRI - liver, spleen
    • HCC s/p operation. A biloma (2.6cm) at left liver margin. Right HCC s/p TACE with stable size (2.3cm).
    • Liver cirrhosis with splenomegaly.
  • 2020-09-18 CT - liver, spleen, biliary duct, pancreas
    • A newly-developed HCC 2.3 cm in S7 of the liver is suspected. please correlate with AFP, sonography, or MRI.
  • 2020-06-26 SONO - abdomen for follow-up
    • S/P surgical resection S2. S3, S4, and S7, and cholecystectomy.
  • 2020-04-02 SONO - abdomen for follow-up
    • S/P left hepatic lobe operation and cholecystectomy.
  • 2020-01-10 CT - liver, spleen, biliary duct
    • S/P cholecystectomy, Whipple operation, left lateral segmentectomy and partial resection of S4/7/8 of the liver.
    • There is no evidence of tumor recurrence.
  • 2019-10-29 SONO - abdomen for follow-up
    • S/P surgical resection S2. S3, S4, and S7, and cholecystectomy.
  • 2019-07-31 CT - liver, spleen, biliary duct
    • Liver cirrhosis
    • HCC s/p op. and TACE without evidence of tumor recurrence.
  • 2019-05-06 SONO - abdomen for follow-up
    • Hepatic fibrocalcified lesion
    • Parenchymal liver disease
    • Status post cholecystectomy, left lateral segmentectomy, and partial resection of S4/7/8
    • Mild splenomegaly
  • 2019-02-12 CT - liver, spleen, biliary duct
    • S/P cholecystectomy, Whipple operation, left lateral segmentectomy and partial resection of S4/7/8 of the liver.
    • There is no evidence of tumor recurrence.
  • 2018-11-01 SONO - abdomen
    • diagnosis
      • Suspected chronic liver parenchyma disease (Please correlate with liver function)
      • S/p left lobectomy
      • S/p cholecystectomy
      • Pancreas not shown
    • suggestion
      • OPD f/u
      • Follow liver function test and AFP
  • 2018-07-10 CT - liver, spleen, biliary duct
    • s/p op. and TACE with radiopaque materials in the rest of the liver.
    • Lobulated appearance of the liver is found. No significant abnormal enhancement is found but lobulated nodule at dome up to 4.6cm is found. suspected regereration nodule. In comparison with CT dated on 2017-10-27, the lesion is stationary.
  • 2018-04-09 SONO - abdomen
    • Liver cirrhosis with mild splenomegaly
    • Compatible with HCC s/p resection
  • 2018-02-06 CT - liver, spleen, biliary duct
    • S/P operation and TACE with minimal viable tumors.
  • 2018-01-04 CT - lung/pleura (chest and upper abdomen)
    • Loculated Rt subphrenic fluid collection and diaphgramatic pleural effsuion, post op change or infection fluid collections.
    • No lung lesion.
  • 2018-01-03 Echo - chest
    • Echo diagnosis:
      • Pleural thickening, right CP angle
      • No pleural effusion
      • Consolidation, minimal, RLL
    • Comment:
      • Arrange abdominal echoi, AFP recheck and abdominal/lung CT may be indicated also
  • 2017-12-15 SONO - hepatobiliary
    • S/P operation. Mild liver cirrhosis.
    • A hypoechoic lesion (1.92x2.51cm) at left hepatic lobe.
    • S/P cholecystectomy.
    • Mild splenomegaly.
    • A hypoechoic lesion (2.21x3.95cm) at left kidney.
  • 2017-10-27 CT - liver, spleen, biliary duct
    • Post-op and S/P TACE for HCCs, with decreased liver size and some defects, could be due to some viable tumors, suggest further treatment.
  • 2017-07-28 CT - liver, spleen, biliary duct
    • HCC and pancreas tumor, s/p operation
    • suspected recurrent HCCs
    • suspected peritoneal seeding
  • 2017-05-02 SONO - abdomen
    • Chronic liver parenchymal disease
    • Post operation change
    • Focal liver lesion, S6, possible tumor or previous abscess in regression.
    • Post cholecystectectomy
  • 2017-02-07 CT - liver, spleen, biliary duct
    • S/P operation. No evidence of tumor recurrence.

[MedRec]

  • 2023-07-06 MultiTeam - Palliative Care
    • Palliative Care Multidisciplinary Recommendation
    • Referral Date: 2023-07-05
    • Response Content:
      • The patient has cancer with distant metastasis and is still undergoing treatment. The original medical team referred the case to the palliative care team due to the patient’s flu and slight breathlessness. However, when the palliative care nurse and Dr. Xia visited together, the patient seemed a bit startled. The nurse explained that this is a routine referral for cancer patients to enhance the understanding of palliative care, to advocate against emergency resuscitation, and to complete a pre-established palliative care wish form. The patient seemed more relaxed and indicated that he understands the concept of palliative care and is inclined to forego emergency resuscitation. The nurse explained that if the patient does not fill out the form, it will be completed by the family. The patient said he would discuss it with his wife. The patient himself agreed to palliative co-care and to befriend the care team first.
    • Conclusion and Recommendation: Co-management with palliative care
    • Respondent: Yu XiuHong
    • Response Date: 2023-07-05 19:03

[consultation]

  • 2023-07-05 Family Medicine
    • Q
      • A 58 years old man is a patient of pancreatic intraductal papillary mucinous carcinoma and hepatocellular carcinoma with bilateral lung metastasis and bone T11 metastasis, he was admitted under the impression of influenza A in this time, we need your help in planning future medical care due to terminal cancer, thank you
    • A
      • A 58 years old male had history of pancreatic intraductal papillary mucinous carcinoma and hepatocellular carcinoma with bilateral lung metastasis and bone T11 metastasis.
        • He was admitted for influenza A.
        • con’:E4V5M6
        • ECOG:1
      • We will arrange hospice combine care and follow up his condition.
      • Patient said he will discussed with his wife and other family.
      • Indication: pancreatic cancer, HCC with lung and bone metastasis.
      • Plan: hospice combined care
  • 2023-05-30 Radiation Oncology
    • Q
      • The consultation is for T11 bone lesion radiotherapy evaluation.
      • Brief history: This was a 58 yr case of HCC with lung mets post partial hepaectomy and TACE; first diagnosed in 2016, then recurrent several times after. The patient was now on palliative chemotherapy with FOLFOX and Nivolumab.
      • This time he was admitted for unspecific origin fever; we treated with Brosym, no fever was detected during admission and CRP today was 2.7.
      • However, in the follow up ABD CT on 20230529, we found a osteolytic lesion in T11, may paralleled with the patient’s complaint about back pain.
      • We would love to have your consultation for radiotherapy
    • A
      • The ABD CT on 2023/5/29 showed a osteolytic lesion in T11. However, he said he had no backpain for now. Only his Rt flank pain was mentioned. Tracing back the previous CTs, the spine T11 metastatic lesion was first shown on Abd. CT on 2021/09/01. After long period of palliative systemic treatment, the T11 lesion has been under control and the re-ossification can be observed on recent CT images. Therefore, immediate RT to the T11 might not be indicated for now. If new back pain develops, palliative RT might be considered by then. Thank you very much.
  • 2022-11-25 Chest Medicine
    • Q
      • The 58 y/o man has HCC with lung metastasis. Due to pneumonia with green like sputum, so he received antibiotics as Tapimycin and Targocid for infection control. Today, his SOB in progress and CXR showed right lung space decrease. We need your help for assessment. Thanks!
    • A
      • We were consulted for PN progression.
      • PE
        • E4V5M6, clear cons, shallow/rapid respiratory pattern with accessory muscle use
        • SpO2 > 95% under NRM full, no wheezing
        • much greenish/sticky sputum formation
      • ABG(2022/11/22)
        • PH 7.4/PCO2 39.9/PO2 163/HCO3 24.3/SpO2 99, FiO2 100%
        • PF ratio 163
      • Chest CT (2022/11/23)
        • lobar consolidation with air-bronchograms over both lower lobes and extensive consolidation over RML.
        • stationary of metastatic nodules in both lungs as compared with previous CT on 9/14
      • Impression
        • Bilateral pneumonia, impending hypoxic respiratory failure
        • Recurrent HCC with lung metastasis
      • Suggestion
        • May adjusted antibiotic treatment according to clinical condition and Sp/C reports
        • May check atypical pneumonia pathogen and TB/C*3
        • keep O2 support, if hemodynamic unstable or conscious change due to hydercapnia or hypoxia, ETT intubation is indicated
        • Chest care, percussion, and suction frequently
        • Treat underlying disease as your expertise
  • 2020-11-17 Thoracic Surgery
    • Q
      • for diaphragm repair
      • This 56-year-old man had past histories of
        • Chronic hepatitis
        • Frequent acute pancreatitis episodes in 2006, 2007, 2008, 2014/03/05 and 2014/09/30,
        • Pancreatic intraductal papillary mucinous carcinoma, invasive pStage(pT1N0M0)s/p PPPD in 2014
        • HCC s/p S8 segmentectomy on 2016/06/30, pT2Nx(cMx), stage II.
        • Post S8 segmentectomy with liver abscesss/p pig-tail drainage on 2016/07/12, discharged on 2016/07/20.
        • Hepatocellular carcinoma, recurrent (S2-3 and S7) rpT3bNx(cMx) stage IIIb s/p op on 2016/10/03 discharge on 2016/10/08.
        • Hepatocellular carcinoma, recurrent (S2-3 and S7) rpT3bNx(cMx) stage IIIb s/p op on 2016/10/03. with Target therapy (Nexavar) side effect management since 2016/10/23 ~ 2016/10/26.
        • Post Hepatocellular carcinoma, recurrent (S2-3 and S7)rpT3bNx(cMx) stage IIIb operation, liver abscess again s/p pig-tail insertion on 2016/11/02.
      • This time, abdomen CT on 2020/09/18 which revealed a newly-developed HCC 2.3 cm in S7 of the liver is suspected. AFP on 2020/09/18 showed 10.3ng/mL was noted. TACE was performed on 2020/09/29. Liver MRI was performed on 2020/10/27 which revealed a biloma (2.6cm) at left liver margin. Right HCC s/p TACE with stable size (2.3cm). This time, he was admitted for S7 resection today. We need your help for combine surgery for diaphragm repair. Thanks for your help!!
    • A
      • I have performed diaphragm repair for this patient. Thanks for your consultaiton!

[surgical operation]

  • 2020-11-16
    • Surgery
      • Diaphragm repair
    • Finding
      • HCC invasion to right diaphragm.
    • Procedure
      • Under GA, the patient was put in supine position. We was consulted for suspected tumor invasion to diaphram. Elliptical incision was made for involving area of diaphragm with electrocautery. Pneumolysis was performed for underlying lung parechyma. The resected diraphgram was sent for frozen section. The margin showed negative to malignancy. The residual diaphragm was repaired with No.2 silk with vertical matress suture. Then, GS Dr. Wu took over for following procedure.
  • 2020-11-16
    • Surgery
      • S7 paritla hepatectomy
      • adhesivelysis with bowel repair
      • diaphragm resection with repair by chest surgeon
      • IOE
    • Finding
      • IOE revealed 1.8 x 1.8cm hypereechoic tumor at S7
      • tumor direct invadion to right diaphragm
      • severe intraabdominal adhesion
      • chronic abscess at previous resection space
    • Procedure
      • ETGA
      • midline extended to right subcostal laparotmy
      • adhesivelysis with small bowel repair
      • IOE
      • S7 partial resection
      • diaphragm partial resection with repair by chest surgeon
      • tow J-vac inserted
      • wound closed

[embolization]

  • 2022-05-17 Embolization (TAE) - abdomen for tumor
  • 2022-03-23 Embolization (TAE) - abdomen for tumor
  • 2021-12-30 Embolization (TAE) - abdomen for tumor
  • 2021-09-14 Embolization (TAE) - abdomen for tumor
  • 2020-09-29 Embolization (TAE) - abdomen for tumor
  • 2017-08-08 Embolization (TAE) - abdomen for tumor

[chemoimmunotherapy]

  • 2023-07-10 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 200mg/m2 350mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 700mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1050mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-06-12 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 200mg/m2 360mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 730mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1095mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-08 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 710mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 710mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1065mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-07 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 710mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 710mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1065mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-01 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 690mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 690mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1035mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-08 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 675mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 670mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1035mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-02 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 700mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1000mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-06 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 700mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1000mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-09-05 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 670mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1000mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-08-08 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 660mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 990mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-07-05 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + leucovorin 200mg/m2 330mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 660mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 990mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-06-07 - nivolumab 3mg/kg 100mg NS 100mL 60min + oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + leucovorin 200mg/m2 330mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 660mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 1000mg NS 500mL 22hr D1-2 (nivo + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-03-23 - nivolumab 3mg/kg 100mg 1hr
  • 2022-01-24 - nivolumab 3mg/kg 100mg 1hr
  • 2021-12-30 - nivolumab 3mg/kg 100mg 1hr
  • 2021-12-07 - nivolumab 3mg/kg 100mg 1hr
  • 2021-11-09 - nivolumab 3mg/kg 100mg 1hr
  • 2021-10-05 - nivolumab 3mg/kg 100mg 1hr
  • 2021-12-31 ~ 2022-08-19 - Stivarga (regorafenib 40mg/tab) 4# QD (hand foot syndrome due to stivarga side effect?)
  • 2017-10-06 ~ 2018-01-16 - Nexavar (sorafenib 200mg/tab) 1# BIDAC

[note]

Chemotherapy for advanced or metastatic disease treatment regimen listed in in-hospital “Revised Edition of Chemotherapy Prescription Collection for Liver Cancer” version 2022-03-01

  • FOLFOX4
    • Oxaliplatin 85 mg/m2 I.V D1
    • Leucovorin 200 mg/m2 I.V 2 hrs D1 & D2
    • 5-FU 400 mg/m2, I.V bolus D1 & D2
    • 5-FU 600 mg/m2, I.V 22 hrs D1 & D2
    • Every 2 weeks
    • References: Qin S et al, J Clin Oncol. 2013;31:3501-3508

Principles of Systemic Therapy - NCCN Clinical Practice Guidelines in Oncology - Hepatocellular Carcinoma - Version 1.2023 - 2023-03-10 - HCC-G 1 of 2, p23

  • First-Line Systemic Therapy
    • Preferred Regimens
      • Atezolizumab + bevacizumab (Child-Pugh Class A only) (category 1)
      • Tremelimumab-actl + durvalumab (category 1)
    • Other Recommended Regimens
      • Sorafenib (Child-Pugh Class A [category 1] or B7)
      • Lenvatinib (Child-Pugh Class A only) (category 1)
      • Durvalumab (category 1)
      • Pembrolizumab (category 2B)
    • Useful in Certain Circumstances
      • Nivolumab (Child-Pugh Class B only)
      • Atezolizumab + bevacizumab (Child-Pugh Class B only)
      • For TMB-H tumors:
        • Nivolumab + ipilimumab (category 2B)
  • Subsequent-Line Systemic Therapy if Disease Progression
    • Preferred Regimens
      • Regorafenib (Child-Pugh Class A only) (category 1)
      • Cabozantinib (Child-Pugh Class A only) (category 1)
      • Lenvatinib (Child-Pugh Class A only)
      • Sorafenib (Child-Pugh Class A or B7)
    • Other Recommended Regimens
      • Nivolumab + ipilimumab (Child-Pugh Class A only)
      • Pembrolizumab (Child-Pugh Class A only)
    • Useful in Certain Circumstances
      • Ramucirumab (AFP >=400 ng/mL and Child-Pugh Class A only) (category 1)
      • Nivolumab (Child-Pugh Class B only)
      • For MSI-H/dMMR tumors
        • Dostarlimab-gxly (category 2B)
      • For RET gene fusion-positive tumors:
        • Selpercatinib (category 2B)
      • For TMB-H tumors:
        • Nivolumab + ipilimumab (category 2B)

Nivolumab: Drug information 2023-03-02 https://www.uptodate.com/contents/nivolumab-drug-information

  • Dosing: Adult
    • Hepatocellular carcinoma
      • Hepatocellular carcinoma: IV: 1 mg/kg once every 3 weeks (in combination with ipilimumab) for 4 combination doses, followed by 240 mg once every 2 weeks (Yau 2020) or 480 mg once every 4 weeks (nivolumab monotherapy) until disease progression or unacceptable toxicity.

Regorafenib: Drug information 2023-03-02 https://www.uptodate.com/contents/regorafenib-drug-information

  • Dosing: Adult
    • Hepatocellular carcinoma
      • Hepatocellular carcinoma: Oral: 160 mg once daily for the first 21 days of a 28-day cycle; continue until disease progression or unacceptable toxicity (Bruix 2017).
  • Dosing: Adjustment for Toxicity: Adult
    • If dose reduction is necessary, reduce in 40 mg increments; the lowest recommended dose is 80 mg/day.
      • Dermatologic:
        • Grade 2 hand-foot skin reaction (HFSR; palmar-plantar erythrodysesthesia syndrome [PPES]) of any duration: Reduce dose to 120 mg once daily for first occurrence. If grade 2 HFSR recurs at this dose, further reduce the dose to 80 mg once daily. Interrupt therapy for grade 2 HFSR that is recurrent or fails to improve within 7 days in spite of dosage reduction.
        • Grade 3 HFSR: Interrupt therapy for a minimum of 7 days. Upon recovery, reduce dose to 120 mg once daily. If grade 2 to 3 toxicity recurs at this dose, further reduce dose to 80 mg once daily upon recovery. Interrupt therapy for grade 2 to 3 HFSR that is recurrent or fails to improve within 7 days in spite of dosage reduction.
        • Recurrent or persistent HFSR at 80 mg once daily: Discontinue treatment.
        • Other dermatologic toxicity: Withhold treatment, reduce dose or permanently discontinue treatment depending on the severity and persistence of the dermatologic toxicity. Symptomatic relief may be managed with supportive measures.
      • Hypertension: Grade 2 (symptomatic): Interrupt therapy.
      • Infection: Grade 3 or 4 (or worsening infection of any grade): Interrupt therapy; resume regorafenib at the same dose following infection resolution.
      • Other toxicity: Any grade 3 or 4 adverse reaction (other than hepatotoxicity or infection): Interrupt therapy; upon recovery, reduce dose to 120 mg once daily (except infection). If any grade 3 or 4 adverse reaction occurs (other than hepatotoxicity or infection) while on this reduced dose, may further reduce dose to 80 mg once daily upon recovery. For any grade 4 adverse reaction, only resume therapy if the benefit outweighs the risk. Permanently discontinue therapy if unable to tolerate 80 mg once daily.
      • Gastrointestinal perforation/fistula: Discontinue permanently.
      • Hemorrhage (severe or life-threatening): Discontinue permanently.
      • Reversible posterior leukoencephalopathy syndrome (RPLS): Discontinue.
      • Dosage adjustment for surgery: Temporarily withhold regorafenib at least 2 weeks prior to elective surgery; do not administer regorafenib for at least 2 weeks following major surgery and until adequate wound healing.

==========

2023-07-11

Our gastroenterologist prescribed a multiple refill prescription for Baraclude (entecavir) on 2023-06-26, which the patient is using for prophylaxis of his HBV reactivation. This medication is included in the patient’s active medication list as a patient-carried item and no reconciliation issue has been identified.

2023-06-13

  • This patient relies only on our hospital for his medical need on liver cell carcinoma, no other healthcare providers found in the PharmaCloud database, no medication reconciliation issues identified.

  • The dosage of FOLFOX4 administered to this patient during this current treatment cycle has been adjusted in accordance with our in-hospital guidelines outlined in the “Revised Edition of Chemotherapy Prescription Collection for Liver Cancer, version 2023-03-01.” No issues have been identified with this adjustment.

  • The lab data show a fluctuation in the tumor marker AFP levels, which initially decreased (2022 Q2 to Q3), troughed around 2022 Q3/Q4, and then increased after 2022Q4. This pattern suggests that the “nivolumab + FOLFOX4” regimen, administered monthly since 2022-06, might have become less effective after approximately a year of treatment, indicating potential disease resistance.

    • 2023-06-12 AFP 23.6 ng/mL
    • 2023-03-28 AFP 13.9 ng/mL
    • 2022-10-06 AFP 4.1 ng/mL
    • 2022-09-14 AFP 4.4 ng/mL
    • 2022-06-15 AFP 77.4 ng/mL
    • 2022-06-07 AFP 94.0 ng/mL
    • 2022-05-06 AFP 170.4 ng/mL
  • This patient has previously been treated with sorafenib (from 2017-10 to 2018-01), regorafenib (from 2021-12 to 2022-08), and nivolumab (since 2021-10). If the disease is confirmed to have developed resistance to these treatments, then potential next-line therapy options could include cabozantinib or lenvatinib.

  • According to the current version (2023-05-23) NHI medication reimbursement rules, for advanced hepatocellular carcinoma, patients can only choose to use either sorafenib or lenvatinib, but they cannot switch between the two. Additionally, cabozantinib is only covered for patients with intermediate or high-risk advanced renal cell carcinoma who have not previously undergone treatment. Thus, in this patient’s case, it appears cabozantinib or lenvatinib may not be covered based on these regulations.

2023-05-09

  • During this chemotherapy session, facial flushing was noted approximately halfway through the oxaliplatin infusion (at 133 cc of a total of 250 cc). It might be beneficial to consider extending the infusion time beyond the current 2 hours to minimize this reaction.
  • According to PharmaCloud records, all recent medications were prescribed at our hospital and no medication reconciliation issues were identified.

2023-03-02

  • The CT scan conducted on 2023-02-10 revealed that the bilateral lung mets were regressing, indicating that the current treatment regimen (nivo + FOLFOX4) was still effective.
  • Pulmonary symptoms was properly managed with the patient’s self-carried medications.

2022-12-06

Currently, Tecopin (teicoplanin 200mg/vial) is out of stock and has been replaced with Targocid (teicoplanin 200mg/vial). If the teicoplanin treatment should continue, please prescribe Targocid.

2022-11-21

  • As of 2022-11-19 and 2022-11-20, the urine volume was recorded as 3850mL and 3350mL, respectively. This problem “decreased urine output” registered since 2022-11-19 should have been mitigated.
  • As long as the body temperature remains high (38.5 degrees Celsius at 08:43 on 2022-11-21), there is no issue with the ongoing use of antimicrobial flomoxef.
  • Please monitor the patient for anymore GI bleeding signs to determine the need to adjust the PPI.

2022-09-06

  • A multicenter phase II trial (RENOBATE) demonstrated that regorafenib plus nivolumab as first-line therapy for unresectable hepatocellular carcinoma shows promising efficacy outcomes without unexpected safety signals. (ref: Regorafenib plus nivolumab as first-line therapy for unresectable hepatocellular carcinoma (uHCC): Multicenter phase 2 trial (RENOBATE). Changhoon Yoo, etc. Journal of Clinical Oncology 2022 40:4_suppl, 415-415. https://ascopubs.org/doi/abs/10.1200/JCO.2022.40.4_suppl.415 )

  • Since the end of 2021, Stivarga (regorafenib 40mg/tab) has been prescribed. It is administered at 160mg once daily (4# QD) for the first 21 days of a 28-day cycle. Hand-foot skin reaction has been observed.

    • For grade 2 hand-foot skin reaction of any duration, it is recommended to reduce dose to 120 mg once daily for first occurrence. If grade 2 hand-foot skin reaction recurs at 120mg once daily, further reduce the dose to 80 mg once daily. Interrupt therapy for grade 2 hand-foot skin reaction that is recurrent or fails to improve within 7 days in spite of dosage reduction.
    • For grade 3 hand-foot skin reaction, it is recommended to interrupt therapy for a minimum of 7 days. Upon recovery, reduce dose to 120 mg once daily. If grade 2 to 3 toxicity recurs at 120 mg once daily, further reduce dose to 80 mg once daily upon recovery. Interrupt therapy for grade 2 to 3 hand-foot skin reaction that is recurrent or fails to improve within 7 days in spite of dosage reduction.
    • For recurrent or persistent hand-foot skin reaction at 80 mg once daily, it is recommended to discontinue the treatment.

2022-07-06

  • Nivolumab was administered from early October 2021 to late March 2022. On 2022-06-25 CT, several recurrent HCCs were found in the right lobe liver, and on 2022-03-11 CT, recurrent HCCs were found with mild increases in size.
  • There has been a shift in the regimen to FOLFOX4 + nivolumab since 2022-06-07. The AFP level declined to 77 (2022-06-15) from its recent peak 170 (2022-05-06), while CT results (2022-06-15) showed partial responses in right hepatic lobe and lung mets.
  • A rapid drop in blood pressure (92/63 at 9:19 2022-07-06) has been recorded. Tracking of hemodynamics might be necessary.

701475086

230711

[lab data]

2023-04-07 Anti-HBc Reactive
2023-04-07 Anti-HBc-Value 6.97 S/CO
2023-04-07 Anti-HBs 49.82 mIU/mL
2023-04-07 SCC 1.9 ng/mL
2023-04-07 CEA 0.82 ng/mL

2023-03-29 RPR/VDRL Nonreactive
2023-03-29 HBsAg Nonreactive
2023-03-29 HBsAg (Value) 0.44 S/CO
2023-03-29 Anti-HCV Nonreactive
2023-03-29 Anti-HCV Value 0.09 S/CO
2023-03-29 HIV Ab-EIA Nonreactive
2023-03-29 Anti-HIV Value 0.06 S/CO

[exam findings]

  • 2023-05-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (81 - 27) / 81 = 66.67%
      • M-mode (Teichholz) = 66
    • Conclusion:
      • Concentric LV hypertrophy and RV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild PR; mild aortic root calcification.
      • Sinus tachycardia.
  • 2023-05-08 CXR
    • Enlargement of cardiac silhouette.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-04-17 Pure Tone Audiometry
    • Reliabilty Fair
    • PTA
    • R’t : 14 dB HL
    • L’t : 16 dB HL
    • Bil WNL
  • 2023-04-01 CT - abdomen
    • No definite abnormality in this study
  • 2023-03-31 MRI - larynx
    • Impression (Imaging stage) : T:4a N:2b M:0 STAGE:IVA
  • 2023-03-29 Tc-99m MDP bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in the maxilla, mandible, some T- and L-spine, bilateral shoulders, elbows, sternoclavicular juncions, S-I joints, hips, knees, and right ankle.
  • 2023-03-29 Patho - stomach biopsy
    • Stomach, midbody, GC side. Biopsy (A) — Hyperplastic polyp
    • EC junction, biopsy (B)— low grade dysplasia. Please follow up.
  • 2023-03-20 Patho - tongue biopsy
    • Tongue, right, biopsy— moderately differentiated squamous cell carcinoma
    • Microscopically, section shows moderately differentiated squamous cell carcinoma consisting of nests of tumor cells in infiltrative growth pattern with squamous differentiation and areas of dyskeratosis.The tumor cells have abundant eosinophilic cytoplasm,round to oval nuclei,prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
    • Immunohistochemical stain reveals CK(+) and p16(-).

[consultation]

  • 2023-04-17 Dermatology
    • Q
      • The 49 y/o man has right tongue cancer, moderately differentiated squamous cell carcinoma, cT4aN2b stage IVA. He was admitted for chemotherapy. Due to skin itchy over legs, scrotum, axillary. We need your help for r/i scabies. Thanks!
    • A
      • This patietn suffered from multiple erytheamtous papules on trunk for days.
      • Imp: Scabies
      • Suggestion:
        • BB lotion (benzyl benzoate) x 1 BT /QD
        • Ulex cream (hydrocortisone, crotamiton) x 15 tubes /BID
  • 2023-04-01 Hemato-Oncology
    • Q
      • For chemotherapy.
      • This 49-year-old male denied of having chronic disease before. The patient is a case of right lateral tongue cancer. He was admitted for cancer work up. Larynx MRI arranged and showed right lateral tongue cancer T4aN2bM0, STAGE:IVA. We request your consultation for chemotherapy.
    • A
      • Patient examined and Chart reviewed, my suggestions would be:
        • Well explain and educate to the patient (Already done).
        • Surgical intervention would be first considered if no distant mets.
        • If the surgical intervention is not feasible, may consider CCRT.
        • Please arrange my OPD visit after being discharged.
  • 2023-03-30 Oral and Maxillofacial Surgery
    • Q
      • This 49-year-old male denied of having chronic disease before. The patient is a case of right lateral tongue cancer. He was admitted for cancer work up. We request your consultation for dental evaluation.
    • A
      • Panoramic findings:
        • impacted tooth: 38,48
        • deep caries: tooth 18
        • Missing tooth: nil
        • cystic change of impacted tooth 48 was present
      • Plan:
        • Explain the findings
        • suggest extraction of tooth 18 and 48 prior to radiotherapy or remove the tooth 18 and 48 perioperatively

[MedRec]

  • 2023-04-13 SOAP Hemato-Oncology
    • Anti-HBc (+), Anti-HBs (+), HBs Ag (-), Anti-HCV (-)
  • 2023-04-13 SOAP Oral and Maxillofacial Surgery
    • O: full mouth heavy plaque and calculusdeposition
    • P: full mouth scaling
  • 2023-04-07 SOAP Radiation Oncology
    • This 49 year old man is a case of right tongue cancer, moderately differentiated squamous cell carcinoma, cT4aN2b stage IVA
    • Suggest (OP + adjuvant CCRT) or (induction C/T + OP + adjuvant CCRT)
  • 2023-04-06 SOAP Oral and Maxillofacial Surgery
    • S: pre-CCRT dental evalution
    • O: deep caries of tooth 18 and cystic change of impacted tooth 48
    • A: Tongue cancer, prepared for CCRT.
    • P:
      • Explain the risk/benefit of the treatment to the patient, about the risk of communication between the maxillary sinus and oral cavity
      • Sign informed consent.
      • Block anesthesia of right maxilla
      • Complicated extraction of tooth 18
      • Suture the gingiva with Vicryl 4-0.
      • Prescribe Acetal and Amoxicillin.
      • Teach the patient how to do home care and OPD follow-up.
  • 2023-04-06 SOAP Hemato-Oncology
    • A:
      • cT4aN2bM0, Stage IVA.
        • Suggest OP is the first consideration.
        • If OP is not feasible, then consider CCRT.
    • P:
      • Surgical intervention would be first considered if no distant mets.
      • If the surgical intervention is not feasible, may consider CCRT.
  • 2023-03-24 SOAP ENT
    • 2023/03/20 PATHO - tongue biopsy: Tongue, right, biopsy — moderately differentiated squamous cell carcinoma
    • suggest admission for staging
  • 2023-03-14 SOAP ENT
    • right tongue swelling tender ulcer for 6 months
    • right tongue border indurated ulcer, suggest biopsy first

[chemotherapy]

  • 2023-07-10 - docetaxel 60mg/m2 120mg NS 250mL 1hr D1 + cisplatin 75mg/m2 145mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) D3 + furosemide 20mg NS 30mL 10min (after cisplatin) D3 + fluorouracil 1000mg/m2 2000mg NS 500mL 24hr D2-5 (TPF Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D2 + NS 250mL D2 + aprepitant 125mg PO D2-4
  • 2023-06-09 - docetaxel 60mg/m2 120mg NS 250mL 1hr D1 + cisplatin 75mg/m2 145mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) D2 + furosemide 20mg NS 30mL 10min (after cisplatin) D2 + fluorouracil 1000mg/m2 2000mg NS 500mL 24hr D2-5 (TPF Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D2 + NS 250mL D2 + aprepitant 125mg PO D2-4
  • 2023-04-24 - docetaxel 60mg/m2 120mg NS 250mL 1hr D1 + cisplatin 75mg/m2 145mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) D2 + furosemide 20mg NS 30mL 10min (after cisplatin) D2 + fluorouracil 1000mg/m2 2000mg NS 500mL 24hr D1-4 (TPF Q3W)
    • dexamethasone 4mg D1 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg PO D1-3

TPF regimen in in-hospital “Prescription Collection of Chemotherapy for Head and Neck Cancer” protocol (dated 2023-03-31)

  • Neo-adjuvant Chemotherapy regimen - TPF
    • Docetaxel 40 mg/m2 IVD (1 hs) D1, 8
    • Cisplatin 40 mg/m2 IVD (2 hs) D1, 8
    • 5-FU 750~1000 mg/m2 IVD (24 hs) D1-2, D8-9
    • Q3W for 1~3 cycles
    • Modified from Posner MRI et al. N.Engl.J.Med.357 (2007):1705-1715.
  • Induction Chemotherapy modified with TPF
    • Docetaxel 40 mg/m2 IVD (1 hs) D1, 8
    • Cisplatin 40 mg/m2 IVD (2 hs) D1, 8
    • 5-FU+Leucovorin 1000mg/m2+100mg/m2 IVD (24 hs) D2, 9
    • Q3 week x 3cycles (Q1W, Q2W, Q3W: rest)
    • Modified from Jérôme Fayette et al. Oncotarget 2016;7(24):37297-37304

Docetaxel, cisplatin, and fluorouracil induction chemotherapy followed by radiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX323) 2023-06-12 https://www.uptodate.com/contents/image?imageKey=ONC%2F72461&topicKey=ONC%2F85694

  • Cycle length: Every 21 days for 4 cycles.

  • Regimen

    • Docetaxel
      • 75 mg/m2 IV
      • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
      • Day 1
    • Cisplatin
      • 75 mg/m2 IV
      • Dilute in 250 mL NS and administer over 60 minutes. Do not administer with aluminum needles or IV sets.
      • Day 1
    • Fluorouracil (FU)
      • 750 mg/m2/day IV
      • Dilute in 500 to 1000 mL D5W or NS and administer as a continuous infusion over 24 hours.
      • Days 1 through 5

Docetaxel, cisplatin and fluorouracil induction chemotherapy followed by chemoradiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX324) 2023-06-12 https://www.uptodate.com/contents/image?imageKey=ONC%2F65438&topicKey=ONC%2F85694

  • Cycle length: Every 21 days for 3 cycles.

  • Regimen

    • Docetaxel
      • 75 mg/m2 IV
      • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
      • Day 1
    • Cisplatin
      • 100 mg/m2 IV
      • Dilute in 250 mL NS and administer over 30 minutes to three hours. Do not administer with aluminum needles or IV sets.
      • Day 1
    • Fluorouracil (FU)
      • 1000 mg/m2/day IV
      • Dilute in 500 to 1000 mL D5W or NS and administer as a continuous infusion over 24 hours.
      • Days 1 through 4

==========

2023-07-11

[reconciliation]

According to the PharmaCloud database, the patient only receives medical services from our hospital. Therefore, there are no identified medication reconciliation issues.

2023-06-12

  • After examining the PharmaCloud medical records, it’s evident that this patient has been solely receiving care from our hospital over the past three months. All prescriptions have been issued by our outpatient and inpatient hemato-oncology services. Consequently, no medication reconciliation issues have been identified.

  • The docetaxel/cisplatin/fluorouracil regimen was administered to the patient on 2023-04-24 and 2023-06-09. Historical lab data showed a drop in WBC count below 1000/uL from 2023-05-01 to 2023-05-05, indicating leukopenia roughly 1 to 2 weeks after the initial round of the regimen. A total of 6 doses of Granocyte (lenograstim 250ug) were administered daily between 2023-05-01 and 2023-05-07. Given that the seconnd round of the regimen started on 2023-06-09 with the same dosage as the first, it is plausible that another leukopenia episode could occur about one week after treatment. Therefore, a prophylactic administration of G-CSF post-chemotherapy might be considered.

    • 2023-06-09 WBC 7.39 x10^3/uL
    • 2023-05-23 WBC 6.43 x10^3/uL
    • 2023-05-16 WBC 7.54 x10^3/uL
    • 2023-05-12 WBC 6.38 x10^3/uL
    • 2023-05-10 WBC 9.71 x10^3/uL
    • 2023-05-08 WBC 15.33 x10^3/uL
    • 2023-05-06 WBC 1.89 x10^3/uL
    • 2023-05-05 WBC 0.57 x10^3/uL
    • 2023-05-04 WBC 0.30 x10^3/uL
    • 2023-05-03 WBC 0.16 x10^3/uL
    • 2023-05-02 WBC 0.12 x10^3/uL
    • 2023-05-01 WBC 0.52 x10^3/uL
    • 2023-04-17 WBC 6.25 x10^3/uL
    • 2023-03-28 WBC 5.14 x10^3/uL

2023-04-18

  • Our dermatologist suggested BB lotion (benzyl benzoate) and Ulex cream (hydrocortisone, crotamiton) for the patient’s scabies treatment. If the symptoms do not improve, topical permethrin or oral ivermectin may also be considered as subsequent treatment options.

701325918

230710

{metastatic renal cell carcinoma} (not completed)

[history]

  • left renal cancer with gastric and lung metastasis, status post target therapy and immunotherapy at Taipei Veterans General Hospital
  • nodular goiter s/p total thyroidectomy 10+ years ago
  • breast nodular s/p operation.

[exam findings]

  • 2023-07-07 Tc-99m MDP bone scan
    • A hot spot in the left 1st rib. Bone metastasis should be watched out.
    • Increased activity in the upper L-spine. Either bone metastasis or severe degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the lower L-spine. Degenerative change is more likely. Please follow up bone scan for further evaluation and to rule out other possibilities.
    • Some faint hot spots in the skull. The nature is to be determined (post-traumatic change? early bone metastases). Please also follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
  • 2023-07-06 CT - abdomen
    • History and indication: Left renal cell carcinoma
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Clinical history of left renal cancer with calcifications. Some LNs at retroperitoneum with calcification.
      • A calcification (3.2cm) at left neck.
      • Multiple nodules in bil. lungs.
      • R/O bony metastases at right iliac bone and L2.
      • S/P gastric bypass procedure.
    • IMP:
      • Clinical history of left renal cancer with calcifications. Some LNS at retroperitoneum with calcification. A calcification (3.2cm) at left neck. Multiple nodules in bil. lungs. R/O bony metastases at right iliac bone and L2.
  • 2023-04-17 Patho - lymphnode biopsy
    • Labeled as “neck mass, left”, SONO guided biopsy — papillary carcinoma.
    • Section shows soft tissue with many papillary carcinoma. Numerous psammoma bodies are present.
    • IHC stains: PAX-8 (+), TTF-1 (-), Thyroglobulin (-), CD10 (equivocal), RCC (equivocal). Please correlate with clinical and image findings.
  • 2023-03-25, -03-09, -03-07 KUB
    • S/P hot AXIOS lumen apposing metallic stent is placed between the stomach and jejunum loop.
  • 2023-03-13 Gastric emptying study
    • The gastric emptying study was performed after the patient consumed a standard test meal of two eggs radiolabeled with 0.3 mCi of Tc-99m phytate, two slices (50 gm) of white bread, and 300 ml of orange juice. The gastric emptying study in solid phase revealed fair gastric emptying, and the half time of radioactivity (T1/2) was 92.76 min according to the exponential fitting of the time-activity curve.
    • IMPRESSION: The half time (T1/2) of gastric emptying of solid phase is 92.76 min (within normal limit).
    • COMMENT: The normal half time (T1/2) of gastric emptying of solid phase for adults is 45 to 110 minutes.
  • 2023-03-06 Endoscopic Ultrasonography, EUS
    • Indication: RCC with duodenal 3rd portion obstruction
    • Symptoms: refractory vomiting
    • Pre-EUS diagnosis: duodenal outlet obstruction
    • Diagnosis: Recurrent RCC with duodenal 3rd portion obstruciton s/p AXIOS LAMS
    • Suggestion: standing abdomen C.M.
  • 2023-03-02 Upper GI series
    • Retention of contrast medium in the duodenum, 3rd portion, could be due to obstruction.
  • 2023-02-14 CT - abdomen
    • Diffuse dense calcified tumors in left retroperitoneum and paraaortic regions, stationary.
    • Diffuse nodules in bilateral lungs, r/o lung metastasis.
    • Enlarged lymph nodes in bilateral inguinal and axillary regions.
    • Dilatation of duodenum due to tumor compression at duodenojejunal area.
  • 2022-10-28 CT - abdomen
    • History and indication:
      • Left renal cell carcinoma, pT1a, FG2 type II s/p left partial nephrectomy, local recurrent of left retroperitoneal s/p target therapy with Erlotinib/Bevacizumab s/p Nivolumab/Cabozantinib, local recurrent of retroperitoneum LN metas
      • Findings:
        • Prior CT identified lobulated mass with dense calcification in left retroperitoneal space (in between left kidney, left pasoas muscle, and para-aortic space) is noted again, mild decreasing in size that is c/w local recurrent renal cell carcinoma S/P target therapy with partial response.
          • In addition, Left kidney shows small size and thin parenchyma that is c/w S/P partial nephrectomy and chronic renal disease.
        • Prior CT identified Some small nodules in bil. lungs are noted again, stationary.
        • Prior CT identified bony metastases at left lateral aspect of L2 vertebral body is noted again, stationary.
        • Prior CT identified scattered calcified nodes in para-aortic space and para-cava space are noted again, stable in size that are c/w metastatic nodes S/P target therapy with complete response.
        • Prior CT identified several enlarged nodes in bilateral inguinal area are noted again, decreasing in size that are c/w metastatic nodes S/P C/T with partial response. please correlate with clinical condition.
    • Impression:
      • Local recurrent RCC at left retroperitoneal space S/P target therapy show partial response.
      • Lymph nodes in bilateral inguinal area show partial response.
  • 2022-03-25 CT - abdomen
    • Findings:
      • Prior CT identified lobulated mass with dense calcification in left retroperitoneal space (in between left kidney, left pasoas muscle, and para-aortic space) is noted again, stable in size that is c/w local recurrent renal cell carcinoma S/P target therapy with stable disease.
        • In addition, Left kidney shows small size and thin parenchyma that is c/w S/P partial nephrectomy and chronic renal disease.
      • Prior CT identified Some small nodules in bil. lungs are noted again, stationary.
      • Prior CT identified bony metastases at left lateral aspect of L2 vertebral body is noted again, stationary.
      • Prior CT identified scattered calcified nodes in para-aortic space and para-cava space are noted again, stable in size that are c/w metastatic nodes S/P target therapy with complete response.
      • Prior CT identified several enlarged nodes in bilateral inguinal area are noted again, increasing in size. please correlate with clinical condition.
    • Impression:
      • Local recurrent RCC at left retroperitoneal space with lung, lymph nodes, and bone metastases S/P target therapy show stable disease.
      • Lymph nodes in bilateral inguinal area show mild increasing in size.
  • 2021-12-23 CT - abdomen
    • Findings
      • Clinical history of left renal tumor (3.5x5.2cm) with calcifications. Some LNS at retroperitoneum.
      • Some small nodules in bil. lungs.
      • R/O bony metastases at right iliac bone and L2.
    • IMP:
      • Clinical history of left renal tumor (3.5x5.2cm) with calcifications. Some LNS at retroperitoneum. R/O lung and bony metastases.
  • 2021-12-03 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (98.8 - 30.3) / 98.8 = 69.33%
      • M-mode (Teichholz) = 69.3
    • Conclusion:
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Very trivial tricuspid regurgitation
      • Mildly thick IVS and LVPW
  • 2021-08-12 CT - whole abdomen, pelvis
    • clinical history of left renal tumor (6.0cm) with solid/cystic components and calcifications. probable abscess formation (6.7x12.9cm) at left retroperitoneum with adjacent muscle invasion. some LNs at retroperitoneum.
  • 2021-08-12 general and gastroenterological surgery
    • less likely cholecystitis related
    • favor left retroperitoneal abscess related
  • 2021-08-13 gastroenterology
    • upper gastrointestinal bleeding, gastric metastasis related?

[MedRec]

[immunotherapy]

  • 2023-07-10 - nivolumab 3mg/kg 100mg NS 100mL 1hr

    • diphenhydramine 30mg + NS 250mL
  • 2023-06-13 - nivolumab 3mg/kg 100mg NS 100mL 1hr

    • diphenhydramine 30mg + NS 250mL
  • 2023-05-12 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

    • diphenhydramine 30mg + NS 250mL
  • 2023-04-14 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

    • diphenhydramine 30mg + NS 250mL
  • 2023-03-24 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

    • diphenhydramine 30mg + NS 250mL
  • 2023-02-24 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

    • diphenhydramine 30mg + NS 250mL
  • 2022-04-22 - nivolumab 3mg/kg 100mg NS 100mL 1hr

    • diphenhydramine 30mg + NS 250mL
  • 2023-03-28 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

    • diphenhydramine 30mg + NS 250mL
  • 2023-03-01 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

    • diphenhydramine 30mg + NS 250mL
  • 2022-02-09 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

    • diphenhydramine 30mg + NS 250mL
  • 2022-01-18 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-12-28 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)

  • 2021-11-30 - pembrolizumab 200mg NS 100mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL
  • 2021-11-05 - pembrolizumab 200mg NS 100mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL
  • 2021-10-15 - pembrolizumab 200mg NS 100mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL
  • 2021-09-08 - pembrolizumab 200mg NS 100mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL
  • 2020-10 erlotinib + bevacizumab followed with nivolumab + carboplatin.

==========

2023-07-10

[availability of entrectinib and/or alectinib]

According to the latest National Health Insurance (NHI) Drug Reimbursement Guidelines (version dated 2023-05-23), Rozlytrek (entrectinib) is only covered when used alone in adults with ROS-1 positive locally advanced or metastatic NSCLC. Alecensa (alectinib) is covered only for first-line treatment of ALK-positive advanced NSCLC. Both are not covered for papillary renal cell carcinoma.

Both Rozlytrek (entrectinib 200mg/capsule) and Alecensa (alectinib 150mg/capsule) are available in the hospital’s inventory, so no prior authorization is required (no temporary purchase procedure is necessary). The out-of-pocket cost for the former is 1802.5 TWD (NHI price 1530 TWD) and for the latter 487.5 TWD (NHI price 390 TWD).

700072194

230707

{autologous Peripheral Blood Stem Cell Transplantation}

  • past history
    • DM with triopathy for 10+ years with regular OHA control. (triopathy of diabetes - retinopathy, nephropathy, and neuropathy.)
  • lab data
    • 2022-08-18 EB VCA IgG Positive Ratio
    • 2022-08-18 EB VCA IgG Value 6 Ratio
    • 2022-08-17 EB VCA IgM Negative Ratio
    • 2022-08-17 EB VCA IgM Value 0.2
    • 2022-08-15 RPR/VDRL Nonreactive
    • 2022-08-15 Anti-HCV Nonreactive
    • 2022-08-15 Anti-HCV Value 0.04 S/CO
    • 2022-08-15 Anti-HBc Reactive
    • 2022-08-15 Anti-HBc-Value 5.04 S/CO
    • 2022-08-15 HBsAg Nonreactive
    • 2022-08-15 HBsAg (Value) 0.39 S/CO
    • 2022-08-15 Anti HTLV I/II Nonreactive
    • 2022-08-15 Anti HTLV I/II Value 0.06 S/CO
    • 2022-08-15 CMV IgM Nonreactive
    • 2022-08-15 CMV IgM Value 0.04 Index
    • 2022-08-15 CMV_IgG Reactive
    • 2022-08-15 CMV_IgG Value 157.5 AU/mL
    • 2022-08-15 HIV Ab-EIA Nonreactive
    • 2022-08-15 Anti-HIV Value 0.06 S/CO
    • 2022-05-25 %CD34+ 0.09 %
    • 2022-05-25 CD34+ Count 322 /uL
    • 2022-05-25 %CD34+ 0.01 %
    • 2022-05-25 CD34+ Count 4 /uL
    • 2022-05-24 %CD34+ 0.13 %
    • 2022-05-24 CD34+ Count 535 /uL
    • 2022-05-24 %CD34+ 0.02 %
    • 2022-05-24 CD34+ Count 10 /uL
    • 2022-05-23 %CD34+ 0.14 %
    • 2022-05-23 CD34+ Count 610 /uL
    • 2022-05-23 %CD34+ 0.04 %
    • 2022-05-23 CD34+ Count 17 /uL
    • 2022-02-17 %CD34+ 0.21 %
    • 2022-02-17 CD34+ Count 880.0 /uL
    • 2022-02-16 %CD34+ 0.27 %
    • 2022-02-16 CD34+ Count 1030 /uL
    • 2022-02-15 %CD34+ 0.31 %
    • 2022-02-15 CD34+ Count 1638 /uL
    • 2022-01-14 %CD34+ 0.02 %
    • 2022-01-14 CD34+ Count 50 /uL
    • 2022-01-13 %CD34+ 0.05 %
    • 2022-01-13 CD34+ Count 100 /uL
    • 2022-01-12 %CD34+ 0.04 %
    • 2022-01-12 CD34+ Count 60 /uL
    • 2022-01-11 %CD34+ 0.04 %
    • 2022-01-11 CD34+ Count 20 /uL
    • 2019-08-09 %CD34+ 0.11 %
    • 2019-08-09 CD34+ Count 610 /uL
    • 2019-08-08 %CD34+ 0.08 %
    • 2019-08-08 CD34+ Count 410 /uL
    • 2019-08-07 %CD34+ 0.07 %
    • 2019-08-07 CD34+ Count 255 /uL
    • 2019-07-05 %CD34+ 0.14 %
    • 2019-07-05 CD34+ Count 230 /uL
    • 2019-07-04 %CD34+ 0.06 %
    • 2019-07-04 CD34+ Count 55 /uL
  • exam finding
    • 2022-07-18 Whole body PET scan
        1. The increased FDG uptake in the right posterior pleura and adjacent soft tissue, in bilateral axillary lymph nodes, and in an upper abdominal preaortic lymph node disappears or comes to very faint compared with the previous study on 2021-09-16, indicating partial to good response to current therapy.
        1. Increased FDG accumulation in bilateral kidneys, probably physiological uptake of FDG.
        1. Lymphoma s/p treatment with partial to good response, by this F-18 FDG PET scan.
    • 2022-07-09 CT - chest
      • S/p port-A placement with its tip at Superior vena cava
      • No evidence of lymphadenopathy in the study.
    • 2022-06-30 CXR
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
      • Atherosclerotic change of aortic arch
    • 2022-03-08 CT - chest
      • stationary of Rt posterior inferior pleural thickening as compared with CT on 2021/12/17, could be posterior treatment change.
    • 2022-01-17 Bronchoscopy
      • Diagnosis
          1. LUL and Left lingular lobe acute bronchitis
          1. Sleep apnea
          1. Chronic sinusitis
      • Findings
        • The nasal mucosa was hypertrophic.
        • The nasal lumen was severely narrowed.
        • The was copious mucoid nasal discharge retained in the nasal cavity.
        • Mucosa of nasopharynx was hypertrophic .
        • Nasopharynx was severely narrowed.
        • Mucosa of pharynx cobble-stone in shape .
        • Movement of the both. vocal cord(s) was / werenormal .
        • Bilateral arytenoid proceww was normal .
        • Trachea whole segment . : patent and the mucosa was hypertrophic .
        • Main carina: sharp and movable on deep breathing.
        • Bilateral endobronchial trees:
          • LUL, left lingular lobe mucosal swelling with some purulent sputum.
          • No endobronchial lesions
    • 2021-12-17 CT - chest
      • No evidence of recurrent/residual lymphadenopathy in the study.
      • Calcified coronary arteries is found.
    • 2021-10-06 Patho - bone marrow biopsy
      • Bone marrow, iliac, (clinical history of Hodgkin’s lymphoma stage IV, biopsy — Negative for malignancy.
      • IHC stains: CD30: (-).
      • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
    • 2021-09-27 Patho - pleural/pericardial biopsy
      • Tissue, labeled “right chest”, CT-guide biopsy — Nodular sclerosis classical Hodgkin lymphoma, recurrent
      • Immunohistochemical stain profiles: CD3: positive, CD20: positive, CD15: focal positive, CD30: focal positive
    • 2021-09-25 CT guide biopsy
      • Right pleural mass, s/p CT-guided biopsy
    • 2021-09-16 Whole body PET scan
      • The FDG PET finding are compatible with recurrent lymphoma (stage IV) involving the right posterior pleura and adjacent soft tissue (Deauville 5), some bilateral axillary lymph nodes (Deauville 4) and an upper abdominal preaortic lymph node (Deauville 5) 2. Mild glucose hypermetabolism in some bilateral inguinal lymph nodes (Deauville 2). The nature is to be determined (inflammation? lymphoma of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
    • 2021-09-08 CT - chest
      • progression of Rt posterior inferior pleura tumor compared with CT on 20210209.
    • 2021-02-09 CT - abdomen
        1. Stationary right lower pleural thickening.
        1. Bilateral inguinal lymph nodes.
        1. Ascending colon diverticula.
    • 2020-11-16 Tc-99m MDP whole body bone scan
        1. In comparison with the previous study on 2017/12/29, the lesion in L3 spine had disappeared, indicating a malignant lesion with response to treatment and in metabolic regression.
        1. Mildly increased radiotracer uptake in diffusely increased radiotracer uptake in posterior aspect of right lower rib cages was newly noted in this study. Increased vascularity and vascular permeability associated with malignant pleural effusion in right lower posterior pleural space may show such a picture. Please correlate with other imaging modalities and keep follow up, however, to exclude the possibility of lymphomatous marrow involvement in multiple right lower ribs.
        1. Mildly and non-focally increased radiotracer uptake in middle T-spine, lower L-spine and sacrum, degenerative spine diseases may show such a picture.
        1. Some areas of mildly increased radiotracer uptake in maxilla and mandible, dental lesions may show such a picture.
        1. Probably degenerative joint lesions in shoulders, sternoclavicular junctions, and knees.
    • 2020-11-05 CT - abdomen
      • Thickening of right lower pleura.
      • Some LNs (5-11mm) in bil. inguinal regions.
    • 2020-07-02 CT - chest
      • Mild bronchiectatic change over right middle lobe with increased peribronchial infiltration at right middle lobe
      • Right pleural effusion. Mild.
      • Small left axillary lymph nodes
    • 2020-03-06 CT - abdomen
      • Finding
          1. Prior CT identified some enlarged lymph nodes in bilateral inguinal area are noted again, stable in size. However, a newly-developed soft tissue mass measuring 2.8 cm in right inguinal area, near the penis base is noted that may be recurrent lymphoma.
          1. Mild thickening in right posterior basal CP angle pleura area is noted that also may be recurrent lymphoma. please correlate with clinical condition.
      • IMP:
        • Recurrent lymphoma in right posterior basal CP angle pleura and right inguinal area are suspected. please correlate with clinical condition.
    • 2019-10-24 Whole body PET scan
        1. In comparison with the previous study on 2019/04/01, the previous FDG avid lesions in the right posterior chest wall, multiple skeletal sites, and a right supraclavicular lymph node all disappeared (Deauville score 1).
        1. Faint glucose hypermetabolism (Deauville score 2) in some bilateral inguinal lymph nodes. The nature is to be determied (inflammatory process? other nature?). Please correlate with other clinical findings for further evaluation.
        1. Mild glucose hypermetabolism in the right hip. Benign joint lesion such as arthritis may show this picture.
        1. Increased FDG accumulation in the colon. Physiological FDG accumulation is more likely.
    • 2019-10-21 CT - abdomen
      • Some LNs (5-10mm) in bil. inguinal regions.
    • 2019-08-05 CXR - chest
      • Hypoinflation of both lung is noted.
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura thickening or effusion ?
    • 2019-07-20 CT - abdomen
        1. Regression of right posterior intercostal tumor as compare with CT study on 20190307.
        1. Ascending colon diverticula.
    • 2019-04-01 PET
      • In comparison with the previous study on 2018/07/06, the lesions in the right posterior chest wall, multiple skeletal sites, and a right supraclavicular lymph node were all new lesions (Deauville 5), suggesting lymphoma in progression.
        1. Hodgkin’s lymphoma, rc-stage IV (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
    • 2019-03-18 Surgical pathology Level IV
      • clinical diagnosis
        • Hodgkin’s disease, nodular sclerosis, intra-abdominal lymph nodes;
      • pathologic diagnosis
        • Mass, unspecified ciste?, biopsy — Compatible with Hodgkin lymphoma
      • Microscopically, the section shows a picture of some lymphoid cells with follicles embedded in collagenous stroma, consists of mixed lymphocytes, neutrophils, eosinophils, macrophages and a few atypical large cells, which immunohistocehmcial study reveals CD15(+, focal), CD30(+), CK(-), CD20(-) and EMA(+, scatter). According to above histopathologic findings and previous pathologic report, it is compatible with Hodgkin lymphoma.
    • 2019-03-07 CT - abdomen
      • A mass lesion (5x6cm) in right posterior back.
    • 2018-11-02 CT - abdomen
      • Stationary lymph nodes in left pelvic cavity and inguinal regions.
    • 2018-07-06 PET
        1. In comparison with the previous study on 2017/12/19, the glucose hypermetabolism at multiple lymph nodes in the abdominal left paraaortic region (Deauville score 2), right inguinal region (Deauville score 2), left lower pelvic region (Deauville score 2) and left inguinal region (Deauville score 3) and the glucose hypermetabolism at the L3 spine (Deauville score 2) are all less evident, suggesting partial response to the treatment. Please correlate with other clinical findings for further evaluation.
        1. Increased FDG accumulation in the colon. Physiologic FDG accumulation may show this picture. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • 2018-06-19 CT - abdomen
      • Left inguinal lymph nodes, in regression
    • 2018-03-02 CT - abdomen
      • Regression of enlarged lymph nodes in left inguinal region and pelvic cavity.
    • 2017-12-29 Tc-99m MDP whole body bone scan
        1. Increased activity in the L3 spine. Bone metastasis can not be ruled out. Please correlate with other imaging modalities for further evaluation.
        1. Increased activity in the lower C-spines. Degenerative change may show this picture. However, please follow up bone scan to rule out the possibility of bone metastasis.
        1. Some faint hot spots in the lateral aspect of bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
        1. Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and knees, compatible with benign joint lesion.
    • 2017-12-19 PET
        1. Glucose hypermetabolism at multiple lymph nodes in the abdominal left paraaortic region (Deauville 4), right inguinal region (Deauville 4), left lower pelvic region (Deauville 4) and left inguinal region (Deauville 5), compatible with lymphoma involving multiple lymph node regions on the same side of the diaphragm.
        1. Glucose hypermetabolism in the L3 spine (Deauville 5). Lymphoma involving L3 spine should be considered. Please correlate with other clinical findings for further evaluation.
    • 2017-12-18 Doppler color flow mapping
        1. Borderline dilated LA and LV; adequate LV systolic function with normal resting wall motion
        1. Trivial MR and trivial TR
        1. Preserved RV systolic function
    • 2017-12-07 Surgical pathology Level IV
      • clinical diagnosis
        • Neoplasm of uncartain behavior of connective and other soft tissue;
      • pathologic diagnosis
        • Tumor, left pelvis, excisional biopsy — Compatible with Hodgkin lymphoma, nodular sclerosis
      • Microscopically, the section shows a picture of broad bands of collagen replace patches of remaining tissues with focal marked crushed artifact, consists of mixed lymphocytes, neutrophils, eosinophils, macrophages and a few atypical individual or multinucleated large cells, which immunohistocehmcial study reveals CD15(+), CD30(+), PAX-5(scant, weakly +), CK(-), S-100(-), SMA(-) and ALK(-). According to above histopathologic findings, it is compatible with Hodgkin lymphoma, nodular sclerosis type.
    • 2017-11 Initial presentation
      • the patient noted fever and cold sweating, and palpable abdominal mass over left lower abdomen also found.

chemotherapy with Mabthera on 12/27,Etoposide 500mg/m2 total given 963mg Q12H on 12/28-30 followed by PBSC harvest,GCSF 300mcg QD on 12/31-1/14.Port-A removal on 2022/1/14.

  • radiotherapy
    • 2017 after ABVD chemotherapy

[chemoimmunotherapy]

  • 2023-07-07 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-30 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-08 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-17 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-08-17 - busulfan 3.2mg/kg 260mg 2hr D1-3 + etoposide 400mg/m2 567mg 1hr D3-4 + cyclophosphamide 50mg/kg 4000mg D5-6 (BuCyE)

  • 2021-12-27 - rituximab 375mg/m2 720mg 8hr D1 + etoposide 500mg/m2 963mg 4hr D2-4

  • 2021-11-19 - etoposide 100mg/m2 190mg 2hr D1-3 + carboplatin AUC5 350mg 24hr D2 + ifosfamide 5000mg/m2 9400mg 24hr D2 + mesna 5000mg/m2 9400mg with ifosfamide (ICE) followed by PBSC harvest, GCSF 300mcg QD on 2021-12-31 ~ 2022-01-14.

  • 2021-10-27 - etoposide 100mg/m2 190mg 2hr D1-3 + carboplatin AUC5 350mg 24hr D2 + ifosfamide 5000mg/m2 9400mg 24hr D2 + mesna 5000mg/m2 9400mg with ifosfamide (ICE)

  • 2021-10-06 - etoposide 100mg/m2 190mg 2hr D1-3 + carboplatin AUC5 350mg 24hr D2 + ifosfamide 5000mg/m2 9400mg 24hr D2 + mesna 5000mg/m2 9400mg with ifosfamide (ICE)

  • 2019-04-03 ~ 2019-09-07 - ESHAP 7 cycles

  • 2017-12-30 ~ 2018-06-01 - ABVD

==========

2023-07-07

The patient underwent an autoPBSCT procedure in August 2022, almost a year ago. Based on the Guidelines for Vaccination of Adult BMT Patients provided by Stanford Healthcare, the proposed vaccination schedule is as follows (ref: https://med.stanford.edu/content/dam/sm/bugsanddrugs/documents/clinicalpathways/SHC-Vaccination-BMT.pdf):

  • Influenza: Annually starting at 6 months post transplant
  • Pneumococcal: 12 months post transplant
  • Meningococcal Group A: 12 months post transplant
  • Haemophilus: 12 months post transplant
  • Diptheria/tetanus/pertussis: 12 months post transplant
  • Hepatitis: 12 months post transplant
  • Papillomavirus: 12 months post transplant

According to the guideline, most vaccinations are started 12 months after transplant, so it may be an appropriate time to start planning the vaccination schedule for this patient. This can help reduce the risk of infection and promote the patient’s overall health and recovery.

2022-08-19

[preparation and administration of mesna]

  • Usual diluents
    • D5W, NS
  • Usual dose
    • 100 ml, 15-30 min, concentration range: 1-20 mg/ml
  • Dosing
    • usual dose=20% of ifosfamide dose given just before and 4 and 8 hours after ifosfamide (total=60%).
    • May also be given as a continuous IV infusion concurrently with ifosfamide. Total daily dose= 60% to 160% of ifosfamide dose or 60% to 200% of cyclophosphamide dose. May give 20% W/W 15min prior, and then q3hrs x 3-6 doses.
  • Administration
    • IVPB in 50 ml or more of D5W or normal saline over 5 minutes or longer. Also by continuous IV infusion.
  • Storage/stability:
    • Vials stored at RT. Diluted solutions (1-20 mg/ml) - 24 hrs. 20 mg/ml (D5W) - 48hrs RT; 1-mg/ml (D5W) - 24 hours RT.
  • Preparation:
    • May be further diluted in D5W, NS, D5/.45NS, or LR to a final concentration of 1-20 mg/ml.
  • Prevention of cyclophosphamide-induced hemorrhagic cystitis: Limited data available: Note: Specific protocols should be consulted for combination regimens with cyclophosphamide. Mesna dosing schedule is typically repeated with each day cyclophosphamide is received; mesna dosing should be adjusted if cyclophosphamide dose is adjusted (decreased or increased) to maintain the mesna-to-cyclophosphamide ratio for the protocol.
    • Infants, Children, and Adolescents:
      • Standard (low)-dose cyclophosphamide: Note: Some pediatric oncology experts have defined as cyclophosphamide dose <1800 mg/m2/day in protocols.
        • IV: Reported regimens variable: Mesna doses equivalent usually 60% to 100% of the cyclophosphamide daily dose although some protocols have used up to 160%.
          • Short IV infusion (intermittent): Mesna dose equal to 60% of the cyclophosphamide dose given in 3 divided doses (0, 4, and 8 hours after the start of cyclophosphamide) has been used by some centers; others have used a mesna dose equal to 100% of the cyclophosphamide dose as short IV infusions in 5 divided doses (0, 3, 6, 9, and 12 hours after the start of cyclophosphamide) (Gal 2007).
          • Continuous IV infusion: Some centers have used a mesna dose equal to 60% of the cyclophosphamide dose as a continuous IV infusion beginning 15 to 30 minutes before the first cyclophosphamide dose and completed at least 8 hours after the end of the cyclophosphamide infusion.
        • Oral: Some centers have used a total mesna dose equal to 100% of the cyclophosphamide dose, begin with IV dose equal to 20% for initial dose followed by oral dose at 40% of the cyclophosphamide dose at 2 and 6 hours after start of cyclophosphamide; Note: Typically, oral doses of mesna are twice the IV dose.
      • High-dose cyclophosphamide: Note: Some pediatric oncology experts have defined cyclophosphamide dose ≥1800 mg/m2/day in protocols: IV: Some centers have used a mesna dose equal to 100% of the cyclophosphamide dose as short IV infusions in 5 divided doses (0, 3, 6, 9, and 12 hours after the start of) (Gal 2007) or as a continuous IV infusion beginning 15 to 30 minutes before the first cyclophosphamide dose.
    • Other dosing strategies have been used in combination with cyclophosphamide for specific regimens/protocols: Limited data available: HDCAV/IE regimen for Ewing sarcoma: Children and Adolescents: IV: 2100 mg/m2/day continuous infusion (mesna dose is equivalent to the cyclophosphamide dose) for 2 days with cyclophosphamide infusion during cycles 1, 2, 3, and 6 (Kolb 2003).
  • reference:

2022-11-01

[Teicoplanin Dose]

  • blood creatinine readings reported:
    • 2022-01-10 1.64mg/dL
    • 2022-01-08 1.83mg/dL
    • 2022-01-06 1.72mg/dL
    • 2022-01-03 1.31mg/dL
  • teicoplanin has been administered since 2022-01-06, the elevated serum creatinine maintains stable for half week, no dose adjustment needed for now, keep monitoring renal function as regular.

700904907

230707

[diagnosis] - 2023-03-09 admission note

  • Malignant neoplasm of sigmoid colon
  • Adenocarcinoma of sigmoid colon with obstruction s/p colostomy (2023-01-05), and s/p Exp. Lap with sigmoidectomy, adhesiolysis, removal of some tumor seedings and closure of T-loop colostomystatus post open sigmoidectomy on 2023/02/03, pT4aN0M1c(0/19), LVI(+), PNI(+), CRM(+), stage IVc (metastases of omentum, low abdomen wall and pelvic seedings, carcinomatosis)
  • Hypertensive heart disease without heart failure
  • Mixed hyperlipidemia
  • Type 2 diabetes mellitus with hyperglycemia

[past history] - 2023-03-09 admission note

  • under medication control
    • HTN
      • Norvasc 5mg/tab 0.5# PO QD, Hyzaar 100mg & 12.5mg/tab 1# PO QD, Coxine 20mg/tab 1# PO QD, Concor 5mg/tab 1# PO QD
    • DM
      • Dibose F.C. 100mg/tab 1# PO TIDAC, Uformin 500mg/tab 1# PO TIDCC, Kludone MR 60mg/tab 1# PO BID, Canaglu 100mg/tab 1# PO QDAC
  • surgical
    • thyroid goiter s/p op
    • s/p LC    
    • T-loop colostomy on 2023/01/05
    • Exp. Lap with sigmoidectomy, adhesiolysis, removal of some tumor seedings over omentum, pelvic and abdominal wall and closure of T-loop colostomy on 2023/02/02
    • left cephalic vein port A implantation on 2023/02/22

[allergy]

  • NKDA

[family history]

  • No family history of chronic medical disease or cancer  

[exam findings]

  • 2023-02-06 All-RAS + BRAF
    • ALL-RAS: Detected (KRAS codon 12 GGT > GAT, p.G12D)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-02-03 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Sigmoid colon, open sigmoidectomy — Adenocarcinoma, moderately differentiated
      • Resection margins, open sigmoidectomy — Radial margin is invoved by carcinoma
      • Lymph nodes, mesocolic, open sigmoidectomy — Negative for malignancy (0/19)
      • Omentum, tumor removal — Metastatic adenocarcinoma
      • Pelvis, tumor removal — Metastatic adenocarcinoma
      • Colostomy, closure T-loop colostomy — Metastatic adenocarcinoma
      • Pathology stage: pT4aN0M1c; Stage IVC
    • MACROSCOPIC EXAMINATION
      • Operation procedure: Open sigmoidectomy + removal tumor seeding + closure T-loop colostomy
      • Specimen site: Sigmoid colon, omentum, pelvic tissue, and colostomy
      • Specimen size: 10.5 cm (sigmoid colon), 18 x 12 x 5 cm (omentum), multiple pieces up to 1.5 x 1.2 x 1.2 cm (pelvic seeding) and 8 x 4 x 3 cm (colostomy)
      • Tumor size: 6.5 x 3.5 cm
      • Tumor location: 2.5 cm away from the one resection margin
      • Depth of invasion grossly: Pericolic soft tissue
      • Mucosa elsewhere: Unremarkable
      • Representative parts are taken for section and labeled: A1-A5= tumor, A6-A8 and X1-X4= regional lymph nodes, B= proximal end, C= distal end, D1-D2= omentum, E1-E2= pelvic seeding, F1-F2= colostomy
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: Moderately differentiated
      • Depth of invasion: To serosa
      • Angiolymphatic invasion: Present
      • Perineural invasion: Present
      • Tumor cell budding: High
      • Circumferential (radial) margin: Involved by carcinoma
      • Lymph node metastasis, mesocolic: Negative for malignancy (0/19) (No. Positive / No. Total)
      • Extranodal involvement: N/A
      • Omentum: Metastatic adenocarcinoma
      • Pelvic seeding: Metastatic adenocarcinoma
      • Colostomy: Metastatic adenocarcinoma
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): pT4a (Tumor invades serosa)
        • Regional Lymph Nodes (pN): pN0 (no regional lymph node metastasis)
        • Distant Metastasis (pM): pM1c (metastatic to the peritoneal surface)
      • Type of polyp in which invasive carcinoma arose: Tubulovillous adenoma
      • Additional pathologic findings: None identified
      • Tumor regression grading S/P CCRT: N/A
      • IHC (S2023-00555): EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • 2023-02-01 ECG
    • Possible Left atrial enlargement
    • Septal infarct, age undetermined
    • Nonspecific ST and T wave abnormality
  • 2023-01-09 Patho - colon biopsy
    • Sigmoid colon, 30 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    • The sections show adenocarcinoma, composed of columnar neoplastic cells, arranged in glandular and cribriform patterns with desmoplastic stromal reaction.
    • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
  • 2023-01-09 Simoidoscopy
    • One tumor mass was noted in the sigmoid colon with lumen obstruction, Size 4.0 cm. ( 30 cm from anal verge)
  • 2023-01-04 KUB
    • S/P operation with retention of surgical clips.
    • Compression fracture of T12.
  • 2023-01-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (73.4 - 22.5) / 73.4 = 69.35%
      • M-mode (Teichholz) = 69.3
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Mild MR, trivial TR
    • Impaired LV relaxation
    • Mildly dilated LA, thick IVS
  • 2023-01-02 CT - abdomen
    • IMP: Sigmoid colon segmental wall thickening with ascites formation. Sigmoid colon cancer is favored.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T: T2(T_value) N: N0(N_value) M: M0(M_value) STAGE: ____(Stage_value)
  • 2022-12-30 Abdomen - standing (diaphragm)
    • S/P operation with retention of surgical clips.
    • Degeneration and spondylosis of L-S spine.
  • 2020-12-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (63.1 - 12.7) / 63.1 = 79.87%
      • M-mode (Teichholz) = 79.9
    • Normal heart size.
    • Normal RV & LV systolic function. No regional wall motion abnormalities.
    • Impaired LV relaxation.
    • Mild mitral regurgitation.
    • Mild tricuspid regurgitation.
    • Mild pulmonic regurgitation
  • 2020-11-20 Treadmill Exercise Test
    • Resting ECG : non specific ST changes
    • ST changes during TET : 1-mm upslope ST-segment depression at leads II, III, AVF and V4-6 at recovery phases
    • Interpretation : Submaximal heart rate achievement, Non-diagnostic test
  • 2017-08-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (87.9 - 19.5) / 87.9 = 77.82%
      • M-mode (Teichholz) = 77.8
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Trivial MR
    • Mildly thicked IVS

[MedRec]

  • 2023-07-04 SOAP Hemato-Oncology
    • P
      • During admission, arrange colonscopy but no biopsy due to avastin use.
      • consult CV due to SBP 160
  • 2023-04-25 SOAP Hemato-Oncology
    • Prescription
      • Smecta (dioctahedral smectite 3mg) 1# TIDAC
      • Ulstop (famotidine 20mg) 1# BID
      • loperamide 2mg 1# PRNQD
  • 2023-03-09 ~ 2023-03-11 POMR Hemato-Oncology
    • Discharge disgnosis
      • Adenocarcinoma of sigmoid colon with obstruction s/p colostomy on 2023/01/05, and s/p Exp.Lap with sigmoidectomy, adhesiolysis, removal of some tumor seedings and closure of T-loop colostomy s/p open sigmoidectomy on 2023/02/03, pT4aN0M1c(0/19), LVI(+), PNI(+), CRM(+), stage IVC (metastases of omentum, low abdomen wall and pelvic seedings, carcinomatosis), KRAS codon 12 GGT>GAT, p.G12D, s/p FOLFOX from 2023/03/09~
      • Hypertensive heart disease without heart failure
      • Type 2 diabetes mellitus with hyperglycemia
      • Mixed hyperlipidemia
  • 2023-03-07 SOAP Hemato-Oncology
    • O: Now on FOLFOX +/- bevacizumab
    • P: C/T with FOLFOX +/- bevacizumab
  • 2023-03-04 SOAP Colorectal Surgery
    • S: doing well, s/p port-A, suggest CCRT followed by C/T + target
    • P:
      • stage IVc, suggest CCRT (pelvic tumor seedings), then C/T + target therapy
      • refer to oncologist
  • 2023-02-20 SOAP Radiation Oncology
    • A/P: CT-simulation will be arranged on 20230306. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the visible residual tumor and preOP S-colon tumor bed to 54 Gy/ 30 fx. RT will start around 20230308.
  • 2023-02-14 SOAP Colorectal Surgery
    • A: Adenocarcinoma of sigmoid colon with obstruction s/p colostomy (2023-01-05), and s/p Exp.Lap with sigmoidectomy, adhesiolysis, removal of some tumor seedings and closure of T-loop colostomystatus post open sigmoidectomy on 2023/02/03, pT4aN0M1c(0/19), LVI(+), PNI(+), CRM(+), stage IVc (metastases of omentum, low abdomen wall and pelvic seedings, carcinomatosis)
    • P:
      • stage IVc, suggest CCRT, then C/T+ target therapy
      • check RAS status
  • 2023-01-20 SOAP Colorectal Surgery
    • S
      • Tumor of sigmoid colon with obstruction status post T-loop colostomy on 2023/01/05
      • doing well, arrange staged surgery
    • A: Adenocarcinoma of S-colon with obstruction s/p colostomy (2023-01-05)
    • P: admission (20230201), ERAS, then laparoscopic sigmoidectomy+ close colostomy (20230202, BUT may laparotomy)
  • 2023-01-10 SOAP Metabolism
    • Prescription
      • Zulitor (pitavastatin 4mg 1# QN
      • Canaglu (canagliflozin 100mg) 1# QDAC
      • Kludone (gliclazide 60mg) 1# BID
      • Uformin (metformin 500mg) 1# TIDCC
      • Dibose (acarbose 100mg) 1# TIDAC
  • 2023-01-03 SOAP Colorectal Surgery
    • S: Intermittent and progressively abdominal cramping pain with difficult passage of stool in recent 2 weeks and obstipation for 4-5 days
    • O: 2023/01/02 CT: ABD - Imp: Sigmoid colon segmental wall thickening with ascites formation. Sigmoid colon cancer is favored. Dilated loops of colon with wall edema(+)
    • A: Tumor of S-colon with obstruction
    • P: admission, nutritional support (PPN), clear liquid diet, suggest colostomy first (20230105) followed by sigmoidectomy 3-4 weeks later
  • 2017-01-18 SOAP Metabolism
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, uncontrolled [E11.65]
      • Gouty arthropathy [M10.00]
      • HCVD, malignant without CHF [I11.9]
      • Mixed hyperlipidemia [E78.2]
      • Other specified acquired hypothyroidism [E01.8]
      • Obesity, unspecified [E66.9]
    • Prescription
      • Jardiance (empagliflozin 25mg) 1# QD
      • Uformin (metformin 500mg) 1# TIDCC
      • Glucobay (acarbose 100mg) 1# TIDAC
      • NovoNorm (repaglinide 1mg) 2# TIDAC
  • 2017-01-03 SOAP Cardiology
    • Diagnosis
      • Other and unspecified angina pectoris [I20.9]
      • HCVD, benign without CHF [I11.9]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Prescription
      • Hyzaar (losartan 100mg + hydrochlorothiazide 12.5mg) 0.5# QD
      • Coxine (isosorbide-5-mononitrate 20mg) 1# QD
      • Concor (bisoprolol 5mg) 1# QD

[surgical operation]

  • 2023-02-02
    • Surgery
      • Exp. Lap with sigmoidectomy, adhesiolysis, removal of some tumor seedings over omentum, pelvic and abdominal wall and closure of T-loop colostomy        
    • Finding
      • Much adhesions and tumor seedings was found after initial laparoscopic procedure, thus we chenged to open laparotomy method    
      • A locally advanced tumor over S-colon with multiple tumor seedings over pelvic wall, and near bil.overy sites, pelvic floor, low abdominal wall and great omentum. Excisions of the gross seeding tumors was performed except seeding tumors at pelvic floor (densely invasion), some clips was put around pelvic floow and bil.ovary sites for possible further R/T treatment.    
      • Sigmoidectomy was done and anastomosis was achieved using endo-GIA EZ/green 60+ CDH-29+ TISSEEL. Air test is ok.     
      • Closure of T-loop colostomy was also done by segmental resection of T-colon and anastomosis was achiseved using hand-sewn side-to-side anastomosis (endo-GIA EZ/green for both ends, then 4/0 PDS + silk)    
      • The whole procedure was smooth. Blood loss was anout 100ml.  
  • 2023-01-05
    • Surgery
      • T-loop colostomy        
    • Finding
      • Dilation of colon due to S-colon tumor obstruction    
      • T-llop colostomy was created at RUQ adbomen

[immunochemotherapy]

  • 2023-06-20 - bevacizumab 5mg/kg 300mg NS 100mL + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-31 - bevacizumab 5mg/kg 300mg NS 100mL + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-04 - bevacizumab 5mg/kg 300mg NS 100mL + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-14 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-27 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-09 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 250mL 10min + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-07-07

[reconciliation]

  • The patient has two prescriptions that are eligible for refill, one given by our department of metabolism and endocrinology dated 2023-04-11, which includes Canaglu (canagliflozin), Zulitor (pitavastatin), Kludone (gliclazide), Uformin (metformin), and Dibose (acarbose) to address her type 2 diabetes mellitus. The other prescription was provided by the cardiology department on 2023-06-30, encompassing Concor (bisoprolol), Coxine (isosorbide-5-mononitrate), Hyzaar (losartan, hydrochlorothiazide), and Norvasc (amlodipine) for her hypertensive heart disease and angina pectoris. All these medications are accounted for in the present medication list and no discrepancies have been detected during the reconciliation process.
  • Be aware that the refillable prescription’s validity is capped at a duration of 3 months. As such, the supply of medication prescribed by the metabolism and endocrinology department should be nearing exhaustion soon. Please ensure to advise the patient about the necessity to schedule another appointment with our endocrinologist for a prescription renewal.

[optionally increase Norvasc to 1# daily]

  • If the patient’s SBP persistently remains above 140 in most situations, as observed at 14:22 (163mmHg) and 16:52 (150mmHg) on 2023-07-06, it would be advisable to consider increasing the dosage of Norvasc (amlodipine 5mg) from 0.5# to 1# QD.

2023-06-21

  • This patient has two refillable prescriptions, one from our Metabolism and Endocrinology department issued on 2023-04-11 for Canaglu (canagliflozin), Zulitor (pitavastatin), Kludone (gliclazide), Uformin (metformin), and Dibose (acarbose) to manage her type 2 DM. The other prescription was issued on 2023-03-24 by the Cardiology department for Concor (bisoprolol), Coxine (isosorbide-5-mononitrate), Hyzaar (losartan, hydrochlorothiazide), and Norvasc (amlodipine) for her hypertensive heart disease and angina pectoris. All these medications have been integrated into the current formulary with no reconciliation issues found.
  • Please note that the maximum validity duration of a refillable prescription is limited to 3 months. Therefore, the medication prescribed by the Cardiology department should soon be depleted. Please remind the patient to revisit our cardiologist to renew her prescription.

2023-06-01

  • According to PharmaCloud, this patient visited a local clinic for heartburn on 2023-05-03. However, the prescribed medication for a duration of 3 days is now expired. Currently, no issues with medication reconciliation have been identified.

  • Aside from anemia, the laboratory results from 2023-05-31 were largely within normal limits. There appears to be a downward trend in HGB levels in this patient following the initiation of FOLFOX treatments on 2023-03-09, with hemoglobin levels not fully recovering. This trend warrants continued monitoring.

    • 2023-05-31 HGB 9.9 g/dL
    • 2023-04-25 HGB 10.5 g/dL
    • 2023-03-22 HGB 10.7 g/dL
    • 2023-02-03 HGB 11.8 g/dL

2023-05-05

  • Although the patient is taking metformin, acarbose, gliclazide, and canagliflozin, all serum glucose measurements during this hospitalization were above 200 mg/dL, suggesting inadequate glycemic control.
  • Bevacizumab, part of the patient’s current treatment regimen, has been associated with hyperglycemia (26% of cases). If elevated blood glucose levels continue to be a problem, it may be worthwhile to consider adding insulin to help control the patient’s blood glucose.

2023-03-28

  • Despite receiving metformin, acarbose, gliclazide, and canagliflozin, the patient has experienced episodes of serum glucose above 200mg/dL during her current hospital stay, indicating poor glycemic control. It is recommended that the patient be arranged to the metabolism and endocrinology outpatient department to renew her prescription for diabetes medications, as her previous refillable prescription is only valid for a limited time (approximate early Apr 2023).

2023-03-10

  • The patient has an underlying condition of type 2 diabetes with blood sugar levels fluctuating between 272, 263, and 159mg/dL in high variability, serum glucose management might be further improved. By the way, the patient’s hypertension is well managed, and their vital signs are stable according to the TPR panel.
  • The evidence supports that the patient’s diabetes is showing a worsening trend in the mid-term blood sugar index. It is recommended to measure a new value for HbA1c.
    • 2022-12-30 HbA1c 8.1 %
    • 2022-10-07 HbA1c 7.9 %
    • 2022-07-15 HbA1c 7.0 %

700068505

230706

{Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC}

  • diagnosis
    • 2022-08-18 discharge diagnosis
      • Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC s/p bone radiotherapy and chemotherapy with Avastin/FOLFIRI from 2021/08/04, partial response
      • Hypertensive heart disease without heart failure
      • Type 2 diabetes mellitus without complications
      • Hyperlipidemia, unspecified
      • Chronic viral hepatitis B without delta-agent
  • past history (as of Aug 2022)
      1. Hypertension and hyperlipidemia for 20 years with regular medication at Tzu Chi H.
      1. Hyperuricemia and gout for years with irregular medication.
      1. Pre-diabetes mellitus was noted for 13 years with diet control.
      1. Birth control s/p vasectomy at 2013-06-19 at Tzu Chi H.
  • initial presentation
    • 2021 Feb low back pain, pain aggravated when changing position

[lab data]

  • 2021-07-20
    • All-RAS mutation detected
    • BRAF mutation not detected

[exam findings]

  • 2023-06-15 CT - abdomen
    • History and indication: Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Progression of peritoneal seeding, LNs, bony/ liver and lung metastases. Ascites and right pleural effusion. General subcutaneous edema.
      • S/P Port-A infusion catheter insertion.
      • Renal cysts (up to 5.7cm).
      • Hyperplasia of bil. adrenal glands.
      • Atherosclerosis of aorta.
      • S/P posterior longitudinal transpedicular screws and rods fixation.
    • IMP:
      • Progression of peritoneal seeding, LNs, bony/ liver and lung metastases. Ascites and right pleural effusion. General subcutaneous edema.
  • 2023-06-14, -04-19, -04-03 Forearm LT
    • Pathologic fracture of left proximal radius S/P external fixation.
  • 2023-04-18 AP and lateral films of the T-L spine
    • S/P posterior longitudinal transpedicular screws and rods fixation.
    • Degeneration and spondylosis of L-S spine.
  • 2023-04-18 KUB
    • S/P foley catheter indwelling.
    • Degeneration and spondylosis of L-S spine.
  • 2023-03-14 T-spine AP + Lat.
    • S/P posterior instrumentation fixation from T7 To T9.
    • Spondylosis of the T-spine and L-spine .
  • 2023-03-13 Patho - interveterbral disc (Y1)
    • Bone and joint, vertebra, thoracic 8, excision of intraspinal malignant tumor and posterior spinal fusion with instrumentation — adenocarcinoma.
    • Section shows pieces of bone, degenerated ligament, and cartilage with focal adenocarcinoma.
    • IHC stains: CDX2 (+), CK7 (-), CK20 (+), PSA- (-), TTF-1 (-), a pattern, in favor of colorectal origin.
  • 2023-03-11 Long Bones series
    • Osteolytic fracture of left proximal radius is noted that is c/w bony metastasis.
  • 2023-03-09 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-03-09, 2022-10-07 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2023-03-08 MRI - T-spine
    • Indication: Sigmoid cancer with T-spine bone metastasis, T3N2aM1c, stage IVC, with severe back pain
    • With and Without-contrast multiplanar spine MRI revealed
      • severe extenal mass effect on the T8 cord.
      • heterogeneous enhancing tumors in the T8, L2, S1, S2, S3 and S4 vertebral bodies with peri-vertebral invasion and invasion the the T7, T8 and T9 spinal canal.
      • multiple hepatic metastasis.
    • IMP
      • multiple vertebral body metastasis, more on the T8 vertebral body with significant mass effect on the T8 cord.
      • multiple hepatic metastasis.
  • 2022-12-28 Tc-99m MDP whole body bone scan
    • As compared with the previous study on 2022-10-04, some new bone lesions in the right rib cage nd left S-I joint are noted and most of the previous bone lesions are more evident, suggesting multiple bone metastases in progression.
    • Suspected benign lesions in the maxilla, sternum and right shoulder.
  • 2022-12-28 CT - abdomen
    • Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC s/p bone radiotherapy and chemotherapy with Avastin/FOLFIRI from 2021/08/04, partial response
    • Findings:
      • Prior CT identified several metastases on both hepatic lobes are noted again, increasing in size in most lesions.
      • Prior CT identified multiple metastases in the omentum and mesentery are noted again, stable in size.
      • Prior CT identified regional/ non-regional LNs, are noted again, stable in size.
      • Prior CT identified lung metastases are noted again, decreasing in size.
      • Prior CT identified bony metastases in right sacrum and bilateral acetabulum, and T8 vertebral body are noted again, stable in size.
      • Hyperplasia of bil. adrenal glands.
      • Renal cysts (up to 3.5cm).
    • Impression:
      • Prior CT identified several metastases on both hepatic lobes are noted again, increasing in size in most lesions. please correlate with clinical condition.
  • 2022-10-05 CT - abdomen
    • Indication: Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC s/p bone radiotherapy and chemotherapy with Avastin/FOLFIRI from 2021/08/04, partial response
    • Findings:
      • Prior CT identified several metastases on both hepatic lobes are noted again, stable in size in few lesions. However, three of them show mild increasing in size.
      • Prior CT identified multiple metastases in the omentum and mesentery are noted again, stable in size.
      • Prior CT identified regional/ non-regional LNs, are noted again, stable in size.
      • Prior CT identified two lung metastases are noted again, stable in size.
      • Renal cysts (up to 3.5cm).
      • Hyperplasia of bil. adrenal glands.
    • Impression:
      • Prior CT identified several metastases on both hepatic lobes are noted again, stable in size in few lesions. However, three of them show mild increasing in size. please correlate with clinical condition.
  • 2022-10-04 Tc-99m MDP whole body bone scan
    • As compared with the previous study on 2022-06-29, some new bone lesions are noted and most of the previous bone lesions are a little more evident, suggesting multiple bone metastases in progression.
    • Suspected benign lesions in the maxilla, sternum and right shoulder.
  • 2022-06-30 CT - abdomen
    • Findings
      • Stable condition of S-colon cancer, regional/ non-regional LNs, peritoneal seeding, bony/liver and lung metastases.
      • S/P Port-A infusion catheter insertion.
      • Renal cysts (up to 3.5cm).
      • Hyperplasia of bil. adrenal glands.
      • Atherosclerosis of aorta.
    • IMP:
      • Stable condition of S-colon cancer, regional/non-regional LNs, peritoneal seeding, bony/liver and lung metastases.
  • 2022-06-29 Tc-99m MDP whole body bone scan
    • Most of the previous metastatic bone lesions come to less evident compared with the previous study on 2021-10-06; a lesion in middle T-spine, however, becomes more prominent, and the nature is to be determined (severe DJD, new bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
    • Suspected benign lesions in the maxilla, sternum, L3-4 spine, and bilateral shoulders.
  • 2022-03-31 CT - abdomen, pelvis
    • Stable condition of S-colon cancer, regional/non-regional LNs, peritoneal seeding, bony/ liver and lung metastases.
  • 2022-01-24 2D transthoracic echocardiography
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA, concentric LVH; impaired LV relexation
    • Trivial MR, mild AR and trivial TR
    • Preserved RV systolic function
  • 2022-01-06 CT
    • Much regression of S-colon cancer, regional/non-regional LNs, peritoneal seeding, bony/liver and lung metastases.
  • 2021-10-06 Tc-99m MDP whole body bone scan
    • Multiple hot spots in bilateral rib cages and increased activity in the sacrum, bilateral S-I joints, and right acetabulum, cancer with bone metastasis is highly suspected.
    • Suspected benign lesions in the maxilla, sternum, middle T-spine, L3-4 spine, bilateral shoulders and right foot.
  • 2021-10-05 CT
    • Diffuse metastatic tumors in the liver, peritoneum, bones, metastatic lymph nodes in paraaortic and left neck.
    • Regression as compare with CT study on 2021-6-21.
    • Mild pericardial effusion.
  • 2021-06-25 Patho - Colon biopsy
    • Colon, sigmoid 20cm above anal verge, biopsy - Adenocarcinoma.
    • IHC: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
  • 2021-06-22 Tc-99m MDP whole body bone scan
    • Increased activity in the sacrum, right S-I joint and right iliac bone. Bone metastases should be considered first.
    • Increased activity in the middle T-spines and L4 spine. Either degenerative change or bone metastases may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Multiple hot spots in the sternum and bilateral rib cages and mildly increased activity in bilateral femoral trochanters. The nature is to be determined (bone metastases? post-traumatic change? other nature?).
    • Increased activity in bilateral shoulders. Benign joint lesions is more likely.
  • 2021-06-21 CT
    • Impression (Imaging stage): T3N2aM1c, stage IVC
  • 2021-06-15 Patho - Bone pathologic fragment, at right first sacral tumor/mass.
    • Labeled as “sacrum”, CT guided biopsy - adenocarcinoma.
    • IHC:
      • CK20(+), CDX2(+): please check gastrointestinal tract first.
      • PSA(-): dis-favor prostatic origin.
      • TTF-1(-), Napsin-A(-): dis-favor pulmonary origin.
  • 2021-06-02 MRI - L-spine:
    • tumors in the sacrum.

[consultation]

  • 2023-04-20 Oral and Maxillofacial Surgery
    • Q: For 1) The area behind the left tooth has collapsed, and the tooth keeps scraping the tongue. 2) Xgeva use. We need your consultation for evaluation.
    • A
      • We are consulted for dental problem.
      • As the patient appeared with weakness muslce strength, we wil examine the condition at bedside this afternoon.
  • 2023-04-20 Orthopedics
    • Q: For left proximal radius pathological fracture was noted since 2023/03/11, we need your consultation for evaluation.
    • A:
      • 59 Male
      • Dx: Left proximal radius pathological fracture, displaced
      • Plan:
        • OPD f/u
        • Keep current management
        • Pain management
        • Surgical intervention not indicated due to poor prognosis of the underlying disease
  • 2023-03-11 Orthopedics
    • Q: For radial bone fracture
    • A
      • left proximal radius pathological fracture was noted
      • considering patient’s condition
      • splint immobilization and sling protection is suggested
  • 2023-03-09 Anesthesiology
    • Q
      • This time, for prepare 2023/03/10 T8 spine OP. Now, for anesthesia assessment. Thank you.
    • A
      • I’ve vistied the patient and reviewed the past history:
        • Pt: 58 y/o M
        • Current problem: T8 spine bone metastasis
        • Operation: intraspinal tumor excision on 3/10
        • Past History : Sigmoid cancer with lung, liver and bone metastasis s/p bone radiotherapy and chemotherapy; HTN, DM, HBV
        • GCS: E4 V5 M6
        • Vitals stable
        • Labs : Within acceptable range for anesthesia
          • Hb 12.7
          • EKG pending
          • CXR pending
        • 2021 Cardiac echo LVEF 75%
      • Assessment: ASA 3
      • Plan
        • We will arrange ETGA for this patient
        • The patient and his family have been informed on the anesthesia- and surgery-associated risks, including cardiovascular risks (hypotension, stroke, acute myocardial infarction, shock), pulmonary risks (hypoxia, pulmonary embolism,delay extubation) and other possible complications
        • Postoperative ICU care might be needed
  • 2023-03-08 Neurosurgery
    • Q
      • This 58-year-old man patient is a case of sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC s/p bone radiotherapy and chemotherapy with Avastin/FOLFIRI from 2021/08/04 to 2022/09/16 for 25 cycles, progression s/p palliative chemotherapy with FOLFOX from 2022/10/05 to 2023/02/21 for 9 cycles, progression of liver tumor and bone metastases. palliative radiotherapy evaluation of S-I joint, 1600cGy/8 fractions of the right SI joint to right hip area from 2023/02/15 to 2023/02/24. T-spine MRI on 2023/03/08 showed multiple vertebral body metastasis, more on the T8 vertebral body with significant mass effect on the T8 cord and multiple hepatic metastasis. Now, for evaluate T8 spine surgery of pain control. Thank you.
    • A
      • T8 spine surgery is indicative for the patient.
      • We will arrange operation for the patient this Friday. We will full explained risk and outcome to the patient and family.
  • 2023-02-09 Radiation Oncology
    • A
      • A: Adenocarcinoma of the sigmoid colon, stage cT3N2aM1c, with liver, lung, and bone metastasis, s/p palliative radiotherapy, with progression.
      • P: Radiotherapy is indicated for this patient with the following indicators: pain of the right SI joint to right hip area.
        • Goal: palliation
        • Treatment target and volume: right SI joint to right hip area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 1600cGy/8 fractions of the right SI joint to right hip area.
        • The treatment modality and the possible effects of re-irradiation were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2023-2-13.
  • 2021-07-14 Rehabilitation
    • Assessment
      • sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC s/p Palliative radiotherapy to sacrum, right S-I joint and peripheral involved area from 2021/07/01~2021/07/14 for 2000cGy/10 fractions. Chemotherapy with FOLFOX(Oxalip 85mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2)(C1D1) from 2021/07/02~2021/07/04.
      • Polio with LLE weakness
    • Plan
      • Rehabilitation programs: Bedside PT rehabilitation programs
      • Goal: recondition, improve endurance and muscle strength
  • 2021-07-01 Dermatology
    • This patient suffered from erytheamtous plaque on back and buttock for days
    • Imp: Tinea corporis
    • Suggestion: Excelderm cream x 2 tubes/bid

[surgical operation]

  • 2023-03-10
    • Surgery: Excision of intraspinal malignant tumor and posterior spinal fusion with instrumentation, microscopy and fluoroscopy
    • Finding: Thoracic 8 level pathological fracture (metastaticl lesion)

[chemoimmunotherapy]

  • 2023-06-12 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRINOX, no 5-FU bolus, reduced Oxa)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-17 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRINOX, no 5-FU bolus for 20230515 WBC 2.9K)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-24 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRINOX)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-31 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRINOX) (20230419 WBC 2.27K)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-21 - oxaliplatin 65mg/m2 114mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-07 - oxaliplatin 65mg/m2 114mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-17 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3
  • 2022-12-29 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3
  • 2022-12-12 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3
  • 2022-11-28 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3
  • 2022-11-10 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3
  • 2022-10-24 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3
  • 2022-10-06 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3
  • 2022-09-16 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

    • diphenhydramine 30mg + dexamethasone 4mg + palonosetron 250ug + atropine 0.5mg SC
  • 2022-08-30 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

    • diphenhydramine 30mg + dexamethasone 4mg + palonosetron 250ug + atropine 0.5mg SC
  • 2022-08-15 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

  • 2022-08-01 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

  • 2022-07-15 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

  • 2022-06-30 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

  • 2022-06-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

  • 2022-05-25 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

  • 2022-05-04 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

  • 2022-04-19 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

  • 2022-03-30 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

  • 2022-03-14 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

  • 2022-02-24 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

  • 2022-02-11 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

  • 2022-01-24 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

  • 2022-01-03 - irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

  • 2021-12-20 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 400mg/m2 690mg 10min + fluorouracil 2400mg/m2 4100mg 46hr (FOLFIRI, Q2W)

  • 2021-11-23 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 400mg/m2 690mg 10min + fluorouracil 2400mg/m2 4100mg 46hr (FOLFIRI, Q2W)

  • 2021-11-10 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 400mg/m2 690mg 10min + fluorouracil 2400mg/m2 4100mg 46hr (FOLFIRI, Q2W)

  • 2021-10-22 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

  • 2021-10-07 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

  • 2021-09-14 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

  • 2021-09-01 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

  • 2021-08-19 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

  • 2021-08-04 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

  • 2021-07-16 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFOX, Q2W)

  • 2021-07-02 - oxaliplatin 85mg/m2 130mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 3900mg 46hr (FOLFOX, Q2W)

==========

2023-07-06

  • This patient has only been visiting our hospital for the past three months, primarily to the Hemato-Oncology Department and secondarily to the Cardiology Department. The former is for the treatment of sigmoid colon cancer, while the latter is for the treatment of type 2 diabetes mellitus and hypertensive heart disease.
  • The medications Concor (bisoprolol), Doxaben (doxazosin), Forxiga (dapagliflozin), Hyzaar (losartan, hydrochlorothiazide), Pravafen (pravastatin, fenofibrate), and Zanidip (lercanidipine) prescribed by our cardiologist on 2023-04-12 have been added to the active formulary. No medication reconciliation issues were identified.

2023-06-13

  • Based on the PharmaCloud database, it’s evident that this patient has been receiving outpatient and inpatient medical services exclusively at our hospital for the past three months. As per the records, our Cardiologist prescribed a refillable order of Concor (bisoprolol), Doxaben (doxazosin), Forxiga (dapagliflozin), Hyzaar (losartan, hydrochlorothiazide), Pravafen (pravastatin, fenofibrate), and Zandip (lercanidipine) on 2023-04-12. These medications are accurately reflected in the patient’s active medication list. Consequently, no medication reconciliation issues have been identified.

  • Lab data showed a worsening liver function. The patient is currently prescribed OxyNorm (oxycodone 5mg). The package insert for OxyNorm indicates that plasma concentrations may increase in patients with mild to moderate renal impairment and mild hepatic impairment. Therefore, a conservative approach should be taken when adjusting the dosage. For patients with hepatic impairment, the starting dose should be one third to half of the usual initial dose, followed by careful dose adjustment. It is worth noting that 10 mg oral oxycodone is equivalent to 20 mg oral morphine. There is no evidence to suggest that the current dosage of 5mg Q6H is inappropriate. However, close monitoring for potential adverse reactions is recommended.

    • 2023-06-12 Bilirubin total 2.06 mg/dL
    • 2023-05-15 Bilirubin total 0.90 mg/dL
    • 2023-06-12 Bilirubin direct 1.15 mg/dL
    • 2023-05-15 Bilirubin direct 0.26 mg/dL
    • 2023-06-12 S-GOT/AST 74 U/L
    • 2023-05-15 S-GOT/AST 45 U/L
    • 2023-06-12 S-GPT/ALT 24 U/L
    • 2023-05-15 S-GPT/ALT 13 U/L

2023-06-12

  • The most recent lab data (2023-05-16) shows a direct bilirubin level of 0.26mg/dL and an AST level of 45U/L, both slightly exceeding the upper limit of normal. This could indicate potential liver insufficiency. Since fentanyl is primarily metabolized into inactive metabolites in the liver, hepatic insufficiency could potentially slow its elimination. Therefore, patients with impaired liver function using the fentanyl transdermal patch should be monitored for signs of toxicity, and the dose might need to be reduced if necessary. Please update the patient’s liver function readings. If mild to moderate hepatic impairment is confirmed, then the dose is adviced to be reduced by 50%. It’s not recommended to use the fentanyl patch in patients with severe hepatic impairment.

  • The patient was treated with FOLFIRI from 2021-08 to 2022-09, then with FOLFOX from 2022-10 to 2023-02, and then with FOLFIRINOX since 2023-03. However, due to the obvious upward trend of tumor markers, it is possible that the disease may have developed further resistance to these changed regimens.

    • 2023-06-12 CEA 733.40 ng/mL
    • 2023-05-16 CEA 621.44 ng/mL
    • 2023-04-19 CEA 676.57 ng/mL
    • 2023-03-31 CEA 450.06 ng/mL
    • 2023-01-11 CEA 189.62 ng/mL
    • 2022-11-22 CEA 156.62 ng/mL
    • 2022-10-19 CEA 53.26 ng/mL
    • 2022-09-13 CEA 33.27 ng/mL
    • 2023-05-16 CA199 1794.87 U/mL
    • 2023-04-19 CA199 1447.66 U/mL
    • 2023-03-31 CA199 1173.49 U/mL
    • 2023-01-11 CA199 497.53 U/mL
    • 2022-11-22 CA199 285.59 U/mL
    • 2022-10-19 CA199 180.53 U/mL
    • 2022-09-13 CA199 156.34 U/mL
  • The current FOLFIRINOX regimen is being administered without a bolus of 5-FU and with a reduced dose of oxaliplatin, due to observed adverse events and/or patient’s performance status. This is considered an appropriate adjustment and there are no issues identified with this approach.

2023-05-16

  • This patient has been diagnosed with sigmoid colon cancer that has metastasized to the lungs, liver and bones. He has also undergone posterior longitudinal transpedicular screw and rod fixation and is dealing with degeneration and spondylosis of the L-S spine as well as a pathologic fracture of the left proximal radius for which he has undergone external fixation.
  • Given the high risk of fractures, it is advisable to consider adding therapeutics such as oral bisphosphonates, zoledronic acid, vitamin D3, denosumab, or teriparatide to the patient’s treatment regimen, as these may help reduce the risk of potential fractures. ref: Bone health in cancer: ESMO Clinical Practice Guidelines https://www.annalsofoncology.org/article/S0923-7534(20)39995-6/fulltext

2022-12-28

  • It has been arranged for a CT and bone scan to be performed during this hospitalization at intervals of three months.
  • The patient’s blood pressure has returned to normal range (186/121 -> 135/72 mmHg) and there are no abnormalities in his vital signs or 2022-12-27 laboratory results.
  • The underlying conditions of hypertension, diabetes mellitus, hyperlipidemia, and hepatitis B are appropriately managed with self-carried medication without complications.

2022-12-13

  • The blood pressure was still high (at around 170/95) under Concor (bisoprolol), Doxaben (doxazosin), Hyzaar (losartan, hydrochlorothiazide) and Zanidip (lercanidipine).
  • For hypertensive emergencies, hydralazine 10 to 20 mg every 4 to 6 hours might be used (a beta-blockers has been used to prevent reflex tachycardia).

2022-11-29

  • After image studies in early Oct 2022 revealed a number of lesions with a mild increase in size, and multiple bone metastases in progress, the regimen was changed from FOLFIRI to FOLFOX.

  • In the past three months, certain tumor markers have been elevated.

    • CEA
      • 2022-11-22 CEA 156.62 ng/mL
      • 2022-10-19 CEA 53.26 ng/mL
      • 2022-09-13 CEA 33.27 ng/mL
    • CA199
      • 2022-11-22 CA199 285.59 U/mL
      • 2022-10-19 CA199 180.53 U/mL
      • 2022-09-13 CA199 156.34 U/mL
  • As SBP highly fluctuated between 136 and 231 under treatment with (patient-carried medication) Concor (bisoprolol), Zanidip (lercanidipine) and Hyzaar (losartan + hydrochlorothiazide), please monitor this closely. The drug Atanaal (nifedipine 5mg) 1# PRNQ6H might be considered in case where the blood pressure exceeds 200mmHg.

  • SBP flucturated at a wide range 136~231mmHg under patient-carried antihypertensive agents Concor (bisoprolol) and Hyzaar (losartan + hydrochlorothiazide), please keep a closer eye on it.

  • Pre-prandial blood sugar levels were higher than 170mg/dL for 2 days; metformin 500mg BID is recommended.

2022-10-25

  • The blood pressure remains high, around 185/100, since this hospital stay, despite the use of current antihypertensive medications: Concor (bisoprolol 5mg) 1.5# QD + Hyzaar (losartan 100mg + hydrochlorothiazide 12.5mg) 1# QD + Zanidip (lercanidipine 10mg) 1# QD + Atanaal (nifedipine 5mg) 1# PRNQ6H.
  • For severe asymptomatic hypertension, might consider hydralazine short-term use for blood pressure lowering (eg, over hours) if there is concern that severe blood pressure elevation will precipitate an acute cardiovascular event. Hydralazine initial: 10 mg 4 times daily for 2 to 4 days, then 25 mg 4 times daily for the remainder of the week followed by titration based on response to 50 mg 4 times daily; usual dosage range: 100 to 200 mg/day in divided doses.
  • Besides, minoxidil (not available in this hospital at present) is reserved for patients with resistant hypertension who do not respond adequately to an optimized 4-drug regimen, ideally consisting of a thiazide-like diuretic and a mineralocorticoid-receptor antagonist. Minoxidil is usually used in combination with a beta-blocker to prevent reflex tachycardia.

2022-08-31

  • The underlying diseases were managed with self-carried medications without the need for urgent adjustment. At the time of this hospital stay, blood pressure levels were 170(+-10)/90(+-10), blood sugar levels were 146~162, which were just slightly above normal ranges. The lab data on 2022-08-30 were generally normal.
  • Bevacizumab was last administered on 2022-06-13. The levels of CEA and CA199 have increased in the last three months.
  • CEA
    • 2022-08-10 CEA 31.80 ng/mL
    • 2022-07-12 CEA 21.34 ng/mL
    • 2022-06-10 CEA 17.51 ng/mL
    • 2022-05-03 CEA 10.98 ng/mL
    • 2022-03-29 CEA 10.39 ng/mL
  • CA199
    • 2022-08-10 CA199 171.05 U/mL
    • 2022-07-12 CA199 174.30 U/mL
    • 2022-06-10 CA199 162.79 U/mL
    • 2022-05-03 CA199 92.68 U/mL
    • 2022-03-29 CA199 92.15 U/mL

2022-08-02

  • The patient’s blood glucose level was approximately (140 +- 10) mg/dL, and his blood pressure was approximately (160 +- 20 ) / (95 +- 10) mmHg during this hospitalization.
  • Norvasc (amlodipine 5mg/tab) #1 QD for HTN is recommended.

2022-05-26

  • CT images taken on 2022-01-24 showed a regression, while CT images taken on 2022-03-31 showed the disease stable, which could hint a decline in the effect of the regimen or the tumor has acquired a certain degree of resistance, this is consistent with the slow rise in tumor markers in recent months.
  • Lab data
    • CEA
      • 2022-05-03 92.68 U/mL
      • 2022-03-29 92.15 U/mL
      • 2022-02-23 82.61 U/mL
      • 2022-01-18 72.41 U/mL
      • 2021-12-14 69.99 U/mL
    • CA199
      • 2022-05-03 10.98 ng/mL
      • 2022-03-29 10.39 ng/mL
      • 2022-02-23 8.55 ng/mL
      • 2022-01-18 6.69 ng/mL
  • In the event the disease progresses, since this patient is receiving irinotecan-based therapy without oxaliplatin, the next regimen candidates could be FOLFOX or CAPEOX.
  • Lab results on 2022-05-18 showed liver and kidney function, blood electrolytes were normal, however WBC 2700/uL (Neutrophil 61%) was relatively lower which should be addressed.
  • Since the evening of 2022-05-25, the SBP has risen up to 180mmHg, even with the use of bisoprolol, losartan, hydrochlorothiazide, and lercanidipine. Keeping a close eye on the blood pressure should be done to check if more intervention is necessary.

2022-03-31

  • According to latest CT images on 2022-01-06, the disease showed response to current regimen which has been introduced since 2021-08, compared with the images on 2021-10-25, 2021-06-21.
  • There has been an increase in biomarker readings since 2022 [CEA 10.39(2022-03-29) <- 8.55(2022-02-23) <- 6.69(2022-01-18); CA199 92.15(2022-03-29) <- 82.61(2022-02-23) <- 72.41(2022-01-18)], which is not consistent with the CT images that are updated not so frequently.
  • When the disease becomes resistant to current treatment, since this patient is on irinotecan-based therapy without oxaliplatin, the next regimen candidates might be FOLFOX or CAPEOX.

700575407

230706

[diagnosis] - 20221220 admission note

  • Follicular lymphoma, grade 1 with left axillary, mediastinum, mesentery and retroperitoeum invasion, stage III, FLIPI:4, IPI:2
  • Irritable bowel syndrome with diarrhea
  • Type 2 diabetes mellitus without complications
  • Pure hypercholesterolemia
  • Chronic viral hepatitis B without delta-agent

[exam findings]

  • 2023-06-20 Mammography
    • Impression: No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
    • BI-RADS: Category 1: negative. - annual screening.
  • 2023-06-08 Sono-guide aspiration of right thyroid
    • Benign follicular nodule
    • Two wet smears show colloid, blood, lymphocytes, pigmented macrophages and benign follicular cell clusters with focal reactive atypia.
  • 2023-05-10 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2023-05-05 Thyroid Ultrasound
    • Echo: Heterogeneous echo
    • Ultrasound Result - Nodules:
      • Right side: 0.30.20.4 cm ; 1.10.91.5 cm
    • Diagnosis: Multinodular goiter, Autoimmune thyroid disease
  • 2023-04-18, -04-14 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
    • There are several nodular opacities on both lung and Patchy consolidation at right lower lung. Please correlate with clinical condition and CT.
  • 2023-04-13 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A (minimal)
  • 2023-04-12 CT - abdomen
    • History and indication: Follicular lymphoma
    • Findings:
      • There are several patchy consolidations of the RML, RLL and LLL of the lung.
        • In addition, few nodular infiltrations in RUL and LUL of the lung are suspected.
        • Bronchopneumonia is highly suspected. please correlate with clinical condition.
      • Mild bilateral pleura effusion are noted.
      • Prior CT identified a cystic lesion (7.8cm) at left axillary region. is noted again, marked decreasing in size to 2.4 cm.
      • Prior CT identified some LNs (up to 2.3cm) at bil. axillary regions, inguinal regions, mediastinum, mesentery and para-aortic space are noted again, decreasing in size.
      • Prior CT identified prominence in size of the spleen (long axis: 11.8 cm) is noted again, mild decreasing in size to 10.5 cm.
    • Impression:
      • Bronchopneumonia on both lungs are suspected.
  • 2023-04-08 CXR
    • Consolidation in right lower lung.
    • Thoracic spondylosis.
  • 2023-03-06 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2023-01-17 Sacrum & Coccyx
    • Spondylolisthesis of L4-5 or L5-S1 (< Grade I) is noted.
    • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
  • 2023-01-03, 2022-11-30 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2022-11-29 Whole body PET scan
    • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm as mentioned above (stage III).
  • 2022-11-28 Patho - bone marrow biopsy
    • PATHOLOGIC DIAGNOSIS
      • Bone marrow, buttock, biopsy — Free from lymphoma involvement
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consisted of two strips of bone marrow tissue measuring up to 1.8 x 0.3 x 0.3 cm in size, fixed in B-5 solution. Grossly, it was red-tan in color and bony hard in consistence. All embedded for sections after short decalcification.
    • MICROSCOPIC EXAMINATION -Relatively normocellularity for her age, 40% -No increase of blast -A few lymphocyte aggregates, a mixture of T and B cells, interstitial or paratrabecular distribution, CD10(-) and Bcl-6(-), compatible with benign aggregates and free from follicular lymphoma involvement -Immunohistochemistry: CD3(+), CD20(+), CD34(+ for blast), CD10(-) and Bcl-6(-)
  • 2022-11-28 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (85 - 27) / 85 = 68.24%
      • LVEF (%) = 68
      • M-mode (Teichholz) = 68
    • Normal LV systolic function with normal wall motion.
    • Normal LV diastolic function.
    • Normal RV systolic function.
    • Mild MR; mild TR.
  • 2022-11-26 CT - abdomen
    • A cystic lesion (7.8cm) at left axillary region. Some LNs (up to 2.3cm) at bil. axillary regions, inguinal regions, mediastinum, mesentery and retroperitoeum. Splenomegaly.
  • 2022-11-17 Thyroid Ultrasound
    • R’t : 0.30.20.3 cm ; 1.10.91.5 cm
    • Multinodular Goiter, Autoimmune thyroid disease
  • 2022-11-09 Patho - lymph node region resection
    • DIAGNOSIS:
      • A: Lymph node, left mediastinum, group 5, dissection — Follicular lymphoma, grade 1
      • B: Lymph node, left mediastinum, group 11, dissection — Follicular lymphoma, grade 1
      • C: Lymph node, left axillary, dissection — Follicular lymphoma, grade 1
    • GROSS DESCRIPTION:
      • A: Specimen submitted in formalin consists of several lymph nodes measuring up to 1.3 x 1.1 x 0.5 cm. All for section in one cassette A.
      • B: Specimen submitted in formalin consists of a lymph node measuring 1.3 x 0.6 x 0.5 cm. All for section in one cassette B.
      • C: Specimen submitted in formalin consists of several lymph nodes measuring up to 4.0 x 2.2 x 1.5 cm. Representative sections are taken in 4 cassettes C1-4.
    • MICROSCOPIC DESCRIPTION:
      • Sections of specimens A, B, and C show enlarged lymph nodes with closely packed, atypical follicles.
      • The immunohistochemical stains reveal CD3(-), CD20(+), BCL2(+), BCL6(+), CD10(+), CD43(-), Cyclin D1(-), CD15(-), and CD30(-).
      • The centroblasts are < 5/HPF. The results are consistent with grade 1 follicular lymph
  • 2022-10-17 Patho - lymphnode biopsy
    • DIAGNOSIS:
      • Lymph node, left axillary, core needle biopsy — reactive lymphoid hyperplasia
    • Description:
      • The specimen submitted consists of 2 tissue fragments measuring up to 0.8x 0.1x 0.1 cm in size, fixed in formalin. Grossly, they are brownish and elastic.
      • Microscopically, it shows hyperplasia of small-type lymphocytes.
      • Immunohistochemical stain reveals CK(-), CD3 (immunoreative at T-cells), CD20 (immunoreative at B-cells),
  • 2022-10-13 CT - chest
    • Indication:
      • Neoplasm of uncertain behavior of skin
      • Unspecified lump in breast
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Extensive lymphadenopathy at left axillary region and in lesser degree at right axillary area.
        • Small lymph nodes are found at both sides of the mediastinum and subcarina region.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Small lymph nodes are found in the mesentery.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Bilateral axillary lymphadenopathy and mediastinal, mesenterric lymphadenopathy
  • 2022-10-03 Patho - lymphnode biopsy
    • Lymph node, left axillary, CNB — Negative for malignancy
  • 2022-10-03 SONO - breast
    • Findings
      • Parenchymal pattem, Involuted
      • Focal sonographic lesion, enlarged left axillary LNs
    • Diagnosis
      • enlarged left axillary lymph nodes, suspected LAPs
    • Treatment
      • Sono-guided biopsy, Core-needle biopsy
    • Suggestion and Plan
      • arrange biopsy
      • BI-RADS 4B - intermediate suspicion of malignancy Biopsy Should Be Considered
  • 2022-09-29 SONO - breast
    • CC and Indication
      • Palpable axillary lymph nodes
    • History
      • No specific risk factors
    • Findings
      • Parenchymal pattem
        • Involuted
      • Focal sonographic lesion
        • tiny FCDs
        • enlarged left axillary LNs
    • Diagnosis
      • Benign neoplasm of breast, infavor of benign fibrocystic disease(FCD)enlarged left, axillary lymph nodes, suspected LAPs
    • Treatment
      • Sono-guided biopsy,Core-needle biopsy
    • Suggestion and Plan
      • arrange biopsy
      • chest CT scan
      • BI-RADS 4B - intermediate suspicion of malignancy Biopsy Should Be Considered
  • 2022-08-18 Thyroid Ultrasound
    • R’t : 0.20.10.3 cm ; 1.00.71.5 cm
    • Multinodular Goiter
  • 2022-04-19 SONO - breast
    • Findings
      • Parenchymal pattem, Involuted
      • Focal sonographic lesion, tiny FCDs
    • Diagnosis
      • Benign neoplasm of breast, infavor of benign fibrocystic disease (FCD)
    • Treatment
      • No need to biopsy
    • Suggestion and Plan
      • Regular OPD follow-up, Follow up breast sonography in next OPD visit
      • BI-RADS 2 - Benign Finding

[surgical operation]

  • 2022-10-03
    • Surgery
      • Lymph node biopsy
      • Intraoperative sonography (19002B)
    • Finding
      • IOUS: multiple enlarged axillary LNs, suspected LAPs, or occult breast cancer with axillary LAPs

[chemoimmunotherapy]

  • 2023-07-05 - rituximab 375mg/m2 600mg NS 500mL 12hr + vincristine 1mg NS 50mL 10min (rituximab maintenance, Q3M x8 cycles for 2 years, vincristine will be DC next time)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + acetaminophen 500mg PO + NS 250mL
  • 2023-03-27 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-CHOP Q3W) (WBC 180/uL 2023-04-08)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
  • 2023-03-06 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-CHOP Q3W) (WBC 760/uL 2023-03-16)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
  • 2023-02-13 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-COP, leukopenia, WBC 620/uL 2022-12-13)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
  • 2023-01-16 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-CHOP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
  • 2022-12-20 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-CHOP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
  • 2022-12-01 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD PO D1-D5 (R-CHOP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-D3
  • G-CSF Granocyte (lenograstim 250ug) CGRAN01
    • 2023-04-08 ~ 2023-04-15 (20230408 IPD)
    • 2023-04-08 (20230408 OPD)
    • 2023-03-16 ~ 2023-03-18 (20230316 OPD)
    • 2023-02-20 ~ 2023-02-22 (20230213 IPD)
    • 2023-01-23 ~ 2023-01-25 (20230116 IPD)
    • 2022-12-27 ~ 2022-12-29 (20221220 IPD)
    • 2022-12-13 ~ 2022-12-15 (20221213 OPD)
  • WBC
    • 2023-04-10 WBC 2.59 x10^3/uL
    • 2023-04-08 WBC 0.18 x10^3/uL *
    • 2023-03-23 WBC 5.89 x10^3/uL
    • 2023-03-16 WBC 0.76 x10^3/uL *
    • 2023-03-02 WBC 5.64 x10^3/uL
    • 2023-02-23 WBC 7.05 x10^3/uL
    • 2023-02-13 WBC 2.64 x10^3/uL
    • 2023-01-31 WBC 3.35 x10^3/uL
    • 2023-01-10 WBC 4.36 x10^3/uL
    • 2023-01-03 WBC 3.45 x10^3/uL
    • 2022-12-20 WBC 5.59 x10^3/uL
    • 2022-12-13 WBC 0.62 x10^3/uL *
    • 2022-12-01 WBC 3.65 x10^3/uL
    • 2022-11-24 WBC 5.56 x10^3/uL
    • 2022-11-08 WBC 3.07 x10^3/uL
    • 2022-10-25 WBC 4.92 x10^3/uL

==========

2023-07-06

  • This patient has only visited our hospital in the past three months, mainly attending the hemato-oncology department, followed by the metabolism and endocrinology department. The former is for the treatment of follicular lymphoma, while the latter is for the management of type 2 diabetes mellitus.

  • The Uformin (metformin 500mg) 1# BID and Januvia (sitagliptin 100mg) 1# QD prescribed on 2023-05-12 by the metabolism and endocrinology department have been listed as patient-carried items in the active medication list. No medication reconciliation issues have been identified.

  • The last CT is dated on 2023-04-12, now in the beginning of July, a new CT scan could be considered to be arranged.

2023-04-10

  • The patient’s ANC was 12.7/uL on 2023-04-08. However, after receiving lenograstim 250ug daily since that day, her ANC increased to 1725/uL on 2023-04-10.
  • The patient has been experiencing intermittent fever since 2023-04-08. She is currently being treated with cefepime 2g Q8H for neutropenic fever.
  • The management of serum glucose has been better during this hospitalization as it has not exceeded 200mg/dL except for the first day, which is an improvement compared to before.
  • There is no problem with the active prescription when it comes to medication reconciliation.

2023-03-07

  • WBC > 5K/uL post last leukopenia (WBC 620/uL 2022-12-13).
  • The patient’s pre-prandial blood sugar level has increased from 208 to 225 mg/dL during this hospitalization. If hyperglycemia persists or worsens, the addition of some insulin regimen may be beneficial.

2023-02-14

  • A leukopenia event was observed (WBC 620/uL 2022-12-13). The R-CHOP was changed to the R-COP (hold doxorubicin, 2023-02-13 lab WBC 2.65K/uL, Neutrophil 55% => ANC 1450/uL) during this hospitalization.
  • The level of blood sugar is rising (127 -> 170 -> 232mg/dL). For individuals with pre-existing diabetes, their diabetes medications might need to be adjusted while taking steroids (R-COP’s P). If preprandial blood sugar level >= 200mg/dL, it is suggested to add some insulin to mitigate the steroid-induced hyperglycemia. (ref: Steroid hyperglycemia: Prevalence, early detection and therapeutic recommendations: A narrative review. World J Diabetes. 2015;6(8):1073-1081. doi:10.4239/wjd.v6.i8.1073)

2023-01-17

  • 2023-01-10 lab data showed HGB 10.5g/dL, MCV 69.4fL, MCH 20.8pg, MCHC 30.0g/dL. These readings were all below their normal ranges.

  • Assessment based on the above lab items:

    • MCV (mean corpuscular volume) is the average volume (size) of the RBCs. Microcytosis (low MCV), a decreased MCV (usually <80 fL) reflects a defect in cellular hemoglobin synthesis. Iron deficiency and thalassemia are the most likely causes of a very low MCV (<80 fL).
    • MCH (mean corpuscular hemoglobin) is the average hemoglobin content in a RBC. A low MCH is typically reflected in an enlarged area of central pallor in RBCs on the peripheral blood smear (greater than one-third of the RBC diameter), which defines “hypochromia” on the blood smear. This may be seen in iron deficiency and thalassemia.
    • MCHC (mean corpuscular hemoglobin concentration) is the average hemoglobin concentration per RBC. Very low MCHC values are typical of iron deficiency anemia
  • Recommendation:

    • Foliromin (ferrous sodium citrate 50mg/tab) 1~2# BID PO

2022-12-21

  • Pre-prandial FS glucose levels recorded as 222, 346, 241 mg/dL, under current oral metformin and RI injection, still remain high, so it might be appropriate to gradually increase the dose of RI by 2 to 3 units or to add back Januvia (sitagliptin 100mg) QD.
  • A grade 4 leukopenia event occurred 2 weeks after the first R-CHOP treatment (WBC 620/uL 2022-12-13). The event is no more observed after immediate administration of G-CSF for the next 3 consecutive days. WBC levels might be monitored closely after chemotherapy, especially for the first 1 to 2 weeks.
  • The bowl movement in this patient reached four times during the first half of the day 2022-12-21. Loperamide can help with short-term diarrhoea or irritable bowel syndrome. Loperamide can also be used for recurring or longer lasting diarrhoea from bowel conditions such as Crohn’s disease, ulcerative colitis and short bowel syndrome.

701090711

230706

[lab data]

2023-06-07 HBsAg Nonreactive
2023-06-07 HBsAg (Value) 0.28 S/CO
2023-06-07 Anti-HBc Reactive
2023-06-07 Anti-HBc-Value 7.60 S/CO
2023-06-07 Anti-HCV Nonreactive
2023-06-07 Anti-HCV Value 0.11 S/CO
2023-06-07 Anti-HBs 4.14 mIU/mL

[exam findings]

  • 2023-06-07 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 25 dB HL, LE 28 dB HL
    • bil normal to moderate SNHL
  • 2023-06-02 CXR
    • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
    • widening of Rt and Lt paratracheal stripes and prominent Rt supraclavicular soft-tissue due to paratracheal lymph node enlargement
  • 2023-05-31 Tc-99m MDP bone scan
    • Faint hot spots in both rib cages, the nature is to be determined (post-traumatic reaction, early bone mets or other nature ?), suggesting further investigation and follow-up with bone scan in 3 months.
    • Suspected benign lesions in the maxilla, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, hips, knees, and feet.
  • 2023-05-30 Patho - esophageal biopsy
    • Middle esophagus, 25 cm to 28 cm below the incisors, biopsy — Squamous cell carcinoma, moderately differentiated
    • Middle esophagus, 24 cm below the incisors, biopsy — Squamous cell carcinoma, moderately differentiated
    • The sections of both parts show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation is evident.
  • 2023-05-30 PET scan
    • Glucose hypermetabolism involving the middle portion of the esophagus, compatible with primary esophageal malignancy.
    • Glucose hypermetabolism in a right lower paratracheal lymph node, confluent left upper paratracheal lymph nodes and confluent right supraclacular lymph nodes. Metastatic lymph nodes may show this picture.
    • Increased FDG in the colon, right kidney and right ureter. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-05-29 SONO - abdomen
    • Liver cysts
    • Liver calcification, S7
    • Renal cysts
    • R/o lymphadenopathy, near heptic hilum area
  • 2023-05-27 MRI - brain
    • No brain nodule or metastasis. Old right putamen lacunar infarcts. Mild cortical brain atrophy.
  • 2023-05-26 Patho - bronchus biopsy
    • Lung, left, bronchoscopic biopsy —- mild chronic inflammation
    • Section shows bronchial mucosa with mild chronic inflammation. No granuloma or malignancy is found.
    • The immunohistochemical stains of CK and p40 show no invasive tumor.
  • 2023-05-25 CXR
    • widening of Rt and Lt paratracheal stripes and prominent Rt supraclavicular soft-tissue due to paratracheal lymph node enlargement
    • Tortousity of thoracic aorta
  • 2023-05-17 CT - chest
    • Findings
      • Lungs: centrilobular nodular opacities at RLL and RUL, may be aspiration bronchiolitis. substantial subpleural paraseptal emphysema in both upper lobes and superior segment of LLL. partial atelectasis with focal fibrosis or subpleural paraseptal emphysema in RML
      • visible lowee neck, chest wall, mediastinum and hila: marked Rt medial wall thickening at M/3 of thoracic esopahgus (65mm in lenght) with luminal narrowing and invading adjacent mediastinal fat. multiple metastatic lymphadenopathy in the visceral space and left anterior prevascular space, and Rt supraclavicular fossa(large left upper paratracheal LAP indents and displaces the trachea and adjacent greater vessels) RT vocal cord palsy.
      • Heart: normal in size of cardiac chambers.
      • Pleura: no effusion or nodule.
      • Visible abdominal contents: multiple small low attenuations in the liver, may be hepatic cysts and metastatic lesions.
      • normal appearance of gall bladder..several RT and Lt renal cysts up to 3.7cm, unremarkable of the spleen, both adrenal glands, pancreas, and Lt kidneyno enlarged lymph node.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression: M/3 esophageal cancer T4N3M1(E1)
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:M1(M_value) STAGE:____(Stage_value)

[MedRec]

  • 2023-07-05 SOAP Hemato-Oncology
    • O
      • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 20230627
        • cT4bN3M0 stage IVA => CCRT.
  • 2023-06-21 SOAP Hemato-Oncology
    • O
      • Cancer Treatment Chemoradiotherapy/Targeted Therapy Side Effects Assessment (20230621)
        • Vomiting: G1: 1-2 times within 24 hours
          • Vomiting [Treatment]: Observe
  • 2023-06-16 SOAP Radiation Oncology
    • P
      • Plan to deliver 45 Gy/ 25 fx to the bil. SCFs, U/3+M/3 esophagus and adjacent lymphatic drainage area. Then boost the esophageal tumor and LAPs to 50.4 Gy/ 28 fx.
  • 2023-05-25 ~ 2023-06-14 POMR Hemato-Oncology
    • Discharge diagnosis
      • Squamous cell carcinoma of middle third of esophagus, cT4N3M0 stage IVA status post feeding jejunostomy and left port-A implantation on 2023/06/02
      • Hypertension
      • Anxiety disorder
      • Constipation, unspecified
      • Chronic viral hepatitis B without delta-agent
    • CC
      • suffered from dysphagia for solid material with epigastric dull pain for 6 months, associated with weight loss 6-7 kg in recent 2 months.        
    • Present illness
      • This 68-year-old man, a heavy smoker and alcoholism. He has suffered from dysphagia for solid material with epigastric dull pain for 6 months, associated with body weight loss 6-7 kg in recent 2 months.
      • According to the patient statement, he suffered from dysphagia with epigastric dull pain since 6 months ago. He didn`t pay much attention to it in the beginning.
      • In recent one month, he suffered from hoarseness and visited otolaryngology clinic for help. Nasopharyngoscopy showed left vocal palsy. Right supra-clavicular mass status post fine needle aspiration was done on 2023-05-16. The cytology report showed negative finding. Due to right eye ptosis for 2 months.
      • He visited ophthalmology clinic and Ach receptor Ab, chest CT were checked. It revealed medial wall thickening at middle third of esopahgus (65mm in lenght) with luminal narrowing and invading adjacent mediastinal fat. Multiple metastatic lymphadenopathy in the visceral space and left anterior prevascular space, and right supraclavicular fossa. Impression: M/3 esophageal cancer T4N3M1.
      • He was treferred to our chest surgery clinic for help. After discussing with the patient and his family about further treatment. He was admitted for cancer work-up under impression of middle third esophageal cancer, cT4N3M1 stage IVB.        
    • Course of inpatient treatment
      • After admitted, Chest CT on 2023/05/17 showed M/3 esophageal cancer T4N3M1. Brain MRI on 2023/05/27 showed no brain nodule or metastasis, old right putamen lacunar infarcts and mild cortical brain atrophy. Abdominal echo on 2023/05/29 showed liver cysts, liver calcification, S7, renal cysts and R/O lymphadenopathy, near heptic hilum area.
      • PES on 2023/05/29 showed 1. Advanced esophageal cancer(Lesion B-25 28cm), middle esophagus, s/p biopsy(B) 2. Advanced esophageal cancer(Lesion A-24cm), middle esophagus, s/p biopsy(C) 3. Lugol voiding area, lower esophagus, s/p biopsy(D) 4. Reflux esophagitis LA Classification grade A 5. Gastric polyp, multiple, s/p biopsy(A). Middle esophagus, 25 cm to 28 cm pathology showed Squamous cell carcinoma, moderately differentiated and Middle esophagus, 24 cm pathology showed Squamous cell carcinoma, moderately differentiated.
      • Whole body PET scan on 2023/05/30 showed middle portion of the esophagus, compatible with primary esophageal malignancy with right lower paratracheal lymph node, confluent left upper paratracheal lymph nodes and confluent right supraclacular lymph nodes metastases. Whole body bone scan on on 2023/05/31 showed no bone metastases. Feeding jejunostomy and Left Port-A catheter implantation on 2023/06/02. PTA on 2023/06/07 showed reliability FAIR, average RE 25 dB HL // LE 28 dB HL.
      • Actein 600mg 1# po BID for sputum. Famotidine 1# po BID for GERD. Morphine 1# po Q8H, Panadol 1# po Q8H and Morphine 5mg IVD PRNQ6H for pain control. Radiotherapy for 45 Gy/ 25 fractions to the bil. SCFs, U/3+M/3 esophagus and adjacent lymphatic drainage area. Then boost the esophageal tumor and LAPs to 50.4 Gy/ 28 fractions from 2023/06/08~.
      • Chemotherapy with PF(CDDP 75mg/m2, 5FU 1000mg/m2) on 2023/06/09~2023/06/13(C1). Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting. NS 1000ml IVF Q8H Y-sited chemotherapy -> change NS 500ml IVF Q8H for bilateral hand edeam on 2023/06/12. Hypertension with Concor 1.25mg 1# po QD and Olmetec 20mg 1# po QD. Anxiety disorder with Ativan 1# po HS and Eurodin 1# po PRNHS for insomnia. Constipation with Bisadyl supp 1 pill RECT PRNQD and Lactulose 20ml po PRNBID. Chronic viral hepatitis B with Vemlidy 1# po QD. Xylocaine 2pc in NS 500ml for mouse rinse.
      • Patient tolerated the chemotherapy with nausea without vomiting. With the stable condition, he was discharged on 2023/06/14 and OPD followed up later.
    • Discharge prescription
      • Actein (acetylcysteine 600mg) 1# BID
      • Lactul (lactulose 666mg/mL) 20mL PRNBID
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg , lysozyme 90mg) 1# TID
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Ulstop (famotidine 20mg) 1# BID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • morphine 15mg 1# Q8H
      • Eurodin (estazolam 2mg) 1# PRNHS
      • Acetal (acetaminophen 500mg) 1# Q6H
      • Bisadyl supp (bisacodyl 10mg) 1# PRNQD RECT
      • Nincort Oral Gel (triamcinolone) PRNBID TOPI
      • Parmason Gargle Solution (chlorhexidine) BID GAR

[consultation]

  • 2023-06-07 Hemato-Oncology
    • Q
      • This 68-year-old man, a heavy smoker and alcoholism. He has suffered from dysphagia for solid material with epigastric dull pain for 6 months, associated with body weight loss 6-7 kg in recent 2 months. Chest CT revealed medial wall thickening at middle third of esopahgus (65mm in lenght) with luminal narrowing and invading adjacent mediastinal fat. Multiple metastatic lymphadenopathy in the visceral space and left anterior prevascular space, and right supraclavicular fossa. Impression: M/3 esophageal cancer T4N3M0. He was admitted for cancer work-up under impression of middle third esophageal cancer, cT4N3M0 stage IVA.
      • After admission, cancer work-up were done, the cancer staging revealed squamous cell carcinoma of middle third of esophagus cT4N3M0, stage IVA. We had well explaining with patient and his family about further treatment. Operation of port-A and feeding jejunostomy implantation was done on 2023-06-02. Now smooth digestion was presented after jejunostomy feeding, advanced diet to 1230 Kcal/day.
      • We need consult you for further chemotherapy. Thank you very much.
    • A
      • This 68 year old man is a case of squamous cell carcinoma of M/3 esophagus, c T4N3M0, stage IVA s/p port-A and feeding jejunostomy implantation was done on 2023-06-02. Initial presentation was dysphagia for solid material with epigastric dull pain for 6 months, associated with weight loss 6-7 kg in recent 2 months.      
      • We are consulted for CCRT.
      • Please check 24 urine CCR and arrange auditory test and check HBsAg, Anti HBc, Anti HBs, Anti HCV. Book 11A or 10B.
  • 2023-06-02 Radiation Oncology
    • A
      • He can still have porridge and drink water. CCRT is indicated. CT-simulation will be arranged on 6/5. Plan to deliver 45 Gy/ 25 fx to the bil. SCFs, U/3+M/3 esophagus and adjacent lymphatic drainage area. Then boost the esophageal tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 6/7 or 8. Thank you very much.

[surgical operation]

  • 2023-06-02
    • Surgery
      • Feeding jejunostomy + port-A insertion.
    • Finding
      • 8.0 Fr. Polysite, left cephalic vein. cut-down method.
      • 18 Fr. silicon Foley catheter.

[chemotherapy]

  • 2023-07-05 - cisplatin 75mg/m2 100mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF, Q4W, lower CDDP and 5-FU)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-06-09 - cisplatin 75mg/m2 120mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF, Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2023-07-06

According to the PharmaCloud database, this patient sporadically visits local clinics for his sleep disorder, chest pain, and acute upper respiratory infections. He has been given prescriptions with a duration of only three days, all of which are now invalid. The patient has sought medical attention multiple times due to his sleep disorder, and Eurodin (estazolam) is listed among his active medications. No reconciliation issues have been identified.

2023-07-05

Mild hyponatremia was observed in the patient on 2023-07-05, with a serum sodium level of 131 mmol/L. The planned administration of furosemide on 2023-07-06 (concurrent with the PF regimen) may exacerbate this condition, as furosemide may cause increased sodium excretion. Please continue to monitor the patient’s sodium levels closely to determine if further intervention is needed.

700938395

230705

[lab data]

2023-06-27 Urine-Creatinine 105.41 mg/dL
2023-06-27 U-Cr (24hr) 1633.9 mg/kg/24 hr
2023-06-27 Total Volume(24hr) 1550 mL
2023-06-27 C.C.R. 120.7 mL/min

2023-06-20 EBV DNA PCR 159 copies/mL

2023-06-14 Anti-HBc Nonreactive
2023-06-14 Anti-HBc-Value 0.06 S/CO
2023-06-14 Anti-HBs 0.40 mIU/mL

2023-06-07 RPR/VDRL Nonreactive
2023-06-07 HBsAg Nonreactive
2023-06-07 HBsAg (Value) 0.27 S/CO
2023-06-07 Anti-HCV Nonreactive
2023-06-07 Anti-HCV Value 0.11 S/CO
2023-06-07 HIV Ab-EIA Nonreactive
2023-06-07 Anti-HIV Value 0.07 S/CO
2021-08-17 RPR/VDRL Nonreactive

[exam findings] (not completed)

  • 2023-06-29 Pure Tone Audiometry, PTA
    • Reliabilty Fair
    • R’t : 59 dB HL, mild to severe mixed type HL
    • L’t : 21 dB HL, normal to mild SNHL.
  • 2023-06-09 Tc-99m MDP bone scan
    • Mildly increased activity in the skull base. Local hyperemia may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Mildly increased activity in some L-spines. Degenerative change may show this picture.
    • Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, elbows, hips, knees and feet, compatible with benign joint lesions.
  • 2023-06-08 SONO - abdomen
    • Fatty liver, moderate
    • Gallbladder polyps
    • Renal cyst, right kidney
  • 2023-06-07 MRI - nasopharynx
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:1(T_value) N:2(N_value) M:0(M_value) STAGE:III(Stage_value)
  • 2023-06-06 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
  • 2023-05-30 Patho - nasopharyngeal/oropharyngeal biopsy
    • Tumor, left nasopharynx, biopsy — Non-keratinizing squamous cell carcinoma, undifferentiated subtype
    • Microscopically, the sections show a picture of squamous cell carcinoma, non-keratinizing, undifferentiated subtype of the nasopharyngeal tissue characterized by tumor cells with ovoid vesicular nuclei, prominent nucleoli, and indistinct cell borders arranged in syncytial pattern, infiltrate in the inflamed stroma.
    • Immunohistochemistry shows CK(+) and P63(+) for tumor.

[consultation]

  • 2023-06-06 Oral and Maxillofacial Surgery
    • Q
      • This is a 46 y/o male with history of GERD
      • This time, he was admitted to our ward for Nasopharyngeal cancer survey. Under the impression of NPC, radiotherapy is indicated. We need your expertise on dental evaluation before radiotherapy.
    • A
      • After the exam of this 46 y/o male
      • O:
        • Fair oral hygiene
        • Caries over tooth 27 was noted
      • Pano finding:
        • Missing: 18 28 38 48
        • Crown and bridge: 35X37
        • Impaction: Nil
      • There is no tooth extraction is indicated now, radiotherapy can be delivered safely.
      • Suggest restoration of 27 caries after him discharge

[chemotherapy]

  • 2023-06-30 - docetaxel 75mg/m2 140mg NS 250mL D1 + cisplatin 75mg/m2 150mg NS 500mL D2 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 2000mg NS 500mL D2-5 (TPF Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + NS 250mL D1-2 + aprepitant 125mg PO D1-3

==========

2023-07-05

[bedside visit: poor appetite. patient education: docetaxel, cisplatin, fluorouracil]

  • I visited the patient at about 13:15 on 2023-07-05. He was lying on his bed with his eyes closed, and I saw that the medications on his IV stand had been changed to KCl and Nako No.5, indicating that his chemotherapy had ended.
  • I gently woke him up, gave him the patient medication information for docetaxel, cisplatin, and fluorouracil, and highlighted the serious side effects of each drug with a colored marker.
  • I advised him to stay hydrated to maintain kidney function. I asked if he had any family or friends to take care of him while he was in the hospital, and he said he was alone.
  • I asked if he was feeling unwell in any way and he replied that he had a poor appetite. I told him that the medication he was taking included an appetite stimulant and suggested that we wait a few days to see if his appetite improved.

701344079

230705

[lab data]

2021-11-10 ROS1 FISH NOT detected

2021-11-09 EGFR G719X not detected
2021-11-09 EGFR Exon19 del detected
2021-11-09 EGFR S768I not detected
2021-11-09 EGFR T790M not detected
2021-11-09 EGFR Exon20 ins not detected
2021-11-09 EGFR L858R not detected
2021-11-09 EGFR L861Q not detected

2021-11-08 PD-L1 (28-8) TC <1%
2021-11-03 PD-L1 (22C3) TPS<1%

2021-11-03 ALK IHC Negative

2021-10-27 Aspergillus Ag Negative
2021-10-27 Aspergillus Ag Value 0.05 Ratio
2021-10-27 Aspergillus Ag Negative
2021-10-27 Aspergillus Ag Value 0.08 Ratio

2021-10-25 Mycoplasma IgM Negative Index
2021-10-25 Mycoplasma IgM Value 0.1 Index

2021-10-22 Anti-HBs 11.64 mIU/mL

2021-10-22 HBsAg Nonreactive
2021-10-22 HBsAg (Value) 0.47 S/CO

2021-10-22 Anti-HBc Nonreactive
2021-10-22 Anti-HBc-Value 0.31 S/CO

2021-10-22 Anti-HCV Nonreactive
2021-10-22 Anti-HCV Value 0.04 S/CO

2021-10-22 HIV Ab-EIA Nonreactive
2021-10-22 Anti-HIV Value 0.06 S/CO

[exam findings] (not completed)

  • 2023-06-29 CXR
    • Scoliosis of the T-spine with convex to right side.
    • Atherosclerotic change of aortic arch
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2023-06-27 Patho - stomach biopsy
    • Stomach, PW of low body, biopsy — Hyperplastic polyp. No H.pylori present
  • 2023-06-26 SONO - abdomen
    • suspected liver parenchymal disease (incomplete exam of liver)
    • bilateral renal cysts
    • pancreas obscured
  • 2023-06-26 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade D
    • Hiatal hernia
    • Atrophic gastritis, s/p CLO test
    • Gastric polyp, PW of low body, s/p biopsy
  • 2023-06-23 MRI - brain
    • Indication: Lung cancer with lymph node, pleural and bone metastases, T2N2M1, Stage IVB
    • IMP: No evidence of brain metastasis. General brain atrophy.
  • 2023-05-28 CXR
    • Known a case of Lung cancer with bone mets.
    • Tortuosity of the aorta with atherosclerotic change.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2023-05-28 KUB
    • No definite opaque stone detected.
    • Degenerative joint disease of lumbar spine with marginal osteophytes.
    • Scoliosis of L-spine.
    • There is fecal materials impaction in the course of colons.

[MedRec]

  • 2023-06-07 SOAP Urology
    • S
      • hematuria today
      • chronic frequency
    • A: r/o UTI
    • P: RTC with report
    • Prescription
      • Transamin (tranexamic acid 250mg) 1# BID 3D
      • cephalexin 500mg 1# TID 7D
      • Harnalidge (tamsulosin 0.4mg) 1# QD 7D
  • 2023-05-23 SOAP Nephrology
    • Prescription
      • Pentop (pentoxifylline 400mg) 0.5# HS
  • 2023-05-18 SOAP Hemato-Oncology
    • Plan: Request visit ER if SBP < 80
    • Prescription
      • Tagrisso (osimertinib 80mg) 1# QD 28D
  • 2023-03-30 SOAP Hemato-Oncology
    • P: Chest CT on 2022-10-20 -> 2023-01-20 -> 2023-04-10, Bone scan on 2022-10-18 -> 2023-01-18 -> (May consider non-contrast Chest CT due to impaired renal funciton)
  • 2023-03-02 SOAP Hemato-Oncology
    • Plan: On 2023-02-02 and 03-02, request salt intake again and again
  • 2023-02-02 SOAP Hemato-Oncology
    • Prescription
      • Tagrisso (osimertinib 80mg) 1# QD 28D
      • Norvasc (amlodipine 5mg) 1# QL 28D
  • 2022-12-08 SOAP Hemato-Oncology
    • Chest CT on 2022-10-20 -> 2023-01-20, Bone scan on 2022-10-18 -> 2023-01-18 (May consider non-contrast Chest CT due to impaired renal funciton)
  • 2022-09-16 SOAP Nephrology
    • O
      • 2022/09/15 Creatinine = 2.17 mg/dL;
      • 2022/09/15 eGFR = 31.02;
      • 2022/07/21 Creatinine = 1.60 mg/dL;
      • 2022/07/21 eGFR = 44.09;
  • 2022-09-01 SOAP Neurology
    • O
      • 2022/08/29 NCV: This abnormal NCV study suggested bilateral lumbosacral rdiculopathy.
    • Prescription
      • Saline (nicametate citrate 50mg) 1# TID 28D
  • 2022-08-18 SOAP Neurology
    • S
      • P’t is a case of lung CA and received tagrisso treatment.
      • P’t noted left leg pain about 2 years ago and noted lung CA with L-spine meta. After treatment, condition statioanry but bilateral feet numbness was noted about 1 year but in recent numbness ascent to bilateral lower leg.
    • Prescription
      • Saline (nicametate citrate 50mg) 1# TID 14D
  • 2022-08-18 SOAP Hemato-Oncology
    • Plan: Refer to Neuro for numbness
  • 2022-01-06 SOAP Hemato-Oncology
    • Plan: May consider XGEVA after bone scan in 2022-01
  • 2021-12-08 SOAP Hemato-Oncology
    • Plan
      • Shift Estengy (Amlodipine / Valsartan 5/80 mg) 1# QD to Diovan (160) 0.5# QD
    • Prescription
      • Tagrisso (osimertinib 80mg) 1# QD 15D
      • Diovan (valsartan 160mg) 0.5# QD 15D
  • 2021-11-25 SOAP Hemato-Oncology
    • Prescription
      • Tagrisso (osimertinib 80mg) 1# QD 13D
  • 2021-10-21 ~ 2021-11-11 POMR Hemato-Oncology
    • Discharge diagnosis
      • Malignant neoplasm of unspecified part of unspecified bronchus or lung
      • Lung cancer with lymph node, pleural and bone metastases, T2N2M1, Stage IVB
      • Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
      • Pleural effusion in other conditions classified elsewhere
      • Chronic obstructive pulmonary disease, unspecified
      • Enlarged prostate with lower urinary tract symptoms
    • Present illness
      • This 82y/o male was a case of denied any majort systemic disease or operation history.
      • According to the statement of the patient families and ER medical record. This time, he had suffered from dyspnea for 4 days, the symptoms became to serious and visited frist to Cardinal Tien Hospital. Due to massive amount left pleraul effusion and bed adjustment mechanism, referred to our hospital.
      • At MER, O2 therapy and the chest films disclosed left massive plerual effusion. Chest CT was arranged and the conculsion of severe left pleural effusion with suspected left hilar lung mass. However, elevation of breathing work with paradoxical movement were also note, then emergency intubation was done. Empiric antiboltic with Rocephin was perscribed.
      • Under the impression of acute respiratory failure s/p intubation and severe left plerual effusion, R/I lung cancer. He was admitted to our ICU for further observation and management.
    • Course of inpatient treatment
      • After admitted, Left pigtail insertion on 2021/10/21 and keep left pigtail drainage for Left massive amount plerual effusion. Chest CT on 2021/10/21 showed severe left pleural effusion with suspected left hilar lung mass, R/O lung cancer, T2N2M0, suggest contrast enhanced study, enlarged prostate and infra-renal aortic aneurysm. 2D echo on 2021/10/25 showed 1. Thickened AV with mild AR 2. Thickened and calcification of MV, no MR 3. LV septal hypertrophy 4. Preserved LV and RV systolic function 5. Moderate PR, mild TR, normal IVC size. Explain his condition to his family.
      • Acetin 1pk po BID and Cough mixture 10ml po HS for cough with sputum. Brain MRI on 2021/10/29 showed no evidence of brain metastasis, general brain atrophy, hydrocephalus and cervical spondylosis. Whole body bone scan on 2021/10/29 showed the scintigraphic findings suggest multiple bone metastases. Chest CT on 2021/10/30 showed left lower lobe lung cancer with left malignant pleural effusion and extensive lymphadenopathy. A family meeting was held to explain his condition and therapy to patient and his family on 2021/11/01. Consult rahabilitation department for bedside rehabilitation exercises on 2021/11/01. Remove NG tube on 2021/11/02. Target therapy with Iressa 1# po QD from 2021/11/02. Remove left pigtail on 2021/11/08. Explain his deta and condition to his family on 2021/11/09. Major illness was applied on 2021/11/11.
      • Foster 4puff INHL BID and Spiriva 2puff INHL HS for Chronic obstructive pulmonary disease. Urief F.C 0.5# po QD for BPH. With the stable condition, he was discharged on 2021/11/11 and OPD followed up later.
    • Discharge prescription
      • Cough Mixture (platycodon) 10mL HS
      • Urief (silodosin 8mg) 0.5# QD
      • Actein (acetylcysteine) 1pk BID
      • Iressa (gefitinib 250mg) 1# QD

[treatment]

  • 2021-11-25 ~ undergoing - Tagrisso (osimertinib 80mg) 1# QD

  • 2021-11-11 ~ 2021-11-24 - Iressa (gefitinib 250mg) 1# QD

==========

2023-07-05

  • I visited the patient around 11:10 on 2023-07-05 with the osimertinib medication pamphlet. The patient was lying in bed and his son was on a bench against the wall.

  • I explained to the patient and his son that he has been using osimertinib for a relatively long period of time and based on the pamphlet, I described the potential side effects to watch for during the use of this drug. The patient’s son said that the main issue was digestive tract symptoms, but other than that, everything else felt fine, and the tumor has been controlled for a good period of time, they are still satisfied with the efficacy. I left the contact information for the hospital’s pharmacy counseling window, so the patient and his family can call when needed.

700561643

230703

[exam findings]

  • 2023-07-01 CXR
    • Tortous aorta with calcification is noted.
    • Superior mediastinum mass like lesion is found. Suggest CT.
    • Osteopenia of the bony structure is noted.
  • 2023-07-01 CT - chest
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Confluent soft tissue mass at superior, anterior mediastinum and middle mediastinum is found. The SUPERIOR VENA CAVA is compressed. Lymphoma or germ cell tumor is suspected and lymphoma is most likely.
        • The lung fields are clear.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Confluent soft tissue mass at mediastinum with SUPERIOR VENA CAVA compression. Lymphoma is favored.

[MedRec]

  • 2023-07-01 Hemato-Oncology VS note on admission day
    • She experienced troublesome cough and it could be exaggerated by lying down.
    • CT revealed mediastinum tumor with compression of trachea and SVC, Tissue proof will be done on 2023-07-03.

[consultation]

  • 2023-07-01 Hemato-Oncology
    • Q
      • Productive cough and orthopnea for 2 months
      • Face edema was told by daughter
      • Past history: anxiety, HTN
      • Allergy: NKA
      • Surgical hx: thyroid s/p OP now under eltroxin
    • A
      • This 73 year old woman is a case of anterior mediastinum tumor r/o lymphoma. We are consulted for further evaluation.
      • Please arrange admission for CT guide biopsy. Add steroid for r/o lymphoma related SVC syndrome. Thanks for your consultation.
  • 2023-07-01 Thoracic Surgery
    • Q
      • Productive cough and orthopnea for 2 months
      • Face edema was told by daughter
      • Past history: anxiety, HTN
      • Allergy: NKA
      • Surgical hx: thyroid s/p OP now under eltroxin
    • A
      • The patient had dyspnea. CT scan showed huge mediastininal tumor with SVC compression
      • Lymphoma, small cell lung cancer was suspected
      • Please consult oncologist for treatment

==========

2023-07-03

  • As per the PharmaCloud database, this patient frequently visits RenJi Hospital (last visit on 2023-06-19) and routinely refills his prescription at a local pharmacy. The prescription includes sennoside, ubidecarenone, bisoprolol, valsartan, pitavastatin, levothyroxine, alprazolam, carbinoxamine, and dextromethorphan.

  • Except for carbinoxamine (a first-generation antihistamine used to treat allergic rhinitis and vasomotor rhinitis), all other drugs are included in the active medication list. However, no current diagnosis or active medical problems relating to allergic rhinitis or vasomotor rhinitis have been identified. Thus, there is no evidence of discrepancies in medication reconciliation.

701031265

230630

[present illness] - 2023-03-20 admission note

  • This 92-year-old male had history of
    • Benign prostate hyperplasia
    • Hypothyroidism
    • Hypertension
    • status post left total knee replacement about 10 years ago
    • Adenocarcinoma of ascending colon, pT2N0M0 stage I status post Single-incision laparoscopic right hemicolectomy on 2021/11/03
  • He was under regular follow up at CRS/Meta/Uro OPD.
  • Liver metastasis after RFA on 2023/02/03. On 2023/03/04 whole abdominal CT showed suspect of three new liver metastasis.
  • Under the impreession of colon cancer with liver metastases, he was admitted for port-A and palliative chemotherapy after further advanced evalaution on 2023/03/20.

[past history]

  • Benign prostate hyperplasia
  • Hypothyroidism
  • Hypertension
  • status post left total knee replacement about 10 years ago
  • Adenocarcinoma of ascending colon, pT2N0M0 stage I status post Single-incision laparoscopic right hemicolectomy on 2021/11/03
  • Liver metastasis after RFA on 2023/02/03         

[allergy]

  • NKDA     

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-06-19 CT - abdomen
    • Findings
      • Lobulated low density lesion at S5 of liver measuring 2.38cm in largest dimension is found. Liver meta is considered. In comparison with CT dated on 2023-03-04, the lesion regressed. Another low density lesion at dome up to 1.68cm is noted. stable.
      • Enlarged prostate up to 5.68cm is found.
      • One hepatic cyst at S6 of liver measuring 1.3cm is noted.
      • s/p RAR.
      • Calcified right posterior pleura is found.
      • Senile fibrotic change is noted at lung fields.
      • Interstitial change at bilateral lower lobes is found.
    • Imp:
      • s/p RAR.
      • Liver meta at dome. Stationary. S5 meta, in regression.
  • 2023-05-15, -03-24, -03-20 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Enlargement of cardiac silhouette.
    • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
  • 2023-04-26 KUB + L-spine Lat
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L3-4 and L4-5 (more severe on L4-5).
    • Spondylolisthesis of L5-S1 (< Grade I) is noted.
  • 2023-03-23 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (133 - 36) / 133 = 72.93%
      • M-mode (Teichholz) = 72
    • Conclusion:
      • Borderline dilated LV; Adequate LV systolic function with normal resting wall motion
      • Dilated aortic root; mild to moderate AR
      • Trivial MR, mild to moderate TR
      • LV diastolic dysfunction, Gr 1
      • Preserved RV systolic function
  • 2023-03-22 Spirometry
    • normal lung volume and ventilatory function
  • 2023-03-20 ECG
    • Normal sinus rhythm
    • Voltage criteria for left ventricular hypertrophy
  • 2023-03-04 CT - abdomen
    • Indication: refer from CRS a case of colon cancer R/O single liver metss/p RFA on 2023-02-03 no AE. now CT 1 m F/U
    • With and without contrast enhancement CT of abdomen shows:
      • Colon CA, s/p operation. No local recurrent tumor.
      • No enlarged lymph nodes in para-aortic and pelvic regions.
      • Right posterior segment liver metastasis, s/p RFA. Three poor enhancing lesions in right hepatic lobes: 1.4cm in S7, 0.8cm and 1.0cm in S5.
      • No ascites, nor extraluminal free air.
      • No bony destructive lesion on these images.
    • Impression
      • Colon CA, s/p operation
      • Suspect three new liver metastasis. Suggest sonography correlation.
  • 2023-02-03 RFA
    • Indication: colon ca with single mets for RFA
    • Procedure
      • Metastatic liver tumor (1.8 cm) s/p RFA (2 sessions; 2 cm active tip)
    • Course
      • By sono-guided, RFA probe was inserted to the tumor (stop after 3 pauses; 2 sessions). The patient tolerated the procedure. Iv anesthesia was performed during the procedure.
    • Findings
      • A 1.8 cm mass at rt post seg near liver surface.
  • 2023-02-02 ECG
    • Normal sinus rhythm
    • Moderate voltage criteria for LVH, may be normal variant
    • Borderline ECG
  • 2023-01-11 ENT Hearing Test
    • Reliabilty Fair
    • PTA
      • R’t : 71 dB HL
      • L’t : 66 dB HL
      • Bil mild to profound SNHL.
  • 2022-12-28 SONO - abdomen
    • Diagnosis
      • Chronic liver parenchymal disease
      • Hepatic tumor C/W single metastatic tumor
      • Calcified spot of liver
      • Liver cyst
    • Suggestion
      • RFA if needed
  • 2022-12-21 ENT Hearning Test
    • Tymp:
      • Bil type B.
    • ART:
      • Bil absent.
    • PTA
      • Reliability FAIR
      • Average RE >101 dB HL; LE 70 dB HL.
      • RE moderately severe to profound MHL.
      • LE moderate to profound SNHL. (BC masking dilemma)
  • 2022-11-28 CT - abdomen
    • A colon cancer s/p SILS right hemicolectomyp T2N0M0 on 20211103
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Abdominal CT with and without enhancement revealed:
      • s/p RAR.
      • Low density lesion at S6 of liver up to 1.1cm is found. In comparison with CT dated on 2021-10-09, the lesion is new. New liver meta is suspected.
      • Enlarged prostate up to 5.9cm is found.
      • Ground glass opacity over right lower lobe is found.
    • IMp:
      • s/p RAR.
      • new low density lesion at S6 of liver. 1.1cm, suspected liver meta.
  • 2022-09-28 Nerve Conduction Velocity, NCV
    • Findings
      • Decreased amplitudes and slowed NCVs in bilateral peroneal and tibial CMAP.
      • Decreasd amplitudes and slowed NCVs in bilateral sural SNAPs.
      • Prologed F-wave latencies followed bilateral peroneal and tibial nerve stimulations.
      • Prolonged H-reflex latencies followed right tibial nerve stimulations.
    • Conclusion
      • This abnormal NCV study suggested mix-type sensorimotor polyneuropathy may superimposed polyradiculopathy
        • note ChatGPT: Polyneuropathy refers to damage or disease affecting multiple peripheral nerves throughout the body. Sensorimotor polyneuropathy involves both sensory and motor nerves, which can cause symptoms such as numbness, tingling, weakness, and pain. Polyradiculopathy refers to damage or disease affecting multiple spinal nerve roots, which can cause similar symptoms.
  • 2022-05-19 SONO - abdomen
    • Diagnosis
      • Suspected liver cyst,right
      • Suspected liver calcification,right
      • Pancreas not shown
      • Suboptimal examination of liver due to poor echo window
    • Suggestion
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
      • Because of poor echo window,infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months
  • 2022-04-23 Bladder Sonography
    • PVR: 23.89 mL
  • 2022-04-23 Uroflowmetry
    • Q max: low
    • flow pattern: obstructive
  • 2021-11-03 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Large intestine, ascending colon, laparoscopic right hemicolectomy — Adenocarcinoma, well differentiated, arising from tubulovillous adenoma
      • Resection margins: free
      • Lymph node, mesocolic, dissection — Negative for malignancy (0/22)
      • Lymph node, IMA / SMA, dissection — N/A.
      • Terminal ileum, laparoscopic right hemicolectomy — Negative for malignancy
      • Appendix, appendectomy — Negative for malignancy
      • Pathology stage: pT2N0(if cM0); AJCC stage I
    • MACROSCOPIC EXAMINATION
      • Operation procedure: laparoscopic right hemicolectomy
      • Specimen site: ascending colon
      • Specimen size: colon: 30 cm in length ; Terminal ileum: 8 cm
      • Tumor size: 11x 8x 5 cm
      • Tumor location: 12 cm away from the closest resection margin
      • Depth of invasion grossly: muscularis propria
      • Mucosa elsewhere: Not remarkable
      • Representative sections and labeled: A1:appendix, A2-3:bilateral marfins, A4-7:LNs, A8:non-tumor part, A9-15:tumor
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: well differentiated
      • Depth of invasion: muscularis propria
      • Angiolymphatic invasion: Not identified
      • Perineural invasion: Not identified.
      • Discontinuous extramural tumor extension: Not identified.
      • Circumferential (radial) margin of rectum: Serosal margin status of colon: Uninvolved
      • Lymph node metastasis, mesocolic: 0 / 22
      • Lymph node metastasis,, IMA / SMA: N/A.
      • Extranodal involvement: N/A.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT)
          • pT2: Tumor invades the muscularis propria
        • Regional Lymph Nodes (pN)
          • pN0: No regional lymph node metastasis
        • Distant Metastasis (pM)
      • Type of polyp in which invasive carcinoma arose: Tubulovillous adenoma.
      • Additional pathologic findings: None identified.
      • TNM descriptors: N/A
      • Tumor regression grading S/P CCRT: N/A.
      • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2021-10-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (133 - 36) / 133 = 72.93%
      • M-mode (Teichholz) = 72
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH without outflow tract obstruction; impaired LV relaxation.
      • Normal RV systolic function.
      • Aortic valve sclerosis with no AS, mild to moderate AR; mild MR; mild TR; mild PR.
      • Atherosclerosis of aorta with mildly diated aortic root and ascending aorta.
  • 2021-10-19 Patho - colon biopsy
    • Clinical Finding
      • One huge tumor with partial obstruction was noted A-colon, s/p biopsy
    • PATHOLOGIC DIAGNOSIS
      • Colon tumor, ascending colon, biopsy — Villotubular adenoma with high grade dysplasia
    • MICROSCOPIC EXAMINATION
      • Microscopically, the sections show a picture of villotubular adenoma, composed of colonic mucosal tissue with atypical glands lined by low grade dysplastic columnar cells, in tubular, fused glandular or cribriform arrangement. No convincing stromal invasion present in the limited specimen. Repeat biopsy is advised for further evaluation is advised, if malignancy is suspected clinically. Closely follow up
  • 2021-10-19 Colonoscopy
    • Diagnosis
      • Highly suspect colon cancer with partial obstruction, A-colon, s/p biopsy
      • Mixed hemorrhoids
    • Suggestion
      • F/U pathology report
    • Complication
      • No immediate complication
  • 2021-10-14 Bronchodilator Test
    • probably normal screening
    • negative BDT
    • Inadequate tracing
  • 2021-10-09 CT - abdomen
    • Abdominal CT with and without enhancement revealed:
      • Huge soft tissue mass up to 7.69cm in largest dimension at ascending colon with dilatation of the cecum is found. Colon cancer is favored. Two tiny lymph nodes are found.
      • Mild consolidation over right lower lobe and left lower lobe is found.
      • Borderline heart size is found.
      • Tiny subpleural nodule at right middle lobe up to 0.cm, in largest dimension is found.
      • Bula formation at bilateral upper chest is found.
      • Hepatic cyst at S6 of liver up to 1.25cm in largest dimension is found. S (CVP line placement Im63).
      • Very enlarged prostate up to 5.67cm in largest dimension is found.
    • Imp:
      • Suspected huge Colon cancer at ascending colon.
      • Consolidation over bilataral basal lungs.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T2(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2021-07-10 Bladder Sonography
    • PVR: 8.32 mL
  • 2018-07-20 Renal Echo
    • Bilateral parenchymal renal disease
    • Calcification lesion, left kidney
    • Enlarged prostate
  • 2018-03-22 Pure Tone Audiometry & Tymanometry
    • Tymp: bil type A.
    • PTA:
      • reliability: fair
      • R’t mild to severe SNHL, average 66 dB HL.
      • L’t mild to profound SNHL, average 60 dB HL.
      • Audiogram: bil BC 2k and 4k Hz at 70 dB HL NR.
  • 2017-11-09 Barium Enema Double Contrast study of LGI series
    • Findings:
      • The contrast medium passage from anus to the cecum smoothly without obstruction.
      • Normal contour, haustration and peristalsis of the colon.
      • Redundant of sigmoid colon.
    • IMP:
      • Redundant of sigmoid colon.
        • note ChatGPT: “Redundancy of sigmoid colon” is a condition in which the sigmoid colon, which is the last part of the large intestine, is abnormally long and twisted. This results in the sigmoid colon being bunched up or looped on itself, which can cause constipation, bloating, and abdominal pain.

[consultation]

  • 2021-10-12 Dermatology
    • A
      • This patient suffered from multiple erythematous papules on trunk and limbs for months
      • Imp: Asteatotic dermatitis
      • Suggestion:
        • Zaditen 1 / Bid
        • Clobetasol x 6 tubes/bid

[surgical operation]

  • 2021-11-03
    • Surgery
      • SILS right hemicolectomy        
    • Finding
      • Villotubular adenoma with high grade dysplasia of ascending colon, cT2N1M0
      • Anastomosis by GIA 75/4.8mm x2
      • One JP drain in pelvic area
      • Close abdomen by surgical assister

[chemotherapy]

  • 2023-08-31 - FOLFOX

  • 2023-08-04 - FOLFOX

  • 2023-07-20 - FOLFOX

  • 2023-06-29 - FOLFOX

  • 2023-06-07 - FOLFOX

  • 2023-05-15 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 760mg NS 250mL 2hr + fluorouracil 2800mg/m2 3735mg NS 500mL 46hr (FOLFOX Q2W, Oxa and 5FU 30% off for his senior age)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-24 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 770mg NS 250mL 2hr + fluorouracil 2800mg/m2 3800mg NS 500mL 46hr (FOLFOX Q2W, Oxa and 5FU 30% off for his senior age)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-24 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 775mg NS 250mL 2hr + fluorouracil 2800mg/m2 3800mg NS 500mL 46hr (FOLFOX Q2W, Oxa and 5FU 30% off for his senior age)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[note]

Refillable prescriptions for patients with chronic illnesses - ref: https://www.nhi.gov.tw/Glossary/Glossary.aspx?page=6

==========

2023-09-01

Our neurologist prescribed Saline (nicametate) on 2023-07-05, our endocrinologist prescribed Eltroxin (levothyroxine), and our urologist prescribed Betmiga (mirabegron), Eurodin (estazolam), Harnalidge (tamsulosin), Minirin (desmopressin), Norvasc (amlodipine), and Uretropic (furosemide) on 2023-07-08. These drugs are included in the list of active medications and reconciliation issues found.

2023-06-30

  • Our Urology department issued refillable prescriptions for the patient with chronic illnesses for Betmiga (mirabegron), Eurodin (estazolam), Harnalidge (tamsulosin), Minirin (desmopressin), Norvasc (amlodipine), and Uretropic (furosemide), on 2023-04-08. These medications have been accurately incorporated into the current medication list, hence no issues were encountered during the medication reconciliation process.

2023-06-08

  • The patient has exclusively sought medical care at our hospital, with the exception of a visit to a local clinic for low back pain on 2023-04-28, where he was prescribed mephenoxalone for a duration of 5 days. Since low back pain isn’t mentioned in the admission note or in the current list of medical problems, there appear to be no medication reconciliation issues.

2023-05-16

  • Subclinical hypothyroidism is biochemically characterized by a normal serum free thyroxine (T4) concentration along with an elevated serum thyroid-stimulating hormone (TSH) concentration. Our endocrinologist has previously prescribed a refillable dose of Eltroxin (levothyroxine). This drug is currently listed in the patient’s active medication regimen. However, the patient continues to have normal free T3 and free T4 levels, while there is a significant increase in TSH levels (approximately doubled every 2 months this year). Therefore, it may be prudent to consult with the endocrinologist to determine if an adjustment in levothyroxine dose is necessary.
    • 2023-05-05 TSH 35.330 uIU/mL
    • 2023-03-21 TSH 19.587 uIU/mL
    • 2023-01-12 TSH 9.573 uIU/mL
    • 2022-09-12 TSH 7.507 uIU/mL
    • 2023-03-22 Free T3 2.5 pg/mL
    • 2023-03-22 Free T4 1.085 ng/dl

2023-03-25

  • The FOLFOX regimen has been adjusted by reducing the dose of oxaliplatin and fluorouracil by 30% due to the patient’s advanced age.
  • According to the TPR panel, the patient’s blood pressure and serum glucose levels are well controlled with the appropriate medications based on his age.
  • No issues have been identified with the patient’s active prescriptions.

700523705

230629

[exam findings]

  • 2023-06-28 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Increase soft tissue density of the left lower neck is suspected. Please correlate with sonography or CT for further evaluation.
    • Several Compression fracture of the T-spine S/P vertebroplasty.
  • 2023-06-28 ECG
    • Normal sinus rhythm
    • CCWR
    • Minimal voltage criteria for LVH, may be normal variant
    • T wave abnormality, consider anterior ischemia
  • 2023-06-22 T-spine AP + Lat
    • S/P VP.
    • Compression fracture of spine.
  • 2023-06-22 KUB + L-spine Lat
    • S/P VP.
    • Non-specific small bowel and colon gas pattern.
    • A calcification at pelvic cavity.
  • 2023-06-07 Tc-99m MDP bone sccan with SPECT
    • No evidnece of bone lesion at the left shoulder and left scapula.
    • Suspected benign lesions in both rib cages, maxilla, sternum, some T- and L-spine, left sternoclavicular junction, bilateral shoulders, S-I joints, and hips.
  • 2023-06-05 CXR
    • No active lung lesion
    • No pleural lesion
    • Borderline enlarged cardiac sihoutte
    • Tortuous thoracic aorta with intimal calcification
    • General osteoporosis
    • Multilevel compression fracture of T-L spine
  • 2022-12-17 SONO - nephrology
    • Left borderline small kidney with chronic parenchymal changes.
  • 2022-12-17 Bladder sonography
    • PVR: 10.1 ml
  • 2022-10-15 Bladder sonography
    • PVR: 10.8 ml
  • 2022-10-13, -07-21, -04-02 Gynecologic ultrasonography
    • Uterine myoma
  • 2021-08-28 Bladder sonography
    • PVR: 1.52 ml
  • 2019-07-13 Colonoscopy
    • Diagnosis
      • There was no abnormal mucosa or mass up to the ileocecal valve
      • Mixed hemorrhoids,minimal
    • Suggestion
      • CRS OPD follow up
      • Repeated colon scopy was suggested for follow-up in 1-2 yrs
      • Small lesion may be masked by semifluid like feces
  • 2019-05-08 L-spine Lat (including sacrum)
    • Gr.I spondylolisthesis of L5/S1
    • Facet degeneration of lumbar spine
    • Disc space narrowing of L2-S1
  • 2019-04-01 CTA - abdomen
    • No evidence of ischemic colitis.
  • 2019-03-31 CXR
    • Increase bilateral lung markings.
    • Mild cardiomegaly.
    • Tortuous thoracic aorta with intimal calcification.

==========

2023-06-29

  • According to PharmaCloud records, the patient had visited JingMei Hospital for a wedge compression fracture of the first lumbar vertebra on 2023-05-31. She was given short-term prescriptions for dexamethasone (1 day), tramadol (7 days), and mephenoxalone (7 days), all of which have now expired and are therefore invalid.
  • Currently, intravenous formulations of Limadol (tramadol) and morphine have been prescribed for pain management since her admission date of 2023-06-28. Based on the information available, there are no apparent medication reconciliation issues found.

701319969

230628

{metastatic breast cancer}

[exam findings]

  • 2023-05-26 MRI - brain
    • Indication: Breast cancer with brain and lung mets
    • Pre- and poat-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) reveal:
      • Post-operation change at right parieto-occipital skull with localized CSF accumulation, and white matter edema in underlying arain parenchyma. Stationary as compared with MRI on 20230130.
      • A small rim-enhancing lesion, about 7 mm, with perifocal edema in left paramedial frontal lobe, indicating a metastatic lesion.
      • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
      • No remarkable finding of nasopharynx visible in these images.
    • IMP: A new metastatic lesion (7 mm) at left paramedial frontal lobe. Stationary of the post-operation change at right parieto-occipital lobe.
  • 2023-05-04 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2023/02/02, the the lesion in the right acetabulum is a little more evident. Bone metastasis in a little more progression should be considered.
    • The previous faint hot spot in the anterior aspect of left 3rd rib is slightly more evident.
    • Increased activity in the right parietal area of the skull, compatible with post-operative change.
    • Other bone lesions are possibly more benign in nature.
  • 2023-05-03 CT - chest
    • Indication: Breast cancer with brain and lung mets
    • Comparison was made with previous CT dated on 2022/11/01
      • Lungs: interval stationary in size nodular lesions in both lungs as compared with CT on 2023/02/01
      • Mediastinum and hila: no enlarged LN or mass. the great vessels in the hila and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
      • Chest wall and visible lower neck: Ulcerative tumor at left breast and a smaller nodule at lateral anterior chest wall and two nodular lesions at right breast, stationary as compared with CT on 2023/2/1
      • Visible abdominal-pelvic contents:
        • moderate splenomegaly and hyperplasia of left adrenal gland, stable.
        • small residual hepatic metastatic tumors, stable.
        • enlarged uterus with many myomas.
        • normal appearance of gall bladder.
        • unremarkable of the Rt adrenal gland, pancreas, and both kidneys. bile ducts.
      • Visualized bones: unremarkable.
    • Impression:
      • advanced breast cancer with lung and liver metastases, stationary as compared with CT on 2023/02/01
  • 2023-02-02 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2022/11/17, no prominent chanhge is noted in the the lesion in the right acetabulum. Bone metastasis in stationary status may show this picture.
    • Increased activity in the right parietal area of the skull, compatible with post-operative change.
    • The faint hot spot in the anterior aspect of left 3rd rib is a little less evident and no prominent change is noted in other bone lesions, possibly more benign in nature.
  • 2023-02-01 CT - chest
    • Impression: advanced breast cancer with lung and liver metastases, stationary and increase in size of left breast tumor compared with CT on 2022/11/01
  • 2023-01-30 MRI - brain
    • Post OP at right parieto-occipital lobe and skull, no evidence of tumor recurrence.
  • 2022-11-17 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2022/08/05, the the lesion in the right acetabulum is a little less evident. Bone metastasis with some resolution may show this picture.
    • Increased activity in the right parietal area of the skull, compatible with post-operative change.
    • No prominent change is noted in other bone lesions, possibly more benign in nature.
  • 2022-11-01 CT - chest
    • Indication: Breast adenocarcinoma with metastasis to right cerebral parietal lobe status post craniectomy for brain tumor excision and intracranial pressure monitoring on 2022/09/29.
    • Findings
      • Lungs: interval increase in size nodular lesions in both lungs compared with CT on 20220804.
        • mosaic attenuation changes with centrilobular micronoduels in both lower lobes.
      • Mediastinum and hila: no enlarged LN or mass.
        • the trachea and main bronchi are normallly identified without endobronchial lesion.
      • Vessels:
        • the great vessels in the hila and mediastinum are normal in distribution and appearance.
        • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
        • Chest wall and visible lower neck: Ulcerative tumor at left breast and a smaller nodule at lateral anterior chest wall, increase in size and stationary of two nodular lesions at right breast compared with CT on 8/4.
      • Visible abdominal-pelvic contents: moderate splenomegaly and hyperplasia of left adrenal gland, stable.
        • small residual hepatic metastatic tumors, stable.
        • enlarged uterus with many myomas.
        • normal appearance of gall bladder.
        • unremarkable of the Rt adrenal gland, pancreas, and both kidneys. bile ducts.
      • Visualized bones: unremarkable.
    • Impression:
      • CT of brain: s/p Rt parietal craniectomy with residual vasogenic edema and suspect residual metastatic tumor still present.
    • Impression: advanced breast cancer with lung, liver, and brain metastases, in progression of lung metastasis and increase in size of left breast tumors compared with CT on 20220928.
  • 2022-09-30 Patho - brain/meninges (tumor)
    • Brain, right medial parietal, tumor excision — metastatic invasive carcinoma, compatible with breast origin
    • The specimen submitted consists of 5 tissues measuring up to 3x 2x 1.5 cm in size, in fixed state.
    • Microscopically, sections show invasive carcinoma composed of neoplastic nests in infiltrative growth pattern, arranged in solid architecture and foci of tumor necrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism, and high N/C ratio.
    • Immunohistochemical study demonstrates ER (-), PR (-), Her2/neu: positive (3+), GATA3 (+), Ki-67 inedex: 30%.
  • 2022-09-28 MRA - brain
    • indication: Left breast cancer with right breast, bilateral lung and liver meta
    • findings
      • decreased intraventricular and extraventricular CSF spaces; 13.7mm midline shift to the left side
      • rihgt parahippocampal hernia; a heterogeneous enhancing tumor, about 37mm xm38mm x 44mm, in the right parietal lobe with severe perifocal edema. The lesion revealed heterogeneous high SI on T2WI withfluid-fluid layrings and heterogeneous low SI on T1WI and several high density spots within it. Mass effect on the right lateral centricle was noted.
      • unremarkable change in the skull base
    • IMP: suspected a metastatic tumor or maligment glioma in the right parietal lobe, causing significant mass effect on the brain.
  • 2022-09-28 CT - brain
    • History and indication: severe headache
    • Findings
      • Right brain metastases with calcifications, perifocal edema causing midline shift to left and right lateral ventricle compression.
      • No evidence of intracranial hemorrhage.
      • Intact bony structures.
      • Widening of cortical sulci and dilatation of ventricles.
    • IMP: Right brain metastases with mass effect.
  • 2022-08-05 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2022/05/06, the the lesion in the right acetabulum is slightly more evident. Bone metastasis in slight progression should be watched out.
    • No prominent change is noted in other bone lesions, possibly more benign in nature.
  • 2022-08-04 CT - chest
    • Left breast cancer with right breast, bilateral lung and liver meta. Right axillary lymphadenopathy, these tumor size and extension are stationary.
  • 2022-05-10 CT - chest
    • advanced Lt breast cancer with liver, lungs, and axillary LNs metastases, stationary as compared with CT on 20220210
  • 2022-05-06 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2022/02/07, no prominent change is noted in the the lesion in the right acetabulum, compatible with bone metastasis in stationary status.
    • The previous lesion in the left 3rd rib is less evident.
    • No prominent change is noted in other bone lesions, possibly more benign in nature.
  • 2022-02-10 CT - chest
    • Left breast tumor with right breast subcutaneous meta. Stationary.
    • Lung meta, in regression.
  • 2022-02-07 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2021/11/11, the lesion in the right acetabulum is more evident, suspected bone metastasis in progression.
    • Increased tracer uptake at the left hip comes to more prominent also, and the nature is to be determined (metastasis, compensatory effect or other nature ?). Please correlate with other clinical findings for further evaluation.
    • No prominent change is noted in other bone lesions.
  • 2021-11-11 Tc-99m MDP whole body bone scan
    • In comparison with the previous study on 2021/08/11, the lesion in the right acetabulum is a little more evident, compatible with bone metastasis in a little more progression.
    • A new hot spot in the anterior aspect of left 3rd rib. Either post-traumatic change or bone metastasis may show this picture. Please correlate with the clinical history and follow up bone scan for further evaluation.
    • The lesions in the upper L-spines and right S-I joint are slightly more evident. The nature is to be determined (early metastases? degenerative change in a little more severe status?). Please correlate with other clinical findings for further evaluation.
    • No prominent change is noted in other bone lesions.
  • 2021-11-10 CT - chest
    • advanced Lt breast cancer with liver, lungs, and axillary LNs metastases, in progression of lung metastasis, but regression of hepatic metastasis and primary breast tumor as compared with CT on 20210810
  • 2021-08-11 Tc-99m MDP whole body bone scan
    • Markedly increased activity in the right acetabulum, the nature is to be determined (post-traumatic change, early bone mets or other nature ?), suggesting further investigation and follow-up with bone scan in 3 months.
    • Suspected benign lesions in the maxilla, some T- and L-spine, bilateral shoulders, S-I joints, left hip, and knees.
  • 2021-08-10 CT, lung/mediastinum/pleura:
    • advanced Lt breast cancer with liver, lungs, and axillary LNs metastases, in progression compared with CT on 6/24.
    • decreased size of Rt breast mass with axillary lymphadenopathy compared with CT on 6/24.
    • uterine myomas.
  • 2021-08-10 SONO, breast:
    • left breast cancer, upper hemisphere.
    • suspicious right breast tumors at 4’ and 10’ (#2, #3), contralateral cancer cannot be excluded. suggest biopsy.
    • BI-RADS category 6, known Biopsy-proven malignancy. surgical excision should be considered when clinically appropriate.
  • 2021-08-10 Doppler color flow mapping, 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (78 - 27) / 78 = 65.38%
      • M-mode (Teichholz) = 66
    • Normal LV systolic function with normal wall motion.
    • LV diastolic dysfunction Gr 2.
    • Normal RV systolic function.
    • Trivial MR; mild TR.
  • 2021-07 right breast palpable mass with oozing and purulent discharge were noted.
    • left breast cancer, stage IV, with liver and right femoral bone metastasis? s/p 8 cycles chemotherapy and herceptin for 2-3 cycles at Taipei city hospital Fuyou branch, and hold since 2021-04.
    • hypertension.

[counsultation]

  • 2022-10-06 Radiation Oncology
    • Q
      • She visited our ER due to headache, vomiting and general weakness for 3 days. CT showed right brain metastases with calcifications, perifocal edema causing midline shift to left and right lateral ventricle compression. MRI showed suspected a metastatic tumor or maligment glioma in the right parietal lobe, causing significant mass effect on the brain on 20220928. Concern of the mass effect by brain tumor, she agreed to undergo craniectomy for metastatic brain tumor excision on 20220929 . After operation, she was sent to ICU for intensive monitoring. She was sent to normal ward after her condition improved. During our ward, her condition was stable without ICP elevation or infection sign or loss of GCS. The pathology of brain tumor revealed breast tumor metastasis, and further management was needed.
      • We strongly need your expertise for radiotherapy arrangement and further advises for current breast cancer. Thank you very much.
    • A
      • Postoperative RT is indicated. CT-simulation will be arranged on 2022/10/12. Plan to deliver 18 Gy/ 6 fx to the whole brain. Then boost the preOP tumor bed to 36 Gy/ 12 fx. RT will start around 10/13 or 14. Thank you very much.
  • 2022-09-28 Neurosurgery
    • A
      • 54 y/o female.
        • Left breast cancer with right breast, bilateral lung, and liver metastases.
        • c/o headache and nausea.
      • Head CT scan: R hemipheric edema.
      • IMP: breast ca with brain metastasis.
      • Rx: Brain MRI/MRA with/without contrast.
      • Admitted to ward if the patient and family consent to undergo craniotomy.
      • Poor prognosis.
  • 2021-08-23 Rehabilitation
    • Q
      • For educating the patient learning to use mobility aids, such as walkers, canes, and also needs to learn how to turn over, get in and out of bed, get in and out of a wheelchair, and walk to alleviate pain.
      • This 53-year-old woman patient has suffered from left breast huge mass for one year and she visited our OPD for help. Left breast cancer was suspect after breast mammography and echo examination. Echo guide core needle biopsy was performed on 2020/06/09 and invasive ductal carcinoma was confirmed by pathology. After 4-8 courses Neo-adjuvant chemotherapy with AC-T for 8 cycles(AC x 4 and taxotere x 4) and herceptin for 2-3 cycles at FuYou Hospital (hold since 2021-04). Due to severe side effect of the chemotherapy, she was admitted for supportive treatment. She was refer to our oncologist of right palpable mass with oozing and purulent discharge without change. Current stage is cT4cN1M1, Stage IV. Now, she was admitted to our ward for further treamtent.
    • A
      • Assessment
        • Left breast cancer with liver and right femoral bone metastasis ,cT4cN1M1, Stage IV
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation programs
        • Goal: recondition, improve endurance and muscle strength
  • 2021-08-12 Radiation Oncology
    • Q
      • This 53-year-old woman patient is a case of Left breast cancer with liver and right femoral bone metastases, Stage IV. Right thigh pain developed in 2021/05. Whole body bone scan on 2021/08/11 showed right pelvis bone metastasis. Now, for evaluate palliative radiotherapy for pain control. Thank you.
    • A
      • Palliative RT is indicated. CT-simulationi will be arranged today. Plan to deliver 30 Gy/ 10 fx to the Rt hip joint region. RT will start on 2022/08/16. Thank you very much.

[immunochemotherapy]

  • 2023-06-27 - Enhertu (trastuzumab deruxtecan) 5.4mg/m2 200mg D5W 100mL 90min
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg D1-3
  • 2023-06-06 - Kadcyla (trastuzumab emtansine) 3.6mg/m2 210mg NS 250mL 90min (T-DM1, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-05-16 - Kadcyla (trastuzumab emtansine) 3.6mg/m2 210mg NS 250mL 90min (T-DM1, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-03-28 - Kadcyla (trastuzumab emtansine) 3.6mg/m2 210mg NS 250mL 90min (T-DM1, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-02-21 - Kadcyla (trastuzumab emtansine) 3.6mg/m2 210mg NS 250mL 90min (T-DM1, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-01-31 - Kadcyla (trastuzumab emtansine) 3.6mg/m2 210mg NS 250mL 90min (T-DM1, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-01-03 - Kadcyla (trastuzumab emtansine) 3.6mg/m2 210mg NS 250mL 90min (T-DM1, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-12-13 - Kadcyla (trastuzumab emtansine) 3.6mg/m2 210mg NS 250mL 90min (T-DM1, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-11-23 - Kadcyla (trastuzumab emtansine) 3.6mg/m2 210mg NS 250mL 90min (T-DM1, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-10-31 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-08-18 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • 2022-07-27 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • 2022-07-06 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • 2022-06-15 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • 2022-05-25 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • 2022-05-04 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • 2022-03-30 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • 2022-03-02 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • 2022-02-09 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • 2022-01-12 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • 2021-12-15 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • 2021-11-24 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • 2021-11-03 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • 2021-10-13 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • 2021-09-22 - docetaxel 60mg/m2 100mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • 2021-09-02 - docetaxel 35mg/m2 60mg NS 250mL 1hr + trastuzumab 600mg SC 0hr
  • 2021-08-26 - docetaxel 35mg/m2 55mg NS 250mL 1hr
  • 2021-08-12 - docetaxel 35mg/m2 55mg 1hr

==========

[underdose] (not posted)

Enhertu 5.4mg/kg

2023-06-28

[reconciliation]

  • Currently, we are unable to access the patient’s PharmaCloud database, likely due to lack of authorization. However, after reviewing the medication records in HIS5, it’s apparent that all valid prescriptions have been issued by the Hemato-Oncology department. Therefore, we did not find any issues related to medication reconciliation.

[patient education]

  • On this hospitalization, the patient is receiving Enhertu ADC for the first time. I visited the patient around 14:00 on 2023-06-28, carrying a leaflet explaining the possible side effects and precautions of this medication. During my visit, the patient’s younger sister arrived, and I also explained the details to her, especially emphasizing on the risk of Interstitial Lung Disease. I informed them that they should immediately notify the medical team if any suspected symptoms occur. The patient’s sister inquired about how to contact the doctor on regular days, to which I advised that she could call the hospital to reach the clinic or contact nurse practitioner Zheng for relay. I also provided the contact information of the Pharmacy Consultation Window for their future reference.

2022-11-23

  • In terms of PFS and OS, trastuzumab deruxtecan outperforms trastuzumab emtansine (ref: Trastuzumab Deruxtecan versus Trastuzumab Emtansine for Breast Cancer. N Engl J Med. 2022;386(12):1143-1154. doi:10.1056/NEJMoa2115022), however trastuzumab deruxtecan remains unreimbursed by the National Health Insurance program.
  • The patient has met the criteria (had received trastuzumab and a taxane) to apply for trastuzumab emtansine coverage under the National Health Insurance Program.
  • Ado-trastuzumab emtansine for patients with breast cancer, metastatic, HER2+: IV 3.6 mg/kg every 3 weeks until disease progression or unacceptable toxicity.
  • As long as trastuzumab emtansine is used, it is recommended to monitor any possible hepatotoxicity and cardiotoxicity on a regular basis.

2022-09-29

  • Neurosurgery suggests craniotomy for the patient’s severe headache due to brain mets.
  • Neratinib has been tested in combination with capecitabine in patients with HER2+ breast cancer brain metastases. Of the 37 patients, 89%, 22% and 14% were previously treated with trastuzumab, T-DM1 and another investigational HER2-directed agent, respectively, and most had received previous radiotherapy (65% WBRT and 32% SRS) and several chemotherapy agents. It is reported that 18 partial responses, with a brain metastasis volumetric response of 49%, 6-month PFS of 38% and a median time-to-brain-mets progression of 5.5 months. 51% of patients experienced grade 3 toxicities, of which 32% were gastrointestinal events, mostly diarrhoea, requiring specific prophylactic management.
    • ref: a phase II trial of neratinib and capecitabine for patients with human epidermal growth factor receptor 2-positive breast cancer and brain metastases. J. Clin. Oncol. 37, 1081–1089 (2019).
  • The above result was supported by the NALA -randomised second-/third-line trial, including 130 patients with non-progressive BM at study entry. The overall cumulative incidence of intervention for BM was reduced from 29.2% with lapatinib–capecitabine to 22.8% with neratinib–capecitabine (P = 0.043).
    • ref: Neratinib + capecitabine versus lapatinib + capecitabine in patients with HER2+ metastatic breast cancer previously treated with >= 2 HER2-directed regimens: findings from the multinational, randomized, phase III NALA trial. J. Clin. Oncol. 37, 1002–1002 (2019).
  • In an investigator-initiated prospective, open-label, single-arm phase II TUXEDO-1 study conducted among patients with newly diagnosed or progressive brain metastases from HER2-positive breast cancer, antibody drug conjugate trastuzumab deruxtecan yielded responses by response assessment in neuro-oncology brain metastases (RANO-BM) criteria in 11 of 15 patients with a response rate by central review of 73.3% in the intention-to-treat (ITT) population. Median progression-free survival (PFS) was 14 months, and median overall survival (OS) was not reached at a median follow-up of 12 months.
    • ref: Trastuzumab deruxtecan in HER2-positive breast cancer with brain metastases: a single-arm, phase 2 trial. Nat Med 28, 1840–1847 (2022).
  • Trastuzumab deruxtecan is available as a ‘temporary purchase’ item in the inventory.

2021-08-12

  • stage workup is renewing, continuing HTN management for the moment with patient-carried drugs
    • Adapine (nifedipine) 30mg PO QD
    • Diovan (valsartan) 80mg PO QD
    • Syntrend (carvedilol) 12.5mg PO QD
  • brain and/or spine MRI with contrast should be indicated if CNS symptoms, back pain or symptoms of spinal cord compression.
    • bone scan or sodium fluoride PET/CT, if needed.
  • all or some of ER, PR, HER2, BRCA, PIK3CA, PD-L1, NTRK, MSI-H/dMMR, TMB-H tests might have been done at Taipei city hospital Fuyou branch, order the tests for new biopsy if needed.
    • since the patient received herceptin before, HER2 should be positive.
  • for preoperative/adjuvant therapy for HER2(+), options including:
    • paclitaxel/trastuzumab
    • docetaxel/carboplatin/trastuzumab
    • docetaxel/carboplatin/trastuzumab/pertuzumab
    • doxorubicin/cyclophosphamide followed by paclitaxel/trastuzumab
    • doxorubicin/cyclophosphamide followed by paclitaxel plus trastuzumab/pertuzumab

701474048

230628

[exam findings]

  • 2023-04-18 PD-L1 (22C3)
    • Block No: S2023-04371
    • RESULTS:
      • Combined Positive Score (CPS) assessment: CPS >= and <10
      • Combined Positive Score (CPS): X
  • 2023-04-01, -03-20 SONO - abdomen
    • moderate fatty liver (suboptimal exam of liver)
    • fatty infiltration of pancreas
    • suspected right renal cysts or focally dilated right renal pelvis
  • 2023-03-21 MRI - breast
    • Clinical history: 72 y/o female patient with left breast cancer.
    • With and without enhancement MRI of breast (axial T1, T1FS, sagittal T2, T2FS, axial and sagittal T1FS contrast, dynamic study):
      • Large irregular tumor, up to 6cm in right subareolar region with periareolar skin thickening, prominent heteregeneous enhancement, c/w breast malignancy.
      • There are multiple enlarged lymph nodes in bilateral axillary regions (mainly in right side, up to 2.2cm), r/o lymph nodes metastasis.
    • IMP:
      • Right breast malignancy with skin invasion and bilateral axillary lymph nodes metastasis.
    • BI-RADS:
      • Category 6 - proven malignancy.
  • 2023-03-20 ECG
    • Normal sinus rhythm
    • Increased R/S ratio in V1, consider early transition or posterior infarct
  • 2023-03-13 PET
    • Glucose-hypermetabolism in the right breast with nipple and skin of the anterior chest wall involvement, in the right axillary lymph nodes, and in a right SCF lymph node, highly suspected breast cancer with regional lymph nodes metastases.
    • Increased FDG uptake in a level II lymph node of the right neck and in a left axillary lymph node, highly suspected cancer with distant metastases.
    • Right breast cancer, cT4N3cM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-03-10 Patho - lymphnode biopsy
    • Labeled as “right axillary lymph node”, core needle biopsy — invasive carcinoma.
    • Section shows lymph node with invasive carcinoma.
  • 2023-03-10 Patho - breast biopsy
    • Breast, right, core biopsy — Invasive carcinoma, no special type, NST.
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
    • IHC stains: ER (-, 0%), PR(-, 0%), Her2/neu: negative(score=1+), Ki-67(25 %), p63 (-).
  • 2023-03-10 SONO - breast
    • Right breast tumors with enlarged axillary lymph nodes, suggest biopsy.
    • BI-RADS: Category 5 - highly suggestive of malignancy - appropriate action should be taken.
  • 2023-03-10 Mammography
    • Digital mammography of both breasts with MLO and CC views:
      • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
      • Diffuse increased density in right breast with periarolar skin thickening, r/o malignancy.
      • No periareolar skin thickening.
      • Enlarged right axillary lymph nodes.
    • Impression:
      • Dense breast. R/O right breast malignancy with lymph nodes metastasis, suggest biopsy.
    • BI-RADS: Category 5 - highly suggestive of malignancy - appropriate action should be taken.

[chemotherapy]

  • 2023-06-21 - docetaxel 75mg/m2 120mg NS 250mL 1hr (D, Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-05-31 - liposome doxorubicin 35mg/m2 56mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 955mg NS 500mL 1hr (AC(lipo), Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + famotidine 20mg + NS 250mL
  • 2023-05-03 - liposome doxorubicin 35mg/m2 56mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 960mg NS 500mL 1hr (AC(lipo), Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + famotidine 20mg + NS 250mL
  • 2023-04-12 - liposome doxorubicin 35mg/m2 56mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 960mg NS 500mL 1hr (AC(lipo), Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-21 - liposome doxorubicin 35mg/m2 56mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 960mg NS 500mL 1hr (AC(lipo), Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

2023-06-27 G-CSF (filgrastim 150ug) SC ST 2023-06-21 Granocyte (lenograstim 250ug) SC QD 3D

==========

2023-06-28

  • The pathology results from the breast biopsy performed on 2023-03-10 confirmed that the patient has triple-negative breast cancer (TNBC) with HER2-low characteristic (ER negative, PR negative, and Her2/neu score=1+).

  • Following this diagnosis, the patient underwent four cycles of liposomal doxorubicin with cyclophosphamide (AC) on 2023-03-21, 2023-04-12, 2023-05-03, and 2023-05-31. Docetaxel was then administered on 2023-06-21.

  • Leukopenia episodes were observed on the 20th day after the 3rd AC administration and the 6th day after the 1st docetaxel administration, with WBC levels marked with an asterisk (*) representing WBC < 2K/uL and double asterisks (**) representing WBC < 1K/uL.

    • 2023-06-27 WBC 0.93 x10^3/uL **
    • 2023-06-27 WBC 0.79 x10^3/uL **
    • 2023-06-20 WBC 3.02 x10^3/uL
    • 2023-05-30 WBC 5.99 x10^3/uL
    • 2023-05-23 WBC 1.74 x10^3/uL *
    • 2023-05-02 WBC 4.50 x10^3/uL
    • 2023-04-12 WBC 4.29 x10^3/uL
    • 2023-03-08 WBC 7.64 x10^3/uL
  • To manage the episodes of leukopenia, filgrastim 150ug was given on 2023-06-27 and lenograstim 250ug was given consecutively for 3 days starting from 2023-06-21. Following these interventions, the patient’s WBC level has begun to show signs of improvement. Regular monitoring is essential to ensure this upward trend continues and to ensure the patient’s safety during further chemotherapy treatments.

  • The NHI in Taiwan approves the use of G-CSF for patients with non-hematologic malignancies who have a WBC count of less than 1000/uL or an ANC of less than 500/uL after chemotherapy. As the patient meets these criteria, the use of G-CSF is covered by NHI.

  • The patient received G-CSF with the chemotherapy regimen on 2023-06-21. For primary and secondary prophylaxis, G-CSF administration should typically begin 24 to 72 hours after completion of chemotherapy.

  • If the current chemotherapy regimen becomes less effective, Enhertu (fam-trastuzumab deruxtecan-nxki) may be used. This medicine is indicated for adult patients with unresectable or metastatic HER2 low (IHC 1+ or IHC 2+/ISH-) breast cancer who have received prior chemotherapy in the metastatic setting or who have experienced disease recurrence within six months of completing adjuvant chemotherapy. However, Enhertu is currently not covered by NHI in Taiwan.

700769074

230627

[exam findings]

  • 2023-06-05 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (135 - 54) / 135 = 60.00%
      • M-mode (Teichholz) = 60
    • Conclusion:
      • Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Mildly dilated LV with preserved LV and RV systolic function.
      • Mildly dilated aortic root.
  • 2023-05-24 Patho - soft tissue debridement
    • PATHOLOGIC DIAGNOSIS
      • Breast, left, partial mastectomy — Invasive carcinoma of no special type, recurrent
      • Resection margin, breast, left, simple mastectomy — Free
      • Lymph node, left axilla sentinel, SLNB — Negative for malignancy (0/6)
      • AJCC 8 th edition, Pathology stage: rpT1c(m)N0(sn); Anatomic stage IA; Prognostic stage IA if cM0
      • Specimen labeled “capsule”, left breast, release constracture — Chronic inflammation, fibrosis and foreign body reaction
    • MACROSCOPIC EXAMINATION
      • Breast Size: 6.5 x 4.1 x 1.8 cm
      • Skin Size: 6.2 x 1.1 cm
      • Nipple: Not included
      • Tumor Size: Two tumors, 1.5 x 1.0 x 0.8 cm (9’ tumor) and 1.0 x 1.0 x 0.8 cm (8’ tumor) , respectively
      • Resection Margin: Free, 0.4 cm from the deep margin
      • Lymph node: Axilla sentinel
      • Specimen labeled “capsule, left breast”: two pieces, measuring up to 3.5 x 2.8 x 0.4 cm.
      • Representative parts are taken for section and labeled: F2023-00239FS A1= 12’ 3’, 6’’ margins, FSA2= 9’ and deep margins, FSB1-FSB2= left axilla sentinel lymph nodes, A= skin, A2-A4= 9’ tumor, A5-A6= 8’ tumor, A7= non-tumor. S2023-10135= capsule, left breast
    • MICROSCOPIC EXAMINATION
      • Histology
        • Histologic type: Invasive carcinoma of no special type (both 9’ and 8’ tumors)
        • Size of invasive carcinoma: 1.5 x 1.0 x 0.8 cm (9’ tumor) and 1.0 x .0 x 0.8 cm (8’ tumor)
        • Histologic grade (Nottingham histologic score): Grade 2 (score= 7, both tumors)
        • Skin involvement: Absent
        • Ductal carcinoma in situ: Absent
      • Margins: Negative, Closest margin ( 4 mm from deep margin)
      • Nodal status: Negative (0/6)
        • number of lymph node examined: 6 (sentinel)
        • number with macrometastases (> 2mm): 0
        • number with micrometastases (> 0.2~2mm and/or > 200 cells): 0
        • number with isolated tumor cells (<= 0.2mm and <= 200 cells): 0
      • Treatment Effect: Not applicable
      • Lymphovascular invasion: Absent
      • Perineural invasion: Absent
      • Specimen labeled “capsule, left breast”: Chronic inflammation, fibrosis, and foreign body granuloma
    • IMMUNOHISTOCHEMICAL STUDY (S2023-08643)
      • 8’ tumor, left breast
        • ER: Positive (+, 100%, strong intensity),
        • PR: Positive (+, 100%, strong intensity)
        • HER-2/Neu: Negative (score=1+)
        • Ki-67: 10%
      • 9’ tumor, left breast
        • ER: Positive (+, 80%, strong intensity)
        • PR: Positive (+, 80 %, strong intensity)
        • Her2/neu: Positive (score=3+)
        • Ki-67: 10 %
  • 2023-05-22 MRI - breast
    • Clinical history: 45 y/o female patient with left breast cancer and right breast tumor.
    • With and without enhancement MRI of breast
      • S/P left breast mammoplasty.
      • There is spiculated tumor in 9’region of left breast, 2.4x2.2cm, around the implant, with prominent enhancement, malignancy considered.
      • Irregular tumor, 1.4cm in 8’region of left breast, malignancy considered.
      • Right subareolar oval shaped tumor, 1.3cm.
      • There are stipple enhancement in right breast, r/o fibrocystic disease.
      • No periareolar skin thickening.
      • There are bilateral axillary lymph nodes.
      • Prominent internal mammary lymph nodes, left side.
    • IMP:
      • S/P left breast mammoplasty, recurrent tumors (8’region and 9region).
      • Right subareolar tumor.
      • Bilateral axillary lymph nodes.
      • Prominent left internal mammary lymph nodes, metastasis?
    • BI-RADS:
      • Category 6 - proven malignancy.
  • 2023-05-15 Tc-99m MDP bone scan
    • Two hot spots in the sternal body, the nature is to be determined (bone mets, post-traumatic change or other nature ?), suggesting PET scan for investigation and follow-up with bone scan in 3 months.
    • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, hips, knees, and feet.
  • 2023-05-05 Patho - breast biopsy (no need margin)
    • Breast, left, 8’clock, core biopsy — Invasive carcinoma, no special type, NST. IHC stains: ER (+, 100%, strong intensity), PR(+ , 100%, strong intensity), Her2/neu: negative(score=1+), Ki-67(10 %), E-cadherin (+).
    • Breast, left, 9’clock, core biopsy — Invasive carcinoma, no special type, NST. IHC stains: ER (+, 80%, strong intensity), PR(+, 80 %, strong intensity), Her2/neu: positive(score=3+), Ki-67(10 %), E-cadherin (+).
  • 2023-04-25 SONO - breast
    • Right breast subareolar tumor, suggest biopsy.
    • S/P left mammoplasty. Irregular hypoechoic lesion in left 9’region, post-op scar or recurrence. Suggest further study.
    • BI-RADS 4b

[consultation]

  • 2023-05-23 Hemato-Oncology
    • Q
      • This is a 45 years old woman patient. Due to left breast cancer and right breast tumor, she was admitted for surgery of left partial mastectomy + SLNB and right tumor excision on 2023/05/23. However, Hb:5.6 was noted. Anemia over 3 years without follow up by this patient told. We need your help for anemia assessment. Thank you so much!!
    • A
      • This 45 year old woman is a case of Lt breast ca s/p op at Cathay General Hospital in 2010-12, Lt breast ca recurrence proved by CNB on 2023-05-05 and Rt intraductal papilloma. she was admitted for surgery of left partial mastectomy + SLNB and right tumor excision on 2023/05/23. We are consulted for anemia.
      • 2023-05-23 did not encounter the patient during visitation.
      • For microcytic anemia, please check Hb electrophoresis, Ferritin, Fe/TIBC, stool OB (if positive, please arrange colonoscopy and panendoscopy to rule out GI bleeding).
      • Please add Foliromin 1 tab QD (or HS) and increase vitamin C intake. Arrange our OPD after discharge. Thanks for your consultation.

[immunochemotherapy]

  • 2023-06-27 - trastuzumab 600mg SC 5min + docetaxel 75mg/m2 132mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr (DCH)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-06-06 - trastuzumab 600mg SC 5min + docetaxel 75mg/m2 132mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr (DCH)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

Regimen Reference Order - BRST - DCH — ref: https://www.cancercare.mb.ca/export/sites/default/For-Health-Professionals/.galleries/files/treatment-guidelines-rro-files/regimen-reference-orders/breast/BRST-DCH.pdf — Updated: June 14, 2023

  • Planned Course: DCH every 21 days for 6 cycles, followed by trastuzumab every 21 days for 12 cycles
  • Indication for Use: Breast Cancer Adjuvant; HER2 positive

==========

2023-06-27

  • The patient received two cycles of the DCH regimen on 2023-06-06 and 2023-06-27. However, lab data shows that there was already a noticeable decrease in HGB levels before the initiation of the regimen, with the lowest record on 2023-05-22 at 5.6g/dL. Subsequently, multiple blood transfusions were conducted on 2023-05-22, 2023-06-05, and 2023-06-27.

    • 2023-06-27 HGB 7.4 g/dL
    • 2023-06-12 HGB 9.2 g/dL
    • 2023-06-05 HGB 8.1 g/dL
    • 2023-05-24 HGB 6.8 g/dL
    • 2023-05-23 HGB 6.6 g/dL
    • 2023-05-22 HGB 5.6 g/dL
  • Trastuzumab has been associated with a low occurrence of anemia, affecting approximately 4% of patients, with less than 1% experiencing a severe (grade 3) form, according to UpToDate. However, both docetaxel and carboplatin, which are part of the patient’s treatment regimen, are known to significantly increase the risk of anemia. Docetaxel can cause anemia in 65% to 97% of patients, with 8% to 9% experiencing severe anemia (grades 3/4). Carboplatin can cause anemia in a wide range of 21% to 90% of patients. Therefore, these drugs could be contributing to the patient’s current anemia.

  • MCV is at the lower end of the normal limit, and both MCH and MCHC are below the lower limit of normal, suggesting possible iron deficiency. This is further supported by the ferritin level measured on 2023-05-24, which was significantly below the lower limit of normal. It may be necessary to further investigate and address this possible iron deficiency.

    • 2023-06-27 MCV 82.3 fL
    • 2023-06-27 MCH 21.8 pg
    • 2023-06-27 MCHC 26.5 g/dL
    • 2023-05-24 Ferritin 4.9 ng/mL

700402514

230626

[exam findings]

  • 2023-05-09 Pure Tone Audiometry
    • PTA
    • Reliability FAIR
    • Average RE 24 dB HL; LE 19 dB HL.
    • RE normal to moderately severe SNHL.
    • LE normal to moderate SNHL.
  • 2023-05-06 MRI - brain
    • Venous angioma in right frontal lobe. No evidence of brain metastases.
  • 2023-05-05 Patho - colon biopsy
    • Colon, descending, 40 cm above anal verge, polypectomy — tubulovillous adenoma with low grade dysplasia
    • Colon, descending, 30 cm above anal verge, biopsy — tubular adenoma with low grade dysplasia
    • Colon, transverse, 50 cm above anal verge, polypectomy — Hyperplastic polyp
    • Colon, transverse, 60 cm above anal verge, biopsy — tubulovillous adenoma with low grade dysplasia
    • Colon, hepatic flexure, biopsy — Hyperplastic polyp
  • 2023-05-05 Miniprobe endoscopy ultrasound
    • Indication: for staging
    • Symptoms: for staging
    • Pre-EUS diagnosis: Eso adeno Ca
    • Endoscopic findings
      • With white light endoscopy, a easily touch-bleeding elevated lesion was noted at EC junction. With NBI-ME, focal JES-IPCL B3 pattern. Chromoendoscopy was performed with lugol-solution and showed no LVLs above EC junction. A few sessile polyps were scattered at remnant stomach.
    • EUS findings
      • With UM-DP20-25R, it showed 6.5x7.7mm hypoechoic lesion, invading to 4th layer of esophageal wall. At least two hypoechoic lesions up to 4.3mm were noted at paraesophageal space.
    • Diagnosis
      • Esophageal adenocarcinoma, EC junction, EUS staging at least cT2N1
      • Gastric polyps, remnant stomach.
  • 2023-05-04 Tc-99m MDP whole body bone scan
    • Mildly increased activity in the lower T-spines and some L-spines. Degenerative change is more likely.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, left wrist, bilateral hips, knees, ankles and feet, compatible with benign joint lesions.
  • 2023-05-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (107 - 47) / 107 = 56.07%
      • M-mode (Teichholz) = 55
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Septal hypertrophy
      • Trivial MR and trivial TR
      • Preserved RV systolic function
  • 2023-05-03 PET
    • Increased FDG uptake in the lower third of esophagus, near E-G junction, compatible with the primary esophageal cancer.
    • Increased FDG uptake in a focal soft tissue in the right supraclavicular fossa, the nature is to be determined (esophageal cancer with regional lymph nodes metastases, the other primary cancer, or other nature ?), suggesting biopsy for investigation.
    • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    • Highly suspected lower esophageal cancer with regional lymph nodes metastases, cTxN1-2M0, stage IIIA-B (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-04-20 CT - chest
    • IMP: Esophageal tumor at EG junction. 1.6cm.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T1(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-04-10 Patho - stomach biopsy
    • Esophagus, EC junction, biopsy — Adenocarcinoma in situ, at least
    • Microscopically, it shows adenocarcinoma in situ composed of high-grade atypical neoplastic glands admixed with necrotic tissues and stromal fibrosis.
  • 2023-04-10 Esophagogastroduodenoscopy, EGD
    • Gastric A2 ulcer, anastomosis site, s/p biopsy (A)
    • Esophageal erosion, EC junction, s/p biopsy (B)
    • Remnant gastritits
    • Post subtotal gastrectomy with Billroth II anastomosis
  • 2023-05-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 24) / 79 = 69.62%
      • M-mode (Teichholz) = 69.9
    • Conclusion:
      • Normal chamber size
      • Septal hypertrophy
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • Mild MR
      • No regional wall motion abnormalities
  • 2021-03-31 Patho - appendix (non-incidental)
    • Appendix, L.A. — Early appendicitis and myxoid degeneration of appendix wall
  • 2021-03-30 CT - abdomen
    • Mild dilatation of appendix, r/o acute appendicitis, suggest clinical correlation.
    • S/P gastrectomy.
    • Left renal cysts.
  • 2020-05-25 ENT Hearing Test
    • Tymp: Bil type A.
    • ART:
      • R’t ipsi 4k Hz reduced, and contra 2-4k Hz elevated and absent.
      • L’t ipsi 4k Hz and contra 4k Hz absent.
    • PTA
      • Reliability: fair
      • Average: R’t 33 dB HL, L’t 25 dB HL.
      • Bil normal to moderately severe SNHL. (4k Hz notch)

[consultation]

  • 2023-05-09 Radiation Oncology
    • A
      • This 46 years old male has history of subtotal gastrectomy, alcohol(+), smoke(+). He was admitted to our GI ward due to tarry stool. Biopsy at EC junction revealed adenocarcinoma in situ, at least. The PET revealed the right supraclavicular lymph node metastasis. PET and EUS clinical staging revealed at least cT2N1-2M0,stage IIIA-B.
      • Neoadjuvant CCRT is indicated. CT-simulation will be arranged on 2023/05/15. Plan to deliver 45 Gy/ 25 fx to the lower half esophagus, the adjacent lymphatic drainage area, and Rt SCF. Then boost the esophageal tumor, LAPs, and Rt SCF LAP to 50.4 Gy/ 28 fx. RT will start around 2023/05/17 or 18. Thank you very much.
  • 2023-05-08 Hemato-Oncology
    • Q
      • For lower third esophageal maglignancy further evlauation and mangement.
      • This 46 years old male has history of subtotal gastrectomy, alcohol(+), smoke(+). He was admitted to our GI ward due to tarry stool. Panendoscope was done and tissue biopsy at anastomosis revealed ulcer,no H.pylori present. However, biopsy at EC junction revealed adenocarcinoma in situ, at least. Thus, he was admitted to our chest surgery ward for furteher cancer survey and pre-operative evaluation. However, the PET reported his right supraclavicular lymph node metastasis, PET and EUS clinical staging revealed at least cT2N1M0,stage IIIA-B.
      • Thus, we need your expertise for the patient’s further evaluation and further managment, thanks a lot!
    • A
      • This 46 year old man is a case of EG junction cancer, cT2N1M0,stage III, biopsy show adenocarcinoma in situ with initial presentation epogastric pain. He had history of HTN, GU, obesity s/p subtotal gastrectomy. He was admiited for cancer work up. We are consulted for pre-op CCRT.
      • Please arrange port A insertion. Please arrang auditory test and 24 urine CCR and check Anti HBc, Anti HBs, HBsAg, Anti HCV. We will arrange chemotherapy concurrent with RT. Please consult Radio-oncologist. Thanks for your consultation

[chemotherapy]

  • 2023-06-23 - cisplatin 75mg/m2 150mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 2000mg NS 500mL 24hr D1-4 (PF, CCRT, Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-22 - cisplatin 75mg/m2 150mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 2000mg NS 500mL 24hr D1-4 (PF, CCRT, Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-06-26

  • According to the PharmaCloud database, our hospital is the sole provider of all medical services and medications required by the patient in recent months. Therefore, no medication reconciliation issues have been identified.

700856655

230621

[exam findings]

  • 2023-06-05 SONO - abdomen
    • Hepatic hemangiomas, right lobe
    • Renal stone, RK
  • 2023-06-02 Tc-99m MDP bone scan
    • No definite evidence of bone metastasis.
    • Increased activity in the lower L-spines. Degenerative change may show this picture.
    • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral hips and right foot, compatible with benign joint lesions.
  • 2023-06-01 MRI - nasopharynx
    • Oralcavity
      • Impression (Imaging stage) : T:4a N:0 M:0 STAGE:
  • 2023-05-17 Patho - gingival/oral mucosa biopsy
    • Oral cavity, left tongue, incisional biopsy — Squamous cell carcinoma, moderately differentiated
    • Section shows squamous mucosal tissue with infiltration of nests of neoplastic squamous cells.

[immunochemotherapy]

  • 2023-06-19 - cetuximab 400mg/m2 600mg 2hr + docetaxel 40mg/m2 60mg NS 150mL 2hr + cisplatin 40mg/m2 60mg NS 500mL 3hr + fluorouracil 1000mg/m2 1600mg NS 1000mL 22hr + leucovorin 100mg/m2 160mg in 5-FU 22hr (longer infusion taxel and platin)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-06-09 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 1000mg/m2 1600mg NS 1000mL 22hr + leucovorin 100mg/m2 160mg in 5-FU 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg

==========

2023-06-21

  • The patient’s medical history, as recorded in the HIS5 database, shows previous episodes of leukopenia and thrombocytopenia in 2018-01. No chemotherapy was administered at that time.

  • More recently, in mid to late May 2023, the patient was diagnosed with SCC of the left tongue margin. The patient then received TPF chemotherapy on 2023-06-09 and a combination of TPF and cetuximab on 2023-06-19. Leukopenia, defined here as a WBC count of less than 3K/uL, was observed on 2023-06-16. To treat this, 3 doses of Granocyte (lenograstim 250ug) were administered on 2023-06-16, 2023-06-17, and 2023-06-21.

    • 2023-06-19 WBC 5.80 x10^3/uL
    • 2023-06-16 WBC 2.26 x10^3/uL *
    • 2023-06-01 WBC 3.57 x10^3/uL
  • Given that the WBC count prior to the 2nd dose of TPF was higher than that prior to the 1st dose, and given that G-CSF was administered 2023-06-21 morning, the likelihood of severe leukopenia following the 2nd round of chemotherapy is expected to be reduced. However, the patient’s blood counts should continue to be monitored closely.

[reconciliation]

  • The patient regularly visits a local psychiatric clinic to manage her episodic paroxysmal anxiety. The prescribed medications for this condition are clonazepam, fludiazepam, estazolam, and escitalopram. These medications have all been integrated into the patient’s current medication list, and no reconciliation issues have been identified. Please ensure the patient is adhering to her psychiatric medication regimen, as disruptions could potentially exacerbate her anxiety symptoms.

701243929

230620

{esophageal SCC moderately differentiated T3N2M1 with lung mets}

[exam findings]

  • 2023-05-17, -04-17, -04-14, -02-23, -01-31 CXR
    • Multiple metastases on both lungs.
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2023-04-14 Patho - lung wedge biopsy
    • Lung, left, CT-guide biopsy — squamous cell carcinoma, moderately differentiated, consistent with metastatic
    • Sections show dysplastic keratinized squamous cell carcinoma infiltrating in a fibrotic stroma. The morphology is consistent with metastatic squamous cell carcinoma. Please correlate with the clinical presentation.
  • 2023-03-21 CT - chest
    • Indication: Esophageal cancer of squamous cell carcinoma, moderately differentiated T3N2M1 with lung mets progression, stage IV
    • Comparison was made with previous CT dated on 2022/12/08
      • post op change with staple lines in LLL. left upper lobe medial fibrotic change, related to treatment.
      • multiple randomly distributed nodules/masses of varing sizes in both lungs, increase in size and number of these lesions as compared with previous CT on2022/12/8. interlobular septal thickening in Rt lung and LUL.
      • Mediastinum and hila: s/p esophagectomy and gastric conduit in middle mediastinum, enlarged LNs in visceral space and Rt hilum.
      • mild pericardial effusion.
    • Impression
      • bilateral lung metastases and mediastinal and hilar metastatic LAP, in progression as compared with previous CT study on 2022/12/08
  • 2022-12-08 CT - chest
    • Indication: Esophageal cancer of squamous cell carcinoma, moderately differentiated T3N2M1 with lung mets progression, stage IV
    • Chest CT with and without IV contrast ehnancement shows:
      • Soft tissue mass at both lungs up to 6.7cm at left lower lobe and right upper lobe up to 4.67cm is found. Lung mets is considered. In comparison with CT dated on 2022-08-17, the lesios enlarged.
      • S/p port-A placement with its tip at Superior vena cava.
      • s/p esophagectomy and gastric tube reconstruction.
    • Imp: Lung meta at both lungs. In progression.
  • 2022-12-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (83 - 32) / 83 = 61.45%
      • M-mode (Teichholz) = 60
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR, trivial TR and trivial PR
    • Minimal pericardiac effusion
    • Preserved RV systolic function
    • left pleural effusion
  • 2022-12-07 CXR
    • S/P port-A implantation.
    • Multiple metastases on both lungs.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2022-08-17 CT - Lung/Mediastinum/Pleura
    • Findings
      • Lungs:
        • post op change with staple lines in LLL. left upper lobe medial fibrotic change, related to treatment.
        • multiple nodules in both lungs, some with intrinsic cavitations slightly inecrease in size of these nodules as compared with previous CT on 2022/5.17
      • Mediastinum and hila: s/p esophagectomy and gastric conduit in middle mediastinum, no enlarged LN or mass..
    • Impression
      • bilateral lung metastases, sligthly in progression as compared with previous CT study on 20220517
  • 2022-05-17 CT - Lung/Mediastinum/Pleura
    • Findings
      • Lungs:
        • post op change with staple lines in LLL. left upper lobe medial fibrotic change, related to treatment.
        • multiple nodules in both lungs, some with intrinsic cavitations slightly decrease in size as compared with previous CT on 20220208
      • Mediastinum: s/p esophagectomy and gastric conduit in middle mediastinum, no enlarged LN or mass..
      • Hila: no enlarged LN.
      • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: minimal effusion.
      • Chest wall and visible lower neck: no LAP.
      • Visible abdominal-pelvic contents:
        • distended U-bladder filled with urine.
        • normal appearance of gallbladder. unremarkable of the liver, spleen, adrenal glands, pancreas, and kidneys. no enlarged lymph node. no ascite.
    • Impression:
      • bilateral lung metastases, sligthly in regression as compared with previous CT study on 2022-02-08
  • 2022-02-08 CT - Lung/Mediastinum/Pleura
    • Impression: bilateral lung metastases, sligthly in regression as compared with previous CT study on 2021-12-08.
  • 2021-12-08 CT - Lung/Mediastinum/Pleura
    • Impression: bilateral lung metastases, in progression as compared with previous CT study on 2021-08-20.
  • 2021-02-08 Patho - Lung wedge biopsy
    • Diagnosis: Lung, left, upper lobe, wedge resection - Squamous cell carcinoma, moderately differentiated, consistent with metastatic esophageal tumor
    • The HER2/NEU In-Situ Hybridization Test is NEGATIVE. There is NO amplification of HER2 detected.
    • IHC: Her-2/neu (Ab) equivocal(2+).
  • 2020-09-25 Patho - Esophageal biopsy
    • Esophagus, middle, 32cm to 34cm below incisor - squamous cell carcinoma, moderately differentiated
    • IHC: CK(+), p63(+)
  • 2020-07-09 Patho - Esophageal biopsy
    • Esophagus, middle, 25cm below incisor - squamous cell carcinoma, moderately differentiated
    • IHC: p63(+), CD56(focal +)

[consultation]

  • 2020-07-08 Radiation Oncology
    • A
      • History:
        • This 48 year-old male patient denied the systemic disease or specific medical history before. He has suffered from dysphagia and food stuck in the chest for 1-2 months. He can tolerate regular food now. Upper G- I panendoscopy showed esophageal ulcerative lesion, favor malignancy. Biopsy pathology showed squamous cell carcinoma. Esophageal cancer, middle to lower third, was diagnosed at the Yeezen General Hospital in TaoYuan. EUS on 2020078 and Chest CT on 20200709 were arranged for further survey.
        • Previous RT: denied.
        • Other disease: denied.
        • Family history: denied.
        • Habit: Alcohol, 1 bottle/day for 20 yr; smoking: 1/2 PPD for 20 yr; betel nuts: 20#/day for 20 yr.
        • Married, 3 sons (grade 5, kindergarten middle class, baby class). Caregiver: his wife. Job: worker and driver. Mild economic stress at least. Lives in XinWu Dist. TaoYuan City.
        • Language: Mandarin, Taiwanese.
        • Religion: Buddhism
      • Objective:
        • General Condition-ECOG: 1.
        • PE, 20200709: No palpable neck LNs.
        • Pathology, 202007: esophagus, squamous cell carcinoma.
        • Images:
          • Chest CT, 20200710: pending.
          • EUS, 20200710: pending.
          • CXR, liver echo, 20200706: negative.
      • Diagnosis: Esophageal cancer, middle to lower third, squamous cell carcinoma, fresh case, ECOG = 1.
      • Plan: Staging workup as your order. CCRT (5040cGy/28 fx) will be indicated if upfront surgery is not favored by the surgeon. Please contact us later to arrange CT simulation later. Diet education, psychological and spiritual support is given.

[surgical operation]

  • 2021-02-05
    • Surgery
      • VATS, LUL wedge + LLL wedge resection
    • Finding
      • mutiple lung nodule suspected esophageal cancer metastasis s/p LUL wedge (a solid nodule about 6mm x1); LLL wedge (two soft nodules about 7mm and 4mm)
      • a 14 Fr. pigtail inserted in 7 ICS
      • blood loss: minimal
  • 2020-10-05
    • Surgery
      • VATS esophagectomy + gastric tube reconstruction.
    • Finding
      • Esophageal tumor was noted over middle third esophagus, adhesion to left main bronchus, s/p CCRT.
      • One 28 Fr. straight chest tube was inserted via right 8th ICS.
      • 18 Fr. Foely catheter as jejunostomy tube.
  • 2020-07-10
    • Surgery
      • Port-A + feeding jejunostomy
    • Finding
      • 18 Fr. Foley as jejunostomy tube
      • 8 Fr. polysite, left cephalic vein, cut-down method.

[radiotherapy]

  • 2020-08 ~ 2020-08 CCRT 5040cGy/28fx

[chemotherapy]

  • 2023-06-19 - oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 245mg NS 500mL 90min + leucovorin 400mg/m2 655mg NS 250mL 2hr + fluorouracil 2800mg 4590mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-05-18 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg NS 500mL 90min + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 2800mg 4745mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-04-18 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg NS 500mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg 4765mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-03-20 - gemcitabine 1000mg/m2 1735mg NS 250mL 30min + leucovorin 200mg/m2 345mg NS 250mL 2hr + fluorouracil 2000mg/m2 3475mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-24 - gemcitabine 1000mg/m2 1775mg NS 250mL 30min + leucovorin 200mg/m2 355mg NS 250mL 2hr + fluorouracil 2000mg/m2 3550mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-01 - gemcitabine 1000mg/m2 1775mg NS 250mL 30min + leucovorin 200mg/m2 355mg NS 250mL 2hr + fluorouracil 2000mg/m2 3550mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-27 - gemcitabine 1000mg/m2 1775mg NS 250mL 30min + leucovorin 200mg/m2 355mg NS 250mL 2hr + fluorouracil 2000mg/m2 3550mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-05 - gemcitabine 1000mg/m2 1770mg NS 250mL 30min + leucovorin 200mg/m2 350mg NS 250mL 2hr + fluorouracil 2000mg/m2 3540mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-14 - gemcitabine 1000mg/m2 1800mg NS 250mL 30min + leucovorin 200mg/m2 350mg NS 250mL 2hr + fluorouracil 2000mg/m2 3600mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-24 - gemcitabine 900mg/m2 1600mg NS 250mL 30min + leucovorin 200mg/m2 350mg NS 250mL 2hr + fluorouracil 2000mg/m2 3570mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-09-29 - gemcitabine 900mg/m2 1600mg NS 250mL 30min + leucovorin 200mg/m2 350mg NS 250mL 2hr + fluorouracil 2000mg/m2 3570mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-09-07 - gemcitabine 900mg/m2 1400mg NS 250mL 30min + leucovorin 200mg/m2 350mg NS 250mL 2hr + fluorouracil 1800mg/m2 3000mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-08-17 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-07-26 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-06-27 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-06-06 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-05-16 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-04-19 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-03-30 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-03-08 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-02-09 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-01-24 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-01-03 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2021-12-08 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2021-11-22 - irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg
  • 2021-11-08 - irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg
  • 2021-10-15 - irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg
  • 2021-09-16 - irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/2 4700mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg
  • 2021-09-03 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/2 4700mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-08-19 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/2 4700mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-08-03 - oxaliplatin 85mg/m2 147mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4840mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-07-20 - oxaliplatin 85mg/m2 147mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4840mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-06-30 - oxaliplatin 85mg/m2 146mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-06-10 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-05-27 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4850mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-05-11 - oxaliplatin 60mg/m2 100mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4860mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-04-27 - docetaxel 40mg/m2 60mg 1hr + cisplatin 40mg/m2 69mg 2hr + fluorouracil 2000mg/m2 3450mg 46hr
    • doxamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-04-27 - docetaxel 40mg/m2 60mg 1hr + cisplatin 40mg/m2 60mg 2hr + fluorouracil 2000mg/m2 3380mg 46hr
    • doxamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-03-25 - docetaxel 40mg/m2 60mg 1hr + cisplatin 40mg/m2 60mg 2hr + fluorouracil 2000mg/m2 3380mg 46hr
    • doxamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-03-11 - docetaxel 40mg/m2 60mg 1hr + cisplatin 40mg/m2 60mg 2hr + fluorouracil 2000mg/m2 3340mg 46hr
    • doxamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-02-23 - docetaxel 40mg/m2 60mg 1hr + cisplatin 40mg/m2 60mg 2hr + fluorouracil 2000mg/m2 3390mg 46hr
    • doxamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2020-08-24 - cisplatin 50mg/m2 84mg 2hr + fluorouracil 1000mg/m2 1700mg 22hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2020-07-27 - cisplatin 50mg/m2 87mg 2hr + fluorouracil 1000mg/m2 1750mg 22hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

==========

2023-06-20

The patient has been prescribed Bafen (baclofen 5mg) 1# PRNQ12H for hiccups. Metoclopramide is also included in the active medication list. Both baclofen and metoclopramide are regarded as first-line therapy for hiccups. However, it’s advisable to note that there have been numerous cases reported in the literature indicating neurotoxicity due to oral baclofen accumulation in adult patients with varying levels of renal impairment. Additionally, abrupt discontinuation of oral baclofen has been linked to altered mental status. While the current dosage seems unlikely to cause these adverse reactions, it’s worth mentioning as a precaution.

2022-12-27

  • The elevated serum uric acid level (8.1 mg/dL on 2022-11-22) has returned to normal levels (5.6 mg/dL on 2022-12-27).
  • First-line chemotherapy for advanced esophageal squamous-cell carcinoma results in poor outcomes. The monoclonal antibody nivolumab has shown an overall survival benefit over chemotherapy in previously treated patients with advanced esophageal squamous-cell carcinoma (for PD-L1 expression of 1% or greater). ref: Doki Y, Ajani JA, Kato K, et al. Nivolumab Combination Therapy in Advanced Esophageal Squamous-Cell Carcinoma. N Engl J Med. 2022;386(5):449-462. doi:10.1056/NEJMoa2111380

2022-12-06

  • CT scan on 2022-08-17 revealed bilateral lung metastases that were slightly in progress compared to previous CT scans on 20220517, after which the current regimen was initiated in September 2022. A CT update in this hospital stay has been arranged.

2022-06-07

2022-05-17

  • CT image might be updated. The progression was seen to have slowed in last CT dated on 2022-02-08, which implies that the present [5-FU + Cisplatin + Paclitaxel] regimen, which begins in December 2021, has had an effect.
  • As of 2022-05-16, lab data showed that liver functions, serum electrolytes were generally normal. However, there were elevated blood creatinine 1.41 mg/dL, elevated Neutrophil 85% and decreased blood magnesium 1.3 mg/dL. Estimated creatinine clearance based on Cockcroft-Gault is 60 L/min. Kintzel 1995 recommended administration 75% of cisplatin dose for CrCl 46 to 60 mL/minute patients.
  • On 2022-05-16, high stool frequency was observed (5 times). There has been a decline in blood magnesium levels over the last 12 months, which may be a result of diarrhea depleting magnesium levels. Magnesium sulfate has been prescribed. Some loperamide might also be helpful.

2022-04-20

  • The progression was seen to have slowed in the most recent CT dated 2022-02-08, which implies that the present [5-FU + Cisplatin + Paclitaxel] regimen, which begins in December 2021, has had an effect.
  • As of 2022-04-19, lab data showed that liver and kidney functions, serum electrolytes, and blood cell counts were grossly normal.
  • No PD-L1, NTRK, MSI/MMR, TMB results found. HER2 overexpression is not evident, trastuzumab might not be applicable.
  • There has been a slight decline in blood magnesium levels (<1.9mg/dL) that might be asymptomatic for at least 12 months. Magnesium depletion is more prevalent as a result of diarrhea than vomiting in general. The causal relationship could be further clarified if clinically needed.

2022-02-23

  • the on going progression slightly slowed down according to CT findings on 2022-02-08, it seems that the current 5-FU + Cisplatin + Paclitaxel regimen since Dec 2021 showed certain effect.
  • ANC ~ 1.23 x 0.85 (based on 2022-02-23 lab data) is just above 1 with fluctuation which should be monitored.

2022-01-25

  • in progresstion, several subsequent therapies have been tried.
  • HER2 overexpression is not evident, trastuzumab might not be applicable.
  • PD-L1, NTRK, MSI/MMR, TMB test might be ordered optionally.
  • no drug allergy recorded in database, no issue with current medication.

700096683

230619

[lab data]

2023-06-16 Anti-HBc Reactive
2023-06-16 Anti-HBc-Value 8.30 S/CO
2023-06-16 Anti-HBs 0.91 mIU/mL
2023-06-16 Anti-HCV Nonreactive
2023-06-16 Anti-HCV Value 0.10 S/CO
2023-06-16 HBsAg Nonreactive
2023-06-16 HBsAg (Value) 0.27 S/CO
2021-06-10 HBsAg (NM) Negative
2021-06-10 HBsAg Value (NM) 0.359
2021-06-10 Anti-HCV (NM) Negative
2021-06-10 Anti-HCV Value (NM) 0.00292

[exam findings]

  • 2023-05-24 Patho - liver biopsy needle/wedge
    • Liver, needle biopsy — Metastatic colonic adenocarcinoma
    • The sections show a picture of metastastic colonic adenocarcinoma, composed of liver tissue with nests of columnar neoplastic cells arragned in cribriform pattern with dirty necrosis.
    • IHC, the neoplastic cells shows: CK7(-), CK20(+) and CDX2(+).
  • 2023-05-22 SONO - abdomen
    • Diagnosis:
      • Hepatic hypoechoic lesion, S6/7, nature?
      • Fatty liver, moderate
    • Suggestion:
      • Lesion could be masked due to fatty liver background.
      • Correlated with triphase CT and tumor markers
  • 2023-04-17 CT - abdomen
    • Indication: Adenocarcinoma of cecum status post single incision laparoscopic right hemicolectomy on 2021/06/10, pT2N0M0(0/12), stage I
    • Abdominal CT with and without enhancement revealed:
      • s/p single incision laparoscopic right hemicolectomy
      • Low density lesion at S6 of liver up to 0.93cm is found. In comparison with CT dated on 2022-05-16, the lesion is new. Metastatic tumor cannot be excluded.
      • The GB is well distended without soft tissue lesion
      • Enlarged prostate up to 5.3cm is found.
    • Imp:
      • Cecal cancer s/p operation.
      • New low density lesion at S6 of liver. 0.93cm, r/o meta.
      • Enlarged prostate.
  • 2023-04-17 Colonoscopy
    • No definite mucosal lesion was seen.
  • 2022-05-16 CT - abdomen
    • Cecal cancer s/p operation. No evidence of tumor recurrence.
  • 2022-05-16 Colonoscopy
    • C/W colon cancer s/p right hemicolectomy
    • Internal hemorrhoid
  • 2021-06-10 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Tumor, cecum, SILS R’t hemicoloectomy — Adenocarcinoma
      • Resection margins, bilateral, ditto — Free from tumor invasion
      • Lymph nodes, mesocolic, dissection — Free from metastasis (0/12)
      • Appendix, ditto — Free from tumor, periappendiceal congestion
      • AJCC pathologic stage — pT2N0, if cM0, stage I
    • MACROSCOPIC EXAMINATION
      • Operation procedure: SILS right hemicolectomy
      • Specimen site: ascending colon, terminal ileum and appendix
      • Specimen size: (a) A-colon: 10.5 cm in length, 3.2 cm in diameter, (b) Terminal ileum: 1.7 cm in length, 3.7 cm in diameter and (c) Appendix: 6.3 cm in length, 0.5 cm in diameter
      • Tumor size: 3.2 x 2.8 cm
      • Tumor location: 2.2 and 7.2 cm away from bilateral resection margins
      • Tumor appearance: elevated mass
      • Depth of invasion grossly: muscular propria
      • Representative sections as follows: A1: bilateral margins, A2: appendix, A3-A7: tumor, A8-A12: lymph nodes
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: G2: moderately differentiated
      • Depth of invasion: muscular propria
      • Angiolymphatic invasion: present
      • Perineural invasion: present
      • Discontinuous extramural tumor extension: not present
      • Circumferential (radial) margin of rectosigmoid: not involved
      • Lymph node metastasis, mesocolic: free from metastasis (0/12)
      • Lymph node metastasis, IMA / SMA: N/A
      • Extranodal involvement: N/A
      • Pathological TNM Stage: pT2N0, stage I
      • Type of polyp in which invasive carcinoma arose: N/A
      • Additional pathologic findings: N/A
      • TNM descriptors: N/A
      • Tumor regression grading S/P CCRT: N/A
    • IMMUNOHISTOCHEMISTRY
      • SMA highlights muscle tissue
  • 2021-05-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (96.3 - 24.1) / 96.3 = 74.97%
      • LVEF (%) = 80
      • M-mode (Teichholz) = 75.0
    • Conclusion:
      • Normal AV with no AR
      • Normal MV with no MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, normal IVC size
  • 2021-05-06 CT - abdomen
    • History and indication: A flat and depressed 2cm tumor at cecum, R/O cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Focal wall thickening of cecum.
      • Grade 5 fatty liver.
      • Right renal cyst (6mm).
      • Enlargement of prostate.
      • Atherosclerosis of aorta, iliac arteries.
      • Several cysts (5-6mm) at RUL.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T2(T_value) N:N0(N_value) M:M0(M_value) STAGE:I(Stage_value)
  • 2021-05-03 Patho - colon biopsy
    • Large intestine, cecum, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2021-05-03 Colonoscopy
    • Suspect early colon cancer, cecum, s/p biopsy
    • Mixed hemorrhoid

[MedRec]

  • 2023-06-01 SOAP Hemato-Oncology
    • P: Arrange Neoadjuvant chemtoehrapy with FOLFOX +/- targeted therapy
  • 2021-06-09 ~ 2021-06-14 POMR Colorectal Surgery
    • Discharge diagnosis
      • Adenocarcinoma of cecum status post single incision laparoscopic right hemicolectomy on 110/06/10, pT2N0M0(0/12),G2, LVI(+), PNI(+), CRM(-), stage I
      • Malignant neoplasm of cecum
      • Type II diabetes mellitus
    • CC
      • for preoperative preparation and surgical treatment for cecal cancer.
    • Present illness
      • This 62 years old male patient has the history of 1) colon polyp s/p polypectomy at Wanfang Hospital in MK 102; 2) mixed hemorrhoids s/p hemorrhoidectomy on 2015-09-22; 3) DM under OHA control for 5-6 years.
      • He received health examination and FOBT revealed postive. He denied abdominal discomfort, bowel habit change, bloody stool passage and body weight loss. He visited CRS for help and colonoscopy revealed suspect early colon cancer, cecum, s/p biopsy. Pathology proved adenocarcinoma. Abdominal CT revealed cecal ctumor, cT2N0M0, stage: I. This time, he admitted to our ward for preoperative preparation and surgical treatment.
    • Course of inpatient treatment
      • After admission with ward routine and pre-op study were done. After well explain the risk of surgery including heart, lung complications and risk of leakage. Operation of SILS right hemicolectomy under general anesthesia were performed on 2021-06-10. NPO and adequate IV fluid supplement. His wound pain is acceptable by Dynastat. Early activity is encouraged. Chewing cookies, toast, rice with gum was started at op day. The wound healing well and no erythema change. He had flatus passage and abdominal wound pain subsided. So he started to take oral diet well and no abdominal discomfort after meal. He had passed stool with normal bowel movement. Oral intake with soft diet is tolerated well. Drain is clear ascites and removal of JP drain at post-op day 4. His abdominal wound pain had got much better. In stable condition, he was discharged on 2021/06/14 and will receive OPD follow up next week.

[surgical operation]

  • 2021-06-10
    • Surgery
      • SILS Right-hemicolectomy        
    • Finding
      • Cecal tumor, cT2N0M0 stage I
      • Anastomosis by GIA 75/4.8mm x2
      • TISSEL 4ml at anastomosis site and wound clot
      • One 15# JP drain at Morison’s pouch

==========

2023-06-19

  • There’s no available data from PharmaCloud, possibly due to the patient not providing consent for access.

  • Based on the records from our hospital, the patient has visited the departments of Colorectal Surgery, General and Digestive Surgery, and Hematology-Oncology in the past three months. No prescriptions were issued by the first two departments, hence, no medication reconciliation issues were found.

  • Several data points have indicated that the patient’s fasting plasma glucose levels are exceeding 200mg/dL, even while being under medication with Januvia (sitagliptin 100mg) 0.5# BID and Uformin (metformin 500mg) 1# BID. There are no HbA1c readings available in the HIS5 data. It is recommended to obtain an HbA1c reading to get an understanding of the average blood glucose levels over the past two to three months.

  • Additionally, the patient has also been prescribed Zulitor (pitavastatin 4mg) 0.5# QD, an HMG-CoA reductase inhibitor used to lower lipid levels and reduce the risk of cardiovascular disease. However, there are no diagnoses, medical problems, or lab data related to dyslipidemia. The status of the patient’s dyslipidemia might need to be checked and clarified.

700421458

230619

==========

2023-06-19

  • Vitacal (CaCl2) 120mL IVD ST is just prescribed. It is recommended in HIS5 not to exceed 100mL in each administration. The most recent lab data on 2023-05-15 showed normal calcium and chloride readings. It is prudent to check the use of CaCl 120mL.
  • This patient is a stem cell donor. If calcium supplementation is required, particularly during hematopoietic stem cell (HSC) harvesting where citrate-based regional anticoagulation is used, it might be advisable to utilize a sliding scale for the continuous infusion of calcium chloride. This would help maintain systemic ionized calcium levels between approximately 3.6 to 5.2 mg/dL (~0.9 to 1.3 mmol/L). Regular monitoring of systemic ionized calcium levels, ideally every 6 hours or more frequently when necessary, is also recommended under these circumstances.

In continuation of the previous pharmacist note.

  • I just had a phone conversation with the patient’s nurse practitioner. She indicated that for the HSC harvesting procedure, 120mL of CaCl2 is commonly used, and calcium levels are regularly monitored both before and after the procedure. Therefore, it doesn’t seem to present any issues at present.

700761500

230619

[lab data]

2023-06-19 JAK2 single site mutation Undetectable
2023-06-14 HBsAg (NM) Negative
2023-06-14 HBsAg Value (NM) 0.392
2023-06-14 Anti-HCV (NM) Negative
2023-06-14 Anti-HCV Value (NM) 0.047
2023-06-14 Anti-HBc (NM) Positive
2023-06-14 Anti-HBc Value (NM) 0.009
2023-06-14 Anti-HBs (NM) Negative
2023-06-14 Anti-HBs value (NM) 4.930 mIU/mL
2023-03-13 CK 14 U/L
2023-03-03 Zinc,Zn 648 ug/L
2023-02-16 ANA Homogeneous 1:1280; Speckled 1:1280
2023-02-15 Anti-ds DNA Antibody 5.6 IU/ml
2023-02-15 Anti-ENA(Jo-1) EliA U/ml
2023-02-15 Anti Jo-1 antibody 0.3 EliA U/ml
2023-02-15 Anti-ENA (Scl-70) EliA U/ml
2023-02-15 Anti-ENA Scl-70 Ab 2.0 EliA U/ml
2023-02-14 ESR 31 mm/hr
2023-02-09 CK 10 U/L
2021-05-15 ESR 45 mm/hr
2021-03-17 LA1 52.8 sec
2021-03-17 LA2 38.0 sec
2021-03-17 LA1/LA2 ratio 1.1
2021-03-13 ESR 33 mm/hr
2020-07-04 Ferritin 101.9 ng/mL
2020-05-20 ESR 44 mm/hr
2020-05-14 Aspergillus Ag Negative
2020-05-14 Aspergillus Ag Value 0.13 Ratio
2020-05-06 LA1 51.4 sec
2020-05-06 LA2 39.4 sec
2020-05-06 LA1/LA2 ratio 1.1
2020-05-05 Anti-beta2-glycoprotein-I Ab 3.5 U/mL
2020-05-05 Anti-cardiolipin-IgM 3.0 MPL U/mL
2020-05-05 Anti-cardiolipin IgG GPL-U/mL
2020-05-05 Anti-Cardiolopin 8.0 GPL-U/mL
2020-05-05 Anti-ENA Sm 7.0 EliA U/ml
2020-05-05 Anti-ENA RNP 2.4 EliA U/ml
2020-05-05 Anti-ds DNA Antibody 14 IU/ml
2020-05-05 C4 30.4 mg/dL
2020-05-05 C3 102.8 mg/dL
2020-04-20 Aspergillus Ag Positive
2020-04-20 Aspergillus Ag Value 0.5 Ratio
2020-04-20 Anti-ENA SS-A (Ro) >2400 EliA U/ml
2020-04-20 Anti-ENA SS-B (La) >3200 EliA U/ml
2020-04-20 ANA Homogeneous ; 1:1280
2020-04-17 Cryptococcus Ag Negative
2020-04-17 Antibody Identification Anti-M
2020-04-15 Anti-ENA Sm 7.5 EliA U/ml
2020-04-15 Anti-ENA RNP 2.4 EliA U/ml
2020-04-15 Anti-ds DNA Antibody 14 IU/ml

[exam findings]

  • 2023-06-09 CXR
    • reticular and hazy areas of increased opacities over Rt and Lt lower lung zones, due to fibrosis
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
    • partial atelectasis of inferior lingular segment and RML
    • Minimal dextroscoliosis of the T-spine
    • marginal spurs of multiple vertebral bodies
  • 2023-06-09 SONO - abdomen
    • Liver cysts
    • Splenomegaly with heterogenous parenchyma.
  • 2023-05-08 Spirometry
    • There is mild restrictive lung defect.
    • The bronchodilator test is negative.
  • 2023-04-08 CT - chest
    • Bronchiectatic change over right middle lobe and left lingula lobe.
    • The pneumonic patch resolved.
    • Splenomegaly with heterogenous appearance of the splenic parenchyma. Suggest contrast enhanced study.
  • 2023-02-08, -01-20, -01-06, 2022-12-26, -12-19 CXR
    • Consolidation and volume reduce over Rt and Lt lower lung zones, further in progression
    • mild enlarged cardiac silhoutte due to dilated cardiac chamber (LAD) and prominent cardiophrenic angle mediastinal fat pad
    • partial atelectasis of inferior lingular segment and RML
  • 2023-02-08 SONO - chest
    • Pleural thickening and subpleural consolidation, bilateral
  • 2022-12-15 SONO - chest
    • Bilateral lower lobes pneumonia with airbronchogram inside, 3x4 cm in size, bilaterally.
    • Only trivial amounts of plerual effusion, bil.
    • High risk of chest tapping.
  • 2022-12-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 35) / 89 = 60.67%
      • M-mode(Teichholz) = 60
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Dilated LA
      • Mild MR, mild TR and mild PR
      • Mild pulmonary hypertension
      • Preserved RV systolic function
  • 2022-12-14 CT - chest
    • consolidation in the lower lobes of the bilateral lung.
  • 2022-09-05 CT - Temporal Bone HRCT
    • Noncontrast high resolution CT (HRCT) of bilateral temporal bones in thin axial cut and with coronal reformation shows:
      • Decreased right mastoid air cells pneumotization indicating chronic mastoiditis.
      • Soft tissue within right middle ear.
      • No obvious bone erosion.
    • IMP: Osteitis media with soft tissue within right middle ear.
  • 2022-08-01 ENT Hearing Test
    • Tymp:
      • R’t grommet inserted (ECV 1.0 was noted); L’t type A.
    • ART:
      • R’t ipsi CNT and contra absent.
      • L’t ipsi absent and contra CNT.
    • PTA
      • Reliability FAIR
      • Average RE 65 dB HL; LE 49 dB HL.
      • R’t moderate to profound mixed type HL.
      • L’t mild to profound mixed type HL.
  • 2022-02-05 MRI - C-spine
    • herniated disc in the C5/6 disc.
  • 2021-10-02 ENT Hearing Test
    • Tymp:
      • R’t type B; L’t type A.
    • ART:
      • Bil absent.
    • PTA
      • Reliability FAIR
      • Average RE 73 dB HL; LE 44 dB HL.
      • R’t moderate to profound mixed type HL.
      • L’t normal to severe SNHL with 15 dB ABG at 4k Hz.
  • 2021-04-06 Ga-67 whole body inflammation scan with SPECT
    • The whole-body gallium-67 inflammation scan with SPECT was performed at the 24th and the 48th hour after injecting 6 mCi of Ga-67 to the patient. The images showed relatively increased radiotracer uptake in the liver, spleen, and bilateral shoulders. In addition, there was increased radiotracer accumulation in the colon.
    • IMPRESSION:
      • Relatively increased radiotracer uptake in the liver and spleen, the nature is to be determined. Please correlate with other clinical findings for further evaluation.
      • Mildly increased radiotracer uptake in bilateral shopulders, mild inflammation may show this picture.
      • Increased Ga-67 accumulation in the colon, physiological accumulation of Ga-67 may show this picture.
  • 2021-03-17 SONO - chest
    • Pleural effusion, minimal, left
    • Consolidation, LLL, minimal
  • 2021-03-15 CT - chest
    • post inflammatory fibrosis in LLL and RLL, stationary.
    • splenomegaly
    • hyperplastic LNs in both axillary region, stationary.
    • new left pleural effusion.
  • 2021-03-15 Spirometry
    • mild restrictive ventilatory impairment, FVC 74%, FEV1 75%
  • 2020-09-22 CT - chest
    • post inflammatory fibrosis in LLL and RLL.
    • splenomegaly with poorly enhanced foci.
    • regression of hyperplastic LNs in both axillary compared with CT on 2020/04/06
  • 2020-07-09 Bronchodilator Test
    • mild restricitve ventilatiory impairemnt
  • 2020-04-30 Bronchodilator Test
    • mild restrictive ventilatory impairment, FEV1/FVC = 86%, FVC = 70%, FEV1 = 74%
    • without significant reversibility
  • 2020-04-07 SONO - chest
    • Bilateral thorax: minimal amount pleural effusion (thoracocentesis was not performed).
  • 2020-04-06 CT - chest
    • nonspecific inflammation r/o infection in lower lungs with pleural effusion. splenomegaly and LAPs in both axillae, hematological disorder?, suggest further correlation with lab. data.
  • 2019-12-04 Acoustic Radiation Force Impulse, AFRI
    • CC: For measurement of fibrosis stage
    • Diagnosis: ARFI = F0
    • Suggestion
      • V median = 1.31
      • V IQR/median = 13.4%
  • 2019-12-04 SONO - abdomen
    • Liver cysts, three
    • Splenomegaly, mild
  • 2018-08-16 Flow Volume Curve
    • Mild restriction
  • 2018-08-16 SONO - abdomen
    • Multiple (>20) splenic hemangiomas up to 1.4cm.
  • 2017-01-12 SONO - abdomen
    • splenic tumors, C/W hemangioma (by prior study)
    • liver cysts

[MedRec]

  • 2023-03-27 SOAP Rheumatology and Immunology
    • Prescription
      • Plaquenil (hydroxychloroquine 200mg) 1# QDCC
      • Celebrex (celecoxib 200mg) 1# QD
      • Evoxac (cevimeline 30mg) 1# BID
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNHS
  • 2023-02-25 SOAP Dermatology
    • S
      • hair loss for months,acute exacer bated
      • enlarged neck (+)
      • malar rash on face for months
    • Prescription
      • Topsym (fluocinonide 0.05%) HS TOPI
      • Zinga (zinc gluconate 78mg) 1# QD
  • 2020-05-07 SOAP Rheumatology and Immunology
    • A
      • Sjogren syndrome
      • r/o fibromyalgia
    • Prescription
      • Hydroquine (hydroxychloroquine 200mg) 1# QDCC
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# HS
      • Bokey (aspirin 100mg) 1# QD
      • LacTam (acetaminophen 500mg) 1# PRNBID
      • Compesolon (prednisolone 5mg) 1# QD

==========

2023-06-19

  • Based on the PharmaCloud database, our hospital is the sole medical provider for the patient in the past 3 months. No issues related to medication reconciliation have been identified.

  • Cyclophosphamide is a potential therapeutic option for severe, refractory cases of dermatomyositis/polymyositis, and it is often administered as an adjunctive treatment. The recommended oral dose typically ranges from 1.5 to 2 mg/kg/day (ref: UpToDate). As of 2023-06-18, the patient’s body weight is 53.3kg, and the current prescription of cyclophosphamide at 50mg QD is below the suggested dosage range. Please continue to monitor the treatment’s effectiveness and consider whether a dose adjustment might be required.

701097074

230619

[MedRec]

  • 2022-02-18 ~ 2022-05-10 POMR Hemato-Oncology
    • Discharge diagnosis
      • Multiple myeloma, IgG kappa, ISS stage IIIA
      • Type 1 diabetes mellitus with unspecified complications
      • Nausea with vomiting, unspecified
      • Diabetes mellitus without mention of complication, Type I [insulin dependent type] [IDDM] [juvenile type], not stated as uncontrolled
    • CC
      • Nausea with vomit for 2 days, right shoulder and back pain over month    
    • Present illness
      • This 53-year-old female has history of
        • Type 1 diabetes mellitus since age of 19
        • Hypertension
        • Secondary hypoparathyroidism
        • Sacrum and right ilium fracture after fell down in 2021/06
        • Osteoporosis with BMD: T score -4.2.
        • Right Scapula fracture
      • This time, she suffered from persistent back pain for over one month and nausea with vomit for 2 days. According to the patient’s statement, she had been to our Ortho. OPD for help on 2021/12/15, when KUB + L-spine Lat was revealed compression fractures at L5, L4, L2, L1 and T12 vertebral bodies, mild decreased disc spaces in the upper L-spine discs.
      • Due to above symptoms, she came to our ER for help. At ER, tachycardia with BP 153/73 were noted. Physical examination showed tenderness at bilateral flank and T-L spinal process. Laboratory data revealed hypercalcemia of Calcium: 3.17 mmol/L. T-L spine X-ray revealed compression fracture of L1 and L2. Under the impression of 1) Hypercalcemia, 2) Right Scapula and back pain, she was admitted for pain control and further management on 2022/02/18.    
    • Course of inpatient treatment
      • This 53 y/o female has history of type 1 diabetes mellitus since age of 19, anemia, hypertension, secondary hypoparathyroidism, sacrum and right ilium fracture after fell down in 2021/06, osteoporosis with BMD: T score -4.2, and retinal hemorrhage OU s/p OP. She suffered from persistent back pain for about one month. Under the impression of T7, T8 compression fracture and old compression frature of T12, L1/2/4/5, the patient was admitted.
      • After admitted, she received pain killer and IV fluid supplement for compression fracture pain control. During hospitalization, she had nausea with vomit and hyperglycemia with diabetic ketoacidosis were noted on 2022/02/21. The laboratory data revealed hyponatremia, favor hyperglycemia related. The endocrinologist was consulted, RI pump (2/21~22), 0.298 KCL were perscribed and titrate insulin dose. The Oncologist was consulted for hypercalcemia with low PTH, suspect multiple myeloma. Blood test and urine Protein EP/IFE/Free Light Chain κ/λ were performed by Oncologist advice and they arrange bone marrow examination on 3/2. She will transfer to oncologist ward for further management.
      • Due to bone marrow report showed MM IgG kappa, stage IIIB. Major illness and family conference were done this week. RT was consulted and positioning on 3/8. Feburic F.C 80mg 1# qd for hyperuricemia and rechecked level decerased well. This week, the bone marrow for FISH test was done and we gave Thalidomide 2# qn and dexamethasome 40mg qw. Painful condition got improvement. Sugar poor control and we comfirm Meta for adjust Apidra and Tresiba. RT (2022-03-10 ~ 2022-03-23): 2000cGy/10 fractions (6MV photon) of the upper T spine and peripheral area. Chemotherapy as VTd (C1 Velcade since 2022/3/29, weekly) and XGEVA on 2022/3/30. Hypocalcemia and Hypomagnesemia were correct during hospitalization. Nutritional assessment for DM diet with energy and protein requirement during hospitalization. RT again for bilateral hip pain (2022-4-12 ~): at 600cGy/3 fractions (6MV photon) of the right hip to upper femur.
      • Under the stable condition, VTD (C1 on 2022/3/29, C2 on 4/6, C3 on 4/13, C4 on 4/20, C5 on 4/27, C6 on 5/4, C7 on 5/9). Pain control with Neurontin 100mg/cap (Gabapentin) 1# bid, Celebrex 200mg/cap (Celecoxib) 1# q12h,Muaction 100 mg/SR tab (Tramadol) 1# hs.
      • With the relatively stable condition,she was discharged on 2022/05/10 and will OPD follow up later
      • VTD regimen
        • Days 1,8,15,22: Bortezomib 1.3mg/m2 subcutaneous
        • Days 1-21: Thalidomide 50-200mg (usual dose range) orally once daily at bedtime
        • Days 1-2, 8-9, 15-16, 22-23: Dexamethasone 40mg orally once daily
        • Repeat cycle every 3 weeks
    • Discharge prescription
      • Limeson (dexamethasone 4mg) 5# QN 5/9-5/10
      • Thado (thalidomide 50mg) 2# QN 5/9-30, take 3 weeks, skip 1 week
      • Muaction (tramadol 100 mg) 1# HS
      • Concor (bisoprolol 1.25mg) 1# QD      
      • Tresiba FlexTouch 16 Unit QD SC (If F/S HS < 140, eat something before go to bed, Tresiba should not be stopped)
      • Apidra 8 Unit TIDAC SC (As correction scales)
      • Celebrex (celecoxib 200mg) 1# Q12H
      • Neurontin (gabapentin 100mg) 1# BID
      • Stogamet (cimetidine 300mg) 1# TID
      • Through (sennoside 12mg) 2# HS
      • Pentop (pentoxifylline 400mg) 1# BID

[chemotherapy]

  • 2023-04-28 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-04-21 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-04-14 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-04-07 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-03-03 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-02-23 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-02-17 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-02-10 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-02-03 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-01-27 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-01-06 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-12-30 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-12-23 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-12-16 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-12-09 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-12-02 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-11-11 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-11-04 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-10-28 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-10-21 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-10-14 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-10-07 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-09-30 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-09-23 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-09-16 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-09-09 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-09-02 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-08-26 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-08-19 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-08-12 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-08-05 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-07-29 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-07-15 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-07-08 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-07-01 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-07-24 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-06-17 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-06-09 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-06-02 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-05-26 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-05-19 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-05-09 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-05-04 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-04-25 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-04-19 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-04-13 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-04-06 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-03-29 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC

==========

2023-06-19

  • The patient had an appointment at TaiAn Hospital on 2023-05-16, where she was prescribed oral Pentop (pentoxifylline) and several eye drops for a 28-day course, which has now concluded. If the patient continues to experience eye symptoms, it might be advisable to consult our ophthalmologist for reevaluation.

700394537

230616

[exam findings]

  • 2023-06-07 MRI - brain
    • no evidence of brain metastasis.
  • 2023-06-06 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in multiple C-, T- and L-spines, sternum, bilateral multiple ribs, left scapula, pelvic bones, right humerus, and left femur.
    • IMPRESSION: As compared with the previous study on 2023-02-15, some of the previous bone lesions are a little more evident, suggesting multiple bone metastases in a little more progression.
  • 2023-06-05 CXR
    • Osteoblastic metastasis in spine
  • 2023-06-05 CT - chest
    • Indication: Lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis
      • Malignant neoplasm of upper lobe, right bronchus or lung
    • Comparison was made with previous CT dated on 2023/02/13
      • Lungs: the small spiculated nodule at posterior RUL is still visible. interval regression of miliary and small nodules in both lungs, and resolution of septal thickening and peribronchovascular bundle thickening as compared with CT on 2023/2/13
      • Mediastinum and hila: no more enlarged LNs.
      • Vessels: the great vessels in the hila and mediastinum are normal in caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: minimal residual bilateral effusions
      • Chest wall and visible lower neck: no enlarged LNs at supraclavicular fossae
      • Visible abdominal contents: distended gallbladder. unremarkable of the spleen, liver, adrenal glands, pancreas, and both kidneys. no enlarged lymph node
      • Visualized bones:
        • multiple marginal spurs of vertebrae.
        • blastic metastatic change spine and sternum.
    • Impression: RUL cancer T4M1c, in regression as compared with CT on 2023/02/13
  • 2023-03-22 Shoulder Lt
    • Narrowed joint or discal space with bony sclerosis but without acute fracture, bone destruction or dislocation.
    • A small focal hyperdense osteoblastic metastasis at medial humeral neck?
  • 2023-03-22 MRI - C-spine
    • spinal canal stenosis at the imddle and lower C-spine
    • herniated discs in the C4/5 and C5/6 discs.
    • multiple bone metastasis in the visible T-spine and L-spine.
  • 2023-02-23 MRI - brain
    • no evidence of brain metastasis.
  • 2023-02-21 EGFR
    • Two mutations were detected at exon 19 (Del) and exon 20 (T790M) of EGFR gene in this specimen.
  • 2023-02-16 Patho - lung transbronchial biopsy
    • Lung, side ?, CT-guide biopsy —adenocarcinoma, moderately differentiated
    • Sections show acinar, papillary, and micropapillary tumor cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(focal +), and CD56(-). The results are supportive for the diagnosis.
  • 2023-02-15 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in multiple C-, T- and L-spine, sternum, bilateral multiple ribs, left scapula, bilateral multiple pelvic bones, right humerus, and right acetabulum.
    • IMPRESSION: Some of above-mentioned bone lesions including sternum, several T-spine, and left rib cage come to more evident, while other lesions such as left scapula, left iliac bone and right acetabulum become less prominent compared with the previous study on 2022-11-30, indicating dissociated response to current therapy.
  • 2023-02-13 CT - chest
    • Lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis, ECOG 1
    • Comparison was made with previous CT dated on 2022/11/21
      • Lungs: the smallm spiculated nodule at posterior RUL is readily identified. miliary and small nodules throughout both lungs, and septal thickening and peribronchovascular bundle thickening visible, due to lung to lung metastases. dependent atelectasis over both lower lobes.
      • Mediastinum and hila: residual small and enlarged LNs in visceral and left anterior perivascular spaces.
      • Vessels: the great vessels in the hila and mediastinum are normal in caliber. minimal left pericardial effusion.
      • Heart: normal in size of cardiac chambers.
      • Pleura: small bilateral effusions, increase in volume.
      • Chest wall and visible lower neck: no enlarged LNs at supraclavicular fossae
      • Visible abdominal contents: distended gallbladder. unremarkable of the spleen, liver, adrenal glands, pancreas, and both kidneys. no enlarged lymph node
      • Visualized bones: multiple marginal spurs of vertebrae. blastic metastatic change spine and sternum, .
      • CECT of brain shows no brain metastasis
    • Impression: RUL cancer T4M1cN2, in progression as compared with CT on 2022/12/21
  • 2022-11-30 Tc-99m MDP bone scan
    • All of above-mentioned bone lesions are old and most of them show less evident compared with the previous study on 2022-7-14, indicating partial response to current therapy.
  • 2022-11-21 CT - chest
    • Impression: RUL cancer T4M1c, stationary as compared with CT on 2022/8/8
  • 2022-10-27 Cardiopulmonary Exercise Testing
    • Conclusion
      • maximal exercise
      • low exercise capacity (VO2 39%, WR 51%)
      • normal stroke volume response during exercise
      • normal ventilatory function (FEV1/FVC 78 , FVC 81%, FEV1 77%)
      • low expiratory muscle strength (MIP 100%, MEP 50%)
      • Health-related quality of life, CAT= 4
    • Suggestions:
      • treat underlying condition
      • suggest exercise training
  • 2022-08-08 CT - chest
    • Impression: RUL cancer T4N3M1c, with new bony metastasis as compared with CT on 2022/03/01 and resolution of patchy consolidations in both lungs compared with CT on 2022-04-28
  • 2022-07-14 Tc-99m MDP bone scan
    • The scintigraphic findings suggest multiple bone metastases. In comparison with the previous study on 2022/03/07, some new bone lesions are noted and some previous bone lesions are more evident. However, some previous bone lesions in the lower L-spines, sacrum and bilateral S-I joints are a little less evident.
  • 2022-04-28 CT - chest
    • Pneumonic patch at both lungs with bilateral pleural effusion.
  • 2022-04-28 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (96.3 - 25.8) / 96.3 = 73.21%
      • M-mode (Teichholz) = 73
    • Conclusion:
      • Mild dilated aortic root
      • Septal hypertrophy
      • Adequate LV and RV systolic function
      • Mild MR, AR, TR and PR
      • No regional wall motion abnormalities
  • 2022-03-18 Spirometry
    • mild obstructive combine restrictive lung defect with significant reversibility
    • FEV1/FVC=81%, FVC= 70% FEV1= 69%
    • small airway disease FEF25-75% = 44%
  • 2022-03-09 Patho - pleural/pericardial biopsy
    • Lymph node, right neck, dissection — adenocarcinoma, moderately differentiated, metastatic, consistent with lung origin (8/10)
    • Sections show 10 lymph nodes with metastatic acinar and papillary glandular tumor cells in 8 lymph nodes. Extranodal extension is seen. The morphology is consistent with metastatic adenocarcinoma from lung.
  • 2022-03-09 CXR
    • Diffuse miliary lesions in both hypoinflated lungs due to lung to lung metastases
    • superior mediastinal widening due to lymph node enlargement,
    • Blunting of left costophrenic angle, pleural effusion?
  • 2022-03-07 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
      • S2022-3466
      • Tumor type: adenocarcinoma
      • Tumor location: supraclavicular fossa lymph node
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark XT
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: Pass,
      • Adequate tumor cells present (>=50 viable tumor cells): Yes,
    • Result:
      • Tumor cell (TC) staining assessment: TC category: TC < 1%
      • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2023-03-07 Tc-99m MDP bone scan
    • Highly suspected cancer with multiple bone metastases in multiple C-, T- and L-spine, sternum, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, S-I joints, right humerus, and left femur.
  • 2023-03-07 MRI - brain
    • No evidence of brain metastasis.
  • 2023-03-04 PET
    • Glucose hypermetabolism in a focal area in the upper lobe of right lung. Primary lung malignancy may show this picture. Please correlate with other clinical findings.
    • Glucose hypermetabolism in the right lower neck lymph nodes, bilateral supraclavicular lymph nodes, right axillary lymph nodes, bilateral pulmonary lymph nodes and bilateral mediastinal lymph nodes, compatible with metastatic lymph nodes.
    • Glucose hypermetabolism in some small focal areas in bilateral lung fields, in some small focal area in the liver and in multipe bones as mentioned above, suggesting lung to lung metastases and multiple liver and bone metastases.
  • 2022-03-03 Patho - lymphnode biopsy
    • Soft tissue, supraclavicular fossa lymph node, sono-guiding biopsy — Metastatic adenocarcinoma, consistent with lung origin
    • Sections show solid nests and acinar glandular tumor cells infiltrating in a fibrotic stroma. No lymphoid tissue is seen. The morphology is consistent with S2022-3326. The immunohistochemical stains are done in S2022-3326.
  • 2022-03-02 Patho - bone marrow biopsy
    • Bone marrow, iliac crest, biopsy — Metastatic adenocarcinoma, consistent with lung origin
    • Sections show 20-30 % cellularity. The M/E ratio is about 3/1 - 4/1. Megakaryocytes are found about 2-8/HPF. No increase of blasts is noted. There are no granulomas. Nests of papillary and acinar tumor cells are seen.
    • The immunohistochemical stains reveal CK(+) and TTF-1(+). The results are consistent with metastatic adenocarcinoma from lung. Please correlate with the clinical presentation and image study.
  • 2022-03-01 CT - chest
    • Imaging Report Form for Lung Carcinoma
  • 2022-02-21 MRI - L-spine
    • History
      • PH: no DM; no HTN
      • OP hx: nil
      • 20220215: LBP, esp ant banding; buttock/ thigh radiaiton for 2 months; walk level < 30 mins; ineffective to L-traction/ hot packing/ pain killer for 1 month; relief by lying down
    • Thoraco-lumbar spine (including sagittal T2WI of cervical spine) MRI without IV Gd-DTPA administration shows:
      • Multiple bone destructing lesions in TL spine, esp. at L1-2-3 levels, including posterior parts of L2-3.
      • Multiple bone destructions at bil. pelvic bones.
      • Bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression.
      • Normal cord size and signal intensity.
    • IMP: Multiple bone metastases, or multiple myelomas?
      • C-spine: Bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression.
  • 2022-02-21 KUB + L-spine Lat
    • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.

[consultation] (not completed)

  • 2023-06-05 Dermatology
    • Q
      • for herpus around anus and abdominal
      • This 49-year-old man who with past history of gastric ulcer. 1) Gastric ulcer. 2) Right upper lung cancer, adenocarcinoma, T4N3M1c, stage IVB with  lung to lung, liver, bone metastasis, ECOG 1, NGS LAPs: EGFR - amplification, exon 19 deletion (E746_A750del).
        • The lung cancer treatment regimen as below:
          • First TKI with Giotrif 30mg on 2022-03-18 to 2023-03-08, changed to Tagrisso on 2023-03-08.
          • Angiogenesis inhibitor C1 Ramucirumab since 2022-03-22.
          • Radiotherapy 3000cGy/10 fx to T12-sacrum, SI, Rt iliac crest 2022/03/08 to 2022/03/02
          • Radiotherapy 3000cGy/10 fractions (6 MV photon) to left upper femur, 2022/06/08 to 2022/06/21.
          • Radiotherapy 3500cGy/10 fractions (6 MV photon) to Lt sternum, scapula and Lt humerus, 2022/12/15 to 2022/12/28; 2450cGy/7 fractions (6 MV photon) to Rt iliac and ischial bone; 1050cGy/3 fractions (6 MV photon) to Rt iliac bone, 2022/12/29 to 2023/01/06.
        • Tracing back the past history, his complained low back pain since 2021-11, especially anterior banding, buttock, and thigh radiaiton, he can only walk less than 30 minutes, relief by lying down.
          • He first went to the clinic to receive anti-inflammatory and pain-relieving injections and oral medication, which were ineffective; then he was transferred to the orthopaedic clinic, where suggested rehabilitation.
          • He received rehabilitation treatment with traction and hot packing for about a month, but it was also ineffective, then he was referred to our neurosurgery clinic in 2022-02. Neurosurgery Clinic on 2022/02/15, the neurological assessment revealed consciousness E4V5M6, JOMAC and cranial nerves examinatin were intact, pupil right 3.0(+), left 3.0(+), muscle power upper limbs 5+, lower limbs 5-, deep tendon reflex upper limbs 2-3+, right lower limb 2+, left lower limb +, negative result of Hoffmann sign and Spurling sign, there were left shoulder pain and suspect numbness, and bilateral thigh hypesthesdia, limited of gait, normal coordination and finger-nose-finger test, continence of sphincter.
          • The impression was cervical and lumbar spine spondylosis. Pain-killers with Celebrex and Sketa were prescribed to him back home, a magnetic resonance imaging of lumbar spine was arranged and it revealed multiple bone destructing lesions in TL spine, especially at L1-2-3 levels, including posterior parts of L2-3, multiple bone destructions at bil. pelvic bones, bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression, and bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression. Suspect metastasis?
          • He was was referred to the Department of Hematology and Oncology for follow-up survey. He is hospitalized on 2022/02/28. After admission, check tumor marker CEA=20.78ng/ml, kept pain-killer for symptoms relief, arranged Chest CT on 2022/03/01, which revealed a 13 mm spiculated solid nodule at posterior RUL consistent with a primary lung cancer, with innumerable small nodules and miliary nodules randomly distributed throughout both lungs due to lung to lung metastases. Mediastinum and hila: extensive metastatic lymphadenopathy in the visceral aand anterior prevascular spaces. Impression: RUL cancer T4N3M1c.
          • Arranged bone marrow and biopsy was done and smoothly on 2022/03/02 and show Metastatic adenocarcinoma, consistent with lung origin. Due to primary lung cancer, sona guide biopsy was done that reveal metastatic adenocarcinoma, consistent with lung origin. Sent EGFR, PD-LI and ALK, that report EGFR mutation Exon 19 detect. Painless of endoscopy was complete that show Reflux esophagitis LA grade A. Superficial gastritis. Gastric erosions, mid body, LC and GC, s/p biopsy. Pursue pathology report. Check sputum and TB culture data in negative finding. Brain MRI reveal no evidence of brain metastasis. Bone scan was complete that show highly suspected cancer with multiple bone metastases in multiple C-, T- and L-spine, sternum, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, S-I joints, right humerus, and left femur.
          • Consult oncology of radiotherapy that suggest radiotherapy to L1-2 and pelvic bone metastasis for 3000cGy/10 fractions is suggested for pain control. Possible treatment toxicity is told. CT simulation was arranged on March 07 08:30 and treatment will be started after pathological proof is available. Xgeva 120mg was administrated. PET disclose 1.Glucose hypermetabolism in a focal area in the upper lobe of right lung. 2.Glucose hypermetabolism in the right lower neck lymph nodes, bilateral supraclavicular lymph nodes, right axillary lymph nodes, bilateral pulmonary lymph nodes and bilateral mediastinal lymph nodes, compatible with metastatic lymph nodes. 3.Glucose hypermetabolism in some small focal areas in bilateral lung fields, in some small focal area in the liver and in multipe bones as mentioned above, suggesting lung to lung metastases and multiple liver and bone metastases.
          • Vemidy was prescribed for Hepatitis B and abd echo was done that reveal Fatty liver, mild hepatic tumor, S5, r/o metastatic lesion. Neck lymphnode dissection and a minivac in placed on 2022-03-09 post consult CS. TKI with Giotrif 30mg was presribed on 2022-03-18. Arrange agiogenesis inhibitor C1 Cyramza 500mg on 2022-03-22 was done smoothly. This time he was admitted to our ward on 20230530 for C15-3 Ramu 500, C2 Durva (1+1) CEA, BT with PLT 2ph.
      • We sincerely need your professional assistance!!!
    • A
      • This patient suffered from multiple grouped vesicles on L’t trunk for days and graulation on R’t thumb for days.
      • Imp:
        • Herpes Zoster
        • Pyogenic granuloma
      • Suggestion:
        • Lyrica x1 /bid
        • Serenel x1 /hs
        • ZnO x1 tube/bid
        • Arrange He-Na laser
        • Liq N2
  • 2023-02-17 Radiation Oncology
    • A
      • Diagnosis: Lung cancer, RUL, adenocarcinoma, with military lung to lung & multiple bone metastasis, cT4N3M1c; EGFR mutation: L858R(-), exon 19(+), under Afatinib since 2022/03/12, Ramicurimab since 2022/3/22 & multiple RT course to bone, last on 2023/01/13 with disease progression; ECOG:1.
      • Plan: RT to T3-11 spines and possible left scapula for 3000cGy/10 fractions is suggested for pain control. Possible treatment toxicity is told. CT simulation was arranged on Feb 20 14:30 and treatment will be started on Feb 22 or 23. Diet education & psychological support is done.
  • 2022-06-07 Dermatology
    • Q
      • A 48-year-old man with a past medical history of 1) asthma, 2) gastric ulcer, 3) Lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis, ECOG 1, under TKI with Giotirf, chemotherapy and radiotherapy treatment.
      • Due to left hand erythematous rash, so we sincerely need your help for evaluation. Thanks a lot!!!
    • A
      • This patient suffered from erytheamtous papules-with scaling for wks
      • Imp: Subacute dermatitis
      • Sugestion:
        • please check ANA, TSH, IgE
        • Xyzal x 1 /Hs
        • Topsym cream x 5 tubes/bid
  • 2022-05-05 Psychosomatic Medicine
    • Q
      • this consultation is for depression management.
      • This 48-year-old man had past history of gout. He was diagnosed with lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis on March, 2022. Since then he became depressed and need hypnotic agent. He was admitted to our ICU for desaturation noted at chest ward. He had extubation on 2022/05/02 and he had no SOB under n/c use. We planned to transfer him back to chest ward on 2022/05/05. However, he claimed that he became more depressed and had insomnia. No suicidal ideation or decreased appetite were noted. Due to above reason, we sincerely need your expertise for depression management. Thanks!
    • A
      • Impression: Major depressive disorder
      • Clincial course and symptoms:
        • This is a 48-year-old man had past history of gout. No psychiatric history.
        • He was diagnosed with lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis on March, 2022. We were consulted for his depression and insomnia recently.
        • Upon visit, he said he had depressed mood, insomina, negative thought, decreased appetite, lack of reward sensation, since 2022/03, and he kept crying during the interview, intermittent suicide ideation was noted.
        • The patient has been diagnosed with cancer after this March, and recently he has often crying and feeling down, with insomnia. He has lost 5kg in 2 months. He feels guilty and apologetic to his family. In the past few days, he has had suicidal thoughts, but currently, he is not planning to commit suicide due to his daughter.
        • And he had no depresive episode or psychiatric history before.
      • Suggestion:
        • Use mirtazapine 15mg HS firstly for his depression, if no oversedation tomorrow, please tirtrated to 30mg HS
        • please arrange our OPD follow up after he dsicahrge.
  • 2022-05-03 Dermatology
    • Q
      • Dear doctor, this consultation is for skin lesion management.
      • This 48-year-old man had past history of
        • Lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis.
        • asthma
        • gastric ulcer
      • He was admitted to ICU due to OHCA and acute respiratory failure s/p ETT s/p extubation 2022/05/02.
      • A skin lesion over his left knee was noted. We ever prescribed biomycin but in vain. He denied painful sensation. There was no swelling or discharge from the wound. Due to above reason, we sincerely need your expertise for skin lesion management. Thanks!
    • A
      • This patient suffered from ulceration w’d on L’t thigh for months.
      • Imp: Chronic wound
      • Suggestion:
        • ZnO x1 tube/bid
        • Fucidin cream x2 tubes/bid

[immunochemotherapy] (not completed with small molecular targeted therapeutics)

  • 2023-06-06 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2023-05-02 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr + durvalumab 240mg NS 100mL 1.5hr D2
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2023-04-06 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2023-02-14 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2023-01-16 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-12-19 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-11-21 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-10-24 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-09-26 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-08-09 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-07-10 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-06-06 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-04-18 - ramucirumab 10mg/kg 500mg NS 250mL 90min
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-03-22 - ramucirumab 10mg/kg 500mg NS 250mL 90min
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

==========

2023-06-16

  • This year, there have only been 2 episodes of leukopenia with a WBC count less than 3K/uL, occurring on 2023-01-14 and 2023-04-06. The injectable Cyramza (ramucirumab) has been used since 2022-03-22. Oral TKI treatment was divided at 2023-03-15: before this date, the patient was taking Giotrif (afatinib), and after this date, the patient was taking Tagrisso (osimertinib). The relationship between the usage of these drugs and the WBC level is shown in the table below, with asterisks indicating the dates when the WBC count was less than 3K/uL.

    • 2023-06-05 WBC 3.33 x10^3/uL 2023-05-02 ramucirumab osimertinib
    • 2023-04-27 WBC 4.95 x10^3/uL osimertinib
    • 2023-04-06 WBC 2.88 x10^3/uL * 2023-04-06 ramucirumab osimertinib
    • 2023-04-03 WBC 3.35 x10^3/uL osimertinib
    • 2023-03-30 WBC 3.72 x10^3/uL 2023-02-14 ramucirumab osimertinib
    • 2023-02-11 WBC 6.33 x10^3/uL 2023-01-16 ramucirumab afatinib
    • 2023-01-14 WBC 2.88 x10^3/uL * afatinib
    • 2022-12-19 WBC 4.24 x10^3/uL 2022-12-19 ramucirumab afatinib
    • 2022-11-21 WBC 5.87 x10^3/uL 2022-11-21 ramucirumab afatinib
    • 2022-10-24 WBC 6.04 x10^3/uL 2022-10-24 ramucirumab afatinib
    • 2022-09-26 WBC 6.75 x10^3/uL afatinib
  • The administration time of ramucirumab does not appear to directly correlate with the episodes of leukopenia. However, all three drugs mentioned above have been reported to be associated with leukopenia. For ramucirumab, neutropenia has been reported in 5% to 24% of patients, with grade >=3: 8%. Afatinib has been associated with lymphocytopenia in 38% of patients, with grades 3/4: 9%, and decreased white blood cell count in 12% of patients, with grades 3/4: 1%. Osimertinib has been reported to cause leukopenia in 54% of patients, neutropenia in 26% to 41% of patients, with grades 3/4: <= 3%. (ref: UpToDate)

  • In conclusion, it is difficult to determine whether leukopenia is caused by a specific drug or a combined effect of all drugs.

  • As per the reimbursement guidelines of Taiwan’s NHI, the administration of G-CSF is approved for patients with non-hematological malignancies who demonstrate a WBC count of less than 1000/uL or an ANC of less than 500/uL following chemotherapy. In this particular patient’s case, the specific criteria are not fulfilled, which means that the use of G-CSF is not covered by the NHI, if G-CSF is desirable.

700532802

230616

[diagnosis]

  • 2023-04-23 discharge note
    • Metachronous adenocarcinoma transverse colon cancer with lung metastasis, cT4aN1bM1a stage IVA, status post right hemicolectomy on 2022/12/21, pT3N2aM0, stage IIIB, s/p chemothearpy with FOLFOX from 2023/02/21
    • Chronic viral hepatitis B without delta-agent
    • Tuberculosis of lung
    • Insomnia, unspecified
    • Idiopathic gout, unspecified site
  • 2023-02-20 admission note
    • Malignant neoplasm of transverse colon
    • Chronic persistent hepatitis, not elsewhere classified
    • Tuberculosis of lung
    • Functional dyspepsia
  • 2023-01-03 discharge note
    • Metachronous transverse colon cancer with lung nodule suspect metastasis status post right hemicolectomy on 2022/12/21, pT3N2aif cM0, stage IIIB.
    • Left lung nodule status post video-assisted thoracoscopic surgery left lower lobe and left upper lobe wedge lymph node dissection on 2022/12/21.
    • Chronic persistent hepatitis

[past history]

  • The patient had no systemic diseases, including endocrine, CNS, CV, and infection
  • Tuberculosis of lung under treatment from 2023/01/13 (AKuriT-4 (RIF 150mg/INH 75mg/PZA 400mg/EMB 275mg)/tab)
  • History of operation: Ascending colon s/p right hemi 15 years ago.
  • Denied recent traveling history
  • Blood transfusion history: NIL
  • Occupational function (premorbid): OK。
  • Regular medications or herb: no  

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings] (not completed)

  • 2023-03-10 CXR
    • Atherosclerotic change of aortic arch
    • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
  • 2023-03-01 SONO - abdomen
    • Liver cirrhosis
    • GB polyp
    • Splenomegaly, mild
  • 2023-02-09 CXR
    • Tortous aorta with calcification is noted.
    • Faint aveolar opacity over left central lung is found.
    • Emphysematous change over both lungs.
  • 2023-01-02 Cepheid Xpert MTB/ RIF Test
    • Result: Positive
  • 2022-12-23 CXR
    • Ground glass opacity in LLL.
  • 2022-12-22 Patho - lung wedge biopsy
    • Diagnosis
      • A: Lung, LUL, wedge resection —- fibrotic nodules with surrounding granulomatous inflammation
      • B: Lung, LLL, wedge resection —- necrotizing granulomatous inflammation
      • C: Lymph node, left, group 7, dissection —- negative for malignancy (0/3)
      • D: Lymph node, left, group 9, dissection —- negative for malignancy (0/1)
      • E: Lymph node, left, group 10, dissection —- negative for malignancy (0/3)
      • F2022-00622 Lung, LLL, biopsy —- necrotizing granulomatous inflammation
  • 2022-12-22 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, transverse colon, anastomosis of small intestine and colon, colectomy —- Adenocarcinoma, moderately differentiated
        • Omentum, omentectomy —- Negative for malignancy
        • Peritoneum ?, excision —- Negative for malignancy
      • Resection margins: free
      • Lymph node, mesocolic, dissection —- Adenocarcinoma, metastatic (4/17)
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: pStage IIIB, pT3N2a(if cM0) or pStage IVA, pT3N2a(if cM1a)
    • Gross Description:
      • Operation procedure: colectomy, s/p right hemicolectomy
      • Specimen site: transverse (anastomosis of small intestine and colon)
      • Specimen size: small intestine and colon: 15.5 cm in length; omentum: 21 x 8 x 1.5 cm; peritoneum ?: 1.7 x 0.7 cm
      • Tumor size: 6.5 x 4 cm, annularly ulcerated
      • Tumor location: 6.5 cm and 2.5 cm away from the two resection margins
      • Depth of invasion grossly: mesocolic soft tissue
      • Mucosa elsewhere: congestion
      • Macroscopic Tumor Perforation: Not identified
      • Sections are taken and labeled as: A1-2: bilateral resection margin; A3: colon, non-tumor; A4: omentum; A5-8: tumor (A5 and A8 with peritoneum ?); A9-12: lymph node, mesocolic.
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Uninvolved, Distance of tumor from margin: 1 mm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Tumor Budding: Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: not applicable
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes: 4/17
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): not applicable
          • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
          • Regional Lymph Nodes (pN): pN2a: Four to six regional lymph nodes are positive
          • Distant Metastasis (pM): if cM0 or cM1
      • Additional Pathologic Findings (select all that apply): None identified
  • 2022-12-14 CT - abdomen
    • History: A-Colon cancer, s/p right hemicolectomy. now 1 yr F/U, Hb 8.2,
      • 20221130 colonoscopy:One huge ulcerative mucosa lesion, probable at transverse colon to hepatic flexure, s/p biopsy
    • Findings:
      • S/P right hemicolectomy.
        • There is asymmetrical wall thickening at the proximal transverse colon with irregular fuzzy contour that is c/w newly-developed adencarcinoma (T4a).
        • In addition, three enlarged nodes in the adjacent mesocolon are noted that are c/w metastatic nodes (N1b).
      • There are three soft tissue nodules in LLL of the lung that are c/w lung metastases (M1a).
      • There are several calcification in LUL of the lung that are c/w old granulomas.
      • Several hepatic cysts in both lobes are noted and the largest one 0.8 cm in size at S2/3.
      • There is minimal ascites in the cul-de-sac.
  • 2022-12-01 Patho - colon biopsy
    • Colorectum, probable at transverse colon to hepatic flexure, biopsy — Adenocarcinoma.
    • IHC stains: CK20 (+), CD56 (-), EGFR (+); PMS2 (-), MSH6 (+), MSH2(+), MLH1 (-).
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • 2022-11-30 Colonoscopy
    • Highly suspect colon cancer, probable transverse colon to hepatic flexure, s/p biopsy
  • 2022-10-19 SONO - abdomen
    • Diagnosis
      • Liver cirrhosis
      • GB polyp
      • Splenomegaly, mild
      • R/O colon leison
    • Suggestion
      • suggest colonoscopy

[MedRec]

  • 2023-03-07 SOAP Hemato-Oncology
    • A/P
      • Check TB PCR first -> If negative, then C/T with FOLFOX. -> Because the lung nodules are TB, the stage would be pT3N2aM0, Stage IIIB -> Adjuvant FOLFOX would be given.
      • Port-A insertion on 2023-02-14
      • Admission on 2023-02-20.
  • 2023-02-02 SOAP Gastroenterology and Hepatology
    • Prescription: Baraclude (entecavir 0.5mg) 1# QDAC 28 days
  • 2023-01-13 SOAP Infectious Disease
    • Diagnosis: A15.0 Tuberculosis of lung, confirmed by sputum microscopy with or without culture or confirmed molecularly.
    • A/P; check blood tests, begin anti-TB regimen
    • Prescription
      • AKuriT-4 (RIF 150mg + INH 75mg + PZA 400mg + EMB 274mg) 4# QDAC 14 days
      • Vit B6 (pyridoxine 50mg) 1# QD 14 days
  • 2023-01-10 SOAP Hemato-Oncology
    • A/P:
      • Check TB PCR first -> If negative, then C/T with FOLFOX
      • Refer to GS for Port-A insertion
      • RTC 3 weeks
  • 2023-01-09 SOAP Infectious Disease
    • A/P: collect sputum for TB
  • 2023-01-09 SOAP Colorectal Surgery
    • S
      • Colon cancer, A colon. s/p. OP, 200712
      • Loss follow up for years and then a newly found tumor at T-colon
      • 20221221 Right hemicolectomy, Colon cancer, metachronous pT3N2aM0
      • Lung nodule: necrotizing granulomatous inflammation
    • A/P
      • Suggest post-op chemotherapy
      • Refer to Infection due to R/O TB
  • 2022-12-20 ~ 2023-01-03 POMR Colorectal Surgery
    • Discharge Diagnosis
      • Metachronous transverse colon cancer with lung nodule suspect metastasis status post right hemicolectomy on 2022/12/21, pT3N2a if cM0, stage IIIB.
      • Left lung nodule status post video-assisted thoracoscopic surgery left lower lobe and left upper lobe wedge lymph node dissection on 2022/12/21.
      • Chronic persistent hepatitis
    • CC: Accidentally finding of local recurrence of ascending colon carcinoma during OPD follow up.
  • 2022-12-15 SOAP Thoracic Surgery
    • S: for consultation about lung nodules.
    • O:
      • 20221214 Abd CT showed LUL and LLL nodules,
      • suggest VATS for tissue proof and culture.
      • 20221221 VATS LLL wedge followed by CRS
  • 2022-12-15 SOAP Colorectal Surgery
    • O
      • 20221214 Abd CT done
    • A/P
      • Enhanced Recovery After Surgery, ERAS
  • 2022-12-08 SOAP Gastroenterology and Hepatology
    • S
      • colon cancer, recurrence
      • Hb 8.2
      • refer for CRS
  • 2022-11-30 SOAP Gastroenterology and Hepatology
    • S
      • colonoscopy R/O colon cancer
      • dizziness R/O anemia
  • 2022-11-03 SOAP Gastroenterology and Hepatology
    • S
      • Colon cancer, A colon. s/p. now 1 yr F/U
      • CH-B. LC. HBeAg (-).
      • start ETV on 20110421
      • Now ETV tx for 12 yrs 7 m. HBV DNA (-) (1 yr, 3 yr, 4 yr, 7, 8 yrs). normal AFP.
    • O
      • US 20221019:
        • Liver cirrhosis, GB polyp, Splenomegaly, mild
        • R/O colon leison
    • Diagnosis
      • Malignant rectosigmoid junction neoplasm [C19]
      • Chronic persistent hepatitis [K73.0]
  • 2017-03-01 SOAP Gastroenterology and Hepatology
    • S
      • Colon cancer, A colon.
      • CH-B. LC. HBeAg (-). anti-HBe (+). Splenomegaly mild. check HBV DNA 1.21E+4 IU/mL (20110413)
      • start ETV on 20110421 (ETV = Endoscopic Third Ventriculostomy)
      • Now ETV tx for 6 yrs 4 m. HBV DNA (-) (1yr, 3 yr, 4 yr). normal AFP.
    • Diagnosis
      • Malignant rectosigmoid junction neoplasm [C19]
      • Chronic persistent hepatitis [K73.0]
      • Dyspepsia & other specified disorders of function of stomach [K30]
      • Acute upper respiratory infection, unspecified [J06.9]

[surgical operation]

  • 2022-12-21
    • Surgery
      • Right hemicolectomy        
    • Finding
      • Metachronous T-colon cancer
  • 2022-12-21
    • Surgery
      • 3D VATS LLL and LUL wedge + LND.
    • Finding
      • Multiple solid lung nodules over LUL and LLL, size about 0.7 to 1.0cm.
      • Frozen section: benign
      • One 24 Fr. straight chest tube was inserted via left 8th ICS.

[chemotherapy]

  • 2023-06-15 - oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2000mg 3000mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL D1-3 + aprepitant 125mg PO D1-3 + lorazepam 1mg IVD D1-3
  • 2023-05-26 - oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2000mg 3000mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-24 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg 3400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-31 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg 3400mg NS 500mL 46hr (FOLFOX, lower Oxa, skip 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-10 - oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2400mg 3400mg NS 500mL 46hr (FOLFOX, lower Oxa and LV, skip 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-21 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg 3400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-06-16

  • On 2023-06-15, the patient commenced the 6th cycle of FOLFOX chemotherapy. In this cycle, the dosage of oxaliplatin was reduced to 65mg/m2, leucovorin to 300mg/m2, and infusional 5-FU to 2000mg/m2. This dosage reduction was a continuation from the 5th cycle (2023-05-26). It’s also worth noting that the bolus 5-FU was excluded from the regimen from the 2nd cycle (2023-03-10) onwards.
    • 2023-06-15 WBC 2.58 x10^3/uL *
    • 2023-06-07 WBC 4.31 x10^3/uL
    • 2023-05-26 WBC 3.76 x10^3/uL
    • 2023-05-04 WBC 3.23 x10^3/uL
    • 2023-04-12 WBC 3.56 x10^3/uL
    • 2023-03-28 WBC 3.39 x10^3/uL
    • 2023-03-10 WBC 2.38 x10^3/uL *
    • 2023-02-20 WBC 3.89 x10^3/uL
    • 2023-02-09 WBC 4.43 x10^3/uL
    • 2023-01-13 WBC 5.21 x10^3/uL
  • The patient’s WBC level does not yet meet the criteria for G-CSF reimbursement under Taiwan’s NHI rules. However, considering that the WBC level was already below the LLN just before the administration of this regimen cycle, it might be beneficial to administer G-CSF on a self-pay basis. The G-CSF administration is recommended to be started at least 24 to 72 hours after the end of this regimen cycle.

[optional addition of antiemetics]

  • Even though premedication with palonosetron and aprepitant was administered prior to the dose-reduced FOLFOX regimen, the patient is still experiencing grade 2 vomiting (3-5 instances within 24 hours) today. If the administration of Imperan (metoclopramide) PRNQ6H is found to be ineffective, it might be worth considering the addition of olanzapine or prochlorperazine. However, this would require careful monitoring for signs of extrapyramidal reactions or neuroleptic malignant syndrome. (Dexamethasone is already in use.)

2023-04-25

  • Vital signs are relatively stable during this hospitalization, and the most recent lab data on 2023-04-12 showed grossly normal readings.
  • On 2023-03-10, the patient’s WBC level was at 2.38K/uL, which led to a reduction of oxaliplatin from 85mg/m2 to 65mg/m2 and the skipping of the 5-FU bolus in the FOLFOX regimen. Oxaliplatin has since been titrated back to the standard dose, and no instances of WBC levels below 3K/uL have been observed up to this point.
  • Underlying conditions including HBV and TB are properly managed with Baraclude (entecavir), Epbutol (ethambutol) and Rina (rifampicin, isoniazid).

700209819

230615

  • 2023-06-13 Patho - esophageal biopsy
    • Esophagus, lower, 33 cm to 37 cm belwo incisors, biopsy — Squamous cell carcinoma, moderately differentiated
    • The sections of a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and subtle stromal invasion. Rare keratin formation is noted.
  • 2023-06-10 CT - brain
    • CC: General weakness for daysDizziness and headache. Cough, throat pain, abdominal pain, nausea.
    • Cranial CT scans without IV contrast medium enhancement was performed smoothly and show:
      • Extensive encephalomalacic change in left frontal and temporal lobes.
      • Diffusely prominent cerebral fissures, cisterns & sulci.
      • Moderate dilated lateral & 3rd ventricles most severe on Lt.
      • Atrophy of the left cerebral peduncle and anterolateral of pons.
      • No evidence of acute intracranial hemorrhage.
      • Hypodensity in the periventricular white matter of bilateral frontal and parietal lobes.
      • No mid-line structure deviation.
      • s/p large Lt and Rt craniotomies.
    • IMP:
      • No evidence of intracranial hemorrhage.
      • Moderate brain atrophy. Extensive encephalomalacic change in left frontal and temporal lobes. Wallerian degeneration of brain stem,
  • 2023-06-10 CXR
    • focal increased opacity over Lt lower lung zone with obscuring costophrenic angle
    • old fracture of Rt distal clavicle
  • 2023-06-10 KUB
    • large amount of fecal material filled nondilated colon
    • fracture of left pubic rami old
  • 2019-04-12 EEG
    • Normal, no focal cortical dysfunction or epileptic form discharges were recorded.
  • 2017-10-06 CT - brain
    • Clinical history: 39 y/o
      • 2017-09-18_TBI s/p op (Left F-T-P craniotomy) in Dec 2016 at Hua-Lien TCH. Alcoholism. Facial abrasions. Two episodes of convulsions and upward gaze. Unsteady gait. Poor memory.
      • 2010_right traumatic SDH s∕p craniotomy, double vision.
    • Without enhancement CT of brain:
      • Encephalomalacic change in left temporal lobe.
      • Soft tissue swelling over right periorbital region.

==========

2023-06-15

  • Upon reviewing the PharmaCloud database, no issues with medication reconciliation were found.

  • According to the records from the neurosurgery OPD, this patient has a long history of alcohol use. The patient also has a history of epilepsy, which is currently managed with Depakine (valproate). This medication is not typically recommended for use in patients with hepatic disease because its clearance is reduced in liver impairment. Therefore, it might be prudent to order comprehensive LFTs for further assessment.

701187733

230615

[past history] - 2023-03-23 admission note

  • ovarian cancer, pT2a N1a cM0, pStage: IIIA s/p ATH and BSO on 2019-07-31 and s/p post-Op adjuvant C/T wt Taxol / carboplatin IV Q3W x 6 finishing in Feb 2020 & recurrent tumor in the abd wall in June 2021 s/p 2nd line palliative C/T wt Avastin/Taxotere/Carboplatin IV Q3W x 6 ceased in Oct 2021        
    • ChatGPT: The patient has a history of ovarian cancer with the pathological stage of pT2a N1a cM0, resulting in a pStage of IIIA. The patient underwent abdominal total hysterectomy (ATH) and bilateral salpingo-oophorectomy (BSO) on 2019-07-31. Post-operatively, the patient received adjuvant chemotherapy with Taxol and carboplatin intravenously every 3 weeks for a total of 6 cycles, which was completed in February 2020. The patient had a recurrent tumor in the abdominal wall in June 2021 and underwent second-line palliative chemotherapy with Avastin, Taxotere, and Carboplatin intravenously every 3 weeks for a total of 6 cycles, which was discontinued in October 2021.

[allergy]

  • NKDA         

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.    

[exam findings]

  • 2023-06-14 CXR
    • Several nodular opacity projecting in the both lung show stationary.
    • Spondylosis of the T-spine
  • 2023-03-24 CT - abdomen
    • Clinical history: Ovarian CA s/p Op on 7/31 19 by Pro Huang SiCheng. Papillary serous adenocarcinoma. pT2a N1a cM0, pStage: IIIA
    • IMP:
      • S/P HIPEC catheter implantation
      • Mild ascites in left subphrenic space, right subhepatic space and right paracolic gutter space is noted.
      • In addition, there are soft tissue nodules in the omentum that may be carcinomatosis.
  • 2023-01-19 Patho - soft tissue tumor, extensive resection
    • PATHOLOGIC DIAGNOSIS
      • Tumor, midline abdominal wall, excision — Metastatic carcinoma
      • Peritoneum, RLQ, ditto — Metastatic carcinoma
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consisted of (A) one piece of tumor tissue measuring 9.8 x 6.5 x 2.8 cm in size without skin and (B) multiple small pieces of peritoneum tumor tissue measuring up to 6.5 x 3.3 x 1.7 cm in size respectively, fixed in formalin. Representatively embedded for sections as A1-A4: abdominal wall tumor and B1-B2: peritoneum tumor.
    • MICROSCOPIC EXAMINATION
      • Microscopically, the sections show pictures as follows:
        • Midline abdominal wall tumor: a poorly-differentiated carcinoma arranged in nest or papillary pattern with necrosis and tumor emboli, compatible with metastaic carcinoma.
        • Peritoneum tumor: metastatic carcinoma
      • Immunohistochemistry (S2023-01270A2) show PAX-8(+), WT-1(+), CK7(+), TTF-1(-) and CDX-2(-), compatible with metastatic ovarian serous carcinoma
  • 2023-01-18 ECG
    • Septal infarct, age undetermined
  • 2022-11-07 CT - abdomen
    • Indication
      • Malignant neoplasm of left ovary
      • Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
    • Imp:
      • Herniation with intestines at anterior abdominal wall is found. In comparison with CT dated on 2022-02-22, the lesion is stationary in extension.
      • s/p ATH and BSO. No evidence of recurrent/residual tumor in the study.
  • 2022-02-22 CT - abdomen
    • s/p ATH and BSO. No evidence of recurrent/residual tumor in the study.
  • 2022-02-14, 2021-11-22 CT - abdomen
    • S/P hysterectomy. No evidence of tumor recurrence.
    • Ventral hernia.
  • 2021-06-01 CT - abdomen
    • Clinical history: 52 y/o female patient with CA 125:592.
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P bilateral oophorectomy.
      • Irregular soft tissue (1.8x1.5cm) in the abdominal wall (surgical scar region), r/o abdominal wall recurrence.
      • Outpouching lesion in ascending colon, suggesting ascending colon diverticulum.
      • Presence of ascites in the pelvic cavity.
    • Impression:
      • S/P hysterectomy and oophorectomy.
      • R/O recurrent tumor in the abdominal wall (surgical scar region).
      • Ascites in the pelvic cavity, progression.
  • 2021-02-16 CT - abdomen
    • s/p ATH and BSO. No evidence of abnormal soft tissue mass in the study.
  • 2020-09-02 CT - abdomen
    • Clinical history: Ovarian CA s/p Op on 7/31 19. Papillary serous adenocarcinoma. pT2a N1a cM0, pStage: IIIA
    • IMP: S/P hysterectomy. There is no evidence of tumor recurrence.
  • 2020-04-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (95.4 - 23.0) / 95.4 = 75.89%
      • M-mode (Teichholz) = 75.9
    • Conclusion:
      • Normal AV with no AR
      • Normal MV with mild MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • Mild PR, trivial TR, normal IVC size
  • 2019-07-31 Surgical pathology Level VI
    • PATHOLOGIC DIAGNOSIS
      • Ovary, left, salpingo-oophorectomy — Papillary serous adenocarcinoma.
        • IHC stains: ER +, 90%, strong intensity); PR: (+, 80%, strong intensity), WT-1 (+), PAX-8 (+), Napsin-A (-).
      • Ovary, right, salpingo-oophorectomy — Free.
      • Fallopian tube, left, salpingectomy — Free.
      • Fallopian tube, right, salpingectomy — Seeding.
      • Uterus, corpus, total hysterectomy — Atrophic endometrium and myomas
      • Uterus, cervix, total hysterectomy — Free.
      • Omentume, omentectomy — Free.
      • Lymph node, bilateral pelvic and paro-aortic, dissection — Metastatic adenocarcinoma (1/27)
      • Appendix, appendectomy —- Not received.
      • pT2a N1a (if cM0); pStage: IIIA1i
    • MICROSCOPIC EXAMINATION
      • Histologic type: papillary serous adenocarcinoma.
      • Histologic grade: high grade
      • Contralateral ovary involvement: absent
      • Tumor side ovarian surface involvement: absent
      • Contralateral ovary surface involvement: absent
      • Right tube involvement: present (in peri-tubal soft tissue)
      • Left tube involvement: absent
      • In situ adenocarcinoma in right &/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: present
      • Left adnexa soft tissue involvement: absent
      • Pelvic soft tissue involvement: absent
      • Uterine serosa involvement: absent
      • Omentum involvement: absent
      • Uterine Cervix involvement: absent
      • Endometrium involvement: absent
      • Myometrium involvement: absent
      • Appendix involvement: not received
      • Largest Extrapelvic Peritoneal Focus : abscent
      • Peritoneal/Ascitic Fluid: see N2019-2801Results pending
      • Regional Lymph Nodes: A1-2: left external iliac LNs (0/7); B: left obturator lymph nodes (0/4); C: right iliac lymph nodes (1/3); D1-2: right obturator lymph nodes (0/6); E: left para-aortic lymph nodes (0/3); F: right para-aortic lymph nodes (0/4).
        • No lymph nodes submitted or found: 27
        • Positive for metastasis: 1, see above. (size: 0.5 x 0.1 cm)
        • Negative for metastasis: 27 see above
      • Other organs or specimens involvement: absent

[MedRec]

  • 2021-10-04 SOAP Hemato-Oncology
    • S: 52 y/o female, a pt of Ovarian CA, pT2a N1a cM0, pStage: IIIA s/p Op on 7/31 19 by Pro Huang SiCheng & s/p post-Op adjuvant C/T wt Taxol / carboplatin IV Q3W x 6 finishing in Feb 2020 & recurrent tumor in the abd wall in June 2021 s/p 2nd line palliative C/T wt Avastin/Taxotere/Cisplatin IV Q3W x 6 since 6/11 21.
  • 2020-02-25 SOAP Hemato-Oncology
    • S: 50 y/o female, a pt of Ovarian CA, pT2a N1a cM0, pStage: IIIA s/p Op on 7/31 19 by Pro Huang SiCheng & s/p post-Op adjuvant C/T wt Taxol / carboplatin IV Q3W x 6 finishing in Feb 2020.
  • 2019-07-25 SOAP Obstetrics and Gynecology
    • O
      • 2019-07-25 sona
        • EM 5.5 mm, Pelvis mass: 311 x 137 mm, RI: 0.26
      • R/O OV tumor
    • Diagnosis
      • Abdominal pain, unspecified site [R10.9]
      • Irregular menstruation, unspecified [N92.6]
      • Malignant neoplasm of right ovary [C56.1]

[MultiTeam]

  • 2023-04-25 Social Services
    • Consultation Date: 2023-04-24
    • Reason for Consultation: Other: Low-income household
    • Case Status: No Case Opened
    • Reason for not opening case: 2023.04.24 - Conversation with client and review of past case records
    • Family Situation:
      • The client is 54 years old, an ethnic Chinese from Indonesia, divorced with three sons, and has been unemployed in recent years due to illness. The client is registered as a low-income family in Taipei City but does not receive any subsidies. The client has no labor insurance or private medical insurance.
      • The eldest son is 28 years old, unmarried with a daughter (11 years old), and recently returned to vocational high school (weekend classes), thus only engaging in part-time work; the second son is 24 years old, studying at Chung Hua University in the Department of Multimedia and working as a part-time employee in a health food store, earning over 20,000 NTD per month; the youngest son is 22 years old, currently working as a mobile phone tester. The sons are now jointly helping to cover the family’s expenses.
      • The granddaughter, 11 years old, has been raised by the client since childhood. The client stated that because the sons have found jobs recently, the family now qualifies as a low-income household, and the granddaughter receives a monthly subsidy of over 4,000 NTD.
      • The family lives in Nangang social housing with a monthly rent of 11,000 NTD.
      • The client’s parents have passed away, and they have seven sisters and four brothers, with the client being the ninth child. The eldest sister is deceased, the younger sister and brother have both moved to Taiwan, and the remaining family members still live in Indonesia. Both the younger sister and brother are married with two children each and have occasional contact with the client.
    • Assessment and treatment:
      • The client is automatically referred as a low-income family in Taipei City, exempt from part of the health insurance burden and able to bear medical expenses independently. This time, the client was provided with related welfare consultation, but the client stated that the sons are currently employed, so they may not meet the application criteria. However, the family’s current living situation is still manageable. Additionally, the client expressed concern about the impact of her treatment on her granddaughter and was provided with emotional support by the social worker. It was also suggested that the client seek resources such as the school counseling office for the granddaughter, which the client accepted.
      • This consultation provided the above treatment, and it was noted that the client has experienced discomfort and vomiting after chemotherapy in the past. The team is advised to pay attention to this issue.

[surgical operation]

  • 2023-01-19
    • Surgery
      • excision of intraabdominal tumor, malignancy
      • excision of abdomianl wall tumor, malignancy
    • Finding
      • firm mass over lower abdominal wall, favor malignancy
      • multiple seeding tumors over whole peritoneal cavity, total PCI: 26/39
      • UOQ 3
      • epigastria 1
      • LUQ 1
      • right flank 1
      • central 3
      • left flank 0
      • RLQ 3
      • inferior 3
      • LLQ 3
      • small bowel PCI: 1 + 2 + 2 + 3 = 8
  • 2019-07-31
    • PreOP Dx: Malignant neoplasm of ovary and other uterine adnexa
    • PostOP Dx: Malignant neoplasm of ovary and other uterine adnexa
    • PCS code: 80418B
    • Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, small military nodules over right vesicouterine fold
      • Adnexa:
        • LOV: 30x20 cm, capsule intact, intra-op rupture(-)
        • ROV: 4x3 cm, capsule intact,
        • Fallopian tube: bilateral grossly normal
      • CDS: no adhesion
      • Ascites: yellowish and clear, about 200 ml
      • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
      • Omentum: no nodules noted
      • Liver: grossly normal & smooth
      • Bilateral peritonium: miliary tumor seeding(+), bean sized
      • Appendix: grosslt normal.
      • After the operation, optimal debulking surgery was achieved.
      • Residue tumor: multiple tumors, maximal diameter smaller then 1 cm, over peritoneal wall and bladder base
    • Estimated blood loss: 300ml
    • Blood transfusion: nil
    • Complication: nil

[chemoimmunotherapy]

  • 2023-06-14 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + topotecan 0.35mg/m2 0.6mg NS 30mL 30min D1-3 + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin) + [docetaxel 40mg/m2 65mg + cisplatin 40mg/m2 65mg + gentamycin 40mg + sodium bicarbonate 2800mg + NS 500mL] IP 1hr (Q3W x 6)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-04-24 - topotecan 0.35mg/m2 0.5mg NS 30mL 30min D1-3 + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin) + [docetaxel 40mg/m2 65mg + cisplatin 40mg/m2 65mg + gentamycin 40mg + sodium bicarbonate 2800mg + NS 500mL] IP 1hr (Q3W x 6)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-23 - topotecan 0.35mg/m2 0.5mg NS 30mL 30min D1-3 + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin) + [docetaxel 40mg/m2 65mg + cisplatin 40mg/m2 65mg + gentamycin 40mg + sodium bicarbonate 2800mg + NS 500mL] IP 1hr (Q3W x 6)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-02-17 - topotecan 0.35mg/m2 0.5mg NS 30mL 30min D1-3 + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin) + [docetaxel 40mg/m2 65mg + cisplatin 40mg/m2 65mg + gentamycin 40mg + sodium bicarbonate 2800mg + NS 500mL] IP 1hr (Q3W x 6)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2021-10-25 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-10-04 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-09-06 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-08-02 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-07-08 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 60mg/m2 100mg NS 250mL 1hr + NS 500mL 2hr (before cisplatin) + cisplatin 60mg/m2 100mg NS 500mL 2hr + NS 500mL (after cisplatin) 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-06-11 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 60mg/m2 100mg NS 250mL 1hr + NS 500mL 2hr (before cisplatin) + cisplatin 60mg/m2 100mg NS 500mL 2hr + NS 500mL (after cisplatin) 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-02-13 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 3 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + acetaminophen 500mg PO
  • 2020-01-09 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 3 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + acetaminophen 500mg PO
  • 2019-12-19 - ditto
  • 2019-11-26 - ditto
  • 2019-11-05 - ditto
  • 2019-10-15 - ditto

==========

2023-07-13

  • For the past three months, this patient has used only the outpatient and inpatient hemato-oncology services at our hospital. No medication reconciliation issues have been identified.

2023-06-15

  • According to the PharmaCloud database, all of this patient’s prescribed medications for the past 3 months have been provided exclusively by our hospital’s hemato-oncology department. There are no identified medication reconciliation issues.

2023-04-25

  • Since the last episode of leukopenia (2.81K/uL) on 2023-03-10, the patient’s WBC count has remained consistently above 4K/uL. However, the patient has experienced post-chemotherapy discomfort with the feeling of wanting to vomit. A short-term prescription of Emend (aprepitant) at 1# QD may help alleviate these symptoms.

2023-03-24

  • On 2023-01-19, the patient underwent surgery to remove malignant intra-abdominal and abdominal wall tumors and subsequently began receiving the topotecan/cisplatin regimen on 2023-02-17. Approximately 2 weeks after starting the regimen, an episode of leukopenia was observed with a WBC count of 2.81K/uL on 2023-03-10. It is recommended that the patient’s blood counts continue to be monitored as usual.

701474917

230615

[exam findings]

  • 2023-03-28 Peropheral Vascular Test: AV fistula
    • Result:Intra-operative sonography finding: Adequate size of LIJV
  • 2023-03-27 Patho - gingival/oral mucosa biopsy
    • Diagnosis
      • Right buccal mucosa, incisional biopsy (frozen section) — Moderately differentiated squamous cell carcinoma
      • Skin, right, incisional biopsy — Moderately differentiated squamous cell carcinoma
      • Right posterior molar area, right, incisional biopsy — Moderately differentiated squamous cell carcinoma
      • Soft palate, right, incisional biopsy — Moderately differentiated squamous cell carcinoma
      • Buccal mucosa, right, incisional biopsy — Moderately differentiated squamous cell carcinoma
    • Microscopically, sections shows moderately differentiated squamous cell carcinoma consisting of nests of tumor cells in infiltrative growth pattern with squamous differentiation and areas of dyskeratosis. The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
    • Immunohistochemical stain reveals p16: negative (patchy immunoreactive, < 70%), and P40: positive.
  • 2023-03-27 Frozen Section
    • FROZEN SECTION INITIAL DIAGNOSIS: Oral cavity, right buccal mucosa, frozen section — squamous cell carcinoma
  • 2023-03-27 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Esophageal papilloma, upper esophagus
      • Gastric ulcer, shallow, antrum, LC
      • Gastritis, antrum and body
      • Hiatal hernia
      • Duodenal ulcer scar with deformed bulb.
    • Suggestion
      • consider PPI Rx
      • consider HP eradication at GI OPD.
  • 2023-03-24 Tc-99m MDP bone scan
    • IMPRESSION:
      • Increased activity in the right aspect of the mandible. Malignancy with local bone invasion may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Increased activity in the right and left aspects of the maxilla. The nature is to be determined (dental problem? other nature?). Please correlate with other clinical findings for further evaluation.
      • A hot spot in the anterior aspect of left 4th rib. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, hips, knee and feet, compatible with benign joint lesions.
  • 2023-03-24 MRI - nasopharynx
    • Oralcavity: Impression (Imaging stage) : T:4b N:2b M:0 STAGE:IVB
  • 2023-03-23 SONO - abdomen
    • Gallbladder polyps
    • Cholecystopathy
  • 2023-03-14 Patho - gingival/oral mucosa biopsy (Y1)
    • Ulcerative tumor, right cheek, incisional biopsy — Ulcer with high grade dysplasia, at least
    • Microscopically, the sections show a picture of ulcer with high grade (moderate at least) dysplasia characterized by enlarged atypical cells with prominent nucleoli, occasional mitoses and focal dyskeratosis. However, early stromal budding or invasion can not be excluded entirely due to interface inflammation and fibrosis. Closely follow up.

[consultation]

  • 2023-04-26 Vascular Surgery
    • Q
      • This is 66 y/o male patient had squamous cell carcinoma of right buccal mucosa extending to right masticator space and encasement of right carotid artery, cT4bN2bM0, Stage IVB.
      • For port-A wound redness with pus, suspect infection, we need your consultation for evaluation. Thanks a lot!!!
    • A
      • I have had the pleasure of involving with the patient’s care. In brief, He is a 67 year old male seen in consultation for opinion regarding treatment options for port-A wound suspected infection
      • The pt’s hx/Dx was noted for
        • Squamous cell carcinoma of right buccal mucosa extending to right masticator space and encasement of right carotid artery, cT4bN2bM0, Stage IVb
        • Inflammatory conditions of jaws
        • Gallbladder polyps
        • Reflux esophagitis LA Classification grade A
        • Chronic viral hepatitis B without delta-agent
      • Lab/CXR reviewed, noted for leukocytosis, the pt appeared easy looking, denied febrile/chillness. b/c sent. results pending
      • I personally examined the wound, there was no frank pus, yet there was deshiscnce ~ 0.3cm defect, and port-A was exposed
      • SUGGESTION & PLAN:
        • wound debridement will be arranged on 4/28 8AM under local anesthesia.
        • If primary team w’d like to alternate C/T access, we can put in CVC or PICC if needed.
  • 2023-03-30 Hemato-Oncology
    • Q
      • Dx: Squamous cell carcinoma of right buccal mucosa, cT4bN2bM0
      • According to NCCN guideline, the tumor was unresectable or the patient was unfit for the surgery due to encasement of right carotid artery and involvement of right masticator space.
      • We strongly suggest induction chemotherapy followed by CCRT in accordance with NCCN guideline after the family meeting.
      • Thus we need your help for chemotherapy. Thank you for your help
    • A
      • This 68 year old man is a case of right buccal cancer, SCC, cT4bN2b M0 stage IVB, we are consulted for induction chemotherapy follow by CCRT.
      • We will discuss with patient (Induction with TPF). Transfer to 11A on Dr Xia. Thanks for your consultation.
  • 2023-03-28 Family Medicine
    • Q
      • This is a 68-year-old man who noticed a ulcerative mass on his right cheek but was unwilling to receive treatment until this month. After thorough examination, malignancy of right buccal mucosa was highly suspected. Incisional biopsy revealed high-grade dysplasia but malignancy was still suspected. Incisional biopsy under general anesthesia was done and left subclavian Port-A implantation was done on 2023/03/27 after a series of tumor work-up.
      • Dx: Squamous cell carcinoma of right buccal mucosa, cT4bN2bM0
      • According to NCCN guideline, the tumor was unresectable or the patient was unfit for the surgery due to encasement of right carotid artery and involvement of right masticator space.
      • We strongly suggest induction chemotherapy followed by CCRT in accordance with NCCN guideline after the family meeting (20230328). We need your help, Thanks!
    • A
      • 68-year-old male, Squamous cell carcinoma of right buccal mucosa, cT4bN2bM0
      • Consciousness alert, ECOG 3
      • We will arrange hospice combined care and follow up his condition (20230328 family meeting, the patient and family members agreed to accept cancer treatment.)
      • Indication: Right buccal SCC
      • Plan: Hospice combined care
  • 2023-03-28 Gastroenterology
    • Q
      • This is 66 y/o male patient had suffered from SCC of right buccal mucosa and right retromolar area, cT4bN2bM0, cstage IVb. We will arrange chemotherapy with Taxotere, Cisplatin and 5-Fu for him. However, his laboratory showed AFP 1.4 ng/mL , serum Anti-HBc (+) , Anti-HBs (+) were found.  Gastroscopy showed 1) Reflux esophagitis LA Classification grade A 2) Esophageal papilloma, upper esophagus and CLO test (+) were found. We need your further evaluation and suggestion. Thanks !!
    • A
      • We are consulted for pre-chemotherapy evaluation.
      • Lab
        • 2023-03-27 HBsAg Nonreactive
        • 2023-03-27 HBsAg (Value) 0.51 S/CO
        • 2023-03-27 Anti-HBs 60.07 mIU/mL
        • 2023-03-27 Anti-HBc Reactive
        • 2023-03-27 Anti-HBc-Value 3.71 S/CO
        • 2023-03-27 Anti-HCV Nonreactive
        • 2023-03-27 Anti-HCV Value 0.13 S/CO
        • 2023-03-27 Creatinine 0.71 mg/dL
        • 2023-03-22 APTT 29.6 sec
        • 2023-03-22 PT 10.5 sec
        • 2023-03-22 INR 1.02
      • A
        • Pre-chemotherapy evaluation
        • CLO test positive
      • P
        • Check CBC, AST/ALT, PT, ALB, T.BIL, AFP, HbeAg, Anti-Hbe Ab, Anti-Hbc IgM Ab, Anti-Hbc Ab, HBV DNA
        • Arrange abdominal sonography
        • Baraclude 0.5mg (GFR >50 QD, GFR 30-49 QOD, GFR 15-29 Q3D, GFR <15 or HD QW)
          • NHI reimbursement: HBV carrier (HbsAg(+) or HbsAg(-) but anti-Hbc ab(+)) (Anti-HBc on 2023/03/27 showed Reactive)
            • Coverage begins 1 week prior to chemotherapy and continues for 6 months after completion of chemotherapy.
        • GI OPD follow up

[surgical operation]

  • 2023-03-27
    • Surgery
      • Port-A insertion (LIJV approach, B Braun 8.5Fr)        
      • Intra-op venogram    
    • Finding
      • Intra-operative sonography finding: Adequate size of LIJV, yet difficult wiring into SVC occurred, which aided by 5 Fr sheath, venogram guided, .35” terumo wire, finally we were able to wiring into desired position.  
  • 2023-03-27
    • Surgery: Incisional biopsy
    • Finding: ulcerative mass on the right buccal mucosa more than 4cm in size with skin perforation.

[chemotherapy]

  • 2023-06-14 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + cisplatin 75mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 250mL 10min (after CDDP) D2 + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D2-5 (TPF)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-05-19 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + cisplatin 75mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 250mL 10min (after CDDP) D2 + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (TPF)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-04-26 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + cisplatin 75mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 250mL 10min (after CDDP) D2 + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (TPF)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-03-30 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + cisplatin 75mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D1 + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (TPF)
    • dexamethasone 4mg IVD D1 + dexamethasone 8mg BID PO D1-3 + palonosetron 250ug D1 + aprepitant 125mg D1-3 + NS 250mL D1 + NS 2000mL D1-5

Neoadjuvant Chemotherapy regimen in In-hospital “Prescription Collection of Chemotherapy for Head and Neck Cancer” protocol (dated 2022-02-11).

  • TPF
    • Docetaxel 40 mg/m2 IVD (1 hs) D1, 8
    • Cisplatin 40 mg/m2 IVD (2 hs) D1, 8
    • 5-FU 750~1000 mg/m2 IVD (24 hs) D1-2, D8-9
    • Q3W for 1~3 cycles
    • H&N Committee suggestion
    • References: Modified from Posner MRI et al. N.Engl.J.Med.357 (2007):1705-1715.
  • PF +/- Docetaxel
    • Docetaxel 50~75 mg/m2 IVD (1 hs) D1
    • Cisplatin 70~100 mg/m2 IVD (2 hs) D1
    • 5-FU 1000 mg/m2 IVD (24 hs) D1-3 +/- D4
    • Q3W for 1~3 cycles
    • H&N Committee suggestion
    • References
      • Modified from Posner MRI et al. N.Engl.J.Med.357 (2007):1705-1715.
      • Modified from Van Cutsem E et al. NEJM 2007;357(17):1695-1704.
  • Induction Chemotherapy modified with TPF
    • Docetaxel 40 mg/m2 IVD (1 hs) D1, 8
    • Cisplatin 40 mg/m2 IVD (2 hs) D1, 8
    • 5-FU + Leucovorin, 1000mg/m2 + 100mg/m2 IVD (24 hs) D2, 9
    • Q3 week x 3cycles (Q1W, Q2W, Q3W: rest)
    • H&N Committee suggestion
    • References: Modified from Jérôme Fayette et al. Oncotarget 2016;7(24):37297-37304

Docetaxel, cisplatin and fluorouracil induction chemotherapy followed by chemoradiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX324) 2023-04-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F65438&topicKey=ONC%2F85694

  • Cycle length: Every 21 days for three cycles.

  • Regimen

    • Docetaxel
      • 75 mg/m2 IV
      • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
      • Day 1
    • Cisplatin
      • 100 mg/m2 IV
      • Dilute in 250 mL NS and administer over 30 minutes to three hours. Do not administer with aluminum needles or IV sets.
      • Day 1
    • Fluorouracil (FU)
      • 1000 mg/m2/day IV
      • Dilute in 500 to 1000 mL D5W or NS and administer as a continuous infusion over 24 hours.
      • Days 1 through 4

Docetaxel, cisplatin, and fluorouracil induction chemotherapy followed by radiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX323) 2023-04-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F72461&topicKey=ONC%2F85694

  • Cycle length: Every 21 days for four cycles.

  • Regimen

    • Docetaxel
      • 75 mg/m2 IV
      • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
      • Day 1
    • Cisplatin
      • 75 mg/m2 IV
      • Dilute in 250 mL NS and administer over 60 minutes. Do not administer with aluminum needles or IV sets.
      • Day 1
    • Fluorouracil (FU)
      • 750 mg/m2/day IV
      • Dilute in 500 to 1000 mL D5W or NS and administer as a continuous infusion over 24 hours.
      • Days 1 through 5

==========

2023-06-15

  • According to the PharmaCloud database, all of this patient’s prescribed medications for the past 3 months have been provided exclusively by our hospital. There are no identified medication reconciliation issues.

  • The leukocytosis seems to be improving as the patient’s WBC count is nearing ULN. The medications recently used, which include esomeprazole, entecavir, and megestrol, have been reviewed, but none of them are known to significantly affect the WBC count. At the moment, there don’t seem to be any medication-related problems associated with this issue.

    • 2023-06-14 WBC 13.43 x10^3/uL
    • 2023-06-06 WBC 32.62 x10^3/uL
  • Hypomagnesemia has been noted. This might be due to the use of the TPF regimen, which contains cisplatin, and/or the PPI, esomeprazole. During the regimen administration and hospital stay, the patient receives magnesium supplements. Given that hypomagnesemia has been persistent for several months, it may be beneficial to consider magnesium supplementation upon discharge.

    • 2023-06-14 Mg (Magnesium) 1.5 mg/dL
    • 2023-06-06 Mg (Magnesium) 1.4 mg/dL
    • 2023-05-18 Mg (Magnesium) 2.7 mg/dL
    • 2023-05-14 Mg (Magnesium) 1.8 mg/dL
    • 2023-04-18 Mg (Magnesium) 1.7 mg/dL
    • 2023-03-22 Mg (Magnesium) 2.1 mg/dL

2023-04-27

  • The patient started receiving “PF +/- Docetaxel” regimen on 2023-03-30 and lab showed obvious decrease in SCC reading.
    • 2023-04-18 SCC 2.6 ng/mL
    • 2023-03-29 SCC (NM) 9.14 ng/mL
  • The 2nd dose of the regimen has been postponed due to the development of signs of infection such as redness and pus at the port-A wound site. Pus culture is currently pending. The patient is being treated with the empiric antibiotic Sintrix (ceftriaxone) 2000mg QD since 2023-04-26, and there have been no issues with this treatment to date.

700154194

230614

[lab data]

  • 2020-12-17 ROS1 Not detected
  • 2020-12-11 EGFR G719X Not detected
  • 2020-12-11 EGFR Exon19 Del Detected
  • 2020-12-11 EGFR S768I Not detected
  • 2020-12-11 EGFR T790M Detected
  • 2020-12-11 EGFR Exon20 Ins Not detected
  • 2020-12-11 EGFR L858R Not detected
  • 2020-12-11 EGFR L861Q Not detected
  • 2020-12-11 ALK IHC Negative
  • 2020-12-09 PD-L1 (22C3) TPS <1%

[exam findings]

  • 2023-06-08 MRI - L-spine

    • The lumbar spine shows spondylosis and disk space degeneration at the L2/3 through L5/S1 levels.
    • Scoliosis of L-spine.
    • Spondylolisthesis of L5 on S1, grade I.
    • Severe narrowing of right L5/S1 neural foramen, caused by protusion disc. Compression of right L5 nerve root.
  • 2023-05-20 MRI - brain

    • no evidence of brain metastasis.
  • 2023-05-19 CXR

    • LUL atelectasis with increased density with obliteration of the hilum and adjacent mediastinal border, and compensatory overflation of LLL, with elevated hemidiaphgram and left shift of heart.
  • 2023-05-19 ECG

    • Unusual P axis, possible ectopic atrial tachycardia
    • Abnormal ECG
  • 2023-04-24 Patho - colon biopsy

    • Colorectum, sigmoid colon, (15 cm from anal verge) , Specimen: A — HIGH grade dysplasia.
    • Section shows fragment(s) of polypoid colonic mucosal tissue with proliferative tubular mucinous glands lined by cells containing hyperchromatic, elongated nuclei with HIGH grade dysplasia. The possibility of a more advanced lesion cannot be excluded.
  • 2023-04-21 Patho - soft tissue nontumor/mass/lipoma/debridement (Y2)

    • Labeled as “left shoulder”, core needle biopsy — carcinoma, poorly differentiated.
    • Section shows soft tissue infiltrated by andulated irregular nests of carcinoma.
    • IHC stains: WT-1(-), Napsin-A (-), TTF-1 (-), GATA-3 (+), TRPS-1 (-), CK20 (-), vimentin (+).
  • 2023-04-21 CT - abdomen

    • History: LUL lung adenocarcinoma, cT4N2M1, stage: IV.
      • 20200613 CT: Mass in Lt pelvis, 6.1cm with left hydronephrosis. S/P left pelvic mass resection and left ureteronephrectomy.
        • Patho: metastases (endometrioid cancer) with ureter invasion
      • 20210908 CT: Few metastases in left pelvis retroperitoneal space?
        • S/P CT guided biopsy: metastatic adenocarcinoma
      • 20210908 CT: multiple liver tumors, R/O mets. B (-), C (-), s/p biopsy. patho: adenocarcinoma. refer back to chest doctor.
        • R/O lung ca with liver mets or multiple CCC
      • 20210802 tumor marker: SCC:7.23 ng/ml (normal: < 2.7),
        • CA125: 55.55 U/ml (normal: < 35), CEA and CA199: normal
    • Findings: Comparison prior chest CT dated 2022/07/08.
      • Prior CT identified several poor enhancing lesions on both hepatic lobes are noted again, increasing in size that is c/w Metastases S/P C/T with progressive disease.
      • There are two newly developed soft tissue mass 1.1 cm and 2.2 cm in the retroperitoneal space of left lower abdomen and left upper pelvis that are c/w metastasis.
        • In addition, there is a third newly developed rim enhancing soft tissue mass 2.1 cm in the mesentery of right upper pelvis that is also c/w metastasis.
      • S/P left nephrectomy.
      • S/P hysterectomy
    • Impression:
      • Prior CT identified several poor enhancing lesions on both hepatic lobes are noted again, increasing in size that is c/w Metastases S/P C/T with progressive disease.
      • Two Metastasis in the retroperitoneal space of left lower abdomen and left upper pelvis, and one metastasis in the mesentery of right upper pelvis.
  • 2023-04-21 Bone densitometry - spine + hip

    • L-spines BMD performed by DXA revealed:
      • AP L-spines, BMD of L1-4 1.175 gms/cm2, about 1.2 SD above the peak bone mass (112%) and 3.0 SD above the mean of age-matched people (162%).
    • Hip BMD performed by DXA revealed:
      • Left hip, BMD is 0.582 gms/cm2, about 2.4 SD below the peak bone mass (69%) and 0.2 SD above the mean of age-matched people (102%).
    • Impression
      • Osteopenia
  • 2023-04-17 CT - chest

    • LUL cancer T4M1c, stationary of primary tumor and hepatic metastases as compared with previous CT on 2023/01/07
  • 2023-03-14 Whole body PET scan

    • Glucose hypermetabolism in the anterior aspect of the upper lobe of left lung. Residual or recurrent malignancy may show this picture. Please correlate with other clinical findings for further evaluation.
    • Multiple glucose hypermetabolic lesions in the pelvic cavity, compatible with metastatic lesions.
    • Glucose hypermetabolism in some lymph nodes in the right aspect of the mediastinum, compatible with metastatic lymph nodes.
    • Glucose hypermetabolism in the posterior aspect of right 4th rib, in a focal area in the soft tissue in the anterior aspect of proximal portion of left humeral shaft, in multiple focal areas in the right lobe of the liver and in a focal area in the left buttock. Metastatic lesions in the bone, liver and soft tissues may show this picture.
  • 2023-02-08 Tc-99m MDP

    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed a faint hot area in the post. aspect of the right 4th rib, and increased activity in the maxilla, some C- and L-spine, bilateral shoulders, S-I joints, hips, and knees in whole body survey.
    • IMPRESSION:
      • A faint hot area in the post. aspect of the right 4th rib is new compared with the previous study on 2022-03-28; the nature is to be determined (post-traumatic change or other nature?), suggesting follow-up with bone scan in 3 months for investigation.
      • Suspected benign lesions in the maxilla, some C- and L-spine, bilateral shoulders, S-I joints, hips, and knees.
  • 2023-01-17 MRI - upper abdomen

    • History and indication:
      • Endometrial cancer with liver mets
      • Lung cancer
    • IMP:
      • Poor enhancing tumors (up to 1.4cm) in right hepatic lobe.
      • Absence of left kidney.
      • Partial consolidation at left lingual lung.
  • 2023-01-07 CT - chest

    • Indication: reuse Tagrisso (osimertinib) due to the liver lesion was endometrial cancer with liver meta (not from lung after pathologist revision)
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Left hilar mass with encasing left lobe bronchus, causing collapsed left lingula lobe is found. In comparison with CT dated on 2022-07-08, the lesion is stationary.
        • Enlarged lymph nodes at left axillary region are ofund.
        • S/p port-A placement with its tip at Superior vena cava.
        • Enlarged lymph nodes are found at right anterior chest wall is found.
      • Visible abdomen:
        • Hepatic cystic lesion at right lobe of liver are found. Stable.
        • Aortic wall thickening is found.
        • Scoliotic alignment of the thoracolumbar spine is noted.
    • Imp: Left hilar lung cancer with collapsed left lingula lobe, chest wall lymphadenopathy and probably liver lesions. Stationary.
  • 2022-11-09, -09-07 CXR

    • LUL atelectasis with increased density with obliteration of the hilum and adjacent mediastinal border, and compensatory overflation of LLL, with elevated hemidiaphgram and left shift of heart
  • 2022-07-08 CT - chest

    • Indication: Endometrioid carcinoma with ureter invasion with etastatic pulmonary adenocarcinoma, T3N0Mx, stage IIIB
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Consolidation over left upper lobe with air-bronchogram is found. In comparison with CT dated on 2022-03-25, the lesion is stationary in size.
        • Mild pericardial effusion is found.
      • Visible abdomen:
        • Low density lesions are found at both lobes of liver up to 1.32cm in largest dimension. These lesions are stationary in size and numbers.
        • s/p left nephrectomy.
    • IMp:
      • Left upper lobe lung cancer, stationary in size.
      • Hepatic metastatic tumors at both lobes liver, stable.
  • 2022-05-18 Pure Tone Audiometry, PTA

    • Reliability FAIR
    • Average RE 31 dB HL // LE 41 dB HL
    • RE normal to moderately sevre SNHL
    • LE normal to severe SNHL
  • 2022-05-11 Pure Tone Audiometry, PTA

    • Tymp: Bil type C.
    • ART: Bil absent.
    • PTA
      • Reliability FAIR
      • Average RE 35 dB HL; LE 51 dB HL.
      • R’t normal to severe SNHL.
      • L’t normal to severe mixed type HL.
  • 2022-04-27, 2022-04-20 CXR

    • LUL atelectasis with increased density with obliteration of the hilum and adjacent mediastinal border, and compensatory overflation of LLL, with elevated hemidiaphgram and left shift of heart.
    • Port-A catheter inserted into cavo-atrial junction via right subclavian vein.
  • 2022-03-28, 2021-12-22 Tc-99m MDP whole body bone scan

    • No strong evidence of bone metastasis.
    • Suspected benign lesions in the left 7th rib, maxilla, some C- and L-spine, bilateral shoulders, S-I joints, hips, and knees.
  • 2021-12-20 KUB

    • Compression fracture of L2 vertebral body
    • moderate dextroscoliosis of the L-spine
    • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, L-spine.
    • significant amount of fecal material filled nondilated colon
  • 2021-12-09 CT - lung/mediastinum/pleura

    • Left upper lobe lung cancer with stationary size.
    • Liver meta, in enlargement.
  • 2021-10-25 Patho - soft tissue biopsy, simple excision, non lipoma

    • left pelvic - Adenocarcinoma, metastatic.
    • IHC: CK7(focal positive), CK20(-), PAX8(+), PR(+), TTF-1(-), Napsin A(-), p40(-), and CD56(-).
    • The morphology and immunohistochemical stains are consistent with S2020-8600 (Endometrioid carcinoma).
  • 2021-10-21 CT - whhole abdomen, pelvis

    • Partial consolidation at left lingual region.
    • Tumors in liver, prevertebral region and LLQ tumor metastases.
  • 2021-09-08 CT - lung/mediastinum/pleura

    • LUL cancer T4M1c, in progression of primary tumor and hepatic metastases as compared with previous CT study on 2021-06-02
  • 2021-09-08 CT - liver, spleen, biliary duct, pancreas

    • Metastases are highly suspected.
    • Multiple Cholangiocarcinomas are less likely.
  • 2021-07-16 Patho - liver biopsy

    • IHC: CK7(+), CK20(-), TTF1(-), Napsin A(-), and p40(focal + in squamous component).
    • Primary liver adenocarcinoma (cholangiocarcinoma) can not be completely excluded.
    • Metastatic pulmonary adenocarcinoma is less likely in IHC result.
    • Additional IHC: ER(focal +), PAX8(focal +)
    • Comment: The IHC finding is compatible with metastatic endometroid carcinoma.
  • 2021-07-07 Tc-99m MDP whole body bone scan

    • A faint hot spot in the lateral aspect of the left 7th rib, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3-6 months for investigation.
    • Suspected benign lesions in the maxilla, some C- and L-spine, bilateral shoulders, S-I joints, hips and knees.
  • 2020-12-17 ROS1 FISH not detected

  • 2020-12-11 EGFR, ALK IHC, PD-L1(22C3) S2020-18026 (bronchus biopsy)

    • EGFR
      • G719X (-)
      • Exon19 deletion (+)
      • S768I (-)
      • T790M (+)
      • Exon20 insertion (-)
      • L858R (-)
      • L861Q (-)
    • ALK IHC (-)
    • PD-L1 Tumor proportion score TPS < 1%
  • 2020-11-25 Patho - bronchus biopsy

    • CT-guide biopsy - adenocarcinoma, moderately differentiated
    • IHC: TTF-1(+).
    • The result is supportive for the diagnosis of malignant neoplasm of left bronchus or lung.
  • 2020-11-13 CT - lung/mediastinum/pleura

    • left upper lobe lung cancer with probably right lung meta. the primary left upper lobe lung cancer progressed.
  • 2020-08-12 CT - lung/mediastinum/pleura

    • LUL tumor involving mediastinum and hilum and Rt lung metastasis, in progression as compared with previous CT study on 20200320.
  • 2020-06-30 Patho - Ureter resection

    • pathologic diagnosis
      • Ureter, left, frozen section + open nephroureterectomy - Endometrioid carcinoma with ureter invasion
      • Kidney, left, ditto - Chronic pyelonephritis
    • IHC for tumor cells: CK7(+); CK20 (-); ER(+); GATA-3(-), TTF-1(-), WT-1(-), PAX-8(+), P63(-) and CDX-2(+, focal) for tumor cells
  • 2020-06-29 Patho

    • Tumor, urinary tract?, frozen section - Adenocarcinoma, uncertain origin
  • 2020-06-13 CT - whole abdomen, pelvis

    • S/P hysterectomy.
    • Malignant tumors in the pelvic cavity, up to 6.1cm in left side with left hydronephrosis. Probably metastasis(TCC? GYN or GI tract). Suggest tissue study.
  • 2020-03-30 CT - lung/mediastinum/pleura

    • LUL tumor involving mediastinum and hilum, stationary as compared with previous CT study on 20191230.
  • 2019-12-30 CT - lung/pleura

    • LUL tumor involving mediastinum and hilum, stationary as compared with previous CT study on 20190918.
  • 2019-09-18 CT - lung/pleura

    • LUL tumor involving mediastinum and hilum, stationary as compared with previous CT study on 20190612.
  • 2019-06-12 CT - lung/pleura

    • LUL tumor involving mediastinum and hilum, in regression as compared with previous CT study on 20190312.
  • 2019-04-11 MRI - L-spine

    • Lumbar spondylosis, canal stenosis and small L1/2 HIVD. No tumor or metastasis found.
  • 2019-03-15 MRI - brain

    • No evidence of brian metastasis.
    • Mild ventriculomegaly.
  • 2019-03-14 Surgical pathology Level IV

    • indication: Malignant bronchus and lung neoplasm, NOS;
    • diagnosis: Lung, ? side, needle biopsy - adenocarcinoma, moderately differentiated
    • IHC: TTF-1(+), Napsin A(+), and p63(-). The results are supportive for the diagnosis.
  • 2019-03-12 CT - lung/pleura

    • Progression of LUL lesion (6.1x7.1cm) with mediastinal LAP. TNM: T4N2Mx
    • Right tiny renal stones (1-2mm). Left hydronephrosis.
  • 2019-03-02 CT - brain

    • No brain lesion.
    • A 6.4mm dense calcification at left parasagittal region, calcified meningioma or benign parafalcal calcification.
  • 2018-06-06 Surgical pathology Level IV

    • indication: bilateral lung nodules
    • diagnosis: Lung, ? side, needle biopsy - Interstitial fibrosis with atypical pneumocytes
    • Sections show alveolar lung tissue with interstitial fibrosis and atypical pneumocytes proliferating along the alveolar wall. No stromal invasion is seen. The immunohistochemical stain of CK reveals no invasive tumor. The TTF-1 is positive. Please correlate with the clinical presentation and further examination is suggested.
  • 2018-05-31 Low-dose CT - lung cancer screening

    • A spiculated mass (4.2x6.1cm) at LUL suspected cancer.

[MedRec] (not completed)

  • 2022-02-09 SOAP Hemato-Oncology
    • A/P
      • On 2022-02-09. C/O Toxicity of C/T, e.g., four limbs numbness, especially left upper limb; decreased acuity of eye; fatigue and weakness. Already told the worse of prgnosis. Options are given e.g., change C/T regimen to NHI re-imbursement; rest for one week; continue current regiemen and C/T on 2022-02-09. They dedicde continue current C/T on 20220-02-09.
      • Admission 3rd course of C/T on 2022-02-09
      • Due to acnefirom skin rash over face, order clindaymicin gel.
      • Already told the C/T-irelated neuropathy, patient would like to try one more time on 2022-02-09. If not tolerated, may chnage to other regimen
  • 2022-01-05 SOAP Hemato-Oncology
    • O
      • Now on palliative C/T with TP, C1D1 on 2021-12-29
      • AEs: Fatigue
  • 2021-11-11 SOAP Chest Medicine
    • Prescription (part)
      • Navelbine (vinorelbine 20mg) 3# QW
  • 2021-11-05 SOAP Hemato-Oncology
    • A/P: She is receiving IO and navelbine for her lung ca by Dr Wu. (20211105)
  • 2021-09-01 SOAP Chest Medicine
    • Prescription
      • Tagrisso (osimertinib 80mg) 1# QD
  • 2021-07-13 SOAP Hemato-Oncology
    • A
      • s/p local radiotherapy after operation for Lt nephrectomy and endometrioid ca with ureter invasion
      • Liver metastases noted in CT abdomen (20210713)
    • P
      • Suggest liver biopsy
  • 2021-06-04 SOAP Chest Medicine
    • A/P
      • 2021/05/28 chest CT with/without contrast suspected MET and/or c797 metastasis
      • biopsy of LUL by CS
      • She refused and hope to use qd Tagrisso
  • 2020-12-23 SOAP Chest Medicine
    • Prescription
      • Tagrisso (osimertinib 80mg) 1# QD (change)
      • Romicon-A 1# TID
      • Through (sennoside 12mg) 2# HS
      • Sketa 1# TID
  • 2020-10-14 SOAP Chest Medicine
    • Prescription
      • Iressa (gefitinib 250mg) 1# Q3D
      • codeine phosphate 15mg 1# BID
      • Zalain External Gel (sertaconazole 2%) Q3D EXT
  • 2020-09-16 SOAP Chest Medicine
    • A/P
      • we discuss with patient and final decision was shifted to Iressa 1# Q3D
    • Prescription
      • Iressa (gefitinib 250mg) 1# Q3D (longer interval)
      • Topsym (fluocinonide 0.05%) BID TOPI
  • 2020-08-19 SOAP Chest Medicine
    • A/P
      • we discuss with patient and final decision was shifted to Iressa 1# QOD => If after 3 months, on improve => Arrange rebiopsy
    • Prescription
      • Iressa (gefitinib 250mg) 1# QOD (shorter interval)
  • 2020-07-22 SOAP Chest Medicine
    • A/P
      • Iressa 1# Q3D
      • prepare to receive RT and C/T for endometrial ca
    • Prescription
      • Iressa (gefitinib 250mg) 1# Q3D
      • Allegra (fexofenadine 60mg) 1# BID
  • 2020-04-16 SOAP Radiation Oncology
    • Plan
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 1200cGy/3 fractions to vaginal cuff mucosa surface by IVRT.
  • 2020-07-16 SOAP Obstetrics and Gynecology
    • Objective
      • Multi-disciplinary Oncology Team Meeting Conclusion, Meeting Date: 2021-07-16
        • Cancer staging: rypT3bNx(cM0), stage IIIB.
        • Treatment: Radiotherapy followed by Chemotherapy.
      • Multi-disciplinary Oncology Team Meeting Conclusion, Meeting Date: 2021-07-09
        • Wait for the pathology report to confirm if the primary cancer is endometrial cancer or cervical cancer.
        • Hematology doctor: Since the patient is old (70 years old) and has lung cancer (Lung adenocarcinoma, T4N0M1, stage IV, post Iressa since 2019-03), the significance of chemotherapy is not high. Suggest initial Local Radiotherapy.
  • 2020-02-04 SOAP Chest Medicine
    • Diagnosis
      • Lung cacer with adenocarcinoma, T4N0M1bx, ECOG 0. [C34.90]
      • Cellulitis and abscess other specified sites [L02.811]
    • Prescription
      • Iressa (gefitinib 250mg) 1# Q3D (even longer interval)
      • Allegra (fexofenadine 60mg) 1# BID
      • Mosflow (moxifloxacin 400mg) 1# QDAC
  • 2019-06-25 SOAP Chest Medicine
    • Prescription
      • Iressa (gefitinib 250mg) 1# QOD (longer interval)
  • 2019-06-11 SOAP Dermatology
    • S
      • Multiple painful erythematous papule-nodules on face, trunk and 4-limbs
      • Heavy scaling over erythematous patchs on scalp, and eyelid and nasolabial fold with moderate itching
    • Diagnosis
      • Lung cacer with adenocarcinoma, T4N0M1bx, ECOG 0. [C34.90]
      • Acne varioliformis [L70.2]
      • Other erythematosquamous dermatosis [L30.3]
      • Seborrheic dermatitis, unspecified [L21.9]
      • Type 2 diabetes mellitus without complications [E11.9]
      • Right eye hypertropia [H50.21]
    • Prescription
      • doxycycline 100mg 1# BID
      • Kefen (ketotifen fumarate 1mg) 1# BID
      • Mycomb BID TOPI
  • 2019-06-11 SOAP Chest Medicine
    • Plan:
      • change to Iressa due to severe adverse effect of giotrif, but adverse effect persist, so hold Iressa 2 weeks and wait CT result
  • 2019-05-28 SOAP Chest Medicine
    • Objective
      • Assessment of Side Effects of Cancer Treatment (2019-05-28)
        • Skin rash: G2: Moderate rash, or single moist desquamation, mostly in skin folds and moderate edema
        • Oral mucositis: G2: Moderate pain, can eat, need to adjust diet
    • Plan
      • change to Iressa due to severe adverse effect of giotrif
    • Prescription
      • Iressa (gefitinib 250mg) 1# QD (new)
      • Ulstop (famotidine 20mg) 1# BID
      • Allegra (fexofenadine 60mg) 1# BID
      • Mycomb Cream BID TOPI
  • 2019-05-14 SOAP Chest Medicine
    • Objective
      • Assessment of Side Effects of Cancer Treatment (2019-05-14)
        • Skin rash: G1: Superficial rash or dry scales
        • Hand-foot syndrome: G3: Skin changes with pain, affecting daily life
        • Oral mucositis: G1: No lesions
    • Prescription
      • same as 2019-04-30
  • 2019-04-30 SOAP Chest Medicine
    • Objective
      • Assessment of Side Effects of Cancer Treatment (2019-04-30)
        • Diarrhea: G1: Up to 4 times per day
        • Skin rash: G2: Moderate rash, or single moist desquamation, mostly in skin folds and moderate edema
        • Oral mucositis: G2: Moderate pain, can eat, need to adjust diet
    • Prescription
      • Giotrif (afatinib 30mg) 1# QDAC (lower dose)
      • Ulstop (famotidine 20mg) 1# BID
      • Allegra (fexofenadine 60mg) 1# BID
      • Mycomb Cream BID TOPI
  • 2019-04-24 SOAP Chest Medicine
    • Objective
      • Conclusion of the Multidisciplinary Team Meeting for Cancer, Meeting Date: 20190326): Check PD-L1, EGFR and ALK status, if positive mutation is found, then initiate targeted therapy.
      • EGFR Exon 19 Del, PD-L1 5%, ALK negative
    • Prescription
      • Giotrif (afatinib 40mg) 1# QDAC
      • Ulstop (famotidine 20mg) 1# BID
      • Allegra (fexofenadine 60mg) 1# BID
      • Imolex (loperamide 2mg) 1# BID
  • 2019-03-27 SOAP Chest Medicine
    • Diagnosis
      • Lung cacer with adenocarcinoma, T4N0M1bx, ECOG 0. [C34.90]
      • Type 2 diabetes mellitus without complications [E11.9]
      • Right eye hypertropia [H50.21]
      • constipation [K59.00]
    • Prescription
      • Navelbine (vinorelbine 20mg) #3 QW
      • Sketa (acetaminophen 300mg + chlorzoxazone 250mg) 1# TID
      • Through (sennosides 12mg) 1# HS
  • 2019-03-08 SOAP Ophthalmology
    • Diagnosis
      • Senile cataract, unspecified [H25.9]
    • Prescription
      • ONSD (neostigmine methylsulfate) 0.01% 10mL eye drop BID
  • 2019-03-01 SOAP Neurology
    • Diagnosis
      • Disorder of binocular vision, unspecified [H53.30]
      • Sixth or abducens nerve palsy [H49.22]
    • Prescription
      • Compesolon (prednisolone 5mg) 1# BID
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
  • 2018-06-01 SOAP Chest Medicine
    • Dx: bilateral lung nodules
  • 2017-03-24 SOAP Family Medicine
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Gout, unspecified [M10.9]
      • Urinary calculus, unspecified [N20.9]
      • Mixed hyperlipidemia [E78.2]
      • Constipation [K59.00]
    • Prescription
      • Uformin (metformin 500mg) 1# QD
      • Lipanthyl (fenofibrate 160mg) 1# QOD
      • Euricon (benzbromarone 50mg) 0.5# QOD

[consultation]

  • 2023-05-22 Oral and Maxillofacial Surgery
    • Q
      • She would like to receive Xgeva (denosumab)
      • We need your expertise and evaluation for her jaw because of propable MRONJ
    • A
      • After intraoral dental examination, no dental decay or mobile teeth was noticed.
      • Xgeva could be used safely.
  • 2023-05-22 Radiation Oncology
    • Q
      • This 72-year-old woman with underlying histories of
        • LUL adenocarcinoma, Stage= T4N2M1 stage IV with probably right lung metastasis
        • Malignant tumors in the pelvic cavity, up to 6.1cm in left side with left hydronephrosis. Probably metastasis (endometrioid cancer)。
        • DM
        • hyperuricemia
        • Endometrioma sp ATH+BSO 2011
        • Abdominal benign mass lesion sp surgical removal x3 many years ago.
      • This time, she was admitted to ward for restaging of Brain MRI (no meta) and NGS evaluation.
      • The patient complaint about her left arm pain and liver meta. She would like to receive radiotherapy
      • We need your expertise and evaluation for her treatment and symptoms control
    • A
      • History: This 72-year-old woman suffers from LUL adenocarcinoma, cT4N2M1 stage IV with probably right lung metastasis s/p Durvalumab and navelbine s/p Taxol/Carboplatin for 3 cycles in 2022/07 under Tagrisso now;
      • This time, she was admitted to ward for restaging of Brain MRI (no meta) and NGS evaluation. The patient complaint about left shoulder pain with movement limitation and progressive liver metastasis noted by CT on 2023/04/21.
      • Previous RT: Endometrial carcinoma of the uterus, s/p hysterectomy and BSO at ZhongShan Hospital in 2011, with recurrence and left ureter invasion, s/p operation (Nephrourterectomy with bladder cuff resection, left (open); Excision of retroperitoneal tumor, retrorectal tumor, left exteranl iliac LAP on 2020/07/06; stage rypT3bNx (cM0), stage IIIB, s/p adjuvant RT on 2020/09/11; RT to Rt posterior 4th rib for 3500cGy/10 fx on 2023/4/06.
      • Diagnosis: Metastatic soft tissue tumor over left shoulder (origin from lung cancer or endometrial cancer?); ECOG =1.
      • Plan: RT to left shoulder for 4000cGy/10 fx is suggested for pain control. Possible radiation toxicity (radiation dermatitis) is told to her. CT simulation will be arranged on May 30, 10:30.
  • 2021-12-21 Hemato-Oncology
    • Q
      • This 70 y.o female was a case with past history of (1) Endometrioid carcinoma with ureter invasion with Metastatic pulmonary adenocarcinoma is less likely in IHC result (2) DM.
    • A
      • This 70 year old woman had history of
        • s/p Hystectomy & BSO due to endometriosis in 2011 at ZhongShan Hospital.
        • LUL tumor involving mediastinum and hilum and Rt lung metastasis, NSCLC T4N0M1 stageIV adenocarcinoma, moderately differentiated s/p navelbine since 2019/03/27, Exon 19 Del, PD-L1 5%, ALK negative s/p afatinib since 2019/04/24, change to Iressa due to severe adverse effect of Giotrif (afatinib) since 2019/05, 2020/11 re biopsy, t790m mutation, shift to osimertinib 2020/12/23, 2021/02 CT: left upper lobe lung cancer with probably liver meta, s/p C1 Alimta 600mg on 2021/09/14 and C1 Durvalumab 240mg(1+1) on 2021/09/15.
        • Endometrioid carcinoma with ureter invasion status post retroperitoneal tumor s/p 1.excision of retroperitoneal tumor, LN. with enterolysis, 2.debulking, 3.ureterorenoscopic exam and DBJ insertion pT3N0M0 stage III on 2020-06-29: CK7(+); CK20 (-); ER(+); GATA-3(-), TTF-1(-), WT-1(-), PAX-8(+), P63(-) and CDX-2(+, focal) for tumor cells
        • 2021/07/16 liver biopsy: Adenocarcinoma with focal squamous differentiation, IHC shows following features: CK7(+), CK20(-), TTF1(-), Napsin A(-), and p40(focal + in squamous component). Primary liver adenocarcinoma (cholangiocarcinoma) can not be completely excluded. Metastatic pulmonary adenocarcinoma is less likely in IHC result. 2021-09-08 CT: 1. LUL cancer T4M1c, in progression of primary tumor and hepatic metastases as compared with previous CT study on 2021/06/02 2. There are multiple well-defined ring-enhancing masses on both heatic lobes, the largest one 3 cm in S7/8, at arterial phase images and contrast washout in portal and delayed phase images. Several larger lesions show central tunor necrosis. Metastases are highly suspected. Multiple Cholangiocarcinomas are less likely.
        • LLQ tumor seen in 2021/10/21 CT, biopsy:adenocarcinoma, metastatic, The morphology and immunohistochemical stains are consistent with S2020-8600 (Endometrioid carcinoma).
      • Impression:
        • Recurrent Endometrioid carcinoma (left lower quadrate mass biopsy result)
        • Lung adenocarcioma, EGFR mutation, cT4N2M1c, cStage IVb, s/p afatinib, s/p Gefitinib, s/p osimertinib, now under durvalumab
        • Liver lesions r/o lung meta or endometrioid meta, primary Cholangiocarcinomas are less likely
      • Suggestion:
        • Please contact pathologist for more IHC stain of liver biopsy to differentiate the possible origin from endometrioid cancer; in addition, may request pathologist to perform MMR, regarding the MSI-H or not.
        • As for the chemotherapy regimen, may consider palictaxel plus platinum to cover lung cancer and endometriroid cancer, if the final result of the possible cholangiocarcinoma is not coming out.
  • 2021-10-18 Gastroenterology
    • Q
      • This was a 70 y/o female with lung adenocarcinoma stage IVb, and she was admitted for immunotherapy (durvalumab). She complaint of constipation for long time. So MgO TID and sennoside 2 tab HS was given. Her constipation was relieved but she started to have LLQ pain since 20211014. So we stopped MgO and keep sennoside 1 tab HS. But she still have intermittant LLQ pain. The pain always exacerbated at night and could be relieved by Tramacet. Her colonscopy showed brownish pigmentation of mucosa on 2021/08/10. No bloody stool and watery diarrhea was noted.
    • A
      • 70F Phx:
        • Lung adenocarcioma, EGFR mutation, cT4N2M1c, cStage IVb, s/p Gefitinib, s/p osimertinib, now under durvalumab
        • Endometrial carcinoma of the uterus, s/p total hysterectomy with BSO 9 years ago
        • Pelvic malignancy tumor with left ureter invasion, s/p nephrourterectomy and tumor resction 1 year ago, followed by RT 4500cGy
        • DM, controlled with sitagliptin
      • S:
        • LLQ abdominal pain, raidating to LUQ and back since 2021/10/15. (Last durvalumab course)
        • Quality: dull with intermittent bloating
        • Do not relief after defecation nor flatulence
        • The pain would be precipitated at walking
        • Pain score: 3-5
      • O:
        • Abdomen:
          • soft and flat with multiple OP Scar
          • marked tenderness over LLQ, mild rebound tenderness, percussion tenderness (+)
          • knocking tenderness at left lower back
      • A
        • Acute LLQ abdominal pain,
        • r/o intraperitoneal or retroperitoneal inflammatory process
        • r/o colitis (immunotherapy related?)
      • P
        • Arrange KUB (standing)
        • Arrange abdominal echo
        • Check stool routine and urinanlysis
        • Consider CT scan if the aforementioned examinations are inconclusive
  • 2020-07-01 Infectious Disease
    • Q
      • This 69-year-old female wtih a known history of
        • Lung Ca s/p CM since March 2019
        • s/p Hystectomy & BSO due to endometriosis    
      • This time, she had Retroperitoneal tumor. Thus, excision of retroperitoneal tumor, retrorectal tumor, LN. with enterolysis were performed on 20200629. However, we found pneumonia, abdominal pain and leucocytosis (WBC 18680, CRP 9.38). We need your expertised for further evaluation and management. Thank you!!
    • A
      • Consultation for Tienam antibiotic.
        • 69-year-old lung cancer female patient received retroperitoneal tumor surgery two days ago.
        • There is post-operative fever that white count up to 18680 thismorning, with CRP level 9.38.
        • Mild elevated serum PCT level also noted.
        • CxR film this morning shows newly-developed infiltration patches over BLL and LUL, that postoperative pneumonia is the first impression.
        • Tienam is prescrbed.
      • Suggestion:
        • Continue Tienam for five days first.
        • Check blood and sputum culture report.

[surgical operation]

  • 2020-06-29
    • Operation
      • Excision of retroperitoneal tumor
      • Excision of retrorectal tumor
      • Ex of left exteranl iliac LN
      • Adhesionolysis
    • Finding
      • Moderate adhesion of small bowel and omentum of lower abdomen, no gross peritoneal seedings
      • A bulky tumor in pelvic retroperitoneal space and adjacent to left external iliac vessels and encasing left ureter
      • A rectal submucosa tumor in upper rectum, 3cm in diameter
      • Drain: 19Fr Blake drain x 2 in left retroperitoneal space
      • Washing cytology: 100cc normal saline irrigation for peritoneal cavity
      • Wound: treated with New Epi 5cc
  • 2020-06-09
    • Surgery
      • Nephrourterectomy with bladder cuff resection, left (open)
    • Finding
      • EBL: 1500cc
      • 300 cc during bladder cuff
      • 600 cc at renal pedicule
      • 6cm stone hard tumor at middle ureter –> after explanation of risk and alternative treatment, family member agreed nephroureterectomy
      • Frozen section: adenocarcinoma

[chemotherapy]

  • 2022-07-07 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-06-15 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-05-27 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-03-29 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-02-09 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-01-19 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-12-28 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 250mg D5W 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-11-25 - durvalumab 240mg NS 250mL
    • none
  • 2021-11-03 - durvalumab 240mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + NS 50mL
  • 2021-10-12 - durvalumab 240mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + NS 50mL
  • 2021-09-15 - durvalumab 240mg NS 250mL
    • none
  • 2021-09-14 - pemetrexed 600mg NS 100mL
    • dexamethasone 4mg + hydroxocobalamin 1mg + NS 50mL
  • 2021-11 ~ 2021-12 - vinorelbine
  • 2020-12 ~ ongoing - osimertinib (for NSCLC)
  • 2019-05 ~ 2020-11 - gefitinib
  • 2019-04 ~ 2019-05 - afatinib
  • 2019-03 ~ 2019-04 - vinorelbine

NCCN Non-Small Cell Lung Cancer Evidence Block 20220316 p89 — targeted therapy or immunotherapy for advanced or metastatic NSCLC

  • EGFR Exon 19 Deletion or L858R
    • First-line therapy -Afatinib -Erlotinib -Dacomitinib -Gefitinib -Osimertinib -Erlotinib + ramucirumab -Erlotinib + bevacizumabc (nonsquamous)
    • Subsequent therapy -Osimertinib9

-EGFR S768I, L861Q, and/or G719X - First-line therapy -Afatinib -Erlotinib -Dacomitinib -Gefitinib -Osimertinib - Subsequent therapy -Osimertinib9

  • EGFR Exon 20 Insertion Mutation Positive
    • Subsequent therapy -Amivantamab-vmjw -Mobocertinib
  • KRAS G12C Mutation Positive
    • Subsequent therapy -Sotorasib
  • ALK Rearrangement Positive
    • First-line therapy -Alectinib -Brigatinib -Ceritinib -Crizotinib -Lorlatinib
    • Subsequent therapy -Alectinib -Brigatinib -Ceritinib -Lorlatinib
  • ROS1 Rearrangement Positive
    • First-line therapy -Ceritinib -Crizotinib -Entrectinib
    • Subsequent therapy -Lorlatinib -Entrectinib
  • BRAF V600E Mutation Positive
    • First-line therapy -Dabrafenib/trametinib -Dabrafenib -Vemurafenib
    • Subsequent therapy -Dabrafenib/trametinib
  • NTRK1/2/3 Gene Fusion Positive
    • First-line/Subsequent therapy -Larotrectinib -Entrectinib
  • MET Exon 14 Skipping Mutation
    • First-line therapy/Subsequent therapy -Capmatinib -Crizotinib -Tepotinib
  • RET Rearrangement Positive
    • First-line therapy/Subsequent therapy -Selpercatinib -Pralsetinib -Cabozantinib
  • PD-L1 >=1%
    • First-line therapy -Pembrolizumab -(Carboplatin or cisplatin)/pemetrexed/pembrolizumab (nonsquamous) -Carboplatin/paclitaxel/bevacizumab/atezolizumab (nonsquamous) -Carboplatin/(paclitaxel or albumin-bound paclitaxel)/pembrolizumab (squamous) -Carboplatin/albumin-bound paclitaxel/atezolizumab (nonsquamous) -Nivolumab/ipilimumab -Nivolumab/ipilimumab/pemetrexed/ (carboplatin or cisplatin) (nonsquamous) -Nivolumab/ipilimumab/paclitaxel/carboplatin (squamous)
  • PD-L1 >=50% (in addition to above)
    • First-line therapy -Atezolizumab -Cemiplimab-rwlc

==========

2023-06-14

  • For the past 3 months, the patient has been receiving exclusive medical services, both outpatient and inpatient, from our hospital, in particular, from our departments of thoracic medicine and hemato-oncology. On 2023-06-02, our thoracic specialist prescribed a 14-day medication regimen that included acetaminophen, bisoprolol, megestrol, cortisone, osimertinib, sennoside, fentanyl patch, rabeprazole, and Romicon-A. These medications are accurately listed on the active prescription with no reconciliation issues identified.

2022-06-16

  • Audiometric test of pure tones indicated recovery to some degree in hearing loss (2022-05-18 Average RE 31 dB HL and LE 41 dB HL <- 2022-05-11 Average RE 35 dB HL and LE 51 dB HL).

2022-01-20

  • drug allergy: alimta (pemetrexed) moderate skin rash recorded in database as from 2021-12-20.
  • HER2 test might be tried to opt-in Trastuzumab as a backup candidate.

700223701

230614

[past history]

  • Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa
  • Hypertension    

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.  

[exam findings]

  • 2023-05-12 Sonography for peripheral vessel
    • Peripheral Vascular Test: Vein, lower limbs
    • Conclusion:
      • No evidence of deep vein thrombosis at bilateral common femoral, femoral and popliteal veins (by color flow filling, direct compression, and distal augmentation response)
      • Left thigh swelling and inguinal lymphadenopathy, consider more proximal vein problem or external compression
  • 2023-05-09 CT - abdomen
    • With and without contrast enhancement CT of abdomen - whole:
      • Wall thickening at rectum and anus, regression.
      • Left adrenal tumor, 1cm. Stationary.
      • Liver cyst, 0.5cm in S4.
      • Regression of left inguinal lymph nodes.
    • Impression:
      • Rectal malignancy and left inguinal lymph nodes with regression.
      • Left adrenal tumor, stationary.
      • Liver cyst.
  • 2023-05-04 Knee Bilat
    • Both knee AP/Lat view: Swelling of left lower extremity.
  • 2023-03-13 CXR
    • Enlargement of cardiac silhouette.
  • 2023-03-10 CXR
    • Cardiomegaly is noted.
    • Scoliotic alignment of the thoracolumbar spine is noted.
    • Tortous aorta with calcification is noted.
    • S/p port-A placement with its tip at Superior vena cava.
  • 2023-02-03 CXR
    • Borderline cardiomegaly
    • Increased lung markings on left lower lung are noted. Please correlate with clinical condition.
  • 2023-01-31 24hr portable ECG
    • Baseline was sinus rhythm
    • Frequent isolated VPCs / VPC couplets (burden 2%)
    • 1 episode VPC salvo / idioventricular rhythm (3 beats, 81 bpm)
    • Rare isolated APCs / APC couplet
    • No long pause
  • 2023-01-31 Ankle-Brachial Index
    • both lower limbs normal
  • 2023-01-31 Neurosonology
    • Minimal atherosclerosis in right subclavian artery.
    • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
  • 2023-01-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (105 - 37) / 105 = 64.76%
      • M-mode (Teichholz) = 64
  • 2023-01-24 MRA - brain
    • Right MCA occlusion at M2 segment with right MCA territory infarct.
  • 2023-01-24 CT - brain
    • Low attenuations in right parietal and temporal regions suspected infarcts.
  • 2023-01-24 ECG
    • Normal sinus rhythm
    • Cannot rule out Inferior infarct, age undetermined
    • T wave abnormality, consider anterior ischemia
  • 2023-01-17 Patho - soft tissue biopsy/simple excision (non lipoma)
    • Labeled as “left neck mass”, SONO guided biopsy — poorly differentiated.
    • IHC stains: CK20 (+), TTF-1 (-).
    • Section shows lymph node with poorly differentiated carcinoma.
  • 2023-01-09 Whole body PET scan
    • There was increased FDG uptake in the anorectal region (SUVmax early: 17.21, delay: 21.74), in bilateral lower pelvis lymph nodes (SUVmax early: 8.94, delay: 12.81), bilateral inguinal lymph nodes (SUVmax early: 11.70, delay: 15.82), bilateral para-aortic lymph nodes (SUVmax early: 8.61, delay: 13.92), gastrohepatic lymph nodes (SUVmax early: 5.44, delay: 6.64), and left mediastinal lymph nodes (SUVmax early: 5.29, delay: 8.80). In addition, increased FDG uptake was also noted in the left adrenal region (SUVmax early: 8.77, delay: 14.81), left lobe of the thyroid gland (SUVmax early: 9.57, delay: 11.41), and left several level V cervical lymph nodes (SUVmax early: 6.06, delay: 8.71).
    • IMPRESSION:
      • Glucose hypermetabolism in the anorectal region, compatible with the primary anorectal cancer.
      • Glucose hypermetabolism in bilateral lower pelvis lymph nodes, bilateral inguinal lymph nodes, bilateral para-aortic lymph nodes, and gastrohepatic lymph nodes, highly suspected anorectal cancer with regional and distant lymph nodes metastases.
      • Glucose hypermetabolism in the left mediastinal lymph nodes, the nature is to be determined (reactive or metastatic nodes, or other nature ?), suggesting follow-up with PET scan for investigation.
      • Increased FDG uptake in the left adrenal region, probably a functioning tumor in the left adrenal gland, suggesting further investigation.
      • Increased FDG uptake in the left lobe of the thyroid gland and left several level V cervical lymph nodes, highly suspected another primary thyroid cancer with regional lymph nodes metastases, suggesting biopsy for investigation.
      • Anorectal cancer with regional and distant lymph nodes metastases, cTxN2bM1b, stage IVB (AJCC 8th ed.); highly suspected left thyroid cancer with left cervical lymph nodes metastases, by this F-18 FDG PET scan.
  • 2023-01-03 Patho - colon biopsy
    • Colorectum, rectum, biopsy — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-01-02 CT - abdomen
    • History and indication: Anorectal cancer
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of anus and rectum with adjacent fat stranding and regional LAP.
      • Enlarged LNs at left neck, retroperitoneum and left inguinal region.
      • Enlargement of left adnexa (3.0cm) with calcification.
      • Enlargement of left adrenal gland.
      • Left liver cysts (up to 7mm).
  • 2022-12-30 Anoscopy
    • Impression:
      • Buttock & perianal region: No discharge, no abscess or fistula
      • DRE/Anoscopy: normal anal tonicity; mixed hemorrhoids with congestion, tumor mass like lesion at low rectum!
  • 2022-12-30 Sigmoidoscopy
    • Suspected anorectal cancer with impending obstruction

[MedRec]

  • 2023-06-08 MultiTeam
    • Multi-team Recommendations
      • Medical Team Discussion
        • Dr. He Jingliang: Briefly described the patient’s condition and current treatment direction. Currently, the pain control is mainly morphine, and oral chemotherapy drugs are used to control metastatic skin tumors.
        • Dr. Chang Youkang: Attempted to do radiotherapy positioning on Tuesday, but it failed due to severe lower back pain. Maybe we can try using oral chemotherapy for a week. If the effect is limited, we can move towards palliative care.
        • Psychologist: The patient has actively asked about palliative care and actively expressed a desire to be as comfortable as possible at the end of life.
        • Palliative Care Nurse: Discussed with the family about the advance medical directive and palliative care.
        • Discharge Preparation Center: Recommended hospice care.
        • Social Worker: Will continue to care about the economic situation and contact available resources.
        • Disability Handbook: The functional recovery after the stroke does not meet the rules for issuing the handbook.
        • Patient’s Sister: Respect the patient’s wish to be comfortable and hope that the social worker can help find available financial resources.
        • Patient’s Son: Asked about dyspnea, bowel movement, and left lower limb edema issues.
          • The current shortness of breath is not a lung problem (5/31 CHEST CT: no lung meta.) It might be caused by pain.
          • Bowel movement problem: The lower frequency of bowel movements is due to the lower food intake, but medication can assist treatment.
          • Left lower limb edema: Due to lymph node metastasis and after radiotherapy, causing lymphatic damage and blockage, currently can only symptomatic treatment, cannot fully recover.
    • Conclusion
      • Try a week of oral chemotherapy drugs and then palliative care.
      • Refer to the family medicine department to discuss subsequent advance medical directives and palliative care.
  • 2023-02-10 SOAP Hemato-Oncology
    • Objective
      • Multi-disciplinary Oncology Team Meeting Conclusion, Meeting Date: 2023-01-10
        • Arrange for a neck tumor biopsy first to plan for thyroid cancer.
  • 2023-02-10 SOAP Neurology
    • Impression
      • Acute ischemic stroke in right MCA territory, onset on 2023/01/23, r/o cancer related hypercoagulability (TOAST:5. Undetermined etiology - conflict date)
      • Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa, with impending obstruction and left inguinal LNs enlargement and left lower limb edema
      • Malignant neoplasm of rectum
      • Unspecified viral hepatitis B without hepatic coma
      • Modified ranking scale 2
      • Hyperlipidemia, unspecified
      • Essential (primary) hypertension
      • Contusion of unspecified part of head, initial encounter
      • Laceration without foreign body of left eyelid and periocular area, initial encounter
    • Plan
      • Keep Bokey, Crestor, Diovan
    • Prescription
      • Diovan (valsartan 160mg) 1# QD
      • Bokey (aspirin 100mg) 1# QD
      • Crestor (rosuvastatin) 1# QD

[consultation]

  • 2023-01-30 Rehabilitation
    • Q
      • We sincerely need your help for arrange rehab. program.
    • A
      • Rehabilitation programs: GYM PT, OT rehabilitation programs
      • Goal: Ambulation with/without device ID, BADL ID
  • 2023-01-27 Hemato-Oncology
    • Q
      • This is a 57-year-old woman with history of
        • Hypertension
        • Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa, with impending obstruction and left inguinal LNs enlargement and left lower limb edema, s/p neoadjuvant chemotherapy and radiotherapy,
        • Thyroid papillary carcinoma.
      • The patient was arrnged to accept chemotherapy and radiotherapy for her Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa as schedule. But unfortunately, she had acute ischemic stroke with right MCA infarction. Now the patient was in our ward for stroke therapy.
      • Acue ischemic stroke for right MCA infarction
      • Assessment
        • MRA showed acute infarct in
          • Right temporo-parietal area,
          • Right MCA posterior M2 occlusion
          • subacute small infarct in left parietal lobe.
        • CT showed low attenuations in right parietal and temporal regions suspected infarcts.
        • NE showed
          • Left side central type fascial palsy
          • MP: Upper limbs-> Rt:5, Lt:4+ , Lower limbs-> Rt:5, Lt:4
          • Rombers test : unstable, Tanden gait : unstable
      • Plan
        • Antiplatelet therapy: Bokey 1# QD
        • Hypolipidemic agents: Crestor 1# QD
        • Anti-dizziness drugs: Diphenidol 1# BID
        • Stress ulcer prevention: ULSTOP 1# BID
      • We hope your visit to evaluate her adenocarcinoma of anorectum radiotherapy and chemotherapy condition.
    • A
      • This 57 year old woman is a case of Anorectal cancer with regional and distant lymph nodes metastases, cT4N2bM1b, stage IVB. She was admiited to neuro ward due to acute ischemia stroke (Right MCA occlusion at M2 segment with right MCA territory infarct). For cancer treatment, we are consulted.
      • CCRT for down staging is suggested at tumor board. Please send All-RAS (sample number S2023-00082) for further cancer work up.
      • However, due to the patient’s stroke condition (right MCA infarction) and it sequela that might be, chemotherapy may not change much. If the family still consider aggressive treatment,
      • After stroke condition stable, we may take over this case in the next week if you agree.
  • 2023-01-24 Neurology
    • A
      • S
        • This is a 57-year-old woman with history of hypertension and adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa, with impending obstruction and left inguinal LNs enlargement and left lower limb edema, s/p neoadjuvant chemotherapy and radiotherapy, and thyroid papillary carcinoma. She still could walk and speak without any difficulty before the noon on 2023/01/23. She presented with slower speech and slurred speech at night. Her family found she had a laceration wound in the left forehead and left upper eyelid in the midnight (00:30) on 2023/01/24. Thus, she was sent to our ED.
        • Non-contrast brain CT showed hypodensity in right MCA territory.
      • O
        • NE Consciousness: E4V5M6, alert
        • EOM: full and free, preferential gaze to left side
        • left side hemianopia
        • pupil 3/3, light reflex +/+
        • left central facial palsy
        • mild intelligible dysarthria
        • MP: right upper 5, right lower 5
        • left upper 4+, left lower 4+
        • FNF and HKS: no dysmetria
        • Sensation: anesthesia in the left limbs
        • NIHSS: 8 (000 111 1010 02010)
      • Assessment
        • Acute ischemic stroke in right MCA territory, onset on 2023/01/23, suspected cancer related hypercoagulability
        • HTN
        • Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa
      • Suggestion
        • Please arrange brain MRA with/without contrast to clarify large vessel occlusion and to exclude brain metastasis
        • Keep Aspirin 100mg QD.
        • Keep adequate hydration with normal saline at 40 ml/hr.
        • keep BP < 220/120 mmHg.
        • Arrange admission to NEURO ward. Thanks. (Stroke survey in the NEURO ward: check D-dimer, lipid profile, HbA1C, carotid duplex+TCD, cardiac echo, Holter EKG)
  • 2023-01-16 Radiation Oncology
    • A
      • Diagnosis: Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa, with impending obstruction, left inguinal, pelvis, paraaortic LAP metastasis and lympoedema of left lower limb; ECOG =1.
      • Plan: CCRT to anorectal tumor, pelvic and paraaortic LAPs for 5040cGy/28 fx is suggested for locoregional control. CT simulation was arranged on 2023/01/17, 08:30am. Treatment will be started on 2023/01/27.
  • 2023-01-16 Hemato-Oncology
    • Q
      • This is a 57 years old female with hypertension and asthma suffers from constipation, distended pain of low abdomen for 1-2 month. Progressive swelling of the left lower extremity for one month.
      • 2022-12-30 sigmoidoscopy: R/O Anorectal cancer with impending obstruction
      • 2023-01-02 CT showed wall thickening of anus and rectum with adjacent fat stranding and regional LAP, enlarged LNs at left neck, retroperitoneum and left inguinal region.
      • CEA:149
      • Colorectum, rectum, biopsy — Adenocarcinoma.
      • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • Under impression of adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa, with impending obstruction and left inguinal LNs enlargement and left lower limb edema, she was admitted for port-A, biopsy of neck mass and further survey
      • We would like to consult for your expertise, thank you.
    • A
      • This 57 year old woman is a case of Anorectal cancer with regional and distant lymph nodes metastases, cT4N2bM1b, stage IVB and highly suspected left thyroid cancer with left cervical lymph nodes metastases.
      • CCRT for down staging is suggested at tumor board. Pending neck biopsy result. In addition, please send All-RAS (S2023-00082) for further work up. We may take over this case if you agree.

[chemotherapy]

  • 2023-02-03 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 2hr + fluorouracil 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-06-14

  • Lab data indicate a deterioration in renal function, accompanied by rising levels of CRP and WBC. - Lab data indicate a deterioration in renal function, accompanied by rising levels of CRP and WBC. Please keep a close eye on the patient for any indicators of an escalating infection.
    • 2023-06-05 Creatinine 0.60 mg/dL
    • 2023-06-12 BUN 37 mg/dL
    • 2023-06-05 BUN 16 mg/dL
    • 2023-06-12 CRP 11.7 mg/dL
    • 2023-06-05 CRP 6.2 mg/dL
    • 2023-06-12 WBC 23.30 x10^3/uL
    • 2023-06-05 WBC 10.59 x10^3/uL
  • Valsartan, an ARB, can indeed be associated with increases in serum Cre levels and/or AKI, particularly in patients who have renal artery stenosis or who are volume depleted. Typically, the increase in serum Cre levels due to ARBs is expected to stabilize within a range of 20% to 30% above baseline levels. However, in this patient’s case, Diovan (valsartan 160mg) has been prescribed by our neurologist since 2023-02-10 and has been used for several months. This long-term use makes it less likely that valsartan is the cause of the recent worsening in renal function.

2023-05-24

  • The D-dimer levels in this patient have remained elevated for nearly one month. Elevated plasma D-dimer levels indicate that coagulation has been activated, fibrin clot has formed, and clot degradation by plasmin has occurred. A long-lasting high D-dimer level could be a sign of an ongoing or chronic medical condition that is associated with increased blood clotting or fibrinolysis (breakdown of blood clots).
    • 2023-02-21 D-dimer 7638.09 ng/mL(FEU)
    • 2023-01-30 D-dimer 7283.81 ng/mL(FEU)
    • 2023-01-25 D-dimer 8056.38 ng/mL(FEU)

2023-02-22

  • The patient was admitted to the hospital yesterday (2023-02-21), and the admission note indicates that she just experienced abdominal distension and watery diarrhea up to 10 times per day according to the review of systems. Nevertheless, the patient has been prescribed sennoside and lactulose, and she is currently taking these medications. Please verify the patient’s current bowel movement status.
  • If the patient’s heavy diarrhea is related to chemotherapy, it might be beneficial to consider omitting the 400mg/m2 5-FU bolus and adjusting the 5-FU infusion dose to 2800mg/m2 from 2400mg/m2 to keep the dose unchanged in the FOLFOX regimen.

700514981

230614

[exam findings]

  • 2023-03-29 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a faint hot spot in the lateral aspect of the left rib cage, and increased activity in the maxilla, some T- and L-spine, sacrum, bilateral shoulders, hips, and knees, in whole body survey.
    • IMPRESSION:
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in the left rib cage, maxilla, some T- and L-spine, sacrum, bilateral shoulders, hips, and knees.
  • 2023-03-28, -02-13 ECG
    • Normal sinus rhythm
    • Low voltage QRS
    • Borderline ECG
  • 2023-01-02 Patho - breast mastectomy with regional lymph nodes
    • PATHOLOGIC DIAGNOSIS
      • Tumor, L’t breast, frozen + partial mastectomy — Invasive carcinoma of no special type
      • Resection margins, frozen — Tumor involved at above tumor, others are free
        • Margin, above tumor recut, frozen — Free of tumor invasion
      • L’t axillary sentinel lymph nodes, frozen — Tumor metastasis (2/5) without extracapsular extension (0/2)
        • L’t axillary non-sentinel lymph nodes, ditto — Free of tumor metastasis (0/4)
      • AJCC Pathologic Anatomic Stage — pT1cN1a, if cM0, stage IIA; Prognostic Stage — Stage IIA
  • 2022-12-30 Lymphoscintigraphy
    • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the left breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the left axilla.
    • IMPRESSION: Probably a sentinel lymph node at the left axillary region.
  • 2022-12-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (81 - 23) / 81 = 71.60%
      • M-mode (Teichholz) = 70
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Mild MR, mild TR and trivial PR
      • Preserved RV systolic function
  • 2022-12-28 CT - chest
    • Indication: Left breast cancer
    • Findings
      • Lungs: mild fibrosis at both apical lung regions.
        • normal appearance of both lower lobes and RML.
      • Mediastinum and hila: no enlarged LN or mass.
        • the trachea and main bronchi are normallly identified without endobronchial lesion.
      • Vessels:
        • well opacification of proximal segments of the LAD, and LCX, and right coronary arteries.
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
      • Chest wall and visible lower neck: a small enhancing nodule in Lt breast (15cm) and enlarged LNs in left axilla
      • Visible abdominal contents:
        • normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.no enlarged lymph node. no ascites..
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • Lt breast cancer with axillary LAP
  • 2022-12-20 Patho - breast biopsy
    • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
    • IHC stains: ER (-, 0%), PR(-), Her2/neu: positive (score=3+), Ki-67(30 %), E-cadherin (+).
  • 2017-11-15 Thyroid Ultrasound
    • Autoimmune thyroid disease

[surgical operation]

  • 2022-12-30
    • Surgery
      • Left partial mastectomy and Left axillary lymph node dissection
      • Right subclavian vein port-a implantation
    • Finding
      • Left breast invasive ductal carcinoma at 3/3cm, size: [su2.15x2.00cm, invasive ductal carcinoma, cT2N1M0, ER(-), PR(-), HER-2(3+). (1/8)

[immunochemotherapy]

  • 2023-06-12 - trastuzumab 600mg SC 5min (Herceptin)

  • 2023-05-17 - cyclophosphamide 300mg/m2 457mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 53mg D5W 250mL 2hr (AC(lipo) Endoxan 50%)

    •                    betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-04-25 - cyclophosphamide 600mg/m2 970mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 57mg D5W 250mL 2hr (AC(lipo))

    • lenograstim 250ug SC + betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO
  • 2023-03-28 - cyclophosphamide 600mg/m2 996mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr (AC(lipo))

    • lenograstim 250ug SC + betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO
  • 2023-02-13 - cyclophosphamide 600mg/m2 992mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr (AC(lipo))

    •                    betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO

==========

2023-06-14

  • On 2023-01-02, breast mastectomy with regional lymph node pathology revealed the disease to be pT1cN1a; if cM0, stage IIA. Adjuvant chemotherapy with trastuzumab is indicated for this disease.

  • The dose-dense AC regimen (cyclophosphamide 600mg/m2, original doxorubicin 60mg/m2 replaced by liposomal doxorubicin 35mg/m2) was administered on 2023-02-13, 2023-03-28, 2023-04-25, 2023-05-17, with cyclophosphamide at 50% of the planned dose on the last administration.

  • The timeline of the patient’s WBC level is organized in the following table, with asterisks indicating instances where the WBC count was less than 2K/uL. The lowest WBC values occurred 2 to 4 weeks after administration of the adjusted AC regimen, suggesting a prolonged nadir or slow recovery of the white blood cells given the dosage and frequency at that time, even G-CSF was administered.

    • 2023-06-12 WBC 1.74 x10^3/uL * trastuzumab 06-12
    • 2023-06-05 WBC 1.07 x10^3/uL *
    • 2023-05-22 WBC 2.28 x10^3/uL
    • 2023-05-17 WBC 2.73 x10^3/uL CT 05-17
    • 2023-05-03 WBC 1.25 x10^3/uL * CT 04-25
    • 2023-04-24 WBC 2.35 x10^3/uL
    • 2023-04-17 WBC 1.33 x10^3/uL *
    • 2023-04-03 WBC 2.81 x10^3/uL CT 03-28
    • 2023-03-27 WBC 2.70 x10^3/uL
    • 2023-03-13 WBC 3.29 x10^3/uL
    • 2023-03-06 WBC 1.74 x10^3/uL *
    • 2023-02-13 WBC 4.35 x10^3/uL CT 02-13
    • 2022-12-28 WBC 3.81 x10^3/uL
    • 2018-11-14 WBC 4.65 x10^3/uL
  • According to Taiwan’s NHI reimbursement rules, the use of G-CSF is permitted for patients with non-hematological malignancies who have a WBC count of less than 1000/uL or an ANC of less than 500/uL post-chemotherapy. In this patient’s case, the criteria are not met, so G-CSF is not covered by the NHI.

  • Granocyte (lenograstim) was administered concurrently with the adjusted AC regimen on 2023-03-28, 2023-04-25, and 2023-05-17. It’s recommended for primary and secondary prophylaxis that G-CSF administration typically starts 24 to 72 hours after the end of chemotherapy treatment (https://www.uptodate.com/contents/use-of-granulocyte-colony-stimulating-factors-in-adult-patients-with-chemotherapy-induced-neutropenia-and-conditions-other-than-acute-leukemia-myelodysplastic-syndrome-and-hematopoietic-cell-transplantation). ref(1): Delayed Granulocyte Colony-Stimulating Factor (G-CSF) Administration after Chemotherapy Reduces Total G-CSF Doses without Affecting Neutrophil Recovery in a Randomized Clinical Study in Children with Solid Tumors. Pediatr Hematol Oncol. 2020;37(8):665-675. ref(2): Efficacy of delayed administration of post-chemotherapy granulocyte colony-stimulating factor: evidence from murine studies of bone marrow cell kinetics. Exp Hematol. 2008;36(1):9-16.

700928067

230614

[diagnosis]

  • Rectal cancer, adenocarcinoma, 10 cm from anal verge, cT4aN2M0, stage IIIC.

[exam findings]

  • 2023-06-17 Nasopharyngoscopy
    • right buccal leukoplakia, smooth NPx, OPx, HPx
  • 2023-04-28 CT - abdomen
    • History and indication:
      • 20230103 colonoscopy: Rectal cancer at right lateral wall, 8 cm from AV
      • 20230103 CT: rectal cancer, invades the visceral peritoneum, cT4aN0M0, stage IIB
    • Findings:
      • Prior CT identified mild focal wall thickening at right lateral aspect of the rectum is not noted again.
        • Please correlate with colonoscopy.
      • S/P resection of S5, S6, and S7 of the liver.
      • Gallbladder stone (3mm).
      • Prior CT identified several nodular soft tissue lesions in the pre-sacral space are noted again, stationary. Benign process is suspected.
    • Impression:
      • Prior CT identified mild focal wall thickening at right lateral aspect of the rectum is not noted again.
      • Please correlate with colonoscopy.
  • 2023-01-13 MRI - pelvis
    • CC: Bloody stool passage
      • Rectal cancer, 10cm from AV Dx at TSGH, CCRT was arranged
      • 20230103 colonoscopy: Rectal cancer at right lateral wall, 8 cm from AV.
      • 20230103 CT:Rectal cancer, cT4aN0M0, cSTAGE:IIB
    • Findings - Comparison: prior CT dated 2020/12/04 and 2021/06/18.
      • There is a soft tissue mass measuring 2 x 1.5 cm in right lateral wall of the rectum that is c/w adenocarcinoma.
        • In addition, There are few engorged vascular structure at the right lateral perirectal tumor space that may be extramural vascular invasion (EMVI) (T4a).
      • There are five enlarged nodes in right perirectal space and right superior rectal space (N2a).
      • S/P near total right hepatectomy and S/P cholecystectomy. (E1)
      • Prior CT identified several nodular lesions in pre-sacral space are noted again, stable in size and feature.
        • All lesions show enhancement in portal venous phase images.
        • Benign vascular lesions are highly suspected.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)
  • 2023-01-03 Patho - colorectal polyp
    • Colorectum, proximal transverse colon, suspect previous polypectomy site, Biopsy, Specimen: A — chronic inflammation.
      • Section shows piece(s) of benign colon mucosa with chronic inflammation. Cryptitis or crypt abscess is not present.
    • Colorectum, D-colon, 40 cm & 25cm , suspect previous polypectomy sites, biopsy was done at 40cm sites, Specimen: B — ulcer with acute and chronic inflammation.
      • Section shows piece(s) of benign colon mucosa with ulcer, acute and chronic inflammation. Cryptitis or crypt abscess is not present.
    • Colorectum, rectum, right lateral wall, 8 cm from AV, Biopsy Specimen: C — Adenocarcinoma.
      • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
      • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-01-03 CT - abdomen
    • History and indication: Rectal cancer, 10cm from AV
    • Findings
      • Focal wall thickening of rectum with adjacent fat stranding.
      • S/P liver operation.
      • Gallbladder stone (3mm).
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N0(N_value) M:M0(M_value) STAGE:IIB(Stage_value)
  • 2022-09-17 L-spine AP + Lat. (including sacrum):
    • Disc space narrowing at L2-3 level.
    • Lumbar spondylosis.
  • 2021-06-18 CT - abdomen
    • History and indication: Diffuse abdominal pain. suspect peritionitis
    • Findings
      • S/P liver operation.
      • A patchy density (1.9cm) at RLL.
      • Distention of gallbladder. Mild dilatation of IHD.
      • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
    • IMP:
      • S/P liver operation.
      • A patchy density (1.9cm) at RLL.
      • Distention of gallbladder. Mild dilatation of IHD.
  • 2021-06-03 KUB
    • S/P operation with retention of surgical clips.
    • Degeneration and spondylosis of L-S spine.
    • Stool retention in the bowel.
  • 2020-12-04 CT - abdomen
    • History and indication: RUQ tender, suspected cholecystitis
    • IMP: Distention of gallbladder. R/O distal CBD stone (6mm).
  • 2020-01-20 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Fish bone misswallowing s/p endoscopic foreign body extraction.
      • Reflux esophagitis LA Classification grade A
      • Gastric erosion, antrum.
    • Suggestion
      • PPI and Sucralfate use.

[radiotherapy]

  • 2022-01-13 ~ undergoing - 5040cGy/28 fx, preoperative CCRT

[chemotherapy]

  • 2023-07-03 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-06-13

  • 2023-05-23

  • 2023-04-28

  • 2023-04-06

  • 2023-03-24

  • 2023-03-14

  • 2023-03-23

  • 2023-02-06 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-01-13 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2023-07-04

The medications Janumet (sitagliptin, metformin), Kentamin (B1, B6, B12), Diovan (valsartan), and Livalo (pitavastatin) were prescribed at Tri-Service General Hospital on 2023-06-10 and recently refilled on 2023-06-30. However, none of these drugs are currently included in the active medication list. Please verify whether these medications are still required for the patient’s current condition.

2023-06-14

  • This patient recently visited Tri-Service General Hospital for his primary diagnosis of malignant neoplasm of the rectum. The medications prescribed during this visit were sitagliptin, thiamine, valsartan, pitavastatin, ambroxol, and glycyrrhiza extract. These medications, or their equivalent therapeutic classes, are already included in the current active prescription. No issues with medication reconciliation were identified.

700325303

230613

[lab data]

2023-05-10 Blood gas (Vein) 2023-05-10 PH 7.499
2023-05-10 PCO2 39.6 mmHg
2023-05-10 PO2 82.5 mmHg
2023-05-10 HCO3 30.1 mmol/L
2023-05-10 ctCO2 31.3 mmol/L
2023-05-10 Base Excess 7.1 mmol/L
2023-05-10 BEecf 6.9 mmol/L
2023-05-10 SBC 29.7 mmol/L
2023-05-10 O2 Saturation 97.2 %

2023-05-10 Blood Osmolality 291 mOsm/Kg

2023-05-08 Blood gas (Vein) 2023-05-08 PH 7.488
2023-05-08 PCO2 47.6 mmHg
2023-05-08 PO2 47.9 mmHg
2023-05-08 HCO3 35.3 mmol/L
2023-05-08 ctCO2 36.7 mmol/L
2023-05-08 Base Excess 10.6 mmol/L
2023-05-08 BEecf 11.9 mmol/L
2023-05-08 SBC 33.0 mmol/L
2023-05-08 O2 Saturation 87.9 %

2023-05-08 Free Light Chain κ/λ (blood) ratio 2023-05-08 FKLC 8.6 mg/L
2023-05-08 FLLC 10900.0 mg/L
2023-05-08 FK/FL ratio <0.01 ratio

2023-05-02 Protein EP 2023-05-02 Protein, total 6.1 g/dL
2023-05-02 Albumin 59.6 %
2023-05-02 Alpha-1 3.2 %
2023-05-02 Alpha-2 16.6 %
2023-05-02 Beta 11.1 %
2023-05-02 Gamma 9.5 %
2023-05-02 M-peak Negative
2023-05-02 A/G Ratio 1.50

2023-04-29 B2-Microglobulin 13021 ng/mL
2023-04-28 IgG (blood) 687 mg/dL
2023-04-27 Ca (Calcium) 2.89 mmol/L
2023-04-27 LDH 706 U/L

2023-03-17 CD45+Total leukocyte 149733 /uL
2023-03-17 %CD34+ 0.56 %
2023-03-17 CD34+ Count 846 /uL

2023-03-17 HPC Ratio 0.15 %
2023-03-17 HPC# 0.029 10^3/ul

2023-03-16 CD45+Total leukocyte 127292 /uL
2023-03-16 %CD34+ 0.67 %
2023-03-16 CD34+ Count 848 /uL

2023-03-16 HPC Ratio 0.25 %
2023-03-16 HPC# 0.036 10^3/ul

2023-03-15 CD45+Total leukocyte 117620 /uL
2023-03-15 %CD34+ 0.78 %
2023-03-15 CD34+ Count 915 /uL
2023-03-15 HPC Ratio 0.47 %
2023-03-15 HPC# 0.038 10^3/ul

2023-03-15 Ca (Calcium) 2.21 mmol/L
2023-03-15 Alkaline phosphatase 74 U/L
2023-03-15 LDH 235 U/L

2023-03-10 Ca (Calcium) 2.18 mmol/L
2023-03-10 Alkaline phosphatase 69 U/L
2023-03-10 LDH 183 U/L

2023-03-05 Alkaline phosphatase 74 U/L
2023-03-05 LDH 197 U/L

2023-03-05 Total protein 6.3 g/dL

2023-03-05 PT 10.4 sec
2023-03-05 INR 1.01
2023-03-05 APTT 26.7 sec

2023-02-20 Free Light Chain κ/λ (blood) ratio
2023-02-20 FKLC 13.3 mg/L
2023-02-20 FLLC 101 mg/L
2023-02-20 FK/FL ratio 0.13 ratio

2023-02-17 Protein EP 2023-02-17 Protein, total 5.4 g/dL
2023-02-17 Albumin 58.3 %
2023-02-17 Alpha-1 3.1 %
2023-02-17 Alpha-2 11.8 %
2023-02-17 Beta 13.1 %
2023-02-17 Gamma 13.7 %
2023-02-17 M-peak Negative
2023-02-17 A/G Ratio 1.40

2023-02-16 B2-Microglobulin 2245 ng/mL
2023-02-15 IgG (blood) 588 mg/dL

2023-02-15 HBsAg Nonreactive
2023-02-15 HBsAg (Value) 0.29 S/CO

2023-02-15 Anti-HBc Nonreactive
2023-02-15 Anti-HBc-Value 0.09 S/CO

2023-02-15 Anti-HCV Nonreactive
2023-02-15 Anti-HCV Value 0.06 S/CO

2023-02-15 Total protein 5.7 g/dL
2023-02-15 Ca (Calcium) 2.22 mmol/L
2023-02-15 LDH 206 U/L

  • 2022-12-12 (at Cardinal Tien Hospital)
    • IgG: 5288mg/dl
    • IgA: 34mg/dl
    • IgM: 29mg/dl
    • IgD: <46.7IU/ml
    • B2-Microglobulin: 3241ng/ml

[exam findings]

  • 2023-05-08 ECG
    • Sinus rhythm with 1st degree A-V block
    • Left atrial enlargement
  • 2023-05-08 CXR
    • Thoracic aortic arch calcified atheriosclerotic plaque
    • Dilation of central pulmonary arteries pulmonary trunk
    • Moderate enlarged cardiac silhoutte
    • Clean lung fields based on plain image
    • Normal appearance of both hila
  • 2023-05-02 Patho - bone marrow biopsy
    • Bone marrow, ilium, biopsy — Plasma cell myeloma
      • NOTE: Correlation of bone mrrow smear, peripheral blood data, molecular genetic study, flow cytometery and clinical findings is recommended.
    • Microscopically, it shows hypercellularity (>90%) and marked proliferation of plasm cells. Blast-like cells highlighted by CD117 is seen (<=2%). Megakaryocytes are present in normal in numbers (1 per HPF) and demonstate no significant morphologic abnormalities.
    • Immunohisotchemical stain reveals CD34(-), Kappa ligh chain(-), Lambda light chain (diffuse+), CD138 (diffuse+), MPO(focal +, <=2%), CD71(<1%).
  • 2023-04-28 CT - abdomen
    • Indication: Multiple myeloma not having achieved remission
    • Findings:
      • Both kidneys show several ill-defined wedge-shaped poor-enhancing areas that may be acute pyelonephritis.
        • The differential diagnosis includes infiltrative lesions.
        • Please correlate with urine routine.
      • A hepatic cyst 2 cm in S7 is noted.
      • There is an ill-defined poor enhancing lesion 6 mm in the spleen. Follow up is indicated.
    • Impression:
      • Acute pyelonephritis of both kidney is highly suspected. The differential diagnosis includes infiltrative lesions. Please correlate with urine routine.
  • 2022-07-20 Patho - bone marrow biopsy (at Cardinal Tien Hospital)
    • C/W Plasma cell myeloma, IgG/Lambda type
    • Immunostatins: CD138 +++, Kappa light chain -, Lambda light chain ++, CD34 Focally +, CD71 ++.
  • 2022-07 MRI - right femur (at Cardinal Tien Hospital)
    • suspect multiple bone metastasis.
  • 2022-03 CT - chest (at Cardinal Tien Hospital)
    • hepatic cyst in segment 7 of right lobe liver.

[consultation]

  • 2023-05-09 Oral and Maxillofacial Surgery
    • Q
      • Today, she was admitted for short of breathing, hyperkalemia on 2023/05/09, and plan to receive Xgeva treatment, so we need your help for oral health assessment, thanks a lot!!
    • A
      • After intraoral dental examination, no dental decay or mobile teeth was noticed.
      • Xgeva could be used safely.

[MedRec]

  • 2023-05-04 SOAP Nephrology
    • S
      • Hypokalemia was detected during admission
      • Hypercalcemia was also detected
      • Urine K 22.4
      • DM (+) for 10 years.
      • Actos 1# qd, metformin 1# bid, Diamicron 1# qd
    • O
      • BP: 145/66; HR: 87;
      • leg edema (-)
      • CVA knocking pain (-)
      • 2023-05-02 Creatinine 1.21 mg/dL
      • 2023-04-27 Creatinine 1.60 mg/dL
      • 2023-03-15 Creatinine 0.44 mg/dL
      • 2023-02-15 Creatinine 0.64 mg/dL
    • A
      • Suspected poor oral intake with hypercalcemia (diuresis) related hypokalemia.
  • 2023-04-07 ~ 2023-05-04 POMR Hemato-Oncology
    • Course of Inpatient Treatment
      • After admission, owing to blood test showd Balst: 5%, R/O multiple myeloma change to AML. We check total protine, Alb, IgG, B2-Microglobulin, AML+ALL/Myeloid, Protein EP, Free Light Chain κ/λ on 4/27 23 and report showed B2-Microglobulin: 13021 ng/mL, IgG: 687mg/dl, total protine: 6.5g/dl, Alb: 3.8g/dl, protine EP: total protine: 6.1, Alpha-1: 3.2, Alpha-2: 3.2. Beta: 11.1, Gamma: 9.5, M-peak: negative, A/G Ratio: 1.50.
      • Bone marrow on 5/2 23 for further diagnosis and pathology (5/5 23) proved Plasma cell myeloma, hypercellularity (> 90%) and marked proliferation of plasm cells. Blast-like cells highlighted by CD117 is seen (<= 2%). Megakaryocytes are present in normal in numbers (1 per HPF) and demonstate no significant morphologic abnormalities. Immunohisotchemical stain reveals CD34(-), Kappa ligh chain(-), Lambda light chain (diffuse +), CD138 (diffuse +), MPO(focal +, <= 2%), CD71(< 1%).
      • LYRICA 75mg 1# po hs, Deflam-K 25mg 1# po bidprn was added for neuropathic pain due to herpes zoter related.
      • Intervenous KCL 500ml qd, MgSo4 1amp in N/S 100ml IVF 1hr qd, Miacalcic 100 unit q12h were given for hypokalemia, hypomagnesemia and hypercalcemia.
      • The abdominal CT (4/28 23) shwoed Acute pyelonephritis of both kidney is highly suspected. The differential diagnosis includes infiltrative lesions. Septic work-up was performed and antibiotic with Seforce 400mg ivd q12h since 4/28 23. She felt bilateral flanks pain much better.
    • Prescription
      • Const-K (potassium chloride 750mg/10mEq) 1# QD
      • MgO 250mg 1# TID
      • Cinolone (ciprofloxacin 250mg) 2# BIDAC
  • 2023-03-31 SOAP Hemato-Oncology
    • O: 2023/03/17 CD45+ Total leukocyte = 149733/uL
  • 2023-03-05 ~ 2023-03-17 POMR Hemato-Oncology
    • Discharge diagnosis
      • Multiple myeloma not having achieved remission, Bone marrow biopsy (2022/7/20) proved C/W Plasma cell myeloma, IgG/Lambda type, immunostatins: CD138+++, Kappa light chain -, LAmbda light chain ++, CD34 Focally +, CD71 ++. The laboratory showed IgG: 5288mg/dl, IgA:34mg/dl, IgM:29mg/dl, IgD:<46.7IU/ml, B2-Microglobulin :3241ng/ml on 2022-12-12. C1 chemotherapy with Endoxan on 3/6, 3/15, 3/16, 3/17 collect PBSC
      • Endometrium cancer stage I S/P operation on 2013-04
      • Diabetes mellitus due to underlying condition without complications
      • Anemia due to antineoplastic chemotherapy
    • Present Illness
      • This 64-yeasr-old woman, a patient of multiple myeloma, IgG, ISS stage II, S/P VRD therapy X 6 with very good partial response at Cardinal Tien Hospital, suffered from right thight pain when walking June 2022 then visited to Cardinal Tien Hospital for survey and treatment.
      • Image study with right femur MRI (2022/07) showed suspect multiple bone metastasis. Chest CT (2022/07) shwoed negative and abdominal CT (2022/03) revealed hepatic cyst in segment 7 of right lobe liver.
      • Bone marrow biopsy (2022/07/20) proved C/W Plasma cell myeloma, IgG/Lambda type, immunostatins: CD138 +++, Kappa light chain -, Lambda light chain ++, CD34 Focally +, CD71 ++. The laboratory showed IgG: 5288mg/dl, IgA: 34mg/dl, IgM: 29mg/dl, IgD: <46.7IU/ml, B2-Microglobulin: 3241ng/ml on 2022-12-12.
      • She received chemotherapy with VRD (VELCADE / Revlimid / Dexamethasone 20mg) Q3W x 6 since 2022/08/17 to 2022/12/29 finished.
    • CC: for C1 chemotherapy with Cycolphosphamide/Mesna & collect stem cells
    • Course of Inpatient Treatment
      • After admission, chemotherapy with Cyclophosphamide/Mesna was given on 3/6 23 & Mesna 0.6g/m2 from Endox for 4hrs start/from Endox for 8hrs start/from Endox for 12hrs start on 3/6 23, smoothly without obvious side effect.
      • Lenograstim 500mcg & G-CSF 150mcg total 650mcg sc qd was administered post C/T 24hrs given on 3/7 to 3/17 23. right neck double Lumen Catheter was inserted and collect stem cells on 3/15, 3/16, 3/17 23 was done and Vitacal was added for symptom relief of hypocalcemia. Mild bone pain was told due to Lenograstim related and NSAID was given for pain control. Blood transfusion with LPRBC 2U was given on 3/16 23.
  • 2023-02-15 SOAP Hemato-Oncology
    • Plan
      • recheck the disease status
      • prepare for chemotherapy at 2023-03-06, and collection of the stem cell at 2023-03-15.
  • 2023-01-04 SOAP Hemato-Oncology
    • S: She was referred on account of multiple myeloma, IgG, ISS stage II, S/P VRD therapy X 6 with very good partial response, for discussion about auto_HSCT
      • Review the referring sheet and system review.
      • Past history: Nothing in particular.
      • Family history: No systemic disease in the family members.
      • Personal history:
      • Smoking (no), alcohol consumption (no), betel nut chowing (no)
      • Allergy: NKA.
      • Travel history: No traveling history within one month.
      • Occupation: Salesperson
    • Assessment: multiple myeloma, IgG, ISS stage II, S/P VRD therapy X 6 with very good partial response, for discussion about auto_HSCT
    • Plan: discussion about auto-HSCT
    • Diagnosis: Multiple myeloma not having achieved remission C90.00

[chemotherapy]

  • 2023-06-13 - bortezomib 1.3mg/m2 2.0mg SC 0.5min D1 + daratumumab 16mg/kg 900mg NS 500mL 6hr D1
    • dexamethasone 20mg PO + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL
  • 2023-05-23 - bortezomib 1.3mg/m2 2.3mg SC 0.5min D1
  • 2023-05-15 - bortezomib 1.3mg/m2 2.3mg SC 0.5min D1
    • dexamethasone 20mg PO D1-2
  • 2023-05-12 - bortezomib 1.3mg/m2 2.0mg SC 0.5min D1 + daratumumab 16mg/kg 1000mg NS 1000mL 6hr D1
    • dexamethasone 20mg PO D1-2
  • 2023-03-06 - cyclophosphamide 2000mg/m2 3400mg NS 500mL 60min + mesna 0.6mg/m2 1000mg NS 500mL 60min (Y-sited Endoxan) and 3 times (each 30min at 4, 8, 12hr after Endoxan)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2022-08-17 ~ 2022-12-29 - VRd

Bortezomib (Velcade), lenalidomide (Revlimid), and “low dose” dexamethasone (VRd) for multiple myeloma 2023-05-10 https://www.uptodate.com/contents/image?imageKey=ONC%2F91054&topicKey=HEME%2F6647

  • Cycle length: 21 days.

  • Regimen

    • Bortezomib
      • 1.3 mg/m2 SC
      • Given as a single SC injection.
      • Days 1, 8, and 15
    • Lenalidomide
      • 25 mg by mouth
      • Administer with water. Swallow capsule whole; do not break, open, or chew.
      • Daily, on days 1 through 14
    • Dexamethasone
      • 40 mg by mouth
      • Take with food (after meals or with food or milk) in the morning.
      • Days 1, 8, and 15
  • Pretreatment considerations:

    • Emesis risk
      • MINIMAL TO LOW.
    • Prophylaxis for infusion reactions
      • Routine premedication is not indicated. If a hypersensitivity reaction (not including local reactions) occurs with bortezomib or lenalidomide, then neither drug should be readministered.
    • Antithrombotic prophylaxis
      • Routine antithrombotic prophylaxis is warranted. Thromboembolism was reported in 2 to 6% of patients in clinical trials receiving VRd despite antithrombotic prophylaxis.
      • The risk of thromboembolism was over 10% with another lenalidomide and high-dose dexamethasone (RD) regimen.
    • Infection prophylaxis
      • Bortezomib therapy may be associated with an increased risk of herpes zoster and infections not related to neutropenia.
      • Antiviral prophylaxis (eg, acyclovir 400 mg orally twice a day) should be administered to all patients receiving VRd.
      • Some clinicians also administer prophylactic trimethoprim-sulfamethoxazole (eg, one double-strength tablet once daily on Mondays, Wednesdays, and Fridays) during treatment.
      • Primary prophylaxis with G-CSF is not indicated.
    • Vesicant/irritant properties
      • Bortezomib is an irritant.
    • Dose adjustment for baseline liver or renal dysfunction
      • Bortezomib: No dosage adjustment for bortezomib secondary to renal insufficiency is necessary.[6] For patients undergoing hemodialysis, bortezomib should be administered after dialysis. Patients with moderate or severe hepatic impairment (serum bilirubin level >1.5 times the ULN) should be started on bortezomib at a reduced dose of 0.7 mg/m2 per injection during the first cycle, with further dose modifications based upon patient tolerance.
      • Lenalidomide: Patients with renal insufficiency experience more neutropenia with lenalidomide.[7] Dose adjustment is recommended for patients with CrCl <60 mL/min.[8] At this time, studies have not been conducted in patients with hepatic impairment.
  • Monitoring parameters:

    • Assess CBC with differential, electrolytes, renal function, and liver function prior to starting each cycle. A CBC should also be performed prior to the day 8 and 15 doses of bortezomib during induction therapy.
    • Weekly assessment for peripheral neuropathy and/or neuropathic pain.
    • Monitor for hypotension during bortezomib therapy; adjustment of antihypertensives and/or administration of IV hydration may be needed.
  • Suggested dose modifications for toxicity:

    • Myelotoxicity
      • A cycle of VRd should not be started unless the ANC is >=1000/microL and the platelet count is >=70,000/microL. If platelets are <50,000/microL or the ANC is <1000/microL on day 15, hold day 15 bortezomib dose. If several doses are held, reduce bortezomib dose by one level (from 1.5 mg/m2 to 1.3 mg/m2 or from 1.3 mg/m2 to 1 mg/m2 or from 1 mg/m2 to 0.7 mg/m2) and decrease the daily dose of lenalidomide by 5 mg. Growth factor support can be given on day 8 of the second and subsequent cycles for ANC <500/m2 lasting >7 days or for an episode of febrile neutropenia.
    • Neuropathy
      • Dose adjustment guidelines for bortezomib in patients who develop peripheral neuropathy or neuropathic pain are available:
        • Grade 1 (asymptomatic, loss of deep tendon reflexes or paresthesia without pain or loss of function): No action required.
        • Grade 1 (with pain) or Grade 2 (interfering with function but not activities of daily living): Reduce by one level (from 1.5 mg/m2 to 1.3 mg/m2; or from 1.3 mg/m2 to 1 mg/m2; or from 1 mg/m2 to 0.7 mg/m2).
        • Grade 2 (with pain) or Grade 3 (interfering with activities of daily living): Hold until resolution, may reinitiate at 0.7 mg/m2 once weekly.
        • Grade 4 (life-threatening, disabling, eg, paralysis): Discontinue.
      • Rarely, bortezomib has been associated with RPLS, which can present with seizures, hypertension, headache, lethargy, confusion, blindness, or as other visual or neurological disturbances. Bortezomib should be discontinued if the diagnosis of RPLS is confirmed on brain MRI.
    • Thrombotic microangiopathy
      • Rarely, bortezomib has been associated with TMA, which can present with Coombs-negative hemolysis, thrombocytopenia, renal failure, and/or neurologic findings.[6] If TMA is suspected, stop bortezomib and evaluate.
    • Other nonhematologic toxicity
      • For grade 3 or 4 nonhematologic toxicity other than neuropathy, hold lenalidomide and bortezomib. Once symptoms have resolved to grade 1 or baseline, reinitiate therapy with lower doses. Reduce dexamethasone dose for grade 2 muscle weakness, grade 3 gastrointestinal tract toxicity, hyperglycemia, confusion, or mood alterations.
    • If there is a change in body weight of at least 10%, doses should be recalculated.

DVd (Daratumumab + Velcade (bortezomib) + dexamethasone) is a Chemotherapy Regimen for Multiple Myeloma (MM) 2023-05-10 https://www.chemoexperts.com/dvd-daratumumab-velcade-bortezomib-dexamethasone.html

  • How does DVd work?
    • Each of the medications in the DVd (Daratumumab, Velcade, dexamethasone) regimen is designed to kill or slow the growth of myeloma cells.
  • Regimen
    • D - Daratumumab (Darzalex)
    • V - Velcade (bortezomib)
    • d - dexamethasone (dex)
  • Goals of therapy:
    • DVd is not given to cure multiple myeloma, but rather to slow the progression of the disease and to decrease symptoms.
  • Schedule
    • Drugs
      • Daratumumab intravenous (I.V.) infusion or subcutaneous (SubQ) injection (Darzalex Faspro) on Days 1, 8, and 15 of Cycles 1, 2, and 3; then Day 1 only of Cycles 4, 5, 6, 7, and 8, then once monthly (every 28 days) thereafter. The time of infusion varies depending upon the tolerability and number of previous infusions.
      • Bortezomib subcutaneous (S.Q.) injection on Days 1, 4, 8 and 11 of Cycles 1, 2, 3, 4, 5, 6, 7, and 8
      • Dexamethasone 20 mg (five 4 mg tablets) by mouth on Days 1, 2, then Days 4, 5, then Days 8, 9, then Days 11, 12 of Cycles 1 through 8.
    • Cycles 1 through 8 are repeated every 21 days.
  • Estimated total infusion time for this treatment:
    • For daratumumab, Cycle 1 Day 1 may take up to 8 hours because of the possibility of experiencing infusion reactions. If you do not experience any with the first infusion, Cycle 1 Day 8 may be reduced to 6 hours. If you do not experience any infusion reactions during the first two daratumumab doses, it may only take up to 4 hours after that. There is also a 90-minute rapid infusion option if it is well tolerated.
    • If daratumumab is given by subcutaneous injection (Darzalex Faspro), there may be an observation time of up to 6 hours after the first dose to observe for reactions. If no reactions are seen, the observation times for future doses may be much shorter or not needed at all.
    • On days that only bortezomib and dexamethasone are given, infusion time may be as little as 1 hour
    • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time.
    • DVd is usually given in an outpatient infusion center, allowing the person to go home afterwards. It is repeated every 21 days. This is known as one Cycle. Each cycle may be repeated up to eight times and then ONLY daratumumab is given (no Velcade or dexamethasone) until daratumumab no longer works or until unacceptable side effects occur.
  • Side Effects
    • In clinical studies, the most commonly reported DVd (daratumumab + Velcade + dexamethasone) side effects are shown here:
      • Increased bleeding risk [low platelet count; thrombocytopenia] (59%)
      • Pins-and-needles feeling in fingers and toes (47%)
      • Diarrhea (32%)
      • Anemia [low red blood cell count] (26%)
      • Sinus infection (25%)
      • Cough (24%)
      • Fatigue (21%)
      • Constipation (20%)
      • Shortness of breath (19%)
      • Low white blood cells (18%)
      • Trouble sleeping (17%)
      • Fluid retention (17%)
      • Fever (16%)
      • Pneumonia (12%)
      • Weakness (9%)
      • High blood pressure (9%)
  • Monitoring
    • How often is monitoring needed?
      • Labs (blood tests) may be checked before treatment and periodically during treatment. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), serum protein electrophoresis (SPEP), urine protein electrophoresis (UPEP), serum free light chains (FLC), quantitative immunoglobulins, plus any others your doctor may order.
    • How often is imaging needed?
      • Imaging may be checked during treatment. Imaging may include: bone scans, computerized tomography (CT) scans, or magnetic resonance imaging (MRI).
    • How might blood test results/imaging affect treatment?
      • Depending upon the results, your doctor may advise to continue DVd as planned, reduce the dose of future treatments, delay the next dose until the side effect goes away, or switch to an alternative therapy.

NHS - Chemotherapy Protocol - Myeloma - DVd (Weekly) Bortezomib-Daratumumab-Dexamethasone (cycles 1 to 8) https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Myeloma/DVd-Weekly-Daratumumab-Bortezomib-Dexamethasone-Cycles-1-to-8.pdf

==========

2023-06-21

2023-06-13

The DVd regimen (Daratumumab + Velcade (bortezomib) + dexamethasone) was initiated on 2023-05-12. Pancytopenia was observed, but it’s important to note that bicytopenia (anemia and thrombocytopenia) was already present even before the regimen started. Furthermore, the fluctuations in HGB and PLT levels are smaller than those in the WBC count. This can be attributed to the fact that the patient has received multiple blood transfusions at our hospital (on 2023-03-16, 2023-04-28, 2023-05-09, 2023-05-15, 2023-05-19, 2023-05-26, 2023-05-31, 2023-06-08, 2023-06-13), which have helped replenish red blood cells and platelets.

  • 2023-06-13 PLT 45 x10^3/uL

  • 2023-06-11 PLT 10 x10^3/uL

  • 2023-06-08 PLT 51 x10^3/uL

  • 2023-06-05 PLT 24 x10^3/uL

  • 2023-06-02 PLT 34 x10^3/uL

  • 2023-05-31 PLT 14 x10^3/uL

  • 2023-05-29 PLT 54 x10^3/uL

  • 2023-05-28 PLT 89 x10^3/uL

  • 2023-05-26 PLT 8 x10^3/uL

  • 2023-05-24 PLT 33 x10^3/uL

  • 2023-05-23 PLT 57 x10^3/uL

  • 2023-05-22 PLT 19 x10^3/uL

  • 2023-05-19 PLT 78 x10^3/uL

  • 2023-05-17 PLT 25 x10^3/uL

  • 2023-05-15 PLT 58 x10^3/uL

  • 2023-05-12 PLT 15 x10^3/uL

  • 2023-05-10 PLT 49 x10^3/uL

  • 2023-05-08 PLT 23 x10^3/uL

  • 2023-06-13 HGB 7.7 g/dL

  • 2023-06-11 HGB 7.5 g/dL

  • 2023-06-08 HGB 6.7 g/dL

  • 2023-06-05 HGB 7.4 g/dL

  • 2023-06-02 HGB 8.7 g/dL

  • 2023-05-31 HGB 7.5 g/dL

  • 2023-05-29 HGB 8.5 g/dL

  • 2023-05-28 HGB 8.1 g/dL

  • 2023-05-26 HGB 8.9 g/dL

  • 2023-05-24 HGB 9.4 g/dL

  • 2023-05-23 HGB 8.5 g/dL

  • 2023-05-22 HGB 7.6 g/dL

  • 2023-05-19 HGB 8.4 g/dL

  • 2023-05-17 HGB 9.0 g/dL

  • 2023-05-15 HGB 6.8 g/dL

  • 2023-05-12 HGB 8.8 g/dL

  • 2023-05-10 HGB 8.2 g/dL

  • 2023-05-08 HGB 8.0 g/dL

Since the VRd (bortezomib, lenalidomide, dexamethasone) regimen has already been utilized from 2022-08-17 to 2022-12-29, and the DVd regimen is preferred in patients who are refractory to full doses of lenalidomide or a lenalidomide-containing triplet, the choice of DVd regimen is reasonable in this case. The major toxicities of the DVd regimen include peripheral neuropathy, transient cytopenias, acute or delayed hypersensitivity reaction, fatigue, and nausea. At present, the WBC count has exceeded the upper limit of normal, reversing the previous leukopenia and presenting as a problem of leukocytosis.

  • 2023-06-13 WBC 16.35 x10^3/uL
  • 2023-06-11 WBC 11.96 x10^3/uL
  • 2023-06-08 WBC 8.48 x10^3/uL
  • 2023-06-05 WBC 5.33 x10^3/uL
  • 2023-06-02 WBC 2.48 x10^3/uL
  • 2023-05-31 WBC 1.32 x10^3/uL
  • 2023-05-29 WBC 0.90 x10^3/uL
  • 2023-05-28 WBC 0.73 x10^3/uL
  • 2023-05-26 WBC 0.68 x10^3/uL
  • 2023-05-24 WBC 0.41 x10^3/uL
  • 2023-05-23 WBC 0.39 x10^3/uL
  • 2023-05-22 WBC 0.36 x10^3/uL
  • 2023-05-19 WBC 0.42 x10^3/uL
  • 2023-05-17 WBC 0.64 x10^3/uL
  • 2023-05-15 WBC 2.06 x10^3/uL
  • 2023-05-12 WBC 21.19 x10^3/uL
  • 2023-05-10 WBC 28.72 x10^3/uL
  • 2023-05-08 WBC 34.88 x10^3/uL

[DVd regimen renal dosing checked]

The recent lab data indicates that the patient’s renal function has stopped deteriorating and shows signs of slight recovery.

  • 2023-06-13 Creatinine 1.86 mg/dL
  • 2023-06-11 Creatinine 1.92 mg/dL
  • 2023-06-08 Creatinine 1.99 mg/dL
  • 2023-06-05 Creatinine 1.86 mg/dL
  • 2023-06-02 Creatinine 1.60 mg/dL
  • 2023-05-31 Creatinine 1.45 mg/dL
  • 2023-05-29 Creatinine 1.51 mg/dL
  • 2023-05-28 Creatinine 1.56 mg/dL
  • 2023-05-26 Creatinine 1.45 mg/dL
  • 2023-05-24 Creatinine 1.25 mg/dL
  • 2023-05-23 Creatinine 1.11 mg/dL
  • 2023-06-13 BUN 31 mg/dL
  • 2023-06-11 BUN 38 mg/dL
  • 2023-06-08 BUN 41 mg/dL
  • 2023-06-02 BUN 21 mg/dL
  • 2023-05-31 BUN 18 mg/dL
  • 2023-05-29 BUN 16 mg/dL
  • 2023-05-28 BUN 18 mg/dL
  • 2023-05-26 BUN 22 mg/dL
  • 2023-05-24 BUN 16 mg/dL
  • 2023-05-23 BUN 16 mg/dL

For patients with CrCl between 15 to 89 mL/minute, there are no dosage adjustments provided in the daratumumab manufacturer’s labeling. Studies show that this range of renal function does not significantly affect the pharmacokinetics of daratumumab. Additionally, no dosage adjustment is necessary for bortezomib in patients with renal insufficiency. For the current treatment regimen of multiple myeloma, there is no need for dosage adjustment.

2023-05-15

[tube feeding]

  • As of 2023-05-15, the patient’s serum potassium level has been measured at 3.7 mmol/L, which falls within the normal range. Therefore, it may be less necessary to continue potassium supplementation, unless there’s clear evidence of ongoing potassium loss.
    • 2023-05-15 K(Potassium) 3.7 mmol/L
    • 2023-05-12 K(Potassium) 3.3 mmol/L
    • 2023-05-11 K(Potassium) 3.0 mmol/L
    • 2023-05-10 K(Potassium) 2.6 mmol/L
  • Currently, Const-K is the only oral potassium supplement available in this hospital. If intravenous potassium supplementation is not the preferred method, it’s recommended to crush the Const-K tablet into particles small enough to pass through the feeding tube and administer the supplement with sufficient water. It’s preferable to give this medication with meals due to its original extended-release design.

2023-05-10

  • Based on the PharmaCloud database, the patient has been diagnosed with “Other postherpetic nervous system involvement - B02.29”. The patient has an active, refillable prescription, including medications diclofenac, chlorzoxazone, and pregabalin. At present, the corresponding symptoms are being managed with these medications, or with others that have similar pharmacological effects. Therefore, no issues with medication reconciliation have been identified at this time.
  • The patient’s MM was previously treated with the VRd regimen (Velcade (bortezomib), Revlimid (lenalidomide) and dexamethasone) from mid-Aug to late Dec 2022 at Cardinal Tien Hospital. The DVd regimen (Darzalex (daratumumab), Velcade (bortezomib) and dexamethasone) is being considered as a new therapeutic strategy in the face of disease relapse.
  • If the DVd regimen is ultimately chosen, the first dose of daratumumab on Cycle 1 Day 1 may take up to 8 hours due to the potential infusion reactions. If the patient does not experience any reactions with the first infusion, the infusion time on Cycle 1 Day 8 can be reduced to 6 hours. If no infusion reactions occur during the first two doses of daratumumab, subsequent infusions may be shortened to around 4 hours.
  • By the way, daratumumab is no longer in stock at this time (and isatuximab remains unavailable).

701254669

230612

[diagnosis] - 2023-04-01 admission note

  • Epilepsy, unspecified, not intractable, without status epilepticus
  • Malignant neoplasm of unspecified site of left female breast
  • Constipation, unspecified
  • Pleural effusion in other conditions classified elsewhere
  • Chronic viral hepatitis B without delta-agent
  • Cachexia

[past history]

  • Breast ca with brain meta, lung meta with bilateral pleural effusion
  • HBV

[allergy]

  • NKDA

[family history]

  • Deny any family history

[exam findings]

  • 2023-06-10 CXR
    • Bilateral pleural effusion.
    • Compression fracture of T12. R/O bone lesions at right clavicle and right 5th rib.
  • 2023-05-09 KUB
    • Bilateral pleural effusion.
    • Compression fracture of T12-L1.
  • 2023-04-12 SONO - chest
    • Pleural effusion, moderate, bilateral, left>right, organizing
    • Atelectasis, LLL, RLL
    • Pleural thickening, irregular, bilateral
  • 2023-05-24, -05-05, -04-17, -04-11, -04-07, -03-29, -03-15, …, -01 CXR
    • Bilateral Pleura effusion
    • S/P port-A implantation.
    • S/P partial left Mastectomy?
    • Compression fracture of T12 and L1 vertebral body.
    • Old fracture of right clavicle?
  • 2023-04-07 KUB
    • Fecal material store in the colon.
    • Compression fracture of T12 and L1 vertebral body.
  • 2023-04-01 KUB
    • Stool retention in the bowel.
  • 2023-04-01 CXR
    • R/O bony metastases at right clavicle and right ribs.
    • Bilateral pleural effusion.
  • 2023-04-01 CT - brain
    • Findings
      • Minimal SAH at right frontal region.
      • No midline shift.
      • No abnormal low attenuation lesion in the brain parenchyma.
      • Widening of cortical sulci and dilatation of ventricles.
      • Degeneration and spondylosis of C-spine. Compression fracture of 4-6.
    • IMP:
      • Minimal SAH at right frontal region.
      • Brain atrophy.
  • 2023-01-17 Cell block
    • 50 cc yellow turbid pleural effusion — Atypia
    • The smears show lymphocytes, reactive mesothelial cells and scant atypical cell clusters show hyperchromasia and degenerative quality.
  • 2023-01-17 SONO - chest
    • Bilateral large amount pleural effusion s/p insertion of right side, 14 Fr. pig-tail catheter and fixed at 18cm.
  • 2023-01-16 ECG
    • Sinus tachycardia
    • Low voltage QRS
    • Borderline ECG
  • 2022-12-22 SONO - chest
    • pleural effusion
    • Chest echography was performed first. The suitable intercostal space was selected and located.
    • Catheter was inserted with negative pressure smoothly.
    • Right/Left side pleural effusion was drawn smoothly.
    • Watch out BP after tapping.
    • Send left side pleural effusion for examination about cytology (cell block),
    • biochemistry, culture, Gram stain, cell count, and TB exam. TB PCR.
  • 2022-12-12 MRA - brain
    • Findings
      • Extradural dura-based lobulated tumors (15 mm and 38 mm) with diffusion restriction and vivid enhancement at right frontal convexity, associating with white matter edema beneath the larger one. Meningiomas are first considered. Pachymeningeal metasatses are less likely.
    • IMP: -Right frontal extra-axial tumors (15 mm and 38 mm). Meningiomas are first considered. D/D: metastases.
  • 2022-12-12 CT - brain
    • Indication:
      • 05:30 Wake up
      • 07:00 Dizziness started, no weakness.
      • Dizziness and left face twitchness.
      • PHx: breast ca with pleural effusion and bone metastasis
      • NKDA
    • Cranial CT scans without IV contrast medium enhancement was performed smoothly and show:
      • A hyperdense right frontal dural based tumor (meningioma)? with white matter edema, up to 35 mm, infarct seems less likely.
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
      • The interhemispheric fissure is centered on the midline.
      • The basal ganglia, internal capsule, corpus callosum, and thalamus appear normal.
      • Sella and pituitary are normal, parasellar structures are unremarkable.
      • There are no abnormalities in the cerebellopontine angle areas on both sides.
      • There are no abnormalities in the calvarium.
    • Imp:
      • suspected a right frontal dural based tumor (meningioma) with white matter edema, infarct seems less likely.
  • 2022-12-12, -11-26 ECG
    • Sinus tachycardia
    • Low voltage QRS
  • 2022-09-19 CT - chest
    • Comparison was made with previous CT dated on 2022/05/31
      • moderate to massiave bilateral pleural effusions, increase in volume and parietal pleural thickening.
      • lungs: mild dependent atelectasis of LLL and RLL.
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels: normal caliber of thoracic aorta and central pulmonary arteries
      • Heart: normal in size of cardiac chambers.
      • Chest wall and visible lower neck: irregular soft tissue tumor with stippled calcifications and surrouding nodules at left breast, aasociated diffuse thickening over the overlying skin. small LNs at left axilla
      • Visible abdominal contents: normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node.
      • Visualized bones: lytic or blastic change in bony structures still visible.
    • Impression:
      • advanced Lt breast cancer with skin involvement, bony metastasis, stationary, and increase in volume of pleural effusion, as compared with CT on 2022/05/31
  • 2022-09-13 SONO - chest
    • Right thorax: moderate amount pleural effusion s/p drainage of 700cc, yellowish pleural effusion.
    • Left thorax: small amount pleural effusion.
  • 2022-08-01 SONO - chest
    • Bilateral pleural effusion (Left: small and Right: small to moderate), post bilateral therapeutic thoracentesis.
  • 2022-05-31 CT - chest
    • Comparison was made with previous CT dated on 2022/03/03
      • moderate bilateral pleural effusions, stationary.
      • lungs: mild dependent atelectasis of LLL and RLL.
      • Chest wall and visible lower neck: irregular soft tissue tumor (at least 43 mm in longest dimesion with surrouding nodules at left breast, aasociated diffuse thickening over overlying skin. small LNs at left axilla
      • Visualized bones: lytic or blastic change in bony structures still visible.
    • Impression:
      • advanced Lt breast cancer with skin involvement, bony metastasis, and moderate pleural effusion, seem stationary.
  • 2022-03-03 CT - chest
    • Findings
      • Soft tissue lesion at left breast up to 2.26cm in largest dimension. The lesion decreased minimally as compared with previous CT on 2021-11-25.
      • There is bilateral pleural effusion. r/o pleural meta. sdtationary.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Imp:
      • Left breast cancer with bone meta and pleural meta. The primary tumor regressed minimally.
  • 2021-11-26 Tc-99m MDP bone scan with SPECT
    • In comparison with the previous study on 2020/12/24, some of the previous bone lesions are a little more evident, suggesting multiple bone metastases in a little more progression.
  • 2021-11-25 CT - chest
    • Indication: left breast cancer with pleural & bone mets
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Loculated, modereate right pleural effusion is found.
        • s/p pigtail placement at left hemithorax. Minimal left pleural effusion is found.
        • Soft tissue mass at left breast up to 2.67cm in largest dimension. In comparison with CT dated on 2021-05-06, mild progression is found.
        • Tiny nodular lesion at left lower lobe is found. Lung meta is considered.
        • S/p port-A placement with its tip at Superior vena cava.
      • Visible abdomen:
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • The GB is well distended without soft tissue lesion
        • There is no evidence of paraarotic LAPs.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
    • Imp:
      • Left breast cancer with left lung and bone meta. Bilateral pleural effsuion. The main mass increased in size slightly
  • 2021-11-22 Cell block
    • 50 cc yellow turbid pleural effusion — Positive for malignancy
    • The smears and cell block show lymphocytes, reactive mesothelial cells and many hyperchromatic atypical epithelial cell clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
  • 2021-11-22 SONO - chest
    • Bilateral pleural effusion (Left: massive and Right: moderate), s/p left diagnostic thoracentesis plus pig-tail insertion and right therapeutic thoracentesis.
  • 2021-05-06 CT - chest
    • Indication: breast ca for further staging
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Soft tissue nodule at left breast up to 2.34*1.79cm in largest dimension. Breast cancer is favored. In comparison with CT dated on 2020-10-01, the lesion regressed.
        • There is moderate bilateral pleural effusion.
        • The lung fields are clear.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
      • Visible brain
        • Marked prominent sulci, fissue and dilated ventricles indicate brain atrophy.
        • No evidence of space occupying lesion in the brain parenchyma is found.
    • Imp:
      • Left breast cancer, in regression.
      • Bilateral pleural effusion.
      • Spine meta. Please correlate with bone scan for treatment respoonse.
  • 2020-12-24 Tc-99m MDP bone scan with SPECT
    • In comparison with the previous study on 2020/10/05, some new bone lesions are noted and some of the previous bone lesions are more evident, suggesting multiple bone metastases in progression.
  • 2020-10-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 32) / 93 = 65.59%
      • M-mode (Teichholz) = 65
    • Conclusion:
      • Adequate LV,RV systolic function with normal wall motion
      • Thick LVPW, Impaired LV relaxation
      • Poor echo window
  • 2020-10-07 SONO - chest
    • Pleural effusion, massive, left
    • No pleural effusion, right
  • 2020-10-06 Patho - breast biopsy
    • Unspecified site, Labeled as “Left breast tumor with bone metastasis”, biopsy — carcinoma.
    • Section shows pieece of fibroadipose tissue with carcinoma highlighted by IHC stain of CK (+).
  • 2020-10-05 Tc-99m MDP bone scan
    • The scintigraphy suggests skeletal metastasis in skull, spine, rib cages, sternum, scapulae, clavicles, bilateral pelvic bones, and left femur.
  • 2020-10-03 MRI - brain
    • No brain nodule found.
    • Right skull metastases was highly suspected.
  • 2020-10-02 Cell block
    • 50 cc red turbid pleural effusion — Positive for malignancy
    • The smears and cell block show lymphocytes, reactive mesothelial cells and many atypical epithelial cell clusters.
    • Immunocytochemistry shows TTF-1(-), GATA-3(+), ER(1+, 50-60%), PR(3+, 10-20%) and Her2/neu(-, Dako score 1+) for tumor cells. According to clinical information and cytomorphologic findings, it is compatible with metastatic carcinoma of breast origin.
  • 2020-10-01 CT - chest
    • History and indication: PLEURAL EFFUSION, BILATERAL
    • Non-contrast CT of chest revealed:
      • A soft tissue tumor (4.3cm) at left breast with adjacent skin thickening and bil. neck and axillary LAP.
      • Osteolytic lesions at L1 and L4.
      • Bil. pleural effusion with adjacent lung collapse.
      • Some LNs at mediastinum.
      • A tumor (3.9cm) at uterus r/o myoma.
    • IMP:
      • In favor of left breast cancer with multiple LNs and spine metastases.
      • Bil. pleural effusion with adjacent lung collapse.
  • 2020-10-01 CXR
    • Bilateral pleural effusion.

[MedRec]

  • 2023-03-15 SOAP Hemato-Oncology
    • Xgeva 120mg
  • 2023-02-15 SOAP Hemato-Oncology
    • Xgeva 120mg
  • 2023-01-06 SOAP Radiation Oncology
    • 2022/12/27~ - RT to the whole brain: 18 Gy/ 6 fx. The metastatic brain tumor: 27 Gy/ 9 fx.
  • 2022-12-30 SOAP Radiation Oncology
    • Plan to deliver 18 Gy/ 6 fx to the whole brain. Then boost the Rt convexity metastases to 36 Gy/ 12 fx.

[consultation]

  • 2023-02-02 Family Medicine
    • Q
      • for share care or hospice care
      • Owing to disease progression noted and we explained her poor condition to her family and DNR was consented. We need expertise to evaluate her condition thanks!
    • A
      • S: 56-year-old female, left breast cancer with bones metastasis & possible pleural metastasis with massive pleural effusion and brain metastasis, stage IV.
      • O:
        • Now under bilateral pig-tail drainage
        • Consciousness alert, ECOG 2
        • Patient herself prefer continuation of chemotherapy
        • We will arrange hospice combine care and follow her condition
        • Indication: Left breast cancer
      • Plan
        • Combined Hospice Care
  • 2023-01-24 Infectious Disease
    • Q
      • Suspect hopital acquired pneumonia
      • Will de-escalate when culture results are available
    • A
      • Consultation for IV Zyvox antibiotic
      • 56-year-old breast cancer female patient, who has both-lung effusion with pigtail drainage, has newly developed pneumonia of both lower lobes.
      • Besides Brosym and Cravit, iv Zyvox is added for coverage of possible MRSA infection.
      • Since patient can take oral medications, oral Zyvox is preferred in this case.
      • Please cancel iv Zyvox and add oral Zyvox for 3 days first.
      • Check blood and sputum culture report for further antibiotic adjustment.
  • 2022-12-14 Radiation Oncology
    • A
      • This 56 y/o female was diagnosed left breast cancer with pleura and bone meta. Bilateral pleura effusion was noted.
      • This time, she sufferred from seziure attack. She came to our ER for help. Brain CT and MRA showed suspect right convexity metastasis with leptomeningeal seeding, tumor perifocal edema.
      • Palliative radiothearpy is indicated. CT-simulation will be arranged on 2022/12/20. Plan to deliver 18 Gy/ 6 fx to the whole brain. Then boost the Rt convexity metastases to 36 Gy/ 12 fx. RT will start around 2022/12/21 or 22. Thank you very much.
  • 2022-12-12 Neurosurgery
    • Q
      • 05:30 Wake up
      • 07:00 Dizziness started, no weakness.
      • Dizziness and left face twitchness.
      • PHx: breast ca with pleural effusion and bone metastasis
      • NKDA
    • A
      • O
        • at present,
          • E4V5M6
          • pupil: 3+/3+
          • MP R L
          • UE 5 4+
          • LE 5 5
        • ct/MRI: suspect right convexity metastasis with leptomeningeal seeding, tumor perifocal edema
      • Plan:
        • please admit to my service
        • give AED and dexan iv
  • 2022-12-12 Neurology
    • Q
      • 05:30 Wake up
      • 07:00 Dizziness started, no weakness.
      • Dizziness and left face twitchness.
      • PHx: breast ca with pleural effusion and bone metastasis
      • NKDA
    • A
      • S: This 56 y/o patient with terminal breast CA presented with left face twiching for 8 mins
      • O
        • GCS: E4V5M6
        • MP: RU:4 RL:4 LU:4 LL:4
        • Brain MRA with contrast: Right frontal extra-axial tumors, suspected meningioma
      • Imp:
        • Focal onset aware seizures, might due to right frontal extra-axial tumors
      • Suggestion:
        • Keppra 1000mg ST and 500mg #1 BID
        • Consult NS for right frontal extra-axial tumors
  • 2020-11-12 Dermatology
    • Q
      • for left leg skin rash & icthing for half year ago
      • This 54-year-old woman, a patient of left breast cancer with bone mets S/P C/T. She was admitted for chemotherapy. She complained of left leg skin rash & icthing for half year ago. We need expertise to evaluate her condition thanks!
    • A
      • Skin finding: annular erythematous patches with scalings on left lower leg
      • Imp: tinea corporis
      • Plan: exelderm cream BID topical used

[radiotherapy]

[chemotherapy]

  • 2023-06-07 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-05-27 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-05-05 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-04-18 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-29 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-15 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-01 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-02-15 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-11-08 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-25 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-11 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-09-26 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-09-12 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-08-29 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-08-15 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-07-11 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-07-04 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-05-30 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-05-23 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-05-09 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-05-02 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-04-18 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-04-11 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-03-21 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-03-14 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-03-01 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-02-21 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-02-07 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-01-24 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-01-10 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-01-03 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-12-20 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-12-13 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-04-23 - docetaxel 75mg/m2 110mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-04-01 - docetaxel 75mg/m2 110mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-03-11 - docetaxel 75mg/m2 117mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-02-18 - docetaxel 60mg/m2 90mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-01-14 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 940mg NS 250mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2020-12-24 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 940mg NS 250mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2020-11-12 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 940mg NS 250mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2020-10-22 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 940mg NS 250mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

Xgeva (denosumab 120mg) CXGEV01

  • 2023-05-05 OPD
  • 2023-03-15 OPD
  • 2023-02-15 OPD
  • 2022-10-25 OPD
  • 2022-09-26 OPD
  • 2022-06-20 OPD
  • 2022-05-09 OPD
  • 2022-04-11 OPD
  • 2022-03-01 OPD
  • 2022-01-10 OPD
  • 2021-11-09 IPD
  • 2021-05-04 OPD
  • 2021-04-01 IPD
  • 2021-01-26 OPD
  • 2020-12-24 IPD
  • 2020-11-12 IPD
  • 2020-10-01 IPD

==========

2023-06-12

  • According to the PharmaCloud database, this patient has been exclusively seeking medical services from our hospital, specifically from the hemato-oncology department and the emergency room, for the past three months. No issues related to medication reconciliation have been identified.
  • The patient’s CRP level was recorded as 11mg/dL on 2023-06-10 and bilateral pleural effusion was observed in a chest X-ray. As a response, Brosym (cefoperazone + sulbactam) 4000mg was administered Q12H starting from 2023-06-11. Following the treatment, the patient’s body temperature, which was previously elevated, decreased to under 37°C from 2023-06-11 and has consistently remained below that level since then.
  • The medication Keppra (levetiracetam) is generally prescribed for the management of focal (partial) onset seizures and generalized onset seizures. The usual immediate release oral dosage starts at 500 mg twice daily and can be increased every two weeks by 500 mg per dose, based on the patient’s response and the medication’s tolerability. The maximum recommended dose is 1.5 g twice daily. Considering the patient’s liver and kidney functions are within normal limits, if the current dose of Keppra (500mg daily) appears to be ineffective, there might be a scope to increase the dosage.
  • Xgeva (denosumab 120mg) is typically used to prevent skeletal-related events in patients with bone metastases from solid tumors, and it is usually administered Q4W. Given that the patient’s last administration of this medication was on 2023-05-05 in an outpatient setting, it appears that more than a month has passed. Therefore, it may be appropriate to administer another dose. Denosumab is covered by National Health Insurance for patients with multiple myeloma and patients with breast cancer, prostate cancer, and lung cancer with osteolytic bone metastases.

700857239

230609

[exam findings]

  • 2023-06-08 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • There is no evidence of destructive bone lesion.
    • Pleural effusion over left side is found.
  • 2023-02-21 SONO - nephrology
    • Chronic renal parenchymal disease
  • 2022-05-25 Neurosonology
    • Minimal atherosclerosis in left distal CCA and bilateral proximal ICAs.
    • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
    • Poor bilateral temporal windows for transcranial insonation.
  • 2022-05-24 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (95 - 34) / 95 = 64.21%
      • LVEF (%) = 64
      • M-mode (Teichholz) = 64
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated ascending aorta; LV diastolic dysfunction Gr 1.
      • Normal RV systolic function.
      • Trivial AR; mild to moderate MR; mild TR; mild PR.
      • Mininmal pericardial effusion.
  • 2022-05-23 MRA - brain
    • Indication
      • Triage level: 3, Stroke symptoms (sudden dysarthria/unilateral limb sensory abnormalities/sudden visual abnormalities) > Symptoms onset time > 4.5 hours or already alleviated. Refer to Neurology OPD. The symptoms of right limb weakness began on 2022-05-21.
      • PH: THROMBOCYTOPENIA, SLE
      • NKDA
      • COVID 19 VACCINATION: NONE
    • MRI of the brain in multiplanar projections, multisequences imaging acquisition without IV Gd-DTPA administration shows:
      • Acute left cerebellum, left corona radiata, bilateral thalamus infarcts. Old bilateral basal ganglia, left corona radiata, left cerebellar lacunar brain infarcts also were noted.
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • The MRA study shows mild arteriosclerosis of the neck and intracranial vessels with irregular outline but without focal severe stenosis or complete occlusion.
    • Imp: Acute left cerebellum, left corona radiata, bilateral thalamus infarcts. Old bilateral basal ganglia, left corona radiata, left cerebellar lacunar brain infarcts also were noted.
  • 2022-05-23 CXR
    • s/p bilateral shoulder arthroplasty
    • mild enlarged cardiac silhoutte
  • 2022-05-23 CT - brain
    • Brain atrophy with multiple old bilateral basal ganglia, corona radiata, left thalamus, left cerebellar lacunar brain infarcts.
  • 2021-03-23 Patho - lymphnode biopsy
    • Lymph node, left axillary, core needle biopsy — lymphoid hyperplasia
    • Section shows cores of reactive lymphoid tissue without malignancy.
    • The immunohistochemical stain of CK is negative. The immunohistochemical stains of CD3 and CD20 show relatively preserved lymphoid architecture. Please correlate with the clinical presentation.
  • 2020-06-18 Patho - synovium
    • Labeled as “right knee OA, SLE synovitis”, “open” — Synovial tissue with acute and chronic inflammtion, calcification, as well as panniculitis.
    • Section shows 1 piece(s) of synovial tissue with acute and chronic inflammtion, calcification, as well as panniculitis.
  • 2020-05-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 19) / 89 = 78.65%
      • M-mode (Teichholz) = 79
    • Conclusion:
      • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Trivial MR; trivial TR; mild PR

==========

2023-06-09

  • The two medications, Plaquenil (hydroxychloroquine) and dipyridamole, which were prescribed by our Rheumatology and Immunology OPD on 2023-05-15, are correctly listed on the active medication list. No issues with medication reconciliation were identified.

  • Given that hematemesis was just added to the patient’s medical problem list on 2023-06-08, the inclusion of tranexamic acid could be beneficial in reducing gastrointestinal bleeding.

701471389

230609

==========

2023-06-09

[IVIG usage]

According to UpToDate, immune globulin can be used for acute disseminated encephalomyelitis, IV: 400 mg/kg once daily for 5 days.

Based on the patient’s body weight of 80kg and Privigen at 5gm per vial, a dosage schedule of 7-7-6-6-6 vials over 5 days appears to fulfill the recommended dosage.

While the package insert doesn’t specify a need for dilution, if dilution is preferred, D5W can be used as the solvent.

Infusions should ideally begin at a rate of 0.5 to 1 mL/kg/hour for the first 15 to 30 minutes. If no adverse reactions occur, the rate can be incrementally increased every 15 to 30 minutes to a maximum of 3 to 6 mL/kg/hour. This information is referenced from https://www.ncbi.nlm.nih.gov/books/NBK554446/. An alternative infusion rate reference can be found at https://www.gov.nl.ca/hcs/files/bloodservices-resources-pdf-adult-invig-inf-table.pdf.

701453808

230607

[diagnosis] - 2023-03-27 admission note

  • Acute interstitial pneumonitis
  • Malignant neoplasm of hypopharynx, unspecified

[past history]

  • squamous cell carcinoma from right hypopharynx cancer with right LN mass metastasis status post tracheostomy, cT4N3bM0 stage IVB post TPF (2022/08/25) and Pembrolizumab(2022/08/31)at Cathay Hospital        

[allergy]

  • NKDA     

[family history]

  • There is no family history of cancer, hypertension

[lab data]

  • 2022-10-06 HBsAg Negative
  • 2022-10-06 HBsAg Value 0.412
  • 2022-10-06 Anti-HCV Negative
  • 2022-10-06 Anti-HCV Value 0.0392
  • 2022-10-06 Anti-HBc Positive
  • 2022-10-06 Anti-HBc Value 0.00682
  • 2022-10-06 Anti-HBs Negative
  • 2022-10-06 Anti-HBs value 5.16

[exam findings]

  • 2023-04-14 Electromyography, EMG
    • Findings
      • No pick-up on right facial stimulation.
      • Abcense of right R1, R2 and right R2’ latencies on blink reflex study.
    • Conclusion
      • The above finding may suggest right facial nerve neuropathy. Advice clinical correlation
  • 2023-04-07 Nasopharyngoscopy
    • Findings: tube in place
    • Conclusion: right hypopharynx cancer with right LN mass metastasis status post tracheostomy, cT4N3bM0 stage IVB post CCRT
  • 2023-03-28 CT - neck
    • Findings:
      • Lobulated mass lesion over laryngeal space and hypopharyngeal space with involvement of A-E folds, vocal cords and right thyroid cartilage. Favor malignancy.
      • One huge lobulated necrotic lesion (8.0cm in size) over right parotid space and level II, favor a malignant node.
      • S/P tracheostomy.
  • 2023-03-24, -03-03 CXR
    • S/P tracheostomy
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
  • 2023-03-13 Nasopharyngoscopy
    • Findings
      • several mucosal injuries within trachea, beyond tracheostomy level. smooth nasopharynx. much saliva accumulated in oropharynx and hypopharynx, poor visualization.
    • Conclusion
      • mucosal injury of trachea
  • 2023-02-20 CXR
    • Cardiomegaly is noted.
    • S/p port-A placement with its tip at Superior vena cava.
    • Bronchiectatic change over left lower lobe is found.
    • Senile fibrotic change is noted at lung fields.
    • Osteopenia of the bony structure is noted.
  • 2023-02-06 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • S/p port-A placement with its tip at Superior vena cava.
    • Faint aveolar opacity over left lower lobe is found.
    • S/p tracheal tube placement with its tip in place.
  • 2023-01-31, -01-16, -01-09, -01-04, 2022-12-05, -11-29 CXR
    • S/P tracheostomy
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-12-10 MRA - brain
    • Indication: squamous cell carcinoma from right hypopharynx cancer with right LN mass metastasis status post tracheostomy, cT4N3bM0) stage IVB post TPF (2022/08/25) and Pembrolizumab(2022/08/31)left leg weakness
    • With- and without-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial FLAIR images and axial DWI; using 4 mm thickness for sagittal section and 5 mm thickness for the others) revealed
      • mild dilated intraventricular and extraventricular CSF spaces
      • punctate white matter gliosis in the supratentorial brain; atrophic change in the right frontal lobe.
      • unremarkable change in the skull base
      • multiple foci with low SI change on T1WI in the skull bones.
      • a heterogeneous enhancing lesion, about 69mm, in the right parotid gland and right posterior cervical space.
    • IMP:
      • no evidence of brain metastasis
      • multiple low SI lesions on T1WI in the skull bones
      • a large mass lesion in the right parotid gland and right posterior cervical space
  • 2022-12-07 Nerve Conduction Velocity (NCV) and Electromyography (EMG)
    • Findings
      • prolonged motor DLs on left peroneal n. with lower CMAP ampltidues and normal NCVs.
      • prolonged sensory DLs on bil. median and ulnar n. with lower SNAP amplitudes on right median n. and slowed NCVs.
      • the F-wave latencies of bil. median, ulnar, peroneal and tibial n. were normal
      • the H-reflex study of bil. tibial n. were normal.
    • Conclusion:
      • bil. median and ulnar sensory neuropathies at distal region.
  • 2022-11-29 CT - chest
    • Indication: squamous cell carcinoma from right hypopharynx cancer with right LN mass metastasis status post tracheostomy, cT4N3bM0) stage IVB post TPF (2022/08/25) and Pembrolizumab(2022/08/31)suspect insterstitial lung disease
    • MDCT (256-detector rows, GE Revolution, was performed with 0.625 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the neck, chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • large necrotic tumor (metsatatic lymphadenopathy, 64x82mm axial dimensions) at Rt neck and infiltrative mass at Rt hypopharyngeal region.
      • lungs: extensive centrilobular emphysema with extensive inhomogeneous opacities at both upper lobes (Rt greater than Lt), lingula, and RML.
        • there is subpleural reticulation and ground-glass opacity, with areas of consolidation at both lower lobes
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels: moderate calcified plaques of the LAD and LCX coronary arteries.
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch.
      • Central pulmonary arteries: normal caliber.
      • Heart: dilated LV; old myocardial infarction at cardiac apex and anterior interventricular septum (with calcification and low attenuated appearance).
      • Pleura: no effusion
      • Visible abdominal-pelvic contents: normal appearance of gall bladder.
        • unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node.
        • mild atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • interstirial lung disease (NSIP), drug toxicity?
      • emphysema with area or infection or edema at upper lobes?
      • moderate 2V-CAD and old AMI in LAD teritrory.
      • Rt hypopharygeal cancer with Rt neck LNs metastasis
  • 2022-11-22 Nasopharyngoscopy
    • Findings
      • right hypopharynx bulging with larynx airway compression (vocal cord not clearly seen, left false cord normal), left pyriform sinus visible and smooth mucosa; trachea ok
    • Diagnosis/conclusion
      • hypopharyngeal cancer under chemotherapy
  • 2022-10-24, -10-14 CXR
    • S/P tracheostomy
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2022-10-11 Neck soft tissue
    • S/P tracheostomy in place.
    • S/P Port-A infusion catheter insertion.
    • Thickening of retropharyngeal tissue.
  • 2022-08-30 CT (Cathay Hospital)
    • A large right laryngea tumor or cancer with superior extension through right supraglottis to vallecula and direct invasion through the right thyroid cartilage.
    • A large regional enlarged lymph node (50mm) with extrapsular invasion at right cervical levels II and III.
    • Multifocal centrilobular emphysema in bilateral upper lobes of lungs and pulmonary fibrotic change in both lungs.
    • Bilateral pleural effusions and partial atelectasis at RLL of lungs.
    • Cardiomegaly and atherosclerosis of aorta and coronary arteries.
    • Several small hepatic cysts.
    • Suspicious annular wall thickening at the ascending colon.
    • Mild scoliosis and marked osteoarthritis of the visible thoracolumbar spine.
  • 2022-08-19 Pathology (Cathay Hospital)
    • Hypopharynx, right, direct laryngoscopic biopsy, — squamous cell carcinoma
    • The specimen submitted consists of two tissue fragments measuring up to 0.9 x 0.6 x 0.3 cm in size, fixed in formalin. Grossly, they are gray to tan and firm. All for section.
    • Tumor type: Squamous cell carcinoma
    • Histological grade: Moderately differentiated (grade 2)
    • Histological pattern: Neoplastic squamous epithelial cells growing in confluent solid sheets
    • Nuclear pleomorphism: Moderate
    • Keratin pearl formation: Focally present
    • Tumor necrosis: Present
    • Subepithelial stroma: Included, with desmoplastic change
    • Lymphocytic response: Absent
  • 2022-08-15 CT (Cathay Hospital)
    • A 7.6cm tumor at right piriform sinus, right aryepiglotic fold, bilateral posterior wall of hypopharynx, extending superiorly right posterior wall oropharynx and laterally the right thyroid cartilage and adjacent right strap muscle (T4a).
    • A 8.3x7.0cm abnormal enlarged necrotic LN with extracapsular extention at right level II/III, probably invasion adjacent right SCM muscle, encasement/occlusion of adjacent right IJV, and compression on adjacent right ICA.(N3b)
    • Suspect a small round LAP at right III area.

[consultation]

  • 2023-03-13 Ear Nose Throat
    • Q
      • Bloody sputum and bloody clot was noted after replacement of tracheostomy on 2023/03/12, we need your expertise for further management
    • A
      • Scope: several mucosal injuries within trachea, beyond tracheostomy level. smooth nasopharynx. much saliva accumulated in oropharynx and hypopharynx, poor visualization.
      • Impression: mucosal injury of trachea, probably due to suction.
      • Plan: May provide inhalation for mucolysis.
  • 2023-03-11 Ear Nose Throat
    • Q
      • This time,he was admitted for scheduled chemotherapy.
      • Now, his Tr. tube slip off , so we need tour help for re on Tr. tube, thanks a lot!!
    • A
      • S
        • tracheostomy dislodge
        • fair breathing pattern and saturation (SaPO2: 97-98% when visiting)
      • O
        • Potable scope: visible tracheal ring and carina after tracheostomy replacement
      • A
        • tracheostomy dislodge, s/p replacement
      • P
        • replacement of tracheostomy smoothly
  • 2023-03-07 Infectious Disease
    • A
      • This is a case of A squamous cell carcinoma from right hypopharynx cancer with right LN mass metastasis status post tracheostomy, cT4N3bM0) stage IVB under chemotherapy and immunotherapy.
      • blood culture yielded Staphylococcus caprae.
      • Agree with the use of Zyvox (linezolid).
      • Please adjust antibiotic according to culture results and clinical conditions.
  • 2023-03-01 Ear Nose Throat
    • Q
      • We need your expertise for changing tracheostomy (11fr.), thanks
    • A
      • New Teflon #11 inserted smoothly
      • Scope: smooth NPx,
      • swelling epiglottis, larynx and hypopharynx can’t be clearly seen
      • saliva pooling
  • 2023-01-09 Infectious Disease
    • Q
      • This time, he had suffered from fever for one day and was brought to our ER. Laboratory test revealed leukopenia, impaired liver and renal function.
      • Chest film disclosed no specific penumonia patch. Empiric antibiotics with Tapimycin was adminiustered. Under the impression of fever, cause unknown. He was admitted for further management
      • After admissoin, empiric antibiotics with Tapimycin was administered on 2022/12/27~2023/01/09, blood culture yielded negative. selfpaid of weekly Taxotere was administered on 2022/12/30.
      • Radiotherapy was complete on 2023/01/02. keep Baktar 2tab QD for prevent pjp infection. Ganciclovir 250mg q12h was administered from 2023/01/03 due to Cytomegaloviral reactivation.
      • However, spiking fever was noted this morning and laboratory test revealed elevated CRP and PCT level. Empiric antibiotics with Targocid and Culin were administered.
      • We need your expertise for further management, thanks
    • A
      • Assessment
        • Persistent fever is noted in the past few days and lab data showed higher CRP and PCT levels.
        • Bacterial infection is considered first.
        • Serial CXR films showed no definite newly-developed pneumonia and urinalysis showed no UTI picture.
        • Previous Cravit is replaced by Culin and Targocid today.
        • There was detectable CMV viral load on 2022-12-28, that patient has received 6-day Cymevene till now, since 2023-01-03.
        • Further work up is necessary, including repeated blood culture, check Port-A site, fungus and TB studies.
      • Suggestion
        • Check blood Aspergillus antigen again and cryptococcal antigen, send sputum for TB-PCR.
        • Continue the present antibiotic regimen.
        • Check blood culture report.
  • 2022-12-16 ENT
    • Q
      • We need your expertise for changing tracheostomy (11fr.), thanks
    • A
      • The tracheostomy tube was replaced smoothly.
      • In addition, mucosal erosion with whitish exudative coating was noted in oropharynx.
      • If not contraindicated, please give Nystatin for oral gargling and swallowing, along with pain killer.
  • 2022-12-05 Neurology
    • Q
      • He complained of left leg weakness in recent days. We need your expertise for further management, thanks
    • A
      • S: left arm weakness followed by left leg weakness in recent days
      • NE: aware, fluent speech, normal cranial nerves, no visual field defect
        • decreased dexterity on left hand as well as left leg, and equivocal Babinski signs
      • Impression:
        • Suspected tumor encasing on right carotid artery
        • Suspected polyneuropathies
      • Suggest:
        • brain MRA with contrast might be considered if tolerable
        • nerve conduction study (motor + sensory NCS, upper and lower limbs) might be arranged
  • 2022-12-01 Chest Medicine
    • Q
      • This time, he had suffered from dyspnea with stinky sputum for one week then came to our OPD for help. Laboratory test revealed anemia and hypoalbuminemia.
      • Chest film disclosed suspect instertitial lung pneumonitis. Under the impression of acute instertitial pneumonitis, suspect immunotherapy related. He was admitted for further management
      • After admission, CT revealed interstirial lung disease (NSIP), drug toxicity? emphysema with area or infection or edema at upper lobes? moderate 2V-CAD and old AMI in LAD teritrory. Rt hypopharygeal cancer with Rt neck LNs metastasis.
      • Dexamethasone and empiric Cravit, Baktar were administered. We need your expertise for further management, thanks
    • A
      • Diagnosis
        • Acute interstitial pneumonitis; suspect immunotherapy related
        • Malignant neoplasm of hypopharynx, unspecified
      • Suggestion
        • Keep Dexamethasone 4mg Q12H for 1 week and shifted to oral form
        • Empiric antibiotics with Cravit
        • Keep adequate oxygenation
  • 2022-11-30 Infectious Disease
    • Q
      • After admission, CT revealed interstirial lung disease (NSIP), drug toxicity? emphysema with area or infection or edema at upper lobes? moderate 2V-CAD and old AMI in LAD teritrory. Rt hypopharygeal cancer with Rt neck LNs metastasis.
      • Dexamethasone and empiric Cravit, Baktar were administered. We need your expertise for further management, thanks
    • A
      • Assessment
        • 62-year-old stage 4 hypopharyngel cancer male patient, who contracted recent Covid-19 infection on 2022-11-03, has interstitial lung with right lung secondary infection now.
        • No fever, but tachypnea and desaturation noted.
        • There was Stenotrophomonas isolate from sputum culture on 2022-11-04, which should be selected by previous broad spectrum antibiotic use since the mid-October, including Tienam (imipenem + cilastatin).
        • Secondary bacterial infection is still the first considration, Aspergillus possibility exists, but CMV or PJP not very likely.
        • Patient is receiving Cravit and Baktar now, that change of antibiotic regimen seems not necessary.
        • Further work up necessary.
      • Suggestion:
        • Continue Cravit and Baktar
        • Send sputum for PJP-PCR, TB-PCR
        • Check serum Aspergillus antigen, CMV viral load too.
  • 2022-10-27 Oral & Maxillofacial surgery
    • Q
      • RT was consulted for further radiotherapy. We need your expertise for dental examination before RT simulation, thanks
    • A
      • Dear doctor, we are consulted for dental evaluation prior the radiotherapy for squamous cell carcinoma from right hypopharynx cancer
      • Dental findigns:
        • Dental panoramic film showed multiple retained root and full mouth tooth attrition caused by betul nut chewing
        • Retained root 21,22
        • Extraction wound of tooth of 34 and 35 with stitches
        • Extra-oral
          • A large neck mass more than 6 cm with skin color change and peeling was noticed.
      • Problem:
        • Retained root 21, 22 with poor prognosis
      • Plan:
        • Explain the findings to the patient and her caregiver
        • Complicated extraction of tooth 21 and 22 under local anesthesia
        • Removal stitches of extraction wound tooth of 34 and 35
        • Suggest follow up for the wound condition next week
        • Antibiotic for infection control.
  • 2022-10-17 Oral & Maxillofacial surgery
    • Q
      • RT was consulted for further radiotherapy. We need your expertise for dental examination before RT simulation, thanks
    • A
      • Dear doctor, we are consulted for dental evaluation prior the radiotherapy for squamous cell carcinoma from right hypopharynx cancer
      • Dental findigns:
        • Dental panoramic film showed multiple retained root and full mouth tooth attrition caused by betul nut chewing
        • Retained root 21,22,34,35,44
        • Extra-oral
          • A large neck mass more than 6 cm with skin color change and peeling was noticed.
      • Problem:
        • Retained root 21, 22, 34, 35, 44 with poor prognosis
      • Plan:
        • Explain the findings to the patient and her caregiver
        • Suggest extraction of tooth 21, 22, 34, 35, 44 prior to radiotherapy (Fractured teeth may cause local cellulitis. To avoid possible osteonecrosis of the jaw after future radiation therapy, it is important to prevent tooth extraction.)
  • 2022-10-14 Radiation Oncology
    • A
      • A: Squamous cel carcinoma of the hypopharynx, stage cT4aN3bM0 (stage IVB), s/p induction chemotherapy (TPF regimen) and pembrolizumab.
      • P: Radiotherapy is indicated for this patient with the following indicators: stage cT4aN3bM0 (stage IVB)
        • Goal: pallaition
        • Treatment target and volume: hypopharyngeal tumor, peripheral, to bilateral neck
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5000cGy/25 fractions of the hypopharyngeal tumor, peripheral, to bilateral neck, and 7000cGy/35 fractions of the hypopharyngeal tumor and right neck involved nodal lesions.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2022-10-19.
        • Please consult Dental department for pre-RT dental evaluation and management.
  • 2022-10-13 Dermatology
    • Q
      • This 62-year-old male was diagnosed of hypopharynx cancer with right LN mass metastasis (cT4N3bM0) stage IVB post TPF and C1 Pembrolizumab on 2022/08/31 at Cathay hospital.
      • He has psoriasis for several years and skin rash over whole body was noted after the immunotherapy. We need your expertise for further management, thanks
    • A
      • The patient had sufferred from hypopharynx cancer undr PD-L1 therapy and post-herpestic neurogenia with residual wound.
      • Under the impression of replasing psoriasis.
      • The following sugeetion:
        • Belolin onit. (clobetasol) 4 tube topcial QD use and Xamiol gel (calcipotriol hydrate + betamethasone dipropionate) 1 tube topical QN use over psoriatic lesions.
        • Sinphraderm 2 tube topical QN use after body wash for enhance mositurization.

[radiotherapy]

  • 2022-11-14 ~ undergoing - at 5000cGy/25 fractions(6MV photon) of the hypopharyngeal tumor, peripheral, to bilateral neck, and 5800cGy/29 fractions of the hypopharyngeal tumor and right neck involved nodal lesions.

[chemoimmunotherapy]

  • 2023-04-29 - docetaxel 35mg/m2 60mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-28 - pembrolizumab 100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-04-14 - docetaxel 35mg/m2 60mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-30 - docetaxel 35mg/m2 60mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-29 - pembrolizumab 100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-03-02 - docetaxel 35mg/m2 60mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-01 - pembrolizumab 100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-01-31 - pembrolizumab 100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-12-30 - docetaxel 35mg/m2 60mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-16 - pembrolizumab 100mg NS 100mL 30min + docetaxel 35mg/m2 60mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-18 - pembrolizumab 100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-11-02 - docetaxel 35mg/m2 60mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-26 - docetaxel 35mg/m2 60mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-21 - pembrolizumab 100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

==========

2023-06-07

[tube feeding]

According to the package insert of Valcyte (valganciclovir), once ingested, it rapidly converts to ganciclovir, which has been shown in animal studies to be mutagenic, teratogenic, and carcinogenic. This morning I called the drug supplier (YuLi Co., Ltd.), who advised against direct contact with the drug substance on the mucous membranes to avoid exposure, so they don’t recommend crushing or splitting the pill by hand. However, they suggested that the pill could be broken into smaller pieces without the operator’s hands directly touching it, dissolved in an appropriate amount of drinking water, and then administered with food via tube feeding.

2023-05-02

  • It appeared that the SCC readings were dropping slowly. However, the 2023-03-28 neck CT findings indicated the presence of two malignant lesions. The first is a lobulated mass in the laryngeal and hypopharyngeal space, involving the aryepiglottic folds, vocal cords, and right thyroid cartilage. The second is a large (8.0 cm) lobulated necrotic lesion in the right parotid space and level II, likely representing a malignant lymph node.
    • 2023-04-24 SCC, Squamous cell carcinoma antigen (nuclear medicine) 41.60 ng/mL
    • 2023-04-19 SCC, Squamous cell carcinoma antigen (nuclear medicine) 43.40 ng/mL
    • 2023-04-07 SCC, Squamous cell carcinoma antigen (nuclear medicine) 54.90 ng/mL
    • 2023-03-27 SCC, Squamous cell carcinoma antigen (nuclear medicine) 48.20 ng/mL
  • No medication reconciliation issues were identified during this hospitalization.

2023-03-28

  • Lab data from early Feb 2023 showed a short trough. However, recent results indicate that the SCC antigen has doubled compared to late Dec 2022.

    • 2023-03-27 SCC, Squamous cell carcinoma antigen (nuclear medicine) 48.20 ng/mL
    • 2023-02-09 SCC, Squamous cell carcinoma antigen (nuclear medicine) 9.02 ng/mL
    • 2022-12-27 SCC, Squamous cell carcinoma antigen (nuclear medicine) 20.10 ng/mL
  • The patient is currently being treated with Valcyte (valganciclovir), Morcasin (sulfamethoxazole/trimethoprim), and Mycostatin (nystatin) for suspected respiratory infections.

  • During this hospital stay, no issues with medication reconciliation were identified, and the drugs recently prescribed and listed in the NHI PharmaCloud System were properly prescribed as self-carried items to address the patient’s underlying conditions.

2023-03-01

  • 2023-02-27 lab results indicated that the CMV viral load was not detected, which is a positive indication. Additionally, the reading for squamous cell carcinoma antigen (SCC) has shown a trend of decreasing levels.
    • 2023-02-09 SCC, Squamous cell carcinoma antigen (nuclear medicine) 9.02 ng/mL
    • 2022-12-27 SCC, Squamous cell carcinoma antigen (nuclear medicine) 20.1 ng/mL
  • Morcasin (sulfamethoxazole, trimethoprim) is appropriately prescribed to treat Pneumocystis pneumonia since 2023-02-07. Typically, treatment for Pneumocystis jirovecii pneumonia lasts for 14 to 21 days. It is suggested to monitor symptoms and response to determine if a longer course of treatment is necessary.

2023-01-11

There is no specific pharmacist shift handover to follow in this patient.

[Zavicefta 2g/0.5g powder for concentrate for solution for infusion - Usage and Precautions ] for the patient’s primary nurse

  • Compatibilities (ref: MicroMedex)
    • D5W (Dextrose 5% in water)
    • NS (Normal saline (Sodium chloride 0.9%))
    • Lactated Ringer’s Injection
    • Dextrose 2.5% in sodium chloride 0.45%

2022-10-12

  • It has been reported that fungitech (terbinafine) itself may cause the following dermatologic adverse reactions: pruritus (3%), rash (6%), and urticaria (1%).

700173157

230606

[exam findings]

  • 2023-06-05 CXR
    • Bilateral pleural effusion.
    • Multiple nodules at bil. lungs.
  • 2023-06-05 ECG
    • Normal sinus rhythm
    • Low voltage QRS
    • Cannot rule out Inferior infarct, age undetermined

[consultation]

  • 2023-06-05 Family Medicine
    • Q
      • Chief Complaints: SOB for a long time, more severe recently
      • no fever, no URI s/s
      • Past History: malignant tumor of right submandibular gland? with pleural metastases, pleural effusion and pericardial effusion
      • Drug allergy: NKDA
      • 2023/04/21 NTU Cancer Center - Neck + Lung CT: Right suprahyoid neck lymphadenopathy; Progressive bilateral lung and left pleural metastases; Right pleural effusion and pericardial effusion; Indeterminate hepatic lesions at left medial segment;
    • A
      • 52 y/o lady Malignant tumor of right submandibular gland? with pleural metastases, Dyspnea
      • CXR Bilateral pleural effusion. Multiple nodules at bil. lungs.
      • BEd full
      • Our share care would follow up.

==========

2023-06-06

  • This patient has recently been visiting the NTU Cancer Center and Cheng Hsin Hospital for her malignant neoplasm of the pleura (at least since April). The medications prescribed during these visits are already included in her current active prescription list, with no discrepancies identified during the medication reconciliation process.

700790807

230606

{gastric cancer with peritoneal seeding, pT4aN2M1, stage IV, (poorly cohesive carcinoma, signet-ring cell type) s/p total gastrectomy with D2 LN dissection & CCRT}

  • past history
    • gastric cancer with peritoneal seeding, pT4aN2M1, stage IV, (poorly cohesive carcinoma, signet-ring cell type),
      • s/p total gastrectomy with D2 LN dissection IP C/T wt Mitomycin-C on 20211004,
      • s/p port-A implantation on 20211020,
      • under post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T then post-Op adjuvant C/T wt Oxaliplatin / HDFL IV Q2W x 12 (since 20211026)
    • open cholecystectomy
    • operation for left kidney staghorn stone
  • exam findings
    • 2022-09-26 CXR
      • Patchy consolidation projecting at right middle lung show near complete resolving.
    • 2022-09-22 CXR
      • Patchy consolidation projecting at right middle lung is noted. Please correlate with clinical condition and CT to rule out Bronchopneumonia.
    • 2022-08-17 CT - abdomen
      • Findings
        • S/P total gastrectomy.
        • Mild ascites is highly suspected. Please correlate with sonography.
        • Prior CT identified two tiny nodule at RUL are noted again, stationary. Prior CT identified small amount left pleural effusion and Small amount pericardial effusion are noted again, stationary.
        • Prior CT identified few ground-glass opacity at bil. basal lungs are not noted again.
        • Prior CT identified A vesical stone (1.8cm) shows stationary.
        • There are few poor enhancing lesions in the spleen at portal venous phase images and homogeneous enhancement in delayed phase images that may be hemangiomas. Please correlate with sonography.
      • Impression
        • S/P total gastrectomy.
        • Mild ascites is highly suspected. Please correlate with sonography.
    • 2022-05-17 CT - abdomen
      • History and indication:
        • gastric cancer with peritoneal seeding, pT4aN2M1, stage IV
      • Findings
        • S/P gastric operation. Moderate amount ascites.
        • A tiny nodule at RUL. Some patchy densities at bil. basal lungs. Bil. pleural effusion. Small amount pericardial effusion.
        • Left renal stone (up to 4mm). A stone (1.8cm) in urinary bladder.
        • General subcutaneous edema.
      • IMP:
        • S/P gastric operation. Moderate amount ascites.
        • A tiny nodule at RUL r/o metastases. Some patchy densities at bil. basal lungs. Bil. pleural effusion. Small amount pericardial effusion.
        • Left renal stone (up to 4mm). A stone (1.8cm) in urinary bladder.
    • 2021-10-08 Upper GI series
      • Indication:
        • gastric cancer s/p total gastrectomy on 2021/10/04
      • Impression
        • There is no leakage of the contrast medium from esophagus into small intestines.
        • The peristasis of the esophagus and small intestines are intact.
    • 2021-10-05 Patho - Stomach
      • Stomach, total gastrectomy - Poorly cohesive carcinoma, signet-ring cell type
      • Margins, total gastrectomy - Radial margin is involved by tumor
      • Lymph nodes, D2 LN dissection - Metastatic carcinoma (3/55)
      • AJCC Pathologic staging - pT4aN2M1, stage IV
    • 2021-09-27 Patho - Stomach, low body, biopsy
      • Adenocarcinoma, poorly differentiated
      • IHC: CK(+), CDX2(+), and Her-2/neu(Ab): Negative(0).
  • surgical operation
    • 2021-10-04
      • Surgery
        • total gastrectomy with LN 1-9,11,12,14v dissection
        • cholecystectomy
        • IPCT with normotemperature with Mitomycin C 15mg/m2 (30mg) fo 90 mins
      • Finding
        • distal gastric tumor with complete gastric outlet obstruction cT4aN3M1
        • Frozen section: lesser curvature stomach serosa 3 cm below EG junction. positive tumor seeding(+)
  • radiotherapy
    • 2021-11-05 ~ 2021-12-09 - 4500cGy/25 fractions (15MV photon) of the gastric tumor bed, peripheral, and regional lymphatic area.
  • chemotherapy
    • 2022-10-06 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4700mg 46hr
    • 2022-09-21 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4700mg 46hr
    • 2022-08-29 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2800mg/m2 4720mg 46hr
    • 2022-07-27 - oxaliplatin 75mg/m2 120mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • 2022-07-07 - oxaliplatin 75mg/m2 120mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2800mg/m2 4600mg 46hr
    • 2022-06-22 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2800mg/m2 4600mg 46hr
    • 2022-05-16 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4750mg 46hr
    • 2022-04-26 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4780mg 46hr
    • 2022-03-22 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
    • 2022-03-07 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2022-02-21 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4990mg 46hr
    • 2022-02-07 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2022-01-24 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2022-01-13 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2021-11-29 - fluorouracil 200mg/m2 380mg 24hr D1-5 (CCRT)
    • 2021-11-22 - fluorouracil 200mg/m2 380mg 24hr D1-5 (CCRT)
    • 2021-11-18 - fluorouracil 200mg/m2 380mg 24hr D1-2 (CCRT)
    • 2021-10-06 - fluorouracil 750mg 1hr IP D1-5 + gentamicin 40mg IP D1-5 + sodium bicarbonate 2800mg IP D1-5
    • 2021-10-04 - mitomycin-c 15mg/m2 30mg 90min IP + gentamycin 40mg IP + sodium bicarbonate 4200mg IP

==========

2023-06-06

[compatibility]

There is no compatibility information available in Micromedex for concurrent administration of Nako No.5 and Oliclinomel N4-550E.

Nako No.5 injection contains: - sodium chloride - sodium acetate anhydrous - potassium acetate - magnesium chloride 6H2O - potassium phosphate monobasic - dextrose monohydrate

Oliclinomel N4-550E Emulsion for Infusion contains: - sodium acetate 3H2O - sodium glycerophosphate 5H20 - potassium chloride - magnesium chloride 6H2O - glucose monohydrate - calcium chloride 2H2O

The electrolyte components in both Nako No.5 and Oliclinomel N4-550E share a high degree of similarity, which suggests that they are unlikely to be incompatible when administered concurrently through a Y-line immediately prior to administration.

2022-10-07

  • A HGB level of 6.6g/dL (CTCAE v5 grade 3 anemia) was detected on 2022-10-06, as well as dizziness and mild fatigue. The myelosuppressive chemotherapy might be put on hold for a while if no other consideration.

2022-03-23

  • According to lab data reported on 2022-03-22, serum potassium, magnesium and HGB were low (2.6 mmol/L, 1.4 mg/dL, 6.7 g/dL respectively).
  • KCl (IV), potassium gluconate (PO), MgSO4 (IV), MgO (PO) are prescribed and blood products are ordered.

2022-02-08

  • HER2 tested negative, trastuzumab might not be indicated.
  • PD-L1, microsatellite testing outcome not found, not sure nivolumab should be applicable.
  • Over 95% of gastric cancers are adenocarcinomas, which are typically classified based on anatomic location (cardia/proximal or noncardia/distal) and histologic type (diffuse or intestinal). The diffuse type, which is characterized by poorly differentiated and discohesive tumor cells with a signet-ring or non-signet-ring morphology diffusely infiltrating the gastric wall in a desmoplastic stroma, is more prevalent in low-risk areas and is mostly associated with heritable genetic abnormalities.
    • according the patient’s pedigree chart, he has 3 direct descendants alive, who should be aware of suspected higher risk of gastric cancer.
  • no drug allergy recorded in database, no issue found in active medication.

700051397

230605

{SCC of esophagus, lower third, with mediastinal & SCF LAPs and multiple brain metastases, stage IV}

[diagnosis] - 20230110 admisstion note

  • Malignant neoplasm of lower third of esophagus
  • Squamous cell carcinoma of lower third esophagea with multiple brain metastases, ypT3N1M1, ypStage IVB, mediastinal lymph node and aorta invasion s/p immunity therapy with Nivolumab/chemotherapy with FOLFOX6 from 2022/12/01
  • Hypothyroidism, unspecified
  • Ulcer of esophagus without bleeding
  • Secondary malignant neoplasm of mediastinum
  • Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck
  • Secondary malignant neoplasm of brain
  • Hypokalemia

[past history]

  • Esophageal cancer, SqCC, L/3, with mediastinal & SCF LAPs, s/p port-A insertion and feeding jejunostomy on 20210707, neoadjuvant CCRT (3600 cGy/12 fx) for brain metastases from 2021/07/08 ~ -07/23, neoadjuvant CCRT (5040 cGy/28 fx) for primary tumor from 2021/07/26 ~ 09/01, with FOLFOX from 2021/07 ~ 2021/11, s/p VATS esophagectomy and gastric tube reconstruction on 2022/07/04

[family history]

  • Mother has colon cancer
  • Denied DM, H/T, HCVD or CAD history in his family

[exam findings]

  • 2023-04-11 CXR
    • Atherosclerosis of the aorta.
    • Ground glass opacities in bil. lungs.
    • Bilateral pleural effusion.
  • 2023-04-11 ECG
    • Sinus tachycardia
    • Low voltage QRS
    • Nonspecific T wave abnormality
  • 2023-04-03 SONO - chest
    • Left
      • LEft side trivial pleural effusion, risk of tapping -> suggest closely follow up
        • if progression of pleurale ffusion -> arrange Chest echo again
    • Right
      • Right side trivial pleural effusion, RLL consolidation
  • 2023-03-29 CXR
    • Lt pleural effusion with loculation and nodular metastasis
    • Rt pleural effusion and partial atelectasis of RLL
    • Rt-sided convexity of the Rt hilum and Rt upper cardiac border with narrowing of Rt main bronchus and increased density over mediasttinum, lower tracheal level to lower mediastinum due to large tumor
    • s/p EVAR in Descending thoracic aorta (EVAR: endovascular aneurysm repair)
    • Multiple nodules in both lungs and Rt pleural nodularity due to metastases
  • 2023-03-13, -03-09, -03-06 CXR
    • Left pleura effusion.
    • S/P metalic stent implantation at the descending thoracic aorta.
    • Few nodular opacities on both lungs are noted that are c/w metastases after correlate with CT.
    • Patchy consolidation of the left middle and lower lung is noted. Please correlate with clinical condition to rule out inflammatory process.
  • 2023-02-16 CT - chest
    • Indication: Malignant neoplasm of lower third of esophagusdyspnea RULING OUT BRONCHIAL OBSTRUCTION, PARTIAL
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Necrotic mass at lower third esophagus with consolidation over right lower lobe is found. In comparison with CT dated on 2022-11-03, the lesion enlarged.
        • s/p gastric tube reconstruction.
        • s/p aortic stent placement.
        • Enlarged mass anterior to right heart border measuring 4.08cm in largest dimension, in progression.
        • One soft tissue mass at left heart border about 2.82cm is found.
        • Left mild pleural effusion is found.
      • Visible abdomen:
        • Low density lesions are found at left lobe liver up to 4.2cm in largest dimension. In enlargement.
        • The GB is well distended without soft tissue lesion
        • The spleen, pancreas, both kidneys and adrenals are intact.
    • Imp:
      • Lower third esophageal cancer with probably tumor rupture, causing right lower lobe conoslidation. The primary tumor enlarged.
      • Mediastinal lymphadenopathy, in progression.
      • Liver meta, in enlargement.
  • 2023-02-10 CXR
    • Port-A catheter inserted into SVC via left subclavian vein.
    • Lt pleural effusion with loculation and nodular metastasis
    • Rt pleural effusion and partial atelectasis of RLL
    • Rt-sided convexity of the Rt hilum and Rt upper cardiac border with narrowing of Rt main bronchus and increased density over mediasttinum lower tracheal level to lower mediastinum due to tumor
    • s/p EVAR in Descending thoracic aorta
    • Multiple nodules in both lungs and Rt pleural nodularity due to metastases
  • 2023-02-01, -01-19, -01-10, -01-03 CXR
    • Left pleura effusion.
    • S/P metalic stent implantation at the esophagus or descending thoracic aorta?
    • Few nodular opacities on both lung are noted.
  • 2022-12-22, -12-05, -11-30 CXR
    • Left pleura effusion S/P pigtail catheter implantation.
    • S/P metalic stent implantation at the esophagus or descending thoracic aorta?
    • Enlargement of cardiac silhouette.
  • 2022-11-25, -11-15, -11-05 CXR
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-11-18 Chest Decubitus Bilat
    • Pleura effusion of left costal-phrenic angle.
    • Peri-bronchial wall thickening of the RML of the lung is suspected? Please correlate with clinical condition or CT.
  • 2022-11-18 Cell block
    • Negative
  • 2022-11-18 SONO - chest
    • left side small amount of loculated and septated pleural effusion, 60cc serosangious fluid was aspirated for analysis.
  • 2022-11-10 Stroboscopy
    • right vocal cord palsy
    • left vocal fold compensation
  • 2022-11-04 Cell block
    • Negative
  • 2022-11-04 SONO - chest
    • left side small amount of pleural effusion, 550cc serosangious fluid was aspirated for analysis.
  • 2022-11-03 CT - chest
    • Indication: Esopageal cancer s/p OP f/u (LLL pleural effusion)
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Soft tissue mass at lower third esohpagus about 6.6cm in largest dimension. In comparison with CT dated on 2022-05-19, the lesion enlarged.
        • Consolidation over right lower lobe is found.
        • There is moderate bilateral pleural effusion.
        • s/p gastric tube reconstruction at anterior mediastinum is found.
      • Visible abdomen:
        • Low density lesion at left lobe liver about 1.7cm in largest dimension. Liver meta is favored.
        • The GB is well distended without soft tissue lesion
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Esophageal cancer at lower third s/p gastric tube reconstruction. The primary tumor enlarged.
      • New liver meta.
      • Bilateral pleural effusion.
  • 2022-11-02 CXR
    • Lung markings: opacification in the left lower lung field.
    • blurred left hemidiaphram
  • 2022-07-22 Upper GI series
    • UGI series was done partially due to very frequent aspirtion and shows
    • Contrast medium stasis at pyriform sinus with leakage into trachea easily
    • post op. of the esophagus is found.
    • Oral intact is not suggested in the current status.
  • 2022-07-18 MRI - brain
    • Indication: brain meta re-follow up
    • History: The 46-y/o man has esophageal cancer, SqCC, L/3, with medastinal & SCF (supraclavicular fossa) LAPs and multiple brain metastases. He has suffered from progressive dysphagia for 2 years. SCC of esophagus, lower third, stage II was diagnosed by other hospital in 2019/10 but only Chinese medicine was done by decision of patient.
    • MRI of the brain in multiplanar projections, multisequences imaging acquisition with and without IV Gd-DTPA administration shows:
      • comparison: 2021/10/08, 2022/01/07 MRI
      • Normal cisterns and sulcal systems.
      • Normal bilateral ventricular size and shapes.
      • Normal appearance of bilateral cochlear and vestibular nerves complexes.
      • No evidence of severe mass effect or midline structural deviation.
      • Small poor enhancing nodules in left frontal and right occipital lobes,stationary.
    • Imp:
      • Small poor enhancing nodules in left frontal and right occipital lobes, regressed and stationary.
      • Regressed size and edema of left occipital nodule, stationary.
  • 2022-07-11, -07-05 CXR, Portable supine chest AP view shows:
    • Port-A catheter inserted into SVC via left subclavian vein.

    • approriately positioned endotracheal tube in place

    • s/p VATS esophagectomy and gastric tube reconstruction with gastric tube inserted

    • Right internal jugular central venous catheter with tip in the SVC

    • s/p right chest tube in place, its tip directed superomedially, projecting over Rt upper hemithorax

    • s/p left chest tube in place, its tip directed superomedially, projecting over 6th rib

    • extensive increased opacity over Rt lung field

    • Lung volume reduction and increased opacity over RLL

    • Subcutaneous emphysema in the right neck and chest wall

    • 2022-07-15 Patho - esophagus subtotal/total resection

      • Diagnosis
        • Esophagus, lower third, VATS McKeown esophagectomy —- Squamous cell carcinoma, moderately differentiated, s/p CCRT
          • Stomach, cardia, partial gastrectomy —- Negative for malignancy
          • Azygous vein, excision —- Negative for malignancy
          • Thoracic duct, excision —- Negative for malignancy
        • Resection margin: Circumferential resection margin: involved
        • Lymph node
          • Lymph node, peri-gastric, specimen 1, dissection — Negative for malignancy (0/10)
          • Lymph node, right, group 2, dissection —- Negative for malignancy (0/1)
          • Lymph node, right, group 3, dissection —- Negative for malignancy (0/1)
          • Lymph node, right, group 4, dissection —- Negative for malignancy (0/1)
          • Lymph node, right, group 7, dissection —- Metastatic squamous cell carcinoma (2/2)
          • Lymph node, upper para-esophageal, dissection —- Negative for malignancy (0/0)
          • Lymph node, middle para-esophageal, dissection —- Negative for malignancy (0/0)
          • Lymph node, lower para-esophageal, dissection —- Negative for malignancy (0/1)
        • AJCC 8 th edition pT N M Pathology stage: ypStage IVB, ypT3N1 (if cM1)
      • Gross Description:
        • Procedure: VATS McKeown esophagectomy; Size: Esophagus: 2 segments, the upper segment measuring 6.7 cm in length, the lower segment measuirng 6.2 cm in length with a portion of gastric tissue measuring 3.2 cm in length.
        • Tumor Site: Distal esophagus (low thoracic esophagus)
        • Relationship of Tumor to Esophagogastric Junction: Tumor midpoint lies in the distal esophagus and tumor involves the esophagogastric junction
        • Tumor Size: annularly involving the lower esophagus and measuring 7.5 cm in length
        • Proximal cut end, azygous vein (2.6 cm in length and 0.4 cm in diameter), thoracic duct (5.5 cm in length and 0.3 cm in diameter), group 2, 3, 4, 7, 10, and upper para-esophageal, middle para-esophageal, and lower para-esophageal lymph nodes are received in the another bottles.
        • Sections are taken and labeled as: A1-2: distal gastric resection margin; A3: stomach, non-tumor; A4: esophagus, non-tumor; A5: middle para-esophageal tissue; A6: tumor, upper segment; A7-12: tumor (A7-9: the same level), lower segment; B: lymph node, group 2; C: lymph node, group 3; D: lymph node, group 4; E: lymph node, group 7; F: lymph node, upper paraesophageal; G: lymph node, middle paraesophageal; H1-3: lymph node, lower paraesophageal; I: azygous vein; J: thoracic duct; K: proximal cut.
      • Microscopic Description:
        • Histologic Type: Squamous cell carcinoma
        • Histologic Grade: G2: Moderately differentiated
        • Tumor Extension: Tumor invades adventitia
        • Margins
          • Margin(s) involved by invasive carcinoma
          • Specify involved margin: circumferential
          • Proximal resection margin: 5.5 cm
          • Distal resection margin: 3.2 cm
        • Treatment Effect: Absent: Extensive residual cancer with no evident tumor regression (poor or no response, score 3)
        • Lymphovascular Invasion: Present
        • Perineural Invasion: Present
        • Regional Lymph Nodes: please see diagnosis
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • TNM Descriptors: y (posttreatment)
            • Primary Tumor (pT): pT3: Tumor invades adventitia
            • Regional Lymph Nodes (pN): pN1: Metastasis in one or two regional lymph nodes
            • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM1
        • Additional Pathologic Findings: The azygous vein and thoracic duct are free of malignancy.
    • 2022-07-01 Pulmonary Flow Volume Loop

      • Mild restrictive ventilatory impairment, possibly due to small airway obstruction
      • Please consult chest specialist
    • 2022-06-27 CXR

      • Patchy infiltration with air-bronchogram projecting at right infrahilum and right lower medial lung zone is noted.
    • 2022-06-01 Patho - bronchus biopsy

      • Labeled as “right lower lobe”, bronchoscopic biopsy — benign respiratory epithelium lined lung tissue with focal fibrosis and focal mild chronic inflammation.
    • 2022-05-19 CT - chest

      • Indication: Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV
      • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
      • Chest CT with and without IV contrast ehnancement shows:
        • Chest:
          • S/p port-A placement with its tip at Superior vena cava.
          • Soft tissue mass encircling lower third esophagus is found. The tumor causes a fistula connecting right posterolateral esophageal wall to RLL lung. Consolidation over right lower lobe and right middle lobe and left lower lobe is found.
          • Some lymph nodes are found at bilateral paratracheal region.
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • Right renal stone is found.
      • Imp:
        • Esophageal cancer at lower third esophagus and mediastinal lymph nodes.
        • Tumor invasion causes fistula at the right posterolateral esophageal wall, and resulting in RLL pneumonia.
    • 2022-03-10 Patho - esophageal biopsy

      • Esophagus, 30 cm below the incisor, biopsy - Compatible with squamous cell carcinoma
      • IHC: CK(+); P16(-), P63(+) and P53 (+, focal) for atypical cells.
      • According to histopathologic finding and past history, it is compatible with poorly-differentiated squamous cell carcinoma, although no convincing stromal invasion.
    • 2022-03-01 Esophagography

      • Severe stenosis at middle esophagus
    • 2022-01-17 MRI - brain

      • Small poor enhancing nodules in left frontal and right occipital lobes, regressed. Regressed size and edema of left occipital nodule.
    • 2022-01-14 CT - lung/mediastinum/pleura

      • Compatible with middle third esophageal cancer and mediastinal lymph nodes, in regression.
    • 2021-10-11 CT - lung/mediastinum/pleura

      • Esophageal cancer with mediastinal lymph nodes metastasis, in regression post CCRT, but a suspect new RLL nodular metastasis and inflammation or infection in LLL of lungs, compared with CT on 20210428.
    • 2021-10-08 CT - brain

      • Multiple brain metastases, size slightly smaller as compared to that in previous CT done on 20210705.
    • 2021-04-28 Whole body PET scan

      • A glucose-hypermetabolic lesion in the esophagus, L/3, compatible with the primary esophageal cancer.
      • Glucose-hypermetabolic lesions in bilateral mediastinal lymph nodes, probably cancer with regional lymph nodes involvement.
      • Glucose-hypermetabolic lesions in the right lower lung, probably benign in nature.
      • Increased FDG uptake in the colon, probably physiological uptake of FDG.
      • Esophageal cancer, cTxN3M0, by this F-18 FDG PET scan.
    • 2021-04-28 CT - lung/mediastinum/pleura

      • lower third esophageal cancer T3N3M0 IVA

[consultation]

  • 2023-03-03 Family Medicine
    • Q
      • For further hospice care
      • Follow up in this year showed disease progression despite chemotherapy and immunotherapy. Poor prognosis was told, the patient signed Advance Care Directive (ACD). We need your expertise for hospice care, thank you!
    • A
      • When I visited, the patient sit on the bed and his caregiver stood by him. His consciousness was clear, and his ECOG was 4. After discussion, I decided to arrange hospice combine care for this patient. Thanks for your consultation.
      • Indication for hospice combine care: Esophageal cancer
      • Plan: Hospice combined care.
  • 2023-03-03 Radiation Oncology
    • A
      • Objective:
        • General Condition-ECOG: 2.
        • PE, 2023/3/03: No palpable neck LNs.
        • Images:
          • Chest CT, 2022/02/16: Lower third esophageal cancer with probably tumor rupture, causing right lower lobe consolidation s/p bypass surgery with gastric tube. The primary tumor & pleural metastasis enlarged. Mediastinal lymphadenopathy, in progression. Liver meta, in enlargement. Thin body fat, c/w cachexia.
          • CXR, 2023/03/02: new LLL consolidation due to pneumonia & lung metastasis; RLL consolidation due to broncho-esophageal fistula. Small nodular lesions in the bilateral lung fields.
      • Diagnosis: Esophageal cancer, SqCC, L/3, diagnosed in 2019/10 without treatment (Chinese Medicine only) with mediastinal & SCF LAPs and multiple brain metastases s/p RT (3600 cGy/12 fx) for brain metastases from 2021/7/8-7/23, neoadjuvant CCRT (5040 cGy/28 fx) for primary tumor from 2021/7/26-9/1, s/p C/T with FOLFOX, PF, s/p VATS esophagectomy and gastric tube reconstruction on 2022/7/4 for esophageal cancer and fistula, s/p TEVAR stent placement on 2022/11/29, Zone III TEVAR (Medtronic VALIANT), s/p immunotherapy with Opdivo & FOLOFX6 with disease progression (pleural, lung and liver metastasis); ECOG = 2.
      • Plan: RT is not suggested due to disease progression, cachexia and active infectious process. If he recovers from pneumonia, immunotherapy with R/T may be considered.
    • 2022-11-28 Anesthesiology
      • Q
        • For aorta invasion -> TEVAR (thoracic endovascular aortic/aneurysm repair) stent placement on 2022/11/29, due to poor condition, we need your anesthesia consultation for evaluation. Thanks a lot!!!
      • A
        • To doctor or nurse practitioner, We were consulted for pre-op anesthesia evaluation.
        • Pt: 47 y/o M
        • Op: TEVAR
        • Past hx:
          • VATS esophagectomy and gastric tube reconstruction on 2022/7/4
        • GCS: 456
        • Vitals: stable
        • EKG: sinus tachy
        • CXR: blunting of left CP angle
        • 2D-echo:
          • EF54%
          • Trivial AR
        • Lab:
          • Hb10.3
        • PLAN
          • ASA II
          • EtGA
          • Post-ICU care if needed
          • We have informed the risks of anesthesia and the possible complications to the patient and the patient’s family.
    • 2022-11-28 Family Medicine
      • Q
        • This 47 y/o man is a case of SqCC of the lower third esophagus diagnosed at FuJen Catholic University Hospital in 2019/10 who went to National Taiwan University Hospital for second opinion in 2019/12. He refused chemotherapy and received only chinese medicine. With progression, his current disease status was esophageal cancer, SqCC, L/3, with mediastinal & SCF LAPs and multiple brain metastases, s/p port-A insertion and feeding jejunostomy on 20210707, neoadjuvant CCRT (3600 cGy/12 fx) for brain metastases from 2021-07-08 ~ -07-23, neoadjuvant CCRT (5040 cGy/28 fx) for primary tumor from 2021-07-26 ~ -09-01, with FOLFOX from 2021-07 ~ 2021-11 (9 cycles). He also received chemotherapy with PF (Cisplatin + 5-Fu) since 2021-12-07 to 2022-04-23 (8cycles). He has received VATS esophagectomy and gastric tube reconstruction on 2022-07-04 for esophageal cancer and fistula. This time, he suffered from progressive dyspnea for at least one month.
        • For Combined Hospice Care, thanks
      • A
        • 47-year-old male, esophageal cancer with mediastinal & SCF lymphadenopathy and multiple brain metastases
          • s/p neoadjuvant CCRT, s/p FOLFOX, s/p VATS esophagectomy and gastric tube reconstruction for esophageal cancer with fistula
          • Suffer from exertional short of breath
          • Consciousness alert, ECOG 2
        • We will arrange hospice combine care and follow his condition
          • Indication: Esophageal cancer
          • Plan: Combined Hospice Care
    • 2022-11-26 Cardiac Surgery
      • Q
        • Chest CT on 20221103 showed new liver metastasis and CXR on 20221115 still showed left pleural effusion.
        • For tumor recurrence with aorta invasion, we need your consultation for evaluation. Thanks a lot!
      • A
        • I have had the pleasure of involving with the patient’s care. In brief, He is a 47 year old male seen in consultation for opinion regarding treatment options for Squamous cell carcinoma of lower third esophagea
        • Prophylatic TEVAR (thoracic endovascular aortic/aneurysm repair) is scheduled on 20221130 yet this time the pt was admitted and c/o (complaint of) SOB, not sure if such was caused by airway compression or large amount of pleural effuion
        • SUGGESTION & PLAN:
          • TEVAR stent placement can be brought forward to tuesday 20221129 ETGA, on call, pigtail/chest tube insertion may be performed as combined procedure to relieve his resp. distress.
    • 2022-05-26 Chest Medicine
      • Q
        • The 45 y/o male he has Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV. This time, he was admitted for fever and cough, the CXR showed pmeumonia over RLL, so we need your help. Thank you.
      • A
        • S: short of breath with exertion
        • O:
          • The chest CT showed RLL consoildation. The CXR showed RLL consolidation in progression.
          • According to the patient’s self-report, the taste of sputum after coughing is the same as that of drinks he has had.
        • A:
          • Suspected tracheo-esophageal fistula [T-E fistula]
          • right lower lung pneumonia
          • Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV
        • P:
          • consider gastroscopy if possible for diagnosis of T-E fistula
          • suggest bronchoscopy for diagnosis of T-E fistula, however having undergone a bronchoscopy previously, the patient would be more breathless following the procedure. In order to proceed, the patient desired to wait for his condition to stabilize.
          • if T-E fistula is proved, please consult Thoracic Surgery to evaluate esophageal stent or tracheal stent
          • check sputum culture and adjusted antibiotics for pneumonia
          • check sputum TB x3
          • check serum aspergillus antigen
    • 2022-05-23 Infectious Disease
      • Q
        • The 47 y/o man has Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV. This time, he sufferes from cough, SOB and high fever since 20220513. We gave antibiotic as Tapimycin for RLL pneumonia treatment, but condition progress and repeat CXR showed significant patch noted, so we need your help for management. Thanks!
      • A
        • O
          • 20220518 WBC: 4070
          • 20220519 S/C: Group F streptococci and mixed flora
        • A
          • Lobar pneumonia, RLL is impressed.
        • Suggestion:
          • Recheck CBC and CRP level
          • Antibiotics with cravit 750mg iv st and qd is suggested
    • 2022-05-19 Chest Medicine
      • Q
        • The 47 y/o man has esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV. Due to fever, cough with sputum since 20220513. RLL pneumonia noted and CT was done today. We need your help for management.
      • A
        • Lab:
          • WBC:4070, band:11%, Hb:10.8, PLT:171K, BUN:28, Cr:0.66, Na:141, K:3.3, AST:45, ALT:41, PCT:0.27
        • Chest CT:
          • Esophageal cancer at lower third esophagus and mediastinal lymph nodes with stationary considition.
          • Consolidation over right lower lobe , probably due to aspiration pneumonia.
        • Impression:
          • Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV.
          • Suspected Aspiration pneumonia
        • Suggestion
          • Change to Tapimycin or avelox for covering anaerobic pathogen
          • Tracing all culture
          • F/U CXR
          • Moniter fever and respiratory pattern
    • 2022-01-25 Oral and Maxillofacial Surgery
      • A
        • S
          • This 47 year old male patient had SqCC of the esophagus and mediastinal lymph nodes invasion.
          • He complained swelling discomfort of his right upper jaw for 4 days.
        • O
          • The mouth finding showed chronic periodontitis. Swelling of 21 palate side were noted.
        • Plan:
          • Oral hygiene.
          • Pain control.
          • Add antibiotic agent with Amoxicllin 500mg q8h were prescribed.
          • Explained to patient home care.
    • 2021-07-06 Radiation Oncology
      • Q
        • The 46 y/o man has Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastases, we need your help for brain RT management. Thanks!
      • A
        • Diagnosis: Esophageal cancer, SqCC, L/3, diagnosed in 2019/10 without treatment (Chinese Medicine only) with mediastinal & SCF LAPs and multiple brain metastases; ECOG = 2.
        • Suggest: Radiotherapy.
        • Goal: Palliative.
        • RT Plan:
          • Target & Volume: Brain metastasis (and esophageal tumors/LAPs).
          • Technique: IMRT & VMAT by linear accelerator.
          • Dose & Fractionation: 3600cGy/12 fractions to brain metastasis (3600cGy/12 fractions to esophageal tumor if feasible).
        • Plan: Brain RT is suggested for tumor control. Possible radiation effects (malaise, IICP, dermatitis) is told. CT simulation is arranged on July 06 16:10 2021. Treatment will be started 1-2 days later. Dexamethasone and mannitol may be prescribed to control the IICP during brain R/T. RT to esophageal tumors/LAPs may be arranged if his condition is stable.

[surgical operation]

  • 2022-11-29
    • Surgery
      • Zone III TEVAR (Medtronic VALIANT)     
      • Left pleural pigtail insertion     - Finding
      • Pre-OP / Post-op diagnosis: advanced esophageal cancer with DsAo adventitia invasion
      • Operative Indications:
        • The patient is a 47 year old male with history of advanced esophageal cancer with DsAo adventitia invasion; he presented with worsening SOB, CT demonstrated aortic encasement by the tumor at low thoracic DsAO; He desired to proceed with prophylactic TEVAR.   
    • Operative Findings:
      • Medtronic VALIANT VAMF2222C100 & VAMF2626C100 were sequentially deployed. (Via RCFA)
      • Left pleral effusion was subseqeuntly drained by a pigtail.
  • 2022-07-04
    • Surgery
      • VATS McKeown esophagectomy gastric tube reconstruction + decortication
    • Finding
      • previous ruptured malignant esophagus with abscess formation and severe orgainzed adjacent tissue s/p esophagectomy + decortication
      • thick mediastinum pleural, dilated and bulky esophagus, subcarina lymphnode necrosis, and main tumor stiffness with partial necrosis were noted
      • severe adhesion of necrotic main tumor to left main bronchus
      • remove azygus vein and thoracic duct abide with esophagus
      • gastric tube reconstruction via retrosternal route, esophagogastric anastomosis at left neck, hand-sewn
      • chest tube insertion: righ pleural cavity: 28Fr; left: 24 Fr.

[radiotherapy]

  • 2021-07-26 ~ 2021-08-30 - 5040cGy/28 fractions (15 MV photon) to esophageeal tumor and LAPs
  • 2021-07-08 ~ 2021-07-23 - 3600cGy/12 fractions (6 MV photon) to brain metastasis

[chemotherapy]

  • 2023-05-17 - nivolumab 3mg/kg 180mg NS 100mL 30min D1
  • 2023-05-08 - docetaxel 35mg/m2 60mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-02 - docetaxel 35mg/m2 60mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-21 - nivolumab 3mg/kg 180mg NS 100mL 30min D1 + docetaxel 35mg/m2 60mg NS 100mL 1hr D2
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D2
  • 2023-04-12 - docetaxel 35mg/m2 60mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-03 - nivolumab 3mg/kg 180mg NS 100mL 30min D1 + docetaxel 35mg/m2 60mg NS 100mL 1hr D2
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D2
  • 2023-02-21 - nivolumab 3mg/kg 180mg NS 100mL 30min D1 + oxaliplatin 85mg/m2 148mg D5W 500mL 2hr D2 + leucovorin 400mg/m2 680mg NS 250mL 2hr D2 + fluorouracil 2800mg/m2 4800mg NS 500mL 44hr D2 (Opdivo/FOLFOX6 Q2W)
    • dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2 + NS 250mL D2
  • 2023-01-30 - nivolumab 3mg/kg 180mg NS 100mL 30min D1 + oxaliplatin 85mg/m2 148mg D5W 500mL 2hr D2 + leucovorin 400mg/m2 680mg NS 250mL 2hr D2 + fluorouracil 2800mg/m2 4800mg NS 500mL 44hr D2 (Opdivo/FOLFOX6 Q2W)
    • dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2 + NS 250mL D2
  • 2023-01-10 - nivolumab 3mg/kg 180mg NS 100mL 30min D1 + oxaliplatin 85mg/m2 148mg D5W 500mL 2hr D2 + leucovorin 400mg/m2 680mg NS 250mL 2hr D2 + fluorouracil 2800mg/m2 4800mg NS 500mL 44hr D2 (Opdivo/FOLFOX6 Q2W)
    • dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2 + NS 250mL D2

    • 2022-12-21 - nivolumab 3mg/kg 200mg 30min D1 + oxaliplatin 85mg/m2 145mg 2hr D2 + leucovorin 400mg/m2 700mg 2hr D2 + fluorouracil 2800mg/m2 4800mg 44hr D2 (Opdivo/FOLFOX6 Q2W)

      • dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2
    • 2022-12-01 - nivolumab 3mg/kg 180mg 30min D1 + oxaliplatin 85mg/m2 148mg 2hr D2 + leucovorin 400mg/m2 680mg 2hr D2 + fluorouracil 2800mg/m2 4800mg 44hr D2 (Opdivo/FOLFOX6 Q2W)

      • dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2
    • 2022-04-22 - cisplatin 40mg/m2 77mg 4hr + leucovorin 400mg/m2 775mg 2hr + fluorouracil 2800mg/m2 5430mg 46hr

      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-03-29 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-03-14 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-02-15 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-01-24 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-01-11 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2021-12-22 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2021-12-07 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2021-11-18 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-11-02 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-10-18 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5435mg 46hr (FOLFOX)

      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-09-29 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5435mg 46hr (FOLFOX)

      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-08-24 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-08-10 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-07-27 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-07-14 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

==========

2023-04-12

  • After reviewing PharmaCloud, which showed that the recent patient’s medications were all prescribed at our hospital, no medication reconciliation issue was identified.
  • Combined hospice care was arranged due to progression after trying several chemoimmunotherapy regimens.

2023-02-21

  • During this hospital stay, the drugs recently prescribed and disclosed in the NHI PharmaCloud System have been correctly prescribed as self-carried items currently with no medication reconciliation issues found in the patient.

2023-01-11

  • A combined hospice care arrangement has been made for this patient since 2022-11.
  • Medications (ROMICON-A, Pulmicort Nebulising Susp INHL) already prescribed to relieve respiratory symptoms.
  • Underlying conditions hypothyroidism and hypokalemia are appropriately managed with Eltroxin (levothyroxine) and Radi-K (potassium gluconate), respectively.

2022-03-29

  • Nexium (esomeprazole) must not be ground. Instead, it should be dissolved in adequate drinking water prior to tube feeding.

700507760

230605

[exam findings]

  • 2023-05-23 CXR
    • Enlarged heart shadow with tortuous aorta.
    • Placement of right subclavian port-A catheter.
    • Peribronchial thickening at bilateral lower lung field.
    • Bilateral clear costophrenic angles.
    • Degenerative change of the spine with marginal spur formation.
    • Surgical implant fixation at lumbar spine.
  • 2023-05-23 ECG
    • Normal sinus rhythm
    • Septal infarct, age undetermined
  • 2023-04-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (165 - 31) / 165 = 81.21%
      • M-mode (Teichholz) = 81
    • Conclusion:
      • Dilated LA and LV; Adequate LV systolic function with normal resting wall motion
      • Moderate to severe MR, moderate TR, mild AR
      • Impaired LV relexation
      • Preserved RV systolic function
  • 2023-04-11 CXR
    • S/P CVP line insertion from right jugular vein and the tip located at SVC.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • A mass-like opacity projecting in the left lower medial lung shows stationary that is c/w hiatal hernia after correlate with CT.
  • 2023-03-18 CT - chest
    • Rt L4 radiculopathy since 202207. History of melanoma post operation at Cardinal Tien Hospital in Apr 2021 and path revealed Lt femoral LN (20/27) melanoma, metastatic.
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lobulated nodule at left lingula lobe is found.
        • Subcarina lymph node is found. Meta is considered.
        • Hiatus hernia is found.
        • No evidence of bilateral pleural effusion.
        • Senile fibrotic change is noted at lung fields.
      • Visible abdomen:
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • Scoliotic alignment of the thoracolumbar spine is noted.
        • The GB is well distended without soft tissue lesion
    • Imp:
      • left lingula lobe nodule. 1.5cm.
      • Hiatus hernia
      • Mediastinal lymphadenopathy
      • Bone meta.
  • 2023-02-09 KUB + L-spine Lat
    • s/p PI, PD, and PLF at L2-3-4
    • Disc space narrowing at L1/2 and L4/5
  • 2022-12-28 KUB + L-spine Lat
    • post-OP change from L2 to L4
    • severe decreased disc space in the L4/5 disc.
    • mild anterior spur formation at the L-spine
    • compression fractures at L1 and T12 vertebral bodies.
  • 2022-12-27 Spinal angiography
    • The spinal angiograms were done via right femoral approach and show:
      • Tortuous abdominal aorta.
      • Prominent tumor stain with engored tumor feeding vessels were found in right L3 segmental artery.
  • 2022-12-26 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Septal infarct, age undetermined
  • 2022-12-02 MRI - L-spine
    • Indication: Melanoma with mediastinal lymph nodes, left upper lung, and L3 spine metastases at least
    • MRI of lumbar spine without/with Gadolinium-based contrast enhancement shows:
      • abnormal bone marrow signal lesion with contrast enhancement at the L3 vertebral body, with a heterogeneously enhancing bone mass protruding laterally to the right side, obliterating right L3-4 neuroforamen and compressing or involving right L3 nerve root. Bone metastasis is compatible.
      • marked degenerative change of the spine with marginal spur formation and dehydrated discs at multiple levels.
      • severe right L5-S1 neuroforaminal narrowing.
      • no evidence of abnormal signal lesion in visible spinal cord.
    • Impression:
      • Bone metastasis at L3 vertebral body, with bone mass protruding laterally to right side, obliterating right L3-4 neuroforamen and compressing or involving right L3 nerve root.
      • Degenerative spinal and disc disease.
      • Severe right L5-S1 neuroforaminal narrowing.
  • 2022-10-24 PET scan
    • Increased FDG uptake at the L3 spine, compatible with the pathological findings of metastatic melanoma.
    • Glucose hypermetabolic lesions in mediastinal lymph nodes and in a nodular lesion in the left upper lung, highly suspected melanoma with distant metastases.
    • Glucose hypermetabolic lesions in the right lobe of the thyroid gland and in the left SCF lymph nodes, the nature is to be determined, suggesting biopsy for further investigation.
    • Increased FDG uptake in bilateral knees, the nature is to be determined also (post-traumatic change, melanoma, or other nature ?), suggesting further investigation.
    • Increased FDG uptake in bilateral palatine tonsils, probably a chronic inflammation process.
    • Increased FDG uptake in the colon, probably physiological uptake of FDG.
    • Melanoma with mediastinal lymph nodes, left upper lung, and L3 spine metastases at least, c-stage IV (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2022-10-14 Tc-99m MDP bone scan
    • Prominently increased activity in the L3-5 spines. The nature is to be determined (malignancy/metastases? other nature?). Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the middle C-spine and middle T-spines. Degenerative change may show this picture. However, please keep follow up to rule out other possibilities.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, knees and left foot, compatible with benign joint lesions.
  • 2022-10-13 Patho - bone biopsy/curetting
    • Vertebral body, L3, CT-guided biopsy — Melanoma, metastatic
    • The sections show a picture of melanoma, metastatic, composed of sheets of large epitheloid neoplastic cells with pleomorphic nuclei and abundant cytoplasm. Small amount of melanin pigment deposition can be found.
    • IHC: CK(-), S100(+), Melan A(+) and SOX10(+).
  • 2022-10-11 ECG
    • Sinus bradycardia
    • Poor wave progression
  • 2022-09-27 MRI - L-spine
    • The lumbar spine shows spondylosis and disk space degeneration at the L2/3 through L5/S1 levels.
    • Scoliosis of L-spine.
    • One large lobulated mass lesion (5.1cm) over right-side of the L3 vertebral body with destruction of bone cortex. Suggest check enhanced MRI or tissue proof to rule out malignancy.
    • Narrowing of right L5/S1 neural foramen.
  • 2022-09-08 KUB + L-spine Lat
    • Facet degeneration of lower lumbar spine
    • Disc space narrowing at L2-3-4-5-S1
    • General osteoporosis
    • Concave vertebrae of T-L spine
  • 2022-09-08 Merchant view (patella 45 0) Bil
    • No lateral subluxation or lateral tilting of the patella
    • s/p bilateral total knee replacements
  • 2022-09-08 Knee Bilat. standing AP and Lat views:
    • S/P total knee arthroplasty, Bil
    • Good alignment without prosthesis loosening

[MedRec]

  • 2023-04-09 ~ 2023-04-14 POMR Hemato-Oncology
    • Discharge diagnosis
      • Melanoma with mediastinal lymph nodes, left upper lung and L3 spine metastases, cstage IV, status post L3 posterior decompression + L2-4 posterior instrumentation and fusion on 2022/12/28
      • Atherosclerotic heart disease of native coronary artery without angina pectoris
      • Hypertensive heart disease without heart failure
  • 2022-11-24 ~ 2022-12-02 POMR Hemato-Oncology
    • Discharge diagnosis
      • Malignant melanoma of left lower limb, including hip
      • Melanoma with mediastinal lymph nodes, left upper lung and L3 spine metastases at least, cstage IV
      • Secondary malignant neoplasm of bone
      • Osteoarthritis of knee, unspecified
      • Other spondylosis, lumbar region
      • Radiculopathy, site unspecified
      • Constipation, unspecified
  • 2022-11-22 SOAP Hemato-Oncology
    • Objective: no V600E mutation (dabrafenib not indicated)
  • 2022-10-28 SOAP Hemato-Oncology
    • Plan to apply Tafinlar (dabrafenib) if V600E mutation is documented
      • Note: as monotherapy, dabrafenib is indicated to treat unresectable or metastatic melanoma with BRAF V600E mutation

[chemotherapy]

  • 2023-05-12 - Nab-paclitaxel 150mg/m2 200mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-05-05 - Nab-paclitaxel 150mg/m2 200mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-04-20 - Nab-paclitaxel 150mg/m2 200mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-04-13 - Nab-paclitaxel 150mg/m2 200mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

Nanoparticle albumin bound paclitaxel (nab-paclitaxel) 2023-05-24 https://www.uptodate.com/contents/nanoparticle-albumin-bound-paclitaxel-nabpaclitaxel-drug-information

  • Melanoma, metastatic (off-label use):
    • Previously treated patients: IV: 100 mg/m2 on days 1, 8, and 15 of a 28-day cycle; if tolerated, may increase dose by 25 mg/m2 in cycle 2 and beyond; continue until disease progression or unacceptable toxicity.
    • Previously untreated patients: IV: 150 mg/m2 on days 1, 8, and 15 of a 28-day cycle; continue until disease progression or unacceptable toxicity.

==========

2023-06-05

  • The patient was prescribed famotidine, sennosides, clopidogrel, isosorbide dinitrate, nicorandil, bisoprolol, valsartan, rosuvastatin, and alprazolam by WanFang Hospital for the primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris on 2023-04-27. The patient refilled these medications at a local pharmacy on 2023-05-24. Among these, alprazolam and sennosides are not included in the current active medication list. These medications may be excluded if there’s no ongoing indication. All the cardiovascular drugs prescribed are properly integrated into the active medication list without any medication reconciliation issues.
  • It has been noted that the disease does not possess the BRAF V600E mutation; however, the status of the V600K mutation is currently undocumented (not found). If the presence of a V600K mutation is confirmed, the combined therapy of dabrafenib and trametinib might be also considered as a treatment option.

2023-05-24

  • The patient made a visit to WanFang Hospital on 2023-04-27, where several medications were prescribed for a duration of 28 days to manage her atherosclerotic heart disease. It appears that clopidogrel, one of the prescribed medications, is not currently listed on the active medication list. If there are no contraindications or other clinical concerns, it might be beneficial to add clopidogrel back into the patient’s regimen to maintain an accurate and up-to-date medication reconciliation.
  • The patient, who has metastatic melanoma, is currently receiving off-label treatment with nab-paclitaxel at a dose of 150mg/m2 on days 1, 8 and 15 of a 28-day cycle. Targocid (teicoplanin) and tapimycin (piperacillin + tazobactam) are currently used to treat cellulitis with pus formation over the port-a-wound. There is no issue with the active prescription.

701482774

230601

[exam findings]

  • 2023-06-01 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 29 dB HL; LE 26 dB HL.
    • RE normal to moderate SNHL.
    • LE normal to mild SNHL.
  • 2023-06-01 SONO - abdomen
    • Diagnosis
      • Fatty liver, mild
      • Suspected fatty infiltration of pancreas
      • Small GB
      • Splenomegaly, mild
      • Suboptimal examination of liver,especially the subcostal view due to poor echo window
    • Suggestion
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • 2023-05-30 Nasopharyngoscopy
    • left arytenoid swelling, blood clots over larynx and hypopharynx, penetration and impending aspiration
    • bulging tongue tumor, airway compromised+
  • 2023-05-25 CT - chest
    • Submental and right submandibular lymphadenopathy
    • COPD. Moderate.
    • Diffuse Swelling of the gastric wall is found. Suggest endoscopy.
  • 2023-05-18 MRI - larynx
    • Oralcavity
      • Impression (Imaging stage) : T:4b N:3b M:0 STAGE:IVB
  • 2023-05-17 CXR
    • Multifocal opacities of left lung. Increased infiltration over both lungs. May be active infection.
  • 2023-05-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79.0 - 23.2) / 79.0 = 70.63%
      • M-mode (Teichholz) = 70.6
      • 2D (M-simpson) = 71.0
    • Conclusion:
      • Normal AV/MV with mild MR
      • Concentric LVH, normal LV wall motion
      • Preserved LV and RV systolic function
      • No PR, no TR, normal IVC size
  • 2023-05-15 Patho - tongue biopsy (Y1)
    • Tongue, right lateral, biopsy— well differentiated squamous cell carcinoma
    • Microscopically, section shows well differentiated squamous cell carcinoma consisting of squamous tumor nests in infiltrative growth pattern and areas of dyskeratosis. The tumor cells have abundant eosinophilic cytoplasm, nuclear pleomorphism, hyperchromasia, and mitiotic activity.
    • HC stain— p16(-)
  • 2023-05-15 ECG
    • Normal sinus rhythm
    • Increased R/S ratio in V1, consider early transition or posterior infarct
    • Prolonged QT
  • 2023-05-13 Nasopharyngoscopy
    • granular tumor right tongue border, whitish lesion over left hard palate, smooth NPx, protuding of right tongue base with yellowish discharge, sputum pooling over HPx, fair vocal cord movement

[MedRec]

  • 2023-05-24 SOAP Hemato-Oncology
    • Arrange admission for PET-CT, Chest CT (including whole body if possibile), EGD, Abdominla sonography and Port-A implantation
    • Refer to CS for Port-A implantation
  • 2023-05-23 SOAP Ear Nose Throat
    • A: Tongue cancer, stage IVb
    • Treatment plan: induction CT + CCRT, referred to Hema

[consultation]

  • 2023-05-30 Anesthesiology
    • Q
      • Injury Severity Score: 3 Difficulty Swallowing > Acute Central Moderate Pain (4-7) Tongue cancer, tongue bleeding for 1 week, significant bleeding today, the patient expresses desire for DNR (Do Not Resuscitate)
      • 5/18 ENT (Ear, Nose, and Throat) discharge diagnosis
        • Right deep neck infection status post right deep neck incision & drainage on 2023-5-14.
        • Right lateral tongue cancer status post biopsy (squamous cell carcinoma) on 2023-5-14.
        • Localized swelling, mass and lump, neck
        • Hypertension
        • Type II diabetes mellitus
    • A
      • Visited the patient in the emergency department
      • The patient was not using any oxygen assistance at the time
      • If the ENT doctor indicates that the patient may have a risk of airway loss at any time
      • Please have the emergency tracheotomy on standby for intubation in the operating room, or directly proceed with a tracheostomy
      • The patient had previously been treated for difficult airway in the operating room, and a direct tracheostomy should be considered.
  • 2023-05-30 Ear Nose Throat
    • A1
      • S:
        • intermittent oral bleeding for 1 week, progressed today
        • the patient complained dyspnea and can’t lying down
        • Deep neck infection s/p I+D and right lateral tongue biopsy
        • Right tongue cancer. T4bN3BM0, Stage IVB
      • O:
        • Scope:
          • left arytenoid swelling, blood clots over larynx and hypopharynx, penetration and impending aspiration
          • bulging tongue tumor, airway compromised+
      • Plan:
        • Suggest tracheostomy, but the patient strongly refused
        • Well explanation to the patient and his family about the risk of active bleeding and airway obstruction with possible death
        • Well education: if bleeding again, sit up with mouth open and head downward to prevent aspiration
        • ENT OPD f/u
    • A2 2023/05/30 16:50
      • We were informed that the patient agreed to receive tracheostomy
      • We will arrange tracheostomy under ETGA on 2023/6/1
      • OA to oncology, if active bleeding or respiratory failure -> intubation
    • A3 2023-05-30 18:00:58
      • We will arrange tracheostomy operation today for airway protection.
      • Keep NPO and finish preOP survey
    • A4 2023-05-30 22:09:46
      • staus post tracheostomy (shiley 6 #)
      • adequate pain control and antibiotics
      • f/u CXR to check tracheostomy position
      • hemoclot and bosmin gauze prn for oral tumor bleeding
      • suction prn carefully (The tumor is located on the right rear side, do not poke too deep.)
  • 2023-05-14 Cardiology
    • Q
      • This 53-year-old male has histories of HTN, D.M, type II and hyperlipidemia. This time, he was admitted to ENT ward for under impression of deep neck infection on May 13, 2023. He underwent 1. Incision and drainage of right deep neck infection 2. Biopsy of right lateral tongue and left soft palate tumor on May 14, 2023. But, acute respiratory failure at POR, re-intubation with ventialtor support was performed on May 14, 2023, and he was transferred to our SICU for intensive care today. Due to ST depression by 12 leads EKG, and elevated of hs Tropnin I (from 179.4 tp 308.4 pg/mL), We need your expertise for suspect acute coronary syndrome evaluation. Thanks a lot!!
    • A
      • We were consulted for diffuse STD and elevated hs-troponin I
      • The STT change was noted while the routine screening of his cardiac enzyme and ECG. Since this patinet was clear consciousness, he could inform us that he had no subjective symptom.
      • S:
        • patient is clear conscious under ventilator support.
        • Denied of chest pain, chest tightness right now and in the past.
      • O:
        • Clear breathing sounds
        • No pitting edema
        • EKG:
          • 20230513 - Q wave in inferior leads, and T wave invertion at anterolateral leads
          • 20230514 - diffuse STD from V2-V6
        • Labs
          • 20230514 - hsTrop I 180 -> 300
        • Bedside echo: adequate EF and no abnormal wall motion, poor echo window.
      • Impression
        • R/o demand ischemia
        • Deep neck infection
      • Suggestion
        • ST EKG V1-V6 + V7-V9 showing recovery of STD changes (spontaneous recovery)
        • F/u hs-Trop and EKG 2hr later.
        • Might consider plavix 1# QD if no bleeding tendency and secure hemostasis at OP site.
        • F/u electrolytes ( Mg, Ca, Ip, Na/K), CAD risk factors including lipid profile, HbA1c and uric acid.
        • Arrange 2D cardioechography. CV OPD follow up
  • 2023-05-13 Ear Nose Throat
    • Q
      • Chief Complaints:
        • left neck pain for one week
        • dysphagia
      • Past History: Nil
      • Surgical history: Denied
      • Drug allergy: Denied
    • A
      • S
        • Right neck pain for one week
        • Previous R tongue border leukoplakia s/p biopsy = benign in 2023/01.
        • Hx of DM, HTN
      • O
        • Local findings: granular tumor over right tongue border, whitish lesion over left hard palate
        • Scope: smooth NPx, protuding of right tongue base, yellowish discharge pooling over HPx, mild airway compromized
      • A
        • Impression: Highly suspect Oral ca with deep neck infection
      • P
        • OA to ENT, continue IV anti, pain control
        • Arrange I&D on 2023/05/14

==========

2023-06-01

This patient visited a local clinic on 2023-05-11 for his primary hypertension (PharmaCloud only reveals one main diagnosis, there should be also diabetes diagnosed) and be prescribed with amlodipine, losartan and glimepiride. Currently Norvasc (amlodipine), Amepiride (glimepiride) and 與 losartan 同藥理作用的 Olmetec (olmesartan) are shown in the active medication list, no reconciliation issue identified.

2023-05-19 anaerobic culture for deep neck wound/pus showed peptostreptoccus spp. 3+

701267240

230531

[exam findings]

  • 2023-05-22 Laryngoscopy
    • Findings
      • flap at right oropharynx and hypopharynx, right vocal movement decreased, glottic closure fair; a nodular lesion at right nasopharynx (flap upper edge), size stable favor granulation; saliva accumulation at bi hypopharynx and on pharyngeal wall
    • Diagnosis/conclusion
      • Malignant neoplasm of pyriform sinus, tumor recurrence at right oropharynx and right parapharyngeal space, s/p op
      • Swallowing dysfunction, under swallowing rehabilitation
  • 2023-05-08 Laryngoscopy
    • Findings
      • flap at right oropharynx and hypopharynx, right vocal movement decreased, glottic closure fair; a nodular lesion at right nasopharynx (flap upper edge), favor granulation
    • Diagnosis/conclusion
      • Malignant neoplasm of pyriform sinus, tumor recurrence at right oropharynx and right parapharyngeal space, s/p op
      • Swallowing dysfunction, under swallowing rehabilitation
  • 2023-04-27 Laryngoscopy
    • Findings
      • Scope: flap at right oropharynx and hypopharynx, right vocal movement decreased, glottic closure fair; a nodular lesion at right nasopharynx (flap upper edge)
      • FEES: soft diet: premature leak +, residual + at vallecula and pyriform sinus, penetration +
    • Diagnosis/conclusion
      • Malignant neoplasm of pyriform sinus, tumor recurrence at right oropharynx and right parapharyngeal space, s/p op
      • Swallowing dysfunction, under swallowing rehabilitation
  • 2023-04-20 Patho - nasopharyngeal/oropharyngeal biopsy
    • Right nasopharyngeal lesion, biopsy — Necrotic ulcer debris, acute inflammatory exudates, and granulation tissue only.
  • 2023-04-20 Nasopharyngoscopy
    • Findings
      • Scope: flap at right oropharynx and hypopharynx, right vocal movement decreased, glottic closure fair; a nodular lesion at right nasopharynx (flap upper edge), size increase >>> biopsy done
    • Diagnosis/conclusion
      • Malignant neoplasm of pyriform sinus, tumor recurrence at right oropharynx and right parapharyngeal space, s/p op
      • Right nasopharyngeal lesion, biopsy done
  • 2023-04-06 Laryngoscopy
    • Findings
      • Scope: flap at right oropharynx and hypopharynx, right vocal paresis, glottic closure fair; flap upper edge swelling, granulation, r/o tumor
      • FEES:
        • liquid diet: premature leak +, residual + at vallecula and pyriform sinus, penetration +, aspiration +
        • soft diet: premature leak -, residual + at vallecula and pyriform sinus, penetration +
    • Diagnosis/conclusion
      • Malignant neoplasm of pyriform sinus, tumor recurrence at right oropharynx and right parapharyngeal space, s/p op
      • Swallowing dysfunction
  • 2023-03-24 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana) S2023-3886 G1
      • Tumor type: squamous cell carcinoma
      • Tumor location: Oropharynx
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark XT
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: Pass,
      • Adequate tumor cells present (>=50 viable tumor cells): Yes,
    • Result:
      • Tumor cell (TC) staining assessment:
        • TC category: TC >=1% and <5%
        • Percentage of PD-L1 expressing tumor cells (%TC): 3%
      • Tumor-infiltrating immune cell (IC) staining assessment:
        • IC category: IC >= 10%
        • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): 15%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2023-03-24 PD-L1 IHC
    • Tissue blocks/unstained slides received labeled as: S2023-03886 G1
      • Tumor type: Labeled H&N cancer
      • Testing assay: 28-8 pharmDx Assay (Agilent/Dako)
    • RESULT:
      • Tumor cell (TC) staining assessment: TC < 1%
  • 2023-03-24 PD-L1 22C3
    • Unstained slides received labeled as: S2023-03886 G1
      • Tumor type: oral cancer
      • Testing assay: 22C3 pharmDx Assay (Agilent/Dako)
    • RESULTS:
      • Tumor Proportion Score (TPS) assessment: TPS >=1% and <50%
        • Tumor Proportion Score (TPS): 1%
      • Combined Positive Score(CPS) assessment: CPS >=1 and <10
        • Combined Positive Score (CPS): 5
  • 2023-03-06 Patho - oral cancer (wide excision + lymph node)
    • Diagnosis:
      • Oropharynx, right, wide excision —- Squamous cell carcinoma, moderately differentiated, AJCC 8th edition: pStage IVB, pT4bN0(if cM0); The immunohistochemical stain of p16 is negative.
      • Lymph node, right neck, level III, selective neck dissection—- Negative for malignancy (0/9)
      • Lymph node, right neck, level IIb, selective neck dissection —- Negative for malignancy (0/2)
      • Lymph node, right neck, level IIa, selective neck dissection —- Negative for malignancy (0/7)
      • Lymph node, right neck, level I, selective neck dissection —- Negative for malignancy (0/5)
      • Submandibular gland, right, excision —- Negative for malignancy
      • Sublingual gland, right, excision —- Negative for malignancy
      • Parapharyngeal space tissue, right, excision —- Negative for malignancy
      • Lymph node, parapharyngeal space tissue, right, excision —- Negative for malignancy (0/1)
      • Prevertebral fascia and muscle, right, excision —- Negative for malignancy
      • Tissue close to skull base, right, excision —- Squamous cell carcinoma
      • Carotid sheath close to skull base, right, excision —- Squamous cell carcinoma
      • Prevertebral tissue close to carotid artery, right, excision —- Squamous cell carcinoma
      • F2023-00085
        • FsA: Carotid sheath, biopsy — Negative for malignancy
        • FsB: Superior margin, biopsy — Negative for malignancy
        • FsC: Medial margin, biopsy — Negative for malignancy
        • FsD: Inferior margin, biopsy — Negative for malignancy
        • FsE: Deep margin, biopsy — Squamous cell carcinoma
        • FsF: Carotid sheath close to skull base, biopsy — Squamous cell carcinoma
    • Macroscopic examination
      • Surgical Procedure(s): wide excision
      • Specimen Type:
        • Main location: oropharynx
        • Other part(s) included: Sublingual gland, Parapharyngeal space tissue, Prevertebral fascia and muscle, Tissue close to skull base, Carotid sheath close to skull base, Prevertebral tissue close to carotid artery
        • Lymph node dissection: yes, (specify) III, IIb, IIa, I
      • Specimen Integrity: intact
      • Specimen Size: Greatest dimensions: 3.0 x 2.5 x 2.2 cm
        • Additional dimensions (if more than one part): Sublingual gland: a piece, 2.6 x 2.0 x 1.0 cm; Parapharyngeal space tissue: a piece, 3.3 x 2.6 x 1.4 cm; Prevertebral fascia and muscle: 7 pieces, measuring up to 2.2 x 2.0 x 0.3 cm; Tissue close to skull base: 8 pieces, measuring up to 1.4 x 1.0 x 0.5 cm; Carotid sheath close to skull base: 4 pieces, measuring up to 1.5 x 0.4 x 0.2 cm; Prevertebral tissue close to carotid artery: multiple pieces, measuring up to 1.5 x 0.9 x 0.7 cm
      • Depth of invasion: 6 mm
      • Tumor Site: oropharynx
        • Laterality: right  
      • Tumor Focality: single focus with involving several areas, (specify) Tissue close to skull base, Carotid sheath close to skull base, Prevertebral tissue close to carotid artery
      • Tumor Size: Greatest dimension: 1.8 x 1.0 cm
        • Additional dimensions (if available): not applicable
      • Mucosal Surface: Intact
      • Gross Tumor Extension: (specify) Tissue close to skull base, Carotid sheath close to skull base, Prevertebral tissue close to carotid artery
      • Representative sections are taken and labeled as: A: lymph node, level III; B: lymph node, level IIb; C: lymph node, level IIa; D1: submandibular gland; D2-3: lymph node, level I; E: sublingual gland; F1-2: Parapharyngeal space tissue; G1-2: through section from superior (ink green) to inferior (ink blue); G3: anterior margin; G4: posterior margin; H: Prevertebral fascia and muscle; I: Tissue close to skull base; J: Carotid sheath close to skull base; K: Prevertebral tissue close to carotid artery.
        • F2023-00085
          • A: Specimen submitted in fresh and labeled as “Carotid sheath” consists of 2 pieces of tan, irregular tissue measuring up to 0.5 x 0.4 x 0.3 cm. All for section in one cassette FsA1.
          • B: Specimen submitted in fresh and labeled as “Superior margin” consists of a piece of tan, irregular tissue measuring 1.4 x 0.6 x 0.3 cm. All for section and inked green in one cassette FsA1.
          • C: Specimen submitted in fresh and labeled as “Medial margin” consists of a piece of tan, irregular tissue measuring 2.1 x 1.3 x 0.4 cm. All for section and inked purple in one cassette FsA1.
          • D: Specimen submitted in fresh and labeled as “Inferior margin” consists of a piece of tan, irregular tissue measuring 1.4 x 0.5 x 0.3 cm. All for section in one cassette FsA2.
          • E: Specimen submitted in fresh and labeled as “Deep margin” consists of a piece of tan, irregular tissue measuring 1.6 x 0.6 x 0.3 cm. All for section and inked green in one cassette FsA2.
          • F: Specimen submitted in fresh and labeled as “Carotid sheath close to skull base” consists of several pieces of tan, irregular tissue measuring up to 0.4 x 0.2 x 0.2 cm. All for section and inked purple in one cassette FsA2.
    • Microscopic examination
      • Histologic Type: Squamous cell carcinoma, The immunohistochemical stain of p16 is negative.
      • Histologic Grade: G2: Moderately differentiated,
      • Microscopic Tumor Extension: (specify) Tissue close to skull base, Carotid sheath close to skull base, Prevertebral tissue close to carotid artery
      • Margins (obtained from the main resection specimen):
        • F2023-00085: Deep margin involved by invasive carcinoma
        • S2023-03886: Anterior resection margin: 1.2 cm; Posterior resection margin: 0.2 cm; Superior resection margin: 0.4 cm; Inferior resection margin: 0.2 cm
      • Lymph-Vascular Invasion: present
      • Perineural Invasion: not identified
      • Neck Lymph Nodes: please see diagnosis
        • Ipsilateral: Number examined: 24; Number involved: 0
        • Contralateral (if available): not received
        • Size (greatest dimension) of largest metastatic deposit: not identified
        • Extranodal extension: not identified
      • F2023-00085
        • Sections of specimens A, B, C and D are free of malignnacy. Sections of specimens E and F show invasive squamous cell carcinoma.
  • 2023-03-03 Frozen section
    • Preliminary diagnosis:
      • FsA: Carotid sheath, biopsy — Negative for malignancy
      • FsB: Superior margin, biopsy — Negative for malignancy
      • FsC: Medial margin, biopsy — Negative for malignancy
      • FsD: Inferior margin, biopsy — Negative for malignancy
      • FsE: Deep margin, biopsy — Squamous cell carcinoma
      • FsF: Carotid sheath close to skull base, biopsy — Squamous cell carcinoma
  • 2023-01-16 Patho - larynx biopsy
    • PATHOLOGIC DIAGNOSIS
      • R’t pyriform sinus, anterior wall, LMS — Benign squamous epithelium
      • Tumor, right posterior oropharyngeal wall, excision — Squamous cell carcinoma
    • MICROSCOPIC EXAMINATION
      • R’t pyriform sinus anterior wall: benign squamous epithelium without underlying stromal tissue included
      • Right posterior oropharyngeal wall tumor: squamous cell carcinoma with moderate differentiation characterized by solid tumor nests infiltration with focal keratin formation, perineural invasion, tumor emboli and ulceration. Besides, unlabelled peripheral margin and deep margin are involved by tumor. Follow up
  • 2023-01-11 PET scan
    • The right oropharynx wall lesion shown on the previous larynx MRI reveals glucose hypermetabolism, indicating highly suspected tumor recurrence. Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in the left lower lung, probably inflammation precess, suggesting follow-up.
    • Glucose hypermetabolism in bilateral pulmonaty hilar lymph nodes, and right mediastinal lymph nodes, probably reactive nodes.
    • Increased FDG uptake at bilateral shoulders, probably benign in nature.
    • Increased FDG accumulation in both kidneys and colon, probably physiological uptake of FDG.
    • Right pyriform sinus cancer s/p treatment with highly suspected tumor recurrence in the lateral wall of the right oropharynx, rcTxN0M0, by this F-18 FDG PET scan.
  • 2023-01-09 MRI - larynx
    • Comparison: 2022/10/04, 2022/06/28, 2021/01/25 Neck CT, 2021/0929 MRI
      • No obvious local recurrent right hypopharynx mass or nodule. -Highly suspected tumor recurrence in right oropharynx wall, and recrurent LAP at right carotid space with well post contrast enhancement.
        -No obvious right hypopharynx mass or nodule. -Post OP at right submandiublar gland and LNs. -Small left level I-II LNs. -Dental caries? in left low jaw with signal intensity change of the mandible bone, stationary.
        -A small right maxillary sinus retention cyst or mucocele, stationary.
    • IMP:
      • No obvious local recurrent right hypopharynx mass or nodule.
      • Highly suspected tumor recurrence in right oropharynx wall, and recrurent LAP at right carotid space.
  • 2023-01-07 CT - chest
    • Indication: pyriform sinus cancer s/p OP and CCRT
    • Chest CT with and without IV contrast ehnancement shows:
      • s/p left lower lobe op.
      • Calcified coronary arteries is found.
      • Subpleural nodular lesion at left upper lobe measuring 0.89cm is found. In comparison with CT dated on 2022-07-07, the lesion is stationary. Smaller lesion at left upper lobe measuring 0.4cm is found.
      • Calcified dot at right upper lobe measuring 0.3cm is found.
    • Imp:
      • Left upper lobe nodules. 0.4cm to 0.89cm, stationary.
      • Right upper lobe calcified dot.
      • s/p left lower lobe op.
  • 2022-10-11 CT - chest
    • two LLL solid nodules (up to 9mm) stationary.
    • RUL granuloma 3mm.
  • 2022-10-04 MRI - larynx
    • No obvious right hypopharynx mass or nodule. No evidence of tumor recurrence. No neck LAP.
  • 2022-08-03 Patho - larynx biopsy
    • Labeled as “superior part of lesion, right”, Oral tumor or oropharynx excision — ulcer with benign squamous mucosa.
    • Labeled as “inferior part of lesion, right”, Oral tumor or oropharynx excision — fibrotic necrotic tissue.
  • 2022-07-20 Patho - larynx biopsy (Y1)
    • Labeled as “right pyriform sinus”, excision with frozen section for margins (F2022-336FSA) — squamous cell carcinoma. 1 mm from all margins. IHC stain: p16 (-).
  • 2022-07-07 CT - chest
    • Left upper lobe perifissural nodule. 1.04cm, aolid nodule. 3mm, these two nodules are stationary.
  • 2022-06-28 MRI - larynx
    • The current study was compared to the prior one obtained on 2022/04/01.
    • Known a case of right pyriform sinus cancer S/P CCRT. Still effacement of right pyriform sinus with mild mucosal thickening. Suggest clinical correlation.
  • 2022-04-01 MRI - larynx
    • No obvious recurrent hypopharyngeal tumor in this study.
    • A 1.0cm enhancing lesion at the left mandible, stationary. Dental problem or other etiology? Suggest close follow up.
  • 2022-01-05 CT - chest
    • two solid nodules in LLL (9 mm, 4 mm) and a LUL solid nodule 3 mm, suggest f/u at 6-12 months later.
    • RUL granuloma 3 mm.
  • 2021-12-30 MRI - larynx
    • No obvious right hypopharynx mass or nodule.
    • Post OP at right submandiublar gland and LNs.
  • 2021-10-20 Patho - lung wedge biopsy
    • Lung, left lower lobe, VATS LLL wedge — Lymphoid hyperplasia
    • IHC stain — CK(-)
  • 2021-10-06 CT - chest
    • RUL tiny granuloma. Two LLL solid nodules 9 mm and 4 mm. suggest f/u at 6 months with CT.
  • 2021-09-29 MRI - larynx
    • a heterogeneous enhancing lesion at the left mandibular alveolar region, stationary.
  • 2021-09-03 CT - brain
    • Brain atrophy.
    • Chronic maxillary sinusitis.
  • 2021-09-03 ECG
    • Normal sinus rhythm with sinus arrhythmia
    • T wave abnormality, consider inferior ischemia
    • Abnormal ECG
  • 2021-06-09 MRI - larynx
    • a heterogeneous enhancing lesion at the left mandibular alveolar region.
  • 2021-04-28 Endoscopic radiofrequency ablation
    • Indication: Esophageal high grade dysplasia
    • Anesthesia: Dormicum + alfentanil + propofol titrated given
    • Procedure: Endoscopic radiofrequency ablation with catheter type RFA catheter
    • Course:
      • Radiofrequency Ablation is performed with TTS type 90 RFA catheter. After Lugol soln (1.5%) spraying, leopard spots scattering at the whole esophagus was noted. Three Lugol-voiding lesions needed to be ablated.
      • Three lesions are localized at the 37 cm, 30cm and 25 cm.
      • The procedure is done with ablation -ablation-clean- ablation-ablation mode with energy 12 jouls delivered.
    • Other finding
      • Short mucosal breaks noticed at the lower esophagus.
    • Diagnosis
      • Esophageal carcinoma in situ s/p RFA
      • Reflux esophagitis Gr.A
    • Suggestion
      • PPI & sucrafate use
    • Complication
      • No immediate complication
  • 2021-04-09 Tc-99m MDP bone scan
    • Increased activity in the lower C-spine. Degenerative change may show this picture.
    • Increased activity in the maxilla and left aspect of mandible. The nature is to be determined (dental problem? other nature?). Please correlate with other clinical findings for further evaluation.
    • Some hot and faint hot spots in the skull. The nature is to be determined (post-traumatic change? other nature?). Please correlate with the clinical history and follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
  • 2021-04-06 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 24 dB HL; LE 20 dB HL.
    • R’t normal to severe SNHL.
    • L’t normal to moderate SNHL
  • 2021-03-23 MRI - larynx
    • Comparison: 2021/01/25 Neck CT
      • Poor defined right hypopharynx mass or nodule.
      • Post OP at right submandiublar gland and LNs.
      • Small left level I-II LNs.
      • Dental caries? in left low jaw with signal intensity change of the mandible bone.
      • A small left oropharynx wall LN?
      • Suggest clinical correlation.
  • 2021-03-17 Patho - larynx biopsy
    • Labeled as “right AE fold”, biopsy — squamous cell carcinoma.
    • IHC stains: CK5/6 (+), p40 (+), p16 (-)
  • 2021-02-26 PET
    • A prominent glucose hypermetabolic lesion in the left aspect of mandible. Either dental problem or malignancy may show this picture. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the right aspect of the hypopharynx, right aspect of the soft palate, right tonsil, some bilateral neck level II lymph nodes and a left submandibular lymph node. The nature is to be determined (inflammatory process? other nature?). Please also correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the right submandibular area, compatible with post-operative inflammation.
    • Increased FDG accumulation in both kidneys and colon. Physiological FDG accumulation is more likely.
  • 2021-02-19 Patho - salivary gland resection
    • Lymph nodes, submandibular gland, right, excision — Squamous cell carcinoma, metastatic; p16(-)
    • The sections show a picture of squamous cell carcinoma, metastatic, composed of nests of moderately differentiated neoplastic squamous cells in lymphoid tissue. Keratin formation, focal tumor necrosis, and extranodal extension are evident. The surgical margin is free of carcinoma.
    • IHC: p16(-).
  • 2021-01-25 CT - neck
    • IMP: An ill-defined tumor mass in middle posterior part of right submandibular gland, at least, up to 3.1 cm.
    • Imaging Report Form for major salivary gland malignancy
    • Impression (Imaging stage): T:T2(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IVA (Stage_value)

[MedRec]

  • 2023-04-13 SOAP Hemato-Oncology
    • Waiting for the result of PD-L1 -> Consider IO-based Tx -> Due to trail started since 2023-07, already suggest patient start PF. But patient would like to get better performance status.
  • 2023-03-23 SOAP Hemato-Oncology
    • Waiting for the result of PD-L1 -> Consider IO-based Tx
  • 2021-03-23 SOAP Hemato-Oncology
    • Conclusions of the Multidisciplinary Cancer Team Meeting, meeting date 20210305
      • It is recommended to arrange an MRI examination.
      • Seek the opinion of the original ENT doctor.
      • Further search for the primary (source of cancer).

[consultation]

  • 2023-03-18 Hemato-Oncology
    • Q
      • for chemotherapy
      • This 54 y/o man had history of DM and hypopharyngeal cancer s/p op + CCRT in 2021. Under the impression of right oropharyngeal cancer, he was admitted and received tumor excision + right neck disection + tracheostomy + flap reconstruction on 20230303 to 20230304. He was tranfered to SICU for intensive care on 2023/03/04 to 2023/03/06. After wound condition stable, he was transferred to our service on 20230309. Tracheostomy removed on 20230313. Remove neck suture wound on 20230317. Today, tumor board meeting discussion, which suggest chemotherapy. We need yor help for further evaluation and management. Thank you very much!!
    • A
      • Due to RT treatment history, the dose of RT in the patient is limitation. Systemic therapy is indicated in the patient (Ex: immuno, chemo…). We will also discuss with patient about clinical trial (head and neck cancer with IO naive). Please arrange our OPD after discharge. Thanks for your consultation.
  • 2023-03-16 Dermatology
    • Q
      • for right face some rash with itching
      • This 54 y/o man had history of DM and hypopharyngeal cancer s/p op + CCRT in 2021. Under the impression of right oropharyngeal cancer, he was admitted and received tumor excision + right neck disection + tracheostomy + flap reconstruction on 20230303 to 20230304. He was tranfered to SICU for intensive care on 2023/03/04 to 2023/03/06. After wound condition stable, he was transferred to our service on 20230309. Tracheostomy removed on 20230313, and keep neck wound care. Right face some rash with itching was found on 20230315. We need yor help for further evaluation and management. Thank you very much!!
    • A
      • The patient had sufferred from erythematous plaques with fine scales over face and chin
      • Under the impression of seborrheic dermatitis over face.
      • The following sugeetion:
        • Betason-N onit 1 tube topical bid use first on the wound and curst lesions first.
        • Mycomb cream 1tube topical bid use over large erytheamtous papules and plaques area on the face.
        • If still itchy or spreading erythema, consider Rinderon cream 1 tube topical QN use (depends on the situation, only needed on areas with red and scaly skin, strengthen locally).
  • 2021-05-28 Radiation Oncology
    • A: Squamous cell carcinoma of right hypopharynx (pyriform sinus), , p16 (-), stage cT2N2bM0 (IVA), s/p induction chemotherapy.
    • P: Radiotherapy is indicated for this patient with the following indicators: hypopharygeal cancer, stage cT2N2bM0 (IVA)
      • Goal: curative
      • Treatment target and volume: right hypopharyngeal cancer to bilateral neck,
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5000cGy/25 fractions of the bilateral neck, and 7000cGy/35 fractions of the right hypopharyngeal tumor bed to involved neck nodal lesions.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy. The treatment planning of radiotherapy will be started at 10AM, 2021-6-2.

[chemotherapy]

  • 2023-05-30 - cisplatin 75mg/m2 120mg NS 500mL 24hr D1 (Y site 5-FU) + [magnesium sulfate 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL D1-4
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-30 - cisplatin 75mg/m2 120mg NS 500mL 24hr D1 (Y site 5-FU) + [magnesium sulfate 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL D1-4
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-07-27 - carboplatin AUC 2 150mg D5W 250mL 2hr + NS 1000mL (Y site carboplatin)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-07-20 - carboplatin AUC 2 150mg D5W 250mL 2hr + NS 1000mL (Y site carboplatin)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-07-13 - cisplatin 40mg/m2 70mg NS 500mL 3hr + NS 1000mL (Y site cisplatin)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-07-06 - cisplatin 40mg/m2 70mg NS 500mL 3hr + NS 1000mL (Y site cisplatin)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-06-29 - cisplatin 40mg/m2 70mg NS 500mL 3hr + NS 1000mL (Y site cisplatin)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-06-22 - cisplatin 40mg/m2 70mg NS 500mL 3hr + NS 1000mL (Y site cisplatin)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-06-15 - cisplatin 40mg/m2 70mg NS 500mL 3hr + NS 1000mL (Y site cisplatin)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-05-27 - docetaxel 75mg/m2 130mg NS 250mL 1hr + cisplatin 75mg/m2 130mg NS 500mL 24hr (Y site 5-FU) + fluorouracil 750mg/m2 1300mg NS 500mL 24hr D1-5
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-05-03 - docetaxel 75mg/m2 130mg NS 250mL 1hr + cisplatin 75mg/m2 130mg NS 500mL 24hr (Y site 5-FU) + fluorouracil 750mg/m2 1300mg NS 500mL 24hr D1-5
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-04-10 - docetaxel 75mg/m2 130mg NS 250mL 1hr + cisplatin 75mg/m2 130mg NS 500mL 24hr (Y site 5-FU) + fluorouracil 750mg/m2 1300mg NS 500mL 24hr D1-5
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-05-31

Based on the PharmaCloud database, this patient has only sought medical care at our hospital in the past three months. On 2023-05-27, our metabolic physician recently prescribed refillable medications including Uformin (metformin), Trajenta (linagliptin), Lipanthyl (fenofibrate), and Zulitor (pitavastatin). These drugs have been correctly integrated into the current active medication list without any issues in medication reconciliation.

700647993

230530

[exam findings]

  • 2023-05-29 CT - abdomen
    • Clinical information: 1) High grade serous carcinoma of fallopian tube with peritoneal metastasis and pleural effusion with positive cytology, cT3N0M1 stage IV, post debulking surgery + Hyperthermic Intraperitoneal Chemotherapy on 2023/04/24. 2) GERD. 3) HTN
    • The CT scan of the whole abdomen was performed without/with IV contrast medium enhancement and revealed that:
      • Known a case of fallopain tube cancer with peritoneal carcinomatosis S/P operation and chemotherapy. No presence of recurrent or residual tumor.
      • The both kidneys show normal contrast excretion, size, and contour without evidence of renal stone or tumors.
      • The liver parenchyma reveals no evidence of focal lesion.
      • The gallbladder is normal in size and wall thickness.
      • The pancreas & spleen appears normal in size and contour.
      • There is fecal materials impaction in the sigmoid colon and rectum.
  • 2023-04-26 CXR
    • Bilateral parahilar infiltrates with blunting of left costophrenic angle, r/o lung edema. Progression as compare with CXR on 2023-04-24. suggest clinical correlation.
    • Mild cardiomegaly.
  • 2023-04-25 Patho - uterus (with or without SO) neoplastic
    • Diagnosis:
      • Ovary, bilateral, oophorectomy —- high grade serous carcinoma, metastatic
      • Fallopian tube, right, salpingectomy —- high grade serous carcinoma, metastatic, tumor seeding on serosa
      • Fallopian tube, left, residual, salpingectomy —- high grade serous carcinoma, metastatic, tumor seeding on serosa, s/p salpingectomy (S2023-01126)
      • Uterus, corpus, total hysterectomy —- negative for malignancy
      • Uterus, cervix, total hysterectomy —- negative for malignancy
      • Lymph node, left external ilaic, dissection —- high grade serous carcinoma, metastatic (1/8)
      • Lymph node, left obturator, dissection —- high grade serous carcinoma, metastatic (1/11)
      • Lymph node, right external ilaic, dissection —- high grade serous carcinoma, metastatic (1/9)
      • Lymph node, right obturator, dissection —- negative for malignancy (0/13)
      • Lymph node, left para-aortic, dissection —- high grade serous carcinoma, metastatic (2/20)
      • Lymph node, right para-aortic, dissection —- high grade serous carcinoma, metastatic (1/7)
      • Soft tissue on intestine, excision —- high grade serous carcinoma, metastatic
      • Omentum, omentectomy —- high grade serous carcinoma, metastatic
      • AJCC 8th edition: ypStage IIIC, ypT3cN1a(if cM0), FIGO Stage IIIAIi or ypStage IVA, ypT3cN1aM1a (pleural effusion with positive cytology), FIGO Stage: IVA; please correlate with the clinical presentation and image study.
    • Gross description:
      • Procedure (select all that apply): Debulking surgery (ATH + BSO + Cytoreduction surgery + bilateral pelvic & paraaortic lymphadectomy + infracolic omentectomy); No appendix is received
    • Microscopic Description:
      • Histologic Type: High-grade serous carcinoma
      • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors): not applicable
      • Implants (required for advanced stage serous/seromucinous borderline tumors only)
        • Serous tumor implants that were formerly classified as “invasive implants” are now classified as low-grade serous carcinoma of the peritoneum.: Present (specify sites): soft tissue on intestine and omentum
      • Other Tissue/ Organ Involvement (select all that apply): bilateral ovary, bilateral fallopian tube, soft tissue on intestine and Omentum
      • Largest Extrapelvic Peritoneal Focus (required only if applicable): Macroscopic (greater than 2 cm) (omentum)
      • Peritoneal/Ascitic Fluid: N2023-01554: Atypical
      • Regional Lymph Nodes: please see diagnosis;
      • Additional Pathologic Findings: endometrial polyp, adenomyoma and leiomyomas are seen.
  • 2023-04-20 CT - abdomen
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A tumor (3.6cm) at uterur. Some soft tissues in peritoneal cavity. A cystic lesion (3.1x6.1cm) at pelvic cavity.
      • Bil. pleural effusions.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • Peritoneal carcinomatosis.
      • A tumor (3.6cm) at uterus. A cystic lesion (3.1x6.1cm) at pelvic cavity.
      • Bil. pleural effusions.
  • 2023-03-27 CXR
    • Right Pleura effusion.
  • 2023-02-03 CXR
    • Bilateral Pleura effusion.
  • 2023-01-26, -01-23, -01-19 CXR
    • S/P port-A implantation.
    • Bilateral Pleura effusion S/P pigtail catheter implantation at right CP angle.
    • Borderline cardiomegaly
    • Hypoinflation of both lung is noted.
  • 2023-01-20 SONO - breast
    • diagnosis: no mass lesion
    • BI-RADS: 1. negative
  • 2023-01-17 Patho - fallopian tube biopsy
    • Peritoneum, biopsy — high grade serous carcinoma, metastatic, consistent with fallopian tube origin
    • Section shows fibrous tissue with metastatic high grade serous carcinoma.
    • The immunohistochemical stains reveal PAX8(+), WT-1(focal +), p53(aberrant expression present), PR(-), CD56(focal +), p40(-).
    • The results are consistent with metastatic high grade serous carcinoma from fallopian tube. Focal neuroendocrine feature can not be excluded.
  • 2023-01-17 Patho - fallopian tube biopsy
    • Fallopian tube, left, salpingectomy — high grade serous carcinoma
    • Section shows fallopian tube with high grade serous carcinoma arising from fimbriae.
    • The immunohistochemical stains reveal CK(+) and PAX8(focal +).
    • Tumor seedings on serosa are seen.
  • 2023-01-16 Body fluid cytology - ascites
    • cell block cytology: Malignancy
    • The immunohistochemical stains reveal CK(+), CK7(+), CK20(-), TTF-1(-), Napsin A(-), Calretinin(-), GATA3(-), CDX2(-), and PAX8(equivocal). There are no conclusive results. Please correlate with the clinical presentation for tumor origin.
    • Smears and cell block show clusters of pleomorphic tumor cells and focal glandular pattern. Metastatic adenocarcinoma is favored.
  • 2023-01-12 MRI - brain
    • NO evidence of brain metastasis.
  • 2023-01-11 Whole body PET scan
    • Glucose hypermetabolism in the T-colon, the nature is to be determined (benign or malignant neoplasm, s/p colon fibroscopy change or other nature ?), suggesting further investigation.
    • Glucose hypermetabolism in the right lobe of the liver and in some right subphrenic lymph nodes, malignnacy with distant metastases should be considered.
    • Glucose hypermetabolism in the spleen, the nature is to be determined also, suggesting further investigation.
    • Increased FDG uptake in the uterus, malignancy should be considered, suggesting pelvis CT or MRI for further investigation.
    • No prominent abnormal focal FDG uptake is noted elsewhere.
  • 2023-01-10 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the lower L-spines, L5-sacrum junction, bilateral shoulders, hips and feet in whole body survey.
    • IMPRESSION:
      • Increased activity in the lower L-spines and L5-sacrum junction. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
      • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, hips and feet, compatible with benign joint lesions.
  • 2023-01-10 Patho - stomach biopsy
    • Stomach, body, biopsy — Hyperplastic polyp
  • 2023-01-10 Patho - colon biopsy
    • Colorectum, rectum. Cold snaring polypectomy (A) — Tubular adenoma with low grade dysplasia
    • Colorectum, descending colon. Cold snaring polypectomy (B) — Tubular adenoma with low grade dysplasia
  • 2023-01-09 CT - chest
    • favor peritonei carcinomatosis, cause and origin to determined.
    • no lung nodule or mass.
  • 2023-01-05 Body fluid cytology - ascites
    • The immunohistochemical stains reveal CK(+), CK7(+), CK20(-), TTF-1(-), Napsin A(-), Calretinin(-), GATA3(-), CDX2(-), and PAX8(equivocal). There are no conclusive results. Please correlate with the clinical presentation for tumor origin.
    • Smears and cell block show clusters of pleomorphic tumor cells and focal glandular pattern. Metastatic adenocarcinoma is favored.

[surgical operation]

  • 2023-01-17
    • Surgery
      • Diagnosis: peritoneal cacinomatosis
      • Operation: SILS left salpingectomy     
    • Finding
      • Uterus: AVF, adhesion to uterus, with mural mass on the surface
      • Adnexae: adhesion to pelvix wall, with mural mass on the surface of tube
      • Bil ovary : graossly normal
      • Cul-de-sac: with ascites, about 3000ml
      • peritoneal carcinomatosis noted, multiple tumors between omentum and bowels
      • Estimated blood loss: minimal
      • Blood transfusion: nil
      • Complication: nil  

[chemotherapy]

  • 2023-05-16 - paclitaxel 135mg/m2 260mg NS 300mL 3hr + carboplatin AUC 5 800mg NS 250mL 2hr + [paclitaxel 40mg/m2 77mg + cisplatin 30mg/m2 58mg + gentamicin 40mg + sodium bicarbonate 2800mg NS 800mL] IP 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + NS 500mL pre-C/T + NS 500mL post-C/T
  • 2023-04-23 - [Liposome doxorubicin 30mg/m2 60mg D5W 250mL 90min + carboplatin AUC 5 700mg NS 250mL] IP (HIPEC)

  • 2023-03-28 - paclitaxel 175mg/m2 345mg NS 300mL 1hr + carboplatin AUC 5 750mg NS 250mL 2hr

    • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-03-07 - paclitaxel 175mg/m2 345mg NS 300mL 1hr + carboplatin AUC 5 750mg NS 250mL 2hr

    • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-02-09 - paclitaxel 175mg/m2 345mg NS 300mL 1hr + carboplatin AUC 5 750mg NS 250mL 2hr

    • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-01-20 - paclitaxel 175mg/m2 360mg NS 300mL 1hr + carboplatin AUC 5 740mg NS 250mL 2hr

    • dexamethasone 8mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

701182498

230530

[exam findings]

  • 2023-05-29 CXR
    • There are few nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    • Borderline cardiomegaly
  • 2023-04-19 CT - abdomen
    • History and indication: Endometrial CA s/p TAH + BSO + BPLND and para-aortic LND on 20190612, pT2N1a(cM0), stage III & s/p CCRT.
      • 20230104 chest CT: bilateral pulmonary metastases and mediastinal and hilar LNs metastases, in progression as compared with CT on 2022/11/10
    • MD CT (Revolution) of the chest, abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images with axial and coronal reformatted isotropic images were obtained in non-contrast scan and portal venous phase scan after IV contrast injection.
    • FINDINGS: Comparison: prior chest CT dated 2023/01/04.
      • Prior CT identified bilateral pulmonary metastases are noted again, decreasing in size that is c/w lung metastases S/P C/T with partial response.
        • In addition, Prior CT identified mediastinal and hilar LNs metastases are noted again, decreasing in size that is c/w mediastinal and hilar LNs metastases S/P C/T with partial response.
      • S/P hysterectomy
      • Left renal angiomyolipoma 1.3 cm is noted.
      • Few small gallstones are noted.
    • IMP:
      • Lung metastases S/P C/T show partial response.
      • Mediastinal and hilar LNs metastases S/P C/T show partial response.
  • 2023-03-19 CXR
    • One nodular opacity over right middle lung zone.
  • 2023-02-06 CXR
    • There are few nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
  • 2023-01-04 CT - chest
    • Indication: endometrioid adenocarcinoma, pTNM: pT2N1a(cM0), stage III s/p TAH + BSO + BPLND and para-aortic LND, recurrent lung mets
    • Comparison was made with previous CT dated on 2022/11/10
      • Lungs:
        • s/p op change in left upper and lower lobes.
        • multiple solid nodules in bilateral lungs up to 23mm at RLL
        • consistent with metastatic tumors.
      • Mediastinum and hila: metastatic LAP at Lt hilum and Lt
      • Pleura: unremarkable.
      • Visible abdominal contents: a left renal angiomyolipoma (7 mm) and a few tiny stone in the gallbladder. unremarkable of the liver, spleen, adrenal glands, pancreas, and Rt kidney. no enlarged lymph node.
      • Visualized bones: unremarkable.
    • Impression:
      • bilateral pulmonary metastases and mediastinal and hilar LNs metastases, in progression as compared with CT on 2022/11/10
  • 2023-01-03 CXR
    • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
  • 2022-11-28 CXR
    • Solitary pulmonary nodule at bil. lungs.
  • 2022-11-10 CT - chest
    • Indication: Malignant neoplasm of endometrium; Sleep disorder, unspecified
    • Chest:
      • Nodular lesions are found at both lungs up to 1.84cm in largest dimension. In comparison with CT dated on 2022-04-07, the lesions are enlarged.
      • No evidence of bilateral pleural effusion.
    • Visible abdomen:
      • There is stone at dependent portion of GB. GB stone(s) are noted.
      • Fat containing tumor at middle zone of left kidney up to 1.0cm in largest dimension. Angiomyolipoma.
    • Imp: Nodular lesions are found at both lungs. In enlargement. Lung meta is favored.
  • 2022-11-01 CT - abdomen
    • Clinical history: 42 y/o female patient with endometrioid adenocarcinoma, pTNM: pT2N1a(cM0), stage III s/p TAH + BSO + BPLND and para-aortic LND on 6/12 19 s/p CCRT
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P hysterectomy.
      • Fatty content tumor, 1.5cm in left kidney, r/o renal AML.
      • Presence of gallbladder stones.
      • Bilateral lower lung tumors, up to 1.5cm in left lower lung, r/o lung metastasis.
    • Impression:
      • S/P hysterectomy.
      • Left renal AML.
      • Gallbladder stones.
      • Bilateral lung tumors, r/o lung metastasis.
  • 2022-08-09 SONO - abdomen
    • Few gallstones are noted and the size < 1 cm.
    • Angiomyolipoma 1.37 cm in left kidney middle pole.
  • 2022-04-07 CT - chest
    • Left renal angiomyolipoma.
    • s/p right upper lobe and left lower lobe op.
    • There is no evidence of recurrent/residual tumor in the study.
  • 2022-03-08 CT - abdomen
    • S/P hysterectomy. A nodule (4mm) at left lower lung. R/O left renal angiomyolipoma (9mm). Small gallbladder stones (2-4mm).
  • 2021-12-17 CT - abdomen
    • S/P hysterectomy. There is no evidence of tumor recurrence.
  • 2021-09-03 CT - abdomen
    • S/P hysterectomy. There is no evidence of tumor recurrence.
    • Prior CT identified few small nodules in bilateral lower lung are not noted in the current CT. Follow up chest CT 3 months later is indicated.
  • 2021-07-27 CT - chest
    • endometrial CA recurrence wt lung mets s/p C/T.
    • Comparison made with previous CT dated on 2021/6/12
      • Lungs:
        • s/p op change in left upper and lower lobes.
        • multiple solid nodules in bilateral lungs up to 10 mm at LLL
        • consistent with metastatic tumors.
      • Mediastinum: no enlarged LN or mass.
        • the trachea and main bronchi are normallly identified without endobronchial lesion.
      • Hila: unremarkable.
      • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
      • Chest wall: unremarkable.
      • Visible abdominal contents: a left renal angiomyolipoma (7 mm) and a few tiny stone in the gallbladder. unremarkable of the liver, spleen, adrenal glands, pancreas, and Rt kidney. no enlarged lymph node.
      • Visualized bones: unremarkable.
    • Impression:
      • bilateral pulmonary metastases are still visible.
  • 2021-06-12 CT - chest
    • Indication: Endometrioid adenocarcinoma, Grade 2, pTNM: pT2N1a(cM0), FIGO stage IIIC1 s/p TAH + BSO + BPLND and recurrent lung mets S/P op
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
        • s/p left upper lobe and left lower lobe op.
        • Minimal fobritc like change at right upper lobe is found. In comparison with CT dated on 2021-01-06, the lesion regressed markedly.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • s/p ATH and BSO.
        • There is no ascites accumulation at abdominal cavity.
        • No evidence of abnormal soft tissue mass at pelvic cavity.
        • No definite inguinal or pelvic sidewall LAP
    • Imp:
      • s/p ATH and BSO.
      • s/p left upper lobe and left lower lobe op.
      • Regression of right upper lobe and right middle lobe nodules.
  • 2021-01-26 Patho - lung wedge biopsy
    • Lung, left, lower lobe, wedge resection —- Consistent with metastatic endometrioid adenocarcinoma
    • Lung, left, upper lobe, wedge resection —- Consistent with metastatic endometrioid adenocarcinoma
    • Histologic Type (select all that apply): Consistent with metastatic endometrioid adenocarcinoma
    • The immunohistocehmical stains reveal CK7(focal +), CK20(-), PAX8(+), PR(-), and TTF-1(-).
    • Histologic Grade: G2: Moderately differentiated
  • 2021-01-25 CXR
    • nodules in both lungs due to metastasis.
    • s/p left chest tube in place, its tip directed superiorly
  • 2021-01-06 CT - chest
    • Findings: multiple solid nodules in bilateral lungs up to 12 mm in LLL, consistent with metastatic tumors.
    • Impression: consistent bilateral pulmonary metastases.
  • 2020-12-17 CT - abdomen
    • Findings
      • Small nodules (4-8mm) at bil. lower lungs.
      • R/O left renal angiomyolipoma (9mm).
      • Small gallbladder stone (4mm).
    • Impression:
      • S/P hysterectomy. Small nodules (4-8mm) at bil. lower lungs r/o metastases.
  • 2020-09-24 SONO - abdomen
    • Sonography of hepatobiliary system revealed:
      • Gallbladder stone (0.61cm).
      • R/O left renal angiomyolipoma (0.94x1.05cm).
    • IMP: gall stone and left renal angiomyolipoma.
  • 2020-05-15 CT - abdomen
    • S/P hysterectomy. There is no evidence of tumor recurrence.
  • 2020-04-10 Treadmill exercise test, TET
    • Resting ECG : Normal
    • ST changes during TET : No significant ST changes
    • Interpretation : negative for ischemia
  • 2020-04-10 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (81.3 - 22.5) / 81.3 = 72.32%
      • M-mode (Teichholz) = 72.3
    • Conclusion:
      • Normal AV with no AR
      • Thickened MV with mild MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • No PR, mild TR, normal IVC size
  • 2019-12-18 CT - abdomen
    • S/P hysterectomy. No evidence of tumor recurrence.
  • 2019-06-19 Phleborheograph (PRG) & Perivasculary doppler flowmetry
    • Doppler study: (N= Normal, A= Abnormal, T= Thrombus)
      • Lower limbs R-CFV R-SFV R-PV R-PTV R-SV L-CFV L-SFV L-PV L-PTV L-SV
      • Spontaneous signal A A A A A A A A A A
      • Respiratory changes N N N N N N N N N N
      • Cough response N N N N N N N N N N
      • Compression study N N N N N N N N N N
    • Findings
      • Thrombus :None
      • Varicose vein :None
    • Conclusion
      • No evidence of DVT, bilateral lower legs
      • Biateral CFV contiunce flow pattern, etiology; upstream stenosis could not be rule out.
  • 2019-06-17 CT - pelvis
    • S/P operation. Some fluid and air collection in pelvic cavity (s/p drainage) and left posterior pararenal space. R/O left renal angiomyolipoma (9mm). Bil. pleural effusion. General subcutaneous edema.
  • 2019-06-12 Surgical pathology Level VI
    • PATHOLOGIC DIAGNOSIS:
      • Uterus, endometrium, total abdominal hysterectomy — endometrioid adenocarcinoma, Grade 2 — pTNM: pT2N1a(cM0) , FIGO stage: IIIC1, pStage IIIC1
      • Uterus, myometrium, total abdominal hysterectomy — involved by endometrioid adenocarcinoma (> 1/2 thickness)
      • Uterus, cervix, otal abdominal hysterectomy — involved by endometrioid adenocarcinoma (stromal connective tissue involvement) — free of lower cervical margin
      • Fallopian tube, bilateral, salpingectomy — negative for malignancy
      • Ovary, bilateral, oophorectomy — negative for malignancy
      • Lymph node, left iliac, dissection — negative for malignancy ( 0 / 1 )
      • Lymph node, left obturator, dissection — positive for malignancy ( 2 / 7 )
      • Lymph node, right iliac, dissection — positive for malignancy ( 2 / 10 )
      • Lymph node, right obturator, dissection — positive for malignancy ( 1 / 4 )
      • Lymph node, left para-aortic, dissection — negative for malignancy ( 0 / 4 )
      • Lymph node, rightt para-aortic, dissection — negative for malignancy ( 0 / 4 )
      • Pathology stage:pTNM: — pTNM: pTNM: pT2N1a(cM0), FIGO stage: IIIC1, pStage IIIC1
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: total abdominal hysterectomy, LN dissection
      • Specimens include: uterus with bilateral adnexae,regional LNs,
      • Tumor site: upper and lower body, fundus and cervix
      • Tumor size: 9x 6 cm
      • The myometrium: Tumor invades more than one-half of myometrium (2 cm)
      • The cervix: free of tumor (0.5 cm away from margin)
      • Adnexa: unremarkable
      • Lymph node: bilateral iliac, obturator and para-aortic LNs are received.
    • MICROSCOPIC EXAMINATION
      • Histology type: endometrioid adenocarcinoma
      • Histology grade: grade 2
      • Depth of invasion: Tumor invades more than one-half of myometrium (2 cm)
      • Lymphovascular invasion: Present
      • The cervical stromal connective involvement: Present
      • Resection margins of the cervix (or vagina): free (0.5 cm)
      • Additional pathologic findings:
        • Endometrial hyperplasia: Absent
        • (squamous) metaplasia: Present
        • adenomyosis: Absent
      • Bilateral adnexa: free of tumor
      • Lymph node metastasis
        • Group as specified No. Positive / No. Total
        • Left iliac ( 0 / 1 )
        • Left obturator ( 2 / 7 )
        • Right iliac ( 2 / 10 )
        • Right obturator ( 1 / 4 )
        • Left para-aortic ( 0 / 4 )
        • Right para-aortic ( 0 / 4 )
        • over all 5 / 30
      • IHC stain — ER(-), PR(-), TTF-1(-), CK20(-), PAX-5(-)
  • 2019-06-10 Surgical pathology Level IV
    • Uterus, endometrium, D&C — Adenocarcinoma
    • Uterus, cervix, biopsy — Adenocarcinoma.
    • IHC stains: (S2019-9114) ER (-, 0%), PR (-, 0%); vimentin (+++), p16 (equivocal 20-60%), CK (+).
  • 2019-06-06 MRI - pelvis
    • Clinical history: 39 y/o female patient with huge cervical mass, R/O myoma or malignancy.
    • WITHOUT enhancement MRI pelvis:
      • There is huge soft tissue tumor (12cm), extention from uterine cavity into the cervical area, can’t rule out malignancy.
      • Minimal ascites.
      • No enlarged lymph node in the pelvic cavity and paraaortic region.
      • Cystic lesion, 1.5cm in right pelvic cavity, r/o lymphocele.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression:
        • Huge soft tissue tumor(12cm), extention from uterine cavity into the cervical area, can’t rule out malignancy.
        • R/O lymphocele in right pelvic cavity, 1.5cm.
      • Clinical proven endometrial malignancy, cstage T2N0Mx.
  • 2019-06-06 Gynecologic ultrasonography
    • R/O Huge cervical mass (58mmx71mm)

[chemotherapy]

  • 2023-04-18 - topotecan 0.6mg/m2 1mg NS 100mL 30min D1-3 + cisplatin 40mg/m2 68mg NS 500mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-06 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + topotecan 0.6mg/m2 1mg NS 100mL 30min D1-3 + cisplatin 40mg/m2 68mg NS 500mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-04 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + topotecan 0.6mg/m2 1mg NS 100mL 30min D1-3 + cisplatin 40mg/m2 68mg NS 500mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-12-03 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2021-11-10 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2021-10-19 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2021-09-28 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2021-09-03 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2021-08-04 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2021-07-13 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-06-11 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-05-03 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-04-08 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-03-15 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr + docetaxel 75mg/m2 126mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-02-23 - bevacizumab 7.5mg/kg 500mg NS 250mL 1.5hr + docetaxel 60mg/m2 100mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-02-10 - paclitaxel 175mg/m2 210mg D5W 250mL 3hr + carboplatin AUC 4 250mg 4hr mannitol 20% 80mL NS 250mL 4hr
    • dexamethasone 5mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2020-01-03 - paclitaxel 175mg/m2 210mg D5W 250mL 3hr + carboplatin AUC 4 250mg 4hr mannitol 20% 80mL NS 250mL 4hr
    • dexamethasone 5mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

[note]

Systemic Therapy for Endometrial Carcinoma - Endometrial Carcinoma - NCCN Clinical Practice Guidelines in Oncology - NCCN Evidence Blocks - Version 2.2023 - April 28, 2023 - ENDO-D

Primary or Adjuvant Therapy (Stage I-IV)

  • Chemoradiation Therapy
    • Preferred Regimens
      • Cisplatin plus RT followed by carboplatin/paclitaxel
  • Systemic Therapy
    • Preferred Regimens
      • Carboplatin/paclitaxel
      • Carboplatin/paclitaxel/pembrolizumab (for stage III-IV tumors, except for carcinosarcoma) (category 1)
      • Carboplatin/paclitaxel/dostarlimab-gxly (for stage III-IV tumors) (category 1)
      • Carboplatin/paclitaxel/trastuzumab (for stage III/IV HER2-positive uterine serous carcinoma)
      • Carboplatin/paclitaxel/trastuzumab (for stage III/IV HER2-positive carcinosarcoma) (category 2B)

Recurrent Disease

  • First-Line Therapy for Recurrent Diseaseh
    • Preferred
      • Carboplatin/paclitaxel (category 1 for carcinosarcoma)
      • Carboplatin/paclitaxel/pembrolizumab (except for carcinosarcoma) (category 1)
      • Carboplatin/paclitaxel/dostarlimab-gxly (category 1)
      • Carboplatin/paclitaxel/trastuzumab (for HER2-positive uterine serous carcinoma)
      • Carboplatin/paclitaxel/trastuzumab (for HER2-positive carcinosarcoma) (category 2B)
    • Other Recommended Regimens
      • Carboplatin/docetaxel
      • Carboplatin/paclitaxel/bevacizumab
    • Useful in Certain Circumstances (Biomarker directed: after prior platinum-based therapy including neoadjuvant and adjuvant)
      • Lenvatinib/pembrolizumab (category 1) for mismatch repair proficient (pMMR) tumors
      • Pembrolizumab for TMB-H or MSI-H/dMMRm tumors
      • Dostarlimab-gxly for dMMR/MSI-H tumors
  • Second-Line or Subsequent Therapy
    • Other Recommended Regimens
      • Cisplatin/doxorubicin
      • Cisplatin/doxorubicin/paclitaxel
      • Cisplatin
      • Carboplatin
      • Doxorubicin
      • Liposomal doxorubicin
      • Paclitaxel
      • Albumin-bound paclitaxel
      • Topotecan
      • Bevacizumab
      • Temsirolimus
      • Cabozantinib
      • Docetaxelf (category 2B)
      • Ifosfamide (for carcinosarcoma)
      • Ifosfamide/paclitaxel (for carcinosarcoma)
      • Cisplatin/ifosfamide (for carcinosarcoma)
    • Useful in Certain Circumstances (Biomarker directed therapy)
      • Lenvatinib/pembrolizumab (category 1) for mismatch repair proficient (pMMR) tumors
      • Pembrolizumabb for TMB-H or MSI-H/dMMR tumors
      • Dostarlimab-gxly for dMMR/MSI-H tumors
      • Larotrectinib or entrectinib for NTRK gene fusion-positive tumors (category 2B)
      • Avelumab for dMMR/MSI-H tumors
      • Nivolumab for dMMR/MSI-H tumors
  • Hormonal Therapy for Recurrent or Metastatic Endometrial Carcinoma
    • Preferred Regimens
      • Megestrol acetate/tamoxifen (alternating)
      • Everolimus/letrozole
    • Other Recommended Regimens
      • Medroxyprogesterone acetate/tamoxifen (alternating)
      • Progestational agents
        • Medroxyprogesterone acetate
        • Megestrol acetate
      • Aromatase inhibitors
      • Tamoxifen
      • Fulvestrant
  • Hormonal Therapy for Uterine Limited Disease Not Suitable for Primary Surgery
    • Preferred Regimens
      • Progestational agents
        • Medroxyprogesterone acetate
        • Megestrol acetate
    • Useful in Certain Circumstances
      • Levonorgestrel intrauterine device (IUD)

==========

2023-05-30

  • According to the PharmaCloud database, the patient has visited a local clinic in Xindian for an unspecified acute upper respiratory infection 4 times in the past 3 months, beginning on 2023-03-15. The patient’s most recent visit was yesterday, on 2023-05-29, during which ibuprofen, dextromethorphan, and pseudoephedrine were prescribed. None of these medications are present on the current active medication list, and the acute upper respiratory infection is not listed in the clinical problem list. Please confirm whether the respiratory symptoms are still present. Thank you!

700762682

230529

[exam findings]

  • 2022-04-13 CT - abdomen, pelvis
    • S/P segmental small intestine resection and side-to-side duodenojejunostomy.
    • There is marked dilatation from the stomach to duodenum.
  • 2021-12-03 Patho - small intestine resection for tumor
    • pathologic diagnosis
      • Jejunum, proximal, segmental resection – Adenocarcinoma, well differentiated
      • Resection margins, segmental resection – Free
      • Lymph nodes, regional and group 12, segmental resection and LN dissection — Negative for malignancy
      • Pathology stage: pT4N0; Stage IIB if cM0
    • microscopic examination
      • Histology: Adenocarcinoma
      • Histology Grade: well differentiated
      • Depth of invasion: To serosa
      • Angiolymphatic invasion: Not identified
      • Perineural invasion: Present
      • Tumor cell budding: intermediate
      • Circumferential (radial) margin: Uninvolved, 5 mm from the margin
      • Lymph node metastasis, mesenteric (11) and LN 12(1): Negative (0/12)
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition) pT4N0, if cM0
      • Type of polyp in which invasive carcinoma arose: Tubular adenoma
      • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • 2021-11-25 Patho - small intestine biopsy
    • Tumor, possibly proximal jejunum, biopsy — Villotubular adenoma with high grade dysplasia
  • 2021-11-23 MRI - liver, spleen
    • Bil. liver hemangiomas (up to 15.5cm). Inviaible left portal vein.
  • 2021-11-17 CT - abdomen, pelvis
    • Huge Hemangioma in S2-3 of the liver with central fibrosis and cystic degeneration is highly suspected.
    • Hemangioma in S4 liver is also suspected.
    • Left lobe portal vein shows small size that may be tumor compression? This feature is relative unusual.
    • Please correlate with MRI to R/O angiosarcoma.
  • 2021-05-20 CT - abdomen, pelvis
    • Left liver hemangioma (15.3cm).
    • S/P hysterectomy? Bil. ovary cysts (up to 3.2cm).
  • 2021-05-12 Peripheral Vascular Test - Vein, lower limbs
    • Conclusion:
      • No evidene of DVT, bilateral lower legs
      • Both LSV and SSV without reflux
      • Right CFV, LSV and DFV, venous pulstile flow pattern, etiology?
      • Both leg MVO/SVC is related low
    • Suggestion:
      • Because of low MVO/SVC and venous pulstile flow pattern; maybe follow up CT to rule out upstream lesion.

[MedRec]

  • 2023-03-28 SOAP Hemato-Oncology
    • O
      • 2023/03/15 Tc-99m MDP whole body bone scan
        • Hot spots in the L4-5 spines, the nature is to be determined (severe DJD or others?), suggesting follow-up with bone scna in 3-6 months for investigation.
        • Suspected benign lesions in both rib cages, maxilla, some lower T-spine, bilateral shoulders, S-I joints, and hips.
      • 2023/03/10 PATHO - peritoneum biopsy
        • R’t ovary tumor, frozen section + RSO — Metastatic adenocarcinoma
        • Pelvic peritoneum, Exp.Lap. — Metastatic adenocarcinoma
    • P
      • Admission for C/T with DFL
  • 2021-12-25 SOAP Hemato-Oncology
    • small bowel adenocarcinoma, pT4N0 cM0, Stage IIB, s/p Op on 20211202.
  • 2019-04-20 SOAP Cardiology
    • Diagnosis
      • Other forms of angina pectoris [I20.8]
      • Heart failure, unspecified [I50.9]
      • Other pulmonary embolism and infarction [I26.99]
      • Autoimmune disease not eleswhere classified [D89.89]
    • Prescription
      • Coxine (isosorbide-5-mononitrate 20mg) 0.5# PRNQD
  • 2019-02-20 SOAP Rheumatology
    • Diagnosis
      • Autoimmune disease not eleswhere classified [D89.89]
      • Arterial embolism and thrombosis of lower extremity [I74.3]
    • Prescription
      • Bokey (aspirin 100mg) 1# QD
      • Plaquenil (hydroxychloroquine 200mg) 1# QD
  • 2019-01-22 SOAP Rheumatology
    • S
      • persistent R’t lower leg swelling pain & soreness
    • Diagnosis
      • Autoimmune disease not eleswhere classified [D89.89]
      • Arterial embolism and thrombosis of lower extremity [I74.3]
  • 2019-01-15 SOAP Rheumatology
    • S
      • Limb swelling & stiffness sensation, high D-dimer was detected in LMC after mycoplasma infection.
      • Family Hx: SLE (her daughter)
      • Allergy: amoxicillin
    • O
      • maculopapules over bilateral palms
    • Diagnosis
      • Autoimmune disease not eleswhere classified [D89.89]

[consultation]

  • 2023-05-25 Diagnostic Radiology
    • Q: This 50-year-old woman patient is a case of Small bowel adenocarcinoma, pT4N0cM0, Stage IIB, s/p left hepatectomy, segmental small intestine resection and side-to-side duodenojejunostomy reconstruction and cholecystectomy on 2021/12/02, s/p adjuvant chemotherapy with FOLFOX finishing in 2022/07/25 (2022/01/03 to 2022/07/25), pelvic cavity metastasis, s/p cytoreductive surgery HIPEC with oxaliplatin, right salpingo-oophorectomy and bilateral ureteral catheterization on 2023/03/09, pT4N0M1, Stage IV s/p palliative chemotherapy with DFL from 2023/04/21. She was admitted for chemotherapy. This time, for Port-A catheter obstruct. Now, for evaluate Antegrade Venograghy. Thank you.
    • A: According to the clinical condition and imaging findings, venography is indicated.
  • 2023-03-07 Urology
    • Q: On 2022/11/15 following abdomen CT showed soft tissue tumor, 3.9cm in right pelvic cavity, r/o metastasis. On 11/25 arrange PET revealed a mild glucose hypermetabolic lesion in the right pelvic cavity. The nature is to be determined (a metastatic lesion of low FDG uptake? other nature?). However, she suffered from RLQ dull pain since 2023/02/08, nausea since yesterday. She also had tenesmus, denied of appetite change, no body weight loss, no tarry nor bloody stool. Abdomen CT was performed which revealed a large tumor (10.2cm) in pelvic cavity r/o tumor seeding on 2023/02/14. Physical examination showed abdomen soft and ovoid, mild tenderness over lower abdominal, no palpable mass. Under impression of pelvic tumor suspect small bowel cancer recurrent, she admitted for surgical intervention. She will receive exploratory laparotomy with pelvic tumor excision +- HIPEC on 2023/03/09. We need your expertise for ureteral catheter insertion. Thanks for your times.
    • A: I will arrange catheter insertion
  • 2023-02-17 Colorectal Surgery
    • Q: Abdomen CT was performed which revealed a large tumor (10.2cm) in pelvic cavity r/o tumor seeding on 02/14. We need your expertise for pelvic tumor evaluation for colonscopy or sigmoidoscopy.
    • A: please arrange colonoscopy (booking time with 3F GI room), thanks a lot!
  • 2023-02-17 Obstetrics and Gynecology
    • Q: On 2022/11/15 following abdomen CT showed soft tissue tumor, 3.9cm in right pelvic cavity, r/o metastasis. On 11/25 arrange PET revealed a mild glucose hypermetabolic lesion in the right pelvic cavity. The nature is to be determined (a metastatic lesion of low FDG uptake? other nature?). However, she suffered from RLQ dull pain since 2023/02/08, nausea since yesterday. She also had tenesmus, denied of appetite change, no body weight loss, no tarry nor bloody stool. Abdomen CT was performed which revealed a large tumor (10.2cm) in pelvic cavity r/o tumor seeding on 02/14. We need your expertise for pelvic tumor for GYN sono evaluation. Thanks for your times.
    • A
      • S
        • This 50 y/o female: 1) Sjogren syndrome; 2) small bowel cancer, pT4N0M0 Stage IIB s/p segmental small intestine resection and side-to-side duodenijejunostomy reconstruction on 2021/12/02 and s/p chemotherapy on 2022/01/03 to 2022/07/05; 3) GYN history of left salpingectomy on 1995, Uterine myoma s/p laparoscopic assisted vaginal hysterectomy on 2017/08/25.
        • She had RLQ pain since 2023/02/08, she denied vaginal bleeding or discharge
        • Pap smear done this year and normal finding was told
      • O
        • 2022/11/15 abdomen CT: soft tissue tumor, 3.9cm in right pelvic cavity, r/o metastasis.
        • 2023/02/14 abdomen CT: A large tumor (10.2cm) in pelvic cavity r/o tumor seeding.
        • 2022/11/25 PET revealed a mild glucose hypermetabolic lesion in the right pelvic cavity
        • Lab:
          • CEA 5ng/mL (2022/11/09)
          • 2023/02/15 WBC 8460, CRP 2.31, Hb 15.6
        • Sono:
          • s/p ATH
          • pelvic mass 113*75mm
          • CDS minimal fluid
      • A
        • Impression: Huge pelvic mass (size 113*75mm), malignancy suspected, tumor seeding cannot be rule out
      • P
        • Suggestion:
          • please f/u tumor marker: CEA, CA199, CA125
          • if operation decided and GYN problem noted, fell free to contact us
  • 2021-12-15 Hemato-Oncology
    • Q
      • For further chemotherapy evaluation
      • This 49 years old female has underlying of (1) autoimmune disease under AIR OPD follow and medication control, (2) liver hamengioma was noted for 3years. According to her statement, body weight loss 20kg within 6 months and anemia (Hb: 12 -> 9g/dL) was noted on Sep 2021. Denied of nausea or vomiting, dysphgia, no diarrhea or constipation, no tarry or bloody stool, no abdomen pain. On 2021/09/28 arrange UGI pendoscopy at a local clinic which showed reflux erosive esophagitis, LA grade A, healing GU s/p biopsy, gastric polyp s/p biopsy, chronic superficial gastritis. The pathology revealed chronic gastritis consistent with healed ulcer and polyp. Colonscopy was done and showed mixed hemorrhoids, rectal polyp, s/p biopsy, patholegy revealed hyperplastic polyp.
      • After UGI scopy examination, she suffered from nausea with vomiting postprandial frequently and easy abdomen fullness. Therefore, she visited to our GI OPD on Nov. Abdomen echo was done which revealed (1) liver hemangioma of left lobe, (2) suspicious GB stone, (3) suspicious SMA syndrome. Abdomen CT was arranged and showed huge hemangioma in S2-3 of the liver with central fibrosis and cystic degeneration is highly suspected. However, pertise of symptoms, she went to our ER for help on 2021/11/22. Admitted for further survey and jejuunum tumor s/p biopsy was done. The pathology revealed Villotubular adenoma with high grade dysplasia. She underwent left hepatectomy, segmental small intestine resection and side-to-side duodenijejunostomy reconstruction and cholecystectomy on 2021/12/02. The final pathology showed adenocarcinoma, well differentiated, lymph node with metastesis, pT4N0; Stage IIB if cM0. We need your expertise for further chemotherapy evaluation. Thanks for your times.
    • A
      • The further Tx for the pt wt small bowel adenocarcinoma, pT4N0 cM0, Stage IIB, s/p Op is to be proposed.
      • PH:
        • autoimmune disease under AIR OPD follow and medication control
        • liver hamengioma was noted for 3years.
      • Lab:
        • Jejunum, proximal, segmental resection (2021/12/02): AdenoCA, WD
        • Resection margins, segmental resection – Free
        • LNs, regional and group 12, seg. Resection & LN dissection: Negative for malignancy
      • Pathology stage: pT4N0; Stage IIB if cM0
        • Histology: Adenocarcinoma
        • Histology Grade: well differentiated
        • Depth of invasion: To serosa
        • Perineural invasion: Present
        • Tumor cell budding: intermediate
        • Circumferential (radial) margin: Uninvolved, 5 mm from the margin
        • LN metastasis, mesenteric (11) and LN 12(1): Negative (0/12) (No. Positive / No. Total)
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): pT4 (Tumor invades serosa)
        • Regional Lymph Nodes (pN): pN0 (No regional LN metastasis)
        • Distant Metastasis (pM): Not applicable
        • Type of polyp in which invasive carcinoma arose: Tubular adenoma
        • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
        • Tumor, possibly proximal jejunum, biopsy (11/25 21): Villotubular adenoma with high grade dysplasia
    • Image study:
      • UGI series (11/24 21): Luminal narrowing of proximal jejunum.
      • EGD (11/24 21)
        • Proximal jejunal tumor, with obstruction, s/p biopsy
        • Reflux esophagitis LA Classification grade A
        • Superficial gastritis
        • Bile reflux in stomach
      • CXR (12/11 21):
        • S/P operation.
        • Right CVP inserted to SVC in position.
        • S/P NG tube indwelling.
        • Pneumoperitoneum.
        • Normal appearance of trachea and bil. main bronchus.
        • Normal size of heart
      • Abd CT (11/17 21):
        • Huge Hemangioma in S2-3 of the liver with central fibrosis and cystic degeneration is highly suspected.
        • Hemangioma in S4 liver is also suspected.
        • Left lobe portal vein shows small size that may be tumor compression? This feature is relative unusual.
      • Liver MRI (11/23 21):
        • Bil. liver hemangiomas (up to 15.5cm). Inviaible left portal vein.
    • Medical advice:
      • Small bowel adenocarcinoma ( SBA ) is rare cancer that has been treated similarly to colorectal cancer in the advanced setting. Few studies have been published to help guide management of this dz, and resectable and advanced SBA have been primarily treated as an extensin of CRC.
        • Despite SBA being treated as a large intestinal cancer, pt outcomes are inferior.
        • SBA tends to be diagnosed at a later stage compared wt CRC.
          • 33.7% of pt wt SBA ( excluding duodenal ) were diangosed wt stage I-II Dz compared wt 52.3 % of those wt colon cancer.
          • 32.1% of pt wt SBA diagnosed wt distant mets compared wt 15.6% of those wt CRC, from SEER-Medicare database.
        • Molecular biology progress had expanded understanding of SBA.
          • Several hereditary cancer syndromes can predispose individuals to developing SBA. Hereditary nonpolyposis CRC (HNPCC) or Lynch syndrome is an autosomal dominant inheritance of germline mutations in DNA mismatch repair (MMR) genes, including MLH1, MSH2, MSH6, and PMS2, and rarely EPCAM and PMS1.
        • IHC staining of small bowel adenoCA of this pt showed normal MLH1, MSH2, MSH6, and PMS2.
        • The lifetime risk of developing SBA in Lynch-affected individuals remains low at about 1%, according to European registry studies, and therefore no small bowel screening recommendations currently exist.
          • routinely assessing all SBA tumors for deficient MMR (dMMR) gene expression or high microsatellite instability (MSI-H) is indicated and may help predict better therapies, including immune checkpoint therapy, for these patients.
        • Molecular Alterations
          • Recent studies have made major strides in understanding the molecular drivers of SBA and demonstrated SBA to represent a unique molecular entity with distinct differences between both CRC and gastric cancer.
          • APC (26.8% vs 75.9%; P,.001), TP53 (58.4% vs 75%; P,.001), and CDKN2A (14.5% vs 2.6%; P,.001), showed statistically different molecular alterations between SBA and CRC.
      • By NCCN guideline 2021 for small bowel adenocarcinoma, T3, N0,M0 wt high risk features or T4,N0,M0 (MMS or pMMR) , observation or FOLFOX or CAPEOX (3~6 mo) or 5-FU/LV or capecitabine (6 mo) was recommended.
      • The pt is relatively young & pMMR, post-Op adjuvant C/T wt FOLFOX or CAPEOX is recommended.
  • 2021-11-22 General and Gastroenterological Surgery
    • assessment:
      • BW loss since 2021-05, 10kg in 4 months (2021-05 ~ 2021-09)
      • frequent abdominal fullness and vominting since 2021-09, BW loss 13kg in 2 months
      • liver tumor over left lobe, favor hemangioma, size stationary
    • impression:
      • dyspepsia, not related to liver tumor, SMA syndrom related?
      • liver tumor over left lobe, favor hemangioma, less likely hemangiosarcoma
    • suggest:
      • admit for UGI series survey
      • PPN support
      • MRI survey

[surgical operation]

  • 2021-12-02
    • Surgery
      • left hepatectomy
      • segmental small intestine resection and side-to-side duodenijejunostomy reconstruction
      • cholecystectomy
    • Finding
      • huge hemangioma over left lobe of liver
      • suspect small bowel cancer over proximal jejunum, 10cm distal to the Treiz ligament, no significant LAP
      • no peritoneal seeeding
      • one small gallstone
  • 2017-08-25 Laparoscopy hysterectomy
    • Diagnosis
      • adenomyosis
    • Finding
      • Uterus: enlarged, 15x12x5cm, 235gm, adenomyosis-like
      • EM – thickened, endometrial hyperplasia?
      • cervix eroded, dysplasia?
      • bil adnexa: normal-looking
      • CDS: no fluid but pelvic endometriosis and pelvic adhesion were noted between post uterus, bil US ligaments, pelvic walls and bowels s/p laparoscopic fulguration of pelvic endometriosis and lysis

[chemoimmunotherapy]

  • 2023-05-25 - docetaxel 60mg/m2 100mg NS 250mL 1hr + leucovorin 300mg/m2 520mg NS 250mL 2hr + fluorouracil 300mg/m2 520mg NS 250mL 10min + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-04-21 - docetaxel 60mg/m2 100mg NS 250mL 1hr + leucovorin 300mg/m2 520mg NS 250mL 2hr + fluorouracil 300mg/m2 520mg NS 250mL 10min + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-03-09 - [oxaliplatin 300mg/m2 530mg D5W 3000mL + sodium bicarbonate 4200mg + gentamicin] IP 30min

  • 2022-07-25 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4760mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-07-05 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4760mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-06-21 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4790mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-06-08 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4770mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-05-11 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4750mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-04-19 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4790mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-03-28 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-03-14 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-02-24 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-02-11 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-01-19 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-01-03 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-05-29

  • The patient received two cycles of the docetaxel and fluorouracil regimen on 2023-04-21 and 2023-05-25. The lowest WBC count (nadir) was observed on 2023-05-02, 11 days after the first dose.
    • 2023-05-25 WBC 4.57 x10^3/uL
    • 2023-05-09 WBC 5.74 x10^3/uL
    • 2023-05-02 WBC 1.03 x10^3/uL (nadir, Granocyte (lenograstim 250ug) QD 5/2 ~ 5/4)
    • 2023-04-20 WBC 5.36 x10^3/uL
  • Since the second dose was the same as the first, the patient is likely to experience leukopenia again. To prevent severe leukopenia, it is recommended that G-CSF be prepared and administered approximately one week after the second cycle of chemotherapy.

2023-05-26

  • Based on the PharmaCloud data, this patient has exclusively sought medical care at our hospital. The drug Plaquenil (hydroxychloroquine), as prescribed by our attending rheumatologist, has been included in the active medication regimen for the patient. There were no discrepancies or issues identified in the medication reconciliation process for this patient.

2022-05-12

  • This patient has stage IIB small bowel adenocarcinoma s/p segmental small intestine resection on 2021-12-02, and has been receiving Folfox since 2022-01-03.
  • CT images on 2022-04-13 CT showed a marked dilatation from stomach to duodenum, however, it is not symptomatic to be enrolled as an active problem.
  • Lab data on 2022-05-11 indicated generally normal readings.

700823721

230529

[past history]

  • Hypertension for 10 years with regular medication control.
    • Norvasc 1# PRNQD
  • Type 2 diabetes mellitus for 15+ years with regular OHA control.
    • Relinide 1mg 0.5# po TIDAC
    • Januvia 100mg 1# po QD
    • Uformin 500mg 1# po TIDCC
  • Hyperlipidemia for 15+ years with regular medication control.
    • Crestor 10mg 0.5# po QD
    • Dipyridamole 25mg 1# po BID
  • Operation history: PHACO + PCIOL OD on 2015/07/21
    • ChatGPT:
      • “PHACO + PCIOL OD” is a term used in ophthalmology and it refers to a type of eye surgery.
        • PHACO: Stands for “Phacoemulsification,” which is a modern cataract surgery in which the eye’s internal lens is emulsified with an ultrasonic handpiece and aspirated from the eye.
        • PCIOL: Stands for “Posterior Chamber Intraocular Lens,” which is an artificial lens that is implanted in the eye to replace the natural lens that was removed during cataract surgery.
        • OD: Stands for “Oculus Dexter,” which is Latin for “right eye”.
      • So, “PHACO + PCIOL OD” means the patient underwent phacoemulsification cataract surgery with posterior chamber intraocular lens implantation in the right eye.

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-05-22 CT - chest
    • Indication: Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck s/p C/T
    • Comparison was made with previous CT
      • Lungs: several subpleural nodular opacities at LLL.
      • minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine.
      • Mediastinum and hila: multiple small LNs in the visceral space and left anterior prevascular space
      • Vessels: extensive calcified plaques of the LAD, and LCX, and right coronary arteries.
      • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: dilated LA and concentric LVH. mild calcified aortic valves
      • Pleura: no effusion.
      • Chest wall and visible lower neck: marked enlarged thyroid gland with calcifications extending to superior mediastinum, and with mass effects on the trachea calcification.
      • Visible abdominal-pelvic contents: normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
      • Extensive atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
    • Impression:
      • nodular lesions in LLL of lung, recurrent lymphoma in lung or other pathology?
      • extensive 3V-CAD.
      • thyroid goiter with mediastinal extension.
  • 2023-04-10 Nasopharyngoscopy
    • NP lymphoma
    • PND (postnasal drip), mucopus
  • 2023-03-06 Nasopharyngoscopy
    • NP mass smaller
    • neck mass smaller after C/T
    • nasal mucopus
  • 2023-02-19 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Low voltage QRS
  • 2023-02-17 CXR
    • Widening of the upper mediastinum is noted, which may be due to torturous innominate vessel or tumor. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2023-02-17 MRI - nasopharynx
    • Indication: Right nasopharynx diffuse large B cell lymphoma, non-gernimal cell type
    • Findings
      • Diffuse mucosal thickening at nasopharynx.
      • Numeorus enlarged lymph nodes at both sides of the neck, including bilateral retrophayrngeal lymph nodes, and bilateral levels II, III, IV and V, and in visible superior mediastinum. The largest one, about 50 mm, confluent with necrotic change at left level V.
      • Severe enlargement of bilateral thyroid glands, with diffuse heterogeneous intensity, protruding into mediastinum, encasing trachea and compressin on great vessels.
      • A soft tissue intensity lesion, about 30 mm x 15 mm x 16 mm, with vivid enhacnement in right nasal cavity (mainly middle meatus).
    • IMP
      • C/W lymphoma involving nasopharynx, lymph nodes of both sides of neck, superior mediastinum and suspiciouly right nasal cavity.
  • 2023-02-16 CT
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Some enhanced lymph nodes are found at bilateral neck, epiglottic, pharyngeal space, axillary, bilateral paratracheal region.
        • Enlarged thyroid tissue at both lobes with calcification is found.
        • No evidence of bilateral pleural effusion.
        • Patent airway is found.
        • Calcified coronary arteries is found.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
      • Imp:
        • Lymphadenopathy at bialteral neck, pharyngeal space, bilateral axillary and mediastinal region.
        • Enlarged bilateral thyoid glands.
        • Calcified coronary arteries is found.
  • 2023-02-15 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
    • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • 2023-02-14 ENT Hearing Test, PTA:
    • Reliability FAIR
    • Average RE 70 dB HL; LE 69 dB HL
    • RE moderately severe SNHL
    • LE moderately severe to severe SNHL
  • 2023-02-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (91 - 22) / 91 = 75.82%
      • M-mode (Teichholz) = 75
    • Preserved LV and RV systolic function with normal wall motion
    • Dilated LA, grade 1 LV diastolic dysfunction
    • Mild MR, PR, trivial TR
  • 2023-02-01 Whole body PET scan
    • The [F-18] Fluorodeoxyglucose (FDG) PET scan from head to upper thigh regions was performed at 40 minutes after i.v. injection 218 MBq of FDG on a GE Discovery ST PET-CT system. Fasting for at least 6 hours was required prior to this examination. Images were reconstructed iteratively with CT scan attenuation correction.
    • There was increased FDG uptake in bilateral N-P regions and right nasal cavity (SUVmax early: 28.95, delay: 41.80), bilateral cercial and SCF lymph nodes (SUVmax early: 30.05, delay: 32.62), bilateral axillary lymph nodes (SUVmax early: 7.85, delay: 10.53), left mediastinal and pulmonary hilar lymph nodes (SUVmax early: 7.87, delay: 15.17), right mediastinal and pulmonary hilar lymph nodes (SUVmax early: 4.76, delay: 8.86), and lymph nodes in the abdomen, pelvis, bilateral inguinal and upper thigh regions (SUVmax early: 12.35, delay: 9.02). In addition, increased FDG uptake was also noted in the left adrenal gland (SUVmax early: 4.24, delay: 7.76), bilateral kidneys and colon.
    • IMPRESSION:
      • Glucose-hypermetabolism in bilateral N-P regions and right nasal cavity (Deauville score 5), compatible with B-cell lymphoma.
      • Glucose-hypermetabolism in bilateral cercial and SCF lymph nodes, bilateral axillary lymph nodes, bilateral mediastinal and pulmonary hilar lymph nodes, and lymph nodes in the abdomen, pelvis, bilateral inguinal and upper thigh regions (Deauville score 5), highly suspected B-cell lymphoma with involvement of lymph node regions.
      • Increased FDG uptake in the left adrenal gland, probably a functing or non-functing benign tumor of the left adrenal gland, suggesting further investigation.
      • Increased FDG uptake in bilateral kidneys and colon, probably physiological uptake of FDG.
      • Diffuse large B-cell lymphoma with involvement of bilateral N-P regions, right nasal cavity and lymph node regions on both sides of the diaphragm, by this F-18 FDG PET scan.
  • 2023-01-31 SONO - abdomen
    • A cystic lesion 1.88 x 0.74 cm in S5 of the liver, near the gallbladder, is noted. Follow up is indicated.
  • 2023-01-30 Patho - nasopharyngeal/oropharyngeal biopsy
    • Labeled as “right nasopharynx”, biopsy — diffuse large B cell lymphoma, non-gernimal cell type. High grade.
    • IHC stains: CK (-), CD3 and CD20: a predominant B cell sub-population.
      • Bcl-2 (+, 90%), Bcl-6 (+, 90%), CD10 (<5%), C-myc: (+, 30-40%), Ki-67: (95%), MUM-1: (+, 90%), cyclin-D1 (-), CD23 (-). P16 (-), EBV (-).
  • 2023-01-30, 2022-06-10 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Abnormal ECG
  • 2023-01-30 Nasopharyngoscopy
    • Findings:
      • R NP tumor with yellowish crust coating; epiglottis lingual side tumor with patent airway; smooth HPx.
    • Diagnosis/Conclusion:
      • Nasopharyngeal and oropharyngeal tumor, suspect malignancy.
  • 2022-06-22 Electroencephalography
    • This EEG study recorded background alpha rhythm (9-10Hz) and beta activity with transient diffuse slow waves.
    • No epileptiform discharge.
    • Please correlate with clinical features.
  • 2022-06-22 Brainstem Auditory Evoked Potential, BAEP
    • Normal waveforms, amplitudes, peak latencies, interpeak intervals following click stimulation to each ear.
    • This is a normal BAEP study.
    • Please correlate with clinical features.
  • 2018-08-10 Flow Volume Curve
    • Mild restriction
  • 2018-08-10 Bone densitometry - hip
    • Hip BMD performed by DXA revealed:
      • Left hip, BMD is 0.539 gms/cm2, about 2.5 SD below the peak bone mass (67%) and 0.0 SD below the mean of age-matched people (100%).
    • IMP: Osteoporosis

[MedRec]

  • 2023-05-25 SOAP Hemato-Oncology
    • P
      • Already mention the lesion over LLL of lung. Will discuss with family for options
        • Biopsy, or
        • PET-CT, or
        • Observation.
  • 2023-05-04 SOAP Gastroenterology
    • Diagnosis
      • Gastro-esophageal reflux disease with esophagitis K21.0
      • Constipation, unspecified K59.00
      • Generalized anxiety disorder F41.1
      • Type 2 diabetes mellitus without complications E11.9
    • Prescription (refillable)
      • Spasmotin (hyoscyamine sulfate 0.125mg) 1# TID
      • Strocain (oxethazaine, polymigel 5mg) 1# TIDAC
      • Alpraline (alprazolam 0.5mg) 1# PRNHS
      • MgO 250mg 2# TID
  • 2023-04-28 SOAP Metabolism and Endocrinology
    • Diagnosis - same as 2023-03-03
    • Prescription (refillable)
      • dipyridamole 25mg 1 tab BID
      • Crestor (rosuvastatin 10mg) 0.5 tab QD
      • Galvus Met (vildagliptin 50mg, metformin 500mg) 1 tab BID
      • Norvasc (amlodipine 5mg) 1 tab PRNQD
      • Relinide (repaglinide 1mg) 1 tab TIDAC
      • Uformin (metformin 500mg) 1 tab BIDCC
      • Tresiba FlexTouch (insulin degludec) 6 unit QN (during steroid used)
  • 2023-03-03 SOAP Metabolism and Endocrinology
    • Diagnosis
      • Type 2 diabetes mellitus without complications E11.9
      • Mixed hyperlipidemia E78.2
      • Nontoxic multinodular goiter E04.2
      • Chronic kidney disease, stage 2 (mild) N18.2
      • Anemia, unspecified D64.9
      • Atherosclerosis of other arteries I70.8
    • Prescription (refillable)
      • Crestor (rosuvastatin 10mg) 0.5# QD
      • Norvasc (amlodipine 5mg) 1# PRNQD
      • Relinide (repaglinide 1mg) 1# ASORDER (0.5# TIDAC, 1# TIDAC if ACD > 180)
      • Uformin (metformin 500mg) 1# BIDCC
      • Galvus Met (vildagliptin 50mg, metformin 500mg) 1# BID
  • 2023-03-02 SOAP Hemato-Oncology
    • O: AE Leukopenia Gr 1 3000~4000/mm3
  • 2023-03-02 SOAP Dermatology
    • S
      • Heavy scaling over erythematous patchs on scalp, and eyelid and nasolabial fold with moderate itching.
      • fissuriform wound formaiton.
    • O
      • seborrhic dermatitis on scalp and face and trunk for yrs,
      • Generalized eczeam (+)
      • Polytar liquid for shampooing QOD
      • PHx:
        • sea food allergy (+-)
        • allergic rhinitis (+)
      • Travel histry: denied
      • fissuriform wound formaiton. -> hand eczema.
    • Plan:
      • education about drug side effec and explain
      • strongly suggested OPD f/u
    • Diagnosis
      • Seborrhoeic dermatitis, unspecified - L21.9
      • Infective dermatitis - L30.3
    • Prescription
      • Zalain External Gel (sertaconazole 2%) Q3D EXT
      • Topsym (fluocinonide 0.05%) BID TOPI
      • Asthan (ketotifen 1mg) 1# QN PO
      • Biomycin (neomycin, tyrothricin) BID TOPI
  • 2023-02-13 ~ 2023-02-25 POMR Hemato-Oncology
    • Discharge diagnosis
      • Diffuse large B-cell lymphoma with involvement of bilateral nasopharynx regions, right nasal cavity and lymph node, non-gernimal cell type. High grade. IHC stains: CK (-), CD3 and CD20: a predominant B cell sub-population. Bcl-2 (+, 90%), Bcl-6 (+, 90%), CD10 (<5%), C-myc: (+, 30-40%), Ki-67: (95%), MUM-1: (+, 90%), cyclin-D1 (-), CD23 (-). P16 (-), EBV (-)
      • Type 2 diabetes mellitus without complications
      • Mixed hyperlipidemia
      • Gastro-esophageal reflux disease with esophagitis
      • Osteoarthritis of knee, unspecified
      • Essential (primary) hypertension
      • Insomnia, unspecified
      • Sensorineural hearing loss, bilateral
      • Constipation, unspecified
      • Oral mucositis (ulcerative), unspecified
    • Prescription
      • Alpraline (alprazolam 0.5mg) 1# HS
      • Crestor (rosuvastatin 10mg) 0.5# QD
      • dipyridamole 25mg 1# BID
      • MgO 250mg 2# TID
      • Spasmotin (hyoscyamine sulfate 0.125mg) 1# TID
      • Uformin (metformin 500mg) 1# TIDCC
      • Relinide (repaglinide 1mg) 0.5# TIDAC
      • Norvasc (amlodipine 5mg) 1# QD
      • Januvia (sitagliptin 100mg) 1# QD
      • diphenidol 25mg 1# TID
      • Arcoxia (etoricoxib 60mg) 1# QD
  • 2023-02-07 SOAP Hemato-Oncology
    • S
      • 2022/08/29 Free-T4 = 0.74 ng/dL; TSH = 0.165 uIU/mL
      • 2023/01/30 HGB = 10.2 g/dL; HbA1c = 7.3 %;
      • 2023/01/30 fiber: large R NP tumor with downward extension, Bx done, L tonsil: uneven, bil huge epiglottic mass (smooth surface)
      • 2023/01/30 SCC/CRP (-)
        • SCC (NM) = 1.37 ng/mL; SCC = 1.4 ng/mL, CRP = 0.69 mg/dL
      • 2023/02/03 EBV DNA PCR <120 copies/mL
      • 2023/02/06 NP: diffuse large B-cell lymphoma + bil NM
      • Referred from Dr. Gao at BanQiao LMC due to bilateral neck mass.
      • Poor appetite and BW loss 1-2 kg in recent 2 months
    • O
      • History: lipid, DM, HT at Meta, GERD, OA knee
      • Living alone with her husband, four sons take turns to care for her.
    • P
      • Arrange admission for HN MRI, Chest/Abd/Pelvis CT and bone marrow study (aspiration, biopsy, chromosome study), cardiac echography, C/T with R-COP or R-CHOP.

[chemotherapy]

  • 2023-05-09 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 900mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 9# BID D1-5 (R-COP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-04-11 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 9# BID D1-5 (R-COP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-15 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 9# BID D1-5 (R-COP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-02-20 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 5mg/tab 9# BID D1-5 (R-COP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[note: R-COP, R-mini-CHOP, R-CHOP21, EPOCH-R, daEPOCH]

R-CVP 2023-05-19 https://www.cancer.gov/about-cancer/treatment/drugs/r-cvp

  • Drugs in the R-CVP combination:
    • R = Rituximab
    • C = Cyclophosphamide
    • V = Vincristine Sulfate
    • P = Prednisone
  • R-CVP is used to treat: Non-Hodgkin lymphoma (NHL) that is indolent (slow-growing).
    • ChatGPT - Indolent NHL
      • “Indolent NHL” refers to a type of non-Hodgkin lymphoma that grows and spreads slowly. Non-Hodgkin lymphoma (NHL) is a group of blood cancers that includes all types of lymphomas, except Hodgkin’s lymphomas.
      • Examples of indolent NHL include follicular lymphoma, marginal zone lymphoma, and small lymphocytic lymphoma. Indolent lymphomas are typically associated with a relatively good prognosis, but they are usually not curable in advanced clinical stages.
      • It’s important to note that the term “indolent” doesn’t mean the disease is not serious. It’s still a type of cancer and requires treatment, but generally, it progresses more slowly than other types of lymphoma.

Initial treatment of advanced stage diffuse large B cell lymphoma 2023-05-19 https://www.uptodate.com/contents/initial-treatment-of-advanced-stage-diffuse-large-b-cell-lymphoma

  • R-mini-CHOP - SPECIAL SCENARIOS - Older adults

    • Older patients with DLBCL generally have a worse prognosis compared to younger patients due, in part, to more comorbid conditions and lower treatment tolerance.
    • For patients >80 years with adequate heart, kidney, and liver function and for patients 60 to 80 years with modest impairments, we generally treat with R-mini-CHOP to reduce adverse effects (AE) associated with more intensive regimens.
  • Pretreatment evaluation

    • For older patients, a comprehensive geriatric assessment can aid assessment of comorbid conditions and functional status and facilitate formulation of an appropriate, individualized treatment plan. Special considerations for the use of chemotherapy in older patients are discussed separately
  • R-mini-CHOP Treatment

    • rituximab 375 mg/m2 D1
    • cyclophosphamide 400 mg/m2 D1
    • doxorubicin 25 mg/m2 D1
    • vincristine 1 mg D1
    • prednisone 40 mg/m2 D1-5
  • A pre-treatment phase of a systemic steroid, with or without rituximab, may improve the patient’s performance status (PS) and facilitate treatment with R-mini-CHOP.

  • Frail patients who require symptom palliation but cannot tolerate R-mini-CHOP may benefit from a systemic steroid (with or without rituximab) or single chemotherapeutic agents.

Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP21) for non-Hodgkin lymphoma 2023-05-19 https://www.uptodate.com/contents/image?topicKey=HEME%2F4729&imageKey=ONC%2F63586

  • Cycle length: 21 days.

  • Regimen

    • Rituximab
      • 375 mg/m2 IV
      • Dilute in NS or D5W to a final concentration of 1 to 4 mg/mL. Initial infusion: Start at 50 mg/hour; escalate in 50 mg/hour increments every 30 minutes to a maximum of 400 mg/hour, as tolerated.[2] For subsequent infusions, administer 20% of the total dose over the first 30 minutes and the remaining 80% over 60 minutes, as tolerated. The 90-minute infusion schedule should NOT be used in patients who have clinically significant cardiovascular disease or have a circulating lymphocyte count ≥5000/microL. Day 1
    • Cyclophosphamide
      • 750 mg/m2 IV
      • Dilute in 250 mL NS or D5W and administer over 30 minutes.
      • Day 1
    • Doxorubicin
      • 50 mg/m2 IV
      • Dilute in 50 mL NS or D5W and administer over three to five minutes.
      • Day 1
    • Vincristine
      • 1.4 mg/m2 IV (max dose 2 mg)
      • Dilute in 50 mL NS or D5W and administer over 15 to 20 minutes.
      • Day 1
    • Prednisone
      • 100 mg orally
      • Administer 30 minutes prior to chemotherapy on day 1, then every 24 hours on days 2 to 5. Days 1 to 5

Infusional etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R) for non-Hodgkin lymphoma 2023-05-19 https://www.uptodate.com/contents/image?topicKey=HEME%2F4729&imageKey=ONC%2F88411

  • Cycle length: 21 days.

  • Regimen

    • Rituximab
      • 375 mg/m2 IV
      • Dilute in NS or D5W to a final concentration of 1 to 4 mg/mL. Initial infusion: Start at 50 mg/hour; escalate in 50 mg/hour increments every 30 minutes to a maximum of 400 mg/hour, as tolerated. In the absence of an initial infusion reaction, for subsequent infusions, administer 20% of the total dose over the first 30 minutes and the remaining 80% over 60 minutes, as tolerated. The 90-minute infusion schedule should NOT be used in patients who have clinically significant cardiovascular disease or have a circulating lymphocyte count >=5000/microL.
      • Day 0 or 1
    • Etoposide
      • 50 mg/m2 per day IV
      • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
      • Days 1 to 4 (96 hours)
    • Doxorubicin
      • 10 mg/m2 per day IV
      • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
      • Days 1 to 4 (96 hours)
    • Vincristine
      • 0.4 mg/m2 per day IV (dose not capped)
      • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
      • Days 1 to 4 (96 hours)
    • Cyclophosphamide
      • 750 mg/m2 IV
      • Dilute with 250 mL NS or D5W and administer over 30 minutes.
      • Day 5
    • Prednisone
      • 60 mg/m2 orally twice daily
      • Administer first dose 30 minutes prior to chemotherapy on day 1.
      • Days 1 to 5
    • Granulocyte colony stimulating factor (G-CSF)
      • Start day 6

Chemotherapy regimens for non-Hodgkin lymphoma: Dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (daEPOCH) 2023-05-19 https://www.uptodate.com/contents/image?topicKey=ONC%2F85686&imageKey=ONC%2F105216

  • Cycle length: 21 days.
  • Regimen
    • Etoposide
      • 50 mg/m2 per day IV
      • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
      • Days 1 to 4 (96 hours)
    • Doxorubicin
      • 10 mg/m2 per day IV
      • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
      • Days 1 to 4 (96 hours)
    • Vincristine
      • 0.4 mg/m2 per day IV (dose not capped)
      • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
      • Days 1 to 4 (96 hours)
    • Cyclophosphamide
      • 750 mg/m2 IV
      • Dilute with 250 mL NS or D5W and administer over 30 minutes.
      • Day 5
    • Prednisone
      • 60 mg/m2 orally twice daily
      • Administer first dose 30 minutes prior to chemotherapy on day 1.
      • Days 1 to 5
    • Granulocyte colony-stimulating factor
      • Start day 6

==========

(not posted)

  • Because chemotherapy-induced immunosuppression can potentially lead to HBV reactivation, which can result in discontinuation of cancer treatment, fulminant hepatitis, liver failure, and even death, proactive measures should be taken. The patient’s lab data from 2023-02-08 shows anti-HBc reactivity and an anti-HBc level of 5.18 S/CO. As a preventive measure, it is recommended that the patient be prescribed either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD.

2023-05-10

  • The patient’s current active medication list correctly reflects the refillable prescriptions provided by our gastroenterologist and endocrinologist. These medications include Spasmotin (hyoscyamine), Strocain (oxethazaine), Alpraline (alprazolam), MgO from the gastroenterologist, and Crestor (rosuvastatin), Galvus Met (vildagliptin, metformin), Norvasc (amlodipine), Relinide (repaglinide), Uformin (metformin), Tresiba FlexTouch (insulin degludec), and dipyridamole from the endocrinologist. As such, there are no identified medication reconciliation issues at this time.

  • Hyoscyamine, a tropane alkaloid and the levo-isomer of atropine, is often employed to manage acute episodes of gastric secretion, visceral spasm, hypermotility in spastic colitis, pylorospasm, and associated abdominal cramps. Additionally, it can serve as adjunctive therapy in the treatment of peptic ulcers. However, considering the patient’s constipation (in the clinical problem list), and the fact that metoclopramide is concomitantly prescribed to mitigate potential nausea and vomiting effects caused by the R-COP regimen, it might be advisable to temporarily withhold hyoscyamine during the chemoimmunotherapy sessions.

  • The HbA1c level, which reflects the average blood glucose level over the past two to three months, has reached a record high of 8.1%. This suggests that the patient’s current diabetes management plan may not be effectively controlling her blood sugar levels.

    • 2023-04-22 HbA1c 8.1 %
    • 2023-02-13 HbA1c 6.9 %
  • Despite the patient’s current use of antidiabetic agents Galvus Met (vildagliptin, metformin), Relinide (repaglinide), Uformin (metformin), and Tresiba FlexTouch (insulin degludec), recent blood glucose readings have exceeded 200mg/dL (187mg/dL at 17:03 2023-05-09, 204mg/dL 20:25 2023-05-09 and 202mg/dL at 06:13 2023-05-10). This suggests that the patient’s glycemic control is currently suboptimal. An adjustment to the patient’s insulin regimen may be needed. It is recommended that the dose of insulin degludec be increased to 7 or 8 units, with close monitoring of the patient’s blood glucose levels. This adjustment should be particularly considered during periods when the patient is receiving steroids (as part of the R-COP regimen).

2023-03-16

  • Due to the patient’s senior age, R-COP was selected over R-CHOP as the regimen. The patient is currently admitted for the second cycle of this chemoimmunotherapy.

  • According to the available data from the past 6 months, there have been no instances of leukopenia or thrombocytopenia observed. However, there has been a slight presence of anemia during this time period, which is unlikely to be caused by the R-COP regimen since it was present even before the start of treatment.

  • Please ensure that the patient is adequately hydrated and monitor her BUN readings, which have been trending upward, while serum creatinine remains normal.

    • 2023-03-14 BUN 38 mg/dL
    • 2023-03-02 BUN 40 mg/dL
    • 2023-02-17 BUN 28 mg/dL
    • 2023-02-07 BUN 20 mg/dL
  • This patient has a history of diabetes, and despite taking Uformin (metformin 500mg) 1# BID, Galvus Met (vildagliptin 50mg + metformin 500mg) 1# BID, and Relinide (repaglinide 1mg) total 2# daily (the daily dose of metformin has already reached 2g and should not be increased further), her blood sugar levels range from 284 to 301mg/dL. R-COP chemotherapy regimen includes high doses of prednisolone, which can contribute to hyperglycemia. Similar to the management of type 2 diabetes, stepwise intensification of antihyperglycemic therapy and frequent re-evaluation should be considered in cases of steroid-induced hyperglycemia. ref: A Practical Guide for the Management of Steroid Induced Hyperglycaemia in the Hospital. J Clin Med. 2021;10(10):2154. Published 2021 May 16. doi:10.3390/jcm10102154

  • The addition of a rapid-acting insulin (RI) may be beneficial for controlling hyperglycemia in this patient. However, careful monitoring of blood glucose levels and titration of insulin dose are necessary to prevent hypoglycemia. It is also important to continue evaluating and adjusting the patient’s antihyperglycemic therapy as needed.

2023-02-21

  • The patient’s HGB reading has decreased by more than 10%, which should be monitored closely. It may be necessary to investigate for any potential underlying bleeding.
    • 2023-02-17 HGB 9.1 g/dL
    • 2023-02-13 HGB 9.1 g/dL
    • 2023-02-07 HGB 10.6 g/dL
  • 2023-02-14 cardiac sonography reveals normal wall motion and preserved systolic function in both the left and right ventricles, with a LVEF of 75%. 2023-02-19 ECG showed a normal sinus rhythm, left axis deviation, and low voltage QRS. Started R-COP (R-CVP) on 2023-02-20. No dose adjustment is needed based on grossly normal 2023-02-17 lab data except for a slightly high BUN (28mg/dL), which warrants monitoring.
  • Patients with high white cell count or bulky disease are at an increased risk of developing tumor lysis syndrome and reacting to Rituximab. As the patient’s WBC count was 4.52K/uL on 2023-02-17, it is less likely for her to develop tumor lysis syndrome.
  • Patients should be advised that cyclophosphamide can irritate the bladder mucosa, and it is important to maintain a fluid intake of at least 3 liters a day for the next few days.
  • Given that this patient is more than 70 years old but not immunosuppressed prior to chemotherapy, primary prophylaxis with G-CSF may not be absolutely necessary.
  • (ref: https://nssg.oxford-haematology.org.uk/lymphoma/documents/lymphoma-chemo-protocols/L-82-r-cvp.pdf)

2023-02-14

  • This patient is diagnosed with high grade DLBCL (2023-01-30 patho IHC (not FISH): MYC + 30-40%, BCL2 + 90%, BCL6 + 90%; triple hit)

  • International Prognostic Index = 3 => Risk Group: High-intermediate, 5-yr OS 43% (ref: UpToDate)

    • (+) Age >60 : 81
    • (-) Serum lactate dehydrogenase concentration above normal : 148U/L 2023-02-07
    • (-) ECOG performance status >=2 : score = 1, 2023-02-13
    • (+) Ann Arbor stage III or IV : PET 2023-02-01 both sides of the diaphragm
    • (+) Number of extranodal disease sites >1
  • Considering the patient is elderly, R-CHOP might be an alternative to R-DA-EPOCH. It might be necessary to perform a cardiac ultrasound prior to the treatment in order to establish a baseline. A lumbar puncture may be necessary if the CNS is involved.

[drug identification]

  • We did not receive the drugs awaiting identification that day. The next day, we contacted the nurse by phone, who explained that the medication was too fragmented, so only the in-house medication was used instead.

701393260

230529

[diagnosis] - 2022-12-15 admission note

  • Right breast cancer - invasive carcinoma of no special type, Immunohistochemical study demonstrates ER(-), PR(-), Her2/neu: positve(3+), p53(patchy+, weak to moderate, wild-type), p63(-), Ki-67 inedex: 30%, CK5/6(-), stage IV, with multiple liver and lymph nodes metastases.
  • Diffuse bone metastases involving C2-C7, T1-T4 spine, with left C1, C2 lateral mass tumors encasing left vertebral artery.
  • epatomegaly
  • poor liver function
  • hyperbilirubinemia

[exam findings]

  • 2023-05-19 MRI - brain
    • History and indication: Speaking unclearly, there are multiple metastases of breast cancer.
    • With and without-contrast multiplannar and multisequences MRI of brain revealed:
      • Multiple enhancing nodules in brain parenchyma.
  • 2023-04-20, -03, 24, -02-02 CXR
    • Borderline cardiomegaly
    • Enlargement of cardiac silhouette.
  • 2023-02-13 CT - abdomen
    • History and indication:
      • Right breast cancer - invasive carcinoma of no special type, stage IV, with multiple liver and lymph nodes metastases.
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Much regression of right breast cancer. Necrosis and regression of liver metastases.
      • Left ovary cyst (4.6cm) with minimal hemorrhage. Minimal ascites.
      • Multiple bony metastases.
    • IMP:
      • Much regression of right breast cancer. Necrosis and regression of liver metastases.
      • Left ovary cyst (4.6cm) with minimal hemorrhage. Minimal ascites.
      • Multiple bony metastases.
  • 2022-12-15, -12-02, -11-23 CXR
    • Borderline cardiomegaly
    • Enlargement of cardiac silhouette.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-11-25 Gynecologic ultrasonography
    • Ascites
    • EM: 7.7mm
  • 2022-11-14 CT - abdomen
    • Indication
      • Right breast cancer–invasive carcinoma of no special type
      • Secondary malignant neoplasm of liver and intrahepatic bile duct
      • Secondary malignant neoplasm of bone
      • Diffuse bone metastases
    • Findings
      • Massive ascites is found. Several confluent low density lesions are found at both lobes of liver up to 12.4cm at right lobe liver. Liver meta is considered. In comparison with CT dated on 2022-08-03, the lesions become necrotic. Chemotherapy effect is considered.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Mild enhancement of the peritoneum at pelvis is found. Cancerous peritonitis is suspected.
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
      • Soft tissue mass at right lateral breast is found about 2.5cm. In comparison with CT dated on 2022-08-03, the lesion is decreased in size.
      • Right massive pleural effusion is found.
      • Suggest clinical correlation
    • Imp:
      • Right breast cancer with liver meta with primary tumor regression and liver tumors necrosis. Chemotherapy effect is considered.
      • Bone meta, please correlate with bone scan study.
      • Massive ascites and right pleural effsuion. suspected cancerous peritonitis.
  • 2022-11-11 CXR
    • Enlargement of cardiac silhouette.
    • Right Pleura effusion is noted.
    • Few nodular opacity projecting in the left lung are suspected. Follow up is indicated. Otherwise, Please correlate with CT.
  • 2022-11-02, -10-20, -10-17, -10-10, -10-06 CXR
    • Bilateral Pleura effusion with more severe on right side.
    • Few nodular opacity projecting in the left lung are suspected. Follow up is indicated. Otherwise, Please correlate with CT.
  • 2022-10-28 SONO - chest
    • Echo diagnosis:
      • left side trivial amount of pleural effusion
      • right side moderate amount of pleural effusion, 750cc serosangious fluid was aspirated for analysis.
  • 2022-10-20, -09-26 Ascites tapping
    • After echo localization, local anesthesia was performed at RLQ and 2000ml straw-colored ascites was drained out with 18Fr catheter.
    • Moderate clear ascites was noted.
  • 2022-10-17 SONO - chest
    • Echo diagnosis:
      • Bilateral pleural effusion (Left: trivial and Right: small to moderate), post right diagnostic and therapeutic thoracentesis.
      • Abdominal ascites
  • 2022-10-11 SONO - chest
    • Echo diagnosis:
      • Right thorax: large amount pleural effusion s/p drainage of 910cc, yellowish pleural effusion
      • Left thorax: no pleural effusion.
  • 2022-10-04 SONO - chest
    • Echo diagnosis:
      • Left thorax: no pleural effusion.
      • Right thorax: moderate amount pleural effusion s/p drainage of 960 cc, yellowish pleural effusion.
  • 2022-10-03 Ascites tapping
    • The RLQ of the abdomen was prepped and draped in a sterile fashion using chlorhexidine scrub. The paracentesis catheter was inserted and advanced with negative pressure until STRAW colored fluid was aspirated
  • 2022-09-26 SONO - chest
    • Echo diagnosis:
      • Right thorax: moderate amount pleural effusion s/p drainage of 600 cc, yellowish pleural effusion.
      • Left thorax: minimal amount pleural effusion
  • 2022-09-21 SONO - chest
    • Echo diagnosis:
      • Pleural effusion, moderate, right
      • Pleural effusion, minimal, left
      • Atelectasis, RLL
  • 2022-08-11 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (60.8 - 19.1) / 60.8 = 68.59%
      • M-mode (Teichholz) = 68.6
    • Adequate LV,RV systolic function with normal wall motion
    • Thick IVS, Impaired LV relaxation
    • Left pleural effusion
  • 2022-08-18, -08-15, -08-12, -08-09, -08-08 CXR
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Enlargement of cardiac silhouette.
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2022-08-09 Patho - breast biopsy (no need margin)
    • Breast, right, core biopsy — Invasive carcinoma of no special type
    • The specimen submitted consists of 4 tissue cores measuring up to 1.7x0.1x 0.1 cm in size, in fixed state. Grossly, they are tan and elastic.
    • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in solid to ductal architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic activity.
    • Immunohistochemical study demonstrates ER(-), PR(-), Her2/neu: positve(3+), p53(patchy+, weak to moderate, wild-type), p63(-), Ki-67 inedex: 30%, CK5/6(-).
  • 2022-08-09 Tc-99m MDP whole body bone scan with SPECT
    • The scintigraphic findings suggest multiple bone metastases.
  • 2022-08-09 SONO - chest
    • Echo diagnosis:
      • Bilateral thorax:
        • minimal amount pleural effusion;
        • bilateral lower lung consolidation (+);
        • thoracocentesis was not performed.
  • 2022-08-08 Breast Ultrasound in Operation
    • Diagnosis: Highly suspicious of malignancy, with sonographic negative axillary LNs
    • Treatment: Core-needle biopsy
    • Suggestion and Plan:
      • Arrange core biopsy with 18 guage puncture needle
      • BI-RADS: 5-Highly Suggestive of Malignancy (>95% malignant) Appropriate Action Should Be Taken
  • 2022-08-05 MRI - C-spine
    • Indication: breast tumor with liver and C-spine meta
    • Findings
      • diffuse enhancing bone masses involving C2-C7, T1-T4 spine, compatible with bone metastases. There is pathological compression fracture at C5, C7 vertebral bodies. Exophytic masses at left C1, C2 lateral masses and transverse processes causing encasement of left vertebral artery (VA) is noted.
      • enlarged bilateral cervical lymph nodes, suspect lymphadenopathy.
      • no evidence of abnormal signal lesion and pathological enhancement in visible spinal cord.
    • Impression:
      • Diffuse bone metastases involving C2-C7, T1-T4 spine, with left C1, C2 lateral mass tumors encasing left VA.
  • 2022-08-05 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Metastatic invasive carcinoma, consistent with breast primary
    • The specimen submitted consists of two strips of yellow gray soft tissue, labeled liver, measuring up to 2.0 x 0.1 x 0.1 cm.
    • The sections show metastastic invasive carcinoma of no special type, breast primary, composed of nests and cords of large pleomorphic neoplastic cells in fibrous stroma. Focal ductal differentiation and tumor necrosis are present.
    • IHC shows following features:
      • ER (Ab): Negative
      • PR (Ab): Negative
      • HER-2/Neu (Ab): Positive (score= 3+)
      • Ki-67 index: 30%
      • GATA3: Positive
  • 2022-08-03 MRI - brain
    • a heterogeneous enhancing tumor in the left C1 vertebral body
  • 2022-08-03 CT - abdomen
    • History: epigastric protruding sensation with fullness.
      • abnormal LFT: AST/ALT 62/100 GGT 83 (2022-04-20 at Taichung)
      • HBsAg non-reactive. HBsAb(anti-HBs) reactive
      • 20220801 echo: numerous liver tumors, suspected metastasses
      • AST/ALT 472/167: we’ve strongly suggested admission for supportive care and close observation and exam: but patient refused admission.
    • Findings:
      • There is a well-defined rim-enhancing soft tissue mass in right breast, measuring 3.4 cm. Breast cancer is suspected.
        • Please correlate with sonography and mammography.
      • There are multiple variable-sized poor enhancing tumors on both hepatic lobes that are c/w metastases.
        • In addition, There is hepatomegaly and the greatest cranial-caudal dimension measuring about 21.7 cm in length.
      • There are multiple enlarged nodes in gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space that are c/w metastatic nodes.
      • There is mild ascites in the cul-de-sac.
        • Please correlate with sonography.
      • Bilateral ovarian cysts are suspected.
        • Please correlate with GYN. sonography.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Right breast cancer with multiple liver and lymph nodes metastases is highly suspected.
      • Please correlate with breast sonography and mammography.
  • 2022-08-01 SONO - abdomen
    • Diagnosis
      • mild fatty liver
      • liver tumors, favor metastatic tumors
      • pancreas obscured
    • Suggestion
      • 4 phase CT scan

[body fluid]

  • 2022-08-24 pleural effusion 720ml (orange, turbid)
  • 2022-08-26 ascites 75ml (orange)
  • 2022-08-30 pleural effusion 760ml (red, turbid)
  • 2022-09-02 pleural effusion 600ml (orange, turbid)
  • 2022-09-06 pleural effusion 630ml (red, turbid)
  • 2022-09-08 pleural effusion 550ml
  • 2022-09-15 pleural effusion 700ml (yellow, turbid)
  • 2022-09-21 pleural effusion 600ml (yellow, turbid)
  • 2022-09-26 ascites 2000ml
  • 2022-09-27 pleural effusion 600ml (yellow, slight turbid)
  • 2022-10-03 ascites 1750ml
  • 2022-10-04 pleural effusion 960ml (yellowish)
  • 2022-10-11 pleural effusion 910ml
  • 2022-10-17 pleural effusion 860ml (yellowish, cloudy)
  • 2022-10-21 ascites 2000ml

[MedRec]

  • 2023-05-24 SOAP Radiation Oncology
    • A: Invasive carcinoma of no special type of the right breast with multiple including liver and bone metastases.
    • P: Radiotherapy is indicated for this patient with the following indicators: multiple brain metastases
      • Goal: palliation
      • Treatment target and volume: whole brain
      • Technique: 3D
      • Preliminary planning dose: 3000cGy/12 fractions of the whole brain.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his family. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2023-05-30.

[consultation]

  • 2022-08-17 Rehabilitation
    • Q
      • For correct body posture and movement
    • A
      • Assessment
        • right breast tumor with liver, and C-spine metastasis
      • Conclusion
        • The patient refused to transfer or sit-up when I visited due to dyspnea, abominal fullness and severe discomfort. Please contact us if the patient get better and has willing to take rehab training.
  • 2022-08-04 Radiation Oncology
    • Q
      • for C-spine radiotherapy evaluation
      • The 31-year-old female who denied having any past history, the she was getting the COVID-19 on June 25, 22.
      • This time, she suffered from stiff neck since end of April, then the symptoms intensify, so she went to our Chinese Medicine department for help, however, treatment was ineffective. And the liver index too high from health examination and epigastric protruding sensation with fullness, so she went to our GI OPD for help. The abdomen echo: numerous liver tumors: suspected metastatic tumors, the abdomen CT showed right side breast lesion with multiple liver metastasis, the brain MRI: C-spine metastasis, so we need your help, thanks a lot!!
    • A
      • S:
        • For radiotherapy due to suspicious metastatic lesion over left C1 vertebral body.
        • PI: The patient suffered from stiff neck since end of April, 2022. The symptoms intensify, so she went to our Chinese Medicine department for treatment but was ineffective. The abdomen echo showed numerous liver tumors: suspected metastatic tumors, the abdomen CT showed right side breast lesion with multiple liver metastasis, the brain MRI: C-spine metastasis.
        • Family history: (-)
        • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
        • Personal Hx: DM(-); HTN(-)
        • Previous RT Hx: (-)
      • O:
        • ECOG: 1
        • PE: neck and bil SCF: pain of the left upper neck.
        • Abd sono (2022-08-01): mild fatty liver; liver tumors, favor metastatic tumors; pancreas obscured.
        • MRI of brain (2022-08-03): a heterogeneous enhancing tumor in the left C1 vertebral body.
        • CT scan of abdomen (2022-08-03): pending.
      • A:
        • Suspicious right breast cancer with multiple including liver and bone metastases.
      • P:
        • Radiotherapy is indicated for this patient with the following indicators: metastatic lesions in the left C1 vertebral body.
        • Goal: palliation
        • Treatment target and volume: possible the left C1 vertebral body.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 3000cGy/15 fractions
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her family. Further work-up including tissue proven should be completed. The treatment planning of radiotherapy will be started after positive pathologic report available (please notify me).

[surgical operation]

  • 2022-08-08
    • Surgery
      • Port-A insertion, L’t after L’t cephalic vein exploration        
      • Sonography guided R’t breast tumor core biopsy     
    • Finding
      • We explore and identify the L’t cephaic vein & use cutdown method to insert the 7 Fr cathter into it. We also use intra-operative EKG to check its position.        
      • A 5x2.72x1.78 cm hard tumor over R’t (1, 2).   

[chemoimmunotherapy]

  • 2023-05-26 - Herceptin (trastuzumab) 6mg/kg 240mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 95mg 6hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-04-21 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 100mg 6hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-03-24 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 100mg 6hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-02-27 - Herceptin (trastuzumab) 6mg/kg 240mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 95mg 6hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-02-03 - Herceptin (trastuzumab) 6mg/kg 240mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 95mg 6hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-01-10 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 100mg 6hr (<- 3hr)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-12-15 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 100mg 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-11-23 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 100mg 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-11-03 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 80mg 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-10-12 - Herceptin (trastuzumab) 6mg/kg 280mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 60mg 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-09-21 - Herceptin (trastuzumab) 6mg/kg 280mg 90min + Perjeta (pertuzumab) 840mg 1hr + Intaxel (paclitaxel) 80mg/m2 20mg 3hr (pertuzumab loading dose)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-09-12 - Intaxel (paclitaxel) 80mg/m2 20mg 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2022-08-29 - Herceptin (trastuzumab) 6mg/kg 440mg 90min (loading)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[note]

PREVIOUSLY UNTREATED PATIENTS - Trastuzumab plus pertuzumab plus a taxane - 2022-11-24 UpToDate - https://www.uptodate.com/contents/systemic-treatment-for-her2-positive-metastatic-breast-cancer

  • Preferred option
    • While there is no ideal strategy for the management of patients with HER2-positive metastatic breast cancer, one reasonable approach stratifies patients by whether or not they were previously treated with trastuzumab in the adjuvant setting. For previously untreated patients, we suggest trastuzumab, pertuzumab, and a taxane (docetaxel or paclitaxel). This regimen improves clinical outcomes compared with trastuzumab plus docetaxel. For most patients receiving treatment with trastuzumab or pertuzumab, we administer the HER2-directed agent along with chemotherapy. However, patients with hormone receptor- and HER2-positive metastatic breast cancer may receive HER2-directed therapy in combination with endocrine therapy, especially if their disease is not rapidly progressive or symptomatic, or is not characterized by significant visceral involvement (ie, multiorgan metastases). For women with hormone receptor-positive, HER2-positive disease, endocrine plus HER2-directed therapy may offer a less toxic approach compared with HER2 treatment combined with chemotherapy.
  • Trastuzumab plus pertuzumab plus a taxane
    • For patients with untreated HER2-positive metastatic breast cancer who did not receive adjuvant therapy at the time of the initial diagnosis, we administer trastuzumab plus pertuzumab in combination with a taxane (docetaxel or paclitaxel). In our practice, we often use weekly paclitaxel rather than docetaxel with this combination as a less toxic and better tolerated taxane. However, other taxanes are appropriate in this setting. Alternatives to this regimen, and particular considerations for those with hormone receptor-positive disease, are discussed below.
    • The evidence to support the three-agent combination of trastuzumab plus pertuzumab and a taxane comes from the phase III CLEOPATRA trial, including 808 women with HER2-positive metastatic breast cancer who were treated with trastuzumab (8 mg/kg loading dose then 6 mg/kg intravenous [IV]) and docetaxel (75 mg/m2 IV) and then randomly assigned to treatment with pertuzumab (840 mg loading dose then 420 mg) or placebo. Treatment was administered every three weeks and continued until disease progression or intolerable side effects. Approximately 10 percent of these patients had previously received trastuzumab in the adjuvant or neoadjuvant setting. At a median follow-up of 19 months, the addition of pertuzumab to docetaxel plus trastuzumab resulted in (see “Treatment protocols for breast cancer”, section on ‘THP (docetaxel, trastuzumab, and pertuzumab)’ https://www.uptodate.com/contents/image?imageKey=ONC%2F96342&topicKey=ONC%2F85677):
      • Improvement in the overall response rate (ORR, 80 versus 69 percent).
      • Improvement in progression-free survival (PFS) compared with placebo (median, 19 versus 12 months; hazard ratio [HR] 0.62, 95% CI 0.51-0.75).
      • At over eight years of follow-up, the addition of pertuzumab resulted in: Improvement in overall survival (OS) compared with placebo (median, 57 versus 41 months without pertuzumab; eight-year survival rates of 37 versus 23 percent without pertuzumab; HR for death 0.69, 95% CI 0.58-0.82).
    • Trastuzumab, pertuzumab, and docetaxel is associated with higher rates of toxicity compared with trastuzumab and docetaxel. These included higher rates of diarrhea (67 versus 46 percent), neutropenia (53 versus 50 percent), rash (34 versus 24 percent), mucosal inflammation (27 versus 20 percent), dry skin (10 versus 4 percent), and serious (grade 3/4) febrile neutropenia (14 versus 8 percent). However, there was no increase in the rate of left ventricular dysfunction, which was very low in both arms (1 versus 2 percent).
    • Although the CLEOPATRA trial described above used docetaxel, we consider other taxanes to be acceptable alternatives to docetaxel in combination with trastuzumab and pertuzumab. In the first reporting from the PERUSE study, among 1436 patients with advanced HER2-positive breast cancer, median PFS was comparable between docetaxel, paclitaxel, and nanoparticle albumin-bound paclitaxel (nabpaclitaxel; 20, 23, and 18 months, respectively). Compared with docetaxel-containing therapy, paclitaxel-containing therapy was associated with more neuropathy (31 versus 16 percent), but less febrile neutropenia (1 versus 11 percent) and mucositis (14 versus 25 percent). A limitation in interpretation of these data, however, is that patients were not randomly assigned to different taxanes.
    • The addition of trastuzumab to chemotherapy has shown OS benefits in the adjuvant setting as well. (See “Adjuvant systemic therapy for HER2-positive breast cancer”, section on ‘Benefits’.)
  • Formulations
    • Subcutaneous forms of trastuzumab as well as trastuzumab and pertuzumab have received approval by the US Food and Drug Administration based on similar pathologic complete response rates as the IV forms of these therapies when used with chemotherapy in the neoadjuvant setting. Either formulation may be used in the metastatic setting.

==========

2023-06-08

[tube feeding]

A grinding substitution method for Tykerb (lapatinib 250mg) tab

  • Please prepare the medications to be given, a cup, chopsticks (for stirring), and room temperature drinking water.
  • Put all the medications in the cup, add 20ml of room temperature drinking water.
  • Let it sit for 5 to 10 minutes.
  • Stir evenly with chopsticks to form a suspension, and then it can be given.
  • Add another 20ml of room temperature drinking water to the cup to rinse the cup and then drink it. For patients with a nasogastric tube, the medication solution should be poured into a feeding syringe, and then add another 20ml of room temperature drinking water to the cup to rinse the cup.
  • Then pour it into the feeding syringe again to flush into the nasogastric tube, which is used to rinse the tube wall.

2023-01-11

  • After over 15 kg of weight loss between late August and early December in 2022, the patient’s weight has remained at approximately 41kg for one month, with no further noticeable decline in her weight.

  • The elevated D-dimer readings are getting closer to the normal limits in a gradual manner. Given that the half-life of the D-dimer is only 15.8 (13.1 - 23.1) hours (ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2693750/), could this slow decline be indicative of latent fibrin degradation?

    • 2022-12-23 D-dimer 3391.46 ng/mL(FEU)
    • 2022-12-15 D-dimer 4269.08 ng/mL(FEU)
    • 2022-12-02 D-dimer 5167.01 ng/mL(FEU)
    • 2022-11-11 D-dimer 6070.93 ng/mL(FEU)
    • 2022-10-28 D-dimer 6632.74 ng/mL(FEU)
    • 2022-09-26 D-dimer 9267.55 ng/mL(FEU)
    • 2022-08-29 D-dimer > 10000.00 ng/mL(FEU)
  • It is advised to assess LVEF immediately prior to pertuzumab/trastuzumab initiation, every 3 months during pertuzumab/trastuzumab therapy, every 3 weeks if pertuzumab/trastuzumab is withheld for significant left ventricular cardiac dysfunction, and every 6 months for at least 2 years following completion of adjuvant pertuzumab/trastuzumab therapy. Pre-pertuzumab/trastuzumab 2D transthoracic echocardiography was performed on 2022-08-11, so it might be in need of updating. (Nov and Dec 2022 CXR showed borderline cardiomegaly and enlargement of cardiac silhouette.)

  • Since bilirubin total was 0.95 mg/dL on 2023-01-11, there is no need to adjust the dose of paclitaxel.

2022-12-16

  • Over 15 kg of body weight have been lost in the past four months (41.2kg 2022-12-15 <- 55.8kg 2022-08-24). It is possible that the serum creatinine level remains below LLN since August 2022 as a result of insufficient dietary intake or muscle mass loss (malnutrition, muscle wasting). It should be necessary to encourage the patient to consume more food and there may be benefits to prescirbe megestrol as an appetite stimulant.

  • The presence of elevated plasma D-dimer concentrations indicates recent or ongoing intravascular coagulation and fibrinolysis. Although the reading remained high, it trended downward, a relatively positive sign. The metastatic liver lesion reduced clearance of fibrin degradation products?

    • 2022-12-15 D-dimer 4269.08 ng/mL(FEU)
    • 2022-12-02 D-dimer 5167.01 ng/mL(FEU)
    • 2022-11-11 D-dimer 6070.93 ng/mL(FEU)
    • 2022-10-28 D-dimer 6632.74 ng/mL(FEU)
    • 2022-09-26 D-dimer 9267.55 ng/mL(FEU)
    • 2022-08-29 D-dimer > 10000.00 ng/mL(FEU)
  • According to the patient’s updated liver function lab results, paclitaxel dosage does not need to be adjusted.

2022-11-24

  • 2022-11-23 AST 79 > 2x ULN(39), ALT 76 > 1.5x ULN(41), Bilirubin T 1.21 > 1x ULN(1.0), Bilirubin D 0.43 > 2x ULN(0.18). The dose of paclitaxel in this chemotherapy (3-hour infusion setting) does not need to be adjusted.

701466853

230529

[chemoimmunotherapy]

  • 2023-05-26 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr + docetaxel 75mg/m2 135mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-05-05 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 840mg NS 250mL 2hr + docetaxel 75mg/m2 135mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-04-14 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1075mg NS 500mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-03-24 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1073mg NS 500mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-03-01 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1075mg NS 500mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-02-07 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1082mg NS 500mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

2023-05-29

  • Trastuzumab and Pertuzumab, both monoclonal antibodies utilized in the management of HER2-positive breast cancer, can lead to several dermatologic side effects.

  • With Trastuzumab, patients may experience a skin rash in approximately 4% to 18% of cases.

  • Our dermatologist has prescribed Mycomb (nystatin, neomycin, gramicidin, triamcinolone) TOPI and Exelderm (sulconazole nitrate) EXT for the symptom on 2023-05-15.

  • In case of Grade 3 or higher paronychia - which is inflammation of the skin around the nails - the following approach is generally recommended aiming to manage the paronychia effectively while minimizing the impact on the patient’s overall cancer treatment plan. (ref: Prevention and management of dermatological toxicities related to anticancer agents: ESMO Clinical Practice Guidelines. Ann Oncol. 2021;32(2):157-170)

    • First, it’s crucial to interrupt the causative treatment until the severity of the paronychia has reduced to Grade 0 or 1. This will help to prevent exacerbation of the condition.
    • If there is suspicion of an underlying infection, bacterial, viral, and fungal cultures should be taken. This will help to determine the appropriate antimicrobial therapy, if necessary.
    • The ongoing management of the skin reaction should involve the use of topical treatments such as 2% povidone-iodine, topical beta-blocking agents, and topical antibiotics and corticosteroids. These can all help to reduce inflammation and prevent secondary infection.
    • Oral antibiotics can also be administered, particularly if there is concern about a more widespread infection.
    • After two weeks of this approach, the patient’s condition should be reassessed to evaluate the effectiveness of the intervention and to determine whether it’s safe to resume the original treatment.

700899684

230523

[diagnosis] - 2022-11-01 discharge note

  • Adenocarcinoma of descending colon with impending obstruction, status post laparoscopic-assisted left hemicolectomy on 2022/08/11, pT3N1bM0(3/13), G2, LVI(+), PNI(-), stage IIIB s/p chemotherapy with FOLFOX from 2022/09/28
  • Hyperlipidemia
  • Type 2 diabetes mellitus
  • Chronic viral hepatitis B without delta-agent
  • Herniated Intervertebral Disc
  • Diarrhea, unspecified

[past history]

  • Type 2 diabetes mellitus, hyperlipidemia, and hypertension for 8 years under medications treatment and follow up at endocrinology & metabolism clinic.

  • History of operation:

    • Liver abscess at right posterior lobe s/p needle aspiration on 2015/01/21.
    • CBD stone with cholangitis s/p laparoscopic cholecystectomy on 2015/07/09; and s/p EST and balloon lithotripsy on 2015/08/10.
    • T11, 12 compression fracture s/p T11, T12 vertebroplasty on 2018/03/23.

[Current Medication] - 20230220 admission note

  • Kentamin (B1 50mg & B6 50mg & B12 500mcg) 1# PO BID
  • Rivotril 0.5mg/tab (Clonazepam) 1# PO HS
  • Nicametate citrate (saline) 50mg/tab 1# BID (2023/02/03 Hold)
  • Uformin 500mg/tab (metformin) 1# PO BID
  • Zulitor 4mg/tab (pitavastatin) 1# PO QN
  • Kludone MR 60mg/tab (Gliclazide) 1# PO BID
  • Canaglu 100mg/tab (canagliflozin) 1# PO QDAC                            

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-01-20 CT - abdomen
    • S/P segmental resection of the descending colon.
    • There is no evidence of tumor recurrence.
  • 2022-12-27 CXR
    • S/P posterior longitudinal transpedicular screws and rods fixation.
    • Ground glass opacities in bil. lungs.
  • 2022-12-27 ECG
    • Normal sinus rhythm
    • Inferior infarct, age undetermined
    • Anterior infarct, age undetermined
    • Prolonged QT
  • 2022-12-19 Colonoscopy
    • not well prepare of colon
    • no obvious mucosal lesion is seen
  • 2022-12-06 Pelvis & Rt. Hip Lat
    • S/P posterior instrumentation fixation from L4 To L5 and s/p cage implantation within the L4-5 disk space.
    • Atherosclerotic change of superficial femoral artery.
  • 2022-09-27 CXR
    • Atherosclerotic change of aortic arch
  • 2022-08-20 KUB
    • degenerative change of the bony structure with marginal osteophyte formation is identified.
    • s/p posterior fixation of the lumbar spine is found.
    • phlebolith at pelvic cavity is also found.
  • 2022-08-12 All-RAS + BRAF mutations assay
    • All-RAS mutations assay
      • Detection range
        • KRAS codon 12, 13, 59, 61, 117, 146
        • NRAS codon 12, 13, 59, 61, 117, 146
      • Results
        • Detected (KRAS codon 12 GGT>GTT, p.G12D)
      • Interpretation
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF mutations assay
      • Detection range
        • BRAF codon 600
      • Results
        • There was no variant detected in the BRAF gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with BRAF mutation maynot benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • 2022-08-11 Patho - colon segmental resection for tumor
    • Diagnosis:
      • Intestine, large, descending colon, laparoscopic-assisted left hemicolectomy — Moderately differentiated adenocarcinoma
      • Cut-end, proximal and distal, descending colon, laparoscopic-assisted left hemicolectomy — Free of tumor
      • Lymph node, regional, dissection — Metastatic adenocarcinoma (3/13)
      • AJCC 8th edition pathology stage:pT3N1b(if cM0); AJCC stage IIIB
    • Gross Description:
      • Procedure: laparoscopic-assisted left hemicolectomy
      • Tumor Site: Descending colon
      • Tumor Size: 5.4x 4.5 cm
      • Macroscopic Tumor Perforation: Not identified
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Uninvolved
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Not identified
      • Tumor Budding:
        • Number of tumor buds in 1 ‘hotspot’ field (specify total number in area = 0.785 mm2)
        • Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: Not identified
      • Tumor Deposits: Not identified
        • Specify number of deposits: N/A
      • Regional Lymph Nodes:
        • Number of Lymph Nodes Involved/Examined: 3/13
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition):
        • TNM Descriptors (required only if applicable) (select all that apply)
          • m (multiple primary tumors) r (recurrent) y (posttreatment)
        • Primary Tumor (pT)
          • pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN):
          • pN1b: Two or three regional lymph nodes are positive
        • Distant Metastasis (pM):
          • N/A
      • Additional Pathologic Findings (select all that apply):
        • None identified
  • 2022-08-09 Patho - colon biopsy
    • Intestine, large, descending colon, biopsy— adenocarcinoma
    • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, tumor necrosis and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • 2022-08-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (73 - 15) / 73 = 79.45%
      • LVEF (%) = 80
      • M-mode (Teichholz) = 80
    • Normal LV systolic function with normal wall motion.
    • LV posterior wall thickening, dilated LA; LV diastolic dysfunction Gr 1.
    • Normal RV systolic function.
    • Aortic valve scleorsis with no AS and AR; posterior mitral annulus calcification with no MS, mild MR; mild TR; mild PR. - 2022-08-08 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Pulmonary disease pattern
    • Inferior infarct, age undetermined
    • Abnormal ECG
  • 2022-08-08 Colonoscopy
    • colon cancer, descending colon, s/p biopsy
  • 2022-08-05 CT - abdomen
    • History: LLQ pain for 1 month
      • Low abdomen pain and fever happened this morning
      • Past Hx of DM, liver abscess
    • Findings:
      • There is segmental wall thickening at the descending colon with irregular contour and lumen narrowing, measuring 1.7 cm in the maximal wall thickness that may be adenocarcinoma (T4a) with near complete obstruction. Please correlate with colonoscopy.
        • In addition, There are five enlarged nodes in the adjacent mesocolon (N2a).
      • S/P cholecystectomy.
        • There is dilatation and pneumobilia on IHDs, CHD, and CBD. Please correlate with serum alk-p and bilirubin level.
      • A renal cyst measuring 1.8 cm in left upper pole is noted.
    • Imaging Report Form for Colorectal Carcinoma
      • T:T4a (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIC (Stage_value)
  • 2022-07-28 SONO - abdomen
    • Diagnosis
      • Suspected pneumobilia,bil
      • S/p cholecystectomy
      • Suspected left renal cyst
      • Pancreas not shown
    • Suggestion
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • 2019-12-13 Pure Tone Audiometry
    • Tymp: Bil type A.
    • PTA
      • Reliability: fair
      • Average: R’t 19 dB HL, L’t 20 dB HL.
      • Bil high frequency mild SNHL.
  • 2019-03-20 Echo for liver, gall bladder, pancreas, spleen
    • Postcholecystectomy
    • Fatty liver, moderate
    • Pneumobilia
  • 2018-06-25 Doppler color flow mapping
    • LVEF = (LVEDV - LVESV) / LVEDV = (127 - 38) / 127 = 70.08%
      • M-mode (Teichholz) = 70
    • Mild septal hypertrophy with indeterminate LV filling pressure and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • AV sclerosis and prominnet posterior mitral annulus calcification with trivial MR; trivial PR.
    • Mild aortic root calcification.
  • 2018-04-02 Bone densitometry - Hip
    • Hip BMD performed by DXA revealed:
      • Left hip, BMD is 0.607 gms/cm2, about 1.8 SD below the peak bone mass (76%) and 0.5 SD above the mean of age-matched people (108%).
    • IMP: Osteopenia
  • 2017-08-23 Echo for liver, gall bladder, pancreas, spleen
    • Postcholecystectomy
    • Pneumobilia
    • Renal cyst, left
    • Fatty liver, moderate

[MedRec]

  • 2023-05-11 SOAP Neurology
    • S
      • P’t is a case of DM with regular F/U.
      • P’t suffered bilateral feet numbness for 1 year and hand cramping in recent days.
      • 20230216: Condition stationary, for medicine
      • 20230511: stationary, for medicine.
    • Diagnosis
      • DKA, NIDDM Type, adult-onset or unspecified type, not stated as uncontrolled [E11.65]
      • DM with neurological manifestation, NIDDM Type, adult-onset or unspecified type, not stated as [E11.40]
      • Displacement of lumbar intervertebral disc without myelopathy [M51.27]
    • Prescription
      • Rivotril (clonazepam 0.5mg) 1# HS
      • Saline (nicametate citrate 50mg) 1# BID
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
  • 2023-05-03 SOAP Dermatology
    • S: severe itchy papules and plaques erupition over trunk after medication.
    • O
        1. urticaria/angioedema type
        1. maculopapular type
        1. urticaria-purpura type
    • A
      • hand-foot syndorme. r/o erythema mutiformis.
      • Suspect related medication: chemotherapy.
    • P
      • education about drug side effec and explain
      • strongly suggested OPD f/u
    • Diagnosis
      • Localized skin eruption due to drugs and medicaments taken internally L27.1
    • Prescription
      • Topsym cream (fluocinonide 0.05%) BID EXT
      • Compesolon (prednisolone 5mg) 2# PRNQD
      • tetracycline BID EXT
      • Sinpharderm cream (urea) QN TOPI
  • 2023-04-25 SOAP Metabolism and Endocrinology
    • S: type 2 DM since 2013, hypertension, irregular Tx before, hyperlipidemia, hyperuricemia, poor control, family Hx of DM: (+)
      • patient refuse insulin injection
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
      • Obesity, unspecified [E66.9]
    • Prescription
      • Uformin (metformin 500mg) 1# BID
      • Zulitor (pitavastatin 4mg) 1# QN
      • Kludone (gliclazide 60mg) 1# BID
      • Canaglu (canagliflozin 100mg) 1# QDAC

[consultation]

  • 2022-12-06 Rehabiliation
    • A
      • Physical examination
        • Tenderness point: right lateral posterior lower back, near qudratus lumborum
          • Right lower back pain will exagerate when spine flexion and standing.
          • She denied pain over spine, SI joint or hip joint, muscle weakness or numbness.
          • suspected muscle strain or HIVD
        • L spine X ray: pending report
      • Assessment
        • Adenocarcinoma of descending colon with impending obstruction, status post laparoscopic-assisted left hemicolectomy on 2022/08/11, pT3N1bM0(3/13), G2, LVI(+), PNI(-), stage IIIB s/p chemotherapy with FOLFOX from 2022/09/28
        • Hyperlipidemia
        • Type 2 diabetes mellitus
        • Chronic viral hepatitis B without delta-agent
        • Herniated Intervertebral Disc s/p OP
        • Constipation
      • Plan
        • patient education for core-strengthening exercise, but the patient and her family refuse to do them.
        • keep current pain control medication;
          • NSAID or toricam could be considered if no contraindication
        • arrange rehab OPD follow up for further evaluation and treatment.
  • 2022-09-28 Dermatology
    • Q
      • For skin itchy, and skin rash at back, four limbs
      • This 77 years old female patient was a case of type 2 diabetes mellitus, hyperlipidemia, and hypertension for 8 years under medications treatment.
      • She also had surgical history of 1) s/p needle aspiration of liver abscess at right posterior lobe in 2015; 2) CBD stone with cholangitis s/p laparoscopic cholecystectomy on 2015/07/09; and s/p EST and balloon lithotripsy on 2015/08/10; 3) s/p T11, T12 vertebroplasty in 2018.
      • According to patient statement, she suffered from left low abdominal dull pain while defecation was noted for one month; the LLQ pain was got worse with difficult defecation in recenyly days. The colon biopsy showed: adenocarcinoma, stage: pT3N1b(if cM0); AJCC stage IIIB. Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+). This time, she is admitted for chemotherapy with FOLFOX, and she denied having a fever, chillness, abdomen pain, or TOCC history.
      • She complaints skin itchy, and skin rash at back, four limbs since 2022/09/21, so we need your help, thanks a lot!!
    • A
      • The patient had sufferred from diffuse itchy papules over dry xerotic skin over back and upper limbs.
      • Under the impression of xerotic dermatitis over four limbs and eczema over back
      • The following sugeetion:
        • keep Allegra (fexofenadine) 1# bid po use and consider add ketotifen 1# bid po use.
        • consider shift Mycomb (nystatin, neomycin, triamcinolone, gramicidin) to Topysm cream (fluocinonide) 2 tube topical bid use for itchy papules over back/four limbs.
        • add Sinphraderm (urea, hydrocortisone) 1 tube topical QN use after body wash for skin mositurating enhancement, especially on the four limbs.
        • Keep patient’s back from becoming stuffy by avoiding prolonged bed rest.
  • 2022-08-05 Colorectal Surgery
    • Q
      • LLQ pain for 1 month
      • Low abdomen pain and fever happened this morning
      • No vomiting, loose stool noted yesterday
      • Past Hx of DM, liver abscess
    • A
      • Abdomen: soft, mild tenderness at left, no distended
      • CT: Adenocarcinoma of the descending colon with near complete obstruction is highly suspected. Please correlate with colonoscopy.
        • According to American Joint Committee on Cancer(AJCC) staging system, 8th edition for colon cancer: T4a N2a M0, stage: IIIC
      • A: Tumor of D-colon, cT4aN2aM0
      • P: admission, nutrition support
        • we’ll arrange sigmoidoscopy next Monday for identification of colon lesion

[surgical operation]

  • 2018-03-23 T11, 12 compression fracture s/p T11, T12 vertebroplasty
  • 2015-08-10 EST and balloon lithotripsy (EST = endoscopic sphincterotomy)
  • 2015-07-09 CBD stone with cholangitis s/p laparoscopic cholecystectomy
  • 2015-01-21 Liver abscess at right posterior lobe s/p needle aspiration

[chemotherapy]

  • 2023-05-22 - leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr
    • dexamethasone 4mg + NS 250mL + aprepitant 125mg
  • 2023-04-20 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-03-08 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-02-20 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-02-03 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Due to ANC 1262, Ox 85 -> 65, DC 5FU bolus)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-01-18 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-12-15 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-12-05 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-11-17 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-11-01 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-10-18 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-09-28 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

==========

2023-05-23

  • Based on the PharmaCloud database, it appears that the patient has only been seen at our hospital for the past three months. No discrepancies or issues were identified in the medication reconciliation process for the patient upon admission this time.

  • The CT scan performed on 2023-01-20 showed no evidence of tumor recurrence. In addition, on 2023-05-03, both tumor markers, CEA and CA199, fell into the normal range for the first time. This is an encouraging development in the patient’s condition to date.

  • The patient experienced a severe eruption of pruritic papules and plaques over the trunk in early May 2023, probably in response to medication. The dermatologist has prescribed appropriate medications to treat this skin reaction. Please monitor closely for any recurrence of these symptoms.

  • The patient’s serum glucose levels have remained high, exceeding 270 mg/dL for the past two days. All medications prescribed by our endocrinologist have been added to the active formulary, and the patient is unwilling to take insulin injections. This makes appropriate dietary control even more important. It may be beneficial to schedule a consultation with a dietitian during the patient’s hospitalization to provide guidance on dietary changes to manage blood glucose levels.

2023-04-21

  • Blood glucose control becomes less effective, as evidenced by rising HbA1c levels.
    • 2023-04-12 HbA1c 8.0 %
    • 2023-01-11 HbA1c 6.8 %
    • 2022-10-12 HbA1c 6.0 %
    • 2022-07-11 HbA1c 5.8 %
  • Since the patient has been taking at least 3 therapeutic categories of oral antihyperglycemic agents for a long time, it is recommended that injectable insulin be introduced to assist with glycemic control.

2023-03-09

  • The patient has been receiving FOLFOX treatment since late Sep 2022. In early Feb 2023, the patient’s oxaliplatin dose was reduced from 85mg/m2 to 65mg/m2, and her 5FU bolus was skipped. Since then, there have been no further occurrences of severe leukopenia.
    • 2023-03-07 WBC 3.39 x10^3/uL
    • 2023-02-15 WBC 3.04 x10^3/uL
    • 2023-02-01 WBC 2.97 x10^3/uL
    • 2023-01-11 WBC 6.52 x10^3/uL
    • 2022-12-27 WBC 2.63 x10^3/uL
    • 2022-12-15 WBC 4.83 x10^3/uL
    • 2022-12-01 WBC 3.93 x10^3/uL
    • 2022-11-15 WBC 3.30 x10^3/uL
    • 2022-11-01 WBC 4.29 x10^3/uL
    • 2022-10-12 WBC 4.10 x10^3/uL
    • 2022-09-27 WBC 6.83 x10^3/uL
    • 2022-08-20 WBC 9.71 x10^3/uL
  • The patient has poor blood sugar control, which has been observed across multiple recent hospital stays. Despite taking Uformin (metformin), Canaglu (canagliflozin), and Kludone (gliclazide), the patient’s blood sugar levels have been poorly controlled during her hospital stay, increasing from 214 to 339 to 333mg/dL. It might be necessary to consider insulin as an option to help manage her blood sugar levels.

2023-02-21

  • The drugs that were recently prescribed at our Neurology, Metabolism & Endocrinology department and were disclosed in the NHI PharmaCloud System have been appropriately prescribed as self-carried items during this hospital stay. There have been no medication reconciliation issues found in the patient.
  • The results of the finger prick blood glucose tests indicate high readings (304 <- 316 <- 351mg/dL) despite the current use of Uformin (metformin), Canaglu (canagliflozin), and Kludone (gliclazide).
  • In consideration of the patient’s longstanding diabetes and development of neuropathy, retinopathy might need to be checked.
  • Consideration can be given to adding basal insulin if the patient’s fasting plasma glucose levels continue to remain consistently above 300mg/dL.

2023-01-19

  • The patient’s blood sugar level appears to have become less under control over the past half year. The results of finger prick blood glucose tests indicate that the readings are also high. (266 <- 296 <- 354mg/dL)
    • 2023-01-11 HbA1c 6.8 %
    • 2022-10-12 HbA1c 6.0 %
    • 2022-07-11 HbA1c 5.8 %
  • In the absence of iodinated contrast imaging, Uformin (metformin 500mg/tab) 1# BID can be added to help improve blood glucose control as long as the patient’s creatinine level remains low (2023-01-11 0.72mg/dL).

2022-12-16

  • The vital signs are stable and lab results on 2022-12-15 showed no extreme abnormalities. The control of blood sugar levels is better than it was during the last hospitalization.

2022-12-06

  • The lab results (2022-12-01) were generally normal except for a low PLT reading (107 x10^3/uL).
  • Despite treatment with metformin, gliclazide, and canagliflozain, the blood sugar level was still high at 205 mg/dL on 2022-12-06 06:09. An addition of DPP4 inhibitors, such as Trajenta (linagliptin), may be beneficial in lowering blood sugar levels.

2022-11-18

  • The lab results (2022-11-15) were generally normal without extreme readings.
  • There was a slight increase in blood pressure and blood sugar levels compared to normal. Please monitor on a regular basis.
  • There are no issues with the scheduled chemotherapy and the current prescription.

2022-11-02

  • A rise in pulse rate and drop in blood pressure were observed (2022-11-02 08:40 109/59, pulse 102), while SpO2 remained above 95%. Could it be caused by a lack of hydration?
  • Diabetes is managed by oral hypoglycemic agents and ordered human insulin, however, blood glucose levels are volatile and maintained high. Please continue to monitor it on a regular basis.
  • The active prescription is not subject to any issues.

2022-10-19

  • The patient has a history of diabetes. Under self-carried metformin, gliclazide, and canagliflozin medication, fasting blood sugar levels were highly volatile (231mg/dL 2022-10-19 06:17 <- 102mg/dL 2022-10-18 16:39) and should be closely monitored.
  • The most recent data on renal and liver function, serum electrolytes, CBC, WBC DC are dated 2022-10-12 and might be updated prior to chemotherapy.
  • Please keep the patient’s back from becoming stuffy by avoiding prolonged bed rest. (skin itchy, and skin rash at back, four limbs were observed during last hospital stay)

2022-09-28

All-RAS + BRAF + IHC results were like 700811991’s.

  • Using patient-carried antiglycemic agents Uformin (metformin), Kludone (gliclazide), and Canaglu (canagliflozin), the blood sugar level of the patient was acceptable.
  • TPR and BP readings were stable. The results of the lab test on 2022-09-27 were grossly normal.
  • No problems are identified that would make it inappropriate for the patient to receive the chemotherapy he is scheduled to receive.

700516200

230522

  • 2023-05-19 SONO - chest
    • Echo diagnosis:
      • right side small amount of pleural effusion
      • left side moderate amount of pleural effusion, 600cc straw-color fluid was aspirated for analysis.
    • Special Procedure:
      • echo-assisted pleural tapping 18# needle Left side 600ml straw-color
  • 2023-05-18 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Massive bilateral Pleura effusion
  • 2023-05-17 CXR
    • Sinus tachycardia
    • Left axis deviation
    • Low voltage QRS
    • T wave abnormality, consider anterior ischemia
    • Abnormal ECG
  • 2023-05-11 Cell block cytology - pleural effusion, left side
    • 50 ml urbid — positive for malignancy
    • SMEARS and CELLBLOCK: Many red blood cells, lymphocytes, mesothelial cells, and neoplastic cells present.
  • 2023-05-11 KUB
    • Spondylosis with scoliosis of the L-spine with convex to left side.
    • There are few calcified nodular shadows projecting over the both side buttock area, which may be due to old injection granuloma or bone island of the ilium. please correlate with clinical history.
    • S/P CVP line insertion from right femoral vein and the tip located at IVC.
  • 2023-05-11 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Massive left Pleura effusion
  • 2023-05-11 SONO - chest
    • Special Procedure:
      • Pleural tapping 16 #-needle Left side 500 ml straw-color
        • Chest echography was performed first. The suitable intercostal space was selected and located.
        • Catheter was inserted with negative pressure smoothly.
        • Left side pleural effusion was drawn smoothly.
        • Watch out BP after tapping.
    • Echo diagnosis:
      • Pleural effusion, left side.
    • Suggestion:
      • check BP for one hour. supine position for taking rest after tapping.
      • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, cell count, and TB exam. TB PCR.
  • 2023-05-10 Patho - esophageal biopsy
    • Esophagus, lower, biopsy — Esophageal ulcer
    • The sections show a picture of esophageal ulcer, composed of necrotic debris, inflammatory exudate and clusters of degenerative atypical cells.
    • IHC, the degenerative atypical cells reveal: CK(-), WT1(-) and Leukocyte common antigen (focal +). There is no evidence of carcinoma involvement in the sections examined.
  • 2023-05-10 ECG
    • Sinus tachycardia
    • Low voltage QRS
    • Nonspecific T wave abnormality
  • 2023-05-10 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Suboptimal survey, due to severe belching during exam
      • Reflux esophagitis LA Classification grade D
      • Esophageal ulcer, 25cm to 40cm below incisors
      • Superficial gastritis
      • Antral deformity
    • Suggestion
      • Suboptimal survey, due to severe belching during exam
      • PPI and sucralfate use
  • 2023-04-06 Patho - stomach biopsy
    • Stomach, upper body, AW, Biopsy — Hyperplastic polyp
  • 2023-04-06 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis, middle and lower esophagus, LA classification, grade D
      • Esophageal ulcer, middle and lower esophagus
      • Edematous change of gastric mucosa, body
      • Gastric polyp, upper body, AW, s/p biopsy
    • Suggestion
      • Please check albumin level
  • 2023-04-03, -02-06 Abdomen - Standing (Diaphragm)
    • Rim gas shadow in the pelvis is noted. please correlate with clinical condition or CT.
    • Non-specific bowel gas pattern in right lower abdomen and pelvis is noted. please correlate with clinical condition. Follow up is indicated.
    • Spondylosis with scoliosis of the L-spine with convex to left side
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L3-4.
    • There are few calcified nodular shadows projecting over the both side buttock area, which may be due to old injection granuloma or bone island of the ilium. please correlate with clinical history.
  • 2023-02-23 CT - abdomen
    • History and indication: ovarian ca
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. Some soft tissues at peritoneal cavity r/o tumor seeding. Some fluid collection at left subhepatic region.
      • Atherosclerosis of aorta.
      • Disc space narrowing at L3/4.
    • IMP:
      • S/P hysterectomy. Some soft tissues at peritoneal cavity r/o tumor seeding. Some fluid collection at left subhepatic region.
  • 2022-11-22 Body fluid cytology - ascites
    • Finding: ovarian cancer with recurrence
    • 46 cc, orange, cloudy — Positive for carcinoma
    • Smears show clusters of carcinomatous cells with nuclear hyperchromasia, irregular contour and pleomorphism.
  • 2022-11-17 CT - abdomen
    • Findings
      • S/P hysterectomy. Some soft tissues at peritoneal cavity r/o tumor seeding. Large amount ascites.
      • Right liver cyst (7mm).
      • Atherosclerosis of aorta.
      • Disc space narrowing at L3/4.
    • IMP:
      • S/P hysterectomy. Some soft tissues at peritoneal cavity r/o tumor seeding. Large amount ascites.
  • 2022-09-03 CT - abdomen
    • s/p hysterectomy and salpingo oophorectomy
    • No evidence of tumor recurrence
    • Some soft tissue at abdominal wall, stationary
  • 2022-05-06, -01-07 CT - abdomen
    • Prior CT mentioned Some soft tissues at abdominal wall are noted again, stationary. Benign process is highly suspected. Follow up is indicated.
  • 2022-01-05 Nerve Conduction Velocity, NCV
    • Findings
      • normal motor DLs, CMAP amplitudes and NCVs of bil. median, ulnar, peroneal and tibial n.
      • prolonged sensory DLs on right median and bil. ulnar n. with slowed NCVs, otherwise normal SNAP amplitudes and NCVs of bil. sural n.
      • the F-wave latencies of bil. median, ulnar, peroneal and tibial n. were normal.
      • the H-reflex study of bil. tibial n. were normal.
    • Conclusion: left median and bil. ulnar sural sensory neuropathies at distal region
  • 2022-01-04 Cerebral perfusion SPECT
    • There was no prominently abnormal focal radiotracer uptake in bilateral cerebral hemispheres. Please correlate with clinical findings for further evaluation.
  • 2022-01-04 MRI - brain
    • Chronic bil. paranasal sinusitis, chronic left mastoiditis.
    • Brain atrophy. Mild Bilateral subcortical and periventricular white matter change (leukoaraiosis).
  • 2021-12-28 CT - brain
    • No brain parenchymal lesion.
    • Intracranial ICAs and VAs atherosclerosis.
    • Brain atrophy.
    • Chronic left sphenoid-posterior ethmoid sinusitis and left mastoiditis.
  • 2021-09-23 CT - abdomen
    • S/P hysterectomy. Some soft tissues at peritoneal cavity r/o tumor seeding (stable). Stationary condition of anterior abdominal wall.
  • 2021-03-18 CT - abdomen
    • S/P hysterectomy. Increased soft tissues at peritoneal cavity r/o tumor seeding. Small amount ascites.
    • Wall thickening of gallbladder.
  • 2020-12-15 CT - abdomen
    • S/P hysterectomy. Increased soft tissues at right lower peritoneal cavity, r/o tumor seeding. Increased enhancement at anterior abdominal wall.
  • 2020-08-07 CT - abdomen
    • Prior CT identified a cystic lesion at right adenxa 6.2 x 5.2 cm is noted again, mild increasing in size to 6.8 x 6.4 cm. Please correlate with clinical condition.
  • 2020-08-04 Gynecologic ultrasonography
    • ATH + BSO
    • IMP: R/O Pelvis mass: (63mmx59mm), no blood flow
  • 2020-06-09 Patho - peritoneum biopsy
    • Labeled as “pelvic tumor”, clinical history: “ovarian cancer s/p op”, excision biopsy — fibrosis
    • Section shows 1 piece(s) of fibrotic tissue. No maligmancy.
  • 2020-04-27 CT - abdomen
    • S/P hysterectomy. Cystic lesions at bil. pelvic cavity.
  • 2020-02-02 KUB
    • Non-specific bowel gas pattern in left lower abdomen is noted. please correlate with clinical condition or CT. Follow up is indicated.
    • Spondylosis with scoliosis of the L-spine with convex to left side .
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L3-4.
    • There are few calcified nodular shadows projecting over the both side buttock area, which may be due to old injection granuloma or bone island of the ilium. please correlate with clinical history.
  • 2020-01-22 MRI - brain
    • no evidence of recent infarction.
  • 2020-01-10 ECG
    • Normal sinus rhythm
    • Prolonged QT
    • Abnormal ECG
  • 2020-01-07 Patho - soft tissue tumor, extensive resection
    • PATHOLOGIC DIAGNOSIS
      • Ovary, right, debulking — Serous adenocarcinoma, high grade.
        • IHC stains: ER (+), PR (-), WT-1 (+), PAX-8 (+): compatible with ovarian origin, vimentin (-): dis-favor endometrial origin.
      • Ovary, left, debulking — Serous adenocarcinoma, high grade
      • Fallopian tube, right, debulking — Serous adenocarcinoma, high grade
      • Fallopian tube, left, debulking — Serous adenocarcinoma, high grade
      • Uterus, corpus, total hysterectomy — Myomas; benign strophic endometrium.
      • Uterus, cervix, total hysterectomy — Free
      • Omentume, omentectomy (S20-289) — Serous adenocarcinoma, high grade
      • Lymph node, bilateral pelvic and para-aortic, dissection — Free
      • Urinary bladder, mass above bladder, excision — Transmural tumor invasion to bladder mucosa.
    • MICROSCOPIC EXAMINATION
      • Histologic type: serous carcinoma,
      • Histologic grade: high grade
      • Contralateral ovary involvement: present
      • Tumor side ovarian surface involvement: present
      • Contralateral ovary surface involvement: present
      • Right tube involvement: present (in parenchyma)
      • Left tube involvement: present (in parenchyma)
      • In situ adenocarcinoma in right &/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: present
      • Left adnexa soft tissue involvement: present
      • Pelvic soft tissue involvement: present
      • Uterine serosa involvement: absent
      • Omentum involvement: present (invasive ) The largest tumor: 8 x 5 x 1.1 cm.
      • Uterine Cervix involvement: not received
      • Endometrium involvement: absent
      • Myometrium involvement: absent
      • Appendix involvement: not received
      • Largest Extrapelvic Peritoneal Focus Macroscopic (greater than 2 cm)
      • Peritoneal/Ascitic Fluid: N2019-05003 - Malignant (positive for malignancy)
      • Regional Lymph Nodes: Free (0/56)
        • left external iliac (0/9);
        • left obturator (0/12);
        • right external iliac (0/6);
        • right obturator (0/12);
        • left para-aortic (0/12);
        • right para-aortic (0/5).
      • Other organs or specimens involvement: N/A.
  • 2020-01-07 Immunohistochemistry, IHC
    • Using block omental tissue S2020-289A1: IHC stains: ER (+), PR (-); WT-1 (+), PAX-8: (+): favor ovarian origin; vimentin (-): dis-favor endometrial origin.

[consultation]

  • 2023-05-11 Family Medicine
    • Q
      • The 74y/o woman has left ovarian serous adenocarcinoma, stage IIIC /p chemo with Avastin + Topotecan on 20230319. She has can’t intake and vomit coffee ground, suspect disease progress, so we need your help for hospice share care. Thanks!
    • A
      • 74-year-old female, left ovarian serous adenocarcinoma, stage IIIC s/p chemotherapy
      • This time suffer from poor intake & coffee ground vomitus
      • Consciousness alert, ECOG 3
      • We will arrange hospice combine care and follow up her condition

[chemotherapy]

  • 2023-03-20 - bevacizumab 15mg/kg 500mg NS 100mL 1.5hr + topotecan 3mg/m2 3.7mg NS 120mL 0.5hr (Avastin Q3W + topotecan D1,8,15)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-14 - topotecan 3mg/m2 3.7mg NS 120mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-06 - bevacizumab 15mg/kg 500mg NS 100mL 1.5hr + topotecan 3mg/m2 3.7mg NS 120mL 0.5hr (Avastin Q3W + topotecan D1,8,15)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-13 - topotecan 3mg/m2 3.8mg NS 120mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-06 - topotecan 3mg/m2 3.8mg NS 120mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-16 - topotecan 3mg/m2 3.8mg NS 120mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-06 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr + topotecan 4mg/m2 5.1mg NS 150mL 30min (Avastin Q3W + topotecan D1,8,15)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-11-05 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-09-28 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-08-20 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-07-20 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-06-29 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-06-01 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-05-11 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-04-20 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-04-07 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-05-26 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 500mL
  • 2020-05-05 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 500mL
  • 2020-04-14 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 500mL
  • 2020-03-24 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 250mL
  • 2020-03-03 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 250mL
  • 2020-02-05 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 250mL
  • 2020-01-05 - [liposome doxorubicin 30mg/m2 40mg D5W 100mL + carboplatin AUC 5 450mg NS 100mL] IP 2min

701451122

230522

[diagnosis] - 2023-04-09 admission note

  • Multiple myeloma not having achieved remission

[exam findings]

  • 2023-04-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (156 - 43) / 156 = 72.44%
      • M-mode (Teichholz) = 72.6
    • Conclusion
      • Adequate LV,RV systolic function with normal wall motion
      • LV hypertrophy, Impaired LV relaxation
      • Mild MR,TR,AR,PR
      • Calcified aortic valve
  • 2023-04-06 MRI - L-spine
    • Intravenous injection of gadolinium was not given.
    • Findings:
      • The lumbar spine shows spondylosis and disk space degeneration at the L2/3 through L5/S1 levels.
      • Retrolisthesis of L3 on L4, grade I.
      • Spondylolisthesis of L5 on S1, grade I.
      • One low signal intensity nodular lesion within T11 vertebral body. May be secondary to multiple myeloma.
  • 2022-09-05 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — plasma cell neoplasm (plasmacytoma or multiple myeloma).
    • Section shows piece(s) of bone marrow with 60-70% cellularity and M:E ratio of approximately 1:2. Three cell lineages are present with normal maturation of leukocytes and a predominant plasmacytoid subpopulation. Megakaryocytes are adequate in number.
    • IHC stains: CD138: 70%; Lambda and Kappa light chains: a predominant lambdsa light chain population, MPO: 10 %; CD71: 20% (of the nucleated cells). The findings are a pattern of plasmacytoma or multiple myeloma. Please correlate with image findings.

[MedRec]

  • 2023-05-05 SOAP Neurosurgery
    • S - BMT soon (20230521); walk level > 10 mins; Rt LE soft/weakness told
    • Prescription
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD
      • Saline (nicametate citrate 50mg) 1# QD
  • 2023-04-07 SOAP Neurosurgery
    • S - respsone to neurotine; still bil legs soreenss; lying worser;
    • Prescription
      • Neurontin (gabapentin 100mg) #1 PRNBID
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
      • Saline (nicametate citrate 50mg) 1# BID
  • 2023-03-17 SOAP Neurosurgery
    • S - LBP with Rt > Lt LE radiatioanl pain/ numbness to foot for months; Associated with Weakenss; Pitting edema; night pain
    • Prescription
      • Neurontin (gabapentin 100mg) #1 PRNBID
  • 2022-09-29 SOAP Hemato-Oncology
    • O: 2022/09/27 Albumin = 2.8 g/dL
    • P:
      • NHI reimbursement - Bortezomib (such as Velcade) is limited to use in combination with other cancer treatment drugs for patients with multiple myeloma.
        • Maximum of 16 treatment cycles per person; Myzomib has a maximum of 8 treatment cycles per person.
        • Requires prior application before use, applying for 4 treatment cycles at a time.
        • After using 4 treatment cycles, it is necessary to confirm that paraprotein (M protein) has not increased after drug use (indicating response or stable status), or for some non-secretory type MM patients, the treatment effect is based on the ratio of plasma cells in bone marrow examination, only then can the treatment continue.
  • 2022-09-27 SOAP Hemato-Oncology
    • S: He was diagnosed to have multiple myeloma presenting as normocytic anemia
    • O: 2022/09/17 IgA = 6539 mg/dL;
    • Multidisciplinary Cancer Team Meeting Conclusion, Meeting Date: 20220926
      • Multiple myeloma IgA Lambda
      • ISS stage 2 at least
      • use VTD followed by autoPBSCT
  • 2022-09-16 SOAP Hemato-Oncology
    • O
      • 2022/09/16 Free Light Chain κ/λ
        • FKLC = 7.44 mg/L;
        • FLLC = 155 mg/L;
      • 2022/09/13 Protein EP
        • M-peak = Positive;
  • 2022-09-09 SOAP Hemato-Oncology
    • S: He was informed to have anemia since March 2022 and he received check up at HuaLien TzuChi Hospital
    • O:
      • 2022/09/09 Reticulocyte count = 6.340 %;
      • 2022/09/09 CBC
        • HGB = 7.2 g/dL;
        • MCV = 97.1 fL;
      • 20220909: BP 126/74; Pulse 74;
    • A:
      • Normocytic anemia requiring transfusion

[chemothereapy]

  • 2023-04-14 - cyclophosphamide 3000mg/m2 5500mg NS 500mL 2hr (Endoxan for PBSC mobilization protocol)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + Uromitexan (mesna) NS 100mL 1hr + NS 250mL
  • 2023-03-10 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2023-02-09 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2023-01-31 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1 (VTd)
  • 2023-01-10 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2022-12-27 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2022-12-13 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2022-11-29 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2022-11-15 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2022-11-01 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2022-10-18 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2023-10-11 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1 (VTd)

Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma 2023-05-22 https://www.uptodate.com/contents/image?imageKey=ONC%2F101205&topicKey=HEME%2F6647

  • Cycle length: 28 days.
  • Regimen
    • Bortezomib
      • 1.3 mg/m2 SC
      • Given as a single SC injection.
      • Days 1, 8, 15, and 22
    • Thalidomide
      • 100 mg for first 14 days then 200 mg per day thereafter by mouth
      • Take with water on an empty stomach at least one hour after the evening meal.
      • Daily, days 1 through 21
    • Dexamethasone (“low dose”)
      • 40 mg by mouth
      • Take with food (after meals or with food or milk) in the morning.
      • Days 1, 8, 15, and 22

[lab data]

prior to peripheral blood stem cell harvest

2023-04-17 CMV viral load assay Target not detecetedIU/mL
2023-04-17 EBV DNA quantitative amplification test <120 copies/mL
2023-04-13 EB VCA IgG Positive Ratio
2023-04-13 EB VCA IgG Value 5.3 Ratio
2023-04-12 EB VCA IgM Negative Index
2023-04-12 EB VCA IgM Value 0.0 Index
2023-04-10 RPR/VDRL Nonreactive
2023-04-10 CMV IgM Nonreactive
2023-04-10 CMV IgM Value 0.54 Index
2023-04-10 CMV_IgG Reactive
2023-04-10 CMV_IgG Value 834.1 AU/mL
2023-04-10 HIV Ab-EIA Nonreactive
2023-04-10 Anti-HIV Value 0.05 S/CO
2023-04-10 Anti-HBc Nonreactive
2023-04-10 Anti-HBc-Value 0.24 S/CO
2023-04-10 Anti-HCV Nonreactive
2023-04-10 Anti-HCV Value 0.06 S/CO
2023-04-10 HBsAg Nonreactive
2023-04-10 HBsAg (Value) 0.50 S/CO
2023-04-10 Anti HTLV I/II Nonreactive
2023-04-10 Anti HTLV I/II Value 0.05 S/CO

700901572

230518

[lab data]

  • 2023-05-15 CMV_IgG Reactive
  • 2023-05-15 CMV_IgG Value 628.6 AU/mL
  • 2023-05-15 CMV IgM Nonreactive
  • 2023-05-15 CMV IgM Value 0.16 Index

[exam findings]

  • 2023-05-14 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • Linear infiltration over right and left lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2023-02-20 Patho - bone marrow biopsy
    • Bone marrow, iliac reast, biopsy— Hypercellularity (near 100%) with presence of blasts (about 10%)
      • NOTE: Differential diagnosis includes chronic myeloid leukemia and myeloproliferative neoplasm. Correlation of CBC data, molecular cytogenetic study, BCR/ABL1 test and bone marrow smear is recommended.
    • Microscopically, it shows hypercellularity (near 100%) with myloid cell proliferation. Blasts highlighted by CD34 and CD117 are seen and about 10%. Megakaryocytes are increased.
    • Immunohistochemical stain reveals MPO(+), CD61(+), CD71( focal+), CD20(-), CD138(-), TdT(-).
  • 2023-02-20 SONO - abdomen
    • Liver cysts
    • bilateral pleural effusion
    • right renal cyst
  • 2023-02-17 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 35.9) / 116 = 69.05%
      • M-mode (Teichholz) = 69.1
    • Conclusion
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Mild to moderate MR and TR, mild AR
      • Impaired LV relaxation
      • Dilated LA, thick IVS
  • 2020-09-09 MRI - thyroid, parathyroid
    • Indication: L thyroid tumor
    • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed
      • a cystic lesion, about 24.76mm, in the left thyroid gland. NO obvious enhancement was noted.
      • no neck LAP.
      • unremarkable change in the skull base.
      • unremarkable change in the naspharynx, oropharynx, and hypopharynx
    • IMP:
      • a thyroid cystic lesion in the left thyroid gland.
  • 2020-09-07 Nasopharyngoscopy
    • Findings: Lymphoid tissue noted in posterior pharyngeal wall
    • Conclusion: thyroid cyst, left
  • 2020-06-18 Patho - intradermal nevus
    • Skin, face, excision biopsy — Seborrheic keratosis
    • Section shows piece(s) of hyperkeratosis, papillomatous skin with keratin cysts and interdigitation of epidermis and papillary dermis.

[MedRec]

  • 2023-05-09 SOAP Hemato-Oncology
    • P
      • RTC 1 weeks -> Due to elevated WBC > 400K
      • Visit Dermatologist for skin induration
      • Visit Urologist for urine frequency
  • 2023-03-30 SOAP Hemato-Oncology
    • A: Body weight loss might be related to poor dental condition
  • 2023-03-16 SOAP Hemato-Oncology
    • S: 2022-03 Chromosome: 46~47,XX,+8[cp19]
    • O: 2023/03/09 JAK2 single site gene mutation = Undetectable
  • 2023-03-02 SOAP Hemato-Oncology
    • O:
      • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date 20230227: waiting for JAK2 data
      • 2023/02/27 BCR/abl = Undetectable
  • 2023-02-16 ~ 2023-02-24 POMR Hemato-Oncology
    • Discharge diagnosis
      • R/O Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission
      • Gout, unspecified
    • CC
      • for higher WBC and PLT level
      • for SOB
    • Present illness
      • This 84 y/o female with dyslipidemia was admitted to our ward via ER due to abnormal leukocytosis during OPD examination.
      • According to the patient’s family, she started to cough and suffered from dyspnea, especially on exertion one week ago. She was brought to LMD for help, and came to our OPD today again for persisted symptoms. At our Family medicine OPD, her lab data showed leukocytosis with WBC level of 84810/uL, and thrombocytosis of 1118K. And the data was significantly different from last data in 2022/02, with WBC level of only 11070/uL. She was then refered to Hema OPD, and follow-up lab data showed even higher WBC count of 88170/uL, and metamyelocyte 19%, myelocyte 31.0 %, promyelocyte 2.0 %, blast 2%, PL 1118000/uL. Therefore, admission for further survey on 2023/02/17.
    • Course of inpatient treatment
      • After admission, she received NS hydration, Hydrea 2# qd (2/17-2/20), Feburic 0.5# qd and Bokey 1# qd for higher WBC and PLT. Critical condition for closely monitor. She will do the bone marrow, abd echo and echocardigraphy for general survey. Empiric antibiotic as Flumarin for low grade fever. Heart echo was done, LVEF 69%. Abd echo showed no splenomegaly. Bone marrow was done and no hematoma, report showed Hypercellularity (near 100%) with presence of blasts (about 10%) on 2023/2/23 and pending BCR-ABL. Norvasc 1# qd for hypertension, but lower limbs mild edema, so we shifted Olmetec and consult CV for assessment. After treatment, her WBC and PLT level decrease, so she can be discharged on 2023/02/24.
    • Prescription
      • Ulstop (famotidine 20mg) 1# QD
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
      • Olmetec (olmesartan medoxomil 20mg) 1# QD
      • Feburic (febuxostat 80mg) 0.5# QD
      • Bokey (aspirin 100mg) 1# QD
  • 2023-02-16 SOAP Hemato-Oncology
    • Diagnosis
      • Chronic myeloid leukemia, BCR/ABL-positive C92.1
      • Dyspnea, unspecified R06.00
    • Prescription
      • Bokey (aspirin 100mg) 1# QD
      • Ulstop (famotidine 20mg) 1# QD
      • Hydrea (hydroxyurea 500mg) 2# QD
  • 2023-02-16 SOAP Family Medicine
    • O
      • 2023/02/16 CBC
        • WBC = 84.81 x10^3/uL;
        • HGB = 11.4 g/dL;
        • PLT = 1118 x10^3/uL;
    • P: refer to hema OPD

[consultation]

  • 2023-02-21 Cardiology
    • Q
      • The 84 y/o woman has hypertension without drug use. We gave Norvasc, but lower limbs pitting edema weak 1+. LVEF not dysfunction. We shift to ARB for control. We need your help for anti-hypertension agent assessment. Thanks!
    • A
      • Currently the patient’s blood BP is relatively stable.
      • Keep SBP 140-150 mmhg during admission with current medication.
      • CV OPD f/u.

==========

2023-05-18

[assessment]

  • Based on the serial trend of WBC counts, it appears that hydroxyurea 1000mg daily might be excessively suppressing WBC levels, while 250mg or 500mg daily might not be sufficient. It might be worthwhile considering a daily dose of 750mg, using a combination of 500mg QD and 500mg QOD to achieve the desired therapeutic effect.
    • 2023-05-18 hydroxyurea 500mg 2# QD
    • 2023-05-17 WBC 57.14 x10^3/uL hydroxyurea 500mg 1# QD 1# ST
    • 2023-05-15 WBC 49.31 x10^3/uL hydroxyurea 500mg 1# QD
    • 2023-05-13 WBC 52.53 x10^3/uL hydroxyurea 500mg 1# QD
    • 2023-05-09 WBC 46.73 x10^3/uL hydroxyurea 500mg 1# QOD
    • 2023-04-26 WBC 11.91 x10^3/uL hydroxyurea 500mg 1# QOD
    • 2023-04-13 WBC 8.67 x10^3/uL hydroxyurea 500mg 1# QOD
    • 2023-03-30 WBC 12.58 x10^3/uL hydroxyurea 500mg 1# QOD
    • 2023-03-23 WBC 26.55 x10^3/uL hydroxyurea 500mg 1# QOD
    • 2023-03-16 WBC 59.00 x10^3/uL hydroxyurea 500mg 1# QOD
    • 2023-03-02 WBC 5.00 x10^3/uL
    • 2023-02-24 WBC 3.62 x10^3/uL
    • 2023-02-22 WBC 4.46 x10^3/uL hydroxyurea 500mg 2# QD
    • 2023-02-20 WBC 19.99 x10^3/uL hydroxyurea 500mg 2# QD
    • 2023-02-18 WBC 62.40 x10^3/uL hydroxyurea 500mg 2# QD
    • 2023-02-16 WBC 88.17 x10^3/uL hydroxyurea 500mg 2# QD
    • 2023-02-16 WBC 84.81 x10^3/uL hydroxyurea 500mg 2# QD 2# ST
  • In addition, the PLT count is clearly in a downtrend, which would also be closely watched.
    • 2023-05-17 PLT 285 *10^3/uL
    • 2023-05-15 PLT 281 *10^3/uL
    • 2023-05-13 PLT 324 *10^3/uL
    • 2023-05-09 PLT 414 *10^3/uL
    • 2023-04-26 PLT 456 *10^3/uL
    • 2023-04-13 PLT 419 *10^3/uL
    • 2023-03-30 PLT 399 *10^3/uL
    • 2023-03-23 PLT 536 *10^3/uL
    • 2023-03-16 PLT 664 *10^3/uL
    • 2023-03-02 PLT 637 *10^3/uL
    • 2023-02-24 PLT 702 *10^3/uL
    • 2023-02-22 PLT 678 *10^3/uL
    • 2023-02-20 PLT 928 *10^3/uL
    • 2023-02-18 PLT 1102 *10^3/uL
    • 2023-02-16 PLT 1091 *10^3/uL
    • 2023-02-16 PLT 1118 *10^3/uL

Dacogen (decitabine)

  • The drug candidate for the treatment of this patient, Dacogen (decitabine 50mg/vial), is currently being temporarily purchased by both Hualien General Hospital and Taipei Xindian Branch. The “temporary procurement” process for a drug usually takes about 1 to 2 months.
  • The in-hospital unit prices for Dacogen (decitabine 50mg/vial) are TWD 14,280 for patients covered by NHI and TWD 16,422 for self-pay patients.
  • Current “National Health Insurance Drug Reimbursement” for decitabine (2023-04-24 updated)
    • For patients with high-risk myelodysplastic syndromes: RA with excess blasts, RAEB; RAEB in transformation, RAEB-T; chronic myelomonocytic leukemia, CMMoL.
    • Pre-approval review is required for the initial application of this drug.
    • Continuation of this drug does not require pre-approval review, but the medical record should keep pathology or imaging diagnosis proofs, and clinical data related to the treatment. If the patient’s condition worsens to acute myeloid leukemia, the drug should be stopped.
    • Definition of acute myeloid leukemia: myeloblast count greater than 30%.
    • This drug and azacitidine can only be used alternatively. Except for intolerability, they should not be interchanged. If this drug is ineffective, azacitidine cannot be applied for again.

700561422

230517

[past history]

  • Heart:(-)

  • Chest:(-)

  • Liver:(-)

  • Kidney:(-)

  • H/T:(-)

  • DM:(-)

  • Other medical:denied

  • Surgical: s/p Peripheral glioma excision 20+ years ago

  • Menstrual history: G4P2SA2, NSD x2

  • Menarche at the age of 13 years old

  • Menopaused at the age of 56 years old

  • Menstrual cycle:Duration/Interval:4days/28days                 

[allergy]

  • NKDA                 

[family history]

  • Father: prostate cancer
  • Mother: HTN, DM

[exam findings]

  • 2023-04-28 Body fluid cytology - ascites
    • negative
  • 2023-04-26 Body fluid cytology - ascites
    • negative
  • 2023-03-23 Patho - uterus with or without SO non-neoplastic/prolapse
    • PATHOLOGIC DIAGNOSIS
      • Ovarian mass, bilateral, debulking surgery (s/p C/T) — Endometrioid carcinoma, grade 3
      • Fallopain tube, bilateral, ditto — Free of tumor invasion
      • Cervix, uterus, total hysterectomy — Free of tumor invasion
      • Endometrium, uterus, ditto — Endometrioid carcinoma, favor metastatic
      • Myometrium, uterus, ditto — Adenomyosis
      • Lymph node, left iliac, dissection — Free of tumor metastasis (0/4)
      • Lymph node, left obturator, ditto — Tumor metastasis (5/5) without extracapsular extension (0/5)
      • Lymph node, right iliac, ditto — Free of tumor metastasis (0/4)
      • Lymph node, right obturator, dissection — Tumor metastasis (2/10) without extracapsular extension (0/2)
      • Lymph node, left paraaortic, dissection — Free of tumor metastasis (0/5)
      • Lymph node, right paraaortic, dissection — Free of tumor metastasis (0/5)
      • Omentum, omentectomy — Metastatic adenocarcinoma
      • Bilateral parametria — Free of tumor invasion
      • AJCC Pathologic staging — ypT3cN1b, if cM0, stage IIIC
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: debulking surgery
      • Specimen type: uterus, R’t ovary mass, L’t ovary mass, pelvic and paraaortic LNs, and omentum
      • Specimen size:
        • L’t ovarian mass: 4.5 x 3.3 x 3.2 cm, solid mass with cystic change
        • L’t fallopian tube: 3.7 cm in length, 0.5 cm in diameter
        • R’t ovary mass: 7.2 x 7.2 x 4.1 cm, cystic mass with solid area and surface involvement
        • R’t fallopian tube: 6.2 cm in length, 0.4 cm in diameter
        • Uterus: 11 x 5.9 x 4.3 cm in size and 130 gm in weight. One yellow necrotic tumor mesured 1.2 x 0.5 cm within endometrium is seen, invades less than half the myometrium
        • Omentum: 34 x 13 x 2.2 cm with some firm masses
      • Tumor site: bilateral ovary and endometrium
      • Tumor size: (A) R’t ovary: 7.2 x 7.2 x 4.1 cm, (B) L’t ovary: 4.5 x 3.3 x 3.2 cm and (C) endometrium: 1.2 x 0.5 cm
      • Tumor appearance: (A) bilateral ovary: cystic tumor with solid area (B) endometrium: yellow necrotic tumor
      • Specimen integrity: intact, tumor on surface of right ovarian mass
      • Lymph node: pelvic and bilateral paraaortic LNs
      • Representative sections as: A: left iliac LNs, B: left obturator LNs, C: right iliac LNs, D: right obturator LNs, E: left paraaortic LNs, F: right paraaortic LNs, G1-G2: bilateral parametria, G3: cervix, G4: corpus, G5-G6: endometrial tumor, H1: L’t fallopian tube, H2-H6: L’t ovarian mass, I1: R’t F-tube, I2-I8: R’t ovarian mass, J1-J2: omentum
    • MICROSCOPIC EXAMINATION
      • Histologic type: Endometrioid carcinoma
      • Histologic grade: Grade 3
      • Contralateral ovary involvement: involved
      • Tumor side ovarian surface involvement: involved
      • Contralateral ovary surface involvement: Not involved
      • Right tube involvement: absent
      • Left tube involvement: absent
      • In situ adenocarcinoma in right &/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: absent
      • Left adnexa soft tissue involvement: absent
      • Pelvic soft tissue involvement: N/A
      • Uterine serosa involvement: Not involved
      • Omentum involvement: tumor involved
      • Uterine Cervix involvement: absent, Nabothian cysts
      • Endometrium involvement: present
      • Myometrium involvement: present and adenomyosis
      • Lymph nodes metastasis: tumor metastasis (7/33) without extracapsular extension (0/7) in total number
      • Immunohistochemistry: PAX-8(+), ER(+), WT-1(-), PR (+) and P53(wild type)
      • Ascites: positive for tumor metastasis
  • 2023-03-23 Cytology - ascites
    • 32 cc red turbid ascites — Positive for malignancy
    • The smears show lymphocytes, reactive mesothelial cells and some hyperchromatic atypical epithelial clusters, compatible with metastatic carcinoma. Clinical correlation is advised.
  • 2023-03-22 CXR
    • Increased bilateral lung markings.
    • Borderline cardiomegaly.
    • Thoracic spondylosis.
  • 2023-03-08 CT - abdomen
    • Indication
      • 20221215 sono: ascites, cause unknown. One hyperechoic lesion in the peritoneal cavity. Probable thickened omentum.
      • 20221221 CT: cystic adenocarcinoma of bilateral ovary is suspected. cT3cN1bM, STAGE: IIIC
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
    • Findings:
      • Prior CT identified massive ascites and omentum cake is noted again, marked decreasing in size that is c/w carcinomatosis S/P C/T with partial response.
      • Prior CT identified two multilocular cystic mass with some septa and enhancing mural nodules in right and left lower abdomen and pelvis, measuring 11.5 cm (right) and 10.4 cm (left) in size (the largest dimension), are noted again, marked decreasing in size to 6.8 cm (right) and 5.2 cm (left).
        • Cystic adenocarcinoma of bilateral ovary S/P C/T show partial response.
      • Prior CT identified several kissing enlarged nodes in left para-aortic space, left common iliac chain, left internal iliac chain, and left external iliac chain are noted again, marked decreasing in size that are c/w metastatic nodes S/P C/T with near complete response.
      • Prior CT identified few poor enhancing lesions in the uterus are not noted again.
      • Others
        • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidneys.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery.
    • Impression:
      • Carcinomatosis S/P C/T show partial response.
      • Cystic adenocarcinoma of bilateral ovary S/P C/T show partial response.
      • Metastatic lymph nodes S/P C/T show near complete response.
  • 2023-01-10 Cytology - ascites
    • 42 cc orange turbid ascites — Atypia
    • The smears show some lymphocytes, neutrophils, reactive mesothelial cells and only one atypical cell cluster show hyperchromatic nuclei with vacuolated cytoplasm. Follow up.
  • 2022-12-27 Cell block cytology
    • 40 cc, red, cloudy — Adenocarcinoma
    • Smears and cell block show dense clusters of atypical cells admixed with lymphoplasmcytes, leukocytes and mesothelial cells.
    • IHC stain— CK7(+), CK20(-), PXA-8(+), WT-1(focal+).
  • 2022-12-22 Gynecologic ultrasonography
    • Ascites
    • Bilateral Ovarian mass, malignancy cannot be ruled out
    • Endometrial hyperplasia
  • 2022-12-21 CT - abdomen
    • Indication: 20221215 sono: Acites, cause unknown. One hyperechoic lesion in the peritoeal cavity. Propable thickened omentum.
    • Findings:
      • There is massive ascites and omentum cake that is c/w carcinomatosis.
      • There are two multilocular cystic mass with some septa and enhancing mural nodules in right and left lower abdomen and pelvis, measuring 11.5 cm (right) and 10.4 cm (left) in size (the largest dimension).
        • Cystic adenocarcinoma of bilateral ovary (T3c) is suspected. Please correlate with CA125 and ascites cytology.
      • There are several kissing enlarged nodes in left para-aortic space, left common iliac chain, left interal iliac chain, and left external iliac chain that are c/w metastatic nodes.
        • The largest node in left common iliac chain measuring 2 cm in the largest dimension (N1b).
      • There are few poor enhancing lesions in the uterus that may be myomas. Please correlate with GYN. sonography.
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N1b (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)
  • 2022-12-16 Patho - stomach biopsy
    • Stomach, cardia, biopsy — Helicobacter-associated non-atrophic chronic gastritis
    • Stomach, antrum, biopsy — Helicobacter-associated non-atrophic chronic gastritis
  • 2022-12-15 SONO - abdomen
    • Fatty liver, mild
    • Suspected fatty infiltration of pancreas
    • Small amount ascites
    • One hyperechoic lesion in the peritoeal cavity. Propable thickened omentum

[surgical operation]

  • 2023-03-22
    • Surgery
      • Operation
        • Excision of intraabdominal malignant tumor
        • HIPEC
        • Tenckhoff tube insertion
    • Finding
      • s/p neoadjuvant chemotherapy
      • PCI: total = 0 (PCI = Peritoneal Cancer Index)
        • [#] region – score
        • [0] central – 0
        • [1] RU – 0
        • [2] epigastrium – 0
        • [3] LU – 0
        • [4] left flank – 0
        • [5] LL – 0
        • [6] pelvis – 0
        • [7] RL – 0
        • [8] right flank – 0
        • [9] upper jejunum – 0
        • [10] lower jejunum – 0
        • [11] upper ileum – 0
        • [12] lower ileum – 0
      • HIPEC regimen: Lipo-dox 35mg/m2 + Carboplatin AUC 5
      • Drain: 15 Fr J-VAC x2 in the pelvic cavity
  • 2023-03-22
    • Surgery
      • Diagnosis: Ovarian cancer
      • Frozen: Debulking surgery (hysterectomy + bil. salpingo-oopherectomy + BPLND + omentectomy)
    • Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, tense contact with bladder
      • Adnexa:
        • LOV: 5x4x4 cm, with enlarged mass
        • ROV: 8x8x8 cm, with papillary tumor growth
        • Fallopian tube: bilateral grossly normal
      • CDS: adhesion band to the bowel (+)
      • Ascites: bloody, about 50 ml
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • Omentum: grossly normal, infracolic omentectomy completed
      • After the operation, suboptimal debulking surgery was achieved.
      • Estimated blood loss: 850 mL
      • Blood transfusion: 2U pRBC
      • Complication: nil
  • 2023-03-22
    • Surgery
      • bilateral ureter catheterization
    • Finding
      • grossly no tumor in bladder, no external compression
      • bilateral UO clean urine jet

[chemotherapy]

  • 2023-05-16 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 1000mL] IP 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-04-25 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 1000mL] IP 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-03-21 - liposome doxorubicin 35mg/m2 60mg D5W 250mL IP 90min + carboplatin AUC 5 600mg NS 250mL IP 90min (for HIPEC in operation)

  • 2023-02-23 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1000mg NS 250mL 2hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-01-31 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1000mg NS 250mL 2hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-01-09 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1100mg NS 250mL 2hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

==========

2023-05-17

  • The patient’s vital signs are stable, labs are largely within normal limits, and no significant adverse reactions have been reported. A review of the PharmaCloud database shows that all of the patient’s recent medications were prescribed by our hospital, and no medication reconciliation issues were identified.

2023-04-26

[assessment]

  • On 2023-04-26, lab results showed normal blood cell counts, electrolytes, liver, and kidney function levels, as well as stable vital signs on the TPR panel since this hospitalization.
  • The patient experienced no significant discomfort other than mild abdominal distension following normal saline infusion via the IP tube. Naproxen was administered to relieve the abdominal pain in the IP wound area.
  • The patient’s underlying condition of hepatitis B (anti-HBc positive) is being adequately treated with Vemlidy (tenofovir alafenamide).
  • According to the PharmaCloud database, all recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.

700757059

230517

[exam findings]

  • 2023-04-21 CXR
    • Lung markings: emphysematous change in the bilateral lung fields
    • mild blunting bilateral costophrenic angles
    • fractures at the right ribs and left lower ribs
  • 2023-04-21 KUB
    • compression fractures at L1, L2 and L3 vertebral bodies; compression fracture at L5 vertebral body.
    • s/p right THR at right hip
  • 2023-04-21 ECG
    • Normal sinus rhythm
    • Nonspecific ST and T wave abnormality
    • Prolonged QT
    • Abnormal ECG
  • 2023-03-06, 2022-12-12, -11-28 CXR
    • linear high density structures over over Rt infrahilum, lower lung zone and left lung, may be pulmonary foreign bodies embolic priop vertebroplasty
    • reticulonodular opacities over left lung too
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad/supine position
    • compression fracture of multiple vertebral bodies
    • priop vertebroplasty in many levels
    • Osteoporotic change of spine and bones of both shoulder regions
    • old fracture of multiple Lt and Rt ribs
    • Avascular necrosis of Rt humeral head, with marginal spurs
  • 2023-01-17 Clinical Dementia Rating
    • CDR score: 2
  • 2023-01-17 Mini-Mental State Examination
    • MMSE score: 13
  • 2022-12-09 MRA - brain
    • Indication:
      • suspect Multiple myeloma, DM. unknown dementia history
      • can communicate 1.5 months ago. marked cognitive decline and disorientation after admission 1 month ago.
    • Impression:
      • Brain atrophy and leukoaraiosis.
      • No evidence of recent infarct.
      • A 0.6cm enhancing bone nodule in dens, nature to be determined.
  • 2022-12-01 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Plasma cell myeloma
    • The sections show normocellular marrow (25%). The marrow space is largely replaced by a population of medium-sized immature and mature CD138+ plasma cells, constitue 80% of marrow cells. The plasma cells also shows lambda light chain restriction and negative for kappa light chain .
  • 2022-11-15 Electroencephalography, EEG
    • This EEG were composed by continuous diffuse theta wave with 5-6 Hz, 10-20 uv in bilateral hemisphere. There were no obvious photic driving response. This EEG suggest moderate diffuse cortical dysfunction. Advise clinical correlation.
  • 2022-11-10 MRI - T-spine
    • Multiple compression fracture of thoracic vertebrae.
    • S/P vertebroplasty of T7.
  • 2022-11-08 MRI - L-spine
    • Acute compression fracture of L4 vertebral body.
    • Severe old compression fracture of T12, L1 and L3 vertebrae.
    • Moderate spinal stenosis at L3/4 level, caused by posteriorly displaced bony component.
    • S/P veretebroplasty, L1-3 and T7.
  • 2022-11-07 CXR
    • Bilateral parahilar infiltrates with pleural effusion, r/o lung edema. Mild regression.
    • Deformity of right proximal humerus.
    • S/P vertebroplasty at T-L spine.
    • Diffuse osteoporosis of the bones.
    • Fractures at bilateral ribs.
  • 2022-11-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (60 - 16) / 60 = 73.33%
      • M-mode (Teichholz) = 74
    • Conclusion:
      • Normal LV filling pressure; impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis.
      • Degenerative changes of mitral valve and mild mitral annulus calcification with trivial MR; mild TR.
      • Sinus tachycardia.
  • 2022-06-27 SONO - nephrology
    • Chronic parenchymal renal disease

[consultation]

  • 2022-11-16 Hemato-Oncology
    • Q
      • This 74y/o female with past history of compression fracture was admitted due to UTI,
      • lab data showed Hb:8.7 g/dL, M-peak positive
      • we need your expertise for better her condition!
    • A
      • The 74 y/o female showed M-peak (+) in serum protein electrophoresis & anemia, MM or some other myeloma related Dz is highly suspected.
      • Lab:
        • Serum protein eletrophoresis (11/9 22): positive.
        • TP (11/7 22):5.8, A/G: 3.2/ 2.6.
        • IgG, IgM, IgA (11/7 22): WNL.
        • Free light chain assay (11/10 22): FLLC / KLLC ratio: 451 ( 8487.5 / 18.8 )
        • b-2 microglobulin (11/8 22): 6172, LDH:296
        • BUN / Cre (11/14 22): 23 / 0.98, Ca: 2.26
        • Hb (11/7 22):8.6, MCV:97.2, MCHC:31.5, plt:313K, WBC:7210
        • NT-proBNP (10/31 22): 1785.
      • Dx: Anemia & M-peak (+), hypoalbuminemia.
        • R/I Lambda light chain amyloidosis
        • R/I Multiple myeloma ( MM ).
        • monoclonal gammopathy of undetermined significance
          • (M-protein in serum < 3 g/dL, < 10% clonal plasma cell on BM Bx, no end organ damage).
        • Smoldering myeloma
          • (M-protein in serum > 3 g/dL, > 10% clonal plasma cell on BM Bx, no end organ damage ).
      • Medical advice:
        • Owing to IgG, IgM, IgA (11/7 22): WNL, Free light chain assay (11/10 22): FLLC / KLLC ratio: 451 ( 8487.5 / 18.8 ), Lambda light chain amyloidosis is highly suspected.
          • In light chain disease, 50% did not show SPEP M-protein (+). but serum free light chain ( FLC ) assay may show abnormality of kappa or lambda chains & kappa / lambda ratio.
          • May do 24-h urine for total protein. Urin protein electrophoresis (UPEP), urine immunofixation electrophoresis ( UIFE).
          • Will do Unilateral bone marrow aspirate + biopsy & Congo red staining for amyloid.
          • The percentage of clonal bone marrow plasma cells (≥10%) is a major criterion for the diagnosis of MM or some other myeloma related Dz.
        • Identification of light chains in the serum or urine without confirmation of the amyloid composition in tissue is not adequate, as patients with other forms of amyloidosis may have an unrelated monoclonal gammopathy of undetermined significance (MGUS).
          • Will try biopsy of organ involvement of amyloidosis
        • Kidney:
          • 24-h urine protein >0.5 g/d, predominantly albumin.
          • Mx: may do 24 hr urine collection for protein loss evaluation.
        • Nerve:
          • Peripheral: clinical; symmetric lower extremity sensorimotor peripheral neuropathy
        • Autonomic: gastric-emptying disorder, pseudo-obstruction, voiding dysfunction not related to direct organ infiltration
          • Mx: may consult neurologist to R/I peripheral neuropathy & may do electromyography (EMG) ( if clinically significant peripheral neuropathy) / nerve conduction studies.
        • Soft tissue:
          • Tongue enlargement, clinical
          • Arthropathy
          • Claudication, presumed vascular amyloid Skin
          • Myopathy by biopsy or pseudohypertrophy
          • Lymph node (may be localized)
          • Carpal tunnel syndrome
            • Mx: If tongue enlargement, may do tonue biopsy. May try abdominal fat pad sampling to confirm amyloid deposit.
        • Liver:
          • Total liver span >15 cm in the absence of heart failure or alkaline
          • phosphatase >1.5 times institutional upper limit of normal
          • Mx: if gastroparesis present, may do Gastric emptying scan.
          • May do abd ultrasound or abd CT scan to document craniocaudal liver span.
        • Heart:
          • Echo: mean wall thickness >12 mm, no other cardiac cause or an elevated
          • NT-proBNP (>332 ng/L) in the absence of renal failure or atrial fibrillation
          • the pt has higher NT-ProBNP ( 1785 ), suggestive of heart failure. R/I light chain amylodosis related.
          • Mx: may do cardiac echo.
        • LDH and beta-2 microglobulin levels reflect tumor cell characteristics.
        • Higher b2-micoglobulin ( b2M ) means larger tumor load ( but renal failure will make b2-microglobulin accumulate. This pt has poor renal function ).
        • Higher LDH may suggest MM tumor aggression.
        • If light chain amyloidosis is confirmed, preferred Regimen:
          • Daratumumab and hyaluronidase fihj / bortezomib / cyclophosphamide / dexamethasone
          • Bortezomib ± dexamethasone
          • Bortezomib/cyclophosphamide/dexamethasone
          • Bortezomib/lenalidomide/dexamethasone
          • Bortezomib/melphalan/dexamethasone (if ineligible for HCT)
  • 2022-11-12 Neurology
    • Q
      • For cognitive function assessment, is there dementia or ??? (Patient reports urinary and fecal incontinence without sensation, but sometimes says she feel bowel movements and other times says she does not feel them)
      • This 74 y/o woman is a case of type 2 DM, CKD stage 3 and anemia, cause to be determined. Operation history of
        • post lumbar spine surgery due to HIVD about 40 years ago at Gengshen Hospital
        • Pancreatic duct tumor with p-duct dilatation s/p Whipple’s operation (PPPD) in 2014
        • LUL lung nodule s/p thoracoscopic wedge resection and LN dissections in 2015
        • Right hip fracture s/p bipolar hemiarthroplasty in 2020
        • Multiple compression fracture post vertebroplasty at L3 in 2021, and vertebroplasty at L1 and L2 on 2022/04/07 at Tzu Chi H.
      • She was discharged from our isolation ward due to Covid-19 infection on 10/19, and admission again on 2022/10/31 due to urosepsis with drowsy consciousness, right lung infiltration with dyspnea, and hypokalemia.
      • After admission, she received KCL in fusion for correct hypokalemia, and antibiotics as sintrix treatment since 11/01 to 11/03, and change to Brosym 4.0 gm IVD Q12H since 11/03 for urine culture grew Escherichia coli. Improve of infection of urine and the consciousness return to near clear. Right lung edema improve after lasix use. Due to lumbar pain, paresthesia over both legs? light touch decrease at lateral aspect of lower leg and dorsum of foot? and incontinence? The T-L spine MRI was performed, showed multiple T-L compression fracture and Moderate spinal stenosis at L3/4 level, caused by posteriorly displaced bony component. Posterior decompression of L3 to L5 maybe is indication, but this moment, the patient complained incontinence condition improve? seems to feel sensation when stool output (But the words are inconsistent, sometimes says they feel bowel movements, sometimes says they don’t feel them, no sensation during urination, rectal examination: no relaxation of the anal sphincter).
      • Now, we need your help for evaluation about cognitive function assessment, whether there is dementia or other problem. Thanks.
    • A
      • the patient complainted incontinence condition improve ? seems to feel sensation when stool output
      • E4M6V4
      • Cranial nerve: intact
      • motor: all>3
      • Imp: may have dementia+ delirium
      • P: Check BUN, Crea, CBC, ALT, AST, Ca, Na, Mg, TSH free T4, ammonia
        • Arrange EEG
        • Neurology OPD f/u after this acute illness for diagnosis of dementia
  • 2022-11-07 Orthopedics
    • A
      • The 74 y/o women had T7 compression fracture post vertebroplasty on 2022/04/28
      • L1-2 compression fracture status post L1, L2 vertebroplasty on 2022/04/07.
      • Patient complain urination and defication incontinence for one week
      • She also complain numbness over anal area
      • X-ray: mutiple compression fracture
      • => transfer to our ward and arrange MRI
  • 2022-11-05 Chest Medicine
    • Q
      • The 74 y/o women had COVID 19 2 weeks ago
      • She was admited to our weard due to dyspnea and back pain and UTI
      • Pleural effusion arrange aspiration today
      • Diuretic use for r/o pulmonary edema
      • We need your help for progress dyspnea, Thanks!
    • A
      • The pleural effusion was bilaterally symmetric, CT density favor transudate, possible due to:
        • long term malnutrition with hypoalbuminemia (the albumin level was pseudo-high due to severe intravascular volume depletion)
        • bed-ridden with lung atelectasis
        • chronic hypoxic lung disease (bed-ridden related) with right side CHF
        • Repeated infection (aspiration pneumonia and UTI and recently COVID-19 infection) with SIRS
      • Suggestion:
        • May repeat chest echo at next W3AM or W4 AM for possible diagnostic tapping
        • Lung expansion therapy
        • Increase intravascular volume (including hydrostatic and oncotid fluid)
        • Keep Hb not less than 10.0
        • choking was noted, NG feeding and totally avoid oral feeding/intake is suggested
        • keep present anti
        • check thyroid and adrenal function
        • Thanks and f/u prn.

[MedRec]

  • 2023-04-07 SOAP Hemato-Oncology
    • Anemia, unspecified [D64.9]
    • Muliple myeloma, Light chain
      • #1 Velcade 1.5mg/m2 ( give 2.5mg ) SC D1 & D4, D8, D11 Q4W x 4 plus Dexa on 1/3 23. ( fee )
      • #2 on 02/06 23.
      • #3 on 03/17
      • #4 on 04/07
  • 2023-01-03 SOAP Hemato-Oncology
    • #1 Velcade 1.5mg/m2 ( give 2.5mg ) SC D1 & D4, DD8, D11 Q4W x 4 plus Dexa on 1/3 23. ( fee )
    • RTC 1wk later on 1/9 23 for #2 Bortezomib / cyclophosphamide / dexa.
  • 2022-11-28 SOAP Hemato-Oncology
    • Lab
      • 2022/11/17 U-TP(24hr) = 2200.5 mg/day;
      • 2022/11/10 Free Light Chain κ/λ (blood)
        • FKLC = 18.8 mg/L;
        • FLLC = 8487.5 mg/L;
        • FK/FL ratio = 0.002215 ratio;
      • 2022/11/09 M-peak = Positive;
      • 2022/11/08 B2-Microglobulin = 6172 ng/mL;
      • 2022/11/07 IgG (blood) = 687 mg/dL;
      • 2022/11/07 IgM = 31.0 mg/dL;
      • 2022/11/07 IgA = 39 mg/dL;
      • 2022/11/07 LDH = 296 U/L;
    • Light chain Dz, lambda, ISS stage ? is highly suspected (11/28 22).
    • will do BM biopsy on 12/1 22 (11/26 22).
    • If light chain amyloidosis is confirmed, preferred Regimen:
      • Daratumumab and hyaluronidase / bortezomib / cyclophosphamide / dexa.
      • Bortezomib ± dexamethasone
      • Bortezomib/cyclophosphamide/dexamethasone
      • Bortezomib/lenalidomide/dexamethasone
    • will apply Bortezomib / cyclophosphamide / dexa (11/28 22).
    • RTC 1wk later on 12/5 22 for possible #1 Bortezomib / cyclophosphamide / dexa.
    • Diagnosis C90.0 Multiple myeloma
  • 2022-09-19 SOAP Hemato-Oncology
    • 73 y/o female was noted to have anemia (Hb:5.6) in Sep 2022 even poor renal function improves.
    • Lab 2022/09/14
      • Ferritin = 361.5 ng/mL;
      • Fe (Iron-bound) = 74 ug/dL;
      • TIBC = 237 ug/dL;
    • R/I
      • IDA
      • thalassemia
      • Vit B12 & folic acid deficiency related.
      • anemia due to chronic liver dz
      • anemia due to malnutirtion
      • anemia of chronic inflamnmation / infection ( eg: DM ).
      • hematologic dz ( eg MDS, pure red cell aplasia )
      • Viral infection related
      • hemolysis
    • will do CBC & DC, reticulocyte, RBC morphology, RF, ANA, Ferritin, Haptoglobin, LDH, BilT/D, Direct & Indirect Coombs test & abd sono R/I splenomegaly. (9/19 22).
    • will do CBC & DC, Ferritin, Fe/TIBC, SOB, LFT, RFT (9/19 22).
    • give P-RBC 2U (9/19 22).
    • SBP: 190+ mmHg noted at daycare before P-RBC, give Norvasc (9/19 22).
    • If definitive Dx is not made, will do BM biopsy (9/19 22).
    • RTC 1 wk later on 5/4 20 for IDA report.

[chemotherapy]

  • 2023-04-07 - bortezomib 1.5mg/m2 2.0mg SC 5min D1,4,8,11
  • 2023-03-17 - bortezomib 1.5mg/m2 2.0mg SC 5min D1,4,8,11
  • 2023-02-06 - bortezomib 1.5mg/m2 1.9mg SC 5min D1,5,8,12
  • 2023-01-09 - bortezomib 1.5mg/m2 1.9mg SC 5min D1,5
  • 2023-01-03 - bortezomib 1.5mg/m2 1.9mg SC 5min D1,4

[note]

Bortezomib (Velcade) plus cyclophosphamide and dexamethasone (VCD or CyBorD) for multiple myeloma 2023-04-24 https://www.uptodate.com/contents/image?topicKey=ONC%2F85687&sectionRank=1&imageKey=ONC%2F50061

  • Cycle length: 28 days.

  • Regimen

    • Bortezomib
      • 1.5 mg/m2 SC or IV
      • Given subcutaneously or as a rapid IV bolus over three to five seconds.
      • Days 1, 8, 15, and 22
    • Cyclophosphamide
      • 300 mg/m2 by mouth, once weekly
      • Dose rounding to the nearest 50 mg. Do not cut or crush. Take during or after meal in the morning.
      • Days 1, 8, 15, and 22
    • Dexamethasone
      • 40 mg by mouth, once weekly
      • Take with food (after meals or with food or milk) in the morning.
      • Days 1, 8, 15, and 22
  • Pretreatment considerations:

    • Hydration
      • Patients receiving cyclophosphamide should maintain adequate oral hydration (2 to 3 L/day during administration and for one to two days thereafter) and void every two to three hours to reduce the risk of hemorrhagic cystitis. Risk of bladder irritation is also decreased by avoiding bedtime administration.
    • Emesis risk
      • LOW or VERY LOW.
    • Prophylaxis for infusion reactions
      • Routine premedication is not indicated. If a hypersensitivity reaction occurs with cyclophosphamide, then neither oral nor IV cyclophosphamide should be readministered.
    • Infection prophylaxis
      • Bortezomib therapy may be associated with an increased risk of herpes zoster and infections not related to neutropenia. Antiviral prophylaxis (eg, acyclovir 400 mg orally twice a day) should be administered to all patients receiving VCD/CyBorD. Some clinicians also administer trimethoprim-sulfamethoxazole double strength once daily on Mondays, Wednesdays, and Fridays during treatment. Primary prophylaxis with G-CSF is not indicated.
    • Antithrombotic prophylaxis
      • While patients with multiple myeloma have an increased risk of thrombosis, the risk of thrombosis with the VCD/CyBorD regimen was ≤7% in two trials. Routine antithrombotic prophylaxis is not warranted.
    • Dose adjustment for baseline liver or kidney dysfunction
      • Bortezomib: No dosage adjustment for bortezomib secondary to kidney impairment is necessary. For patients undergoing hemodialysis, bortezomib should be administered after dialysis. Patients with moderate or severe hepatic impairment (serum bilirubin level >1.5 times the upper limit of normal) should be started on bortezomib at a reduced dose of 0.7 mg/m2 per injection during the first cycle, with further dose modifications based upon patient tolerance.
      • Cyclophosphamide: For patients with preexisting hepatic impairment, dose adjustments in cyclophosphamide dose may be needed. The need for cyclophosphamide dose reduction in patients with kidney impairment is controversial; some suggest dose reduction if the creatinine clearance is <30 mL/minute.
  • Monitoring parameters:

    • Assess CBC with differential, electrolytes, kidney function, liver function, and M protein prior to starting each cycle. A CBC should also be performed prior to the day 15 dose of bortezomib.
    • Weekly assessment for peripheral neuropathy and/or neuropathic pain.
    • Monitor for hypotension during therapy; adjustment of antihypertensives and/or administration of IV hydration may be needed.
  • Suggested dose modifications for toxicity:

    • Myelotoxicity
      • If platelets are <50,000/microL or the absolute neutrophil count is <1000/microL on day 15, hold bortezomib and cyclophosphamide. If several doses are held, reduce bortezomib dose by one level (from 1.5 mg/m2 to 1.3 mg/m2; or from 1.3 mg/m2 to 1 mg/m2; or from 1 mg/m2 to 0.7 mg/m2) and decrease the number of doses of cyclophosphamide given each cycle by one level (serial levels are: Days 1, 8, 15, and 22; days 1, 8, and 15; days 1 and 8; day 1 only).
    • Neuropathy
      • Dose adjustment guidelines for bortezomib in patients who develop peripheral neuropathy or neuropathic pain are available:
        • Grade 1 (asymptomatic, loss of deep tendon reflexes or paresthesia without pain or loss of function): No action required.
        • Grade 1 (with pain) or Grade 2 (interfering function but not activities of daily living): Reduce by one level (from 1.5 mg/m2 to 1.3 mg/m2; or from 1.3 mg/m2 to 1 mg/m2; or from 1 mg/m2 to 0.7 mg/m2).
        • Grade 2 (with pain) or Grade 3 (interfering with activities of daily living): Hold until resolution, may reinitiate at 0.7 mg/m2 once weekly.
        • Grade 4 (life-threatening, disabling, eg, paralysis): Discontinue.
      • Rarely, bortezomib has been associated with RPLS, which can present with seizures, hypertension, headache, lethargy, confusion, blindness, or as other visual or neurological disturbances. Bortezomib should be discontinued if the diagnosis of RPLS is confirmed on brain MRI.
    • Cystitis
      • For grades 1 or 2 cystitis (minor symptoms responding to outpatient management), decrease the number of doses of cyclophosphamide given each cycle by one level (serial levels are: Days 1, 8, 15, and 22; days 1, 8, and 15; days 1 and 8; day 1 only). Cyclophosphamide should be discontinued if cystitis symptoms are distressing or affect lifestyle (grade 3 or 4).
    • Thrombotic microangiopathy
      • Rarely, bortezomib has been associated with TMA, which can present with Coombs-negative hemolysis, thrombocytopenia, kidney failure, and/or neurologic findings. If TMA is suspected, stop bortezomib and evaluate.
    • Other nonhematologic toxicity
      • For grade 3 or 4 nonhematologic toxicity other than neuropathy, bortezomib should be held. Once symptoms have resolved to grade 1 or baseline, bortezomib may be reinitiated with one dose level reduction (from 1.3 mg/m2 to 1 mg/m2; or from 1 mg/m2 to 0.7 mg/m2). Dexamethasone dose should be reduced for grade 2 muscle weakness, grade 3 gastrointestinal tract toxicity, hyperglycemia, confusion or mood alterations.
    • If there is a change in body weight of at least 10%, doses should be recalculated.

Treatment of Clostridioides difficile infection (CDI) in adults 2023-05-17 https://www.uptodate.com/contents/image?topicKey=ID%2F2698&imageKey=ID%2F53273

  • Nonfulminant disease
    • Initial episode (nonsevere or severe disease) - Management of an initial CDI episode consists of treatment with an antibiotic regimen.
      • Nonsevere disease is supported by the following clinical data: White blood cell count <=15,000 cells/mL and serum creatinine level <1.5 mg/dL
      • Severe disease is supported by the following clinical data: White blood cell count >15,000 cells/mL and/or serum creatinine level >=1.5 mg/dL
      • Antibiotic regimens:
        • Fidaxomicin 200 mg orally twice daily for 10 days
        • Vancomycin 125 mg orally 4 times daily for 10 days
        • For nonsevere disease, alternative regimen if above agents are unavailable:
          • Metronidazole◊ 500 mg orally 3 times daily for 10 to 14 days
    • Recurrent episode - Management of a recurrent CDI episode consists of treatment with an antibiotic regimen, in addition to adjunctive bezlotoxumab¶ if feasible.
      • First recurrence
        • Antibiotic regimens:
          • Fidaxomicin
            • 200 mg orally twice daily for 10 days, OR
            • 200 mg orally twice daily for 5 days, followed by once every other day for 20 days
          • Vancomycin in a tapered and pulsed regimen, for example:
            • 125 mg orally 4 times daily for 10 to 14 days, then
            • 125 mg orally 2 times daily for 7 days, then
            • 125 mg orally once daily for 7 days, then
            • 125 mg orally every 2 to 3 days for 2 to 8 weeks
          • Vancomycin 125 mg orally 4 times daily for 10 days
        • Adjunctive treatment:
          • Bezlotoxumab 10 mg/kg intravenously, given once during administration of standard antibiotic regimen.
      • Second or subsequent recurrence
        • Antibiotic regimens:
          • Fidaxomicin
            • 200 mg orally twice daily for 10 days, OR
            • 200 mg orally twice daily for 5 days, followed by once every other day for 20 days
          • Vancomycin in a tapered and pulsed regimen (example as above)
          • Vancomycin followed by rifaximin:
            • Vancomycin 125 mg orally 4 times daily by mouth for 10 days, then
            • Rifaximin 400 mg orally 3 times daily for 20 days
        • Adjunctive treatment:
          • Bezlotoxumab 10 mg/kg intravenously, given once during administration of standard antibiotic regimen.
        • Role of fecal microbiota transplantation (FMT):
          • For patients who have received appropriate antibiotic treatment for at least 3 CDI episodes (ie, initial episode plus 2 recurrences), who subsequently present with a fourth or further CDI episode (third or subsequent recurrence), we favor FMT in regions where available. Pending referral for FMT, we treat with an antibiotic regimen as outlined above.
  • Fulminant disease
    • Fulminant disease is supported by the following clinical data: Hypotension or shock, ileus, megacolon
      • Absence of ileus: Enteric vancomycin plus parenteral metronidazole:
        • Vancomycin 500 mg orally or via nasogastric tube 4 times daily, AND
        • Metronidazole 500 mg intravenously every 8 hours
      • If ileus is present, additional considerations include:
        • FMT (administered rectally) OR
        • Rectal vancomycin (administered as a retention enema 500 mg in 100 mL normal saline per rectum; retained for as long as possible and readministered every 6 hours)
  • The standard course of treatment for an initial episode of CDI is 10 days. Some patients, particularly those treated with metronidazole or with severe disease, may have a delayed response; in such circumstances, treatment may be extended to 14 days. For patients with inflammatory bowel disease, an extended duration of 14 days is also appropriate. If continuation of antibiotic(s) for a primary infection is essential, we continue CDI treatment for one week after completion of other antibiotics.
  • The criteria proposed for defining severe or fulminant CDI are based on expert opinion and may need to be reviewed upon publication of prospectively validated severity scores for patients with CDI. Patients with severe or fulminant CDI also warrant assessment for surgical indications; refer to UpToDate topic on treatment of CDI for further discussion.
  • For patients with nonfulminant disease, we suggest a fidaxomicin-based regimen over a vancomycin-based regimen. In addition, for patients with nonfulminant recurrent disease and prior CDI in the last 6 months, we suggest adjunctive bezlotoxumab. Use of fidaxomicin or bezlotoxumab have each been associated with a small benefit with respect to CDI recurrence rates (10 to 15% decrease). In the setting of cost constraints, we prioritize use of these agents for patients at greatest risk for CDI recurrence (age >=65 years, severe CDI, or immunosuppression). Vancomycin remains an acceptable agent for treatment of initial and recurrent CDI.
  • Systemic absorption of enteral vancomycin can occur in patients with mucosal disruption due to severe or fulminant colitis; this consideration is particularly important for patients with kidney insufficiency (creatinine clearance <10 mL/minute). Therefore, monitoring serum vancomycin levels is warranted for patients with kidney failure who have severe or fulminant colitis and require a prolonged course (>10 days) of enteral vancomycin therapy.
  • Metronidazole should be avoided in patients who are frail, age >65 years, or who develop CDI in association with inflammatory bowel disease. Caution is also warranted during pregnancy and lactation.
  • The approach to antibiotic management of nonfulminant recurrent CDI is the same regardless of severity, but varies depending on the number of recurrences, as outlined above. For patients with a recurrent episode of CDI that is severe, refer to UpToDate topic on treatment of CDI for further discussion.
  • The bezlotoxumab prescribing information in the United States warns that in patients with a history of congestive heart failure, the drug should be reserved for use when the benefit outweighs the risk, given reports of increased heart failure exacerbations and associated deaths in such patients. In addition, data for use of bezlotoxumab combined with fidaxomicin are limited.
  • In contrast to the above approach, some favor FMT for patients who have received antibiotic treatment for at least 2 CDI episodes (ie, initial episode plus one recurrence), who subsequently present with a third or further CDI episode (second or subsequent recurrence).
  • Continue dosing for 10 days. If recovery is delayed, treatment can be extended to 14 days.
  • In the setting of ileus, we favor FMT over rectal vancomycin. However, such procedures are associated with risk of colonic perforation; therefore, they should be restricted to patients who are not responsive to standard therapy, and the procedure should be performed by personnel with appropriate expertise. Refer to the UpToDate topic on FMT for discussion of safety, efficacy, and delivery protocols.
  • Rectal vancomycin may be administered as a retention enema, either in addition to oral vancomycin (if the ileus is partial) or in place of oral vancomycin (if the ileus is complete). Given potential risk of colonic perforation in setting of CDI, rectal vancomycin instillation should be performed by personnel with appropriate expertise.

==========

2023-05-17

  • On 2023-05-14, the patient’s WBC was 7.37K/uL, creatinine was 1.01mg/dL, and stool occult blood was 2+. Stool culture obtained on 2023-05-15 was negative for Clostridioides difficile toxin A/B but positive for glutamate dehydrogenase (GDH). The patient had 9 and 8 bowel movements on 2023-05-15 and 2023-05-16, respectively. Therefore, the prescription of oral vancomycin at a dose of 125 mg 4 times daily is appropriate and unproblematic.

  • Now that the pathogen has been identified, the previously prescribed and currently active medication, Metrozole (metronidazole) 500mg PO Q8H, could potentially be discontinued, assuming there are no hypotension or shock, ileus, megacolon and/or other ongoing infectious conditions.

  • According to the HIS5 database, there have been no other culture reports on Clostridioides Difficile Infection (CDI) in the past 6 months. In the event of a recurrent infection, a tapered and pulsed regimen of vancomycin could be considered. Here is a possible schedule:

    • 125 mg orally four times daily for 10 to 14 days, followed by
    • 125 mg orally twice daily for 7 days, followed by
    • 125 mg orally once daily for 7 days, and then
    • 125 mg orally every 2 to 3 days for 2 to 8 weeks.

2023-04-24

[assessment]

  • The patient has been diagnosed with Multiple Myeloma (MM) and was started on VCd regimen on 2023-01-03. All of the patient’s medications listed in PharmaCloud were prescribed by our hospital. No medication reconciliation issues were identified.

  • After starting the VCd regimen, there was a decrease in the B2 microglobulin level. However, the most recent reading indicates that the level has nearly doubled from the previous low in approximately 1.5 months.

    • 2023-04-22 B2-Microglobulin 8692 ng/mL
    • 2023-03-04 B2-Microglobulin 4648 ng/mL
    • 2022-11-08 B2-Microglobulin 6172 ng/mL
  • Currently, there is no evidence that the patient is developing thrombocytopenia, peripheral neuropathy or neuropathic pain.

701179622

230517

[exam findings]

  • 2023-05-17 Sono-guide aspiration of right thyroid mass
    • IMP: right thyroid mass, s/p FNA
  • 2023-04-20 Bronchodilator Test
    • mild obstructive ventilatory impairment, FEV1/FVC = 45%, FVC = 138%, FEV1 = 81%
    • without significant reversibility
  • 2023-04-20 CT - chest
    • Indication
      • Chronic obstructive pulmonary disease, unspecified
      • Allergic rhinitis, unspecified
      • Unspecified asthma, uncomplicated
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Semi-solid nodule at left upper lobe measuring 1.6cm in largest dimension is found.
        • Moderate centrilobular Emphysematous change over both lungs is found.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
        • No evidence of bilateral pleural effusion.
        • Cystic lesion at right lobe thyroid with calcified wall measuring 3.7cm in largest dimension is found.
      • Visible abdomen:
        • Low density lesions at both lobes of liver is found up to 3.3cm at S7. r/o liver meta.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
    • Imp:
      • Left upper lobe nodular lesion. 1.6cm
      • Right thyroid cystic lesion. 3.7cm, thyroid cancer?
      • Liver meta.
  • 2023-02-02 CXR
    • Displacement of the tracheal axis to left at thoracic inlet and superior mediastinum probably due to enlarged thyroid gland or other mediastinal mass
    • a small nodular opacity (polylobular borders) over LUL,
    • suggest do CT study
    • Increased lung volume and areas of hyperlucency and decreased upper vascular markings due to emphysematous change of both lungs upper lung predominance
    • enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
  • 2022-11-03, -02-24 CXR
    • Displacement of the tracheal axis to left at thoracic inlet and superior mediastinum probably due to enlarged thyroid gland and other mediastinal mass
    • Increased lung volume and areas of hyperlucency and decreased upper vascular markings due to emphysematous change of both lungs upper lung predominance
    • enlarged cardiac silhoutte due to prominent pericardial fat/ prominent cardiophrenic angle mediastinal fat pad
  • 2022-02-24 Bronchodilator Test
    • moderate obstructive ventilatory impairment (FEV1/FVC: 46.4%, FVC:105%, FEV1: 62%)
    • without significant reversibility
  • 2021-03-25 CXR
    • Displacement of the tracheal axis to left at thoracic inlet and superior mediastinum probably due to enlarged thyroid gland
    • Increased lung volume and areas of lucency due to emphysematous change of both lungs
    • prominent pericardial fat/cardiophrenic fat
  • 2021-03-25 Bronchodilator Test
    • moderate obstructive ventilatory impairment, FEV1/FVC = 47%, FVC = 104%, FEV1 = 74%
    • without significant reversibility
  • 2020-04-16 Bronchodilator Test
    • moderate obstructive ventilatory impairment, FEV1/FVC = 48%, FVC = 104%, FEV1 = 63%
    • without significant reversibility
  • 2019-06-13 Bronchodilator Test
    • moderate obstructive ventilatory impairment, FEV1= 66 %
    • with significant reversibility
  • 2019-05-16 CXR
    • Senile fibrotic change is noted at lung fields.

==========

2023-05-17

  • The patient’s underlying conditions of COPD, asthma, HTN, and electrolyte imbalance are managed with appropriate medications on the active medication list. After reviewing PharmaCloud, no medication reconciliation issues were identified.

700818206

230516

[present illness] - 2023-02-23 admission note

  • Radiotherapy for 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed from 2023/02/23~. Now, he was admitted to ward for concurrent chemoradiotherapy with 5FU(225mg/m2)(C1) from 2023/02/23.

[past history]

  • Hypertension for 5 years under medication treatment.
    • Exforge F.C 5mg & 160mg 1# po QD
    • Concir 5mg 1# po QD
    • Lipanthyl Supra F.C 160mg 1# po QD
  • HIVD (herniated intervertebral disc) post operation twice at 30-year-old and 40-year-old.
  • Perianal tumor status post excision of perianal tumor on 2020/04.
  • Grade IV hemorrhoids status post hemorrhoidectomy on 2020/04.
  • Lumbar spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, esp L5-S1 by L-spine MRI on 2021/04/26.   
  • Gastrorrhaphy, umbilical hernia repair and laparoscopy examination on 2021/11/10

[allergy]

  • amoxicillin: Redness and swelling of the lips and oral mucosa

    

[family history]

  • Denied any major disease or cancer history of his family member.

[exam findings]

  • 2023-05-04 Colonoscopy
    • Rectal cancer s/p CCRT with partial response
  • 2023-02-08 MRI - pelvis
    • History: Newly diagnosed rectal cancer at 8cm from AV
    • MR Imaging of the pelvis was performed on a 1.5 T superconducting magnet and phase arrayed body coil. Patient kept in supine position with field of view 28 cm, slice thickness 5 mm and gap 1 mm.
    • Scanning protocol:
      • Axial plane: spin echo T1WI, Non-Fat-saturation FSE T2WI, and HASTE T2WI, Diffusion weighted images
      • Coronal and sagittal plane: Non-Fat-saturation FSE T2WI
      • Dynamic study: Fat saturated T1WI with IV Gd-DTPA 0.1mmol/Kg and images were obtained at 70 second.
    • Findings:
      • There is asymmetrical wall thickening at left lateral aspect of the rectum, measuring 1.3 cm in wall thickness, that is c/w adenocarcinoma (T3).
        • In addition, There are two enlarged nodes in the presacral space that may be metastatic nodes (N1b).
      • There is a hyperintensity nodule 1.8 cm in right central zone of the prostate on both T2WI and DWI that is c/w hyperplasia.
      • There are several renal cysts on left kidney and the largest one measuring 3.3 cm in size at left middle pole.
      • A hepatic cyst measuring 0.5 cm in S2 is noted.
      • Abdominal aorta shows atherosclerosis and focal ectasia 2.1 cm at left lateral aspect.
      • Others
        • There is no focal abnormality in the seminal vesicle.
        • There is no focal abnormality in the urinary bladder.
        • There is no evidence of ascites.
        • The visible IVC are grossly unremarkable.
    • IMP:
      • Rectal cancer is highly suspected.
      • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T3 N1b M0, stage:IIIB
  • 2023-02-03 CT - abdomen
    • CC: Hemorroidectomy at CRS on W2, Anal bleeding since then.
      • FOBT (+), External hemorrhoids
      • Anal protruding mass noted
      • Anal pain developed these days
      • Anal bleeding also noted occasionally
      • 20210202 colonoscopy: One mass in the rectum (8 cm AAV) Indication: Newly diagnosed rectal cancer for staging.
    • Findings:
      • There is asymmetrical wall thickening at left lateral aspect of the rectum, measuring 1.3 cm in wall thickness, that is c/w adenocarcinoma (T3).
        • In addition, There are three enlarged nodes in the perirecal space that may be metastatic nodes (N1b). Please correlate with MRI.
      • Abdominal aorta shows atherosclerosis and focal ectasia 2.1 cm at left lateral aspect.
      • There are several renal cysts on left kidney and the largest one measuring 3.3 cm in size at left middle pole.
      • A hepatic cyst measuring 0.5 cm in S2 is noted.
        • In addition, There is a poor enhancing lesion 1 cm in S8 of the liver dome subphrenic space or liver capsule area. Follow up is indicated.
      • There is no focal lesion in both lung and mediastinum.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N1b (N_value) M:M0 (M_value) STAGE:IIIB(Stage_value)
  • 2023-02-03 ECG
    • Normal sinus rhythm
    • Minimal voltage criteria for LVH, may be normal variant
    • Borderline ECG
  • 2023-02-03 Patho - colorectal polyp
    • Intestine, large, rectum, 8 cm from nal verge, biopsy— adenocarcinoma
    • Immunohistochemical stain— EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli,and high N/C ratio.
  • 2023-02-03 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (123 - 29) / 123 = 76.42%
      • M-mode (Teichholz) = 76
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Mild AR, MR, and PR+
  • 2023-02-03 Bronchodilator Test
    • normal ventilation; non-significant bronchodilator response
  • 2023-02-02 Colonoscopy
    • D-colon polyp s/p polypectomy
    • Retcal cancer s/p biopsy
  • 2022-11-18 SONO - nephrology
    • Chronic renal parenchymal disease, mild degree
    • Left renal cysts
  • 2022-10-21 Knee BIL standing AP and Lat views
    • Mild to moderate osteoarthritis of both knees
    • Ahlback calcification: grade 2, 2
  • 2022-10-21 Merchant view (patella 45 0) Bil :
    • Mild lateral subluxation of the patella
    • Patellofemoral osteoarthritis
    • Sperner classification: 2-3
  • 2023-02-03 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (115 - 31) / 115 = 73.04%
      • M-mode (Teichholz) = 72.8
    • Normal chamber size
    • Thickening of IVS (interventricular septum) and LVPW (left ventricular posterior wall thickness)
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • AV (aortic valve) sclerosis with mild AR (aortic regurgitation), mild MR (mitral regurgitation), TR (tricuspid regurgitation) and PR (pulmonary regurgitation)
    • No regional wall motion abnormalities
  • 2022-08-23 CXR
    • Atherosclerotic change of aortic arch
  • 2022-03-02 Patho - stomach biopsy
    • Stomach, antrum, GC site, biopsy — chronic gastritis. No H.pylori present
    • Stomach, middle body, GC/AW site, biopsy — fundic gland polyp. No H.pylori present
  • 2022-03-01 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA grade A(minimal)
      • Superficial gastritis
      • Gastric polyp, middle body, GC/AW site (A)
      • Gastric erosion, antrum, GC site, s/p biopsy (B)
      • C/W s/p gastrorrhaphy
    • Suggestion
      • Pursue biopsy result
  • 2021-11-11 Patho - stomach biopsy
    • Stomach, antrum, midline laparotomy and repair of perforation — Ulcer with perforation, H pylori NOT present
  • 2021-11-10 CT - abdomen
    • History and Indication: Abdominal pain for 3 days. INITIAL SHOULDER SORENESS AND COLD SWEATING, NO VOMITING, NO DIARRHEA
      • Allergy: amoxicillin
      • PHx: HTN, hyperlipidemia, NKDA
    • MD CT (256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.
    • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
    • Findings:
      • There is ascites and free gas bubbles in peritoneal cavity (pneumoperitoneum) that is c/w hollow organ perforation.
        • In addition, focal fluid collection and gas bubbles in the gastrohepatic ligament is also noted.
      • Right side Pleura effusion and mild atelectasis in bilateral posterior basal lung are noted.
      • Two renal cyst 2.7 cm and 1 cm in left middle pole are noted.
      • Hyperplasia of right adrenal gland is noted.
      • Umbilical hernia with omentum fat herniation is noted.
      • Others
        • There is no hyper-or hypodense lesion in the liver, gallbladder, biliary system, pancreas, spleen & right kidney.
        • There is no lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
    • IMP: Hollow organ perforation is highly suspected.
  • 2021-04-26 MRI - L-spine
    • Lumbar spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, esp L5-S1 (with right HIVD).
  • 2021-03-15 Patho - skin cyst/tag/debridement
    • Eyelid mass, OS, excisional biopsy — Papillary squamous hyperplasia, compatible with papilloma
  • 2000-04-15 Patho - hemorrhoids
    • Colon, rectum, hemorrhoidectomy — Hemorrhoid
    • Skin, peri-anal, excision — Epidermal inclusion cyst

[MedRec]

  • 2023-05-04 SOAP Hemato-Oncology
    • P: During admission on 2023-05-04, consult dermatologist (for hand-foot syndorme) and reduce oxaliplatin to 75, DC bolus 5-FU.
  • 2023-03-22 SOAP Hemato-Oncology
    • P: Encourage patient to continue the treatment
  • 2023-02-09 SOAP Hemato-Oncology
    • O:
      • 2023/02/03 Abd CT: T3 N1b M0 STAGE:IIIB(Stage_value)
      • 2023/02/08 MRI Pelvis: Rectal cancer is highly suspected. According to AJCC staging system, 8th edition for colon cancer: T3 N1b M0, stage:IIIB
    • A/P
      • Suggest pre-op CCRT (Favor TNT) then OP
      • CCRT with FU followed by FOLFOX 12 16 weeks, then OP, the F/U

[consultation]

  • 2023-03-28 Dermatology
    • Q
      • This 65-year-old man diagnosis was rectum cancer, T3N1bM0, stage IIIB under radiotherapy for 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed from 2023/02/23. He received concurrent chemoradiotherapy with 5FU(225mg/m2) from 2023/02/23-27(C1). Now, he was admitted to ward for concurrent chemoradiotherapy with 5FU(225mg/m2)(C2) from 2023/03/27.  
      • For skin lesion in palms of both hands, we need your further evaluation and management.
    • A
      • The patient had sufferred from dry, xerotic skin texture with fine excoriaiton scales.
      • Under the impression of hand-foot syndorme favor 5 FU related and xerotic dermatitis.
      • The following sugeetion:
        • add Tetracycline onit topical bid use. firts for wound.
        • enhance skin mositurization with body cream and add sinphraderm cream 1 tube topical QN use on the scaling lesions.
  • 2021-11-10 General and Digestive Surgery
    • Q
      • Abd Pain for 3 days, INITIAL SHOULDER SORENESS AND COLD SWEATING
      • NO VOMITING, NO DIARRHEA
      • Allergy: amoxicillin
      • PHx: HTN, hyperlipidemia, NKDA
    • A
      • hollow organ perforation was impressed
      • PE: peritonitis sign
      • CT: minimal free air r/o colon perforation
      • suggest laparotomy

[surigcal operation]

  • 2021-11-10
    • Surgery
      • gastrorrhaphy
      • umbilical hernia repair
      • laparoscopy examination
    • Finding
      • turbid ascites, with food debrides
      • one perforation at antrum, GC side, about 2cm in diameter, less likely malignancy
  • 2021-03-22
    • Right L5 DRG PRF (right fifth lumbar dorsal root ganglion pulsed radiofrequency)
    • Right SI (sacroiliac) joint arthorgram and injection
  • 2021-03-15
    • Surgery
      • excision biopsy (OS)
    • Finding
      • eyelid mass (OS)
  • 2020-04-14
    • Surgery
      • Excision of perianal tumor
      • Hemorrhoidectomy        
    • Finding
      • Left anterior perianal tumor 1.5x1x1cm
      • Prolasped hemorrhoids at 3,7,11 o’clock 

[radiotherapy]

[chemotherapy]

  • 2023-04-25 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFOX)

  • 2023-03-27 - fluorouracil 225mg/m2 430mg NS 100mL 10min D1-4 (CCRT)

  • 2023-02-23 - fluorouracil 225mg/m2 430mg NS 100mL 10min D1, 2, 5, 7 (excluding weekend and 2/28 holiday) (CCRT)

==========

2023-05-16

  • According to the PharmaCloud database, all of the patient’s recent medications have been prescribed by our hospital, and no issues with medication reconciliation have been detected.

  • On 2023-05-15, the patient’s WBC count was observed to be 1.89K/uL, indicating leukopenia. This was first noted in the HIS5 system 3 weeks after the last administration of FOLFOX on 2023-04-25. When this event became known, Granocyte (lenograstim) was administered for two consecutive days. The nadir may occur later than expected, or blood cell monitoring should be more frequent.

  • This patient experienced hand-foot syndrome following the second dose of concurrent chemotherapy with 5-FU in late March 2023. The patient is currently undergoing FOLFOX treatment. If hand-foot syndrome reoccurs, it may be advisable to omit the 5-FU bolus.

  • The patient has underlying kidney concerns, and the NSAID Celebrex (celecoxib) is currently prescribed as needed. If the primary purpose of using celecoxib is for pain management, considering an alternative like acetaminophen could be less harmful to the kidneys.

    • 2023-05-15 BUN 34 mg/dL
    • 2023-05-15 Creatinine 1.42 mg/dL
    • 2023-05-15 eGFR 53.18

2023-02-24

[assessment]

  • No medication reconciliation issues were found during this hospital stay, and the recently prescribed drugs disclosed in the NHI PharmaCloud System have been accurately prescribed as self-carried items that cover the patient’s underlying conditions.

701346431

230512

{malignant neoplasm of unspecified site of left female breast, cT4aN3M1, stage IV}

[exam findings]

  • 2023-01-17 Tc-99m MDP whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the skull, some T- and L-spines, sacrum, sternum, left scapula, bilateral multiple ribs, multiple pelvic bones, S-I joints, and femurs.
    • IMPRESSION:
      • In comparison with the previous study on 2021/11/08, most of the previous bone lesions are either less evident or disappeared. The scintigraphic findings suggest multiple bone metastases with some resolution.
  • 2023-01-17, 2022-12-28, -12-07, -11-14, -10-24, -09-29, -08-29, -08-05, -07-11, -06-14 - CXR
    • A nodular opacity projecting in the left middle lung shows stationary. Follow up is indicated.
    • Left CP angle Pleura effusion or thickening.
    • Left hemi-diaphragm elevation is noted, which may be due to eventration or left lower lung volume decrease.
    • Spondylosis with scoliosis of the T-spine with convex to right side
    • S/P Mastectomy, left.
  • 2022-11-16 CT - chest
    • Indication: Malignant neoplasm of unspecified site of left female breast
    • Findings - Comparison was made with previous CT dated on 20220713
      • Lungs:
        • There is interlobular septal thickening and ground-glass opacities in both lungs scatteredly, seem stationary.
        • Mediastinum and hila: a well-defined fluid density mass (33mm in longest dimension) at left thymic bed. no enlarged LN.
      • Vessels:
        • Aorta: normal caliber of thoracic aorta.
        • Central pulmonary arteries: normal caliber.
        • Heart: dilated LA and LV.
      • Pleura: minimla Rt and small Lt effusions.
      • Chest wall and visible lower neck: interval increase in size infiltrative bilateral breast tumors with overlying skin thickening as compared with previous CT.
        • two small thyroid cysts or nodules.
      • Visible abdominal-pelvic contents:
        • two small Rt hepatic cysts and an ill-defined hypodense lesion at S4 is still visible. a 5mm Lt renal cyst.
        • several small stones in gallbladder. unremarkable of the spleen, both adrenal glands, pancreas, and Rt kidney.
        • no enlarged lymph node.
      • Visualized bones: compression fracture of T7 and blastic metastasis in pedicle of T8.
    • Impression:
      • both breast cancers with pulmonary lymphangitic carcinomatosis and hepatic and bony metastases, in progression compared with CT on 20220713, a thymic cyst.
  • 2022-07-13 CT - chest
    • both breast cancers, statiionary, with pulmonary lymphangitic carcinomatosis and hepatic and bony metastases, stationary, a thymic cyst.
  • 2022-04-02 CT - chest
    • Breast cancer at both breast, in regression.
    • Diffuse intersitial change at both lungs. suspected lymphangitis carcinomatosis.
    • Bone meta and liver meta.
  • 2022-01-19 Cell Block
    • Smears and cell blockshow lymphocytes, reactive mesothelial cells, and clusters of large, pleomorphic tumor cells.
    • IHC: CK(+), GATA3(+), and Calretinin(-).
    • The results are consistent with metastatic breast carcinoma.
  • 2021-12-28 Pleural Effusion
    • 50 cc yellow cloudy pleural effusion
    • The smears show lymphocytes, reactive mesothelial cells and a few hyperchromatic atypical cell clusters, compatible with metastatic carcinoma.
  • 2021-11-09 Patho - breast biopsy
    • pathologic diagnosis
      • Breast, right, biopsy - Invasive carcinoma of no special type
      • The sections show invasive carcinoma of no special type, composed of breast tissue with nests and cords of polygonal neoplastic cells, embedded in fibrous stroma.
      • IHC:
        • ER (Ab): Negative
        • PR (Ab): Negative
        • HER-2/Neu (Ab): Positive (score= 3+)
        • Ki-67: 25%
  • 2021-11-08 Tc-99m MDP whole body bone scan with SPECT
    • The scintigraphic findings suggest multiple bone metastases in the skull, some T- and L-spine, sacrum, sternum, left scapula, bilateral multiple ribs, multiple pelvic bones, S-I joints, and femurs.
    • Increased tracer uptake at bilateral shoulders, the nature is to be determined (bone mets, DJD, or other nature ?)
  • 2021-11-08 SONO - Breast
    • Bilateral breast tumors with left axillary lymph node, suspected malignancy.
    • BI-RADS: Category 5 - highly suggestive of malignancy, appropriate action should be taken.
  • 2021-11-04 Pleural Effusion
    • diagnosis: Adenocarcinoma
    • smears show tumr cells with large hyperchromatic nuclei, pleomorphism, prominent nucleoli and mitoses.

[surgical operation]

  • 2021-11-09
    • Surgery
      • Port-A insertion, R’t after R’t cephalic vein exploration        
      • R’t breast tumor core biopsy under sonography guided       
    • Finding
      • We explore and identify the R’t cephaic vein & use cutdown method to insert the 7 Fr cathter into it. We also use intra-operative EKG to check its position.        
      • A 5x5x5 cm hard tumor over R’t subareolar region       

[chemoimmunotherapy]

  • 2023-02-10 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
  • 2023-01-16 - trastuzumab 6mg/kg 290mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 105mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
  • 2022-12-28 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
  • 2022-12-07 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
  • 2022-11-14 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
  • 2022-10-25 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
  • 2022-09-30 - trastuzumab 6mg/kg 290mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
  • 2022-08-30 - trastuzumab 6mg/kg 290mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 500mL
  • 2022-08-05 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-07-12 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-06-15 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-05-20 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-04-21 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-03-31 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-03-08 - trastuzumab 8mg/kg 400mg NS 250mL 90min + pertuzumab 840mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr (loading)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-02-11 - docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + metoclopramide 10mg + NS 250mL
  • 2022-01-20 - doxorubicin 60mg/m2 80mg NS 100mL 10min + cyclophosphamide 600mg/m2 800mg NS 250mL 90min
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2021-12-28 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 900mg NS 250mL 90min
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2021-12-03 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 900mg NS 250mL 90min
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2021-11-12 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 900mg NS 250mL 90min
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[blood WBC]

  • 2023-02-10 WBC 7.41 *10^3/uL
  • 2023-02-01 WBC 10.99 *10^3/uL
  • 2023-01-15 WBC 12.72 *10^3/uL
  • 2023-01-06 WBC 3.91 *10^3/uL
  • 2022-12-28 WBC 9.28 *10^3/uL
  • 2022-12-16 WBC 3.59 *10^3/uL
  • 2022-12-07 WBC 8.85 *10^3/uL
  • 2022-11-25 WBC 16.46 *10^3/uL
  • 2022-11-14 WBC 7.13 *10^3/uL
  • 2022-11-04 WBC 15.00 *10^3/uL
  • 2022-10-26 WBC 4.23 *10^3/uL
  • 2022-10-24 WBC 6.53 *10^3/uL
  • 2022-10-07 WBC 2.24 *10^3/uL
  • 2022-09-29 WBC 6.27 *10^3/uL
  • 2022-09-09 WBC 7.98 *10^3/uL
  • 2022-08-29 WBC 5.24 *10^3/uL
  • 2022-08-17 WBC 14.06 *10^3/uL
  • 2022-08-05 WBC 8.61 *10^3/uL
  • 2022-07-27 WBC 9.02 *10^3/uL
  • 2022-07-11 WBC 6.59 *10^3/uL
  • 2022-06-24 WBC 6.87 *10^3/uL
  • 2022-06-14 WBC 6.48 *10^3/uL
  • 2022-05-27 WBC 2.86 *10^3/uL
  • 2022-05-19 WBC 6.17 *10^3/uL
  • 2022-04-29 WBC 2.90 *10^3/uL
  • 2022-04-20 WBC 6.51 *10^3/uL
  • 2022-04-08 WBC 5.58 *10^3/uL
  • 2022-03-30 WBC 5.88 *10^3/uL
  • 2022-03-16 WBC 1.72 *10^3/uL
  • 2022-03-08 WBC 3.99 *10^3/uL
  • 2022-02-18 WBC 0.84 *10^3/uL
  • 2022-02-11 WBC 7.70 *10^3/uL
  • 2022-02-04 WBC 5.58 *10^3/uL
  • 2022-01-26 WBC 7.65 *10^3/uL
  • 2022-01-24 WBC 2.41 *10^3/uL
  • 2022-01-18 WBC 4.81 *10^3/uL
  • 2022-01-07 WBC 0.60 *10^3/uL
  • 2021-12-31 WBC 4.52 *10^3/uL
  • 2021-12-27 WBC 11.22 *10^3/uL
  • 2021-12-10 WBC 1.82 *10^3/uL
  • 2021-12-03 WBC 8.73 *10^3/uL
  • 2021-12-01 WBC 4.32 *10^3/uL
  • 2021-11-27 WBC 25.99 *10^3/uL
  • 2021-11-25 WBC 2.41 *10^3/uL
  • 2021-11-23 WBC 0.75 *10^3/uL
  • 2021-11-22 WBC 0.69 *10^3/uL
  • 2021-11-19 WBC 1.92 *10^3/uL
  • 2021-11-17 WBC 2.64 *10^3/uL
  • 2021-11-12 WBC 5.80 *10^3/uL
  • 2021-11-10 WBC 5.34 *10^3/uL
  • 2021-11-08 WBC 7.80 *10^3/uL
  • 2021-11-04 WBC 7.79 *10^3/uL

[G-CSF]

  • Granocyte (lenograstim) CGRAN01
    • 2022-02-18 ~ 2022-02-20 250ug SC 2022-02-18 IPD
    • 2022-01-07 ~ 2022-01-09 250ug SC 2022-01-07 IPD
    • 2021-11-22 250ug SC 2021-11-04 IPD
  • Neulasta (pegfilgrastim) CNEUL01
    • 2022-10-02 6mg SC 2022-09-29 IPD
    • 2022-08-08 6mg SC 2022-08-05 IPD
    • 2022-07-14 6mg SC 2022-07-11 IPD
    • 2022-04-02 6mg SC 2022-03-30 IPD
    • 2022-03-11 6mg SC 2022-03-08 IPD
    • 2022-01-24 6mg SC 2022-01-18 IPD

==========

2023-05-12

[tube feeding]

As of 2023-05-12, the patient’s serum potassium level was measured at 3.2 mmol/L. Currently, Const-K is the only oral potassium supplement available in this hospital. If intravenous potassium supplementation is not the preferred method, it’s recommended to crush the Const-K tablet into small enough particles to pass through the feeding tube, and administer the supplement with sufficient water. It’s preferable to give this medication with meals due to its original extended-release design.

2023-02-13

  • 2023-01-17 bone scan showed most of the previous bone lesions are either less evident or have disappeared in comparison with the previous study on 2021-11-08.
  • According to the CT scan performed on 2022-11-16, both breast cancers had pulmonary lymphangitic carcinomatosis and hepatic and bony metastases that were in progression, as compared to the earlier CT scan performed on 2022-07-13.

2022-11-15

  • 2022-11-16 CT scan suggested that the disease was progressing.
  • Following the administration of AC-THP (doxorubicin and cyclophosphamide followed by docetaxel, trastuzumab, and pertuzumab) for one year (since November 2021), it seems that the disease has gradually developed resistance to these drugs.
  • The subsequent line treatment options for the patients with HER2+ metastatic breast cancer might include trastuzumab emtansine or lapatinib, which are covered by NHI, and trastuzumab deruxtecan, which is not covered by NHI at this time.

2022-03-09

  • The patient is diagnosed with breast cancer cT4aN3M1 stage IV and bone mets, and she is fitted with AC followed by docetaxelc + trastuzumab + pertuzumab regimen (the latter two drugs started on 2022-03-08).

701465142

230511

[past history]

  • Heart:(-)

  • Chest:(-)

  • Liver:(-)

  • Kidney:(-)

  • H/T:(-)

  • DM:(-)

  • Surgical:

    • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy) Paraaortic lymphadenectomy on 2022/12/29
    • Port implantation on 2023/01/31
  • Menstrual history: G2P2, menopause at age of 48

[allergy]

  • NKDA     

[family history]

  • There is no family history of cancer,hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[lab data]

2023-01-11 Anti-HBc Nonreactive
2023-01-11 Anti-HBc-Value 0.89 S/CO
2023-01-11 Anti-HBs 329.77 mIU/mL
2023-01-11 Anti-HCV Nonreactive
2023-01-11 Anti-HCV Value 0.07 S/CO
2023-01-11 HBsAg Nonreactive
2023-01-11 HBsAg (Value) 0.31 S/CO

[exam findings]

  • 2023-04-22 CT - abdomen
    • History and indication: Endometrioid carcinoma of the right ovary s/p Debulking surgery and paraaortic lymphadenectomy on 2022/12/29, pT1cN0M0, stage IC1, FIGO IC1, s/p chemotherapy with Taxol(175mg/m2)/Carboplain(AUC:6) from 2023/02/17
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Tumors (4.7cm, 7.9cm) at pelvic cavity with adjacent structures invasion causing right hydronephrosis and hydroureter. Some small LNs at retroperitoneum.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Recurrent tumors (4.7cm, 7.9cm, progression) at pelvic cavity with adjacent structures invasion causing right hydronephrosis and hydroureter. Some small LNs at retroperitoneum.
  • 2023-02-16 MRI - pelvis
    • Clinical history: 54 y/o female patient with Malignant neoplasm of unspecified ovary.
    • With and without contrast enhancement CT of abdomen - whole:
      • S/P hysterectomy and oophorectomy.
      • There is irregular soft tissue tumors, 5x4.9cm (RLQ) and 1.2cm in lower abdomen, suspected recurrence.
      • Cystic lesion in bilateral pelvic side wall regions (right 2.7x1.3cm and left 3.2x1.3cm), suspected lymphocele.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • Presence of some ascites in the pelvic cavity.
    • Impression:
      • S/P hysterectomy and oophorectomy. Suspected recurrnt tumors in lower abdomen.
      • Suspected lymphocele in the pelvic cavity. (Lymphoceles are collections of lymphatic fluid)
  • 2023-02-08 Gynecologic ultrasonography
    • ATH + BSO
    • Asictes (+)
  • 2023-02-07, -01-31 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-02-07 Mammography (magnification)
    • Dense calcifications in left breast, LOQ (around 6’region), suggest close follow up.
    • BI-RADS: Category 3: probably benign finding-short interval follow-up suggested.
  • 2023-02-07 Pure Tone Audiometry
    • PTA:
    • Reliability FAIR
    • Average RE 13 dB HL; LE 16 dB HL
    • bil normal to moderate SNHL
  • 2023-01-12 Mammography
    • Screening digital mammography of both breasts with MLO and CC views:
    • Findings
      • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
      • There is no obvious mass lesion.
      • No obvious architectural distortion.
      • Group amorpohrus microcalcificatios in left breast, LIQ of left breast (around 6’region posterior third portion), suggest spot magnification study.
      • No periareolar skin thickening.
      • No enlarged axillary lymph node.
    • Impression:
      • Dense breast.
      • Group amorpohrus microcalcificatios in left breast, LIQ of left breast (around 6’region posterior third portion), suggest spot magnification study.
      • BI-RADS: Category 0 (incomplete. Need additional imaging evaluation.)
  • 2023-01-11 SONO - breast
    • Benign neoplasm of breast, infavor of benign fibrocystic disease(FCD)
    • Regular OPD follow-up
    • BI-RADS 2 - Benign Finding
  • 2022-12-29 Patho - ovary (tumor)
    • PATHOLOGIC DIAGNOSIS
      • Ovary, right, salpingo-oophorectomy (tumor intra-operative rupture) —- carcinoma.
        • IHC stains: CK7 (+), CK20 (-), GATA-3 (+), PAX-8 (-), CDX-2 (-), P40 (-), Napsin-A (-). Please check urinary tract and breast.
      • Ovary, left, salpingo-oophorectomy —- endometrioma
      • Fallopian tube, right, salpingo-oophorectomy —- free
      • Fallopian tube, left, salpingo-oophorectomy—– free
      • Uterus, corpus, total hysterectomy — myoma; atrophic endometrium.
      • Uterus, cervix, total hysterectomy — free
      • Omentume, omentectomy —- endometriosis.
      • Lymph node, bilateral pelvic and left para-aortic, dissection — Free.
    • MACROSCOPIC EXAMINATION:
      • Procedure-Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy) : Uterus: 170 gms, 13 x 8 x 5 cm; myoma: 7 x 5 x 3 cm; omentum: 31 x 15 x 3 cm, endometriosis; right ovary: 21 x 15 x 6 cm. Solid part: 12 x 9 x 5 cm.   
        • Pleurocentesis (pleural fluid)
      • Specimen size:
        • right ovary: 21 x 15 x 6 cm; cystic; solid part: 12 x 9 x 5 cm
        • left ovary: 2 x 1.5 x 1.4 cm;
        • right tube: 5 x 0.5 x 0.5 cm;
        • left tube: 5 x 0.5 x 0.5 cm;
        • uterus: 13 x 8 x 5 cm.
      • Specimen Integrity:
        • Specimen Integrity of Right Ovary- ruptured: intra-operative ruture
        • Specimen Integrity of Left Ovary -Capsule intact
        • Specimen Integrity of Right Fallopian Tube-Serosa intact
        • Specimen Integrity of Left Fallopian Tube- Serosa intact
      • Tumor Site: right ovary
      • Ovarian Surface Involvement - Absent
      • Fallopian Tube Surface Involvement - Absent
      • Tumor Size - 12 x 9 x 5 cm
      • Greatest dimension (centimeters): 12 cm
      • Additional dimensions (centimeters): 9 x 5 cm
      • Sections are taken and labeled as: A: left iliac lymph nodes; B: left obturator lymph nodes; C: right iliac lymph nodes; D: right obturator lymph nodes; E: left para-aortic lymph nodes; F: omentum; G1: cervix; G2: myoma; G3: endometrium; G4: right tube; G5: left adnexa; H1-5: right ovary (H1-3: solid part; H4-5: non-solid part).
    • MICROSCOPIC EXAMINATION:
      • Histologic type: carcinoma; please check urinary tract and breast. IHC stains: CK7 (+), CK20 (-), GATA-3 (+), PAX-8 (-), CDX-2 (-), P40 (-), Napsin-A (-).
      • Histologic grade: grade 3
      • Contralateral ovary involvement: absent
      • Tumor side ovarian surface involvement: absent
      • Contralateral ovary surface involvement: absent
      • Right tube involvement: absent
      • Left tube involvement: absent
      • In situ adenocarcinoma in right and/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: absent
      • Left adnexa soft tissue involvement: absent
      • Pelvic soft tissue involvement: absent
      • Uterine serosa involvement: absent
      • Omentum involvement: absent
      • Uterine Cervix involvement: absent
      • Endometrium involvement: absent
      • Myometrium involvement:absent
      • Appendix involvement: absent
      • Largest Extrapelvic Peritoneal Focus -none.
      • Peritoneal/Ascitic Fluid- N2022-04855: Negative
      • Regional Lymph Nodes: free
        • Negative for metastasis: describe locations (0/17) = A: left iliac lymph nodes (0/4); B: left obturator lymph nodes (0/1); C: right iliac lymph nodes (0/3); D: right obturator lymph nodes (0/2); E: left para-aortic lymph nodes (0/7).
      • Other organs or specimens involvement: absent.
  • 2022-12-21 CT - abdomen - urinary bladder
    • Hx: P2 NSDX2, menopause at the age of 48
      • patient noticed that she has the tumor over the right side of the ovary, she has regular follow up, covid (+) in May 2022
      • BW decreased from 72kg -> 58kg, difficulty of voiding
      • 20221221 CA125 427U/mL (<35), CA199 231U/mL (<35), CEA normal.
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is a huge cystic mass with enhancing mural nodules in the lower abdomen and pelvis, measuring 22.4 x 14 x 28 cm (width x depth x cranial-caudal length).
        • The uterus shows right lateral displacement.
        • Cystic adenocarcinoma of left ovary is highly suspected.
        • Please correlate with clinical oondition.
      • There are several enlarged nods in para-aortic space and bilateral inguinal area. please correlate with clinical condition.
      • Others
        • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no ascites.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Cystic adenocarcinoma of left ovary is highly suspected. Please correlate with clinical oondition.
      • There are several enlarged nods in para-aortic space and bilateral inguinal area. please correlate with clinical condition.
  • 2022-12-21 Gynecologic ultrasonography
    • Huge pelvis mass size over: 345x178mm with papillary: (1) 91x36mm (2) 51x39mm
    • Adenomyosis

[consultation]

  • 2023-02-17 Dermatology
    • Q
      • The 54 y/o ovary cancer with disease progress. Due to left heel skin itchy with redness, so we need your help for assessment. Thanks!
    • A
      • This patient suffered from erytheamtous papules on bil feet for days
      • Imp: Subacute dermatitis
      • Suggestion
        • Sinpharderm x 1 tube/bid
        • Topsym cream x 3 tubes/bid

[MedRec]

  • 2023-03-09 SOAP Hemato-Oncology
    • O
      • Now on C/T with TP
      • AE: Gr 2 Anemia
  • 2023-03-01 SOAP Hemato-Oncology
    • O
      • Cancer Treatment Radiotherapy/Targeted Therapy Side Effect Evaluation
        • Decreased white blood cells: G1: 3000 - 4000/mm3
        • Decreased white blood cells [Management]: Observation
  • 2023-02-07 ~ 2023-02-20 POMR Hemato-Oncology
    • Discharge diagnosis
      • Malignant neoplasm of unspecified ovary
      • Fever, unspecified
      • Vaginitis, U/C: Gardnerella vaginalis
      • Subacute dermatitis
    • Course of Inpatient Treatment
      • After admission, will do schedule chemotherapy, but fever was noted without chillness, check lab and follow up culture for infection survey.
      • Empirical antibiotic with Cefuroxime 750mg/vial 1500mg IVD Q8H from 2023/02/07, Acetal 500 mg/tab 1# PO PRNQ6H if BT > 38.3’C. and consult GYN for check Gynecologic ultrasonography on 2023/02/08, no special finding.
      • Naproxen 250 mg/tab 0.5# PO BID for suspect tumor fever, close monitor -> DC 2/10, start from 2/16.
      • Due to urine/culture showed Gardnerella vaginalis, given Metrozole 250mg/tab 2# PO BID 7days from 2023/02/10 to 2023/02/17.
      • Before chemotherapy, PTA and 24 Ccr were done. PTA on 2023/02/07 showed bil normal to moderate SNHL. 24hrs CCr, urine output 3700ml, CCr 70.9mL/min.
      • Mammography (Magnification) on 2023/02/07 showed dense calcifications in left breast, LOQ (around 6’region), probably benign finding.
      • Pelivs MRI for survey on 2023/02/16 showed S/P hysterectomy and oophorectomy, R/O recurrent tumors in lower abdomen, R/O lymphocele in the pelvic cavity.
      • Pre-medication as Dorison 20mg PO on 2/16 23:00 and 2/17 05:00, chemotherapy as C1 Paclitaxel 175mg/2 + Carboplatin 150mg/15mL/vial (AUC 6) on 2023/02/17.
      • Consult for erytheamtous papules on bil feet for days, suggest Sinpharderm x 1 tube/bid、Topsym cream x 3 tubes/bid use. Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, she/he was discharged on 2023/02/20 and OPD followed up later.   
    • Prescription
      • naproxen 250mg 0.5# BID
      • Smecta (dioctahedral smectite 3mg) 1# PRNQ8H (if watery diarrhea > 3 times)
      • Sinpharderm Cream (urea) BID TOPI (for subacute dermatitis)
      • Topsym Cream (fluocinonide) BID EXT (for subacute dermatitis)
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
  • 2023-02-02 SOAP Hemato-Oncology
    • O
      • Conclusion of the Multidisciplinary Cancer Team Meeting, Meeting Date: 20230105
        • Treatment Plan: Arrange cystoscopy (GATA-3+) and breast ultrasound examination, and then refer to the hematology department for further evaluation.
    • A/P
      • Lab
      • RTC by herself
      • Waiting for the conclusion from Breast and GU
      • Arrange admission with magnification Mammography and then C/T

[surgical operation]

  • 2022-12-29
    • Surgery
      • Diagnosis: Cystic adenocarcinoma of right ovary s/p debulking surgery.
    • Operation
      • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy)    
      • Paraaortic lymphadenectomy

[chemotherapy]

  • 2023-05-02 - topotecan 1.5mg/m2 2.3mg NS 70mL 30min + gemcitabine 1000mg/m2 1400mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-24 - topotecan 1.5mg/m2 2.3mg NS 70mL 30min + gemcitabine 1000mg/m2 1400mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-03-13 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + carboplatin AUC 6 510mg NS 300mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-17 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 6 570mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL

2023-05-11

[assessment]

  • The PharmaCloud database reveals that the patient’s recent drugs have all been prescribed at our hospital. Currently, there are no issues detected with medication reconciliation in the active prescription.

  • The patient’s anemia, as evidenced by a decrease in hemoglobin level from 10.2 g/dL on 2023-05-02 to 8.1 g/dL on 2023-05-09, is currently being treated with a transfusion of 2 units of packed red blood cells (P-RBC), scheduled for 2023-05-11, as indicated.

  • The patient’s lab data reveals a decreasing trend in serum albumin levels, raising the possibility of a protein-losing gastroenteropathy. However, current records do not indicate the presence of edema, ascites or pleural and pericardial effusions. Furthermore, liver and kidney function appear to be within or not far from normal ranges based on the lab data, suggesting that heavy proteinuria or impaired protein synthesis due to liver disease are less likely causes. It is recommended to encourage the patient to pay more attention to nutritional supplementation to prevent malnutrition.

    • 2023-05-09 Albumin 2.8 g/dL
    • 2023-05-02 Albumin 3.1 g/dL
    • 2023-04-19 Albumin 3.0 g/dL
    • 2023-04-12 Albumin 3.1 g/dL
    • 2023-03-30 Albumin 3.1 g/dL
    • 2023-03-23 Albumin 3.1 g/dL
    • 2023-03-09 Albumin 3.2 g/dL
  • Intestinal leakage of plasma proteins occurs via one of the following mechanisms:

    • Inflammatory exudation: Mucosal injury results in exudation of protein-rich fluids across the eroded epithelium. The degree of mucosal involvement typically correlates with the severity of protein loss.
    • Increased mucosal permeability: Altered integrity of the mucosa of the stomach, small bowel, and colon due to inflammatory, infiltrative, and genetic causes results in protein leakage into the lumen.
    • Intestinal loss of lymphatic fluid: Lymphatic obstruction, congenital abnormalities of the lymphatic system, or disorders of increased central venous pressure (eg, congestive heart failure or constrictive pericarditis) result in increased lymphatic pressure.
  • The CT scan on 2023-04-22 revealed recurrent tumors in the pelvic cavity measuring 4.7cm and 7.9cm, respectively. These tumors have invaded adjacent structures, causing right hydronephrosis and hydroureter, and lymph nodes are also evident in the retroperitoneum. These findings might be related to the observed clinical phenomena mentioned above?

2023-03-14

[assessment]

  • On 2023-03-13, the second cycle of paclitaxel/carboplatin began with the addition of antiemetics (palonosetron and aprepitant) and a larger volume of normal saline for each drug compared to the first cycle which began on 2023-02-17. Specifically, the volume for both paclitaxel and carboplatin was increased from 250mL to 300mL.
  • Based on the available lab data, the patient’s HGB levels have been often below 10g/dL, and since mid-Feb, they have decreased to below 9g/dL. On 2023-03-13, the patient received a blood transfusion of 2 units of LPRBC. Please continue to monitor changes in blood cell count as always.
  • Thre is no medication reconciliation issue found in the patient.

701477623

230511

[exam findings]

  • 2023-05-09 CT - abdomen
    • Clinical history: 60 y/o male patient with rectal swelling with suspect infection.
    • With and without contrast enhancement CT of abdomen:
      • Severe swelling/edema at middle and lower rectum.
      • Wall edema at gallbladder.
      • Liver cysts, up to 2.5cm in S7.
      • Bilateral pleural effusion.
      • Diffuse subcutaneous edema.
    • Impression:
      • Severe swelling/edema at middle and lower rectum. R/O colitis, suggest clinical correlation.
      • Wall edema of Gallbladder.
      • Bilateral pleural effusion, diffuse subcutaneous edema.
      • R/O liver cysts.
  • 2023-05-09 CXR
    • There are diffuse nodular and linear infiltrations in both lungs. please correlate with clinical condition or CT.
    • Enlargement of cardiac silhouette.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-04-18 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (129 - 39) / 129 = 69.77%
      • M-mode (Teichholz) = 70
    • Conclusion:
      • Mildly dilated LV; normal LV systolic function with normal wall motion.
      • Normal LV diastolic function.
      • Normal RV systolic function.
      • Mild AR; mild MR; mild TR; mild PR.
      • Mildly dilated aortic root.
  • 2023-04-17 Patho - bone marrow biopsy
    • Bone marrow, iliac crest, biopsy — Compatible with acute myeloid leukemia with maturation
    • The sections show hypercellular marrow (90%). The erytrhoid precursors are depressed in CD71 stain. The marrow space is partially replaced by a population of medium to large-sized immature cells with oval nucleus and moderate amount cytoplasm.
    • IHC: increased CD34- /CD117+ blasts, constitue 30% of marrow cells. Most marrow are also positive for MPO (80%) and a few are positive for CD68 (5%). The finding is compatible with acute myeloid leukemia with maturation. Suggest bone marrow smear evaluation and clinic correlation.
  • 2023-04-14 ECG
    • Normal sinus rhythm with sinus arrhythmia
    • RSR or QR pattern in V1 suggests right ventricular conduction delay
    • ST & T wave abnormality, consider lateral ischemia
    • Abnormal ECG

[MedRec]

  • 2023-04-14 SOAP Hemato-Oncology
    • O
      • 2023/04/14 WBC = 30.60 x10^3/uL;
      • 2023/04/07 WBC = 19.13 x10^3/uL;
      • 2023/04/14 PLT = 77 *10^3/uL;
      • 2023/04/07 PLT = 98 *10^3/uL;
      • 2023/04/07 Blast = 19.0 %;
    • P
      • Suspect Acute leukemia -> refer to ER for admission
  • 2023-04-07 SOAP Hemato-Oncology
    • S
      • 177 cm, 70 kg, 60 y man
      • Occupation: Notebook R/D chief
      • PH: healthy platelet donor since 1992 until 2022
      • 2023-01-01: common cold, and anemia found, Hb: 10.0, in China
      • 2023-03-31: WBC 14000, Hb 11.1, Plt 122k, monocytes 20%, blast is found on PB smear
      • 2023-04-03: WBC 15400, Hb 11.2, blast 10.5%, mono 21%
      • 2023-04-06: BM exam at Shin Kong Hospital, acute leukemia was told
    • O
      • No hepatosplenomegaly
    • Imp:
      • Suspected Acute leukemia

[consultation]

  • 2023-05-09 Colorectal Surgery
    • Q
      • The 60 y/o man has AML (Acute Myeloid Leukemia) undergoing induction chemotherapy and is in the stage of neutropenia.
      • Because he has been feeling a heavy sensation of anal fullness and downward pressure, we need your help for management.
    • A
      • This is a case of AML with neutropenia. Anal pain and dysuria develo[ed thses days.
      • DRE: no palpable mass, no fistula, no abscess, rectal wall edema and wall swelling.
      • Suapect leukemic infiltration of the rectum, AML induced anorectal pain.
      • Please arrange pelvic MRI for detail information.
  • 2023-05-09 Urology
    • Q
      • The 60 y/o man has AML under induction chemotherapy with neutropenia stage.
      • Due to acute urine retention cause unknown, so we need you for management. Thanks!
    • A
      • We were consulted for AUR s/p Foley
        • This 60 yo male has underlying BPH
        • PI: no straining, no weak stream
        • Lab: UTI
      • Impression: AUR due to UTI
      • Suggestion:
        • keep anti
        • keep Foley and alpha-blocker for one week
        • arrange UFM and PVR after Foley removal
  • 2023-05-05 Infectious Disease
    • Q
      • The 60 y/o man has AML under induction chemotherapy with neutropenia stage, he had spiky fever with shaking chills on 20230503.
      • We need you agree for give micarfuncgin. Thanks!
    • A
      • The 60-year-old AML male patient, who received recent chemotherapy, has neutropenic fever in recent two days.
      • CBC today revealed severe pancytopenia, with WBC only 90 and no neutrohils.
      • Besides Targocid and cefepime, anti-fungal Mycamine is added since yesterday for coverage of possible fungal infection, especially Candida species.
      • Please continue the present antimibrocial regimen and check blood culture report.

[chemotherapy]

  • 2023-04-20 - daunorubicin 45mg/m2 84mg NS 100mL D1-3 + cytarabine 100mg/m2 187mg NS 500mL 24hr D1-7 (daunorubicin/cytarabine 3+7, Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-7

2023-05-11

  • Please be aware that the patient’s renal function has been declining over the past three days. At present, there’s no need for a dose adjustment, but it’s crucial to continue monitoring closely.

    • 2023-05-11 Creatinine 1.11 mg/dL
    • 2023-05-09 Creatinine 0.92 mg/dL
    • 2023-05-08 Creatinine 0.65 mg/dL
    • 2023-05-11 eGFR 71.82
    • 2023-05-09 eGFR 89.19
    • 2023-05-08 eGFR 133.18
  • Lab data has shown signs of recovery in the patient’s WBC count. However, the PLT count continues to hover at relatively low levels, never reaching 100K/uL.

    • 2023-05-11 WBC 2.38 x10^3/uL
    • 2023-05-09 WBC 0.24 x10^3/uL
    • 2023-05-08 WBC 0.12 x10^3/uL
    • 2023-05-06 WBC 0.12 x10^3/uL
    • 2023-05-05 WBC 0.09 x10^3/uL
    • 2023-05-03 WBC 0.24 x10^3/uL
    • 2023-05-02 WBC 0.32 x10^3/uL
    • 2023-04-29 WBC 0.53 x10^3/uL
    • 2023-04-27 WBC 1.64 x10^3/uL
    • 2023-04-26 WBC 2.75 x10^3/uL
    • 2023-04-24 WBC 8.09 x10^3/uL
    • 2023-04-23 WBC 18.55 x10^3/uL
    • 2023-04-22 WBC 25.63 x10^3/uL
    • 2023-04-21 WBC 40.55 x10^3/uL <= 4/20 started “daunorubicin/cytarabine 3+7”
    • 2023-04-19 WBC 35.06 x10^3/uL
    • 2023-04-16 WBC 37.99 x10^3/uL
    • 2023-04-14 WBC 30.60 x10^3/uL
    • 2023-04-07 WBC 19.13 x10^3/uL
  • Indications for platelet transfusion include actively bleeding patients with thrombocytopenia who should receive immediate platelet transfusion to maintain platelet counts above 50K/uL in most bleeding situations, including disseminated intravascular coagulation (DIC), and above 100K/uL in central nervous system bleeding.

  • Unfortunately, there are no perfect tests to predict spontaneous bleeding. Studies in patients with thrombocytopenia suggest that spontaneous bleeding can occur even with platelet counts above 50K/uL. However, bleeding is much more likely when the platelet count falls below 5K/uL. For individuals with platelet counts between 5K and 50K/uL, clinical observations may be useful in deciding whether to transfuse platelets.

2023-04-21

  • The patient started his first “3+7 daunorubicin/cytarabine” treatment on 2023-04-20 for his AML. No identified issue found in the active prescription.

700072177

230509

[diagnosis] - 2023-05-08 admission note

  • Adenocarcinoma of the low rectum just above dentate line, cT4aN2bM0, stage IIIC, status post concurrent chemoradiotherapy with 5-Fu from 2023/02/02 to 2023/03/09, s/p TNT chemotherapy with FOLFOX from 2023/03/24
  • Squamous cell carcinoma of left lower lip, cT2N0M0, stage II
  • Constipation, unspecified

[MedRec]

  • 2023-01-12 SOAP Colorectal Surgery
    • Assessment: Suggest neoadjuvant chemotherapy Favor TNT then restaging, Consider observation if cCR or local excision (TAMIS) for sphincter preserving.
  • 2023-01-11 SOAP Radiation Oncology
    • A:
      • Squamous cell carcinoma of the left buccal to lip commissure area, stage T4aN0M0, s/p induction chemotherapy, and s/p CCRT.
      • Adenocarcinoma of the low rectum just above dentate line, stage cT4aN2bM0(IIIC)
    • P:
      • Radiotherapy is indicated for this patient with the following indicators: Adenocarcinoma of the low rectum just above dentate line, stage cT4aN2bM0(IIIC)
        • Goal: curative
        • Treatment target and volume: pelvic including low rectal tumor.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-02-01.
  • 2023-01-11 SOAP Hemato-Oncology
    • O
      • 2022/12/19 PATHO - Colon biopsy: Colorectum, low rectum just above dentate line, (3 cm from anal verge), Biopsy. Specimen: B — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • 2023/01/05 CT: ABD: T:T4a(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
    • P
      • Arrange PET-CT
      • Refer to CRS for surgical evaluation
      • Refer to RTO for CCRT
      • Arrange admisson for CCRT

[radiotherapy]

  • 2023-02-02 ~ 2023-03-14 - 4500cGy/25 fractions (15MV photon) of the pelvic, and 5040cGy/28 ractions of the rectal tumor bed area.
  • 2018-03-20 ~ 2018-05-08 - 5000cGy/25 ractions (6MV photon) of the bilateral neck, 6000cGy/30 fractions of the left buccal to lip commissure tumor, and 7000cGy/35 fractions of the reduced left buccal to lip commissure tumor bed.

[chemotherapy]

  • 2023-05-08 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX, Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PD D1-3
  • 2023-04-12 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 400mg/m2 730mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PD D1-3
  • 2023-03-24 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 400mg/m2 730mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PD D1-3
  • 2023-03-03 - fluorouracil 225mg/m2 420mg NS 100mL D1-4 (CCRT)
    • none
  • 2023-02-13 - fluorouracil 225mg/m2 420mg NS 100mL D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-02-09 - fluorouracil 225mg/m2 420mg NS 100mL D1-2 (CCRT)
    • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2
  • 2020-04-23 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1900mg leucovorin 100mg/m2 190mg NS 1000mL 22hr (TPFL Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-04-16 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1900mg leucovorin 100mg/m2 190mg NS 1000mL 22hr (TPFL Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-04-02 - docetaxel 40mg/m2 80mg NS 150mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 3hr + fluorouracil 1000mg/m2 1900mg leucovorin 100mg/m2 190mg NS 1000mL 22hr (TPFL Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-03-27 - docetaxel 40mg/m2 80mg NS 150mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 3hr + fluorouracil 1000mg/m2 2000mg leucovorin 100mg/m2 200mg NS 1000mL 22hr (TPFL Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-03-13 - docetaxel 40mg/m2 80mg NS 150mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 3hr + fluorouracil 1000mg/m2 2000mg leucovorin 100mg/m2 200mg NS 1000mL 22hr (TPFL Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-03-06 - docetaxel 40mg/m2 80mg NS 150mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 3hr + fluorouracil 1000mg/m2 2000mg leucovorin 100mg/m2 200mg NS 1000mL 22hr (TPFL Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg

[assessment]

  • On 2023-01-12, the PET scan showed no significant abnormal focal FDG uptake elsewhere except in the rectum with two regional lymph nodes and an old lesion in the left buccal region. The patient has been treated with TNT for rectal cancer. CCRT with FU was performed in February and March of 2023. The patient is currently being treated with the FOLFOX regimen.
  • According to PharmaCloud records, all recent medications were prescribed at our hospital and no medication reconciliation issues were identified.

700536063

230509

[diagnosis] - 2023-03-23 admission note

  • Adenocarcinoma of gastric antrum, pT3N1 (1/48) M0, Stage IIB, s/p Op.
  • Diabetes mellitus, type 2
  • Hypertension
  • Viral hepatitis B anti-Hbc: positive

[past history]

  • medical
    • Anemia
    • Diabetes mellitus, type 2
    • Hypertension
  • operation
    • Gallballder stones status post laparoscopic cholecystectomy on 2022/02/14

[allergy]

  • NKDA                                         

[family history]

  • Father had history of hypertension, colo-rectal cancer
  • No members of the family with diabetes.

[exam findings]

  • 2023-02-01 CT - abdomen
    • History: General fatigue for months, poor appetite ++, epigastric discomfort +, Anemia (Hb 8.2), stool: OB 4+
      • 20220622 gastroscopy: One raised and nodularity mucosa lesion with clean base ulcer was noted at LC site of low body to antrum, suspected cancer, s/p biopsy. Patho: adenocarcinoma.
      • 20220629 CT:gastric antrum cancer, cT3N1M0, cSTAGE:III
      • 20220711 S/P subtotal gastrectomy:pT3N1 (1/48) M0, Stage IIB
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • S/P subtotal gastrectomy and S/P cholecystectomy.
      • Prior CT identified Adenoma or hyperplasia 1.2 cm in left adrenal gland is noted again, stationary.
      • A renal cyst 1.5 cm in right middle-lower pole is noted.
    • Impression:
      • There is no evidence of tumor recurrence.
  • 2022-09-28 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis with scoliosis of the T-spine with convex to right side
  • 2022-07-12 Patho - stomach subtotal/total (tumor)
    • pathologic diagnosis
      • Stomach, subtotal gastrectomy — Tubular adenocarcinoma, poorly differentiated
      • Margins, bilateral cutting ends, subtotal gasdtrectomy — Free of tumor invasion
      • Lymph nodes, D2 LN dissection — Metastatic adenocarcinoma (1/48)
      • Omentum, omentectomy — Free of tumor invasion
      • AJCC Pathologic staging — pT3N1 (if cM0), stage IIB
    • microscopic examination
      • Histologic type: Tubular adenocarcinoma (Lauren classification: intestinal type)
      • Histologic grade: Poorly differentiation (G3)
      • Depth of tumor invasion: Tumor invades the subserosa
      • Margins: All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin: 1 mm from radial margin
      • Perineural invasion: Present
      • Lymphovascular space invasion: Absent
      • Regional lymph nodes: Metastatic adenocarcinoma (1/48)
        • 0/3 (omentum), 0/5 (LN 1), 1/8 (LN 3), 0/10 (LN 4), 0/2 (LN 5), 0/5 (LN 6), 0/15 (LN 7, 8, 9, 11p), 0 (LN 12a), 0 (LN14v) (Number of LN involved/Number of LN examined) 3
      • Extracapsular extension: Absent
      • Omentum: free of tumor invasion
      • Additional pathologic findings: Helicobacter-associated non-atrophic chronic gastritis
      • Pathologic Staging: pT3N1, stage IIB, if cM0
      • IHC: HER2 (Negative, score= 1+)
  • 2022-07-07 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (118 - 43) / 118 = 63.56%
      • M-mode (Teichholz) = 63
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
    • Mild MR and trivial TR
    • Preserved RV systolic function
  • 2022-07-05 ECG
    • Sinus tachycardia
    • Septal infarct, age undetermined
  • 2022-06-29 CT
    • History: General fatigue for months, poor appetite ++, epigastric discomfort +, Anemia (Hb 8.2), stool: OB 4+
      • 20220622 gastroscopy: One raised and nodularity mucosa lesion with clean base ulcer was noted at LC site of low body to antrum, suspected cancer, s/p biopsy. Patho: adenocarcinoma.
    • Indication: CT for gastric cancer staging
    • Findings:
      • There is lobulated wall thickening at the gastric low body and antrum, measuring 2.1 cm in wall thickness that is c/w adenocarcinoma (T3).
      • There are two lymph nodes in the gastrohepatic ligament that may be metastatic nodes (N1).
      • Adenoma 1.2 cm in left adrenal gland is suspected.
      • A renal cyst 1.5 cm in right middle-lower pole is noted.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N1 (N_value) M:M0 (M_value) STAGE:III(Stage_value)
  • 2022-06-22 Patho - stomach biopsy
    • Stomach, angle to LC site of antrum, biopsy — Adenocarcinoma
    • Microscopically, the sections show a picture of adenocarcinoma, poorly differentiated, characterized by tumor cells arranged in crowded nest or tubular pattern with enlarged and hyperchromatic nuclei infiltrating in ulcerative stroma with mild intestinal metaplasia.
    • Immunohistochemistry of CK(+), P53(+) and Her2/neu (2+, equivocal) for tumor.
  • 2022-06-22 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, s/p CLO test
      • Gastric mucosa lesion with ulcer, LC site of low body to antrum, s/p biopsy, suspected gastric cancer
      • Duodenal ulcer scar, bulb, AW site
    • Suggestion
      • PPI use
      • Pursue CLO test and biopsy result
  • 2022-02-14 Patho - gallbladder (benign lesion)
    • Gallbladder, laparoscopic cholecystectomy — Chronic cholecystitis and cholelithiasis
  • 2022-02-11 SONO - abdomen
    • Diagnosis
      • Fatty liver, moderate
      • Suspected fatty infiltration of pancreas
      • Propable GB stones
      • Heterogeneous echogenecity in somach and duodenum area(?). Please correlate with EGD
      • Suboptimal examination of liver due to poor echo window caused by severe fatty infiltration
    • Suggestion
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
      • Because of poor echo window,infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months

[consultation]

  • 2022-10-17 Cardiology
    • Q
      • The 67 y/o woman has gastric cancer, stage IIB. She was admitted for chemotherapy. She regular take anti-hypertension from CV OPD. We need your help for hypertension assessment. Thanks!
    • A
      • This is a 67 years old lady who has gastric cancer for chemotherapy with FOLFOX (self-paid) IV Q2W x 12 on 20221017.
      • He recieved sevkiar and natrilix at CV OPD for BPcontrol.        
      • BP on 20221017
        • 192/ 94
        • 205/107
        • 211/115
        • 226/105
        • 141/ 82
      • Cardiac echo 2020/07/07
        • Echo EF: 63%
        • Adequate LV systolic function with normal resting wall motion
        • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
        • Mild MR and trivial TR
        • Preserved RV systolic function
      • EKG: 20220705 sinus tachycardia
      • CXR 20220928 no cardiomegaly
      • echocardiogram 20220707
        • Findings:
          • AO(mm) = 31; LA(mm) = 42;
          • IVS(mm) = 12; LVPW(mm) = 9;
          • LVEDD(mm) = 50; LVESD(mm) = 32;
          • LV mass(gm) = 201;
          • TAPSE(mm) = 27;
          • M-mode(Teichholz) = 63
          • TR: Trivial; Max pressure gradient = 27 mmHg
          • E/A ratio = 0.6
          • IVC size 14 mm with respiratory collapse > 50%
        • Conclusion:
          • Adequate LV systolic function with normal resting wall motion
          • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
          • Mild MR and trivial TR
          • Preserved RV systolic function
      • Impression
        • Hypertensive cardiovascular disease.
      • Suggestion
        • Keep sevikar + natrilix as OPD
        • Might add norvasc 1# qd and hydralazine 1# prn-Q8h if SBP > 160mmhg
        • If still poor control, add nebivolol 1# qd
        • Watch sleeping condition or pain status
  • 2022-07-20 Hemato-Oncology
    • Q
      • This 66-year-old female had history of
        • Anemia
        • Diabetes mellitus, type 2
        • Hypertension
      • She was a case of Adenocarcinoma of gastric antrum, poorly differentiated, cT3N1M0
      • Laparoscopic subtotal gastrectomy, D2 LN dissection with B-II gastrojejunostomy anastomosis was done on 20220711
      • Pathology revealed
        • Stomach, subtotal gastrectomy — Tubular adenocarcinoma, poorly differentiated (G3)
          • Tumor site: Antrum, lesser curvature, 3.2 cm from distal margin
          • Tumor size: 6.1 x 4.8 cm
        • Margins, bilateral cutting ends, subtotal gasdtrectomy — Free of tumor invasion
        • Lymph nodes, D2 LN dissection — Metastatic adenocarcinoma (1/48), LN3
        • Omentum, omentectomy — Free of tumor invasion
        • AJCC Pathologic staging — pT3N1 (if cM0), stage IIB
      • We need your expertise for post-op chemotherapy +/- radiotherapy
    • A
      • Impression:
        • Adenocarcinoma of gastric antrum s/p Radical subtotal gastrectomy with D2 LN dissection on 20220711, pT3N1M0, stage IIB, pathology show tubular adenocarcinoma, poorly differentiated(G3), HER-2 negative
        • Diabetes mellitus, type 2
        • Hypertension
      • Suggestion:
        • Postoperative chemotherapy is recommended following primary D2 lymph node dissection (Capecitabine and oxaliplatin (category 1) or Fluorouracil and oxaliplatin)
        • Arrange port A insertion and arrange our OPD after discharge
        • Please check HbsAg, Anti Hbc, Anti HCV
      • PostOperative Chemotherapy (for patients who have undergone primary D2 lymph node dissection)
        • Capecitabine and oxaliplatin
          • Capecitabine 1000 mg/m2 PO BID on Days 1–14
          • Oxaliplatin 130 mg/m2 IV on Day 1
          • Cycled every 21 days for 8 cycles
        • Fluoropyrimidine and oxaliplatin
          • 1
            • Oxaliplatin 85 mg/m2 IV on Day 1
            • Leucovorin 400 mg/m2 IV on Day 1
            • Fluorouracil 400 mg/m2 IV Push on Day 1
            • Fluorouracil 1200 mg/m2 IV continuous infusion over 24 hours daily on Days 1 and 2
            • Cycled every 14 days
          • 2
            • Oxaliplatin 85 mg/m2 IV on Day 1
            • Leucovorin 200 mg/m2 IV on Day 1
            • Fluorouracil 2600 mg/m2 IV continuous infusion over 24 hours on Day 1
            • Cycled every 14 days

[surgical operation]

  • 2022-07-11
    • Surgery
      • Radical subtotal gastrectomy with D2 LN dissection
    • Finding
      • 7 * 5 cm ulcerative mass at lesser curvature of antrum
      • Previous cholecytectomy
      • Omentum adhension
    • Procedure
      • ETGA
      • 12-12-5-3.5 mm trocars
      • Adhesiolysis
      • subtotal gastrectomy with 1,3,4,5,6,7,8,9,11p,12a,14v LN dissection
      • Frozen section : margin free of carcinoma
      • GJ B-II anastomosis with EndoGIA
      • two J-vac inserted
      • wound closed
  • 2022-02-14
    • Surgery
      • LC
    • Finding
      • two 1.2cm pigment stones iwth chroinc inflam
    • Procedure
      • ETGA
      • 10-5-3.5 mm trocars
      • cholecystectomy
      • wound closed

[radiotherapy]

  • 2022-10-31 ~ 2022-12-02 - completed RT to the stomach and adjacent lymphatic drainage area: 45 Gy/ 25 fx.

[chemotherapy]

  • 2023-05-08 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4695mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-12 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-23 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-07 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-20 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-30 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-20 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL + fluorouracil 2800mg/m2 4670mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO
  • 2022-11-28 - + fluorouracil 200mg/m2 330mg NS 500mL 24hr D1-5 (CCRT QW)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-11-24 - + fluorouracil 200mg/m2 330mg NS 500mL 24hr D1-5 (CCRT QW)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-11-07 - + fluorouracil 200mg/m2 330mg NS 500mL 24hr D1-5 (CCRT QW)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-11-02 - + fluorouracil 200mg/m2 330mg NS 500mL 24hr D1-3 (CCRT QW)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-10-18 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4685mg 46hr
  • 2022-09-26 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4715mg 46hr
  • 2022-09-12 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4715mg 46hr
  • 2022-08-29 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
  • 2022-08-15 - oxaliplatin 70mg/m2 100mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr

==========

2023-03-08

  • The patient’s underlying diabetes mellitus is well controlled. However, on admission to the hospital, her systolic blood pressure was found to be over 200 mmHg. Her current blood pressure is 142/65 mmHg.
  • Based on the lab data resulted on 2023-03-23, the patient’s results were generally within normal limits. In addition, no medication reconciliation issues were noted for the patient.

2022-11-25

  • The results of the laboratory test on 2022-11-24 were generally normal.
  • A pre-prandial blood sugar level was recorded as 181 mg/dL (2022-11-25 07:20) this morning. It might be necessary to consider additional anti-diabetic agents if the reading persists high (> 180 mg/dL) for two consecutive days.
  • Around the ULN, blood pressure fluctuates up and down. Please keep a close eye on the reading as always.

2022-09-13

  • The underlying conditions of HTN and T2DM were treated with the patient-carried medications Natrilix (indapamide), Sevikar (amlodipine + olmesartan) and Xigdou (dapagliflozin + metformin) without extremely outlier findings during this hospitalization.
  • The results of the laboratory test on 2022-09-12 were grossly normal.

2022-08-16

  • As there is no fluorouracil bolus used in the current chemotherapy regimen, the dose of leucovorin may be reduced to 200mg/m2.

700598723

230509

{not completed}

[MedRec]

  • 2023-03-02 SOAP Hemato-Oncology
    • A/P
      • Ovary, left, left salpigo-oophorectomy (20230220) — pT1c2 pN0 (if cM0); pStage: IC; FIGO stage: IC2 with clear cell component
      • Her sister worked in another hospital.
  • 2023-02-17 SOAP Obstetrics and Gynecology
    • S
      • a case of ovarian endometiroid adenocarcinoma, s/p LSC LSO + pelvic adhesion lysis + TCR-P on 2023/02/09
    • O
      • Cancer Multidisciplinary Team Meeting Conclusion, meeting date: 20230216
        • Postoperative adjuvant chemotherapy (referred to hematoma department Dr. Wan Xianglin / patient expressed desire to preserve fertility).
        • Consensus on the period: pT1c2N0M0, FIGO IC2. -> Suggest staging/debulking surgery due to pathology revealing clear cell carcinoma.

[chemotherapy]

  • 2023-05-08 - paclitaxel 70mg/m2 100mg NS 250mL 1hr + carboplatin AUC 2 565mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-07 - paclitaxel 70mg/m2 100mg NS 250mL 1hr + carboplatin AUC 2 565mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-14 - paclitaxel 70mg/m2 100mg NS 250mL 1hr + carboplatin AUC 2 565mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[assessment]

  • Prior to the current chemotherapy session, WBC counts were observed to decrease approximately one week after the previous two sessions on 2023-03-14 and 2023-04-07, with levels dropping to 3.07K/uL on 2023-03-21 and 2.68K/uL on 2023-04-14. Given these observations, it is reasonable to anticipate potential leukopenia following this current session, which should be noted.
    • 2023-05-08 WBC 3.50 x10^3/uL
    • 2023-04-14 WBC 2.68 x10^3/uL
    • 2023-04-06 WBC 3.83 x10^3/uL
    • 2023-03-21 WBC 3.07 x10^3/uL
    • 2023-03-12 WBC 4.21 x10^3/uL
    • 2023-02-27 WBC 3.33 x10^3/uL
    • 2023-02-24 WBC 5.97 x10^3/uL
  • According to PharmaCloud records, all recent medications were prescribed at our hospital and no medication reconciliation issues were identified.

701457374

230509

[MedRec]

  • 2023-04-27 ~ 2023-05-08 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • Nasopharynx MRI showed squamous cell carcinoma of right tongue and floor of mouth with lymph node metastasis cT4bN3bM0 stage IVb.
      • His treatment plans were palliative chemotherapy followed by salvage surgeries.
      • lntraoral wound change dressing qd. Oral intake with clear liquid diet because of patient refused N-G placement.
      • Systemic antibiotic with Cefa 1g Q8H IV for infection control.
      • He finished modified induction chemotherapy with #1a 80% TPF (Taxotere 32mg/M2, Cisplatin 32mg/M2, 5-Fu 800mg/M2 plus Leucovorin 80mg/M2, MTX 24mg/M2) on 2023/05/3-2023/05/06.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. Zinga 1 tab PO QD for zinc supplement, B-Red 1 mg IVD QD for hematogenesis, Magnesium Sulfate 10% 20 mL IVD QD for hypomagnesemia.
    • Prescription
      • Actein (acetylcysteine 600mg) 1# BID
      • Acetal (acetaminophen 500mg) 1# PRNQ6H (if pain)
      • Zinga (zinc gluconate 78mg) 1# QD
      • Foliromin (ferrous sodium citrate 50mg) 1# BID
      • loperamide 2mg 2# PRNQ8H (if diarrhea >= 4 times)
      • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC (if vomit)
  • 2023-04-25 SOAP Oral and Maxillofacial Surgery
    • S: The patient has been missing for 4 months
      • Body: Apart from oral cancer, there are no other systemic diseases,
      • Mind: The patient is not anxious
      • Spirit: No specific beliefs
      • Social: Family’s financial situation is poor (rent is about 30,000, high stress), very thin
    • A: SCC of right tongue (cT3N2bM0) with local inflammation (now progressed to T4bN3bMx)
  • 2022-12-22 ~ 2022-12-26 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • After admission, we had arranged physcial examination which his ANC showed 3630/mm2.
      • Then we had arranged induction chemotherapy with #3b TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) were delivered on 2022/12/22 - 2022/12/24.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. No obvious of discomfort were noted excepted mild mucositis of right buccal mucosa were noted.
  • 2022-12-15 ~ 2022-12-19 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • After admission, we had arranged physcial examination for him which ANC showed 2901/mm2.
      • Then we had arrange induction chemotherapy with #3a TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) were delivered on 2022/12/15 - 2022/12/17.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. Intraoral wound change dressing qd. Mouth care and cool soft diet were educated.
    • Prescription
      • Smecta (dioctahedral smectite 3mg) 1# PRNBID (if watery diarrhea > 3 times)
      • Acetal (acetaminophen 500mg) 1# Q8H (if pain)
      • amoxicillin 250mg 2# Q8H
  • 2022-11-28 ~ 2022-12-03 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • After admission, we had arranged physcial examination for him which ANC showed 3351/mm2.
      • Then we had arrange induction chemotherapy with #2b TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) on 2022/11/28 - 2022/11/30.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. Radi-K 2 tab PO TID for prevent hypokalemia. Zinga 1 tab  PO  QD for zinc supplement. Folina 15mg 1 tab PO QD for hematogenesis. B-Red 1 mg IVD  QD for hematogenesis. Intraoral wound change dressing qd. Ice packing of face, mouth care and cool soft diet were educated.
  • 2022-11-21 ~ 2022-11-25 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • After admission, we had arranged physcial examination for him which ANC showed 3769/mm2. Empirical antibiotic agents with Cefa 1g Q8H IV was prescribed. Then we had arrange induction chemotherapy with #2a TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) on 2022/11/21 - 2022/11/23.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. Intraoral wound change dressing qd. Ice packing of face, mouth care and cool soft diet were educated.
    • Prescription
      • Strocain (oxethazaine, polymigel 5mg) 1# TIDAC
      • Zinga (zinc gluconate 78mg) 1# QD
      • Folina (folinate 15mg) 1# QD
      • Eurodin (estazolam 2mg) 1# PRNHS
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
  • 2022-11-07 ~ 2022-11-12 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • After admission, we had arranged physcial examination for him which ANC showed 7918 /mm2. Empirical antibiotic agents with Cefa 1g Q8H IV was prescribed.
      • Then we had arrange induction chemotherapy with #1b TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) on 2022/11/07 - 2022/11/09.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer.
      • Additional, hopeless tooth with local inflammation were noted, We had arranged extraction of 14 15 and curettage of the extraction socket under local anesthesia on 2022/11/11. Intraoral wound change dressing qd. Ice packing of face, mouth care and cool soft diet were educated.
    • Prescription
      • Acetal (acetaminophen 500mg) 1# Q6H
      • Eurodin (estazolam 2mg) 1# HS
      • amoxicillin 250mg 2# Q8H
      • Megest (megestrol 40mg/mL) 10mL BID
  • 2022-10-24 ~ 2022-11-02 POMR Oral and Maxillofacial Surgery
    • Discharge diagnosis
      • Squamous cell carcinoma of right tongue cT4aN2bM0 stage IV in process chemotherapy
      • Malignant neoplasm of border of tongue
      • INFECTION OF TONGUE AND FLOOR OF MOUTH
      • Encounter for antineoplastic chemotherapy
      • HOPELESS CARIES OF MANY TEETH
    • CC
      • HE WAS ADMITTED BECAUSE HE HAD an ulcerative MALIGNANT mass at HIS right tongue for more than 6 weeks    
    • Illness
      • The local finding showed a BIG ulcerative malignant tumor WITH INDURATION AND LOCAL INFECTION at his right tongue border AND VENTRAL SURFACE with muscle invasion, about 5.0 cm in size. BESIDES, several palpate lymph nodes at the right neck are detected. After we had adequately explained the finding and treatment plans to the patient and his WIFE, he recided to accept our treatment plans for him. His treatment plans were induction chemotherapy follow by surgery and CCRT. Under the impression of squamous cell carcinoma of right tongue cT4aN2bM0 stage IV, he was admitted to ward for tumor work up and prepare induction chemotherapy.
    • Inpatient Treatment Process
      • The induction chemotherapy with TPF (Taxotere 40mg/M2, cisplatin 40mg/M2, 5-FU 1000mg/M2) were delivered on 10/28~10/30/2022. He did’t had nausea and vomiting after chemotherapy. Intraoral wound change dressing qd. Mouth care with Parmason solution q3h.
    • Prescription
      • Acetal (acetaminophen 500mg) 1# Q6H
      • Eurodin (estazolam 2mg) 1# HS
      • loperamide 2mg 1# ASORDER (if diarrhea > 4 times)
      • Promeran (metoclopramide 3.84mg) PRNTIDAC (if N/V)
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
  • 2022-10-21 SOAP Oral and Maxillofacial Surgery
    • S
      • He came to our OS OPD for help because is a tongue cancer patient who had been proved in ShuangHe Hospital ENT.
    • O
      • An ulcerative SCC with local inflammation at the right tongue border with muscle invasion, about 4.0 cm in size, is noted. several palpate lymph nodes at the right neck are detected. many hopeless caries are noted. edntulous ridge of mandible was noted. gingivitis and gingival recession of residual teeth are noted. no crown, no bridges and no wisdom teeth are noted.
    • A
      • SCC of right tongue (cT3N2bM0) with local inflammation
    • P
      • Panoramic film showed no bone destruction by tumor. periodontal bone loss is noted.
      • explain the finding and treatment plan to the patient.
      • debridement and cruettage at the right tongue border to remove food debris and necrotic tissue.
      • amoxilline + scanol to control pain and infection.
      • arragne admission for further treatment

[chemotherapy]

  • 2023-05-03 - docetaxel 32mg/m2 50mg NS 100mL 1hr + cisplatin 32mg/m2 NS 150mL 3hr + fluorouracil 800mg/m2 1200mg leucovorin 80mg/m2 120mg NS 1000mL 22hr D2 + methotrexate 24mg/m2 35mg NS 100mL 30min D4
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2022-12-22 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-15 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-11-28 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-11-21 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-11-07 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-10-28 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg

[assessment]

  • The patient’s weight dropped dramatically from 57kg on 2023-04-25 to 48kg on 2023-05-03, a loss of 9 kilograms in just 8 days. This significant weight loss could be due to a data entry error or rounding inconsistencies, as the patient had a lapse in follow-up between late December 2022 and late April 2023.
  • Even as early as November 2022, there was a need to enhance the patient’s appetite (megestrol was prescribed at discharge on 2022-11-12). As of the most recent chemotherapy session on 2023-05-03, the same regimen was used but the dose was reduced to 80% of the original. It seems unlikely that the recent chemotherapy is the sole culprit for the patient’s severe weight loss.
  • If the patient is still able to consume food orally, it would be advisable to reintroduce megestrol to help stimulate his appetite. This may potentially help to counteract the significant weight loss he has been experiencing.

701470089

230509

[lab data]

  • 2023-03-03 Anti-HBc Reactive
  • 2023-03-03 Anti-HBc-Value 6.75 S/CO
  • 2023-03-03 Anti-HBs 68.82 mIU/mL
  • 2023-03-03 HBsAg Nonreactive
  • 2023-03-03 HBsAg (Value) 0.39 S/CO
  • 2023-03-03 Anti-HCV Nonreactive
  • 2023-03-03 Anti-HCV Value 0.09 S/CO
  • 2023-02-16 MTBC PCR NOT DETECTED CFU/ml
  • 2023-02-16 MTBC PCR Value <11.8 CFU/ml

[exam findings]

  • 2023-04-29 MRI - L-spine
    • Indication: Squamous cell carcinoma of upper to lower third esophagus with bilateral lung and bone metastasis, cT3N3M1, stage IVB. This time, lower back pain for 1 week
    • Thoraco-lumbar spine MRI without and with IV Gd-DTPA administration shows:
      • Abnormal thick nerve roots and the filum terminale.
      • After IV contrast administration shows well nodular like enhancement along those nerve roots.
      • A small right SI joint lesion, nature?
      • Bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression at L4/5/S1.
    • IMP: Highly suspected lumbar nerve roots, arachnoid tumor seeding/metastasis. No obvious lumbar spine bone destructing lesion. A small right SI joint lesion, metastasis?
  • 2023-04-27 ECG
    • Decreased disc height at L5/S1 is found.
    • Phlebolith at pelvic cavity is also found.
  • 2023-03-27 CXR
    • Fibrosis of right and left upper lung are suspected.
  • 2023-03-06 Pure Tone Audiometry
    • PTA:
    • Reliability FAIR
    • Average RE 14 dB HL, LE 15 dB HL
    • bil WNL
  • 2023-02-13 CXR
    • widening of Lt paratracheal stripe due to space taking lesion or paratracheal lymph node enlargement
  • 2023-02-11 MRI - brain
    • No evidence of intracranial lesion.
  • 2023-02-10 Patho - esophageal biopsy
    • Ulcerative lesion, 19-33 cm below the incisors, biopsy — Squamous cell carcinoma
    • Microscopically, the sections show a picture of squamous cell carcinoma, poorly differentiated characterized by solid tumor nests show enlarged, hyperchromatic and pleomorphic nuclei infiltrating in the stroma without keratin formation and ulcer with necrotic debris.
    • Immunohistochemistry of CK(+), P63(+) and P16(-) for tumor
  • 2023-02-10 SONO - abdomen
    • Suspected liver hemangioma, three
    • Renal stones, both kidney
    • Renal cyst, right kidney
  • 2023-02-10 Miniprobe Endoscopic Ultrasound
    • Highly suspected esophageal cancer, s/p biopsy*6
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
  • 2023-02-09 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a faint hot spot in the posterior aspect of right rib cage and increased activity in some middle T-spines, right 9th costovertebral junction, right S-I joint and greater trochanter of right femur in whole body survey.
    • IMPRESSION:
      • Increased activity in some middle T-spines, right 9th costovertebral junction and right S-I joint. Bone metastases should be watched out. Please correlate with other imaging modalities for further evaluation.
      • A faint hot spot in the posterior aspect of right rib cage and mildly increased activity in the greater trochanter of right femur. The nature is to be determined (post-traumatic change? bone metastases?). Please follow up bone scan for further evaluation.
  • 2023-02-08 PET scan
    • Glucose-hypermetabolism in the upper to middle esophagus, compatible with the primary esophageal cancer.
    • Glucose-hypermetabolism in bilateral SCF lymph nodes and bilateral pulmonary hilar and mediastinal lymph nodes, highly suspected cancer with regional lymph nodes metastases.
    • Glucose-hypermetabolism in the left axillary lymph nodes, probably reactive nodes.
    • Glucose-hypermetabolism in bilateral lungs and skeleton including T5, T6 spines, right 9th costovertebral junction, and right iliac bone, highly suspected cancer with distant metastases.
    • Esophageal cancer with regional lymph nodes, bilateral lungs and multiple bones metastases, cTxN3M1, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-02-08 Nasopharyngoscopy
    • Findings:
      • smooth NPx, OPx, HPx, mild saliva pooling at Hpx, left vocal palsy at paramedian position, congested
    • Diagnosis/conclusion
      • L vocal palsy, related to esophageal ca
  • 2023-02-07 Bronchoscopy
    • Abnormal Tracheal mucosa infiltration due to esophageal cancer invades
  • 2023-02-04 CT - chest
    • Indication: esophageal cancer
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 2.5 mm lung window, 5 mm soft-tissue window slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Diffuse ground glass patches at both lungs is found.
        • Diffuse wall thickening at upper third esophagus is found about 8.5cm*1.2 in length and width.
        • Enlaged lymph nodes (n>8) are found around the main mass.
        • No evidence of bilateral pleural effusion.
        • Multiple round solid nodules (each about 0.6cm) scattered in both lungs, favor lung metastases.
      • Visible abdomen:
        • Bilateral renal stones are found.
        • The spleen, pancreas and adrenals are intact.
        • Low density lesion at liver surface measuring 1.7cm is found. Hemangioma is favored.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
      • Suggest clinical correlation
    • IMP:
      • Long segmental wall thickening at upper third esophagus, with bilateral lung nodules. Esophageal cancer with bilateral lung metastases is considered.
      • Diffuse ground glass pacthes at both lungs. Previous repeated inflammation is considered.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M1(M_value) STAGE:IV__(Stage_value)

[consultation]

  • 2023-05-02 Radiation Oncology
    • Q
      • Progression lower back pain for 1 week. Fall developed on 2023/04/24. Lspine MRI on 2023/04/29 showed highly suspected lumbar nerve roots, arachnoid tumor seeding/metastasis. No obvious lumbar spine bone destructing lesion. A small right SI joint lesion, metastasis? Now, for evaluate palliative radiotherapy to L spine. Thank you.
    • A
      • This 52-year-old man patient is a case of Squamous cell carcinoma of upper to lower third esophagus with bilateral lung and bone metastasis, cT3N3M1, s/p CCRT.
      • Progression lower back pain for 1 week. Fall developed on 2023/04/24. Lspine MRI on 2023/04/29 showed highly suspected lumbar nerve roots, arachnoid tumor seeding/metastasis.
      • Palliative RT is indicated. CT-simulation will be arranged on 2023-05-10. Plan to deliver 30 Gy/ 10 fx to the L-spine and partial S-I joint (at least the Rt side metastatic lesion shown on PET). RT will start around 2023-05-11. Thank you very much.
  • 2023-02-11 Hemato-Oncology
    • A
      • This 52 year old man is a case of esophagus squamous cell carcinoma with lung metastasis, cT3N3M1, stage IV (initial presentation was hoarseness for 3 months and dysphagia with body weight loss). He had been admitted to HsinChu Cathay Hospital on 2023/01/30, where Panendoscope on 2023/01/31 showed esophageal tumor with stricture, biopsy show squamous cell carcinoma, moderate to poorly differentiated. We are consulted for further evaluation.
      • Systemic therapy is indicated for metastasis esophagus SCC. Palliative CCRT followed by systemic chemotherapy may consider in this case. Please arrange our OPD after discharge. Thanks for your consultation.
  • 2023-02-10 Radiation Oncology
    • A
      • This 52-year-old man, a heavy smoker and alcoholism denied any systemic disease. He has suffered from hoarseness since 3 months ago. Dysphagia even liquid diet for 2 weeks, associated with weight loss 4 kg in a month. Endoscopic biopsy was done, and pathology reported squamous cell carcinoma, moderate to poorly differentiated. Chest CT on 2023-02-04 showed long segmental wall thickening at upper third esophagus, with bilateral lung nodules. Esophageal cancer with bilateral lung metastases is considered. Stage cT3N3M1. Whole body PET and bone scan showed highly suspected spine and lung mets.
      • He can’t swallow the saliva. Palliative CCRT is indicated. CT-simulation will be arranged on 2023/02/16. Plan to deliver 45 Gy/ 25 fx to the esphagus and bil. SCF. Then boost the esophageal tumor and LAPs to 54 Gy/ 30 fx. If the dose distribution is feasible, spine mets can be included in the RT field. RT will start around 2023/02/20 or 21.

[MedRec]

  • 2023-03-02 SOAP Hemato-Oncology
    • A
      • C15.9 Malignant neoplasm of esophagus, unspecified
    • P
      • Admission for systemic chetmoehrapy when admission, 24 hours CCr and audiometry
      • Plan: palliative radiohterapy with systemic chemotherapy followed by paliative C/T with PF
  • 2023-02-24 SOAP Radiation Oncology
    • P: Plan to deliver 45 Gy/ 25 fx to the esphagus and bil. SCF and T-spine mets. Then boost the esophageal tumor and LAPs to 54 Gy/ 30 fx.

[radiotherapy]

[chemotherapy]

  • 2023-05-09 - cisplatin 75mg/m2 110mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF, CCRT)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3
  • 2023-03-30 - cisplatin 75mg/m2 125mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF, CCRT)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3
  • 2023-03-07 - cisplatin 75mg/m2 125mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF, CCRT)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3

2023-05-09

[tube feeding]

Nexium (esomeprazole) should not be crushed. Instead, it should be dissolved in sufficient drinking water before tube feeding.

2023-04-28

[tube feeding]

  • All of the oral medications prescribed can be administered via a feeding tube.

2023-03-27

[tube feeding]

  • All of the oral medications in the patient’s active prescription are able to be administered through a feeding tube.

700070514

230508

[diagnosis] - 2023-05-07 admission note

  • K-RAS mutation Adenocarcinoma of the sigmoid colon near complete obstruction invasion to bladder with fistula formation, and carcinomatosis and liver metastases, cT4bN2bM1c, stage IVc status post T-loop colostomy on 2022/10/26
  • Iron deficiency anemia, unspecified

[present illness]

  • This 57-year-old male has past history of major depressive disorder comorbid with alcohol dependence under medication treatment at our PSY OPD.

[past history] - 2023-05-07 admission note

  • Systemic disease:
    • Major depressive disorder comorbid with alcohol dependence under medication treatment at our PSY OPD.
  • Surgery:
    • Left femoral fracture s/p THR

[family history]

  • Father has diabetes
  • No cancer history in his family

[lab data]

  • 2022-10-01 HBsAg Nonreactive
  • 2022-10-01 HBsAg (Value) 0.37 S/CO
  • 2022-10-01 Anti-HBc Reactive
  • 2022-10-01 Anti-HBc-Value 5.99 S/CO
  • 2022-10-01 Anti-HCV Nonreactive
  • 2022-10-01 Anti-HCV Value 0.15 S/CO

[exam findings]

  • 2023-05-02, -04-24, -04-22, -03-19 CXR
    • There are multiple nodular opacity projecting in both lung that are c/w lung metastases after correlate with CT.
  • 2023-03-07 CT - abdomen
    • History and indication: Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected and urinary bladder fidtula, cT4bN2bM1c, stage IV
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Mild regression of S-colon cancer and peritoneal invasion but progression of LN/ lung/ liver and left sacral metastases.
      • Left hydronephrosis.
      • S/P left THR.
      • Minimal ascites.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Mild regression of S-colon cancer and peritoneal invasion but progression of LNs/ lung/ liver and left sacral metastases.
      • Left hydronephrosis.
  • 2023-02-03 Tc-99m MDP bone scan
    • Increased activity in the sacrum. Please correlate with other imaging modalities for further evaluation and to rule out the possibility of bone metastasis.
    • Mildly increased activity in the lower C-spine, some middle and lower T-spines. Degenerative change may show this picture. However, please keep follow-up to rule out other possibilities.
    • Some hot and faint hot spot in bilateral rib cages and increased activity in the right clavicle and right ischium. The nature is to be determined (bone metastases? post-traumatic change? ). Please correlate with other clinical findings for further evaluation.
  • 2023-02-01 Long Bones series
    • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
    • S/P total hip arthroplasty, left hip
  • 2022-12-02 CT - abdomen
    • History
      • 20221202 CC: Started to have a fever this morning, vomiting, general weakness, abdominal pain, blood pressure in the right hand 79/52mmhg
      • 20220921 CC: diarrhea for 1/2 yrs. bw loss 14 kg. CEA 33.86; anemia (initial 8.2); favor IDA (iron deficiency anemia)
      • 20220921 sigmoidoscopy: Suspected colon ca, R-S juncton s/p biopsy
      • 20220923 CT: R-S juncton cancer, cT4b(UB)N2bM1c, cSTAGE:IVC
    • Indication: sepsis
    • Findings: Comparison: prior CT dated 2022/09/23.
      • Prior CT identified long segmental sigmoid colon cancer is noted again, stable in size.
        • S/P colostomy at right transverse colon.
        • There is no gas in the urinary bladder.
        • Prior CT identified Multiple Metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space are noted again, mild increasing in size and number that are c/w progressive disease.
        • In addition, There is mild hydroureteronephrosis and delayed contrast excretion of left kidney and the etiology is due to metastatic node in left common iliac chain with passive compression left side ureter.
      • There are newly-developed multiple poor enhancing masses on both hepatic lobes that are c/w liver metastases with progressive disease.
        • The largest one measuring 5.9 cm in S6/7.
      • Prior CT identified smuddgy appearance of the omentum is noted again, stationary. Follow up is indicated.
      • There are multiple newly-developed soft tissue nodules on both lung that are c/w lung metastases.
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & right kidney.
      • There is no evidence of ascites.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
    • Impression:
      • Multiple liver and lung metastases c/w progressive disease.
      • Multiple Metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space show progressive disease.
  • 2022-10-31 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (101 - 35) / 101 = 65.35%
      • M-mode (Teichholz) 65
    • Adequate LV systolic function with normal resting wall motion
    • Septal hypertrophy
    • Mild MR, trivial TR
    • Preserved RV systolic function
  • 2022-10-31 CXR
    • Pneumoperitoneum (note: Pneumoperitoneum is the presence of air or gas in the abdominal (peritoneal) cavity. It is usually detected on x-ray, but small amounts of free peritoneal air may be missed and are often detected on computerized tomography (CT).)
    • A nodule at RLL.
  • 2022-10-25 Barium Enema with water soluble contrast medium
    • Findings
      • Obstruction at sigmoid colon.
      • A defect at between sigmoid colon and urinary bladder. Prominent air the the urinary bladder.
    • Impression
      • Obstruction at sigmoid colon
      • c/w sigmoid colon-vesical fistula (may be dominate at proximal end)
  • 2022-10-05 Whole body PET scan
    • Glucose-hypermetabolic lesions in the lower abdomen, pelvis, and in a left para-arotic lymph node, highly suspected S-colon cancer with carcimatosis.
    • A glucose hypermetabolic lesion in the right lobe of the liver, highly suspected colon cancer with liver metastasis.
    • Increased uptake of FDG at the left hip joint, probably benign in nature.
    • S-colon cancer with carcimatosis and liver metastases, cTxN2bM1c, stage IVC (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2022-10-03 All-RAS + BRAF mutations assay
    • All-RAS mutations assay
      • Detection range
        • KRAS codon 12, 13, 59, 61, 117, 146
        • NRAS codon 12, 13, 59, 61, 117, 146
      • Results
        • Detected (KRAS condon 61 CAA>CTA, p.Q61L)
      • Interpretation
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF mutations assay
      • Detection range
        • BRAF codon 600
      • Results
        • There was no variant detected in the BRAF gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with BRAF mutation maynot benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • 2022-09-30 ECG
    • Sinus rhythm with short PR
    • Nonspecific ST abnormality
    • Abnormal ECG
  • 2022-09-23 CT - abdomen
    • Findings:
      • There is a long segmental lobulated wall thickening with irregular contour at the sigmoid colon, measuring 10 x 5.3 cm in size, causing lumen narrowing and proximal colon dilatation that is c/w adenocarcinoma of the sigmoid colon with near complete obstruction.
        • In addition, there is fistula formation between the sigmoid colon mass and the urinary bladder, causing air-fluid level in the urinary bladder that is c/w tumor invasion (T4b).
        • In addition, There are multiple enlarged nodes in the sigmoid mesocolon and perirectal space, the largest one measuring 4 cm, that are c/w metastatic nodes (N2b).
      • There is a poor enhancing mass measuring 0.9 cm in S6 of the liver. Liver metastasis is highly suspected (M1a). Please correlate with sonography or MRI.
        • The omentum shows smuddgy appearance that may be tumor seeding (M1C).
      • There is no focal lesion in both lung and mediastinum.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b (T_value) N:N2b (N_value) M:M1c (M_value) STAGE:IVC(Stage_value)
  • 2022-09-22 Patho - colon biopsy
    • Colon, R-S junction, biopsy — Adenocarcinoma, moderately differentiated
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2022-09-21 Colonoscopy
    • Diagnosis
      • Highly suspected colon cancer, R-S junction, s/p biopsy
      • Mixed hemorrhoid
      • Incomplete colonoscopy due to tumor stricture
    • Suggestion
      • F/U pathology report
      • Further image for cancer staging may be indicated.
    • Complication
      • No immediate complication
  • 2022-08-30 Patho - stomach biopsy
    • Esophagus, EC junction, biopsy — Barrett’s esophagus
    • Microscopically, it shows chronic inflammation with lymphoplasmacytic infiltrate and intestinal metaplasia with goblet cells present.
  • 2022-08-29 SONO - abdomen
    • suspected liver parenchymal disease.
  • 2022-08-29 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Hiatus hernia
      • Suspect Barrett’s esophagus, s/p biopsy, C1M3
      • Superficial gastritis
      • Gastric polyp, high body, GC/PW site
    • Suggestion
      • Pursue biopsy result
  • 2022-08-25 ECG
    • Sinus tachycardia
    • Nonspecific ST abnormality
    • Abnormal ECG

[consultation]

  • 2022-12-07 Colorectal Surgery
    • A: Diver-T-loop colostomy was done, please control underline disease
  • 2022-11-22 Radiation Oncolgoy
    • A
      • The 57 y/o man has adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC. s/p T-colonostomy. Palliative C/T has been started on 2022/11/21.
      • Palliative CCRT is indicated. CT-simulation will be arranged on 11/28. Plan to deliver 45 Gy/ 25 fx to the S-colon tumor and adjacent carcinomatoses. r/o IVC thromboemboli shown on abd. CT (2022/09/23) with PVT? I will consult radiologist Dr. Yu later. Thank you very much.
      • no PVT. just r/o IVC thromboemboli.
  • 2022-10-06 Colorectal Surgery
    • Q
      • Under the impression of Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC, pending RAS report. He was admitted for further management. Port-A insertion on 2022/10/04 and PET was arrange on 2022/10/05.
      • we had explained the current condition to patient and family,they agreed to do the T-loop colostomy. We need your expertise for further management, thanks
    • A
      • This is a 57-year old man with the impression of Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC,
      • protective T-loop colostomy will be considered
      • we will arrange operation for him
  • 2022-10-05 Radiation Oncology
    • Q
      • This 57-year-old male has past history of major depressive disorder comorbid with alcohol dependence under medication treatment at our PSY OPD.
      • He had suffered from watery diarrhea with body weight loss 17kg in half year. The condition is worse than before within this year. EGD on 2022/08/29 showed Reflux esophagitis LA Classification grade A. Hiatus hernia. Suspect Barrett’s esophagus, s/p biopsy, Superficial gastritis. Gastric polyp, high body, GC/PW site. Biopsy proved Barrett’s esophagus.
      • He came to our GI OPD and colonscopy was performed on 2022/09/21 which showed Highly suspected colon cancer, R-S junction, s/p biopsy. Mixed hemorrhoid. Biopsy proved Adenocarcinoma, moderately differentiated.
      • CT of abdomen was performed on 2022/09/25 revealed There is a long segmental lobulated wall thickening with irregular contour at the sigmoid colon, measuring 10 x 5.3 cm in size, causing lumen narrowing and proximal colon dilatation that is c/w adenocarcinoma of the sigmoid colon with near complete obstruction. In addition, there is fistula formation between the sigmoid colon mass and the urinary bladder, causing air-fluid level in the urinary bladder that is c/w tumor invasion (T4b). In addition, There are multiple enlarged nodes in the sigmoid mesocolon and perirectal space, the largest one measuring 4 cm, that are c/w metastatic nodes (N2b). There is a poor enhancing mass measuring 0.9 cm in S6 of the liver. Liver metastasis is highly suspected (M1a). The omentum shows smuddgy appearance that may be tumor seeding (M1C).
      • Under the impression of Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC, pending RAS report. He was admitted for further management. Port-A insertion on 2022-10-04. We need your expertise for radiotherapy evalaution, thanks
    • A
      • He was persuaded to have colostomy first.
      • CCRT will be arranged thereafter.
  • 2022-08-26 Psychosomatic Medicine
    • A
      • MSE: thin and cachexia, impaired attention focus and sustain, low mood, poor energy, psychomotor retardation, suicidal ideation, alcohol drinking all day long.
      • PE: mild upper limb tremor, yellowish skin, icteria scerdela
      • IMP:
        • Major depressive disorder, recurrent, severe
        • Suspected alcohol induced mood disorder
        • Alcohol use disorder, in withdrawal status.
      • Suggestion:
        • Correct electrolytes, treat physical condition
        • Saline hydration with B-complex 1 amp QD, with kentamin supply for B12 defiency.
        • Add dosage of our medications: keep zoloft 50mg 1# QN, add utapine to 25mg 2# HS, Eurodin 1# HS, and add anxiedin to 2# Q12H
        • Arrange psy OPD f/u.

[MedRec]

  • 2023-03-19 ~ 2023-03-24 POMR Hemato-Oncology
    • Inpatient Treatment Process
      • After admission, C6 Avastin plus C2D1 FOLFIRI was administered on 2023/03/21-23.
      • Dizziness and headache was noted during chemotherapy and adequate hydration was done.
      • With the relatively stable condition, he was discharged on 2023/03/24 and will OPD follow up later.
  • 2022-11-29 SOAP Hemato-Oncology
    • A/P: Bevacizumab 5 mg/kg iv q2wks for 36 wks (18 wks each apply) colostomy in late Oct. 2022
  • 2022-09-30 SOAP Hemato-Oncology
    • A/P: Discussed the suggestion of a protective T-loop colostomy with the patient and his wife (which could also help reduce the risk of urinary tract infections). The patient indicated that he is currently able to have bowel movements and would like to try chemotherapy and radiation first.

[surgical operation]

  • 2022-10-26 T loop colostomy        
    • adenocarcinoma of Sigmoid colon with invasion to bladder and fistula formation    
    • short T-colon with adhesion to liver and middle colic mesentery region 

[radiotherapy]

  • 2022-11-29 ~ 2023-01-10 - completed RT to the pelvisthe S-colon tumor, partial bladder, and adjacent carcinomatoses: 45 Gy/ 25 fx.

[chemoimmunotherapy]

  • 2023-04-06 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 2800mg/m2 2150mg NS 500mL 46hr (FOLFIRI, 5FU infusion 50% off)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
  • 2023-03-21 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 2150mg NS 500mL 46hr (FOLFIRI, 5FU infusion 50% off due to encephalopathy during last time)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
  • 2023-03-01 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
  • 2023-02-13 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
  • 2023-01-27 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4250mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
  • 2023-01-09 - bevacizumab 5mg/kg 245mg NS 100mL 90min + oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-26 - bevacizumab 5mg/kg 255mg NS 100mL 90min + oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-13 - oxaliplatin 85mg/m2 133mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-11-21 - oxaliplatin 85mg/m2 133mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-05-08

  • From 2022-11-21 to 2023-01-09, the patient was treated with Avastin plus FOLFOX for his K-RAS-mutated sigmoid colon adenocarcinoma. However, a CT scan on 2022-12-02 showed progressive disease with multiple liver and lung metastases, as well as metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space. As a result, the regimen was changed to Avastin plus FOLFIRI on 2023-01-27. Due to dizziness and headache experienced during chemotherapy on 2023-03-01, the fluorouracil dose was reduced by half starting on 2023-03-21.

  • After the new regimen was applied, the tumor marker CEA has remained relatively unchanged; however, the readings are approximately twice as high as they were before.

    • 2023-04-21 CEA (nuclear medicine) 1376.700 ng/ml
    • 2023-04-03 CEA (nuclear medicine) 1203.450 ng/ml
    • 2023-03-17 CEA (nuclear medicine) 1261.1 ng/ml
    • 2023-02-24 CEA (nuclear medicine) 1322 ng/ml
    • 2023-02-14 CEA (nuclear medicine) 1371.12 ng/ml
    • 2023-01-27 CEA (nuclear medicine) 667.3 ng/ml
    • 2023-01-09 CEA (nuclear medicine) 627.64 ng/ml
    • 2022-12-29 CEA (nuclear medicine) 907.05 ng/ml
    • 2022-11-29 CEA (nuclear medicine) 382.654 ng/ml
    • 2022-10-07 CEA (nuclear medicine) 52.567 ng/ml
  • The Covid-19 fast screen was positive on 2023-04-24, but the patient has since recovered. Vital signs are currently stable. CT and CXR revealed lung mets with multiple nodular opacities in both lungs, which do not significantly impair the patient’s respiratory function yet.

  • The underlying conditions are currently being managed with appropriate medications: anemia is treated with Foliromin (ferrous sodium citrate), toe numbness is treated with Kentamin (B1, B6, B12), right upper quadrant abdominal and rib area pain is treated with Tramacet (tramadol, acetaminophen) and Neurontin (gabapentin), respiratory symptoms are treated with Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), oral candidiasis is treated with Mycostatin (nystatin), and intermittent diarrhea is managed with loperamide and Smecta (dioctahedral smectite) as needed (PRN).

2023-01-10

[drug interaction]

  • The ability of oral iron preparations to reduce the absorption of oral quinolones is well established and has been demonstrated in numerous pharmacokinetic studies. Various oral iron preparations have been reported to reduce quinolone AUCs by the following percentages: ciprofloxacin (33% to 70%), levofloxacin (19%), lomefloxacin (14%), moxifloxacin (61%), norfloxacin (51% to 73%), ofloxacin (25%), and sparfloxacin (28%). The maximum serum concentrations of oral quinolones were reduced by the following percentages: ciprofloxacin (46% to 75%), levofloxacin (45%), lomefloxacin (28%), moxifloxacin (41%), norfloxacin (75% to 82%), ofloxacin (36%), and sparfloxacin (46%). It is recommended to administer oral quinolones at least several hours before (4 h for moxifloxacin and sparfloxacin, 2 h for others) or after (8 h for moxifloxacin, 6 h for ciprofloxacin and delafloxacin, 4 h for lomefloxacin, 3 h for gemifloxacin, 2 h for enoxacin, levofloxacin, norfloxacin, ofloxacin, pefloxacin, or nalidixic acid) oral iron preparations.

  • Due to the fact that Cravit (levofloxacin) and Foliromin (ferrous sodium citrate) were prescribed as QDAC and BID, respectively. To maintain Cravit’s effectiveness, Foliromin might be moved to QL and QN.

  • Please monitor for diminished effects of the quinolone if dose separation cannot be achieved.

2023-01-09

  • Oxaliplatin is associated with high incidence of peripheral neuropathy (76%, grades 3/4: 7%; acute: 65%, grades 3/4: 5%; delayed (persistent): 43%, grades 3/4: 3%) Ref: UpToDate
  • The acute neurotoxicity that is seen frequently in the 72 to 96 hours after each infusion of oxaliplatin is often linked to cold exposure (drinking cold liquids, inhaling cold air, placing hands in the freezer). Avoidance of cold during this time frame should mitigate this toxicity to some extent, but not all symptoms (eg, perioral numbness, hand cramping) are related to cold. As of now, no evidence of peripheral neuropathy has been recorded.
  • The patient vomited several times throughout the week as documented in the record of 2023-01-06. A prescription for metoclopramide has been issued.

2022-12-26

  • The patient is receiving bevacizumab for the first time during this hospital stay. The patient was recently diagnosed with gastro-esophageal reflux disease (2022-11-17), however, no CVD related records have been kept for the past three months. As bevacizumab is associated with concerns regarding gastrointestinal perforation/fistula, heart failure, and hemorrhage. There may be a need for regular monitoring.

2022-12-05

  • The patient’s body temperature fluctuated between 36.2 and 38.2, with two peaks at around 08:00 and 22:00 on a daily based cycle roughly.
  • In this instance, tapimycin (piperacillin + tazobactam) is used, which has been shown to be effective against the 2022-12-02 blood cultured Escherichia coli (MIC <= 4 mcg/mL according to the lab report).
  • There was a downward trend in renal function, especially in late November 2022, which should be noted. In the event of CrCl < 40mL/min, the dose of tapimycin should be reduced to two thirds.
    • 2022-12-02 Creatinine 0.91 mg/dL
    • 2022-11-28 Creatinine 0.96 mg/dL
    • 2022-11-21 Creatinine 0.59 mg/dL
    • 2022-11-17 Creatinine 0.58 mg/dL
    • 2022-10-31 Creatinine 0.48 mg/dL
    • 2022-10-24 Creatinine 0.43 mg/dL
    • 2022-10-17 Creatinine 0.41 mg/dL

2022-11-21

  • Glomerular hyperfiltration (eGFR 150 2011-11-21, recent peak 229 2022-10-17) was noted. Intraglomerular hypertension, resulting from the transmission of systemic pressures or via glomerular-specific processes, may be deleterious over the long term. The use of NSAIDs (celecoxib in current prescription as a patient-carried item) should be limited to the necessary duration and should not be prolonged.

2022-10-03

  • Hypoalbuminemia (2.8 g/dL 2022-09-30) <= decreased hepatic albumin synthesis <= possible liver mets? (2022-09-23 CT)
  • The use of Alglutol (acamprosate 333mg/tab) 2# TID may be considered as a means of helping the patient quit alcohol following his withdrawal symptoms.

700138669

230508

[diagnosis] - 2023-04-26 admision note

  • Hemoptysis
  • Malignant neoplasm of nasopharynx, unspecified
  • Essential (primary) hypertension
  • Hypertensive heart disease without heart failure

[past history] - 2023-04-26 admision note

  • Nasopharyngenl Carcinoma T4N3M1, stage IVB, proved at 2020/05 at Wan Fang Hospital (No biopsy) s/p radiotherapy to the C- and T- spine bone mets: 21 Gy/ 7 fx. on 2023-01-03 ~ 11, (early termination due to the patient reject) at our hospital
  • hypertension for years with Concor 5mg/tab 0.5tab QD, Bokey 100mg/cap 1cap QD, Cozaar 50mg/tab 0.5tab QD, Norvasc 5mg/tab 0.5tab QD control and the clinic follow-up.
  • hyperlipidemia for years with Lipitor 40mg/tab 1tab QD control and the clinic follow-up.
  • L3 compression fracture without surgery for years.

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-04-25 Nasopharyngoscopy
    • Findings: massive blood-coating mass over right nasopharynx, much sputum over hypopharynx
    • Conclusion: nasopharyngeal carcinoma
  • 2023-02-17, -01-13 Nasopharyngoscopy
    • Findings: rt NP tumor
    • Conclusion: NPC
  • 2022-12-28 Bone Scan
    • Hot areas at the skull base, some C-, T- and lower L-spine, NPC with bone mets shoulde be consideded, suggesting PET scan for further evaluation.
    • Suspected benign lesions in the maxilla, mandible, bilateral shoulders, and knees.
  • 2022-12-19 MRI - nasopharynx
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • Right nasopharynx tumor mass, with skull invasion, extending to right Foramen of ovale, up to 4.5 cm.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Multiple right necrotic LAPs were noted down to supraclavicular fossa.
      • Decreased right mastoid air cells pneumotization indicating chronic mastoiditis.
      • Destruction of right transverse process of T1 also was noted indicating bony metastasis.
    • IMP: Right NPC with multiple right neck LAPs and right T1 bony metastasis. T4N3M1 stage IVB (AJCC 9th edition).
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:1(M_value) STAGE:IVB (Stage_value)
  • 2022-12-02 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopahrynx, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B).
    • IHC stains: CK highlights infiltrative epithelum. EBV (-).
  • 2022-11-23 Nasopharyngoscopy
    • rt NP tumor
  • 2022-11-23 ENT Hearing Test
    • Tymp:
      • R’t type B; L’t type A.
    • ART:
      • Bil absent.
    • PTA
      • Reliability FAIR
      • Average RE 70 dB HL; LE 56 dB HL.
      • R’t moderaet to profound MHL.
      • L’t mild to severe HL. (BC masking dilemma)
      • Dialogue: R’t 65 dB HL; L’t 45 dB HL.
      • SDT: R’t 60 dB HL; L’t 40 dB HL.
  • 2021-10-26 MRI - L-spine
    • Multiple old compression fractures at T11, L2,3, poor healing at upper L3 body. A left T10/11 perineural cyst.
  • 2018-08-07 Bone densitometry - hip
    • Hip BMD performed by DXA revealed:
      • Hip, BMD is 0.674 gms/cm2, about 1.2 SD below the peak bone mass (84%) and 1.8 SD above the mean of age-matched people (131%).
    • IMP: osteopenia

[lab data]

  • 2022-12-24 EBV DNA quantative PCR <120 copies/mL
  • 2022-12-01 EB VCA IgA Borderline Ratio
  • 2022-12-01 EB VCA IgA Value 0.9 Ratio
  • 2022-12-01 EBV EA/NA IgA Negative EU/mL
  • 2022-12-01 EBV EA/NA IgA Value 2.97 EU/mL

[consultation]

  • 2023-04-25 Ear Nose Throat
    • Q
      • Chief complaint: coughing of blood with clots this morning
        • difficult swallowing, poor intake, nausea and vomiting, easy choking after eating for months
        • denied fever, respiratory symptoms, or urinary discomfort
      • Past Medical History: NPC, T4N3M1 stage IVB (2020/05)
        • currently R/T at bone metastasis areas
        • hypertension, hyperlipidemia
        • L3 compression
      • History of Operation: denied
      • Regular Medications: Aspirin
    • A
      • A case of NPC end stage, under palliative treatment
      • dysphagia recently, and family ask for NG insertion
      • scope: massive blood-coating mass over right nasopharynx, much sputum over hypopharynx
      • status post NG insertion under scope
      • sugget CXR f/u before feeding from NG tube

[MedRec]

  • 2023-04-14 SOAP Hemato-Oncology
    • Plan: referred to hospice care
  • 2023-01-13 SOAP Radiation Oncolgoy
    • She decided to quit RT.
  • 2022-12-30 SOAP Radiation Oncolgoy
    • Plan: CT-simulation will be arranged on 20230102. Plan to deliver 30 Gy/ 10 fx to the C- and T- spine and Rt shoulder bone mets. RT will start around 20230104.
  • 2022-12-23 SOAP Radiation Oncolgoy
    • Plan: arrange bone scan for palliative bone mets RT.
      • RTC: around 1 wk.
  • 2022-12-23 SOAP Hemato-Oncology
    • O
      • 2022/12/19 MRI Nasopharynx: Right NPC with multiple right neck LAPs and right T1 bony metastasis. T4N3M1 stage IVB (AJCC 9th edition).
    • Assessment:
      • NPC, T4N3M1 stage IVB
    • Plan:
      • apply for major disease
      • refer to the radiation oncologist
      • pain control
  • 2022-11-23 SOAP Hemato-Oncology
    • S
      • She was referred on account of NPC proved at 202005 at Wan Fang Hospital. (No biopsy)
      • No treatment was applied from that time. Hospice care from that time.
      • Headache for 3 weeks, bilateral ear cannal ulceration without discharge from one month ago.
      • Hearing loss progressed
    • Assessment
      • NPC, staging
      • Check MRI
    • Plan
      • Check BCS
      • Check CBC&DC, PT, aPTT, bleeding time and stool OB
      • Check CXR
      • refer to the ENT

==========

2023-05-08

  • On 2023-05-08 at 06:05, the patient’s SpO2 dropped to 69%, accompanied by an increased heart rate of 100 bpm. This indicates possible respiratory distress or compromised oxygenation, and an O2 mask is placed appropriately.

  • If the patient continues to experience hemoptysis, inhaled tranexamic acid could be considered as a potential treatment option to reduce bleeding. This antifibrinolytic agent has been shown to effectively control bleeding and may provide relief to the patient.

2023-04-27

  • Alpraline (alprazolam 0.5mg) 1# HS QD for 28 days and Bokey (aspirin 100mg) 1# QD for 28 days were prescribed at RenJi Hospital on 2023-02-28, with the 2nd refill on 2023-03-27. These medications are not currently shown in the patient’s medicine list. Please consider adding them back if they are still needed for the patient’s ongoing care. (Aspirin should be added to the patient’s medication list only after the hemoptysis has resolved.)

2023-04-26

  • Hemoptysis was noted in the patient. The solitary pulmonary nodule in the left mid-lung zone seen on chest x-ray 2023-04-25 was not seen on chest x-ray 2023-04-26. However, ground-glass opacities remain in the right lower lobe. The patient is currently being treated with Amsulber (ampicillin and sulbactam), Mycostatin (nystatin), and Hemoclot (tranexamic acid) without issues.
  • On 2023-04-26 at 10:31, the patient’s blood pressure was recorded as 177/85. If this elevated level persists, it is recommended that the dosage of Norvasc (amlodipine 5mg) be increased from 0.5 tablet once daily to 1 tablet once daily. If the blood pressure still remains high, then consider increasing Cozaar (losartan 50mg) from 0.5 tablet once daily to 1 tablet once daily as well.

701199326

230508

[exam findings]

  • 2023-05-05, -05-01, -04-24, -04-17, -04-10, -04-08, -03-28, -03-15, -03-01, -02-24 CXR
    • Osteolytic defect in left humeral head is suspected.
    • Please correlate with CT to R/O bony metastasis.
    • S/P port-A implantation.
    • Blunting of bilateral right costal-phrenic angle is noted, which may be due to pleura effusion and atelectasis?
    • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    • S/P metalic autosuture at right upper lung.
  • 2023-04-05 CXR
    • Deformity of left humeral head.
    • S/P Port-A infusion catheter insertion.
    • Ground glass opacities in bil. lungs.
    • Presence of ileus.
    • Normal appearance of trachea and bil. main bronchus.
    • Right pleural effusion.
  • 2023-04-05 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Possible Inferior infarct , age undetermined
    • Abnormal ECG
  • 2023-03-10 SONO - joint soft tissue
    • Finding:
      • Bulging of the left ACJ.
      • Heterogeneous hypoechoic appearance of the left supraspinatus tendon.
    • Impression And Suggestions:
      • Left AC distention.
      • Left supraspinatus tendinosis. Please correlate with the clinical presentations.
  • 2023-03-01 Shoulder LT
    • Osteolytic defect and deformity of left humeral head and neck is noted. Please correlate with CT to R/O bony metastasis.
  • 2023-01-04, 2022-12-15, -10-20 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion and atelectasis?
    • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    • S/P metalic autosuture at right upper lung.
  • 2022-12-17 CT - chest
    • Indication: Rectal cancer with liver and lung metastasis, stage IV status post microwave ablation on 2022/02/11 with capsule hematoma and hepatitis
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • Nodular and mass like lesions (n>5) at both lungs up to 4.09 cm in largest dimension at left lower lobe is found. Lung meta is considered. In comparison with CT dated on 2022-04-14, the lesions enlarged.
        • Miliary lesions scattered at both lungs are found. Lung meta is considered.
        • Collapsed right lower lobe with soft tissue like change attaching to right hemidiaphragm is found.
      • Visible abdomen:
        • s/p RFA at S7, S4 and S6 of liver. No evidence of recurrent/residual tumor at both lobes of liver.
        • The GB is well distended without soft tissue lesion
        • Right hydronephrosis and hydroureter is found. Distal obstruciton is considered
    • Imp:
      • Rectal cancer with bilateral lung meta and bone meta. In progression.
      • Liver meta s/p RFA. NO recurrent/residual tumor at both lobes of liver.
      • Right hydronephrosis and hydroureter, suggest double J catheter placement.
  • 2022-11-02 SONO - abdomen
    • Poor echo window due to bowel gas
    • Chronic liver parenchymal disease
    • Hepatic tumors, two C/W mets s/p MWA
    • Renal cysts, bil
    • Hydronephrosis, right kidney
  • 2022-10-20 CT - abdomen
    • History and indication: rectal ca
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Rectal cancer with liver/ lung metastases s/p operation and RFA.
      • Multiple nodules at bil. lungs.
      • Right hydronephrosis. Bil. renal cysts (up to 1.3cm).
      • A cystic lesion (4.0cm) at LUQ.
      • Collapse of gallbladder.
      • Atherosclerosis of aorta, iliac arteries.
  • 2022-09-29 Cell block cytology
    • one panc tumor was noted at neck with downstream P duct dilate, s/p FNB.
      • a case of rectal cancer with liver and lung mets
    • 15 cc pink clear fluid — Atypia
    • The smears and cell block show few epithelial clusters with mild enlarged nuclei. Please correlate with S2022-16564 for conclusive diagnosis.
  • 2022-09-29 Patho - pancreas biopsy
    • Labeled as “pancreas”, needle biopsy — benign pancreas tissue with fibrosis.
    • IHC stains: CK highlights regular acinar structures. CD56 (-).
  • 2022-08-16 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis, body
    • Duodenal ulcer scar, bulb, AW site
  • 2022-07-20 CT - abdomen
    • History: Rectal cancer with liver and lung metastasis, stage IV
      • rectal ca with liver mets at inital s/p op then two liver mets s/p RFA at VGH, then lung mets, refer for r/o liver mets
      • 20220120 CT: Several poor enhancing tumors (up to 5.4cm) in liver c/w metastases.
      • 20220211 S/P MWA for liver tumor
    • Findings:
      • There are four poor enhancing lesions measuring 3.5 cm in S8, 6.7 cm in S4/8, 8.7 cm (the largest dimension) in S7 liver and 2.4 cm in S5 liver that are c/w metastases S/P MVA.
      • Some soft tissue nodules in RUL, RLL, LUL, and LLL of the lung are noted that are c/w lung metastases.
        • In addition, There are several enlarged nodes in paratracheal space that are c/w metastatic nodes.
      • Encapsulated fluid collection in right CP angle pleura space with passive atelectasis and few linear hyperdense shadow are noted. please correlate with clinical history.
      • S/P LAR with autosuture retention over the rectum.
  • 2022-07-20 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion and atelectasis?
    • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
    • S/P metalic autosuture at right upper lung.
  • 2022-06-14 SONO - abdomen
    • Chronic liver parenchymal disease
    • Hepatic tumors, two C/W mets s/p MWA
    • Renal cysts, bil
  • 2022-06-14 Esophagogastroduodenoscopy, EGD
    • Suboptimal study due to much food residual retention at stomach
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis,body, s/p CLO test
    • Duodenal ulcer scar, bulb, AW site
    • Duodenal shallow ulcer, 2nd portion
  • 2022-04-14 CT - lung/mediastinum/pleura
    • Bilateral pulmonary metastasis with progression.
    • Consolidation over right lower lobe with right pleural effusion.
    • Heterogeneous low density lesions are found at residual right lobe liver is found. Liver hematoma is favored.
  • 2022-02-16 Abdominal Ultrasonography
    • chronic liver parenchymal disease
    • hepatic tumors, three c/w mets s/p MWA
    • ascites, mild
    • subcapsule hematoma
    • GB sludge
  • 2022-02-11 CT - liver, spleen, biliary duct, pancreas
    • Hematoma in S4-8 of the liver subcapsule is noted.
    • Hematoma or bloody ascites in subphrenic space, perisplenic space, and bilateral paracolic gutter space.
  • 2022-01-20 CT - liver, spleen, biliary duct, pancreas
    • Rectal cancer with liver/lung metastases s/p operation and RFA. Segeral poor enhancing tumors (up to 5.4cm) in liver c/w metastases.
    • Right pleural effusion with adjacent lung collapse. Some nodules at bil. basal lungs c/w metastases.
  • 2022-01-13 CT- lung/mediastinum/pleura
    • Colon cancer with liver and lung meta s/p op. and RFA at both lungs. Recurrent/residual tumor at both lungs and liver, suggest further treatment.
  • 2021-09-28 Patho - pleura/pericardial biopsy
    • Lung and pleura, right, decortication
      • empyema
      • metastatic adenocarcinoma, moderately differentiated, consistent with colonic origin
    • IHC: CK7(-), CK20(-), CDX2(focal +), and TTF-1(-). The results are consistent with metastatic colonic adenocarcinoma.
  • 2021-09-21 CT - lung/mediastinum/pleura
    • S/P right lung operation. Right pneumothorax with right lung collapse. Right pleural effusion. Some patchy densities at left lung.
  • 2021-07-27 CT - lung/mediastinum/pleura
    • bilateral pulmonary metastatic tumors, in progression compared with CT on 20210311.
  • 2021-03-29 Patho - lung wedge biopsy
    • Pathologic Diagnosis
      • Lung, left, upper lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor
      • Lung, left, lower lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor
      • Lymph node, group No.9, lymphadenectomy —- Negative for malignancy (0/1)
    • Microscopic Description
      • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobe (S2021-4686)
      • Histologic Type (select all that apply): Adenocarcinoma; The morphology is consistent with metastatic colonic tumor.
      • Histologic Grade: G2: Moderately differentiated
      • Spread Through Air Spaces (STAS): Not identified
      • Visceral Pleura Invasion: Not identified
      • Lymphovascular Invasion (select all that apply): present
      • Direct Invasion of Adjacent Structures: No adjacent structures present
      • Margins (select all that apply): All margins are uninvolved by carcinoma
      • Treatment Effect: No known presurgical therapy
      • Regional Lymph Nodes: group 9: 0/1
      • Extranodal Extension: Not identified
      • Additional Pathologic Findings: No tumor is seen in specimen A.
  • 2021-03-11 CT - chest
    • Multiple spiculated nodules, in enlargement. Compatible with lung mets.
  • 2021-03-04 CT - abdomen
    • Mild decreased size of liver metastases. Small nodules at bil. lower lungs.
    • Left hydronephrosis and hydroureter. Bil. tiny renal stones.
  • 2020-12-30 CT - abdomen
    • Two metastases in S7/8 and S7 show stable disease.
    • Two lung metastases show stable disease.
  • 2020-09-23 CT - abdomen
    • Two metastases in S7/8 and S7 show stable disease.
    • A metastasis 5 mm in LUL of the lung is suspected.
    • Left L/3 ureter stone causing hydroureteronephrosis and delayed contrast excretion of left kidney.
  • 2020-07-19 CT - chest
    • right pneumothorax
    • suspicious a nodular lesion, about 20mm, in the lower lobe of the right lung.
  • 2020-07-02 Patho - lung wedge biopsy
    • Lung, right, middle lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colorectal origin
    • Lung, right, lower lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colorectal origin
  • 2020-07-01 Patho - lung wedge biopsy
    • Lung, right, upper lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colorectal origin
    • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobes (S2020-8766 and S2020-8767)
    • IHC: MSH2(+), MSH6(+), MLH1(+), and PMS2(+).

[consultation]

  • 2023-04-18 Ear Nose Throat
    • Q
      • for tinnitus & obstruction sensation for one day
      • This 59-year-old man, a patient of colon cancer with liver & lung mets progression S/P C/T. He was admitted due to dyspnea & pneumonia for anti treatment. He complained of tinnitus & obstruction sensation for one day. We need expertise to evaluate his condition thanks!
    • A
      • S
        • Hx of COM and OME?
        • Complained of aural fullness, s/s relieved intermittently via Vasalva maneuver
      • O
        • Ear: bil intact, no sign of OME
        • NPx: smooth via scope
      • Imp: Eustachian tube dynsfuction
      • Plan:
        • May try Sindecon nasal spray 2 puff QD per NA
        • Explained th further tx of ventilation tube insertion and tuboloplasty to patient
  • 2023-04-06 Family Medicine
    • Q
      • for share care or hospice care
      • This 59-year-old man, a patient of colon cancer with liver & lung mets progression S/P C/T. He was admitted due to dyspnea & pneumonia for anti treatment. Owing to disease progression noted and we explained his poor condition to patient and DNR was consented. We need expertise to evaluate his condition thanks!
    • A
      • 59 y/o gentleman Advanced Colon cancer
      • DNR(+)
      • Our share care would follow up.
      • Would put p’t on hospice ward list if family agree.
  • 2023-03-23 Infectious Disease
    • Q
      • The 59 y/o male was Dx: (1) COVID-19 (2) Pneumonia (3) Rectal cancer with liver and lung metastasis, stage IV status post microwave ablation on 2022/02/11 with capsule hematoma and hepatitis . Allergy: Penicillin. We need your expertise for further treatment. Thank you very much
    • A
      • keep present antibiotic Rx, and adjust to culture data later
      • monitor CRP
  • 2023-02-27 Rehabilitation
    • Q
      • for left hand pain & limited of activity (unable to raise hands)
      • for nerve block or steroid treatment
      • This 60-year-old man, a patient of colon cancer with liver & lung mets S/P C/T. He was admitted due to pneumonia for anti treatment. He complained of left hand pain & limited of activity (unable to raise hands) for days. We need expertise to evaluate his condition thanks!
    • A
      • The patient complained left shoulder pain and ROM limitation for at least 1 year, rather than left hand pain or weakness.
        • Due to left shoulder pain and ROM limitation, we were consulted for further evaluation and treatment.
        • Present illness: The patient fell in 2021/11 with hitting to left shoulder. The pain and ROM limiation progressed. He had a diagnosis of left rotator cuff tear 0.5cm over left shoulder in other rehab clinic, and recieved prolo-injection with glucose, amniotic membrane (2022/09) or steriod injection, but all in vain during 2022 ~ 2023.
      • Left shoulder ROM(a/p)
        • Flex: 30’/90’
        • ABD: 30’/80’
        • Ext.: 70’/75’
        • Int: 15’/15’
      • Left shoulder sonogram at 2023/2/27 1700:
        • No tear was noted. (but we could not see all tendon part due to severe ROM limiation)
        • SS tendinitis.
      • Assessment
        • Rectal cancer with liver and lung metastasis, stage IV status post microwave ablation on 2022/02/11 with capsule hematoma and hepatitis
        • r/o left frozen shoulder
      • Plan
        • Please send patient to 5F Sono Room at 20230303 08:30 for treatment
        • Please arrange left shoulder X ray
        • Please arrange rehab OPD follow up after discharge
  • 2022-09-29 Ophthalmology
    • Q
      • this consultation is for right eye foreign body sensation management.
      • We have arranged EUS FNB for gastric submucosal lesion on 2022/09/28. After he came back from examination room, he complained right eye foreign body sensation and painful sensation. The symptom persisted after ice packing. He had no blurred vision, visual field defect. There was also no swelling nor subconjuntival hemorrhage noted. Due to above reason, we sincerely need your expertise for right eye foreign body sensation management.
    • A
      • S OD FBS since yesterday
      • O
        • FBS, tearing
        • EUS FNB under aesthesia yesterday
        • rectal cancer with liver and lung metastasis, DU, hypothyroidism and chronic hepatitis B
        • denied oph hx
        • nka
        • BCVA od 0.8x-1.75/-1.0x25 os 0.9x-1.50/-0.50x80
        • IOP 14/13mmHg
        • Pupil 3/3 +/+
        • conj np ou
        • K od peripheral ED 3*2.8mm, no infiltration os clear
        • AC D/cl ou
        • Lens ns+ ou
      • A Corneal ED od
      • P
        • Cravit 1gtt qid + duratear 1qs bid od
        • inform the risk of infection, if worsen vision, come back asap
        • the patient will follow at LMD first
  • 2022-09-24 General and Gastroenterological Surgery
    • Q
      • this consultation is for gastric submucosal lesion management.
      • This 59 y/o man is a case of rectal cancer with liver and lung metastasis, DU, hypothyroidism and chronic hepatitis B. He had sudden onset of epigastric pain on 2022/09/22 and went to Tamsui Mackey’s ER for help. PES and abdominal CT showed a huge submucosa tumor around 6.2cm at posterior wall of the body. He was suggested admission but patient refused and visited our ER for his previous medical record at our hospital.
      • Due to above reason, we sincerely need your expertise for gastric submucosal lesion management. Thanks!
    • A
      • A case of rectal ca with liver and lung meta s/p tx
      • sudden on set of upper abd pain and CT scan revealed an submucosal gastric mass that was not noted at last two months CT scan.
      • gastric submucosal tumor with bleeding may considered. I wound like to suggested EUS and aspiration cystology to proved any tumor present, Thanks and let me know if there is any tumor present.
  • 2022-02-11 Diagnostic Radiology
    • Q
      • FOR ANGIO.
      • this is a 58 y/o, a case of rectal ca with liver and lung meta. s/p RFA on 2022/02/11.
      • CTA showed HYPODENSE LESION over RUQ, r/o hematoma after RFA.
      • we need your expertise for angio.
    • A
      • According to the clinical condition and imaging findings, angiography is indicated.
  • 2021-09-21 Thoracic Surgery
    • Q
      • dyspnea.
      • chest ct in 2021/07: bilateral pulmonary metastatic tumors, in progression compared with CT on 2021/03/11.
    • A
      • The patient had metastastic lung cancer s/p RF, Rt. treatment recently.
      • Dyspnea, hemoptysis and hemopneumothorax was found today
      • Suggestion:
        • Catheter drainage
        • ICU monitoring
  • 2021-09-17 Diagnostic Radiology
    • Q
      • Purpose: for lung nodules RFA, right
      • This 58-year-old a case of Rectum cancer metastasis to liver and lung.
      • Rectum cancer with liver and lung metastases, cT3N1M1, stage IVB s/p neoadjuvant short radiotherapy s/p subsegmentectomy, ypT3N2aM1,s/p chemotherapy and RFA
      • There were no discomfort was told, included cough, sputum, chest pain, chest tightness and hemoptesis.
      • We need your help to arrange right lung nodules RFA on 2021-09-16 12:30. Thank you very much.
    • A
      • CT guided RFA for lung tumor is scheduled at 12:30 2021/09/16. Thank you for your consultation.
  • 2020-07-20 Thoracic Surgery
    • Q
      • PH: rectal cancer ; lung cancer s/p op this July
      • allergy: penicillin
    • A
      • I will take over this case. Thanks for your consultaiton!!

[surgical operation]

  • 2022-02-11 MWA, Microwave ablation

    • Procedure
      • Liver metastatic tumors, three (5.5 cm, 2.5 cm and 1.9 cm) s/p MWA x (total 11 sessions)
    • Course
      • By sono-guided, MWA probe was inserted to the 1st tumor (total 9 sessions; 100 W, 5 mins). MWA probe were inserted to the other two tumors (total 2 sessions; 70 W, 3 mins). The patient tolerated the procedure. IV anesthesia was performed during the procedure.
    • Findings
      • A 5.5 cm tumor was noted at S7 near diaphragm. A 2.5 cm mass at rt post seg near liver surface. A 1.9 cm mass at rt ant seg near liver surface.
  • 2021-09-27 VATS, decortication

    • Loculated serosanguenous pleural effusion with fibrotic debris over visceral and parietal pleura
    • Necrotic RLL parenchyma were bleeding during debridement s/p 4D field hemostatic powder treatment
  • 2021-03-29 VATS, LUL and LLL wedges resection for metastasectomy + pneumolysis

    • multiple solid nodules over LUL and LLL r/o rectal cancer metastasis
    • LUL nodules x7 and LLL nodules x3 were resected with one of the maximum about 1cm in diameter
    • no noted pleural effusion. Intrapleural cavity adhesion s/p pneumolysis
  • 2021-09-16 RFA, Radiofrequency Ablation

  • 2021-08-19 RFA, Radiofrequency Ablation

  • 2020-07-01 3D VATS RUL, RML and RLL wedge resections + LND. decortication        

    • Multiple lung nodules were noted over right lung field.
  • 2018-03-29 laparoscopic lower anterior resection w/ TaTME and S3, S8 subsegmentectomy + S5 cyst unroofing (Taipei Veterans General Hospital)

[radiotherapy]

  • 2018-002-01 ~ 2018-02-06 - neoadjuvant short radiotherapy of 25Gy/5fx for adenocarcinoma of lower rectum with liver mets, at Taipei Veterans General Hospital

[chemoimmunotherapy]

  • 2023-01-31 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 5mg/kg 300mg NS 100mL 1.5hr + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + irinotecan 175mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-01-04
  • 2022-12-15
  • 2022-11-21
  • 2022-10-31
  • 2022-09-05
  • 2022-08-16
  • 2022-07-19
  • 2022-06-30
  • 2022-06-06
  • 2022-05-03
  • 2022-04-19 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 5mg/kg 400mg NS 100mL 1.5hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 175mg/m2 320mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5200mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2021-07-14 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 5mg/kg 400mg NS 100mL 1.5hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 175mg/m2 320mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5200mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2021-06-21
  • 2021-05-27
  • 2021-05-04 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 5mg/kg 400mg NS 100mL 1.5hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 175mg/m2 320mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5200mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2021-02-17 - bevacizumab 5mg/kg 400mg NS 100mL 1.5hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 175mg/m2 330mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5400mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2021-02-02
  • 2021-01-13
  • 2021-12-30
  • 2020-12-09
  • 2020-11-25
  • 2020-11-10
  • 2020-10-27
  • 2020-10-13
  • 2020-09-29
  • 2020-09-15
  • 2020-09-01 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 175mg/m2 330mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2020-08-18 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 160mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2020-08-03 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 140mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

[note]

FOLFOXIRI chemotherapy for metastatic colorectal cancer 2023-04-25 https://www.uptodate.com/contents/image?topicKey=ONC%2F2503&imageKey=ONC%2F70559

  • Cycle length: 14 days.

  • Regimen

    • Irinotecan
      • 165 mg/m2 IV
      • Dilute with 500 mL D5W to a final concentration of 0.12 to 2.8 mg/mL and administer over 60 minutes.
      • Day 1
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute with 500 mL D5W and administer over two hours after irinotecan. Administer concurrently with leucovorin in separate bags via y-line connection. Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Levoleucovorin
      • 200 mg/m2 IV
      • Dilute with 250 mL D5W and administer over two hours, concurrent with oxaliplatin.
      • Day 1
    • Fluorouracil (FU)
      • 2400 to 3200 mg/m2 IV
      • Dilute in 500 to 1000 mL D5W and administer over 48 hours, after leucovorin. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL). The original protocol used 3200 mg/m2, but many United States oncologists use a lower starting dose (2400 mg/m2) and escalate as tolerated to reach a final dose of 3200 mg/m2.
  • Pretreatment considerations:

    • Emesis risk
      • HIGH (>90% frequency of emesis).
    • Prophylaxis for infusion reactions
      • There is no standard premedication regimen.
    • Vesicant/irritant properties
      • Oxaliplatin and fluorouracil are irritants, but oxaliplatin can cause significant tissue damage; avoid extravasation.
    • Infection prophylaxis
      • Routine primary prophylaxis with G-CSF is not warranted (estimated risk of febrile neutropenia 5%). However, given the high rate of grade 3 or 4 neutropenia (approximately 50%), primary prophylaxis may be considered for high-risk patients.
    • Dose adjustment for baseline liver or renal dysfunction
      • A lower starting dose of oxaliplatin and irinotecan may be needed for patients with severe renal insufficiency.[4,5] A lower starting dose of irinotecan and FU may be needed for patients with hepatic impairment.
    • Maneuvers to prevent neurotoxicity
      • Pharmacologic methods to prevent/delay the onset of oxaliplatin-related neuropathy are controversial due to the absence of large clinical trials proving benefit. Counsel patients to avoid exposure to cold during and for approximately 48 hours after each infusion. Prolongation of the oxaliplatin infusion time from two to six hours may mitigate acute neurotoxicity.
    • Cardiac issues
      • QT prolongation and ventricular arrhythmias have been reported after oxaliplatin. ECG monitoring is recommended if therapy is initiated in patients with heart failure, bradyarrhythmias, coadministration of drugs known to prolong the QT interval, and electrolyte abnormalities. Avoid oxaliplatin in patients with congenital long QT syndrome. Correct hypokalemia and hypomagnesemia prior to initiating oxaliplatin.
  • Monitoring parameters:

    • CBC with differential and platelet count prior to each treatment.
    • Assess electrolytes (especially potassium and magnesium) and liver and renal function prior to each treatment.
    • Irinotecan is associated with early and late diarrhea, both of which may be severe. Patients must be instructed in the early use of loperamide for late diarrhea. Patients who develop diarrhea should be closely monitored and supportive care measures (eg, fluid and electrolyte replacement, loperamide, antibiotics, etc) should be provided as needed. For patients who develop abdominal cramping and/or diarrhea within 24 hours of receiving irinotecan, administer atropine (0.3 to 0.6 mg IV) and premedicate with atropine for later cycles.
    • Assess changes in neurologic function prior to each treatment.
  • Suggested dose modifications for toxicity (The specific dose alteration parameters for the FOLFOXIRI regimen in colorectal cancer patients were not published in the original phase III trial. The following suggestions are based upon dose reductions used in a trial using a comparable regimen (FOLFIRINOX) for advanced pancreatic cancer.)

    • Myelotoxicity
      • Do not retreat unless granulocyte count >= 1500/microL and platelet count is >= 75,000/microL.
      • Neutropenia:
        • If day 1 treatment delayed for granulocytes < 1500/microL or febrile neutropenia or grade 4 neutropenia > 7 days, reduce irinotecan dose to 150 mg/m2 and reduce the continuous infusion FU to 75% of original doses. For second occurrence, reduce oxaliplatin dose to 60 mg/m2 and the dose of infusional FU an additional 25%. If nonrecovery after two weeks, delay or third occurrence of granulocytes < 1500/microL on day 1, or febrile neutropenia or grade 4 neutropenia at any time during cycle, discontinue treatment.
      • Thrombocytopenia:
        • If day 1 treatment delayed for platelet count is < 75,000/microL, reduce oxaliplatin dose to 60 mg/m2 and reduce the continuous infusion FU to 75% of original doses. For second occurrence, reduce irinotecan dose to 150 mg/m2. If nonrecovery after two weeks delay or third occurrence of platelets < 75,000/microL, discontinue treatment. For grade 3 or 4 thrombocytopenia during treatment, reduce oxaliplatin dose to 60 mg/m2 and the infusional FU dose to 75% of the original dose. For the second occurrence, reduce dose of irinotecan to 150 mg/m2 and the dose of infusional FU an additional 25%. Discontinue treatment for third occurrence.
    • Diarrhea
      • Do not retreat with FOLFOXIRI until resolution of diarrhea for at least 24 hours without antidiarrheal medication. For diarrhea grade 3 or 4, or diarrhea with fever and/or grade 3 or 4 neutropenia, reduce irinotecan dose to 150 mg/m2 and the continuous FU dose to 75% of original dose. For second occurrence, reduce the oxaliplatin dose to 60 mg/m2 and the dose of infusional FU an additional 25%. Discontinue treatment for third occurrence.
      • NOTE: Severe diarrhea, mucositis, and myelosuppression after FU should prompt evaluation for DPD deficiency.
    • Mucositis or palmar-plantar erythrodysesthesia
      • For grade 3 to 4 toxicity, reduce dose of infusional FU by 25%.
    • Neurotoxicity
      • For transient grade 3 paresthesias/dysesthesias or grade 2 symptoms lasting more than seven days, decrease oxaliplatin dose by 25%. Discontinue oxaliplatin for grade 4 or persistent grade 3 paresthesia/dysesthesia.
      • There is no recommended dose for resumption of FU administration following development of hyperammonemic encephalopathy, acute cerebellar syndrome, confusion, disorientation, ataxia, or visual disturbances; the drug should be permanently discontinued.
    • Pulmonary toxicity
      • Oxaliplatin has rarely been associated with pulmonary toxicity. Withhold oxaliplatin for unexplained pulmonary symptoms until interstitial lung disease or pulmonary fibrosis is excluded.
    • Cardiotoxicity
      • Cardiotoxicity observed with FU includes myocardial infarction/ischemia, angina, dysrhythmias, cardiac arrest, cardiac failure, sudden death, ECG changes, and cardiomyopathy. There is no recommended dose for resumption of FU administration following development of cardiac toxicity, and the drug should be discontinued.
    • Other toxicity
      • Any other toxicity >= grade 2, except anemia and alopecia, can justify dose reduction if medically indicated.
      • For other nonhematologic toxicities, if grade 2, hold treatment until ≤grade 1; if grade 3 or 4, hold treatment until ≤grade 2.[5]
    • If there is a change in body weight of at least 10%, doses should be recalculated.

2023-05-08

  • Blood culture results from 2023-05-04 and 2023-04-27 indicate that Acinetobacter nosocomialis is susceptible to cefepime with a MIC of 2 ug/mL and levofloxacin with a MIC of less than 0.12 ug/mL. Cefepime has been administered since 2023-04-25, while levofloxacin was administered between 2023-04-06 and 2023-04-20. Since the 2023-05-08 CXR shows no significant improvement in the pneumonia, it might be appropriate to consider including meropenem or imipenem-cilastatin as potential next candidate antibiotics for treatment.

[tube feeding]

  • Since Harnalidge (tamsulosin 0.4mg PO QDAC) is not suitable for tube feeding, it is recommended to switch to Urief (silodosin 8mg PO QD) as an alternative for the patient’s needs.

2023-04-25

  • On 2023-04-25, the patient’s CRP was 4.03mg/dL, WBC count was 23.36K/uL, and neutrophils were at 89.1%. Tachycardia and tachypnea were also observed, along with a body temperature exceeding 38 degrees Celsius in the morning. Signs of lung infection remain evident. Cefim (cefepime) at 2000mg Q8H has been administered, and blood culture results are pending. Cravit (levofloxacin) was used for 2 weeks prior to cefepime.
  • Ipratran (ipratropium bromide), Sindecon (oxymetazoline), Actein (acetylcysteine) and Medason (methylprednisolone) are used to relieve respiratory symptoms.
  • The patient’s underlying conditions are being managed with appropriate medications: hypothyroidism is treated with Eltroxin (levothyroxine), HTN with Amtrel (amlodipine and benazepril), constipation with Through (sennoside), BPH with Harnalidge (tamsulosin), oral thrush with Mycostatin (nystatin) and pain with morphine and fentanyl.
  • No medication reconciliation issues have been identified after reviewing the PharmaCloud database. As the lab results indicate generally normal liver and kidney function, there is no need to adjust the drug dosages for liver or kidney-related reasons.
  • The patient has experienced a weight loss of more than 5 kg in the past two weeks (48.7 kg on 2023-04-05 and 54.5 kg on 2023-04-19). Adequate nutritional support may be needed to address this problem.

2022-04-20

  • This patient has MMR-proficient lower rectal cancer with liver and lung metastases (2020-07-01 pathology). The lung mets were confirmed to be in progress (2022-04-14 CT) followed by the MWA (2022-02-11) for the liver mets.
  • During this hospital stay, the patient resumed using FOLFOXIRI plus self-paid bevacizumab and pembrolizumab as a palliative treatment, the same regimen was used during 2021-05-04 to 2021-07-14. Before that, FOLFOXIRI plus bevacizumab were also used from August 2020 to February 2021.
  • Lab data reported on 2022-04-19 revealed that liver and kidney function, serum electrolytes, and blood cell counts were generally normal.
  • The nursing note does not indicate any intolerances so far since this hospitalization. No issue with current medication.

700358146

230505

{not completed}

[MedRec]

  • 2023-05-05 POMR progress note
    • Leukocytosis, suspect CML
      • Assessment: improved (WBC 225330 -> 72330 -> 71950 -> 64290 /uL)
      • Plan:
        • Bone marrow biopsy performed on 2023/05/02
        • Plasma exchange + Vitacal 60mL IVD for calcium supplement on 2023/05/02
        • Hydrea 500 mg/cap 2# BID start from 2023/05/02
    • Type 2 diabetes mellitus
      • Assessment: stable
      • Plan:
        • Januvia 100mg/tab 1# QD
        • Glucose one touch QDAC
        • Diet modification
    • Hypertension and hyperlipidemia
      • Assessment: stable
      • Plan:
        • Norvasc 5mg/tab 1# QD
        • Crestor 10mg/tab 0.5# QD
    • Hypokalemia + hypomagnesemia
      • Assessment: improving
      • Plan:
        • 0.298% KCl in 0.9% NaCl Injection 500 mL BID
        • Magnesium Sulfate 10% 20mL BID
  • 2023-04-27 SOAP Hemato-Oncology
    • S
      • Referred for leukocytosis noted on 2023-04-27.
      • Occupation touched paint solvent in the past
    • O
      • 2023/04/26
        • Band = 12.0 %;
        • Neutrophil = 51.0 %;
        • Lymphocyte = 2.0 %;
        • Monocyte = 6.0 %;
        • Eosinophil = 0.0 %;
        • Basophil = 1.0 %;
        • Metamyelocyte = 10.0 %;
        • Myelocyte = 3.0 %;
        • Promyelocyte = 15.0 %;
        • WBC = 104.08 x10^3/uL;
        • RBC = 3.61 x10^6/uL;
        • HGB = 11.6 g/dL;
        • HCT = 34.9 %;
        • MCV = 96.7 fL;
        • MCH = 32.1 pg;
        • MCHC = 33.2 g/dL;
        • PLT = 380 x10^3/uL;
        • RDW-CV = 16.1 %;
        • MPV = 11.1 fL;
    • A/P
      • Admission for BM study and leukopheresis
      • Already request patient to ER if any condition

[exam findings]

  • 2023-05-02 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Myeloproliferative neoplasm (Differential diagnosis: Chronic myeloid leukemia and, … etc.)
      • NOTE: Correlation of bone mrrow smear, peripheral blood data, molecular genetic study (BCR/ABL), flow cytometery and clinical findings is recommended.
    • Microscopically, it shows nhyper cellularity (> 95%), 10:1 of M:E ratio. Both myeloid and erythroid lineages demonstrate maturation. Megakaryocytes are present in increased in numbers (6~8 per HPF) and demonstate hypholobulated morphologic pattern. Blast-like cells (CD117+, < 5%) are present.
    • Immunohisotchemical stain reveals CD34(-), CD138(focal+, 1~2%), MPO(+), CD71(focal +), CD61(+).

[assessment - not posted]

  • Hyperleukocytosis has been mitigated by the administration of Hydrea (hydroxyurea 500mg) 2# BID since 2023-05-02.
    • 2023-05-05 WBC 64.29 x10^3/uL
    • 2023-05-04 WBC 71.95 x10^3/uL
    • 2023-05-03 WBC 72.33 x10^3/uL
    • 2023-05-02 WBC 225.33 x10^3/uL
    • 2023-05-02 WBC 107.47 x10^3/uL
    • 2023-04-30 WBC 90.67 x10^3/uL
    • 2023-04-29 WBC 93.95 x10^3/uL
    • 2023-04-26 WBC 104.08 x10^3/uL
  • While allopurinol or febuxostat might be considered for prophylaxis of potential tumor lysis syndrome, laboratory data shows a decrease in serum uric acid levels.
    • 2023-05-03 Uric Acid 6.9 mg/dL
    • 2023-04-30 Uric Acid 8.1 mg/dL
    • 2023-04-29 Uric Acid 8.3 mg/dL

700514733

230505

[exam findings]

  • 2023-04-13 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette
  • 2023-04-13 All-RAS + BRAF
    • ALL-RAS: Detected(KRAS codon 12 GGT>AGT, p.G12S)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-03-31 CT - abdomen
    • CC: BW loss (+), anemia
      • 20230320 colonoscopy: An ulcerative tumor with lumen obstruction was noted at level probably at ascending colon
      • PATHO: Adenocarcinoma, moderately differentiated
    • Findings:
      • There is segmental circumferential asymmetrical wall thickening at the ascending colon with irregular contour and adjacent omentum fatty stranding, measuring 8 cm in length that is c/w adenocarcinoma (T4b).
        • In addition, there are seven enlarged nodes in the adjacent mesocolon (N2b).
      • There is mild ascites in the cul-de-sac.
      • There is a small soft tissue nodule in RLL of the lung, measuring 3 mm in size at lung window setting.
        • Follow up chest CT 3 months later is indicated.
      • There are several stones in the distal CBD.
        • In addition, there are multiple gallstones.
      • The spleen shows prominence in size (long axis:11.4 cm).
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2023-03-27 Bronchodilator Test
    • Normal ventilatory function
    • Not significant bronchodilator reversibility
  • 2023-03-21 Patho - colon biopsy
    • Colon, ascending, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2023-03-20 Colonoscopy
    • Colon cancer, ascending colon, s/p biopsy
    • Colon polyp, transvers colon, s/p biopsy
    • Internal hemorrhoid
  • 2023-03-20 Esophagogastroduodenoscopy, EGD
    • Superfical gastritis, antrum
    • Duodenal ulcer scar, bulb, LC
  • 2023-03-03, -02-27 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Interstitial and alveolar infiltrates involving predominantly the mid-and lower-lung fields, and mild pleura effusions are seen. Acute pulmonary edema is highly suspected.
  • 2023-02-24 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (171 - 64) / 171 = 62.57%
      • M-mode (Teichholz) = 62
    • Conclusion
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA and LV, elevated LA filling pressure
      • Mild to moderate TR, moderate MR, PR
      • Pulmonary hypertension
  • 2023-02-23 ECG
    • Sinus tachycardia
    • Nonspecific ST and T wave abnormality
  • 2023-02-23 SONO - nephrology
    • No significant abnormality from echography for both kidneys.
    • Bilateral plerual effusion.

[MedRec]

  • 2023-04-12 ~ 2023-04-15 POMR Hemato-Oncology
    • Discharge diagnosis
      • adenocarcinoma, moderately differentiated of colon cancer T4N2bM0 stage IIIC S/P C1 chemotherapy with Erbitux (self-paid)/FOLFIRI
      • chronic viral hepatitis B without delta-agent HBsAg positive
    • CC
      • for C1 chemotherapy with Erbitux (self-paid)/FOLFIRI
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC 7D
      • loperamide 2mg 1# PRNQ6H 7D (if watery diarrhea > 3 times)
      • Roumin (prochlorperazine maleate 5mg) 1# TID 7D (note: used to treat severe nausea and vomiting)
  • 2023-04-07 SOAP Hemato-Oncology
    • O
      • 2023/04/07 CA-199 (NM) = 192.235 U/ml;
      • 2023/04/07 CEA (NM) = 347.620 ng/ml;
    • A/P
      • arrange admission on April 10 + port-A chemotherapy
  • 2023-04-06 SOAP Colorectal Surgery
    • A/P
      • Lung nodule, cause ?? metastasis ??
      • Advanced A-colon cancer with retroperitoneal invasion;
      • Suggest systemic chemotherapy +/- target therapy for tumor shrinkage and may increase resectability
  • 2023-03-15 SOAP Hemato-Oncology
    • O
      • 2023/03/08 FKLC = 39.3 mg/L;
      • 2023/03/08 FLLC = 51.0 mg/L;
      • 2023/03/08 FK/FL ratio = 0.77 ratio;
      • 2023/03/04 M-peak = Positive;
      • 2023/03/04 Stool OB (LIA) = Positive;
      • 2023/03/04 Occultblood (LIA) quantitative value = >999 ng/mL;
      • 2023/03/03 B2-Microglobulin = 2906 ng/mL;
      • 2023/03/02 Ferritin = 23.1 ng/mL;
      • 2023/02/27 WBC = 9.48 x10^3/uL;
      • 2023/02/27 HGB = 8.7 g/dL;
      • 2023/02/27 PLT = 412 x10^3/uL;
      • 2023/02/24 OB = Negative;
      • 2023/02/24 Fe (Iron-bound) = 363 ug/dL;
      • 2023/02/24 TIBC = 442 ug/dL;
      • 2023/02/24 UIBC = 79 ug/dL;
    • A/P
      • suggest to check bone marrow
      • patient is scheduled to check colonfibroscopy at 2023/03/20
      • wait the colonfibroscopy result.
  • 2023-02-23 ~ 2023-02-27 POMR Cardiology
    • Discharge diagnosis
      • Heart failure, EF 62%, moderate MR, NT pro BNP 1812
      • Anemia, Fe 363, stool OB negative
      • Essential (primary) hypertension
      • Hypoalbuminemia, proteinuria(+/-)
    • CC
      • bilateral lower limbs edema and exertional shortness of breath progressively for the past 2 weeks
    • Discharge prescription
      • spironolactone 25mg 0.5# QD 5D
      • Zanidip (lercanidipine 10mg) 0.5# QD 5D
      • Ulstop (famotidine 20mg) 1# BID 5D
      • Torsix (torsemide 5mg) 1# QD 5D
      • Torsix (torsemide 5mg) 0.5# PRNQD 5D (prepared for BW increase > 0.5kg or edema)
      • Blopress (candesartan 8mg) 1# QD 5D
  • 2023-02-23 SOAP Nephrology
    • S
      • Bilateral lower leg edema for one week
      • DOE (+) for one week
      • Orthopnea (-) PND (-)
      • Foamy urine (-)
      • PH: DM (-) HTN (-) Drug allergy: denied
      • Herb use : denied
      • To ER for CHF with severe anemia.
    • O
      • BP:170/54; HR:105;
      • BW not measured
      • Leg edema (+++)
      • CVA knocking pain (-)
      • BS: clear
      • NT-proBNP elevated
      • Bilateral pleural effusion
      • Hb 4.4
      • MCV 56.9
      • Urine examination: not collected
    • A/P:
      • Refer to ER for suspected CHF with severe anemia.

[chemoimmunotherapy]

  • 2023-05-04 - cetuximab 500mg/m2 700mg 2hr + irinotecan 160mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 3360mg NS 500mL 46hr (cetuximab + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + acetaminophen 500mg PO + NS 250mL
  • 2023-04-13 - cetuximab 400mg/m2 500mg 2hr + irinotecan 160mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (cetuximab + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + acetaminophen 500mg PO + NS 250mL

[assessment]

  • Microcytic anemia, possibly caused by iron deficiency, has been present in the patient’s laboratory data for months, with low RBC, HGB, MCV, MCH, MCHC, and high RDW, even before the start of Cetuximab/FOLFIRI chemoimmunotherapy. Iron supplementation is recommended. After the planned blood transfusion, the addition of an oral form such as Foliromin tablets (ferrous sodium citrate 50mg) or Ferrum Hausmann drops (ferric hydroxide polymaltose complex) or an injectable form such as Ferrum (ferric hydroxide sucrose) may be considered.
    • 2023-05-04 HGB 7.7 g/dL
    • 2023-04-21 HGB 8.5 g/dL
    • 2023-04-12 HGB 7.0 g/dL
    • 2023-03-31 HGB 7.1 g/dL
    • 2023-02-27 HGB 8.7 g/dL
    • 2023-02-24 HGB 7.7 g/dL
    • 2023-02-23 HGB 4.4 g/dL
    • 2023-05-04 MCV 76.8 fL
    • 2023-04-21 MCV 76.8 fL
    • 2023-04-12 MCV 74.9 fL
    • 2023-03-31 MCV 74.3 fL
    • 2023-02-27 MCV 71.1 fL
    • 2023-02-24 MCV 66.6 fL
    • 2023-02-23 MCV 56.9 fL
    • 2023-05-04 MCH 22.3 pg
    • 2023-04-21 MCH 22.9 pg
    • 2023-04-12 MCH 21.7 pg
    • 2023-03-31 MCH 21.0 pg
    • 2023-02-27 MCH 20.4 pg
    • 2023-02-24 MCH 19.6 pg
    • 2023-02-23 MCH 14.9 pg
    • 2023-05-04 MCHC 29.1 g/dL
    • 2023-04-21 MCHC 29.8 g/dL
    • 2023-04-12 MCHC 28.9 g/dL
    • 2023-03-31 MCHC 28.3 g/dL
    • 2023-02-27 MCHC 28.7 g/dL
    • 2023-02-24 MCHC 29.5 g/dL
    • 2023-02-23 MCHC 26.2 g/dL
    • 2023-05-04 RDW-CV 22.7 %
    • 2023-04-21 RDW-CV 23.5 %
    • 2023-04-12 RDW-CV 27.0 %
    • 2023-02-24 RDW-CV 30.5 %
    • 2023-02-23 RDW-CV 21.2 %

700732120

230505

{not completed}

[MedRec]

  • 2021-03-30 ~ 2021-05-06 POMR General and Digestive Surgery
    • Discharge diagnosis
      • Adenocarcinoma of renmant anterior gastric with liver S2-3 invasion, pT4bN2(cM0); pStage: IIIB, status post total gastrectomy with splenectomy + en block S2-3 resection and lymph node dissection on 2021/04/22. ECOG:2
      • Malignant neoplasm of stomach, unspecified
      • Distal common bile duct stone status post common bile duct explore with stone resection with scope and common bile duct primary repair on 2021/04/22.
      • Bacteremia due to Acinetobacter ursingii related
      • Hypoalbuminemia
    • CC
      • RUQ abdominal pain with radiation to back for over 1 week

[surgical operation]

  • 2021-04-22
    • Surgery
      • total gastrectomy with splenectomy
      • en block S2-3 resection
      • retreoperitoneal LN dissection
      • CBDE with stone retraction with scope and CBE primary repair
    • Finding
      • 7 x 6.5 cm ulcerative mass at renmant anterior stomach with S2-3 invasion
      • multiple LN enlarge at 7,8,9
      • multiple pigment stones at distal CBD with CBD 1.8cm diameter

[medication]

2023-03-15 ~ 2023-03-29 - UFT (tegafur 100mg, uracil 224mg) 2# BID

2022-02-08 ~ 2022-04-25 - TS-1 (tegafur, gimeracil, oteracil) 2# BID

2021-09-09 ~ 2021-10-15 - Xeloda (capecitabine 500mg) 2# BID

B-Red (hydroxocobalamin 1mg)

700930564

230505

[diagnosis] - 2023-03-22 SOAP

  • pancrease cancer with liver metastasis and perinteal seeding stage IV, with maligancy ascites
  • gastric adenocarcinoma in situ

[past history]

  • Denied TB, Asthma, DM, HTN or Malignancy diseases.
  • No known allergens
  • Denied other admission or operation history.    

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-05-02 Ascites Tapping
    • 3000ml yellowish color ascites were drained.
  • 2023-04-28 ECG 24hr portable
    • Sinus rhythm
    • Occasional isolated apcs
    • Frequent apc couplets
    • Paroxysmal atrial flutter-fibrillation
    • Occasional isolated vpcs
    • No long pause
  • 2023-04-28 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (53 - 10) / 53 = 81.13%
      • M-mode (Teichholz) = 81
    • Conclusion:
      • Normal LV filling pressure; impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis and prominent posterior mitral annulus calcification with mild AR; mild MR.
      • Sinus tachycardia.
      • Ascites and pleural effusions.
  • 2023-04-27 ECG
    • Supraventricular tachycardia
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2023-03-27 Ascites Tapping
    • Indication: Ascites
    • Symptoms: Abdominal fullness
    • Course: 18G needle was inserted at RLQ under echo guided insertion.
    • Findings: 3000 ml straw color ascites was drained.
  • 2023-03-26 KUB
    • Fecal material store in the colon.
    • Ascites is highly suspected. Please correlate with sonography.
    • Spondylosis with scoliosis of the L-spine with convex to right side
  • 2023-03-17 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
  • 2023-03-09 Patho - pancreas biopsy
    • PATHOLOGIC DIAGNOSIS
      • Pancreas, FNB — Ductal adenocarcinoma, poorly differentiated
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consists of multiple small pieces of tan gray soft tissue, labeled pancreas, measuring up to 1.0 x 0.1 x 0.1 cm. All for section.
    • MICROSCOPIC EXAMINATION
      • The sections show a picture of adenocarcinoma, composed of nests, cords, and single pleomorphic neoplastic cells in fibrous stroma. Focal glandular differentiation and mucin secretion can be found. Tumor necrosis is present also.
  • 2023-03-08 Endoscopic Ultrasound
    • Diagnosis
      • Pancreatic body tumor, s/p CH-EUS & EUS/FNB
      • Pancreatic cystic tumor, body
      • Lymphadenopathy, periarotic area
    • Suggestion
      • Pursue pathology result
      • regular F/U
  • 2023-03-03 MR Cholangiography, MRCP
    • History
      • 20230226 CC: Abdominal Pain
      • 20230226 CT: A poor enhancing lesion (3.2x5.1cm) at pancreatic body and tail with SMA and SMV invasion r/o malignancy. R/O peritoneal carcinomatosis and liver metastases.
      • 20230227 CA199:582 U/mL (< 35), CEA: normal.
    • Findings:
      • There is a mass lesion in the pancreatic body and tail, 7.8 x 3.2 cm in size, showing hypointensity on T1WI, mild hyperintensity on T2WI and DWI. During contrast enhanced study, this lesion shows poor enhancement in arterial phase, portal venous phase, and delayed phase images.
        • Adenocarcinoma of the pancreatic body and tail (T3) is noted.
        • In addition, there is non-visualization of the splenic vein that is c/w tumor invasion.
      • There are five enlarged nodes in the celiac trunk, gastrohepatic ligament, and hepatoduodenal ligament that are c/w metastatic nodes (N2).
      • There are two masses 1.8 cm and 1.2 cm in S7 of the liver, shows mild hyperintensity on both T2WI and DWI, and poor enhancement.
        • Two liver metastases (M1) are noted.
      • There is massive ascites and multiple soft tissue nodules in the omentum that is c/w carcinomatosis (M1).
        • Please correlate with ascites cytology.
      • Bil. renal cysts (up to 6.6cm).
      • Hyperplasia of left adrenal gland.
    • IMP:
      • Adenocarcinoma of the pancreatic body and tail with liver metastases and carcinomatosis is suspected.
      • According to American Joint Committee on Cancer (AJCC) staging system,8th edition for pancreatic cancer: T3 N2 M1, stage: IV
  • 2023-03-01 Patho - stomach biopsy
    • Duodenum, SDA to second portion, biopsy (A) — chronic inflammation and Brunner’s gland hyperplasia.
    • Stomach, Gastric ulcer, AW of lower antrum, s/p biopsy(B)— Chronic gastritis with intestinal metaplasia, H pylori NOT present
    • Stomach, Gastric erosion, PW of upper antrum, s/p biopsy(C)— ulcer with adenocarcinoma in situ (AIS), demonstrated with IHC stain of cytokeratin.
    • Stomach, Gastric lesion, GC of upper antrum, s/p biopsy(D)— Chronic gastritis, H pylori NOT present
  • 2023-02-27 Cell Block - Ascites
    • DIAGNOSIS:
      • SMEARS and CELLBLOCK: positive for malignancy; IHC stains: CK7 (+), CK20 (-), CDX2 (-), CA19-9 (-), CK19 (-).
    • GROSS DESCRIPTION:
      • 21 ml turbid
    • MICROSCOPIC DESCRIPTION:
      • SMEARS and CELLBLOCK: clusters of papillae with large nuclei and large cytoplasmic vacuole, a picture od adenocarcinoma.
      • IHC stains: CK7 (+), CK20 (-), CDX2 (-), CA19-9 (-), CK19 (-). The picture does NOT support gastric or pancreato-biliary origin.
  • 2023-02-26 CTA - abdomen
    • A poor enhancing lesion (3.2x5.1cm) at pancreatic body and tail with SMA and SMV invasion r/o malignancy. R/O peritoneal carcinomatosis and liver metastases. Massive ascites. Enlargement of prostate.

[MedRec]

  • 2023-03-22 SOAP Hemato-Oncology
    • S
      • This 78 year old man is a case of pancrease cancer with liver and peritoneal metastasis, stage IV, and gastric adenocarcinoma in situ.
      • The patient is currently unaware of the pancreatic cancer situation and only knows about the presence of a gastric tumor.
    • O
      • Lab
        • 2023-02-27 CA199 582.59 U/mL
        • 2023-02-27 CEA 1.82 ng/mL
      • Will on Abraxane plus gemcitabine
    • A
      • pancrease cancer with liver metastasis and perinteal seeding stage IV, with maligancy ascites
      • gastric adenocarcinoma in situ
    • P
      • admiited for port A insertion, family meeting, symptom control, discuss with palliative chemotherapy
      • refer to ER for ascites tapping and then admission for further management.
  • 2023-02-26 ~ 2023-03-09 POMR Gastroenterology and Hepatology
    • Discharge diagnosis
      • Suspicious pancreas cancer of body and tail with liver and peritoneum metastasesis T3N2M1, stage: IV, ECOG:2, status post paracentesis, status post endoscopic ultrasound-guided fine needle biospy on 2023/03/08
      • Gastric adenocarcinoma in situ
      • Gastric ulcer
      • Duodenal erosion
      • Colon polyps, cecum, proximal ascending and transverse colon, status post polypectomy
    • CC: abdominal distention for days
    • Prescription
      • spironolactone 25mg 2# QD
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Through (sennoside 12mg) 1# HS
      • Curam (amoxicillin 875mg + clavulanic acid 125mg) 1# Q12H 3D

[chemotherapy]

  • 2023-04-24 - Nab-paclitaxel 80mg/m2 100mg 90min + gemcitabine 800mg/m2 800mg NS 100mL 30min (D1) dose reduced due to adverse reactions
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-04-03 - Nab-paclitaxel 100mg/m2 120mg 90min + gemcitabine 1000mg/m2 1200mg NS 100mL 30min (D1,8,15)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-03-27 - Nab-paclitaxel 100mg/m2 120mg 90min + gemcitabine 1000mg/m2 1200mg NS 100mL 30min (D1,8,15)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

[note]

hyperbilirubinemia - ref: 2023-05-05 UpToDate

  • An increase in unconjugated bilirubin in serum results from overproduction, impairment of uptake, or impaired conjugation of bilirubin. Unconjugated hyperbilirubinemia may be caused by:
    • Hemolysis
    • Extravasation of blood into tissue
    • Dyserythropoiesis
    • Stress situations (eg, sepsis) leading to increased production of bilirubin
    • Impaired hepatic bilirubin uptake
    • Impaired bilirubin conjugation
  • An increase in conjugated bilirubin is due to decreased excretion into the bile ductules or leakage of the pigment from hepatocytes into serum. Conjugated hyperbilirubinemia may be caused by:
    • Biliary obstruction (eg, gallstones, pancreatic or biliary malignancy, AIDS cholangiopathy, parasites)
    • Viral hepatitis
    • Alcoholic hepatitis
    • Nonalcoholic steatohepatitis
    • Primary biliary cholangitis
    • Drugs and toxins
    • Ischemic hepatopathy
    • Liver infiltration
    • Inherited disorders (eg, Dubin-Johnson syndrome, Rotor syndrome, progressive familial intrahepatic cholestasis)
    • Total parenteral nutrition
    • Postoperative jaundice
    • Intrahepatic cholestasis of pregnancy
    • End-stage liver disease
    • Organ transplantation (eg, bone marrow, liver)

CA199, CEA - ref: 2023-05-05 ChatGPT

  • CA199: Elevated levels of CA199 can be associated with certain types of cancer, particularly pancreatic cancer. It may also be elevated in other malignancies such as colorectal, gastric, liver, and bile duct cancers.
  • CEA: CEA is a tumor marker, which means that its levels in the blood can become elevated in the presence of certain types of cancer, particularly colorectal cancer. However, CEA is not a specific marker, and its levels can also be elevated in other malignancies, such as lung, breast, stomach, pancreas, and ovarian cancers.

==========

2023-05-05

  • Nab-paclitaxel and gemcitabine treatment was first initiated on 2023-03-27 and is currently ongoing. The 3rd dose was administered on 2023-04-24 with a 20% reduction in dosage due to dizziness, nausea, and vomiting. The patient also experienced conscious disturbance and abdominal fullness, which led to ascites tapping on 2023-05-02.

  • After receiving 3 doses of the regimen, the patient’s tumor marker CA199 remains relatively unchanged, while there is a significant increase in CEA levels.

    • 2023-05-05 CA199 1087.93 U/mL
    • 2023-04-11 CA199 1161.06 U/mL
    • 2023-03-28 CA199 (Nuclear Medicine) 1151.56 U/ml
    • 2023-02-27 CA199 582.59 U/mL
    • 2023-05-05 CEA 5.54 ng/mL
    • 2023-04-11 CEA 3.78 ng/mL
    • 2023-03-28 CEA (Nuclear Medicine) 1.869 ng/ml
    • 2023-02-27 CEA 1.82 ng/mL
  • The TPR panel indicated no bowel movement on 2023-05-03 and 2023-05-04. It is suggested to assess whether the patient has developed constipation, as bisacodyl is prescribed as needed (PRN) for this issue.

2023-05-02

[tube feeding]

  • As of 2023-05-01, the patient’s serum potassium level has returned to the normal range of 3.5 mmol/L. However, the current prescription for Const-K will expire on 2023-05-04, and it may be worth considering discontinuing this medication. It should be noted that the potassium content of fruits is relatively low (for example, about 2.2 mEq/inch or 0.9 mEq/cm in bananas), meaning that it would take about two to three bananas to provide 40 mEq. Const-K is an extended-release formulation containing 10 mEq/tab, which is less potassium than is found in one banana. If injectable potassium supplementation is not preferred (Const-K remains the only oral potassium supplement available today), please crush the tablet into particles and administer it with water.

  • For patients who have difficulty swallowing Protase (pancrelipase) capsules, the capsule can be opened and the enteric-coated granules can be released into a small amount of liquid food with a pH not exceeding 5.5. Tube feed the drug particles with drinking water or juice to ensure complete ingestion.

  • As for Megejohn (megestrol acetate), since our hospital has Megest (megestrol 40mg/mL, 120mL/bot) in stock, it is suggested to switch Megejohn to the Megest oral suspension.

2023-03-25

  • The patient has been diagnosed with stage IV pancreatic cancer with liver metastasis and peritoneal seeding, as well as in situ gastric adenocarcinoma. Although the patient is currently only aware of the stomach tumor, the pancreatic cancer is more advanced and should be prioritized for treatment.
  • It is possible that the modified FOLFIRINOX regimen could be considered for this patient, provided that the patient has an ECOG score of 0 or 1.

701300015

230505

[exam findings]

  • 2023-02-14 CT - abdomen
    • History and indication:
      • CEA = 89.37 ng/mL;
      • Adenocarcinoma of sigmoid colon with obstruction, cT3N1M0, stage IIIB post T-loop colosotmy (2021/06/16) status post laparoscopic sigmoidectomy on 2021/08/05, pT3N1bM0(3/14), G2, LVI(+), PNI(+), CRM(+), stage IIIB
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P colon operation with colostomy. Recurrent tumors (up to 3.0cm) at LLQ.
      • Right renal stone (8mm).
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • S/P colon operation with colostomy. Recurrent tumors (up to 3.0cm) at LLQ.
  • 2023-01-17 Colonoscopy
    • Findings
      • 10cm to previous operation site, ulcerative lesion but re-stenosis
      • 30cm from distal osteomy, then much old clot in colon and can not be removed.
    • Diagnosis
      • Anastomosis s/p transanal dissection but re-stenosis
    • Suggestion
      • OPD discuss treatment strategy.
  • 2022-12-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (56 - 11) / 56 = 80.34%
      • M-mode (Teichholz) = 81
    • Conclusion
      • Asymmetrical septal hypertrophy and apical hypertrophy, suspected non-obstructive type hypertrophic cardiomyopathy; indeterminated LV filling pressure and impaired RV relaxation; severely dilated LA.
      • Normal LV and RV systolic function
      • Aortic valve sclerosis with mild AR.
      • Degenerative changes of mitral valve with mild to moderate MR; mild TR; moderate PR.
      • Prominent aortic root calcification with multiple protruding non-mobile atheromas (7-10 mm of thickness).
  • 2022-12-07 ECG
    • Sinus bradycardia
    • Left ventricular hypertrophy
    • Marked ST abnormality, possible anterior subendocardial injury
  • 2022-12-05 CT - abdomen
    • s/p colostomy with its orifice at RLQ.
    • s/p LAR with autosuture retention. No evidence of recurrent/residual tumor in the study.
  • 2022-08-24, -05-20 CT - abdomen
    • There is no evidence of tumor recurrence.
  • 2022-02-11, 2021-11-03 CT - abdomen
    • S/P LAR with autosuture retention over the sigmoid colon.
    • S/P colostomy of right transverse colon.
    • There is no evidence of tumor recurrence.
  • 2021-05-05 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Large intestine, sigmoid colon, laparoscopic sigmoidectomy — Adenocarcinoma, moderately differentiated
      • Resection margins, proximal and distal: Free
      • Lymph node, mesocolic, dissection — Metastatic adenocarcinoma (3/14)
      • Pathology stage: pT3N1b(if cM0); AJCC stage IIIB
    • MACROSCOPIC EXAMINATION
      • Operation procedure: laparoscopic sigmoidectomy
      • Specimen site: sigmoid colon
      • Specimen size: 12 cm in length
      • Tumor size: 4x 3 cm
      • Tumor location: 3 cm away from the closest resection margin
      • Depth of invasion grossly:pericolorectal tissue
      • Mucosa elsewhere: Not remarkable
      • Representative section: A1-2:LNs, A3-6:tumor, B&C:cut-ends
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: moderately differentiated
      • Depth of invasion: pericolorectal tissue
      • Angiolymphatic invasion: Present.
      • Perineural invasion: Present
      • Discontinuous extramural tumor extension: Not identified.
      • Circumferential (radial) margin of rectum: Uninvolved
      • Lymph node metastasis, mesocolic: Positive (3/14)
      • Lymph node metastasis, IMA/SMA: N/A.
      • Extranodal involvement: Present.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT)
          • pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN)
          • pN1b: Two or three regional lymph nodes are positive
        • Distant Metastasis (pM)
          • N/A
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: None identified
      • TNM descriptors: N/A
      • Tumor regression grading S/P CCRT: N/A.
  • 2021-08-03 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (126 - 33) / 126 = 73.81%
      • M-mode (Teichholz) = 74
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, LVH, grade 2 LV diastolic dysfunction
      • Mild AR, and PR, mild to moderate MR
  • 2021-06-21 Patho - colon biopsy
    • Colon, 18 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2021-06-13 CT - abdomen
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N1(N_value) M:M0(M_value) STAGE:IIIB(Stage_value)

[MedRec]

  • 2023-02-22 SOAP Radiation Oncology
    • A: Adenocarcinoma, moderately differentiated, of the sigmoid colon, stage cT3N1bM0(IIIB), s/p Laparoscopic sigmoidectomy, stage pT3N1b(cM0), AJCC stage IIIB, with local recurrence, status during chemotherapy.
    • P: Radiotherapy is indicated for this patient with the following indicators: local recurrence
      • Goal: curative
      • Treatment target and volume: abdominal LLQ to pelvic area.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the abdominal LLQ to pelvic area.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2023-03-07.
  • 2021-08-27 SOAP Hemato-Oncology
    • A: Adenocarcinoma of sigmoid colon with obstruction, cT3N1M0, stage IIIB post T-loop colosotmy (2021/06/16) status post laparoscopic sigmoidectomy on 2021/08/05, pT3N1bM0(3/14), G2, LVI(+), PNI(+), CRM(+), stage IIIB
    • P
      • F/U CEA (2021-09), CXR, CT, colonoscopy (2022-05)
      • suggest adjuvant chemotherapy, arrange chemotherpay
      • close colostomy 3 months later (2021-11)

[radiotherapy]

  • 2023-03-15 ~ 2023-04-20) - 4500cGy/25 fractions of the abdominal LLQ to pelvic area.

[chemotherapy]

  • 2023-05-04 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4555mg NS 250mL 46hr (FOLFIRI)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-04-07 (FOLFIRI)

  • 2023-03-22 (FOLFIRI)

  • 2023-03-08 (FOLFIRI)

  • 2023-02-22 (FOLFIRI)

  • 2022-02-23 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-02-09 (FOLFOX)

  • 2022-01-26 (FOLFOX)

  • 2022-01-12 (FOLFOX)

  • 2021-12-29 (FOLFOX)

  • 2021-12-15 (FOLFOX)

  • 2021-12-01 (FOLFOX)

  • 2021-11-17 (FOLFOX)

  • 2021-11-03 (FOLFOX)

  • 2021-10-20 (FOLFOX)

  • 2021-10-01 (FOLFOX)

  • 2021-09-09 (FOLFOX)

[assessment]

  • No medication reconciliation issues have been identified for this patient.

  • The patient appears to be tolerating the current regimen well, and his labs are mostly within normal ranges, with the exception of slightly elevated liver function tests and BUN.

700279535

230504

[allergy]

  • NKDA

[family history]

  • Aunt: DM
  • Uncle: Colon ca
  • Father: heart disease, ESRD under hemodialysis

[exam findings]

  • 2023-05-03 Endoscopic Ultrasound, EUS
    • Pancreatic body cancer, s/p CH-EUS & EUS/FNB (B)
    • Hepatic tumors, s/p CH-EUS & EUS/FNB (A)
    • Lymphadenopathy
  • 2023-05-02, -04-27 CXR
    • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
  • 2023-04-17 CT - abdomen
    • Indication:
      • HBV f/u, elevated CEA and CA-199
      • multiple liver tumor, suspicious pancreatic tumor with liver metastasis.
    • Abdominal CT with and without enhancement revealed:
      • Soft tissue mass at pancreatic body/neck junction measuring 2.9cm in largest dimension is found. Pancreatic cancer is considered. The distal pancreatic duct is obstructed with dilatation.
      • Low density lesions scattered at both lobes of liver measuring 2.8cm are found. Liver meta is considered.
    • IMP: Pancreatic cancer with liver meta.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T2(T_value) N:N0(N_value) M:M1(M_value) STAGE:____(Stage_value)
  • 2023-04-15 SONO - abdomen
    • Diagnosis
      • Liver tumors, favor metastatic tumors
      • pancreatic tumor
      • mild fatty liver, suspected mild liver parenchyma disease
    • Suggestion
      • 4 phase CT or dynamic MRI study
  • 2022-10-08 SONO - abdomen
    • Diagnosis
      • Liver tumor favor hemangioma
      • mild fatty liver, suspected mild liver parenchyma disease
      • fatty infiltration of pancreas
      • suspected pancreatic lesion: hypoechoic
    • Suggestion
      • suggest further image study such as CT scan or MRI or EUS
  • 2022-03-26 SONO - abdomen
    • Diagnosis
      • Liver tumor favor hemangioma
      • mild fatty liver, suspected mild liver parenchyma disease
      • some parts of pancreas not shown
    • Suggestion
      • Regular F/U

[consultation]

  • 2023-05-04 Dermatology
    • Q
      • Patient was 50 years old men, history of HBV carrier regular follow up.
      • For suspect pancreatic cancer with liver meta. cT2N0M1, This time, admission for EUS biopsy and/or CT-guided biopsy, Chest CT, Port A insertion.
      • He has psoriasis more than ten years, we need your consultation for evaluation.

[MedRec]

  • 2023-04-19 SOAP Hemato-Oncology
    • A: Suspect pancreatic cancer with liver meta. cT2N0M1
    • P: Admission for EUS biopsy and/or CT-guided biopsy, Chest CT, Port A insertion

701103011

230504

[diagnosis] - 2023-05-06 discharge note

  • Gastric cancer with pancreas, spleen and liver metstases, stage IV s/p oral chemotherapy with UFUR from 2022/08/16 to 2023/05/02 with lung metastasis s/p chemotherapy with CapOx at SYSCC s/p chemotherapy with FOLFOX (Oxalip 65mg/m2, LV 400mg/m2, 5FU 400mg/m2, 5FU 2400mg/m2) from 2023/05/03
  • Chronic viral hepatitis B without delta-agent

[MedRec]

  • 2023-04-19 SOAP Hemato-Oncology
    • S:
      • Hx of gastric cancer s/p C/T with UFUR
    • O:
      • 2018/01/30 Surgical pathology Level IV
        • Stomach, antrum and body, AW, LC, PW, biopsy — modertaely differentiated adenocarcinoma
    • P:
      • Admssion for checking HBV, HCV, CBC/DC, Biomchemistry and AFP/CA125/CA199/CEA, FOLFOX

[chemotherapy]

  • 2023-05-03 - oxaliplatin 65mg/m2 90mg D5W 250mL 6hr + leucovorin 400mg/m2 550mg NS 500mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFOX, Oxa long infusion to prevent allergy)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

[assessment]

  • The patient received the FOLFOX regimen on 2023-05-03, with a reduced dose of oxaliplatin (85mg/m2 to 65mg/m2) and an extended infusion time (from 2 hours to 6 hours), as well as the addition of famotidine 20mg as premedication. As of now, no significant adverse reactions have been observed.

701158070

230504

[exam findings]

  • 2023-05-02 CT - abdomen
    • Without contrast enhancement CT of abdomen shows:
      • Presence of splenomegaly. Focal fluid density at its dorsal part, r/o infarct.
      • Right renal stone. Mild dilatation of right urotract.
      • Suspect increased density of bony structures.
    • Impression
      • Splenomegaly with suspected splenic infarct
      • Increased density of bony structures

[assessment]

  • Hyperleukocytosis (leukostasis) was confirmed by laboratory tests, and the patient has been treated with Hydrea (hydroxyurea 500mg) 2# TID since 2023-05-03, which has helped to control the high WBC count.

    • 2023-05-04 WBC 237.23 x10^3/uL
    • 2023-05-03 WBC 295.36 x10^3/uL
    • 2023-05-02 WBC 412.38 x10^3/uL
    • 2023-04-24 WBC 364.18 x10^3/uL
    • 2023-05-04 Blast 1.0 %
    • 2023-05-03 Blast 1.0 %
    • 2023-05-02 Blast 11.0 %
  • Leukostasis can be diagnosed when a biopsy of affected tissue shows white cell clots in the microvasculature (2023-05-02 CT: suspected splenic infarct). Please be aware of possible clinical signs of leukostasis, such as

    • Pulmonary signs and symptoms: dyspnea, hypoxia with or without diffuse interstitial or alveolar infiltrates on imaging studies. Pulse oximetry provides a more accurate assessment of O2 saturation in this setting.
    • Neurologic signs and symptoms: visual changes, headache, dizziness, tinnitus, gait instability, confusion, somnolence, and occasionally coma.
  • Feburic (febuxostat) is used as prophylaxis for potential tumor lysis syndrome. Lab data show that elevated serum uric acid levels have returned to normal following administration of the drug.

  • Caution should be exercised when using intravenous contrast at a time when renal function may be compromised by leukostasis or tumor lysis syndrome and dehydration. (2023-05-04 BUN 29mg/dL, Cre 1.10mg/dL, eGFR 70.75, normal values in K. The patient is currently hydrated with NS 500mL BID. No apparent renal insufficiency at this time).

701476884

230504

[lab data]

  • 2023-05-03 Anti-HBc Reactive
  • 2023-05-03 Anti-HBc-Value 8.55 S/CO

[exam findings]

  • 2023-04-14 Patho - pancreas biopsy
    • Pancreas, EUS FNA/B — Ductal adeocarcinoma, moderately differentiated
    • The sections show a picture of ductal adenocarcinoma, moderately differentiated, composed of nests, cords and single large pleomorphic neoplastic cells in fibrous stroma. Focal tubular formation and mucin secretion can be found.
  • 2023-04-14 Endoscopic Ultrasound, EUS
    • Diagnosis
      • Pancreatic head cancer s/p CH-EUS & EUS/FNB
      • MPD and CBD dilatation
      • Reflux esophagitis
    • Suggestion
      • Follow up pathology
  • 2023-04-14 SONO - abdomen
    • Diagnosis
      • Pancreatic tumor favor cancer
      • Dilated CBD
      • GB polyp
      • Parenchymal liver disease
    • Suggestion
      • further investigation
  • 2023-04-07 CT - abdomen
    • Indication: 2023/03/28 abdominal pain off and on for several months, BW loss (+)
      • PI: appetite: good
      • PHx: HTN (+), HBV carrier
    • Findings:
      • There is a well-defined poor enhancing mass measuring 4.5 x 3.4 cm in the pancreatic neck, causing upstream pancreatic duct dilatation. This mass shows direct attachment and narrowing of the trifurcation of portal vein, superior mesenteric vein, and splenic vein that is c/w portal vein invasion and encasement.
        • Adenocarcinoma of the pancreatic neck (T4) is highly suspected.
        • Please correlate with CA199 and EUS.
        • In addition, there are four lymph nodes in gastrohepatic ligament and hepatoduodenal ligament that are c/w metastatic nodes (N2).
      • There is mild dilatation of IHDs and CHD that is due to upper described pancreatic neck mass with directly invasion the CHD.
      • There is an ill-defined equivocal faint poor enhancing area in S7 of the liver that may be flow artifact.
        • The differential diagnosis includes metastasis.
        • Please correlate with sonography and MRI.
      • There is a renal stone 0.9 cm in left lower pole and another tiny renal stone in left upper pole.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T4(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)

[MedRec]

  • 2023-04-26 SOAP Hemato-Oncology
    • P
      • Family request admission
  • 2023-04-25 SOAP Hemato-Oncology
    • O
      • 2023/04/14 Fine needle aspiration cytology - Pancreatic aspiration (Pancereas) — Malignancy
      • 2023/04/14 HBsAg = Reactive;
      • 2023/04/14 HBsAg (Value) = 4773.38 S/CO;
      • 2023/04/14 2023/04/14 Anti-HCV = Nonreactive;
      • 2023/04/14 2023/04/14 CEA = 11.25 ng/mL;
      • 2023/04/14 2023/04/14 CA199 = 2507.98 U/mL;
      • 2023/04/14 planning: neoadjuvant C/T first
      • 2023/04/14 arrange Port-A
    • A
      • May try OPD C/T with biweekly FOLFIRINOX.

[note]

FOLFIRINOX chemotherapy for metastatic pancreatic cancer 2023-05-04 https://www.uptodate.com/contents/image?topicKey=ONC%2F2475&imageKey=ONC%2F79571

  • Cycle length: 14 days.
  • Regimen
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 180 mg/m2 IV
      • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 400 mg/m2 IV bolus
      • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
      • Day 1
    • FU
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

[chemotherapy]

  • 2023-05-02 - irinotecan 120mg/m2 200mg D5W 250mL 90min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 500mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + NS 250mL + aprepitant 125mg D1-3

[assessment]

  • This is the first time the patient has received FOLFIRINOX chemotherapy for his pancreatic cancer, with a reduced dose of irinotecan (180mg/m2 reduced to 120mg/m2) and oxaliplatin (85mg/m2 reduced to 65mg/m2). Thus far, no significant adverse reactions have been observed.

  • 2023-05-03 Anti-HBc Reactive
    2023-05-03 Anti-HBc-Value 8.55 S/CO

701432621

230503

[diagnosis] - 2023-05-02 admission note

  • Adenocarcinoma of gastric middle body anterior wall, pT4aN1M0 stage IIIA status post total gastrectomy with lymphadenectomy of station 1 to 12 and 14V, retrocolic Roux-en-Y anastomosis reconstruction with Endo GIA on 2022-09-05.
  • Iron deficiency anemia, unspecified

[exam findings]

  • 2022-12-26 PET
    • Increased FDG uptake in several celiac lymph nodes, gastric cancer with regional lymph nodes involvement should be considered, suggesting further investigation.
    • Increased FDG uptake in the right lobe of the liver, highly suspected gastric cancer with distant metastases.
    • Increased FDG uptake in the right nasopharynx, the nature is to be determined (inflammation/infection process or other nature ?), suggesting further investigation.
    • Gastric cancer s/p treatment with suspected regional lymph nodes and liver metastases, cTxN2M1, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2022-11-28 CT - abdomen
    • Indication: Adenocarcinoma of gastric middle body anterior wall, pT4aN1M0 stage IIIA status post total gastrectomy with lymphadenectomy of station 1 to 12 and 14V, retrocolic Roux-en-Y anastomosis reconstruction with Endo GIA on 2022-09-05.
    • Abdominal CT with and without enhancement revealed:
      • s/p gastrectomy.
      • Hepatic tumors at S7 about 3.2cm and S6 about 2.9cm in largest dimension is found. Liver meta is considered. In comparison with CT dated on 2022-07-19, the tumors are enlarged.
    • Imp:
      • s/p gastrectomy.
      • Liver meta. In progression.
  • 2022-09-06 Patho - stomach subtotal/total (tumor)
    • PATHOLOGIC DIAGNOSIS
      • Stomach, total gastrectomy — Tubular adenocarcinoma
      • Margins, bilateral cutting ends and radial, total gastrectomy — Free of tumor invasion
      • Lymph nodes, LN dissection — Metastatic adenocarcinoma (2/40)
      • Omentum, omentectomy — Free of tumor invasion
      • AJCC Pathologic staging — pT4aN1(cM0), stage IIIA
    • MACROSCOPIC EXAMINATION
      • Specimen type: Stomach, lymph nodes, omentum
      • Specimen size: (a) Stomach: 36 cm long greater curvature and 19 cm along lesser curvature, (b) Omentum: 35 x 20 x 5.0 cm
      • Number of lesions: Solitary
      • Tumor site: Middle body, anterior wall, lesser curvature, 6.0 cm from distal margin
      • Tumor size: 9.2 x 7.5 x 3.5 cm
      • Tumor configuration: Fungating tumor with central ulceration
      • Representative sections as follows: A1= proximal margin, A2= distal margin, A3-A9= tumor, A10= lesser curvature LN, B= LN 1, C= LN 2, D= LN 3, E1-E2= LN 4, F= LN 5, G= LN 6, H1-H2= LN 7,8,9,11,12, I= LN 10, J= LN 14v, K1-K3= omentum
    • MICROSCOPIC EXAMINATION
      • Histologic type: Tubular adenocarcinoma (Lauren classification: intestinal type)
      • Histologic grade: Moderately differentiated (G2)
      • Depth of tumor invasion: Tumor invades the serosa
      • Margins: All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin: 3 mm from radial margin
      • Perineural invasion: Present
      • Lymphovascular space invasion: Present
      • Regional lymph nodes: Metastatic adenocarcinoma (2/40)
        • 1/1 (lesser curvature LN), 0/2 (LN 1), 0/3 (LN 2), 1/4 (LN 3), 0/6 (LN 4), 0 (LN 5), 0/8 (LN 6), 0/13 (LN 7, 8, 9, 11, 12), 0/3 (LN 10), 0 (LN14v) (Number of LN involved/Number of LN examined)
      • Extracapsular extension: Present
      • Omentum: Free of tumor invasion
      • Additional pathologic findings: Non-atrophic chronic gastritis
      • Pathologic Staging: pT4aN1(cM0), stage IIIA
      • IHC (S2022-12775): HER2 (Positive, score= 3+)
  • 2022-08-30 MRI - liver, spleen
    • History and indication: Gastric cancer, suspect liver metastasis
    • With and without contrast MRI of liver revealed:
      • Gastric cancer with peritoneal seeding and LNs metastases.
      • Two enhancing tumors (2.7cm, 2.9cm) at S5 and S7 of liver without venous wash out pattern. Another small enhancing nodules at both hepatic lobes.
      • Tiny liver and renal cysts.
    • IMP:
      • Gastric cancer with peritoneal seeding and LNs metastases.
      • Suspected liver hemangiomas.
  • 2022-08-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (205 - 59) / 205 = 71.22%
      • M-mode (Teichholz) = 71
    • Conclusion:
      • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis.
      • (suboptimal parasternal echo window barrel chest)
  • 2022-08-04 Patho - stomach biopsy
    • Stomach, AW side of mid body, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands.
    • The immunohistochemical stains reveal CK(+) and Her-2/neu (Ab): Positive (3+).
  • 2022-08-04 Esophagogastroduodenoscopy, EGD
    • Highly suspected gastric malignancy, s/p biopsy
    • Reflux esophagitis LA grade A
    • Superficial gastritis
  • 2022-07-19 CT - abdomen
    • History: easy hunger(+),
      • weight loss 72 (before) -> 68.5 (2022/04) -> 63kg (2022/06)
      • 2022/07/07 exertional dyspnea recent months.
      • 2022/07/18 s/p one week iron supplement, no adverse effect
    • Indication: Abnormal weight loss
    • Findings:
      • There is lobulated circumferrential irregular wall thickening at the stomach fundus and body, measuring 2.8 cm in the maximal wall thickness (T3).
        • Lymphoma is highly suspected.
        • The differential diagnosis include signet ring cell carcinoma.
        • Please correlate with gastroscopy.
        • In addition, There are ten enlarged nodes in the adjacent omentum, gastrohepatic ligament and hepatoduodenal ligament that may be metastatic nodes (N3a).
      • There are two ill-defined homogeneous enhancing lesion measuring 2.5 cm in S7 and 2.2 cm in S5 of the liver at arterial phase images but isodensity (no contrast washout) in portal venous phase and delayed phase images.
        • The differential diagnosis include Atypical hemangioma, FNH and metastasis. Please correlate with MRI.
      • There are several small poor enhancing lesions on both hepatic lobes, the largest one 5 mm, that may be cysts?
        • However, they are too small to chracterize.
      • Please correlate with sonography.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N3a (N_value) M:M0 (M_value) STAGE:III(Stage_value)
  • 2022-07-12 SONO - abdomen
    • Diagnosis
      • Liver tumors, S5 and S7
      • Possible small para-aortic pymph nodes
    • Suggestion
      • 4 phase CT or dynamic MRI study

[consultation]

  • 2022-08-30 Gastroenterology
    • Q
      • This is a 61 year-old male, without underlying disease, admitted because of body weight loss 5 kg in 3months.
      • Panendoscope revealed one massive ulcerative tumor at gastric body. Pathology showed adenocarcinoma.
      • Abdominal CT also revealed 2 Liver tumor, differential diagnosis included atypical hemangioma, FNH and metastasis.
      • We need your expertise for TPN support
    • A
      • A case of gastric cancer who request pre-op nutrition support.
        • General appearance: ill looking
        • GI tract: Dysphagia (-), Abd pain (-), Abd distension (-), Nausea (-), Vomiting (-), Diarrhea (-), Poor appetite (-), Poor digestion (-), BW loss (+, 5kg/3Ms) , stool (+), Bowel sound (-)
        • Feeding: as tolerance
        • Allergy: NKA
        • Nutrition assessment:
          • BH 176cm BW 64.5kg
          • IBW 68.2kg 95%IBW BMI 20.8
          • BEE 1421kcal TEE 2217kcal
        • Lab data: Alb 3.7 K 4.2 TP 7.0 BS 98
        • According to the patient’s present conditions, parenteral nutrition plus enteral feeding (as tolerance) will be suitable for nutrition supply. We will follow this case for adjustment of optimal nutrition support.
      • PN Use Suggestion:
        • DC SMOFkabiven peri 1440ml QD (KCL 10ml)
        • SMOFkabiven central 1477ml QD, 61.5ml/hr
        • Lyo-Povigent 4ml/QD (add in TPN) (when out of stock, switch to adding B-complex 1ml/QD and Vitacicol 2ml/QD in TPN)
        • Addaven 10ml/QD(add in TPN)
      • Items to monitor during PN (Parenteral Nutrition) use:
        • TPN is used with single route, do not mix with other medications besides TPN drugs.
        • Check BW QW5 and record I/O Q8H
        • Check one touch Q6H x 2days, if stable QD check
        • Please control BS <200 mg/dl with RI sliding scale
        • QW1 check CBC/DC
        • QW1 check BUN. Cr. AST. ALT. T/D Bil. TG. ALP. rGT. Na. K. Cl. Ca. P. Mg. Zinc. Alb. Prealbumin or Transferrin
        • When TPN is insufficient, substitute with YF5 or D10W
        • On the day of surgery, temporarily hold the lipid emulsion
        • Kabiven requires daily pump set replacement

[MedRec]

  • 2022-12-27 SOAP Hemato-Oncology
    • S
      • PET scan (12/26 22):
        • several celiac LNs, gastric CA wt regional LNs involvement should be considered.
        • Lesion at R lobe of the liver, R/I mets. Imp: Gastric CA s/p Tx wt suspected regional LNs & liver mets, cTxN2M1, stage IVB (AJCC 8th ed.).
      • Liver mets poved by PET scan post post-Op adjuvant C/T wt mFOLFOX (self-paid) IV Q2W x 6 (12/27 22).
      • Adm 2 wk later on 1/9 23 for #1 2nd line palliative C/T wt FOLFIRI IV Q2W x 6.
  • 2022-09-24 SOAP Hemato-Oncology
    • S
      • adjuvant C/T wt mFOLFOX IV Q2W x 12 & post-Op adjuvant CCRT (9/24 22).
      • HBsAg, anti-HCV (7/26 22): negative. will do anti-HBc (9/24 22).
      • will consult Dr in Radiation Oncology for R/T to gastric tumor bed. (9/24 22).
      • will give post-Op adjuvant C/T wt mFOLFOX (self-paid) IV Q2W x 6 then post-Op adjuvant CCRT wt 5-FU 24hr QD x 5 per wk x 6 plus R/T then post-Op adjuvant C/T wt mFOLFOX (self-paid) IV Q2W x 6 (9/24 22).
      • Adm 1 wk later on 10/3 22 for #1 post-Op adjuvant C/T wt mFOLFOX ( self-paid ) IV Q2W x 6.
    • A
      • Gastric CA, pT4aN1 (2/40) cM0, stage IIIA, s/p total gastrectomy on 9/5 22
  • 2022-08-11 SOAP Gastroenterology and Hepatology
    • Assessment
      • Consider gastric cancer with LN metastasis
      • the liver tumor may be not metastasis but may arrange MRI to check if it was hemangioma or FNH.

[surgical operation]

  • 2022-09-05
    • Surgery
      • Total gastrectomy with lymphadenectomy of station 1 to 12a and 14v.
      • Retrocolic Roux-en-Y anastomosis reconstruction with Endo GIA.
    • Finding
      • 8x7x4 cm tumor at middle body anterior wall of stomach invaded the serosa.
      • Lymph node enlargement at station 3.
      • Scarring around gastroduodenal junction.
      • No ascites, no peritoneal seeding and no liver surface metastasis.
      • cT4aN2M0 stage III.

[chemoimmunotherapy]

  • 2023-05-02 - trastuzumab 440mg NS 100mL 1.5hr + irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2400mg/m2 4090mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2023-04-07 - trastuzumab 440mg NS 100mL 1.5hr + irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2023-03-17 - irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2023-02-21 - irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2023-02-06 - irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2023-01-12 - irinotecan 170mg/m2 285mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2022-12-23 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-09 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-25 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-10 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-24 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-05 - oxaliplatin 70mg/m2 100mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4760mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[assessment]

  • The patient was diagnosed with gastric adenocarcinoma, pT4aN1M0 stage IIIA in July 2022. Total gastrectomy with lymphadenectomy was performed on 2022-09-05, followed by FOLFOX treatment starting on 2022-10-05.

  • A CT scan on 2022-11-28 showed liver metastases in progression, and a PET scan on 2022-12-26 revealed that the gastric cancer had progressed, with suspected regional lymph nodes and liver metastases, cTxN2M1, stage IVB. After receiving six doses of FOLFOX (with the last dose administered on 2022-12-23), the patient’s regimen was changed to FOLFIRI starting on 2023-01-12.

  • The patient was admitted to the hospital for his 6th dose of FOLFIRI (trastuzumab was added to the regimen since 2023-04-07, making this the 2nd dose). The patient tolerates the regimen well, and no significant adverse reactions have been observed.

  • After partial or total gastrectomy, the availability of gastric acid and intrinsic factor, both essential for vitamin B12 absorption, is reduced or eliminated. As a result, individuals who have undergone partial or total gastrectomy would benefit from supplementing their diet with oral vitamin B12 or receiving intramuscular or subcutaneous injections of vitamin B12. B-Red (hydroxocobalamin) is appropriately administered as a daily supplement for this patient.

  • The patient’s underlying condition of chronic viral hepatitis B is appropriately treated with Baraclude (entecavir).

  • A review of the PharmaCloud database reveals that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.

The patient was proved with gastric adenocarcinoma, pT4aN1M0 stage IIIA in July 2022. Total gastrectomy with lymphadenectomy was performed on 2022-09-05 then FOLFOX was applied since 2022-10-05.

2022-11-28 CT showed liver mets in progression and 2022-12-26 PET showed the gastric cancer progressed with suspected regional lymph nodes and liver mets, cTxN2M1, stage IVB. After administration of 6 times of FOLFOX (last dose on 2022-12-23), then the regimen changed to FOLFIRI since 2023-01-12.

The patient admitted this hospitalization for his 6th dose of FOLFIRI (trastuzumab was added to the regimen since 2023-04-07, this time the 2nd dose). The patient tolerates the regimen well and no obvious adverse reaction is found.

The PharmaCloud database shows that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.

700758055

230502

[diagnosis]

  • Malignant neoplasm of left renal pelvis, small cell neuroendocrine carcinoma, ypT4NxcM0, ypStage IV

[past history]

  • hypertension
  • type II diabetes mellitus
  • dyslipidemia
  • insomnia
  • OP history: appendectomy 30 years ago, left laparoscopic nephroureterectomy on 2021-08-30.      

[family history]

  • Father - CVA.
  • Mother - hepatoma.

[exam findings]

  • 2023-04-29 CT - abdomen
    • Indication: Small cell neuroendocrine carcinoma of left kidney, ypT4NxcM0, ypStage IV s/p chemotherapy with Topotecan from 2023/01/16
    • With and without contrast enhancement CT of abdomen shows:
    • Imaging Protocol: 5mm slice thickness, axial scan and coronal reconstruction
      • s/p left nephrectomy.
      • Para-aortic mass lesions, in progression.
      • Enlarged lymph nodes along bilateral iliac vessels.
      • Small nodular lesions, up to 0.8cm, in liver.
      • No ascites or extraluminal free air.
      • No bony destructive lesion on these images.
    • Impression
      • s/p left nephrectomy
      • Para-aortic mass lesion, in progression; DDx: recurrent tumor, lymph node metastasis
      • Suspect liver metastasis
  • 2023-02-06, -01-23, -01-16 Standing KUB
    • Fecal material store in the colon.
  • 2023-01-27 PD-L1 IHC 28-8
    • S2021-11516A9, renal pelvic cancer
    • Tumor cell (TC) staining assessment: >= 1% and <5%
    • Percentage of PD-L1 expressing tumor cells (TC):1%
  • 2023-01-27 PD-L1 IHC 22C3
    • Combined Positive Score (CPS) assessment: >=1 and <10
    • Combined Positive Score (CPS) : 2
  • 2023-01-05 CT - abdomen
    • History and indication: renal pelvis tumor, s/p OP
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • Non-contrast CT of abdomen-pelvis revealed:
      • S/P left nephrectomy. Soft tissues in paraaortic region and pelvic cavity (progression).
      • Collapse of gallbladder.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • S/P left nephrectomy. Progression of tumor recurrence.
  • 2022-11-09 Gynecologic ultrasonography
    • EM: 3.7mm
  • 2022-11-02 KUB
    • Disc space narrowing at L4/5.
  • 2022-10-07 CT - abdomen
    • History:
      • 20210510 CT: left renal pelvis UC with LN metastases, cT3N1M1
      • 20210830 left nephrectomy: pT4Nx (if cM0), pstage:IV
      • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.
        • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
      • Findings:
        • S/P left nephrectomy.
          • Prior CT idenified metastatic nodes in left para-aortic space are noted again, increasing in size that are c/w metastatic nodes S/P C/T with progressive disease.
            • In addition, Prior CT idenified enlarged nodes in right para-cava space are noted again, stable in size.
            • Follow up is indicated.
        • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
      • IMP:
        • Prior CT idenified metastatic nodes in left para-aortic space are noted again, increasing in size that are c/w metastatic nodes S/P C/T with progressive disease.
  • 2022-09-23 Tc-99m MDP whole body bone scan
    • Increased activity in the middle and lower T-spines and lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Some faint hot spots in the right rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, wrists, hips, knees and feet, compatible with benign joint lesions.
  • 2022-07-22 CT - abdomen
    • Findings:
      • S/P left nephrectomy.
        • Prior CT idenified metastatic nodes in left para-aortic space are noted again, mild decreasing in size that are c/w metastatic nodes S/P C/T with partial response .
      • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
    • IMP:
      • Prior CT idenified metastatic nodes in left para-aortic space are noted again, mild decreasing in size that are c/w metastatic nodes S/P C/T with partial response .
  • 2022-04-07 CT - abdomen
    • Findings
      • S/P left nephrectomy. Soft tissues in paraaortic region.
    • IMP:
      • S/P left nephrectomy. Soft tissues in paraaortic region suspected tumor recurrence.
  • 2022-01-05 CT - abdomen
    • Findings:
      • S/P left nephrectomy.
        • There is lobulated soft tissue lesions in left para-aortic space and left common iliac chain that may be metastatic nodes.
      • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
    • IMP:
      • Metastatic nodes in left para-aortic space and left common iliac chain are suspected.
  • 2021-09-06 Cystography
    • Cystography via foley catheter administration revealed:
      • The bladder capacity is about 100cc.
      • No evidence of contrast medium leakage.
  • 2021-08-31 Patho - kidney partial/total resection
    • Diagnosis
      • A
        • Kidney, left pelvis, laparoscopic nephroureterectomy — Small cell neuroendocrine carcinoma, s/p chemotheraphy, AJCC 8th edition: ypStage IV, ypT4Nx(if cM0)
        • Ureter, left, nephrectomy — Negative for malignancy
        • Blood vessel, left, nephrectomy — Negative for malignancy
        • Capsule, left kidney, nephrectomy — Small cell neuroendocrine carcinoma, by direct invasion
      • B: Soft tissue, labeled as “para-aortic lymph node”, excision — Negative for malignancy (0/0)
    • Gross Description
      • Procedure: laparoscopic nephroureterectomy
      • Laterality: Left
      • Specimen size:
        • Kidney: 7.4 x 4.0 x 2.5 cm; 60 gm
        • Ureter: 15.9 cm in length and 0.4 cm in maximal diameter
        • Adrenal gland: not received
      • Tumor size: 1.5 x 1.5 x 1.2 cm
      • Tumor site: Renal pelvis, parenchyma, hilar soft tissue, and invasion through the capsule to the perinephric fat
      • Tumor appearance: fibrosis
      • Tumor focality: Unifocal
      • A piece of tissue, labeled as “para-aortic lymph node”, is received.
      • Sections are taken and labeled as: A1: ureteral resection margin; A2: capsule; A3: blood vessel; A4: kidney, non-tumor; A5: ureter; A6-7: hilar soft tissue; A8-13: tumor (A11: with upper ureter); A14-16: tumor with capsule and the perinephric fat; B: para-aortic lymph node.
    • Microscopic Description
      • Histological type:: Small cell (neuroendocrine) carcinoma;
        • The immunohistochemical stains reveal CK(+), CD56(+), Synaptophysin(+), Chromogranin A(focal +), CD10(-), PAX8(-), CK5/6(-), and GATA3(-).
        • The Ki-67 is < 5%.
      • Histological grade: poorly differentiated
      • Pathological staging (pTNM, AJCC 8th edition):
        • TNM Descriptors: (required only if applicable) (select all that apply): y (posttreatment)
          • Primary tumor (pT): pT4: Tumor invades adjacent organs, or through the kidney into the perinephric fat
          • Regional lymph nodes (pN): pNx: Regional lymph node cannot be assessed
          • Distant metastasis (pM): (required only if confirmed pathologically in this case): if cM0
      • Section margins: Uninvolved by invasive carcinoma; 15.9 cm away from the ureteral resection margin; 0.8 cm away from the hilar soft tissue resection margin; 0.5 cm away from the perinephric fat resection margin.
      • Lymphovascular invasion: Present
      • Pathologic findings in ipsilateral nonneoplastic kidney: lymphocytic infiltration and fibrosis
      • Additional pathologic findings: No lymph node is seen in “para-aortic lymph node” specimen.
      • Perineural invasion is seen.
  • 2021-08-29 CXR
    • Intimal calcification of thoracic aorta.
  • 2021-08-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 32) / 79 = 59.49%
      • M-mode (Teichholz) = 59
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA; septal hypertrophy; LV diastolic dysfunction, Gr 1
    • Mild MR and trivial TR
    • Preserved RV systolic function
  • 2021-08-10 CT - abdomen
    • Clinical history: 76 y/o female patient with right renal pelvis UC with lymph node metastasis, cT3N1M1, PD-L1 all negative.
    • WITHOUT contrast enhancement CT: ABD — whole abdomen, pelvis:
      • Regression of left renal tumor and paraaortic soft tissue, could be due to regression of renal pelvis UC with lymph nodes metastasis.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
    • Impression:
      • Left renal UC with lymph nodes metastasis, regression.
  • 2021-06-09 PD-L1 (SP142)
    • VENTANA PD-L1 (SP142) Assay for Urothelial Carcinoma
      • PD-L1 Expression: <5% IC
      • Scores: Immune cells (IC): <1%; Tumor cells (TC): 0%
  • 2021-05-29 KUB
    • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
    • Mild lumbar spondylosis.
  • 2021-05-29 Bladder Sonography
    • PVR 10.7mL
  • 2021-05-24 Patho - kidney biopsy
    • Kidney, left, CT guided biopsy — Compatible with invasive urothelial carcinoma, high-grade
    • The sections show sheets of spindle to oval-shaped pleomorphic neoplastic cells with hyperchromatic nuclei, embedded in fibrous stroma. Severe crush artifact is present.
    • IHC: GATA3(focal +), CK5/6(focal +), PAX8(-), CD10(focal +), and Vimentin(focal +).
    • The finding is compatible with high-grade invasive urothelial carcinoma. Renal cell carcinoma is less likely.
  • 2021-05-24 Body fluid cytology - urine
    • Diagnosis: Atypia
    • Macroscopic examination: L’t ureter: 6 cc colorless clear urine by URS
    • Microscopic examination: Smears show a few urothelial cells with mild enlarged nuclei. No morphologic evidence of high grade, but low grade urothelial carcinoma can not be excluded completely due to cytologic limitation. Please correlate with the biopsy result for conclusive diagnosis.
  • 2021-05-23 ECG
    • Normal sinus rhythm
    • Cannot rule out Inferior infarct, age undetermined
    • T wave abnormality, consider anterior ischemia

[chemotherapy]

  • 2023-03-31 - topotecan 0.75mg/m2 1.2mg NS 30mL 30min D1-4
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-4
  • 2023-03-06 - topotecan 0.75mg/m2 1.2mg NS 30mL 30min D1-4
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-4
  • 2023-02-13 - topotecan 0.75mg/m2 1.2mg NS 30mL 30min D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3
  • 2023-01-18 - topotecan 0.75mg/m2 1.2mg NS 30mL 30min D1-3 (topotecan 1.5mg/m2 adjusted to 0.75mg/m2 due to impaired renal function)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3
  • 2023-01-16 - topotecan 1.5mg/m2 2mg NS 50mL 30min D1-5
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-5
  • 2022-07-21 - [etoposide 100mg/m2 120mg NS 500mL 2hr + cisplatin 25mg/m2 30mg NS 200mL 3hr] D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-3 + granisetron 1mg D1
  • 2022-06-23 - [etoposide 100mg/m2 120mg NS 500mL 2hr + cisplatin 25mg/m2 30mg NS 200mL 3hr] D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-3 + granisetron 1mg D1
  • 2022-05-26
  • 2022-04-28
  • 2022-01-04
  • 2021-12-07
  • 2021-10-28
  • 2021-10-05 - [etoposide 100mg/m2 120mg NS 500mL 2hr + cisplatin 25mg/m2 30mg NS 200mL 3hr] D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-3
  • 2021-08-10 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-08-03 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-07-20 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-07-13 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-06-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-06-22 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-06-08 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-06-01 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)

==========

2023-05-02

  • On 2022-10-07, 2023-01-05, and 2023-04-29, CT scans demonstrated disease progression, with the most recent scan also revealing possible liver metastases. This information highlights the need for close monitoring and potentially re-evaluating the patient’s treatment plan.

  • The patient’s renal function improved according to the most recent lab values.

    • 2023-04-28 Creatinine 0.92 mg/dL
    • 2023-04-19 Creatinine 1.46 mg/dL
    • 2023-04-11 Creatinine 1.44 mg/dL
    • 2023-03-28 Creatinine 1.47 mg/dL
    • 2023-04-28 eGFR 62.91
    • 2023-04-19 eGFR 36.92
    • 2023-04-11 eGFR 37.52
    • 2023-03-28 eGFR 36.63
  • If the initial consideration for reducing the dose of topotecan was due to the patient’s inadequate renal function, this reason becomes less important. However, the patient also experienced leukopenia and thrombocytopenia after the standard dose of 1.5 mg/m2 topotecan in January 2023. The full standard dose may potentially lead to episodes of leukopenia and/or thrombocytopenia. A moderate titration to 0.9 or 1.0 mg/m2 from 0.75mg/m2 could be considered as a feasible option to balance treatment efficacy and side effect profile if the same regimen is intended to be continued.

2023-03-07

  • This patient has a tendency to develop leukopenia and/or thrombocytopenia after receiving the normal dose of 1.5mg/m2 topotecan. However, after the dose was reduced to 0.75mg/m2, no further high-grade adverse reactions were observed.

    • 2023-03-02 WBC 5.87 x10^3/uL

    • 2023-02-23 WBC 12.24 x10^3/uL

    • 2023-02-16 WBC 3.07 x10^3/uL

    • 2023-02-13 WBC 4.44 x10^3/uL

    • 2023-02-09 WBC 22.96 x10^3/uL

    • 2023-02-06 WBC 2.70 x10^3/uL

    • 2023-02-03 WBC 2.09 x10^3/uL

    • 2023-02-01 WBC 2.32 x10^3/uL

    • 2023-01-30 WBC 1.66 x10^3/uL

    • 2023-01-27 WBC 0.71 x10^3/uL

    • 2023-01-26 WBC 0.70 x10^3/uL

    • 2023-01-22 WBC 2.41 x10^3/uL

    • 2023-01-16 WBC 5.05 x10^3/uL

    • 2023-03-02 PLT 234 x10^3/uL

    • 2023-02-23 PLT 109 x10^3/uL

    • 2023-02-16 PLT 275 x10^3/uL

    • 2023-02-13 PLT 308 x10^3/uL

    • 2023-02-09 PLT 270 x10^3/uL

    • 2023-02-06 PLT 123 x10^3/uL

    • 2023-02-03 PLT 65 x10^3/uL

    • 2023-02-01 PLT 47 x10^3/uL

    • 2023-01-30 PLT 50 x10^3/uL

    • 2023-01-27 PLT 154 x10^3/uL

    • 2023-01-26 PLT 38 x10^3/uL

    • 2023-01-22 PLT 155 x10^3/uL

    • 2023-01-16 PLT 312 x10^3/uL

2023-02-14

  • S2021-11516A9 (renal pelvic cancer) 2023-01-27 PD-L1 IHC lab results:

    • [28-8]
      • Tumor cell (TC) staining assessment: >= 1% and <5%
      • Percentage of PD-L1 expressing tumor cells (TC): 1%
    • [22C3]
      • Combined Positive Score (CPS) assessment: >=1 and <10
      • Combined Positive Score (CPS): 2
  • PD-L1 expression is not high, suggesting that certain PD-L1 targeted drugs are less likely to be effective against the tumor.

  • In light of the patient’s diarrhea episodes last month, please keep an eye on her bowel movements. Topotecan is associated with nausea (grade 3/4 8-10%), diarrhea (grade 3/4 6%), and vomiting (grade 3/4 10%). Since the administration days and daily dose of topotecan have been reduced (1.5mg/m2 -> 0.75m2/m2; 5 days -> 3 days), the adverse reaction should be mitigated. As well, Smecta (dioctahedral smectite) 3mg PO PRNTIDAC has been prescribed.

2023-01-27

  • 2023-01-27 WBC 710 cells/uL, Neutrophil 5%, ANC < 500 cells/uL, grade 4 neutropenia developed, Granocyte (lenograstim) and Cefim (cefepime) have been initialized since 2023-01-26 morning. Since 2023-01-26 19:00, the patient’s body temperature has not exceeded 37.5 degrees Celsius.
  • During the period of 2023-01-24 to 26, there were 3, 2, 3 bowel movements, and Nako No.5 (electrolyte supplement) was administered appropriately.
  • As far as the active prescription is concerned, there is no problem.

700509855

230428

[diagnosis] - 2023-04-27 admission note

  • Malignant neoplasm of stomach, unspecified
  • Secondary malignant neoplasm of right ovary
  • Secondary malignant neoplasm of retroperitoneum and peritoneum
  • Essential (primary) hypertension

[exam findings]

  • 2023-04-27 KUB
    • S/P port-A insertion.
    • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
    • Lumbar spondylosis.
    • T12 and L1 compression fractures.
  • 2023-04-27 CXR
    • Emphysematous change of bilateral lungs.
    • No cardiomegaly.
    • Thoracolumbar spondylosis.
    • R/O old fractures at left ribs.
  • 2023-04-24 Cytology - ascites
    • 17 cc yellow turbid ascites — Atypia (before IP C/T)
  • 2023-04-20 CT - chest
    • Indication: GIST with peritoneal and ovarian metastasis, stage IV s/p HIPEC and operationr/o other metastasis
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Calcified dot at subpleural space of right lower lobe is found measuring 0.24cm in largest dimension.
        • Bilateral apical pleura fibrosis is found.
        • Calcified coronary arteries is found.
        • There is moderate bilateral pleural effusion.
      • Visible abdomen:
        • Moderate ascites formation is found. Dirty appearance of the mesentery is found. Cancerous peritonitis is considered. In comparison with CT dated on 2022-12-13, the lesion is stationary.
        • Bilateral hydronephrosis and hydroureter is found. Stable.
        • Dilatation of the IHDs and CBD is noted.
        • The intestines are dilated.
    • IMp:
      • Moderate bilateral pleural effuison and massive ascites with cancerous peritonitis
      • Bilateral hydronephrosis and hydroureter. Stable
      • Dilatation of the IHDs and CBD
  • 2023-04-19 Tc-99m MDP bone scan with SPECT
    • The hot spot in the lateral aspect of a left lower rib (10th rib ?) comes to faint compared with the previous study on 2023-01-04, probably post-traumatic change.
    • However, there are several new lesions of increased tracer uptake in the posterior aspect of the left rib cage and in three lower T- and upper-L-spine, bone metastasis and/or pathological fracture should be considered, suggesting MRI for investigation.
    • Suspected benign lesions in the maxilla, both rib cages, bilateral shoulders, and hips.
  • 2023-04-17 ECG
    • Low voltage QRS
  • 2023-03-27 L-spine Ap + Lat (including sacrum)
    • Degeneration and spondylosis of L-S spine.
    • Atherosclerosis of the aorta.
  • 2023-03-27 Peripheral Vascular Test - vein, lower limbs
    • Conclusion
      • No evidence of venous thrombosis at bilateral lower limbs venous systems.
      • No significant venous refluxes at biateral lower limbs venous systems.
      • Tissue edema at bilateral lower legs.
      • The ratios of MVO and SVC of bilateral legs were within normal limits.
  • 2023-03-10 ECG
    • Sinus rhythm with Premature atrial complexes
  • 2023-02-16 SONO - abdomen
    • Hepatic cysts
    • Bil hydronephrosis
    • Ascies, mild
    • CBD dilatation
    • Rt renal cyst
  • 2023-01-13 Patho - peritoneum biopsy
    • DIAGNOSIS:
      • Peritoneum, biopsy — metastatic adenocarcinoma, consistent with gastric origin
      • Soft tissue, right pelvic tumor, biopsy — metastatic adenocarcinoma, consistent with gastric origin
      • Ovary, right, oophorectomy — Metastatic adenocarcinoma, consistent with gastric origin — Serous cystadenoma
      • Fallopian tube, right, salpingectomy — Metastatic adenocarcinoma, consistent with gastric origin
    • MICROSCOPIC DESCRIPTION:
      • Section shows fibroadipose tissue with infiltration of signet-ring cells.
        • The immunohistochemical stain of CK is positive. Metastatic adenocarcinoma from stomach is favored. Please correlate with the clinical presentaion.
      • Sections show ovary with metastatic glandular and signet-ring tumor cells. An ovarian cyst lined by a single layer of benign serous epithelium is also seen. The fallopian tube reveals transmural invasion of glandular and signet-ring tumor cells. Lymphovascular and perineural invasion is seen.
        • The immunohistochemical stains reveal CK7(+), CK20(+), CDX2(+), and PAX8(-). The results are consistent with metastatic adenocarcinoma from stomach.
  • 2023-01-04 Tc-99m MDP bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed a hot spot in the lateral aspect of a left lower rib (10th rib ?), faint hot spots in both rib cages, and increased activity in the maxilla, some T- and L-spine, bilateral shoulders, and S-I joints, in whole body survey. Radiotracer retention in bilateral kidneys was noted.
    • IMPRESSION:
      • A hot spot in a left lower rib, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral shoulders, and S-I joints.
      • Radiotracer retention in bilateral kidneys, the nature is to be determined, suggesting further evaluation.
  • 2022-12-29 Cell block
    • Clinical Finding: ovary cancer
    • 50cc, turbid, orange — Positive for malignancy
    • Smears and cell block show atypical neoplastic cells with abundant clear cytoplasm and pushing nuclei with signet ring-like picture.
  • 2022-12-28 CT - chest
    • Indication: moderate right pneumothorax.
    • Findings
      • lungs: dependent partial atelectasis of RLL and band subsegmental atelectasis of RUL. tiny granuloma (3mm) at LLL and two tiny granulomas (3mm) at RLL. two noncalcified solid nodules (up to 6mm) and several faing lobular GGOs at LUL. suspicious cylindrical bronchiectasis at LLL.
      • Mediastinum and hila: no enlarged LN or mass. mild calcified plaques of the LAD and LCX coronary arteries.
      • Aorta: normal caliber, minimal atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers..
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal contents:
        • massive ascites and soft tissue densities in the omentum, along peritoneum.
        • a ulcerative tumor at posterior wall of the body of stomach.
        • Lt heaptic cyst 7cm, Rt renal cyst 1.6cm, and bilateral hydronephrosis.
        • normal appearance of gall bladder. unremarkable of the spleen, both adrenal glands, and pancreas.
        • no enlarged lymph node.
      • Visualized bones: unremarkable. .
    • Impression:
      • moderate right pneumothorax. tiny granulomas in RLL and LLL and small nodules in LUL (favor benign nodules) of lung.
      • gastric cancer with massive ascites and peritoneal carcinomatosis
  • 2022-12-27 Patho - stomach biopsy (Y1)
    • Stomach, upper body, PW, biopsy — Adenocarcinoma, signet ring-like, non-cohesive.
    • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands and signet ring-like neoplastic cells.
      • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0).
      • ADDENDUM: IHC stains: PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2022-12-26 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis, lower esophagus, LA classification, grade A
    • Superfical gastritis, antrum
    • Advanced gastric cancer, type III, upper body, PW, s/p biopsy
  • 2022-12-26 Colonoscopy
    • The scope had been inserted up 20 cm above anal verge, probably at level of rectal-sigmoidal juncction. Futher insertion is difficult because acute angle. Thus, the exam was stopped
    • Diagnosis
      • Internal hemorrhoid
      • Incomplete study
  • 2022-12-19 ECG
    • Low voltage QRS
    • Nonspecific T wave abnormality
  • 2022-12-19 CXR
    • Mild cardiomegaly.
    • Tortuous thoracic aorta with intimal calcification.
    • Thoracic spondylosis.
    • Osteoporosis of the bones.
  • 2022-12-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 24) / 93 = 74.19%
      • M-mode (Teichholz) = 75
    • Conclusion:
      • Normal LV filling pressure; impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis with mild AR; mild MR; mild TR.
      • Mild aortic root calcification with multiple protruding atheromas (4-5 mm of thickness).
  • 2022-12-13 CT - abdomen
    • Clinical history: 77 y/o female patient with p3 (NSD)
      • prev abd op(-), low abd pain, leukorrhea and dysuria, low abd pain, leukorrhea and dysuria
      • 2022/12/12 sonar: EM 0.85cm RASD mass 7.3x7cm, solid?? uterine myoma or ROV tumor? ovarian malignancy cannot be excluded ROV cyst 5.3 x 5cm ascites > 500 c.c
    • With and without contrast enhancement CT of abdomen–whole:
      • Heteregneous cystic tumor, 7.6cm in right adnexa, r/o right ovarian malignancy.
      • Dilatation of the appendix with enhancement, r/o appendiceal malignancy.
      • Presence of massive ascites and soft tissue densities in the omentum, along peritoneum, r/o peritoneal carcinomatosis.
      • Large cystic tumor, 6.9cm in left lobe liver, r/o liver cyst.
      • Bilateral renal cysts, up to 1.6cm in right kidney.
      • Bilateral hydronephrosis.
      • No enlarged lymph node in the paraaortic region.
    • Impression:
      • Peritoneal carcinomatosis.
      • Dilatation of appendix with focal enhancement, r/o appendiceal malignancy.
      • Right ovarian cystic tumor, r/o right ovarian malignancy.
      • Liver and renal cysts.
      • Bilateral hydronephrosis.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1(M_value) STAGE:IV(Stage_value)
  • 2022-12-12 Gynecologic Ultrasonography
    • Uterus Position: AVF
      • Size: 68 x 40 mm
    • Endometrium
      • Thickness: 8.5 mm
    • IMP
      • Ascites
      • R/O Rt mass or bowel ?? 73x33mm
      • R/O Rt cyst: 51x46mm

[consultation]

  • 2023-04-18 Hemato-Oncology
    • Q
      • This is a 78 y/o female with diagnosis of gastric adenocarcinoma with peritoneal carcinomatosis and ovarian metastases, cT4aN2M1, stage IV, s/p laparoscopic examination and tumor excisional biopsy + laparoscopic HIPEC + IP port implantation + laparoscopic tumor excision/debulking with right salpingo-oophorectomy + right pelvic tumor excision and adhesiolysis on 2023/01/12.
      • She received neoadjuvant intraperitoneal and systemic chemotherapy with Oxaliplatin 130mg/m2 IV + Xeloda 1000mg BID PO + Paclitaxel 20mg IP Q4W on 2023/02/14. However, general malaise, oral ulcer, poor appetite, skin rash , bilateral lower limbs edema and diarrhea were noted after first cycle of chemotherapy and was admitted during 2023/03/14 ~ 28.
      • Due to above reason, we would like to consult your expertise on evaluation and recommendation on chemotherapy for the patient, thank you!
    • A
      • This 78 year old woman is a case of gastric adenocarcinoma with peritoneal carcinomatosis and ovarian metastases, cT4aN2M1, stage IV, s/p laparoscopic examination and tumor excisional biopsy + laparoscopic HIPEC + IP port implantation + laparoscopic tumor excision/debulking with right salpingo-oophorectomy + right pelvic tumor excision and adhesiolysis on 2023/01/12, s/p systemic chemotherapy with Oxaliplatin 130mg/m2 IV + Xeloda 1000mg BID PO + Paclitaxel 20mg IP on 2023/02/14. Due to symptom after first cycle chemotherapy, we are consulted for furhter evaluation.
        • Perform HER2, programmed death ligand 1 (PD-L1), and microsatellite testing (if not done previously).
        • If intolerable to CapOx or FOLFOX, might consider docetaxel (30-35 mg/m2) plus 5-FU 2000-2600 mg/m2 and leucovorin 200 mg/m2 with or without cisplatin (20-30 mg/m2) Q2W.
        • Thanks for your consultation.
  • 2023-02-14 Gastroenterology
    • Q
      • for pre-chemotherapy HBV treatment
      • This 78 y/o female a case of gastric cancer with ovarian and peritoneal metastasis. She underwent HIPEC on 20230112. Further neo-adjuvant chemotherapy will arrange. However, we check hepatitis showed HBsAg and anti-HCV (-), but anti-HBc (reactive). We need your expertise for pre-chemotherapy HBV treatment. Thanks for your times.
    • A
      • P
        • Check HBV DNA
        • Arrange abdominal sonography
        • Vemlidy 25mg (GFR > 15 no adjustment; GFR < 15 contraindicated; HD: no adjustment, after HD)
        • GI OPD follow up
  • 2022-12-30 Anesthesiology
    • Q
      • For CVC insertion
      • This 77y/o female a case of suspect gastric cancer with ovarian metastasis. She had poor appetite and body weight loss was noted. She need TPN for nutrition supplement. She ever tried right neck for CVC insertion, but failure and iatrogenic pneumothorax was noted. Following CXR showed pneumothorax with pleural effusion of right side, thus pig-tail was inserted on 20221229. We need your expertise for CVC insertion. Thanks for your times. On femoral, thanks.
    • A
      • Finding
        • The sonography reported small, much thrombosis and overlapped with artery at right IJV and SCV.
        • After positioning via Trendelenburg position,head rotated, elevated shoulder, the skin was sterilized and anesthetized with 2% lidocaine 2 ml.
        • We performed 3-lumen 7 fr CVC insertion to LEFT internal jugular vein under Seldinger technique
        • The CVC was fixed at 16cm
        • The pt tolerant the procedure well.
        • There was no sign of hematoma, pneumothorax, infection after the procedure.
      • The recommandation is as followed:
        • Please check chest roentgenography for localization.
        • Change IV set QD if TPN used or Q4D if general fliud.
        • Change OP site at least every week. IF loosening or blood accumulation please change it ASAP.
        • We do not recommand routinely change the CVC unless there are some infectious signs.
      • Thanks for your consultaion.
  • 2022-12-27 Thoracic Surgery
    • Q
      • For CVC insertion
      • This 77y/o female a case of suspect gastric cancer with ovarian metastasis. She had poor appetite and body weight loss was noted. She need TPN for nutrition supplement. We need your expertise for CVC insertion. Thanks for your times.
    • A
      • Central venous catheterization has been tried but failed. Please consult ANES for the procedure. Thanks for your consultation.
  • 2022-12-26 Urology
    • Q
      • For on D-J catheterization.
      • This 77-year-old female with ovarian cancer was admitted for Debulking surgery at 20221227 . We need your evaluation of her condition for on D-J catheterization. Thanks for your help!
    • A
      • CT showed massive ascites and mild bilateral hydronephroiss
      • We will arrange bilateral DBJ insertion.
  • 2022-12-26 General and Digestive Surgery
    • Q
      • For combine surgery
      • This 77-years-old female with ovarian cancer and ascites was admitted Debulking surgery.
      • The abdomen CT scan revealed
        • Peritoneal carcinomatosis.
        • Dilatation of appendix with focal enhancement, r/o appendiceal malignancy.
        • Right ovarian cystic tumor, r/o right ovarian malignancy.
      • Debulking surgery will arrange on 20221227 . We need your evaluation of her condition for combine surgery. Thanks for your help!
    • A
      • BW loss 7kg (49 -> 42) in past one month
      • suggest
        • we will performe combined surgery for her tomorrow
        • we will resected GI tract if necessary
        • PN support after operation
        • consult urologist for double J catheter implantation
        • We did not discuss with the family about HIPEC due to too weak to receive HIPEC
    • Supplementary reply 2022-12-26 17:41:10
      • PES: Advanced gastric cancer, type III, upper body, PW
      • impression: gastric cancer with peritoneal carcinomatosis and krukengerg tumor
      • suggest
        • debulking surgery is not indicated now
        • pending the report of pathology
        • nutrition support
        • may consider neoadjuvant intraperitoneal and systemic chemotherapy (NIPS) with following total gastrectomy, cytoreductive surgery, BSO and HIPEC
      • we wound like to take over this case if the patient and her family agree

[MedRec]

  • 2023-04-06 SOAP General and Gastroenterological Surgery
    • S
      • fair appetite
      • tarry stool passage?
      • SOB?
    • O
      • smooth respiration
      • pink conjunctiva
      • bilateral lower limb pitting edema
    • P
      • admit for TS-1 and IP chemotherapy
  • 2023-03-07 SOAP General and Gastroenterological Surgery
    • S
      • poor appetite, bilateral lower limbs edema
      • pink conjunctiva
    • O
      • smooth respiration
      • but poor general condition
      • hold xeloda and dexamethasone
  • 2023-01-27 SOAP General and Gastroenterological Surgery
    • S
      • Gastric adenocarcinoma with peritoneal carcinomatosis and ovarian metastases, cT4aN2M1, STAGE:IV post status laparoscopic examination and tumor excisional biopsy, laparoscopic tumor excision/debulking with right salpingo-oophorectomy, laparoscopic HIPEC and IP port implantation on 2023/01/12
      • Postprocedural pneumothorax status post thoracentesis on 2022/12/28
      • Malignant ascites
    • P
      • admission on 20230206 for bidirectional chemotherapy

[surgical operation]

  • 2023-01-12
    • Surgery
      • Diagnosis: suspected gastric cancer with ovarian metastasis (Krukenberg tumor?); pelvic bowel adhesion
      • laparoscopic tumor excision/debulking with right salpingo-oophorectomy + right pelvic tumor excision and adhesiolysis
    • Finding
      • previous gastric biopsy – malignancy (adenocarcinoma)
      • suspected gastric cancer with ovarian metastasis (Krukenberg tumor?)
      • right ovary and tube: 9x8cm, two parts–solid part 7x7cm, fragile, suspected metastastic cancer? ; cystic part 5x4cm with clear fluid
      • right tube -np (ROV + tube)
      • right pelvic tumor –2x2cm, solid suspected metastastic cancer?
  • 2023-01-12
    • Surgery
      • laparoscopic examination and tumor excisional biopsy
      • laparoscopic HIPEC
      • IP port implantation
    • Finding
      • serous ascites, about 2700ml
      • diffuse peritoneal carcinomatosis, total PCI: 23/39
      • RUQ 2
      • epigastrium 2
      • LUQ 2
      • right flank 1
      • central 1
      • left flank 1
      • RLQ 3
      • pelvis 3
      • LLQ 2
      • small bowel PCI: 2+2+1+1/12
      • HIPEC: oxalipatin 400mg + paclitaxel 120mg in D5S 3000ml, 90min, 42 degree

[chemotherapy]

  • 2023-04-21 - docetaxel 30mg/m2 38mg D5W 250mL 1hr + leucovorin 200mg/m2 250mg NS 250mL 2hr + fluorouracil 2000mg/m2 2515mg NS 500mL 24hr + [paclitaxel 20mg NS 1000mL + gentamicin 40mg + sodium bicarbonate 4200mg] IP 1hr (NIPS)

  • 2023-02-14 - oxaliplatin 130mg/m2 150mg D5W 250mL 2hr + [paclitaxel 20mg NS 1000mL + gentamicin 40mg + sodium bicarbonate 2800mg] (with 2023-02-16 ~ 2023-03-14 oral capecitabine)

  • 2023-01-12 - [oxaliplatin 400mg + paclitaxel 120mg + D5W 2500mL] IP 90min

Xeloda (capecitabine 500mg) KXEL)01

  • 2023-02-16 ~ 2023-03-14 2# BID

[assessment]

  • Significant weight loss has been observed in the patient, from 43.5kg on 2023-01-06 to 33.3kg on 2023-04-27. Megestrol has been prescribed intermittently between late Dec 2022 and late Feb 2023. If the patient can still tolerate oral intake and there are no contraindications, it may be beneficial to consider adding megestrol back into the patient’s treatment plan to help increase appetite and promote weight gain.

  • Additionally, providing nutritional support and guidance, including a consultation with a dietician, may further assist in addressing the patient’s weight loss.

  • The patient has had 7 episodes of diarrhea since 2023-04-26, as noted in the admission record. It is recommended that the number of bowel movements be included in the TPR panel along with the I/O data. If the symptom persists, the addition of loperamide may be beneficial in the management of diarrhea.

  • Both docetaxel and fluorouracil are associated with diarrhea as a side effect. If diarrhea is suspected to be more related to fluorouracil (2000mg/m2 D1), reducing the dose of fluorouracil (70~80% of the intended dose) at the next treatment may be an option to consider.

701445069

230428

[exam findings]

  • 2023-04-26 CXR
    • extensive heterogeneous consolidation in both hypoinflated lungs due to severe pulmonary fibrosis in progression as compared with the previous image
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • enlarged cardiac silhoutte due to dilated prominent pericardial fat/prominent cardiophrenic angle mediastinal fat pad/ supine position
  • 2023-04-21 CT - chest
    • Indication: Malignant neoplasm of unspecified part of left bronchus or lung
    • Chest and Abdominal CT with and without enhancement revealed:
      • Chest:
        • S/p port-A placement with its tip at Superior vena cava.
        • There is enlarged lymph nodes in the mediastinum. In comparison with CT dated on 2023-02-17, these lymph nodes increased in size and numbers
        • There is interstitial change at both lungs with honey combing mostly at bilateral peripheral and lower lungs. In comparison with CT dated on 2023-02-17, the extension and severity progressed slightly.
        • Minimal pericardial effusion is found.
      • Visible abdomen:
        • The GB is well distended without soft tissue lesion
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The urinary bladder is well distended without soft tissue lesion.
        • There is no evidence of destructive bone lesion.
    • Imp:
      • Interstitial change of both lungs. In progression.
      • Enlarged lymph nodes in the mediastinum. In enlargement.
      • Minimal pericardial effusion.
  • 2023-03-22, -03-15, -02-15, -01-26, -01-20, -01-16, -01-11, -01-06, -01-03, 2022-12-29, -12-26, -12-22, -12-19, -12-08, … CXR
    • There are linear and nodular opacities projecting at bilateral middle and lower lung that are c/w subpleural boneycombing feature after correlate with CT.
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Spondylosis of the T-spine
  • 2023-02-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (47 - 11) / 47 = 76.60%
      • M-mode (Teichholz) = 75
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, grade 1 LV diastolic dysfunction
      • Mild TR
  • 2023-07-17 CT - chest
    • Diagnosis
      • Malignant neoplasm of unspecified part of left bronchus or lung
      • Hypertensive heart disease without heart failure
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Soft tissue mass at left upper lobe with bony erosion measuring 4.57x1.45cm in largest dimension. In comparison with CT dated on 2023-01-17, the lesion is stationary or slightly regressed.
        • Diffuse interstitial change at both lungs with honey combing at bilatearl lower lungs are found. IPF is considered.
        • Ground glass patches at both lungs is found. In regression.
        • Calcified coronary arteries is found.
        • Hypertrophic left ventricle is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
    • Imp:
      • left upper lobe lung cancer with bony erosion, in regression.
      • Diffuse intertitial change at both lungs with lower lobes predominance. IPF is suspected.
      • Hypertrophic left heart with Calcified coronary arteries is found.
  • 2023-01-17 CT - chest
    • Indication: Lung cancer with dyspnea
    • Comparison was made with previous CT dated on 2022/12/16
      • Chest
        • interval significant decrease in size of a large tumor at left upper anterior chest wall and heterogeneous consolidation at LUL as compared with CT on 2022/12/16.
        • there is subpleural and basal predominant pulmonary fibrosis charaterized by reticulation, traction bronchiectasis, traction bronchioectasis, archiectural distortion, and subpleural honeycombing.
        • extensive centrilobular emphysema and subpleural paraseptal emphysema at both upper lobes too.
        • Mediastinum and hila: interval regression of extensive lymphadenopathy the visceral space and both hila,as compared with CT on 2022/12/16
        • mild calcified plaques of the LAD, and LCX, and right coronary arteries.
        • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: mild dilated right main artery.
        • Heart: normal in size of cardiac chambers.
        • Pleura: trace Lt-sided effusion
      • Visible abdominal-pelvic contents:
        • normal appearance of gall bladder.
        • several bilateral renal cysts measuring up to 1.5cm (longest axial diameter)
        • unremarkable of the liver, spleen, both adrenal glands, pancreas, and no enlarged lymph node.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • LUL cancer with chest invasion and mediastinal-hilar LAP, signficant as compared with CT on 2022/12/16.
      • combined emphysema and IPF.
  • 2023-01-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (43 - 19) / 43 = 55.81%
      • M-mode (Teichholz) = 55
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
      • Mild MR, trivial TR
      • Preserved RV systolic function
  • 2022-12-22 MRI - brain
    • Clinical information: Lung cancer with lymph nodes and bone metastases, cT4N3M1b, stage IVA, R/O brain metastasis
    • Findings:
      • Known a case of lung cancer. No evidence of brain metastasis.
      • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
      • An outpouch (8.5 mm) projecting anteriorly from ACom artery, indicating an aneurysm. Suggest endovascular treatment.
  • 2022-12-16 CT - chest
    • < BGB-A317-A1217-302 (iIRB No: 10-FS-043) C3D15 Visit >
      • IP: Tislelizumab or Pembrolizumab 200 mg (D1) + BGB-A1217 900 mg or Placebo (D1) Q3W
    • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Mass like lesion occupying left anterior chest about 7.9cm in largest dimension is found. Stable.
        • S/p port-A placement with its tip at Superior vena cava.
        • Centrilobular Emphysematous change over both lungs and honey combing at peripheral lungs is found. IPF like change is considered. In comparison with CT dated on 2022-10-07, the lesion progressed rapidly.
        • Tortous aorta with calcification is noted.
        • Enlarged, enhanced lymph nodes are found at both sides of the mediastinum, in enlargement.
        • No evidence of bilateral pleural effusion.
        • Calcified coronary arteries is found.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • Suggest clinical correlation
    • Imp: Left anterior chest wall lung cancer s/p treatment with immune related pulmonary fibrosis. The primary tumor is stationary in size but the mediastinal lymph nodes enlarged. Pseudoprogression? Suggest close observation.
  • 2022-12-08 CXR
    • Patchy opacity projecting at left upper lateral lung was noted that is c/w lung cancer after correlate with CT.
    • There are several nodular opacities projecting at both lung. Please correlate with CT to R/O lung to lung metastases?
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2022-11-17, -10-27 CXR
    • Patchy opacity projecting at left upper lateral lung or pleura was suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2022-10-12 CXR
    • Patch densities at bil. lungs.
    • Atherosclerosis of the aorta.
  • 2022-10-07 CT - chest
    • < BGB-A317-A1217-302 (iIRB No: 10-FS-043) Screening ICF Process >
      • I myself have already discussed the whole details concerning the investigational product, A1217, an anti TIGIT antibody, in combination with Tislelizumab compared to Pembrolizumab, and the trial, BGB-A317-A1217-302 (iIRB No: 10-FS-043), with subject and family via both on-site and remote on 2022.09.15, and on site disscussion on 2022.09.28.
    • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Soft tissue mass attaching left anterior chest about 6.28cm in largest dimension is found. In comparison with CT dated on 2022-08-04, the lesion enlarged.
        • Centrilobular Emphysematous change over both lungs is found.
        • Cystic fibrotic change and cystic Bronchiectatic change at both peripheral lungs is found. Stationary.
        • Patent airway is found.
        • Enlarged lymph nodes are found at both sides of the mediastinum. Stationary.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Left upper lobe lung cancer with mediastinal lymphadenopathy, The primary tumor enlarged.
      • COPD.
  • 2022-10-06 MRI - brain
    • ACom aneurysm (8.5 mm).
    • No interval change as compared with MRI on 20220822.
    • Please close follow up and consult neurosurgeon.
    • No evidence of brain metastases.
  • 2022-10-04 Tc-99m MDP whole body bone scan
    • Increased activity in the antelateral aspect of left 3rd rib, compatible with malignancy with local bone invasion.
    • Increased activity lower T- to upper L-spines and lower L-spines. Either bone metastases or degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Some faint hot spots in the sternum and bilateral rib cages. Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2022-10-04 Pulmonary Function Test, Spirometer
    • preexam spo2:98%; postexam spo2:94%
    • mild obstructive ventilatory impairment with partial reversibility, FEV1/FVC 65%, FVC 81->92%, FEV1 68->77%
    • normal slow vital capacity, SVC 89%
    • airway trapping, RV/TLC 131%
    • normal diffusing capacity, DLCO/VA 73% (low DLCO 58% favor due to low VA)
    • suggest to use bronchodilator such as spiriva for mild obstructive ventilatory impairment
  • 2022-08-31 ROS1 FISH
    • ROS1 fluorescent-in-situ hybridization report
    • Rearrangement of ROS1 gene is NOT detected.
    • Patients with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
  • 2022-08-31 ALK IHC
    • Result: Negative
    • The immunostaining of the section slide labeled S2022-13261, using ALK antibody D5F3 along with a Ventana autostainer system, revealed no staining of tumor cells.
  • 2022-08-23 Tc-99m MDP whole body bone scan with SPECT
    • Increased activity in the antelateral aspect of left 3rd rib, compatible with malignancy with local bone invasion. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the lower T- to upper L-spines and lower L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Some faint hot spots in the sternum and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2022-08-22 MRI - brain
    • History and Indication
      • hemoptysis and severe chest pain
      • A case of HTN and 2-V CADs/p POBA for trifurcation lesion in ShinKong hospital got medical treatment
      • Active smoking 1/2+ PPD for 30+ years
      • Complained of migratory localized chest pain in the recent 2~3 days, duration lasted for seconds, but denied effort related angina
      • 20220803 EKG: sinus rhythm, 1st AV block
      • 20220803 Current medications: aspirin 1# QD, inderal 1# BID, atozet 1# QD, gaster 1# BID, erispan 1# BID, stilnox 1# prnHS, uricin 1# QD
      • CXR yesterday at LMD revealed left lung tumor, refer to chest clinic
    • Without- and with-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) reveal:
      • Mild degree of general enlargement of ventricles, cistern spaces and cortical sulci, indicating general brain atrophy.
      • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
      • No midline shift, nor space-occupying lesion.
      • No remarkable finding of skull base and bony structures.
      • No remarkable finding of nasopharynx visible in these images.
      • An outpouch (8 mm) projecting anterolaterally from ACom artery, indicaitng an aneurysm.
    • IMP: ACom aneurysm (8 mm). Mild general brain atrophy.
  • 2022-08-19 EGFR gene mutation
    • No mutation was detected at exons 18, 19, 20, 21 of EGFR gene in this specimen S22-13261
  • 2022-08-19 PD-L1 (22C3)
    • PD-L1 Immunostaining Result
      • Tumor Proportion Score (TPS) assessment: 95%
      • Combined Positive Score (CPS) assessment: 95
  • 2022-08-12 Patho - bronchus biopsy
    • Labeled as “left chest wall tumor”, needle biopsy — non-small cell carcinoma.
    • IHC stains:
      • TTF-1 (-), Napsin-A (-), p40 (focal +), calretinin (-), CK7 (+), CK20 (-).
      • GATA-3 (-), CK5/6 (+), p63 (+). The pattern is in favor of squamous cell carcinoma.
    • Section shows fibrotic soft tissue with infiltration of irregular nests of non-small cell carcinoma.
  • 2022-08-11 Myocardial perfusion SPECT with persantin
    • Probably mild myocardial ischemia at the inferolateral wall, basal lateral wall and posterior wall.
  • 2022-08-11 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 31) / 79 = 60.76%
      • M-mode (Teichholz) = 60
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA, concentric LVH; LV diastolic dysfunction, Gr 1
    • Trivial MR, trivial AR and trivial TR
    • Preserved RV systolic function
  • 2022-08-04 CT - chest
    • Findings
      • Chest:
        • Severe centrilobular Emphysematous change over both lungs is found.
        • Pleural based fibrotic change at both lungs more on peripheral lung is found.
        • Soft tissue mass encasing left atnerior chest wall with bony invasion is found up to 4.5cm. suggest tissue proof.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • Suggest clinical correlation
    • IMp:
      • Severe COPD.
      • Soft tissue mass encasing left atnerior chest wall with bony invasion is found. suggest tissue proof.
  • 2022-08-03 CXR
    • Patchy opacity projecting at left upper lateral lung or pleura was suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2022-08-03 ECG
    • Sinus rhythm with 1st degree A-V block
    • Nonspecific ST abnormality

[MedRec]

  • 2023-04-26 SOAP MER
    • S
      • SOB and desaturation during OPD
      • He developed decreased O2 Sat 5 days (90-95% initially), S/S exacerbated recent 2 days (<90%, about 84%)
        • no fever
        • no chest pain
      • A case of lung ca received clinical trial Tx, got PCP, CMV infection Hx
      • CXR showed pneumonitis
    • A/P
      • Respiratory failure, hypoxia, Critical, CRP15, bil PN
      • Hx: left lung CA, HTN, COPD; Patent CAD many years ago, PCP, CMV infection
      • CRP 15.4, WBC 7k, Medason, Tapimycin; OA Hema
      • 20230421 lung CT: Interstitial change of both lungs. In progression.
  • 2023-04-26 SOAP Dermatology
    • S: itchy and sweating sensation over trunk for weeks.
    • O
      • Diffuse annular lesions with spreading tendernecy and mild pruritus over trunk and gerion for weeks.
      • Past history: denied major systemic disease
      • Impression: tinea cruris et intertrigo eczema.
    • P
      • education about drug side effec and explain
      • strongly suggested OPD f/u
    • Prescription
      • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI 7D
      • Zalain (sertaconazole nitrate) BID TOPI 7D
  • 2023-04-19 SOAP Hemato-Oncology
    • P
      • Due to purpura over arms and legs, the subject uses Hirudoid Gel, which is over the counter medicine, from 2023-04-19.
      • For prevention of contrast-induced nephropathy, hydration is given to the subject from 2023-04-19 to 2023-04-21.
  • 2023-04-12 SOAP Infectious Disease
    • A: refill Valcyte dose to 2# qd for 4 more weeks, has received 3-week full dose Valcyte till 2023-02-22.
    • P: FU on 2023-05-10
  • 2023-03-29 SOAP Hemato-Oncology
    • P: For creatinine increased, hydration is given to the subject from 2023-03-29 to 2023-03-31.
  • 2023-03-29 SOAP Infectious Disease
    • A: refill Valcyte dose to 2# qd for two more weeks, has received 3-week full dose Valcyte till 2023-02-22.
    • P: FU on 2023-04-12
  • 2023-03-22 SOAP Hemato-Oncology
    • P: Due to improvement of appetite, the dose of megestrol was adjusted from 160 mg PO QD to 80 mg PO QD since 2023-03-16.
  • 2023-03-16 SOAP Hemato-Oncology
    • AE:
      • Fever Gr 1 on 2022-10-20, related to IP.
      • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
      • Mucositis oral Gr 2 from 2023-01-26 to now, not related to IP. (Related to removable denture)
      • Hyperkalemia Gr 2 from 2022-11-24 to 2022-11-29, not related to IP.
      • Diarrhea Gr 1 from 2022-12-05 to 2022-12-18, not related to IP.
      • Anorexia Gr 2 from 2022-12-05 to now, not related to IP.
      • Lung infection Gr 2 from 2023-01-21 to 2023-01-26, not related to IP.
      • Cytomegalovirus infection reactivation Gr 1 from 2023-01-16 to 2023-01-30, Gr 2 from 2023-01-31 to 2023-03-14, not related to IP.
      • Alanine aminotransferase increased Gr 1 from 2023-02-22 to 2023-03-14, not related to IP.
      • Aspartate aminotransferase increased Gr 1 from 2023-02-08 to 2023-02-21, not related to IP.
      • Anemia Gr 2 from 2023-01-09 to 2023-01-12, not related to IP.
      • Creatinine increased Gr 1 from 2023-03-01 to 2023-03-07, not related to IP.
      • Blood bilirubin increased Gr 1 from 2023-03-08 to now, not related to IP.
  • 2023-03-15 SOAP Infectious Disease
    • A: refill Valcyte dose to 2# qd for two more weeks, has received 3-week full dose Valcyte till 2023-02-22.
    • P: FU on 2023-03-29
  • 2023-03-15 SOAP Hemato-Oncology
    • O
      • 2023/03/13 CMV viral load assay = Target not deteceted IU/mL;
      • 2023/02/20 CMV viral load assay = <35 IU/mL;
      • 2023/02/06 CMV viral load assay = 181 IU/mL;
      • 2023/01/27 CMV viral load assay = 62 IU/mL;
      • 2022/12/24 CMV viral load assay = Target not deteceted IU/mL;
    • P: For prevention of creatinine increased, hydration is given to the subject from 2023-03-15 to 2023-03-16.
  • 2023-03-01 SOAP Hemato-Oncology
    • P: For Gr 1 creatinine increased, hydration is given to the subject from 2023-03-01 to 2023-03-03.
  • 2023-02-22 SOAP Infectious Disease
    • A: reduce Valcyte dose to 2# qd for two weeks, has received 3-week full dose Valcyte till 2023-02-22
    • P: FU on 2023-03-08
  • 2023-02-22 SOAP Hemato-Oncology
    • O
      • 2023/02/20 CMV viral load assay = <35 IU/mL;
      • 2023/02/06 CMV viral load assay = 181 IU/mL;
      • 2023/01/27 CMV viral load assay = 62 IU/mL;
      • 2022/12/24 CMV viral load assay = Target not deteceted IU/mL;
  • 2023-02-15 SOAP Hemato-Oncology
    • P: For prevention of contrast-induced nephropathy, hydration is given to the subject from 2023-02-15 to 2023-02-17.
  • 2023-02-08 SOAP Hemato-Oncology
    • O
      • 2023/02/06 CMV viral load assay = 181 IU/mL;
      • 2023/01/27 CMV viral load assay = 62 IU/mL;
      • 2022/12/24 CMV viral load assay = Target not deteceted IU/mL;
    • P: Highly suspect CMV reactivation complicated with hepatitis -> After discussion with infection expertise, follow up CMV viral load after 2 weeks of using Valcyte and adjust Prednisolone from 4 tab QD to 2 tab QD.
  • 2023-02-08 SOAP Infectious Disease
    • S: CMV related hepatitis follow up, easy fatigue, exertional dyspnea, intake still acceptable, loss of weight 1kg.
    • O
      • BT no fever, BW 65.2kg
      • 20230208 AST/ALT 80/335,
      • 20230206 CMV viral load 181
    • A
      • refill Valcyte for the 2nd and 3rd week therapy
      • reduction of steroid use indicated
    • P: FU on 2023-02-22
  • 2023-02-01 SOAP Infectious Disease
    • S
      • 2023/02/01 Referred from Onco OPD for CMV related hepatitis
      • no cough, exertional dyspnea and easy fatigue still noted,
      • PJP and interstitial lung discharged from Onco on 2023-01-20, with prednisolone and Baktar use
      • Underlying lung cancer, cT4N3M1b stage IVA SCC, cachexia.
    • O
      • BT no fever
      • 20230131 WBC 23290, AST/ALT 131/252
      • 20230127 CMV viral load assay = 62 IU/mL;
      • 20230117 CT chest: LUL cancer with chest invasion and mediastinal-hilar LAP, signficant as compared with CT on 2022/12/16. combined emphysema and IPF.
      • 20221224 CMV viral load not deteceted;
    • A
      • refill Valcyte for one week first, under CMV-related hepatitis impression.
    • P
      • FU on 20230208
  • 2023-01-31 SOAP Hemato-Oncology
    • O
      • 2023/01/27 CMV viral load assay = 62 IU/mL;
      • 2022/12/24 CMV viral load assay = Target not deteceted IU/mL;
    • P: Highly suspect CMV reactivation complicated with hepatitis -> After discussion with infection expertise, prescribe Valcyte and refer to Infection expertise for futher evaluation and management.
    • Prescription
      • Valcyte (valganciclovir 450mg) 2# BID 1D
  • 2023-01-26 SOAP Hemato-Oncology
    • P:
      • Due to impaired renal function which might be related dehydration, IV fluid support will be given.
      • In addition, potassium-binding agent will be used for hyperkalemia.
    • Presciption
      • Kalimate (calcium polystyrene sulfonate 5mg) 1# QD 5D
  • 2022-12-15 SOAP Hemato-Oncology
    • P: Because new main ICF (Version 2.0, 12-Oct-2022) and Optional Future Research ICF (Version 1.0, 12-Oct-2022) are proven, I give the new version ICF to the subject and let the subject have adequate time to read it, subsequently ask question and discuss with us. Then the subject sign the version ICF on 2022-12-15. A copy of the signed main ICF and Optional Future Research ICF were provided to the subject.
      • For prevention of contrast-induced nephropathy, hydration is given to the subject from 2022-12-15 to 2022-12-17.
      • The subject discontinued Cyproheptadine from 2022-12-15, and switched to Megestrol Acetate 160 mg PO QD for anorexia from 2022-12-15.
      • Due to relatively lower BP and occasionally dizziness, the subject hold Bisoprolol Fumarate from 2022-12-08.
      • The subject discontinued Lorazepam from 2022-12-08, and switched to Quetiapine from 2022-12-08.
      • Due to Morphine induced dry mouth, the subject discontinued Morphine and switched to Tramacet from 2022-12-08.
      • On 2022-12-16, the CT revealed the possibility of lung infection or pneumonitis. Therefore, oral empirical antibiotics with cephalexin 500 mg Q6H is given since 2022-12-16. If not working, admission for lung infection would be done.
    • Prescription
      • cephalexin 500mg 1# Q6H 7D
  • 2022-12-07 SOAP Hemato-Oncology
    • O
      • AE:
        • Fever Gr 1 on 2022-10-20, related to IP.
        • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
        • Mucositis oral Gr 2 from 2022-11-03 to 2022-11-08, not related to IP. (Related to removable denture)
        • Hyperkalemia Gr 2 from 2022-11-24 to 2022-11-29, not related to IP.
        • Diarrhea Gr 1 from 2022-12-05 to now, not related to IP.
        • Anorexia Gr 2 from 2022-12-05 to now, not related to IP.
    • P
      • Due to sweating a lot, hydration is given to the subject from 2022-12-07 to 2022-12-09.
      • Cyproheptadine 4 mg PO TID for anorexia from 2022-12-07.
      • The subject discontinued Orolisin from 2022-11-30.
  • 2022-11-30 SOAP Hemato-Oncology
    • O
      • AE:
        • Fever Gr 1 on 2022-10-20, related to IP.
        • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
        • Mucositis oral Gr 2 from 2022-11-03 to 2022-11-08, not related to IP. (Related to removable denture)
        • Hyperkalemia Gr 2 from 2022-11-24 to 2022-11-29, not related to IP.
        • Diarrhea Gr 1 from 2022-11-28 to 2022-11-29, not related to IP.
    • P
      • Due to suspect the sweating coming from taking Tramacet (tramadol/acetaminophen), discontinued Tramacet from 2022-11-17.
      • Because the subject mentions the eczema over bilateral upper limbs which is actually existed before being enrolled onto this trial, Levocetirizine, Fluocinonide and Urea are prescribed by dermatologist on 2022-11-30.
      • Due to sweating a lot, hydration is given to him on 2022-11-30.
  • 2022-11-30 SOAP Dermatology
    • S: itchy over exposesite of upper limbs
    • O: Widespread multiple reddish to brownish maucles, papules and confluent plaques with excoriations and scales over the upper limbs for months. No fever
      • Past history: denied major systemic disease
      • Impression: eczema, less likely drug-related. r/o pityriasis disorder.
    • P:
      • education about drug side effec and explain
      • strongly suggested OPD f/u
    • Prescription
      • Xyzal (levocetirizine 5mg) 1# QN
      • Topsum Cream (fluocinonide 0.05%) BID EXT
      • Sinpharderm Cream (urea) BID TOPI
  • 2022-11-24 SOAP Hemato-Oncology
    • O
      • AE:
        • Fever Gr 1 on 2022-10-20, related to IP.
        • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
        • Mucositis oral Gr 1 from 2022-10-31 to 2022-11-02, Gr 2 from 2022-11-03 to 2022-11-08, not related to IP. (Related to removable denture)
        • Hyperkalemia Gr 2 from 2022-11-24 to now, not related to IP.
    • P
      • Sodium Chloride for hyperkalemia (K: 5.9 mmol/L)
      • Triamcinolone 1 qs TOPI PRNBID for prevention of mucositis.
  • 2022-11-09 SOAP Hemato-Oncology
    • O
      • AE:
        • Fever Gr 1 on 2022-10-20, related to IP.
        • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
        • Mucositis oral Gr 1 from 2022-10-31 to 2022-11-02, Gr 2 from 2022-11-03 to 2022-11-08, not related to IP. (Related to removable denture)
        • Hyperkalemia Gr 2 from 2022-11-03 to 2022-11-08, not related to IP.
    • P: Due to sweating after taking Tramacet (tramadol/acetaminophen), hydration is given to him on 2022-11-09.
  • 2022-11-03 SOAP Hemato-Oncology
    • O
      • AE:
        • Fever Gr 1 on 2022-10-20, related to IP.
        • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
        • Mucositis oral Gr 1 from 2022-10-31 to 2022-11-02, Gr 2 from 2022-11-03 to now, not related to IP. (Related to removable denture)
        • Hyperkalemia Gr 2 from 2022-11-03 to now, not related to IP.
    • P
      • Triamcinolone for mucositis oral from 2022-11-03.
      • Sodium Chloride for hyperkalemia (K: 5.7 mmol/L)
  • 2022-10-27 SOAP Hemato-Oncology
    • S
      • BGB-A317-A1217-302 (iIRB No: 10-FS-043) C1D8 Visit
        • IP: Tislelizumab or Pembrolizumab 200 mg (D1) + BGB-A1217 900 mg or Placebo (D1) Q3W
        • C1D1 on 2022-10-20
    • O
      • PE (Body system: vision, general, HEENT, cardiovascular, chest and respiratory, abdomen, extremities/musculoskeletal, neurological) –> Yes & maculopapular rash and plaques
      • Examinations and Tests
        • Sample collection:
          • Lab tests:
            • Blood collection at 08:57 AM on 2022-10-27
            • PK of Tislelizumab or Pembrolizumab & A1217 or Placebo; ADA of Tislelizumab or Pembrolizumab & A1217 or Placebo (pre-dose): Nil
            • PK of Tislelizumab or Pembrolizumab & A1217 or Placebo (post dose within 30mins): Nil
      • AE: Fever Gr 1 on 2022-10-20, related to IP.
    • P
      • Monitor adverse event
  • 2022-10-18 SOAP Hemato-Oncology
    • P
      • Acetylcysteine 600 mg PRBBID PO for productive cough.
      • Piroxicam 1 QS PRNBID TOPI for tumor pain.
  • 2022-10-12 SOAP Hemato-Oncology
    • P
      • Refil the medicine
      • The subject has still Aspirin, Bisoprolol, Atozet, Candesartan, Famotidine, Sennoside, Morphine, MgO, Acetylcysteine, Fluocinonide, Orolisin, Exelderm Cream, Urea at home, no priscription on 2022-10-12.
  • 2022-10-04 SOAP Hemato-Oncology
    • P
      • Refil the medicine
      • Actein for prevention of contrast-induced nephropathy.
      • Preliminarily discuss the content of trial on 2022-09-15 and 2022-09-26.
  • 2022-09-20 SOAP Hemato-Oncology
    • S
      • << BGB-A317-A1217-302 (iIRB No: 10-FS-043) Pre-screening ICF Process >>
        • I myself have already discussed the whole details concerning the investigational product, A1217, an anti TIGIT antibody, in combination with Tislelizumab compared to Pembrolizumab, and the trial, BGB-A317-A1217-302 (iIRB No: 10-FS-043), with subject and family on 2022.09.15, using the virtual discussion via web.
        • Before the Pre-screening informed consent form (V1.1_TC_20May2021) is signed, the Pre-screening ICF was read by patient and family with adequate time.
        • They had enough time to ask questions and I answered their questions thoroughly as well.
        • The subject agreed to provide the tumor slides to central lab for determination of PD-L1 expression, and had signed Pre-screening informed consent form on 2022.09.20.
        • A copy of the signed Pre-screening informed consent form was provided to the subject.
    • O
      • Study Title: BGB-A317-A1217-302
      • A Phase 3, Randomized, Double-Blind Study of BGB A1217, an Anti TIGIT Antibody, in Combination With Tislelizumab Compared to Pembrolizumab in Patients With Previously Untreated, PD L1 Selected, and Locally Advanced, Unresectable, or Metastatic Non Small Cell Lung Cancer
      • Pre-screening No.: SCR-886019-001
      • Initial: SJC
      • Date of birth: 1940.11.23
      • Gender: Male
      • ALK IHC: Negative
      • EGFR: Negative
    • A
      • Anticipate to arrange the freshly cut unstained FFPE slides on 2022-09-20.
  • 2022-09-15 SOAP Hemato-Oncology
    • O
      • 2022/08/31 Anti-HBc = Reactive;
      • 2022/08/31 Anti-HBc-Value = 7.15 S/CO;
      • 2022/08/31 ROS1 FISH: Negative
      • 2022/08/31 ALK IHC: Negative
      • 2022/08/19 EGFR: Negative
  • 2022-08-30 SOAP Hemato-Oncology
    • A
      • ALK, ROS1 and lab
      • T3N0M1a stage M1a SCC
  • 2022-08-17 SOAP Cardiology
    • Prescription
      • Bokey (aspirin 100mg) 1# QD 14 days
      • Concor (bisoprolol 5mg) 0.5# QD 14 days
      • Atozet (ezetimibe 10mg + atorvastatin 20mg) 1# QD 14 days
      • Blopress (candesartan 8mg) 1# QD 14 days
      • Ulstop (famotidine 20mg) 1# QD 14 days
  • 2022-08-03 SOAP Chest Medicine
    • S
      • hemoptysis
      • A case of HTN and 2-V CADs/p POBA for trifurcation lesion in ShinKong hospital got medical treatment
      • Active smoking 1/2+ PPD for 30+ years
      • Denied past history of DM
      • Complained of migratory localized chest pain in the recent 2~3 days, duration lasted for seconds, but denied effort related angina
      • 20220803 EKG: sinus rhythm, 1st AV block
      • 20220803 Current medications:
        • aspirin 1# QD,
        • inderal 1# BID,
        • atozet 1# QD,
        • gaster 1# BID,
        • erispan 1# BID,
        • stilnox 1# prnHS,
        • uricin 1# QD
      • CXR yesterday at LMD revealed left lung tumor, refer to chest clinic
      • Arrange echocardiography and Tl-201 myocardial perfusion scan for further evaluation

[chemoimmunotherapy]

  • 2023-04-07 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
  • 2023-03-16 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
  • 2023-02-23 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
  • 2022-12-01 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
  • 2022-11-10 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
  • 2022-10-20 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)

==========

2022-12-29

[Trimethoprim/Sulfamethoxazole (TMP/SMX) dosing]

  • Trimethoprim/sulfamethoxazole(TMP/SMX) for patients with moderate to severe Pneumocystis pneumonia infection: IV 15 to 20 mg/kg/day (TMP component) in 3 or 4 divided doses; may switch to oral therapy after clinical improvement.

    • In-hospital Baktar spec: sulfamethoxazole 400mg + trimethoprim 80mg in 5mL/amp. The patient’s body weight is 70kg.
    • 70kg * 15 = 1050mg ~ 13.125 amp ~ 4amp TID or 3amp QID
    • 70kg * 20 = 1400mg ~ 17.5 amp ~ 6amp TID or 4amp QID
  • As recent lab results revealed no abnormalities in the liver and kidney functions, it is less likely that dosage adjustments will be needed.

  • Patients with moderate or severe infection (PaO2 <70 mm Hg at room air or alveolar-arterial oxygen gradient >= 35 mm Hg) should receive adjunctive glucocorticoids.

700691239

230427

{not completed}

[exam findings] (not completed)

  • 2023-04-25 MRI - pelvis
    • Indication: posterior iliac crest tender mass, r/o abscess formation
    • With and without-contrast multiplannar and multisequences MRI of pelvis revealed:
      • Fluid accumulation in right pelvis, involving erector spinae muscle, iliopsoas muscles, and sacroiliac joint. Marginal enhancement after contrast adminstration. Another fluid collection in left L1-2 paravertebral region.
      • An intramudullar lesion in right sacral ala, adjacent to right sacroiliac joint. Enhancement after contrast administration.
      • T2 hyperintense lesions in spine and left acetabulum. Enhancement after contrast administration.
    • Impression
      • c/w tuberculous infection with cold abscess in right pelvis and left paravertebral regions, in progression
      • c/w bone metastasis in spine, right sacral ala, and left acetabulum
  • 2023-04-13 CXR
    • Scoliotic alignment of the thoracolumbar spine is noted.
  • 2023-04-06 SONO - abdomen
    • Right renal cyst (0.90x1.38cm).
  • 2023-03-23 MTBC PCR
    • S2023-04099 — Positive
  • 2023-03-07 Patho - bone exostosis
    • Soft tissue, labeled as “bone, right sacral”, CT-guide biopsy — Necrosis
      • NOTE: Correlation of micro-organism culture, image study and clinical findings is recommended.
    • Microscopically, it shows necrotic debris, mixed inflammatory infiltrate of lymphocytes and leukocytes and focal stromal fibrosis.
    • Immunohistochemical stain reveals CK(-) and GATA3(-) for tumor.
    • Acid-fast stain — Positive for mycobacterial bacilli, PAS stain — Negative; Suggest of mycobacterial infection
  • 2023-03-06 CXR
    • Old fracture of right clavicle S/P compression plate and screws fixation shows good alignment and good union.
    • There is soft tissue density in paraspinal area in T11-T12 level. Please correlate with CT.
    • Osteolytic lesion in T12 vertebral body is highly suspected.
  • 2023-03-01 PET scan
    • Increased FDG uptake in the T10-L1 spines, right aspect of sacrum, and inferior aspect of the left acetabulum, highly suspected tumor (breast or others ?) with multiple bone metastases. .
    • Increased FDG uptake in soft tissue in the RLQ and LUQ of abdomen, the nature is to be determined (another primary malignancy or others ?), suggesting biopsy for further investigation.
    • Right breast cancer s/p treatment, highly suspected tumor (breast or others ?) with multiple bone metastases, by this F-18 FDG PET scan.
  • 2023-02-16 Tc-99m MDP bone scan
    • In comparison with the previous study on 2022/02/16, the lesions in the lower T-spines, manubrium of the sternum, right aspect of sacrum, adjacent right iliac bone and inferior aspect of left acetabulum are new.
    • Multiple bone metastases should be watched out.
  • 2023-02-10 CT - abdomen
    • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
    • Findings:
      • There are osteoblastic change from T11 to L1.
        • In addition, There is osteolytic lesion in T12 vertebral body and soft tissue tumor extension from T12 vertebral body into anterior and left lateral aspect of the vertebral body and left psoas muscle.
        • Metastases are highly suspected. Please correlate with tumor marker and PET scan.
      • There is an ill-defined osteoblastic change and osteolytic lesion in right 1st sacrum that also may be bony metastasis.
      • Two low density lesion in the upper pole of both kidney are noted. Please correlate with sonography to R/O cyst?
      • There is no hyper-or hypodense lesion in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
    • IMP:
      • Bony metastases are highly suspected.
      • Please correlate with tumor marker and PET scan.
  • 2023-02-06 SONO - nephrology
    • Bilateral renal cysts
  • 2022-12-26 SONO - abdomen
    • Right renal cyst and stone.

[consultation]

  • 2023-04-26 Anesthesiology
    • Q
      • This 53-year-old female patient has past history of
        • Left breast tumor s/p left tumor excision in 2003
        • Right clavicle fracture s/p ORIF
        • Right breast tumor s/p tumor excision after needle localization on 2022/01/28
      • Right breast ductal carcinoma in situ status post right axillary sentinel lymph node biopsy on 2022-03-11. She denied any TOCC histories in recent 3 months.
      • This time she was admitted due to right iliac crest biopsy site severe pain with tenderness for 2 days. The pain was accompanied with fever up to 39.5 degC and chillness.
      • Under the impression of right iliac crest cellulitis, she was admitted for antibiotics treatment.
      • 2023/03/01 bone scan: Increased FDG uptake in the T10-L1 spines, right aspect of sacrum, and inferior aspect of the left acetabulum, highly suspected tumor (breast or others ?) with multiple bone metastases.
      • However, on 2023/03/02 Bone marrow biopsy showed no metastatic carcinoma
      • 2023/03/07 CT-guided biopsy of right sacrum showed positive AFS, and subsequently at 2023/03/23 tissue report showed TB positive
      • Lab data (20230424): CRP 12.68, WBC 15010; blood culture result pending
      • Currently the patient has been taking AKuriT-4 for 5 weeks.
      • MRI pelvis done on 20230425 showed c/w tuberculous infection with cold abscess in right pelvis (invading erector spinae muscle, iliopsoas muscles, and sacroiliac joint.), in progression; c/w bone metastasis in spine, right sacral ala, and left acetabulum
      • ID man suggested needle aspiration by radiologist; and Radiologists warned us about the risk of cutaneous fistula formation and skin TB after drainage procedure.
      • This morning, the patient started to notice right leg numbness radiating from hip downward from the side of thigh all the way down to right sole, but resolved after 2 hours
      • PE showed pain on right hip flexion, and restricted AROM on right hip extension.
      • Therefore, we also consulted neurosurgeon and replied no apparent invasion of spine.
      • GS was also consulted, and due to the lesions were deeply located, therefore, surgical debridement was not feasible
      • ORTHO will arrange debridement for her right sacral abscess on 20230427.
      • This time we would really need your expertise in providing preoperative anesthetic evaluation for this patient.
      • Thanks a lot in advance!
    • A
      • I’ve visited the patient and reviewed her data
      • CC: right iliac crest severe pain with tenderness, fever and chillness
      • DX: c/w tuberculous infection with cold abscess in right pelvis (invading erector spinae muscle, iliopsoas muscles, and sacroiliac joint.), in progression; c/w bone metastasis in spine, right sacral ala, and left acetabulum
      • OP: right sacral abscess debridement on 20230427
      • Anes plan:
        • ASA III
        • We will arrange ETGA for this patient
        • The patient has been informed on the anesthesia- and surgery-associated risks
  • 2023-04-25 Neurosurgery
    • Q
      • This time we would really need your expertise in evaluating the feasibility of incisional drainage with biopsy, and the possible cause of right sciatica.
    • A
      • A case of 53 y/o female, Hx have been reviewed; Extrapulmonary TB(+) under Tx.
      • NS is consulted for right LBP and wraist mass with tenderness; Fever(+);
      • O
        • Current status: Cons: clear
        • Walk ok; MP: bil 5-; sensation: symmetric; gait: fair; sphincter: continence
        • A pelvis MRI:
          • Fluid accumulation in right pelvis, involving erector spinae muscle, iliopsoas muscles, and sacroiliac joint. Marginal enhancement after contrast adminstration. Another fluid collection in left L1-2 paravertebral region.
          • An intramudullar lesion in right sacral ala, adjacent to right sacroiliac joint. Enhancement after contrast administration.
          • T2 hyperintense lesions in spine and left acetabulum. Enhancement after contrast administration.
      • A
        • c/w tuberculous infection with cold abscess in right pelvis and left paravertebral regions, in progression
        • c/w bone metastasis in spine, right sacral ala, and left acetabulum; breast cancer
      • P
        • May arrange CT guide or echo guide pigtail drainage and biopsy; pain control; Tx TB as usual;
  • 2023-04-22 Infectious Disease
    • A
      • 81-year-old breasst cancer female patient has right sacroiliac crest TB and has received 5 more week anti-TB treatment till now.
      • O
        • Painful growing mass is noted over right posterior lower back, where previous biopsy site.
        • Lab data revealed no drop of ESR and CRP levels.
      • A
        • Either hematoma or abscess formation is the first consideration.
        • No need for change the anti-TB regimen, but MRI or CT study necessary for the mass lesion nature.
      • Suggestion
        • Continue the present AkuriT-4 medication to complete the first 60-day medication.
        • Continue Tramacet and add Celebrex for pain relief.
        • Arrange MRI of T-L-S spine for evaluation of spine and iliac mass lesion.
  • 2023-03-10 Infectious Disease
    • A
      • 52-year-old breast cancer with suspect multiple bony metastases female patient, received right sacrum bone biopsy on 2023-03-07.
      • Patholgoy report revealed positive AFB smear and no cancer cell, that bone TB is the first consideration.
      • Review the PET report, there are multiple bone lesions, including sternum, T-spine, right sacrum and left acetabulum.
      • TB bone rarely presents so many sites.
      • TB bone culture was not done, that bone tissue TB-PCR study is necessary.
      • Please contact the TB practioner.
      • TB disease notification is necessary first, that anti-TB therapy can be started, even without PCR report.

[assessment]

  • AKuriT-4 (RIF 150mg + INH 75mg + PZA 400mg + EMB 275mg) 3# PO QDAC is administered according to the patient’s bone tuberculosis.

  • It is important to note that the patient is currently taking multiple NSAIDs (Laston (ketorolac) ST, Celebrex (celecoxib) QD, naproxen PRNQ8H). Concomitant use of multiple NSAIDs is not recommended due to the increased risk of side effects such as bleeding and kidney damage. Please monitor the patient closely for signs of bleeding or changes in kidney function and consider adjusting her medication regimen if necessary.

701048984

230427

[diagnosis] - 2023-03-29 admission note

  • gastric cancer with liver invasion, cT4bN1M0, stage IV s/p gastrojejunostomy, choledochoduodenostomy and liver S3 partial resection
  • constipation

[past history] - 2023-03-06 admission note

  • The patient had no systemic diseases
  • history of operation:
    • gastric cancer with liver metastasis, cTT4bN2M1, stage IVB, s/p liver S3 partial resection, cholecystectomy, choledochoduodenal bypass and gastrojejunal bypass on 2023/01/09
  • Regular medications or herb:
    • Tramacet 1tab PO HS
    • Sketa 1tab PO TID
    • Pariet 1tab PO QDAC
    • Mosapride 1tab PO TID         

[allergy]

  • NKDA         

[family history]

  • His father has hypertension.
  • Denied of any families have cancer history.

[exam findings]

  • 2023-04-18 Patho - stomach biopsy
    • Stomach, proximal to the anastomosis site, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows fragments of gastric tissue with chronic inflammation, intestinal metaplasia and focal invasive cribriform glands.
    • The immunohistochemical stain of CK is positive.
  • 2023-04-18 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Gastric ulcer, LC site, proximal to the anastomosis, s/p biopsy
      • Remnant gastritis
      • Post subtotal gastrectomy with Billroth II anastomosis
    • Suggestion
      • Keep PPI therapy
      • Pursue pathology report
  • 2023-04-02, -02-06, -02-04 KUB
    • Presence of ileus.
    • Degeneration and spondylosis of L-S spine.
  • 2023-02-04 CXR
    • Atherosclerosis of the aorta.
    • Presence of ileus.
  • 2023-01-09 Patho - liver partial resection
    • Gallbladder, cholecystectomy — Chronic cholecystitis and cholelithiasis
    • The sections show a picture of chronic cholecystitis and cholelithiasis, composed of congestion, mild chronic inflammatory cells infiltration, mild mural fibrosis, and scattered Rokitansky-Aschoff sinuses.
  • 2023-01-09 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS
      • Liver, S3, partial S3 resection — Adenocarcinoma, moderately differentiated, compatible with gastric origin
    • MACROSCOPIC EXAMINATION
      • Procedures: Partial S3 resection
      • Specimen Size: 4.5 x 3.2 x 2.5 cm
      • Tumor Focality: Solitary
      • Tumor Site: S3
      • Tumor Size: 0.8 x 0.6 x 0.4 cm
      • Large vessel involvement: Not identified
      • Non-tumorous part: Not cirrhotic
      • Sections are taken and labeled as: A1-A2 = tumor, A3 = non-neoplastic liver
    • MICROSCOPIC EXAMINATION
      • Diagnosis: Adenocarcinoma, compatible with gastric origin
      • Histologic grade: Moderately differentiated
      • Tumor growth pattern: Pushing
      • Tumor pseudocapsule: Absent
      • Tumor necrosis: Moderate (40%)
      • Parenchymal margin: Uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margins: 1.2 cm
      • Vascular invasion: Not identified
      • Perineural invasion: Not identified
      • Non-neoplastic liver parenchyma: Mild lymphocytic portal inflammation, no interphase hepatitis, no lobular inflammation, and regenerative hepatocytes
      • Fatty Change: Present (3%)
  • 2023-01-05 CT - abdomen gastric filling with water
    • History and indication: gastric cancer
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A large ulcerative lesion at gastric antrum with regional LAP.
      • Normal appearance of liver, spleen, pancreas, adrenals and kidneys.
      • Gallbladder stone (6mm).
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • No abnormal density at bilateral basal lungs.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)
  • 2023-01-04 Flow Volume Chart
    • normal screening
  • 2023-01-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (94 - 34) / 94 = 63.83%
      • M-mode (Teichholz) = 64
    • Adequate LV systolic function with normal resting wall motion
    • Trivlal MR and trivial TR
    • LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
  • 2022-12-28 Patho - stomach biopsy
    • Stomach, antrum LC, biopsy — Adenocarcinoma.
    • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=1+).
    • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands and isolated neoplastic cells.
  • 2022-12-27 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Superficial gastritis, s/p CLO test
      • Suspected gastric cancer, antrum, LC site, s/p biopsy
    • Suggestion
      • Pursue pathology report
  • 2021-02-23 Auditory Brainstem Response, ABR
    • Absence of ABR wave I was noticed in L’t ear.
    • Prolonged ABR wave I latency in R’t ear.
    • ILD-V 0.08
    • no evidence of retrocochlear lesion
  • 2021-02-16 ENT Hearing Test
    • PTA:
      • Reliability FAIR
      • Average R’t 30 dB HL; L’t 44 dB HL
      • R’t normal to profound SNHL.
      • L’t normal to severe SNHL.
    • Tymp: Bil type A.
    • ART:
      • R’t ipsi 4k Hz and contra absent.
      • L’t absent.

[consultation]

  • 2023-04-17 Anesthesiology
    • Q
      • for anesthesia assessment
      • Arrange painless of EGD on 4/18 8AM
      • This 80-year-old male, who has a histiry of gastric cancer with liver invasion, cT4bN1M1 s/p gastrojejunostomy, choledochoduodenostomy and liver S3 partial resection on 2023/01/09 s/p palliative chemotherapy with mFOLFOX IV, and IP chemotherapy Taxotere/Cisplatin. He suffered from initial presentation of RUQ of abd pain in Jan 2023, s/p sent to ER of ShuangHe Hospital and weight loss (+) (5kg in 12 months). Surgical pathology with liver, S3, partial S3 resection (20230109) proved Adenocarcinoma, MD. c/w gastric origin. Gallbladder, cholecystectomy: Chronic cholecystitis and cholelithiasis. Ascites (20230109) showed negative. Stomach, antrum LC, biopsy (20221227) proved adenocarcinoma.IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=1+). He received gastrojejunostomy, choledochoduodenostomy and liver S3 partial resection on 2023/01/09, and received palliative chemotherapy with mFOLFOX IV, and IP chemotherapy Taxotere/Cisplatin Q2W x 12 , #1 on 20230216, #2 on 20230306, #3 on 20230330 - Acording to the patient describe, he suferred from vomiting dark red once and tarry stool noted on 2023/04/15, so he was brought to ChangGung Hospital for help first, then due to personal reason, so he went to our ER for help. At ER, the vital signs: BT 36.3 degC; HR: 99bpm; RR: 18bpm; SpO2 98% under room air, conscious: E4V5M6. The lab of CBC/DC showed anemia (Hb: 8.8g/dL), so gave blood tranfusion with LPRBC, hydration, Transamine, and PPI with Pantoloctreatment. After treatment, the Hb level go up to 10.1g/dL. Under the impression of Gastrointestinal hemorrhage, so he is admitted for future evaluation.
    • A
      • 80 y/o man has
        • Hx: gastric cancer stage VI
        • gastrojejunostomy, choledochoduodenostomy and liver S3 partial resection on 2023/01/09
      • Dx: GI Bleeing
      • Op: PES
      • Condition: Cons. clear, previous walking ok but now weakness and tired unable to sit on wheelchair, no dyspnea, chest tightness or leg edema
      • Lab: Hb10
      • ASA3
      • Plan:
        • High risk of aspiration, sepsis, shock
        • Anes. plan and risk was told to him at bedside
        • Resucitation, ETT will be procedured if emergence condition.
        • We will arrange IVGA, GI man will injection local anesthsia at GI tract.
        • Correct underly dx such as anemia, hypovulemia as your expertise.
        • Follow onetouch q6h or even q4h when nil per os if DM or high risk of hypoglycemia

[surgical operation]

  • 2023-01-09
    • Surgery
      • Laparoscopy
      • Liver S3 partial resection
      • Cholecystectomy
      • Choledochoduodenal bypass
      • Gastrojejunal bypass
    • Finding
      • A whitish hard tumor was protruding from the anterior wall of gastric antrum near lesser curvature.
      • A whitish tumomr was noted at the posterior wall of S3 segment, r/o direct invasion from the gastric tumor.
      • Hard tumors were noted at the pancreatic head and retroperitoneum.
      • After discussion with his family, tumors could not excised entirely. His son agreed with performing bypass surgery only.
      • No gallbladder stone was found.
      • At least cT4bN1

[chemotherapy]

  • 2023-04-27 - [oxaliplatin 40mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 100mL 2hr + fluorouracil 2000mg/m2 2900mg NS 500mL 46hr] IVD + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + NS 800mL + gentamycin 40mg + NaHCO3 2800mg] 1hr IP (FOLFOX NIPS)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-29 - [oxaliplatin 40mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 100mL 2hr + fluorouracil 2000mg/m2 2800mg NS 500mL 46hr] IVD + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + NS 800mL + gentamycin 40mg + NaHCO3 2800mg] 1hr IP (FOLFOX NIPS)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-06 - [oxaliplatin 40mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 100mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr] IVD + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + NS 800mL + gentamycin 40mg + NaHCO3 2800mg] 1hr IP (FOLFOX NIPS)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-16 - [oxaliplatin 40mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 100mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr] IVD + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + NS 800mL + gentamycin 40mg + NaHCO3 2800mg] 1hr IP (FOLFOX NIPS)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-04-27

  • 2023-04-26 lab results showed low serum Na (133 mmol/L), K (3.4 mmol/L), Mg (1.4 mg/dL), and albumin (3.3 g/dL). These electrolyte imbalances are currently being addressed with appropriate supplementation. With the exception of mild anemia, the patient’s blood cell counts are within normal limits and do not represent a contraindication to the planned chemotherapy.

  • The PharmaCloud database shows that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.

2023-03-30

  • Laboratory data on 2023-03-29 showed normal liver/kidney function, however, cation electrolytes and HGB were slightly decreased, which would not contraindicate the planned chemotherapy.

  • Ascites cytology on 2023-03-08, 2023-03-07, 2023-02-20, 2023-02-17 showed no evidence of positive results.

  • No medication reconciliation issue identified.

2023-03-07

  • The patient is undergoing FOLFOX NIPS treatment for the second time during this hospital stay. There are no apparent complaints of adverse reactions following the patient’s last treatment.
  • Potassium supplementation is currently administered appropriately to manage low serum K level (2023-03-06 3.0mmol/L) in this patient.

2023-02-17

  • The patient undergos palliative chemotherapy with a combination of mFOLFOX IV/IP C/T every two weeks for a total of 12 cycles since this hospital stay. After the first 6 cycles the patient will undergo an abdominal CT scan to evaluate the response to treatment.
  • Lab data 2023-02-16 showed grossly normal readings, and the patient’s TPR and blood pressure vital signs have remained stable throughout his hospitalization as of now.
  • Megestrol is appropriately used as an appetite stimulant in this patient with poor appetite and unintended weight loss.

701173522

230427

{not completed}

[exam findings]

[surgical operation]

  • 2019-08-26
    • Diagnosis: Malignant ovary neoplasm with peritoneal carcinomatosis
    • PCS code: 73043B
    • Finding
      • ascite (-)
      • small bowel adhesion (++)
      • tumor (-)
  • 2019-07-15
    • Diagnosis: Malignant ovary neoplasm
    • PCS code: 73014B
    • Finding: mutiple tumor seeding over s7, right diaphragm, left paracolic gutter, pelvis, surface of urinary bladder, ascending colon, and sigmoid colon
  • 2019-07-15
    • Diagnosis: Ovarian cancer
    • PCS code: 80418B
    • Finding:
      • Supraumbilical midline vertical skin incision.
      • Uterus: 6x3 cm, tense contact with bladder, no obvious tumor noted
      • Adnexa:
        • Lt: 3x2 cm, capsule intact, papillary surface, severe adhesion to uterus, pelvic wall and rectum due to tumor seeding
        • Rt: 4x3 cm, capsule intact, papillary surface, severe adhesion to uterus, pelvic wall and rectum due to tumor seeding
      • CDS: invisible due to tumor mass occupied
      • Ascites: little
      • Bilateral paraaortic and pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
      • Omentum: with multiple hard, variablesized millitary nodules
      • Liver: with rough surface
      • Subdiaphragmatic surface: miliary tumor seeding(+), bean sized
      • After the operation, HIPEC was performed.
      • Residue tumor: multiple millitary tumors, diameter about 0.1 cm, over peritoneal wall, small intestine and colon
      • Estimated blood loss: 850ml (include ascites)
      • Blood transfusion: nil
      • Complication: nil
  • 2019-04-11
    • Diagnosis: Maliganat cervix uteri neoplas
    • PCS code: 47080B
    • Finding:
      • peritoneal carcinomatosis, PCI: 17/39, small bowel PCI: 4
      • malignant ascites(+), about 2600ml
      • omentum cake(+)
  • 2017-07-15
    • Diagnosis: Malignant ovary neoplasm
    • PCS code: 50010C
    • Finding: bilateral ureter was indwelled with 4Fr. catheter under direct vision

[chemotherapy]

  • 2023-04-19 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-04-12 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-29 - topotecan 1.75mg/m2 2.5mg NS 100mL 30min + bevacizumab 10mg/kg 600mg NS 100mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + metoclopramide 10mg + NS 250mL
  • 2023-03-22 - topotecan 1.75mg/m2 2.5mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + metoclopramide 10mg + NS 250mL
  • 2023-03-08 - topotecan 3.75mg/m2 5.0mg NS 100mL 30min + bevacizumab 10mg/kg 600mg NS 100mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + metoclopramide 10mg + NS 250mL
  • 2023-01-18 - bevacizumab 7.5mg/kg 450mg NS 250mL 90min + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 300mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-26 - bevacizumab 7.5mg/kg 450mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-12-05 - bevacizumab 7.5mg/kg 450mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-11-14 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-10-24 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-10-04 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-09-12 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-22 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-01 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-07-25 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 300mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-07-11 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-06-13 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 300mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-05-30 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-05-03 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 300mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-04-20 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-03-21 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-03-15 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-02-22 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-01-24 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-01-18 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-12-28 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-11-30 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-11-09 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-10-19 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-09-27 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-09-06 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-08-16 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-07-26 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-06-30 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-06-07 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-05-17 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-04-27 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-03-29 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 60mg/m2 90mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-02-01 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-01-04 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-12-07 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-10-26 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-10-05 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-09-01 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

Medication

  • Lynparza (olaparib 150mg) 2# BIDCC PO
    • 2023-04-12 ~ undergoing (OPD)

[assessment]

  • The patient experienced severe neutropenia after their last chemotherapy session on 2023-04-19, with the low WBC count observed on 2023-04-24. G-CSF (filgrastim) 300ug QD for 14 days has been prescribed since 2023-04-24 to address this issue. To date, the WBC count has improved slightly, increasing from a low of 260/uL to 420/uL.
    • 2023-04-27 WBC 0.42 x10^3/uL
    • 2023-04-26 WBC 0.30 x10^3/uL
    • 2023-04-25 WBC 0.26 x10^3/uL
    • 2023-04-24 WBC 0.33 x10^3/uL
    • 2023-04-19 WBC 12.02 x10^3/uL
    • 2023-04-12 WBC 3.56 x10^3/uL
  • The patient has received blood transfusions for their anemia, with 2 units of L-PRBC administered on 2023-04-24 at around 20:00, 1 unit at around 23:00, and an additional 2 units on 2023-04-27 at around 13:00.
    • 2023-04-27 HGB 7.6 g/dL
    • 2023-04-26 HGB 8.1 g/dL
    • 2023-04-25 HGB 8.6 g/dL
    • 2023-04-24 HGB 7.6 g/dL
    • 2023-04-19 HGB 8.8 g/dL
    • 2023-04-12 HGB 10.2 g/dL
  • The patient’s platelet count has shown a steep drop and, as of now, there is no obvious sign of recovery. If the risk of bleeding is high, platelet transfusion may be necessary.
    • 2023-04-27 PLT 18 x10^3/uL
    • 2023-04-26 PLT 28 x10^3/uL
    • 2023-04-25 PLT 47 x10^3/uL
    • 2023-04-24 PLT 7 x10^3/uL
    • 2023-04-19 PLT 91 x10^3/uL
    • 2023-04-12 PLT 184 x10^3/uL

700618096

230426

[past history] - 2023-04-20 admission note

  • Hypertension for 10 years with regular medication control.

  • DM with triopathy for 10+ years with regular OHA, insulin control.

  • Asthma: Asthma since young with regular OPD f/u.

  • Operation history: Appendectomy 10 yrs ago.

  • Denied history of Hypertension, DM, asthma

  • Denied any operation, accident and other medical Hx.        

[allergy]

  • Primperan (metoclopramide): other

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.  

[exam findings]

  • 2023-04-24 Tc-99m MDP bone scan with SPECT
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, maxilla, mandible, some T- and L-spine, sacrum, bilateral sternoclavicular junctions, shoulders, and S-I joints.
  • 2023-04-21 ECG
    • Normal sinus rhythm
    • Low voltage QRS
    • Borderline ECG
  • 2023-04-21 Nasopharyngoscopy
    • Findings: smooth nasopharynx, oropharynx, hypopharynx; fair vocal cord movement without finding of vocal cord lesion.
    • Diagnosis: suspect functional dysphonia, or medication-related dysphonia.
  • 2023-04-20 CXR
    • There are few nodular opacities projecting in right lung that may be metastases. Please correlate with CT.
  • 2022-10-21 CT - abdomen (at other hospital)
    • Findings
      • Fatty liver
      • post-operative change of colon
      • no definite lesion in pancreas, spleen, bilateral adrenal glands, kidneys
      • soft tissue lesions within pelvic cavity, peritoneal, metastases are considered
      • no definite lymphadenopathy
      • no ascites
    • Impression:
      • Peritoneal metastases
      • Fatty liver

[consultation]

  • 2023-04-21 Ear Nose Throat
    • Q
      • The 37 y/o woman has Rectosigmoid cancer diagnosed 3 years ago s/p left hemicolectomy and then adjuvant chemotehrapy with 12 doses of FOLFOX. Due to elevated tumor markers in 2022-02, PET was done and showed disease in progression over lung and peritoneum. Then she received Avastin plus FOLFIRI * 10 doses. Then the PET was arranged and disclosed bilateral lungs, peritoneum and liver. This time, admitted for chemotherapy with FOLFOXIRI.
      • For hoarse was noted for 3 weeks, we need your consultation for evaluation. Thanks a lot!!!
    • A
      • Scope: smooth nasopharynx, oropharynx, hypopharynx; fair vocal cord movement without finding of vocal cord lesion.
      • Impression: suspect functional dysphonia, or medication-related dysphonia.
      • Plan: Please give Broen-C 2# TID and arrange ENT OPD follow-up after discharge.

[lab data]

  • 2023-04-12 Anti-HBc Nonreactive
  • 2023-04-12 Anti-HBc-Value 0.08 S/CO
  • 2023-04-12 HBsAg Nonreactive
  • 2023-04-12 HBsAg (Value) 0.49 S/CO
  • 2023-04-12 Anti-HCV Nonreactive
  • 2023-04-12 Anti-HCV Value 0.06 S/CO

[MedRec]

  • 2023-04-06 SOAP Hemato-Oncology
    • S
      • s/p sigmoidectomy with LND on 2020-03-20
      • s/p Port-A on 2020-04-10
      • s/p adjuvant chemtoehrapy with FOLFOX from 2020-04-20 to 2020-10-28 -> PD over RML of lung and LN of left iliac chain, Stage IVA, rcT0N1bM1a
      • s/p Laparoscopic plevic LND on 2022-03-11
      • s/p A-FOLFIRI
      • s/p Laparoscopic intran-abdominla excision of peritoneal carcinomatosis on 2023-01-09 -> PD over lung, liver, bilateral iliac LNs and peritoneal carcinomosis by 2023-03-16 PET-CT, M1c, Stage IVB
    • P
      • Admission for FOLFOXIRI
  • 2023-04-06 SOAP Hemato-Oncology
    • S
      • Rectosigmoid cancer diagnosed 3 years ago s/p left hemicolectomy and then adjuvant chemotehrapy with 12 doses of FOLFOX.
      • Due to elevated tumor markers in 2022-02, PET was done and showed disease in progression over lung and peritoneum.
      • Then she received A-FOLFIRI 10 doses. Then the PET was arranged and disclosed bilateral lungs, peritoneum and liver.
    • P
      • Request medical records and report
  • 2017-12-14 SOAP Hemato-Oncology
    • O
      • 2017/12/07 Ferritin:5.2 ng/mL
      • Start iron therapy (20171214)
    • A
      • Iron deficiency anemia, unspecified [D50.9]
      • Thrombocytopenia [D69.6]
    • Prescription
      • Foliromin (sodium ferrous citrate 50mg) 1# QN 14 days
  • 2017-12-07 SOAP Hemato-Oncology
    • S
      • Referred from clinic on account of microcytic anemia
      • suspected thalassemia in her sister
      • Unexplained purpura
    • O
      • BH 168 BW 66
      • slight pale skin
    • Diagnosis
      • Anemia, unspecified [D64.9]
      • Thrombocytopenia [D69.6]

[assessment]

  • The patient was diagnosed with rectosigmoid cancer and underwent sigmoidectomy followed by treatment with the FOLFOX regimen in 2020. However, the patient experienced progressive disease. Laparoscopic plevic LND was performed in March 2022, and the patient was subsequently treated with the A-FOLFIRI regimen, but again experienced PD. This time, the patient was admitted to receive the planned FOLFOXIRI regimen.

  • Flumarin (flomoxef sodium) has been administered since 2023-04-23 to address the elevated sediment WBC and leukocyte esterase in the patient’s urine without issues.

  • The patient’s platelet count (PLT) has been decreasing over the past three years, with levels not exceeding 100K/uL in 2023. This should be carefully monitored, as it may suggest the presence of undiagnosed underlying conditions that require further evaluation and management.

    • 2023-04-25 PLT 83 *10^3/uL
    • 2023-04-24 PLT 95 *10^3/uL
    • 2023-04-11 PLT 100 *10^3/uL
    • 2022-12-24 PLT 143 *10^3/uL
    • 2020-12-28 PLT 160 *10^3/uL

701137983

230426

[diagnosis] - 2023-04-25 admission note

  • pancreatic head carcinoma,cT4N0M0, stage III, Dx in June 2022 , obstructive jaundice s/p PTGBD on 20220613
  • Type 2 diabetes mellitus without complications
  • Chronic obstructive pulmonary disease, unspecified
  • Obstruction of bile duct

[past history] - 2023-04-25 admission note

DM, HTN, CHF, COPD, Hyperlipidemia, Asthma                                                    

[allergy]

  • penicillin: rash;

[family history]

no hypertension, diabetes mellitus, cancer history

[exam finding]

  • 2023-04-03 KUB
    • Fecal material store in the colon.
    • S/P PTGBD with pigtail catheter implantation
  • 2023-03-13 CXR
    • Port-A catheter inserted into RA via left subclavian vein.
    • Thoracic aortic arch calcified atheriosclerotic plaque
    • Nodular opacitiy projecting over Rt lower lung zone due to nipple shadow
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad/ supine position
    • S/p PTGB drainage
  • 2023-03-13 ECG
    • Sinus tachycardia with Premature supraventricular complexes
    • ST & T wave abnormality, consider inferior ischemia
  • 2023-03-13 Endoscopic Retrograde Cholangiopancreatography, ERCP
    • Diagnosis
      • Failed Cholangiography
      • Pancreatic cancer s/p PTGBD
    • Suggestion
      • EUS/CDS or Rendevous ERCP
  • 2023-03-09 Cholangiography
    • Cholangiography via PTCD catheter administration revealed:
      • Patency of the catheter.
      • Obstruction of CBD.
  • 2023-03-08 SONO - abdomen
    • Post PTGBD with dilated IHD and CBD
    • Dilated main pancreatic duct
    • Pancreatic head tumor
  • 2023-03-08 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade D
      • Esophageal ulcers and erosions, lower to middle esophagus
      • Superficial gastritis, s/p CLO test
      • Gastric subepithelial lesion, anterior wall of upper body
    • Suggestion
      • PPI Q12H IV
      • EUS
  • 2023-03-06 ECG
    • Sinus tachycardia
    • Premature atrial complexes
    • Premature ventricular complexes
    • Marked ST abnormality, possible inferior subendocardial injury
    • Abnormal ECG
  • 2023-02-18, 2022-11-24 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • S/P pigtail catheter implantation at the gallbladder .
  • 2023-02-01 CT - abdomen
    • History:
      • 20220610 US: R/O pancreatic head tumor with obstructive jaundice.
      • 20220624 CT:Pancreatic head cancer, cT4N0M0, stage:III
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings: Comparison prior CT dated 2022/11/24.
      • Prior CT identified an ill-defined poor enhancing mass measuring 3.5 cm in the pancreatic head, causing marked dilatation of the bile duct and pancreatic duct, is noted again, mild increasing in size to 4 cm.
        • It is c/w adenocarcinoma of the pancreatic head S/P C/T with stable disease.
        • Prior CT identified tumor direct invasion the celiac trunk, superior mesenteric artery, and the trifurcation of superior mesenteric vein, splenic vein, and portal vein is noted again, stationary.
      • Prior CT identified liver metastasis 1.4 cm in S5 of the liver is noted again, mild decreasing in size and poor margination that is c/w liver metastasis S/P C/T with partial response. Follow up is indicated.
      • There are two cyst 1.7 cm and 0.5 cm in S6 liver.
        • Please correlate with sonography.
      • S/P PTGBD with pigtail catheter implantation
    • Impression:
      • Pancreatic head cancer S/P C/T show stable disease.
      • Liver metastasis in S5 S/P C/T show partial response.
  • 2023-01-31 SONO - abdomen
    • Post PTGBD
    • Dilated main pancreatic duct
    • Rule out pancreatic head tumor
  • 2022-11-24 CT - abdomen
    • History and indication: 71 y/o female, a pt of pancreatic head carcinoma, cT4N0M0, stage III
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Stable condition of pancreatic head cancer.
      • S/P PTGBD. Right liver cyst (2.0cm).
  • 2022-09-08 Ocular fundus photography
    • fundus c/d 50% ou
    • moderate NPDR ou
      • ChatGPT: NPDR in the context of ocular fundus photography stands for Non-Proliferative Diabetic Retinopathy. There are two main stages of diabetic retinopathy:
        • Non-Proliferative Diabetic Retinopathy (NPDR): This is the early stage of diabetic retinopathy and is characterized by changes in the retinal blood vessels, including microaneurysms (small outpouchings), retinal hemorrhages (bleeding), and retinal edema (swelling). In some cases, NPDR may progress to a more advanced form called diabetic macular edema (DME), which is characterized by swelling in the central part of the retina (macula) and can lead to vision loss.
        • Proliferative Diabetic Retinopathy (PDR): This is the more advanced stage of the disease and is characterized by the formation of abnormal new blood vessels on the surface of the retina or the optic disc. These new vessels are fragile and prone to bleeding, which can lead to further complications like vitreous hemorrhage, retinal detachment, or severe vision loss.
  • 2022-06-30 Patho - pancreas biopsy
    • Pancreatic head, EUS-FNB — Ductal adenocarcinoma, moderately differentiated
    • The sections show a picture of ductal adenocarcinoma, composed of nests and cords of columnar to cuboidal neoplastic cells with abundant clear cytoplasm, embedded in fibrous stroma. Glandular differentiation and mucin secretion are present. Tumor necrosis can be identified also.
  • 2022-06-30 Cell Block Cytology
    • pancreas, SMEAR and CELL : adenocarcinoma;
    • SMEAR and CELL: show clusters of adenocarcinoma
  • 2022-06-30 Needle Aspiration Cytology - pancreas
    • pancreas, FNA: adenocarcinoma;
    • Smears show clusters of adenocarcinoma
  • 2022-06-30 Endoscopic Ultrasonography, EUS
    • suspected pancreatic head cancer, T4N1Mx, s/p EUS/FNB
    • reflux esophagitis, LA-A
  • 2022-06-29 CXR
    • Atherosclerosis of the aorta.
  • 2022-06-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 20) / 79 = 74.68%
      • M-mode (Teichholz) = 74.7 ~ 61.2
    • Conclusion
      • Normal AV with no AR
      • Normal MV with mild MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • Normal LV wall motion
      • No PR, trivial TR, normal IVC size
  • 2022-06-27 Flow-volume loops
    • Mild obstructive ventilatory impairment
  • 2022-06-24 CT - liver, spleen, biliary duct, pancreas
    • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage): T4N0M0, stage III
  • 2022-06-10 ECG
    • Sinus rhythm with 1st degree A-V block
    • Cannot rule out Inferior infarct, age undetermined
    • Abnormal ECG
  • 2022-06-10 CXR
    • Presence of ileus.
  • 2022-06-10 SONO - abdomen
    • diagnosis
      • suspicious, pancreatic head tumor with obstructive jaundice
      • fatty liver, mild
    • suggestion
      • correlate with other image study and tumor markers
  • 2022-03-17 Optical Coherence Tomography
    • fundus c/d 50% ou
    • moderate NPDR ou
  • 2022-02-14 CXR
    • elongated and tortuosity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • mild enlarged cardiac silhoutte
  • 2021-03-15 CXR
    • elongated and tortuosity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • moderate enlarged cardiac silhoutte
    • ……

[consultation]

  • 2022-06-24 General and Gastrointestinal Surgery
    • Q
      • For operation evaluation
      • This 71 y/o female has hitory of DM, HTN, CHF, COPD, Hyperlipidemia, Asthma under regular follow up at our CV, Meta, and CM’s OPD and this time she came our GI’s OPD for epigastric dullness pain for several weeks and jaundice, where PE and Lab data were surveyed and abdomen echo was also done and pancreatic head tumor with obstructive jaundice was suspected, so referal to ER for Covid-19 PCR checking and admission to GI’s ward for further management was done. However, the PCR result at ER showed positive result with CT value 17, the patient was admitted to our quarantine ward for Covid-19 infection. She transfer to GI ward on 2022/06/24. Abdominal CT was arranged on 2022/06/24. So we need you evaluation and suggestion of this patient. Thank you very much ~
    • A
      • S:
        • The patient was suspected pancreatic head tumor with obstructive jaundice. Surgical evaluation is consulted.
      • O:
        • vital signs: stable, no fever
        • abdomen: a PTGBD over R’t abdomen with bile content, soft, ovoid, decrease bowel sound, no tenderness, no Murphy’s sign
        • lab data: see chart
      • A:
        • Pancreatic head Ca, cT2N0M0, stage IB
      • P:
        • Please arrange echocardiogram & test
        • If heart function & PFT is OK, pylorus preserving pancreaticoduodenectomy is suggested next week.
  • 2022-06-13 Radiation Oncology
    • Q
      • For pancreat cancer with on PTGBD. (PTGBD: percutaneous transhepatic gallbladder drainage)
    • A
      • According to the clinical condition and imaging findings, PTGBD is indicated.

[MedRec]

  • 2022-07-05 SOAP Hemato-Oncology
    • S
      • PH:
        • COVID-19, virus identified
        • Chronic systolic (congestive) heart failure
        • Type 2 diabetes mellitus without complications
        • Chronic obstructive pulmonary disease
      • weight loss (+) (10kg in 2~3 Mo )
      • suffered from initial presentation of genealized jaundice in June 2022
      • referred to our clinic on 7/5 22 for pre-Op neoadjuvant C/T
      • ancreatic head carcinoma, cT4N0M0, stage III, Dx in June 2022
      • obstructive jaundice s/p PTGBD on 6/13 22.
      • explain to pt about the indication & risk / benefit of pre-Op neoadjuvant C/T wt FOLFIRINOX IV Q2W x 6 or more then do abd CT for response / Op evaluation (7/5 22).
      • HBsAg, anti-HBc (6/11 22): negative.
      • will give pre-Op neoadjuvant C/T wt FOLFIRINOX ( self-paid ) IV Q2W x 6 (7/5 22).
      • Adm 1 wk later on 7/15 22 for #1 pre-Op neoadjuvant C/T wt FOLFIRINOX ( self-paid ) IV Q2W x 6.
  • 2017-05-22 SOAP Cardiology
    • Diagnosis
      • Chronic systolic (congestive) heart failure [I50.22]
      • Essential (primary) hypertension [I10]
    • Prescription
      • Hexal (carvedilol 25mg) 1# QD 28 days
      • Blopress (candesartan 8mg) 0.5# BID 28 days
      • Aldactin (spironolactone 25mg) 1# QD 28 days
  • 2017-05-22 SOAP Chest Medicine
    • Diagnosis
      • Pulmonary TB, unspecified, by culture (+) [A15.0]
      • Acute respiratory failure [J96.00]
      • Pneumonia, unspecified organism [J18.9]
      • Congestive heart failure [I50.22]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
      • hyperuricemia [E79.0]
    • Prescription
      • NovoNorm (repaglinide 1mg) 1# TIDAC 7 days
      • colchicine 0.5mg 1# QD 14 days
      • Vit B6 (pyridoxine 50mg) 1# QD 14 days
      • Euricon (benzbromarone 50mg) 1# QD 14 days
      • Through (sennosides) 12mg 1# HS 14 days
      • Rifinah (RIF 300mg + INH 150mg) 2# QD 14 days
      • pyrazinamide 500mg 2.5# QD 8 days
      • Welizen (famotidine 20mg) 1# BID 14 days
      • Epbutol (ethambutol 400mg) 2# QD 8 days
  • 2017-03-25 SOAP Metabolism
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
    • Prescription
      • Trajenta (linagliptin 5mg) 1# QD 4 days
      • Glucobay (acarbose 100mg) 1# TIDAC 4 days
      • Uformin (metformin 500mg) 1# TIDCC 4 days
      • Kludone (gliclazide 60mg) 1# BID 4 days
      • Uretropic (furosemide 40mg) 1# QD 4 days

[chemoimmunotherapy]

  • 2023-04-25 - oxaliplatin 80mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 190mg NS 500mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-04-03 - oxaliplatin 80mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 190mg NS 500mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-03-03 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 205mg NS 500mL 2hr + leucovorin 400mg/m2 545mg NS 250mL 2hr + fluorouracil 2400mg/m2 3285mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-02-13 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 205mg NS 500mL 2hr + leucovorin 400mg/m2 545mg NS 250mL 2hr + fluorouracil 2400mg/m2 3285mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-12-29 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 210mg NS 500mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 3380mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-12-08 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 210mg NS 500mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 3380mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-11-11 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 210mg NS 500mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 3380mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-10-20 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 215mg NS 500mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3440mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-09-12 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 210mg NS 500mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3440mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-08-26 - oxaliplatin 80mg/m2 115mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg NS 500mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3450mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-08-10 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg NS 500mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-07-18 - oxaliplatin 60mg/m2 80mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg NS 500mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

[note]

  • Pancreatic Adenocarcinoma NCCN Evidence Blocks Version 1.2022 - May 3, 2022, p39,41
    • neoadjuvant therapy
      • FOLFIRINOX or modified FOLFIRINOX +- subsequent chemoradiation
      • Gemcitabine + albumin-bound paclitaxel +- subsequent chemoradiation
      • Only for known BRCA1/2 or PALB2 mutations
        • FOLFIRINOX or modified FOLFIRINOX +- subsequent chemoradiation
        • Gemcitabine + cisplatin (>= 2-6 cycles) +- subsequent chemoradiation
    • adjuvant therapy
      • preferred regimens
        • Modified FOLFIRINOX (category 1)
        • Gemcitabine + capecitabine (category 1)
      • other recommended regimens
        • Gemcitabine (category 1)
        • 5-FU + leucovorin (category 1)
        • Continuous infusion 5-FU
        • Capecitabine (category 2B)
        • Induction chemotherapy (gemcitabine, 5-FU + leucovorin, or continuous infusion 5-FU) followed by chemoradiation
        • Induction chemotherapy (gemcitabine, 5-FU + leucovorin, or continuous infusion 5-FU) followed by chemoradiation followed by subsequent chemotherapy  - Gemcitabine followed by chemoradiation followed by gemcitabine -Bolus 5-FU + leucovorin followed by chemoradiation followed by bolus 5-FU + leucovorin -Continuous infusion 5-FU followed by chemoradiation followed by continuous infusion 5-FU
  • Modified FOLFIRINOX chemotherapy for pancreatic cancer (UpToDate 20220719)
    • Cycle length: 14 days.
    • Regimen
      • Oxaliplatin
        • 85 mg/m2 IV
        • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
        • Day 1
      • Leucovorin
        • 400 mg/m2 IV
        • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
        • Day 1
      • Irinotecan
        • 150 mg/m2 IV
        • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
        • Day 1
      • Fluorouracil (FU)
        • 2400 mg/m2 IV
        • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
        • Day 1
    • Pretreatment considerations:
      • Emesis risk
        • HIGH (greater than 90% frequency of emesis).
      • Prophylaxis for infusion reactions
        • Although infusion reactions have been reported with oxaliplatin, there is no recommended standard premedication for this regimen.
      • Vesicant/irritant properties
        • Oxaliplatin and FU are irritants, but oxaliplatin can cause significant tissue damage; avoid extravasation.
      • Infection prophylaxis
        • Primary prophylaxis with G-CSF is not warranted. However, given the risk of grade 3 or 4 neutropenia (46%), primary prophylaxis with G-CSF is used at many institutions, especially when this regimen is used in the adjuvant setting.
      • Dose adjustment for baseline liver or renal dysfunction
        • A lower starting dose of oxaliplatin and irinotecan may be needed for severe renal insufficiency. A lower starting dose of irinotecan and FU may be needed for patients with hepatic impairment.
        • NOTE: We do not recommend administration of FOLFIRINOX unless serum bilirubin is normal.
      • Maneuvers to prevent neurotoxicity
        • Pharmacologic methods to prevent/delay the onset of oxaliplatin-related neuropathy are controversial due to the absence of large clinical trials proving benefit. Counsel patients to avoid exposure to cold during and for approximately 48 hours after each infusion. Prolongation of the oxaliplatin infusion time from two to six hours may mitigate acute neurotoxicity.
      • Cardiac issues
        • QT prolongation and ventricular arrhythmias have been reported after oxaliplatin. ECG monitoring is recommended if therapy is initiated in patients with heart failure, bradyarrhythmias, coadministration of drugs known to prolong the QT interval, and electrolyte abnormalities. Avoid oxaliplatin in patients with congenital long QT syndrome. Correct hypokalemia and hypomagnesemia prior to initiating oxaliplatin.
        • Cardiotoxicity observed with FU includes myocardial infarction/ischemia, angina, dysrhythmias, cardiac arrest, cardiac failure, sudden death, electrocardiographic changes, and cardiomyopathy.
    • Monitoring parameters:
      • CBC with differential and platelet count prior to each treatment.
      • Electrolytes (especially potassium and magnesium) and liver and renal function prior to each treatment.
      • Irinotecan is associated with early and late diarrhea, both of which may be severe. For patients who develop abdominal cramping and/or diarrhea within 24 hours of receiving irinotecan, administer atropine (0.3 to 0.6 mg IV) and premedicate with atropine during later cycles. Patients must be instructed in the early use of loperamide for late diarrhea. Patients who develop diarrhea should be closely monitored and supportive care measures (eg, fluid and electrolyte replacement, loperamide, antibiotics, etc) should be provided as needed.
      • Assess changes in neurologic function prior to each treatment.
    • Suggested dose modifications for toxicity:
      • Myelotoxicity
        • Do not retreat unless neutrophil count is >=1500/microL and platelets are >=75,000/microL. The following dose reduction guidelines for hematologic toxicity are recommended; several of these are based upon recommendations in the original FOLFIRINOX protocol.
        • Neutropenia
          • If day 1 treatment delayed for granulocytes is <1500/microL or febrile neutropenia or grade 4 neutropenia >7 days: Reduce irinotecan dose to 120 mg/m2. For second occurrence: Reduce oxaliplatin dose to 60 mg/m2. If nonrecovery after a two-week delay, or if there is a third occurrence of granulocytes <1500/microL on day 1, discontinue treatment. For grade 4 neutropenia >7 days during treatment or febrile neutropenia, reduce oxaliplatin dose to 60 mg/m2 and the infusional FU dose to 75% of the original dose. For the second occurrence, reduce dose of irinotecan to 120 mg/m2 and the dose of infusional FU an additional 25%. Discontinue treatment for third occurrence.
        • Thrombocytopenia
          • If day 1 treatment delayed for platelet count <75,000/microL, reduce oxaliplatin dose to 60 mg/m2 and reduce the continuous infusion FU to 75% of original doses. For second occurrence, reduce irinotecan dose to 120 mg/m2. If nonrecovery after a two-week delay, or if there is a third occurrence of platelets <75,000/microL, discontinue treatment. For grade 3 or 4 thrombocytopenia during treatment, reduce oxaliplatin dose to 60 mg/m2 and the infusional FU dose to 75% of the original dose. For the second occurrence, reduce dose of irinotecan to 120 mg/m2 and the dose of infusional FU an additional 25%. Discontinue treatment for third occurrence.
      • Diarrhea
        • Do not retreat with FOLFIRINOX until resolution of diarrhea for at least 24 hours without antidiarrheal medication. For diarrhea grade 3 or 4, or diarrhea with fever and/or grade 3 or 4 neutropenia, reduce irinotecan dose to 120 mg/m2. For second occurrence, reduce the oxaliplatin dose to 60 mg/m2 and the continuous FU dose to 75% of original dose. Discontinue treatment for third occurrence.
        • NOTE: Severe diarrhea, mucositis, and myelosuppression after FU should prompt evaluation for DPD deficiency.
      • Mucositis or hand-foot syndrome
        • For grade 3 to 4 toxicity, reduce dose of infusional FU by 25%.
      • Pulmonary toxicity
        • Oxaliplatin has rarely been associated with pulmonary toxicity. Withhold oxaliplatin for unexplained pulmonary symptoms until interstitial lung disease or pulmonary fibrosis is excluded.
      • Neurologic toxicity
        • For persistent grade 3 paresthesias/dysesthesias or transient grade 2 symptoms lasting >7 days, decrease oxaliplatin dose by 25%. Discontinue oxaliplatin for grade 4 or persistent grade 3 paresthesia/dysesthesia.
        • There is no recommended dose for resumption of FU administration following development of hyperammonemic encephalopathy, acute cerebellar syndrome, confusion, disorientation, ataxia, or visual disturbances; the drug should be permanently discontinued.
      • Cardiotoxicity
        • Cardiotoxicity observed with FU includes myocardial infarction/ischemia, angina, dysrhythmias, cardiac arrest, cardiac failure, sudden death, ECG changes, and cardiomyopathy. There is no recommended dose for resumption of FU administration following development of cardiac toxicity, and the drug should be discontinued.
      • Other toxicity
        • Any other toxicity >=grade 2, except anemia and alopecia, can justify dose reduction if medically indicated.
        • For other nonhematologic toxicities, if grade 2, hold treatment until <=grade 1; if grade 3 or 4, hold treatment until <=grade 2.
      • If there is a change in body weight of at least 10%, doses should be recalculated.

==========

2023-04-26

  • There is no medication reconciliation issue for the current active formulary, which includes medications prescribed by our cardiologist, pulmonologist, and metabolic specialist.

  • The patient’s underlying conditions of hypertension (HTN) and type 2 diabetes mellitus (T2DM) are not well controlled during this hospitalization. Blood pressure readings show systolic values between 170 and 184 mmHg, and HbA1c levels have been consistently above 8% for the past 4 months. Serum glucose was recorded as 231mg/dL on the evening of 2023-04-25 and as 158mg/dL on the morning of 2023-04-26. Addition of antihypertensive and/or hypoglycemic agents may be considered if symptoms persist.

    • 2023-04-08 HbA1c 8.3 %
    • 2023-01-14 HbA1c 8.6 %
    • 2022-10-20 HbA1c 7.4 %
    • 2022-07-25 HbA1c 7.0 %
    • 2022-04-30 HbA1c 8.3 %

2022-07-17

  • UGT1A1 genotyping result is not found in HIS5, please monitor if early and/or late (irinotecan caused) diarrhea occurs
  • There has been an upward trend in HbA1c levels over the past 12 months, a follow-up update might be considered.
    • 2022-04-30 HbA1c 8.3 %
    • 2022-02-05 HbA1c 8.2 %
    • 2021-11-13 HbA1c 7.4 %
    • 2021-08-21 HbA1c 7.0 %
  • Since this hospitalization, the level of blood sugar remains high
    • 2022-07-19 06:06 215 mg/dL
    • 2022-07-18 16:18 191 mg/dL
  • As for this patient has been taking metformin (DC for now), vildagliptin (DPP4i), glimepiride (sulfonylurea), and acarbose (alpha-glucosidase inhibitors) for a considerable period of time. Basal insulin might be an optional add-on if HbA1c rises above 8.5% and AC glucose rises above 250 mg/dL for most of the days.
  • A c-peptide test is also recommended for her.

700074348

230424

[exam findings] (not completed)

  • 2023-04-03 PET scan
    • In comparison with the previous study on 2022-02-22, some glucose hypermetabolism lesions in the retroperitoneum and in the left lower pelvic region come to less evident or disappear; several glucose hypermetabolism lesions in the right supra-renal region, in the right para-aortic space, in bilateral common iliac chains, and in soft tissue in RLQ of abdomen, however, are noted. The nature is to be determined (metastatic disease in progression or even another primary malignancy), suggesting biopsy (the soft tissue in RLQ of abdomen) for further investigation,.
    • Glucose hypermetabolism lesions in bilateral pulmonary hilar and mediastinal lymph nodes and in bilateral axillary lymph nodes, probably reactive nodes, suggesting follow-up.
    • Increased FDG uptake in the right lobe of the liver and in two right ribs, highly suspected malignancy with distant metastases.
    • Glucose hypermetabolism in the left shoulder, compatible with arthritis.
    • Seconary malignancy of lymph nodes of head and neck s/p treatment with suspected tumor progression in the abdomen as well as liver and bone metastases, by this F-18-FDG PET/CT scan.
  • 2022-10-31 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, mandible, L3-5 spines, both shoulders, sternoclavicular junctions, elbows, S-I joints, hips, knees, and feet, in whole body survey.
    • IMPRESSION:
      • No strong evidnece of bone metastasis.
      • Suspected benign lesions in the maxilla, mandible, L3-5 spines, both shoulders, sternoclavicular junctions, elbows, S-I joints, hips, knees, and feet.
  • 2022-09-17 MRI - L-spine
    • Past Hx: gouty arthritis; steroid(+); oral cancer. Right tonsillar cancer with right neck lymph node metastasis, T1N2cM0, stage IVA s/p concurrent chemoradiotheraphy in 2006. 20220819: LBP and right sciatica for 6 months; ongoing C/T;
    • Findings
      • General bulging disc, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis and bilateral mild neuroforaminal narrowing at L2-3.
      • Decreased vertebral body height, end-plate degeneration, disc collapse with severe general bulging, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis and bilateral neuroforaminal narrowing at L3-4, much more severe on left side.
      • End-plate degeneration, disc collapse with general bulging and right lateral focal protrusion, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis and bilateral neuroforaminal narrowing at L4-5, much more severe on right side.
      • Mild general bulging disc at L5-S1.
      • No intramedullary lesion.
      • Mild scoliosis of L-spine.
      • A 17-mm T2-hyperintense cyst at left kidney.
    • IMP: Lumbar spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, esp L3-4 and L4-5 (with right HIVD).
  • 2022-06-28 CT - abdomen
    • Left renal cyst (1.4cm).
    • A cyst (9mm) at LLL.

[consultation]

  • 2023-04-24 Diagnostic Radiation
    • Q
      • This is a 58-year-old male with underlying history of:
        • Metastatic squamous cell carcinoma of the neck with unknown primary site, s/p CCRT (2006).
        • Squamous cell carcinoma of the right mouth floor, s/p operation (right mouth floor cancer wide excision. Right selective neck dissection, level 1~3, 2013-10-07), stage pT1N0(cM0).
        • Squamous cell carcinoma of the left mouth floor, s/p induction chemotherapy and operation (wide excision of left side mouth floor cancer with left side; tongue flap; tooth extraction, 2016-05-04), stage ypStage III, ypT1N1(cM0).
        • Metastatic squamous cell carcinoma of the right low neck to SCF, s/p operation (right neck dissection, level III, IV, V, 2020-09-02), and s/p CCRT, with left pelvic metastasis, s/p CCRT, with progression.
        • Squamous cell carcinoma of the anterior mouth floor, s/p wide excision and partial mandibulectomy.
      • On follow-up PET on 2023/04/03, report showed:
        • several glucose hypermetabolism lesions in the right supra-renal region, in the right para-aortic space, in bilateral common iliac chains, and in soft tissue in RLQ of abdomen
        • Seconary malignancy of lymph nodes of head and neck s/p treatment with suspected tumor progression in the abdomen as well as liver and bone metastases was impressed
      • Therefore, this time we would really need your expertise in performing CT-guided biopsy at RLQ abdomen soft tissue mass for this patient. Thanks a lot in advance!
    • A
      • According to the clinical condition and imaging findings, biopsy is indicated.
  • 2021-09-29 Radiation Oncology
    • Q
      • For RT evaluation
      • This is a 56-year-old male patient with a history of
        • right tonsillar cancer, T1N2cM0, stage IVA, status post concurrent chemoradiotheraphy in 2006,
        • right anterior mouth floor squamous cell carcinoma in situ, status post excision and revisional wide excision in 2010,
        • right mouth floor cancer, pT1N0cM0, status post wide excision and right selective neck dissection over level 1~3 in 2013,
        • left mouth floor cancer cT4aN0M0, status post induction chemotherapy and surgical excision in 2016, ypT1N1,
        • right lower neck tumor recurrence s/p right radical neck dissection on 2020-9-16, post-op CCRT completed on 2020-11-06, s/p oral ufur,
        • Left pelvic lesion s/p CT guided biopsy on 2021-03-12 (pathology: Metastatic squamous cell carcinoma, poorly differentiated), PET also revealed a new nodular lesion in RUQ of abdomen s/p CCRT for pelvic lesion (completed on 2021-05-17).
      • This time, he came to our hospital due to left lower gingiva lesion noted for weeks. Therefore, he came to our OPD for help. Abnormal painful leukoplakia-erythroplakia lesion at the left mandible was noted at OPD. Biopsy was done for left lower gingival lesion, and the pathology report was SCC. He received operation of oral tumor wide excision + marginal mandibulectomy +- local flap reconstruction on 2021-09-24, and the pathology was pending.
      • Also, pelvic and abdomen CT f/u on 2021-09-06 revealed A soft tissue lesion (2.4cm) at right perirenal region r/o tumor seeding and Enlarged LNs (up to 2.6cm) at retroperitoneum r/o metastases. Urologist was consulted and suggested CCRT.
      • Therefore, we need your expertised for further RT management for the patient.
    • A
      • Metastatic squamous cell carcinoma of the neck with unknown primary site, s/p CCRT (2006).
      • Squamous cell carcinoma of the right mouth floor, s/p operation (right mouth floor cancer wide excision. Right selective neck dissection, level 1~3, 2013-10-07), stage pT1N0(cM0).
      • Squamous cell carcinoma of the left mouth floor, s/p induction chemotherapy and operation (wide excision of left side mouth floor cancer with left side; tongue flap; tooth extraction, 2016-05-04), stage ypStage III, ypT1N1(cM0).
      • Metastatic squamous cell carcinoma of the right low neck to SCF, s/p operation (right neck dissection, level III, IV, V, 2020-09-02), and s/p CCRT, with left pelvic metastasis, s/p CCRT, with progression.
      • Squamous cell carcinoma of the anterior mouth floor, s/p wide excision and partial mandibulectomy.
    • P: Radiotherapy is indicated for this patient with the following indicators: metastatic lesions over the soft tissue lesion at right perirenal region and enlarged LNs at retroperitoneum.
      • Goal: palliation
      • Treatment target and volume: the soft tissue lesion at right perirenal region and enlarged LNs at retroperitoneum.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his daughter. They understand and would like to receive radiotherapy. The treatment planning of radiotherapy will be started at 11AM, 2021-10-01.
  • 2020-09-01 Colorectal Surgery
    • Q
      • This time, PET scan showed left pelvic lesion, and pelvis CT showed a lymph node (0.8cm) at left pelvic cavity. Owing to his clinical condition mentioned above, we sincerely need your expertise regarding further management for this patient. Thank you very much!
    • A
      • S: Consult for left pelvic nodule.
      • O: CT > A LN (0.8cm) at left pelvic cavity.
        • with suspect adhesion to vessel and sacal bone
        • Also nodule lesion over right inguinal region.
      • A: Multiple PET lesion
      • P:
        • please arrange colonoscopy to check colon tumor
        • high risk for surgical remove this nodule. and PET also show multiple lesion.
        • If no colonic lesion is seen, suggest medical treatment first (by neck etilogy)
  • 2020-09-01 Urology
    • Q
      • This time, PET scan showed left pelvic lesion, and pelvis CT showed a lymph node (0.8cm) at left pelvic cavity. Owing to his clinical condition mentioned above, we sincerely need your expertise regarding further management for this patient. Thank you very much!
    • A
      • 55M with left pelic LNs
      • S: oral cancer, s/p op,
      • O: PET and CT: showed one 1cm LN near left internal ileac artery
      • A: oral cancer, stage IVa
      • P:
        • oral cancer with LNs mets is highly suspected
        • difficult position for CT-guided biopsy
        • please check PSA, U/A, and urine cytology to r/o prostate cancer and bladder cancer

[chemotherapy]

  • 2022-09-27 - doxorubicin 60mg/m2 85mg NS 100mL 10min

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-08-30

  • 2022-08-01

  • 2022-07-01

  • 2022-05-31

  • 2022-01-03 - cisplatin 100mg/m2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1550mg NS 500mL 21hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2021-11-12 - NS 500mL (before cisplatin) + cisplatin 30mg/m2 40mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + 1S 250mL
  • 2021-11-05

  • 2021-10-29

  • 2021-05-11

  • 2021-05-04

  • 2021-04-28

  • 2020-11-03

  • 2020-10-27

  • 2020-10-20

[assessment]

  • On 2023-04-03, a PET scan revealed multiple glucose hypermetabolic lesions in the right supra-renal region, right paraaortic space, bilateral common iliac chains, and soft tissue in the right lower quadrant (RLQ) of the abdomen. These lesions could indicate metastatic disease progression or even another primary malignancy. A CT-guided biopsy of the soft tissue mass in the right lower quadrant of the abdomen is scheduled for 2023-04-25 at 11:00 AM to determine the nature of these lesions.

  • 2023-04-24 eGFR 46. OxyNorm (oxycodone) - CrCl 30 to <60 mL/minute: Immediate release, Oral: Initial: Administer 50% to 75% of usual dose no more frequently than every 6 hours. Use with caution; titrate gradually based on patient response and adverse effects.

700267861

230424

[exam findings]

  • 2023-04-11 Patho - kidney biopsy
    • Kidney, left, CT-guided biopsy — Invasive urothelial carcinoma, high-grade
    • The sections show following features:
      • Histologic type: Urothelial carcinoma, invasive
      • Histologic grade: High-grade
      • Tumor configuration: Nodular
      • Muscularis propria: Absent
      • Lymphovascular invasion: Not identified
    • IHC: CK7(+), CK5/6(+), GATA3(+), CA 9(-), and CD117(-)
  • 2023-04-10 CT - abdomen
    • History and indication: Retroperitoneal tumor with aorta and left kidney involvement, r/o left urothelial carcinoma, suspected renal cell carcinoma
    • With and without-contrast CT of abdomen-pelvis revealed:
      • An infiltrative tumor (4.0x7.8x4.2cm) at left retroperitoneal with adjacent structures (aorta, left renal artery/ vein, left kidney, spine and adjacent vessels) invasion. Left hydronephrosis.
      • Some LNs at retroperitoneum.
      • Liver cysts (up to 1.5cm).
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • An infiltrative tumor (4.0x7.8x4.2cm) at left retroperitoneal with adjacent structures (aorta, left renal artery/ vein, left kidney, spine and adjacent vessels) invasion. Left hydronephrosis.
  • 2023-04-01 CXR
    • Blunting of left CP angle
    • Borderline enlarged cardiac sihoutte
  • 2023-04-01 EXG
    • Sinus tachycardia
    • ST & T wave abnormality, consider inferior ischemia
    • ST & T wave abnormality, consider anterolateral ischemia
    • Abnormal ECG
  • 2023-03-27 SONO - neurology
    • Chronic renal parenchymal disease, mild degree
    • Suspected left renal pelvic mass lesion with hydronephrosis
  • 2023-03-23 CT - abdomen
    • Indication: nausea without vomiting and abdominal pain for half a monthalso, mild dyspnea was notedwent to Feng Rong Hospital, ileus and mild pneumonia was told
    • Without contrast enhancement CT of abdomen shows:
      • Infiltrating mass lesion in retroperitoneum, possibly derived from left ureter. Imperceptible margin with adjacent kidney and aorta. Regional enlarged lymph nodes noted.
      • Left hydronephrosis.
      • No ascites or extraluminal free air.
      • No evidence of bowel obstruction.
      • No bony destructive lesion on these images.
    • Impression
      • Retroperitoneal tumor with aorta and left kidney involvement, suspected left urothelial carcinoma; DDx: renal cell carcinoma
      • Suspect regional lymph node metastsis
  • 2023-03-23 KUB
    • Degenerative change of the lumbar spine
  • 2023-03-23 ECG
    • ST & T wave abnormality, consider anterolateral ischemia

[consultation]

  • 2023-03-24 Urology
    • Q
      • nausea without vomiting and abdominal pain for half a month
      • also, mild dyspnea was noted
      • went to Feng Rong Hospital today, ileus and mild pneumonia was told
      • PH: DM, HF
      • OP: hysterectomy 50 yrs ago, left inguinal hernia, s/p op 10 yrs ago
      • NKA
    • A
      • please treat her ileus and pneumonia first, due to advanced age and poor condition, she may not fit for further diagnostic or therapeutic intervention for cancer currrently.

[MedRec]

  • 2023-04-21 SOAP Hemato-Oncology
    • Con’s:E4V5M6
    • 2023/04/11 PATHO - kidney biopsy
      • Invasive urothelial carcinoma, high-grade
        • Histologic type: Urothelial carcinoma, invasive
        • Histologic grade: High-grade
        • Tumor configuration: Nodular
        • Muscularis propria: Absent
        • Lymphovascular invasion: Not identified
      • IHC: CK7(+), CK5/6(+), GATA3(+), CA 9(-), and CD117(-)
    • 2023/04/10 CT: ABD
      • An infiltrative tumor (4.0x7.8x4.2cm) at left retroperitoneal with adjacent structures (aorta, left renal artery/ vein, left kidney, spine and adjacent vessels) invasion. Left hydronephrosis.
    • 2023/03/23 CT: ABD
      • Retroperitoneal tumor with aorta and left kidney involvement, r/o left urothelial carcinoma
      • Suspect regional lymph node metastsis
    • Lab
      • 2023/04/10
        • HBsAg = Nonreactive;
        • Anti-HBc = Reactive;
        • Anti-HCV = Nonreactive;
  • 2023-04-07 SOAP Hemato-Oncology
    • Past hx : hypertension, hyperlipidemia, T2DM, renal tumor
    • Allergy : NKDA
    • She was treated at Cathay hospital for her CV problem.
    • preliminary impression: R10.9 Unspecified abdominal pain
    • Discussion about tissue proof
    • Inform the patients son and sons wife about the risk and benfit of biopsy
  • 2023-03-23 SOAP Emergency
    • preliminary impression: Retroperitoneal tumor with aorta and left kidney involvement, suspected left urothelial carcinoma
    • lab data
      • 2023/03/23 21:22 BUN = 31 mg/dL;
      • 2023/03/23 21:22 Creatinine = 1.51 mg/dL;

==========

2023-04-01

  • On 2023-03-23, a CT scan revealed a retroperitoneal tumor involving the aorta and left kidney, with a differential diagnosis of left urothelial carcinoma or renal cell carcinoma. Regional lymph node metastasis is also suspected.
  • Further work on staging is pending. Family members requested not to inform the patient about the diagnosis until the pathology report is confirmed.
  • There are no medication reconciliation issues after checking the PharmaCloud database.

700287641

230424

[diagnosis] - 2023-04-22 discharge note

  • Left breast cancer, rpT4bN1M0, stage IIIB,ER (+): +, PR (+): +, HER-2/Neu +:  Negative (1+), Ki-67: 10-20 %. ECOG:1.
  • Right breast invasive carcinoma, pT2N3aM0, stage IIIB. ER (+), PR(-), Her2/neu: negative(score=0), Ki-67:30 %. ECOG:1.
  • For adjuvant chemotherapy with Taxotere
  • Nasopharyngeal carcinoma, cT1N0M0, stage I
  • Essential (primary) hypertension

[exam findings]

  • 2023-03-11 Anoscopy

    • mild mixed hemorrhoids, perianal dermatitis
  • 2023-02-09 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (95 - 20) / 95 = 78.95%
      • M-mode (Teichholz) = 79
    • Conclusion:
      • Gr II LV diastolic dysfunction and impaired RV relaxation; mildly dilated LA.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis; mild MR; mild TR; mild PR.
  • 2022-12-22 Nasopharyngoscopy

    • Findings
      • bi NP smooth, no tumor found; bi MM clear, larynx and hypopharynx np
      • a few watery discharge at left posterior nasal cavity floor
    • Diagnosis/Conclusion
      • NPC s/p treatment, no evidence of recurrence
  • 2022-11-24 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (95.9 - 20.0) / 95.9 = 79.14%
      • M-mode (Teichholz) = 79
    • Conclusion:
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • AV sclerosis with mild AR, mild MR, TR and PR
      • No regional wall motion abnormalities
  • 2022-11-17 SONO - abdomen

    • Right renal cyst (0.87x0.98cm).
  • 2022-10-26 PET scan

    • Glucose hypermetabolic lesions in the right axillary lymph nodes, compatible with metastatic lymph nodes.
    • Glucose hypermetabolism in the right mediastinal lymph nodes, the nature is to be determined (metastatic or reactive nodes ?), suggesting biopsy for further investigation.
    • Increased FDG uptake in the left pulmonary hilar region, probably reactive nodes.
    • Left breast cancer s/p treatment with tumor recurrence and right axillary lymph nodes metastases, by this F-18 FDG PET/CT scan.
  • 2022-10-18 Patho - breast mastectomy with regional lymph nodes

    • PATHOLOGIC DIAGNOSIS
      • Breast tumor, right, modified radical mastectomy —- Invasive carcinoma of no special type
      • Resection margins, ditto — Free of tumor invasion
      • Skin and nipple, ditto — Free of tumor invasion
      • Lymph node, R’t axillary SLN, frozen section — Tumor metastasis (3/3) with extracapsular extension (3/3)
      • Lymph node, R’t axillary non-SLN, MRM — Tumor metastasis (10/10) with extracapsular extension (8/10)
      • AJCC Pathologic Anatomic Stage — pT2N3a, if cM0, stage IIIC; Prognostic Stage — Stage IIIB
    • MACROSCOPIC EXAMINATION
      • Breast: 21 x 13.3 x 3.7 cm
      • Skin: 18 x 5.1 cm, normal appearance
      • Nipple: 1.2 x 1.2 cm, mild retraction
      • Tumor: 3 x 2.2 x 2.1 cm
      • Resection margins: Free, 0.7 cm away from closest base
      • Lymph node: R’t axillary sentinel and non-sentinel lymph node
      • Representatively embedded for sections as: A1-A2: Nipple + skin + tumor, A3-A8: Tumor, X1: tumor + base and X2: four peripheral margins and B1-B2: R’t axillary LNs [Reference F2022-00487, FSA1-FSA2 and A: R’t axillary sentinel LN]
    • MICROSCOPIC EXAMINATION
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma: 3 x 2.2 x 2.1 cm
      • Histologic grade (Nottingham histologic score): Grade II (score 6) including (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1]
      • Margins: Free, 0.7 cm from closest base margin
      • Lymph node, R’t axillary SLN: Tumor metastasis (3/3) with extracapsular extension (3/3)
      • Lymph node, R’t axillary non-SLN: Tumor metastasis (10/10) with extracapsular extension (8/10)
      • Treatment Effect: N/A
      • Lymphovascular space invasion: present, multiple
      • Perienural invasion: present
      • Immunohistochemistry: E-cadherin(+)
  • 2022-10-18 Frozen Section

    • R’t axillar sentinel lymph nodes, frozen section — Tumor metastasis (3/3)
  • 2022-10-17 Flow Volume Loop

    • mild obstructive impairment
  • 2022-10-07 Patho - breast biopsy (no need margin)

    • Breast, right, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (+, 95%, strong intensity), PR(-, 0%), Her2/neu: negative(score=0), Ki-67(30 %), E-cadherin (+).
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • 2022-10-07 SONO - breast

    • S/P left mastectomy.
    • Right subareolar irregular tumor with regional skin edema/thickening. Suggest biopsy.
    • BI-RADS: Category 4: suspicious abnormality-biopsy should be considered.
  • 2022-10-07 Mammography

    • Impression:
      • S/P left mastectomy.
      • Right periareolar skin thickening, suggest further study.
    • BI-RADS: Category 0 (incomplete. Need additional imaging evaluation.)
  • 2022-08-25 SONO - abdomen

    • Right renal cyst (1.08x1.14cm).
  • 2022-08-11 Nasopharyngoscopy

    • Findings: bi NP smooth, no tumor found; bi MM clear, larynx and hypopharynx np
    • Diagnosis/Conclusion: NPC s/p treatment, no evidence of recurrence
  • 2022-06-30 ENT Hearing Test

    • Tymp RE type C, LE type B
    • PTA:
      • Reliability FAIR
      • Average RE 74 dB HL, LE 81 dB HL
      • RE moderately severe to profound HL
      • LE severe to profound MHL
  • 2022-06-08 Neurosonology

    • Moderate to severe atheromatous lesion in R CCA bifurcation; mild (to moderate) atheromatous lesions in R middle CCA and L CCA bifurcation; mild atheromatous lesion in L distal CCA.
    • Elevated flow velocities in bilateral MCAs (PS/ED: R = 234/80, L= 182/55 cm/s), suggesting bilateral MCA stenosis; relatively reduced flow in R cervical VA as compared to L VA.
    • Normal extracranial carotid, L vertebral, and intracranial vertebral, basilar arterial flows.
    • Normal bilateral ophthalmic arterial flows
  • 2022-06-02 SONO - abdomen

    • Right renal cyst (0.85x1.12cm).
  • ……

  • ……

  • 2017-05-26 Surgical pathology Level VI

    • PATHOLOGIC DIAGNOSIS
      • Breast, left, modified radical mastectomy —- Invasive carcinoma of no special type, grade 3
      • Resection margins, ditto — Close, less than 0.1 cm away from base margin and 0.9 cm away from closest peripheral margin
      • Skin, ditto — Tumor invasion
      • Nipple, ditto — Tumor invasion
      • Lymph nodes, left axillary, dissection — Positive for tumor metastasis (1/20) with extracapsular extension (1/1)
      • AJCC Pathologic Stage — pT4N1Mx, stage IIIB at least
    • MACROSCOPIC EXAMINATION
      • Breast: 18 x 12 x 3 cm
      • Skin: 15.5 x 7 cm
      • Nipple: 1.8 x 1.8 x 0.7 cm
      • Tumor: difficult to assess grossly. Only mild fibrosis of skin and few foci of fibrous nodules found. Microscopically, multiple foci of tumor measures up to 2.3 x 2 cm is noted.
      • Resection Margins: Close, less than 0.1 cm away from base margin and 0.9 cm away from closest peripheral margin
      • Lymph node: left axillary LNs
      • Representative sections as follows: A1: nipple, A2-A6: tumor; B1-B6: LNs.
    • MICROSCOPIC EXAMINATION (FOR INVASIVE CARCINOMA)
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma: Multiple foci, up to 2.3 x 2 cm
      • Histologic grade (Nottingham histologic score): Grade III (score 8)
        • [(A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 3 and (C) Mitotic count: score 2]
      • Margins: Close, less than 0.1 cm away from base margin and 0.9 cm away from closest peripheral margin
      • Nodal status: Positive for tumor metastasis (1/20) with extracapsular extension (1/1)
      • Treatment Effect: N/A
      • Immunohistochemical study of CK highlights tumor is very close to base margin
  • 2017-05-25 PET scan

    • Glucose hypermetabolism in the left breast, compatible with breast malignancy.
    • Mild glucose hypermetabolism in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammatory process is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Mild glucose hypermetabolism in the L3 spine. Degenerative spine disease may show this picture.
  • 2017-05-22 Gynecologic ultrasonography

    • Endometrial thickening
  • 2017-05-16 Surgical pathology Level IV

    • Breast, left, sono-guide biopsy — Invasive carcinoma of no special type
    • Immunohistochemical stains:
      • CK14: loss of myoepithelial cells
      • E-cadherin: positive for tumor cells
      • ER: 90%, intensity 2+
      • PR: 10%, intensity 3+
      • Her2/neu: negative; DAKO score 1+
      • P53: positive, 100%
      • Ki67: 60-70% activity
    • Microscopically, the sections show a picture of invasive carcinoma of no special type of the breast tissue characterized by pleomorphic tumor cells show linear or nested pattern, infiltrate in the desmoplastic stroma.
  • 2017-05-16 SONO - breast

    • CC/Indication:
      • Lt breast mass and CNB performed 2012-11-06, 2012-11-19 (CNB = Core Needle Biopsy)
      • DCIS was told. (Chat GPT: DCIS stands for ductal carcinoma in situ. It is a non-invasive form of breast cancer where abnormal cells are found in the lining of the breast ducts but have not spread beyond the ducts into surrounding breast tissue. Although DCIS is not an invasive cancer, it is considered a pre-cancerous condition and has the potential to develop into invasive breast cancer if left untreated. Treatment options for DCIS typically include surgery, radiation therapy, and hormonal therapy.)
    • Suggestion and Plan
      • Bilateral breast cysts and fibroadenomas.
      • Left breast 9’region irregular hypoechoic tumor with prominent vascularity, suggest biosy.
    • BIRADS4

[consultation]

  • 2022-10-17 Rehabilitation
    • Q
      • This 70 year-old women, she has right breast cancer with right simple mastectomy + SLNB on 2022/10/18. We need your help for rehabilitation after surgery, thank you!!
    • A
      • We were consulted for rehabilitation for preventing complications and post-operation lymphedema.
      • Premorbid functional status
        • Walk ID, ADLs ID.
      • Physical examination
        • 2022/10/17 10:42 T/P/R: 36.0 / 61bpm / 18bpm BP:134/64mmHg
        • Consciousness: clear
        • Cognition: intact
        • MP: RUE/RLE: 5/5, LUE/LLE: 5/5
        • Functional status: ID
        • ADLs: ID
        • Bilateral shoulders ROM: nearly full range of ative and passive ROM
      • Past hx: left forzen shoulder (improved)
      • Hand and arm circumference (R/L,cm):
        • Elbow joint above 5cm 25/27
        • Elbow joint below 5cm 22.5/24
      • Left arm lymph edema now:
        • ISL grade I, stage I
        • soft, intact skin, no fibrotic change in left arm
      • previous record:
        • 2021/09/15 rehab OPD
          • Skin test +
          • ISL stage: III: fibrotic changes over the forearm and arm
          • Other complications: Frozen shoulder at end-range
      • Imp
        • Rt breast ca ,cT2N0M0 stage 2A
        • OP: right simple mastectomy + SLNB on 2022/10/18.
        • Past hx:
          • Recurrent lt breast ca s/p MRM on 2017-05-26
          • adjuvant C/T with EC ->T since 2017-06-19
          • Lt upper limb lymphedema
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation (passive ROM, massage, therapeutic exercise) and home program education
        • Goal: Functional ability ID, maintain ROM, prevent post-OP complications

[MedRec]

  • 2022-11-23 SOAP General and Gastroenterological Surgery
    • The multidisciplinary cancer team meeting concluded on 2022-10-28. The treatment plan for the patient is as follows: TC chemotherapy every three weeks for a total of four cycles, followed by CDK4/6 inhibitor (self-paid), radiotherapy, and five years of hormone therapy.
  • 2022-11-08 SOAP Radiation Oncology
    • A:
      • Non keratinizing undifferentiated carcinoma of the nasopharynx, stage cT1N0M0, s/p radiotherapy (2004-05-25 ~ 2004-07-16).
      • Predominant ductal carcinoma in situ, intermediate grade, with focal microinvasive ductal carcinoma of the left breast, stage pStageIA, pT1aN0(0/2)(cMx); ER(weak positive, 30%), PR(weak positive, 30%), Her2/neu: (negative, 1+), s/p partial mastectomy, left axillar sentinel lymph node biopsy, radiotherapy in 2013/03, and status during hormone therapy (Tamoxifen) since 2012/12/10, with left breast recurrence, s/p MRM and ALND (2017-05-26), stage pT4N1(1/20)(cN0), stage IIIB, s/p chemotherapy and radiotherapy, and status during endocrine therapy.
      • Invasive carcinoma of no special type, of the right breast, ER (+, 95%, strong intensity), PR(-, 0%), Her2/neu: negative(score=0),AJCC Pathologic Anatomic Stage pT2N3a, cM0, stage IIIC; Prognostic Stage — Stage IIIB, s/p MRM (2022-10-18)
    • P: Radiotherapy is indicated for this patient with the following indicators: stage pT2N3a, cM0
      • Goal: curative
      • Treatment target and volume: right chest wall, axilla, to low SCF
      • Technique: IMRT
      • Preliminary planning dose: 5000cGy/25 fractions of the right chest wall, axilla, to low SCF
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her elder sister. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started after completion of chemotherapy. RTC: at the last cycle of chemotherapy.

[surgical operation]

  • 2022-10-18
    • Surgery: MRM        
      • ChatGPT: MRM stands for modified radical mastectomy, which is a surgical procedure to remove breast cancer. It involves the removal of the entire breast tissue, including the nipple, areola, and axillary lymph nodes. In addition, the lining over the chest muscles is also removed in this procedure. The goal of MRM is to remove the cancerous tissue and prevent the spread of cancer to nearby lymph nodes and tissues.
    • Finding
      • a 3x2x2 cm slight firm subareolar mass in rt breast
      • SLN 3/3(+)    
      • multiple axillary LNs up to 1.5 cm in size  
  • 2017-05-26
    • Diagnosis: left breast cancer
    • PCS code: 63007B: Radical mastectomy - unilateral
    • Finding
      • Three nodules up to 0.5 cmin size over lt breast
      • axillar LNs sl enlarged

[radiotherapy]

  • 2004-05-25 ~ 2004-07-16 - Past Hx (according to the Hua-Lien record): After admission, systemic work up was done and NPC cT1N0M0 was diagnosed.
    • Non keratinizing undifferentiated carcinoma of the nasopharynx, stage cT1N0M0, s/p radiotherapy. RT total dose was 7020 cGy.

[chemotherapy]

  • 2023-04-21 - docetaxel 75mg/m2 110mg NS 250mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-31 - docetaxel 75mg/m2 111mg NS 250mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-10 - docetaxel 75mg/m2 108mg NS 250mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-02 - docetaxel DC (due to WBC 1.57K/uL)

  • 2023-02-09 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 866mg NS 500mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-01-18 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2022-12-21 - liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 988mg NS 500mL 1hr (2023-01-11 WBC 1.67K/uL)

    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2022-11-29 - liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 864mg NS 500mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL

Femara (letrozole) KFEMA01

  • 2017-12-04 ~ undergoing 2.5mg QD

Granocyte (lenograstim) CGRAN01

  • 2023-04-26 - 250ug 2 days (2023-04-21 IPD)
  • 2023-04-05 - 250ug 2 days (2023-03-31 IPD)
  • 2023-03-13 - 250ug 2 days (2023-03-13 OPD)

Foliromin (ferrous sodium citrate) KFOLIR01

  • 2023-01-18 IPD on and off

==========

2023-04-24

  • The patient’s HGB levels show a marked downward trend, even though there is no record of blood transfusion. With recent MCV and MCH levels both above the normal range, this macrocytic anemia is less likely to be caused by iron deficiency. The addition of oral Kentamine (vitamin B1, B6, B12) may be helpful.

  • The development of anemia during chemotherapy suggests that the patient’s HGB levels are not fully recovered at the current dosage, interval, and frequency of the treatment regimen. In cases of severe chemotherapy-induced anemia, blood transfusion is recommended. Another potential option could be to reduce docetaxel from 75mg/m2 to 65mg/m2.

  • If the patient refuses a blood transfusion, a less optimal alternative may be the use of erythropoiesis-stimulating agents (ESAs). However, it is important to note that ESAs have been associated with shorter overall survival and/or increased risk of tumor progression or recurrence in clinical trials involving patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers. To minimize these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, the lowest effective dose should be used to avoid red blood cell transfusions. ESAs should only be used for anemia resulting from myelosuppressive chemotherapy and are not indicated for patients receiving myelosuppressive chemotherapy when the expected outcome is cure. It is also recommended that ESAs be discontinued after completion of chemotherapy.

2023-04-03

  • On 2022-10-28, the multidisciplinary cancer team held a meeting and decided on the following treatment plan for the patient: TC chemotherapy every three weeks for a total of 4 cycles, followed by a CDK4/6 inhibitor (patient self-paid), radiotherapy, and 5 years of hormone therapy.

  • The patient received 4 cycles of AC (liposome doxorubicin plus cyclophosphamide) on 2022-11-29, 2022-12-21, 2023-01-18, and 2023-02-09. On 2023-01-11, leukopenia occurred with a WBC count of 1.67K/uL, leading to a reduction in liposome doxorubicin dosage from 35mg/m2 to 30mg/m2 for the last two cycles. On 2023-03-02, another leukopenia episode was observed with a WBC count of 1.57K/uL, causing the scheduled docetaxel on that day to be postponed.

  • The patient’s HGB and PLT levels are showing a obvious decline trend, despite no record of blood transfusion being available. This suggests that under the current dose, interval, and frequency of administration, the patient’s HGB and PLT levels are not able to fully recover.

    • 2023-03-31 HGB 7.7 g/dL
    • 2023-03-13 HGB 8.4 g/dL
    • 2023-03-10 HGB 8.3 g/dL
    • 2023-03-02 HGB 8.6 g/dL
    • 2023-02-09 HGB 8.6 g/dL
    • 2023-01-18 HGB 8.4 g/dL
    • 2023-01-11 HGB 8.3 g/dL
    • 2022-12-21 HGB 11.4 g/dL
    • 2022-12-07 HGB 11.5 g/dL
    • 2022-11-28 HGB 11.9 g/dL
    • 2022-10-17 HGB 11.6 g/dL
    • 2022-06-08 HGB 12.6 g/dL
    • 2022-02-24 HGB 12.6 g/dL
    • 2021-04-29 HGB 12.7 g/dL
    • 2023-03-31 PLT 130 x10^3/uL
    • 2023-03-13 PLT 139 x10^3/uL
    • 2023-03-10 PLT 156 x10^3/uL
    • 2023-03-02 PLT 123 x10^3/uL
    • 2023-02-09 PLT 175 x10^3/uL
    • 2023-01-18 PLT 233 x10^3/uL
    • 2023-01-11 PLT 154 x10^3/uL
    • 2022-12-21 PLT 249 x10^3/uL
    • 2022-12-07 PLT 127 x10^3/uL
    • 2022-11-28 PLT 228 x10^3/uL
    • 2022-10-17 PLT 191 x10^3/uL
    • 2022-06-08 PLT 227 x10^3/uL
    • 2022-02-24 PLT 262 x10^3/uL
    • 2021-04-29 PLT 248 x10^3/uL
  • When severe anemia caused by chemotherapy is present, blood transfusion is recommended. However, if the patient refuses to receive transfusion, a suboptimal option could be to use erythropoiesis-stimulating agents (ESAs). It is important to note that ESAs have been associated with a shortened overall survival and/or an increased risk of tumor progression or recurrence in clinical studies of patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers. To decrease these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, the lowest effective dose should be used to avoid RBC transfusions. ESAs should only be used for anemia from myelosuppressive chemotherapy and are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure. It is also suggested to discontinue ESAs following the completion of a chemotherapy course.

700835257

230421

[diagnosis] - 2023-03-22 admissiion note

  • Malignant neoplasm of unspecified site of right female breast
  • Unspecified lump in breast

[past history]

  • The patient had no systemic diseases

  • History of operation: NIL

  • Regular medications or herb: no

  • G2P2

  • menarche : 16y/o

  • menopause: 51y/o

  • Hormone therapy: (-)

  • Family history of breast cancar: NIL                        

[allergy]

  • NKDA         

[family history]

  • Her mother has type II diabetes mellitus and liver cirrhosis, father has pancreatic cancer.

[exam findings]

  • 2023-03-24 CT - chest
    • Indication: Invasive lobular carcinoma of right breast cT1bN0M0, stage IA status post right partial mastectomy and sentinel lymph node biopsy on 2022/11/17, ECOG:0, ER(+), PR(+), Her2/neu(-), Ki-67: 5-10%
    • Imp: s/p op. over right breast. Suggest follow up.
  • 2022-12-19 ECG
    • Right bundle branch block
  • 2022-12-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 24) / 93 = 74.19%
      • M-mode (Teichholz) = 66
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; trivial MR; trivial TR.
  • 2022-11-18 Patho - breast mastectomy with regional lymph nodes
    • Diagnosis
      • Breast, right, partial mastectomy — Invasive lobular carcinoma
      • Resection margin: free
      • Lymph node, right, axilla, sentinel, lymphadenecomy —- Negative for malignancy (0/3)
      • AJCC 8 th edition, Pathology stage: Anatomic stage: pStage IA, pT1cN0(sn)(if cM0) Prognostic stage: IA
    • Gross Description
      • Procedure: partial mastectomy
      • Lymph node sampling (if lymph nodes are present in the specimen): Sentinel lymph node(s)
      • Specimen laterality: Right
      • Breast: Size: 5.7 x 5.5 x 2.0 cm
      • Skin: Size: 2.8 x 0.5 cm.
      • Nipple: Not Included
      • Tumor: Size: 1.1 x 1.0 x 1.0 cm.
      • Resection Margin: Free, 0.2 cm from the deep margin
      • Sections are taken and labeled as: FsA: deep margin; FsB1-2: sentinel lymph nodes (FsB1: a bisected lymph node), for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: skin; X2: breast, non-tumor; X3-5: tumor.
    • Microscopic Description
      • For Invasive Carcinoma
        • Histologic type: Invasive lobular carcinoma; The immunohistochemical stain of E-cadherin is negative.
        • Size of invasive carcinoma (mm): 11 x 10 x 10
        • Histologic grade (Nottingham histologic score): grade II (score 6)
          • Tubule formation: score 3
          • Nuclear pleomorphism: score 2
          • Mitotic count: score 1
        • Extent of tumor (required only if the structures are present and involved)
          • Skin involvement: Absent
          • Chest wall invasion deeper than pectoralis muscle: not received
      • For Ductal Carcinoma In Situ: absent
      • Margins: Negative, Closest margin (2 mm from deep margin)
      • Nodal status: Negative, sentinel
        • No. examined: 3
        • No. macrometastases (>2 mm): 0
        • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): 0
        • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
      • Treatment Effect: patient not received
      • Lymphovascular invasion: absent.
      • Perineural invasion: present
      • Immunohistochemical Study: S2022-16430
  • 2022-11-17 Lymphoscintigraphy
    • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the right breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the right axilla.
    • IMPRESSION: Probably a sentinel lymph node at the right axillary region.
  • 2022-11-16 ECG
    • Normal sinus rhythm
    • Right bundle branch block
    • Abnormal ECG
  • 2022-10-14 Bone Scan
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the mandible, middle C-spine, L4, bilateral shoulders, hips, knees and feet in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the middle C-spine and L4 spine. Degenerative change may show this picture.
      • Increased activity in the mandible. Dental problem may show this picture.
      • Increased activity in bilateral shoulders, hips, knees and feet, compatible with benign joint lesions.
      • No prominent bone abnormality was noted elsewhere.
  • 2022-10-14 CT - chest
    • Right breast cancer with non-specific lymph nodes are found at bilatral axillary region is found.
  • 2022-09-27 Patho - breast biopsy
    • PATHOLOGIC DIAGNOSIS
      • Breast tumor, right 10.5/7 area, core needle biopsy — Invasive lobular carcinoma
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consisted of two strips of breast tissue measuring up to 0.8 x 0.1 x 0.1 cm in size, fixed in formalin. Grossly, they were grey in color and soft in consistence. All embedded for sections in one cassette.
    • MICROSCOPIC EXAMINATION
      • Microscopically, the sections show a picture of invasive lobular carcinoma characterized by dyscohesive tumor cells arranged in linear or cord pattern with desmoplasia. Immunohistochemistry shows CK5/6 and P63: loss of myoepithelial cell, E-cadherin(-), ER(>90%, intensity 2~3+), PR(>90%, intensity 1~2+), Her2/neu(-, Dako score 1+) and Ki-67: 5-10% for tumor.
  • 2022-09-27 SONO - breast
    • Treatment: core needle biopsy
    • Suggestion and Plan: Right breast tumor, suggest biopsy.
    • BI-RADS: Category 4c: suspicious abnormality-biopsy should be considered.
  • 2020-10-22 Gynecologic ultrasonography
    • RT adnexae: free I - EM:4.7mm

[consultation]

  • 2022-11-16 Rehabilitation
    • A
      • Imp
        • Invasive lobular carcinoma of right breast cT1bN0M0, stage IA status post right partial mastectomy and sentinel lymph node biopsy on 2022/11/17, ECOG:0, ER(+), PR(+), Her2/neu(-), Ki-67: 5-10%
      • OP: right partial mastectomy and SLND on 2022/11/17.
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation (passive ROM, massage, therapeutic exercise) and home program education
          • Goal: Functional ability ID, maintain ROM, prevent post-OP complications

[surgical operation]

  • 2022-11-17
    • Surgery
      • partial mastectomy and SLNB        
    • Finding
      • right 10/7 tumor, about 1cm in diameter
      • SLNB: negative of malignancy, 0/3

[chemotherapy]

  • 2023-04-20 - epirubicin 90mg/m2 145mg NS 100mL 30min + fluorouracil 500mg/m2 820mg NS 100mL 30min + cyclophosphamide 500mg/m2 820mg NS 500mL 1hr (CEF, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-22 - epirubicin 90mg/m2 145mg NS 100mL 30min + fluorouracil 500mg/m2 820mg NS 100mL 30min + cyclophosphamide 500mg/m2 820mg NS 500mL 1hr (CEF, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-27 - epirubicin 70mg/m2 100mg NS 100mL 30min + fluorouracil 500mg/m2 800mg NS 100mL 30min + cyclophosphamide 500mg/m2 800mg NS 500mL 1hr (CEF, Q3W) Epicin (decrease dosage from 90mg/m2 to 70mg/m2 due to WBC:3580, seg:37.6, ANC:1346)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-07 - epirubicin 90mg/m2 140mg NS 100mL 30min + fluorouracil 500mg/m2 800mg NS 100mL 30min + cyclophosphamide 500mg/m2 800mg NS 500mL 1hr (CEF, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-11 - epirubicin 80mg/m2 120mg NS 100mL 30min + fluorouracil 500mg/m2 770mg NS 100mL 30min + cyclophosphamide 500mg/m2 770mg NS 500mL 1hr (CEF, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-20 - epirubicin 80mg/m2 120mg NS 100mL 30min + fluorouracil 500mg/m2 770mg NS 100mL 30min + cyclophosphamide 500mg/m2 770mg NS 500mL 1hr (CEF, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[note]

in-hospital “Prescription Collection of Chemotherapy for Breast Cancer” protocol (dated 2022-03-11)

  • CE (Epirubicin or Lipodox) F (Lipodox is not strongly recommended in the adjuvant setting)
    • Cyclophosphamide 500 mg/m2 IV Days 1
    • Epirubicin 90 mg/m2 IV Day 1 or Lipodox 30 mg/m2 IV Day 1
    • 5-fluorouracil 500 mg/m2 IV Days 1
    • _ References
      • Citrom, ML, et al.J Clin Oncol 21:1431-, 2003.1439
      • Martin M, et al. J Natl Cancer Inst 2008; 100:805-814.
      • O’brien, et al. Annals of oncology, 15(3). 440-449.
      • Rau KM, et al. BMC Cancer, 2015; 15: 423

==========

2023-04-21

  • Except for a slightly elevated ALT 52U/L, all other labs were normal on 2023-04-20. No problem with the active prescription.

2023-03-23

  • After the episode of neutropenia on 2023-02-27, the decision to reduce the dose of epirubicin in the CEF regimen was made. Subsequently, no further episodes of neutropenia were observed, even when the dose was increased to the standard recommended level.

700392038

230419

{not completed}

[diagnosis] - 2023-04-21 discharge note

  • Right lower lobe lung cancer, adenocarcinoma, T4N3M1c, stage IVB, with brain and lung to lung metastases s/p Target therapy with Afatinib from 2021/09/08~  
  • Secondary malignant neoplasm of brain
  • Chronic obstructive pulmonary disease, unspecified
  • Type 2 diabetes mellitus without complications
  • Diarrhea, unspecified

[exam findings]

  • 2023-04-10 CXR
    • Patchy opacity projecting at right lower lung zone was noted that is c/w lung cancer after correlate with CT.
    • There are multiple small nodular opacities on both lung that are c/w lung to lung metastases.
    • Atherosclerotic change of aortic arch
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-28 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in multiple T- and L-spines, sternum, some ribs, sacrum, left S-I joint and possible left sternoclavicular junction.
    • IMPRESSION: In comparison with the previous study on 2022/08/08, more new bone lesions are noted. The scintigraphic findings suggest multiple bone metastases.
  • 2023-03-21 CXR
    • Patchy opacity projecting at right lower lung zone was noted that is c/w lung cancer after correlate with CT.
    • There are multiple small nodular opacities on both lung that are c/w lung to lung metastases.
  • 2023-02-08 EGFR mutation
    • Cell block No: S2023-01756
    • Result: Two mutations were detected at exon 20 (T790M) and exon 21 (L858R) of EGFR gene in this specimen.
  • 2023-02-06 CXR
    • A poorly defined large tumor with reticular opacities over Rt lower lobe
    • Enlargement of Rt hilum due to lymphadenopathy
    • Thoracic aortic calcified atheriosclerotic plaque
  • 2023-02-03 Patho - bronchus biopsy
    • Lung, RLL, bronchioscopic biopsy — adenocarcinoma, poorly differentiated
    • Sections show bronchial mucosa with infiltration of large pleomorphic solid tumor cells and acinar galndular cells.
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), CD56(-), and p40(-). The results are supportive for the diagnosis.
  • 2023-02-01 CT - chest
    • Indication: Lung cancer, adenocarcinoma, T4N3M1c with brain, lung to lung metastasis
    • Comparison was made with previous CT dated on 2022/08/03
      • Lungs: interval significant increase in size of RLL tumor with newly developed extensive interlobular septal thickening and peribronchoscular bundle thickeninng and new RML nodule as compared with CT on 2022/8/3. the tumor involves Rt inferior pulmonary artery and hilum.
      • Mediastinum and hila: enlarged LN in Rt hilum.
      • Vessels:
        • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura:small Rt effusion with parietal thickening.
      • Chest wall: metastatic LAP at Lt supraclavilar fossa
      • Visible abdominal contents: several small hepatic cysts and a Lt renal cyst 28mm
        • unremarkable of the adrenal glands, spleen, pancreas, adrenal glands
      • Visualized bones: no lytic or blastic lesion.
        • axial brain images: no evidence of brain metastasis based on noncontrast images. diffuse cerebral atrophy.
    • Impression:
      • RLL tumor, T4N3, in progression as compared with previous CT on 2022/08/03
  • 2023-01-30 ECG
    • Sinus tachycardia
    • Left anterior fascicular block
    • Abnormal ECG
  • 2022-08-08 Tc-99m MDP bone scan
    • A hot area at the L4-5 spines, the nature is to be determined (DJD, post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in both rib cages, some C- and L-spine, bilateral shoulders, and S-I joints.
  • 2022-08-03 CT - chest
    • RLL tumor, inccrease in size of the tumor T4 as compared with previous CT on 2022/03/02. no mediastinal LAP.
  • 2022-03-02 CT - chest
    • RLL tumor, slightly decrease in size of the tumor as compared with previous CT on 2021/11/24. no mediastinal LAP.
  • 2021-11-24 MRI - brain
    • Findings
      • Markedly regression of the nodules seen on Scan MRI, 2021/08/19.
      • Only two small dark noudles were seen in right cerebellum and left anterior temporal lobe.
      • Poor or equivocal abnormal enhancement after contrast administration of those two nodules seen.
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • Imp: Markedly regression of the nodules seen on Scan MRI, 2021/08/19.
  • 2021-11-24 CT - chest
    • RLL tumor, significant decrease in size of the tumor (21 mm on this exam) as compared with previous CT on 2021/08/10
  • 2021-08-31 Patho - bronchus biopsy
    • Lung, RLL, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.

[lab data]

2021-09-23 EGFR Sample No S21-11584
2021-09-23 EGFR G719X not detected
2021-09-23 EGFR Exon19 del not detected
2021-09-23 EGFR S768I not detected
2021-09-23 EGFR T790M not detected
2021-09-23 EGFR Exon20 ins not detected
2021-09-23 EGFR L858R detected
2021-09-23 EGFR L861Q not detected

[MedRec]

  • 2021-09-23 SOAP Chest Medicine
    • S
      • just discharged on 20210917 due to hemoptysis
      • EGFR mutation: L858R (+), exon 19 (-), ALK(-)
    • O
      • Multidisciplinary Cancer Team Meeting Conclusion> Meeting Date: 20210914
      • Dr Huang JunYao: check EGFR mutation status, apply TKIs for this case if indicated
      • Conclusion: palliation C/T, RT, best supportive care, EGFR TKIs if definite mutation
  • 2021-09-08 SOAP Chest Medicine
    • S
      • admission on 20210916 for Cyramza 600mg
      • A case of Lung cancer, adenocarcinoma, T4N3M1c with brain, lung to lung metastasis, ECOG 1,
        • T4: RLL mass with RLL, RML
        • N3: bilateral mediastinal LAPs
        • M1c: multiple brain metasatsis
      • EGFR mutation: L858R (), exon 19 (), ALK(),
      • PD-L1:
      • Right hilum tumor, nature?
  • 2021-08-30 POMR Chest Medicine
    • Discharge Diagnosis
      • Chronic obstructive pulmonary disease, unspecified
      • Right hilum tumor, nature?
      • Right lower lung mass.
    • CC: Cough intermittent with hemoptysis for months
    • Present Illness
      • He suffered from hemoptysis to Zhongxiao Hospital for help in early August, Chest CT on 2021/08/10 showed RLL carcinoma with lung to lung metastasts and mediastinal LAP is considered first. Multiple small hypodense nodules in liver. Brain MRI on 2021/08/19 showed Multiple brain metastatic tumors should be considered. Whole body bone scan on 2021/08/20 showed likely DJD or certain entity in the L4.
  • 2021-08-23 SOAP Chest Medicine
    • S
      • Right hilum tumor, nature?
      • cough intermittent without scanty sputum for months, sorethroat(-), chest tightness for weeks, dyspnea, rhinorrhea(-), nasal congestion(-), post nasal dripping(-), acid regurgitation, DOE(+), exercise limitation(+)
      • Past history: Allergic rhinitis, asthma
      • Family history of asthma
      • Smoking(-)
      • Allergic history(-)
      • Traveling history(-)
    • O
      • BP:120/70, HR:70
      • Throat: hyperemia
      • Tonsil: enlargement
      • Neck LAP(-)
      • Breathing sound: course(+), wheezing(+), crackle(+), decreased(+)
      • HS: RHB
      • Abdomen: soft and flat
      • Pitting edema(-)
  • 2021-05-19 SOAP Dermatology
    • S
      • Multiple painful erythematous papule-nodules on face, trunk and 4 limbs
      • Multiple erythematous scars and keloids on face for months, progressive enlarged recently. Itching(+), keloid(+)
    • O
      • Imp: acne on face and trunk for months, multiple pustule (+), inflammation(+), painful(+)
      • NSAID for pain release
    • Plan
      • education about drug side effec and explain
      • strongly suggested OPD f/u
    • Diagnosis
      • L70.2 Acne varioliformis
      • L73.0 Acne keloid
    • Prescription
      • doxycycline 100mg/cap 1# BID PO 7 days
      • fusidic acid 1 tube BID EXT 7 days
      • Shincort (triamcinolone acetonide) 50mg ST IS (intrasynovial)

[medication]

  • 2023-03-07 ~ undergoing - Giotrif (afatinib 30mg) tab 1# QDAC
  • 2021-09-08 ~ 2022-10-05 - Giotrif (afatinib 30mg) tab 1# QDAC

700181400

230418

[diagnosis] - 2023-04-13 admission note

  • Rectosigmoid colon cancer with lymph node metastases s/p da Vinci robotic assisted radical low anterior resection on 2023/03/17, pT4aN2aM0, pStage IIIC
  • Insomnia, unspecified

[present illness] - 2023-04-13 admission note

  • This 45 year old woman suffered from diarrhea and loose stool passage since 2022/12. She also developed nausea notede, epigastric dull pain, fullness belching, acid regurgitation. Also bloody stool passage was noted on 2023/02/20 evening. Stool was collected and shoed occult blood 3+.
  • Colonoscopy was performed on 2023/03/02 and found one tumor occupied almost intralumenal circumference of colon at 15 cm from anal verge, pathology reported adenocarcinoma. Pelvis MRI on 2023/03/14 showed: 1. Rectosigmoid colon cancer about 3.5cm in length with regional lymphadenopathy about 3 in number. 2. A prominent soft tissue mass at left inguinal canal. 3. Small uterine myoma. 4. A nabothian cyst about 0.7cm. T3N1bMX. Due to above reasons, she was admitted for colon cancer staging. She received da Vinci robotic assisted LAR on 2023/03/17 and pathology showed adenocarcinoma, moderately to poorly-differentiated with lymph node metastatic (6/22), pStage IIIC, pT4aN2aMX, immunohistochemistry (IHC) Testing for Mismatch Repair (MMR) Proteins, no loss of nuclear expression of MMR proteins: low probability of microsatellite instability-high (MSI-H). Now, she was admitted to ward for Port-A catheter insertion and chemotherapy with FOLFOX(C1D1).
    • ChatGPT:
      • The term “no loss of MMR protein” refers to the absence of any detectable decrease or loss in the expression or function of proteins involved in the DNA mismatch repair (MMR) system. The MMR system is a crucial mechanism in cells that helps maintain genomic stability by correcting errors that may occur during DNA replication.
      • The primary MMR proteins include:
        • MLH1 (MutL homolog 1)
        • MSH2 (MutS homolog 2)
        • MSH6 (MutS homolog 6)
        • PMS2 (postmeiotic segregation increased 2)
      • Loss or dysfunction of any of these MMR proteins can lead to a condition called microsatellite instability (MSI), which is characterized by a higher rate of mutations in the DNA. MSI is associated with certain types of cancer, such as colorectal cancer and endometrial cancer, particularly in the context of Lynch syndrome (also known as hereditary nonpolyposis colorectal cancer or HNPCC).
      • When there is “no loss of MMR protein,” it means that the MMR system is functioning properly in the cells, and the risk of developing cancers due to microsatellite instability is reduced. However, it is important to note that the presence of functional MMR proteins does not guarantee the complete absence of cancer risk, as there may be other factors or mechanisms contributing to cancer development.

[past history]

  • DM(-), HTN(-)
  • Uterine myoma uteri status post myomectomy on 2018/08/09
  • GERD, LA grade A history of Hp infection before noted at LMD.
  • da Vinci robotic assisted radical low anterior resection on 2023/03/17

[allergy]

  • NKDA

[family history]

1.There is no family history of cancer, hypertension, mental diseases or asthma. 2.No members of the family with diabetes.

[lab data]

2023-04-17 Anti-HCV Nonreactive
2023-04-17 Anti-HCV Value 0.10 S/CO
2023-04-17 Anti-HBc Reactive
2023-04-17 Anti-HBc-Value 4.11 S/CO
2023-04-17 Anti-HBs 774.10 mIU/mL
2023-04-17 HBsAg Nonreactive
2023-04-17 HBsAg (Value) 0.40 S/CO

[chemotherapy]

[assessment]

  • Lab data for hepatitis B virus is provided. It is recommended to initiate treatment with either Baraclude (entecavir) or Vemlidy (tenofovir alafenamide) before starting chemotherapy to minimize the risk of reactivation.
    • 2023-04-17 Anti-HBc Reactive
    • 2023-04-17 Anti-HBc-Value 4.11 S/CO
    • 2023-04-17 Anti-HBs 774.10 mIU/mL
    • 2023-04-17 HBsAg Nonreactive
    • 2023-04-17 HBsAg (Value) 0.40 S/CO

700534651

230418

[exam findings]

  • 2023-04-06 SONO - chest
    • Special Procedure:
      • echo-assisted
      • Pleural tapping 16 #-needle Left side 550 ml bloody
    • Echo diagnosis:
      • pleural effusion
        • Chest echography was performed first. The suitable intercostal space was selected and located.
        • Catheter was inserted with negative pressure smoothly.
        • Left side pleural effusion was drawn smoothly.
        • Watch out BP after tapping.
    • Suggestion:
      • Send pleural effusion for examination about cytology (cell block),
      • biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
  • 2023-04-03 CT - chest
    • Findings
      • moderate Lt pleural effusion.
      • Lungs: a subsegmental consolidation at LLL-laterobasal segment.
        • mosaic attenuation changes in Rt lung, LUL, and aerated Lt lower lobe. there is subpleural reticulation and ground-glass opacity at both lower lobes too.
      • Mediastinum and hila: a 15mm calcification in posterior Rt hilum.
        • extensive mild calcified plaques of the LAD, and LCX, and right coronary arteries.
      • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: dilated trunk (3.3cm in caliber) and right main artery.
      • Heart: normal in size of cardiac chambers. mild calcified aortic valves.
      • Chest wall and visible lower neck: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • moderate transudative pleural effusion. LLL subsegmental consolidation, infection or suspected tumor.
      • obstructive chronic airway diease in lungs and suspect mild fibrosis in lower lobes of lungs.
      • extensive 3V-CAD.
  • 2023-03-29 CXR
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
    • small Lt pleural effusion
    • volume reduce over Lt lower lung zone
    • a short linear high density over Rt infrahilar shadow, foreign body?
    • S/P posterolateral bony fusion at L-spine
  • 2020-06-29 Right knee standing
    • Osteoarthritis change of right knee with joint space narrowing and marginal spur formation. Loose bodies in the right knee joint.
  • 2020-06-29 KUB and Lumbar spine lateral:
    • Bilateral clear psoas shadows. Unremarkable bowel gas pattern. Grade 1 degenerative spondylolisthesis at L4-5 level. Degenerative change of the spine with marginal spur formation. Osteopenia of visible bones. L5-S1 disc space narrowing.

[SOAP]

  • 2023-04-06 Chest Medicine
    • past history: alzheimzer disease under licodin, HTN
    • chest tapping for exam.
  • 2023-04-06 Hemato-Oncology
    • S
      • This 77 year old woman with dementia, HTN and insomnia came to our OPD due to hemptosis for 10+ days, shortness of breath on excertion, body weight loss (4-5kg in 10 months)
      • Smoking history for 20+ years, quit for 20+ years
      • Lives in Nanshijiao, has five children (lives with the eldest daughter, one passed away from throat cancer, one lives in Tainan, one was given to another family to raise, and the youngest daughter lives in Nangang).
    • O
      • 2023/04/03 CT: Lung/Mediastinum/Pleura
        • moderate transudative pleural effusion. LLL subsegmental consolidation, infection or r/o tumor.
        • obstructive chronic airway diease in lungs and suspect mild fibrosis in lower lobes of lungs.
        • extensive 3V-CAD.
    • A
      • Arrange admisson for CT-guided biopsy
      • Suspected lung cancer
      • Suggestion: admitted for further evaluation
    • P
      • Chest contrast CT
      • CT gudide biopsy
      • check tumor marker
  • 2023-04-03 Chest Medicine
    • chest sono on 2023/04/06 PM0230
    • hold Licodin (ticlopidine) since 2023/04/04
    • refer to oncologist for suspected Left lower lung pleural based tumor
  • 2023-03-29 Chest Medicine
    • S: hemoptysis (blood in phlegm) for 10 days, mld short of breath
      • consciousness: clear
      • breath sound: clear
      • abdomen: soft, no tenderness
      • extremities: freely movable; no pitting edema
      • smoking:quit for 20 years
      • past history: alzheimzer disease, HTN
    • O: CXR: bilateral increased infiltrate
    • P:
      • suggest ER for admission, but the patient and family hesitate (unable to be hospitalized these days)
      • suggest if hemoptysis progressed -> ER admission
      • check lab
      • arrange chest CT on 2023/04/03
      • sputum TB x3
    • Diagnosis
      • R04.2 Hemoptysis
      • J15.9 Unspecified bacterial pneumonia
    • Medication
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) cap 1# TID 5 days
      • Cravit (levofloxacin 500mg) tab 1.5# QDAC 5 days
      • Transamin (tranexamic acid 250mg) cap 1# BID 5 days
  • 2023-02-22 Oral and Maxillofacial Surgery
    • S
      • current medication
        • antihypertensive drug
        • peripheral vasodilators for dementia
    • O
      • Panoramic findings:
        • Missing: nil
        • Impaction: nil
        • Crown and Bridge: 11,15,16,25,26,34-35X,43-44-45XX
        • Caries: nil
        • Periodontal condition: chronic periodontitis
      • vascular spot on the lower alveolar mucosa and tongue was noticed, might be drug-related
  • 2023-02-16 Family Medicine
    • CC
      • HTN loss f/u
      • headache
      • mild petechiae over lips and gum -> ginko related?
    • Past history HTN, dementia
    • Allergy history (-)
    • previous medication: Ginkgo, Stilnox, Xyzal

[assessment]

  • The patient should have been diagnosed with dyslipidemia and hypertension with heart failure, as he has regularly refilled prescriptions for rosuvastatin, valsartan, and spironolactone within the past 3 months, according to PharmaCloud. Additionally, a CT scan on 2023-04-03 revealed extensive 3-vessel coronary artery disease (3V-CAD), indicating significant atherosclerotic plaque in the LAD, LCX, and RCA.

  • If there are no contraindications, it is recommended to reintroduce these medications and consult a cardiologist to assess whether the patient requires aggressive medical management or revascularization procedures, such as coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI angioplasty with stent placement).

700555767

230418

[chief complaint] - 2023-04-17 admission note

  • Vertigo since 2023/01/07, progress for 2 weeks

[present illness] - 2023-04-17 admission note

The 57 y/o woman has history of hypertension. She had fall down in bus on 2022/11 and then fatigue, vertigo and right hip pain since 2023/01/07, so she bedridden for 3 months. Right breast tumor noted also 3 months. This time, she has dizziness and severe vertigo, so she was brought to our ED for help on 2023/04/17. Her right lower limbs MP down to 3 for 3 months. She denied fever, chills, vomit, SOB or hematuria. At ED, the brain CT showed 1. Mild cortical brain atrophy. 2. Left parietal skull osteolytic destruction, metastasis or less likely arachnoid granulation? 3. Chronic left mastoiditis. UTI noted from urinalysis. Under the impression of right breast tumor, vertigo, suspect spinal stenosis, so she was admitted on 2023/04/17.

[past history]

  • hypertension under CV OPD follow up
  • constipation

[allergy]

  • NKDA

[family history]

  • No cancer, CVA, CAD or DM in her family

[exam findings]

  • 2023-04-17 CT - brain
    • CC
      • bedridden for 3 months after falling down
      • dizziness, vertigo, nausea, no tinnitus
      • right hip pain
    • phx: HTN, dyslipidemia, HBV carrier
      • NKDA
      • pregnancy: denied
    • Cranial CT scans without IV contrast medium enhancement was performed smoothly and show:
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
      • The interhemispheric fissure is centered on the midline.
      • The basal ganglia, internal capsule, corpus callosum, and thalamus appear normal.
      • Sella and pituitary are normal, parasellar structures are unremarkable.
      • There are no abnormalities in the cerebellopontine angle areas on both sides.
      • Left parietal skull osteolytic destruction, nature?
    • Imp:
      • Mild cortical brain atrophy.
      • Left parietal skull osteolytic destruction, metastasis or less likely arachnoid granulation?
      • Chronic left mastoiditis.
  • 2023-04-17 Hip joints Rt
    • Permeative osteolysis over Rt acetabulum and superior pubic ramus and body, metastatic lesion d/d diffuse osteoporosis
  • 2023-04-17 CXR
    • marginal spurs of multiple vertebral bodies of T-spine due to spondylosis.

[SOAP]

  • 2023-04-17 Emergency
    • Diagnosis
      • N63 - Unspecified lump in breast
      • M89.59 - Osteolysis, multiple sites
      • R42 - Dizziness and giddiness
      • Z74.01 - Bed confinement status
  • 2021-08-03 Cardiology
    • Objective
      • 2021/08 123/75; 70;
    • Medication
      • Olmetec (olmesartan medoxomil 20mg) 1# QD
      • Concor (bisoprolol 5mg) 0.5# QD
      • Norvasc (amlodipine 5mg) 1# QD
  • 2019-11-21 Cardiology
    • Objective
      • 2019/11 128/80; 65
    • Medication
      • Concor (bisoprolol 5mg) 0.5# QD <- 1# QD
  • 2019-08-02 Cardiology
    • Assessment
      • Essential hypertention, unspecified [I10]
      • Obesity, unspecified [E66.9]
      • Hepatitis B carrier [Z22.51]
      • Gout, unspecified [M10.9]
    • Medication
      • Olmetec (olmesartan medoxomil 20mg) 1# QD
      • Concor (bisoprolol 5mg) 1# QD
      • Natrilix SR (indapamide 1.5mg) 1# QD

[assessment]

  • An unspecified breast lump and multiple-site osteolysis are under investigation.
  • The patient’s underlying hypertension and obesity are well controlled with Olmetec (olmesartan), Norvasc (amlodipine) and Concor (bisoprolol) prescribed by our cardiologist without any medication reconciliation issues.
  • To date, there is no evidence of hyperuricemia (although this diagnosis remains in the cardiology OPD records). On 2023-04-17, the patient’s serum uric acid level was 5.4 mg/dL.
  • The most recent data for total cholesterol, triglycerides, LDL, and HbA1c were obtained on 2022-09-20 and may need to be updated.

700891439

230418

[diagnosis] - 2023-04-12 admission note

  • Malignant neoplasm of rectum
  • Malignant neoplasm of bladder, unspecified
  • Iron deficiency anemia, unspecified
  • Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
  • Intestinal adhesions [bands] with obstruction (postprocedural) (postinfection)

[past history]

  • Squamous cell cacinoma of the Lt buccal region, stage T4aN0M0 (IVA), s/p wide excision, segmental osteotomy, and supraomohyoid neck dissection, radiotherapy, and chemotherapy in 2008
  • Small bowel ileus post enterolysis with bowel decompression in 2018
  • Ileus s/p Explosive laparotomy in 2018
  • Adenocarcinoma of rectum, pT2N2a(cM0), stage IIIB, s/p EXP LAP with AR and enterolysis, and s/p CCRT
  • Invasive urothelial carcinoma s/p transurethral resection of bladder tumor on 2021/05/28
  • Adhesion ileus s/p operation on 2018/04/20

[family history]

  • elder brother: lung cancer
  • father: liver disease
  • No members of the family with colon cancer.

[lab data]

  • 2021-07-14 All-RAS not detected
  • 2021-07-14 BRAF not detected
  • 2021-07-07 PD-L1(22C3) CPS>=1 and <10
  • 2021-07-07 PD-L1(28-8) TC>=1% and <5%

[exam findings]

  • 2023-04-14 Patho - gingival/oral mucosa biopsy
    • Mass, right buccal mucosa, biopsy — Squamous cell carcinoma
    • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated characterized by tumor nests with enlarged, hyperchromatic and pleomorphic nuclei infiltrating in the stroma with keratin material.
    • Immunohistochemical stains show CK(+); P63(+) and P16(-) for tumor.
  • 2023-04-13 Nasopharyngoscopy
    • Finding: granular tumor over right buccal, retromolar, gingivobuccal
    • Conclusion: right buccal ca
  • 2023-03-28 CT - neck
    • Indication: right facial tumor bleeding noted on 1AM. he had similar episode 2 weeks ago. The mass was noted for 2-3 months, which is growing with bleeding and pus formation.
    • Past history: double ca (colon ca and bladder ca) folfox 6 R/T, Bladder cT2N0M0 stage II UC with squamous change
    • Protocols: Axial scans with 2 mm slice thickness with multiplanar image reformation using Aquilion Prime CT.
    • Neck CT without/with contrast enhancement shows:
      • large enhancing mass at right buccal region (maximal diameter about 8cm), with direct invasion to right mandibular bone and right masticator space muscles, including masseter and temporalis muscles and probably also pterygoid muscles. Advanced right buccal cancer is compatible. T4b disease is considered.
      • multiple enlarged lymphadenopathy at right level Ib, II, Va. Possible extranodal invasion cannot be well evaluated in CT. N2b disease is favored.
      • bilateral symmetric pharyngeal mucosa.
      • chronic right maxillary sinusitis with complete sinus opacity and sinus bone thickening.
    • Impression: Advanced right buccal cancer, image staging favor AJCC T4bN2b, stage IVB.
  • 2022-12-24 CT - abdomen
    • s/p LAR. No evidence of recurrent/residual tumor in the study.
  • 2022-07-30 CT - abdomen
    • S/P colon and bladder operation. No evidence of tumor recurrence.
  • 2022-02-15 CT - abdomen
    • Post-op at the colon. Suggest follow up.
    • Liver cysts.
    • Left lower lung nodule 0.4cm, stationary, suggest follow up.
  • 2021-06-24 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Rectum, EXP LAP with low anterior resection — Adenocarcinoma, moderately differentiated
      • Resection margins, EXP LAP low anterior resection — Free
      • Lymph nodes, mesocolorectal, dissection — Metastatic adenocarcinoma (6/22)
      • Pathology stage: pT3N2a(cM0); Stage IIIB
    • MACROSCOPIC EXAMINATION
      • Operation procedure: EXP LAP low anterior resection
      • Specimen site: Rectum + sigmoid colon
      • Specimen size: 20.5 cm in length
      • Tumor size: 5.8 x 4.5 cm
      • Tumor location: 4.0 cm away from the distal resection margin
      • Depth of invasion grossly: Perirectal soft tissue
      • Mucosa elsewhere: Unremarkable
      • Representative parts are taken for section and labeled: A1-A5=tumor, A6-A10= regional LNs, B= proximal end, C= distal end.
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: Moderately differentiated
      • Depth of invasion: Perirectal soft tissue
      • Angiolymphatic invasion: Not identified
      • Perineural invasion: Not identified
      • Tumor cell budding: Intermediate
      • Circumferential (radial) margin of rectum: Uninvolved, 5 mm from the margin
      • Lymph node metastasis, mesocolorectal: Metastatic adenocarcinoma (6/22) (No. Positive / No. Total)
      • Extranodal involvement: Present
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): pT3 (Tumor invades pericolorectal tissues)
        • Regional Lymph Nodes (pN): pN2a (4 to 6 regional lymph nodes are positive)
        • Distant Metastasis (pM): cM0
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: None identified
      • Tumor regression grading S/P CCRT: N/A
      • IHC (S2021-7997): EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • 2021-06-23 PD-L1 (SP142)
    • VENTANA PD-L1 (SP142) Assay for Urothelial Carcinoma (S2021-08015)
      • PD-L1 Expression: <5% IC
      • Scores – Immune cells (IC): 2%; Tumor cells (TC): 0%
  • 2021-06-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (126 - 47.8) / 126 = 62.06%
      • M-mode (Teichholz) = 62.1
    • Conclusion:
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Mitral valve prolapse (posterior leaflet) with trivial regurgitation
      • Trivial tricuspid regurgitation
      • Thick IVS and dilated aortic root
  • 2021-05-28 Patho - urinary bladder TUR
    • PATHOLOGIC DIAGNOSIS
      • Urianry bladder, “tumor”, near neck at 11-1 o’clock, TURBT — Invasive urothelial carcinoma with marked squamous differentiation, high-grade
      • Urinary bladder, “base”, TURBT — Involved by carcinoma
    • MICROSCOPIC EXAMINATION
      • Histologic type: Urothelial carcinoma, invasive, with marked squamous differentiation
      • Histologic grade: High-grade
      • Tumor configuration: Papillary and nodular
      • Muscularis propria: Present
      • Lymphovascular invasion: Not identified
      • Microscopic tumor extension: Tumor invades muscularis propria
      • Specimen labeled “base”: Involved by carcinoma
  • 2021-05-27 Patho - colon biopsy
    • Intestine, large, rectum, near R-S junction, biopsy — adenocarcinoma
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • IHC stain — EGFR(+), PMS2(+), MSH2(+), MSH6(+), MLH1(+)
  • 2021-05-27 Colonoscopy
    • Suspected colon cancer, rectum near R-S junction, 15cm from anal verge, s/p biopsy
    • Mixed hemorrhoid
  • 2021-05-24 CT - abdomen
    • History and indication: fever, L’t abd pain, cause?
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of rectum with regional LAP.
      • A tumor (3.3cm) in urinary bladder r/o malignancy.
      • A soft tissue nodule (2.5x5.8cm) in presacral region r/o GIST.
      • Small liver cysts (3-6mm).
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T2(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIB(Stage_value)

[surgical operation]

  • 2021-06-23
    • Surgery
      • EXP LAP with AR and enterolysis     
    • Finding
      • Rectal tumora invasion to bladder, Adenocarcinoma of rectum, stage T2N2aM0, stage IIIB
      • Anastomosis by CDH 33#
      • Previous surgery, severe adhesion  
  • 2021-05-28
    • Surgery
      • Transurethral resection of bladder tumor
    • Finding
      • urethral trauma during urethral dilation
      • Bilateral U/O normal with clear efflux
      • A large round shape tumor with hypervascularity tumor beneath normal mucosa was noted at anterior wall or urinary bladder. The location is very near 11 o’clock bladder neck. Based on clinical finding, it is hard to tell whelther it came from urinary bladder or prostate
      • Risk evaluation:
        • Tumor size: >3cm
        • Multifocality: solitary
      • a wrinkle at left posterior wall, compatible with location of sigmoid colon with wall thickening

[chemotherapy]

  • 2022-01-24 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4250mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-01-10 - (FOLFOX Q2W)
  • 2021-12-27 - (FOLFOX Q2W)
  • 2021-12-13 - (FOLFOX Q2W)
  • 2021-11-29 - (FOLFOX Q2W)
  • 2021-11-15 - (FOLFOX Q2W)
  • 2021-10-25 - (FOLFOX Q2W)
  • 2021-10-11 - (FOLFOX Q2W)
  • 2021-09-27 - (FOLFOX Q2W)
  • 2021-09-13 - (FOLFOX Q2W)
  • 2021-08-30 - (FOLFOX Q2W)
  • 2021-08-02 - (FOLFOX Q2W)

700154637

230417

[past history] - 2023-04-13 admission note

  • s/p appendectomy at the age of 18
  • Brenner tumor and benign mucinous cystadenoma s/p left salpingo-oophorectomy on 2008-05-20 at our hospital
  • The recurrence of brenner tumor and benign mucinous cystadenoma s/p ATH and right oophorectomy on 2012-02 at CGMH
  • Brenner tumor and benign mucinous cystadenoma with pelvic seeding and partial intestinal obstruction, due to tumor involvement and adhesion s/p excision of pelvic tumor and enterolysis and segmental resection of ileum with anastomosis on 2014-01-20
  • Brenner tumor s/p chemotherapy x3 three years ago (from peripheral line)
  • Colon cancer s/p OP
  • GB stone
  • Hemmorhoids

OB/GYN history:

  • Menarche: 18 Y/O
  • Menopause: 52 y/O
  • G5P4AA1
  • No perimenopausal hormone therapy
  • No smoking
  • No family members had breast CA, endometrial CA, ovary CA and colon CA

[allergy]

  • Ulexin (cephalexin 500 mg/cap) local rash

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-04-14 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, middle and lower T-spines, L5-sacrum junction, bilateral shoulders, right sternoclavicular junction and bilateral elbows in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the middle and lower T-spines and L5-sacrum junction. Degenerative change is more likely.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
      • Increased activity in bilateral shoulders, right sternoclavicular junction and bilateral elbows, compatible with benign joint lesions.
      • No prominent bone abnormality was noted elsewhere.
  • 2023-04-12 CXR
    • Patch density at RUL.
  • 2023-04-12 CT - abdomen
    • CC: abdominal pain, Lower abdominal dull pain for 3 months, progressed in 2 days. No diarrhea, no N/V, No fever, No dysuria
    • Past history:
      • Right ovarian cancer s/p TAH + BSO
      • Metastatic carcinoma in left pelvic cavity with sigmoid colon and left distal ureteral involvement, T4N0Mx s/p sigmoid colon resection
      • GB stones
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There are multiple poor enhancing masses on both hepatic lobes, the largest one 3 cm in S2/3, that are c/w metastases.
      • Multiple gallstones are noted.
      • S/P hysterectomy
      • S/P LAR with autosuture retention over the sigmoid colon.
      • There are two small soft tissue nodules 5 mm in RML of the lung.
        • Please correlate with chest CT to R/O metastases or inflammatory process.
      • Others
        • There is no focal abnormality in the biliary system, pancreas, spleen & both kidneys.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Multiple metastases on both hepatic lobes.
      • Two small soft tissue nodules 5 mm in RML of the lung, nature?
        • Please correlate with chest CT.
  • 2023-04-12 KUB
    • Degeneration of bony structures.
    • Stool retention in bowl.
  • 2023-03-21 KUB
    • Rim calcification in RUQ.
    • Mild lumbar spondylosis.
  • 2023-03-21 Renal ultrasound
    • Grossly normal, bilateral kidneys
  • 2020-06-19 Pap Smear
    • Atrophy with inflammation
  • 2020-03-10 KUB
    • Degenerative change of the lumbar spine
  • 2020-03-10 CT - abdomen
    • Indication: acute onset diffused abdominal pain, with radiation to the back, nausea.
    • PMH: ovarian and uterus cancer s/p OP
    • Protocols: Axial scans with 5 mm slice thickness with multiplanar image reformation using 64-slice MDCT.
    • Abdomen & Pelvis CT without/with contrast enhancement shows:
      • postoperative change with suture material in the pelvic cavity.
      • clustered dilated small bowel loops (mainly ileum) in the pelvic cavity, with abrupt tapering of lumen at transition zone. Adhesion ileus is first considered.
      • colon is not dilated.
      • no ascites; no intraperitoneal free air.
      • tiny simple hepatic cysts in left hepatic lobe.
      • no definite focal lesion in the spleen, pancreas, bilateral kidneys and adrenal glands.
      • multiple gallbladder stones.
    • Impression:
      • Postoperative change in the pelvic cavity. Focal small bowel ileus in the pelvis, favor adhesion ileus.
      • Multiple gallbladder stones.
      • Tiny simple hepatic cysts, left lobe.
  • 2018-11-30 CT - abdomen
    • Chief Complaints: abd pain, upper abodmen, Nausea (+), vomiting (-), Diarrhea (-) Radiation to back (-) constipatin (-)
      • Past History: Nil
      • Surgical history: Hysterectomy and oophorectomy
      • Drug allergy: Ulex
      • Stomach ache sudden onset since 4 pm
    • Indication: R/O intestinal obstruction.
    • Without and with contrast Abdomen CT showed
      • unremarkable change in the solid organs, such as liver, pancreas, spleen, and both kidneys
      • post-OP change in the rectosigmoid colon.
    • Impression: post-OP change in the rectosigmoid colon.
  • 2018-11-30 CXR
    • Scoliotic alignment of the thoracolumbar spine is noted.
    • Osteopenia of the bony structure is noted.
  • 2018-11-30 KUB
    • Osteopenia of the bony structure is noted.
  • 2018-03-06 Surgical pathology Level V
    • Clinical diagnosis: Malignant ovary neoplasm
    • Pathological diagnosis
      • Labeled as “pelvic mass”, excision — Adenocarcinoma.
        • IHC stains: CK7 (+), CK20 (focal +), pattern the same as previos pattern (S2014-1036).
        • Addtional IHC stains: CDX-2 (weak +), PAX-8 (-), WT-1 (-).
      • Labeled as “sigmoid colon”, resction — Free
      • Lymph node, epricolonic, sigmoid colon resection — Metastatic carcinoma (1/1) with extra-nodal extension.
    • MICROSCOPIC DESCRIPTION:
      • Sections of the pelvic tumor mass show adenocarcinoma with neoplastic glands lined by goblet cells and elongated nuclei.
        • IHC stains: CK7 (+), CK20 (focal +), the pattern the same as previos pattern (S2014-1036).
        • Addtional IHC stains: CDX-2 (weak +), PAX-8 (-), WT-1 (-).
      • Section of the sigmoid colon show bland colonic mucosa, submucosa, muscular layer and serosa. One lymph node at the resection margin shows tumor metastasis with extra-nodal extension.
  • 2018-01-30 Sigmoid fiberscopy
    • external compression and scopy can not pass through since 10 cm from AV
  • 2018-01-30 Upper GI panendoscopy
    • Hiatal hernia with reflux esophagitis, Gr A  - Superficial gastritis, antrum and body
  • 2018-01-29 CXR
    • Scoliotic alignment of the thoracolumbar spine is noted.
    • Osteopenia of the bony structure is noted.
  • 2018-01-29 CT - abdomen
    • A multiloculated cystic lesion (4.9x8.8cm) at left pelvic cavity.
    • Gall stones (0.3-1.4cm). A hypodense nodule (0.3cm) at left hepatic lobe.
    • S/P colon operation.
    • Focal wall edema of small bowel at pelvic cavity.
  • 2016-03-15 SONO - OBS
    • L’t adnexal mass: 62x51mm (RI:0.17, RI:0.78)
  • 2016-03-15 CT
    • S/P hysterectomy.
    • R/O recurrence malignancy in left pelvic cavity with sigmoid colon and left distal ureteral involvement.
    • GB stones with GB fundus wall thickening.
  • 2015-04-22 CT
    • In favor of S-colon cancer (T4N0Mx) (The gold standard of evaluation of lymph node metastases and detailed tumor status is microscopic examination).
    • cStage: T4N0Mx.

[consultation]

  • 2023-04-17 Family Medicine
    • Q
      • This 79 year old woman patient is a case of right ovairan cancer s/p TAH + BSO with pelvic cavity, sigmoid, ureteral involvement s/p OP with liver metastases. Laparotomy on 2008/05/21. OP with TAH+BSO in 2012/02 at CGMH. Debulking with pelvic lymph node enlargement, suspect recurrent ovarian tumor and pelvic tumor, r/o recurrent ovarian cancer with invasion to sigmoid colon on 2018/03/05 and pathology showed Adenocarcinoma. IHC stains: CK7 (+), CK20 (focal +), pattern the same as previos pattern (S2014-1036). Addtional IHC stains: CDX-2 (weak +), PAX-8 (-), WT-1 (-). Lymph node, epricolonic, sigmoid colon resection pathology showed metastatic carcinoma (1/1) with extra-nodal extension. Patient and family refuse further chemotherapy.
      • For pain control and hospice care, we need your further evaluation and management.

[surgical operation]

  • 2018-03-05 Debulking
  • 2012-02 (at CGMH) TAH + BSO
  • 2008-05-21 Laparotomy

[assessment]

  • This patient and her family refuse further chemotherapy, so family medicine is consulted for combined hospice care and pain management.
  • Palliative and supportive care is provided. There is no problem with the active prescription.

700824633

230417

[exam findings]

  • 2023-02-22 CT - abdomen
    • History:
      • 20230117 CT: Ileocecal mass lesion causing small bowel obstruction. Please correlate with colonoscopy.
      • 20230118 S/P ileostomy for decompression.
      • 20230216 S/P right hemicolectomy: A locally advanced tumor was found at cecum with adhesion to RLQ abdomen wall and invasion of great omentum, with obstruction s/p loop-ileostomy.
    • Indication: R/O IAI (Intra-Abdominal Infection)
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformatted isotropic images were obtained in non-contrast scan.
    • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ perfusion status cannot be determined without IV contrast.
    • Findings:
      • There is pneumoperitoneum that may be post-operative change.
        • The differential diagnosis includes hollow organ perforation.
      • There are free gas bubbles in the gastrohepatic ligament and ligamentum teres. Please correlate with gastroscopy.
      • S/P right hepatectomy
      • S/P cholecystectomy.
      • S/P Jackson-Pratt drainage tube insertion from right flank area and the tip located over subhepatic space.
      • Others
        • There is no hyper-or hypodense lesion in the liver, biliary system, pancreas, spleen & both kidneys.
        • There is no ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • IMP:
      • There is pneumoperitoneum that may be post-operative change. The differential diagnosis includes hollow organ perforation.
      • There are free gas bubbles in the gastrohepatic ligament and ligamentum teres. Please correlate with gastroscopy.
  • 2023-02-17 Patho - colon segmental resection for tumor
    • Diagnosis:
      • Intestine, large, cecum, right hemicoloectomy — Mucinous adenocarcinoma, poorly differentiated
      • Margin, proximal and distal: Free
      • Omentum, right hemicoloectomy — Adenocarcinoma, seeding
      • Lymph node, regional, dissection — Meatastatic adenocarcinoma (2/17)
      • Ileostomy, closure — Confirmed
      • AJCC 8th edition pathology stage: pT4aN1bM1a; AJCC stage IVA
    • Gross Description:
      • Procedure: Right hemicolectomy
      • Tumor Site: Cecum
      • Tumor Size: 6.2x 4.2 cm
      • Macroscopic Tumor Perforation: Not identified
      • Macroscopic Intactness of Mesorectum (if applicable): Complete
      • Sections are taken and labeled as:1:bil cut-ends, A2:stomy, A3-5:tumor, A6-8:LNs, X1-3:tumor, X4:omentum, X5:LNs
    • Microscopic Description:
      • Histologic Type: Mucinous adenocarcinoma
      • Histologic Grade: G3 - Poorly differentiated
      • Tumor Extension
        • Tumor invades the visceral peritoneum (including tumor continuous with serosal surface through area of inflammation)
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Involved
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Not identified
      • Tumor Budding
        • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2)
          • Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: Not identified
      • Tumor Deposits: Present
        • Specify number of deposits: Mesocolon
      • Regional Lymph Nodes
        • Number of Lymph Nodes Involved/Examined: Positive (2/17)
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply)
        • m (multiple primary tumors) r (recurrent) y (posttreatment)
          • Primary Tumor (pT)
            • pT4a: Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
          • Regional Lymph Nodes (pN)
            • pN1b: Two or three regional lymph nodes are positive
          • Distant Metastasis (pM)
            • pM1a: Metastasis to one site or organ is identified without peritoneal metastasis
      • Additional Pathologic Findings (select all that apply): None identified
      • Ancillary Studies: Pending
      • Comment(s): None
      • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • 2023-02-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (98 - 27) / 98 = 72.45%
      • M-mode (Teichholz) = 73
    • Conclusion:
      • Indeterminated LV filling pressure; mild RV hypertrophy with impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis; trivial MR; trivial TR; mild PR.
  • 2023-02-15 Flow Volume Chart
    • normal ventilation
  • 2023-02-14 CXR
    • A calcification at LUQ.
  • 2023-01-17 CT - abdomen
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N1(N_value) M:M1(M_value) STAGE:____(Stage_value)
  • 2021-03-24 Treadmill Exercise Electrocardiogram
    • The patient exercised according to the BRUCE for 06:16 min:s, achieving a work level of max METS: 7.3. The resting heart rate of 67 bpm rose to a maximal heart rate of 115 bpm. This value represents 77 % of the maximal, age-predicted heart rate. The resting blood pressure of 139/57 mmHg, rose to a maximum blood pressure of 216/70 mmHg. The exercise test was stopped due to Dizziness, Leg discomfort.
    • Conclusion: Inadequate exercise load
  • 2018-11-14 Myocardial perfusion SPECT with persanti
    • The Tl-201 stress myocardial perfusion scan was performed after sequentially injecting 38.1 mg of dipyridamole and 2.3 mCi of the radiotracer to the patient. The images after stress revealed mildly decreased radiotracer perfusion to the apical lateral wall of the left ventricle. The images at rest revealed further decline radiotracer perfusion to aforementioned hypoperfused area of the left ventricle. No dilatation of the left ventricle was noted.
    • IMPRESSION:
      • Probably normal variant or mild myocardial ischemia in the apical lateral wall of the left ventricle.
      • No post-stress dilatation of the left ventricle.
  • 2023-02-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (78.2 - 25.6) / 78.2 = 67.26%
    • Report
      • AO(mm) = 32.8
      • LA(mm) = 36
      • IVS(mm) = 13.1
      • LVPW(mm) = 10.9
      • LVEDD(mm) = 41.9
      • LVESD(mm) = 26.4
      • LVEDV(ml) = 78.2
      • LVESV(ml) = 25.6
      • LV mass(gm) = 177.5
      • RVEDD(mm)(mid-cavity) =
      • TAPSE(mm) = 22.6
      • LVEF =
      • M-mode(Teichholz) = 67.3
      • 2D(M-Simpson) =
    • Diagnosis
      • Heart size: Normal
      • Thickening: IVS
      • Pericardial effusion: None
      • LV systolic function: Normal
      • RV systolic function: Normal
      • LV wall motion: Normal
      • Valve lesions:
        • MV prolapse: None
        • MS: None
        • MR: None
        • AS: None, Max.AV velocity = 1.3 m/s
        • AR: None
        • TR: Trivial, Max.pressure gradient = 22.8 mmHg
        • TS: None
        • PR: None
        • PS: None
      • Mitral E/A = 53.5 / 68.1 cm/s (E/A ratio= 0.79 )
      • Mitral E’/A’ = 6.9 / 12 cm/s (septal MA); E/E’ = 7.8
      • Intracardiac thrombus: None
      • Congenital lesion: None
    • Conclusion
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Trivial tricuspid regurgitation
      • Mildly thicked IVS

[consultation]

  • 2023-01-17 Colorectal Surgery
    • Q
      • For small bowel illeus due to suspected cecum tumor obstruction
      • The 75 year old woman suffered from no stool and no gas release for 1 week and her abdomen became distended and gradually painful. She visited our ER today and KUB showed small bowel illeus, and CT was done that it was suspected a cecum tumor obstructed the bowel. As a result, we need your expertise to evaluate if she needed emergent operation, thanks!
    • A
      • O
        • CT:
          • Dilatation of small bowel and collapse of colon, r/o obstruction.
          • Wall thickening at ileocecal junction with perifocal fat stranding.
          • Several lymph nodes, at least 8, in right mesocolon.
          • Unremarkable chagne of the liver, spleen, pancreas, and kidneys.
          • No ascites or extraluminal free air.
          • No bony destructive lesion on these images.
        • No fever
        • Vital signs: stable
        • Abdomen: soft, no peritoneal signs or muscle guarding, mild tenderness and distended
      • A: R/O tumor of cecum with obstruction
      • P:
        • Diverting ileostomy for decompression first followed by staged right hemicolectomy 2-3 weeks later is recommeneded
        • The operation will be performed tomorrow on call
        • Please keep current treatment (NPO, NG, nutrition support, antibiotics, Albumin use, check tumor makers)
        • We’ll take over this patient tomorrow morning

[surgical operation]

  • 2023-02-16
    • Surgery
      • Exp. Lap with right hemicolectomy and closre of loop-ileostomy
    • Finding
      • A locally advanced tumor was found at cecum with adhesion to RLQ abdomen wall and invasion of great omentum, with obstruction s/p loop-ileostomy
      • Right hemicolectomy was carried out smoothly and anastomosis using endo-GIA for both ends and side-to-side hand-sewn sutures with 4/0 PDS+ silk.
      • Blood loss was about 30ml. A drain in right subhepatic region
  • 2023-01-18
    • Surgery: Loop-ileostomy    
    • Finding: Dilation of small bowel with wall edema and some ascites. Loop-ileostomy was created at RLQ abdomen. The whole procedure was smooth. 
  • 2017-11-20
    • Diagnosis: varicose vein
    • PCS code: 69014B
    • Finding: left varicose vein with posterior thigh varicose lake

[chemotherapy]

  • 2023-04-13 - oxaliplatin 85mg/m2 131mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4323mg NS 1000mL 46hr (FOLFOX Q2W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-27 - oxaliplatin 85mg/m2 131mg D5W 250mL 2hr + leucovorin 400mg/m2 617mg NS 250mL 2hr + fluorouracil 2800mg/m2 4320mg NS 1000mL 46hr (FOLFOX Q2W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[assessment]

  • The modified FOLFOX6 regimen was administered on 2023-03-27 and 2023-04-13, and severe diarrhea with 10 bowel movements each day occurred on 2023-03-28 and 2023-04-14.
  • Treatment should be withheld for grade 2 or worse diarrhea and restarted at a 20% lower dose of all agents after complete resolution. A dose reduction of oxaliplatin is recommended (to 75 mg/m2 for patients in the adjuvant setting and 65 mg/m2 for patients with advanced disease). Since the bolus FU is skipped in the regimen used, consideration may be given to reducing the infusional FU from 2800mg/m2 to 2400mg/m2 after recovery from grade 3 or 4 diarrhea in the previous cycle.
  • Severe diarrhea, mucositis, and myelosuppression following FU should lead to evaluation for DPD deficiency.
  • Loperamide is recommended as initial therapy for chemotherapy-related diarrhea (CRD). For mild to moderate (grade 1 or 2) uncomplicated CRD, an initial dose of 4 mg should be administered, followed by 2 mg every 4 hours or 2 mg after each loose stool (maximum daily dose of 16 mg). For severe (grade 3 or 4) diarrhea, or mild to moderate diarrhea complicated by moderate to severe abdominal cramping, grade 2 or worse nausea/vomiting, decreased performance status, fever, sepsis, neutropenia, frank bleeding, or dehydration, or mild to moderate uncomplicated diarrhea that persists after 24 hours of loperamide, high-dose loperamide (4 mg initially followed by 2 mg every 2 hours; maximum daily dose 16 mg) should be used. Loperamide was prescribed on 2023-03-30 when the patient was discharged after her first dose of FOLFOX.

700841910

230417

{not completed}

[exam findings]

  • 2023-04-16 Nasopharyngoscopy
    • Findings
      • smooth NPx, OPx, supraglottic swelling, vocal cord edema, R vocal palsy, L vocal paresis, saliva pooling over hypopharynx aspirated to trachea, whitish lesion over left AE fold
    • Diagnosis/Conclusion
      • hypopharynx ca
  • 2023-03-02 Nasopharyngoscopy
    • Findings: 3/2 fiber = RT since 3/1 + CT (3/2 3 courses left), dyspnea, R false cord bulging
  • 2023-02-13 MRI - larynx
    • Indication
      • Hypo ca, R+ neck mets (R level Vb, II-III, possible L), cT4aN2bM1 (Abd CT = suspect liver mets), s/p incomplete CCRT (2022-09-21 ~ 10-20).
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows (comparison: 2022/08/19 MRI)
      • No evident abnormal enlarged lymph node in the visible neck. Regressed LNs seen on prior MR study.
      • Markely Regressed hypopharygeal tumor.
      • After IV contrast administration shows well or heterogenous enhancement in right hypopharynx and around the esophagus inlet (around NG tube, edema?).
      • Presence of soft tissue swelling over bil. neck, post R/T change likely.
      • No evident bony destructive lesion.
    • IMP: Markedly regressed neck LAPs. Markely regressed right hypopharyngeal tumor, likely with minimal residual tumor mass or edematous change, suggest follow up.
  • 2023-02-02 Nasopharyngoscopy
    • Hypo ca undergoing CCRT
    • NG+
  • 2023-01-30 CT - abdomen
    • Abdominal CT with and without enhancement revealed:
      • Bilateral renal cysts measuring 4.3cm is found at right side.
      • Enlarged prostate measuring 6.3cm with calcification is found.
      • The GB is well distended without soft tissue lesion
      • S/P NG tube placement.
      • The spleen, pancreas and adrenals are intact.
      • Very small nodule at hepatic hilum measuring 0.8cm in largest dimension. In comparison with CT dated on 2022-10-12, the lesion regressed.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • No definite inguinal or pelvic sidewall LAP
      • Visible chest
        • Normal heart size.
        • Calcified coronary arteries is found.
        • The lung fields are clear.
    • Imp:
      • Hepatic hilar nodule. In regression.
      • Enlarged prostate. 6.3cm
  • 2023-01-05 Nasopharyngoscopy
    • Hypo ca undergoing CCRT
    • NG+
    • saliva stasis
  • 2022-11-03 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2022-10-27 ECG
    • Sinus tachycardia
    • T wave abnormality, consider anterior ischemia
  • 2022-10-12 CT - abdomen
    • Indication:
      • Poor intake after R/T, dysphagia, odynophagia
      • 68 y/o male, a pt of Hypo ca, R+ neck mets (R level Vb, II-III, possible L), cT4aN2bM1 (Abd CT= suspect liver mets) Dx in Aug 2022
    • Findings
      • Regression of S1 liver lesion (or hepatic hilar lesion), from 1.9cm to 1.0cm.
      • Right kidney cyst, 5.2cm.
      • No ascites or extraluminal free air.
      • No evidence of bowel obstruction.
      • No enlarged lymph nodes in para-aortic and pelvic regions.
      • Enlargement of prostate gland.
      • No bony destructive lesion on these images.
    • Impression
      • Regression of S1 liver lesion (or hepatic hilar lesion)
      • Prostate enlargement
  • 2022-09-15 Nasopharyngoscopy
    • 202208 Hypo ca, R+ neck mets(R level Vb, II-III, possible L), cT4aN2bM1 (Abd CT = suspect liver mets) = wish
    • 20220915 fiber = new R vocal palsy + supraglottic smooth bulging progress + no glottis visible (no dyspnea) + mucopus
  • 2022-09-06 Patho - odontogenic/dental cyst
    • Labeled as “granulation tissue in the extraction socket of tooth 34”, removal — Granulation tissue
    • Section shows benign squamous mucosa lined granulation tissue composed of proliferative small blood vessels, fibrosis, and moderate diffuse acute and chronic inflammation.
  • 2022-08-29 CT - abdomen
    • Liver low density lesion at S1, liver meta is favored.
    • Enlarged prostate. Please correlate with PSA.
  • 2022-08-25 Esophagogastroduodenoscopy, EGD
    • Right hypopharynx mass
    • Gastric ulcers, antrum
    • Reflux esophagitis LA Classification grade A
    • Hiatal hernia
    • Superficial gastritis, s/p CLO test
  • 2022-08-25 SONO - abdomen
    • Prob. Parenchymal liver disease
    • Bil renal cysts
  • 2022-08-23 Patho - larynx biopsy
    • Labeled as “right hypopharyngeal tumor”, additional biopsy (S2022-13982) for formalin fixation — squamous cell carcinoma (SCC). IHC stains: p16 (-), Ki-67: 10-15%.
    • Labeled as “right hypopharyngeal tumor”, initial biopsy with frozen section examination (F2022-391) — squamous cell carcinoma in situ (CIS), at least.
  • 2022-08-23 Frozen section
    • Preliminary diagnosis: right hypopharynx, squamous cell carcinoma in situ (CIS), at least.
  • 2022-08-22 Whole body PET scan
    • Glucose-hypermetabolic lesions in the right hypopharynx, highly suspected the primary hypopharyngeal cancer, suggesting biopsy for investigation.
    • Glucose hypermetabolic lesions in lymph nodes in bilateral cervical regions and in the right supraclavicular fossa, highly suspected cancer with regional lymph nodes metastases.
    • A glucose hypermetabolic lesion in the right lobe of the liver, highly suspected cancer with distant metastasis. However, another primary cancer (HCC) should be excluded.
    • Suspected benign lesions in the lesser curventure of the stomach, and physiological uptake of FDG in the colon.
    • Right hypopharyngeal cancer with bilateral cervical and right SCF lymph nodes and liver metastases, cTxN2cM1, stage IVC (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2022-08-19 MRI - larynx
    • Imaging Report Form for Hypopharynx Carcinoma
    • Impression (Imaging stage) : T:4a(T_value) N:2b(N_value) M:0(M_value) STAGE:IVA(Stage_value)
  • 2022-08-18 CT - neck
    • IMP: Right hypopharynx CA with neck LAPs. T4aN2BMx. stage IVA
    • Imaging Report Form for Hypopharynx Carcinoma
    • Impression (Imaging stage) : T:T4A(T_value) N:N2B(N_value) M:M0(M_value) STAGE:IVA (Stage_value)
  • 2022-08-18 Nasopharyngoscopy
    • Findings
      • 3x3 cm palpable non-tender mass over right neck Level I-II region
      • Scope: bilateral intact ear drums, smooth nasopharynx, oropharynx
        • mass lesion over right AE fold, with moderate airway patency
      • Diagnosis and conclusion
        • right hypopharynx mass, cause to be determined
  • 2021-04-09 KUB
    • The psoas shadow is clear.
    • There is no evidence of destructive bone lesion.
    • Calcified dot(s) is found at left paravertebral region, ureter stone(s) is most likely.
    • Increased intestinal gas is found.

[consultation]

  • 2023-04-16 Ear Nose Throat
    • Q
      • Chief Complaints: just done C/T 1 month ago.
      • progressive dyspnea, productive cough today.
      • Past History: hypophagreal ca cT4aN2bM1 sp CCRT. liver metastasis
      • Surgical history: Denied
      • Drug allergy: Denied
    • A
      • Stridor for 20 days.
      • Scope: smooth NPx, OPx, supraglottic swelling, vocal cord edema, R vocal palsy, L vocal paresis, saliva pooling over hypopharynx aspirated to trachea, whitish lesion over left AE fold (compared to 202303)
      • Imp: Supraglottic sweillng, suspect C/T related or acute infection
    • Plan:
      • Failed NG insertion due to supraglottic swelling, may consult GI man for insertion
      • Monitor airway, informed the risk of tracheostomy, prescribed Bosmin (adrenalin) + steroid inhalation, IV steroid (if no contraindication)
  • 2022-10-27 Metabolism and Endocrinology
    • Q
      • The 64 y/o man has DM, HCVD and R hypopharyngeal CA wt bil cervical & R SCF LNs & liver mets, cTxN2cM1, stage IVC. He just did chemotherapy on 2022/10/18. Due to weakness and hyperglycemia noted, suspect DKA, so the RI pump use from ED. We need your help for management. Thanks!
    • A
      • We were consulted for blood sugar control.
      • O:
        • BH: 162 cm, BW: unknown
        • Diet: NPO except water and drugs
        • Medication in OPD: unknown
        • Medication during hospitalization: RI pump 30 ml/hr
        • Na: 123, K: 5.4, Ca: 2.75
        • ALT: 32
        • BUN/Cr: 71/1.95 (eGFR: 36.54)
        • F/S: 275
        • Blood glucose: 673 mg/dL
        • HbA1c: unavailable
        • Blood osm: 317, effective osm: 283
        • Urine ACR: unavailable
        • OPH OPD: nil
      • A: Type 2 DM, poor control
      • Suggestions:
        • Avoid all OADs. Keep NPO except water and drugs
        • RI pump 50U in 500ml N/S run as protocol
        • H/S 500ml Q12H, 0.298% KCl QD + STAT (STAT after serum K reading)
        • Check F/S Q2H. Check Na, K, vein gas Q8H until off RI pump
        • Switch to basal bolus therapy later. (contact us to adjust)
        • Check HbA1c, urine ACR
        • Consult OPH for DM retinopathy if his condition is stable.
        • Consider to consult nutritionist for DM diet education (self-paid approximate TWD 600)
        • Basic educations for Diet control, Hypoglycemic precautions, DM complications and Self-Monitoring of Blood Glucose were given at bedside
        • Contact us if needed. I’d like to follow up this patient. Meta-OPD F/U.
  • 2022-08-18 Ear Nose Throat
    • Q
      • Right neck pain for 1 month
      • Never seek medical help, only took pain-killers and then tarry stool noted. called at our GI OPD this morning. EGD was arranged for R/O UGI bleeding.
      • Right ear tingling pain, horseness also noted
      • Odynophagia (+)
      • No fever noted
      • Occupation: Taxi driver
      • Medication: Bokey for
      • Past hx: DU, DM
      • OP hx: renal stone s/p op
    • A
      • S
        • sore throat with FB sensation for a month
        • fair saturation under room air
        • odynophagia(+), dysphagia(-), dyspnea(-),stridor (-), mouth drooling(-), voice change (+), otalgia (+, right), fever(-), alcohol(+), smoking(+), betelnut(-)
      • O
        • 3x3 cm palpable non-tender mass over right neck Level I-II region
        • Scope:
          • bilateral intact ear drums, smooth nasopharynx, oropharynx
          • mass lesion over right AE fold, with moderate airway patency
      • A
        • Impression: Right hypopharynx or larynx tumor with neck mass, r/o metastasis
      • P
        • inhalation therapy with steroid + bosmin if no contraindication
        • keep monitor breathing pattern and saturation, intubation or cricothyrodectomy may be considered then if s/s worsen
        • we will f/u the patient

[chemotherapy]

  • 2023-03-15 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-08 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-01 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-18 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-11 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-04 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-09-26 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

UFT (tegafur 100mg + Uracil 224mg) KUFT01

  • 2023-02-02 ~ undergoing - 2# BID
  • 2022-08-29 ~ 2022-10-03 - 2# BID

[assessment]

  • For the patient’s shortness of breath (SOB), in addition to the currently prescribed Ipratran (ipratropium bromide), the addition of Butanyl (terbutaline) could be considered if there are no contraindications. Inhaled glucocorticoids such as beclomethasone, budesonide, ciclesonide, fluticasone, mometasone and triamcinolone may also be considered.

701010079

230417

[exam findings]

  • 2023-03-24 MRI - pelvis
    • CC: Stool passage from urine, hematuria, turbid urine
      • 20210111 CT: Rectal cancer,T4bN2aM0,STAGE:IIIC. Rectal-vesical fistula.
      • 20220413 CT: Soft tissue mass in between the rectum and the urinary bladder that is c/w rectal cancer with urinary bladder invasion.
      • 20230218 CT: soft tissue mass at left lateral pelvis with left hydroureteronephrosis.
      • 20230223 TURBT of Bladder tumor: Adenocarcinoma c/w colorectal origin.
    • Past History: Liver abscess S/P right hepatectomy, old TB
    • Findings:
      • There is an ill-defined soft tissue mass-like lesion in between the rectum and the urinary bladder, measuring 4.4 x 2.8 cm in size.
        • Rectal cancer with urinary bladder invasion is highly suspected. Please correlate with contrast enhanced CT or MRI.
        • In addition, rectal-vesical fistula is noted.
      • There is no evidence of left hydroureteronephrosis.
      • There is no focal abnormality in the prostate.
        • Non-visualization of the seminal vesicle is noted.
      • There is no evidence of ascites or lymphadenopathy.
      • The visible abdominal aorta and IVC are grossly unremarkable.
    • IMP:
      • There is an ill-defined soft tissue mass-like lesion in between the rectum and the urinary bladder, measuring 4.4 x 2.8 cm in size.
        • Rectal cancer with urinary bladder invasion is highly suspected. Please correlate with contrast enhanced CT or MRI.
        • In addition, rectal-vesical fistula is noted.
      • No evidence of left hydroureteronephrosis.
  • 2023-02-27 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
      • Tumor type: colorectal adenocarcinoma with bladder invasion
      • Tumor location: urinary bladder
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark ULTRA
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: [V]Pass, [ ]Fail
      • Adequate tumor cells present (>=50 viable tumor cells): [V] Yes, [ ] No
    • Result:
      • Tumor cell (TC) staining assessment:
        • TC category: TC < 1%
        • Percentage of PD-L1 expressing tumor cells (%TC): <1%
      • Tumor-infiltrating immune cell (IC) staining assessment:
        • IC category: IC >=1% and <5%
        • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): 2%
      • Note:
        • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
        • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2023-02-27 PD-L1 IHC
    • Tumor cell (TC) staining assessment:
      • TC: <1%
  • 2023-02-27 PD-L1 (22C3)
    • Combined Positive Score (CPS) assessment: CPS >= 10
    • Combined Positive Score (CPS): 15
  • 2023-02-23 Patho - urinary bladder TUR
    • Bladder tumor, TURBT — Adenocarcinoma, compatible with colorectal origin
    • Microscopic examination
      • Histologic type: Adenocarcinoma, compatible with colorectal cancer with bladder invasion
      • Histologic grade: moderately differentiated
      • Tumor configuration: tubular, cribriform or papillary tumor with focal necrosis and muscle invasion. Besides, normal colonic mucosa is also included in the submitted specimen
      • Immunohistochemistry: CK7(+, scatter), CK20(+), GATA-3(-), CDX2(+) and P63(-) for tumor
      • Clinical correlation is advised.
  • 2023-02-22 CXR
    • Fibrocalcified infiltrates in right upper lung.
    • Right lower lung nodule, 0.9cm, stationary.
  • 2023-02-18 CT - abdomen
    • Indication: new bladder cancer, colon cancer history
    • Abdominal CT without IV contrast ehnancement shows:
      • The urinary bladder is collapsed with thick wall and suspeced soft tissue infiltration to perirectal region measuring 5.65*3.03cm in largest dimension. In comparison with CT dated on 2022-04-13, the lesion enlarged. Suggest further treatment.
      • Left hydronephrosis and hydroureter obliterated by the tumor mass is found.
      • The spleen, liver, pancreas and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • Visible chest
        • Calcified coronary arteries is found.
        • Normal heart size.
        • One calcified dot at right lower lobe is found measuring 0.45cm in largest dimension. Old insult is considered.
        • No pleural effusion is found.
    • IMP: Soft tissue mass at bladder base with left hydronephrosis and hydroureter. Uroepithelial cancer is favored.
    • Imaging Report Form for Urinary Bladder Carcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-12-09 Patho - urinary bladder TUR
    • Urinary bladder, TURBT — high-grade invasive urothelial carcinoma. Muscularis propria not present.
    • Microscopically, section showsinvasive urothelial carcinoma characterized by papillary architecture of the neoplasm lined by high-grade atypical urothelial cells. The tumor cells have irregular nuclear contours with hyperchromasia and pleomorphism, variably prominent nucleoli and mitotic activity. The tumor has invaded subepithelial connective layer. Muscularis propria is not present.
  • 2022-12-07 SONO - nephrology
    • left severe hydronephrosis
  • 2022-04-13 CT - abdomen
    • History: 20210111 CT:rectal cancer with rectal-vesical fistula, cT4bN2aM0, cStage: IIIC
    • Past History: Liver abscess S/P right hepatectomy, old TB
    • Findings:
      • S/P right hepatectomy and S/P cholecystectomy.
      • S/P right transverse colostomy
      • There is soft tissue mass in between the rectum and the urinary bladder that is c/w rectal cancer with urinary bladder invasion.
      • Prior CT identified a metastasis measuring 7.5 mm in RLL of the lung is noted again, stationary.
      • Fibro-calcified shadows of right upper lung are noted, which is c/w old TB.
    • Impression:
      • There is soft tissue mass in between the rectum and the urinary bladder that is c/w rectal cancer with urinary bladder invasion.
      • Prior CT identified a metastasis measuring 7.5 mm in RLL of the lung is noted again, stationary.
  • 2021-09-11 CT - abdomen
    • NO evidence of tumor invasion into urinary bladder is found.
    • The urinary bladder is collaped with thick wall. Although no tumor invasion is found in the current study. Cystoscopy is suggested if hematuria persisted.
    • Right lower lobe nodule, in regression.
  • 2021-01-26 CT - chest
    • Indication: rectal intramucosal adenocarcinoma, Chest x-ray showed right lung nodule
    • MDCT (256-detectors, GE Revolution, was performed with 0.625 mm collimation & 1.25 mm slice thickness) of the chest without contrast enhancement, coronal and sagittal reformatted images and axial MIP images obtained shows:
      • Lungs:
        • reticular and nodular opacities with architextural distortion in RUl. reticular opacities in anterior RLL.
        • two solid nodules in RLL (up to 9 mm in largest axial dimension) and snother smaller solid nodule in RML.
      • Mediastinum and hila: no enlarged LN or mass.
        • old calcified LNs in the mediastinum and hila, sequela of previous TB infection
      • Vessels: mild coronary arterial calcification
      • Aorta: normal caliber, minimal atherosclerotic change of aortic arch.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: Rt apical pleural thickening.
      • Chest wall: unremarkable.
      • Visible abdominal contents: s/p Rt hepatic posterior segmentectomy.
      • Visualized bones: no lytic or blastic lesion.
    • Impression:
      • three solid nodules in Rt lung, firstly considered metastases.
      • post inflammatory fibrotic change in RUL and anterior RLL.
  • 2021-01-25 CXR
    • Interstitial pattern at RUL.
    • A nodule at right middle lung zone.
    • Blunted right costophrenic angle.
  • 2021-01-19 Patho - colorectal polyp
    • Rectal tumor, biopsy — Intramucosal adenocarcinoma at least
    • Microscopically, the sections show a picture of intramucosal adenocarcinoma at least characterized by tumor arranged in cribriform or villous pattern with subtle stromal reaction.
    • Immunohistochemistry shows CDX-2(+); MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.
  • 2021-01-19 Barium Enema (double contrast)
    • LGI series with water soluble contrast medium revealed:
      • Total occlusion of rectum, about 9cm from anal verge. No further passage of contrast medium even on a 10mins delayed image.
      • Plain pelvis CT was performed for comparison and prooved above description.
    • IMP:
      • c/w rectal mass with total occlusion
      • Suggest oral contrast study if a colo-vesical fistula is suspected clinically.
  • 2021-01-19 Colonoscopy
    • Suspected rectal cancer obstruction s/p biopsy
  • 2021-01-11 CT - abdomen
    • History and indication: rectal-vesical fistula
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of rectum with adjacent fat stranding and regional LAP. Presence of rectal-vesical fistula.
      • S/P right hepatic lobe operation.
      • Some small LNs at retroperitoneum.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • S/P cholecystectomy.
      • Patency of portal vein.
      • No ascites.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • No abnormal density at bilateral basal lungs.
      • Degeneration and spondylosis of L-S spine.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIc(Stage_value)

[chemotherapy]

  • 2023-04-14 - leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + NS 250mL
  • 2021-05-05 - irinotecan 120mg/m2 180mg D5W 250mL 90min
    • betamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO + NS 500mL
  • 2021-03-29 - [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouacil 400mg/m2 650mg NS 100mL 10min] D1-2
  • 2021-03-24 - [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouacil 400mg/m2 650mg NS 100mL 10min] D1-2
  • 2021-03-08 - [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouacil 400mg/m2 650mg NS 100mL 10min] D1-2
  • 2021-03-04 - [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouacil 400mg/m2 650mg NS 100mL 10min] D1-2

[assessment]

  • The patient’s serum creatinine has been above 2 mg/dL since 2022Q4 and has not dropped below that level since. The eGFR has been consistently around 30 since 2023.

  • On 2023-04-13 the following lab results were obtained: HGB 5.1g/dL, Iron bound Fe 22ug/dL, UIBC 145ug/dL, TIBC 146ug/dL, AST 14U/L, and ALT 13U/L. On 2023-04-14, Ferritin was 545ng/mL and Transferrin was 124ng/mL. There is no evidence of iron deficiency or liver dysfunction. Anemia of chronic disease and/or anemia of inflammation might be possible, as well as nutritionally deficiency. The body weight of 36.5 kg recorded on the TPR panel on 2023-04-13 appears to be too low, which may be an erroneous entry.

701091164

230417

[diagnosis] - 2022-11-25 admission note

  • Rectal cancer s/p neoadjuvant concurrent chemoradiotherapy at TP-VGH in 2012, with response of CR, so no OP. Due to near total obstruction on 2018/06, receiving T-colostomy on 2018/06/11 followed by neoadjuvant radiotherapy for 17 doses, then neoadjuvant FOLFOX or CapOx for 3 cycles, subsequently receiving APR on 2018/10/11, and then FOLFOX or CapOx for 9 cycles (to 2019-05) at TSGH in 2018 with lung metastases.
  • Malignant neoplasm of colon, unspecified
  • Chronic viral hepatitis B without delta-agent
  • Chronic kidney disease, stage 5
  • Hyperuricemia
  • hypertension
  • Constipation
  • Anemia due to antineoplastic chemotherapy

[past history]

  • Hypertension for years with drug control,
  • CKD stage 5,
  • colorectal cancer s/p operation on 2018 and 2019,
  • Right ureteral stricture with hydronephrosis s/p D-J since 2020.
    • 3-6 months to replace the DBJ regularly
    • Last changed right DBJ in June (at TSGH)

[allergy]

  • penicillin

[family history]

  • Mother had hypertension and diabetes.
  • There is no family history of cancer, mental diseases or asthma.

[exam findings]

  • 2023-03-21 CT - abdomen
    • WITHOUT contrast enhancement CT of abdomen - whole:
      • S/P colostomy, presence of ventral herniation.
      • Soft tissue tumor in presacral region with urinary bladder wall involvement.
      • Hyperdensity in the urinary bladder.
      • S/P double J catheter drainage, right side.
      • S/P PCN catheter drainage, left side.
      • Presence of gallbladder stones.
      • R/O liver cysts, up to 4.7cm in left lobe.
      • Bilateral lung tumors, stationary.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
    • Impression:
      • S/P colostomy, presence of ventral herniation.
      • Soft tissue tumor in presacral region with urinary bladder wall involvement.
      • Hyperdensity in the urinary bladder, hematoma? or tumor.
      • S/P double J catheter drainage, right side. S/P PCN catheter drainage, left side.
      • GB stone.
      • R/O liver cysts.
      • Bilateral lung tumors, stationary. Suspected lung metastasis.
  • 2023-02-14 KUB
    • S/P double J catheter insertion in place, right side.
    • S/P PCN catheter drainage, left side.
    • Lumbar spondylosis.
    • Non-specific bowel gas pattern.
    • Calcifications in the pelvic cavity, could be due to phleboliths.
  • 2023-02-13 ECG
    • Normal sinus rhythm
    • Septal infarct, age undetermined
    • Abnormal ECG
  • 2023-02-01 Nasopharyngoscopy
    • smooth nasopharynx,oropharynx, hypopharynx
    • pale and boggy inf. turbinate, with clear mucus, erosion wound over inferior turbinate and nasal septum
    • intact ear drum with cerumen, s/p removal
  • 2022-10-31, -10-06, -09-22 SONO - kidney
    • Bilateral hydronephrosis
  • 2022-10-24, -10-19 CXR
    • Atherosclerotic change of aortic arch
    • Few nodular opacity projecting in both lower lung are noted that are c/w metastases after correlate with CT.
  • 2022-10-19 CXR
    • Septal infarct, age undetermined
  • 2022-09-20 All-RAS + BRAF mutations assay
    • All-RAS mutations assay
      • Detection range
        • KRAS codon 12, 13, 59, 61, 117, 146
        • NRAS codon 12, 13, 59, 61, 117, 146
      • Results
        • There was no variant detected in the KRAS/NRAS gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF mutations assay
      • Detection range
        • BRAF codon 600
      • Results
        • There was no variant detected in the BRAF gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • 2022-09-15 PET scan
    • Glucose hypermetabolism in the posterior lower pelvic region, compatible with a metastatic lesion.
    • A glucose hypermetabolic lesion in the lower lobe of left lung, compatible with lung metastasis.
    • Two mild glucose hypermetabolic lesions in the right lung. Metastatic lesions can not be ruled out. Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in the lower portion of the esophagus. The nature is to be determined (inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
  • 2022-09-14 Tc-99m MDP bone scan
    • Faint hot spots in both rib cages, and increased activity in bilateral pubic bones, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, and hips.
  • 2022-09-14 Bladder Sonography
    • PVR (post-void residual volume) 16.79 ml
  • 2022-09-13 PD-L1 (22C3)
    • Combined Positive Score (CPS) category: CPS >= 1 and < 10
    • Combined Positive Score (CPS): 2
  • 2022-09-13 PD-L1 (SP142)
    • Result:
      • Tumor Cell Staining Assessment:
        • PD-L1 Expression: Absent (TC = 0%)
      • Tumor Infiltrating Immune Cell Staining Assessment:
        • PD-L1 Expression: 10% Immune cells (IC= 10%)
    • Note:
      • Percent of PD-L1 expression in tumor cells (TC):
        • The percentage of viable tumor cells with membrane positivity at any intensity
      • Percent of PD-L1 expression in immune cells (IC):
        • The percentage of tumor-infiltrating immune cells with discernible staining of any intensity
  • 2022-09-13 PD-L1 (IHC)
    • Result:
      • Tumor cell (TC) staining assessment: 0%
      • Combined Positive Score (CPS) assessment: 0.1
  • 2022-09-12 CT - abdomen
    • S/P colostomy with incisional hernia and small bowel ileus.
    • Increased soft tissue in pelvic cavity. S/P right side double J catheter insertion. S/P left PCN. Some hematoma in left perirenal region.
    • Lung metastases.
  • 2022-09-09 Body fluid cytology - urine
    • DIAGNOSIS: atypia;
    • GROSS DESCRIPTION: 15 ml turbid clear
    • MICROSCOPIC DESCRIPTION: numerous neutrophils and many atypical urothelial cells present. Further work up, including biopsy or tumor excision, may be considered.
  • 2022-09-08 Patho - urinary bladder TUR
    • PATHOLOGIC DIAGNOSIS
      • Urianry bladder, posterior wall, left, TURBT — Adenocarcinoma, enteric type, in favor of colorectal origin
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consists of seven small pieces of gray-brown soft tissue, labeled “bladder tumor, left posterior wall”, measuring up to 0.4 x 0.3 x 0.1 cm. All for sections.
    • MICROSCOPIC EXAMINATION
      • Histologic type: Adenocarcinoma, enteric type, composed of columnar to cuboidal tumor cells, arranged in tubular, papillary and cribriform patterns. Tumor necrosis and neutrophil infiltration are present
      • Histologic grade: Moderately differentiated
      • Tumor configuration: Papillary
      • Muscularis propria: Present
      • Lymphovascular invasion: Not identified
      • Microscopic tumor extension: Tumor invades subepithelial connective tissue
      • IHC: CK7(-), CK20(+), GATA3(-), CDX2(+), and B-catenin (extensive membranous and cytoplasmic expression, only few tumor cells show nuclear staining)
      • Comment: According to histology and immunophenotypes, metastatic colonic adenocarcinoma is most likely
  • 2022-09-08 Patho - urinary bladder TUR
    • PATHOLOGIC DIAGNOSIS
      • Prostatic urethra, TURBT — Adenocarcinoma, enteric type, favors metastatic colonic carcinoma
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consists of multiple small pieces of gray-brown soft tissue, labeled “prostatic urethra”, measuring 2.0 x 1.5 x 0.4 cm in aggregate. All for sections.
    • MICROSCOPIC EXAMINATION
      • Histologic type: Adenocarcinoma, enteric type, composed of columnar to cuboidal tumor cells, arragned in tubular, papillary and cribriform patterns. Tumor necrosis and neutrophil infiltration are present
      • Histologic grade: Moderately differentiated
      • Tumor configuration: Papillary
      • Muscularis propria: Present
      • Lymphovascular invasion: Not identified
      • Microscopic tumor extension: Tumor invades muscularis propria
      • IHC: CK7(-), CK20(+), GATA3(-), CDX2(+), and B-catenin(extensive membranous and cytoplasmic expression, only few tumor cells show nuclear staining)
      • Comment: According to histology and immunophenotypes, metastatic colonic adenocarcinoma most likely
  • 2022-09-01 SONO - nephrology
    • Bilateral hydronephrosis with hydroureter, mild to moderate degree. (right kidney is more prominent)
    • Right chronic parenchymal renal disease.
    • Double J catheter in situ, right kidney.
    • Urinary retention, suspected neurogenic bladder.
    • Gall bladder stones.
  • 2022-09-01 Bronchial Dilator Test
    • normal, FEV1/FVC = 81%, FVC = 93%, FEV1 = 95%
    • without significant reversibility
  • 2022-08-26 CT - lung/mediastinum/pleura
    • Findings
      • Chest:
        • Ground glass nodule at posterior segment of right upper lobe up to 0.47cm in largest dimension is found.
        • One spiculated nodule at subpleural space of right middle lobe up to 0.88cm in largest dimension is found. Another lobulated nodule at left lower lobe up to 1.9cm is found. Lung meta is favored.
        • No evidence of bilateral pleural effusion.
        • Calcified coronary arteries is found.
      • Visible abdomen:
        • There is stone at dependent portion of GB. GB stone(s) are noted.
        • Bulging renal tumor at left side up to 2.83cm in largest dimension. Nature?
        • The spleen, liver, pancreas and adrenals are intact.
    • Imp:
      • Right upper lobe ground glass nodule, suggest follow up.
      • Right middle lobe and left lower lobe nodules, lung meta is favored.
      • Left renal tumor.
  • 2022-08-25 CXR
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • Subtle nodular opacity over Lt retrocardiac lower lobe

[consultation]

  • 2022-09-13 Colorectal Surgery
    • Q
      • For Ventral hernia with intestines herniation and ileus
      • Colon cancer s/p operation on 2018 and 2019 at Tri-Service General Hospital (APR and hemicolectomy?)
      • Abdomen CT (20220912) showed parastomal hernia and lung metastases.
      • The patient is a case of bilateral hydronephrosis, was admitted for surgery of URS.
      • At admission, he accepted antibiotics with flumarin therapy due to urine culture (2022-09-01) showed Klebsiella pneumoniae. Preoperative evaluation and examination were done. Anemia (HGB: 7.9) was found and BT LPRBC 2U. The same day, PPI was given due to vomiting multiple times also found and the vomit showed coffee. Consultation Nephrology for renal function impairment (BUN 124 mg/dL, Cr 8.52->10.36mg/dL).
      • Post TURBT, Left PCN and right URS on 2022-09-08. After surgery, abdomrn fullness also found and KUB showed focal small bowel ileus. Due to no drainage from the left PCN, antegrade pyelography (2022-09-09) was done and which showed dislodgement of the pigtail over left side; Ventral hernia with intestines herniation is found. Ileus is also noted. Therefore, left PCN re-insertion was done on 20220909.
      • He complained small amount of vomiting per day. Abdomen distention still was noticed. Abdomen CT showed parastomal hernia and lung metastases.
      • We need your help for further evaluation and management. Thanks for you.
    • A
      • O:
        • Abdomen: soft, parastomal hernia(+), no tenderness, no distended or rigidity
        • Colostomy: pass flatus or stool(+)
        • TURBT — Adenocarcinoma, enteric type, in favor of colorectal origin
        • 20220912 CT
          • S/P colostomy with incisional hernia and small bowel ileus.
          • Increased soft tissue in pelvic cavity. S/P right side double J catheter insertion. S/P left PCN. Some hematoma in left perirenal region.
          • Lung metastases.
      • A:
        • Para-stomal hernia, without bowel incarceration or strangulation
        • Favor local recurrence of rectal adenocarcinoma in low pelvic region
      • P:
        • Please check CEA, and arrange PET scan for more cancer evaluation
        • We would like to follow this patient and make decision for further management
  • 2022-09-08 Nephrology
    • A
      • S
        • This 66 years old male patient had underlying history of hypertension, CKD stage 5 and colon cancer s/p op and right hydronephrosis s/p DJ since 2020.
        • Consult for renal function impairment
      • O
        • Lab data:
          • Na: 132, K:4.2, albumin: 4.5
          • WBC: 9.49, Hb: 7.9, Plt: 320
          • BUN: 124, cre: 8.52 -> 10.36
        • Renal echo (20220901): bilateral hydronephrosis with hydroureter (DJ in right kidney), distended urinary bladder with urine retention
        • U/O: 652ml under foley
      • Assessment
        • Acute kidney injury on CKD stage 5, suspect post renal with bilateral hydroneophrosis and hydroureter
      • Suggestion
        • Keep Foley patent, record U/O and BW qd.
        • DC exforge, if BP is high, you may add norvasc
        • Give Recormon 500U sc qW for renal anemia
        • Follow up BUN, cre, Na, K, Ca, P, CO2 or VBG
      • Consider HD if refractory hyperkalemia, metabolic acidosis or pulmonary edema is noted.

[chemotherapy]

  • 2023-04-17 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL
  • 2023-03-22 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL
  • 2023-03-03 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL
  • 2023-01-16 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL
  • 2022-12-28 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug
  • 2022-11-30 - irinotecan 50mg/m2 80mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug
  • 2022-11-08 - irinotecan 50mg/m2 80mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug
  • 2022-10-21 - leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI without Iri)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-09-09 - mitomycin-c 30mg/m2 30mg 1hr BI (bladder irrigation)

==========

2023-04-17

  • The patient’s renal function appears to be declining recently, which should be noted.
    • 2023-04-17 Creatinine 2.59 mg/dL
    • 2023-04-06 Creatinine 2.50 mg/dL
    • 2023-03-16 Creatinine 2.07 mg/dL
    • 2023-04-17 eGFR 26.50
    • 2023-04-06 eGFR 27.60
    • 2023-03-16 eGFR 34.32
    • 2023-04-17 BUN 49 mg/dL
    • 2023-04-06 BUN 38 mg/dL
    • 2023-03-16 BUN 35 mg/dL
  • The patient has undergone 7 blood transfusions since September 2022, and elevated ferritin levels of 596 and 545 ng/mL were observed in the last quarter of 2022. Kentamin (B1, B6, B12) has been administered, and the patient’s MCV, MCH, and MCHC levels are normal as of 2023-04-17, making iron deficiency less likely. It is advised to reassess the patient’s iron storage before determining if iron supplements are necessary. Currently, Foliromin (ferrous sodium citrate) is prescribed.

2023-03-22

  • This patient has CKD stage IIIb-IV (eGFR 15-44) and has not undergone dialysis. The patient has received 5 blood transfusions since September of last year and 1 in March of this year. Updated lab results from 2023-03-16 show normal MCV, MCH, and MCHC, but a decreased HGB level of 9.7g/dL, suggesting that iron-deficiency anemia is less likely. The patient’s lab history indicates high ferritin levels of 596 and 545 ng/mL in the last quarter of 2022. The current prescription includes Foliromin (ferrous sodium citrate). It is recommended to assess the patient’s iron storage to determine if iron supplementation is necessary.
  • In accordance with the current National Health Insurance medication reimbursement regulations, EPO - hu-erythropoietin such as Eprex and Recormon) and darbepoetin alfa (such as Aranesp) can be used for chemotherapy-related anemia in cancer patients with solid tumors who have symptomatic anemia and Hb<8 gm/dL. And the regulation requires that EPO treatment should not be used for cancer patients who are expected to have reasonable and sufficient survival time, including curative and expected adjuvant chemotherapy.

2023-01-17

  • His blood lab data indicated that his ferritin level increased by over 30% in less than 20 days after taking iron supplements from time to time.

    • 2022-12-13 Ferritin 596.5 ng/mL
    • 2022-11-22 Ferritin 454.2 ng/mL
  • High ferritin levels suggest an excess of iron or an acute inflammatory reaction in which ferritin is mobilized without excess iron. Ferritin can be used as an indicator of iron overload disorders, such as hemochromatosis or hemosiderosis. Ferritin can increase the liver proinflammatory mediators IL-1b, iNOS, RANTES, IkappaB alpha, and ICAM1. As ferritin is also an acute-phase reactant, it is often elevated in various diseases. A normal C-reactive protein (CRP) can be used to exclude elevated ferritin caused by acute phase reactions. However, our HIS5 does not contain simultaneous data on ferritin levels and CRP levels.

  • As the body content of iron (iron burden) increases beyond that needed for normal production of red blood cells, muscle cells, and iron-containing enzymes, the plasma iron-binding protein transferrin becomes saturated, eventually exceeding its capacity and resulting in binding of iron to other proteins and molecules, including albumin, citrate, acetate, and others. This iron is referred to as non-transferrin-bound iron (NTBI); it begins to appear once the transferrin saturation exceeds 35 percent and rises significantly with transferrin saturation above 70 percent. NTBI is taken up by cells that have active uptake mechanisms. This includes parenchymal cells of the liver, heart, and endocrine organs. In these affected organs, excess iron can chemically interact with hydrogen peroxide. These reactive oxygen species in turn can cause tissue damage, inflammation, and fibrosis. The liver, heart, joints, and endocrine organs appear to be especially susceptible.

  • By the time clinical findings have developed (hepatic fibrosis, heart failure, cardiac conduction defect), it is likely that significant iron deposition and tissue injury has occurred. Please ensure that the patient’s iron level is checked as needed and monitor any signs of iron overload if iron supplements are continued.

2022-12-29

  • The lab data indicated that MCV, MCH, MCHC, UIBC were normal; Ferritin was exceeded; Fe (iron bound) and TIBC was low.

    • 2022-12-28 MCV 89.7 fL
    • 2022-12-28 MCH 29.2 pg
    • 2022-12-28 MCHC 32.5 g/dL
    • 2022-12-13 Ferritin 596.5 ng/mL
    • 2022-12-13 Fe (Iron-bound) 32 ug/dL
    • 2022-12-13 TIBC 189 ug/dL
    • 2022-12-13 UIBC 157 ug/dL
    • 2022-11-22 Ferritin 454.2 ng/mL
    • 2022-11-22 Fe (Iron-bound) 42 ug/dL
    • 2022-11-22 TIBC 197 ug/dL
    • 2022-11-22 UIBC 155 ug/dL
  • Normal MCV, MCH, MCHC may suggest the anemia is less likely to be caused by iron insufficiency. High ferritin may suggest iron overload. Low TIBC can suggest that there is not enough transferrin available to bind to iron, i.e., the patient has high iron level, so most of the transferrin is bound to it, which leaves very little free in his blood. Frequent blood transfusions may cause iron overload.

  • It is recommended to hold the Foliromin (ferrous sodium citrate) until the cause of the anemia is confirmed to be iron deficiency.

2022-11-28

  • 2022-11-22 lab results showed a low serum iron concentration (42 mcg/dL, normal range 60 to 150 mcg/dL), as well as a low transferrin level (TIBC 197 mcg/dL, normal range 300 to 360 mcg/dL), which resulted in a transferrin saturation level of 21% at the lower end of the normal range (20%~45%). In the meantime, ferritin levels increased (545 ng/mL, normal ranges, 30 to 200 mcg/L for women and 30 to 300 mcg/L for men, prior to the planned transfusion).
  • Inflammatory conditions in which cytokine production might lead to altered iron trafficking and decreased production of RBCs. The underlying condition could be a chronic kidney disease or a malignancy.
  • Upon discovery of a serum ferritin level exceeding 1000 mcg/L, a daily dose of 14mg/kg of Jadenu (deferasirox, available at this hospital) with regular serum creatinine monitoring might also be an optional add-on.

2022-11-09

  • Insufficient renal function, 2022-11-02 serum Cre was 2.42mg/dL, BUN was 34mg/dL, and eGFR was 28.66. The active prescription has been well-adjusted to reflect the patient’s renal function.
  • The patient is being administered irinotecan (at a lower dose of 50mg/m2) for the first time. Irinotecan can cause early and late forms of diarrhea. Early diarrhea may be accompanied by cholinergic symptoms which has been dealed with prescribed subcutaneous premedication atropine. In the event of late diarrhea, loperamide should be administered as soon as possible. Please monitor the patient for signs of diarrhea.

2022-10-20

  • This is a patient with rectal cancer who underwent an abdominoperineal resection and a T-colostomy and treated with FOLFOX/CapeOx at Tri-Service General Hospital in 2018.
  • 2022-09-20 All-RAS and BRAF assay showed no detected variant in the KRAS/NRAS/BRAF gene. Treatment with anti-EGFR antibodies might be beneficial. The use of encorafenib would not be preferred.
  • The level of PD-L1 expression was low (outsourced lab results in late Sep 2022). This might limit the use of immunotherapy methods that involve PD-L1.
  • FOLFOX/CapeOx has previously been used, so FOLFIRI (+ bevacizumab or + cetuximab or panitumumab) might be considered as a possible treatment option.
  • Neither fluorouracil nor leucovorin nor irinotecan dosage adjustments are provided in the manufacturer’s labeling for the FOLFIRI regimen in patients with impaired kidney function (2022-10-20 Cre 2.54 mg/dL, eGFR 27.10).

701447197

230417

[diagnosis] - 2023-04-06 admission note

  • Infectious gastroenteritis and colitis, unspecified
  • Diffuse large B-cell lymphoma, lymph nodes of multiple sites
  • Cardiomegaly
  • Diffuse large B-cell lymphoma, extranodal and solid organ sites
  • Diffuse large B-cell lymphoma, spleen
  • Hypertensive heart disease without heart failure
  • Chronic viral hepatitis B without delta-agent

[past history] - 2023-04-06 admission note

  • Hypertension for 15 years with drug control
  • Hyperlipidemia for 15 years
  • Gout for 15 years        
  • COVID-19 positive on 2022/10    
  • Stomach diffuse large B cell lymphoma with multiple metastasis (bilateral lungs, spleen, both kidneys) , Lugano stage IV, IPI score2 s/p chemotheraphy
  • Multiple myeloma, IgG kappa type, ISS stage II            

[allergy]

  • Mobic 7.5mg/tab (meloxicam): skin rash

[family history]

  • No known congenital or systemic disease.
  • Family history is unremarkable.
  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.  

[exam findings]

  • 2023-04-06 CXR
    • Ground glass opacity in RLL.
    • Cardiomegaly.
  • 2023-03-28 PET
    • The FDG PET findings are compatible with lymphoma in bilateral pulmonary hilar and mediastinal lymph nodes, bilateral lungs, spleen and bone marrow (stage IV). However, in comparison with the previous study on 2022/08/17, the previous glucose hypermetabolic lesions are either less evident or disappeared, suggesting partial response to the therapy.
    • Increased FDG accumulation in bilateral renal pelvis. Physiological FDG accumulation is more likely.
  • 2023-03-27 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • There are few nodular opacities projecting in both lung. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-17 CT - chest
    • Indication:
      • Triple cancer, synchronous (lymphoma, myeloma, bladder ca)
      • Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugan 0 stage IV, IPI 2.2: Multiple myeloma, IgG kappa type, ISS stage II
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Diffuse nodular lesiona are found at bilateral lung fields (n>10). In comparison with CT dated on 2022-12-05, the numbers are decreased.
        • Small lymph nodes are found at right paratracheal and AP window.
        • Patent airway is found.
        • Mild bilateral pleural effusion is found.
        • S/p port-A placement with its tip at Superior vena cava.
      • Visible abdomen:
        • Bilateral renal cysts are found.
        • Low density lesion at spleen is found. Stable.
        • The spleen, liver, pancreas and adrenals are intact.
    • IMp:
      • Bilateral lung nodules, decresaed in numbers
      • Mediastinal small lymph nodes
  • 2023-02-19, -02-03, -01-19, -01-06 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • There are few nodular opacities projecting in both lung that may be lymphoma. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-01-06 ECG
    • Atrial fibrillation
    • Inferior infarct, age undetermined
    • Abnormal ECG
  • 2022-12-28 Patho - urinary bladder TUR
    • Urinary bladder, left lateral wall, TUR-BT — Urothelial carcinoma (high grade), focally invading muscularis prorpia.
    • Section of the larger piece and the smaller piece show urothelial carcinoma composed of papillary structures lined by urothelial cells with enlarged, hyperchromatic nuclei, high N/C ratio and mitoses. The larger piece shows focal invasion of muscularis propria. The smaller piece shows no muscularis propria.
    • IHC stains: GATA-3 (+), SMA highlight muscularis propria in the larger tissue. The smaller tissue shows no muscularis propria.
  • 2022-12-27 ECG
    • Atrial flutter with variable A-V block
    • Possible Inferior infarct , age undetermined
  • 2022-12-27 CXR
    • Fibrotic infiltrates in right upper lung.
    • Consolidation in right lower lung.
    • Blunting of costophrenic angle, left side, could be due to pleural effusion.
    • Cardiomegaly.
    • Intimal calcification of thoracic aorta.
  • 2022-12-05 CT - abdomen
    • Stomach diffuse large B cell lymphoma with multiple metastasis (bilateral lungs, spleen, both kidneys), Lugano stage IV, IPI 2
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Abdominal CT with and without enhancement revealed:
      • Bilateral renal cysts are found.
      • The liver, pancreas and adrenals are intact.
      • Irregular shaped low density change at spleen up to 3.06x2.6cm is found.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • One filling defect at lateral wall of the bladder base up to 1.2cm in largest dimension. Bladder uroepithelial cancer is considered. In comparison with CT dated on 2022-08-31,
      • The GB is well distended without soft tissue lesion
      • Small lymph nodes are found at paraaortic region. In regression.
      • Visible chest
        • Cardiomegaly is noted.
        • Nodular leisons at both lungs is found. In regression.
        • Increased pulmonary vasculature is found.
        • NOn-specific lymph nodes are found in the mediastinum.
    • Imp:
      • Mediastinal lymphadenopathy and splenic and lung involvement. The lung involvement regressed.
      • Bladder tumor, suspected uroepithelial cancer.
    • Imaging Report Form for Urinary Bladder Carcinoma
      • Impression (Imaging stage) : T:T2(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-12-27, -11-25, -11-18 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • There are multiple nodular opacity projecting in both lung that may be lymphoma. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Otherwise, there is no significant abnormality of the chest. (Note that ground-glass lesion, small nodule or retrocardiac lesion might be missed on plain chest radiography.)
  • 2022-10-26 CXR
    • Cardiomegaly.
    • Multiple nodules at bil. lungs.
  • 2022-10-26 Panendoscopy
    • Diagnosis
      • Gastric ulcers, multiple, antrum, low and mid body
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
    • Suggestion
      • please search for other possible bleeder.
  • 2022-10-21, -10-11, -09-14 CXR
    • There are multiple nodular opacity projecting in both lung that may be lymphoma. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-09-28 Panendoscopy
    • Diagnosis
      • Gastric ulcers, Forrest classification type IIa, GC site of middle body, s/p hemostasis with APC
      • Gastric ulcers, multiple, GC/PW site of antrum, AW site of low body and middle body
      • Reflux esophagitis LA Classification grade A
      • Esophageal hematoma, EG junction, suspect NG tube friction related
      • Superficial gastritis
    • Suggestion
      • High dose PPI use
      • Consider second-look endoscopy if ACITVE BLEEDING sign or PERESISTED Tarry stool.
  • 2022-08-31 CT - abdomen
    • Findings
      • There are bilateral inguinal hernia with small bowel and omentum fat herniation on right side and omenum fat on left side.
        • In addition, fatty stranding and fluid collection in right inguinal hernia sac is suspected that may be incaceration? please correlate with clinical condition.
      • There are multiple soft tissue lesions on both lung that may be lymphoma?
      • There is a low density mass measuring 4.5 cm in the spleen that may be lymphoma involvement.
      • There are multiple enlarged nodes in gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space that may be lymphoma.
      • There is a soft tissue mass measuring 2 cm in left lateral wall of the urinary bladder. Please correlate with cystoscopy to R/O lymphoma or urothelial cell carcinoma?
      • There are several renal cysts on both kidney and the largest one measuring 4.3 cm in size at right upper pole.
    • Imp
      • Incaceration of right inguinal hernia is highly suspected.
  • 2022-08-28 CXR
    • There are multiple nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
    • Enlargement of cardiac silhouette.
  • 2022-08-25 SONO - nephrology
    • There are two mass lesions 2.34cm and 1.51cm in the lateral and inferior wall of urinary bladder, suspected bladder tumors.
    • Bilateral renal cysts.
    • Parenchymal renal disease.
  • 2022-08-18 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with plasma cell myeloma and free from lymphoma involvement
    • Microscopic Examination
      • Hypercellularity of bone marrow for his age
      • Marked Increased plasma cells, more than 90%, highlights by CD138 and CD117 IHC stains and favor kappa light chain restriction
      • M/E ratio about 1/3 with marked hypoplasia of both series highlights by CD71 and MPO IHC
      • Adequate megakaryocytes with focal mononucleation and hyposegmentation, highlights by CD61 IHC
      • no increase of blast, highlights by CD34 IHC
      • No B-cell lymphoma involvement, CD20 IHC shows scant and scatter positive
      • According to all above histopathologic findings, it is compatible with plasma cell myeloma and free from lymphoma involvement. Clinical and laboratory correlation is advised.
  • 2022-08-17 Whole body PET scan
    • Glucose hypermetabolic lesions in bilateral pulmonary hilar and mediastinal lymph nodes, lymph nodes in the upper to mid-abdomen, a lymph node in the lateral aspect of the left upper thigh region, bilateral lungs, stomach, spleen, and both kidneys (Deauville score 5 in all above-mentioned lesions), highly suspected lymphoma with diffuse involvement of more extralymphatic organs with associated lymph node involvement.
    • Glucose hypermetabolism in the L2 spine (Deauville score 4) and in the right lobe of the thyroid gland (Deauville score 5), the nature is to be determined, suggesting further investigation.
    • Lymphoma, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2022-08-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (126 - 39) / 126 = 69.05%
      • M-mode (Teichholz) = 69
    • Mild septal hypertrophy with Gr II LV diastolic dysfunction and impaired RV relaxation; severely dilated LA.
    • Mildly dilated LV with normal LV and RV systolic function.
    • Dilated aortic root and aortic valve sclerosis with moderate AR; mild MR; mild to moderate PR.
    • Dilated proximal ascending aorta (46mm) with mild calcification.
  • 2022-08-15 CXR
    • Nodular lesions in both lung fields

[consultation]

  • 2022-09-27 Gastroenterology
    • Q
      • vomiting blood and bloody stool today
      • genrenal weakness was noted
      • no dizziness, no dyspnea, no abdominal pain
      • PH: Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys) , Lugona stage IV, IPI 2, anemia, Gastric ulcer, HTN
      • NKA
    • A
      • S
        • 71M
        • Phx: Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2, anemia, Gastric ulcer, HTN
        • CC: Vomiting blood and bloody stool today
        • NPO: 20220927 12:00
      • O
        • BP: 103/62, HR:81, Conscious clear, under N/C, SpO2: 100
        • Hb: 7(9/26)-> 6.3(9/27)
        • PLT: 136(9/27)
        • INR:1.27
      • A
        • Hematemesis, suspect upper GI bleeding
      • P
        • EGD is indicated for this patient, but NPO duration is not adequate, give high dose PPI first. We will arrange EGD tomorrow
        • well inform-consent to the patient and the family, including the indication, the risks (aspiration pneumonia/respiratory failure, arrhythmias/cardiovascular events, organ perforation, etc.), and the alternatives (conservative treatment, etc.)
        • if the patient and the family all understand the EGD intervention, would take the risk, and sign the permit for EGD, we would arrange EGD
        • Arrange adequate blood transfusion and fluid resuscitation for fear of hypovolemic shock
  • 2022-09-21 Urology
    • Q
      • The 71 y/o man has Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2 and multiple myeloma.
      • Due to bladder tumor noted and sometimes has hernia bulge, so we need your help for assessment. Thanks!
    • A
      • This patient has diffuse large B cell lymphoma and multiple myeloma.
      • This time he was admitted for 2nd R-COP chemotherapy.
      • CT: 2cm bladder tumor at left lateral; hernia: 20220831 incarceration, GS was consulted and manual reduction was performed
      • impression: 1. bladder tumor 2. right inguinal hernia suspected incarceration
      • Plan:
        • arrange scrotal echo for suspected incarceration
        • arrange TURBT and hernia repair, time to be determined
  • 2022-09-21 Rheumatology
    • Q
      • The 71 y/o man has Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2.
      • Due to gouty arthritis over left knee, so we need your help for assessment. Thanks!
    • A
      • S
        • History review & physical examination were performed. Patient was admitted due to Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2.
        • I was consulted for Acute L’t knee arthritis. Meanwhile, allergic skin rash was also noted (mobic or uricon-induced?).
      • O
        • RIA condition:
          • Previous GA Hx(+)
          • UA:4.5 -> 7.6 -> 4.7
          • ANA/RF/anti-CCP(-)
          • ALT/Cre:25/0.87
        • erythematous swelling, L’t knee (less effusion than week ago).
      • Suggestion:
        • Treatment as current your expert’s management.
        • Please take L’t knee x-ray, add colchicine 1#BID (if diarrhea, taper to 1#QD), acetaminophen 1#BID & decan 4mg IVD BID x 2-3 days.
        • When recovered from acute stage, please keep colchicine 1#QD & feburic 1#QD.
        • Inform me again if need.

[SOAP]

  • 2022-10-11 Hemato-Oncology
    • Multidisciplinary Cancer Team Meeting Conclusion, Meeting Date: 20220905
      • IgG type MM stage 2
      • Diffuse large B cell lymphoma with lung involved stage 4
      • use R-COP first
  • 2022-10-04 Hemato-Oncology
    • Multidisciplinary Cancer Team Meeting Conclusion, Meeting Date: 20230213
      • Hold off on chemotherapy mR-CHOP for now,
      • First complete bladder cancer CCRT.
    • Multidisciplinary Cancer Team Meeting Conclusion> Meeting Date, 20220912
      • Synchronous DLBCL and myeloma treatment approach cannot wait due to stage 4 diffuse large B cell lymphoma, so R-COP has been used. Treatment strategy will be determined after review.
  • 2022-09-09 Hemato-Oncology
    • Multi-disciplinary team meeting conclusion for cancer patients, Meeting date: 20220829
      • Diffuse large B cell lymphoma stage 4
      • Multiple myeloma IgG kappa ISS stage 2
      • Bladder tumor nature
    • Assessment
      • Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2.
      • Multiple myeloma, IgG kappa type, ISS stage II
      • Gastrointestinal hemorrhage, unspecified
      • Anemia
      • Postive of anti-HBc
      • Port-a implement on 2022/08/18
      • Dilated aortic root and aortic valve sclerosis with moderate AR; mild MR; mild to moderate PR.
      • Agranulocytosis secondary to cancer chemotherapy
      • Neutropenic fever
      • Acinetobacter pittii bacteremia
      • Gouty arthritis attack over left knee
      • Groin Hernia
      • Bladder tumor natrure?

[surgical operation]

  • 2022-12-28
    • Surgery
      • Laparoscopic hernia repair, bilateral
      • Laser TUR-BT
    • Finding
      • TEP OP Finding:
        • Main defect:
          • Right
          • type: primary; M, L
          • Size: II
          • Grading: 2
          • incarceration, adhesion
          • Sac contents: omentum
        • Contralateral occult defect:
          • type: M
          • Size: II
        • Trocar number: 3
        • TEP approach
        • Mesh type: heavy weight
        • Mesh size: Left 13x15 cm; Right 12x15 cm
        • Mesh fixation: absorbatack
    • TUR-BT finding:
      • A cauliflower-like tumor at left lateral wall
      • A diverticulum at right posterior wall
      • Bilateral UO with clear efflux
    • Risk evaluation:
      • Tumor size: <=3cm (V), >3cm()
      • Multifocality: Multifocal(), solitary(V)
      • Recurrence within 1 year: Yes(), No(V)

[chemoimmunotherapy]

  • 2023-03-30 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 + oxaliplatin 100mg/m2 150mg D5W 250mL 2hr D2 (R-GemOx)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2023-02-21 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2023-01-27 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2023-01-13 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)

  • 2023-01-06 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)

  • 2022-12-29 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)

  • 2022-12-05 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2022-11-14 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2022-10-13 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2022-09-22 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2022-08-19 - rituximab 375mg/m2 630mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-COP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2

==========

2023-04-17

  • Tramadol has been associated with vomiting (5% to 10%). ref: UpToDate.

  • Opioid administration can induce nausea or vomiting; the pathophysiology includes peripheral inhibitory effects of opioids on gastrointestinal transit or stimulation of the pyloric sphincter, delaying gastric emptying or causing gastroparesis. However, the primary mechanism of opioid-induced nausea and vomiting is central, with direct stimulation of the chemoreceptor trigger zone in the area postrema in the floor of the fourth ventricle. The clinical efficacy of 5-HT3 antagonists in opioid-induced emesis supports the hypothesis that stimulation of the area postrema may also be relevant to morphine-induced emesis in humans. The addition of a prokinetic (e.g., metoclopramide), prochlorperazine, or a 5-HT3 antagonist (-setron) to the opiate regimen is beneficial. ref: Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol. 2017;15(9):1338-1349. doi:10.1016/j.cgh.2017.05.014

  • Roumin (prochlorperazine maleate) has been prescribed properly. There is no medication reconciliation issue with the active prescription.

2023-04-07

  • On both 2023-01-06 and 2022-12-27, the patient’s ECG showed atrial fibrillation (AF), which is a significant contributor to morbidity and mortality in adults. Additionally, a transthoracic echocardiogram from 2022-08-16 indicated severe dilation of the left atrium. While ischemic stroke resulting from embolization of left atrial thrombi is the most common manifestation of embolization, embolization to other sites in the systemic circulation (as well as the pulmonary circulation from right atrial thrombi) can also occur, albeit less frequently recognized.
  • The patient’s available PLT count data in 2023 ranged from 70K to 245K /uL, touching the upper limit of grade 2 thrombocytopenia (CTCAE v5.0, grade 2: 50K~75K/uL) a few times. Due to the unstable PLT count, LMWH may be preferred over direct oral anticoagulants (DOACs). ref: EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer. Hemasphere. 2022;6(8):e750. Published 2022 Jul 13. doi:10.1097/HS9.0000000000000750

2022-10-27

  • Severe, including fatal, mucocutaneous reactions can occur in patients receiving rituximab products. Unless there is no concern for gastrointestinal bleeding, it is recommended to hold R-CHOP therapy for a period of time.

701473049

230417

[diagnosis] - 2023-04-14 admission note

  • T-colon cancer with partial obstruction, lung and bone metastases, T4N3M1b, stage IVB s/p chemotherapy with FOLFIRI from 2023/03/29~
  • Anemia due to antineoplastic chemotherapy
  • Chronic obstructive pulmonary disease, unspecified
  • Essential (primary) hypertension
  • Constipation, unspecified
  • Hypokalemia

[past history]

  • Hypertension for 10 years without control

[allergy]

  • NKDA     

[family history]

  • Mother with HTN
  • There is no family history of cancer, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-03-27 CXR
    • There are multiple nodular opacities projecting in both lung that are c/w metastases after correlate with CT.
    • Borderline cardiomegaly
  • 2023-03-25 CT - abdomen
    • History and indication: T-colon cancer with partial obstruction, lung and bone metastases, T4N3M1b, stage IVB
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of A-colon with adjacent fat stranding and regional LAP.
      • Multiple lung tumors.
      • Multple bony metastases.
      • R/O left renal angiomyolipoma (1.0cm).
      • Normal appearance of liver, spleen, pancreas, adrenals.
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
  • 2023-03-24 Patho - colorectal polyp
    • Colon tumor, T-colon, biopsy — Compatible with adenocarcinoma, see description
    • Microscopically, the sections show a picture of almost benign colonic mucosa with scant tumor cells arranged in glandular pattern and desmoplasia. According to clinical information and histopathologic fiinding, it is compatible with adenocarcinoma.
  • 2023-03-23 Colonoscopy
    • Suspected T-colon cancer with partial obstruction s/p biopsy
  • 2023-03-08 Patho - lung transbronchial biopsy
    • Lung, ? side, CT-guide biopsy — in favor of metastatic adenocarcinoma from colorectal origin
    • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma with marked tumor necrosis.
    • The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), TTF-1(-), and Napsin A(-). The results are in favor of metastatic adenocarcinoma from colorectal origin. Please correlate with the clinical presentation and image study.
  • 2023-03-07 Whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the skull, multiple T- and L-spines, sternum, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, bilaterla S-I joints and left humerus.
    • IMPRESSION: The scintigraphic findings suggest multiple bone metastases.
  • 2023-03-07 CT - chest
    • Indication: lung ca
    • MDCT (128-detector rows, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Lungs: a large tumor lesion (60 mm in longest dimension, polylobular borders) over lingula.
        • numerous randomly distributed pulmonary nodules/masses of varying sizes in both lungs due to metastases.
        • centrilobular nodular and branching opacities at LUL.
      • Mediastinum and hila: enlarged LNs in the visceral space and left anterior prevascular space and Lt hilum
      • Aorta: normal caliber, minimal atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: dilated LA and concentric LVH. mild calcified mitral annulus
      • Pleura: small Rt-sided effusion with thickening.
      • Chest wall and visible lower neck: infiltrative soft-tissue mass at Rt middle posterior chest wall with destruction pof 8th rib and adjacent vertebra.
      • Visible abdominal contents: mild dilatation of CHD and CBD as well as Lt IHDs.
        • normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
        • bilateral commonl iliac arteries.
    • Impression:
      • lingula ca T4N3M1a
  • 2023-03-06 ECG
    • Normal sinus rhythm
    • Voltage criteria for left ventricular hypertrophy
    • Abnormal ECG
  • 2023-03-05 CXR
    • Presence of multiple lung nodules/masses.

[consultation]

  • 2023-03-29 Radiation Oncology
    • Q
      • This 71-year-old man patient is a case of T-colon cancer with partial obstruction, lung and bone metastases, T4N3M1b, stage IVB. Lower back pain developed with whole body bone scan on 2023/03/07 showede skull, multiple T- and L-spines, sternum, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, bilaterla S-I joints and left humerus multiple bone metastases. Now, for evaluate palliative radiotherapy to bone metastasis of pain control. Thank you.
    • A
      • Palliative RT is indicated. CT-simulation will be arranged on 20230406, or earlier if there is an earlier vacancy.
      • Plan to deliver 30 Gy/ 10 fx to the L-spine and pelvic bone mets. Thank you very much.

[SOAP]

  • 2023-04-02 Emergency
    • S: the patient started to diarrhea for 1 week (5 to 6 times per day) just after discharged on 20230401.
    • prescription: Smecta (dioctahedral smectite) 3mg/pk PRNQ8H for 3 days
  • 2023-03-23 Hemato-Oncology
    • O: Will on FOLFIRI with or without targeted therapy
    • P: Admission for Pelvis MRI, T spine MRI and L-S MRI and Consult RTO, Consult CS or Port-A. Then FOLFOX

[radiotherapy]

[chemotherapy]

  • 2023-04-14 - irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + atropine 0.5mg IVD + aprepitant 125mg PO D1-3
  • 2023-03-29 - irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3

2023-04-17

[assessment]

  • The patient experienced diarrhea (5 to 6 times per day) immediately after discharge on 2023-04-01. Both Smecta (dioctahedral smectite) and Through (sennoside) are currently prescribed. It is suggested to confirm the patient’s bowel movement status and determine if both medications are necessary.
  • Irinotecan was increased from 120 mg to 150 mg/m2 in this second dose of the FOLFIRI regimen.
  • Hypokalemia (2.9 mmol/L) was noted on 2023-04-14 and is currently being treated with oral potassium chloride supplementation.
  • Anemia was noted prior to the patient’s first dose of FOLFIRI on 2023-03-29. A packed red blood cell (P-RBC) transfusion of 2 units was performed on 2023-04-14.
    • 2023-04-14 HGB 8.0 g/dL
    • 2023-04-02 HGB 8.9 g/dL
    • 2023-03-23 HGB 9.6 g/dL
  • There is no medication reconciliation issue with the active prescription.

2023-03-29

[assessment]

  • The patient is a senior with T-colon cancer, partial obstruction, lung and bone metastases, T4N3M1b, stage IVB. He admitted for his first cycle of FOLFIRI with a 2/3 dose of irinotecan (this time 120mg/m2, standard 180mg/m2).
  • Lab results on 2023-03-23 revealed a WBC count of 17K/uL, but no CRP or procalcitonin data were available. Please rule out any infectious symptoms.
  • The patient has a history of uncontrolled hypertension for 10 years, which requires further follow-up.

701473874

230414

[diagnosis] - 2023-04-07 admission note

  • Pancreatic head cancer with gastric and common bile duct involvement with gastric outlet obstruction and liver metastasis , cT4N1M1 stage IV; status post Roux-en-Y hepatico-Jejunosotmy and gastro-Jejunosotmy bypass and cholecsytectomy on 2023/03/27. ECOG:1
  • Encounter for adjustment and management of vascular access device with port-A insertion on 2023/04/06
  • Pancreatic head tumor with gastric and common bile duct involvement with gastric outlet obstruction and obstructive jaundice status post Percutaneous Transhepatic Cholangial Drainage on 2023/03/11
  • Hypokalemia
  • Rheumatoid arthritis history

[exam findings]

  • 2023-04-12 KUB
    • known s/p Roux-en-Y hepatico-Jejunosotmy and gastro-jejunostomy bypass and cholecsytectomy.
    • increased air in nondistended loops of small bowel over lower abdomen and pelvic
  • 2023-03-27 Patho - gallbladder (benign lesion)
    • Gallbladder, laparoscopic cholecystectomy — Chronic cholecystitis
  • 2023-03-16 Patho - pancreas biopsy
    • Labeled as “stomach pyloric wall thickening”, fine needle biopsy (B) — adenocarcinoma.
    • IHC stains: CK 19 (+), CA19-9 (+), CDX-2 (+), CK7 (+), CK20 (-). in favor of pancreato-biliary origin.
  • 2023-03-15 Endoscopic Ultrasonography, EUS
    • susp. Pancreatic IPMN main duct type s/p EUS/FNB (A)
    • Prob. gastric pyloric invasion s/p FNB (B)
    • pancreatic cystic neoplasm, tail susp. MCN type
    • Ascites, minimal
    • lymphadenopathy
  • 2023-03-10 ECG
    • Normal sinus rhythm
    • T wave abnormality, consider inferior ischemia
    • T wave abnormality, consider anterolateral ischemia
    • Prolonged QT
    • Abnormal ECG
  • 2023-03-10 CT - abdomen
    • CC:
      • Mild epigastralgia for 4 days, took medication for ulcer but jaundice noted 2 weeks, Tea color urine, clay color stool, Skin itching
      • No significant poor appetite. mild weight loss.
      • on diet, Alcohol (-) smoking (+). family hepatitis B or C history but she receive hepatitis B vaccination before.
      • PH. RA
    • Occupation: Mount Temple Services
    • Indication: biliary obstruction related jaundice was suspected.
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is marked dilatation of IHDs and CHD, but small size of the gallbladder.
        • Cholangiocarcinoma at the CHD-CBD junction is highly suspected.
        • The differential diagnosis includes metastatic nodes in hepatoduodenal ligament and pancreatic head cancer.
      • There is symmetrical wall thickening at the gastric antrum, causing marked distension of the proximal stomach that is c/w gastric outlet obstruction.
        • The differential diagnosis includes adenocarcinoma and old ulcer with deformity. Please correlate with gastroscopy.
        • In addition, there is a cystic lesion in the dorsal aspect of the stomach fundus that may be duplication cyst.
      • Several cystic lesions in the pancreatic body and tail are suspected.
        • The differential diagnosis includes pancreatic duct dilatation.
        • Please correlate with MRCP.
      • Others
        • There is no focal abnormality in the spleen & both kidneys.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Cholangiocarcinoma at the CHD-CBD junction is highly suspected.
        • The differential diagnosis includes metastatic nodes in hepatoduodenal ligament and pancreatic head cancer.
        • Please correlate with tumor marker, MRCP and ERCP.
      • Stomach cancer at the antrum is highly suspected.
        • Please correlate with gastroscopy.
  • 2023-03-11 Percutaneous Transhepatic Cholangial Drainage, PTCD (drainage)
    • Dilatation of the biliary tree (by CT images).
    • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree smoothly.
  • 2023-03-10 Esophagogastroduodenoscopy, EGD
    • c/w tumor compression or invasion, posterior wall of antrum
    • Gastric outlet obstruction
    • duodenal ulcer, bulb
    • Possible ulcer at posterior wall of bulb or antrum
  • 2023-03-07 SONO - abdomen
    • Diagnosis
      • Suspect distal CBD tumor with biliary tract obstruction
      • Suspect pancresatic body tumor
      • Intra-abdominal cystic lesion, LUQ area
      • Gastric outlet obstruction
    • Suggestion
      • CT and EGD study.

[SOAP]

  • 2023-04-12 Hemato-Oncology
    • Refer to ER for treating BTI (Biliary Tract Infection) and then admission -> consider Abraxane (paclitaxel) plus gemcitabine (see [note] section) after infection under control

[surgical operation]

  • 2023-03-27
    • Surgery
      • Roux-en-Y hepatico-Jejunosotmy
      • GJbypass
      • cholecsytectomy
    • Finding
      • pancreatic head cancer invasion to pyloric and hepatico-duodunostomt
      • LLS liver mets with gastric anerior wall invasion

[note]

Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) for advanced pancreatic and biliary cancer 2023-04-14 https://www.uptodate.com/contents/image?imageKey=ONC%2F89668

  • Cycle length: 4 weeks.
  • Regimen
    • Nabpaclitaxel
      • 125 mg/m2 IV
      • Administer undiluted over 30 minutes.
      • Days 1, 8, and 15
    • Gemcitabine
      • 1000 mg/m2 IV
      • Dilute in 250 mL NS (concentration no greater than 40 mg/mL) and administer over 30 to 60 minutes, after nabpaclitaxel.
      • Days 1, 8, and 15

Treatment protocols for pancreatic cancer REGIMENS 2023-04-14 https://www.uptodate.com/contents/treatment-protocols-for-pancreatic-cancer

  • Adjuvant setting
    • Adjuvant gemcitabine
    • Adjuvant gemcitabine plus capecitabine
    • Modified FOLFIRINOX
  • Locally advanced/metastatic disease
    • Gemcitabine monotherapy
    • Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) (see above for components)
    • Gemcitabine plus capecitabine
    • Gemcitabine plus cisplatin
    • FOLFIRINOX (fluorouracil plus leucovorin, irinotecan, and oxaliplatin)
    • Modified FOLFIRINOX
    • Modified FOLFOX6 (fluorouracil plus leucovorin and oxaliplatin)
    • Liposomal irinotecan and 5-FU for metastatic pancreatic cancer
    • Pembrolizumab monotherapy for microsatellite-unstable (mismatch repair-deficient) advanced cancer

[assessment]

  • Brosym (cefoperazone + sulbactam) 4g IVD Q12H has been prescribed fot the patient’s BTI.

  • It is considered to use nab-paclitaxel plus gemcitabine to treat the patient after her BTI is controlled. Please ensure that the ANC is >1500/uL and the platelet count is >100K/uL prior to administering the regimen. Sepsis has occurred in patients with or without neutropenia (risk factors are biliary obstruction or presence of a biliary stent). During the treatment, it is recommended to initiate broad-spectrum antibiotics in the presence of fever, even if not neutropenic. Interrupt nabpaclitaxel and gemcitabine until sepsis resolves and, if neutropenic, until neutrophils are at least 1500/uL, then resume at lower doses.

  • No medication reconciliation issues were noted for the patient.

700553084

230413

{not completed}

[past history]

  • Myelofibrosis grade 1-2 disease in March 2020 with Bokey treatment.
  • Hypertension with Norvasc since 2023/03/24 due to headache with neck soreness.

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-04-13, -04-10, -04-06, -04-03, -04-01 CXR
    • hazy areas of increased opacity and reticular opacities with poor defination of vessels over Rt and Lt lungs
  • 2023-04-06 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — compatible with essential thrombocythemia with grade 3 myelofibrosis.
    • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 2:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are increased in number.
    • IHC stains: CD117: <2%; CD34: <2 %; MPO:50 %, CD61: 25 %; CD71: 25% (of the nucleated cells).
    • Reticulin stain: marked increased amounts of reticulin.
    • Masson-Trichrome stain: marked increased in the amounts of collage fibers.
  • 2023-03-30 Bronchoscopy
    • Trachea: mid- and lower-1/3 segments was patent and the mucosa was swelling.
    • Main carina: sharp and movable on deep breathing.
    • Right bronchial trees: swelling and easy touch bleeding with dynamic collapse of lower bronchial orifices
    • Left bronchial trees:mucosa swelling and touch bleeding was found.
  • 2023-03-29 CXR
    • Enlargement of cardiac silhouette.
    • Linear infiltration over both lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-28 ECG
    • Sinus tachycardia
    • Possible Left atrial enlargement
  • 2022-03-31 SONO
    • Findings
      • Increased echogenicity of the liver.
      • Normal appearance of gallbladder without stone.
      • Patency of PV, HVs, IVC and aorta in hepatic portion.
      • Normal appearance of pancreatic head. The other portions of pancreas masked by gastric/ bowel gas.
      • Splenomegaly.
      • No evidence of pleural effusion.
      • Normal appearance of kidneys.
    • IMP:
      • Mild fatty liver.
      • Splenomegaly
  • 2020-03-05 Patho - bone marrow biopsy
    • Bone marrow, iliac, history of myeloproliferative neoplasm, JAK2 (+), biopsy — see microscopic description.
    • IHC stains: CD117: <1%, CD34: <1%, MPO: 20-30%, CD61: 30-40%, CD71: 30-40%.
    • Reticulin stain: mild to moderately increased reticulin fibers;
    • Mason-Trichrome stain: mild increase in collagen fibers.
  • 2019-02-12 SONO - spleen
    • Sonography of spleen revealed splenomegaly without nodule.
  • 2017-08-10 SONO - abdomen
    • marked splenomegaly

[SOAP]

  • 2023-02-24 Hemato-Oncology
    • Bokey (aspirin 100mg) QD
  • 2022-09-23 Hemato-Oncology
    • Suggest bone marrow study
    • OPD follow up x 2 months
  • 2022-03-23 Hemato-Oncology
    • Neoplasm of uncertain behavior of polycythemia vera [D45]
    • Hepatitis, unspecified [K75.2]
    • IWG-MRT score 1 (intermediate-1)
    • IPSS: 1. anti-JAK2 inhibitor is not reimbursed by NHI (will be paid on 2 or higher) (202003324).
    • A: MPN wtih myelofibrosis
    • recheck abdominal sonogram
  • 2021-10-05 Hemato-Oncology
    • A
      • Neoplasm of uncertain behavior of polycythemia vera [D45]
      • Hepatitis, unspecified [K75.2]
  • 2017-01-19 Hemato-Oncology
    • O
      • Marked splenomegaly.
      • JAK2 mutation: present.
      • A: Myeloproliferative neoplasms, MPN
    • A
      • Neoplasm of uncertain behavior of polycythemia vera [D45]
      • Essential hypertention, unspecified [I10]
      • Hepatitis, unspecified [K75.2]
      • Gouty arthropathy [M10.00]

[assessment]

  • Triazole antifungal agents include voriconazole, posaconazole, itraconazole, and fluconazole. Fluconazole has no activity against Aspergillus spp, and itraconazole has become a second-line agent for aspergillosis. Voriconazole should be included in the antifungal regimen in most patients with invasive aspergillosis

701244841

230413

[diagnosis] - 2023-03-24 admission note

  • Malignant neoplasm of duodenum
  • Acute duodenal ulcer without hemorrhage or perforation
  • Calculus of gallbladder with chronic cholecystitis without obstruction
  • Noninfective gastroenteritis and colitis, unspecified
  • Benign neoplasm of duodenum

[past history]

Dx history: - Gout - IDA - Alzheimer’s disease - CAD - CVA

Surgery history: - C-spine compression fracture s/p over 10 years ago    

[allergy]

  • NKDA     

[family history]

Father: Liver cancer

[lab data]

  • 2023-03-15 Anti-HBc Reactive
  • 2023-03-15 Anti-HBc-Value 7.62 S/CO
  • 2023-03-15 Anti-HBs 0.30 mIU/mL
  • 2023-03-15 Anti-HCV Nonreactive
  • 2023-03-15 Anti-HCV Value 0.26 S/CO
  • 2023-03-15 HBsAg Reactive
  • 2023-03-15 HBsAg (Value) 125.62 S/CO
  • 2022-12-13 RPR/VDRL Reactive-1:2
    • ChatGPT: RPR (Rapid Plasma Reagin) and VDRL (Venereal Disease Research Laboratory) are blood tests used to screen for syphilis, a sexually transmitted infection caused by the bacterium Treponema pallidum. In this context, “reactive 1:2” means that the test has detected the presence of antibodies against syphilis in the blood at a dilution of 1:2, indicating a low level of infection. However, further confirmatory testing is necessary to determine if the individual has an active syphilis infection or if the antibodies detected are from a past infection that has been successfully treated.
  • 2022-10-20 RPR/VDRL(CSF) Non-Reactive
  • 2022-10-06 TPHA Reactive,1:640
    • ChatGPT: A TPHA (Treponema Pallidum Hemagglutination) result of 1:640 is a high titer and indicates a strong reaction to Treponema pallidum, the bacterium that causes syphilis. This can indicate an active syphilis infection, a previous infection that has been treated, or a false positive result. Further testing and evaluation by a healthcare provider is necessary to determine the significance of the result and whether treatment is needed.
  • 2022-09-15 RPR/VDRL Reactive-1:4
    • ChatGPT: A reactive RPR/VDRL result of 1:4 indicates a higher level of antibodies against syphilis in the blood compared to a result of 1:2. A higher titer result generally indicates a more active infection, but it can also indicate a past infection that has been successfully treated. Further testing and clinical evaluation are needed to determine the stage and treatment of syphilis.

[exam findings]

  • 2023-03-22 Clinical Dementia Rating
    • CDR score: 2
  • 2023-03-22 Mini-Mental State Examination
    • MMSE score: 16
  • 2023-03-14 EEG
    • This EEG study recorded background continuous diffuse theta rhythm (6-7 Hz) and plenty beta activity with occasional frontal slow waves.
    • No epileptiform discharge.
    • This EEG study suggested mild cortical dysfunction.
    • Please correlate with clinical features.
  • 2023-02-17 Patho - small intestine resection for tumor
    • Diagnosis
      • Small intestine, duodenum, second portion, pancreatico-duodenectomy — Adenocarcinoma, moderately differentiated, s/p subtotal gastrectomy with B-II anastomosis
      • Pancreas, head, pancreatico-duodenectomy — Adenocarcinoma, by direct invasion
      • Common bile duct, pancreatico-duodenectomy — Negative for malignancy
      • Lymph node, peri-pancreatic and mesentery, dissection — Adenocarcinoma, metastatic (2/17)
      • Gallbladder, cholecystectomy — Negative for malignancy
      • Lymph node, retroperitoneal, dissection — Negative for malignancy (0/3)
      • AJCC 8th edition: pStage IIIA, pT4N1(if cM0)
    • Gross Description:
      • Specimen Type: pancreatico-duodenectomy and cholecystectomy; s/p subtotal gastrectomy with B-II anastomosis
      • Specimen and size:
        • Head of pancreas: 4.5 x 4.0 x 2.7 cm, the pancreatic duct is dilated
        • Duodenum: 17.0 cm in lenghth
        • Stomach: not received
        • Common bile duct: 6.0 cm in length and 0.8 cm in diameter
        • Gallbladder: 9.2 x 3.8 x 2.0 cm
      • Tumor Site: Duodenum
      • Tumor Size: 5.5 x 5.0 x 4.4 cm with invasion to pancreatic head
      • Sections are taken and labeled as: A1: CBD resection margin; A2-3: pancreatic and soft tissue resection margin; A4: distal duodenal resection margin; A5: blind end margin; A6: peritoneal resection margin; A7: superior soft tissue resection margin; A8: inferior soft tissue resection margin; A9: ampulla Vater, CBD and tumor; A10: panreatic dyct; A11-15: tumor; A16-17: lymph node, peripancreatic and mesentery; B: gallbladder; C: lymph node, retroperitoneal.
    • Microscopic Description:
      • Histologic Type: adenocarcinoma
      • Histologic Grade (applies to ductal carcinoma only): G2: Moderately differentiated
      • Tumor Extension: invasion to pancreatic head and retroperitoneal soft tissue
      • Margins
        • All margins are uninvolved by invasive carcinoma,
        • Distance of invasive carcinoma from closest margin: 12 mm.
        • Specify: retroperitoneal soft tissue resection margin
        • Blid end resection margin: 1.5 cm
        • distal duodenum resection margin: 12.2 cm
        • CBD resection margin: 3.0 cm
        • Pancreatic resection margin: 1.5 cm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Regional Lymph Nodes: peri-pancreatic and mesentery: 2/17; retroperitoneal: 0/3
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable): not applicable
          • Primary Tumor (pT): pT4: invasion of pancreas
          • Regional Lymph Nodes (pN): pN1: Metastasis in one to two regional lymph nodes
          • Distant Metastasis (pM): if cM0
      • Additional Pathologic Findings: The pancreatic parenchyma reveals atrophy. The pancreatic duct is dilated with low grade pancreatic intraepithelial neoplasia.
  • 2023-02-11 MRI - upper abdomen
    • History and indication: Duodenal cancer before surgery
    • With and without contrast MRI of upper abdomen revealed:
      • Motion artifact.
      • Progression of duodenal cancer with adjacent structures invasion causing p-duct dilatation.
      • S/P gastric operation.
      • Distention of gallbladder.
    • IMP:
      • Motion artifact.
      • Progression of duodenal cancer with adjacent structures invasion causing p-duct dilatation.
      • Distention of gallbladder.
  • 2023-02-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (81.3 - 21.7) / 81.3 = 73.31%
      • M-mode (Teichholz) = 73.3
    • Conclusion:
      • Normal chamber size
      • Adequate LV and RV systolic function
      • AV sclerosis with mild AR, mild MR, TR and PR
      • No regional wall motion abnormalities
  • 2023-02-07 Flow Volume Loop
    • poor performance
    • the family expressed that the patient is physically weak and therefore unable to blow air.
  • 2023-02-06 ECG
    • Atrial fibrillation with slow ventricular response
    • Low voltage QRS
    • Left anterior fascicular block
  • 2023-12-30 Patho - doudenum biopsy
    • Labeled as “duodenum, second portion”, biopsy — adenocarcinoma.
    • Section shows piece of duodenal tissue with dysplastic and neoplastic glands.
    • IHC stains: CK 19 (+), CK7 (+), CK20 (focal +), CD56 (-), Ki-67: 90%.
  • 2022-12-27 CT - abdomen
    • History and indication: Abdominal pain
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Pectus excavatum.
      • S/P gastric operation ?
      • Wall thickening of duodenum, 2nd portion, r/o malignancy.
      • Distention of gallbladder. Dilatation of p-duct.
    • IMP:
      • Wall thickening of duodenum, 2nd portion, suspected malignancy.
      • Distention of gallbladder.
      • Dilatation of p-duct.

[consultation]

  • 2023-02-08 Anesthesiology
    • Q
      • This is 72-year-old man with past history of C-spine s/p OP, CAD, Syphilis infection s/p Penicillin IVD x3 on 2022/10-11 (Treatment finished, 2022/12 RPR: reactive [1:2]), Alzheimer’s disease and Gout. The patient was diagnosed duedenal cancer at the end of 2022, and he admitted for operation.
      • The patient was only 50 kg with poor nutrition in recent several months, so we needed TPN to supply the nutrition for him before surgery. He was also TPN supportive care after surgery.
      • The patient had Syphilis infection, and the patient worried about the CVC insertion. We would like to consult your expertise for CVC insertion.
    • A
      • We were consulted for CVC insertion due to peripherally incompatible infusions .
      • The 3-way CVC was inserted into right IJV, fixed at 15 cm, under sonography guidance smoothly.
      • Please arrange portable CXR for CVC position examination.
      • CXR revealed proper position of the CVC.
  • 2022-10-19 Metabolism and Endocrinology
    • Q
      • This 71 y/o man has a history of CAD and C-spine s/p. He visited neurology OPD recently for cognitive decline. Laboratory survey showed syphilis infection and hypothyroidism.
      • We need your expertise for hypothyroidism evaluation and management. Thank you very much.
    • A
      • S
        • This 71-year-old male, with past history of CAD and C-spine s/p, was admitted due to cognitive decline, susp. neurosyphilis or hypothyroidism related. We were consulted for abnormal TFT.
      • O:
        • BW: 49
        • HR: 50-68
        • Possible related medication: nil
        • ALT: 15
        • Cr: 0.95
        • Na/K: unavailable
        • TSH/FT4 (nuclear medicine): 18.697/0.748
        • T3: unavailable
        • ATPO: 3.2, ATG: < 0.9
        • ACTH/Cortisol (random, 3-4pm): ?/8.17
        • Thyroid sono: nil
        • ECG: nil
      • A: Primary hypothyroidism
      • Suggestions:
        • Add on thyroxine 50 mcg, 0.5 tablet, QDAC (please take at least 30 minutes before the first meal of the day), and monitor blood pressure, heart rate, electrolytes, and any cardiovascular complications.
        • Recheck TSH/FT4 (routine biochemistry) in 2 weeks (can be done as outpatient if discharged).
        • Arrange for thyroid sonography (radiology) and ECG for bradycardia.
        • Contact us if necessary. Follow-up with the Endocrine Outpatient Department.

[surigcal operation]

  • 2023-02-16
    • Surgery
      • pancreatico-duodenectomy with retroperitoneal LN dissection
    • Finding
      • 7.5 x 6 x 4 cm fungating mass was noted at duoenal 2nd portal with pancreastic head invasion
      • no peritoneal seeding was noted
      • previous subtotal gastrectomy with B-II anastomosis

[chemotherapy]

  • 2023-04-12 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 48hr (FOLFOX, Oxa 65mg/m2)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-03-24 - leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 48hr (FOLFOX, Hold Oxalip due to old age and performance status)
    • dexamethasone 4mg + NS 250mL

==========

2023-04-13

  • The patient has received a reduced dose of 65mg/m2 of oxaliplatin for the first time during this hospitalization, and no adverse reactions have been observed to date.

  • For the patient’s chronic viral hepatitis B and post-pancreatico-duodenectomy status, Protase (pancrelipase 280mg) TIDCC and Baraclude (entecavir 0.5mg) QDAC have been prescribed.

  • There is no medication reconciliation issue found.

2023-03-27

  • The patient has been exposed to the hepatitis B virus (HBV) at some point in his life, Baraclude (entecavir) is properly prescribed.
    • 2023-03-15 Anti-HBc Reactive
  • A decrease in RPR/VDRL titer from 1:4 to 1:2 may indicate a treatment response to syphilis (Penicillin IVD x3 on 2022/10-11).
    • 2022-12-13 RPR/VDRL Reactive-1:2
    • 2022-09-15 RPR/VDRL Reactive-1:4
  • High levels of thyroid-stimulating hormone (TSH) and normal levels of free thyroxine (T4) may indicate subclinical hypothyroidism. Subclinical hypothyroidism may not cause any symptoms, but it can increase the risk of developing overt hypothyroidism in the future. It can also increase the risk of heart disease. It is recommended to monitor the levels of TSH and T4 further evaluation and management if necessary.
    • 2022-09-19 TSH (nuclear medicine) 18.697 uIU/ml
    • 2022-09-19 Free T4 (nuclear medicine) 0.748 ng/dl
  • On 2023-02-16, the patient underwent a pancreatico-duodenectomy with retroperitoneal lymph node dissection, and started receiving 5-fluorouracil (5FU) infusion on 2023-03-24. It is important to monitor the patient closely for any signs of gastrointestinal adverse reactions, as 5FU infusion may cause such symptoms. Additionally, given the patient’s history of CAD, it is also important to keep a close eye for any potential cardiovascular adverse reactions.

700537283

230412

[exam findings]

  • 2023-04-10 CXR
    • Few nodular opacities projecting in the left middle lung are suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • S/P clips projecting at right lower medial lung.
  • 2023-02-16 CT (at SYKCC)
    • bil. breast masses
    • skin nodularities
    • bil. supraclavicular, Lt axillary and upper mediastinal lymphadenopathy.
    • liver and lung metasis

[SOAP]

  • 2023-03-30 Hemato-Oncology
    • S
      • History of breast ca before but it recurred in Sep 2021 but she did not seek formal medical attentison. She received biopsy at SYKCC where ER positive, PR (+), Her-2 (3) when multiple tumor over Rt chest wall. Double target therapy was done on 2023-03-07.
      • Swelling over port-A site (infected) (20230330)
      • She came for subsequent treatment.
    • O
      • Reason for not informing patient of her condition: Currently not suitable to inform.

[chemoimmunotherapy]

  • 2023-04-11 - docetaxel 35mg/m2 47mg NS 100mL 1hr (docetaxel + herceptin + perjeta)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

700626863

230412

[exam findings]

  • 2023-03-20 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — hypercellularity.
    • Section shows piece(s) of bone marrow with 50-60% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with left of leukocytes. Megakaryocytes are adequate in number.
    • IHC stains: CD117: 30-40%; CD34: 30-40 %; MPO: 50-55 %, CD61: 5 %; CD71: 30-35 % (of the nucleated cells). Acute myelogenous leukemia may be considered.

[POMR]

  • 2023-04-10 Hemato-Oncology
    • Problem: Acute myeloblastic leukemia, FLT3 and NPM1 Undetectable, 46,XX,t(16;21)(p11.2;q22)[20] karyotype
      • Assessment: Induction chemotherapy with D3A7 was administered on 2023/03/31 - 04/06
      • Plan
        • Insertion on 2023/03/30
        • Induction chemotherapy with D3A7 was administered on 2023/03/31 - 04/06
        • Prophylasix antibiotics with Cravit po from 2023/03/31(D11) and antifungas with Fluconazole 2 tab QD from 2023/03/31(D11)
        • Adequate hydration with N/S 1500ml QD
        • Followed up laboratory test regularly  

[SOAP]

  • 2023-03-18 Medical Emergency
    • Menorrhagia for 2 weeks.
    • 2023/03/18 17:24 Blast = 9.8 %;
    • 2023/03/17 17:29 Blast = 5.9 %;
    • preliminary impression: D61.818 Other pancytopenia
      • Pancytopenia, Hb 7.2 to 6.1 to 6.8, blast 5.9% to 9.8%, OA ONC
  • 2023-03-17 Hemato-Oncology
    • 33 y female, PH: IDA (iron deficiency anemia)
    • Abnormal hemogram was informed at Taipei Mackey Hospital
    • recheck here: WBC 2540, Hb 6.1, Plt 116k, balst 5.9%
    • Imp: R/O leukemia

[chemotherapy]

  • 2023-03-31 - daunorubicin 45mg/m2 70mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 156mg NS 500mL 24hr D1-7 (3+7 daunorubicin/cytarabine Q4W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + palonosetron 250ug D1-2 + NS 250mL D1-2

Induction therapy for acute myeloid leukemia in medically-fit adults. 2023-04-10 https://www.uptodate.com/contents/induction-therapy-for-acute-myeloid-leukemia-in-medically-fit-adults

  • 7+3 therapy (cytarabine plus anthracycline)
    • The preferred approach for remission induction is a 7-day continuous infusion of cytarabine and anthracycline treatment on days 1 to 3, which is commonly referred to as “7+3 therapy.”
    • For medically fit patients, we suggest treatment as follows:
      • Cytarabine 100 to 200 mg/m2 daily as a continuous infusion for 7 days
      • Daunorubicin 60 to 90 mg/m2 on days 1 to 3 or idarubicin 12 mg/m2 on days 1 to 3
    • Treatment with 7+3 therapy generally achieves a complete remission (CR) rate of 60 to 80 percent for patients <60 to 65 years old. Long-term outcomes are influenced by cytogenetic/molecular features (the following table) and post-remission management.
      • 2017 European LeukemiaNet risk stratification of acute myeloid leukemia by genetics
        • Risk category: Favorable
          • Genetic abnormality
            • t(8;21)(q22;q22.1); RUNX1-RUNX1T1
            • inv(16)(p13.1;q22) or t(16;16)(p13.1;q22); CBFB-MYH11
            • Mutated NPM1 without FLT3-ITD or with FLT3-ITDlow
            • Biallelic mutated CEBPA
        • Risk category: Intermediate
          • Genetic abnormality
            • Mutated NPM1 and FLT3-ITDhigh
            • Wild type NPM1 without FLT3-ITD or with FLT3-ITDlow (without adverse-risk genetic lesions)
            • t(9;11)(p21.3;q23.3); MLLT3-KMT2A
            • Cytogenetic abnormalities not classified as favorable or adverse
        • Risk category: Adverse
          • Genetic abnormality
            • t(6;9)(p23;q34.1); DEK-NUP214
            • t(v;11q23.3); KMT2A rearranged
            • t(9;22)(q34.1;q11.2); BCR-ABL1
            • inv(3)(q21.3q26.2) or t(3;3)(q21.3;q26.2); GATA2,MECOM(EVI1) –5 or del(5q); –7; –17/abn(17p)
            • Complex karyotype, monosomal karyotype
            • Wild type NPM1 and FLT3-ITDhigh
            • Mutated RUNX1
            • Mutated ASXL1
            • Mutated TP53
    • Patients require aggressive intravenous hydration; monitoring for cardiac, renal, and liver dysfunction; blood product support; and surveillance for infections. Treatment with 7+3 therapy generally causes three to five weeks of profound cytopenias and associated risks of life-threatening infections and bleeding. Many patients will experience nausea and vomiting, mucositis/stomatitis, alopecia, and diarrhea. Cytarabine may cause a flu-like syndrome (including fever and/or rash) and daunorubicin can be associated with infusion reactions and cardiac arrhythmias.
    • Bone marrow examination should be performed 14 to 21 days after initiation of therapy to assess the initial response to therapy and determine whether a second induction course is needed.
    • Approximately four to five weeks after the start of therapy, when sufficient time has passed for recovery of normal blood counts, another bone marrow examination is performed to determine whether the patient has achieved remission.
    • Broadly, findings from randomized trials that examined the dose, schedule, and choice of agents have found that outcomes are similar between daunorubicin and idarubicin; higher dose daunorubicin (ie, 60 or 90 mg/m2/d) is more efficacious but not more toxic than lower dose (ie, 45 mg/m2/d) daunorubicin; and, compared with infusional cytarabine, high dose cytarabine (HiDAC) is associated with increased toxicity without an improvement in efficacy.

==========

2023-04-12

[follow up]

  • Bicytopenia progresses, Cravit (levofloxacin) and FLU-D (fluconazole) are used to manage potential infections.

    • 2023-04-12 WBC 0.21 x10^3/uL
    • 2023-04-09 WBC 0.42 x10^3/uL
    • 2023-04-12 Neutrophil 5.8 %
    • 2023-04-09 Neutrophil 16.5 %
    • 2023-04-12 PLT 37 *10^3/uL
    • 2023-04-09 PLT 47 *10^3/uL
  • No fever in the past 7 days.

  • Blast decreased after 7+3 anthracycline plus cytarabine since 2023-03-31.

    • 2023-04-05 Blast 1.0 %
    • 2023-04-03 Blast 1.3 %
    • 2023-04-02 Blast 7.0 %
    • 2023-04-01 Blast 22.9 %
    • 2023-03-31 Blast 23.0 %
    • 2023-03-28 Blast 12.0 %
    • 2023-03-24 Blast 7.0 %
    • 2023-03-22 Blast 29.0 %
    • 2023-03-21 Blast 17.6 %
    • 2023-03-20 Blast 4.0 %
    • 2023-03-18 Blast 9.8 %
    • 2023-03-17 Blast 5.9 %

2023-04-10

  • The patient diagnosed with AML was admitted and received the first dose of “3+7 daunorubicin/cytarabine” regimen on 2023-03-31. Lab data showed the development of severe neutropenia following administration of the regimen.

    • 2023-04-09 WBC 0.42 x10^3/uL
    • 2023-04-07 WBC 0.92 x10^3/uL
    • 2023-04-05 WBC 1.43 x10^3/uL
    • 2023-04-03 WBC 1.78 x10^3/uL
    • 2023-04-02 WBC 2.64 x10^3/uL
    • 2023-04-01 WBC 3.31 x10^3/uL
    • 2023-03-31 WBC 3.63 x10^3/uL
    • 2023-03-28 WBC 4.49 x10^3/uL
    • 2023-04-09 Neutrophil 16.5 %
    • 2023-04-07 Neutrophil 55.0 %
    • 2023-04-05 Neutrophil 64.0 %
    • 2023-04-03 Neutrophil 39.9 %
    • 2023-04-02 Neutrophil 75.3 %
    • 2023-04-01 Neutrophil 60.0 %
    • 2023-03-31 Neutrophil 33.0 %
    • 2023-03-28 Neutrophil 50.0 %
  • Treatment with the regimen can cause 3 to 5 weeks of profound cytopenias and associated risks of life-threatening infections and bleeding. And cytarabine may cause a flu-like syndrome (including fever and/or rash) and daunorubicin can be associated with infusion reactions and cardiac arrhythmias.

  • It is recommended that a bone marrow examination be performed 14 to 21 days after initiation of therapy to assess the initial response to the therapy and to determine if a second induction course is needed.

  • Initial response to therapy - A bone marrow examination on day 14 of treatment provides an assessment of the clearance of blast cells and a preview of the response to induction therapy. Findings from the day 14 examination may be classified as follows:

    • Hypoplastic: Bone marrow cellularity <5 to 20 percent and <5 percent blasts
    • Indeterminate: Bone marrow cellularity <5 to 20 percent with >=5 percent blasts
    • Persistent leukemia: Some clearing of leukemia or no response, but cellularity >=20 percent
  • Institutions vary in their responses to findings of the day 14 bone marrow examination.

    • For some centers, all medically-fit patients receive a second cycle of the same induction therapy, but those with persistent disease may receive more intensive/alternate treatment (eg, high dose cytarabine [HiDAC] plus mitoxantrone; mitoxantrone, etoposide, and cytarabine [MEC], other regimen.)
    • Other centers use the following approach, guided on the day 14 marrow results:
      • Hypoplastic: Observation for two to four weeks until recovery of blood counts. If pancytopenia persists, then repeat bone marrow biopsy.
      • Indeterminate: Repeat the bone marrow examination one to two weeks later, with subsequent management guided by whether the repeat study demonstrates hypoplasia versus persistent leukemia.
      • Persistent leukemia: Repeat treatment with the regimen, or treat with a more intensive or alternate induction therapy (eg, HiDAC-based therapy, hypomethylating agent plus venetoclax, other regimen).
  • Cravit (levofloxacin) and Flu-D (fluconazole) both have been prescribed to prevent or alleviate the patient from infections. There is no problem that is identified with the active recipe.

700040129

230411

{not completed}

[exam findings]

  • 2023-04-11 MRI - brain
    • Indication: Right upper lobe lung cancer with mediastinal lymphadenopathy, lung, liver and bone metastasis, cT3N2M1c, stage IVB
    • Findings
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
      • The interhemispheric fissure is centered on the midline.
      • Sella and pituitary are normal. The parasellar structures are unremarkable.
      • There are no abnormalities in the cerebellopontine angle areas on both sides.
      • There are no abnormalities in the calvarium.
      • C2 and right C3 metastases/bone destructions.
      • Abnormal enhancement after contrast administration of C2-3 bodies were noted.
    • Imp:
      • No brain or skull metastases.
      • C2 and right C3 metastases.
  • 2023-04-11 Bronchoscopy
    • Endo-bronchial tumor with partial obstruction at RB3, s/p Cryobiopsy
  • 2023-04-07 CT - chest
    • Indication: multiple bone metastasis - from chest to pelvis please,
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lobulated mass at right upper lobe measuring 3.8cm in largest dimension is found.
        • Lymphadenopathy at right hilar and paratracheal region is found.
        • Mild bilateral pleural effusion is found.
        • One nodular lesion at right lower lobe measuring 0.85cm is found. suspected lung meta.
      • Visible abdomen:
        • Low density lesions are found at both lobes of liver are found. Liver meta is considered.
        • Diffuse wall thickening of the ascending colon is found. suspeted colitis.
        • The urinary bladder is well distended without soft tissue lesion.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Imp:
      • Right upper lobe lung cancer with mediastinal lymphadenopathy, lung meta and liver meta, bone meta. T3N2M1c.
  • 2023-04-03 CXR
    • Lung markings: a nodular lesion, about 32mm, in the right upper lung field
  • 2023-04-03 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
  • 2023-04-03 MRI - c-spine
    • IMP
      • mild retrolisthesis at C4-5 and C5-6
      • r/o multiple bone metastasis with pathological fracture at C2 vertebral body. PLease correlate with contrast-enhanced study.
  • 2023-03-31 C-spine AP & Lat
    • Loss of normal lordotic alignment
    • Disc space narrowing and posterior spur at C4-5-6
  • 2023-03-14 C-spine flex & ext view
    • mild angulation at the middle C-spine
    • mild anterior and posterior spur formation at the middle and lower C-spine
    • moderate decreased disc spaces in the C4/5 and C5/6 discs

[consultation]

  • 2023-04-03 Neurology
    • Q
      • posterior neck pain for a week, no arms numb nor weak.
      • c spine on 20230331:
        • Loss of normal lordotic alignment
        • Disc space narrowing and posterior spur at C4-5-6
    • A
      • S: complained of severe neck pain while axial loading (relieved by lying down)
      • O
        • E4V5M6
        • pupil: 3+/3+
        • MP full
        • no limbs paresthesia
        • MRI: suspected multiple bone metastasis with pathological fracture at C2 vertebral body
      • P
        • since there’s no MP weakness, limbs numbness, no operation is indicated now
        • suggest oncologist consultation and tumor survey

700882997

230411

{not completed}

[exam findings]

  • 2023-04-03 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Mild plasmacytosis and see description
    • The sections show normocellular marrow (30%). The erythoid precursors are decreased, dispersed, and scattered in CD71 stain. The myeloid cells show good maturation. The CD61+ megakaryocytes are normal in number and morphology. Increased CD138+ mature plasma cells, account for 15% of marrow cells without lambda or kappa light chains restriction. No CD34+ blasts can be found. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2023-03-13 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-03-10 Patho - colon biopsy
    • Colorectum, ascending colon, s/p biopsy near total removal (A) — Hyperplastic polyp
    • Colorectum, transverse colon, s/p biopsy removal (B) — Hyperplastic polyp
    • Colorectum, descending colon, s/p biopsy removal (C) — Hyperplastic polyp
    • Colorectum, rectum, s/p biopsy removal (D) — Hyperplastic polyp
    • Colorectum, rectum, 5 cm above anal verge, biopsy (E) — Hyperplastic polyp
  • 2023-03-08 Patho - doudenum biopsy
    • Duodenum, bulb to second portion, biopsy — mild to moderate lymphocytic infiltration.
    • Section shows piece(s) of bland duodenal tissue with mild to moderate lymphocytic infiltration.
    • IHC stains: CD3 and CD20: no predominant sub-population, in favor of chronic inflammation.
  • 2023-03-08 SONO - abdomen
    • Parenchymal liver disease
    • Cholecystopathy
    • Gallbladder polyp
    • Minimal ascites
    • Sus lymphadenopathy, beside panc body
  • 2023-03-06 CTA - chest
    • Indication: Fever, unspecified Dizziness and giddiness, Dyspnea, unspecified Anemia, unspecified
    • MDCT (80-detector rows,Aquilion Prime SP, was performed with 0.5 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images and coronal slab MIP PA images shows:
      • Lungs: centrilobular emphysema in both upper lobes (moderate Lt, mild RT), and mild subpleural paraseptal emphysema in LUL. dependent linear band subsegmental atelectasis at lower lobes.
      • Mediastinum and hila:
      • Vessels: mild calcified plaques of the LAD coronary artery.
      • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber and well opacification of ascending
      • Heart: normal in size of cardiac chambers.
      • Pleura: mild bilateral effusions.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal contents: hyperplasia of Lt adrenal gland
        • normal appearance of gall bladder. unremarkable of the liver, spleen, Rt adrenal gland, pancreas, and both kidneys. bile ducts: No dilatation.
        • no enlarged lymph node. no ascites.
        • Atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • emphysema in both upper lobes, most severe on Lt smoking related disease. small pleural effusion, transudate.
  • 2023-03-06 CXR
    • Thoracic aortic arch calcified atheriosclerotic plaque
  • 2022-09-21 Pure Tone Audiometry
    • PTA Reliability FAIR
    • Average RE 30 dB HL; LE 35 dB HL.
    • R’t normal to moderately severe SNHL. (BC masking dilemma at 4k Hz)
    • L’t normal to moderately severe SNHL with ABG at 4k Hz.
  • 2022-03-09 ENT Hearing Test
    • Tymp:
      • R’t type Ad; L’t type A.
    • ART:
      • R’t absent.
      • L’t absent except ipsi 500 Hz.
    • PTA
      • Reliability FAIR
      • Average RE 21 dB HL; LE 26 dB HL.
      • R’t normal to moderate SNHL.
      • L’t normal to moderately severe SNHL.

[consultation]

  • 2023-03-13 Hemato-Oncology
    • Q
      • For anemia and thrombocytopenia
      • This 72-year-old male has past history of Hypertension and Af under medication control at West Garden Hospital. According to his statment, intermittent shortness of breath for 2 weeks ago, accompanied with productive cough, dizziness and bilateral hands tremor for 1 weeks. The symptom got worsen, thus he was brought to our ER for help. At ER, vital signs showed TPR: 35.6’C/121bpm/20; BP:125/60 mmHg. Con’s:E4V5M6. Laboratory data revealed normacytic anemia of Hb 7.8g/dL, elevated CRP (8.78 mg/dL), NTpro BNP (1018 pg/mL) and D-dimer (980.96 ng/mL). Chest CTA showed emphysema in both upper lobes. He denied abdomen pain, tarry stool or bloody stool. Urinalysis showed no pyuria. Denied TOCC history. Under the impression of pneumonia and suspect GI bleeding, he was admitted to our ward for further evaluation and treatment.
      • After admitted, he recevied IV fluid supplement, empirical antibiotic with unasym for infection control.
      • Stool transfirrin/FOB showed positive. EUS and colonscopy were performed for anemia survey, which showed duodenal ulcers and rectal polypoid lesions with ucer.
      • Anemia was correct with Hb > 9.0.
      • Follow laboratory data revealed thrombocytopenia (PLT 65000/uL -> 70000/uL -> 52000/uL -> 35000/uL). Abdomen echo showed no splenomegaly.
      • We need your expertise to evaluate for anemia and thrombocytopenia further evaluation, sincerely thanks.
    • A
      • This 72 year old man is a case of pneumonia. We are consulted for bicytopenia (normocytic anemia and thrombocytoepnia).
      • Pending endoscopy biopsy result. Please check RBC morphology, haptoglobin (done), total/direct bilirubin (done), ANA, RF, C3, C4, anti Ds DNA, AntiRo/La, IgG,IgA,IgM, total protein/albumin, serum EP, serum IFE, serum light chain, lupus anticoagulant, anti-cardiolipid IgM/IgG, anti B2 glycoprotein Ab, Ferritin (done), Fe/TIBC (done), B12 (done), folic acid(done) and tumor marker. Watch for any bleeding sign which may cause platelet consumption. If still unexplained cytopenia, bone marrow aspiration and biopsy is indicated.
      • Typical recommended platelet count thresholds used for some common procedures are listed below. Platelet transfusion may be considered when the patient platelet count is below the threshold for the corresponding procedure.
        • Neurosurgery or ocular surgery - <100,000/microL
        • Most other major surgery - <50,000/microL
        • Endoscopic procedures - <50,000/microL for therapeutic procedures; 20,000/microL for low risk diagnostic procedures
        • Bronchoscopy with bronchoalveolar lavage (BAL) - <20,000 to 30,000/microL
        • Central line placement - <20,000/microL
        • Lumbar puncture - <10,000 to 20,000/microL in patients with hematologic malignancies and <40,000 to 50,000 in patients without hematologic malignancies; lower thresholds may be used in patients with immune thrombocytopenia (ITP)
        • Neuraxial analgesia/anesthesia - <80,000/microL
        • Bone marrow aspiration/biopsy - <20,000/microL

[lab data]

2023-04-11 Ferritin 1154.7 ng/mL
2023-04-11 Transferrin 143.6 mg/dL
2023-04-11 Fe (Iron-bound) 123 ug/dL
2023-04-11 TIBC 206 ug/dL
2023-04-11 UIBC 83 ug/dL
2023-04-10 BUN 29 mg/dL
2023-04-10 Bilirubin direct 0.22 mg/dL
2023-03-21 Direct Coomb Test Positive
2023-03-21 Indirect Coomb Test Positive
2023-03-21 FKLC 156.0 mg/L
2023-03-21 FLLC 193.0 mg/L
2023-03-17 Anti-beta2-glycoprotein-I Ab 9.2 U/mL
2023-03-17 Gamma 44.3 %
2023-03-15 IgG (blood) 2208 mg/dL
2023-03-09 stool FOB Positive
2023-03-09 Transferrin, stool Postive

701452959

230411

[diagnosis] - 2023-04-10 admission note

  • Malignant neoplasm of rectosigmoid junction
  • Adenocarcinoma of the rectum and sigmoid colon,T4N2bM1a, stage III
  • Type 2 diabetes mellitus without complications
  • Essential (primary) hypertension
  • Hyperlipidemia, unspecified

[past history]

  • diabetes mellitus for years under OHA & insulin control at SanChong LMD and hepatitis B.
  • Port-A was inserted on 2023-03-14.     

[allergy]

  • NKDA     

[family history]

  • Mother: breast cancer
  • Sister: lymphoma

[exam findings]

  • 2023-04-10 KUB
    • A renal stone in left lower pole is suspected.
    • Fecal material store in the colon.
    • Vas deferens calcification is noted.
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon at right lateral aspect L4-5.
  • 2023-03-10 Whole body PET scan
    • Glucose hypermetabolism involving the rectosigmoid colon, compatible with primary rectosigmoid colon malignancy.
    • Mild glucose hypermetabolism in six regional lymph nodes. The nature is to be determined (metastatic lymph nodes of low FDG uptake? other nature?). Please correlate with other clinical findings for further evaluation.
    • No prominent abnormal focal FDG uptake was noted in the liver and no prominent FDG uptake was noted in the left external iliac lymph node.
    • Increased FDG accumulation in some focal areas in the colon. The nature is to be determined (physiological FDG accumulation? other nature?). Please also correlate with other clinical findings for further evaluation.
  • 2023-03-01 CT - abdomen
    • CC:
      • bowel habit change and anal discomfort + tenesmus recent times.
      • Constipation with excessive straining (unstable)
    • 20230224 colonoscopy: One circumferential tumor was noted at proximal rectum, 8-9cm above anal verge, s/p biopsy x6. The scope cannot pass through the lesion.
    • Past history: (DM + HTN)
    • Indication: suspect rectum lesion
    • Findings:
      • There is long segmental circumferential asymmetrical wall thickening with irregular contour at the rectum and sigmoid colon, measuring 12 cm in length that is c/w adenocarcinoma (T4a).
        • The fat plane between the sigmoid colon lesion and the urinary bladder shows equivocal obliteration. Please correlate with MRI to R/O urinary bladder invasion or attachment.
        • In addition, there are ten enlarged nodes in the pericolic area that are c/w metastatic nodes (N2b). IIIC
      • There is an ill-defined poor enhancing lesion 1 cm in S6/7 of the liver that may be cyst, pseudo-lesion, or metastasis?
        • Please correlate with MRI.
      • There is one enlarged node in left external iliac chain, measuring 6 mm in short axis (normal cut of value: 7mm) and fat density that may be reactive node.
        • The differential diagnosis includes non-regional metastatic node (M1a).
        • Please correlate with PET scan.
    • Impression:
      • Adenocarcinoma of the rectum and sigmoid colon.
        • Please correlate with MRI.
      • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T4a or T4b, N2b, M1a?
        • Please correlate with Pelvis MRI and PET scan.
  • 2023-02-24 Patho - colon biopsy
    • PATHOLOGIC DIAGNOSIS
      • Proximal rectal tumor, 8-9 cm above anal verge, biopsy — Adenocarcinoma
      • Distal rectal polyp, biopsy removal — Tubular adenoma, low grade dysplasia
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consisted of (A) three small pieces of tumor tissue measuring up to 0.3 x 0.2 x 0.1 cm in size and (B) four tiny pieces of polyp tissue measuring up to 0.2 x 0.2 x 0.1 cm in size respectively, fixed in formalin. Grossly, they were grey in color and soft in consistence. All embedded for sections in cassette A: rectal tumor and B: sessile polyp.
    • MICROSCOPIC EXAMINATION
      • Microscopically, the sections show pictures as follows:
        • Proximal rectal tumor: adenocarcinoma characterized by cribriform or glandular tumor cell infiltrate with desmoplasia.
          • Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor
        • Distal rectal polyp: tubular adenoma with low grade dysplasia
  • 2023-02-24 Colonoscopy
    • high suspected rectal cancer, s/p biopsy (A)
    • rectal polyp, s/p biopsy removal (B)
    • mixed hemorrhoid
  • 2022-10-11 Bladder Sonography
    • PVR: 71mL
  • 2022-09-28 Humerus RT
    • suspected fracture at the right proximal humeral bone.
  • 2022-09-27 Transrectal Ultrasound of Prostate, TRUS-P
    • CC:
      • small stream +
      • nocturia 5/N
    • PH:
      • DM(+), HTN(-), CAD(-), COPD(-), Asthma(-), CVA(-)
    • Surgical history: denied
    • Substance use: denied
    • Prostate:
      • Size of prostate: 4.76(T)cm x 2.59(L)cm x 5.12(AP)cm = 33.0cc
      • Size of adenoma: 3.14(T)cm x 2.25(L)cm x 2.97(AP)cm = 11.0cc
    • Seminal vesicles:
      • L
        • Size:L’t1.68 x 0.802 cm
        • Vas deferens:Normal
        • Cyst:No
        • Abscess:No
        • Tumor:No
      • R
      • Size:R’t1.55 x 1.34 cm
      • Vas deferens:Normal
      • Cyst:No
      • Abscess:No
      • Tumor:No
    • Diagnosis
      • Benign prostatic hyperplasia

[SOAP]

  • 2023-03-07 Radiation Oncology
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 frcations of the rectal to sigmoid colon tumor bed area.
  • 2023-03-07 Hemato-Oncology
    • Arrange admission for C/T (FU or FOLFOX).
    • If the PET indicates as a mets, C/T regimen for CCRT and post-CCRT would be FOLFOX, and TNT is not necessary.
    • If the PET discloses the lesion of liver is not a mets, TNT (CCRT with FU -> FOLFOX x 6-8 cycles -> OP -> follow up) is indicated. The C/T regimen for CCRT would be FU.
    • note ChatGPT:
      • In the context of oncology, TNT stands for “Total Neoadjuvant Therapy.” This refers to a treatment approach where chemotherapy, radiation therapy, or both are given before surgery for the treatment of certain types of cancer. The goal of TNT is to shrink the tumor and potentially increase the chances of a successful surgical outcome.

[chemotherapy]

  • 2023-04-10 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4600mg NS 500mL 46hr (FOLFOX without 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-22 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4600mg NS 500mL 46hr (FOLFOX without 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-04-11

  • The patient has been admitted for the 2nd dose of FOLFOX regimen, and there were no remarkable adverse reactions observed after the 1st dose.
  • On 2023-04-10, the lab results showed grossly normal blood counts, kidney and liver function, and selected electrolytes, indicating that scheduled chemotherapy is not contraindicated.
  • he tumor marker CEA was found to be elevated and increasing before the first chemotherapy, and further follow-up tests can be ordered as necessary.
    023-03-08 CEA: 217.89 ng/mL
    2023-02-25 CEA: 193.69 ng/mL
  • The patient’s blood pressure readings are acceptable, but the serum glucose level remains high and unstable, ranging from 229mg/dL to 150mg/dL, and should be monitored closely. If the high serum glucose level persists, metformin may be considered, given the patient’s non-insufficient kidney function.
  • No issues with medication reconciliation have been identified.

2023-03-23

  • The treatment strategy planned on 2023-03-21 is based on the results of PET: if it indicates the presence of metastases, the recommended chemotherapy regimen for concurrent chemoradiotherapy (CCRT) and post-CCRT would be FOLFOX, and total neoadjuvant therapy (TNT) would not be necessary. However, if PET shows that the lesion in the liver is not a metastasis, then the recommended treatment would be TNT, which consists of CCRT with FU, followed by FOLFOX for 6-8 cycles, then surgery and postoperative follow-up. The chemotherapy regimen for CCRT in this case would be FU.

  • On 2023-03-10, the results of the PET scan were available and the patient began receiving the FOLFOX regimen for the first time while in this hospital stay.

  • According to the patient’s blood glucose records, there is an upward trend and significant variability in his blood glucose levels despite taking Forxiga (dapagliflozin). To address this, it is recommended to investigate if there has been a significant change in the patient’s dietary intake, especially in regards to carbohydrate consumption, as this could have a substantial impact on blood glucose levels.

    • Blood sugar level 148 -> 105 -> 170 -> 173 -> 127 -> 243 mg/dL

701464758

230411

[exam findings]

  • 2023-04-07 Ascites tapping
    • 3000 ml light red color ascites was drained.
  • 2023-04-03 Ascites tapping
    • After echo localization, paracentesis was performed at RLQ and 3000ml straw-colored scites was drained out with 18Fr cathether.
  • 2023-03-29 ECG
    • Sinus rhythm with Premature atrial complexes
    • Poor wave progression
  • 2023-03-29 KUB
    • Abdominal ascites
    • increased air in nondistended loops of small bowel over abdomen and pelvic ,could be mechanical ileus.
    • marginal spurs of multiple vertebral bodies
  • 2023-03-29 CXR
    • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
    • Elevation of both hemidiaphragms may be due to abdominal ascites and supine position
    • Linear band subsegmental atelectasis at lung bases
    • Multiple nodules in both lungs due to metastases.
  • 2023-03-20 Ascites tapping
    • 18G needle was inserted at RLQ under echo guided insertion. Around 75ml ascites was collected for analysis and total 3000 ml for drainage, orange color and symptom relief.
  • 2023-03-17 PET
    • Glucose hypermetabolism in a focal area about ascending colon and some adjacent lymph nodes. Primary colon malignancy with some adjacent lymph node metastases may show this picture.
    • Multiple glucose hypermetabolic lesions in bilateral lungs and in the liver, compatible with multiple lung and liver metastases.
    • Increased FDG accumulation in both kidneys. Physiological FDG accumulation is more likely.
  • 2023-03-15 All-RAS + BRAF
    • ALL-RAS: Detected (KRAS codon 12 GGT>GAT, p.G12D)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-03-12 KUB
    • Presence of ileus.
    • Degeneration and spondylosis of L-S spine.
  • 2023-03-10 Patho - colon biopsy
    • Colorectum, ascending, biopsy — Adenocarcinoma.
    • Section shows piece(s) of colonic tissue with invasive irregular neoplastic glands.
  • 2023-03-09 Colonoscopy
    • A-colon cancer with partial obstruction
  • 2023-03-09 Asictes tapping
    • 18G needle was inserted at RLQ under echo guided insertion. Around 75ml ascites was collected for analysis and total 2000 ml for drainage and symptom relief.
  • 2023-03-07 CXR
    • Solitary pulmonary nodule at RLL.
  • 2023-03-07 CT - abdomen
    • Findings
      • Wall thickening of A-colon with adjacent fat stranding and regional LAP. Multiple liver and lung tumors. Massive ascites.
      • S/P cholecystectomy.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
  • 2022-12-19 SONO - abdomen
    • Large liver tumor in right lobe, HCC? Suggest dynamic CT or MRI study.
    • Liver cysts.

[consultation]

  • 2023-03-14 Hemato-Oncology
    • A
      • This 67 year old man is a case of ascending colon adenocarcinoma with liver and lung metastasis. We are consulted for further evaluation.
      • Please check tumor gene status for RAS and BRAF mutations (All-RAS/BRAF test), Pending tumor mismatch repair (MMR) or microsatellite instability (MSI) status (pathology IHC stains). Arrange PET for complete staging (NHI covered).
      • For metastasis colon cancer, palliative systemic chemoterapy +/- target therapy is indicated. Re-evaluate for conversion to resectable every 2-3 mo if conversion to resectability is a reasonable goal. Furthermore, consult CRS for surgery, if there is present of obstrusion, bleeding or perforation.
      • Arrange our OPD after discharge. Thanks for your consultation.
  • 2023-03-14 Colorectal Surgery
    • A
      • O
        • 2023037: CT: Wall thickening of A-colon with adjacent fat stranding and regional LAP r/o malignancy. Multiple liver and lung tumors r/o metastases. Massive ascites.
        • 20230309: Colonoscopy: One mass was noted in the ascending colon with nearly lumen obstruction biopsy — Adenocarcinoma.
        • Abdomen: distended, no tenderness or muscle guarding
      • A: Adenocarcinoma of A-colon with multiple metastases of liver and lungs, stage IVb
      • P:
        • Due to diffuse liver and lungs metastases, palliative chemotherapy with target therapy is the main treatment option
        • Surgical intervention with bypass surgery or ileostomy may be considered if obstruction symptoms developing
        • Please inform us if any problems

[medication]

  • 2023-03-21 ~ 2023-04-18 ongoing - Xeloda (capecitabine 500mg) KXELO01 2# BID

[note]

Capecitabine 2023-04-11 https://www.uptodate.com/contents/capecitabine-drug-information

  • Dosing: Adult - Colorectal cancer, unresectable or metastatic:
    • Single-agent therapy:
      • Oral: 1,250 mg/m2 twice daily on days 1 to 14 of a 21-day treatment cycle; continue until disease progression or unacceptable toxicity.
        • Note: Capecitabine toxicities, particularly hand-foot syndrome, may be higher in North American populations; therapy initiation at doses of 1,000 mg/m2 twice daily (on days 1 to 14 every 21 days) may be considered.
    • XELOX/CAPOX regimen:
      • Oral: 1,000 mg/m2 twice daily on days 1 to 14 of a 21-day treatment cycle (in combination with oxaliplatin); continue until disease progression or unacceptable toxicity. Some studies administered for a duration of 8 or 16 cycles. A retrospective evaluation of a modified schedule (eg, days 1 to 7 and days 15 to 21 of a 28-day cycle) found improved tolerability and no difference in efficacy outcomes.
    • CAPOX/panitumumab:
      • Oral: 1,000 mg/m2 twice daily on days 1 to 14 every 3 weeks (in combination with oxaliplatin and panitumumab) for at least 6 cycles or until disease progression or unacceptable toxicity.

[assessment]

  • The supplemental report for the IHC staining of EGFR, PMS2, MSH6, MSH2, and MLH1 for the colon biopsy pathology performed on 2023-03-10 is still pending and not yet available.

  • The patient’s last recorded height on 2023-03-30 is 172 cm, and his last recorded weight on 2023-04-10 is 75.7 kg. Based on these measurements, his body surface area (BSA) is calculated to be 1.9 m2. The patient has been receiving capecitabine at a daily dose of 2000 mg since late March 2023, which is a dose of 1052 mg/m2 based on his BSA. This is approximately 84% of the recommended daily dose of 1250 mg/m2.

  • It appears that the patient has had anemia even before the administration of capecitabine, and the cause may be gastrointestinal bleeding (in case of A-colon lesions?) as evidenced by positive occult blood in the stool. Blood transfusion performed on 2023-03-07, 2023-03-29, and 2023-04-07 and PPI is currently prescribed.

    • 2023-04-08 Stool OB 4+
    • 2023-04-01 Stool OB 3+
    • 2023-03-09 Stool OB 3+
    • 2023-04-10 HGB 9.1 g/dL
    • 2023-04-07 HGB 6.8 g/dL
    • 2023-03-29 HGB 8.3 g/dL
    • 2023-03-20 HGB 8.4 g/dL
    • 2023-03-17 HGB 8.8 g/dL
    • 2023-03-13 HGB 8.8 g/dL
    • 2023-03-09 HGB 8.4 g/dL
    • 2023-03-07 HGB 7.1 g/dL
    • 2023-03-07 HGB 5.7 g/dL
    • 2022-12-16 HGB 8.9 g/dL
  • There is currently no record of hand-and-foot syndrome (HFS) or any related symptoms such as palmar-plantar erythrodysesthesia or chemotherapy-induced acral erythema.

701465149

230411

[diagnosis] - 2023-04-02 admission note

  • Mesothelioma of pleura
  • Chronic viral hepatitis B without delta-agent
  • Essential (primary) hypertension

[past history] - 2023-04-02 admission note

  • Medical PH: 1) HTN 2) BPH
  • Inguinal hernia on 2023/01/13
  • TEP and Port-A catheter insertion on 2023/01/30
  • Hypertension for 20-30 years
    • Carvedilol HEXAC 6.25mg 1# po BID
    • Noravsc 1# po QD
    • Doxaben XL 4mg 1# po QNAC    

[allergy]

  • NKDA         

[family history]

  • His parents was DM.
  • No cancer, CAD, CVA history in his family

[exam findings]

  • 2023-04-10, -04-06 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • Pleura thickening in right lateral aspect is noted.
    • Partial atelectasis of RLL and RML is suspected.
    • Please correlate with CT.
    • Borderline cardiomegaly
  • 2023-04-03 SONO - chest
    • Right
      • Right side pleural effusion? -> dry tapping
      • suspect mesothelioma or post R/T related
      • suggest CXR follow up
    • Left
      • Left side negative
  • 2023-04-02 CXR
    • Right pleural effusion.
    • Ground glass opacities in bil. lungs.
  • 2023-04-02 ECG
    • Atrial flutter with variable A-V block
  • 2023-02-24 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • Pleura thickening in right lateral aspect is noted.
    • Partial atelectasis of RLL and RML is suspected.
    • Please correlate with CT.
  • 2023-02-23 ECG
    • Nonspecific T wave abnormality
  • 2023-02-07 Bone Scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed two hot spots in the anterior aspect of right 1st and 2nd ribs and increased activity in the maxilla, middle and lower T-spines, lower L-spines, bilateral shoulders, hips and knees in whole body survey.
    • IMPRESSION:
      • Increased activity in the middle and lower T-spines and lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
      • Two hot spots in the anterior aspect of right 1st and 2nd ribs. Bone metastases can not be ruled out. Please also correlate with other imaging modalities for further evaluation.
      • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
  • 2023-02-02 CXR
    • Rt pleural effusion with loculation still visible s/p chest tube placement,
    • partial atelectasis of RLL and RML
  • 2023-02-01 PET scan
    • Glucose-hypermetabolism in the right pleura, compatible with malignant mesothelioma of pleural status.
    • Glucose-hypermetabolism in the right upper ribs, malignancy with rib involvement should be considered, suggesting bone scan for investigation.
    • Increased FDG uptake in the right inguinal region, compatible with right inguinal hernia.
    • Increased FDG accumulation in the colon, probably physiological uptake of FDG.
    • Malignant mesothelioma of pleural status with suspected right upper ribs involvement by this F-18 FDG PET scan.
  • 2023-01-31 CT - abdomen
    • History and indication: mesothelioma of pleural
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Right mesothelioma with pleural effusion. S/P right chest tube insertion with pneumothorax, subcutaneous emphysema.
      • Minimal pneumoperitoneum.
      • A lipoma (2.8cm) in left thigh.
      • Right inguinal hernia.
      • Some poor enhancing nodules (up to 1.0cm) in liver.
      • Bil. renal cysts (up to 1.0cm).
    • IMP:
      • Right mesothelioma with pleural effusion. S/P right chest tube insertion with pneumothorax, subcutaneous emphysema.
      • Minimal pneumoperitoneum.
  • 2023-01-31 ENT Hearing Test
    • PTA
      • Reliability FAIR
      • Average RE 34 dB HL; LE 31 dB HL.
      • RE normal to severe SNHL.
      • LE normal to severe SNHL
  • 2023-01-18 Patho - pleural/pericardial biopsy
    • PATHOLOGIC DIAGNOSIS
      • Pleura, right, VATS decortication - Malignant mesothelioma, high-grade
      • Tumor subtype — Biphasic type
      • Pathology stage:pT1Nx(if cM0); AJCC stage IA
    • MACROSCOPIC EXAMINATION
      • Operation procedure: VATS decortication
      • Specimen site: right pleura
      • Specimen size: multiple pieces, up to 2.5x 2x 1.5 cm
      • Tumor size: fragmented, at least 2 cm in greatest dimension
      • Tumor description: ill-defined, brownish and solid
      • All for sections are taken and labeled as: F2023-38FSA1-2&A:frozen control of tumor, A1-2:tumor
    • MICROSCOPIC EXAMINATION
      • Histology Type: Malignant mesothelioma
      • Histology Grade:
        • Nuclear grade 3 [Nuclear atypia score: 3 (severe);Mitotic count score: 3 (hight, > 5 mitoses/ 10 HPF); Sum: total score 6].
        • Necrosis: present
        • Overall tumor grade: High-grade
      • Resection Margins: Cannot be assessed
      • Lymphovascular Invasion: Absent
      • Perineural Invasion: Absent
      • Tumor Necrosis: Present / Absent
      • Lymph Node : Not included
      • IHC stain — Ki-67 index: 90%, CK20(-), calretinin(focal+), CK(+), chromomgranin (-), WT-(Afocal+), D2-40(focal+), P40(-), TTF-1(-), Napsin A(-), CK7(+), vimentin (+), SOX-10(-), CK5/6(-), HBME-1(focal+), SYNAPTOPHYSIN(-), GATA-3(+),S100(-).
  • 2023-01-17 Frozen Section
    • FROZEN SECTION INITIAL DIAGNOSIS:
      • Tissue, right pleural, frozen section — Malignant tumor
  • 2023-01-16 SONO - chest
    • Echo diagnosis:
      • right side moderate amount of septated pleural effusion, pig-tail drainage via right 7th ICS posterior mid-axillary
      • line was performed and bloody fluid was drained out. The bloody fluid was sent for study.
  • 2023-01-12 CT - chest
    • The CT scan of the chest was performed without IV contrast medium enhancement and revealed that:
      • Patchy consolidation over RLL. Suggest check enhanced CT scan for furthter evaluation.
      • Moderate amount of right pleural effusion with some high-density materials. Suggest correlate with enhanced study.
      • Bilateral perirenal fatty strandings.
  • 2023-01-12 ECG
    • Possible Left atrial enlargement
    • Nonspecific T wave abnormality
  • 2023-01-12 CXR
    • Right pleural effusion.
    • Borderline cardiomegaly.
    • Thoracic spondylosis.
  • 2022-12-22 Bladder Sonography
    • PVR 4.81 mL

[consultation]

  • 2023-01-28 Hemato-Oncology
    • Q
      • This is a 75 y/o male with underlying disease of HTN.
      • He underwent VATS decortication due to right pleural effusion on 2023-01-17, and the pathological report revealed malignant mesothelioma.
      • We would like to consult your expertise on evaluation and treatment arrangement of the patient, thank you!
    • A
      • This 75 year old man is a case of right malignant mesothelioma (initial presentation: cough and right pleura effusion). He has underline of HTN, BPH and rigth inguinal hernia.
      • For malignant mesothelioma, we are consulted.
        • We will discuss with pahtologist regarding the subtype, e.g., epitheloid, sarcomatoid or biphasic
        • May consider CCRT with weekly CDDP followed by systemic therapy is indicated (cisplatin + pemetrexed +/- bevacizumab) or immunotherapy with dual or single
        • Please check abdominal + pelvic CT extending to chest (+/- contrast), 24hr urine CCR, auditory test
        • Please check HbsAg, Anti Hbc, Anti-HBs, Anti HCV.
        • Arrange Port A insertion
        • We will discuss with patient and family
        • We wound like to follow up this case. May take over or arrange our OPD appointment after discharge.
  • 2023-01-27 Radiation Oncology
    • A
      • A:
        • Malignant mesothelioma, high-grade, of the right pleura, s/p VATS decortication.
      • P:
        • Postoperative radiotherapy is indicated for this patient with the following indicators: Malignant mesothelioma, high-grade, of the right pleura.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his daughter-in-law. They understand and agree to receive radiotherapy. Please consider PET for current tumor status and staging work-up. The treatment planning of radiotherapy will be started after completion of PET.

[SOAP}

  • 2023-03-30 Radiation Oncology
    • P: Go on the radiotherapy. Plan to complete radiotherapy on 2023-04-03. RTC: 2023-04-18.
  • 2023-03-16 Hemato-Oncology
    • Already strong request increasing the salt intake again and again
  • 2023-02-16 Thoracic Surgery
    • CT: R’t massive pleural effusion, cause? liver cysts., report?

[surgical operation]

  • 2023-01-30
    • Surgery: TEP
      • ChatGPT: TEP stands for Totally Extraperitoneal Repair, which is a minimally invasive surgical technique used to repair inguinal hernias. In this procedure, a small incision is made in the abdominal wall and a laparoscope is inserted, which allows the surgeon to view the hernia and repair it from the outside of the peritoneal cavity. The hernia is repaired with a mesh, which is placed over the defect to prevent the hernia from recurring. TEP is considered less invasive than traditional open hernia repair surgery and has a lower risk of complications.
    • Finding
      • Right indirect hernia type III
      • cord lipoma (+)
      • sac descend to scrotum
      • contralateral defect: none
      • post wall repair yes
      • mesh size 14x15 cm
      • absorbable tacks
      • peritoneal defect (+) cloosed with 3-0 Vicryl sutures
  • 2023-01-17
    • Surgery: VATS decortication
      • ChatGPT: VATS decortication refers to a surgical procedure performed to remove the fibrous layer of tissue (pleural peel) that covers the lung. The procedure is performed using a minimally invasive technique called Video-Assisted Thoracic Surgery (VATS), which involves making small incisions in the chest wall and using a video camera and specialized surgical instruments to access and remove the pleural peel. VATS decortication is commonly used to treat conditions such as empyema, a collection of pus in the pleural space, and hemothorax, a buildup of blood in the pleural cavity.
    • Finding
      • Bloody effusion was noted over right pleural cavity, about 800mL
      • Frozen section:carcinoma, unknown origin.
      • One 28 Fr. straight chest tube was inserted via right 8th ICS, another curved one was inserted via right 7th ICS.

[radiotherapy]

  • 2023-02-22 ~ 2023-04-03 - at 3060cGy/17 fractions of the right pleura to right upper ribs, and 4680cGy/26 fractions of the right pleura tumor bed.

[chemotherapy]

  • 2023-04-10 - pemetrexed 500mg/m2 800mg NS 100mL 10min + cisplatin 60mg/m2 100mg NS 500mL 2hr (Alimta + cisplatin, Q3W. cisplatin to normal 75mg/m2 next time)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-16 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (cisplatin within concurrently) (CCRT with weekly CDDP)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-03-09 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (cisplatin within concurrently) (CCRT with weekly CDDP)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-03-02 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (cisplatin within concurrently) (CCRT with weekly CDDP)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-02-24 - cisplatin 40mg/m2 70mg NS 500mL 24hr + magnesium sulfate 10% 20mL NS 100mL 1hr (after cisplatin) + furosemide 20mg NS 30mL 10min (after cisplatin) (CCRT with weekly CDDP)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2023-04-11

  • The patient’s HGB levels have shown a decreasing trend since the start of CCRT in late Feb 2023, which could be a result of the cisplatin and radiotherapy.
    • 2023-04-10 HGB 7.4 g/dL
    • 2023-04-06 HGB 8.9 g/dL
    • 2023-04-02 HGB 8.2 g/dL
    • 2023-03-30 HGB 8.2 g/dL
    • 2023-03-23 HGB 8.9 g/dL
    • 2023-03-16 HGB 10.1 g/dL
    • 2023-03-09 HGB 10.8 g/dL
    • 2023-02-24 HGB 11.0 g/dL
    • 2023-02-07 HGB 9.8 g/dL
    • 2023-01-30 HGB 11.0 g/dL
    • 2023-01-23 HGB 11.1 g/dL
    • 2023-01-20 HGB 11.1 g/dL
    • 2023-01-19 HGB 11.0 g/dL
    • 2023-01-17 HGB 13.3 g/dL
    • 2023-01-12 HGB 13.1 g/dL
  • The combination of pemetrexed and cisplatin, incorporating prophylactic folic acid and vitamin B12, increased OS compared with single-agent cisplatin in patients with malignant pleural mesothelioma whose disease was either unresectable or who were not otherwise candidates for potentially curative surgery. ref: Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol. 2003;21(14):2636-2644. doi:10.1200/JCO.2003.11.136
    • 2023-04-10 MCV 100.9 fL
    • 2023-04-06 MCV 98.1 fL
    • 2023-04-02 MCV 94.8 fL

2022-04-03

The patient’s sputum Gram’s stain results on 2023-04-02 showed G(+) Cocci 2+, GNB 2+, GPB 3+ (Neutrophil/LPF < 10, Epithelial cell/LPF 15~20). Antibiotics with Betamycin 4.5gm Q6H have been prescribed since the same day to treat the patient’s respiratory symptoms. After checking the PharmaCloud database, no medication reconciliation issue is found.

700450583

230410

==========

2023-04-10

[ciclosporin TDM]

On 2023-04-08, the patient’s ciclosporin trough concentration was found to be 169ng/mL, which falls within the acceptable range of 100 to 400ng/mL. However, if the target trough concentration is between 200 and 300 ng/mL, then it is recommended to increase the daily dose from the current 200mg to 250mg and continue with regular follow-up testing.

2023-04-03

The patient’s kidney function results have returned to normal within the last 7 days.

2023-04-03 Creatinine 0.95 mg/dL
2023-03-31 Creatinine 2.45 mg/dL
2023-03-30 Creatinine 3.10 mg/dL
2023-03-28 Creatinine 3.74 mg/dL

2023-04-03 eGFR 98.94
2023-03-31 eGFR 33.16
2023-03-30 eGFR 25.27
2023-03-28 eGFR 20.35

2023-03-20

[cyclosporine IV to PO conversion]

  • There are different recommendations for converting CsA administration from intravenous to oral in HSCT patients, ranging from a 1:1 to a 1:3 conversion rate. For patients receiving voriconazole, it is suggested to use a 1:1 conversion rate. However, for patients receiving fluconazole without azole co-medication, a 1:1.3 substitution is recommended to prevent CsA concentrations from becoming subtherapeutic. ref: Converting cyclosporine A from intravenous to oral administration in hematopoietic stem cell transplant recipients and the role of azole antifungals. Eur J Clin Pharmacol. 2018;74(6):767-773. doi:10.1007/s00228-018-2434-4
  • Based on the intended IV dose of 190mg BID, the daily oral dose would range from 418 to 494mg. To start with, a feasible option would be to use Sandimmun Neoral, which is available as 4 100mg capsules, and 2 25mg capsules can be added to achieve the desired dose. The total dose can be divided into two administrations. However, it is important to monitor the patient’s cyclosporine blood levels at repeated intervals and make subsequent dose adjustments to avoid toxicity from high levels and possible rejection from low absorption of cyclosporine.

2023-03-10

[ciclosporin TDM]

  • Based on the system records, the blood was drawn for ciclosporin at 2023-03-09 08:35, while the medication was administered at 08:24 on the same day. If the intended purpose was to measure the trough concentration, the ideal time for blood draw should be within half an hour before medication administration. Please verify the accuracy of the system records or redraw an blood sample.

2023-03-07

[therapeutic drug monitoring for cyclosporine]

  • The dosage of cyclosporine has remained at 170mg Q12H since 2023-03-02. A blood sample was taken correctly on 2023-03-06 morning, just half an hour before the next scheduled administration. The trough level result was 266.6ng/mL, which falls within the target range of 100 to 400ng/mL without an issue.
  • Based on the trough level result falling within the target range, no dosage adjustment is necessary.

[assessment]

  • Today (2023-03-07) marks the 12th day since the Matched Unrelated Donor Allogeneic Peripheral Blood Stem Cell Transplantation. From the lab data, there is a noticeable upward trend in WBC count in the past two days, which is a positive sign.
    • 2023-03-06 D 11 WBC 0.70 x10^3/uL
    • 2023-03-05 D 10 WBC 0.28 x10^3/uL
    • 2023-03-03 D 8 WBC 0.01 x10^3/uL
    • 2023-03-02 D 7 WBC 0.01 x10^3/uL
    • 2023-03-01 D 6 WBC 0.01 x10^3/uL
    • 2023-02-27 D 4 WBC 0.02 x10^3/uL
    • 2023-02-27 D 4 WBC 0.02 x10^3/uL
    • 2023-02-26 D 3 WBC 0.04 x10^3/uL
    • 2023-02-24 D 1 WBC 0.07 x10^3/uL
    • 2023-02-23 D 0 WBC 0.01 x10^3/uL
    • 2023-02-22 D -1 WBC 0.01 x10^3/uL
    • 2023-02-20 D -3 WBC 0.09 x10^3/uL
    • 2023-02-19 D -4 WBC 0.09 x10^3/uL
    • 2023-02-17 D -6 WBC 0.23 x10^3/uL
    • 2023-02-15 D -8 WBC 0.86 x10^3/uL
    • 2023-02-13 D-10 WBC 1.36 x10^3/uL
    • 2023-02-12 D-11 WBC 1.70 x10^3/uL
    • 2023-02-10 D-13 WBC 4.40 x10^3/uL
    • 2023-02-08 D-15 WBC 9.26 x10^3/uL

2023-03-03

[therapeutic drug monitoring for cyclosporine]

  • The dose of cyclosporine was increased from the original 140mg to 145mg on a later time on 2023-03-01, and further increased to 170mg on 2023-03-02, while the dosing frequency remained Q12H.

  • The TDM for cyclosporine was performed on 2023-03-02 at 08:26:39, and the administration time was recorded as 2023-03-02 11:46. The scheduled administration times for Q12H should be 09:00 and 21:00, and the later actual administration time may be due to delayed medication or delayed registration in the system, so it is recommended to confirm the system usage with nursing staff. However, the 08:26 blood draw is consistent with the trough concentration at Q12H.

  • Since the dose increase has not reached steady state, it is recommended to perform another blood draw in the middle of next week.

2023-03-01

[cyclosporine TDM]

  • The cyclosporine TDM result was 79.3 ng/mL, with the blood sample drawn on February 27, 2023 at 09:09:34 and the medication given at 08:46 on the same day.
  • Since the blood sample was drawn shortly after the medication was given, the measured concentration is unlikely to be a trough concentration.
  • If a trough concentration is desired, a new blood sample should be drawn and tested.

2023-02-24

[therapeutic drug monitoring]

Sandimmun injection (ciclosporin)

  • The recommended therapeutic trough concentration range for cyclosporine typically falls within 100-400 ng/mL. The current administration is 140mg IVD Q12H.

  • Based on the TDM result on 2023-02-23 indicating a level of 43.3 ng/mL, it is suggested to administer a dosage of 180 mg per shot every 12 hours.

  • It is also recommended to perform another blood test to examine the trough concentration in the latter half of next week.

2023-02-09

  • 2023-02-08 Cre 0.72mg/dL, eGFR 136, BUN 19mg/dL, Bil T 0.7mg/dL, Bil D 0.1mg/dL, ALT 455 U/L, AST 123 U/L. The kidneys do not appear to be degraded.
    • Patient body height 180cm, body weight 97kg => BSA 2.2m2
  • Selected chemotherapy drugs in the FuCyMito conditioning regimen
    • fludarabine 30mg/m2 => 66mg, compatible with D5W, NS, L-Ringer’s
      • 250mL NS, 1h is recommended.
      • There are no dosage adjustments provided in the manufacturer’s labeling; however, dosage adjustment for hepatic impairment is not likely necessary (Krens 2019).
    • cytarabine 2000mg/m2 => 4400mg, compatible with D5W, D5NS, Sterile water for injection
      • 500mL NS, 6hr is recommended. (according to Trad Chinese package insert, max conc is 100mg/mL)
      • Dose may need to be adjusted in patients with liver failure since cytarabine is partially detoxified in the liver. There are no dosage adjustments provided in the manufacturer’s labeling.
    • mitoxantrone 6mg/m2 => 13.2mg, compatible with D5W, D5LR, D5NS, NS, L-Ringer, Ringer
      • 500mL NS, 3hr is recommended.
      • There are no dosage adjustments provided in the manufacturer’s labeling; however, clearance is reduced in hepatic dysfunction.

2023-01-30

  • The echocardiography performed on 2023-01-06 showed an improved LVEF (55% versus 33%) compared to 2022-11-11.

  • Readings of bilirubin (direct/total) are within normal limits. AST/ALT levels indicate that impaired liver function is improving. There is no need to adjust the dose of medications in the active prescription for liver function. In addition, there is no laboratory evidence of impaired kidney function.

    • 2023-01-30 S-GOT/AST 60 U/L
    • 2023-01-28 S-GOT/AST 67 U/L
    • 2023-01-27 S-GOT/AST 78 U/L
    • 2023-01-30 S-GPT/ALT 129 U/L
    • 2023-01-28 S-GPT/ALT 154 U/L
    • 2023-01-27 S-GPT/ALT 193 U/L
  • In spite of the fact that Hydrea (hydroxyurea) has been administered since 2023-01-27 afternoon, there has not been an obvious decrease in WBC counts since the second day of administration. The blast percentage remains around 60% with only minor fluctuations.

    • 2023-01-30 WBC 76.58 x10^3/uL
    • 2023-01-29 WBC 73.19 x10^3/uL
    • 2023-01-28 WBC 77.15 x10^3/uL
    • 2023-01-27 WBC 94.09 x10^3/uL
    • 2023-01-30 Blast 61.9 %
    • 2023-01-29 Blast 58.7 %
    • 2023-01-28 Blast 59.6 %
    • 2023-01-27 Blast 61.0 %
  • The PLT count has been trending downward, which should be closely monitored.

    • 2023-01-30 PLT 87 x10^3/uL
    • 2023-01-29 PLT 85 x10^3/uL
    • 2023-01-28 PLT 111 x10^3/uL
    • 2023-01-27 PLT 148 x10^3/uL
  • The active prescription does not pose a problem.

2023-01-27

[drug identification]

  • We have been requested by the patient’s primary nurse to identify one drug. The drug is identified as Vemlidy (tenofovir alafenamide 25 mg) and is indicated for the treatment of chronic hepatitis B virus (HBV) infection in adults and pediatric patients 12 years of age and older with compensated liver disease. The in-hospital porter will return the identified drug to the ward.

  • Not used:

    • The drug to be identified has not been received until the end of the working day.
    • As of the end of working hours, the drug to be identified has not been received.

700698086

230410

[exam findings]

  • 2023-04-10 SONO - abdomen
    • Parenchymal liver disease
    • Fatty liver, mild
    • Mild CBD dilatation
    • Chronic kidney disease
    • Urinary retention
    • Minimal ascites
  • 2023-04-06 MRI - brain
    • MR of the brain and MRA of the intracranial vessels and neck carotid systems were performed on a 1.5 T superconducting magnet on supine position utilizing head coil with 6 mm slice thickness and 24 cm field of view without intravenous injection of Gadolinium.
    • Findings:
      • One small cavernous malformation (5.3mm) over right posterior corona radiata.
      • Mild periventricular small vessel disease. NO acute ischemic infarct.
      • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
      • Mild paranasal sinusitis.
  • 2023-03-28 CXR
    • Solitary pulmonary nodule at right lower lung zone.
    • Normal appearance of trachea and bil. main bronchus.
    • Cardiomegaly.
  • 2023-03-28 ECG
    • Sinus tachycardia
    • Voltage criteria for left ventricular hypertrophy
  • 2023-03-07 CT - brain (at TMUH)
    • Computed tomography of the BRAIN was performed without i.v. contrast administration.
    • Findings:
      • No evidence of acute intracranial hemorrhage (ICH) or space occupying lesion is noted in this study.
      • Widening of the cortical sulci of bilateral cerebral hemispheres, mild dilatation the ventricles, the findings are indicating diffuse brain atrophy, due to aged brain change.
      • Normal mastoid air cells, no evidence of mastoiditis.
      • The paranasal sinuses are clear.
      • Clinical correlation and follow up is needed.
    • IMPRESSION:
      • No evidence of acute ICH or space occupying lesion is noted.
      • Diffuse brain atrophy, due to aged brain change.
  • 2022-11-07 CT - chest (at TMUH)
    • Findings: Chest CT without IV contrast study that show: Lung window-setting is also obtained.
      • Still focal consolidative lesion and internal amorphous calcifications in LLL, relatively prominent, as compared with prior CT on 2022-08-19, consistent with post-treatment change.
      • New small nodules in RLL, favored metastatic nodules.
      • Mild left pleural effusion.
      • Mild fibrotic foci in bilateral lungs.
      • Arteriosclerotic changes with mural calcifications of aorta and coronary arteries, suspect CAD.
      • Degenerative spondylosis with marginal spur over thoracolumbar spine.
      • Otherwise, there is no evidence of masses in the anterior, middle and posterior compartment.
      • The hilar region on each side is unremarkable, and the main bronchi appear normal.
      • There is no lymphadenopathy and there are no perihilar masses.
      • The heart has a normal configuration; the cardiac chambers are normal size.
      • No evidence of abnormalities of liver, GB, pancreas, spleen, bilateral kidneys and adrenal glands.
    • IMPRESSION:
      • Post-treatment change of LLL, with focal consolidations and internal amorphous calcifications, relatively prominent, as compared with prior CT on 2022-08-19. Recommend follow-up.
      • But new presence of RLL metastatic nodules.
      • Mild left pleural effusion.
      • Mild fibrotic foci in bilateral lungs.
      • Arteriosclerotic changes with mural calcifications of aorta and coronary arteries, suspect CAD.

[consultation]

  • 2023-04-06 Neurology
    • Q
      • Impression
        • Acute delirium, suspected psychotic symptoms due to other medical condition, especially brain metastesis and renal failure
      • Suggestion
        • Treat malignancy and renal failure first. Non-contrast brain MRI could not clearly show malignancy. Please arrange contrast-enhanced brain CT instead, but beware of deterioration of renal failure and risk of developing end-stage renal failure.
        • Please consult neurosurgeon for brain metastasis treatment.
        • Check TSH, free T4, cortisol, ACTH, VDRL, vitamin B12, and folic acid. Treat them accordingly if abnormal findings.
        • I agreed with the psychiatrist’s suggestion of anti-psychotic medication (quetiapine). Please contact psychiatrist for further anti-psychotic drugs adjustment.
  • 2023-04-03 Nephrology
    • Q
      • For poor renal function, we need your further evaluation and management.
    • A
      • We visited the patient at the bedside and evaluated his condition. His consciousness was well, speech was coherent and showed no signs of distress. His limbs were not edematous.
      • He complained of poor appetite and minimal fluid intake over the past few days. Blood tests showed progressively deteriorating renal functions but he still urinates approximately 1L everyday.
        • 2023-04-03 BUN 65 mg/dL
        • 2023-04-03 Creatinine 5.29 mg/dL
      • Our advices are as follow:
        • consider ketosteril 2 PC PO TID
        • Keep daily I/O balance
        • CKD diet (Low K, low P)
        • Arrange renal sonography
        • OPD follow up prn
      • Please feel free to contact us should you require further assistance.
  • 2023-04-03 Psychosomatic Medicine
    • Q
      • The patient is restless and keeps saying he wants to find Chen Shui-bian, claiming that Chen Shui-bian is his friend. He is making phone calls everywhere and asking for money from anyone he meets, and he keeps saying that he is going to die. He throws all his belongings on the bed and ties the IV stand to the bed curtain.
    • A
      • This 80-year-old married man previously worked in the construction industry. According to his daughter, he was able to arrange his life and had good memory and daily function, such as supervising construction work in Luodong and taking walks in the park, until one week ago when he developed agitated and disruptive behaviors, such as attacking family members and lying down on the road. He also experienced auditory hallucinations, reality distortion, and hallucinatory behaviors, such as believing that Chen Shui-bian would come to talk to him for 15 minutes every day and telling him to do things. Poor sleep and disturbing behaviors persisted after admission, such as frequently borrowing money from the nursing station and seeking out Chen Shui-bian. The other hospital had diagnosed him with brain metastases. Brain MRI showed white matter intensities.
      • During the mental status examination, he displayed incoherent and irrelevant speech, disorientation (unable to tell the date or how many days he had been hospitalized, and thought he was at VGHTPE), talkativeness, auditory hallucinations, reality distortion, and hallucinatory behaviors.
      • IMP:
        • Acute delirium
        • Suspected Psychotic disturbance due to other medical condition (brain metastesis)
      • Suggestion:
        • Treat physical disease if possible.
        • DC mirtazapine, DC anxiedin. DC PRN haldol. Add utapine 25mg 1# HS, 1# HSPRN. Bini-U 5mg IM PRNQ6H if severe disturbing. Monitor ECG and QTC.
        • Tapper codeine and morphine use if possible.

[SOAP]

  • 2023-03-28 Medical Emergency
    • Hx of
      • Rectal cancer adenocarcinoma T3N0M0, stage IIA post anterior resection on 2015/1/23 and received radiotherapy about 45 Gy/25 fractions from 2015/02/23 to 2015/03/27 and lung metasteses, T3N0M1, stage IV in 2020, ECOG:2
      • Suspect obstructive pneumonitis
      • Left side pleural effusion
      • Hypertension
      • Chronic kidney disease, stage 4
    • Preliminary impression
      • C20 Malignant neoplasm of rectum
      • Agitation, Hx rectal Ca s/p op, R/T, lung metas (not treated), K 7 (hemolysis), F/U K 5, hsT 45 to 40, Hb 9, Cr 4.7, Hx HCVD, CKD

[multiteam]

  • 2023-03-31 Social Service
    • Referral Date: 2023-03-29
    • Reason for Referral: Patient and family members have emotional distress during hospitalization
    • Status: Not opening a case
    • Reason for Not Opening a Case: On 2023-03-30, separate interviews were conducted with the patient and the patient’s daughter:
      • Family Situation:
        • The patient is an 80-year-old married man with three daughters and one son. He is suffering from rectal cancer and has received treatment at TMUH in the past. He used to live alone in Yilan, but has been living with his son’s family in Taipei in recent years.
        • The patient’s wife is bedridden; the patient’s children are all married. The patient’s son and daughter-in-law currently live with the patient and the patient’s daughter in Zhonghe District. The patient’s daughter is currently unemployed and takes care of the patient full-time.
      • Assessment and Treatment:
        • The patient was admitted to the hospital due to a suicide attempt, which had been reported upon his arrival at the emergency department.
        • A social worker visited the patient’s ward today and found that the patient’s mood was stable, and he even smiled during the conversation. The patient said that he was feeling emotionally stable at the moment, but had trouble sleeping the night before. He was only able to fall asleep after being given sleeping pills. The patient also said that he did not remember what had happened before his hospitalization and was unsure who he was living with now.
        • The social worker talked with the patient’s daughter, who said that the patient’s recent abnormal behavior was likely caused by his illness, and the patient has forgotten what had happened during that time. The patient’s mood is stable when there are family members accompanying him. The patient’s daughter said that the patient has not yet received treatment from any relevant departments regarding his condition. However, she plans to take the patient to see a neurologist and other relevant departments in the future. The patient’s daughter is also currently taking care of the patient full-time and will continue to monitor his emotional changes.
        • This referral provides the above assessment and treatment information. It is confirmed that the patient’s suicide attempt had been reported upon his arrival at the emergency department. During his hospitalization, the patient’s mood has been stable, and he has cooperated with relevant medical treatments. The patient’s children are supportive and able to monitor his emotional changes in a timely manner. There are currently no emerging issues.

701240721

230410

[diagnosis] - 2023-04-07 discharge note

  • Left lip and left buccal cancer, cT4aN2cM0, stage IVA

[exam findings]

  • 2023-03-20 Nasopharyngoscopy
    • Findings
      • left nasal cavity clear, nasopharynx smooth, mucus at right nasopharynx, oropharynx and hypopharynx np
    • Diagnosis/Conclusion
      • left buccal and upper and lower lip cancer
  • 2022-09-12 ECG
    • Atrial fibrillation
  • 2022-05-05 MRI - larynx
    • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage) : T:4a(T_value) N:2c(N_value) M:0(M_value) STAGE:IVA(Stage_value)
  • 2022-05-05 Patho - duodenum biopsy
    • Duodenum, bulb, biopsy — capillary hemangioma
  • 2022-05-04 PET
    • Glucose hypermetabolism in the left buccal region, compatible with the primary left buccal cancer.
    • Glucose hypermetabolism in the left cervical lymph nodes and bilateral submandibular lymph nodes, highly suspected cancer with regional lymph nodes metastases.
    • Glucose hypermetabolism in the right N-P region, the nature is to be determined (another primary NPC, metastatic lesion, inflammation/infection process or others ?), suggesting biopsy for further investigation.
    • Glucose hypermetabolism in bilateral palatine tonsils, probably inflammation/infection process.
    • Left buccal cancer, cT4aN2cM0, stage IVA (AJCC, 8th ed.); suspected another right N-P tumor, nature ? by this F-18 FDG PET scan.
  • 2022-05-03 ECG
    • Atrial fibrillation with rapid ventricular response
    • Abnormal ECG
  • 2022-04-19 Patho - gingival/oral mucosa biopsy
    • Labeled as “lower lip area”, biopsy — squamous cell carcinoma.
    • Labeled as “left buccal area”, biopsy — squamous cell carcinoma.
    • Section shows squamous cell carcinoma.
    • IHC stain: p16 (-).

[SOAP]

  • 2022-09-26 General Surgery
    • bulla aspiration
  • 2022-05-12 Ear Nose Throat
    • left lip and left buccal SCC, cT4aN2cM0
    • patient hope bony structure preservation
    • explanation about induction chemotherapy + op (wide excision + left MRND + right SND + tracheotomy + free flap reconstruction) + post-op CCRT
    • consult GS for port-A insertion

[chemotherapy]

  • 2023-04-06 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-22 - docetaxel 40mg/m2 80mg NS 200mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-11-30 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-11-11 - docetaxel 40mg/m2 50mg NS 200mL 1hr + cisplatin 40mg/m2 50mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-11-04 - docetaxel 40mg/m2 70mg NS 200mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-20 - docetaxel 40mg/m2 80mg NS 200mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 2hr + fluorouracil 2000mg/m2 4000mg NS 500mL 46hr (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-14 - docetaxel 40mg/m2 80mg NS 200mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 2hr + fluorouracil 2000mg/m2 4000mg NS 500mL 46hr (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

[note]

TPF regimen (in-hospital Chemotherapy Regimens for Head and Neck Cancer: Collection as of 2022-02-11)

Neoadjuvant Chemotherapy regimen

  • TPF
    • Docetaxel 40 mg/m2 IVD (1 hs) D1, 8
    • Cisplatin 40 mg/m2 IVD (2 hs) D1, 8
    • 5-FU 750~1000 mg/m2 IVD (24 hs) D1-2, D8-9
    • Q3W for 1~3 cycles
    • H&N commission suggestion
    • References: Modified from Posner MRI et al. N.Engl.J.Med.357 (2007):1705-1715.
  • Induction Chemotherapy modified with TPF
    • Docetaxel 40 mg/m2 IVD (1 hs) D1, 8
    • Cisplatin 40 mg/m2 IVD (2 hs) D1, 8
    • 5-FU + Leucovorin 1000mg/m2 + 100mg/m2 IVD (24 hs) D2, 9
    • Q3 week x 3cycles (Q1W, Q2W, Q3W: rest)
    • H&N commission suggestion
    • References: Modified from Jerome Fayette et al. Oncotarget 2016;7(24):37297-37304

[assessment]

  • There was a gap in follow-up from early 2022-12 to mid 2023-03. The recommended dose of docetaxel and cisplatin in the TPF regimen for head and neck cancer, as listed in the in-hospital collection of chemotherapy regimens as of 2022-02-11, was 40mg/m2 for both drugs. However, the actual administered doses of the two drugs ranged from 50mg to 80mg. For fluorouracil, except for the first 2 doses at 4000mg, all other administrations since 2022-11 were at 3000mg.
  • If the patient’s dyspnea occurred on 2023-04-06 or 2023-04-07, the TPF dose administered on 2023-04-06 (the 7th dose) was docetaxel 60mg, cisplatin 60mg, and fluorouracil 3000mg all at a reduced amount, which might be less likely to cause dose-dependent adverse reactions. Is it possible that the patient experienced an infusion reaction? If this possibility cannot be ruled out, it may be worth trying a slower infusion rate or adding famotidine 20mg IVD as part of premedication in the next administration.

700183019

230406

[exam findings]

  • 2023-02-08 Whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed faint hot spots in both rib cages, and increased activity in the maxilla, some C- and L-spine, bilateral sternoclavicular junctions, shoulders, and knees, in whole body survey.
    • IMPRESSION:
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in both rib cages, maxilla, some C- and L-spine, bilateral sternoclavicular junctions, shoulders, and knees.
  • 2023-02-08 MRI - nasopharynx
    • Imaging Report Form for Oropharynx Carcinoma
      • Impression (Imaging stage): T:2(T_value) N:2cP16-, N2 P16+(N_value) M:0(M_value) STAGE:IVA P16-; II P16+(Stage_value)
  • 2023-02-07 SONO - abdomen
    • Liver cyst, S7
    • Gallbladder polyp or stone
  • 2023-01-27 Patho - nasopharyngeal/oropharyngeal biopsy
    • Tonsillar, left, biopsy — Squamous cell carcinoma, non-keratinizing and poorly differentiated (p16+)
    • Immunohistocyhemical stain reveals p16: positive (> 90%), CK: positive, and P40: positive
  • 2023-01-20 Nasopharyngoscopy
    • Findings
      • refer from neuro OPD
      • Suggest ENT evaluation.
    • Diagnosis/Conclusion
      • Nasopharyngoscope:
        • left deviated septum, bil. boggy turbinate
        • although NP was smooth, but MRI showed mild mucosal thickening at right lateral nasopharyngeal recess.
      • Oral:
        • left tonsillar hypertrophy - tumor lesion should rule out
        • biopsy done
  • 2023-01-12 MRA - brain
    • Indication: still complained about vertigo and unsteadiness
    • IMP:
      • Cerebral small vessel disease.
      • Mild mucosal thickening at right lateral nasopharyngeal recess. Suggest ENT evaluation.
  • 2022-11-16 Mini-Mental Status Examination
    • MMSE 23
  • 2022-11-16 Clinical Dementia Rating
    • CDR 0.5
  • 2022-11-10 Brainstem auditory evoked potentials, BAEP
    • Findings: Normal waveforms, amplitudes, peak latencies, interpeak intervals following click stimulaion to each ear.
    • Conclusion: This is a normal BAEP study.
  • 2022-11-10 Neurosonology
    • Minimal atherosclerosis in bilateral CCA bifurcations.
    • Normal PSV in bilateral ICA and CCA. Normal ICA/CCA PS ratio bilaterally
    • Adequate total VA flow (135) may suggest no evidence of VBI
  • 2021-07-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (83.5 - 18.3) / 83.5 = 78.08%
      • M-mode (Teichholz) = 78.1
    • Conclusion:
      • Normal AV with no AR
      • Normal MV with trivial MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • No PR, no TR, normal IVC size

[chemotherapy]

  • 2023-03-22 - carboplatin AUC 2 120mg D5W 500mL with NS 1000mL (CCRT, carboplatin determ by AUC 2)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-15 - cisplatin 40mg/m2 70mg NS 500mL with with NS 1000mL (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-07 - cisplatin 40mg/m2 70mg NS 500mL with with NS 1000mL (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

[assessment]

  • Most patients achieve cooling of the oral mucosa through intraoral administration of ice chips during chemotherapy administration. This is a cost effective and proven beneficial treatment.

  • Both topical and systemic analgesic approaches have been used to manage pain associated with mucositis.

    • Topical lidocaine solutions provide pain relief but require frequent administration. In one trial, topical viscous lidocaine (2 percent) was more effective than diphenhydramine and saline, a kaolin and pectin suspension, or placebo. ref: Treatment of radiation- and chemotherapy-induced stomatitis. Otolaryngol Head Neck Surg. 1990;102(4):326-330. doi:10.1177/019459989010200404
    • Topical lidocaine is frequently combined with cleansing and/or coating agents, a mixture that is often referred to as “miracle mouthwash.” There is no fixed formulation, and these mixtures are compounded differently by individual pharmacies, most of which have no set formula. ref: Survey of topical oral solutions for the treatment of chemo-induced oral mucositis. J Oncol Pharm Pract. 2005;11(4):139-143. doi:10.1191/1078155205jp166oa
  • Currently, lidocaine 2% PO PRNQD and tramadol IVD PRNQ6H have been prescribed.

  • The diet should be limited to foods that do not require significant chewing; acidic, salty, or dry foods should be avoided.

  • If poor feeding compromises the patient’s nutritional status, placement of a nasogastric feeding tube may be considered.

700360398

230406

[diagnosis] - 2023-04-03 discharge note

  • Immune thrombocytopenic purpura
  • Essential (primary) hypertension

[lab data]

  • 2023-02-23 HBsAg Nonreactive

  • 2023-02-23 HBsAg (Value) 0.35 S/CO

  • 2023-02-23 Anti-HCV Nonreactive

  • 2023-02-23 Anti-HCV Value 0.07 S/CO

  • 2023-02-23 Anti-HBs 11.15 mIU/mL

  • 2023-02-23 Anti-HBc Reactive

  • 2023-02-23 Anti-HBc-Value 6.43 S/CO

  • 2023-02-23 Anti-HBc IgM Nonreactive

  • 2023-02-23 Anti-HBc IgM Value 0.10 S/CO

  • 2023-02-10 ANA Negative

  • 2023-02-10 LA1 39.3 sec

  • 2023-02-10 LA2 30.7 sec

  • 2023-02-10 LA1/LA2 ratio 1.2

  • 2023-02-08 Anti-Cardiolopin IgG 0.7 GPL-U/mL

  • 2023-02-08 Anti-cardiolipin-IgM <0.8 MPL U/mL

  • 2023-02-08 Anti-β2-glycoprotein-I Ab 0.9 U/mL

  • 2023-02-08 Anti-ENA Sm 1.2 EliA U/ml

  • 2023-02-08 Anti-ENA RNP 1.1 EliA U/ml

[SOAP]

  • 2023-03-10 Hemato-Oncology
    • Plan:
      • continue steroid therapy
      • arrange admission for mabthera therapy
  • 2023-02-15 Hemato-Oncology
    • Assessment:
      • ITP, suggest steroid therapy 1 mg/kg
    • Plan:
      • continue steroid x 1 week
      • suggest bone marrow study if persisted thrombocytopenia
  • 2023-02-08 Hemato-Oncology
    • S/O
      • He was referred on account of thrombocytopenia, referred from Cardinal Tien Hospital. Dr. Ou
        • 2021-10-24 PLT 135K/cumm
        • 2023-01-11 PLT <10K
        • 2023-01-16 PLT <10K
        • 2023-01-25 PLT <10K
        • 2023-02-08 PLT <10K
      • Past history: Nothing in particular.
      • Family history: No systemic disease in the family members.
      • Personal history: Smoking (no), alcohol consumption (no), betel nut chowing (no)
      • Allergy: NKA.
      • Travel history: No traveling history within one month.
      • Occupation: None
    • Assessment
      • ITP, suggest steroid therapy 1 mg/kg
    • Plan
      • Check BCS
      • Check CBC&DC, PT, aPTT, bleeding time and stool OB
      • Check CXR

[immunotherapy]

  • 2023-04-03 - rituximab 375mg/m2 700mg NS 500mL 8hr
    • hydrocortisone 100mg + diphenhydramine 30mg + granisetron 1mg + acetaminophen 500mg PO + NS 250mL
  • 2023-03-17 - rituximab 375mg/m2 700mg NS 500mL 8hr
    • hydrocortisone 100mg + diphenhydramine 30mg + granisetron 1mg + acetaminophen 500mg PO + NS 250mL
  • 2023-02-23 - rituximab 375mg/m2 700mg NS 500mL 8hr
    • hydrocortisone 100mg + diphenhydramine 30mg + granisetron 1mg + acetaminophen 500mg PO + NS 250mL

[assessment]

  • The patient’s PharmaCloud is currently inaccessible. However, based on in-hospital records, the patient received prednisolone at a dose of 80mg daily from 2023-02-08 to 2023-02-22, and dexamethasone at a dose of 8mg daily from 2023-03-10 to 2023-04-07. The patient also received rituximab on 2023-02-23, 2023-03-17, and 2023-04-03.

  • The peak in PLT count on 2023-03-01 occurred approximately 1 week after the first dose of rituximab and was not during steroid administration. There has been no similar increase since the second dose of rituximab. It is possible that this peak was due to the delayed effect of rituximab, which can take some time for platelet production to increase after treatment. However, without further information, it is difficult to determine the exact cause. Close monitoring of the patient’s platelet levels and response to treatment is recommended.

    • 2023-04-03 PLT 7 x10^3/uL
    • 2023-03-24 PLT 6 x10^3/uL
    • 2023-03-17 PLT 27 x10^3/uL
    • 2023-03-10 PLT 4 x10^3/uL
    • 2023-03-01 PLT 113 x10^3/uL
    • 2023-02-27 PLT 13 x10^3/uL
    • 2023-02-24 PLT 21 x10^3/uL
    • 2023-02-23 PLT 1 x10^3/uL
    • 2023-02-22 PLT 1 x10^3/uL
    • 2023-02-15 PLT 1 x10^3/uL
    • 2023-02-08 PLT 2 x10^3/uL
  • Lab data from 2023-02-08 and 2023-02-10 showed normal values for ANA, LA1, LA2, LA1/LA2 ratio, anti-cardiolipin IgG, anti-cardiolipin IgM, anti-beta2-glycoprotein-I Ab, anti-ENA Sm, anti-ENA RNP, and PT, INR, APTT.

  • In the event that rituximab is no longer effective, splenectomy or TPO-RAs may be considered options.

700028729

230403

{EGFR wild type Adenocarcinoma of RUL with liver metastases, T4N0M1c, stageIVB - not completed}

[diagnosis] - 2023-04-02 admission note

  • Malignant neoplasm of upper lobe, right bronchus or lung
  • Secondary malignant neoplasm of liver and intrahepatic bile duct
  • Chest pain, unspecified
  • Acute kidney failure, unspecified

[past history]

  • Denied history of Hypertension, DM, asthma
  • Denied any operation, accident and other medical Hx.                            

[allergy]

  • NKDA         

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes. 

[exam findings]

  • 2023-04-02, -03-09, -02-10, -02-06 CXR
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • S/P port-A implantation.
    • Patchy opacity projecting in the right upper lung shows stationary.
    • Peri-bronchial wall thickening of bilateral lower lung zone is noted, which may be due to old inflammatory process. Please correlate with clinical history and symptom.
  • 2023-03-24 MRI - branchial plexus
    • Indication: right arm pain from shoulder to arm, twitching like. better on lying down and hot packing. motion exacerbated.
    • Phx: lung ca.
    • MRI of brachial plexus without/with Gadolinium-based contrast enhancement shows:
      • multiple heterogeneously enhancing tumors at right supraclavicular region, right intercostal spaces, and right upper mediastinum, involving right ribs, right hemithorax apex, and involving right brachial plexus.
      • multiple high signal lesions in visible spine and ribs, compatible with bone metastases.
      • massive left pleural effusion.
    • Impression:
      • Multiple tumors at right supraclavicular region, right intercostal spaces, and right upper mediastinum, involving right ribs, right hemithorax apex, and involving right brachial plexus.
      • Multiple ribs and spine metastases.
  • 2023-01-19 SONO - nephrology
    • Left small kidney with chronic parenchymal changes.
    • Hyperechoic pyramids, both kidney, suspected nephrocalcinosis secondary to hypercalcemia, suspected gout or anagelsic nephropathy.
    • Bilateral plerual effusions.
  • 2023-01-17 Abdomen - standing (diaphragm)
    • Right side Pneumothorax with air-fluid level at right CP angle.
    • Peri-bronchial wall thickening of the left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • There are several small stones in bilateral kidney?
    • Please correlate with sonography.
    • Few small calcification projecting at left lower pelvis are noted that may be ureter stones or old granulomas?
  • 2023-01-16 SONO - chest
    • Special Procedure:
      • Pleural tapping 16 #-needle Right side 950ml yellowish, clear
      • Pleural tapping 16 #-needle Left side 1080ml yellowish, clear
    • Echo diagnosis:
      • Bilateral massive pleural effusion, post left diagnostic and bilateral therapeutic thoracentesis.
  • 2023-01-14, -01-05 CXR
    • Patchy opacity projecting in the right upper lung
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • Emphysematous change of both lung field
  • 2022-12-29 CT - chest

EGFR wild type Adenocarcinoma of RUL with liver metastases,T4N0M1c,stageIVB

Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)

Chest CT without IV contrast ehnancement shows: Chest: S/p port-A placement with its tip at Superior vena cava. Massive bilateral pleural effuison and loculated effusion at right hemithorax is found. Patent airway is found. There is no evidence of mediastinal LAP

Visible abdomen: Atrophy of both kidneys are found. The GB is well distended without soft tissue lesion The spleen, pancreas and adrenals are intact. Low density lesion at S4 and S2 of liver is found. Liver meta is considered. In comparison with CT dated on 2022-09-28, regression of the tumor is found. There is no evidence of paraarotic LAPs. There is no ascites accumulation at abdominal cavity. Suggest clinical correlation

Imp: Loculated effusion at both hemithorax. Liver tumor, in regression.

  • 2022-12-27 SONO - chest
    • Bilateral thorax: large amount pleural effusion s/p drainage of left side, 850 cc, yellowish pleural effusion.
  • 2022-12-06 KUB
    • There are several small stones in bilateral kidney? Please correlate with sonography.
    • Few small calcification projecting at left lower pelvis are noted that may be ureter stones or old granulomas?
  • 2022-09-28 CT - abdomen

History:眩暈,想吐,表偶爾會流鼻水,有血絲 Nausea without vomit for 2-3 days, mild dizziness SOB sometimes, very mild Abd distension since last chemo(6 days ago) 20220705 CT:RUL lung ca & liver mets;T3N2M1c, cSTAGE:IVB

MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.

This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.

Findings: 1. Prior CT identified liver metastases in both lobes are noted again, mild decreasing in size. Please correlate with contrast enhanced dynamic CT or MRI. 2. There are bilateral extensive destructive centrilobular emphysema with upper lobes predominant. Prior CT identified RUL lung periphereal mass measuring 5.2 cm is noted again, decreasing in size. Please correlate with contrast enhanced CT. 3. Prior CT identified few cysts in S1 and S2 are noted again, stationary. 4. There are several renal stones, bilateral. Both kidney show small size and thin parenchyma that are c/w chronic renal disease. 5. There is no hyper-or hypodense lesion in the gallbladder, biliary system, pancreas, and spleen. There is no ascites or lymphadenopathy. There is no bowel wall thickening, and no bowel obstruction. The abdominal aorta and IVC are grossly unremarkable. There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.

IMP: 1. Prior CT identified liver metastases in both lobes are noted again, mild decreasing in size. Please correlate with contrast enhanced dynamic CT or MRI. 2. Prior CT identified RUL lung periphereal mass measuring 5.2 cm is noted again, decreasing in size. Please correlate with contrast enhanced CT.

  • 2022-09-28 KUB
    • increased air in nondistended loops of small bowel over LUQ and LLQ, could be paralytic ileus.
  • 2022-09-28 CXR
    • areas of hyperlucency and decreased lung vascular markings dirty marking due to emphysematous change of both lungs upper lung predominance
    • ill-define consolidation in peripheral of RUL due to tumor
  • 2022-08-09 ALK Immunostaining Result
    • The immunostaining of the section slide labeled S2022-11085, using ALK antibody D5F3 along with a Ventana autostainer system, revealed no staining of tumor cells.
  • 2022-07-20 CT - brain
    • no evidence of brain tumors.
  • 2022-07-26 ROS1 fluorescent-in-situ hybridization (FISH) report
    • Result
      • Number of invasive tumor cells counted: 50
      • Number of observers: 1
      • Number of cells (%) classified as negative: 48 (96%)
      • Number of cells (%) classified as positive: 2 ( 4%)
    • Interpretation
      • Rearrangement of ROS1 gene is NOT detected. Patients with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
  • 2022-07-15 PD-L1 (SP142)
    • Pathologic Report for VENTANA PD-L1 (SP142) Assay for Non-Small Cell Lung Cancer
      • Tumor type: Adenocarcinoma, metastatic
      • Tumor location: Liver
      • Testing assay: SP142 Assay (Ventana)
      • Control slide result: [V]Pass, [ ]Fail
      • Adequate tumor cells present (>=100 viable tumor cells): [V] Yes, [ ] No
    • Result:
      • Tumor Cell Staining Assessment:
        • PD-L1 Expression: Absence of any discernible PD-L1 membrane staining in tumor cells (TC < 50%)
      • Tumor Infiltrating Immune Cell Staining Assessment:
        • PD-L1 Expression: < 3% Immune cells (IC < 10%)
    • Note:
      • Percent of PD-L1 expression in tumor cells (TC): The percentage of viable tumor cells with membrane positivity at any intensity
      • Percent of PD-L1 expression in immune cells (IC): The percentage of tumor-infiltrating immune cells with discernible staining of any intensity
  • 2022-07-15 EGFR mutation
    • No mutation was detected at exons 18, 19, 20, 21 of EGFR gene in this specimen.
      • EGFR Status: no mutation detected
      • EGFR Mutation Status: no mutation detected
    • Description
      • The EGFR mutation testing was based on real-time PCR technique for detection of exons 18 (G719X), 19 (Deletions), 20 (T790M, S7681I, Insertions), 21 (L858R, L861Q) mutations of EGFR gene. The limit of detection (LoD) of this test was 10% mutant gene of whole EGFR gene.
  • 2022-07-13 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 25 mCi radiotracer revealed faint hot spots in both rib cages, and increased activity in the maxilla, sternum, some T-spine, bilateral shoulders, S-I joints, and knees, in whole body survey.
    • IMPRESSION:
      • Faint hot spots in both rib cages, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in the maxilla, sternum, some T-spine, bilateral shoulders, S-I joints, and knees.
  • 2022-07-12 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Adenocarcinoma, metastatic, consistent with lung primary
    • The sections show a picture of adenocarcinoma, composed of liver tissue with nests and cords of polygonal neoplastic cells in fibrous stroma. Focal glandular differentiation and tumor necrosis are present.
    • IHC shows: CK7(+), CK20(-), TTF1(+), Arginase-1(-), and Hepatocyte(-). The finding is consistent with metastatic adenocarcinoma, lung primary.
  • 2022-07-09 CTA - chest
    • PH: emphysema
    • With and Without contrast Chest CT and CTA showed
      • emphysematous change in the bilateral lung fields; a heterogeneous enhancing lesion, about 52mm, in the upper lobe of the right chest. suspected chest wall or pleural tumor or lung tumor. Irregular margins was noted.
      • multiple heterogeneous ill-defined tumors in the bilateral lobes of the liver, esp. left side
      • small bilateral renal stones.
    • IMP:
      • suspected right pleural or lung tumor
      • mulitple hepatic tumors
  • 2022-07-05 CT - chest
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1c(M_value) STAGE:____(Stage_value)
  • 2022-07-02 CXR
    • upper lung hyperlucency and decreased upper lung vascular markings due to emphysema
    • Rt apicolateral pleural effusion or thickening

[SOAP]

  • 2022-09-22 Hemato-Oncology
    • EGFR, ROS1, ALK all wild type Adenocarcinoma of RUL with liver metastases, T4N0M1c, stageIVB
    • No fit for cisplatin doublet due to imparied renal function
      • ChatGPT: “Cisplatin doublet” is a type of chemotherapy regimen used to treat various types of cancer, such as lung cancer, bladder cancer, and ovarian cancer. It consists of a combination of two chemotherapy drugs, with cisplatin being one of them, and the other drug depending on the specific cancer being treated. The doublet regimen is used to increase the effectiveness of chemotherapy by combining two drugs with different mechanisms of action, which can enhance tumor cell kill and reduce the likelihood of drug resistance.
  • 2022-08-23 Hemato-Oncology
    • Fail alimta but starting with weekly taxane
  • 2022-07-29 Hemato-Oncology
    • BH 169, BW 52
    • EGFR wild type Adenocarcinoma of RUL with liver metastases, T4N0M1c, stage IVB

[chemotherapy] (not completed)

  • 2023-01-05 - docetaxel 35mg/m2 54mg D5W 150mL 1hr (WBC 1.3K/uL 2023-01-12, WBC 2.15K/uL 2023-01-14)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-12-15 - ditto (WBC 1.87K/uL 2022-12-22, WBC 1.42K/uL 2022-12-26)

  • 2022-12-01 - ditto (WBC 2.54K/uL 2022-12-13)

  • 2022-11-15 - ditto (WBC 2.67K/uL 2022-11-29)

  • 2022-11-03 - ditto

  • 2022-10-25 - ditto

  • 2022-10-18 - ditto

  • 2022-10-06 - ditto

  • 2022-09-22 - ditto

  • 2022-09-15 - ditto

  • 2022-09-01 - ditto

  • 2022-08-25 - ditto

  • 2022-08-10 - ditto

  • 2022-07-19 - pemetrexed 500mg/m2 818mg NS 100mL 10min + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 120mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[medication]

  • G-CSF (filgrastim 150ug) CGCSF01
    • 2022-12-26 - 2022-12-26 IPD
    • 2022-12-13 - 2022-12-13 OPD
    • 2022-11-29 - 2022-11-29 OPD
    • 2022-08-23 - 2022-08-23 OPD
    • 2022-08-07 - 2022-08-07 IPD
  • Granocyte (lenograstim 250ug) CGRAN01
    • 2023-01-12, 13, 14 - 2023-01-12 OPD

[assessment]

  • The patient is currently undergoing supportive and palliative treatment to alleviate his symptoms.
  • Cisplatin was not administered due to his insufficient renal function.
  • He experienced several episodes of leukopenia during chemotherapy, for which G-CSF was used to mitigate the side effects.
  • The last dose of docetaxel was administered on 2023-01-05.

700871378

230403

[diagnosis] - 2023-04-02 admission note

  • Diffuse large B-cell lymphoma, unspecified site
  • Essential (primary) hypertension
  • Chronic viral hepatitis B without delta-agent

[past history]

  • hypertentsion under medication control for 20+ years

[allergy]

  • NKDA                             

[family history]

  • Younger sister has lymphoma

[lab data]

2023-04-03 HBsAg Nonreactive
2023-04-03 HBsAg (Value) 0.52 S/CO
2023-04-03 Anti-HBc Nonreactive
2023-04-03 Anti-HBc-Value 0.91 S/CO
2023-04-03 Anti-HCV Nonreactive
2023-04-03 Anti-HCV Value 0.05 S/CO
2023-04-03 Anti HTLV I/II Nonreactive
2023-04-03 Anti HTLV I/II Value 0.05 S/CO
2023-04-03 HIV Ab-EIA Nonreactive
2023-04-03 Anti-HIV Value 0.06 S/CO
2023-04-03 CMV_IgG Reactive
2023-04-03 CMV_IgG Value 213.4 AU/mL
2023-04-03 CMV IgM Nonreactive
2023-04-03 CMV IgM Value 0.23 Index

[exam findings]

  • 2023-02-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (82.6 - 11.9) / 82.6 = 85.59%
      • M-mode (Teichholz) = 80.1
      • 2D(M-simpson) = 75.3
    • Conclusion:
      • Thickened AV with mild AR
      • Normal MV with no MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • No PR, no TR, mildly dilated LA
  • 2023-02-17 Myocardial perfusion SPECT with persantin
    • The Tl-201 stress myocardial perfusion SPECT performed after intravenous injection 33.6 mg of dipyridamole revealed mildly decreased perfusion of radioactivity to the apex and inferolateral wall. The Tl-201 redistribution myocardial perfusion SPECT revealed reperfusion of radioactivity to the defects and mildly decreased perfusion of radioactivity to the posterior wall.
    • IMPRESSION:
      • Probably mild myocardial ischemia at the apex and inferolateral wall.
      • Mild reverse redistribution of radioactivity to the posterior wall, either normal variant or myocardial ischemia may show this picture.
  • 2023-02-16 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-02-16 CT - chest
    • Triple hit, non-GCB type of diffuse large B-cell lymphoma of left breast, left nasopharyngeal, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Minimal fibrotic change at left lingula lobe is found. Probably due to previous RT
        • The left breast tumor cannot be visualized in the study.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
        • No evidence of bilateral pleural effusion.
        • S/p port-A placement with its tip at Superior vena cava.
      • Visible abdomen:
        • Bilateral renal cysts are found
        • The spleen, liver, pancreas and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • IMp:
      • Left breast cancer s/p RT and C/T without evidence of recurrent/residual tumor in the lung fields.
      • Suggest closely follow up.
  • 2022-11-02 CT - chest
    • Impression:
      • resolution of Lt breast tumor compared with CT on 2022-07-28.
      • extensive V-CAD, suggest further test for evaluation any hemodynamically significant stenosis of coronary arteries.
  • 2022-09-24 KUB
    • S/P left femoral operation.
    • Atherosclerosis of the aorta.
  • 2022-08-02 Patho - bone marrow biopsy
    • Bone marror, biopsy— Negative for malignancy
    • Immunohistochemical stain revesls CD 20 (sparse +, < 5%), CD138 (sparse +, < 2%), CD71(+), MPO(+).
  • 2022-08-01 Whole body PET scan
    • Glucose hypermetabolism lesions in the left breast (Deauville score 5), compatible with lymphoma in the left breast.
    • Glucose hypermetabolism lesions in the left N-P region (Deauville score 5) and in bilateral axillary regions (Deauville score 3-4), the nature is to be determined (lymphoma or chronic inflammation/infection process ?), suggesting further investigation.
    • Glucose hypermetabolism lesions in bilateral pulmonary hilar regions, right mediastinal space, bilateral palatine tonsils, and left hip joint, probably benign in nature.
    • Lymphoma in the left breast, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2022-07-28 CT - lung
    • Left breast cancer with left hilar lymphadenopathy
  • 2022-07-14 Patho - breast biopsy
    • Breast, left, core biopsy — Diffuse large B-cell lymphoma, in favor of non-GCB type
    • Section shows cores of breast tissue with invasion of large, pleomorphic tumor cells.
    • The immunohistochemical stains reveal CK(-), CD20(+), CD3(-), CD10(< 10% +), BCL6(> 90%+), BCL2(> 80% +), MUM1(> 80% +), cMYC(30% +), Cyclin D1(-). The Ki-67 is >90% positive. The results are in favor of non-GCB type of diffuse large B-cell lymphoma.
  • 2022-07-12 SONO - breast
    • Diagnosis:
      • Highly suspicious of malignancy, with sonographic negative axillary LNs
        • clacification
        • lipomas
    • Plan:
      • Core-needle biopsy
    • Suggestion:
      • Regular OPD follow-upsonography guided core biopsy of L’t breast tumor (1,1)
      • BI-RADS 4A - low suspicion for malignancy Biopsy Should Be Considered
  • 2022-07-04 Mammography
    • A 2.8cm lobular hyperdense mass with obscured margin at left subareolar breast.
    • BI-RADS category 0, Need additional imaging evaluation.
    • Suggest ultrasound correlation for left breast tumor.

[consultation]

  • 2023-04-03 Vascular Surgery
    • Q
      • A case of Triple hit ,non-GCB type of diffuse large B-cell lymphoma of left breast, left nasopharyngeal, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1
        • will receive PBSC harvest this time, we need your expertise for double lumen insertion on 2023/04/14, thanks
    • A
      • I have had the pleasure of involving with the patient’s care. In brief, this patient is a 69 year old female seen in consultation for opinion regarding treatment options for double lumen insertion on 2023-04-14.
      • The pt’s hx/Dx was noted for
        • Diffuse large B-cell lymphoma, unspecified site
        • Essential (primary) hypertension
        • Chronic viral hepatitis B without delta-agent
      • Lab/CXR reviewed.
      • SUGGESTION & PLAN:
        • double lumen insertion will be arranged on R’t side on 2022/04/14 under LA, 8 AM.
  • 2023-02-09 Dermatology
    • Q
      • This 69 y/o woman has hypertentsion under medication control for 20+ years. She suffered from a 2.8cm lobular hyperdense mass with obscured margin at left subareolar breast mammography on 2022/07/05.
      • Owing to the symptom exacerbation, the patient called at our OPD for help. Breast sono showed highly suspicious of malignancy, with sonographic negative axillary LNs1 on 2022/07/16.
      • Biopsy on 2022/07/21 showed Diffuse large B-cell lymphoma, in favor of non-GCB type. CK(-), CD20(+), CD3(-), CD10(< 10% +), BCL6(> 90%+), BCL2(> 80% +), MUM1(> 80% +), cMYC(30% +), Cyclin D1(-). The Ki-67 is >90% positive. CT of chest was performed on 7/29 revealed Left breast cancer with left hilar lymphadenopathy.Port-A insertion on 2022/07/29. PET on 2022/08/01 showed glucose hypermetabolism lesions in the left breast, left N-P region, bilateral axillary regions, bilateral pulmonary hilar regions, right mediastinal space, bilateral palatine tonsils, and left hip joint, probably benign in nature. Bone marrow biopsy on 2022/08/02 showed negative of maglignancy. Under the diagnosis of Triple hit, non-GCB type of diffuse large B-cell lymphoma of left breast, left nasopharyngeal, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1.
      • She received C1 R-DAEPOCH (Vincristine not available) on 2022/08/03 ~ -08/08. C2 R-DAEPOCH was administered on 2022/08/29 ~ -09/03, C3 R-DAEPOCH on 2022/10/14 ~ 10/19.
      • Urgency and frequency was noted in August, 2022. Klebsiella pneumoniae urinary tract infection was noted.
      • Followed up CT on 2022/11/02 revealed resolution of Lt breast tumor compared with CT on 2022/07/28. extensive V-CAD,suggest further test for evaluation any hemodynamically significant stenosis of coronary arteries.
      • C4 R-DAEPOCH on 2022/11/14 ~ 2022/11/19.
      • She received the radiotherapy at 3240cGy/18 fractions of the left breast from 2022/12/6 ~ 12/31
      • However, Radiation dermatitis was noted after the radiotherapy. We need your expertise for further management,thanks
    • A
      • The patient had sufferred from itchy erythematous papules and plaques over left breat region.
      • Under the impression of post-radiation dermatitis
      • The following sugeetion:
        • keep oral allegra 1# bid use.
        • Rinderon-V cream 2 tube topical bid use over erytheamtous lesions first, if stable shift to Mycomb cream 1 tube bid use -> (Anti-inflammatory and redness-reducing)
          • body cream mix-up with sinphradem cream 1 tube (1:1) topical QN use.

[radiotherapy]

  • 2022-12-06 ~ 2022-12-31 - 3240cGy/18 fractions of the left breast

[chemoimmunotherapy] (not completed)

  • 2023-04-03 - rituximab 375mg/m2 598mg NS 500mL 8hr D1 + methylprednisolone 500mg NS 100mL 1hr D2-5 + etoposide 40mg/m2 63mg NS 250mL D2-5 + cisplatin 25mg/m2 40mg NS 500mL 18hr D2-5 + cytarabine 2000mg/m2 3000mg NS 500mL 2hr D6 (R-ESHAP)
    • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + NS 250mL D1-6 + acetaminophen 500mg PO D1 + palonosetron 250ug D2-6
  • 2023-02-10 - rituximab 375mg/m2 580mg NS 500mL 8hr D1 + [etoposide 50mg/m2 77mg + vincristine 0.4mg/m2 0.6mg + doxorubicin 10mg/m2 15mg + NS 250mL] 24hr D2-5 + cyclophosphamide 750mg/m2 1100mg NS 500mL 1hr D6 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-DAEPOCH)
    • dexamethasone 4mg D1-5 + diphenhydramine 30mg D1-5 + NS 250mL D1-5 + acetaminophen 500mg PO D1 + granisetron 2mg D2-6
  • 2023-01-12 - ditto R-DAEPOCH
  • 2022-11-14 - ditto R-DAEPOCH
  • 2022-10-14 - ditto R-DAEPOCH
  • 2022-08-29 - ditto R-DAEPOCH
  • 2022-08-03 - rituximab 375mg/m2 580mg 8hr D1 + etoposide 50mg/m2 77mg 24hr D2-5 + doxorubicin 10mg/m2 15mg 24hr D2-5 + cyclophosphamide 750mg/m2 1100mg 1hr D6 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-6 (R-DAEPOCH without vincristine)

[note]

Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in medically-fit patients (ref: https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients)

  • R-ESHAP (Rituximab, etoposide, methylprednisolone, cytarabine, cisplatin) ref: R-ESHAP as salvage therapy for patients with relapsed or refractory diffuse large B-cell lymphoma: the influence of prior exposure to rituximab on outcome. A GEL/TAMO study. Haematologica 2008; 93:1829.
    • Administration – R-ESHAP includes rituximab (375 mg/m2 on day 1), etoposide (40 mg/m2/day as a one-hour infusion on days 1 to 4), methylprednisolone (250 to 500 mg/day as a 15-minute infusion on days 1 to 5), cisplatin (25 mg/m2/day as a continuous infusion from day 1 to 4), and cytarabine (2 g/m2 as a two-hour infusion on day 5), every three or four weeks.
    • Adverse effects – Hematologic toxicity is universal, with significant rates of neutropenic fever (30 percent) if growth factors are not used. Other adverse effects (eg, nausea, vomiting, diarrhea, nephrotoxicity, electrolyte disturbances) are generally mild.
    • Outcomes – A retrospective study of 163 patients reported that ESHAP for relapsed DLBCL was associated with 75 to 86 percent ORR and 41 to 50 percent CR, while for primary refractory DLBCL, ORR was 33 percent and CR was 8 percent.

==========

2023-04-03

  • This time, the patient was admitted for PBSC collection.

2022-08-18

  • It is the first time the patient receive her first chemotherapy in this hospitalization.
  • 2022-08-17 CRP 7.2 mg/dL, 2022-08-18 01:14 body temperature 38.4 degree, Sintrix (ceftriaxone) and Mycostatin (nystatin) have been prescribed.

701134216

230403

[diagnosis] - 2023-04-01 admisstion note

  • Sepsis, unspecified organism
  • Fever, unspecified
  • Malignant neoplasm of rectosigmoid junction
  • Unspecified jaundice

[present illness] - 2023-04-01 admisstion note

  • The 57 y/o man has R-S colon with liver and bone mets s/p OP with colostomy on 2021 and closure it at Cardinal Tien Hospital in early 2023, chemotherapy also at that hospital, postive of anti-HBc.

[exam findings]

  • 2023-04-01 CT - abdomen
    • history: Rectal ca with liver mets and bone mets s/p OP with colostomy
    • With and without contrast enhancement CT of abdomen shows:
      • Recosigmoid colon CA, s/p operation.
      • Multiple lung metastasis.
      • Multiple liver metastasis.
      • Peritoneal nodules, r/o peritoneal carcinomatosis.
      • Enlarged lymph nodes in para-aortic region.
      • Mild compression fractures of L2,3,4.
    • Impression
      • Recosigmoid colon CA, s/p operation
      • Liver, lung, and lymph node metastasis
      • Peritoneal carcinomatosis
  • 2023-03-31 CXR
    • Multiple nodules at bil. lungs.
  • 2018-07-31 Fingers Rt
    • comminuted fracture of distal phalanx, 4th finger post pin fixation
  • 2018-06-19 Fingers Rt
    • fracture of distal phalanx, 4th finger post pin fixation, stable
  • 2018-06-15 Fingers Rt
    • Crush injury with distal phalange destruction is found.
    • Regional soft tissue swelling is identified.

[SOAP]

  • 2023-03-23 Hemato-Oncology
    • Admission for bilirubinemia then C/T
  • 2023-03-16 Hemato-Oncology
    • Last dose of Avastin plus FOLFOXIRI on 2023-03-09.
    • Apply cetuximab

[assessment]

  • The patient’s fever appears to have improved (with a temperature not exceeding 37.5 degrees Celsius) since the administration of Flumarin (flomoxef) on 2023-04-01. However, blood and urine cultures are not yet available.

  • The patient has a high bilirubin level and is icteric 2+. The elevation of serum alkaline phosphatase, which is out of proportion to the serum aminotransferases, indicates possible biliary obstruction or intrahepatic cholestasis. An increased serum alkaline phosphatase is also observed in granulomatous liver diseases, such as tuberculosis or sarcoidosis.

    • 2023-03-31 Alkaline phosphatase 996 U/L
    • 2023-03-31 S-GPT/ALT 50 U/L
    • 2023-03-31 Bilirubin direct 4.26 mg/dL
    • 2023-03-31 Bilirubin total 7.42 mg/dL
    • 2023-03-23 Bilirubin total 6.09 mg/dL
    • 2023-03-14 Bilirubin total 8.87 mg/dL
  • Based on the CT performed on 2023-04-01, there is evidence of liver, lung, lymph node metastasis, and peritoneal carcinomatosis. Further evaluation is recommended, such as ultrasound, magnetic resonance cholangiopancreatography (MRCP), or endoscopic retrograde cholangiopancreatography (ERCP) to investigate the presence of intra- or extrahepatic bile duct dilation.

  • The patient was prescribed Vemlidy (tenofovir alafenamide) appropriately following a positive anti-HBc test result on 2023-03-14.

  • According to PharmaCloud records, medications were prescribed for pulmonary symptoms at Cardinal Tien Hospital in January 2023. If these symptoms are no longer present, then there are no medication reconciliation issues.

700324624

230331

[diagnosis] - 2023-03-30 admission note

  • Malignant neoplasm of unspecified site of left female breast
  • Pleural effusion, not elsewhere classified
  • Acute pulmonary edema
  • Dyspnea, unspecified

[exam findings]

  • 2023-03-29 ECG
    • Atrial fibrillation
    • Low voltage QRS
    • Incomplete right bundle branch block
    • Possible Right ventricular hypertrophy
    • Possible Anterolateral infarct, age undetermined
    • Abnormal ECG
  • 2023-03-29 CTA - chest
    • Indication: Bilateral lower leg edema with shortness of breathing
    • With and Without contrast Chest CT and CTA showed
      • dilated main PA.
      • unremarkable change in the main bronchial trees and the visible trachea
      • consolidation in the lower lobes of the bilateral lung; two nodular lesions, about 17mm, in the upper lobe of the right lung; another small nodular lesion, about 14mm, in the upper lobe of the left lung.
      • moderate bilateral pleural effusion
      • unremarkable change in the chest wall
    • IMP:
      • nodular lesions in the upper lobes of the bilateral lung
      • moderate bilateral pleural effusion.
      • consolidation in the lower lobes of the bilateral lung.
      • no evidence of DAA or PE.
  • 2023-03-29 CXR
    • Unremarkable change in the visible trachea
    • Normal cardiac and vascular shadows
    • Lung markings: consolidation in the right lung field and left lower lung field
    • blurred bilateral hemidiaphrams
    • blunting bilateral costophrenic angles
    • Unremarkable change in bilateral clavicles

[assessment]

  • The patient’s renal function is showing signs of recovery.
    • 2023-03-31 Creatinine 0.91 mg/dL
    • 2023-03-29 Creatinine 1.33 mg/dL
    • 2023-03-31 eGFR 63.55
    • 2023-03-29 eGFR 41.01
  • On 2023-03-31, Ocillina (oxacillin sodium), Rolikan (sodium bicarbonate), and 0.9% saline were prescribed, which may relieve hyponatremia.
    • 2023-03-31 Na (Sodium) 131 mmol/L
    • 2023-03-29 Na (Sodium) 123 mmol/L
  • Hypokalemia was observed on the morning of 2023-03-31, which may be due to the administration of furosemide, which was started on 2023-03-30 after normal serum potassium was detected on 2023-03-29. There were 3 bowel movements without diarrhea recorded on 2023-03-30.
    • 2023-03-31 K(Potassium) 3.3 mmol/L
    • 2023-03-29 K(Potassium) 4.0 mmol/L
  • Please consider prescribing a potassium supplement if necessary and continue to closely monitor the patient’s serum electrolytes. An alternative option is to consider using the combination of furosemide and spironolactone with adequate sodium supplementation and blood pressure monitoring to prevent hypotension.

700892422

230331

[diagnosis] - 2023-03-10 discharge note

  • Squamous cell carcinoma of left upper lip cT4aN0M0 cstage IVA in process chemotherapy
  • Infection of the upper lip
  • Encounter for antineoplastic chemotherapy
  • Hypertension
  • Verrucous carcinom of right buccal mucosa and tongue post of 2017.

[exam findings]

  • 2023-02-01 Whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed two faint hot areas at the T7 and L2-3 spines, respectively, faint hot spots in both rib cages, and increased activity in the maxilla, C-spine, bilateral shoulders, S-I joints, hips, and knees, in whole body survey.
    • IMPRESSION:
      • Two faint hot areas at the T7 and L2-3 spines, respectively, the nature is to be determined (DJD, post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
      • Suspected benign lesions in both rib cages, maxilla, C-spine, bilateral shoulders, S-I joints, hips, and knees.
  • 2023-01-31 MRI - nasopharynx
    • Indication: Malignant neoplasm of upper lip, inner aspect
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • A upper lip tumor mass, up to 4.4 cm, with bone destruction.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • No evident abnormal enlarged lymph node in the visible neck.
      • Multiple oral cavity cancers s/p operation.
    • IMP: Upper lip CA, T4N0M0 Stage IVA.
    • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage) : T:T4A(T_value) N:0(N_value) M:M0(M_value) STAGE:IVA(Stage_value)
  • 2023-01-31 SONO - abdomen
    • GB stone, multiple
    • Adenomyomatosis of GB
  • 2023-01-30 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Inferior infarct , age undetermined
    • ST & T wave abnormality, consider lateral ischemia
    • Abnormal ECG
  • 2023-01-05 Patho - gingival/oral mucosa biopsy
    • Chronic red lesion, left upper lip, incisional biopsy — Cysts with focal opening and irregular epithelial hyperplasia, compatible with squamous cell carcinoma, well-diifferentiated
    • Microscopically, the sections show a picture of some subepithelial cysts with focal surface opening (fistula-like) lined by well-differentiated squamous cells and focal irregular epithelial hyperplasia with dyskeratosis as well as focal epithelial hyperplasia within inflamed and fibrous stroma. According to histopathologic finding and patient’s past history, it is compatible with well-diifferentiated squamous cell carcinoma.
  • 2019-06-19 MRI - nasopharynx
    • SOAP
      • S: He is a patient with double oral cancer at lip and cheek seperately and received operations.
      • O: oral ulcer with malignant potential on the inner surface of left upper lip is noted but improved after injection treatment.
      • A:
        • Dysplasia of right buccal mucosa (2018-01)
        • Verrucous carcinoma of right tongue (2017-05-10)
        • SCC of left buccal mucosa and retromolar area post OP (2015-04)
        • Verrucous carcinoma of right tongue border (2017-05)
        • Verrucous carcinoma of inner surface of left upper lip post OP (2015-04)
      • P
        • check BUN and creatinine before MRI examination
        • arrange MRI examination with contrast to evaluate undermining tumor status
    • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed using the protocol: pre-contrast coronal T1WI and T2WI (thickness=3 mm, gap=1 mm), sagittal T1WI (thickness=4 mm, gap=1 mm), axial T1WI and T2WI with FS (thickness=5 mm, gap=1 mm), and post-contrast coronal T1WI with FS (thickness= 3 mm, gap=1 mm), axial T1-WI (thickness=5 mm, gap=1mm) and sagittal T1WI (thickness= 4 mm, gap=1 mm) and show:
      • Post-operation change at left upper lip, left buccal region, and right tongue border, without abnormal soft tissue intensity, nor abnormal enhancement.
      • An oval-shaped nodular lesion, about 16 mm x 10 mm, at left supraclavicular region, r/o an enlarged lymph node, mildly enlarged as compared with MRI on 20180815. Suggest further evaluation and close follow-up.
      • No remarkable finding at nasopharynx, oropharynx, hypopharynx and larynx.
      • No remarkable finding at parotid, submandibular and sublingual glands.
      • No remarkable finding at skull base and visible intracranial structures.
      • Mucosal thickening in bilateral ethmoid and maxillary sinuses, indicating chronic paranasal sinusitis.
    • IMP: C/W multiple oral cavity cancers s/p operation, without evidence of recurrence based on this study. A suspicious enlarged lymph node at left supraclavicular fossa. Suggest further evaluation (such as PET) and close follow-up.
  • 2018-08-15 MRI - nasopharynx
    • CC: He is a patient with double oral cancer at lip and cheek seperately. He has mild pain at his left upper lip for few days. He also has rough surface lesions on his both cheeks for weeks and mouth-opening limitation for years. He had received cancer surgery on 2015-04. He wears unfitted denture.
    • Indication:
      • S: He is a patient with double oral cancer at lip and cheek seperately. He had received cancer surgery on 2015-04 and 2017-05. He wears unfitted denture.
      • O: ulceration on the left upper lip is noted. that is probablly due to unfit denture. abnormal scar tissue with fungus patches on the bil. buccal mucosa is noted.
      • A:
        • Dysplasia of right buccal mucosa (2018-01)
        • Verrucous carcinoma of right tongue (2017-05-10)
        • Dysplasia of right buccal mucosa,and the right lower lip (2017-05-10)
        • SCC of left buccal mucosa and retromolar area post OP (2015-04)
        • Verrucous carcinoma of right tongue border (2017-05)
        • Verrucous carcinoma of inner surface of left upper lip post OP (2015-04)
      • P:
        • Chech BUN and creatinine before MRI examination
        • Arrange MRI with contrast to evaluate the undermining tumor status
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration showed:
      • No abnormal mass lesion in the nasopharynx, oropharynx, hypopharynx or larynx.
      • No neck LAP.
      • Normal appearance of parotid, submandibular and thyroid glands.
      • Mild mucosal thickening of bilateral maxillary sinuses.
      • Mucosal thickening of rightinferior nasal turbinate.
    • Impression:
      • No obvious buccal or oropharynx mass or nodule.
  • 2017-11-20 MRI - nasopharynx
    • No obvious buccal or oropharynx mass or nodule.
  • 2017-05-10 Surgical pathology Level IV
    • Clinical diagnosis: Chronic periodontits
    • Patho DIAGNOSIS:
      • Labeled as “tumor of right buccal mucosa”, wide excision — Verrucous hyperplasia with submucosa fibrosis.
      • Labeled as “tumor of right tongue”, wide excision — Verrucous carcinoma, margin free of malignancy.
      • Tongue, right, wide excision — Verrucous carcinoma
      • Lymph node—- N/A.
      • Pathology stage: pT1Nx (cM0); pStage: I.
    • MACROSCOPIC EXAMINATION CHECKLIST
      • Surgical Procedure(s): wide excision
      • Specimen Type:
        • Main location: right tongue
        • Other part(s) included: right buccal mucosa
        • Lymph node dissection: no
      • Specimen Integrity: intact
      • Specimen Size: Greatest dimensions: right tongue: 1.2 x 0.9 x 0.35 cm.
        • Additional dimensions: right buccal mucosa: 1 x 0.8 x 0.4 cm.
      • Tumor Site: right tongue, Laterality : right
      • Tumor Focality : single focus
      • Tumor Size: Greatest dimension: 0.25 cm
        • Tumor thickness (for pT1 and pT2 tumors only): 1.5 mm
      • Mucosal Surface : Intact
      • Gross Tumor Extension : submucosa
    • MICROSCOPIC DESCRIPTION:
      • Section of the “tumor of right buccal mucosa” shows verrucous hyperplsia.
      • Section of the “tumor of right tongue” shows one piece of hyperkeratotic squamous mucosa with verrucous carcinoma 2.5 mm in width and 1.5 mm in depth. The tumor is 3. 2, 4, 3, and 2 mm away from the left, right, anterior, posterior and deep margins.
    • MICROSCOPIC EXAMINATION CHECKLIST:
      • Histologic Type: Verrucous carcinom
      • Histologic Grade: G1: Well differentiated
      • Microscopic Tumor Extension: submucosa
      • Margins: Margins free, Distance from closest margin: 3. 2, 4, 3, and 2 mm away from the left, right, anterior, posterior and deep margins.
      • Lymph-Vascular Invasion: not identified
      • Perineural Invasion: not identified
      • Neck Lymph Nodes: N/A.

[consultation]

  • 2023-02-01 Thoracic Surgery
    • Q
      • For port-A insertion
      • This is a 57 y/o male patient denied of HTN, CAD and DM major disease.
      • His oral tumor of left upper lip biposy reported cysts with focal opening and irregular epithelial hyperplasia, compatible with squamous cell carcinoma, well-diifferentiated (sample number: S2023-00290) on 2023-01-05.
      • His nasopharnyx MRI showed upper lip T4AN0M0 stage IVA.
      • His treatment plans were induction chemotherapy follow by surgery and CCRT.
      • He was admitted to ward for tumor work up and prepare induction chemotherapy.
      • We need your help for port-A insertion, Thanks!           
    • A
      • I will arrange insertion of port-A this week. Thanks for your consultation!

[SDM] - 2023-02-02

  • This afternoon, we had a meeting with Mr. Ding and his son to discuss the current status of his illness and future treatment options.
  • Dr. Xia:
    • Mr. Ding, your oral cancer examination has been completed. Currently, the diagnosis is stage III left upper lip oral cancer, which can be diagnosed by direct visual inspection or palpation. However, the magnetic resonance imaging (MRI) report shows that the cancer has invaded the adjacent maxilla bone, so it is stage IV left upper lip oral cancer. The purpose of this family meeting is to discuss your treatment options and the potential side effects of each treatment method. In general, your treatment for left upper lip oral cancer will include surgical resection of the tumor and removal of lymph nodes. Depending on the pathology report, radiotherapy may also be necessary after the surgery. Since your cancer is located in the left upper lip, we will take into consideration the future appearance, clarity of speech, and the side effects of lip dysfunction. Therefore, there are two treatment options that we can discuss, and we will arrange appropriate treatment according to your decision.
      • Treatment option 1: Directly remove the left upper lip oral cancer tumor by surgery. The advantage of this method is that it removes the cancer faster, and it makes the existence of left upper lip oral cancer invisible to the eyes and mind. However, the disadvantage of this method is that the tumor area removed is larger, which will affect your appearance in the future. Losing the upper lip will also affect the clarity of your speech, and you will lose the function of closing your lips, causing food and water to spill out while eating and drinking.
      • Treatment option 2: Use chemotherapy first to kill the left upper lip oral cancer cells. The advantage of this method is that if the chemotherapy is effective, it can shrink the tumor and reduce the surgical area in the future, thus reducing the impact on your appearance. It also reduces the impact on speech clarity and the chance of food and water spilling out while eating and drinking. The disadvantage of this method is that you will first face the side effects of chemotherapy, such as nausea, vomiting, diarrhea, decreased white blood cells causing infections, and even life-threatening conditions, anemia, hair loss, and weakness, etc. Have you and your family understood this?
  • Mr. Ding:
    • Yes, I have heard and understood. How effective is chemotherapy?
  • Dr. Xia:
    • Each person’s oral cancer cells have different characteristics, so the response to chemotherapy will also be different. Basically, about 80% of oral cancer patients respond well to chemotherapy, which can reduce the size of the oral cancer. However, we can only know if it works after injection, and cannot predict it in advance.
  • Mr. Ding:
    • I understand. How long will the chemotherapy last? How do I know if it is effective?
  • Dr. Xia:
    • This chemotherapy will last for about two months. We will treat you in cycles every three weeks, with three cycles in total, so the chemotherapy will last for a total of nine weeks. Simply put, chemotherapy is administered in the first and second weeks, and you will rest at home in the third week. Chemotherapy will resume in the fourth week, and so on. The entire chemotherapy process will last nine weeks. Two weeks after the end of chemotherapy (around the 11th week), you will undergo surgical treatment. I have a chemotherapy manual for you and your family to refer to. As for whether it is effective, it can only be known after injection, and the patient can feel and see whether the tumor has shrunk. So currently, I cannot know whether the chemotherapy will be effective for you.
  • Mr. Ding: What if chemotherapy is not effective?
  • Dr. Xia: I will schedule surgery to remove

[surgical operation]

  • 2017-05-10
    • Diagnosis: Severe dysplasia of right buccal mucosa with maliganant tendency
    • PCS code: 92014C Complicated extraction
    • Finding
      • Abnormal macule (patch) of erythroplakia 1cm x1.5cm at right buccal mucosa WAS NOTED.
      • Abnormal mass on the right tongue 0.5cm x0.5cm WAS NOTED.
      • Severe trismus is noted
      • Enlongation and caries of 17 16 25 34 32 33 34 48 47

[chemotherapy]

  • 2023-03-31 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 800mg/m2 1500mg NS 500mL 22hr + leucovorin 80mg/m2 150mg (in 5-FU drip)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-03-22 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 900mg/m2 1700mg NS 500mL 22hr + leucovorin 90mg/m2 170mg (in 5-FU drip)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-03-06 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 900mg/m2 1700mg NS 500mL 22hr + leucovorin 90mg/m2 170mg (in 5-FU drip)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-27 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 900mg/m2 1700mg NS 500mL 22hr + leucovorin 90mg/m2 170mg (in 5-FU drip)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-13 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 900mg/m2 1700mg NS 500mL 22hr + leucovorin 90mg/m2 170mg (in 5-FU drip)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-03 - docetaxel 40mg/m2 80mg NS 200mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 3hr + fluorouracil 1000mg/m2 2000mg NS 500mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg

Induction chemotherapy should be used when chemotherapy occurs before radiation therapy. The term neoadjuvant chemotherapy should be used to refer to chemotherapy before surgery. ref: https://www.healthline.com/health/cancer/induction-chemotherapy

[assessment]

  • The patient has received (planned total 9-dose) TPF neoadjuvant regimen on 6 occasions, specifically on 2023-02-03, 2023-02-13, 2023-02-27, 2023-03-06, 2023-03-22, and 2023-03-31 (the 6th time during this hospitalization). There was only one episode of WBC less than 3K/uL, which occurred on 2023-02-10, approximately 1 week after the first dose. Otherwise, no other episodes of low WBC count were observed.

    • 2023-03-29 WBC 3.84 x10^3/uL
    • 2023-03-20 WBC 3.46 x10^3/uL
    • 2023-03-10 WBC 4.19 x10^3/uL
    • 2023-03-06 WBC 4.86 x10^3/uL
    • 2023-02-27 WBC 4.16 x10^3/uL
    • 2023-02-17 WBC 3.63 x10^3/uL
    • 2023-02-13 WBC 6.36 x10^3/uL
    • 2023-02-10 WBC 2.80 x10^3/uL
    • 2023-01-31 WBC 5.32 x10^3/uL
  • The TPF regimen was appropriately dose reduced from the second dose, with docetaxel at 32mg/m2 instead of 40mg/m2, cisplatin at 32mg/m2 instead of 40mg/m2, and fluorouracil at 900-800mg/m2 instead of 1000mg/m2. G-CSF was also used in a timely manner.

  • According to the latest information, there are no moderate or severe complaints for the patient about adverse reactions.

  • By the way, there is a decreasing trend in HGB, which indicates that the HGB does not seem to be fully recovered at the current administration interval/frequency. Please continue monitoring and check for need for blood transfusion for the next 3 scheduled doses.

    • 2023-03-29 HGB 9.9 g/dL
    • 2023-03-20 HGB 10.7 g/dL
    • 2023-03-10 HGB 11.4 g/dL
    • 2023-03-06 HGB 10.9 g/dL
    • 2023-02-27 HGB 12.6 g/dL
    • 2023-02-17 HGB 12.2 g/dL
    • 2023-02-13 HGB 13.8 g/dL
    • 2023-02-10 HGB 15.5 g/dL
    • 2023-01-31 HGB 14.0 g/dL

701469037

230331

[diagnosis] - 2023-03-09 admission note

  • Hypopharyngeal squamous cell carcinoma with tonge involvement, bilateral cervical lymph nodes, liver and multiple bones metastases, cT4aN2cM1, stage IVC s/p chemotherapy with with PF (CDDP 75mg/m2 D1 + 5-Fu 1000mg/m2 D1-4) from 2023/02/07~
  • Chronic viral hepatitis B without delta-agent
  • Constipation, unspecified
  • Hypercalcemia
  • Hypomagnesemia
  • Hyponatremia

[lab data]

  • 2023-01-30 HBsAg Reactive
  • 2023-01-30 HBsAg (Value) 686.57 S/CO
  • 2023-01-30 Anti-HCV Nonreactive
  • 2023-01-30 Anti-HCV Value 0.13 S/CO
  • 2023-01-30 HIV Ab-EIA Nonreactive
  • 2023-01-30 Anti-HIV Value 0.06 S/CO
  • 2023-01-30 Anti-HBc Reactive
  • 2023-01-30 Anti-HBc-Value 8.95 S/CO
  • 2023-01-30 Anti-HBs 6.17 mIU/mL

[exam findings]

  • 2023-03-30 CT - abdomen
    • The CT scan of the whole abdomen was performed without/with IV contrast medium enhancement and revealed that:
      • Known a case of right hypopharyngeal cancer. Still presence of this tumor at right pyriform sinus. One enlarged node (4.4cm) over right level IV of neck.
      • Multiple liver metastases.
      • Minimal ascites.
      • Focal atrophy of left kidney with stone (2mm).
      • Small amount of bilateral pleural effusion.
      • Multiple osteoblastic lesions of T-L spine, may be metastatic lesions.
      • S/P N-G tube insertion.
  • 2023-03-09 CXR
    • Mild Increased infiltration over both lower lungs. May be active infection.
  • 2023-02-06 Patho - colorectal polyp
    • Colorectum, descending colon (60 cm from anal verge), Polypectomy — Tubular adenoma with low grade dysplasia
    • Colorectum, rectum Size (10 cm from anal verge), Biopsy removal — Tubular adenoma with low grade dysplasia
  • 2023-02-02 CT - abdomen
    • History and indication: left tongue cancer, cT4aN2CM0, echo with multiple liver lesionfor liver tumors, suspected HCC, suspected metastasis
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Multiple liver metastases.
      • Minimal ascites.
      • Focal atrophy of left kidney with stone (2mm).
      • S/P NG tube indwelling.
    • IMP:
      • Multiple liver metastases.
  • 2023-02-01 Whole body PET scan
    • Glucose-hypermetabolism in the right hypopharynx, compatible with the primary hypopharyngeal cancer.
    • Glucose-hypermetabolism in the middle to basal aspect of tongue and bilateral cervical lymph nodes, highly suspected advanced cancer with regional lymph nodes involvement.
    • Glucose-hypermetabolism in both lobes of the liver and multiple bones, highly suspected cancer with distant metastases.
    • Hypopharyngeal cancer with tonge involvement, bilateral cervical lymph nodes, liver and multiple bones metastases, cT4aN2cM1, stage IVC (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-02-01 Patho - esophageal biopsy
    • Labeled as “esophagus, 35 cm below incisor”, biopsy — squamous mucosa with high grade dysplasia.
    • Section shows squamous mucosa with high grade dysplasia.
    • The possibility of a more advanced lesion cannot be excluded. Please correlate with clinical, and if available, image findings. Further work up might be considered.
  • 2023-01-31 Patho - larynx biopsy
    • Labeled as “right hypopharyngeal tumor”, biopsy — squamous cell carcinoma.
    • IHC stains: p16(+, 95%), CK5/6 (+), p40 (+), Ki-67 (90%).
  • 2023-01-31 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A
    • Suspected esophageal mucosal lesion, L/3, s/p biopsy
    • Esophageal inlet patch, U/3
    • Superficial gastritis
    • C/W hypopharyngeal cancer
  • 2023-01-31 SONO - abdomen
    • multiple hepatic tumors, both lobe
  • 2023-01-30 ECG
    • Sinus tachycardia with short PR
    • Right atrial enlargement
    • Nonspecific ST abnormality
    • Abnormal QRS-T angle, consider primary T wave abnormality
    • Abnormal ECG
  • 2023-01-30 Laryngoscopy
    • right hypopharyngeal tumor
  • 2023-01-26 Nasopharyngoscopy
    • Findings:
      • smooth NPx; right hypopharyngeal mass involved right AE fold, pyriform sinus and laryngx with airway narrowing
    • Diagnosis/Conclusion
      • right hypopharyngeal tumor, favor malignancy
      • left tongue cancer
  • 2023-01-24 CT - neck
    • Neck CT with and without IV contrast enhancement shows:
      • Soft tissue mass occupying hypopharynx more on right side measuring 4.9cm with partially obliteration of the supraglottic airway is found. Some lymphadenopathy at bilateral neck mostly at right neck is found.
      • Abnormal necrotic lesion at tongue about 4.65cm in largest dimension is found.
      • Mild wall thickeing at upper third esophagus is found.
      • Intact bony alignment over cervical spine
    • Imp:
      • Probably tongue cancer with bilateral neck lymphadenopathy and hypopharyngeal exntesion.
    • Imaging Report Form for Oral Cavity Carcinoma
      • T4aN2c
  • 2023-01-24 Nasopharyngoscopy
    • Findings:
      • ulcerative and fragile tissue over posterior tongue (easy bleeding during examination, status post bosmin compression)
      • 3 cm whitish leision over right retromolar trigone region, no bulging over bilateral peritonsilar region or uvular deviation
      • smooth nasopharynx, oropharynx, no pharyngeal wall bulging
      • tumor mass over right hypopharynx
    • Diagnosis/Conclusion
      • mass lesion over posterior tongue, right retromolar trigone region, right hypopharynx
  • 2023-01-19 Pathology (at TuCheng Hospital)
    • SNOMED: 53000-A-M80703
    • DX: Tongue, “posterior”, incisional biopsy — squamous cell carcinoma
    • GROSS D: The specimen submitted consists of a piece of tissue measuring 0.7 x 0.5 x 0.3 cm. Submitted in toto. LYC
    • MICRO D: Sections show squamous mucosa with invasive nests of tumor cells displaying squamous differentiation.

[consultation]

  • 2023-02-26 Hemato-Oncology
    • Q
      • Consultation for take over and chemotherapy.
      • This 48 year-old man is diagnosed of (1) left tongue squamous cell carcinoma T4aN3bM1, stage IVc and (2) right hypopharyngeal squamous cell carcinoma T3-4aN3bM1, stage IVc.
      • After discussing with him and his family, he decided to undergo chemotherapy. Colonoscopy is arranged on 2023/02/06 10:30 due to hyperdensity lesion over upper rectum in abdominal CT.
      • We need your expertise to take over this patient and start chemotherapy as your plan. Thank you very much!
    • A
      • According to tumor board discussion, please arrange colonoscopy due to hyperdensity lesion over upper rectum in abdominal CT r/o colonrectal cancer.
      • In addition, please arrange 24 urine CCR and auditory test. Please book 11A and transfer to our service. Thanks for your consultation.
  • 2023-01-24 Ear Nose Throat
    • A
      • S
        • Sorethroat for a month
        • Right neck progressive swelling for a week
        • A(+)/B(-)/C(+, 1 PPD for 20 years)
        • voice change (+, for a month), trismus (-), oral bleedeing (-), dyspnea (- **), otalgia (-), fever (-), dysphagia (+, mild)
        • Posterior tongue SCC diagnosed at 土城 hospital on 2023/01/16
      • O
        • Oral cavity and oropharynx: ulcerative and fragile tissue over posterior tongue (easy bleeding during examination, status post bosmin compression)
          • 3 cm whitish leision over right retromolar trigone region, no bulging over bilateral peritonsilar region or uvular deviation
        • Neck : 6 cm non-movable painful firm mass over right neck level III-V region
        • Scope: smooth nasopharynx, oropharynx, no pharyngeal wall bulging
          • tumor mass over right hypopharynx
        • CT: heterogenous mass lesion over posterior tongue, right hypopharynx
          • mild deviated but still visible air way, 3 cm heterogenous mass lesion over right neck
      • A
        • Posterior tongue squamous cell carcinoma
        • Mass lesion over right hypopharynx, r/o metastasis, r/o second primary tumor
        • Right neck heterogenous mass, r/o metastasis
      • P
        • prohylatic antibittics with augmentin, keep oral hygeine with parmason, and adequate pain control (acetaminophen, ultracet, or self-paid comfflam) if no contraindication
        • ENT OPD f/u on 2023/01/26 AM
        • Well education. if disease progression (bleeding, short of breath…), back to ER soon

[SOAP]

  • 2023-03-23 Hemato-Oncology
    • Tx Plan: Neoadjuvant TPF followed by CCRT
    • Cancer Multidisciplinary Team Meeting Conclusion
      • Meeting Date: 2023-02-03
      • Treatment Plan:
        • Systemic therapy + Local radiation therapy.
        • Team consensus: Tongue + Hypopharynx: cT4aN3bM1, IVC.

[chemotherapy]

  • 2023-03-09 - cisplatin 75mg/m2 110mg NS 500mL 24hr + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1500mg 24hr D1-4
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-07 - cisplatin 75mg/m2 110mg NS 500mL 24hr + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1500mg 24hr D1-4
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-03-31

2023-03-30 CRP 18.82mg/dL, WBC 12.95K/uL, urine bacteria 1+, urine protein 1+. Blood culture results are not yet available.

There have been no medication reconciliation issues found in the patient. (PharmaCloud not accessible)

2023-03-10

  • The patient is undergoing the PF regimen treatment for the second time during this hospital stay and did not experience discomfort symptoms within two weeks after the previous chemotherapy.
  • Lab results (2023-03-09) indicate the presence of hypercalcemia (2.78mmol/L), hypomagnesemia (1.6mg/dL), and hyponatremia (130mmol/L).
    • Cisplatin treatment is known to cause hyponatremia, hypomagnesemia, and hypocalcemia, as noted in “Electrolyte Disorders Induced by Antineoplastic Drugs” (Front Oncol. 2020;10:779. Published 2020 May 19. doi:10.3389/fonc.2020.00779).
    • Hypercalcemia, which is typically caused by increased osteoclastic bone resorption and affects up to 10 to 30% of cancer patients (ref: Electrolyte disorders with platinum-based chemotherapy: mechanisms, manifestations and management. Cancer Chemother Pharmacol. 2017;80(5):895-907. doi:10.1007/s00280-017-3392-8), has been confirmed to be present due to bone metastases. If this causal relationship is confirmed, the primary treatment approach would be to administer intravenous bisphosphonates. However, it’s worth noting that this treatment may potentially lower magnesium levels as well.

700029976

230330

[present illness] - 2023-03-29 admission note

This is 77-year-old man who has past medical history of Raynaud phenomenon, Diabetes Type II, right lung adenocarcioma RLL status post VATS wedge resection, prostatic cancer status post TURP under regular oral endoxan and prednisolone. This time, he complained of dyspnea for days, OPD CXR showed right pleural effusion. Loss 5 kg due to poor appetite in one month according to himself. He was admitted to our ward for further evalation and treatment.

[past history]

  • Raynaud phenomenon
  • Waldenstrom’s macroglobulinemia
  • Diabetes Type II
  • right lung adenocarcioma RLL status post VATS wedge resection
  • prostatic cancer status post TURP

[allergy]

  • NKDA         

[family history]

  • Dad and mum have diabetes mellulitus.
  • Denied any cancer history.

[SOAP]

  • 2023-03-15 Hemato-Oncology
    • BT with PRBC 2 U today
  • 2023-02-09 Urology
    • Malignant neoplasm of prostate
    • PSA every six months
  • 2023-02-01 Hemato-Oncology
    • BT with PRBC 2 U today
  • 2023-01-11 Hemato-Oncology
    • Waldenstrom macroglobulinemia. (IgM myeloma less likely)
    • hold endoxan and continue steroid therapy
    • continue surgar control.
    • suggest keep warm and OPD follow up.
    • suggest mabthera therapy if continue elevation of IgM

[medication]

  • 2022-04-06 ~ undergoing - Endoxan (cyclophosphamide)

[assessment]

  • The patient has been under follow-up in our Hemato-Oncology OPD due to extremely high IgM levels and was diagnosed with Waldenstrom macroglobulinemia. Cyclophosphamide treatment was initiated in April 2022.
  • The patient’s IgM levels decreased from approximately 7000 mg/dL in Q2/Q3 2021 to approximately 3000 mg/dL in Q2 2022 and have been around 2500 mg/dL since then. However, LDH levels have remained consistently high, with a record high of 1004 U/L in Q1 2023. The patient’s serum glucose levels have fluctuated between 100-200 mg/dL during the same period.
  • The current prescription is appropriate and further evaluation is ongoing.

700199716

230330

[diagnosis] - 2023-03-06 admission note

  • Malignant neoplasm of endometrium
  • Endometroid carcinoma with marked squamous differentiation, pT1aN1mi; stage III C1; FIGO stage IIIC1
  • Polycystic ovarian syndrome
  • Iron deficiency anemia, unspecified

[past history]

  • Heart:(-)

  • Liver:(-)

  • Kidney:(-)

  • H/T:(-)

  • DM:(-) Other

  • DVT 2 years ago

  • medication: Rivaroxaban regularly and had taken Leuplin

  • Surgical: denied

  • Menstrual history: G0P0, Last menstrual period: 2022-09-25

  • sex –

  • Menarche at the age of 12 years old

  • Menstrual cycle:irregular with duration of 7 days

  • Amount: moderate with blood clots

  • Pap smear: denied                

[allergy]

  • NKDA                       

[family history]

  • There is no family history of cancer,hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-03-07 CT - abdomen
    • Clinical history: 49 y/o female patient with endometroid carcinoma with marked squamous differentiation, pT1aN1mi; stage III C1; FIGO stage IIIC1.
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P hysterectomy. Mild fatty infiltrates in the pelvic cavity, could be due to post-op change, suggest follow up.
      • Presence of gallbladder stones.
      • Suspected right renal cyst, 0.58cm.
    • Impression:
      • S/P hysterectomy. Mild fatty infiltrates in the pelvic cavity, could be due to post-op change, suggest follow up.
      • GB stones.
      • Suspected right renal cyst.
    • 2022-11-16 Peripheral Vascular Test: Vein , lower limbs
      • Chronic DVT, mild intramural thrombus involved left popliteal vein with revascularization
      • Right LSV mild reflux, involved right sphenofemal junction(SFJ); with some small varicose veins(LSV) at right lower legs
      • Rigth CFV trivial reflux
      • Left LSV mild reflux, involved left sphenofemal junction(SFJ); with some small varicose veins(LSV) at right lower legs
      • Left CFV trivail reflux
      • Both SSV without reflux
    • 2022-10-31 CT - chest
      • no abnormality of both lungs and mediastinum.
    • 2022-10-26 Patho - ovary (tumor)
      • PATHOLOGIC DIAGNOSIS
        • Uterus, endometrium, LAVH — Endometroid carcinoma with marked squamous differentiation
        • Lymph nodes, pelvic, bilateral, BPLND — Metastatic carcinoma
        • AJCC 8 th edition, Pathology stage: pT1aN1mi; stage IIIC1; FIGO stage IIIC1
      • MACROSCOPIC EXAMINATION
        • Procedure: LAVH + BSO + BPLND
        • Specimen Size: 10.7 x 9.5 x 3.8 cm (uterus), 3 x 2 x 2 cm (Rt ovary), 4.5 x 0.8 cm (Rt tube), 3 x 2 x 2 cm (Lt ovary), 4.5 x 0.8 cm (Lt tube)
        • Specimen Integrity: Intact
        • Tumor Site: Endometrium
        • Tumor Size: Diffusely thickened, up to 2.0 cm in thickness
        • Lymph Nodes: Four groups including left iliac, left obturator, right iliac, right obturator
        • Representative parts are taken for section and labeled as: A= left iliac LNs, B= left obturator LNs, C= right iliac LNs, D= right obturator LNs, E1-E2= left ovary and fallopian tube, F1-F2= left ovary and fallopian tube. F2022-00502FSA1-FSA2= tumor, A1=cervix, A2= cervix + tumor, A3= parametrium, A4-A6= uterine corpus.
      • MICROSCOPIC EXAMINATION
        • Histologic Type: Endometroid carcinoma with marked squamous differentiation
        • Histologic Grade: FIGO grade 1
        • Myometrium Invasin: Present
          • Depth of Invasion: 11 mm
          • Thickness of Myometrium: 25 mm
        • Adenomyosis: Present
        • Uterine Serosal Involvement: Not identified
        • Cervical Stromal Involvement: Not identified
        • Other Tissue/Organ Involvement: Not applicable
        • Peritoneal/Ascitic Fluid: Not submitted
        • Margins: Uninvolved by carcinoma
          • Distance of invasive carcinoma from closest margin: 1.8 cm
        • Lymphvascular Invasion: Present
        • Regional Lymph Nodes: Metastatic carcinoma
          • number of lymph node examined: 7 (left iliac), 4 (left obturator), 4 (right iliac), 8 (right obturator)
          • number with metastases >2 mm: 0
          • number with metastases >0.2 mm and <=2 mm: 2 (left iliac), 1 (left obturator)
          • number with isolated tumor cells (<=0.2mm): 3 (left iliac), 2 (left obturator)
        • Pathologic Stage
          • Primary Tumor: pT1a (tumor limited to endometrium or less than half of myometrium)
          • Regional Lymph Nodes: pNmi (regional lymph node metastasis > 0.2 mm but <= 2 mm)
          • Distant Metastasis: Not applicable
        • FIGO Stage: Stage IIIC1
        • Additional Pathologic Findings
          • Cervix: Chronic cervicitis
          • Myometrium: Adenomyosis
          • Ovaries, bilateral: No remarkable change
          • Fallopian tubes, blateral: No remarkable change
    • 2022-10-26 Frozen Section
      • Uterus, frozen section — Malignant (endometroid carcinoma)
    • 2022-10-03 MRI - pelvis
      • Findings
        • Diffuse thickening endometrium, endometrial hyperplasia?
        • There are cysts in bilateral adnexa, could be due to ovarian cysts.
        • There are cysts in the uterine cervical region, suggesting Nabothin cysts.
        • There are lymph nodes in bilateral obturator regions, suggest follow up.
        • Non-enhancing nodules in right kidney(up to 1cm), r/o right renal cysts.
      • Impression
        • Diffuse thickening endometrium, endometrial hyperplasia or tumor? Suggest clinical correlation.
        • Nabothin cysts.
        • Bilateral obturator lymph nodes, suggest follow up.
      • Imaging Report Form for Endometrial Carcinoma
        • Impression (Imaging stage) : T:T1a(T_value) N:N1(N_value) M:M0(M_value) STAGE:IIIc(Stage_value)
    • 2022-09-15 Patho - endometrium curretage/biopsy
      • Uterus, endometrium, D&C — atypical endometrial hyperplasia with squamous differentiation
      • Microscopically, sections show atypical endometrial hyperplasia composed of complex atypical hyperplasia of endometrial glands with increased glandular complexity and glandular crowding with squamous metaplasia and nuclear atypia.
      • Immunohstochemical stain reveals p16(+), p53(patchy+, wild -type), vimentin(+), CEA (focal +).
    • 2022-09-15 Patho - endometrium curretage/biopsy
      • Uterus, endocervix, ECC — Squamous cell metaplasia with atypia
      • Microscopically, it shows hyperplasia of squamous cells with focal nuclear atypia.
      • Immunohistochemical stain reveals p16(+), p53(patchy+, wild-type), vimentin(+).
    • 2022-05-27, 2021-11-12, 2021-04-23, 2020-08-14 Gynecologic ultrasonography
      • LT adnexae: free
      • adenomyosis
    • 2020-11-16 Peripheral Vascular Test: Vein, lower limbs
      • Acute venous thrombosis from left ostial SFV to distal SFV with minimal recanalization at ostial and proximal SFV; acute venous thrombosis at left popliteal vein with minimal recanalization. Left ATV wasn’t seen. Patent left PTV and LSV.
      • No evidence of venous thrombosis at right lower limb venous systems.
      • Mild venous reflux at right saphenofemoral junction with no varicose change of right LSV.
      • The ratios of MVO and SVC were within normal limtis.

[surgical operation]

  • 2022-10-26
    • Surgery
      • Diagnosis
        • D&C show atypical endometrial hyperplasia with squamous differentiation
        • LAVH then sent uterus for frozen section. => Frozen: Malignant (endometroid carcinoma)
      • Operation:
        • Laparoscopic gynecologic oncology staging surgery        
    • Finding
      • Uterus: normal size, smooth surface, papillary mass in uterus cavity, myometrium invasion depth <1/2
      • Bilateral adnexa: grossly normal
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • CDS: free
      • Estimated blood loss: 100 ml
      • Blood transfusion: nil
      • Complication: nil
  • 2022-09-15
    • Surgery
      • D&C, theraputic and for diagnostic (D&C: Dilatation and Curettage)
    • Finding
      • Uterus: Anteversion, 8 cm.
      • some endometrial tissue were curetted out.
      • Estimated blood loss: 5 mL, Blood transfusion: nil, complication: nil.    

[radiotherapy]

  • 2022-11-30 ~ undergoing - at 2160cGy/12 fractions of the pelvic area.

[chemotherapy]

  • 2023-03-06 - paclitaxel 175mg/m2 330mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-02-09 - paclitaxel 175mg/m2 330mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-01-12 - paclitaxel 160mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-12-19 - paclitaxel 160mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-11-29 - paclitaxel 160mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famodidine 20mg + NS 250mL

==========

2023-03-30

On 2023-03-29, the patient’s lab results indicated generally normal blood cell counts, selected electrolytes, and liver/kidney functions. There is no evidence that contraindicates the scheduled chemotherapy. The patient was diagnosed with acute embolism and thrombosis of the femoral and iliac veins on 2020-11-16 and has been taking Xarelto (rivaroxaban) for this condition. After reviewing the PharmaCloud database, no medication reconciliation issues were identified.

2023-03-07

After a leukopenia event (WBC 1.65K/uL on 2022-12-31), all subsequent data showed WBC counts above 5K/uL. Since receiving paclitaxel + carboplatin regimen in late November 2022, there have been no observations of anemia and/or thrombocytopenia. The patient is currently taking rivaroxaban as a self-carried medication due to a history of DVT. No medication reconciliation issues were found during this hospital stay.

2022-12-20

Based on the lab results (2022-12-19), the scheduled chemotherapy did not appear to be contraindicated.

700805458

230330

[diagnosis] - 2023-03-03 admission note

  • Malignant neoplasm of nasopharynx, unspecified
  • Chronic mucoid otitis media, right ear
  • Gastro-esophageal reflux disease with esophagitis
  • Gastritis, unspecified, without bleeding
  • Postmenopausal atrophic vaginitis
  • Unspecified cirrhosis of liver

[past history]

  • Thyroid papillary cancer status post thyroidectomy in 2008
    • Eltroxin 50mg 3# po QW2,4,6
    • Eltroxin 50mg 2# po QW1,3,5,7
  • Hepatitis B virus infection under medical treatment
    • Vemlidy 1# po QDAC
  • Polyarthralgia under medical treatment  
    • Plaquenil 1# po QOD

[allergy]

  • Omnipaque (iohexol): skin rash

[family history]

  • There is no family history of cancer, diabetes, hypertension, mental diseases or asthma.

[exam findings]

  • 2023-03-03 Gynecologic ultrasonography
    • bilateral adnexae: free
    • IMP: adenomyosis
  • 2023-02-23 Patho - cervix/endometrial polyp
    • Uterus, endometrium, TCR-P— Endometrial polyp with decidual reaction
  • 2023-02-17 Hysteroscopy
    • OBS/GYN history: G 2 P 2 A ____ LMP ____
    • HSC indication/Pre-exam impression: suspect EM lesion
    • Procedure: Under lithotomy position, HSC exam was performed smoothly
    • Hysteroscopy No. : HYF-XP
    • Finding:
      • Endometrial cavity:
      • Endocervix: WNL
      • Fundus: obliterated with polyp
      • Right tubal ostium: obliterated with polyp
      • Left tubal ostium: obliterated with polyp
    • Post-exam impression: endometrial polyp
      • EBL:minimal , Complication: Nil , BT: Nil
  • 2023-02-13 Whole body PET scan
    • No previous study for comparison.
    • The lesion in the right petrous bone shown on the previous MRI of nasopharynx reveals very mildly increased FDG uptake, compatible with NPC s/p R/T.
    • Glucose-hypermetabolism in the esophagus, probably chronic inflammation process.
    • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    • NPC s/p treatment, no evidence of residual, recurrent or metastatic tumor, by this F-18 FDG PET scan.
  • 2023-02-11 SONO - abdomen
    • Cirrhosis of liver
    • GB stones/polyp, multiple
    • Hepatic cysts
    • Splenomegaly
  • 2023-02-10 Nasopharyngoscopy
    • Findings
      • bulging tumor over rt NP, subside
    • Diagnosis/conclusion
      • NPC, cT4N0M0 s/p CCRT
  • 2023-02-10 Gynecologic ultrasonography
    • LT adnexae:free
    • IMP
      • Adenomyosis
      • Uterine myoma
      • EM: 11.5mm, suspect endometrial thickening
  • 2023-02-02 MRI - nasopharynx
    • The current study was compared to the prior one obtained on 2022/09/08.
    • Abnormal soft tissue intensity and enhancement involving right cavernous sinus, foramen lacerum, foramen ovale, carotid canal, petrous bone, longus colli muscle and medial pterygoid muscle.
    • Regression of most of the lesion involving right nasopharynx and paraspinal space, but mild progression of the lesion involving right petrous bone around carotid canal.
    • Favor residual tumor with progression.
  • 2023-02-02 SONO - abdomen
    • Right liver cysts (3.57x4.19cm, 1.26x1.32cm).

    • Gallbladder stones (3-5mm).

    • 2023-01-06 SONO - thyroid gland.

      • no evidence of mass lesion.
    • 2023-01-06, 2022-12-02, -10-28 Nasopharyngoscopy

      • Findings: bulging tumor over rt NP, subside
      • Summary: NPC, cT4N0M0 s/p CCRT
    • 2022-11-24 Gynecologic ultrasonography

      • Uterine myoma
      • Endometrial thickening, EM: 11.4mm
    • 2022-11-16 CT - abdomen

      • Findings:
        • There are two hepatic cysts 4.5 cm in S8/4 and 1.1 cm in S6.
        • There are multiple gallstones.
        • The liver shows mild irregular contour that may be early cirrhosis or normal variation.
        • There is suspicious endometrium or myometrium lesion in the uterus. Please correlate with GYN. sonography.
      • IMP:
        • Two hepatic cysts 4.5 cm in S8/4 and 1.1 cm in S6.
        • Multiple gallstones.
        • Early cirrhosis of the liver is suspected.
        • There is suspicious endometrium or myometrium lesion in the uterus. Please correlate with GYN. sonography.
    • 2022-09-08 MRI - nasopharynx

      • Indication: NPC s/p TPF
      • Findings:
        • Abnormal soft tissue intensity and enhancement involving right cavernous sinus, foramen lacerum, foramen ovale, carotid canal, petrous bone, longus colli muscle and medial pterygoid muscle. Regression of most of the lesion involving right nasopharynx and paraspinal spce, but mild progression of the lesion involving right petrous bone around carotid canal.
        • Mottled T2-hyperintensity in right mastoid air cells, indicating mastoiditis.
      • IMP:
        • NPC s/p treatment, partial regression of most of the tumor, but with mild progression of the lesion in petrous bone, as compared with MRI on 20220426.
    • 2022-09-01, -06-02 SONO - abdomen

      • Cirrhosis of liver
      • GB stones/polyp, multiple
      • Hepatic cysts
      • Splenomegaly
    • 2022-06-14 ECG

      • Normal sinus rhythm
      • Nonspecific T wave abnormality
      • Abnormal ECG
    • 2022-06-14 CXR

      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
    • 2022-06-14 PTA

      • Reliability FAIR
      • Average RE 78 dB HL; LE 29 dB HL.
      • R’t moderately severe to profound mixed type HL.
      • L’t normal to moderate HL. (BC masking dilemma)
    • 2022-04-28 Tc-99m MDP whole body bone scan

      • The Tc-99m MDP bone scan at 4 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the skull base, L3-4 spines, bilateral shoulders, knees and both feet in whole body survey.
      • IMPRESSION:
        • Increased activity in the skull base. Malignancy with local bony involvement may show this picture. Please correlate with other imaging modalities for further evaluation.
        • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
        • Mildly increased activity in the L3-4 spines. Degenerative spine disease is more likely.
        • Increased activity in bilateral shoulders, knees and both feet, compatible with benign joint lesions.
    • 2022-04-28 Gynecologic ultrasonography

      • Bilateral adnexae: free
      • Uterine myoma
    • 2022-04-27 Panendoscopy

      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, body, s/p CLO test
      • Gastric erosion, antrum, LC site
    • 2022-04-27 SONO - abdomen

      • Cirrhosis of liver with splenomegaly
      • Hepatic cysts
      • GB stones/polyp
      • Suboptimal study
    • 2022-04-26 MRI - nasopharynx

      • Indication: Nasopharyngeal carcinoma for cancer work up
        • Allergy to contrast
      • Findings
        • A large lobuated right NPx tumor mass, up to 4.3 cm, invasion of skull base, parapharyngeal space, and foramen of Ovale, ICA encasement and cavernous sinus, possible temporal base.
        • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
        • No evident abnormal enlarged lymph node in the visible neck.
        • Decreased right mastoid air cells pneumotization indicating chronic mastoiditis.
      • IMP: Right NPC, invasion of skull base, parapharyngeal space, and foramen of Ovale, ICA encasement and cavernous sinus, possible temporal base.
      • Impression (Imaging stage): T:T4(T_value) N:0(N_value) M:M0(M_value) STAGE:IVA (Stage_value)
    • 2022-04-26 PTA

      • Reliability FAIR
      • Average RE 63 dB HL; LE 28 dB HL
      • RE mild to profound MHL
      • LE normal to mild SNHL
    • 2022-04-25 ECG

      • Possible Left atrial enlargement
      • Nonspecific T wave abnormality
    • 2022-04-18 PTA

      • Reliability FAIR
      • Average RE 53 dB HL; LE 34 dB HL.
      • R’t mild to severe MHL.
      • L’t mild to moderately severe SNHL.
    • 2022-04-11 Patho - nasopharyngeal/oropharyngeal biopsy

      • Nasopharynx, biopsy — Non-keratinizing squamous cell carcinoma, undifferentiated type
      • The sections show a picture of non-keratinizing squamous cell carcinoma, undifferentiated subtype, composed of nests of large neoplastic cells with oval vesicular nuclei, prominent nucleoli and syncytial growth pattern. Keratin formation is absent.
    • 2022-04-11 Otologic endoscopy

      • rt NP tumor
      • rt MEE
    • 2022-04-11 Nasopharyngoscopy

      • rt NP tumor
    • 2022-03-12 SONO - abdomen

      • Cirrhosis of liver
      • GB stones/polyp
      • Hepatic cysts
      • Splenomegaly
    • 2020-12-16 2D transthoracic echocardiography

      • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 25) / 89 = 71.91%
        • M-mode (Teichholz) = 72
      • Mild septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis and aortic root calcification; trivial TR.
      • Prominent epicardial fat.
  • consultation
    • 2022-06-21 Ophthalmology
      • Q
        • This 63-year-old woman patient is a case of Nasopharyngeal carcinoma, cT4N0M0, stage IVA. She was admitted for chemotherapy with TPF(C1D1) on 2022/06/16.
        • This time, for right eye redness with itch. Now, for evlauate right eye redness with itch therapy. Thank you.
      • A
        • S: Bilateral eye redness and itchy for 5days
        • O:
          • denied bv
          • discharge++, purulent
          • itchy++
          • BCVA od 0.4(0.5x+3.25/-4.00x90) os 0.5(0.7x+1.50/-2.00x70)
          • IOP 15/18mmHg
          • Pupil 3/3 +/+
          • MGD+
          • conj injected with purulent discharge, no pseudomembrane od>os
          • K clear ou
          • AC D/cl ou
          • Lens ns+ ou
          • Fd c/d 0.3, disc pinkish ou
        • A
          • Conjunctivitis od>os, favor EKC (epidemic keratoconjunctivitis)
        • P
          • Alminto 1gtt qid ou + tetracyclin 1qs hs
          • inform the red flags, if worsen vision, come back asap
          • opd f/u
    • 2022-04-29 Radiation Oncology
      • A
        • Diagnosis: Nasopharyngeal carcinoma, NK SqCC, undifferentiated type, cT4N0M0, with invasion of skull base, parapharyngeal space, and foramen of Ovale, ICA encasement and cavernous sinus, possible temporal base and Rt ORX, ECOG =1.
        • Suggest: Radiotherapy.
          • Goal: Curative.
          • RT Plan may be designed as the following one:
            • Target & Volume: NPX tumor and neck lymphatics.
            • Technique: VMAT.
            • Dose & Fractionation: 7140cGy/34 fx, with concurrent chemotherapy.
        • Plan:
          • Either CCRT followed by adjuvant C/T or induction C/T followed by CCRT is suggested for tumor control. Possible toxicity of radiotherapy (radiation mucositis, pharyngitis, dermatitis) is told. Diet education and psychological support are given.
    • 2022-04-28 Obstetrics and Gynecology
      • Q
        • This 63 y/o woman has historiesr of hypothyroidism, hepatitis B under regular medication control. The patient was admitted for NPC work up. The patient complaint perineal itching and urgency to urinate off and on for one month. She has treated at local clinic under Genxate 1# po tid, anbicyn 1# po tid , Amoxicillin 1# po tid.
      • A
        • This 63 y/o woman, G4P2A2(cesarean section), menopaused at her age of 50.
        • The patient complaint perineal + vaginal itching in recent 3 months, urgency to urinate off and on in recent 1 month. She had been to local clinic for help where Genxate 1# po tid, anbicyn 1# po tid, Amoxicillin 1# po tid were given.
        • Lab data: grossly normal, no leukocytosis or anemia.
          • PV: severe vaginal dryness, little whitish vaginal discharge, cervical lifting pain(-)
          • TVUS: Uterus: AVFL, 77x41mm; Endometrium: 4.3mm; 2 myomas( 26x24mm, 26x25mm)
            • Bilateral adnexa: free, no pelvic mass
            • CDS: no ascites
        • IMP: Suspected postmenopausal atrophic vaginitis
        • Suggestion:
          • May keep current LMD medications
          • Add Vaginal estrogen cream (Premarin 14gm/tube) QD HS and oral metronidazole 1# QID x 3 days.
          • GYN OPD f/u if needed
    • 2022-04-26 Oral and Maxillofacial Surgery
      • Q
        • This 52 y/o woman has history of hepatitis B and hypothyroidism for years under regular medication control. She is acase of nasopharyngeal carcinoma. She was admitted for cancer work up.
        • Due to follow up radiotherapy was indicated, we request your consultation for dental evaluation.
      • A
        • This is a 63 y/o female admitted for cancer evaluation(nasopharyngeal carcinoma). This time we were consulted for dental evaluation.
        • S: Oral examination.
          • Hx: epatitis B and hypothyroidism for years under regular medication control
        • O:
          • Residual root of tooth 24, 25, 44
          • Caries of tooth 14, 15, 23 under ill-fitting prosthesis. Percussion pain and periapical radiolucency of tooth 14, 23 were noted.
          • Full mouth chronic periodontitis and poor oral hygiene was noted.
        • A:
          • Residual root of tooth 24, 25, 44
          • Caries of tooth 14, 15, 23
          • Full mouth chronic periodontitis
        • P:
          • Take panoramic film. Explain the findings and treatment plan to the patient and her family.
          • Suggest extraction of residual root of tooth 24, 25, 44 , patient and family want to consider.
          • Suggest removal of ill-fitting prosthesis and re-evaluation of tooth 14, 15, 23 , patient and family want to consider.
          • Suggest OPD follow up.

[SOAP]

  • 2023-03-29 Hemato-Oncology
    • Admission on 2023-03-28 for 4th PF and blood trasfusion due to syncope
  • 2023-02-21 Hemato-Oncology
    • EBV viral load Q3M, next in 2023-05
  • 2022-12-13 Hemato-Oncology
    • EBV viral load Q3M, next in 2023-02
  • 2022-09-20 Hemato-Oncology
    • Due to the tumor invading toward brain stem based on the MRI on 2022-09-08, should consider PF4 after CCRT.
  • 2022-08-09 Hemato-Oncology
    • Already give medication education, e.g., hold Mgo and Primperan when diarrhea, hold smecta if no more diarrhea
  • 2022-08-02 Hemato-Oncology
    • Patient sustaine Gr 1 mucositis over lip, urinary tract and GYN area, Gr 1 anorexia -> does not like to take C/T on 2022-08-02
  • 2022-07-26 Hemato-Oncology
    • If first dose of cycle -> G-CSF for 2 doses
    • If 2nd dose of cycle -> G-CSF for 3 doses
  • 2022-07-19 Hemato-Oncology
    • RTC 1 week and next C/T on 2022-07-26 for OPD 2-2 course with G-CSF suport
  • 2022-05-10 Hemato-Oncology
    • Treatment plan: induction chemotherapy with TPF x 3 (if spliting dose, that would be 6 doses) followed by CCRT with weekly CDDP

[radiotherapy]

  • 2022-09-26 ~ 2022-11-11 - 7140cGy/34 fractions (6 MV photon) to NPX tumor & neck lymphatics

[chemoimmunotherapy]

  • 2023-03-30 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4 (PF Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg + NS 500mL] D2 after cisplatin
  • 2023-03-03 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4 (PF Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg + NS 500mL] D2 after cisplatin
  • 2023-01-13 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4 (PF Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg + NS 500mL] D2 after cisplatin
  • 2022-12-14 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4 (PF Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg + NS 500mL] D2 after cisplatin
  • 2022-11-08 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-11-01 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-10-25 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-10-18 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-10-11 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-10-04 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-09-27 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-08-16 - docetaxel 35mg/m2 50mg NS 160mL 1hr + cisplatin 35mg/m2 50mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-08-09 - docetaxel 35mg/m2 55mg NS 180mL 1hr + cisplatin 35mg/m2 55mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-07-26 - docetaxel 35mg/m2 55mg NS 180mL 1hr + cisplatin 35mg/m2 55mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-07-19 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-07-12 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-07-05 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-06-15 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 500mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + palonosetron 250ug + aprepitant 125mg D1-3

==========

2023-03-30

  • Due to her syncope, the patient was admitted for scheduled chemotherapy and received a blood transfusion.
  • The patient is receiving PF4 regimen since Dec 2022 after CCRT due to tumor invasion towards brainstem based on MRI on 2022-09-08.
  • EBV DNA quantitative amplification results have never exceeded 120 copies/mL since Sep 2022. However, 2023-02-02 MRI showed regression of most of the lesion involving right nasopharynx and paraspinal space, but mild progression of the lesion involving right petrous bone around carotid canal, favoring residual tumor with progression.

2023-03-06

The patient was prescribed ergometrine maleate for an unspecified leiomyoma of uterus by our gynecologist on 2023-03-03. However, this drug is not currently shown in the active medication list. It has no known interaction with the patient’s current medications. Therefore, adding it as a self-carried item to the active medication list is recommended for proper medication reconciliation.

In addition, it is noted that fluorouracil, metoclopramide, and hydroxychloroquine are potential QT-prolonging agents. Administration of these drugs in an overlapping manner may enhance the QTc-prolonging effect, which should be monitored.

2023-01-16

2022-12-14

  • Since October 2022, serum potassium readings have returned to normal levels:
    • 2022-12-13 3.6 mmol/L
    • 2022-11-29 3.7 mmol/L
    • 2022-11-15 4.2 mmol/L
    • 2022-11-08 3.8 mmol/L
    • 2022-10-25 3.7 mmol/L
    • 2022-10-18 3.6 mmol/L
    • 2022-10-11 3.8 mmol/L
    • 2022-10-04 3.6 mmol/L
    • 2022-09-20 3.4 mmol/L
    • 2022-08-23 3.2 mmol/L
    • 2022-08-16 3.1 mmol/L
    • 2022-08-09 3.1 mmol/L
    • 2022-08-02 3.7 mmol/L
    • 2022-07-26 3.5 mmol/L
    • 2022-07-19 4.0 mmol/L
    • 2022-07-12 3.6 mmol/L
    • 2022-07-05 3.7 mmol/L
    • 2022-06-29 4.2 mmol/L
    • 2022-06-23 3.1 mmol/L
    • 2022-06-08 4.0 mmol/L
    • 2022-05-10 4.0 mmol/L
    • 2022-04-25 3.5 mmol/L
  • It may be appropriate to reduce the dosage of the potassium supplement Radi-K (TID -> BID/QD) as well as encourage the patient to consume more potassium-rich foods. Foods with high levels of potassium include: dried figs, molasses, seaweed, dried fruits (dates, prunes), nuts, avocados, bran cereals, wheat germ, lima beans. (Renal function is normal in the patient.)

700998905

230329

[exam findings]

  • 2023-03-24 CXR
    • Enlargement of cardiac silhouette.
  • 2023-03-09 CT - abdomen
    • History and indication: Low rectal cancer involving anal canal
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of low rectum with adjacent fat stranding, anal canal/ sphincter invasion and regional LAP.
      • Gallbladder stones (3-5mm).
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N1b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2023-03-07 Patho - colorectal polyp
    • Colorectum, low rectum, biopsy — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-03-07 ECG
    • Normal sinus rhythm
    • Moderate voltage criteria for LVH, may be normal variant
    • Nonspecific T wave abnormality
  • 2023-03-07 Colonoscopy
    • Low rectal cancer involving anal canal s/p biopsy
  • 2023-03-02 Anoscopy
    • mixed hemorrhoid
    • low rectal mass with bleeding suspected malignancy
  • 2017-09-08 Multiple Sleep Test
    • Summary - The diagnostic nocturnal polysomngraphy demonstrated:
      • Respiratory events were both obstructive and hypopnic (obstructive: 43.6%, central: 0%, Mixed: 0% and hypopnea: 56.4%) with an AHI of 57.1. This is consistent with severe sleep apnea. Snoring was present for 20 % of the diagnostic portion of the study.
      • The baseline oxygen saturation was normal. The oxygen desaturation index was 51.8/hr. severely increased. Desaturation events were continuous and clustered. The lowest SaO2 desaturation associated with a respiratory event was 67%.
      • Sleep structure and quality was (abnormal, fragmented due to respiratory events arousals).
      • The cardiac rate and rhythm showed (normal sinus rhythm) (frequent, PAC’s, PVC’s).
    • Conclusion:
      • This is a case of severe SAS. She had abnormal sleep architecture and nocturnal oxygen desaturation. She is a snorer, too.
        • ChatGPT: SAS in this context refers to Sleep Apnea Syndrome, a condition characterized by repeated episodes of partial or complete obstruction of the upper airway during sleep, resulting in disruptions to breathing and oxygen supply to the body.

[SOAP]

  • 2023-03-14 Radiation Oncolgoy
    • Imp: Low rectal cancer involving anal canal with bleeding, cT4bN1bM0, Stage: IIIC.
    • Plan: Pre-operative CCRT for 5040cGy/28 fx then OP
      • CT simulation on 2023/03/16, 14:30.
  • 2023-03-14 Hemato-Oncology
    • Port-A insertion
    • Arrange admission for FOLFOX on 2023-03-23
  • 2023-03-13 Colorectal Surgery
    • Suggest CCRT then OP (Laparoscopic APR ? due to sphincter invasion)

[radiotherapy]

[chemotherapy]

  • 2023-03-27 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

[assessment]

  • The patient was diagnosed with low rectal cancer involving the anal canal with bleeding, cT4bN1bM0, stage: IIIC.

  • For patients with locally advanced rectal cancer who are at high risk for a margin-positive resection or node-positive disease with a low-lying rectal tumor, total neoadjuvant therapy (TNT) is suggested instead of long-course CRT or short-course RT alone. TNT combines oxaliplatin-based chemotherapy with long-course CRT or short-course RT, leading to increased chemotherapy compliance, improved local control, and the ability to consider nonoperative treatment if the patient declines surgery.

  • The patient has been admitted to receive her first dose of FOLFOX. Lab results on 2023-03-23 showed normal liver and kidney function, blood cell counts, serum electrolytes, and no contraindications to chemotherapy.

  • The patient’s chronic viral hepatitis B without the delta agent is currently being managed with Baraclude (entecavir).

  • The current active prescription has no identified issues.

701064531

230329

[exam findings]

  • 2023-02-10 Whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the maxilla, lower L-spines, bilateral shoulders, sternoclavicular junctions and hips in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the lower L-spines. Degenerative change may show this picture.
      • Increased activity in the maxilla. Dental problem may show this picture.
      • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2022-12-20 CT - abdomen
    • History and indication: ovary CA
    • IMP:
      • S/P operation.
      • A hypodense nodule (4.5mm) at S5-6 junction of liver.
  • 2022-12-12 SONO - kidney urology
    • Grossly normal, bilateral kidneys
  • 2022-12-09 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Borderline ECG
  • 2022-12-09 Gynecologic ultrasonography
    • ATH + BSO
    • Lt fluid
  • 2022-11-24, -11-21 KUB
    • S/P drainage tube in the pelvic cavity.
    • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
    • Non-specific bowel gas pattern.
  • 2022-11-16 Patho - uterus with or without SO non-neoplastic/prolapse
    • Diagnosis:
      • Ovary, right, oophorectomy —- Clear cell carcinoma; AJCC 8th edition: pStage IC, pT1c1N0(if cM0); FIGO Stage: IC1
      • Ovary, left, oophorectomy —- Negative for malignancy
      • Fallopian tube, bilateral, salpingectomy —- Negative for malignancy
      • Uterus, corpus, total hysterectomy —- Negative for malignancy
      • Uterus, endometrium, total hysterectomy —- Negative for malignancy
      • Uterus, cervix, total hysterectomy —- Negative for malignancy
      • Omentum, omentectomy —- Negative for malignancy
      • Lymph node, left iliac, dissection —- Negative for malignancy (0/1)
      • Lymph node, left obturator, dissection —- Negative for malignancy (0/3)
      • Lymph node, right iliac, dissection —- Negative for malignancy (0/3)
      • Lymph node, right obturator, dissection —- Negative for malignancy (0/9)
      • Lymph node, left para-aortic, dissection —- Negative for malignancy (0/8)
      • Lymph node, right para-aortic, dissection —- Negative for malignancy (0/5)
    • Gross description:
      • Procedure (select all that apply): Total hysterectomy, bilateral salpingo-oophorectomy, Omentectomy
      • Specimen Integrity
        • NOTE: For primary ovarian tumors, if the ovary containing primary tumor is removed intact into a laparoscopy bag and ruptured in the bag by the surgeon without spillage into the peritoneal cavity (to allow for removal via laparoscopy port site or small incision), the specimen integrity should be listed as “capsule intact” with a comment explaining this in the report.]
        • Specimen Integrity of Right Ovary (if applicable): intra-op rupture
        • Specimen Integrity of Left Ovary (if applicable): Capsule intact
        • Specimen Integrity of Right Fallopian Tube (if applicable): Serosa intact
        • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
      • Tumor Site: Right ovary
      • Ovarian Surface Involvement (required only if applicable): Absent
      • Fallopian Tube Surface Involvement (required only if applicable): Absent
      • Tumor Size: Greatest dimension (centimeters): 7.0 cm
        • Additional dimensions (centimeters): 6.5 x 5.0 cm
      • Specimen size:
        • left ovary: 2.5 x 1.3 x 0.4 cm;
        • right tube: 5.0 cm in length and 0.3 cm in diameter;
        • left tube: 5.2 cm in length and 0.3 cm in diameter;
        • uterus: 7.0 x 5.1 x 4.0 cm, 88 gm; Cervix: 4.2 x 4.2 x 2.6 cm; Endometrial cavity: 3.2 x 2.0 x 0.2; A leiomyoma: 0.5 x 0.5 x 0.4 cm and adenomyosis are seen
      • Sections are taken and labeled as:
        • F2022-00542: Representative sections are taken and labeled as: FsA1-2, for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: fallopian tube; X2-6: ovary.
        • S2022-20256: A: lymph node, left iliac; B: lymph node, left obturator; C: lymph node, right iliac; D1-2: lymph node, right obturator; E: lymph node, left para-aortic; F: lymph node, right para-aortic; G1: cervix; G2: endometrium; G3: left ovary and fallopian tube; G4: leiomyoma; G5: right posterior wall; G6: right adnexa soft tissue; H: omentum.
    • Microscopic Description:
      • Histologic Type: Clear cell carcinoma; The immunohistochemical stains reveal PAX8(+), Napsin A(+), WT-1(-), p53(wild type), and PR(-).
      • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors)
        • (Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.): not applicable
      • Implants (required for advanced stage serous/seromucinous borderline tumors only): not applicable
      • Other Tissue/ Organ Involvement (select all that apply): Not identified
      • Largest Extrapelvic Peritoneal Focus (required only if applicable): not aplicable
      • Peritoneal/Ascitic Fluid: N2022-04209: Negative for malignancy (normal/benign)
      • Regional Lymph Nodes: Negative for metastasis: please see diagnosis
      • Additional Pathologic Findings: A leiomyoma and adenomyosis are seen in uterus.
  • 2022-11-16 Frozen section
    • Preliminary diagnosis: Ovary, right, oophorectomy — adenocarcinoma
  • 2022-11-15 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, s/p CLO test
      • Gastric erosion, angularis
    • Suggestion
      • Pursue CLO test result
  • 2022-11-14 ECG
    • ICRBBB pattern
      • ChatGPT
        • ICRBBB stands for “Incomplete Right Bundle Branch Block” and refers to a specific pattern seen on an electrocardiogram (ECG). In a normal heart, electrical impulses travel through both the left and right bundle branches, allowing for coordinated contractions of the ventricles. In ICRBBB, the right bundle branch is delayed or blocked, causing a characteristic pattern on the ECG.
        • The ECG in ICRBBB typically shows a widened QRS complex (greater than 120 milliseconds) with a slurred or notched R wave in leads V1 and V2. There may also be ST segment and T wave changes in leads V1 to V3. ICRBBB is considered “incomplete” because the duration of the QRS complex is not as long as it would be in a complete right bundle branch block.
        • ICRBBB is often considered a benign finding and may be present in otherwise healthy individuals. However, it can also be associated with various underlying cardiac conditions, such as pulmonary embolism, right ventricular hypertrophy, and certain congenital heart defects. Further evaluation by a healthcare provider may be warranted in certain cases.
  • 2022-11-14 CTA - pelvis
    • Clinical history: 52 y/o female patient with s/p Chocolate cyst
      • L’t pelvic pain, constipation, Delking on 2022-11-16.
    • With and without contrast enhancement CT of abdomen–whole:
      • There is mulcystic tumor, 8.8x6.1cm in right adnexa, with solid and cystic component and septum, suspected right ovarian malignancy.
      • Liver cyst, 0.5cm in S7.
      • Fibrotic infiltrate in RUL.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
    • If proven ovarian malignancy
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T1(T_value) N:N0(N_value) M:M0(M_value) STAGE: Ia_(Stage_value)
  • 2022-11-08 Gynecologic ultrasonography
    • LT adnexae:free
    • endometrial (+fluid)
    • IMP: Suspected Rt Ovarian mass: (92mm x65mm), papillary:(40mm x31mm), RI: 0.35

[consultation]

  • 2022-12-13 Urology
    • Q
      • This 52 years old female, Right ovarian clear cell carcinoma, pStage IC, pT1c1N0cM0; FIGO Stage IC2 status post Debulking surgery on 2022/11/16 and s/p port-A insertion on 2022/11/25. According to the patient, she had intermittent chills and left flank soreness since 2 days ago. After admitted her vital signs were stable and no fever. The PE found no abdominal tenderness, wound clean and no CP angle knocking tenderness. The lab datas revealed no leukocytosis or pyuria, but elevated CRP upto 12.68 -> 20.5 mg/dL. We need your expertised for renal echo. Thanks a lot!
    • A
      • the patient complained of flank or low back pain trigger by walk
      • USK showed no hydronephroiss
      • Therefore, low back pain (ligament, fascia, intervertebral disc) may be another possible cause of pain

[surgical operation]

  • 2022-11-16
    • Diagnosis:
      • Right ovarian tumor, suspected malignancy
      • Frozen section: adenocarcinoma
    • Surgery:
      • Debulking surgery (ATH + BSO + BPLND)   - Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, tense contact with bladder, marked adhesion to the rectum
      • Adnexa:
        • LOV: capsule intact , smooth surface.
        • ROV: intra-op rupture(+)
        • Fallopian tube: bilateral grossly normal
      • CDS: adhesion (+)
      • Ascites: scanty
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • Omentum: infracolic omentectomy was done.
    • Other
      • Estimated blood loss: 1000 ml
      • Blood transfusion: 2U
      • Complication: nil

[chemotherapy]

  • 2023-03-28 - paclitaxel 175mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W, paclitaxel 20% off due to PLT 88K/uL)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-03-03 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-02-09 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-01-12 - paclitaxel 160mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2022-12-20 - paclitaxel 160mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL

[assessment]

  • The patient experienced nadir levels in her WBC and/or PLT count approximately one week after receiving chemotherapy, as indicated by asterisks in the table below (WBC < 3K/uL, PLT < 100K/uL).

    • 2023-03-28 WBC 3.01 x10^3/uL
    • 2023-03-10 WBC 1.89 x10^3/uL * previous chemo on 03/03 - 7 days
    • 2023-03-02 WBC 5.52 x10^3/uL
    • 2023-02-17 WBC 1.42 x10^3/uL * previous chemo on 02/09 - 7 days
    • 2023-02-08 WBC 4.19 x10^3/uL
    • 2023-01-20 WBC 2.06 x10^3/uL * previous chemo on 01/12 - 8 days
    • 2023-01-12 WBC 5.31 x10^3/uL
    • 2022-12-27 WBC 3.09 x10^3/uL
    • 2022-12-19 WBC 8.25 x10^3/uL
    • 2022-12-12 WBC 5.71 x10^3/uL
    • 2022-12-09 WBC 10.45 x10^3/uL
    • 2023-03-28 PLT 88 x10^3/uL * previous chemo on 03/03 - 25 days (not fully recovered yet)
    • 2023-03-10 PLT 24 x10^3/uL * previous chemo on 03/03 - 7 days
    • 2023-03-02 PLT 100 x10^3/uL
    • 2023-02-17 PLT 131 x10^3/uL
    • 2023-02-08 PLT 117 x10^3/uL
    • 2023-01-20 PLT 64 x10^3/uL * previous chemo on 01/12 - 8 days
    • 2023-01-12 PLT 75 x10^3/uL * previous chemo on 12/20 - 8 days
    • 2022-12-27 PLT 129 x10^3/uL
    • 2022-12-19 PLT 209 x10^3/uL
    • 2022-12-12 PLT 126 x10^3/uL
    • 2022-12-09 PLT 138 x10^3/uL
  • The patient was admitted for her scheduled chemotherapy with a 20% dose reduction of paclitaxel due to her not fully recovered low PLT level.

  • No medication reconciliation issues were found after reviewing PharmaCloud and comparing it to the active prescription.

701241752

230329

[exam findings]

  • 2023-03-28 Whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the lower T- and upper L-spines, L4, bilateral shoulders, sternoclavicular junctions, hips and knees in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the lower T- and upper L-spines and L4 spine. Degenerative change may show this picture.
      • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2023-03-27 KUB
    • Hepatomegaly is suspected.
  • 2023-03-23 CT - abdomen
    • Findings
      • A tumor (5.3cm) in left breast with left chest wall invasion.
      • Multiple liver tumors. A LN (1.5cm) at left subphrenic region.
      • Small amount ascites.
      • Perineural cysts at sacrum.
    • IMP
      • Left breast cancer with left chest wall invasion, LN and liver metastases.
  • 2023-03-23 KUB
    • Focal small bowel ileus in left abdomen.
    • There are calcifications in the pelvic cavity, could be due to phleboliths.
  • 2020-07-01 Gynecologic ultrasonography
    • Suspected Lt Ovarian Cyst
  • 2020-06-17 Gynecologic ultrasonography
    • Endometrial thickening
    • Suspected bilateral ovarian cyst

[assessment]

  • 2023-03-29 FOBT 4+. A result of 4+ means that a significant amount of blood was detected in the sample, indicating a possible gastrointestinal bleeding. Takepron (lansoprazole) has been prescirbed (ST). Further evaluation and testing may be needed to determine the cause of the bleeding.

701356216

230329

[past history] - 2023-03-25 admission note

  • myeloma with amyloidosis (lambda light chain type), s/p renal biopsy and bone marrow biopsy, s/p chemotherapy with VTD from 20220506 ~ 20230210 (C11W2) with medication treatment.
  • hyperlipidemia
  • hepatitis B carrier with Baraclude since 2022/05.
  • gastric ulcer for 10+ years ago.

[allergy]

  • NKDA

[family history]

  • Father: HCC
  • Mother: Type II diabetes mellitus

[exam findings]

  • 2023-03-28 CXR
    • Bilateral pleura effusion.
    • S/P pigtail catheter implantation at right CP angle.
  • 2023-03-27 L-spine AP + Lat. (including sacrum)
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L5-S1.
  • 2023-03-27 CXR
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-27 Hand Lt
    • S/P total amputation of 3rd distal phalanx and middle phalanx, and partial amputation of 3rd proximal phalanx of Left hand.
    • S/P near total amputation of 2nd distal phalanx of Left hand.
    • Angulation deformity of 2nd PIP joint.
  • 2023-03-27 C-spine AP + Lat
    • Small Nuchal ligament calcification over the posterior neck
  • 2023-03-27 Spirometry
    • Mild reduction of total lung capacity
    • Moderate restrictive ventilatory impairment, Not significant bronchodilator reversibility
    • Moderate reduction of diffusion capacity
  • 2023-03-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (102 - 26) / 102 = 74.51%
      • 2D (M-simpson) = 75
    • Conclusion
      • Marked asymmetric septal hypertrophy with Gr II LV diastolic dysfunction; no significant intracardiac pressure; suspected non-obstructive type hypertrophic cardiomyopathy or amyloidosis heart; moderately dilated LA.
      • Preserved LV and RV systolic function.
      • Aortic valve sclerosis with trivial AR; mild MR; mild TR.
      • Multiple oscillation lesions at posterior mitral leaflet with sized 10-12 mm and at tricuspid septal leaflet with sized 8-19 mm, nature? suspected non-bacterial thrombotic endocarditis (NTBE) if no evidence of active infection.
      • Some R’t plerual effusion.
  • 2022-04-18 SONO - abdomen
    • Calcified spot, 0.45cm in right lobe liver.
    • Suspected minimal ascites in subphrenic region, right.
  • 2022-04-18 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (120 - 26) / 120 = 78.33%
      • 2D (M-simpson) = 78
    • Conclusion
      • Septal and RV hypertrophy with Gr I LV diastolic dysfunction.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis; trivial MR.
  • 2022-03-30 Spirometry
    • Normal baseline without significant reversibility
    • FEV1FVC=91.41%, FVC= 87%, FEV1= 98%
    • normal total lung capacity TLC=101%
    • suspect mild air trapping, RV/TLC=42.07%
    • normal diffusion capacity
  • 2022-03-16 Patho - bone marrow biopsy
    • Bone marrow, iliac creast, biopsy — Plasma cell myeloma
    • Microscopically, it shows hypercellularity with hemopoietic components accounting for about 70% of the marrow space, and M/E ration of 2: 1. of the bone marrow space. Plasma cells are increased (> 10%) and highlighted by CD138. Occasional megakaryocytes are seen.
    • Immunohistochemical stain reveals CD34(-), CD117(-), MPO(+), CD71(+), CD20(focal +, < 5%), Kappa light chain(-), Lambda ligh chain (+ for monoclonality).
    • ADDENDUM: Special stain — congo red (+), compatible with amyloidosis
  • 2022-03-07 Surgical pathology Level IV
    • PATHOLOGICAL DIAGNOSIS:
      • Kidney, needle biopsy for light microscopic examination — Compatible with amyloidosis (lambda light chain type) — Mild arteriosclerosis
      • COMMENT: We are limited in our assessment because the specimen submitted for light microscopy contains renal medullary tissue only. No glomerulus is available. The semithin sections prepared for electron microscopic examination show glomeruli with mesangial expansion. By immunofluorescence, the lambda staining is stronger than kappa in the glomerular mesangium and capillary walls. The electron microscopy demonstrates the presence of randomly oriented fibrils 8-12 nm in diameter within the mesangium and along the glomerular basement membranes. Although the Congo red staining is not contributory, the above features are mostly compatible with renal involvement by amyloidosis. Clinical correlation is recommended. For EM findings, please see report S111-80825.
  • 2022-03-07 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Prolonged QT
  • 2022-02-23 SONO -nephrology
    • chronic parenchymal renal disease
    • right renal cyst

[consultation]

  • 2023-03-29 Neurology
    • Q
      • for bilateral last of three fingers numbness, and fall down repeatedly.
      • This is a 54-year-old male, underlying hyperlipidemia, myeloma with amyloidosis (lambda light chain type), s/p renal biopsy and bone marrow biopsy, s/p chemotherapy with VTD from 20220506 ~ 20230210 (C11W2) with medication treatment. The history of hepatitis B carrier with Baraclude. He visited OPD due to proteinuria found by health examination in 2021 October.
      • This time, he is admitted for Auto HSC collection, then he suffered from bilateral last of three fingers numbness, and fall down repeatedly, and the heart echo showed suspected non-bacterial thrombotic endocarditis. So we need your help, thanks a lot!!
    • A
      • hands weakness esp. at bilateral ulnar sides after the fall
      • NE: aware, fluent speech, bil. hearing impairment, no visual field defect, no facial weakness or tongue deviation, bil. Benedict hands and diffuse hypo-reflexia
      • Impression:
        • ulnar neuropathies, suspect entrapment neuropathy
        • amyloidosis
      • Suggest:
        • C-spine MRI, nerve conduction study and BAEP might be arranged
        • I would like to follow up this patient. Thank you for your consultation.
  • 2023-03-27 Cardiology
    • Q
      • for heart function evaluation, hs-Troponin I: 185.1 pg/mL, CKMB: 6.5ng/mL
      • This is a 54-year-old male, underlying hyperlipidemia, myeloma with amyloidosis (lambda light chain type), s/p renal biopsy and bone marrow biopsy, s/p chemotherapy with VTD from 20220506 ~ 20230210 (C11W2) with medication treatment. The history of hepatitis B carrier with Baraclude. He visited OPD due to proteinuria found by health examination in 2021 October.
      • This time, he is admitted for Auto HSC collection, then he suffered from pitting edema 4+ at limbs,and the blood pressure lower (SBP: 70-90mmHg), CXR: bilateral pleural effusion, the lab of cardio enyzam poor (hs-Troponin I: 185.1 pg/mL, CKMB: 6.5ng/mL), 12-Lead EKG: Normal sinus rhythm, Left axis deviation, Low voltage QRS, Cannot rule out Anteroseptal infarct, age. The heart echo will be arranged. So we need your help, thanks a lot!!
    • A
      • S
        • 55 year-old male had the history of Myeloma with Amyloidosis (lambda light chain type), s/p renal biopsy and bone marrow biopsy and lab test. start chemotherapy with Velcade TD from 20220506
      • O
        • LAB NTproBNP 8184 hsTnI167.9 CKMB 6.1 Cre 0.83 ALT 32 albumin 2.2 Hb 13.5 WBC 25960 PLT 219k band 6.8%
        • echocardiogram 20230327
          • Marked asymmetric septal hypertrophy with Gr II LV diastolic dysfunction; no significant intracardiac pressure; suspected non-obstructive type hypertrophic cardiomyopathy or amyloidosis heart; moderately dilated LA.
          • Preserved LV and RV systolic function.
          • Aortic valve sclerosis with trivial AR; mild MR; mild TR.
          • Multiple oscillation lesions at posterior mitral leaflet with sized 10-12 mm and at tricuspid septal leaflet with sized 8-19 mm, nature? suspected non-bacterial thrombotic endocarditis (NTBE) if no evidence of active infection.
          • Some R’t plerual effusion.
        • CXR 20230327 right pleural effusion 20230307 clear lung field
        • ECG 20230327 sinus rhythm, low voltage, left axis deviation
      • Impression
        • Hypertrophic cardiomyopathy, suspected amyloidosis related
        • Oscillating lesions on mitral and tricuspid valves, nature?; with mild MR and TR
        • Severe hypoalbuminemia
      • Suggestion
        • Collecting blood cultures x3 to exclude bacterial endocarditis
        • Correct hypoalbuminemia
        • Right pleural effusion study
        • By echocardiogram, IVC 13mm suggested low intra-vascular volume
        • Check adrenal and thyroid function; may give midodrine for BP support

[SOAP]

  • 2023-02-24 Hemato-Oncology
    • velcade TD (C1W1 20220506, C1W2 20220513, C2W1 20220527, C2W2 20220610, C3W1 20220624, C3W2 20220701 , C4W1 20220715, C4W2 20220722, C5W1 20220923, C5W2 20220930, C6W1 20221014, C6W2 20221021, C7W1 20221104, C7W2 20221111, C8W1 20221202, C8W2 20221209, C9W1 20221223, C9W2 20221230. C10W1 20230113, C10 W2 20230120, C11W1 20230203, C11W220230210 )
    • admission at March 25, prepare for GCSF injection at March 26-30, Auto HSC collection at March 30-31.
  • 2022-09-23 Hemato-Oncology
    • velcade TD (C1W1 20220506, C1W2 20220513, C2W1 20220527, C2W2 20220610, C3W1 20220624, C3W2 20220701 , C4W1 20220715, C4W2 20220722, C5W1 20220923)
    • Dara not approved by NHI
    • continue VTD therapy C5
  • 2022-09-09 Hemato-Oncology
    • check light chain and beta2-microglogulinemia
    • check bone marrow (plasma cell myeoloma)
    • apply for Major disease to NHI (approved)
    • velcade TD (C1W1 20220506, C1W2 20220513, C2W1 20220527, C2W2 20220610, C3W1 20220624, C3W2 20220701 , C4W1 20220715, C4W2 20220722)
    • apply for Velcade and daraturamab
  • 2022-04-20 Hemato-Oncology
    • check light chain and beta2-microglogulinemia
    • check bone marrow (plasma cell myeoloma)
    • apply for Major disease to NHI (approved)
    • apply for velcade
    • start steroid therapy and vemlidy
  • 2022-03-30 Hemato-Oncology
    • P
      • check light chain and beta2-microglogulinemia
      • check bone marrow (plasma cell myeoloma)
      • apply for Major disease to NHI
  • 2022-03-16 Hemato-Oncology
    • P
      • check light chain and beta2-microglogulinemia
      • check bone marrow
  • 2022-03-16 Nephrology
    • P: refer to Hema OPD due to amyloidosis (lambda light chain type)

[chemotherapy]

  • 2023-02-10 - bortezomib 1.3mg/m2 2.47mg SC 5min D1,5
  • 2023-02-03 - bortezomib 1.3mg/m2 2.45mg SC 5min D1,5
  • 2023-01-20 - bortezomib 1.3mg/m2 2.45mg SC 5min D1,5
  • 2023-01-13 - bortezomib 1.3mg/m2 2.45mg SC 5min D1,5
  • 2022-12-30 - bortezomib 1.3mg/m2 2.46mg SC 5min D1,5
  • 2022-12-23 - bortezomib 1.3mg/m2 2.46mg SC 5min D1,5
  • 2022-12-09 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-12-02 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-11-11 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-11-04 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-10-21 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-10-14 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-09-30 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-09-23 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-07-22 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-07-15 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-07-01 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-06-24 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-06-10 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-05-27 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-05-13 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-05-04 - bortezomib 1.3mg/m2 2.39mg SC 5min D1,5

[medication]

  • 2022-05-04 ~ 2023-03-17 - Thado (thalidomide 50mg) 1# HS

[assessment]

  • The patient was admitted for planned HSC harvest, but bilateral numbness in the last three fingers and elevated cardiac enzymes were observed, so further studies are being conducted.
  • There is no issue with the active recipe being used.

700753896

230328

[diagnosis] - 2023-03-27 admission note

  • Squamous cell carcinoma of upper third of esophagus, cT3N1M0, stage II status post feeding jejunostomy and left port-A implantation on 2023/02/20 and concurrent chemoradiotherapy with PF(CDDP 75mg/m2, 5FU 1000mg/m2 x4 days) from 2023/02/27~
  • Gastro-esophageal reflux disease without esophagitis
  • Hypertensive heart disease without heart failure
  • Constipation, unspecified
  • Cachexia
  • Insomnia, unspecified
  • Hypomagnesemia

[exam findings]

  • 2023-03-03 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Scoliosis of the T-spine with convex to right side.
  • 2023-02-22 Pure Tone Audiometry
    • Reliabilty Fair
    • PTA
      • R’t : 10 dB HL, WNL
      • L’t : 13 dB HL, normal to mild SNHL.
  • 2023-02-20 CXR
    • widening of Rt paratracheal stripe due to space taking lesion or paratracheal lymph node enlargement
  • 2023-02-18 MRI - brain
    • no evidence of brain tumors.
  • 2023-02-17 SONO - abdomen
    • suspected liver calcification, left
    • suspected GB stones
  • 2023-02-16 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, mandible, lower L-spines, right S-I joint, bilateral shoulders, hips and left knee in whole body survey.
    • IMPRESSION:
      • Increased activity in the lower L-spines and right S-I joint. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation.
      • Increased activity in the maxilla and mandible. Dental problem may show this picture.
      • Increased activity in bilateral shoulders, hips and left knee, compatible with benign joint lesions.
      • No prominent bone abnormality was noted elsewhere.
  • 2023-02-15 Bronchoscopy
    • no endotreacheal or endobronchial lesions
  • 2023-02-14 Whole body PET scan
    • The [F-18] Fluorodeoxyglucose (FDG) PET scan from head to upper thigh regions was performed at 40 minutes after i.v. injection 284 MBq of FDG. Fasting for at least 6 hours was required prior to this examination. Images were reconstructed iteratively with CT scan attenuation correction.
    • There was increased FDG uptake in a focal area in the proximal portion of the esophagus (SUVmax early: 17.72, delay: 22.73) and in bilateral shoulders (SUVmax early: 3.37, delay: 1.72). In addition, there was increased FDG accumulation in both kidneys and bilateral ureters.
    • IMPRESSION:
      • A glucose hypermetabolic lesion in the proximal portion of the esophagus, compatible with primary esophageal malignancy.
      • Mild glucose hypermetabolism in bilateral shoulders. Arthritis may show this picture.
      • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
      • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-02-13 CXR
    • Widening of Rt paratracheal stripe due to space taking lesion or paratracheal lymph node enlargement
    • Thoracic aortic arch calcified atheriosclerotic plaque
    • Minimal dextroscoliosis of the T-spine
  • 2023-02-03 CT - chest
    • Indication: esophageal inlet mucosal lesion, pending patho. suspected esophageal cancer, for staging
    • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Submucosa soft tissue mass at upper third esophagus measuring 2.49cm is found.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP, but small lymph nodes (n=2) are found at paraesophageal region.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
        • Suggest clinical correlation
    • Imp: Esophageal submucosa tumor, 2.49cm.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T1(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-02-03 Patho - esophageal biopsy
    • Esophageal tumor, 16 cm below the incisors, biopsy — Squamous cell carcinoma
    • Microscopically, the sections show a picture of squamous cell carcinoma, poorly differentiated of the esophageal tumor tissue characterized by some solid tumor nests show enlarged, hyperchromatic and pleomorphic nuclei infiltrating in the fibrotic stroma.
    • Immunohistochemical stains of CK5/6(+), P16(-) and P63 (+) for tumor.
  • 2023-02-02 Esophagogastroduodenoscopy, EGD
    • Suspected esophageal malignancy, L/3, s/p biopsy*4
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
  • 2022-07-22 Nasopharyngoscopy
    • suspected acute thyroiditis
  • 2021-11-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (86.3 - 17.7) / 86.3 = 79.49%
      • M-mode (Teichholz) = 79.5
    • Normal AV/MV with trivial MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • No PR, trivial TR, normal IVC size

[consultation]

  • 2023-02-20 Hemato-Oncology
    • A
      • We are consulted for CCRT.
      • Please check 24 urine CCR, auditory test, HbsAg, AntiHbc, Anti HCV. Arrnage our OPD after discharge.
  • 2023-02-17 Radiation Oncology
    • A
      • CCRT is indicated.
      • CT-simulation will be arranged on 2/22.
      • Plan to deliver 45 Gy/ 25 fx to the upper 2/3 esophagus and bil. SCF. Then boost the esophageal tumor and LAPs to 54 Gy/ 30 fx. RT will start around 2/27.
  • 2023-02-14 Gastroenterology
    • Q
      • This 76-year-old woman denied any systemic disease. She has suffered from dysphagia for solid material with odynophagia for 2 months, associated with weight loss 7 kg in 6 months. She has visited our GI OPD, where PES revealed suspected esophageal malignancy S/P biopsy was done. Chest CT showed esophageal submucosa tumor, 2.49cm. suspected GIST. For this newly diagnosed esophageal cancer, she was admitted for cancer work-up.
      • Thus we need consult you for arrange EUS and abdominal ultrasound. Thank you very much.
      • schedule
        • 112/02/14 10:30 PET scan
        • 112/02/15 bronchoscope
        • 112/02/16 11:00 bone scan
        • 112/02/18 08:40 brain MRI
        • hope to arrange the examination before 112/02/17.
    • A
      • For EUS:
        • Miniprobe EUS is technically challenging and NOT recommended due to the position of the lesion.
        • Please consider other diagnostic/staging modality
      • For abd echo:
        • Already arrange abdominal echo on 0217.

[surgical operation]

  • 2023-02-20
    • Surgery
      • Feeding jejunostomy + port-A
    • Finding
      • 18 Fr. silicon Foley catheter as jejunostomy tube
      • 8.0 Fro. Polysite, left cephalic vein, cut-down method.
  • 2022-11-15
    • Surgery: Hemorrhoidectomy        
    • Finding: Prolasped hemorrhoids at 3,7,11 o’clock
  • 2021-09-23
    • Surgery: lt PF MIS lateral release
      • The patient underwent a lateral release of the lateral patellofemoral ligament using minimally invasive surgery techniques.
    • Finding: PF OA PFPS
      • The patient has patellofemoral osteoarthritis (PF OA) and patellofemoral pain syndrome (PFPS), which are conditions that affect the knee joint. The lateral release surgery was likely performed to address these conditions, as it can be used to alleviate pain and improve the alignment of the patella.
  • 2019-09-23
    • Diagnosis: left knee osteoarthritis
    • PCS code: 64164B
  • 2018-09-03
    • Diagnosis: rt OA knee
    • PCS code: 64164B

[chemotherapy]

  • 2023-03-27 - cisplatin 75mg/m2 80mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] post cisplatin + fluorouracil 1000mg/m2 1000mg NS 500mL 24hr D1-4 (PF CCRT Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3
  • 2023-02-27 - cisplatin 75mg/m2 80mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] post cisplatin + fluorouracil 1000mg/m2 1000mg NS 500mL 24hr D1-4 (PF CCRT Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3

==========

2023-03-28

  • On 2023-03-22, the patient had a BUN/serum creatinine ratio of 31. The normal ratio is 10 to 15:1 but can be greater than 20:1 in prerenal disease due to the increased passive reabsorption of urea that follows the enhanced proximal reabsorption of sodium and water. This selective rise in BUN is known as prerenal azotemia. The serum creatinine concentration will increase in this setting only if the degree of hypovolemia is severe enough to lower the GFR. Therefore, it is recommended to rule out hypovolemia or upper gastrointestinal bleeding as possible causes for the elevated BUN/serum creatinine ratio.
    • 2023-03-22 BUN 29 mg/dL
    • 2023-02-27 BUN 13 mg/dL
    • 2023-02-13 BUN 11 mg/dL
    • 2022-11-14 BUN 9 mg/dL
    • 2023-03-22 Creatinine 0.94 mg/dL
    • 2023-02-27 Creatinine 0.60 mg/dL
    • 2023-02-13 Creatinine 0.71 mg/dL
    • 2022-11-14 Creatinine 0.59 mg/dL

2023-03-01

  • The patient underwent surgery for feeding jejunostomy and port-A placement on 2023-02-20 and she began receiving cisplatin and fluorouracil starting from 2023-02-27.

  • Patients who have undergone feeding jejunostomy surgery often require additional nutritional support and close monitoring of their hydration status. All the oral drugs in the current prescription are compatible with tube feeding.

700947307

230328

[diagnosis] - 2023-03-27 admission note

  • Advanced cecal cancer partial obstruction with perforation to retroperitoneum and dense adhesion/invasion to small bowel status post 3 dimensions single incision laparoscopic right hemicolectomy with laparoscopic adhesion lysis and resection of small bowel on 2021/12/01
  • Metastatic uterine adenocarcinoma status psot Laparoscopic hysterectomy (LESS - laparoendoscopic single site surgery) and bilateral salpingo-oophorectomy on 2021/12/01
  • Hepatitis B carrier

[past history]

  • The patient is B hepatitis carrier
  • history of operation:
    • Status post Caesarean section about 40 years ago
    • Status post Tympanoplasty on 2011/04/19
    • Right renal stone status post extracorporeal shock wave lithotripsy on 2009/04/15
  • Denied recent traveling history
  • Blood transfusion history: NIL
  • Occupational function (premorbid): OK。
  • Regular medications or herb:no                                                                     

[allergy]

  • NKDA                                                             

[family history]

  • Father had liver cancer
  • Mom had diabetes mellitus type 2 and hypertension

[exam findings]

  • 2023-03-27 KUB
    • S/P metalic autosuture and few clips projecting at right lower abdomen.
    • Fecal material store in the colon.
  • 2023-02-09 All-RAS + BRAF mutations assay
    • ALL-RAS:
      • Detected (KRAS codon 12 GGT>GTT, p.G12V)
    • BRAF
      • There was no variant detect in the BRAF gene.
  • 2023-02-08 CT - abdomen
    • History: cecal CA wt terminal ileum invasion (T4b), lung, liver, uterus mets (M1b), pT4bN2aM1b; stage IVB,
    • Indication: multiple lung metastases
    • Findings:
      • There is a newly-developed lobulated enhancing soft tissue mass 1.3 cm in right middle pelvis with direct invasion right L/3 ureter causing moderate hydroureteronephrosis but no delayed contrast excretion of right kidney.
        • Metastasis in right middle pelvis induce obstructive uropathy is highly suspected.
        • In addition, There is a newly-developed lobulated enhancing soft tissue mass 3.2 cm in right uterine fossa that is also c/w tumor recurrence.
      • There are at least seven newly-developed soft tissue nodules in right lower omentum that are c/w tumor seeding.
      • There are several newly-developed metastatic nodes in para-aortic space and para-cava space .
      • Prior CT identified Multiple metastase in bil. lungs are noted again, increasing in size and number that is c/w progressive disease.
      • S/P right hemicolectomy and S/P hysterectomy
      • Right renal stone (5mm).
      • Tiny gallbladder stones.
    • Impression:
      • Two metastases or local recurrent tumor in right middle pelvis and right uterine fossa.
      • Seven tumor seeding in right lower omentum.
      • Metastatic nodes in para-aortic space and para-cava space
      • Multiple lung metastases show progressive disease.
  • 2022-10-04 CT - chest
    • Indication
      • Secondary malignant neoplasm of right lung
      • Malignant neoplasm of cecum
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Several nodular lesions are found at both lungs with some of them shows cavitation. Recurrent/residual metatsatic lung nodules are considered.
          • In comparison with CT dated on 2022-07-25, the numbers of the lesions increased.
        • S/p port-A placement with its tip at Superior vena cava.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Tiny low density lesion at S6/7 of liver is found. Suspected liver meta.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
    • Imp:
      • Bilaeral lung meta. In progression.
      • Suspected liver meta.
  • 2022-07-26 Patho - lung transbronchial biopsy
    • Lung, RLL, CT-guide biopsy — adenocarcinoma, moderately differetiated, consistent with metastatic colorectal orgin
    • Sections show cribriform glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal CDX2(+) and TTF-1(-).
    • The results are consistent with metastatic colorectal adenocarcinoma.
  • 2022-07-25 CXR
    • a ndular lesion with extensive ground glass opacity over Rt upper lobe s/p cryoablation
    • recticular opacities over both lower lung zones
  • 2022-07-25 Right Lower Lobe Lung Mets Cryotherapy
    • Indication: right lower lobe lung meta
    • Position: Prone
    • Cryotherapy was done with cryoneedles placed into right lower lobe lung tumor region. One session of cryotherap with 3-7-10 minutes of cryotherapy was done. Iceball was visualized with total coverage of the tumor.
  • 2022-07-05 CT - abdomen
    • History and indication: cecal cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Cecal cancer s/p operation.
      • Multiple nodules in bil. lungs.
      • Right renal stone (4mm).
      • Tiny gallbladder stones.
    • IMP:
      • Cecal cancer s/p operation.
      • Multiple nodules in bil. lungs c/w metastases.
  • 2022-06-26 Colonoscopy
    • Diagnosis
      • C/W post right hemicolectomy, no evidence of cancer recurrence.
      • Internal hemorrhoid
    • Suggestion
      • OPD F/U
    • Complication
      • No immediate complication
  • 2022-05-17 CT - abdomen
    • Cecal cancer s/p operation.
    • Multiple nodules in bil. lungs suspected metastases.
  • 2021-12-28 CT - chest
    • Indication: colon cancer with liver & lung mets
    • Comparison made with previous CT dated on 2021/11/29 abdominal CT.
      • lungs:
        • multiple numerous nodules of variable sizes in both lungs (up to 8.2 mm at RLL), consistent wth metastatic lesions
      • Mediastinum: no enlarged LN or mass.
      • Hila: unremarkable.
      • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: no effusion or nodule.
      • Chest wall: unremarkable.
      • Visible abdominal-pelvic contents:
        • a metastitc hepatic tumor 23 mm in S7.
        • several small bilateral renal cysts.
        • unremarkable of the spleen, adrenal glands, pancreas, and gall baldder.
        • no enlarged lymph node or ascites.
        • s/p Rt hemicolectomy with retained surgical clips.
      • Visualized bones: unremarkable.
    • Impression:
      • colon ca s/p with multiple lung metastatic tumors and solitary hepatic metastatic tumor.
  • 2021-12-02 Patho - uterus with or without SO non-neoplastic/prolapse
    • DIAGNOSIS:
      • Uterus, myometrium, laparoscopic hysterectomy — Metastatic adenocarcinoma, compatible with colorectal origin — Intramural leiomyoma
      • Uterus, endometrium, laparoscopic hysterectomy — Postmenopausal state.
      • Uterus, cervix, laparoscopic hysterectomy — Negative for malignancy
      • Adnexae, bilateral, salpingo-oophorectomy — Negative for malignancy
    • Microscopically, the myometrium shows metastatic adenocarcinoma composed of invasive neoplastic glands
  • 2021-12-02 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Large intestine, ascending colon, laparoscopic right hemicolectomy — Adenocarcinoma, moderately differentiated
      • Resection margins, proximal and distal — Free
      • Terminal ileum — Involved by adenocarcinoma
      • Lymph node, mesocolic, dissection — Positive for adenocarcinoma (4/12)
      • Labeled posterior abdominal wall — Involved by adenocarcinoma
      • Pathology stage: pT4bN2aM1a; AJCC stage IVA
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
  • 2021-11-29 CT - abdomen
    • Impression:
      • Cecal tumor, with extension to appendix and terminal ileum, and lymphadenopathy at right lower quadrant. Malignancy is highly suspected.
      • A 5.4cm uterine tumor, suspect malignancy. Suggest GYN ultrasound correlation.
      • RLL pulmonary nodule.
      • Mild ascites.
      • Bilateral renal cysts. Right renal stone.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:4b(T_value) N:2a(N_value) M:1a(M_value) STAGE:IV(Stage_value)
  • 2021-11-29 Gynecologic Ultrasonography
    • RT adnexae: free
    • IMP : Uterine mass: (1) 45x38mm, (2) 21x18mm

[surigcal operation]

  • 2021-12-01
    • Surgery
      • Laparoscopic hysterectomy (LESS - laparoendoscopic single site surgery) and bilateral salpingo-oophorectomy
    • Finding
      • Uterus: enlarged, 11x6x3cm, corpus – right posterior uterine mass 6x5cm with iiregular border, primary uterine tumor or colon cancer metastasis?
      • border adhesion to right pelvic wall, tumor adhesion?
      • another small myomas 2~3# 2cm for each
      • EM – np
      • cervix eroded
      • bil adnexa: normal-looking
      • CDS: some pelvic adhesion (due to previous cesarean section and tumor asdhesion>?) were noted between ant peritoneum and bladder; between post uterus, right pelvic wall and bowels s/p laparoscopic lysis
  • 2021-12-01
    • Surgery
      • 3D SILS right hemicolectomy + laparoscopic adhesion lysis + resection of small bowel      
    • Finding
      • Lower abdomen adhesion due to previous C/S Advanced cecal cancer partial obstruction with perforation to retroperitoneum and dense adhesion/invasion to small bowel

[chemoimmunotherapy]

  • 2023-03-27 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOXIRI)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-03-01 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOXIRI)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-02-07 (Avastin + FOLFOX)

  • 2023-01-09 (Avastin + FOLFOX)

  • 2022-12-12 (Avastin + FOLFOX)

  • 2022-11-18 (Avastin + FOLFOX)

  • 2022-10-26 (Avastin + FOLFOX)

  • 2022-07-04 (Avastin + FOLFIRI)

  • 2022-06-08 (Avastin + FOLFIRI)

  • 2022-05-16 (Avastin + FOLFIRI)

  • 2022-04-20 (Avastin + FOLFIRI)

  • 2022-03-29 (Avastin + FOLFIRI)

  • 2022-03-04 (Avastin + FOLFIRI)

  • 2022-02-11 (Avastin + FOLFIRI)

  • 2022-01-12 (Avastin + FOLFIRI)

  • 2021-12-27 (Avastin + FOLFIRI)

[assessment]

  • On 2021-12-01, the patient underwent surgery for cecal cancer with terminal ileum invasion and metastases to the lung, liver, and uterus, resulting in a diagnosis of pT4bN2aM1b, stage IVB. The surgery involved a 3D SILS right hemicolectomy with laparoscopic adhesion lysis and resection of the small bowel, as well as a laparoscopic hysterectomy (LESS - laparoendoscopic single site surgery) and bilateral salpingo-oophorectomy. The patient then received Avastin + FOLFIRI from 2021-12-27 to 2022-07-04, and Avastin + FOLFOX from 2022-10-26 to 2023-02-07.
  • On 2023-02-08, a CT scan showed two metastases or a local recurrent tumor in the right middle pelvis and right uterine fossa, seven tumor seedings in the right lower omentum, and metastatic nodes in the para-aortic space and para-cava space, as well as multiple lung metastases showing progressive disease. Consequently, the patient’s regimen was changed to FOLFOXIRI from 2023-03-01 and the treatment is ongoing.
  • On 2023-02-09, a KRAS mutation was identified in the patient’s tumor (codon 12 GGT>GTT, p.G12V), which suggests that certain targeted therapies, including anti-EGFR therapies such as cetuximab or panitumumab, are unlikely to be effective. Patients with KRAS mutations are typically not eligible for these treatments.
  • The patient has received the 2nd cycle of FOLFOXIRI during this hospital stay, and it is too early to determine its effectiveness. There have been no severe adverse reactions related to the treatment so far.
  • Based on the patient’s prescription records in the PharmaCloud database for the last 3 months, there are no issues with medication reconciliation.

701027894

230328

[diagnosis] - 2023-03-28 discharge note

  • Malignant neoplasm of endometrium
  • Endometrial cancer, grade 2 endometroid carcinoma with bilateral obturator LAP metastasis s/p LAVH + BSO + BPLND + PA LN dissection, partial omentectomy on 2022/09/26, pT1bN1acM0, stage IIIC1; FIGO stage IIIC1, ECOG =1 s/p concurrent chemoradiotherapy
  • Essential (primary) hypertension
  • Constipation, unspecified
  • Hypomagnesemia
  • Anemia due to antineoplastic chemotherapy

[exam findings]

  • 2023-03-03 Mammography
    • Old mammographic study: 2021-04-15 (BIRADS 1)
    • Digital mammography of both breasts with MLO and CC views:
      • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
      • There is no obvious mass lesion.
    • Impression: Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
    • BI-RADS: Category 1: negative.-annual screening.
  • 2022-11-23 ECG
    • Sinus tachycardia
    • Left axis deviation
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2022-10-27 CT - abdomen
    • History and indication: Endometrial cancer
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. Swelling of anterior abdominal wall. A LN (1.5cm) at left paraaortic region. Small LNs at bil. inguinal regions.
      • Grade 4 fatty liver.
      • Left renal cyst (5mm).
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P hysterectomy.
      • Swelling of anterior abdominal wall. A LN at left paraaortic region.
  • 2022-10-27 ENT Hearing Test
    • PTA
    • Reliability FAIR
    • Average RE 19 dB HL; LE 23 dB HL.
    • Bil WNL.
  • 2022-10-01 CT - chest
    • Indication: GYN cancer, suspected metastasis
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • S/p port-A placement with its tip at Superior vena cava.
        • Linear atelectatic change at right lower lobe is found.
        • Subpleural nodule at left upper lobe up to 0.4cm in largest dimension is found. (Se8 Im44).
        • Non-specific lymph nodes are found at right hilar and left paratracheal region.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Marked fatty liver is found.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Compatible with endometrial cancer s/p C/T, No definte lung meta but non-specific lymph nodes in the mediastinum. Suggest follow up.
  • 2022-09-26 Patho - uterus with or without SO
    • pathologic diagnosis
      • Uterus, endometrium, staging surgery — Endometroid carcinoma
      • Fallopian tube, right, BSO — Endometriosis with atypical hyperplasia
      • Lymph nodes, pelvic and para-aortic, bilateral, BPLND+PALND— Metastatic carcinoma (8/35)
      • AJCC 8 th edition, Pathology stage: pT1bN1a; stage IIIC1; FIGO stage IIIC1
    • macroscopic examination
      • Procedure: LAVH + BSO + partial omentectomy + BPLND + para-aortic LN dissection
      • Specimen Size: 15 x 11 x 7.0 cm and 430 gm (uterus), 2.5 x 1.4 cm (Rt ovary), 5.2 x 1.0 cm (Rt tube), 2.2 x 1.5 cm (Lt ovary), 5.0 x 1.2 cm (Lt tube), and 25 x 12 x 5.0 cm (omentum)
      • Specimen Integrity: Intact
      • Tumor Site: Endometrium, diffuse
      • Tumor Size: 7.5 x 5.6 x 2.8 cm
      • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, left para-aortic and right para-aortic LNs
      • Representative parts are taken for section and labeled as: A= left iliac LNs, B1-B4= left obturator LNs, C= right iliac LNs, D1-D2= right obturator LNs, E= left para-aoric LNs, F1-F2= right para-aortic LNs, G1-G4= cerivx, G5-G8= endometrial tumor, G9-G10= right ovary and fallopian tube, G11-G12= left ovary and fallopian tube, H1-H2= omentum
    • microscopic examination
      • Histologic Type: Endometroid carcinoma
      • Histologic Grade: FIGO grade 2
      • Adenomyosis: Present
      • Uterine Serosal Involvement: Not identified
      • Cervical Stromal Involvement: Not identified
      • Other Tissue/Organ Involvement: Not applicable
      • Peritoneal/Ascitic Fluid: Negative
      • Margins: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin: 1.5 cm
      • Lymphvascular Invasion: Present
      • Regional Lymph Nodes: Metastatic carcinoma (8/35)
        • number of lymph node examined: 3 (left iliac), 11 (left obturator), 4 (right iliac), 10 (right obturator), 2 (left para-aortic), and 5 (right para-aortic)
        • number with metastases >2 mm: 4 (left obturator), 4 (right obturator)
        • number with metastases <=2 mm or less: 0
        • number with isolated tumor cells (<=0.2mm): 0
      • Pathologic Stage
        • Primary Tumor: pT1b (tumor invading one-half or more of the myometrium)
        • Regional Lymph Nodes: pN1a (regional lymph node metastasis(> 2mm) to pelvic lymph nodes)
        • Distant Metastasis: Not applicable
      • FIGO Stage: Stage IIIC1
      • AdditionalPathologic Findings
        • Cervix: Chronic cervicitis with Nabothian cyst and squamous metaplasia
        • Myometrium: Adenomyosis
        • Ovary, right: Unremarkable
        • Ovary, left: Endometriosis
        • Fallopian tube, right: Endometriosis with atypical hyperplasia
        • Fallopian tube, left: Endometriosis
        • Omentum: No remarkable change
  • 2022-09-21 MRI - pelvis
    • Clinical history: 47 y/o female patient with 2022/09/14 PATHO-endometrium curretage/biopsy, DIAGNOSIS: Uterus, endometrium, TCR — Endometrioid carcinoma.
    • With and without contrast enhancement MRI: Pelvis (Sag T2, axial T1, T2 and T1FS, coronal T2, post contrast enhancement axial and coronal T1FS, upper abdomen survey)
      • There are diffuse soft tissue tumors in the uterine cavity, suspected endometrial malignancy.
      • Tubular cystic lesion in right adnexa, suggesting hydrosalpinx.
      • Cysts in the uterine cervix, suggesting Nabothin cysts.
      • Unremarkable change of the liver, spleen, pancreas.
      • There are multiple enlarged lymph nodes in bilateral obturator region, internal and common iliac regions. Could be due to metastatic lymph nodes.
      • Non-enhancing nodule in left kidney, 0.45cm, suspected left renal cyst.
      • No ascites.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T:T1b(T_value) N:N1a(N_value) M:M0(M_value) STAGE: IIIC1____(Stage_value)
  • 2022-09-14 Patho - endometrium curretage/biopsy
    • Uterus, endometrium, TCR — Endometrioid carcinoma
    • Specimen submitted in formalin consists of multiple pieces of red, irregular tissue measuring up to 3.2 x 1.4 x 0.5 cm. All for section in 5 cassettes A1-5.
    • Sections show pieces of blood clots and endometrial tissue with solid and cribriform glands. Moderate to severe nuclear atypia and frequent mitoses are seen.
  • 2022-09-09 Gynecologic ultrasonography
    • LT adnexae: free
    • Endometrial thickening (RI:0.15)
    • Rt Ovarian cyst suspected hydrosalpinx

[consultation]

  • 2022-11-28 Radiation Oncology
    • Q
      • This 47-year-old woman patient is a case of Endometrial cancer, grade 2 endometroid carcinoma with bilateral obturator LAP metastasis s/p LAVH + BSO + BPLND + PA LN dissection, partial omentectomy on 2022/09/26, pT1bN1acM0, stage IIIC1; FIGO stage IIIC1, ECOG =1 s/p concurrent chemoradiotherapy.
      • This time, for severe nausea with vomiting after concurrent chemoradiotherapy. Now, for follow up. Thank you.
    • A
      • This 47 Y/O female has received adjuvant CCRT since 2022/10/24. She suffers from grade 2 nausea and vomiting during CCRT, although self-paid Emend has been prescribed.
      • RT dose: 4680cGy/26 fractions to vaginal stump, pelvic & PA lymphatics, 2022/10/24 to 11/28.
      • Concurrent weekly cisplatin: 10/29, 11/04, 11/11, 11/18, 11/25.
      • RT side effects, 11/28: Radiation dermatitis, grade 0; nausea, grade 2; enteritis, grade 1; proctitis, grade 1; cystitis, grade 0.

[surgical operation]

  • 2022-09-26
    • Surgery
      • Diagnosis
        • Pelvic MRI on 09/21 showed Diffuse soft tissue in the uterus with multiple enlarged pelvic lymph nodes, suspected endometrial malignancy, cstage T1bN1aM0, IIIC1.
        • Endometrial cancer
      • Operation
        • Laparoscopic gynecologic oncology staging surgery  
        • change to exploratory laparoscopy + laparotomy (ope) gynecologic oncology staging surgery (BPLND and bilateral para-aortic lymphadenectomy)    
    • Finding
      • Uterus: normal size, smooth surface, papillary mass in uterus cavity, myometrium invasion depth <1/2
      • Bilateral adnexa: severe adhesion, s/p adhesiolysis
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • CDS: ascites (+)
    • Others
      • Estimated blood loss: 300ml
      • Blood transfusion: nil
      • Complication: nil  
  • 2022-09-26
    • Surgery
      • Operation
        • Adhesionolysis
    • Finding
      • s/p lower midline incision with periumbilical hernia
      • severe adhesion of omentum and small bowel in lower peritoneal cavity
  • 2022-09-14
    • Surgery
      • TCR, for endometrial thickening.
      • with D&C      
    • Finding
      • Endometrial thickening, occupying the whole uterine cavity, suspected endometrial hyperplasia.
      • Bilateral ostium: difficult to see.
      • Usage of dextrose water: 1000ml/900 ml.
      • Estimated bloodloss: 10 ml;
      • Blood Transfusion: nil; Complication: nil.  

[radiotherapy]

  • 2022-10-24 ~ 2022-11-28 - 4680cGy/26 fractions to vaginal stump, pelvic & PA lymphatics

[chemotherapy]

  • 2023-03-27 - paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 600mg 2hr (adjuvant Q3W)
    • dexamethasone 4mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-03 - paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 600mg 2hr (adjuvant Q3W)
    • dexamethasone 4mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-03 - paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 600mg 2hr (adjuvant Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-13 - paclitaxel 140mg/m2 240mg NS 500mL 3hr + carboplatin AUC 5 450mg 2hr (adjuvant Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-24 - cisplatin 40mg/m2 70mg 2hr (CCRT)
    • dexamethasone 8mg + palonosetron 250ug + magnesium sulfate 10% 20mL 1hr + aprepitant 125mg D1-3
  • 2022-11-17 - cisplatin 40mg/m2 70mg 2hr (CCRT)
    • dexamethasone 8mg + palonosetron 250ug + aprepitant 125mg D1-3
  • 2022-11-10 - cisplatin 40mg/m2 70mg 2hr (CCRT)
    • dexamethasone 8mg + palonosetron 250ug + aprepitant 125mg D1-3
  • 2022-11-03 - cisplatin 40mg/m2 70mg 2hr (CCRT)
    • dexamethasone 8mg + palonosetron 250ug + aprepitant 125mg D1-3
  • 2022-10-28 - cisplatin 40mg/m2 70mg 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg D1-3

==========

2023-03-28

  • The patient’s hypomagnesemia, which has been ongoing since November 2022, continues to persist (2023-03-23 serum Mg 1.7mg/dL). It is recommended to include magnesium supplements in the patient’s discharge plan.

2023-01-16

  • The hypomagnesemia observed since Nov 2022 might be related to the cisplatin administered as part of the CCRT in early October and November 2022. Creatinine levels rose from roughly 0.6 mg/dL in late September 2022 to 1.0 mg/dL in late November 2022. Hypomagnesemia due to urinary magnesium wasting can occur in over one-half of cases of cisplatin-induced nephrotoxicity. Magnesium supplements have been prescribed for the patient both orally (MgO) and intravenously (MgSO4).
  • Since the end of December 2022, no further hypocalcemia has been observed.
  • At this hospitalization, there have been no symptoms of nausea or vomiting observed (as a result of concurrent chemotherapy and radiotherapy, the patient experienced severe nausea and vomiting in late November 2022).

701320413

230328

{Chronic myelomonocytic leukemia, CMMoL}

  • diagnosis
    • 2022-10-19 adminsion note
      • Anemia, unspecified
      • Chronic myelomonocytic leukemia not having achieved remission
      • Unspecified viral hepatitis B without hepatic coma
      • Type 2 diabetes mellitus without complications
      • Chronic myeloproliferative disease
  • exam finding
    • 2022-11-19 Skull, Pelvis, Femur
      • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
    • 2022-11-18 Abdomen
      • Eqivocal osteoblastic change of the L-spine are suspected. please correlate with clinical condition or CT.
      • Splenomegaly is highly suspected.
    • 2022-10-21 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (84 - 19) / 84 = 77.38%
        • M-mode (Teichholz) = 77
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA
      • Mild MR, TR
    • 2022-10-20 Bronchodilator Test
      • normal ventilation, non-significant bronchodilator response
    • 2022-10-19 Abdomen, standing (diaphragm)
      • Eqivocal osteoblastic change of the L-spine are suspected.
      • Splenomegaly is highly suspected.
    • 2022-09-07 Cardiac Catheter
      • In conclusion
        • Coronary artery disease, tripple vessel disease, with stage PCI to right coronary artery, long diffuse stenosis with 86 % stenosis lesion in RCA-P with 83% stenosis in RCA-M.
        • S/P PTCA to RCA-P, with drug eluting stent (Abbott Xience Sierra drug-eluting stent. 4.0 X 38 mm), self expense, successful, from 86% stenosis reduced to 0% residual stenosis.
        • S/P PTCA to RCA-M, with drug eluting stent (Abbott Xience Sierra drug-eluting stent. 3.5 X 33 mm), successful, from 83% stenosis reduced to 11% residual stenosis.
      • Recommendation
        • Keep DAPT (dual antiplatelet therapy).
    • 2022-08-12 Cardiac Catheter
      • In conclusion :
        • Coronary artery disease, triple vessel diseases, with a A 74% stenosis lesion in LAD-P to LAD-M, A 72% stenosis lesion in LCx and A 85% stenosis lesion in RCA-M.
        • S/P PTCA to LAD-P to LAD-M, Drug eluting stent (Abbott Xience. 3.0 X 48 mm), successful, from 74% stenosis lesion reduced to 4% residual stenosis.
        • S/P PTCA to LCX, Drug eluting stent, (: Abbott Xience. 3.5 X 15 mm), successful, from 72% stenosis lesion reduced to 10% residual stenosis lesion.
      • Recommendation
        • Continue DAPT (dual antiplatelet therapy).
        • Stage PCI for RCA-M later.
    • 2022-07-25 Cardiac Catheter
      • Syntax Score = 22
      • In conclusion: CAD TVD
      • Recommendation: Due the comorbidity of pancytopenia, stem cell transplantation need revascularization earlier, will discuss with the patient and family for further management about CABG or PCI.
      • Left Ventriculogram: Normal LV size and LV wall motion, no MR, LVEF = 66%
      • Left Main: Patent
      • Left Anterior Descending: 80% stenosis ovre proximal LAD and 70% stenosis over mid LAD
      • Left Circumflex: 80% stenosis over proximal LCX and 70% stenosis over mid LCX
      • Right Coronary: diffuse atherosclerosis with 70% stenosis and 90% tandem lesions at mid RCA
    • 2022-07-19 CT - coronary artery calcium score, without contrast
      • Indication: a case of CKD and suspected CAD with chest pain, Hb 6.4
      • Findings
        • Extensive calcification of coronary arteries. LAD:419 LCX:302 RCA:187 total calcium score=908 (Agatston)
        • Unremarkable of the pericardium.
        • Normal size of cardiac chambers.
        • Mild calcified atherosclerosis of the thoracic aorta
      • Impression:
        • extensive atherosclerotic plaque plaque indicating very high cardiovascular disease risk
    • 2022-07-08 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 29) / 104 = 72.12%
        • M-mode (Teichholz) = 71.8
      • Dilated LA
      • Adequate LV,RV systolic function with normal wall motion
      • Mild LV hypertrophy, Impaired LV relaxation
    • 2022-06-17 Myocardial perfusion SPECT with persantin
      • Probably mild to moderate myocardial ischemia at the inferoseptal wall and mild myocardial ischemia at the apex and anteroseptal wall.
      • Mild reverse redistribution of radioactivity to the inferoapical wall, either normal variant or myocardial ischemia may show this picture.
    • 2022-04-26 Patho - bone marrow biopsy
      • Bone marrow, iliac creast, biopsy — myeloproliferative neoplasm, favor chronic myelomonocytic leukemia
      • Microscopically, it shows hypercellularity of bone marrow (90%) with a proliferation of myeloid and monocytic lineage cells highlighted by CD68 and MPO, decreased erythrocytoid cells and megakaryocytes.
      • Immunohistochemical stain reveals CD68(diffuse+), MPO(diffuse+), TdT(-), CD138(<=1%), CD71(focal+), CD34(-) and CD117.
    • 2022-10-20 Patho - bone marrow biopsy
      • Bone marrow, iliac creast, biopsy — myeloproliferative neoplasm
        • NOTE: The differential diagnosis includes chronic myelomonocytic leukemia and ….. etc.
      • Microscopically, the bone marrow shows hypercellularity (90%) with a proliferation of myeloid and monocytic lineage cells highlighted by CD68 and MPO, decreased erythrocytoid cells and a few megakaryocytes.
      • Immunohistochemical stain reveals CD68(diffuse+), MPO(diffuse+), TdT(-), CD138(<5%), CD71(<5%), CD20(-), CD34(-) and CD117(<5%).
  • 2021-07-26 Abdominal Ultrasonography
    • Diagnosis
      • Mild splenomegaly
      • Fatty liver, mild
      • Fatty pancreas
      • Hydropelvis, bilateral
      • Atrophy of right kidney
    • Suggestion
      • Please correlate with clinical information, other imaging and follow sonography in 3-6 mon.
      • Please check LFTs, tumor markers, and metabolic profiles.
  • chemoimmunotherapy
    • 2022-07-08 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2022-06-10 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2022-04-25 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2022-03-21 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2022-02-21 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2022-01-24 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2021-12-27 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2021-11-30 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7

2023-03-28

[ciclosporin TDM]

Based on the available system records, the blood for ciclosporin was drawn at 00:48 on 2023-03-27, approximately 4 hours after medication administration at 20:32 on 2023-03-26. If the purpose of the blood draw was to measure the trough concentration, the ideal time to draw blood is within 30 minutes before next scheduled medication administration. Therefore, it is recommended to verify the accuracy of the system records or to redraw a blood sample at the appropriate time for accurate measurement.

The recorded concentration result for ciclosporin is 331.4ng/mL, but its accuracy as a trough level may be questionable due to the possibility of an inappropriate blood draw time.

2022-12-13

The peak concentration of cyclosporine-A was 326 ng/mL on 2022-12-12, which is within the normal therapeutic range.

2022-12-13 WBC 670/uL, PLT 2000/uL.

2022-11-28

[cyclosporine trough concentration]

As a follow-up of the change in dose of cyclosporine from 100mg Q12H to 120mg Q12H since 2022-11-25, it is recommended that the trough concentration of cyclosporine be renewed by drawing blood within 30 minutes of the first dose on 2022-11-29.

2022-11-25

[cyclosporine trough concentration]

Following the administration of 100 mg Q12H since 2022-11-21, a blood sample was taken for cyclosporine trough concentration, and the level was 63.9 ng/mL. In general, the effective range is considered to be between 100 and 400 ng/mL. In the event that the clinical effect not shown, increasing the daily dose to 300mg (divided in 3 seperate administration) can be considered and then recheck the trough concentration 3 days after the dose alteration. The goal is to limit the concentration with a minimum dose while retaining the necessary clinical effect.

According to UpToDate database, cyclosporine for patients with altered kidney function, CrCl <60 mL/minute: No dosage adjustment necessary (0.1% excreted in the urine unchanged) (Nemecek 2019; expert opinion). For nontransplant indications (eg, autoimmune disease), the manufacturer’s labeling states use is contraindicated in patients with abnormal renal function (not defined); however, when potential benefits outweigh the risks, may consider cautious use with frequent monitoring of kidney function, or consider use of an alternative agent due to increased risk of worsening kidney function, especially for patients with more severe impairment (expert opinion).

2022-10-20

2022-10-20 eGFR 35. The dosage of prescribed drugs is within the recommended range for patients with altered kidney function.

701471705

230328

[Diagnosis] - 2023-03-27 admission note

  • High grade serouns carcinoma of bilateral ovaries, pT2bNxMx, at least 2B, s/p Debulking surgery for ovarian cancer (hysterectomy + right oophorectomy + infracolic omentectomy + bilateral pelvic lymph node dissection) the 2023/03/09, ypTxN0(if cM0)
  • Chronic viral hepatitis B without delta-agent

[present illness] - 2023-03-27 admission note

  • This 47-year-old woman patient is a case of Ovarian malignancy s/p LSO + right ovarian cystectomy + right salpingectomy on 2022/12/15 and three times of taxol chemotherapy (at HuaLien TzhChi Hospital). She had palpable progressively enlarging masses over right inguinal area for 4 months. Three months ago, she went to HuaLien TzhChi Hospital GYN OPD due to her progressively enlarging masses over right inguinal area and LSO + right ovarian cystectomy + right salpingectomy on 2022/12/15 and three times of taxol chemotherapy were done.
  • This time, she came to our GYN OPD on 2023/02/16 seeking second opinion for surgical intervention. Received 3 rd times chemotherapy with Taxol/Carboplatin in Hualien (due to high grade serous carcinoma) on 2023/01/30. Transvaginal sonography on 2023/02/17 revealed multiple myomas 22x18, 23x20, 17x16mm and EM 5.00mm. PES on 2023/03/08 showed chronic superficial gastritis. Colonoscopy on 2023/03/08 showed no immediate complication. Debulking surgery for ovarian cancer (hysterectomy + right oophorectomy + infracolic omentectomy + bilateral pelvic lymph node dissection) on 2023/03/09 and pathology showed AJCC 8th edition pathology stage: ypTxN0(if cM0), high grade serouns carcinoma of bilateral ovaries: pT2b NxMx, at least 2B. Tumor markers on 2023/03/24 showed normal (CA-125:17.8 U/mL, CEA:0.94 ng/mL, CA199- 6.52U/mL). Now, she was admitted to ward for adjuvant chemotherapy with TP (Taxol 175mg/m2, Carboplatin AUC:5)(C4) on 2023/03/28.

[past history] - 2023-03-27 admission note

  • Hypertension without medication control
  • DM:(-) Other
  • medical:denied
  • Not taking any hormone medications
  • Surgical: Ovarian malignancy s/p LSO + right ovarian cystectomy + right salpingectomy on 2022/12/15 and three times of taxol chemotherapy (at HuaLien TzhChi Hospital)
  • Menstrual history: G0P0, Last menstrual period: 2022/11
  • Menarche at the age of 13 years old
  • Menstrual cycle: Duration/Interval: 4-5days/14-28days
  • Amount: moderate without blood clots
  • Last pap smear examination at 2022/9            

[allergy]

  • NKDA

[family history]

  • Father has colon cancer and hypertension.
  • No members of the family with diabetes.

[exam findings]

  • 2023-03-09 Patho - uterus with or without SO non-neoplastic/prolapse
    • Ovarian/ Fallopian tube/ Peritoneum Cancer Checklist
    • Diagnosis:
      • Uterus, endometrium, debulking surgery — No residual malignant tumor
      • Uterus, myometrium, debulking surgery — Intramural myoma; adenomatoid tumor; adenomyosis
      • Uterus, cervix, debulking surgery — No residual malignant tumor
      • Omentum, infracolic omentectomy — No residual malignant tumor
      • Lymph node, left iliac, dissection — Negative for malignancy ( 0 / 9)
      • Lymph node, left obturator, dissection — Negative for malignancy ( 0 / 5)
      • Lymph node, right iliac, dissection — Negative for malignancy ( 0 / 5)
      • Lymph node, right obturator, dissection — Negative for malignancy ( 0 / 5)
    • AJCC 8th edition pathology stage: ypTxN0(if cM0)
  • 2023-03-08 Colonoscopy
    • Diagnosis
      • Mixed hemorrhoid, gr 3-4
      • incomplete study due to poor preparation.
    • Suggestion
      • Small lesions may be missed due to inadequate colon preparation.
    • Complication
      • No immediate complication
  • 2023-03-07 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Nonspecific T wave abnormality
  • 2023-02-16 Gynecologic ultrasonography
    • Bilateral adnexae: free
    • Uterine myoma

[surgical operation]

  • 2023-03-09
    • Diagnosis
      • High grade serous carcinoma of bilateral ovaries, pT2bNxMx (2022/12/15), at least IIB, status post glove-port LSO + right ovarian cystectomy + right salpingectomy on 2022/12/15.
    • Surgery:
      • Debulking surgery for ovarian cancer (hysterectomy + right oophorectomy + infracolic omentectomy + bilateral pelvic lymph node dissection).
    • Finding
      • uterus with multiple small myomas, its total size measuring 7x5cm
      • right side atrophic partial ovary was attached to the posterior wall of the uterus
      • there was dense adhesion from last surgery found between the intestine and left side pelvic wall, adhesionlysis was performed
      • left side pelvic lymph nodes enlarged (+)
      • right side pelvic lymph nodes (-)
      • cytology was performed
      • there was no residual tumor found while entering the pelvic cavity
      • omentectomy was done

[chemotherapy]

  • 2023-03-27 paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3

[assessment]

  • The patient was diagnosed with high grade serous carcinoma of bilateral ovaries, with a pathological stage of pT2bNxMx, at least IIB. She underwent LSO, right ovarian cystectomy, and right salpingectomy on 2022/12/15 and received three cycles of taxol chemotherapy at HuaLien TzhChi Hospital, with the last dose on 2023-01-30. On 2023-03-09, she underwent debulking surgery for ovarian cancer, which included a hysterectomy, right oophorectomy, infracolic omentectomy, and bilateral pelvic lymph node dissection.
  • She was admitted this time for the fourth adjuvant chemotherapy cycle using paclitaxel and carboplatin, with the previous three cycles being administered at HuaLien TzhChi Hospital.
  • Paclitaxel can cause severe hypersensitivity reactions, so the premedication regimen includes dexamethasone, an H1 receptor antagonist (diphenhydramine), and an H2 receptor antagonist (famotidine).
  • Carboplatin is also associated with infusion reactions, which typically occur after six cycles, and no specific premedication regimen is recommended.
  • Lab data on 2023-03-27 showed normal liver and kidney function with CBC grossly in normal range. No dose adjustment is needed for the scheduled chemotherapy.
  • According to the PharmaCloud database, the patient has only taken drugs prescribed at our hospital in the last three months, and there is no medication reconciliation issue.

700335007

230327

[diagnosis] - 2023-03-13 admission note

  • Intrahepatic bile duct carcinoma
  • Type 2 diabetes mellitus without complications
  • Cardiac arrhythmia, unspecified

[past history]

  • Medical PH: recurrent intraductal cholangeicarcinoma cT2N0M0 s/p Lt lobectomy on 2020/04/15, pT2pNx, well differentiated. NTUH, anatomical hepatectomy S5,8 plus cholecystectomy on 2022/03/23 and CCRT under gemcitabine treatment.
  • Hospitalization: several times due to UTI
  • urethral stone s/p at NTUH
  • DM (+): under pioglitazone 15mg/metformin 850mg BID, glimepride 2mg QD
  • HTN (-)
  • Peptic ulcer

    

[allergy]

  • NKDA     

[family history]

  • Mother: DM

[exam findings]

  • 2023-03-24, -03-13 KUB
    • S/P clips projecting at the liver
    • Spondylosis of the L-spine is noted.
  • 2023-03-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (67 - 28) / 67 = 58.21%
      • M-mode (Teichholz) = 57
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Mild to moderate MR, mild AR, moderate TR and trivial PR
        • ChatGPT: In a cardiac echocardiogram, the abbreviations MR, AR, TR, and PR refer to different types of heart valve regurgitation:
          • MR: Mitral regurgitation, which is the backflow of blood from the left ventricle to the left atrium through the mitral valve during systole.
          • AR: Aortic regurgitation, which is the backflow of blood from the aorta to the left ventricle during diastole.
          • TR: Tricuspid regurgitation, which is the backflow of blood from the right ventricle to the right atrium through the tricuspid valve during systole.
          • PR: Pulmonary regurgitation, which is the backflow of blood from the pulmonary artery to the right ventricle during diastole.
      • Preserved RV systolic function
      • Atrial fibrillation with HR 90~128 at the exam
  • 2023-03-14 SONO - abdomen
    • Parenchymal liver disease
    • Post left lobectomy of liver
    • Postcholecystectcomy
  • 2023-03-13 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2023-03-13 ECG
    • Atrial fibrillation with rapid ventricular response
  • 2023-02-16 CT - abdomen
    • History and indication: intraheapatic cholangiocarcinoma
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P left liver operation without interval change.
      • Hydrops of left scrotum.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • S/P cholecystectomy.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • A calcified spot (4.7mm) at RLL.
    • IMP:
      • S/P left liver operation without interval change.
  • 2022-10-24 CT - abdomen
    • Indication
      • First operation for intraheapatic cholangiocarcinoma, cT2N0M0 post Lt lobectomy on 2020/04/15, pT2pNx, well differentiated.
      • NTUH - Anatomical hepatectomy S5,8 plus cholecystectomy on 2022/03/23 NIDDM under OHA for 4 yrs (20220624)
      • History of arrhythmia
    • Abdominal CT with and without enhancement revealed:
      • s/p left hepatic lobectomy.
      • Low density change at caudate lobe about 2.79cm in largest dimension. post op change or others? Suggest closely follow up.
      • Minimal ascites at abdominal cavity is found.
      • Enlarged prostate up to 4.8cm in largest dimension is found.
      • The spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • Non-specific bowel gas at abdominal cavity is found.
      • Visible chest
        • Cardiomegaly is noted.
        • The lung fields are clear.
        • No pleural effusion is found.
      • Suggest clinical correlation
    • Imp: s/p left hepatic lobectomy with low density lesion at caudate lobe about 2.79cm, post op change or recurrent tumor should be D.D. Suggest closely follow up.
  • 2022-06-30 CXR
    • S/P Port-A infusion catheter insertion.
    • Blunted right costophrenic angle.
    • S/P operation with retention of surgical clips.
  • 2022-06-24 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?

MRI (111-2-5, NTUH): 1. operative change of the left lobe of liver; no evidence of local residual tumor is noted; 2. focal area 39.5mm in the surgical margins is noted; the lesion was not identified on MR 2020/9/8; new recurrent tumor is considered. (arrow key images) 3. hepatic veins and portal veins are patent 4. there are no focal lesions in the spleen pancreas both adrenal and kidneys; a tiny cyst in the left kidney; 5. there is no evidence of paraaortic LAPs in abdomen; there is no evidence of paraaortic LAPs in pelvic cavity and bilateral inguingal areas. 6. there is no ascites 7. enlarged prostate is noted with posterior urinary bladder indentation; 8. hydrocele of the left scrotum. PET (111-3-2, NTUH): Some intense hot areas along medial border of the liver (figures 1-1 to 1-4, SUVmax=11.85). * Some moderate hot spots at abdominal paraaortic nodes and left iliac nodes (figures 1-5 to 1-9, SUVmax=5.79). * A faint hot spot at right iliac crest (figure 1-10, SUVmax=1.34), probably benign. * Some mild hot areas at L1-L2 vertebral junction, right hip joint, and right ischial enthesis, probably arthritis and enthesitis. * Intense curvilinear-shaped hot areas at bowel loops, suspicious Metformin-related activity. Pathology (P2202854, 2022-3-26, NTUH): Liver segment 5 8 anatomical hepatectomy cholangiocarcinoma Gallbladder cholecystectomy chronic cholecystitis Lymph node peri-gallbladder lymphadenectomy minimal histological change (1/1). Histologic Grade Grade 2: Moderately differentiated (50% to 95% of tumor composed of glands). Margins (check all that apply) Hepatic Parenchymal Margin Uninvolved by invasive carcinoma. Lymph-Vascular Invasion: not identified. Perineural Invasion Not identified. Pathologic Staging (pTNM according to AJCC v.8): Primary Tumor (pT) pT1b: Solitary tumor >5cm without vascular invasion Regional Lymph Nodes (pN) pN0: No regional lymph node metastasis. MRI (111-5-4, NTUH): 1. operative change of the left lobe of liver; no evidence of local residual tumor is noted; 2. operative change of the anterior right lobe of liver; no evidence of local residual tumor is noted; a small biloma. 3. a recurrent tumor 34.5mm is noted at the S1 of the liver; cholangiocarcinoma is considered. 4. hepatic veins and portal veins are patent 5. there are no focal lesions in the spleen pancreas both adrenal and kidneys 6. there is no evidence of paraaortic LAPs in abdomen 7. there is no ascites

[consultation]

  • 2023-03-24 Gastroenterology
    • Q
      • This is a 74-year-old male with underlying DM (under pioglitazone 15mg/metformin 850mg BID, glimepirde 2mg QD) and recurrent intraductal cholangeicarcinoma cT2N0M0 s/p Lt lobectomy on 2020/04/15, pT2pNx, well differentiated. (NTUH), anatomical hepatectomy S5,8 plus cholecystectomy on 2022/03/23 and CCRT under gemcitabine treatment.
      • The patient was just discharged last week under the diagnosis of general weakness with mild eleavted liver enzyme suspected poor intake related.
      • The patient sufferred from poor appetite with progressive body weight loss from 54kg -> 50kg in recent one month. Easy satiety with nausea and vomit sensation, he can only tolerate liquid diet intake (the solid food can be swallowed, but the patient vomits immediately after eating.) Mild elevated liver enzyme also noted. KUB during last admission: no ileus, will be followed today. Stool passage only under laxative use recently. Depressive mood also noted and had went to PSY OPD for further managment on 2023/03/22, mertazapine 0.5# HS was precribed. Stool OB obtained in last admission: negative.
      • For poor appeitte with general weakness, we need your expertise for further evaluation and management, thank you!
    • A
      • This time, he was admitted for poor appetite and general weakness. And, we are consulted for problem above.
      • S + O
        • At bedside, stable vital signs noted
        • Recieving blood transfusion
        • Clear conscious,
        • According to his daughter, patient ate well without vomitus yesterday, after stool passage
        • But, vomtius noted today
        • Local tenderness at upper quadrat of abdomen, no rebounding pain
        • normoactive bowel sound
        • Percussion: no tympanic
        • Lab
          • 2023-03-24 Na (Sodium) 133 mmol/L
          • 2023-03-24 K(Potassium) 3.9 mmol/L
          • 2023-03-24 Ca (Calcium) 2.03 mmol/L
          • 2023-03-24 Albumin 2.7 g/dL
          • 2023-03-24 Neutrophil 98.0 %
          • 2023-03-24 S-GPT/ALT 101 U/L
          • 2023-03-24 S-GOT/AST 116 U/L
          • 2023-03-24 Alkaline phosphatase 844 U/L
          • 2023-03-24 Creatinine 0.64 mg/dL
          • 2023-03-24 WBC 14.70 x10^3/uL
          • 2023-03-24 HGB 7.9 g/dL
          • 2023-03-24 PLT 396 x10^3/uL
          • 2023-03-17 HbA1c 8.4 %
      • A: poor appetite, vomitus, suspect gastroparesis, suspected obstruction
      • P:
        • Might be on NG feeding with feeding bag or feeding pump for nutrition support, if still vomitus
        • IVF supplement
        • Give medication with gascon and prokinetic agent such as metoclopramide (IV or PO), mosapride or domperidone
        • Regular follow up KUB (standing KUB) to see if symptoms improved
        • Give medication such as sennoside, dulcolax, lactulose, EVAC to keep stool passage
        • Correct electrolytes imbalance
        • Check thyroid and adrenal function.
        • Correct hypoalbuminemia to improve bowel edema.
        • Arrange upper GI series or EGD to rule out mechanical lesion
        • Arrange abdominal CT (with contrast if no contraindication), if still unknow etiology
        • Consider to use megestrol, if cachexia was suspicious and rule out other cause of poor appetite
  • 2023-03-14 Cardiology
    • Q
      • This is a 74-year-old male with underlying DM (under pioglitazone 15mg/metformin 850mg BID, glimepirde 2mg QD) and recurrent intraductal cholangeicarcinoma cT2N0M0 s/p Lt lobectomy on 2020/04/15, pT2pNx, well differentiated. (NTUH), anatomical hepatectomy S5,8 plus cholecystectomy on 2022/03/23 and CCRT under gemcitabine treatment.
      • Under the impression of unintentional body weight loss with elevated liver enzyme, suspected cancer progression, he was admitted for further survey.
      • Tachycardia with follow up ECG showed Af on admission. According to the patient, he knew he had Af and had ever follow up in CV in the past but lost of follow up for years, anticoagulation was suggested but refused due to personal reasons.
      • We add apixaben 5mg BID for stroke prevention (CHA2DS2 VASC score 2 points)
      • We need your expertise for further evaluation and follow up, thank you!
    • A
      • The patient was examined and hx was reviewed.
      • CHA2DS2 score = 2’ ; HAS-BLED 1’-2’;
      • Suggestion
        • Anticoagulant is indicated for the patient; the risk (eg.: major bleeding rate around 0.1-0.3 %) and indication have been well explained to the patient and his family.
        • Educate about the timing of medication withdrawl.
        • Arrange 2D echo for LV function work-ip.
        • Nebivolol 0.5# qd for rate control.
      • Thanks for your consultation.

[radiotherapy]

  • 2022-07-18 ~ 2022-08-22 - 4500cGy/25 fractions of the recurrent tumor and peripheral area.

[chemotherapy]

  • 2023-02-21 - gemcitabine 1000mg/m2 1544mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-02-14 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-02-07 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-01-31 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-01-17 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-01-03 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-12-20 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-12-06 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-11-22 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-11-08 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-10-25 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-10-11 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-09-27 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-09-06 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-16 - gemcitabine 200mg/m2 312mg NS 50mL 15min (reduced dose)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-02 - gemcitabine 200mg/m2 312mg NS 50mL 15min (reduced dose)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-07-19 - gemcitabine 200mg/m2 312mg NS 50mL 15min (reduced dose)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-07-05 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

==========

2023-03-27

  • The patient was prescribed regular insulin 10 units Q12H at 08:05 on 2023-03-27, while his serum glucose levels have been fluctuating significantly, ranging from less than 100mg/dL to over 200mg/dL (81mg/dL at 06:06 on 2023-03-25 and 109mg/dL at 06:22 on 2023-03-27). It is recommended to closely monitor the patient for signs of hypoglycemia after administering the insulin and adjust the dosage as needed.
  • The patient’s stool occult blood test (OB) is positive (4+, 2023-03-26). Hemoclot (tranexamic acid) 500mg IVD Q12H has been prescribed. The anticoagulant indicated for the patient’s atrial fibrillation is currently withheld due to the patient’s current bleeding.
  • The patient’s constipation has been alleviated with the use of Through (sennoside), lactulose, and EVAC Enema, resulting in 1, 0, 0, and 3 bowel movements on March 23rd to March 26th, respectively.
  • There are no issues with the current prescription.

2023-03-14

  • Elevated liver-related enzymes and hemoglobin breakdown readings above the normal range strongly suggest the possibility of hepatic problems.
    • 2023-03-13 S-GOT/AST 89 U/L
    • 2023-03-13 S-GPT/ALT 113 U/L
    • 2023-03-13 Bilirubin total 1.59 mg/dL
    • 2023-03-13 Bilirubin direct 0.66 mg/dL
    • 2023-03-13 Alkaline phosphatase 688 U/L
    • 2023-03-13 r-GT 876 U/L
  • Despite the administration of insulin and oral antiglycemic agents, the patient has experienced blood sugar levels ranging between 320 to 600 mg/dL during this hospitalization. This marked hyperglycemia can lead to an increase in serum glucose, which in turn raises the serum tonicity. This process draws water out of cells and expands the extracellular water space, resulting in a subsequent lowering of the serum sodium concentration. It is recommended to appropriately increase the insulin dose in order to better manage the patient’s hyperglycemia (and the possibly induced hyponatremia).
    • 2023-03-14 Free-T4 1.18 ng/dL
    • 2023-03-14 TSH 0.890 uIU/mL
    • 2023-03-13 Urine osmolarity 675 mOsm/Kg
    • 2023-03-13 Na (Urine) 46 mmol/L
    • 2023-03-13 K (Urine) 19.9 mmol/L
    • 2023-03-13 Na (Sodium) 127 mmol/L
    • 2023-03-13 Albumin 2.7 g/dL

700537683

230327

[exam findings]

  • 2023-03-23 Ascites tapping
    • 3000mL
  • 2023-03-22, -03-21 CXR
    • S/P port-A implantation.
    • Enlargement of cardiac silhouette.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion.
    • Few gallstones.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2023-03-21 CT - abdomen
    • History and indication: Pancreatic cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A poor enhancing lesion (6.8cm) at pancreatic tail with adjacent gastric/ spleen/ left adrenal/ colon/ splenic artery/ splenic vein invasion.
      • Bil. pleural erffusions with adjacent lung collapse.
      • Some LNs at retroperitoneum.
      • Multiple liver tumors.
      • Some soft tissues in peritoneal cavity with ascites.
      • Normal appearance of kidneys.
      • Gallbladder stones (up to 1.2cm).
      • Patency of portal vein.
      • Intact bony structures.
      • No obvious extraluminal free air.
      • Minimal pericardial effusion.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • S/P Port-A infusion catheter insertion.
      • Cystic lesions (up to 3.1cm) at thyroid glands.
    • IMP:
      • Pancreatic tail with adjacent structures invasion, peritoneal carcinomatosis and liver metastases (progression). Ascites and pleural effusion.
  • 2023-03-20, -03-16 Standing KUB
    • Gallbladder stones.
    • Fecal material store in the colon.
    • Ascites is highly suspected. Please correlate with sonography.
    • Degenerative change of the spine with marginal spur formation.
  • 2023-03-14, -02-22 ECG
    • Sinus tachycardia
  • 2022-12-22 CT - chest
    • Indication: pancrease cancer, cT3N1M1, stage IV, for lung metastasis evaluation
    • MDCT (256-detector rows, GE Revolution, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Lungs: multiple small randomly distributed pulmonary nodules of varying sizes up to 11mm at RML consistent metastases.
      • Mediastinum and hila: no enlarged LN or mass.
        • small pericardial effusion.
        • mild calcified plaques of the LAD coronary arter.
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Heart: normal in size of cardiac chambers.
      • Pleura: trace effusion.
      • Chest wall and visible lower neck: enlarged thyroid gland with nodular calcifications and cystic lesions up to 42mm.
      • Visible abdominal contents: a large (6cm) at pancreatic tail canceer with adjacent organs invasion, multiple metastatic tumors, regional LNs metastasis, suspect a small tumor in pancreatic head. two gallstones (1.3mm).
    • Impression:
      • advanced pancreatic cancer (stage IV) with lung metastasis.
      • thyroid goiter.
  • 2022-12-21 whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed a hot area in the right aspect of mandible, faint hot spots in both rib cages, and increased activity in the skull, maxilla, a upper T-spine, sacrum, bilateral shoulders, S-I joints, hips, and knees, in whole body survey.
    • IMPRESSION:
      • A hot area in the right aspect of mandible and increased activity in a upper T-spine, the nature is to be determined (early bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
      • Suspected benign lesions in both rib cages, skull, maxilla, sacrum, bilateral shoulders, S-I joints, hips, and knees.
  • 2022-12-20 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Adenocarcinoma, pancreatobiliary type, compatible with metastatic pancreatic ductal adenocarcinoma
    • The sections show a picture of pancreatobiliary-type adenocarcinoma, moderately differentiated, composed of nests, and cords of low columnar neoplastic cells with intracytoplasmic and intraluminal mucin, arranged in tubular and cribriform patterns, and embdded in fibrous stroma.
    • IHC shows: CK7(+), CA19-9(+), amd CK20 (focal +).
    • The finding is compatible with metastatic pancreatic ductal adenocarcinoma.
    • Suggest clinic coirrelation.
  • 2022-12-17 CT - abdomen
    • History and indication:
      • liver tumors: suspected metastatic tumors. suspected pancreatic tumor(tail)
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A poor enhancing lesion (5.9cm) at pancreatic tail with adjacent gastric/ spleen/ left adrenal/ colon/ splenic artery/ splenic vein invasion.
      • Some LNs at retroperitoneum.
      • Multiple liver tumors.
      • Some soft tissues in peritoneal cavity.
      • Normal appearance of kidneys.
      • Gallbladder stones (up to 1.2cm).
      • Patency of portal vein.
      • Intact bony structures.
      • Small amount ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • Some nodules at bilateral basal lungs.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N1(N_value) M:M1(M_value) STAGE:IV(Stage_value)
  • 2022-12-14 SONO - abdomen
    • Diagnosis
      • Hepatic tumors suspected mets
      • Gall stones, two
      • Pancreatic tumor suspected cancer, tail
    • Suggestion
      • abdomen CT
  • 2022-12-14 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A(minimal)
      • Superficial and atrophic gastritis, antrum, s/p CLO test
      • Gastric polypoid lesion, high body, GC site, suspicious external compression
    • Suggestion
      • Pursue CLO test result
      • Consider arrange CT scan for suspicious external compression
  • 2019-06-03 ENT Hearing Test
    • Tymp: R’t type As; L’t type A
    • ART:
      • R’t ipsi 4k Hz and contra 500 Hz absent
      • L’t ipsi 4k Hz reduced and contra 500 & 4k Hz absent
    • PTA:
      • Reliability fair
      • Average R’t 45 dB HL; L’t 54 dB HL
      • R’t mild to moderately severe SNHL
      • L’t moderate to moderately severe SNHL

[consultation]

  • 2022-12-20 Hemato-Oncology
    • Q
      • This 70 years old female has the history of DM under medication control for years
      • she came to GI OPD for abdomen pain for days and body weight loss 5+ in one month. At OPD abdomen CT was perfromed and reported A poor enhancing lesion (5.9cm) at pancreatic tail with adjacent gastric/ spleen/ left adrenal/ colon/ splenic artery/ splenic vein invasion.
        • Some LNs at retroperitoneum.
        • Multiple liver tumors.
        • Some soft tissues in peritoneal cavity.
      • Pancreatic Carcinoma T3N1M1 STAGE:IV
      • Bone scan was arranged, we need your further further advise. Thanks
    • A
      • This 70 year old woman is a case of suspect pancreae tail cancer with liver and lung metastasis. She receive CT guide bioipsy for liver tumor on 2022/12/20 morning and pending the result. For pancrease cancer, cT3N1M1, stage IV, we are consulted.
      • Suggestions:
        • Well explain to patient and daughter.
        • May arrange contrast enhance chest CT for lung metastasis during this admission, or arrange in my clinics.
        • Please check AntiHbc, HbsAg, AntiHCV
        • Pending the pathology. We will discuss with patient about further treatment according to pathology result.
        • Please arrange our OPD after being discharged.

[chemotherapy]

  • 2023-03-07 - nab-paclitaxel 100mg/m2 170mg 90min D1,8,15 + gemcitabine 1000mg/m2 1700mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-02-14 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-02-07 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-01-31 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-01-17 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-01-10 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-01-03 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

700490718

230324

[exam findings]

  • 2023-03-23 CXR
    • Consolidation or mass lesions in left lower lung zone
  • 2023-03-21 Nasopharyngoscopy
    • right OME(+) –> suggest right grommet
  • 2023-03-14 MRI - nasopharynx
    • The current study was compared to the prior one obtained on 2022/10/25.
    • The previously seen mucosal enhancing lesion on the nasopharyngeal posterior wall is less distinct. Favor tumor in regression.
    • Severe paranasal sinusitis.
    • Severe bilateral mastoiditis.
  • 2023-03-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (113 - 27) / 113 = 76.11%
      • M-mode (Teichholz) = 76
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild PR, AR
  • 2023-03-07 Nasopharyngoscopy
    • Findings: curst over NPx, NE of left NP tumor noted, sticky sputum over posterior pharyngeal wall
    • Conclusion: NPC
  • 2023-03-06 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-03-02 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
    • Peri-bronchial wall thickening of the left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-02-23 CXR
    • Atherosclerosis of the aorta.
    • Ground glass opacity in LLL.
  • 2023-02-23 ECG
    • Sinus rhythm with Premature atrial complexes
    • Nonspecific ST and T wave abnormality
  • 2023-02-04 Nasopharyngoscopy
    • Findings: stage cT1N1M0, under CCRT
    • Conclusion: NPscope: left NP tumor regression, NE of tumor noted, crust(+)
  • 2023-01-07 Nasopharyngoscopy
    • Findings: NPC
    • Conclusion: left NP tumor regression, but still residual tumor
  • 2022-11-20 CXR
    • No cardiomegaly
    • No active lung lesion
    • Normal bony contour
  • 2022-11-10 ENT Hearing Test
    • Reliabilty Fair
    • PTA
      • R’t : 33 dB HL
      • L’t : 35 dB HL
      • Bil normal to moderate SNHL.
  • 2022-11-09 CXR
    • Multiple nodules at bil. lungs.
    • Normal appearance of trachea and bil. main bronchus.
    • Normal size of heart.
    • Intact bony structure(s).
  • 2022-11-02 CXR
    • Blunted left costophrenic angle.
    • Normal appearance of trachea and bil. main bronchus.
    • Atherosclerosis of the aorta.
    • Multiple nodules at RUL.
  • 2022-10-25 CXR
    • No cardiomegaly
    • Increased infiltration over right lung and LLL. May be active infection.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2022-10-26 Tc-99m MDP whole body bone scan
    • IMPRESSION:
      • Increased activity in the skull base and maxilla, either local hyperemia or local bony involvement may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Suspected benign lesions in some T- and L-spine, sacrum, bilateral shoulders, S-I joints, hips, and left knee.
    • SUGGESTION:
      • Please arrange F-18 FDG PET/CT scan for further staging (Insurance reimbursement indication for head and neck cancer staging).
  • 2022-10-25 MRI - nasopharynx
    • Nasopharyngeal Carcinoma
    • Impression ( Imaging stage ): T:T1(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-10-18 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopharynx, left, NP biopsy — Non-keratinizing squamous cell carcinoma, undifferentiated type
    • The specimen submitted consists of a small piece of gray-tan soft tissue, labeled left nasopharynx, measuring 0.5 x 0.3 x 0.2 cm. All for section.
    • The sections show a picture of non-keratinizing squamous cell carcinoma, undifferentiated subtype, composed of nests of large neoplastic cells with oval to spindle-shaped vesicular nuclei and syncytial growth pattern. Keratin formation is absent.
  • 2022-10-18 Nasopharyngoscopy
    • Findings
      • blood tinged NR for one month
      • patient has strong gap reflex, hard to assess NP and larynx by mirror
      • no ABC
    • Diagnosis
      • left NP tumor, suggest NP biopsy
  • 2022-07-27 SONO - abdomen
    • Diagnosis
      • Probable small hemangioma, S6/7
      • Liver cyst, S8
      • Right renal cyst
      • fatty infiltration of pancreas
    • Suggestion
      • OPD follow-up
  • 2022-04-25 Panendoscopy
    • Diagnosis
      • Reflux esophagitis LA Classification grade A (minimal)
      • Superficial gastritis, s/p CLO test
      • Gastric erosions
      • Cardiac insufficiency
    • Suggestion
      • May give PPI trial
      • Pursue CLO test
  • 2022-01-26 SONO - abdomen
    • Diagnosis
      • Probable small hemangioma, S6/7
      • Liver cyst, S8
      • Right renal cyst
      • Splenomegaly, mild
    • Suggestion
      • OPD follow-up

[consultation]

  • 2023-03-07 Ear Nose Throat
    • Q
      • This 67-year-old man patient is a case of Non-keratinizing squamous cell carcinoma, undifferentiated type, of the nasopharynx, cT1N1M0, stage II s/p concurrent chemoradiotherapy from 2022/12/05 ~ 2022/12/29 and chemotherapy with PF4 (CDDP 80mg/m2, 5FU 1000mg/m2 x4 days) from 2022/11/11. Patient refuse chemotherapy. This time, for F/U. Thank you.
    • A
      • S
        • Hx of Non-keratinizing squamous cell carcinoma, undifferentiated type, of the nasopharynx, cT1N1M0, stage II
        • Suffered from bilateral hearing impairment (tympanocentesis was done before but in vain), dysphagia, sticky sputum, PND, tachycardia after chemo with PF4
      • O
        • Ear drum: bil OME
        • Scope: curst over NPx, NE of left NP tumor noted, sticky sputum over posterior pharyngeal wall
      • Imp:
        • NPC, regression
        • OME, bil, suspect side effects of RT
      • Plan:
        • Treat his symptoms with your expertise
        • ENT OPD f/u for NPC and hearing problem

[cancer multidisciplinary team meeting conclusion] - meeting date: 20221111

  • Treatment Plan: Concurrent chemoradiotherapy (CCRT) + adjuvant chemotherapy.
  • Consensus of the team: cT1N1M0, Stage II.

[chemoimmunotherapy]

  • 2023-02-08 - cisplatin 80mg/m2 130mg NS 500mL 24hr (5-FU side insertion) + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) + furosemide 20mg NS 30mL 10min (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-28 - cisplatin 40mg/m2 65mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2022-12-21 - cisplatin 40mg/m2 70mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2022-12-15 - cisplatin 40mg/m2 70mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2022-12-05 - cisplatin 40mg/m2 70mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2022-11-11 - cisplatin 80mg/m2 135mg NS 500mL 24hr (5-FU side insertion) + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) + furosemide 20mg NS 30mL 10min (after cisplatin) + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (PF)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-03-24

  • Although the patient’s serum sodium levels have never reached the lower limit of normal based on available laboratory data in HIS5 since 2022-10-25, it is worth noting that the patient has been receiving CCRT (CDDP) and PF regimen since 2022-11-11. Cisplatin, a component of the chemotherapy regimen, is known to induce nephrotoxicity, which can manifest as acute kidney injury (AKI) or electrolyte disturbances such as hypomagnesemia and salt-wasting hyponatremia. The patient’s creatinine levels have been observed to be above the normal range more frequently after receiving chemotherapeutic agents. The patient has also experienced hypomagnesemia, which has shown a similar trend despite receiving sodium and magnesium supplements.
    • ref:
      • Cisplatin nephrotoxicity: a review of the literature. J Nephrol. 2018;31(1):15-25. doi:10.1007/s40620-017-0392-z
      • Risk Factors for Severe Hyponatremia Related to Cisplatin: A Retrospective Case-Control Study. Biol Pharm Bull. 2019;42(11):1891-1897. doi:10.1248/bpb.b19-00477
      • Hyponatremia timing, incidence, and associated risk factors in patients treated with cisplatin for lung cancer: a retrospective study. J Popul Ther Clin Pharmacol. 2022;29(4):e1-e10. Published 2022 Oct 7. doi:10.47750/jptcp.2022.907
  • Sodium level correction rate recommendation (ref: Diagnosis and treatment of hyponatremia: compilation of the guidelines. J Am Soc Nephrol 2017; 28(5):1340-1349.)
    • Minimum, 4 to 8 mmol/L/day; MAX 10 to 12 mmol/L/day
    • For patients with high-risk of osmotic demyelination syndrome: Minimum, 4 to 6 mmol/L/day; MAX 8 mmol/L/day

2023-02-09

[mucositis]

As of now, Comfflam Anti-inflammatory Spray (benzydamine 1.5 mg/mL) is available in this hospital and can be used as a rinse three to four times daily (depending on the severity of the mucositis).

701337783

230324

{not completed}

[diagnosis] - 2023-03-22 admission note

  • Adenocarcinoma of middle rectum with lung metastasis, cT4bN0M1a, stage IVA, status post T-colostomy on 2022/11/24 s/p concurrent chemoradiotherapy (radiotherapy to the pelvis and rectal tumor) with FOLFOX (Oxalip 85mg/m2, LV 400mg/m2, 5-FU 2800mg/m2) from 2022/12/06 ongoing
  • Chronic viral hepatitis B without delta-agent
  • Type 2 diabetes mellitus without complications
  • Essential (primary) hypertension

[past history]

Irregular drug use

  • Type 2 diabetes mellitus
    • Onglyza 5mg 1# po QD
    • Loditon(Metformin) 850mg 1# po BID
  • Hypertension
    • Carvedilol 6.25mg 1# po QD
    • Nidil 5mg 1# po BID
    • Funazine 10mg 1# po QD
    • Bestan 300mg 1# po QD
    • Rixia 0.5mg 1# po QD
    • Fylin 400mg 1# po QD
    • Lorazepam 1mg 1# po BID
  • Hyperlipidemia
    • Rosuvastatin 5mg 1# po QD
  • Hyperuricemia
    • Febuton 40mg 1# po QD                    

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-02-20 CT - abdomen
    • Indication: Adenocarcinoma of middle rectum with lung metastasis, cT4aN0M1b, stage IVB
    • Abdominal and Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lobulated soft tissue nodule at left upper lobe measuring 2.6cm in largest dimension is found. (Se401 Im15).
        • Enlarged lymph nodes are found at bilateral paratracheal region.
      • Visible abdomen:
        • There is stone at dependent portion of GB. GB stone(s) are noted.
        • s/p colostomy with its orifice at RLQ.
        • Low density lesion at tip of S6 of liver measuring 0.41cm in largest dimension. Simple cyst is favored. Suggest follow up.
        • Eccentric wall thickening at rectum measuring 2.96cm in largest dimension is found. Rectal cancer is favored.
    • Imp:
      • Rectal cancer with suspected left upper lobe lung meta? Mediastinal lymph nodes
  • 2023-02-17 Sigmoidoscopy
    • ircumfererntial rectal cancer s/p CCRT with partial regression (middle rectum, about 7cm AAV). The scope can not be passed through it.
  • 2022-11-23 All-RAS + BRAF mutation
    • Cell Block: S2022-20665
    • RESULTS
      • There was no variant detect in the KRAS/NRAS gene.
      • There was no variant detect in the BRAF gene.
  • 2022-11-23 Whole body PET scan
    • Glucose hypermetabolic lesions at the rectal region, compatible with the primary rectal cancer.
    • Glucose hypermetabolic lesions in the left upper lung, probably a chronic inflammation process, suggesting follow-up.
    • Glucose hypermetabolic lesions in bilateral mediastinal lymph nodes, probably reactive nodes.
    • Glucose hypermetabolic lesions in the right clavicle bone, P/3, gastric region, and left shoulder joint, probably benign in nature.
    • Rectal cancer, no evidence of distant metastasis, by this F-18-FDG PET/CT scan.
  • 2022-11-22 Patho - colon biopsy
    • Rectum, biopsy — Adenocarcinoma, moderately differentiated
    • The sections show adenocarcinoma, composed of cords and single columnarto cuboidal neoplastic cells, arranged in focal glandular pattern with desmoplastic stromal reaction. Mucosal ulcer is present.
    • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
  • 2022-11-22 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (113- 34) / 113 = 69.91%
      • M-mode (Teichholz) = 69
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, grade 1 LV diastolic dysfunction
      • Mild MR, TR and PR
  • 2022-11-21 Flow Volume Loop
    • mild obstructive ventilatory impairment
  • 2021-11-02 Ga-67 Whole body inflammatory scan with SPECT
    • The whole-body gallium inflammation scan with SPECT was performed 24th and 48th hours after injecting 6 mCi of the radiotracer to the patient. The images showed increased radiotracer uptake in a lower C-spine, maxilla, bilateral sternoclavicular junctions, shoulders, elbows, wrists, hands, knees, and feet. In addition, there was inhomogenously increased tracer uptake in the urethra.
    • IMPRESSION:
      • Increased radiotracer uptake in a lower C-spine, bilateral sternoclavicular junctions, shoulders, elbows, wrists, hands, knees, and feet, probably polyarthritis.
      • Increased radiotracer uptake in the maxilla, probably dental problems.
      • Increased radiotracer in the urethra, probably UTI, suggesting further investigation.
  • 2021-10-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (117.9- 46.4) / 117.9 = 60.64%
      • M-mode (Teichholz) = 60.6
    • Conclusion:
      • Adequate LV Systolic function with no regional wall motion abnormality at resting state
      • Mild mitral, tricuspid and pulmonic regurgitation
      • Dilated LA and aortic root
  • 2021-10-25 CT - brain
    • IMP: Brain atrophy.
  • 2021-09-28 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (63.1- 20) / 63.1 = 68.30%
      • M-mode (Teichholz) = 68.3
      • 2D (M-simpson) =70.8
    • Conclusion:
      • Adequate LV systolic function with no regional wall motion abnormality (under dopamine infusion)
      • Moderate mitral regurgitation, mild tricuspid regurgitation
      • Dilated LA and aortic root, thick IVS and LVPW

[consultation, not completed]

  • 2022-11-28 Hemato-Oncology
    • Q
      • This was a 63 y/o male with history of TB. And he was diagnosed with adnocarcinoma of middle rectum, cT4aN0M1b (suspected left lung metastasis) status post T-colostomy on 2022-11-24. Port-A will be arranged today.
      • RT: CT-simulation will be arranged on 2022/11/30. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor to 50.4 Gy/ 28 fx. RT will start around 2022/12/05 or 06.
      • We need your expertise for neoadjuvant CCRT.
    • A
      • Patient examined and Chart reviewed. A case of rectal cancer with suspicious lung and liver mets is noted. I am consulted for the CCRT.
      • My suggestions are:
        • Well discussion with patient and family. (Done)
        • Anti-HBV medication will be prescribed if C/T will be given.
        • For covering the possibility of lung and liver mets, the regimen would be FOLFOX
        • Please arrange the admission to my service if he is discharged.
  • 2022-11-25 Radiation Oncology
    • Q
      • This was a 63 y/o male with history of TB. And he was diagnosed with adnocarcinoma of middle rectum, cT4aN0M1b (suspected left lung metastasis) status post T-colostomy on 2022-11-24. We need your expertise for neoadjuvant CCRT.
    • A
      • Neoadjuvant CCRT is indicated.
      • CT-simulation will be arranged on 2022/11/30. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor to 50.4 Gy/ 28 fx. RT will start around 2022/12/05 or 06. Thank you very much.

[radiotheray]

  • 2022-12-06 ~ 2023-01-13 - completed RT to the pelvis: 45 Gy/ 25 fx. The rectal tumor: 50.4 Gy/ 28 fx.

[chemotherapy]

  • 2023-03-22 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-09 - ditto
  • 2023-02-16 - ditto
  • 2023-01-30 - ditto
  • 2023-01-03 - ditto
  • 2022-12-06 - ditto

[assessment]

  • The patient is tolerating the FOLFOX regimen without any major issues. In addition, based on the TPR panel results, the patient’s blood pressure and blood glucose levels are well-controlled despite having comorbidities of hypertension and diabetes mellitus. Furthermore, there are no identified issues with the active prescription.

700018223

230323

[diagnosis] - 2023-03-22 admission note

  • Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0(cM1a); Stage IVA s/p chemotherapy with FOLFIRI from 2022/11/02 and Target therapy with Avastin (self pay) from 2022/11/15
  • Gastro-esophageal reflux disease with esophagitis
  • Essential (primary) hypertension
  • Constipation, unspecified
  • Unspecified hemorrhoids

[past history] - 20221213 admission note

  • HTN for 15+ years under medical control
  • History of operation: Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0M1.   

[family history]

  • father: colon cancer was diagnosed at the age of 92, died at the age of 99
  • mother: HTN, aplastic anemia
  • younger brother: HTN
  • elder sister: CVA

[exam findings]

  • 2023-01-31 CT - abdomen
    • S/P left hemicolectomy with focal peritoneal infiltrates, post-op change or recurrence? suggest clinical correlation and follow up study.
    • Focal poor enhancement at right renal parenchyma.
    • Bilateral renal cysts, up to 1.3cm in right kidney.
  • 2022-10-12 Patho - soft tissue tumor, extensive resection
    • Pathologic diagnosis
      • Soft tissue, inguinal area, right, excision — Compatible with angiofibroma of soft tissue
    • Microscopic examination
      • Histologic type: Compatible with angiofibroma of soft tissue, composed of uniform spindle cells in a variable myxoid and collagenous stroma with a nectwork of innumerous small thin-walled, branching blood vessels. Prominent collagenous bundles can be identified focally. Neither necrosis nor marked cellular atypia can be found
      • Mitotic rate: <1/10 high power fields
      • Necrosis: Absent
      • Margins: Free and 0.3 cm from closest margin
      • Lymphvascular invasion: No identified
    • IHC
      • IHC: MUC4(-), SMA(-), Beta-catenin(-), MDM2(-), STAT6(-)
      • Previous IHC (S2022-15033): CD34(-), CD117(-), DOG-1(-), Desmin(-), S100(-), MUC4(-), EMA(-).
  • 2022-09-16 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Colon, splenic flexure, left hemicolectomy — Mucinous adenocarcinoma, moderately differentiated
      • Resection margins, left hemicolectomy — Radical margin is involved by carcinoma
      • Lymph nodes, mesocolic, left hemicolectomy — Negative for malignancy (0/19)
      • Pathology stage: pT4aN0(cM1a); Stage IVA
    • MACROSCOPIC EXAMINATION
      • Operation procedure: Left hemicolectomy
      • Specimen site: Left colon
      • Specimen size: 20.5 cm in length
      • Tumor size: 12.0 x 4.5 cm
      • Tumor location: 3.0 cm and 5.5 cm away from the two resection margins, respectively .
      • Depth of invasion grossly: Pericolic soft tissue
      • Mucosa elsewhere: Unremarkable
      • Representative parts are taken for section and labeled: A1-A2 = bilateral resection margins, A3 = omentum, A4-A6 = pericolic LNs, A7-A12 = tumor.
    • MICROSCOPIC EXAMINATION
      • Histology: Mucinous adenocarcinoma
      • Histology Grade: Moderately differentiated
      • Depth of invasion: To serosa
      • Angiolymphatic invasion: Not identified
      • Perineural invasion: Not identified
      • Tumor cell budding: Intermediate
      • Margins:
        • Bilateral resection margins: Free
        • Circumferential (radial) margin: Involved by carcinoma
      • Lymph node metastasis, mesocolic: Negative (0/19) (No. Positive / No. Total)
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): pT4a (Tumor invades serosa)
        • Regional Lymph Nodes (pN): pN0 (no regional lymph node metastasis)
        • Distant Metastasis (pM): cM1a
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: Abscess formation around tumor
      • Tumor regression grading S/P CCRT: N/A
      • IHC: EGFR(+), MLH1(-), PMS2(-), MSH2(+), MSH6(+)
        • Labeled as “right inguinal”, core needle biopsy — spindle cell tumor-like lesion.
        • IHC stains: CD34 (-), CD117 (-), Dog-1 (-): dis-favor gastro-intestinal stromal tumor; desmin (-): dis-favor myomatous origin; S-100 (-): dis-favor nerve origin; Ki-67: <1%. MUC4 (-), EMA (-). No meatstatic adenocarcinoma is present in this specimen.
        • REFERENCE: S2022-15295: colon, splenic flexure: compatible with adenocarcinoma.
  • 2022-09-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 34) / 93 = 63.44%
      • M-mode (Teichholz) = 64
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
    • Trivial MR.
    • Prominent epicardial fat.
  • 2022-09-12 Patho - colon biopsy
    • Colon, splenic flexure, biopsy — Compatible with adenocarcinoma, well differentiated
  • 2022-09-06 CT - abdomen
    • Findings
      • Soft tissue tumor, 11x7.6cm in left upper abdomen with central necrosis, suspected spelnic fluxure malignancy. With left abdominal wall involvement.
      • Large soft tissue tumor, 9.3cm in right inguinal region, suspected metastasis.
      • Right renal cyst, 1.4cm.
      • Unremarkable change of the liver, spleen, pancreas and left kidney.
      • No enlarged lymph node in the paraaortic region.
      • Presence of ascites.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression ( Imaging stage ): T:T4a(T_value) N:N1b(N_value) M:M1(M_value) STAGE:____(Stage_value)
    • Impression:
      • Left upper abdomen tumor, r/o splenic flexure colon malignancy. Right inguinal tumor, r/o metastasis. If proven colon malignancy, cstage T4aN1M1. Suggest tissue study.
      • Right renal cyst.

[consultation]

  • 2023-01-14 Dermatology
    • Q
      • This 71-year-old woman patient is a case of Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0(cM1a); Stage IVA s/p chemotherapy with FOLFIRI from 2022/11/02 and Target therapy with Avastin (self pay) from 2022/11/15.
      • This time, of tinea unguium et keratosis suspected possible chemotherapy alert hand-foot syndrome. Now, for F/U and evaluate therapy. Thank you.
    • A
      • This patient suffered from dyskeratotic nails for months.
      • Imp: Tinea unguium
      • Suggestion:
        • Zalain cream * 2 tubes/bid (sertaconazole)
  • 2022-12-13 Plastic and Reconstructive Surgery
    • Q
      • This 71-year-old man patient is a case of Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0(cM1a); Stage IVA s/p chemotherapy with FOLFIRI from 2022/11/02~ and Target therapy with Avastin(self pay) from 2022/11/15. He was admitted for chemotherapy. He underwent excision of the big tumor over right inguinal region on 2022/10/12. Now, for F/U. Thank you.
    • A
      • I will talk to the patient and explain about the temporary post-operative paresthesia. Thanks.
  • 2022-11-29 Dermatology
    • Q
      • This 71-year-old man patient is a case of Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0(cM1a); Stage IVA s/p chemotherapy with FOLFIRI from 2022/11/02~ and Target therapy with Avastin(self pay) from 2022/11/15~. He was admitted for chemotherapy. This time, for bilateral toenails desquamation, suspected athlete’s foot. Thank you.
    • A
      • The patient had sufferred from thickening nail with desqumation change on the toenail with nearby keratosis.
      • Under the impression of tinea unguium et keratosis suspected possible chemotherapy alert hand-foot syndrome.
      • The following sugestion:
        • step 1: Exelderm lotion 2 bot QN use. Apply the lotion to the nail crevices (sulconazole)
        • step 2: Sinphraderm cream 1 tube topical QN use over keratotic scales. (urea)

[surgical operation]

  • 2022-10-12
    • Surgery
      • Dx: soft tissue tumor over right inguinal region
      • OP: excision
    • Finding
      • 12cm X 9cm X 9cm, multi-lobulated, smooth surfaced mass located between the sartorius, iliopsoas muscles, inguinal cannal, and the femoral artery
      • a 10F JP was placed over anterior side of upper right thigh for post operative drainage
  • 2022-09-15
    • Surgery
      • Gisgnostic laparoscopy + left hemicolectomy
    • Finding
      • very large tumor with sorrounding adhesion over LUQ.
      • anastomosis by endoGIA*3 + V-lock.
      • Drain into pelvis

[chemoimmunotherapy]

  • 2023-03-22 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-15 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-31 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-13 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 400mg/m2 630mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-13 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-29 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-15 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-02 - irinotecan 120mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

[assessment 2023-01-14, not posted]

  • For tinea unguium, if topical Exelderm (sulconazole, applied since late Nov 2022) and Zalain (sertaconazole, applied since mid Jan 2023) failed to cure it, then oral Fungitech (terbinafine 250mg/tab) 1# QD might be considered as a next line treatment.

[assessment]

  • The patient had developed tinea unguium in Jan 2023, but there is no longer any evidence of the condition in the updated medical records.

  • The patient is currently admitted for his 10th cycle of Avastin + FOLFIRI chemoimmunotherapy, and it is planned that he will receive a total of 12 cycles. His liver and kidney function, as well as his electrolyte levels, are normal, although there is a slight anemia based on the 2023-03-21 lab results.

  • There were no medication reconciliation issues found in the patient.

  • CT results from 2023-01-31 indicate the presence of focal peritoneal infiltrates, which could suggest post-operative changes or disease recurrence. Further diagnostic tests or imaging studies may be necessary to make a definitive diagnosis and determine whether new treatment should be planned.

700313252

230322

{not completed}

[exam findings]

  • 2023-03-20, -03-06 CXR
    • S/P tracheostomy
    • S/P nasogastric tube insertion
    • Borderline cardiomegaly
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2023-03-15 Nasopharyngoscopy
    • hypopharynx lymphoma under R/T
  • 2023-02-17 Whole body PET scan
    • Glucose hypermetabolism in the hypopharynx with downward extension to the proximal portion of the esophagus, compatible wtih lymphoma.
    • Glucose hypermetabolism in a focal area in the dome of the liver and in the left adrenal gland. Lymphoma should be considered.
    • Mild and diffuse glucose hypermetabolism in the bone marrow of the skeleton. Lymphoma involving the bone marrow should be watched out. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the posterior aspect of bilateral lower lung fields and around the tracheostomy. Inflammatory process is more likely.
  • 2023-02-11 CT - chest
    • Indication: hypopharyngeal lymphoma, suspect recurrent rectal cancer lung metastasis
    • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Spiculated nodular lesiosn at right upper lobe and left upper lobe. Nature?
        • Soft tissue mass encircling upper esophagus is found measuring 3.8cm in largest dimension.
        • Calcified coronary arteries is found.
        • Mild bilateral pleural effusion is found.
        • Increased pulmonary vasculature is found.
      • Visible abdomen:
        • One low density lesion at dome measuring 3.9cm in largest dimension. Liver meta is considered.
        • The spleen, pancreas, both kidneys and adrenals are intact.
    • IMP:
      • Nodular lesions at both lungs (n>5). Suggest PET
      • Cervical esophageal tumor. 3.8cm
      • Liver meta.
      • Calcified coronary arteries is found.
  • 2023-02-08 Patho - larynx biopsy
    • PATHOLOGIC DIAGNOSIS
      • Pyriform sinus, right, LMS with laser — Diffuse large B-cell lymphoma, NOS
      • Arytenoid, right, LMS with laser — Diffuse large B-cell lymphoma
      • AE fold, right, LMS with laser — Diffuse large B-cell lymphoma
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consists of (1) four small pieces of brownish soft tissue received for frozen section, labeled right pyriform sinus, measuring up to 0.6 x 0.4 x 0.2 cm. All for paraffin section as: F2023-00056FS. (2) multiple small pieces of tan-gray soft tissue, labeled right arytenoid, measuring up to 0.5 x 0.4 x 0.1 cm. All for section as: S2023-02055A. (3) six small pieces of tan-gray soft tissue, labeled right AE fold, measuring up to 0.8 x 0.2 x 0.1 cm. All for section as: S2023-02055B.
    • MICROSCOPIC EXAMINATION
      • The sections of all three specimens show a picture of malignant lymphoma with following features:
      • Specimen: Right pyriform sinus, right arytenoid, and right AE fold
      • Procedure: LMS with laser
      • Tumor site: Right pyriform sinus, right arytenoid, and right AE fold
      • Histologic type: Diffuse large B-cell lymphoma, NOS
      • Immunophenotyping: CD3(-), CD20(+), BCL2(+), CD10(+), BCL6(+), MUM1(+), c-MYC(-) and CD56(-)
  • 2023-02-06 CT - abdomen
    • History and indication: Hypopharyngeal cancer, cT4aN0M0. 20230203 Cr:1.69 liver mass noticed, r/o HCC, r/o metastaisis. DM under metformin
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A poor enhancing tumor (3.5cm) at liver dome.
      • A nodule (6mm) at RML.
      • Left adrenal tumors (1.4cm, 1.6cm).
      • S/P rectal operation.
      • Renal cysts (up to 4.7cm).
      • Normal appearance of spleen, pancreas.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • Suspected liver and lung metastases.
  • 2023-02-03 Tc-99m MDP whole body bone scan
    • Increased activity in some C-, T- and L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junction and right foot, compatible with benign joint lesions.
  • 2023-02-03 SONO - abdomen
    • Diagnosis
      • Hepatic tumor, right lobe, nature?
      • Collapse GB
      • Renal cysts, both kidney
      • Poor echo window and poor cooperation.
    • Suggestion
      • 4 phase CT or dynamic MRI study
      • tumor markers
  • 2023-02-01 ENT Hearing Test
    • Tymp:
      • RE type C; LE type Ad.
    • ART:
      • Bil absent.
    • PTA
      • Reliability FAIR
      • Average RE 80 dB HL; LE >80 dB HL.
      • RE moderately severe to profound MHL.
      • LE moderately severe to profound SNHL.
  • 2023-01-31 CT - neck
    • Imaging Report Form for Hypopharynx Carcinoma
      • Impression (Imaging stage) : T:4a(T_value) N:0(N_value) M:IVA(M_value) STAGE:____(Stage_value)
  • 2023-01-31 Patho - stomach biopsy
    • Stomach, GC of body, biopsy — erosive gastritis with Helicobacter infection
  • 2023-01-31 Patho - gingival/oral mucosa biopsy
    • Labeled as “right hypopharyx”, biopsy — round blue cell infiltration with marked crush artifact.
    • IHC stains: CK (-), dis-favor carcinoma. CD3 and CD20 stains show a predominant B lymphoid sub-population.
    • The possibility of lymphmoa cannot be excluded. Plaes correlate with clinical and image findings. Further work up, including repeat biopsy, might be considered.
  • 2023-01-31 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, antrum
    • Suspected gastric erosion, GC of body s/p biopsy
  • 2023-01-30, -01-27 Nasopharyngoscopy
    • rt pyriform sinus tumor, bil movable cords
    • suspected rt HP cancer
  • 2019-11-19 SONO - nephrology
    • Chronic renal parenchymal disease, mild degree
    • Bilateral renal cysts
  • 2019-11-11 L spine AP + Lat (indluding sacrum)
    • Osteoporosis and spondylosis of L-spine.
    • Disc collapse at L5-S1.
    • Surgical clips at RUQ.
    • Calcification along abdominal aorta.

[consultation]

  • 2023-03-09 Rehabilitation
    • A
      • P
        • Rehabilitation programs: Bedside PT rehabilitation programs
        • Goal: recondition, improve endurance and muscle strength
  • 2023-02-20 Radiation Oncology
    • A
      • Palliative RT to HPX tumor for 3600cGy/20 fx is suggested for symptom control. CT simulation on 2023/02/20 15:30, and RT will be started on Feb 22 or 23 if feasible.
  • 2023-02-09 Colorectal Surgery
    • Q
      • This 90 year-old man has history of
        • hypertension
        • diabetic mellitus
        • Rectal cancer, stage III, s/p operation twice due to recurrence and oral chemotherapy many years ago
      • This time, he was admitted to our ward for Hypopharyngeal cancer (biopsy: pending) survey. Abdominal echogram and CT revealed liver tumor, favor metastasis, origin unknown. We need your expertise on further examination.
      • The patient has had recurrent rectal cancer for several years but has not been followed up on. CT scans were unable to rule out the presence of a rectal tumor. The patient also has a pharyngeal tumor, and if a colonoscopy is needed, it is not suitable for painless general anesthesia.
  • 2023-02-06 Hemato-Oncology
    • Q
      • This is a 90-year-old man with history of
        • Hypertension
        • Type 2 diabetic mellitus
      • This time, he was admitted to our ward for hypopharyngeal cancer (cT4aN0M0) workup. Concurrent chemoradiotherapy may be arranged after staging. We need your expertise for possible chemotherapy arrangement. Thanks a lot!
    • A
      • This 90 year old man with HTN and DM history is a case of suspect Hypopharyngeal cancer, cT4aN0M0, status post biopsy via LMS on 2023/1/30 (pathology: pending). We are consulted for CCRT.
      • Concurrent cisplatin or cetuximab with radiotherapy may consider in this case. (Due to old age, may prefer bioRT)
        • note: BioRT stands for Biological Radiation Therapy, which is a type of radiation therapy that uses biological agents, such as monoclonal antibodies or immunomodulators, to enhance the effects of radiation treatment. The aim of BioRT is to improve the response of tumor cells to radiation by modifying the tumor microenvironment or by enhancing the immune system’s ability to attack cancer cells.
      • Pending pathology report. Please check HbsAg, Anti Hbc, Anti HCV. 24 hr urine CCR. Arrange port A insertion.
      • Please arrange our OPD after discharge.
  • 2023-02-01 Radiation Oncology
    • A
      • Plan: I will discuss with the patient and his second son on Feb 2, 2pm. RT to HPX and cervical esophagus tumor for 7140cGy/34 fx is suggested for locoregional control if he and his son agree. CT simulation will be arranged after teeth extraction (or teeth extraction is declined).
  • 2023-02-01 Oral and Maxillofacial Surgery
    • Q
      • This is a 90-year-old man with history of
        • Hypertension
        • Type 2 diabetic mellitus
      • This time, he was admitted to our ward for right hypopharyngeal cancer workup. Concurrent chemoradiotherapy may be arranged after staging. We need yout expertise for dental evaluation bfore radiotherapy. Thanks a lot!
    • A
      • After an oral surgical examination, it is recommended that at least 9 teeth be extracted.
        • If the patient is to continue staying in the hospital, arrangements will be made to begin extracting the teeth during the hospital stay.
        • If the patient is to be discharged, arrangements will be made for outpatient tooth extraction.
        • A family member should be present to accompany the patient during tooth extraction to be aware of the risks involved.
      • If the patient will be discharged first, a NP should prescribe antibiotics to be taken by the patient, and please inform us of the follow-up progress.

[multiteam]

  • 2023-03-12 Social Service
    • Family situation:
      • The patient is a 90-year-old married individual with three sons. The patient, his spouse, and his eldest son live together, and during the hospitalization period, a foreign caregiver was hired to care for the patient in the hospital.
      • The eldest son is unmarried; the second son is married with a son (in college) and a daughter (in junior high school); the third son is married with a son (in junior high school).
    • Assessment and Treatment:
      • The social worker visited the patient in the hospital and had a written conversation with him about his emotional state and sleep condition. The patient wrote that he was suffering due to poor sleep and recent obstructive bowel movements. The social worker promised to communicate with the team and the patient accepted. The patient had no other concerns. The social worker also had a written conversation with the patient about his family situation, to which the patient responded in writing. During the assessment, the patient did not show any suicidal ideation and his low mood was primarily due to illness and poor sleep, but he was cooperating with medical treatment.
      • During the assessment, it was found that the patient’s mood was mainly affected by illness, but he was still able to cooperate with medical treatment. The social worker conveyed to the NP about the patient’s poor sleep and bowel movements, and asked the team to pay attention to this issue.
      • On the same day, the team invited the eldest son to the hospital to listen to the explanation of the patient’s illness and reminded him to prepare for the patient’s discharge. After the explanation, the eldest son accepted the arrangements.

[surgical operation]

  • 2023-02-07
    • Surgery
      • Laryngomicrosurgery with laser for hypopharyngeal tumor excision       
    • Finding
      • bulging tumor over bilateral pyriform sinus

[radiotherapy]

[chemotherapy]

==========

2023-03-22

  • The patient is currently self-carrying Betaloc Zok (metoprolol 100mg) for his hypertension. However, the hospital does not have any metoprolol-containing drugs available in stock.
  • Instead, Urosin (atenolol 100mg/tab) is available, which selectively blocks beta 1 receptors and has little to no effect on beta 2 receptors except at high doses.
  • Atenolol 75mg is approximately equivalent to metoprolol 150mg (ref: https://www.whocc.no/atc_ddd_index/?code=C07AB). Therefore, if the intended dose of Betaloc is 1 tablet per day, we recommend taking half a tablet of Urosin per day (0.5# QD).

2023-03-13

  • PharmaCloud database reports that Natrilix (indapamide) has been prescribed at VGHTPE on 2022-12-29 as a 84-day refillable prescription, along with other medications such as Norvasc (amlodipine), Betaloc (metoprolol), and Olmetec (olmesartan) to manage the patient’s hypertension. And this patient developed hyponatremia since 2023-02.

    • 2023-03-13 Na (Sodium) 128 mmol/L
    • 2023-03-06 Na (Sodium) 128 mmol/L
    • 2023-03-01 Na (Sodium) 128 mmol/L
    • 2023-02-27 Na (Sodium) 130 mmol/L
    • 2023-02-20 Na (Sodium) 132 mmol/L
    • 2023-02-16 Na (Sodium) 130 mmol/L
    • 2023-01-30 Na (Sodium) 136 mmol/L
  • Indapamide is a type of diuretic known as a low-ceiling diuretic, which functions by inhibiting the sodium-chloride co-transporter in the kidneys. This leads to an increase in the excretion of both sodium and water from the body.

  • Treatment of diuretic-induced hyponatremia consists of discontinuing the diuretic and administering either isotonic saline or, if the hyponatremia is severe or symptomatic, hypertonic saline. There is a potential risk of overly rapid correction of the hyponatremia with either regimen. Once the diuretic has been cleared and the patient becomes euvolemic, antidiuretic hormone (ADH) release will be appropriately suppressed, resulting in the excretion of a dilute urine, which can lead to rapid excretion of the excess water. Thus, patients with moderate to severe hyponatremia must be monitored carefully during treatment to minimize the risk of osmotic demyelination.

  • It is recommended to monitor serum Na levels at a frequency no less than every 12 hours, ensuring that any changes in serum Na levels do not exceed 4-6mEq/L within a 24-hour period to avoid the development of osmotic demyelination syndrome (ODS). Additionally, it is advised to monitor urine output and neurological symptoms. Other recommended tests include checking serum osmolality, TSH, free T4, ACTH (at 8 am), cortisol (at 8 am), urine osmolality, Na, and Cre.

700887556

230322

[exam findings]

  • 2023-03-20 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed hot/faint hot spots in both rib cages, and increased activity in the maxilla, sternum, some T- and L-spine, bilateral shoulders, S-I joints, hips, and knees, in whole body survey.
    • IMPRESSION:
      • No previous study for comparison.
      • Some hot/faint hot spots in both rib cages, and increased activity in the sternum and some T- and L-spine, cancer with bone metastases may be considered, suggesting further evaluation and follow-up with bone scna in 3 months.
      • Suspected benign lesions in the maxilla, bilateral shoulders, S-I joints, hips, and knees.
  • 2023-03-18 CXR
    • Increased infiltration over RLL. May be active infection.
  • 2023-03-16 CXR
    • Enlargement of cardiac silhouette.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-15 Patho - stomach biopsy
    • Nodularity of mucosa, LC side of upper body, biopsy — Compatible with fundic gland polyp
    • Microscopically, the sections show a picture of benign gastric mucosa with parietal and chief cells, compatible with fundic gland polyp.
  • 2023-03-15 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Adenocarcinoma, poorly differentiated
    • The sections show a picture of poorly differentiated adenocarcinoma, composed of solid nests and cords of polygonal neoplastic cells in fibrous stroma. Vascular invasion and subtle glandular differentiation are present.
    • IHC shows following features: CK7(+), CK20(-), p40(-), TTF1(-), and CDX2(-). Metastatic carcinoma from either lung or colon is less likely. Suggest clinic correlation.
  • 2023-03-10 CT - chest
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest abd Abdominal CT with and without enhancement revealed:
      • Chest:
        • Tiny nodule at right middle lobe measuring 0.3cm is found. Suggest follow up.
        • Senile fibrotic change is noted at lung fields.
        • Patent airway is found.
        • Non-specific lymph nodes are found in the mediastinum.
        • Bilateral mild pleural effusion is found.
        • Calcified coronary arteries is found.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Visible abdomen:
        • Left renal atrophy is found.
        • The spleen, liver, pancreas and adrenals are intact.
        • Diffuse liver meta up to 6.8cm at S4 is found.
        • There is no evidence of destructive bone lesion.
        • The GB is well distended without soft tissue lesion
        • Degenerative change of the bony structure with marginal osteophyte formation is identified.
    • Imp:
      • Diffuse liver meta.
        • The primary tumor cannot be estimated in the study.
        • Please correlate with tumor marker and suggest panendoscopy.
      • Bone meta at thoracic spine.
  • 2023-03-08 MRI - T-spine
    • Low back and right hip pain for more than 1 month. Had called at ORT LMD and sciatica was told, and is going to referred to our ORT.
    • With and Without-contrast multiplanar spine MRI (including sagittal and axial T1WI, sagittal and axial T2WI and coronal STIR images) revealed
      • normal bone alignment of the spine
      • unremarkable change in the perivertebral regions
      • unremarkable change in the visible cord.
      • unremarkable change in the disc spaces
      • multiple heterogeneous enhancing lesions in the S1, L5, L4, L3, L2, T11, T10, T5 and T3 vertebral bodies with pathological compression fracture at L4 vertebral body
    • IMP:
      • multiple bone metastasis witohut evidence of significant mass effect on the T-cord and with pathological fracture at L4 vertebral body.
  • 2023-03-07 ECG
    • Normal sinus rhythm
    • Right bundle branch block
    • Left anterior fascicular block
    • Bifascicular block
  • 2023-03-07 L-spine flex. + ext. (including sacrum)
    • Marked degenerative change of the spine with marginal spur formation. Disc space narrowing at multiple levels. Geographic bone lesions at L2, L3, L4 levels. Suggest further evaluation.
  • 2023-03-06 MRI - L-spine
    • Indication: Low back and right hip pain for more than 1 month. Had called at ORT LMD and sciatica was told, and is going to referred to our ORT. The pain became worse in recent days that he needed bed rest. unable to walk.
    • Imaging protocol: 3-4mm slice thickness; sagittal T1, T2 & STIR, axial T1 & T2, and coronal STIR images
    • MRI of lumbar spine without Gadolinium-based contrast enhancement shows:
      • straightening alignment of lumbar spine.
      • marked degenerative change of the spine with marginal spur formation and dehydrated discs at multiple levels.
      • multiple geographic bone lesions of abnormal signal change at anterior T11, L2, L3, L4, L5 vertebral bodies, bilateral L4 pedicles and posterior elements, sacrum (S1) and right iliac bone, suspect bone metastases. Suggest further evluation.
      • L4 compression fracture with curvilinear fracture line, favor pathological compression fracture.
      • severe right L4-5, L5-S1 neuroforaminal narrowing.
      • severe L2-3, L3-4, L4-5 central canal stenosis.
      • no evidence of abnormal signal lesion in visible spinal cord.
      • multiple left renal cysts; left hydronephrosis.
    • Impression:
      • Suspect multiple bone metastases, lumbar spine, sacrum and right iliac bone. Suggest further evaluation.
      • L4 compression fracture, favor pathological fracture.
      • Degenerative spinal and disc disease.
      • Severe right L4-5, L5-S1 neuroforaminal narrowing.
      • Severe L2-3, L3-4, L4-5 central canal stenosis.
  • 2023-03-05 CT - pelvis - bone
    • History and indication: back pain
    • IMP:
      • Atrophy of left kidney. Bil. renal cysts (up to 2.1cm).
      • Compression fracture of L4.
  • 2023-03-04 L-spine AP + Lat (including sacrum)
    • AP and lateral films of the lumbar spine shows:
      • Compression fracture of T12.
      • Degeneration and spondylosis of L-S spine.

[consultation]

  • 2023-03-13 Ear Nose Throat
    • Q
      • This 68-year-old man patient suffered back psin in 2023/01. Progression back pain in 2023/02.
      • Pelvic CT on 2023/03/04 showed atrophy of left kidney, bilateral renal cysts (up to 2.1cm) and compression fracture of L4.
      • L-spine MRI on 2023/03/06 showed
        • Suspect multiple bone metastases, lumbar spine, sacrum and right iliac bone. Suggest further evaluation.
        • L4 compression fracture, favor pathological fracture.
        • Degenerative spinal and disc disease.
        • Severe right L4-5, L5-S1 neuroforaminal narrowing.
        • Severe L2-3, L3-4, L4-5 central canal stenosis.
      • T-spine MRI on 2023/03/08 showed multiple bone metastasis witohut evidence of significant mass effect on the T-cord and with pathological fracture at L4 vertebral body.
      • Tumor mark with SCC on 2023/03/09 showed increased (SCC:2.0ng/mL).
      • Chest CT on 2023/03/10 showed diffuse liver meta. The primary tumor cannot be estimated in the study and bone meta at thoracic spine.
      • Now, for evaluate R/O head and neck cancer with liver and bone metastases for SCC increased. Thank you.
    • A
      • Local finding:
        • Oral cavity: fibrosis over bilateral buccal mucosa.
        • Oropharynx: fibrotic change over bilateral tonsillar fossa.
        • Neck: no palpable neck mass.
      • Portable nasopharyngoscopy: smooth nasopharynx, oropharynx, hypopharynx; fair vocal cord.
      • Impression: No definitive finding of ENT lesion indicating malignancy in this visit.
  • 2023-03-09 Dermatology
    • Q
      • This time, for bilateral lower limbs skin edema with dull dandruff and pain in 2017.
      • Now, for evaluate bilateral lower limbs, R/O jock itch therapy. Thank you.
    • A
      • The patient had sufferred from dry swelling legs with fissiform scales and stasis change.
      • Under the impression of stasis dermatitis with ichthyosis change.
      • The following sugeetion:
        • wound protection:
          • Biomycin onit 1 tube topical bid use for wound care first.
          • Sinphraderm cream 1 tube topical QN use over dry scales for mositurization.
        • notice further circulation state, avoid peripheral swelling edema state.
  • 2023-03-07 Neurosurgery
    • Q
      • Low back and right hip pain for more than 1 month. Had called at ORT LMD and sciatica was told, and is going to referred to our ORT.
      • The pain became worse in recent days that he needed bed rest
      • unable to walk
      • Past Hx of HTN, DM, lower limbs lymphedema
      • stilck used for Lt knee degeneration
      • 2022/12/17 Cre 1.18 mg/dL
    • A
      • 68 y/o male.
      • Low back and right hip pain for more than 1 month. The pain became worse in recent days so that he needed bed rest and was unable to walk.
      • L-spine MRI:
        • Suspect multiple bone metastases, lumbar spine, sacrum and right iliac bone.
        • L4 compression fracture, favor pathological fracture.
        • Degenerative spinal and disc disease.
        • Severe right L4-5, L5-S1 neuroforaminal narrowing.
        • Severe L2-3, L3-4, L4-5 central canal stenosis.
      • Advice:
        • Enhanced L-spine MRI (and T- and C-spine).

==========

2023-03-22

  • On 2023-03-19, the urinalysis results showed bacteriuria, UTI, occult blood, and leukocyte esterase positivity. Additionally, there was a significant increase in serum creatinine and a decrease in eGFR.
    • 2023-03-18 Creatinine 3.32 mg/dL
    • 2023-03-16 Creatinine 1.61 mg/dL
    • 2023-03-13 Creatinine 1.20 mg/dL
    • 2023-03-09 Creatinine 1.14 mg/dL
    • 2023-03-18 eGFR 19.78
    • 2023-03-16 eGFR 45.59
    • 2023-03-13 eGFR 63.99
    • 2023-03-09 eGFR 67.90
  • Please ensure that the patient is receiving enough fluids to maintain adequate hydration, and that his fluid input and output are being closely monitored? Additionally, it is important to closely monitor for any signs of infection and track the patient’s renal function.

2023-03-20

  • Bone mets were found, but the primary original malignancy has not yet been identified. Investigation is ongoing.
  • The patient’s son said on the phone that the patient had no contact with any family members after the divorce with his mother, so no family members would care, and said he would discuss with other family members whether to come to the hospital to understand his condition.
  • 2023-03-18 Cre 3.32mg/dL, eGFR 19.78, no height or weight data currently available, CrCl cannot be calculated. If eGFR is considered CrCl and the planned levofloxacin dose is 750 mg QD, in case of CrCl < 20 mL/min: 750 mg initial dose, then 500 mg QOD is recommended.

701118846

230322

{colon cancer - mucinous adenocarcinoma}

[lab data]

2020-09-30 NRAS/KRAS detected
2020-09-30 KRAS 12/13 Not detected
2020-09-30 BRAF Not detected

2020-08-28 HBsAg (NM) Negative
2020-08-28 HBsAg Value (NM) 0.365
2020-08-28 Anti-HBs (NM) Negative
2020-08-28 Anti-HBs value (NM) <2.00
2020-08-28 Anti-HBc (NM) Negative
2020-08-28 Anti-HBc Value (NM) 2.15
2020-08-28 Anti-HCV (NM) Negative
2020-08-28 Anti-HCV Value (NM) 0.0382
2020-08-28 HBsAg (NM) Negative
2020-08-28 HBsAg Value (NM) 0.365
2020-08-28 Anti-HBs (NM) Negative
2020-08-28 Anti-HBs value (NM) <2.00
2020-08-28 Anti-HBc (NM) Negative
2020-08-28 Anti-HBc Value (NM) 2.15
2020-08-28 Anti-HCV (NM) Negative
2020-08-28 Anti-HCV Value (NM) 0.0382

[exam findings]

  • 2023-03-07 ECG
    • Sinus rhythm with Premature supraventricular complexes
    • Nonspecific T wave abnormality
  • 2022-12-22 CT - abdomen
    • History and indication: Malignant neoplasm of appendix s/p OP and C/T
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Right thyroid nodules (up to 2.6cm).
      • S/P colon operation. Some soft tissues in peritoneal cavity suspected tumor seeding. Ventral hernia with bowel loop herniation.
      • Retroversion of uterus.
      • Liver cysts (up to 2.2cm).
      • Left renal stone (5mm).
      • Normal appearance of spleen, pancreas, adrenals.
      • Gallbladder stone (7mm).
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • No abnormal density at bilateral lungs.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Some soft tissues in peritoneal cavity suspected tumor seeding.
  • 2022-11-24 Clinical Dementia Rating, CDR
    • CDR score = 0.5
    • note: The CDR score ranges from 0 (no cognitive impairment) to 3 (severe dementia). A score of 0.5 indicates very mild dementia, 1 indicates mild dementia, 2 indicates moderate dementia, and 3 indicates severe dementia.
  • 2022-11-24 Mini-Mental Status Examination, MMSE
    • MMSE score = 27
    • note: The total score ranges from 0 to 30. A higher score indicates better cognitive function.
  • 2022-10-06 Needle Aspiration Cytology - thyroid
    • Negative - Benign follicular nodule
  • 2022-09-26 CT - abdomen
    • Indication: Appendiceal cancer s/p OP and C/T, Elalrged thyroid, Elevated CEA
    • Abdominal CT with and without enhancement revealed:
      • Visible chest
        • Cardiomegaly is noted.
        • Lobulated right thyroid lesions are found. Suggest regular sonogrpahy/aspiration if indicated.
        • The lung fields are clear.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
      • Abdomen
        • There is stone at dependent portion of GB. GB stone(s) are noted. The GB wall is not thikening.
        • s/p RLQ op.
        • No evidence of recurrent/residual tumor in the study.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • No evidence of abnormal soft tissue mass at pelvic cavity.
        • No definite inguinal or pelvic sidewall LAP
    • Imp: s/p RLQ op.
      • No evidence of recurrent/residual tumor at RLQ.
      • Right thyroid lesions. Suggest regular follow up.
  • 2022-09-07 SONO - thyroid
    • Autoimmune thyroid disease, multiple nodules
  • 2022-06-29 CT - abdomen
    • History and Indication:
      • 20200823 CT: RLQ tumor with abdominal wall involvement, r/o appendix tumor or appendicitis with tumor formation.
      • 20200827 S/P right hemicolectomy: mucinous adenocarcinoma of the appendix with abscess, pT4N0Mx, stage: IIB. S/P C/T for FU
    • MD CT (Aquilion Prime SP) of the chest, abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images with axial and coronal reformated isotropic images were obtained in non-contrast scan and portal venous phase scan after IV contrast injection.
    • FINDINGS:
      • S/P right hemicolectomy.
        • Ventral hernia in the midline lower pelvis with small bowel herniation.
      • There are several hepatic cysts in both lobes and the largest one is measured about 2.2 cm in size at segment 8.
      • A calcified gallstone 6 mm is noted.
      • Prior CT identified1 a soft tissue nodule 6 mm in the middle mesentery is noted again, mild increasing in size to 8 mm.
      • There is no focal lesion in both lung and mediastinum.
        • Right lobe thyroid shows enlarged in size and few poor enhancing lesions (up to 2.3 cm). Left lobe and isthmus thyroid show few poor enhancing and few enhancing nodules. Nodular goiter is highly suspected. Please correlate with sonography.
      • Others
        • There is no focal abnormality in the biliary system, pancreas, spleen & both kidney.
        • There is no ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion in the omentum.
    • IMP:
      • S/P right hemicolectomy.
      • There is no evidence of tumor recurrence.
  • 2022-04-07 CT - abdomen
    • History and indication: Malignant neoplasm of appendix s/p OP and C/T
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Right thyroid nodules (up to 2.6cm).
      • S/P colon operation. Ventral hernia with bowel loop herniation.
      • Retroversion of uterus.
      • Liver cysts (up to 2.2cm).
      • Left renal stone (5mm).
      • Normal appearance of spleen, pancreas, adrenals.
      • Gallbladder stone (7mm).
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • No abnormal density at bilateral lungs.
      • S/P Port-A infusion catheter insertion.
    • IMP: No evidence of tumor recurrence.
  • 2022-01-21 Needle Aspiration Cytology - thyroid
    • Negative - Smears show colloid and benign follicular cells.
  • 2021-12-30 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA grade A
      • Superficial gastritis, antrum, s/p CLO test
      • Gastric erosions, low body and antrum
      • Gastric shallow ulcers, antrum
    • Suggestion
      • Pursue CLO test result
  • 2021-12-24 Whole body PET scan
    • A mild glucose hypermetabolic lesion in the lower portion of the esophagus near EG junction. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the right pulmonary hilar region and in the soft tissues around bilateral shoulders and hip. Inflammatory process is more likely.
    • Inhomogenously increased FDG uptake in the right lobe of the thyroid gland. The nature is to be determined (multinodular goiter? other nature?). Please correlate with other clinical findings for further evaluation.
    • Some focal areas of increased FDG accumulation in the colon. Physiological FDG accumulation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2021-11-30 CT - abdomen
    • Indication: Colon cancer, CEA gradually elevated
    • Abdominal and chest CT with and without enhancement revealed:
      • Chest:
        • S/p port-A placement with its tip at Superior vena cava.
        • Tortous aorta with calcification is noted.
        • Cardiomegaly is noted.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • s/p RAR. no evidence of recurrent/residual tumor in the study.
        • Left renal stone is found.
        • Ventral herniation from the mid-abdominal wall is found. No strangulation is found.
        • The spleen, liver, pancreas and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is stone at dependent portion of GB. GB stone(s) are noted.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • s/p RAR. no evidence of recurrent/residual tumor in the study.
      • Left renal stone is found.
  • 2021-09-13 MRI - liver, spleen
    • History and indication: Hx of appendeceal cancer s/p right hemicolectomy and C/T 2021-08-11 Abd CT mention a suspected cyst or mets in S6 of liver
    • With and without contrast MRI of liver revealed:
      • S/P colon operation.
      • Bil. liver cysts (up to 2.4cm).
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Gallbladder stones (2-3mm).
      • Patency of portal vein.
      • No ascites, nor enlarged lymph node.
      • No abnormal intensity in bilateral basal lungs.
    • IMP:
      • S/P colon operation.
      • Bil. liver cysts (up to 2.4cm).
      • Gallbladder stones (2-3mm).
  • 2021-08-11 CT - abdomen
    • History and Indication:
      • 20200823 CT: RLQ tumor with abdominal wall involvement, suspected appendix tumor or appendicitis with tumor formation.
      • 20200827 S/P right hemicolectomy: mucinous adenocarcinoma of the appendix with abscess, pT4N0Mx, stage: IIB. S/P C/T for FU
    • FINDINGS:
      • There is a poor enhancing lesion 1.1 cm in S6 liver (Srs:3 Img:64) that may be cyst or metastasis. Please correlate with sonography.
      • There are several hepatic cysts in both lobes and the largest one is measured about 2.2 cm in size at segment 8.
      • A calcified gallstone 6 mm is noted.
    • IMP:
      • There is a poor enhancing lesion 1.1 cm in S6 liver (Srs:3 Img:64) that may be cyst or metastasis. Please correlate with sonography.
  • 2021-05-03 CT - abdomen
    • Clinical history: 72 y/o female patient with R/O PERITONITIS
    • Impression:
      • S/P right hemicolectomy.
      • Gallbladder stone
      • Stationary of peritoneal nodules, up to 0.7cm.
      • R/O liver cysts.
      • Bilateral perirenal fatty infiltrates.
  • 2021-05-03 CT - brain
    • Clinical history: 72 y/o female patient with R/O SDH.
    • Impression:
      • Brain atrophy.
      • R/O chronic sinusitis.
  • 2021-05-03 ECG
    • Normal sinus rhythm
    • T wave abnormality, consider anterolateral ischemia
  • 2021-04-20 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (100 - 33) / 100 = 67.00%
      • M-mode (Teichholz) = 67
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Mild AR, TR
  • 2021-04-19 ECG
    • Normal sinus rhythm
    • T wave abnormality, consider lateral ischemia
  • 2021-04-19 Flow Volume Loop
    • suspected mild restrictive ventilatory defect
  • 2021-03-27 CT - abdomen
    • Indication: 72 y/o female patient with Appendiceal mucinous adenocarcinoma with liver metastasis s/p receving right hemicolectomy on 2020-08-26, pT4aN0M1a, Stage IVA s/p chemotherapy.
    • With and without contrast enhancement CT of abdomen–whole:
      • s/p right hemicolectomy.
      • Peritoneal nodules and stranding, mild in regression.
      • Gallbladder stone.
      • Several liver cysts. 2.4cm of the largest one in right lobe.
    • Impression
      • s/p right hemicolectomy
      • Peritoneal carcinomatosis, mild in regression
  • 2021-03-04 Gynecologic Ultrasonography
    • EM: 4.8mm
  • 2020-12-29 CT - abdomen
    • Post-op at colon with mesentery nodules and lymph nodes, suspected carcinomatosis.
    • Presecne of gallbladder stone.
    • Liver cysts, up to 2.4cm in right lobe.
  • 2022-12-29, -11-10 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2020-09-22 MRI - liver, spleen
    • Liver and renal cysts (up to 2.3cm).
    • Prominent accessory p-duct.
  • 2020-08-31 Tc-99m MDP whole body bone scan
    • Mildly and non-focally increased radiotracer uptake in C-spine and lower L-spine, degenerative spine diseases may show such a picture.
    • Some areas of mildly increased radiotracer uptake in maxilla and mandible, dental lesions may show such a picture.
    • Probably degenerative joint lesions in shoulders, sternoclavicular junctions, sacroiliac joints, and hips.
    • No definite evidence of osteoblastic skeletal metastasis by this bone scan.
  • 2020-08-27 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Appendix, R’t hemicoloectomy — Mucinous adenocarcinoma with abscess
      • Resection margins, bilateral cutting end, ditto — Free of tumor invasion
      • Lymph node, mesocolic, dissection — Negative for tumor metastasis (0/20)
      • Ascending colon, R’t hemicoloectomy — Free of tumor invasion
      • AJCC pathologic stage — pT4aN0 (if cM0), stage IIB
    • MACROSCOPIC EXAMINATION
      • Operation procedure: right hemicolectomy
      • Specimen site: ascending colon, terminal ileum and appendix
      • Specimen size: (a) A-colon: 22.5 x 5.5 cm; (b) Terminal ileum: 4.5 x 3.0 cm; (c) Appendix: 8.5 x 6.0 x 5.5 cm
      • Tumor size: 8.5 x 6.0 x 5.5 cm
      • Tumor location: appendix
      • Tumor appearance: mucinous tumor
      • Depth of invasion grossly: Visceral peritoneum
      • Representative sections as follows: A1: proximal A-colon margin, A2-A4: peri-tumor soft tissue, A5-A12 and A16-A20: tumor, A13: distal colon margin, A14-A15 and A21-A22: lymph node
    • MICROSCOPIC EXAMINATION
      • Histology: mucinous adenocarcinoma
      • Histology Grade: G1-2: well to moderately differentiated
      • Depth of invasion: Visceral peritoneum
      • Angiolymphatic invasion: absent
      • Perineural invasion: present
      • Discontinuous extramural tumor extension: absent
      • Circumferential (radial) margin: Involved
      • Lymph node metastasis, mesocolic: negative (0/20)
      • Lymph node metastasis, IMA / SMA: N/A
      • Extranodal involvement: N/A
      • Pathological TNM Stage: pT4aN0, stage IIB
      • Type of polyp in which invasive carcinoma arose: N/A
      • Additional pathologic findings: abscess formation
      • TNM descriptors: N/A
      • Tumor regression grading S/P CCRT: N/A
    • IMMUNOHISTOCHEMISTRY
      • CDX-2(+), MLH1(+), PMS2(+), MSH2(+) and MSH6(+) for tumor cells
  • 2020-08-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (77.7 - 15.5) / 77.7 = 80.05%
      • M-mode (Teichholz) = 80.1
    • Septal hypertrophy. Dilated AsAO (40mm)
    • Normal RV & LV systolic function. No regional wall motion abnormalities.
    • Impaired LV relaxation.
    • Moderate tricuspid regurgitation.
    • Mild pulmonic regurgitation.
  • 2020-08-24 Bronchodilator Test
    • Normal spirometry, without significant response to bronchodilator
  • 2020-08-24 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis and duodenitis
      • Gastric and duodenal erosions
    • Suggestion
      • PPI therapy
      • No evident malignanct in UGI tract
  • 2020-08-23 CT - abdomen
    • There is soft tissue tumor, 3.56cm in right lower abdomen with abdominal wall involvement, suspected appendix tumor or appendicitis with tumor formation.
    • There is skin tumor, 1.37cm in right lower abdominal wall.
    • Presence of gallbladder stone.
    • Hypodense lesions, up to 2.3cm in S8 of right liver, suspected liver cysts.
    • Ill-defined hypodensities in S6 liver, suggest further study.
  • 2020-08-18 Gynecologic Ultrasonography
    • Bilateral adnexae: free
    • Subcutaneous mass: 59x39mm (no blood flow)

[consultation]

  • 2021-03-04 Obstetrics and Gynecology
    • Q
      • This 72-year-old woman patient is a case of Appendiceal mucinous adenocarcinoma with liver metastasis s/p receving right hemicolectomy on 2020-08-26, pT4aN0M1a, Stage IVA s/p chemotherapy with FOLFIRI, refractory with mesentery carcinomatosis, rT0N0M1c, stage IVB s/p chemotherapy with FOLFIRU/Avastin. She was admitted for chemotherapy with Avastin(C5)/FOLFIRI(C6D1).
      • This time, for perineum mild bleeding. Now, for evlauate perineum bleeding dispose and therapy. Thank you.
    • A
      • PV: atrophic cervix, no obvious lesion
        • discharge: scanty
        • Sono: endometrium 4.8 mm.
      • IMP: vaginal spotting, but improved now
      • suggestion:
        • no obvious GYN problem now. Bleeding tendency or coagulopathy may be consider.
  • 2021-01-26 Ear Nose Throat
    • Q
      • This 72-year-old woman patinet is a case of Appendiceal mucinous adenocarcinoma with liver metastasis s/p receving right hemicolectomy on 2020-08-26, pT4aN0M1a, Stage IVA s/p chemotherapy with FOLFIRI, refractory with mesentery carcinomatosis, rT0N0M1c, stage IVB s/p chemotherapy with FOLFIRU/Avastin. She was admitted for chemotherapy.
      • Hoarseness developed in 2020/12. Now, for evaluate hoarseness examination and therapy. Thank you.
    • A
      • After evaluated via scope, we found bilateral vocal cord atrophy and bilateral vocal nodules.
      • We suggested our OPD f/U and the disease needed to receive operation (already explained to family)

[surgical operation]

  • 2021-04-21
    • Operation
      • Laparoscopy adhesionolysis
      • Pelvic drainage
    • Finding
      • S/P right hemicoletomy with a midline incisional scar
      • Adhesion of greater omentum to abdominal wall
      • No gross peritoneal seedings and minimal ascites. Normal appearance of liver surface and stomach
      • Drain; 10Fr Blake drain *1, in the pelvic cavity.
      • Wound: treated with New Epi Plus, 5cc
  • 2020-08-26
    • Operation
      • Laparoscopic right hemicolectomy
    • Finding
      • A tumor mass over appendix with severe adhesion to omentum and right lower abdoinal wall; with localized abscess
      • Several small liver cysts in right lobe
      • Drain: 15Fr Blake x 1 in the pelvic cavity
      • Wound: treated with New Epi Plus (5cc)

[chemoimmunotherapy]

  • 2023-03-21 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-07 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-20 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-30 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-26 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-03-30 - irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (_______ + FOLFIRI)
  • 2021-03-16 - irinotecan 150mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (_______ + FOLFIRI)
  • 2021-03-02 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Avastin + FOLFIRI)
  • 2021-02-17
  • 2021-01-26
  • 2021-01-12
  • 2020-12-30
  • 2020-12-15
  • 2020-11-27
  • 2020-11-10
  • 2020-10-27
  • 2020-10-13
  • 2020-09-23

[assessment]

  • Between 2020-09 and 2021-03, the patient received bevacizumab + FOLFIRI, and her CEA levels remained within the normal range. After completing the FOLFIRI treatment, the CEA levels began to rise slowly, but no imaging evidence was found until a CT scan on 2022-12-22, which revealed soft tissues in the peritoneal cavity suspected to be tumor seeding. A new regimen of bevacizumab + FOLFOX was initiated on 2022-12-26, and a subsequent decrease in CEA levels was observed, suggesting the effectiveness of the new treatment.
    • 2023-03-07 CEA 340.09 ng/mL
    • 2023-01-11 CEA 397.81 ng/mL
    • 2022-12-22 CEA 629.24 ng/mL
    • 2022-11-24 CEA 543.06 ng/mL
    • 2022-10-28 CEA 396.78 ng/mL
    • 2022-09-26 CEA 231.52 ng/mL
    • 2022-09-01 CEA 212.17 ng/mL
    • 2022-08-04 CEA 142.37 ng/mL
    • 2022-07-07 CEA 109.08 ng/mL
    • 2022-06-09 CEA 86.83 ng/mL
    • 2022-05-12 CEA 67.22 ng/mL
    • 2022-04-07 CEA 42.21 ng/mL
    • 2022-03-17 CEA 33.96 ng/mL
    • 2022-02-18 CEA 24.00 ng/mL
    • 2022-01-20 CEA 16.97 ng/mL
    • 2021-12-24 CEA 16.37 ng/mL
    • 2021-11-25 CEA 12.85 ng/mL
    • 2021-10-28 CEA 8.01 ng/mL
    • 2021-09-30 CEA 6.43 ng/mL
    • 2021-09-03 CEA 5.21 ng/mL
    • 2021-08-06 CEA 4.60 ng/mL
    • 2021-07-08 CEA 4.52 ng/mL
    • 2021-06-10 CEA 3.75 ng/mL
    • 2021-03-17 CEA 4.00 ng/mL
    • 2021-01-26 CEA 3.47 ng/mL
    • 2020-12-29 CEA 2.89 ng/mL
    • 2020-11-25 CEA 2.98 ng/mL
    • 2020-10-27 CEA 2.87 ng/mL
    • 2020-09-30 CEA 3.44 ng/mL
  • No medication reconciliation issue was identified in the patient.

701474112

230322

[exam findings]

  • 2023-03-17 Pathologic Report for PD-L1 (SP142) Assay (Ventana)
    • Sample Number: S2023-4736
      • Tumor type: adenocarcinoma
      • Tumor location: lung
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark XT
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: Pass,
      • Adequate tumor cells present (>=50 viable tumor cells): Yes
    • Result:
      • Tumor cell (TC) staining assessment: TC category: TC < 1%
      • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2023-03-15 CXR
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-15 Patho - lung transbronchial biopsy
    • Lung, LLL, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show acinar glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for the diagnosis.
  • 2023-03-14 Bone Scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed two hot spots in the middle T-spines and increased activity in the skull, lower T-spines, some L-spines, left S-I joint and inferior aspect of left acetabulum in whole body survey.
    • IMPRESSION:
      • Two hot spots in the middle T-spines and increased activity in the skull. Multiple bone metastases may show this picture.
      • Increased activity in the left S-I joint and inferior aspect of left acetabulum. Bone metastases can not be ruled out.
      • Increased activity in lower T-spines and some L-spines. Degenerative change may show this picture. However, please follow up bone scan to rule out the possibility of bone metastasis.
  • 2023-03-13 Bronchoscopy
    • normal
    • no obvious tumor was found
  • 2023-03-09 CT - chest
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Spiculated mass at left lower lobe measuring 2.7cm is found. Lung cancer is considered. The lession attached to descending aorta and pulmonary artery.
        • Interfissural nodules (n > 10) are found at left upper and lower lobes up to 1.07cm in largest dimension.
        • Mild left pleural effusion is found.
        • Enlarged lymph nodes are found at left hilar and left paratracheal region.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
    • Imp: left lower lobe lung cancer with lung to ipsilateral lung meta, pleural meta.
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)
  • 2023-03-09 Nerve Conduction Velocity (NCV) and Electromyography (EMG)
    • Finding: The repetitive stimulation study shows borderline decremental response in Trapezius.
    • Conclusion: The findings are possibly suggestive of myasthenia gravis. Please correlate clinically
  • 2023-03-06 MRA - brain
    • Indication: CT showed brain and skull lesion
    • Imaging protocol: 4-5mm slice thickness; sagittal T2, axial T2 & T2 FLAIR, DWI(b=1000)/ADC, coronal T1, axial T1+C, coronal T1+C images, and TOF MRA images
    • Head MRI without/with Gadolinium-based contrast enhancement shows:
      • multiple heterogeneous enhancing brain tumors scattered in bilateral cerebra and cerebella, on the cortex and in subcortical white matter, some associated with vasogenic edema. Larger ones are 1.8cm at left medial temporal lobe, and 2.0cm at right parietal-occipital lobe junction. Brain metastases are favored.
      • multiple enhancing bone tumors involving skull base and calvarial vault, larger ones are 3.9cm at right high parietal skull, and 2.0cm at clivus. Multiple bone metastases are favored.
      • symmetric size of bilateral ventricles.
      • no brain herniation.
      • TOF MRA shows patent and unremarkable intracranial arteries.
    • Impression:
      • Multiple brain and cerebellar metastases.
      • Multiple bone metastases, skull base and calvarial vault.
  • 2023-03-06 CXR
    • Blunting of left CP angle
  • 2023-03-06 CT - brain
    • Indication: SBP200-220mmHg or DBP110-130mmHg
      • noted today with blurred vision ; no recent head injury
      • no vomiting; no fever ; chest discomfort also noted
    • Imaging Protocol: 4mm slice thickness, axial scan and sagittal reconstruction
    • Without-contrast CT of brain shows:
      • White matter edema in right parietal lobe. Suspicious lesion in left medial temporal lobe.
      • Multiple mass lesions in skull, as well as in clivus.
      • Normal size of the ventricles.
      • No midline shift.
    • Impression
      • White matter edema in right parietal lobe and suspiciously in left medial temporal lobe, suspected brain metastasis
      • Multiple skull lesions; DDx: metastasis, multiple myeloma

[consultation]

  • 2023-03-17 Radiation Oncology
    • A
      • A: Adenocarcinoma of the lung, LLL, stage cT4N2M1, with multiple bone and brain metastases.
      • P: Radiotherapy is indicated for this patient with the following indicators: brain metastases
        • Goal: palliation
        • Treatment target and volume: the metastatic brain tumors and involved skull bone
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 3000cGy/15 fractions of the metastatic brain tumors and involved skull bone
        • The treatment planning of radiotherapy will be started at 0930, 2023-3-20.
  • 2023-03-08 Neurology
    • Q
      • She presented with sudden blurred vision and diplopia from 2023/03/06 morning after waking up. Dizziness and occasionally headache was also noted. Occasionally headache and progression memory deterioration for years.
    • A
      • Under the impression of multiple brain and cerebellar metastases with unknow primary, the patient was recommanded admission for further examination and treatment. I was consulted for further evaluation.
      • O
        • NE E4V5M6
        • CNs: suspect left gaze diplopia, no EOM abnormality
        • MP full
        • sensation: intact
        • FNF: no dysmetria
        • gait: steady
        • Brain CT revealed: 1. White matter edema in right parietal lobe and suspiciously in left medial temporal lobe, r/o brain metastasis 2. Multiple skull lesions; DDx: metastasis, multiple myeloma
        • Brain MRI/MRA: 1. Multiple brain and cerebellar metastases. 2. Multiple bone metastases, skull base and calvarial vault.
      • impression:
        • suspect diplopia, r/o leptomeningeal carcinomatosis, r/o cranial neuropathy
      • suggestion:
        • treat cancer as your expertise and agree with steroid treatment
        • consider CSF study to rule out cranial neuritis or leptomeningeal carcinomatosis
        • check serum ACHR ab and RST to rule out myasthenia gravis/LES
        • contact me if any questions and thank you for consultation.
  • 2023-03-08 Dermatology
    • Q
      • She presented skin itchy at least 10 years, SLE (skin manifestations) was diagnosis in RenAi Hospital, follow up and medication for 3 years. She had lesions of skin on her head, right calf and buttocks. Due to brain metastasis was found, skin malignancy was suspicious. We need your further evaluation and management. Maybe need to biopsy?
      • She receive cryotherapy for skin lesions at LMD (2023/03/03).
    • A
      • The patient had sufferred from several itchy keraotsis over face, forarm and buttock s/p cryotherapy with poor healing state.
      • Under the impression of irriated seborrheic keratosis with partial destruction.
      • The following sugeetion:
        • Tetracycline onit. 1 tube topical bid use over wound and crust and Betason-N onit 2 tube topical bid use over regional erythematous itchy lesion
        • If some remain itchy keraotsis develop, avoid self-scretch and consider add Rinderon-V cream 1 tube topical bid use.
  • 2023-03-07 Neurosurgery
    • Q
      • MRA: Multiple brain and cerebellar metastases
      • Dizziness and blurred vision
    • A
      • 67 y/o female. Comorbid with SLE.
      • Brain MRI:
        • Multiple brain and cerebellar metastases.
        • Multiple bone metastases, skull base and calvarial vault.
      • Rx:
        • Consult with oncologist for systemic work-up and therapy.

2023-03-08

[assessment]

  • This 67-year-old female with comorbid SLE presented with dizziness and blurred vision. Brain MRI showed multiple brain and cerebellar metastases, as well as multiple bone metastases in the skull base and calvarial vault. The patient is currently receiving care from our oncologist for systemic evaluation and treatment.
  • The medications previously prescribed by Taipei City Hospital for the patient’s systemic connective tissue involvement have been properly added to the active medication list without a reconciliation issue.

700045553

230321

{Metastatic colon adenocarcinoma in liver S4-5-8 & S6, pTxN0M1a Stage IVA, post segmental hepatectomy on 2019-06-05}

[diagnosis] - 2023-03-20 admission note

  • Sigmoid cancer with Metastasis in S7 liver S/P C/T shows progressive disease. Metastatic lymphadenopathy in para-aortic space and para-cava space S/P C/T show stable disease. stage IV
  • Viral hepatitis B Anti-HBc positive
  • Type 2 diabetes mellitus without complications

[past history] - 2022-11-25 admission note

  • Type 2 DM
  • Descending colon adenocarcinoma pT4aN1bM0 stage IIIB s/p T-loop colostomy, left hemicolectomy, closure of colostomy and FOLFOX chemotherapy in 2018.
  • Metastatic colonic adenocarcinoma in liver S4-5-8 & S6, pTxN0M1a Stage IVA post segmental hepatectomy on 2019/06/05. RFA for S6/7 metastases at VGHTPE on 20191226
  • Pig-tail drainage for liver abscess since 2019/06/08.
  • Enterocutaneous fistula since 2019/08/03

[family history]

  • His mother had cervical cancer.

[lab data]

  • 2021-07-30 Anti-HCV Nonreactive
  • 2021-07-30 Anti-HCV Value 0.05 S/CO
  • 2021-07-30 HBsAg Nonreactive
  • 2021-07-30 HBsAg (Value) 0.41 S/CO
  • 2021-07-30 Anti-HBc Reactive
  • 2021-07-30 Anti-HBc-Value 6.63 S/CO
  • 2021-07-30 Anti-HBs 22.86 mIU/mL

[exam findings]

  • 2023-01-27 MRI - T-spine
    • Indication: Mid-back pain and soreness, associated numbness.
    • Findings
      • T1-hypointensity, heterogeneous T2-hypointensity and inhomogeneous enhancement involving both anterior and posterior components of C6, C7, T3, T4 and T5 vertebral body, indicating metastases. Much more severe at T3-5 levels with bony destruction and compression on spinal cord.
      • An enhacning soft tissue mass, about 39 mm at the largest dimension, with irregular maring in right lung field, abutting right main bronchus and right side of T5 vertebrla body, indicating metastasis.
      • No intramedullary lesion.
    • IMP: Bony metastases (C6-7 and T3-5 vertebral bodies) and right lung metastasis.
  • 2023-01-16 CT - Sella
    • Findings
      • An extra-axial tumor (36 mm) at anterior cranial fossa base, can be separated from pituitary fossa by diaphragm sella. Suspected meningioma.
      • After IV contrast administration shows well and homogenous enhancement of the mass or tumor.
    • IMP: Favor a middle frontal base meningioma.
  • 2023-01-16 T-spine AP + Lat.
    • Destructions/metastases, at least, at T3-4-5.
  • 2022-12-13 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Adenocarcinoma, metastatic, colonic origin
    • The sections show a picture of adenocarcinoma, moderately differentiated, composed of nests, cords, and single large pleomorphic neoplastic cells in fibrous stroma. Focal glandular differentiation is present. Extensive tumor necrosis is evident.
    • IHC shows: CK7(-), CK20(+) and CDX2(+). The finding is consistent with metastatic colonic adenocarcinoma.
  • 2022-11-28 CT - abdomen
    • Findings
      • Lobulated hepatic tumor at S7/8 of liver up to 5.5cm in largest dimension is found. In comparison with CT dated on 2022-08-10, the lesion enlarged.
      • Diffuse confluent lymphadenopathy at para-aortic and mesenterric region is found. In progression.
      • Mild bilateral pleural effuison is found.
    • Imp:
      • Hepatic meta. In progression.
      • Extensive lymphadenopathy in the abodminal cavity, in enlargement.
  • 2022-09-15 Tc-99m MDP whole body bone scan
    • Prominently increased activity in some upper T-spines. Bone metastases should be considered first.
    • Mildly increased activity in bilateral S-I joints. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, compatible with benign joint lesions.
  • 2022-08-27 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-08-10 CT - abdomen
    • Indication
      • History: D-colon cancer with liver & LNs mets
        • 20180406 CT: Distal D-colon cancer — acute total obstruction
        • 20190520 CT: metastasis in S4/8
        • 20190608 CT: metastasis in S4/8 S/P resection with abscess S/P catheter drainage
        • 20201014 CT: metastasis in S7 S/P C/T with partial response.
        • 20211109 CT: metastasis in S7 1.6 cm.
    • Findings
      • Prior CT identified an ill-defined rim enhancing lesion 4.4 cm in S7 of the liver is noted again, increasing in size to 5.3 cm in the current CT that is c/w liver metastasis S/P C/T with progressive disease.
      • Prior CT identified multiple confluent metastatic lymphadenopathy at para-aortic space and para-cava space are noted again, stable in size that are c/w metastatic nodes S/P C/T with stable disease.
      • S/P surgical resection of S4/8 junction and partial resection of S5/6 of the liver. S/P cholecystectomy. Mild Fatty liver is noted.
      • S/P left hemicolectomy.
      • The spleen shows prominence in size (AP dimension: 11.3 cm).
    • Impression:
      • Metastasis in S7 liver S/P C/T shows progressive disease.
      • Metastatic lymphadenopathy in para-aortic space and para-cava space S/P C/T show stable disease.
  • 2022-08-04 CXR
    • Cardiomegaly is noted.
    • Right pleural effusion is found.
  • 2022-07-21 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-05-26 CT - abdomen, pelvis
    • Progression of liver/ LNs metastases.
  • 2022-03-12 CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2022-01-15 MRI - nasopharynx
    • Metastastic LAPs at left neck. An extra-axial tumor (37 mm) at anterior cranial fossa and pituitary fossa.
    • Suspected meningioma.
    • D/D: craniopharyngioma, pituitary adenoma, metastasis.
  • 2022-01-14 CT - whole abdomen, pelvis
    • Metastasis in S7 liver S/P C/T shows progressive disease.
    • Metastatic lymphadenopathy in para-aortic space and para-cava space S/P C/T show partial response.
  • 2021-11-10 MRI - nasopharynx
    • multiple enlarged and necrotic lymph nodes in the left lower neck and left supraclavicular fossa.
  • 2021-11-09 CT - whole abdomen, pelvis
    • Hepatic meta at S7, in progression.
    • Extensive paraaortic lymphadenopathy, enlarged.
    • Tiny left upper lobe nodule. Stable.
  • 2021-09-16 CT - whole abdomen, pelvis
    • Progression of liver/LNs metastases.
  • 2021-07-19 Patho - peritoneum biopsy
    • newly developed retroperitoneal LNs, R/I recurrence.
    • malignant neoplasm of descending colon
    • Retroperitoneal lymph node, CT-guide biopsy - Adenocarcinoma, metastatic
    • IHC: CK(+), CK20(-), CDX2(+) and CD31 highlights endothelial cell, compatible with metastatic colonic adenocarcinoma.
  • 2020-10-14 CT - whole abdomen, pelvis
    • A metastasis 2.9 x 2 cm in S7 of the liver S/P C/T with partial response. Follow up is indicated.
  • 2020-08-25 CT - whole abdomen, pelvis
    • Post-op at the liver with loculated fluid in right subphrenic region, stationary.
    • Stationary of S7 liver tumor.
  • 2020-06-15 MRI - brain
    • A pituitary macroadenoma. No evidence of brain metastasis.
  • 2020-06-13 CT - whole abdomen, pelvis
    • Post-op at the liver with loculated fluid in right subphrenic region with progression. Post-op biloma or associated with recurrenct, suggest tissue study.
    • Stationary of S7 liver tumor.
    • Small bilateral renal stones.
  • 2020-04-01 CT
    • A metastasis 3.9 x 2 cm in S7 of the liver S/P C/T with stable disease.

    • 2019-11-21 Whole body PET scan

      • Three glucose hypermetabolic lesions in the segment 8 of liver, in the segment 7 of liver and in the right upper abdomen just in the inferomedial aspect of the right lobe of liver respectively. Metastatic lesions should be considered.
      • Mild glucose hypermetabolism in bilateral pulmonary hilar regions and in the soft tissues around bilateral hips. Inflammatory process is more likely.
      • Glucose hypermetabolism in the midline anterior abdominal wall. The nature is to be determined (post-operative change? other nature?).
      • A glucose hypermetabolic lesion the pituitary fossa. The nature is to be determined (some kind of pituitary tumor? other nature?).
    • 2019-11-11 CT - abdomen

      • S/P liver operation. A low attenuation lesion (1.8cm) in S7 of liver without interval change.
    • 2019-08-14 Tc-99m MDP whole body bone scan

      • A faint hot spot in the anterolateral aspect of the right 8th rib, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scna in 3 months for further evaluation.
      • Suspected benign lesions in the left zygomatic bone, inferior angle of the right scapula, bilateral shoulders, and S-I joints.
    • 2019-08-03 MRI - liver, spleen

      • s/p pigtail placement at previous op. region. Some fluid accumulation at previous op. region with tiny air bubble is found. The adjacent liver parenchyma is hyperemic, suspected regional residual abscess formation.
    • 2019-06-06 Surgical pathology Level V

      • pathologic diagnosis
        • Liver, S4-5-8, segmental hepatectomy — Metastatic colonic adenocarcinoma
        • Liver, S7, segmental hepatectomy — Metastatic colonic adenocarcinoma
        • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
        • Lymph nodes, group 12, lymphadenectomy — Negative (0/3)
      • microscopic examination
        • Diagnosis: Metastatic colonic adenoarcinoma x2
        • Histologic grade: Moderately differentiated
        • Tumor growth pattern: Pushing
        • Tumor pseudocapsule: Present
        • Tumor necrosis: Marked (60%)
        • Parenchymal margin: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margins: 0.1 cm (S4-5-8) and 0.1 cm (S7), respectively
        • Vascular invasion: Present
        • Perineural invasion: Not identified
        • Tumor regression grade: Grade 4/5 (residual cancer cells predominate over fibrosis)
        • Lymph nodes, group 12: Negative (0/3) (LN involved/LN examined)
        • Non-neoplastic liver parenchyma: Perivenular congestion, and mild portal lymphocytic infiltration
        • Fatty Change: Moderate (50%)
    • 2019-06-08 CT - abdomen

      • S/P operation. Bil. pleural effusion with adjacent lung collapse.
      • Some air and fluid collection in upper peritoneal cavity and right subphrenic region.
      • Inhomogeneous enhancement of right hepatic lobe.
    • 2019-05-20 CT - abdomen

      • Metastasis 4 cm in size at S4 of the liver is noted and it shows indentation or invasion of the gallbladder wall.
    • 2018-11-16 CT

      • S/P left hemicolectomy. Suggest follow up.
    • 2018-07-07 CT

      • S/P operation. Presence of incisional hernia. Focal fat stranding of abdominal wound.
    • 2018-06-28 Surgical pathology Level III

      • Soft tissue, site?, debridement — Ulcer with granulation tissue
    • 2018-04-26 Surgical pathology Level VI

      • Pathologic diagnosis
        • Descending colon, left hemicolectomy — Adenocarcinoma, moderately differentiated
        • Resection margins: Free
        • Lymph nodes, mesocolic, dissection — Metastatic adenocarcinoma (2/16)
        • Pathology stage: pT4aN1b(cMx); Stage IIIB at least
      • Microscopic examination
        • Histology: Adenocarcinoma
        • Histology Grade: Moderately differentiated
        • Depth of invasion: Mesocolic soft tissue
        • Angiolymphatic invasion: Present
        • Perineural invasion: Present
        • Discontinuous extramural tumor extension: Not identified
        • Serosal margin status of colon: Involved
        • Lymph nodes metastasis, mesocolic: Metastatic adenocarcinoma (2/16) (No. Positive / No. Total)
        • Extranodal involvement: Present
        • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)

[consultation]

  • 2023-02-03 Radiation Oncology
    • A
      • In the past 2 wks, he sufferred from Lt neck enlarging LAPs compression with severe Lt arm and scapular pain. CT-simulation will be arranged on 20230208.
      • Plan to deliver 20 Gy/ 4 fx to the Lt neck LAPs. The dose schedule to the spine mets will be adjusted according to the dose distribution and constraint by then.
      • RT will start around 20230209.
  • 2022-12-14 Radiation Oncology
    • A
      • Paraaortic enlarging LAPs have caused mild lower limbs edema already. Palliative RT is indicated. CT-simulation will be arranged on 20231219.
      • Plan to deliver 40~45 Gy/ 20~25 fx to the paraaortic LAPs. RT will start around 2022/12/21 or 22.
    • 2022-12-12 Radiation Oncology
      • Q
        • for CT guide biopsy of liver
        • This 60-year-old man, a patient of colon cancer with liver mets progression and he was admitted for C/T. The abdominal CT showed hepatic tumor progression. We need expertise to evaluate his condition thanks!
      • A
        • According to the clinical history and imaging findings, biopsy is indicated.
    • 2022-09-27 Radiation Oncology
      • A
        • Mr. Hsu, a 60-year-old man with history of Descending colon adenocarcinoma pT4aN1bM0 stage IIIB s/p T-loop colostomy, left hemicolectomy, closure of colostomy and FOLFOX chemotherapy in 2018. Metastatic colonic adenocarcinoma in liver S4-5-8 & S6, pTxN0M1a Stage IVA post segmental hepatectomy on 2019/06/05. RFA for S6/7 metastases at VGHTPE on 2019/12/26. status during palliative C/T with liver metastases and abdominal LAPs progression.
        • The Lt upper back and shoulder pain and soreness has been noted since one month ago. Bone scan on 20220916 revealed prominently increased activity in some upper T-spines. Bone metastases should be considered first.
        • Palliative RT to the upper T-spine metastases is indicated. CT-simulation will be arranged today. Plan to deliver 30 Gy/ 10 fx to the site mentioned above. RT will start around 20220928 or 20220929. Thank you very much.
    • 2022-08-11 Colorectal Surgery
      • Q
        • for suspected fistular
        • This 60-year-old man, a patient of colon cancer with liver mets progression and Metastatic lymphadenopathy in para-aortic space and para-cava space S/P C/T show stable disease S/P C/T. He was admitted due to dyspnea & bak pain on 8/4 22 night abdominal wound poor healing & pus discharge for one week. pus discharge and stool passage via poor healing wound was noted suspected fistular related. We need expertise to evaluate his condition thanks!
      • A
        • The patient was case of colon cancer with liver and LN metastasis
        • Colo-cutaneous fistula was noted
        • PE: Abd: soft; no peritoneal sign; no abdominal pain
        • Imp: Colon cancer s/p op with enterocutaneous fistula
        • Suggestion:
          • Cover with colostomy bag and may contact stoma nurse if needed
          • Keep on palliative chemotherapy
    • 2022-03-15 Ophthalmology
      • Q
        • For left eye reddish for days
        • This 59-year-old man, a patient of colon cancer with liver & lung mets progression S/P C/T. He was admitted for chemotherapy. He compalined of left eye reddish for days. We need expertise to evaluate his condition. thanks!
      • A
        • S
          • For redness, FBS os for 1 week
          • OPHx: trichiasis s/p epilation od 2wk ago
          • PHx: DM, colon cancer with liver & lung mets progression under Erbitux, FOLFIRINOX
          • NKA
        • O
          • BCVA: OD 0.6(0.9X-0.25/-0.50X40) OS 0.3(0.5X0/-0.50X5)
          • PT: 20/18mmHg
          • Pupil: 3mm, light reflex +, no RAPD
          • Eyelash: entropion with trichiasis os
          • Conj: np od, inferior injected os
          • K: clear ou, inferior spks os
          • A/C: deep/clear ou
          • Lens: ns+ ou
          • Fundus: c/d 0.4, one CWS near disc od, one blot hemorrhage and CWS os
        • A:
          • Entropion with corneal abrasion os
          • Mild diabetic retinopathy ou
        • P:
          • Control blood sugar
          • Sinomin 1gtt QID os + Tetracycline oint HS os + tapping inferior eyelid os
          • OPH OPD f/u for entropion and f/u cotton-wool spot at disc os

[surgical operation]

  • 2019-06-05
    • Segmental hepatectomy
    • Secondary liver malignant neoplasm
  • 2018-06-27
    • Colon cancer s/p op with enterocutaneous fistula
  • 2018-06-22
    • Malignant colon neoplasm, desc
    • 8.5 Fr. B. braun port, left cephalic vein, cut-down method.
  • 2018-05-01
    • D-colon cancer obstruction post op
    • Smoe necrotic tissue at colostomy opened wound
    • Debridement and closure and set a penrose drain
  • 2018-04-25
    • D-colon cancer obstruction s/p colostomy
    • D-colon cancer with complete obstruction 744cm
    • Peristoma dense adhesion with omentum and small intestine
  • 2018-04-10
    • D-colon cancer obstruction
    • Severe dilatation of T-colon and short mesentary
    • Asites (+)

[chemotherapy]

  • 2023-03-20 - irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5290mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-03-01 - cetuximab 250mg/m2 100mg 2hr + irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5280mg NS 500mL 46hr (cetuximab + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-02-06 - cetuximab 250mg/m2 480mg 2hr + irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5400mg NS 500mL 46hr (cetuximab + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-01-04 - cetuximab 250mg/m2 480mg 2hr + irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5300mg NS 500mL 46hr (cetuximab + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-12-14 - cetuximab 250mg/m2 480mg 2hr + irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5300mg NS 500mL 46hr (cetuximab + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

    • 2022-11-25 - cetuximab 250mg/m2 480mg 2hr + oxaliplatin 60mg/m2 115mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5450mg 46hr (FOLFOXIRI Zhang_ShouYi)

      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg IVD + granisetron 2mg + acetaminophen 500mg PO
    • 2022-11-08 - cetuximab 250mg/m2 490mg 2hr + oxaliplatin 60mg/m2 118mg 2hr + irinotecan 150mg/m2 295mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-10-20 - cetuximab 250mg/m2 485mg 2hr + oxaliplatin 60mg/m2 116mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 775mg 2hr + 5-Fu 2800mg/m2 5430mg 46hr (Zhang_ShouYi)

    • 2022-08-12 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 180mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

    • 2022-09-12 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

    • 2022-08-26 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5520mg 46hr (Zhang_ShouYi) patient asked to add oxaliplatin back.

    • 2022-08-12 - cetuximab 250mg/m2 500mg 2hr + irinotecan 180mg/m2 350mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-07-21 - cetuximab 250mg/m2 500mg 2hr + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)

    • 2022-07-01 - cetuximab 250mg/m2 500mg 2hr + irinotecan 160mg/m2 320mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)

    • 2022-06-14 - cetuximab 250mg/m2 500mg 2hr + irinotecan 160mg/m2 320mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi) FOLFIRI

    • 2022-05-24 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 185mg/m2 370mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)

    • 2022-04-27 - cetuximab 400mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-03-29 - cetuximab 400mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-03-15 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-02-10 - cetuximab 400mg/m2 700mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-01-14 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 170mg/m2 330mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2021-12-22 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 160mg/m2 300mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)

    • 2021-12-01 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)

    • 2021-11-11 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5345mg 46hr (Zhang_ShouYi) FOLFOXIRI

    • 2021-09-28 ~ 2021-11-09 - Stivarga (regorafenib 40mg/tab) 4# QD D1-21 Q4W

    • 2021-09-03 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)

    • 2021-08-20 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5640mg 46hr (Zhang_ShouYi)

    • 2021-07-29 - oxaliplatin 70mg/m2 140mg 2hr + leucovorin 400mg/m2 805mg 2hr + 5-Fu 2800mg/m2 5660mg 46hr (Zhang_ShouYi)

    • 2020-08-24 - bevacizumab 5mg/kg 200mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

    • 2020-07-27 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)

    • 2020-06-29 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5460mg 46hr (Zhang_ShouYi)

    • 2020-06-15 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

    • 2020-05-28 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 160mg/m2 300mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

    • 2020-05-07 - bevacizumab 300mg 90min + irinotecan 120mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + 5-Fu 400mg/m2 650mg 15min + 5-Fu 1000mg/m2 1500mg 20hr D1-2 (Liu_JunHuang)

    • 2020-04-20 - bevacizumab 300mg 90min + irinotecan 120mg/m2 220mg 90min + leucovorin 400mg/m2 560mg 2hr + 5-Fu 400mg/m2 560mg 15min + 5-Fu 1000mg/m2 1500mg 20hr D1 (Liu_JunHuang)

    • 2020-04-02 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1 (Liu_JunHuang)

    • 2020-03-16 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)

    • 2020-03-02 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)

    • 2020-02-17 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)

    • 2020-02-03 - irinotecan 270mg 1.5hr + leucovorin 400mg/m2 760mg 0hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)

    • 2020-01-13 - oxaliplatin 85mg/m2 2hr + leucovorin 200mg/m2 380mg 0hr + 5-Fu 400mg/m2 684mg 15min D1-2 + 5-FU 1000 mg 20hr D1-2 (Liu_JunHuang)

    • 2019-12-06 ~ 2019-12-28 - capecitabine

    • 2019-06-12 - FOLFIRI + bevacizumab

    • 2019-05-28 - FOLFIRI + bevacizumab

    • 2019-05-07 - FOLFIRI + bevacizumab

    • 2019-04-20 - FOLFIRI + bevacizumab

    • 2019-04-03 - FOLFIRI + bevacizumab

    • 2019-03-16 - FOLFIRI + bevacizumab

    • 2019-03-02 - FOLFIRI + bevacizumab

    • 2019-02-17 - FOLFIRI + bevacizumab

    • 2019-02-03 - FOLFIRI

    • 2019-01-03 - FOLFIRI

    • 2018-06-08 ~ 2018-06-18: capecitabine

==========

2022-11-28

The control of blood sugar is better than it was during the last hospital stay. As far as the active prescription is concerned, there is no problem.

2022-11-09

The patient continues to have poor blood sugar control despite treatment with acarbose, metformin, and vildagliptin (2 data points over 244 mg/dL on 2022-11-08 and 2022-11-09). SGLT2 inhibitors such as Canaglu (canagliflozin), Forxiga (dapagliflozin) or Jardiance (empagliflozin) might be added to help manage diabetes.

2022-09-13

Although the patient is currently receiving 3 classes of oral antidiabetic medications (metformin, sitagliptin, and dapagliflozin), his blood sugar remains high (381mg/dL on 2022-09-12 17:35, 302mg/dL on 2022-09-13 06:46); HbA1c of 8.4 (2022-08-26 lab), mild diabetic retinopathy has been confirmed (2022-03-15 ophthalmology).

Starting basal insulin (e.g., Toujeo (insulin glargine)) at 0.1 unit/kg/day or 10 units/day is recommended.

2022-07-22

Irinotecan 180 mg/m2 in current regimen is considered a normal dose range for patients with ALT/AST 43/44, BUN 10 (2022-07-21).

There is a history of T2DM in this patient. The most recent HbA1c record dates from 2019, and the AC blood sugar readings have been 271, 327, and 267 since this hospitalization. As there is no hypoglycemic agent in active prescriptions, metformin 500 mg BID is recommended.

2022-03-15

CT and MRI in mid January 2022 showed the disease progressed compared to previous images.

CEA readings since July 2021 at intervals of two to three months showed a peak in November 2021 (1261ng/mL) and a slight fall in February 2022 (886ng/mL), possibly caused by the introduction of FOLFOXIRI from November 2021 (ongoing).

701459963

230321

[diagnosis]

  • Malignant neoplasm of left ovary
  • Left ovary mixed mucinous and aclear cell carcinoma, pT1c3N0M0, stage IC3, post debulking (ATH + BSO + BPLND + artial omentectomy) on 2022/11/18

[past history]

  • Past hx: denied
  • Surgical hx:
    • 2022/11/18 ebulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND) + enterolysis
    • 2202/12/07 port implantaion, left cephalic vein

[allergy]

  • NKDA     

[family history]

  • denied family history

[exam findings]

  • 2023-02-18 SONO - abdomen
    • mild fatty liver
    • right renal cyst
  • 2023-02-16 Nerve Conduction Velocity, NCV
    • Findings
      • The NCV study showed (1) Prolonged distal motor latency, decreased SAP amplitude, slowing sensory conduction velocity in bilateral median nerves. (2) Decreased CMAP amplitude in left median nerve. The F wave study showed no response in left median nerve. The H reflex was within normal limits. The QST study showed abnormal heat and cold sensation in upper and lower limbs.
    • Conclusion
      • The above finding suggest entrapment neuropathy in bilateral median nerves at wrist and small fiber disease. Advise clinical correlation.
  • 2023-02-09 Brainstem auditory evoked potentials, BAEP
    • Findings: Normal waveforms, amplitudes, peak latencies, interpeak intervals following click stimulaion to each ear.
    • Conclusion: This is a normal BAEP study.
  • 2023-02-16 Neurosonology
    • Mild atherosclerosis in left CCA bifurcation and left CCA.
    • Adequate total VA flow volume (234 ml/min).
  • 2023-01-27 MRI - brachial plexus
    • Indication
      • Ovary cancer
      • acute left upper arm pain and left upper limb weakness on 2022/11/21
      • had tenderness point
      • no trauma history
      • 2022/12/15 improving
    • Without- and with-contrast MRI of brachial plexus, including axial, coronal and oblique sagittal T1WI and T2WI (with 3 mm or 4 mm thickness) reveal:
      • Hypertrphic degeneration of C-spine, esp C5-6-7.
      • No abnormality along the course of left brachial plexus.
      • A well-defined non-enhancing cystic lesion infiltrating along muscles at left shoulder joint, including subacromion region, indicating degenerative joint disease.
      • S/P Port-A device at left chest wall.
    • IMP: No evidence of brachial plexus lesion. Cervical spondylosis.
  • 2023-01-27 MRI - C-spine
    • Findings:
      • General bulging disc with central focal protrusion causing mild spinal canal stenosis and bilateral mild neuroformainal narrowing at C4-5.
      • Decreased vertebral body height, end-plate degeneration, general bulging disc with central disc protrusion, posterolateral osteophytes and enlarged facets causing spinal canal stenosis, cord compression and bilateral moderate neuroforaminal narrowing at C5-6-7.
      • No intramedullary abnormality.
      • No abnormal enhancement.
    • IMP: Cervical spondylosis with spinal canal stenosis and neuroforaminal narrowing, esp C5-6-7.
  • 2022-12-09 Nerve Conduction Velocity, NCV
    • Findings
      • The NCV study showed (1) Prolonged distal motor latency in bilateral median nerves. (2) Marked decreased CMAP in left median nerve. (3) Slowing sensory conduction velocity in bilateral median nerve. The F wave study showed prolonged latency in left median nerve. The EMG study showed normal findings in left FDI, left brachioradialis and left biceps brachii muscle. The H reflx was normal.
    • Conclustion
      • The above findings suggest left median neuropathy, left cervical radiculopathy and entrapment neuropathy in right median nerve at wrist. Advise clinical correlation.
  • 2022-12-07 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 24 dB HL; LE 23 dB HL
    • bil normal to moderate SNHL (sensory neural hearing loss)
  • 2022-11-28 MRI - upper arm
    • Partial-thickness intrasubstance tear of supraspinatus tendon
    • Supraspinatus and infraspinatus tendinosis and calcific tendinitis
  • 2022-11-26 Shoulder LT
    • Calcified left rotator cuff tendinitis
  • 2022-11-26 CXR
    • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, T-spine.
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • a small nodular opacity over Lt midlung zone?
  • 2022-11-26 Gynecologic ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2022-11-21 Patho - soft tissue tumor, extensive resection
    • Diagnosis:
      • Ovary, left, oophorectomy —- mucinous carcinoma with focal clear cell carcinoma; AJCC 8th edition: pStage IC, pT1c2N0(if cM0), FIGO Stage IC2 or pStage IC, pT1c3N0(if cM0), FIGO Stage IC3; please correlate with the clinical presentation
      • Ovary, right, oophorectomy —- negative for malignancy
      • Fallopian tube, bilateral, salpingectomy —- negative for malignancy
      • Uterus, corpus, total hysterectomy —- negative for malignancy
      • Uterus, cervix, total hysterectomy —- negative for malignancy
      • Uterus, endometrium, total hysterectomy —- negative for malignancy
      • Omentum, omentectomy —- negative for malignancy
      • Lymph node, left iliac, dissection —- negative for malignancy (0/7)
      • Lymph node, left obturator, dissection —- negative for malignancy (0/10)
      • Lymph node, right iliac, dissection —- negative for malignancy (0/6)
      • Lymph node, right obturator, dissection —- negative for malignancy (0/7)
    • Gross description:
      • Procedure (select all that apply): debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND)
      • Specimen Integrity
        • Specimen Integrity of Right Ovary (if applicable): Capsule intact
        • Specimen Integrity of Left Ovary (if applicable): Capsule ruptured
        • Specimen Integrity of Right Fallopian Tube (if applicable): Serosa intact
        • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
      • Tumor Site: Left ovary
      • Ovarian Surface Involvement (required only if applicable): Absent
      • Fallopian Tube Surface Involvement (required only if applicable): Absent
      • Tumor Size
        • F2022-00552
          • Greatest dimension (centimeters): 7.5 cm
          • Additional dimensions (centimeters): 7.3 x 2.8 cm
      • Specimen size:
        • S2022-20527
          • right ovary: 2.3 x 1.8 x 0.3 cm;
          • right tube: 5.6 cm in length and 0.5 cm in diameter;
          • left tube: F2022-00552: 4.6 cm in length and 0.3 cm in diameter;
          • uterus: 8.6 x 5.6 x 4.8 cm, 135 g; Cervix: 3.8 x 3.5 x 2.8 cm; Endometrial cavity: 4.0 x 3.8 x 0.2 cm; Several leiomyomas, measuring up to: 1.1 x 1.0 x 0.8 cm
          • omentum: 14.7 x 10.5 x 2.0 cm
      • Sections are taken and labeled as:
        • F2022-00552: Representative sections are taken and labeled as: FsA1-3, for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: left fallopian tube; X2: adnexal soft tissue; X3-6: left ovary.
        • S2022-20527: A1: cervix; A2-3: endometrium; A4: leiomyoma; A5: right ovary and fallopian tube; A6: left adnexal soft tissue; A7: posterior wall; B1-2: omentum; C1-2: lymph node, left iliac; D1-2: lymph node, left obturator; E1-2: lymph node, right iliac; F: lymph node, right obturator.
    • Microscopic Description:
      • Histologic Type: Mucinous carcinoma with focal clear cell carcinoma; The immunohistochemical stains reveal PAX8(+), WT-1(-), PR(-), Napsin A(focal +), p53(aberrant expression +)
      • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors)
        • (Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.)
        • WHO Grading System: G2: Moderately differentiated
      • Implants (required for advanced stage serous/seromucinous borderline tumors only): not applicable
      • Other Tissue/ Organ Involvement (select all that apply): Not identified
      • Largest Extrapelvic Peritoneal Focus (required only if applicable): Cannot be determined
      • Peritoneal/Ascitic Fluid: N2022-04283: suspicious
      • Regional Lymph Nodes: left iliac: 0/7; left obturator: 0/10; right iliac: 0/6; right obturator: 0/7
      • Additional Pathologic Findings: Leiomyoma and adenomyosis are seen.
  • 2022-11-18 Body fluid cytology - ascites
    • suspicious for malignancy;
    • few clusters of suspicious cells with high nuclear/cytoplasmic ratio present.
  • 2022-11-18 Frozen section
    • Ovary, left, oophorectomy —- adenocarcinoma
  • 2022-11-17 Colonoscopy
    • Diverticulum, descending colon
    • Internal hemorrhoid
  • 2022-11-17 Panendoscopy
    • Diagnosis
      • Reflux esophagitis LA Classification grade AEsophageal phleboectasia, middle esophagus
      • Superficial gastritis
    • Suggestion
      • No endoscopic evidence of primary malignancy in UGI tract
  • 2022-11-16 ECG
    • Sinus bradycardia
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2022-11-10 Gynecologic ultrasonography
    • suspected pelvis mass: 92 x 47 mm (RI: 0.38)
    • ascites

[surgical operation]

  • 2022-11-18 debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND) + enterolysis

[chemotherapy]

  • 2023-03-20 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
  • 2023-02-24 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
  • 2023-02-07 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
  • 2023-01-18 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
  • 2022-12-28 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
  • 2022-12-09 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3

[note]

First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tube, and peritoneal cancer https://www.uptodate.com/contents/first-line-chemotherapy-for-advanced-stage-iii-or-iv-epithelial-ovarian-fallopian-tube-and-peritoneal-cancer

  • General principles
    • The standard approach to treatment for women requiring first-line chemotherapy for EOC is to use a platinum agent with a taxane. For women with optimally reduced disease (<1 cm of residual disease), there are two options: intravenous (IV) chemotherapy alone or a combination of IV and intraperitoneal (IP) chemotherapy (IV/IP therapy). Women with suboptimally reduced disease (≥1 centimeter of residual disease) are not candidates for IP therapy due to limited penetration into larger tumors. These women should therefore receive IV treatment.
  • Women with optimally cytoreduced disease
    • IV/IP therapy versus IV therapy alone
      • Comparative data
        • For women with optimally cytoreduced disease (no residual or less than 1 cm of residual disease) who have not received neoadjuvant treatment, IV/IP therapy is an appropriate option. Some UpToDate experts prefer IV/IP treatment for optimally cytoreduced disease, while others prefer IV therapy, particularly given that other treatment options including bevacizumab and maintenance therapy with PARP inhibitors are also often included.
      • Preferred IV/IP therapy regimen
        • The most commonly used intravenous/intraperitoneal (IV/IP) regimen comes from GOG 172 and consists of six cycles of
          • IV paclitaxel (135 mg/m2 over 24 hours) on day 1
          • IP cisplatin (100 mg/m2 in a liter of normal saline) on day 2
          • IP paclitaxel (60 mg/m2) on day 8
        • We typically use the above regimen, with the exception of reducing cisplatin to 75 mg/m2, which was the regimen used in GOG 252.
      • Preferred IV therapy regimen
        • For patients with optimally cytoreduced disease in whom intravenous (IV) therapy will be administered, choice of agents and scheduling is the same as for those with suboptimally cytoreduced disease, and is discussed below.
    • Incorporation of HIPEC
      • For patients who undergo neoadjuvant chemotherapy and have an optimal surgical result (ie, residual disease <1 cm), incorporation of HIPEC is discussed separately.
  • Women with suboptimally cytoreduced disease
    • For patients with suboptimally cytoreduced EOC (epithelial ovarian cancer), we suggest IV treatment rather than IV/IP therapy.
    • Choice of agents
      • For women requiring first-line chemotherapy for EOC, the standard IV regimen utilizes platinum and taxane agents. For select patients at higher risk of recurrence (eg, those with pleural effusions or ascites who lack a BRCA mutation), we suggest the addition of bevacizumab, which is administered with chemotherapy and continued as maintenance therapy.
      • Although cisplatin and/or docetaxel are sometimes used in this setting, we prefer carboplatin plus paclitaxel. Our rationale is based on the following:
        • We prefer carboplatin rather than cisplatin because multiple trials have consistently demonstrated that carboplatin produces equivalent response rates and survival outcomes to cisplatin, but is associated with less toxicity.
        • Although both paclitaxel and docetaxel (the most commonly used taxanes for EOC) can be administered along with carboplatin in this setting, we prefer paclitaxel because it is less myelosuppressive than docetaxel. However, a consideration between these two taxanes can be individualized based on their differing toxicities. For paclitaxel, these include a higher risk of neuropathy, myalgias, and weakness compared with docetaxel; for docetaxel, these include a higher risk of neutropenia, hypersensitivity reactions, and nausea and vomiting.
        • We prefer to treat for a maximum of six cycles rather than more because there are no data that treatment beyond six cycles improves outcomes, although further treatment increases the risk of treatment-related toxicities. The administration of further treatment for patients who respond (or do not progress) after six cycles of first-line therapy (ie, maintenance therapy) is covered below.

==========

2023-03-21

  • Some patients with type 1 or type 2 diabetes have a paradoxically high GFR early in their disease course (ie, “glomerular hyperfiltration”). Glomerular hyperfiltration is usually defined as GFR approximately 20 percent or more above that in age-matched, healthy controls without diabetes. In younger individuals, the usual threshold for hyperfiltration is considered 120 to 140 mL/min/1.73m2, whereas in older adults it may be closer to 100 to 120 mL/min/1.73m2. In studies of patients with diabetes that measured GFR, hyperfiltration was associated with greater risks of albuminuria progression and kidney function decline. The kidney protective effects of renin angiotensin system (RAS) and sodium-glucose cotransporter 2 (SGLT2) inhibitors are thought to be mediated, at least in part, by reductions in glomerular hyperfiltration.
    • 2023-03-15 eGFR 155.56
    • 2023-03-09 eGFR 134.22
    • 2023-02-22 eGFR 144.16
    • 2023-02-15 eGFR 151.57
    • 2023-02-07 eGFR 147.78
    • 2023-02-01 eGFR 128.28
    • 2023-01-17 eGFR 144.16
    • 2023-01-12 eGFR 155.56
  • No HbA1c readings or blood glucose levels are accessible in HIS5. It is advised to examine whether the patient has developed type 2 diabetes.

2022-12-29

  • According to the 2022-12-28 lab results, the readings were grossly within the normal range, and no dosage adjustment is necessary.
  • Primarily a distal sensory neuropathy, may occur with paclitaxel. Neuropathy can present as a mixture of paresthesias and dysesthesias, including burning, numbness, tingling, and shooting pains, typically in a stocking-glove distribution. Prior to the chemotherapy, 2022-12-09 nerve conduction velocity test suggested neuropathy, 2022-12-07 pure tone audiometry resulted bilateral normal to moderate sensory neural hearing loss. While severe symptoms are unusual, peripheral neuropathy often leads to subsequent dose reductions in many patients.
  • Carboplatin has also been associated with ototoxicity (1%, UpToDate). Although peripheral neuropathy occurs infrequently, the incidence of peripheral neuropathy is increased in patients >65 years of age and those who have previously received cisplatin treatment (not this case).
  • Please keep an eye out for signs of exacerbated adverse reactions as always.

700035817

230320

{not completed}

He was admitted for hemoptysis with blood clot from oral and nasal cavity for more than a week. History of NPC and CT imaging revealed possible tumor recurrence in Jan 2022.

[exam findings]

  • 2023-03-16 CT - neck
    • Chief Complaints: Tongue swealling and left face redness
    • CT scans of the neck from the level of hard palate to the level of infraclavicular region using a 64-sliced multi-detector row volumetric CT after intravenous injection of 100 c.c. iodinated contrast agent.
    • Coronal reformation was performed. The slice thickness is 5 mm.
    • Findings:
      • Known a case of nasopharyngeal cancer S/P treatment. Large lobulated heterogeneous enhancing lesion over nasopharyngeal space with involvement of left parapharyngeal space and nasal cavity, favor malignancy.
      • Presence of thick fluid accumulation and thickened mucoperiosteum in the paranasal sinuses, bilateral.
      • Large amount of loculated fluid collection over oropharyngeal & hypopharyngeal space with involvement of right carotid space, favor abscess formation.
      • S/P tracheostomy.
      • Post graft stent (Viabahn, 8x50mm x2) placement at right ICA-CCA.
  • 2023-03-16 CXR
    • S/P tracheostomy in place.
    • S/P Port-A infusion catheter insertion.
    • Ground glass opacity in bilateral lower lungs.
  • 2023-03-16, 2022-12-28, -12-10 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Abnormal ECG
  • 2023-01-05 CXR
    • S/p tracheal tube placement with its tip in place.
    • Tortous aorta with calcification is noted.
    • Senile fibrotic change is noted at lung fields.
  • 2022-12-22 CT - abdomen
    • History and indication: Respiratory failure
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P gastrostomy. Mild small bowel ileus.
      • Bil. pleural effusion with adjacent lung consolidation. Some nodules in bil. lungs.
      • Right adrenal nodule (9mm). Hyperplasia of left adrenal gland.
      • Right renal cysts (up to 8mm).
      • Normal appearance of liver, spleen, pancreas.
      • Wall thickening of gallbladder with stone (6mm).
      • Patency of portal vein.
      • Fracture of left femoral neck.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • S/P Port-A infusion catheter insertion. S/P tracheostomy in place. S/P foley catheter indwelling.
    • IMP:
      • S/P gastrostomy. Mild small bowel ileus.
      • Bil. pleural effusion with adjacent lung consolidation. Some nodules in bil. lungs.
      • Wall thickening of gallbladder with stone (6mm).
      • Fracture of left femoral neck.
  • 2022-12-22 Patho - colon biopsy
    • Colorectum, hepatic flexure, s/p biopsy(A) — Granulation tissue
    • Colorectum, hepatic flexure, s/p biopsy(B) — Hyperplastic polyp
  • 2022-12-16 CT - abdomen
    • The rectum and sigmoid colon show distension and hard feces retention. please correlate with clinical condition.
    • Chronic cholecystitis is highly suspected.
      • The differential diagnosis include gallbladder cancer.
      • Please correlate with sonography.
    • There are few soft tissue nodules in LLL of the lung.
      • Please correlate with chest CT.
    • Hyperplasia of bilateral adrenal gland are noted.
  • 2022-11-05 ECG
    • Sinus tachycardia
    • Left anterior fascicular block
    • Abnormal ECG
  • 2022-08-23 CT - neck
    • Presence of thick fluid accumulation and thickened mucoperiosteum in the paranasal sinuses, bilateral.
    • Presence of soft tissue swelling over the region of right face and neck with diffuse fat stranding.
    • Post graft stent (Viabahn, 8x50mm x2) placement at right ICA-CCA.
    • Total occlusion of right ICA and upper-middle part of CCA.
    • Presence of soft tissue swelling over right neck, carotid space, and skull base, recurrent tumor with infection?
    • Old right fronto-temporal insult with brain tissue loss due to ICH.
    • S/P tracheostomy in position.
    • S/P Port-A infusion catheter insertion at right jugular/subclavian region.
    • Suggest clinical correlation and previous films comparison.
  • 2022-05-06 CT - neck
    • Indication: NPC cT4bNx, s/p CCRT + adjuvant PF
    • With and Without contrast Neck CT showed
      • s/p tracheostomy
      • s/p graft stent at the right CCA and right ICA with total occlusion.
      • soft tissue swelling over right neck, carotid space, and skull base, suspected recurrent tumor with infection?
      • mucosal thickening in the bilateral frontal, bilateral ethmoidal, sphenoidal and bilateral maxillary sinuses. Wall thickening in the walls of the bialteral paranasal sinuses was noted.
      • old insult in the right parietal lobe
    • IMP: soft tissue swelling over right neck, carotid space, and skull base, suspected recurrent tumor with infection?
  • 2022-05-05 CXR
    • S/P tracheostomy
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2022-04-16 Chest PA/AP view
    • S/P tracheostomy.
    • S/P port-A insertion via right subclavian vein.
    • Right lower lung infiltrates.
    • No cardiomegaly.
    • Intimal calcification of thoracic aorta.
  • 2022-04-16 KUB
    • Calcifications in the pelvic cavity, could be due to phleboliths.
    • Non-specific bowel gas pattern.
    • Mild lumbar spondylosis.
    • Old fractures at left proximal femur.
  • 2022-01-13 Patho - polyps, inflammatory nasal/sinonasal
    • Labeled as “Granulation tissue at nasopharynx”, biopsy — benign squamous mucosa lined tissue with granulation tissue.
    • Labeled as “Granulation tissue at soft palate, poterior pharyngeal wall”, biopsy — squamous cell carcinoma, granulation tissue and necrotic tissue.
      • IHC stain: p16 (-).
    • Labeled as “Granulation tissue around stoma”, biopsy — necrotic tissue.
  • 2022-01-11 CT - CTA, brain (head, neck)
    • Post graft stent (Viabahn, 8x50mm x2) placement at right ICA-CCA.
    • Total occlusion of right ICA and upper-middle part of CCA.
    • But seems with well blood collateral circulation to right ICA, MCA from left AcomA.
    • Presence of soft tissue swelling over right neck, carotid space, and skull base, recurrent tumor with infection?
    • Old right fronto-temporal insult with brain tissue loss due to ICH.
    • S/P tracheostomy in position.
    • S/P Port-A infusion catheter insertion at right jugular/subclavian region.
  • 2021-04-26 KUB
    • Osteopenia of the bony structure is noted.
    • The psoas shadow is clear.
    • Degenerative change of the bony structure with marginal osteophyte formation is identified.
    • Stool impaction at the abdominal cavity is noted.
    • Phlebolith at pelvic cavity is also found.
    • Suggest clinical correlation
  • 2021-04-18 Sinuses
    • Water’s view of the paranasal sinuses showed
      • obliteration of the bilateral paranasal sinuses
      • no evidence of destructive bone lesions
  • 2021-04-18 Neck soft tissue
    • s/p tracheostomy
    • increased soft tissue thickness in the prevertebral soft tissue
    • s/p stenting at the right neck
  • 2021-04-18 CT - neck
    • s/p tracheostomy.
    • s/p stenting at the right ICA and right CCA with air in the luminal region
    • Diffuse soft tissue densities in nasalpharynx, oropharynx; and bilateral retropharyngeal, right carotid and right masticator spaces with diffuse subcutaneous fatty infiltrates and abscess formation in the right masticator space. Recurrent tumor with abscess, or stent extravasation? Suggest clinical correlation.
    • bilateral CPS.
  • 2020-12-06 CT - abdomen, pelvis
    • PE abdomen: Muscle guarding
    • Without contrast Abdomen CT showed
      • unremarkable change in the solid organs, such as liver, pancreas, spleen, and both kidneys, except multiple GB stones, up to 22mm in the largest one.
      • gastrostomy
    • IMP: GB stones.
  • 2020-12-04 Bronchoscopy
    • Bronchitis
    • Tracheomalasia
    • Profuse purulent bronchorrhea s/p bronchial toilet
    • suspected nasopharyngeal tumor with nearly total obstruction
  • 2020-11-17 Nasopharyngoscopy
    • NPC s/p treatment
    • Trachea granulation
  • 2020-10-28 Whole body PET scan
    • In comparison with the previous study on 2018/12/19, glucose hypermetabolism in the right nasopharyngeal wall disappears, indicating NPC with good response to previous therapy. However, there is a new lesion of glucose hypermetabolism in the left vocal cord in this study, suggesting tumor recurrence with hypopharynx involvement.
    • Glucose hypermetabolism in the left level II cervical lymphh nodes, probably reactive change in response to locoregional inflammation.
    • Glucose hypermetabolism in the right pleura and right axillary lymph nodes, the nature is to be determined (inflammation/ infection process, NPC with distant metastasis, or others ?), suggesting follow-up.
    • Glucose hypermetabolism in the right neck, suggesting s/p tracheostomy with inflammation/infection process.
    • Glucose hypermetabolism in hepatic flexure of colon, bilateral shoulders, and left hip, probably benign in nature.
    • Nasopharyngeal cancer s/p treatment with tumor recurrence, rcT4NxM0-1, stage IVA at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2020-10-18 CT - neck
    • S/P tracheostomy.
    • S/P vascular stenting in right CCA with intraluminal and perivascualr air densities, suspected infection/inflammation.
    • R/O tumor recurrence in nasalpharynx, oropharynx and carotid and masticator spaces (mainly in right side), with cellulitis? Suggest clinical correlation.
    • Multiple enlarged lymph nodes in neck, mediastinum and right axillary regions.
  • 2020-09-09 CT - CTA, brain (head, neck)
    • Total occlusion from the right proximal CCA to the cavernous ICA with air in the stent graft. suspected inflammatory process.
  • 2020-05-27 CT - abdomen, pelvis
    • findings
      • There is an ill-defined mild poor enhancing lesion measuring 3.4 x 1.4 cm in S4 of the liver (Srs:3, Img:23) that may be abscess? please correlate with clinical condition and sonography.
      • There are several gallstones, the size < 1.8 cm), but no evidence of wall thickening, distension or surrounding fatty stranding.
      • Mild swelling of the pancreatic head is suspected. Please correlate with amylase and lipase level.
      • Left adrenal hyperplasia shows stationary.
      • Hyperdense hard Fecal material in the S-colon and rectum.
      • Status post feeding gastrostomy.
      • There is no focal abnormality in the biliary system, spleen & both kidney.
      • There is no ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • There is no evidence of intrinsic or extrinsic bladder mass.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no focal lesion in the mesentery and omentum.
    • IMP:
      • Liver abscess is suspected. please correlate with clinical condition and sonography.
  • 2020-01-06 Carotid angiography bilat
    • IMP: Right distal CCA blow-out with a large pseudoaneurysm and massive active bleeding.
  • 2020-01-05 Embolization (TAE) - neuro
    • Indication: Massive bleeding from the oral cavity
    • Angiography of bilateral ECA shows oozing of the mucosa at right side supplied by branches of rigth ECA and active bleeding is found at left side by left ECA.
    • Embolization was done with fine gelatine sponge from bilateral ECAs till decreased blood flow.
  • 2020-01-05 Carotid angiography bilat
    • Right distal CCA blow-out with one pseudo-aneurysm formation. Suggest covered-stent insertion.
  • 2020-01-05 CT - lung/pleura (chest and upper abdomen) (with and without contrast)
    • Ind: hemoptysis, suspected lung hemorrhage, suspected NPC with tumor bleeding
    • Imp:
      • probably oozing or bleeding at hypopharyngeal region.
      • single nodule at left apical lung. suggest follow up.
      • s/p gastrostomy.
      • s/p tracheal tube placement with its tip in place.
    • 2019-11-25 Abdominal Ultrasonography
      • liver parenchyma disease/ incomplete exam of liver
      • gallstones, GB wall thickening
      • pancreas masked
      • spleen not seen
    • 2019-11-25 Phleborheograph, PRG
      • Venous thrombosis at right internal jugular vein; patent right external jugular vein; patent right subclavian vein.
    • 2019-11-13 CT - sinuses for navigator
      • Increased soft tissue in the bilateral posterior nostrils and the nasopharynx. Nature?
      • CPS
    • 2019-11-05 Nasopharyngolaryngoscopy
      • finding: bi sinus s/p FESS, right choana total synechiae (fibrosis between septum, right inferior T and nasal floor), left NP whitish mass, biopsy done
      • diagnosis
        • NPC s/p treatement
        • Nasopharyngeal lesion, suspect post-RT necrosis, suspected tumor recurrence
    • 2019-10-08 Nasopharyngolaryngoscopy
      • finding: right choana synechiae, left NP mass with whitish exudate coating
      • diagnosis
        • Nasopharyngeal lesion, suspect post-RT necrosis, suspected tumor recurrence
        • suggest debridement/excision of nasopharyngeal lesion + choana-plasy +- FESS for CPS
    • 2019-09-20 Repetitive stimulation test
      • Blink Reflex Studies
      • The repetitive stimulation study at frequency of 2Hz showed no typical decremental responses in the examined muscles.
      • Sympathetic Skin Response (SSR)
    • 2019-09-06 MRA - brain
      • General brain atrophy.
      • Hydrocephalus.
      • Bilateral chronic paranasal sinusitis.
      • Bilateral mastoiditis.
    • 2019-08-30 CT - brain
      • Brain atrophy.
      • Paranasal sinusitis, nasal polyps and mastoiditis.
      • Nasopharyngeal and oropharyngeal lesion. DDX: prolapse of nasal polyps, nasopharyngeal tumor. Suggest ENT check up.
    • 2019-07-26 MRI - nasopharynx
      • post-CCRT change with dissue swelling in the bilateral nasopharynx, oropharynx, amd hypopharyn; and anterior neck. Please f/u 3 months later.
    • 2019-05-24 CT - abdomen
      • Senile fibrotic change is noted at lung fields. Some bronchovascular bundle infiltration at right lower lobe is found.
      • Gallstones with borderline wall thickening but the GB is not distended.
    • 2019-05-15 Myocardial perfusion SPECT with persantin
      • Probably attenuating artifact or mild myocardial ischemia at the inferoseptal wall of LV.
      • No post-stress dilatation of the left ventricle.
    • 2019-05-15 Carotid phonoangiograph, CPA
      • Sonographic diagnosis:
        • Mild to moderate atherosclerosis in Rt CCA.
        • Imcomplete study due to poor temporal windows for transcranial insonation.
        • Partial venous thrombus formation or venous stasis was noted in Rt IVJ with blood flow.
        • Adequate total VA flow volume (126 ml/min), indicating absence of Vertebrobasilar insufficiency.
      • Advise clinical correlation.
    • 2018-12-20 MRI - nasopharynx
      • Image staging(AJCC,8th edition): NPC, T1N1Mx, stage II.
    • 2018-12-19 Whole body PET scan
      • Glucose hypermetabolism in the right nasopharyngeal wall, compatible with the primary lesion of nasopharyngeal cancer.
      • Glucose hypermetabolism in the right level II and III cervical lymph nodes, suggesting cancer with regional lymph node involvement.
      • Mild glucose hypermetabolism in the left level IIa cervical lymphh nodes, reactive change in response to locoregional inflammation may show such a picture.
      • Glucose hypermetabolism in both lobes of the thyroid gland, inflammatory change is more likely. Please correlate with other work-up studies if further evaluation is warranted.
      • Nasopharyngeal cancer, cT1N1M0, stage II (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
    • 2018-12-10 Surgical pathology level IV
      • Nasopharynx, left, biopsy — Non-keratinizing squamous cell carcinoma
      • The sections show non-keratinizing squamous cell carcinoma, undifferentiated subtype, composed of sheets and scattered spindle-shaped neoplastic cells in lymphoid stroma.
      • IHC: CK(+), p63(+).

[consultation]

  • 2023-03-17 Ear Nose Throat

    • Q
      • This is a 68 years old man had history of (1) NPC cT4bNx, s/p CCRT + adjuvant PF, with long term ventilator status under hospice care, Diabetes mellitus, Hypertension, Reflux esophagitis and duodenal ulcer, Chronic obstructive pulmonary disease, Hypothyroidism, Right distal common carotid artery pseudoaneurysm status post transcatheter arterial chemoembolization and stent insertion, Old intracerebral hemorrhage, Old myocardial infarction, Right internal jugular vein thrombosis, Enlarged prostate.
      • This time he was admitted due to Tongue swealling and left face redness for 2 days.
      • CT done at ER reported:
        • Known a case of nasopharyngeal cancer S/P treatment. Large lobulated heterogeneous enhancing lesion over nasopharyngeal space with involvement of left parapharyngeal space and nasal cavity, favor malignancy.
        • Presence of thick fluid accumulation and thickened mucoperiosteum in the paranasal sinuses, bilateral.
        • Large amount of loculated fluid collection over oropharyngeal & hypopharyngeal space with involvement of right carotid space, favor abscess formation.
      • Lab with leukocytosis and bandemia, admission under the impression of progression of NPC with deep neck infection with abscess formation, cannot rule out tumor necrosis.
      • Emperic treatment with brosym was prescribed. The patient’s family request for further surgical treatment for possible symptom relief.
      • We need your expertise for further evaluation of possibilites of surgical drainge of abscess, thank you!
    • A
      • 68 y/o man
        • NPC s/p treatment
        • Oropharyngeal cancer noted since 2022-01 (biopsy of oropharynx on 2022-01-12: squamous cell carcinoma)
        • No further treatment for oropharyngeal cancer
        • Neck CT on 2022-03-16 revealed loculated fluid collection over oropharyngeal & hypopharyngeal space with involvement of right carotid space, favor abscess formation.
      • Suggest antibiotics teatment
        • I & D not recommended because the CT finding was related to his tumor necrosis with 2nd infection (I&D: Incision and Drainage)
        • I will discuss with his family
  • 2023-03-17 Infectious Disease

    • Q
      • Emperic treatment with brosym was prescribed.
    • A
      • This is a case of oropharyngeal & hypopharyngeal abscess with sepsis.
      • Hx NPC s/p op, C/T, ventilator dependent, DM, HCVD.
      • Antibiotcs with meropenem 1g iv q8h is suggested.
      • Please consider debridement.
      • Collect B/C and pus for culture.
      • Please adjust antibiotic according to culture results and clinical conditions.
    • 2021-12-08 ENT
      • Minimal oozing from tracheal wound
      • Portable fiber through tracheal tube: patent airway, no active bleeding site
      • Local treatment done
      • Suggestion:
        • Curam + Paran for Rt. facial cellulitis
        • ENT OPD f/u if needed
    • 2021-05-06 ENT
      • we had changed the trachea already this night but I could not help him to clean the cerumen because the patuient could noy obey our order and he is too heavy that the nurse was hard to move his head
      • we suggested back yo our OPD for crumen removed
    • 2021-05-03 Family Medicine
      • The patient is a case of NPC. This time, he was admitted due to deep neck infection with abscess formation. Due to poor prognosis, we were consulted for further evaluation.
      • When I visited, the patien lied on bed. I asked the nurse about the family’s decision for hospice care. The nurse said that the patient’s wife still need to take the message to other family members. And they didn’t make decision. As a result, I arranged hospice combine care for the patient.
      • Assessment
        • Indication for hospice combine care : NPC with severe infection
        • ECOG 4
    • 2021-04-19 Radiation Oncology
      • Q
        • This 67 year old man is a case of NPC, old CVA, tracheostomy with vewntilation. He suffer form deep neck infection with abscess formation. We need your expertise for pigtail drainage!
      • A
        • According to the clinical condition and imaging findings, drainage is indicated.
    • 2021-04-18 ENT
      • Impression: Deep neck infection with abscess formation, nasopharyngeal carcinoma.
      • Plan:
        • Surgical intervention at the moment is not appropriate owing to high mortality and morbidity rate.
        • Please arrange admission to INFECTION IPD for broad-spectrum antibiotic treatment.
      • Already told the patient to consider hospice care.
    • 2021-03-30 ENT
      • Local finding via portable fiberoscopy:
        • Bil. nasal mucopus and cannot see N-P well, favor post-RT CPS
        • Rt. auricle swelling and EAC cerumen impaction
        • Diffused redness and swelling of Rt. facial, neck and shoulder skin
      • Imp
        • Favor diffused soft tissue infection, suspected post-R/T caused poor circulation
      • Suggestion
        • Keep current Abx
        • If no improvement or even progression, may consider CT for r/o abscess formation
    • 2020-12-24 Rehabilitation
      • Assessment
        • Acute respiratory failure with ventilator support
        • NPC s/p CCRT with airway stenosis s/p tracheostomy
        • Right distal CCA blow-out with a large pseudoaneurysm and massive active bleeding s/p TAE with stent
        • COPD with AE
        • DM
        • HTN
        • old CVA with bedridden status
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation programs
      • Goal: recondition, improve endurance and muscle strength, remove endo tube
    • 2020-10-26 Radiation Oncology
      • Assessment: Non-keratinizing squamous cell carcinoma of the nasopharynx, stage cT1N1M0 (stage II), s/p CCRT.
      • Plan: There is no tissue proven of the suspicious area at the present. ENT further evaluation was suggested.
    • 2020-03-18 Mental Health
      • Psychiatric impression
        • Depressive DISORDER WITH SUICIDE ATTEMPT
        • ADJUSTMENT DISORDER WITH DEPRESSED MOOD,
      • Psychiatric history
        • This 66-year-old male patient was brought to this ER due to self-remove trachia this morning. According to his wife, notable depressed mood and insomnia with initial type since diagnosed with NPC. However, his depression was progressed in recent 3 months since he suffered form hemiparesis due to hemoregic stroke. He also note cooperative for rehabilitation and other treatment. Few and nearly no interpersonal interaction. Previosly, he had self-remove trachia during hospitalization.
        • GIVEN-UP COMPLEX, HELPLESSNESS AND HOPELESSNESS
      • Medical history:
        • Nasopharyngeal, left, non-keratinizing squamous cell carcinoma, cT1N1M0, stage II, with right neck LNs, s/p CCRT and Chemotherapy. Intake form grastostomy
        • Diabetes Mellitus type II.
        • Chronic obstructive pulmonary disease.
        • Right distal common carotid artery pseudoaneurysm status transcatheter arterial chemoembolization and stent on 2020/01/06.
      • Suggestion:
        • prevent suicide, well inform the risk and prevention to his family
        • emotional support
        • correct his medical problem as your expertise
        • may give Mirtapine 1# hs for his depression
        • arrange psychiatric OPD follow up
    • 2020-01-12 General and Gastroenterological Surgery
      • Inform the family members (his wife) of the CT results of the brain, and inform that if the anticoagulant continues to be used, it may aggravate the cerebral hemorrhage, but if the anticoagulant is not used, the stent placed in the aneurysm may be blocked.
    • 2020-01-07 Neurology
      • impression: left hemiplegia, suspect R hemisphere subcortical infarction
      • suggestion:
        • agree with current dual antiplatelet agent therapy if no contraindication such as active bleeding
        • arrange brain MRA (without contrast) for stroke survey (consider contrast enhancement for brain metastasis survey)
    • 2020-01-07 Family Medicine
      • When I visited patient, he lied on the bed and his consicousness was drowsy. Interminttent oozing from oral and trochea were found. Tachycardia was found (HR: 120-130/minute). Breathing sound showed no rhonchi or no wheezing. CT on 20200105 showed tumor local invasion and angiography on 20200106 showed no pneudoaneurym formation. Stent for carotid bleeding was done at that time. Due to NPC with local invasion and persisted bleeding, we will arrange hospice combine care for patient first. If his family prefer to receive palliative care, we will discuss with family about further management or PCU admission issue. If family still want to receive aggressive treatment/management, we will keep current combine care first.
    • 2020-01-07 Infectious Disease
      • Bleeding is the major problem now.
      • Despite there is leukocytosis, no definite infection is found at the present time.
      • Because of repeated embolization, temporary coverage of staphylococci, including MRSA/MRSE possibility, is acceptable.
      • Empirical anti-fungal therapy seems not necessary for him.
      • Please repeat CxR film to see if there is newly-developed pneumonia or not.
    • 2020-01-07 Radiation Oncology
      • We have arranged emergent angiography for this patient 20200106 19:00, which revealed right distal CCA blowout, with active bleeding from pseodoaneurysm. Two stents were placed crossing distal CCA and proximal ICA. No more active bleeding is noted after stenting.
      • Medication: Plavix and Bockey 1# QD at least 3 month, after 3 month Bockey 1# QD life long.
    • 2020-01-07 ENT
      • Local finding: Oozing from oral cavity but cannot see the bleeding origin
      • No epistaxis nor bleeding from tracheostomy
      • s/p 10 pieces Bosmin gauze compression, but may still need TAE again
    • 2020-01-04 ENT
      • Scope: should suspect bleeding from tracheal or lung
        • Yellowish mass over bil. nasopharynx, suspected pus (CPS) or tumor
        • Cannot passed the scope into hypopharynx.
      • However, the patient was using tracheal tube “without” side hole -> less likely from nasal or oral cavity
      • Suggestion: consult chest men for lung CT or bronchoscopy
  • surgical operation

    • 2022-01-12
      • Surgery
        • debride the granulation tissue
        • change gastrostomy tube 20fr for him
      • Finding
        • grandulation tissue around the gastrostomy
    • 2022-01-12
      • Surgery
        • Stomaplasty    
        • Biopsy of oropharynx and nasopharynx mucosal lesion       
      • Finding
        • Granulation around the stoma except inferior part    
        • Yellowish semisolid necrotic substance at soft palate, posterior pharyngeal wall, and bilateral nasopharynx; Diffuse mucosal edema and touch bleeding was noted at above areas  
    • 2020-11-11 excision - granuloma around gastrostomy, easy bleeding(+), pain(+)
    • 2020-04-29 Stomaplasty
      • Surgery
        • Stomaplasty + Nasopharyngeal lesion biopsy
      • Finding
        • Stoma stenosis with granulation formation.
        • Whitish exudate like lesion at bilateral nasopharynx.
    • 2021-04-28
      • Surgery
        • Incision and drainage of right masticator space
      • Finding
        • Much bloody discharge and few pus over right masticator space
    • 2020-04-02
      • Surgery
        • laparoscopic gastrostomy
      • Finding
        • NPC
        • difficulty in NG tube insertion
    • 2020-01-06 Embolization (TAE) - neuro
      • Indication: Right distal CCA blow-out with a large pseudoaneurysm and massive active bleeding.
      • TAE was done with two 8x50 mm stent graft (Viabahn Endoprothesis, overlapped on distal CCA), no more contrast leak after this procedure.
      • Imp: Post stent grafting of the large right CCA pseudoaneurysm.
      • Medication: Plavix and Bockey 1# QD at least 3 month, after 3 month Bockey 1# QD life long.
    • 2019-11-20 Nasopharyngeal necrosis and right choana atresia
    • 2019-08-27 Tracheostomy for respiratory failure
      • neck shortness and stiffness, tracheostomy done with Shily #6
    • 2019-06-10 Jejunostomy - Nasopharyngeal cancer post op, for feeding jejunostomy creation
    • 2017-12-26 R’t soft palate tumor
      • 1.3x2mm granular lesion at right soft palate

==========

2023-03-17

[drug identification]

The medication you are requesting drug identification for is Eltroxin, which contains levothyroxine at a dose of 0.05mg.

This medication is used to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone.

The medication will be sent back to the ward by an in-hospital porter.

2022-05-05

  • Lab data on 2022-05-04 showed PT 10.6 sec, INR 1.02, APTT 40.4 sec, Fibrinogen 474.5 mg/dL, D-dimer 982 ng/mL(FEU).
  • Aspirin, warfarin, vitamin K antagonists, DOACs records found in NHI PharmaCloud.
  • Tranexamic acid 500mg IVD Q8H has been prescribed since 2022-05-05.
  • Hemoptysis no longer appears in the problem list. No issue with current medication.

701252793

230320

[diagnosis] - 2023-03-17 admission note

  • Non-Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck
  • Neoplasm of uncertain behavior of brain, unspecified
  • Other cerebrovascular disease
  • Dizziness and giddiness
  • Other localized visual field defect, unspecified eye
  • Diffuse large B-cell lymphoma, extranodal and solid organ sites
  • Personal history of other infectious and parasitic diseases
  • Chronic obstructive pulmonary disease, unspecified
  • Gout, unspecified

[exam findings]

  • 2023-02-07 MRI - brain
    • No brain infarct was seen. Marked shrinkage of left thalamus and left occipital lesion. Marked regression of peri-tumoral edema.
  • 2022-10-12 MRI - brain
    • Clinical information: Brain, left periventricle lesion, stereotactic biopsy — Diffuse large B cell lymphoma. Primary NHL (Diffuse large B cell lymphoma) of brain
    • Findings
      • Known a case of primary brain lymphoma. As compared with prior MRI (2022/06/20), marked shrinkage of left thalamus lesion (from 29mm to 12mm). But marked progression of lateral lesions (abutting left occipital horn) (from 15mm to 31mm).
      • Prominent peri-tumoral edema over left thalams and temporal lobe.
  • 2022-07-13 Body Fluid Cytology - CSF
    • Negative
    • Smears show some small lymphocytes, plasma cells, and monocytes.
  • 2022-07-12 Whole body PET scan
    • A glucose hypermetabolic lesion in the left deep temporal lobe of the cerebrum, compatible with lymphoma.
    • Mild glucose hypermetabolism in a focal area in the left anterior upper chest wall. Inflammation may show this picture.
    • Increased FDG accumulaton in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
  • 2022-07-11 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
    • Section shows piece(s) of bone marrow with 60 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • 2022-07-09 CXR
    • Atherosclerotic change of aortic arch
  • 2022-07-04 CT - lung/mediastinum/pleura
    • No tumor or LAPs in the neck, chest, and upper abdomen.
  • 2022-07-04 CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2022-06-23 Patho - brain biopsy
    • Brain, left periventricle lesion, stereotactic biopsy — Diffuse large B cell lymphoma
    • Immunohistochemical stain profiles:
      • CD20(diffuse+), CD3 (scant + at T- cells), Bcl-2(+), Bcl-6(+), CD56(-), GFAP(-), Ki-67 index: >90%, cyclin D1(-).
      • MUM-1(+), C-MYC(+)
  • 2022-06-23 Frozen Section
    • Brain, periventricular lesion, frozen section — hypercellular round blue cell-type neoplasm
  • 2022-06-21 CT - brain for navigator
    • Findings
      • An irregular-shaped tumor mass with dense enhancement involving the left deep temporal lobe and adjacent posterior basal ganglion, and with significant perifocal white matter edema and causing mass efect on lateral ventricles and resulting mild midline shift to Rt.
      • Mild dilated right lateral ventricle.
    • Impression:
      • intra-axial tumor, d/d lymphoma or high grade glioma.
  • 2022-06-20 MRA - brain
    • Left temporal lobe-basal ganglion tumor with mass effect.
    • D/D: lymphoma, metastases, GBM. Infectious process is unlikely.
  • 2021-04-29 SONO - kidney
    • Right renal stone 0.44 cm
  • 2020-09-21 Bronchodilator Test
    • diagnosis: COPD
    • conclusion: normal spirometry

[consultation]

  • 2022-10-20 Radiation Oncology
    • Q
      • The 56 y/o man has primary brain diffuse large B cell lymphoma, CD20 (diffuse+), CD3 (scant + at T- cells), Bcl-2(+), Bcl-6(+), CD56(-), GFAP(-), Ki-67 index: >90%, cyclin D1(-). Lugano stage 1E. IELSG score 2 (CSF protein elevated and deep lesions).
      • Due to brain lesion in progress, so we need your help for RT assessment. Thanks!
    • A
      • The patient’s history was reviewed and patient was examined.
      • S: For radiotherapy due to CNS lymphomas s/p chemotherapy.
        • PI: The patient has primary brain diffuse large B cell lymphoma, Lugano stage 1E. IELSG score 2 (CSF protein elevated and deep lesions) s/p chemotherapy (2022-07-14 ~ 2022-10-21). Due to brain tumor progression, he was referred for radiotherapy.
          • Family history: (-)
          • Cancer site specific factors: Alcohol (quit); Smoking (+); Betel nut (-).
          • Personal Hx: DM(-); HTN(-)
          • Previous RT Hx: (-)
      • O: ECOG: 1
        • PE: meck and bil SCF: neg; no motor dysfunction.
        • CXR (2022-06-20): Clean lung fields based on plain image. Normal shape and size of heart. No abnormal mediastinal interfaces, stripes, and lines. Normal appearance of both hila. Costophrenic angles are preserved. Unremarkable of visible trachea
        • MRI of brain (2022-06-20): Left temporal lobe - basal ganglion tumor with mass effect. D/D: lymphoma, metastases, GBM. Infectious process is unlikely.
        • Operation (2022-06-23): Left periventricular tumor for stereotactic biopsy. [Finding]: 1. An irregular-shaped tumor mass with dense enhancement involving the left deep temporal lobe and adjacent posterior basal ganglion, and with significant perifocal white matter edema and causing mass efect on lateral ventricles and resulting mild midline shift to Rt; intra-axial tumor, d/d lymphoma or high grade glioma; Infectious process.
        • Pathology (S2022-10048, 2022-06-29): Brain, left periventricle lesion, stereotactic biopsy — Diffuse large B cell lymphoma
        • CT scan of lung (2022-7-4): no tumor or LAPs in the neck, chest, and upper abdomen.
        • Pathology (S2022-11023, 2022-07-12): Bone marrow, iliac, biopsy — Negative for malignancy.
        • PET (2022-07-12): A glucose hypermetabolic lesion in the left deep temporal lobe of the cerebrum, compatible with lymphoma.
        • CSF (2022-07-13): negative
        • MRI of brain (2022-10-12): 1. Known a case of primary brain lymphoma. As compared with prior MRI (2022/06/20), Left temporal lobe-basal ganglion (abutting left occipital horn) (from 15mm to 31mm). 2. Prominent peri-tumoral edema over left thalams and temporal lobe.
      • A: Diffuse large B cell lymphoma of the left temporal lobe-basal ganglion area, Lugano stage 1E, s/p chemotherapy, with gross residual tumor.
      • P: Radiotherapy is indicated for this patient with the following indicators: gross residual tumor
        • Goal: curative
        • Treatment target and volume: brain
        • Technique: 2D and VMAT/IGRT
        • Preliminary planning dose: 3060cGy/17 fractions of the whole brain, and 4500cGy/25 frcations of the CNS lymphoma area.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2022-10-26.
  • 2022-07-20 Nephrology
    • Q
      • The 55 y/o man has primary CNS lymphoma post HD-MTX and Mabtherapy treatment.
      • Due to AKI with elevated P and Mg, but no oliguria or SOB, so we need your help for management. Thanks!
    • A
      • Lab:
        • BUN 96, Cr 1.09 -> 9.71, Na 133, K 3.5, Mg 3.2, P 7.6, Ca 2.3
      • Impression:
        • AKI stage 3 suspect methotrexate induced
        • primary CNS lymphoma post HD-MXT and Mabthera
      • Suggestion
        • check urinalysis
        • check vein gas
        • IV hydration with urinary alkalinzation; could also prescribe furosemide
        • Follow up VBG and urinalysis in the following day
        • check I/O and body weight qd
        • avoid nephrotoxic agents
        • indication of dialysis has been explained to the patient and family.
      • We will follow up the case. Thank you very much for your consultation.
  • 2022-07-11 Ophthalmology
    • Q
      • The 55 y/o man has primary CNS lymphoma with right eye blurred vision, so we need your help for management.
    • A
      • O
        • bv od > os, no floaters ou
        • oph denied
        • BCVA od 0.2(0.4x-1.25/-1.50x175) os 0.2(0.2x-0.75/-2.50x180)
        • PT 20/20
        • k clear ou
        • ac d/cl ou
        • lens clear ou
        • conj np ou
        • f’d c/ d 40% ou, media clear no vitritis ou
      • A
        • no ocular involvement ou currently
      • P
      • suggest control underlying disease+inform the symptoms/ signs and opd f/u afterward
  • 2022-06-20 Neurosurgery
    • Q
      • Stroke symptoms (sudden slurred speech/unilateral limb paresthesia/sudden visual impairment) > symptom onset more than 4.5 hours or relieved, right limb and visual field incoordination for two weeks
    • A
      • A case of 55 y/o male; progressive headache (night pain)/blurred vision/gait disturbance for 2 weeks;
      • Drug hx: nil
      • A brain MRI/MRA showed A well-defined irregular-shaped mass with T1-hypointensity, T2-hyperintensity, diffusion restriction and vivid enhancement involving left deep temporal lobe and basal ganglion, associating with perifocal white matter edema and causing mass efect on laterla ventricles and midline structures. Lymphoma is first considered. D/D: metastases, GBM.
      • P: admit for tumor survey; Stereotactic biopsy indicated; HIV?; Explained;

[surgical operation]

  • 2022-06-23
    • Surgery
      • Left periventricular tumor for stereotactic biopsy
    • Finding
      • An irregular-shaped tumor mass with dense enhancement involving the left deep temporal lobe and adjacent posterior basal ganglion, and with significant perifocal white matter edema and causing mass efect on lateral ventricles and resulting mild midline shift to Rt; intra-axial tumor, d/d lymphoma or high grade glioma; Infectious process
      • 3 strips/ 2 targets were apllied for tumor biopsy;
      • Frozen section: lymphocyte/ vascular structure/ inflammation cell?; Favor malignancy. Perminent report will be followed;
      • Culture also sent.
    • Remark: FROZEN SECTION INITIAL DIAGNOSIS: Brain, periventricular lesion, frozen section — hypercellular round blue cell-type neoplasm

[C/T history]

C1D1 (#1) HD-MTX (8000mg/m2) on 2022/7/14, C1D2 Leucovorin (100 mg/m2) q6h until serum methotrexate <0.05 mmol/L and C1D3 Mabthera (375mg/m2) = 750mg on 2022/7/16. Rolican + HS hydration for AKI correct after HD-MTX. Feburic 80mg/tab (Febuxostat) 1# qod for prevent elevated uric acid.

C1D14 (#2) HD-MTX (due to AKI history, so change to 4000mg/m2) on 22022/8/09, Leucovorin 100mg q6h, Mabthera on 2022/8/11. Colchine and dexamethaxone for gouty arthritis treatment on 2022/8/17.

C2D1 (#3) HD-MTX (4g/m2), Covorin, Mabthera on 2022/8/24-8/26. C2D14(#4) HD-MTX (4g/m2), Covorin, Mabthera on 2022/9/12-9/14. C3D1 (#5) HD-MTX (4g/m2), Covorin, Mabthera on 2022/9/26-9/28.

2022/10/13 brain MRI: 1. Known a case of primary brain lymphoma. As compared with prior MRI (2022/06/20), marked shrinkage of left thalamus lesion (from 29mm to 12mm). But marked progression of lateral lesions (abutting left occipital horn) (from 15mm to 31mm). 2. Prominent peri-tumoral edema over left thalams and temporal lobe. C3D15 (#6) HD-MTX (8g/m2), Covorin, Mabthera on 2022/10/21-23.

He received the radiotherapy on 2022/11/2 -2022/12/6 with 3060cGy/17 fractions ofthe whole brain, and 4500cGy/25 fractions of the CNS lymphoma area.

C4D1 (#7) HD-MTX (8g/m2), Covorin,Mabthera on 2023/1/6-8. Followed up MRI of brain was performed on 2023/2/8 revealed No brain infarct was seen. Marked shrinkage of left thalamus and left occipital lesion. Marked regression of peri-tumoral edema.

This time, he was admitted for C4D15 (#8) chemotherapy HD MTX/Covorin/Mabthera on 2023/3/17.

[chemoimmunotherapy]

  • 2023-03-17 - methotrexate 8000mg/m2 16000mg NS 800mL 6hr D1 + rituximab 375mg/m2 745mg NS 500mL 8hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg + NS 250mL] D2
  • 2023-01-06 - methotrexate 8000mg/m2 16000mg NS 800mL 6hr D1 + rituximab 375mg/m2 745mg NS 500mL 8hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg + NS 250mL] D2

    • 2022-10-21 - methotrexate 8000mg/m2 16000mg 6hr D1 + rituximab 375mg/m2 745mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3
    • 2022-09-26 - methotrexate 4000mg/m2 7950mg 6hr D1 + rituximab 375mg/m2 745mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3
    • 2022-09-12 - methotrexate 4000mg/m2 7980mg 6hr D1 + rituximab 375mg/m2 748mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3
    • 2022-08-24 - methotrexate 4000mg/m2 7880mg 6hr D1 + rituximab 375mg/m2 740mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3
    • 2022-08-09 - methotrexate 4000mg/m2 7900mg 6hr D1 + rituximab 375mg/m2 744mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3
    • 2022-07-14 - methotrexate 8000mg/m2 16000mg 6hr D1 + rituximab 375mg/m2 750mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3

[note]

methotrexate (https://www.uptodate.com/contents/methotrexate-drug-information 2022-07-20)

  • Dosing: Adult
    • Primary CNS lymphoma, newly diagnosed (off-label use):
      • IV:
        • 8 g/m2 over 4 hours (followed by leucovorin rescue) every 14 days until complete response or a maximum of 8 cycles; if complete response, follow with 2 consolidation cycles at the same dose every 14 days (with leucovorin rescue), followed by 11 maintenance cycles of 8 g/m2 every 28 days (with leucovorin rescue) (Batchelor 2003)
      • R-MPV regimen:
        • 3.5 g/m2 over 2 hours on day 2 every 2 weeks (in combination with rituximab, vincristine, procarbazine, and leucovorin [with intra-Ommaya methotrexate 12 mg between days 5 and 12 of each cycle if positive CSF cytology]) for 5 to 7 induction cycles followed by reduced-dose whole brain radiotherapy and then cytarabine (Morris 2013; Shah 2007) or autologous stem cell transplant (Omuro 2015)
      • R-MP regimen (patients >=65 years of age):
        • 3 g/m2 over 4 hours on days 2, 16, and 30 of a 42-day cycle (in combination with rituximab, procarbazine, and leucovorin) for 3 cycles (Fritsch 2017)
      • MT-R regimen:
        • 8 g/m2 once every 2 weeks (adjusted for creatinine clearance and in combination with leucovorin, temozolomide, and rituximab) for 7 doses, then followed by high-dose consolidation chemotherapy (Rubenstein 2013)
        • 3.5 g/m2 on weeks 1, 3, 5, 7, and 9 (in combination with leucovorin, temozolomide, and rituximab), followed by whole-brain radiotherapy and then post-radiation temozolomide (Glass 2016).
  • Dosing: Kidney Impairment: Adult
    • Regimen-specific dosage adjustments:
      • Primary CNS lymphoma, high dose methotrexate (usual methotrexate dose: 8 g/m2 over 4 hours with leucovorin rescue [Gerber 2007]); CrCl is measured or can be calculated using the Cockcroft-Gault equation (Gerber 2007): IV:
        • CrCl >=100 mL/minute: No methotrexate dosage adjustment necessary.
        • CrCl 50 to 99 mL/minute: Calculate dose using percentage reduction of CrCl below 100 mL/minute. Example: If CrCl is 80 mL/minute, adjust dose to 0.8 x 8 g/m2 = 6.4 g/m2.
        • CrCl <50 mL/minute: Avoid methotrexate use.

leucovorin (https://www.uptodate.com/contents/leucovorin-drug-information 2022-07-20)

  • Dosing: Adult
    • Methotrexate-rescue, high-dose methotrexate:
      • Initial: Oral, IM, IV: 15 mg (~10 mg/m2); start 24 hours after beginning methotrexate infusion; continue every 6 hours for 10 doses, until methotrexate level is <0.05 micromolar. Monitor hydration and electrolyte status, as well as urine alkalinization. Adjust dose per institutional protocol or as follows:
        • Normal methotrexate elimination (serum methotrexate level ~10 micromolar at 24 hours after administration, 1 micromolar at 48 hours, and <0.2 micromolar at 72 hours):
          • Oral, IM, IV: 15 mg every 6 hours for 60 hours (10 doses) beginning 24 hours after the start of methotrexate infusion.
        • Delayed late methotrexate elimination (serum methotrexate level remaining >0.2 micromolar at 72 hours and >0.05 micromolar at 96 hours after administration):
          • Continue leucovorin calcium 15 mg (oral, IM, or IV) every 6 hours until methotrexate level is <0.05 micromolar.
        • Delayed early methotrexate elimination and/or acute renal injury (serum methotrexate level >=50 micromolar at 24 hours, or >=5 micromolar at 48 hours, or a doubling of serum creatinine level at 24 hours after methotrexate administration):
          • IV: 150 mg every 3 hours until methotrexate level is <1 micromolar, then 15 mg every 3 hours until methotrexate level is <0.05 micromolar.
    • Methotrexate overdose, inadvertent:
      • Note: Begin as soon as possible after overdose.
      • Oral, IM, IV: 10 mg/m2 every 6 hours until the methotrexate level is <0.01 micromolar. If serum creatinine is increased >50% above baseline 24 hours after methotrexate administration, if 24 hour methotrexate level is >5 micromolar, or if 48 hour methotrexate level is >0.9 micromolar, increase leucovorin dose to 100 mg/m2 IV every 3 hours until the methotrexate level is <0.01 micromolar.
    • Methotrexate overexposure, high-dose methotrexate:
      • Leucovorin nomogram dosing for high-dose methotrexate overexposure (off-label dosing; generalized dosing derived from reference nomogram figures, refer to each reference [Bleyer 1978; Bleyer 1981; Widemann 2006] or institution-specific nomogram for details):
        • At 24 hours:
          • For methotrexate levels of >=100 micromolar at ~24 hours, leucovorin calcium is initially dosed at 1,000 mg/m2 IV every 6 hours.
          • For methotrexate levels of >=10 to <100 micromolar at 24 hours, leucovorin calcium is initially dosed at 100 mg/m2 IV every 3 or 6 hours.
          • For methotrexate levels of ~1 to 10 micromolar at 24 hours, leucovorin calcium is initially dosed at 10 mg/m2 IV or orally every 3 or 6 hours.
        • At 48 hours:
          • For methotrexate levels of >=100 micromolar at 48 hours, leucovorin calcium is dosed at 1,000 mg/m2 IV every 6 hours.
          • For methotrexate levels of >=10 to <100 micromolar at 48 hours, leucovorin calcium is dosed at 100 mg/m2 IV every 3 hours.
          • For methotrexate levels of ~1 to 10 micromolar at 48 hours, leucovorin calcium is dosed at 100 mg/m2 IV every 6 hours or 10 mg/m2 IV or orally to 100 mg/m2 IV every 3 hours.
        • At 72 hours:
          • For methotrexate levels of ≥10 micromolar at 72 hours, leucovorin calcium is dosed at 100 to 1,000 mg/m2 IV every 3 to 6 hours.
          • For methotrexate levels of ~1 to 10 micromolar at 72 hours, leucovorin calcium is dosed at 10 mg/m2 IV or orally to 100 mg/m2 IV every 3 hours.
          • For methotrexate levels of ~0.1 to 1 micromolar at 72 hours, leucovorin calcium is dosed at 10 mg/m2 IV or orally every 3 to 6 hours.
        • If serum creatinine is increased >50% above baseline, increase the standard leucovorin calcium dose to 100 mg/m2 IV every 3 hours, then adjust according to methotrexate levels above.
        • Follow methotrexate levels daily, leucovorin calcium may be discontinued when methotrexate level is <0.1 micromolar.
        • Some regimens use the following equation when calculating the leucovorin calcium dose (if the methotrexate plasma concentration is >5 micromolar) (Ramsey 2018):
          • Plasma methotrexate concentration (micromolar) x body weight (kg)
  • Warnings/Precautions
    • Disease-related concerns:
      • Anemias: Leucovorin is inappropriate treatment for pernicious anemia and other megaloblastic anemias secondary to a lack of vitamin B12; a hematologic remission may occur while neurologic manifestations progress.
      • Renal impairment: Leucovorin is excreted renally; the risk for toxicities may be increased in patients with renal impairment.
    • Concurrent drug therapy issues:
      • Fluorouracil: Leucovorin may increase the toxicity of 5-fluorouracil; deaths from severe enterocolitis, diarrhea, and dehydration have been reported (in elderly patients); granulocytopenia and fever have also been reported.
      • Sulfamethoxazole-trimethoprim: The combination of leucovorin and sulfamethoxazole-trimethoprim for the acute treatment of Pneumocystis jirovecii pneumonia in patients with HIV infection has been reported to cause increased rates of treatment failure.
    • Other warnings and precautions:
      • Folic acid antagonist overdose: When used for the treatment of accidental folic acid antagonist overdose, administer as soon as possible.
      • Methanol toxicity: Leucovorin is the reduced form of folic acid; leucovorin is rapidly converted to tetrahydrofolic acid derivatives, which are the storage forms of folate in the body. Because leucovorin does not require metabolic reduction, it is the preferred form of folate in the treatment of methanol toxicity. Administration during methanol toxicity is especially important in patients with chronic alcohol use disorder as these patients may have chronic folate deficiency. Clinicians should note that leucovorin is an adjunctive therapy and should never be used as the sole intervention in the management of methanol toxicity (AACT [Barceloux 2002]).
      • Methotrexate overdose: When used for the treatment of a methotrexate overdose, administer IV leucovorin as soon as possible. Monitoring of the serum methotrexate concentration is essential to determine the optimal dose/duration of leucovorin; however, do not wait for the results of a methotrexate level before initiating leucovorin. It is important to adjust the leucovorin dose once a methotrexate level is known. The dose may need to be increased or administration prolonged in situations in which methotrexate excretion may be delayed (eg, ascites, pleural effusion, renal insufficiency, inadequate hydration). Never administer leucovorin intrathecally.
      • Methotrexate rescue therapy: Methotrexate serum concentrations should be monitored to determine dose and duration of leucovorin therapy. Dose may need to be increased or administration prolonged in situations where methotrexate excretion may be delayed (eg, ascites, pleural effusion, renal insufficiency, inadequate hydration). Never administer leucovorin intrathecally.

==========

2023-03-20

  • The patient’s height is 175cm, weight is 80kg, and his lab results from 2023-03-20 showed serum Cre 1.38mg/dL, eGFR 56.65, and CrCl 63~68mL/min.
  • The recommended dosing for methotrexate in adult patients with CNS lymphoma whose CrCl is 50 to 99 mL/minute is to calculate the dose using the percentage reduction of CrCl below 100 mL/minute. For example, if CrCl is 65 mL/minute, the dose should be adjusted to 0.65 x 8 g/m2 = 5.2 g/m2.

2023-02-20

  • The patient’s serum creatinine levels have decreased to nearly the upper limit of normal.
    • 2023-02-02 Creatinine 1.30 mg/dL
    • 2023-01-20 Creatinine 1.54 mg/dL
    • 2023-01-16 Creatinine 1.41 mg/dL
    • 2023-01-13 Creatinine 1.95 mg/dL
    • 2023-01-10 Creatinine 2.09 mg/dL
    • 2023-01-09 Creatinine 2.02 mg/dL
    • 2023-01-08 Creatinine 1.99 mg/dL
    • 2023-01-07 Creatinine 1.36 mg/dL
    • 2023-01-06 Creatinine 1.01 mg/dL

2023-01-10

  • Methotrexate induced acute renal failure is typically nonoliguric and is reversible in almost all cases. Plasma creatinine levels usually peak within the first week and return toward baseline levels within 1 to 3 weeks. The patient’s renal function is decreasing at a much slower rate over time, which is a positive sign that creatinine almost reaches its peak level.

    • 2023-01-10 Creatinine 2.09 mg/dL
    • 2023-01-09 Creatinine 2.02 mg/dL
    • 2023-01-08 Creatinine 1.99 mg/dL
    • 2023-01-07 Creatinine 1.36 mg/dL
    • 2023-01-06 Creatinine 1.01 mg/dL
    • 2023-01-10 eGFR 35.09
    • 2023-01-09 eGFR 36.50
    • 2023-01-08 eGFR 37.13
    • 2023-01-07 eGFR 57.61
    • 2023-01-06 eGFR 81.22
    • 2023-01-10 BUN 27 mg/dL
    • 2023-01-09 BUN 27 mg/dL
    • 2023-01-08 BUN 26 mg/dL
    • 2023-01-07 BUN 21 mg/dL
    • 2023-01-06 BUN 17 mg/dL
  • The likelihood of MTX-induced renal dysfunction in patients receiving high dose MTX can be minimized (but not eliminated) by hydration both to maintain a high urine flow and to lower the concentration of MTX in the tubular fluid and by alkalinization of the urine to a pH above 7.0. Raising the urine pH from 5.0 to 7.0 increases the solubility of MTX 10-fold.

  • It is customary to begin the MTX infusion only after the urine pH is >= 7.0 and to maintain it in this range until plasma MTX levels have declined to less than 0.1 microM.

  • Urinary alkalinization is most easily accomplished by adding ampules of sodium bicarbonate to each liter of IV fluid hydration. This accomplishes both fluid hydration and urinary alkalinization. A typical choice is IV D5W with 100 to 150 mEq of sodium bicarbonate per liter, administered by continuous infusion at 125 to 150 mL/hour. A cation concentration of 80.5 mEq/L is roughly equivalent to one-half normal saline. The amount of bicarbonate in each liter and the IV fluid composition can then be modified according to the urine pH and serum sodium.

  • An alternative oral protocol for sodium bicarbonate can be started with 3000 mg (300mg/tab * 10 tablets) Q6H, and can be escalated the frequency to Q4H as needed; once the urine pH is greater than 7, the 24 hour daily dose can then be lowered and divided into four doses, every six hours.

2023-01-09

  • Lab data indicated that the patient’s renal function is deterioating

    • 2023-01-09 Creatinine 2.02 mg/dL
    • 2023-01-08 Creatinine 1.99 mg/dL
    • 2023-01-07 Creatinine 1.36 mg/dL
    • 2023-01-06 Creatinine 1.01 mg/dL
    • 2023-01-09 eGFR 36.50
    • 2023-01-08 eGFR 37.13
    • 2023-01-07 eGFR 57.61
    • 2023-01-06 eGFR 81.22
    • 2023-01-09 BUN 27 mg/dL
    • 2023-01-08 BUN 26 mg/dL
    • 2023-01-07 BUN 21 mg/dL
    • 2023-01-06 BUN 17 mg/dL
  • In this male patient, who is 56 y/o, Cre 2.02 mg/dL and weighs 82 kg, the estimated CrCl is 47 mL/min. The self-carried Baraclude (entecavir) for patients with CrCl 30 to <50 mL/minute: Administer 50% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 48 hours. QODAC is preferred.

  • Methotrexate is greater 80% excreted as the unchanged drug and is primarily excreted in the urine. Leucovorin 100mg IVD Q6H has been administered since 2023-01-08 06:05.

  • Serum MTX levels are declining at an apparent rate.

    • 2023-01-08 22:39 3.549 umol/L
    • 2023-01-07 22:36 17.473 umol/L
      • ref Toxic:
        • 24 hr > 10 umol/L
        • 48 hr > 1 umol/L
        • 72 hr > 0.1 umol/L
  • If the patient is still able to urinate normally, furosemide may be an option for helping the excretion of methotrexate. For patients with an eGFR greater than 30 mL/minute/1.73m2, furosemide does not require dosage adjustment.

2022-07-20

  • The dosage of leucovorin 200mg Q6H used immediately following methotrexate has been adjusted to 400mg Q6H as of 2022-07-20. Leucovorin is excreted renally, however there are no dosage adjustments provided in manufacturer’s labeling for kidney impairment patients.
  • Items in the active prescription that should be addressed if kidney function is altered.
    • Keppra (levetiracetam)
      • The manufacturer’s labeling recommends estimating CrCl using the Cockcroft-Gault formula adjusted for BSA as follows: CrCl (mL/minute/1.73 m2) = CrCl (mL/minute)/BSA (m2) x 1.73.
        • CrCl 80 to 130 mL/minute/1.73 m2: 500 mg to 1.5 g every 12 hours.
        • CrCl 50 to <80 mL/minute/1.73 m2: 500 mg to 1 g every 12 hours.
        • CrCl 30 to <50 mL/minute/1.73 m2: 250 to 750 mg every 12 hours.
        • CrCl 15 to <30 mL/minute/1.73 m2: 250 to 500 mg every 12 hours.
        • CrCl <15 mL/minute/1.73 m2: 250 to 500 mg every 24 hours (expert opinion).
    • Baraclude (entecavir)
      • Daily-dosage regimen preferred.
        • CrCl >=50 mL/minute: No dosage adjustment necessary.
        • CrCl 30 to <50 mL/minute: Administer 50% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 48 hours.
        • CrCl 10 to <30 mL/minute: Administer 30% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 72 hours.
        • CrCl <10 mL/minute: Administer 10% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 7 days.
    • Furosemide
      • eGFR >30 mL/minute/1.73 m2: No dosage adjustment necessary.
      • eGFR <=30 mL/minute/1.73 m2: Higher doses may be required to achieve desired diuretic response due to decreased secretion into the tubular fluid. However, single doses >160 to 200 mg IV (or oral equivalent) are unlikely to result in additional diuretic effect (Brater 2011).
  • CrCl is 10 mL/min and eGFR is 7 mL/min for this patient based on Cockcroft-Gault formula, CKD-EPI equation and 2022-02-20 updated lab data.

701469357

230320

[lab data]

2023-03-17 Anti-HBc Nonreactive
2023-03-17 Anti-HBc-Value 0.18 S/CO
2023-03-17 Anti-HCV Nonreactive
2023-03-17 Anti-HCV Value 0.17 S/CO
2023-02-03 Anti-HCV Nonreactive
2023-02-03 Anti-HCV Value 0.10 S/CO
2023-02-03 HBsAg Nonreactive
2023-02-03 HBsAg (Value) 0.49 S/CO
2023-02-03 Anti-HBs 1.12 mIU/mL
2023-02-02 MTBC PCR NOT DETECTED
2023-02-02 MTBC PCR Value <11.8 CFU/ml

[exam findings]

  • 2023-03-12 CT - abdomen
    • Clinical history: 51 y/o male patient with cough, headache, chills, fever since this morning, mild nausea, loose stool
    • With and without contrast enhancement CT of abdomen - whole:
      • S/P feeding jejunostomy.
      • Thickening wall at the middle/distal third esophagus, c/w esophageal cancer, with ulceration at left lateral wall with adjacent lung consolidation.
      • Left pleural effusion.
      • There are enlarged lymph nodes in bilateral SCF, pretracheal, subcarina, around GE junction, r/o metastatic lymph nodes.
      • Left renal cyst, 0.8cm.
      • Unremarkable change of the liver, spleen, pancreas and right kidney.
    • Impression:
      • S/P feeding jejunostomy.
      • Esophageal cancer with ulceration and adjacent left lung consolidations, left pleural effusion.
      • Multiple metastatic lymph nodes in lower neck, mediastinum and upper abdomen.
  • 2023-03-12 CXR
    • S/P port-A insertion via left subclavian vein.
    • Increased bilateral lung markings.
    • No cardiomegaly.
    • Thoracic spondylosis.
  • 2023-02-17 Patho - gingival/oral mucosa biopsy
    • Diagnosis:
      • Uvula, wide excision (S2023-2822A) with frozen section (F2023-65) — poorly differentiated carcinoma and sarcomatoid carcinoma.
      • Hypopharyngeal tumor, wide excision (S2023-2822B) — squamous cell carcinoma in situ (CIS), < 1 mm from unspecified margin.
      • Uvula: pT1 pNx (if cM 0); pStage: I.
      • Hypopharynx: pTis pNx (if cM0); pStage: 0.
    • Macroscopic examination
      • Surgical Procedure(s): uvula: wide excision with frozen section. Hypopharynx: wide excision.
      • Specimen Type:
        • Main location: S2023-2822A: uvula; B: hypopharynx.
        • Other part(s) included: F2023-00065A: posterior margin; B: anterior margin.
        • Lymph node dissection: no.
      • Specimen Integrity: intact
    • Microscopic examination
      • Histologic Type: 01: uvular tumor: poorly differentiated carcinoma and sarcomatoid carcinoma. 02. hypopharyngeal tumor: carcinoma in situ (CIS).
      • Histologic Grade: 01: uvular tumor: G3: Poorly differentiated
      • Microscopic Tumor Extension: (specify) submucosa.
      • Margins (obtained from the main resection specimen):
        • Margins uninvolved by invasive carcinoma, uvular tumor:
          • Distance from closest margin: gin and posterior margin. 4 mm. Anterior margin and posterior margin. NOTE: This distance does not include the size of frozen section specimens.
        • Margins uninvolved by squamous cell carcinoma in situ (left hypopharynx)
          • Distance from closest margin: 1 mm. Unspecified margin
      • Lymph-Vascular Invasion: not identified
      • Perineural Invasion: not identified
      • Neck Lymph Nodes: no lymph node submitted.
  • 2023-02-11 MRI - larynx
    • p16(+) Oropharnx
      • Impression (Imaging stage): T: 0(T_value) N: 2c(N_value) M: 0(M_value) STAGE: IVA(Stage_value)
  • 2023-02-08 Nasopharyngoscopy
    • whitish lesion over posterior side of uvula, smooth NPx, granular lesion over left hypopharynx
  • 2023-02-04 MRI - brain
    • MRI of the brain in multiplanar projections, multisequences imaging acquisition without and with IV Gd-DTPA administration shows:
    • Imp: No brain nodule or metastasis. Mild cortical brain atrophy.
  • 2023-02-04 Pure Tone Audiometry
    • PTA:
      • Reliability FAIR
      • Average RE 38 dB HL, LE 43 dB HL
      • Bil normal to moderatly severe SNHL
  • 2023-02-03 Whole body PET scan
    • Glucose hypermetabolism involving the middle to lower portions of the esophagus, compatible with primary esophageal malignancy.
    • Glucose hypermetabolism in a left upper paratracheal lymph node, some bilateral supraclavicular lymph nodes and a lymph node in the upper abdomen near EG junction. Metastatic lymph nodes may show this picture.
    • Mild glucose hypermetabolism in a focal area in the middle lobe of right lung. Inflammation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Glucose hypermetabolism in the uvula, hypopharynx, nasopharynx, bilateral parotid glands, some bilateral upper neck lymph nodes, soft palate and bilateral tonsils. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
  • 2023-02-02 Tc-99m MDP whole body bone scan
    • Increased activity in the lower T-spines and L4-5 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
  • 2023-02-02 Patho - larynx biopsy
    • Labeled as “hypopharynx”, biopsy — squamous cell carcinoma in situ (CIS).
  • 2023-02-02 Patho - nasopharyngeal/oropharyngeal biopsy
    • Labeled as “uvula”, bronchoscopic biopsy — Sarcomatoid carcinoma.
    • Section shows diffuse infiltration of spindle shaped neoplastic cells.
    • IHC stain: Vimentin (diffuse +), CK (focal +), p16 (-).
  • 2023-02-01 Patho - esophageal biopsy
    • Soft palate, left, biopsy — Squamous cell carcinoma in situ
  • 2023-02-01 Cardiopulmonary Exercise Testing
    • summary:
      • low exercise capacity ( VO2 75%, WR 76%)
      • low stroke volume response during exercise
      • normal HR response slope
      • normal ventilatory function ( FVC 102%, FEV1 94%)
      • No SpO2 desaturation during exercise
      • Poor expiratory muscle strength (MIP 77%, MEP 51%)
      • Health-related quality of life, CAT= 0, good
    • suggestions:
      • treat underlying condition
      • for low stroke volume response, suggest to intake adequate fluid, may survey cardiac function
      • arrange pulmonary rehab with exercise training after operation
      • low risk for operation
  • 2023-01-30 CT - chest
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-01-30 Patho - esophageal biopsy
    • Esophagus, 30 cm below the incisors, biopsy — Squamous cell carcinoma, moderately differentiated (G2)
    • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation and tumor necrosis are evident.
  • 2023-01-28 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Highly suspected esophageal cancer, M-L/3, s/p biopsy
      • Incomplete study
    • Suggestion
      • Admission for parenteral nutrition and staging.
      • Watch out for refeeding syndrome.

[radiotherapy]

[chemotherapy]

  • 2023-03-16 - cisplatin 80mg/m2 130mg NS 500mL 4hr + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-2 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

701473264

230316

[drug interaction]

  • Histamine H2 Receptor Antagonists may decrease the absorption of dasatinib. Dasatinib prescribing information states histamine H2 receptor antagonists (H2RAs) should not be coadministered with dasatinib due to the risk of reduced dasatinib concentrations and efficacy. Given the longer-term acid suppression achieved with H2-antagonist or proton pump inhibitor therapy, the manufacturer suggests the use of antacids (with 2-hour dose separation) if acid-reducing therapy is required. The likely mechanism for this apparent interaction is impaired absorption of dasatinib, which does appear to display pH-sensitive solubility, due to the increase in gastric pH caused by a H2-receptor antagonist.

  • Currently, the patient is prescribed Sprycel (dasatinib) and Ulstop (famotidine) with a QD and BID frequency, respectively. These medications are being administered at the same time of 09:00. To prevent any potential drug interactions, it is recommended to shift the administration time of one of the medications to a time that does not overlap with the other medication.

700180610

230315

[exam findings]

  • 2023-02-20 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (76 - 29) / 76 = 61.84%
      • M-mode (Teichholz) = 61
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • Preserved RV systolic function
  • 2023-02-01 whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed faint hot spots in both rib cages, and increased activity in the maxilla, some T- and L-spine, bilateral shoulders, S-I joints, and hips, in whole body survey.
    • IMPRESSION:
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral shoulders, S-I joints, and hips.
  • 2023-01-30 Her-2/neu in situ hybridization
    • RESULT OF HER2/NEU IN SITU HYBRIDIZATION: BREAST
      • Negative: There is NO amplification of HER2 detected
      • METHOD AND DETAILS:
        • Number of observers: 1
        • Number of invasive tumor cells counted: 20
        • Average number of HER2 gene copy signal per cell: 1.8
        • Average number of CEP17 gene copy signal per cell: 2
        • HER2/CEP17 ratio: 0.9
        • Heterogeneous signals: Absent
        • Origin slide and block number: S2023-1401
        • Specimen: Formalin-fixed paraffin embedded breast tumor
        • Adequacy of sample for evaluation: Yes
        • Method of in situ hydridization: CISH (Ventana HER2 dual ISH DNA probe cocktail assay, Roche compancy)
      • INTERPRETATION CRITERIA (ASCO/CAP scoring criteria 2018)
        • Amplified:
          • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number >=4.0
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=6.0 signals/cell
        • Not amplified:
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number <4.0
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=4.0 and <6.0 signals/cell
          • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number <4.0
    • RESULT OF HER2/NEU IN SITU HYBRIDIZATION : LYMPH NODE
      • Negative: There is NO amplification of HER2 detected
      • METHOD AND DETAILS:
        • Number of observers: 1
        • Number of invasive tumor cells counted: 20
        • Average number of HER2 gene copy signal per cell: 1.8
        • Average number of CEP17 gene copy signal per cell: 2
        • HER2/CEP17 ratio: 0.9
        • Heterogeneous signals: Absent
        • Origin slide and block number:S2023-1402
        • Specimen: Formalin-fixed paraffin embedded breast tumor
        • Adequacy of sample for evaluation: Yes
        • Method of in situ hydridization: CISH (Ventana HER2 dual ISH DNA probe cocktail assay, Roche compancy)
      • INTERPRETATION CRITERIA (ASCO/CAP scoring criteria 2018)
        • Amplified:
          • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number >=4.0
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=6.0 signals/cell
        • Not amplified:
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number <4.0
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=4.0 and <6.0 signals/cell
          • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number <4.0
  • 2023-01-30 Patho - breast biopsy (no need margin)
    • Breast, right, core biopsy — Invasive carcinoma, no special type, NST.
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
    • IHC stains (using block: S2023-1401): ER (+, 95%, strong intensity), PR(-, 0%), Her2/neu: equivocal (score=2+), Ki-67(50%), E-cadherin (+). An additional report of Her2 DISH will be followed.
  • 2023-01-30 Patho - lymphnode biopsy
    • Lymph node, right axillary, core biopsy — Invasive carcinoma, no special type, NST.
    • Section shows fragments of lymph node tissue with irregular neoplastic ducts infiltration.
    • IHC stains (using block: S2023-1401): ER (+, 95%, strong intensity), PR(-, 0%), Her2/neu: equivocal (score=2+), Ki-67(50%), E-cadherin (+). An additional report of Her2 DISH will be followed.
  • 2023-01-30 CT - chest
    • Indication: Unspecified lump in breast
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images, and oblique sagittal reconstructed images of the Rt breast shows:
      • chest wall: a large Rt breast solid soft-tissue tumor (93mm in longest axial dimension) with surrounding linear opacities (lymphatic drainage) and skin involvement, and many metastatic lymph nodes at Rt axilla.
      • Lungs: normal appearance of bilateral lungs.
      • Mediastinum and hila: no enlarged LN or mass.
        • the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
      • Visible abdominal contents: a low density focus (24mm) in the uterus, cystic lesion or necrotic myeoma.
        • mltiple stones with collapsed gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
        • no enlarged lymph node. no ascites..
      • Visualized bones: unremarkable.
    • Impression:
      • Rt breast cancer with Rt axillary LNs metastasis T4N1
  • 2023-01-20 SONO - breast
    • Findings
      • Parenchymal pattem
        • Loosely (inhomogeneously) sonodense
      • Focal sonographic lesion
        • right breast huge tumor, with skin involvement, heteogenous, > 10cm, favor malignancy
        • LAP(+)
    • Diagnosis
      • Highly suspicious of malignancy,with sonographic positive axillary LAP
    • Treatment
      • Core-needle biopsy
    • Suggestion and Plan
      • Regular OPD follow-up
      • BI-RADS 5 - Highly Suggestive of Malignancy (>95% malignant) Appropriate Action Should Be Taken

[chemotherapy]

  • 2023-03-14 - doxorubicin 60mg/m2 100mg NS 100mL 10min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-20 - doxorubicin 60mg/m2 100mg NS 100mL 10min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

Granocyte (lenograstim 250ug/vial) CGRAN01 - 2023-03-02 ~ 2023-03-04 - 250ug QD SC - IPD 2023-03-02

[assessment]

  • On 2023-01-30, the Her-2/neu in situ hybridization results indicated a negative status for both breast and lymph nodes.
  • On 2023-03-02, a grade 4 neutropenia event was observed in the patient with a WBC count of 930/uL and Neutrophil count of 18%. Following the administration of three consecutive days of lenograstim since that day, no further episodes of neutropenia have been observed up to the present time.
  • Please prescribe Baraclude (entecavir) 0.5mg tablets, one tablet daily, for the patient’s underlying hepatitis B virus infection.

700541242

230315

{Malignant neoplasm of body of stomach; gastric antrum, pT4aN0M1, stage IV status post radical subtotal gastrectomy with lymph node dissection and B-II gastrojejunostomy}

[diagnosis] - 2023-02-04 discharge note

  • Gastric  antrum, pT4aN0M1, stage IV status post radical subtotal gastrectomy with lymph node dissection and B-II gastrojejunostomy
  • Hepatits B, anti-HBC:positive

[past history]

  • Hypertension
  • right shoulder s/p operation 7+ years ago at NTUH                                        

[allergy]

  • NKDA                             

[family history]

  • Denied family history of cancer and mental diseases.
  • No members of the family with diabetes.  

[exam findings]

  • 2023-01-25 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • S/p port-A placement with its tip at left brachiocephalic vein
    • Emphysematous change over both lungs.
    • Osteopenia of the bony structure is noted.
  • 2023-01-25 CT - abdomen
    • s/p subtotal gastrectomy.
    • Minimal ascites in the abdominal cavity is found.
  • 2023-01-25 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-01-02 CT - abdomen
    • History and indication: gastric cancer wt peritoneal seeing, pT4aN0M1, stage IV
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction.
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P gastric operation.
      • Bronchiectasis at RML, RLL and LLL.
      • Retroversion of uterus.
      • Atherosclerosis of aorta.
    • IMP:
      • S/P gastric operation. No evidence of tumor recurrence.
      • Bronchiectasis at RML, RLL and LLL.
    • 2023-01-02 CXR
      • Borderline cardiomegaly
      • Scoliosis of the T-spine with convex to right side.
    • 2022-11-18, -11-17, -10-27, -10-26, -10-04, -09-14, -09-13, -09-01, -08-30 Body fluid cytology - ascites and others
      • Negative
    • 2022-08-01, -07-29, -07-27, -07-26, -07-24 CXR
      • Ground glass opacities in bil. lungs.
    • 2022-07-24 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Suboptimal study due to much blood and blood clot were noted upon entering stomach.
        • Post subtotal gastrectomy with Billroth II anastomosis
        • Suspicious gastrojejunal anastomosis site ulcers, Forrest calssification IIa and Ib, s/p hemostasis with submucosal epinephrine injection and clipping
      • Suggestion
        • NPO
        • High dose PPI use
        • suggest second-look endoscopy
    • 2022-07-20 CXR
      • Pneumoperitoneum.
      • Right catheterization to SVC in position.
      • Left catheterization to SVC in position.
      • S/P NG tube indwelling.
      • Ground glass opacity in bilateral lower lungs and RUL.
      • Blunted bilateral costophrenic angles.
    • 2022-07-19 Patho - stomach subtotal/total
      • pathologic diagnosis
        • Stomach, subtotal gastrectomy — Poorly cohesive carcinoma, signet-ring cell type
        • Margins, bilateral cutting ends, subtotal gastrectomy — Free of tumor invasion
        • Lymph nodes, D2 LN dissection — Negative for malignancy (0/47)
        • Omentum, subtotal gastrectomy — Metastatic carcinoma
        • AJCC Pathologic staging — pT4aN0M1, stage IV
      • microscopic examination
        • Histologic type: Poorly cohesive carcinoma, signet-ring cell type (Lauren classification: diffuse type)
        • Histologic grade: Poorly differentiation (G3)
        • Depth of tumor invasion: Tumor invades the serosa
        • Margins: All margins are uninvolved by carcinoma
          • Distance of invasive carcinoma from closest margin: 2 mm from radial margin
        • Perineural invasion: Present
        • Lymphovascular space invasion: Absent
        • Regional lymph nodes: Negative for malignancy (0/47)
          • 0/7 (LN 1), 0/7 (LN 3), 0/1 (LN 4), 0/3 (LN 5), 0/3 (LN 6), 0/26 (LN 7, 8, 9, 11p, 12a), 0 (LN14v) (Number of LN involved/Number of LN examined)
        • Duodenum: Involved by carcinoma
        • Omentum: Metastatic carcinoma
        • Additional pathologic findings: Reactive gastropathy
        • Pathologic Staging: pT4aN0M1 (stage IV)
        • IHC (S2022-10770): HER2 (negative, score=1+)
        • Ascites Cytology: Negative
    • 2022-07-13 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (91.5 - 28.5) / 91.5 = 68.85%
        • Normal chamber size
        • Adequate LV and RV systolic function
        • AV sclerosis with trivial AR, trivial MR, TR and PR
        • No regional wall motion abnormalities
    • 2022-07-08 Double contrast upper GI series
      • Findings
        • Normal appearance of the esophagus.
        • There is no evidence of abnormal mucosal pattern at the stomach.
        • Intact EG junction.
        • The gastric angle is intact.
        • Decreased peristasis with poorly opacified gastric pylorous.
      • Imp:
        • Decreased peristasis with poorly opacified gastric pylorous.
    • 2022-07-07 MRI - upper abdomen
      • Suboptimal study due to motion.
      • Hepatic hemangioma. S4/8
      • Enhanced mucosa at gastric pylorous is found. Nature?
    • 2022-07-07 Patho - stomach biopsy
      • Stomach, pyloric ring, biopsy — Poorly cohesive carcinoma with signet-ring cell differentiation
      • Microscopically, the sections show a picture of poorly cohesive carcinoma with signet-ring cell differentiation characterized by individual tumor cells infiltratiion. Immunohistochemistry of CK(+) and Her2 (-, Dako score 1+) for tumor. Besides, mild intestinal metaplasia is also noted.
    • 2022-07-06 SONO - abdomen
      • Diagnosis: Hepatic hemangima, right lobe
    • 2022-07-06 Esophagogastroduodenoscopy, EGD
      • Esophagus: Confluent mucosal breaks more than 75% with fagile mucosa and superficial ulcers were noted from EC junctiob to 25cm below the incisors.
      • Stomach: Upon entry, much food debris was noted in stomach. Mucosal swelling was noted at pylori ring, causing pylori stricture that the scope could not pass through. Biopsy *6 was performed the pylori ring.
      • Duodenum: Not checked
      • Diagnosis
        • Incomplete study
        • Reflux esophagitis, LA D, with ulcers formation, suspected vomiting related
        • Pylori stricture, s/p biopsy
      • Suggestion
        • Please pursue pathology report
    • 2022-07-05 CT - abdomen
      • Addendum Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N1(N_value) M:M0(M_value) STAGE:III(Stage_value)
    • 2022-07-05 ECG
      • Normal sinus rhythm
      • ST & T wave abnormality, consider inferior ischemia
      • ST & T wave abnormality, consider anterolateral ischemia
      • Prolonged QT

[consultation]

  • 2022-07-13 General and Gastrointestinal Surgery
    • Q
      • This 69 years old female has the history of hypertension
      • This time, she came to ER for persisit vomit with dizzness in recently 2 weeks, she ver been to LMD but invain. She denied fever or chills, dyspnea or chest pain , abdomen pain, tarry or bloody stool passage recently. She also denied TOCC history.
      • At ER, physical exammination revealed abdomen soft without tenderness and acitve bowel sound. Lab data showed impaird renal function, hyponatremia hypokalemia and the Non-contrast CT of abdomen-pelvis revealed: Bronchiectasis at RML, RLL and LLL. Distention of stomach and dilatation of esophagus. Retroversion of uterus. Initial NG was placed at ER and coffee ground was noted and gastric juice showed OB 3+. KCAL fluid was given to correct hypokalemia. Under the impresion of Vomit, hypokalemia, she was admitted to GI wrd for further management.
      • EGD was perfromed and reported Incomplete study Reflux esophagitis, LA D, with ulcers formation, suspected vomiting related Pylori stricture, s/p biopsy. The pathology reported Poorly cohesive carcinoma with signet-ring cell differentiation. we need your expertise. Thanks~
    • A
      • please arrange heat echo for pre-op survey
      • TPN for nutrition support
      • we will take over for this case
      • further operation will arrange on next week

[surgical operation]

  • 2022-07-18 Radical subtotal gastrectomy and B-II gastrojejunostomy
    • Tumor visible at antrum at lesser curvature of antrum
    • Ring-like tumor about 3cm width at pyloric antrum
    • cT4aN1M0

[chemoimmunotherapy]

  • 2023-02-21 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + leucovorin 400mg/m2 470mg NS 250mL 2hr + fluorouracil 2000mg/m2 2350mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-02 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + leucovorin 400mg/m2 450mg NS 250mL 2hr + fluorouracil 2000mg/m2 2300mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

    • 2023-01-09 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 450mg 2hr + fluorouracil 2400mg/m2 2760mg 46hr

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-12-22 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2400mg/m2 2840mg 46hr

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-12-08 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 450mg 2hr + fluorouracil 2400mg/m2 2760mg 46hr

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-11-17 - oxaliplatin 40mg/m2 47mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2000mg/m2 2360mg 46hr + [docetaxel 30mg/2 35mg IP 1hr + cisplatin 30mg/m2 35mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-10-25 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2000mg/m2 2370mg 46hr + [docetaxel 30mg/2 35mg IP 1hr + cisplatin 30mg/m2 35mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-09-13 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 490mg 2hr + fluorouracil 2000mg/m2 2470mg 46hr + [docetaxel 30mg/2 37mg IP 1hr + cisplatin 30mg/m2 37mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-08-30 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 490mg 2hr + fluorouracil 2000mg/m2 2470mg 46hr + [docetaxel 30mg/2 37mg IP 1hr + cisplatin 30mg/m2 37mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-08-08 - mitomycin-C 15mg/m2 20mg 2hr D2-3 + [fluorouracil 500mg/m2 645mg IP 1hr D1-5 + gentamicin 40mg IP 1hr D1-5 + sodium bicarbonate 2800mg IP 1hr D1-5]

==========

2023-03-15

  • According to available lab data since 2022-07-05 in HIS5, the patient has experienced frequent occurrences of hyponatremia, hypopotassemia, hypokalemia, and hypomagnesemia. However, during the same time frame, there have been few instances of hyper- or hypophosphatemia.

  • The patient began receiving FOLFOX treatment in August 2022, and the use of carboplatin in this treatment regimen can be associated with hyponatremia, hypokalemia, hypomagnesemia, and hypocalcemia.

  • It is recommended to continue monitoring the patient’s electrolyte levels and prescribe supplements as needed. If it becomes challenging to maintain a balance of electrolytes through supplementation, it may be necessary to consider reducing the dose of carboplatin or switching to a different regimen.

2023-02-22

  • A low serum magnesium level of 1.6mg/dL (2023-02-21) has been observed, and the patient has been prescribed MgSO4 injections and MgO tablets appropriately.
  • Apart from hypomanesia, the patient’s other laboratory readings were within normal limits, and their vital signs have remained stable throughout this hospitalization.

2023-01-10

  • There has been a frequent low level of magnesium in the patient’s blood for months, this hospital currently has only magnesium oxide tablets available for oral administration, so it is recommended to continue prescribing MgO when he is discharged.
  • MgO should be taken with food and at least 240mL of water (absorption: oral up to 30%). Patients might be educated that whole grains, legumes, and dark-green leafy vegetables are dietary sources of magnesium.

2022-12-09

  • As multiple body fluid (primarily ascites) cytological studies (2022-11-18, -11-17, -10-27, -10-26, -10-04, -09-14, -09-13, -09-01, -08-30) did not reveal evidence of malignancy, intraperitoneal chemotherapy was discontinued while systemic FOLFOX is continued.

  • The lab serum magnesium levels indicated a frequent deficiency of serum magnesium in this patient.

    • 2022-12-08 Mg (Magnesium) 1.4 mg/dL
    • 2022-11-16 Mg (Magnesium) 1.7 mg/dL
    • 2022-10-17 Mg (Magnesium) 2.0 mg/dL
    • 2022-10-14 Mg (Magnesium) 1.5 mg/dL
    • 2022-10-11 Mg (Magnesium) 1.8 mg/dL
    • 2022-10-03 Mg (Magnesium) 1.8 mg/dL
  • For the magnesium sulfate prescription will expire on the weekend, a lab data renewal may assist in determining whether the magnesium supplement should continue to be administered.

2022-10-26

  • Body weight has decreased by almost 10 kg in the last 3 months (33.1kg 2022-10-25 <- 42.8kg 2022-07-27 gastrectomized), and a low albumin level (3.2 g/dL 2022-10-25) could indicate malnutrition. Long-term survival may be adversely affected by malnutrition after gastrectomy for gastric cancer (ref: Impact of Malnutrition After Gastrectomy for Gastric Cancer on Long-Term Survival. Ann Surg Oncol. 2018;25(4):974-983. doi:10.1245/s10434-018-6342-8)

  • It is advisable to begin strict nutritional follow-up as soon as possible after surgery in order to prevent a sharp weight loss in the early postoperative phase when most of the dietary problems arise.

  • Vitamin B12 injections might be required, as well as multivitamins and minerals.

  • As this patient’s weight is approximately equivalent to that of a ten-year-old child, the dosage might need to be adjusted accordingly.

2022-09-13

  • Metoclopramide might enhance the CNS depressant effect of lorazepam. The patient should be monitored for signs of increased CNS depressant effects (e.g. somnolence, drowsiness).

700909334

230315

[diagnosis]

  • Malignant neoplasm of overlapping sites of corpus uteri
  • Metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV with obstructive Lt lung collapse; ECOG = 3.
  • Secondary malignant neoplasm of retroperitoneum and peritoneum
  • Thalassemia, unspecified
  • Gastrointestinal hemorrhage, unspecified
  • Allergy, unspecified, initial encounter
  • Dysthymic disorder
  • Insomnia due to other mental disorder
  • Constipation, unspecified
  • Chronic viral hepatitis B without delta-agent

[past history]

  • uterus leiomyosarcoma with bone meta, liver and lung metastases s/p OP, pazopanib target therapy with progression and chemotherapy (cisplatin and ifosphamide).
  • Metastatic uterus leiomyosarcoma, FIGO stage IB, AJCC T1bN0M0 status post staging laparotomy with extrafascial hysterectomy + bilaterla salpingo-oophorectomy + bilateral pelvic and para-aortic LNs dissection + omentectomy + peritoneal washing on 2016/09/26 with vaginal reccurence, status post transvaginal tumor excision on 2017/12/25 status post 6 courses of adjuvant chemotherapy with Paclitaxel plus Carboplatin (20180105~0430) with lung metastases and bone metastases, status post 5 courses of chemotherapy with Cisplatin, Ifosfamide and Mensna (20211110~1224) at Tri-service General Hospital, under current radiation therapy.
  • Gastro-esophageal reflux disease with esophagitis, LA grade D
  • Thalassemia
  • Positive infection of COVID-19 on 2022/05/16

[exam findings]

  • 2023-03-09 CT - brain
    • Clinical information: This 62 y/o female patient has the history of metastatic uterus leiomyosarcoma, FIGO stage IB, AJCC T1bN0M0 status post staging laparotomy with extrafascial hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic and para-aortic LNs dissection + omentectomy + peritoneal washing on 2016/09/26 with vaginal reccurence
    • Cranial CT scans from the vertex to the mid-maxillary level were performed with i.v. contrast injection.
    • Impression:
      • One enhancing nodular lesion (7mm) over right parietal lobe, favor a metastatic lesion.
      • The size of the lateral and third ventricles appears normal.
      • The posterior structures including the brain stem, cerebellum and CP angles look normal.
  • 2023-02-08 CTA - chest
    • Indication: Malignant neoplasm of overlapping site
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.5 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images and coronal slab MIP PA images shows:
    • Comparison was made with previous CT dated on 2022/12/08
      • Lungs: extensive heterogeneous consolidation with air-bronchograms at left perihilar lung region and multiple randomly distributed pulmonary nodules of varying sizes due to metastases.
      • Mediastinum and hila: enlarged LNs in the Rt hilum and intrapulominary LLL.
      • Aorta: normal caliber of thoracic aorta.
      • Central pulmonary arteries: normal caliber and well opacification
      • Heart: normal in size of cardiac chambers.
      • Pleura: small Lt effusion extending to major fissure, Rt pleural metastasis and thickening.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal-pelvic contents:
        • multiple large metastatic hepatic tumors, small metastatic tumors at left kidney and Rt adrenal gland, and a large metastatic tumor at RUQ of abdomial cavity. a large tumor at pelvic cavity involving adjacent organs.
        • small ascites is visible.
    • Impression: Leiomyosarcoma of uterus with multiple sites of metastases, in progression as compared with the previous CT on 2022/12/08
  • 2023-02-08 CXR
    • Extensive heterogeneous consolidation in left perihilar lung region and multiple randomly distributed pulmonary nodules of varying sizes due to metastases
    • Port-A catheter inserted into superior RA via left subclavian vein.
    • Diffuse hepatomegaly.
    • Normal heart size.
  • 2023-02-02 CXR
    • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    • S/P metalic autosuture at left lower lung.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2023-01-25 CXR
    • Cardiomegaly is noted.
    • S/p port-A placement with its tip at Superior vena cava.
    • Mass like lesion at left upper lobe with nodular lesions at both lungs is found.
  • 2023-01-04
    • A nodular opacity projecting in the left upper lung is suspected. Please correlate with CT.
    • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
    • S/P metalic autosuture at left lower lung.
  • 2022-12-13
    • Multiple nodules at bil. lungs.
    • Patch density at LUL.
  • 2022-12-08 CT - chest
    • Indication: Leiomyosarcoma s/p C/T
    • Chest and Abdominal CT with and without enhancement revealed:
      • Chest:
        • S/p port-A placement with its tip at Superior vena cava.
        • Nodular lesions at both lungs up to 3.6cm at right lower lobe is found. In comparison with CT dated on 2021-09-21, the lesion enlarged.
        • Left hilar infiltration is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • s/p ATH and BSO.
        • Soft tissue nodule at right pelvic side wall up to 4.6cm in largest dimension. In progression.
        • Soft tissue mass near uncinate process of the pancreas is found. The lesion enlarged.
        • Low density lesions at both lobes of liver up to 6.4cm in largest dimension is found. In enlargement.
        • The urinary bladder is well distended without soft tissue lesion.
        • Right adrenal enlargment up to 3.09cm is found. In progression. Suggest clinical correlation
    • Imp:
      • s/p ATH and BSO.
      • Residual tumor at pelvis about 4.6cm with liver, lung, right adrenal and uncinate process meta. In progression.
  • 2022-11-15 CXR
    • Progression of left pleural effusion as compare with CXR on 2022-09-21. Suggest clinical correlation.
    • S/P port-A insertion via left subclavian vein.
    • Multiple lung tumors, suspected lung metastasis, progression.
  • 2022-09-21 CT - abdomen
    • History: uterine leiomyosarcoma
      • 20220330 CT from TSGH: a heterogeneous mass 14 cm in the RUQ of abdomen,surround by C-loop of duodenum. Suspected metastasis.
      • 20220524 CC:UGI bleeding, gastroscopy:One 2cm ulcerative mass covering with fresh blood just distal to papilla. Patho:metastatic uterus leiomyosarcoma,
      • 20220623 CT:R/O metastases at pancreatic head and duodenum with duodeno-colon fistula.
    • Indication: Metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis; ECOG 2. s/p palliative RT on 2022/06/07.
    • MD CT (64 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • Prior CT identified a metastasis measuring 3.3 cm in S6 of the liver is noted again, mild decreasing in size to 3 cm.
        • However, There are two newly-developed poor enhancing masses measuring 4.3 cm in S4/5/8 and 1.2 cm in S7 of the liver that are c/w newly-developed metastases.
      • Prior CT identified multiple metastases on both lower lung are noted again, mild increasing in size.
      • Prior CT identified metastasis in between the pancreatic head and duodenum is noted again, marked decreasing in size.
      • S/P hysterectomy.
      • There is mild left pleural effusion.
      • There is a poor enhancing lesion measuring 1.2 cm in left kidney middle pole, nature? Please correlate with sonography.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, spleen & right kidney.
        • There is no ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Two newly-developed liver metastases in S4/5/8 and S7.
      • Multiple lung metastases show mild increasing in size.
      • Prior CT identified metastasis in between the pancreatic head and duodenum is noted again, marked decreasing in size.
  • 2022-09-21, -08-15 CXR
    • Multiple lung tumors, suspected lung metastasis.
    • Regression of left pleural effusion as compare with CXR on 2022-08-15, -07-19.
  • 2022-07-19 CXR
    • Total white-out of left lung and mediastinum shift to left side is noted that may be left lung collapse?
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • There are few nodular opacity projecting in both lung hat may be metastases. Please correlate with CT.
  • 2022-06-28 Abdomen Decubitus LT
    • Left Pleura effusion and left lung volume decrease.
  • 2022-06-28 CXR
    • Left pleural effusion.
    • Deviation of trachea.
    • Multiple nodules at right lung.
  • 2022-06-23 CT - abdomen
    • History and indication: metastatic uterus leiomyosarcoma
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy.
      • Left pleural effusion with adjacent lung collapse. Multiple nodules in right lung.
      • A poor enhancing tumor (3.3cm) at S6 of liver.
      • Suspected metastases at pancreatic head and duodenum with duodeno-colon fistula.
    • IMP:
      • S/P hysterectomy.
      • Left pleural effusion with adjacent lung collapse. Lung and liver metastases. Suspected metastases at pancreatic head and duodenum with duodeno-colon fistula.
  • 2022-05-24 Patho - stomach biopsy
    • Duodenum, just distal to papilla, biopsy (A) — Leiomyosarcoma.
    • IHC stains: desmin (+), CD117 (-), CD34 (-), dog-1 (-), CK (-), melan-A (-), Ki-67: 90%.
    • Section shows 1 piece(s) of benign duodenal tissue and 1 piece of neoplastic spindle cell tumor with markedly enlaged and hyperchromatic nuclei.
  • 2022-05-24 Colonoscopy
    • No active bleeder nor blood clot was noted during this exam, but few tarry stool residual was noted
    • Diverticula, cecum and ascending colon
    • Mild internal hemorrhoid
  • 2022-05-24 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Duodenal ulcerative tumor, 2nd portion, s/p biopsy (A)
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
      • Gastric polyps, body, s/p biopsy (B)
      • Gastric erosion, middle body, PW site, s/p biopsy (C)
    • Suggestion
      • Suggest Abdominal CT with contrast (if not contraindicated) to DDx the duodenal lesion.
      • Keep high dose PPI therapy for 3-5 days
      • If acitive bleeding, consider angiography for embolization and surgical intervention. Endoscopic treatment is NOT suitable for such bleeding lesion.
      • Pursue the result of pathology report
  • 2022-04-13 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA grade D
      • Superficial gastritis
      • Incomplete study
    • Suggestion
      • Consider temporary NG tube for decompression
      • PPI use for severe reflux esophagitis
      • Consider 2nd look endoscopy if active bleeding or persistent tarry stool
  • 2022-04-11 ECG
    • Sinus tachycardia
    • Right atrial enlargement
    • Rightward axis
    • Pulmonary disease pattern
    • Abnormal ECG
  • 2022-04-11 Abdomen -Standing (Diaphragm)
    • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
  • 2021-03-23 CT (performed at another hospital?)
    • There are several small nodules (maximal size: about 1.7 cm) in all lobes (im:87) showing no change in size in comparison with the prior study obtained on 2020-12-02, lung metastasis is suspected. Suggest get tissue diagnosis
    • Multiple hypodense lesions in the spleen. Suggest correlate with abdomen CT study

[consultation]

  • 2023-01-05 Oral and Maxillofacial Surgery
    • Q
      • This is a 62-year-old female who has the underlying disease of the following below: 1. Metastatic uterus leiomyosarcoma, FIGO stage IB, AJCC T1bN0M0 status post staging laparotomy with extrafascial hysterectomy + bilaterla salpingo-oophorectomy + bilateral pelvic and para-aortic LNs dissection + omentectomy + peritoneal washing on 2016/09/26 with vaginal reccurence, status post transvaginal tumor excision on 2017/12/25 status post 6 courses of adjuvant chemotherapy with Paclitaxel plus Carboplatin (20180105-0430) with lung metastases and bone metastases, status post 5 courses of chemotherapy with Cisplatin, Ifosfamide and Mensna (20211110-1224) at Tri-service General Hospital, under current radiation therapy. 2. Gastro-esophageal reflux disease with esophagitis, LA grade D 3. Thalassemia 4. Positive infection of COVID-19 on 2022/05/16.
      • For throbbing pain in upper left tooth, we need your further evaluation and management. (throbbing pain consists of recurring achy pains, may also experience pounding, beating, or pulsing pain.)
    • A
      • deep caries of tooth 26 was noticed.
      • But due to unstable hemodynamic status, Hb = 3.1 g/dL, blood transfusion was performed at ward
      • we suggested symtpom relief/pain relief (NSAID if no contraindicated/gastric ulceration)
  • 2022-07-01 Radiation Oncology
    • Q
      • The 62 y/o female has metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV. This time she has left lung collapse with SOB, patient asks for RT for treamtent.
    • A
      • Diagnosis: Metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis s/p to RUQ tumor from 2022-04-27 to 2022-06-07 with duodeno-tumor fistula and intermittent tumor bleeding; left pleural effusion with adjacent lung collapse, due to tumor obstruction of left main bronchus; ECOG = 2.
      • Suggest: Radiotherapy.
        • Goal: Palliative.
        • RT Plan may be designed as the following one:
          • Target & Volume: Metastatic tumor at left main bronchus.
          • Technique: VMAT & IGRT (OBI).
          • Dose & Fractionation: 2400cGy/6 fractions.
          • Expected benefits: about 60-70% chance to open the left bronchus, improve breathing, and last for about 1-2 months.
      • Plan: Palliative R/T is suggested for tumor obstruction. Possible toxicity (malaise, radiation esophagitis and pneumonitis) is told. CT simulation is arranged on 2022-07-04 15:30pm. Treatment will be started on next Tuesday or Wednesday if feasible.
        • Hospice care is also suggested. It has been recommended that family members be prepared for the best and the worst. Infection, bleeding, and other metastases may pose a threat at any time to the patient. Get to know the wisdom of letting go at the right time and adapt anticipatory grief accordingly.
  • 2022-06-30 Family Medicine
    • Q
      • The 62 y/o female has metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV. This time she has left lung collapse with SOB and abdomen CT with duodeno-colon fistula, can’t do the surgical intervention. Due to terminal stage, so we need your help for share care. Thank you.
    • A
      • When I visited, the patient lied on bed and her caregiver stood by her. She still wanted to receive palliative radiotherapy. After discussion, I decided to arrange hospice combine care for this patient.
      • Current condition: 62 y/o metastatic uterus leiomyosarcoma
      • Indication for hospice combine care: metastatic uterus leiomyosarcoma
  • 2022-06-28 General and Gastroenterological Surgery
    • Q
      • The 62 y/o female has metastatic uterus leiomyosarcoma with liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV. Due to abdomen CT showed metastases at pancreatic head and duodenum with duodeno-colon fistula. So we need your help for surgical indication management. Thank you.
    • A
      • S: Gastroenterological SurgeryDue to UGI bleeding, surgical intervention is consulted.
      • O:
        • vital signs: stable, no fever
        • HEENT: pale conjunctiva, OU
        • abdomen: soft, ovoid, normal bowel sound, RUQand epigastric tenderness, no rebounding pain
        • lab data: see chart
      • A: uterus leiomyosarcoma with multiple metastases,suspect duodeno-colon fistula and UGI bleeding
      • P:
        • Please arrange panendoscopy and colonoscopy for bleeding source and duodeno-colon fistula and possible hemostasis
        • Please use high dose PPI and keep blood transfusion if onging GI bleeding
        • If UGI bleeding is not well control after medication, blood trasfusion, and GI scope hemostasis, TAE is preferred than operation in stage IV case.
  • 2022-06-27 Gastroenterology
    • Q
      • The 62 y/o female has metastatic uterus leiomyosarcoma with liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV. Due to abdomen CT showed metastases at pancreatic head and duodenum with duodeno-colon fistula and stool ob 4+ with anemia Hb: 6.6d/dL. So we need your help. Thanks!
    • A
      • EGD on 20220524 showed a duodenal ulcerative tumor in 2nd portion, which was compatible with the CT finding
      • But the colonoscopy at the same time did not showed evidence of fistula
      • CT scan (20220623) reported a large tumor located between duodenum and pancreatic head region with suspicious duodeno-colonic fistula. Though, intraperitoneal free air accumulated below liver could not be ruled out.
      • Imp: Duodenal or pancreatic head tumor (suspected metastasis) with duodeno-colonic OR duodeno-peritoneal fistula
      • Suggestion:
        • Consult GS for surgical indication
        • Keep on PPI for the sign of UGI bleeding due to the duodenal tumor
  • 2022-04-25 Radiation Oncology
    • A
      • Diagnosis: Metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis; ECOG = 3.
      • Suggest: Radiotherapy.
        • Goal: Palliative.
        • RT Plan may be designed as the following one:
          • Target & Volume: RUQ tumor.
          • Technique: VMAT.
          • Dose & Fractionation: 2500-3000cGy/10-12 fractions.
          • Expected benefit: about 30-40% chance to improve tumor bleeding and obstruction, lasting for about 1-2 months.
      • Plan: Palliative R/T is suggested for tumor obstruction and bleeding. Possible toxicity (malaise, vomiting, radiation gastritis and enteritis) is told. CT simulation is arranged on 20220426 16:00pm. Treatment will be started on Wednesday if feasible.
        • It is recommended that the patient’s spouse and children make an appointment with me to listen to the explanation of the condition and discuss the treatment goals; it is recommended to continue to arrange the hospice ward.

[radiotherapy]

s/p palliative RT on 2022/06/07 (RUQ tumor), 2022/07/18 (left hilum), 2022/08/05 (left hilum), 2022/10/21 (liver, SBRT), 2023/01/02 (LUL).

  • 2023-01-03 ~ 2023-01-19 - 2500cGy/10 fractions (15 MV photon) to duodenal tumor
  • 2022-12-12 ~ 2023-01-02 - 4500cGy/15 fractions (6 MV photon) to LUQ tumors
  • 2022-10-11, -13, -17, -19, -21 - 5000cGy/5 fractions (15 MV photon) to liver tumors over right lobe
  • 2022-08-01 ~ 2022-08-16 - 4200cGy/12 fraction (6 MV photon) to L main bronchus tumor & other 2 tumors
  • 2022-07-05 ~ 2022-07-18 - 2400cGy/6 fractions (6 MV photon) to left main bronchus tumor
  • 2022-04-27 ~ -05-06, -05-15 ~ -06-01, -06,07 - 3000cGy/15 fractions (15MV photon) to RUQ tumor

[immunotherapy]

  • 2023-03-14 - nivolumab 3mg/kg 200mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL
  • 2023-02-20 - nivolumab 3mg/kg 200mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL
  • 2023-02-03 - nivolumab 3mg/kg 200mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL
  • 2023-01-09 - nivolumab 3mg/kg 100mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL
  • 2022-12-19 - nivolumab 3mg/kg 200mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL

==========

2023-03-15

  • Based on the available data, this patient’s HGB level has consistently remained below the lower limit of normal and requires blood transfusions to prevent it from dropping further.
    • 2023-03-13 HGB 6.4 g/dL
    • 2023-03-08 HGB 7.4 g/dL
    • 2023-03-02 HGB 8.2 g/dL
    • 2023-02-15 HGB 8.0 g/dL
    • 2023-02-08 HGB 9.3 g/dL
    • 2023-02-02 HGB 8.7 g/dL
    • 2023-01-31 HGB 10.1 g/dL
    • 2023-01-25 HGB 7.7 g/dL
    • 2023-01-25 HGB 6.6 g/dL
    • 2023-01-17 HGB 8.5 g/dL
    • 2023-01-09 HGB 8.9 g/dL
    • 2023-01-07 HGB 7.9 g/dL
    • 2023-01-04 HGB 3.1 g/dL
    • 2022-12-18 HGB 10.5 g/dL
    • 2022-12-15 HGB 4.9 g/dL
    • 2022-12-13 HGB 8.8 g/dL
    • 2022-12-07 HGB 6.5 g/dL
    • 2022-11-15 HGB 6.1 g/dL
    • 2022-10-18 HGB 6.4 g/dL
    • 2022-09-20 HGB 7.2 g/dL
    • 2022-08-30 HGB 7.9 g/dL
    • 2022-08-16 HGB 6.9 g/dL
    • 2022-07-19 HGB 11.3 g/dL
    • 2022-07-10 HGB 9.1 g/dL
    • 2022-07-06 HGB 7.1 g/dL
    • 2022-06-28 HGB 8.4 g/dL
    • 2022-06-26 HGB 6.6 g/dL
    • 2022-06-23 HGB 8.9 g/dL
    • 2022-06-21 HGB 8.9 g/dL
    • 2022-06-15 HGB 6.8 g/dL
    • 2022-06-07 HGB 8.8 g/dL
    • 2022-05-30 HGB 10.0 g/dL
    • 2022-05-27 HGB 9.3 g/dL
    • 2022-05-26 HGB 9.4 g/dL
    • 2022-05-25 HGB 5.1 g/dL
    • 2022-05-23 HGB 9.6 g/dL
    • 2022-05-22 HGB 5.8 g/dL
    • 2022-05-21 HGB 9.6 g/dL
    • 2022-05-17 HGB 10.8 g/dL
    • 2022-05-12 HGB 9.4 g/dL
    • 2022-05-05 HGB 8.0 g/dL
    • 2022-04-27 HGB 10.0 g/dL
    • 2022-04-25 HGB 10.3 g/dL
    • 2022-04-24 HGB 8.3 g/dL
    • 2022-04-24 HGB 9.7 g/dL
    • 2022-04-18 HGB 7.9 g/dL
    • 2022-04-14 HGB 8.0 g/dL
    • 2022-04-12 HGB 6.8 g/dL
    • 2022-04-08 HGB 11.4 g/dL
    • 2021-05-04 HGB 10.4 g/dL
    • 2020-09-09 HGB 10.0 g/dL
  • This patient has received nivolumab immunotherapy 5 times since 2022-12-19 and has undergone multiple rounds of radiotherapy between late April 2022 and late January 2023. It is unlikely that anemia can be solely attributed to nivolumab, as hematologic immune-related adverse events from nivolumab occur less frequently and the exact mechanism of anemia is unknown. However, they are typically non-dose-related. The anemia in this patient may also be caused by other factors, such as the multiple rounds of radiotherapy she has undergone.

2023-03-14

  • Advanced uterine leiomyosarcoma (ULMS) remains an incurable disease in most cases, and despite new drug approvals, improvements in overall survival have been modest at best. Microsatellite instability and/or high tumor mutational burden are distinctly uncommon in uterine LMS, perhaps explaining the lack of activity of immunotherapy agents observed in phase II trials in LMS.

    • ref:
      • Immunotherapy with single agent nivolumab for advanced leiomyosarcoma of the uterus: Results of a phase 2 study. Cancer. 2017;123(17):3285-3290. doi:10.1002/cncr.30738
      • Pembrolizumab in advanced soft-tissue sarcoma and bone sarcoma (SARC028): a multicentre, two-cohort, single-arm, open-label, phase 2 trial [published correction appears in Lancet Oncol. 2017 Dec;18(12 ):e711] [published correction appears in Lancet Oncol. 2018 Jan;19(1):e8]. Lancet Oncol. 2017;18(11):1493-1501. doi:10.1016/S1470-2045(17)30624-1
  • Based on the available lab data in HIS5 since 2020-09-09, the patient’s HGB level has never reached the lower limit of normal. In 2023, the patient has received her 7th blood transfusion during this hospitalization.

  • There is no medication reconciliation issue found in the patient.

2023-02-21

  • 2023-02-08 CT showed disease progression compared to 2022-12-08 CT.
  • The patient has had a relatively low blood pressure of around 100/70 and a slightly elevated resting heart rate of around 90 during her hospital stay. Adequate hydration may be beneficial in this situation.

2023-02-03

  • Tramectedin is an alkylating agent approved for the treatment of unresectable or metastatic soft tissue sarcomas (liposarcomas or leiomyosarcomas). It is a temporary purchase item in this hospital and could be a subsequent option if nivolumab becomes less effective. For patients previously treated unresectable/metastatic liposarcoma or leiomyosarcoma: IV 1.5 mg/m2 as a continuous infusion over 24 hours once every 3 weeks; continue until disease progression or unacceptable toxicity.
    • ref:
      • Efficacy and Safety of Trabectedin or Dacarbazine for Metastatic Liposarcoma or Leiomyosarcoma After Failure of Conventional Chemotherapy: Results of a Phase III Randomized Multicenter Clinical Trial. J Clin Oncol. 2016;34(8):786-793. doi:10.1200/JCO.2015.62.4734
      • Doxorubicin alone versus doxorubicin with trabectedin followed by trabectedin alone as first-line therapy for metastatic or unresectable leiomyosarcoma (LMS-04): a randomised, multicentre, open-label phase 3 trial. Lancet Oncol. 2022;23(8):1044-1054. doi:10.1016/S1470-2045(22)00380-1
      • The Role of Trabectedin in Soft Tissue Sarcoma. Front Pharmacol. 2022;13:777872. Published 2022 Feb 23. doi:10.3389/fphar.2022.777872

2022-04-15

[tube feeding]

  • All the oral drugs can be administered with a nasogastric tube.
  • The coadministration of fentanyl, diphenhydramine, and estazolam may enhance the CNS depressant effect, please observe for signs of slowed or difficult breathing, and/or sedation.

701388511

230315

{not completed}

{angioimmunoblastic T cell lymphoma, high grade with neck, inguinal, retroperitoneal LN metastases and generalized skin rashes, Lugano stage III, PS:0}

[lab data]

  • PSA
    • 2022-08-08 PSA 8.100 ng/mL
    • 2022-07-15 PSA 7.360 ng/mL

[exam findings]

  • 2022-08-08 Patho - prostate needle biopsy
    • Prostate, right, needle biopsy — Prostatic adenocarcinoma (Gleason score = 7 = 4 +3 ) involving 3 of 6 strips of prostatic tissue by the number of involved strips or 50 % by the involved volume of the specimen.
    • The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
    • Histologic Type: Prostatic adenocarcinoma
    • Histologic Grade: Gleason score = 7 = 4 + 3
    • Tumor Quantitation: For needle biopsy: Proportion of prostatic tissue involved by tumor: 3 of 6 strips of prostatic tissue by the number of strips or 50 % by the volume of the specimen.
  • 2022-08-08 Patho - prostate needle biopsy
    • Prostate, left, PSA = 7.360, needle biopsy — stromal and glandular hyperplasia with multiple foci of chronic inflammation. All prostatic glands are 34betaE12 (+) and AMACR (-) with IHC stains.
  • 2022-06-10 SONO - neck
    • Some LNs in bil. neck.
  • 2022-05-12 PET scan (at Cardinal Tien Hospital)
    • Malignant lymphoma with bilateral sides of neck LNs, submental LNs, mediastinal LNs, bilateral axillary LNs, hepatoduodenal ligament LNs, retroperitoneal LNs, bilateral iliac chain LNs and bilateral inguinal LNs involvement.
  • 2022-05-11 Patho - neck (at Cardinal Tien Hospital)
    • high grade lymphoma, favor T-cell lymphoma, angioimmunoblastic T cell lymphoma is compatible.
    • CD3:(+/diffuse), BCL:(+/diffuse), CD20(-), CD10(+), CD4(+), CD21(+) for follicular dendritic cells, CD8(+), EBV(-), MIB-1: highly increasing proliferative index for tumor cells.
  • 2022-05-05 SONO - abdomen (at Cardinal Tien Hospital)
    • fatty liver, hepatic cyst, GB wall thickening, Intra abdominal LN, renal cyst and splenomegaly.
  • 2022-04-28 CT - neck (at Cardinal Tien Hospital)
    • extensive lymphadenopathy at bilateral neck, upper mediastinum on 2022/4/28.
  • Initial presentation
    • body weight loss 10kg in one month and neck lymphadenopathy

[chemoimmunotherapy]

  • 2022-08-14 - cyclophosphamide 750mg/m2 1600mg 30min + doxorubicin 50mg/m2 100mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-5
  • 2022-07-25 - cyclophosphamide 750mg/m2 1600mg 30min + doxorubicin 50mg/m2 100mg 30min + prednisolone 60mg/m2 40mg TID D1-5
  • 2022-07-04 - cyclophosphamide 750mg/m2 1600mg 30min + doxorubicin 50mg/m2 100mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-5
  • 2022-06-10 - cyclophosphamide 750mg/m2 1600mg 30min + doxorubicin 50mg/m2 100mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-5

[family meeting minutes]

  • In the family meeting, the attending physician Dr. Gao explained the process and precautions of autoPBSCT to the patient and his family members (sister and brother-in-law). The patient expressed his willingness to fully cooperate. However, the patient has been married before and his only daughter is currently studying in the United States and is unaware of her father’s medical condition.

  • The patient’s family support may be insufficient before and after the scheduled transplantation. The nursing station will assist in coordinating caregiver arrangements. The attending physician reminded the patient to inform his daughter about his condition, and the patient indicated his understanding.

701313188

230314

[diagnosis] - 2023-03-13 admission note

  • Diffuse large B-cell lymphoma, extranodal and solid organ sites
  • Localized swelling, mass and lump, neck
  • Chronic sinusitis, unspecified
  • Temporomandibular joint disorder, unspecified

[past history]

Medical history: HTN, Chronic rhinosinusitis

Operation history: - glaucoma - s/p Parotidectomy, left、submandibular gland tumor excision, left - s/p Port-A insertion, L’t after L’t cephalic vein exploration         

[allergy]

  • NKDA     

[family history]

Denied family history

[exam findings]

  • 2023-02-17 SONO - abdomen
    • Liver cysts
    • Gallbladder adenomyomatosis
    • Splenomegaly
  • 2023-02-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (131 - 54) / 131 = 58.78%
      • 2D (M-simpson) = 59
    • Mildly dilated LV with mild hypokinesia of inferior wall, mid-to-apical posterior wall; preserved LV systolic function.
    • Normal RV systolic function.
    • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Aortic valve sclerosis; midl MR; trivial TR.
    • Mildly dilated aoartic root and proximal ascending aorta (35 mm)
  • 2023-02-14 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
  • 2023-02-10 CXR
    • Solitary pulmonary nodule at RUL.
  • 2023-02-09 Whole body PET scan
    • Glucose hypermetabolism in a left posterior upper neck lymh node and in the right submandibular gland. Lymphoma should be watched out.
    • Glucose hypermetabolism in a focal area in the region about left aspect of soft palate and in the region about right posterior gingiva. The nature is to be determined (inflammation? lymphoma?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the left parotid and left submandibular areas. Post-operative inflammation may show this picture.
    • Mild glucose hypermetabolism in some bilateral neck level II lymph nodes, in a focal area in the left anterior upper chest and in a focal area in the lower lobe of left lung. Inflammatory process is more likely.
    • Increased FDG accumulation in both kidneys, bilateral ureters and colon. Physiological FDG accumulation may show this picture.
  • 2023-01-27 Patho - salivary gland resection
    • DIAGNOSIS:
      • A: Salivary gland, left parotid, parotidectomy — Diffuse large B-cell lymphoma, non-GCB type
      • B: Salivary gland, left parotid, inferior pole of deep lobe, parotidectomy — Diffuse large B-cell lymphoma, non-GCB type
      • C: Salivary gland, left parotid, superior pole of deep lobe, parotidectomy — Negative for malignancy
      • D: Salivary gland, left parotid, superior margin, parotidectomy — Diffuse large B-cell lymphoma, non-GCB type
      • E: Salivary gland, left submandibular gland, excision — Diffuse large B-cell lymphoma, non-GCB type
      • F: Lymph node, left, level Ib, dissection — Diffuse large B-cell lymphoma, non-GCB type
      • G: Salivary gland, left residual submandibular gland, excision — Diffuse large B-cell lymphoma, non-GCB type
      • F2023-00041
        • Parotid gland, left, biopsy — Diffuse large B-cell lymphoma, non-GCB type
    • GROSS DESCRIPTION:
      • A: Specimen submitted in formalin consists of a piece of left parotid gland weighing 28.0 gm and measuring 4.7 x 4.7 x 2.5 cm. On cut, there is a gray, solid tumor measuring 4.0 x 3.0 x 1.7 cm. The tumor is involving the anterior, superior, inner resection margins, and 1.2 cm, 0.7 cm, and 0.1 cm away from the posterior, inferior, and outer resection margins. The parenchyma elsewhere is unremarkable. Representative sections are taken and labeled as A1-6: tumor (A1: superior: ink black, outer: ink green, inner: ink yellow; A2: inferior: ink black, outer: ink green, inner: ink yellow; A3: anterior; A4: posterior).
      • B: Specimen submitted in formalin consists of 3 pieces of tan, irregular tissue measuring up to 1.8 x 1.0 x 0.3 cm. All for section in a cassette B.
      • C: Specimen submitted in formalin consists of 3 pieces of tan, irregular tissue measuring up to 0.8 x 0.6 x 0.2 cm. All for section in a cassette C.
      • D: Specimen submitted in formalin consists of a piece of tan, irregular tissue measuring 1.4 x 0.8 x 0.6 cm. All for section in a cassette D.
      • E: Specimen submitted in formalin consists of a piece of left submandibular gland tissue measuring 5.0 x 3.0 x 2.4 cm. On cut, there is a gray, solid tumor measuring 3.7 x 3.0 x 2.4 cm. The tumor is involving the peripheral resection margin. Representative sections are taken and labeled as: E1-2: the same level.
      • F: Specimen submitted in formalin consists of 4 level Ib lymph nodes, measuring up to 1.1 x 0.7 x 0.5 cm. All for section in a cassette F.
      • G: Specimen submitted in formalin consists of a piece of left residular submandibular gland tissue measuring 1.8 x 1.4 x 0.6 cm. On cut, there is a gray, solid tumor almost involving the whole specimen. The tumor is involving the peripheral resection margin. The specimen is bisected and all for section in a cassette G.
      • F2023-00041
        • Specimen submitted in fresh consists of a piece of tan, irregular tissue measuring 0.7 x 0.3 x 0.2 cm. All for section in a cassette for frozen examination.
    • MICROSCOPIC DESCRIPTION:
      • A: Sections show salivary gland with diffusely infiltration of large lymphoid cells. The immunohistochemical stains reveal CD3(-), CD20(+), BCL2(+), BCL6(-), CD10(-), MUM1(+), Cyclin D1(-), and c-MYC(-). The Ki-67 is about 20-30%. The results are consistent with diffuse large B-cell lymphoma, non-GCB type.
      • B: Section shows salivary gland with infiltration of large lymphoid cells.
      • C: Section shows salivary gland without infiltration of large lymphoid cells.
      • D: Section shows salivary gland with infiltration of large lymphoid cells.
      • E: Sections show salivary gland with diffusely infiltration of large lymphoid cells.
      • F: Section shows 4 lymph nodes with infiltration of large lymphoid cells.
      • G: Section shows salivary gland with diffusely infiltration of large lymphoid cells.
      • F2023-00041
        • Section shows salivary gland with diffusely infiltration of large lymphoid cells and marked crushed artifact.
  • 2022-12-20 CT - neck
    • CT scans of the neck from the level of hard palate to the level of infraclavicular region using a 64-sliced multi-detector row volumetric CT after intravenous injection of 100 c.c. iodinated contrast agent.
    • Coronal reformation was performed. The slice thickness is 5 mm.
    • Findings:
      • One well-defined nodular lesion (3.6cm) within left parotid gland, showing homogeneous enhancement. May be a benign mixed tumor. Suggest tissue proof.
      • The oral cavity shows no evidence of focal lesion.
      • The mouth floor and submandibular regions are normal. No focal lesion is identified.
      • Relative hypertrophy of left submandibular gland.
      • The thyroid appears normal in size and enhancement.
      • Effacement of left pyriform sinus.
  • 2022-12-19 Nasopharyngoscopy
    • Findings: synechia between R middle T and septum; bilateral middle T polypoid change with clear to whitish mucus; smooth nasopharynx, oropharynx, hypopharynx.
    • Diagnosis/Conclusion: chronic rhinosinusitis

[chemoimmunotherapy]

  • 2023-03-13 - rituximab 375mg/m2 646mg NS 500mL 8hr D1 + [cyclophosphamide 750mg/m2 1292mg NS 250mL 30min + liposome doxorubicin 30mg/m2 52mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min] D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CDOP)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2023-02-16 - rituximab 375mg/m2 646mg NS 500mL 8hr D1 + [cyclophosphamide 750mg/m2 1292mg NS 250mL 30min + liposome doxorubicin 30mg/m2 52mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min] D2 + prednisolone 60mg/m2 20# as 7#, 7#, 6# TID PO D2-6 (R-CDOP)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2

[assessment]

  • The patient’s underlying hypertension is well controlled with Exforge (amlodipine 5mg + valsartan 160mg) currently and there were no medication reconciliation issues.

701328032

230314

[diagnosis] - 20221219 admission note

  • Malignant neoplasm of stomach, unspecified
  • Mixed hyperlipidemia
  • Chronic gastric ulcer without hemorrhage or perforation
  • Ulcer of esophagus without bleeding

[exam findings]

  • 2022-12-22 Body fluid cytology - ascites
    • atypia
  • 2022-12-14 CXR
    • Atherosclerosis of the aorta.
  • 2022-11-14 CXR
    • Ground glass opacity in bilateral lower lungs.
    • Left pleural effusion.
  • 2022-11-11 Patho - gallbladder (benigh lesion)
    • Gallbladder, laparoscopic cholecystectomy — acute cholecystitis, compatible with cholelithiasis
  • 2022-11-11 Patho - stomach biopsy
    • Diagnosis:
      • Stomach, antrum, partial gastrectomy — Poorly differentiated adenocarcinoma
      • Lymph node 1, dissection — Metastatic adenocarcinoma ( 1 / 5 )
      • Lymph node 3, dissection — Metastatic adenocarcinoma ( 2 / 2 )
      • Lymph node 4, dissection — Metastatic adenocarcinoma ( 3 / 7 )
      • Lymph node 5, dissection — Metastatic adenocarcinoma ( 1 / 1 )
      • Lymph node 6, dissection — Metastatic adenocarcinoma ( 3 / 6 )
      • Lymph node, unspecified, dissection — Metastatic adenocarcinoma ( 2 / 7 )
      • Lymph node 14, dissection — Negative for malignancy ( 0 / 1 )
      • Omentum, omentectomy — Negative for malignancy
      • AJCC 8th edition pathology stage:pT4aN3a(if cM0); AJCC stage IIIB
    • Gross Description:
      • Procedure: Partial gastrectomy, distal
      • Tumor Site: Antrum
      • Tumor Size: 5.5x 4.2 cm
      • Gross configuration - For advanced carcinoma (Borrmann classification): Type III: Ulcerated with poorly defined infiltrative margins
      • Sections are taken and labeled as: F2022-530FS:margin, A1:D-margin, A2-12:tumor, B:LN1, C:LN3, D:LN4, E:LN5, F:LN6, G1-2:lymph node, H:LN14, I:omentum
    • Microscopic Description:
      • Histologic Type
        • Adenocarcinoma
        • Lauren classification of adenocarcinoma: Intestinal type
      • Histologic Grade: G3: Poorly differentiated
      • Tumor Extension: Tumor invades the serosa (visceral peritoneum)
      • Margins
        • Proximal margin: uninvolved by invasive carcinoma
        • Distal margin: uninvolved by invasive carcinoma
        • Radial margin: involved by invasive carcinoma
      • Lymphovascular Invasion: present
      • Perineural Invasion: present
      • Regional Lymph Nodes
        • Number of lymph nodes examined/involved: 12 / 29
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply)
          • m (multiple primary tumors) r (recurrent) y (posttreatment)
        • Primary Tumor (pT)
          • pT4a: Tumor invades the serosa (visceral peritoneum)
        • Regional Lymph Nodes (pN)
          • pN3a: Metastasis in seven to 15 regional lymph nodes
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case)
          • Not applicable
      • Additional Pathologic Findings
        • None identified
        • Intestinal metaplasia
      • Ancillary Studies : None
      • Comment(s): None
  • 2022-11-05 CT - chest
    • A nodule at RML. Emphysema at bil. lungs.
    • Gastric antral cancer with outlet obstruction and regional LAP.
    • Left adrenal tumor (1.7cm).
    • Gallbladder stones (up to 1.3cm).
    • A calcified spot (6mm) at right subphrenic region.
  • 2022-11-01 Flow Vlume Test
    • mild obstructive impairment
  • 2022-10-31 Patho - stomach biopsy
    • Stomach, antrum, biopsy — Adenocarcinoma, moderately differentiated
    • The secvtions show a picture of adenocarcinoma, moderately differentiated, composed of cuboidal neoplastic cells, arranged in tubular and papillary patterns with desmoplastic stromal reaction. Mucosal ulcer is present.
  • 2022-10-31 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Advanced gastric cancer with obstruction, Borrmann type III, antrum, s/p biopsy*3
      • Reflux esophagitis LA grade D
      • Incomplete study
    • Suggestion
      • NG decompression
      • Follow up pathology result
  • 2022-10-28 ECG
    • Normal sinus rhythm
    • Right bundle branch block
    • Abnormal ECG
  • 2022-10-26 CT - abdomen
    • History: hunger epigastric pain for months, being told to have one huge ulcer at antrum, tissue proved adenocarcinoma (2022-10-04) refer to GS Dr.
    • Findings:
      • There is circumferrential asymmetrical wall thickening at the gastric antrum, measuring 1.5 cm in the maximal wall thickness that is c/w adenocarcinoma (T3).
        • In addition, There are five enlarged nodes in the gastrohepatic ligament and hepatoduodenal ligament that may be metastatic nodes (N2).
      • There are several gallstones (< 1.5 cm) and mild wall thickening of the gallbladder.
      • There is a calcification 7 mm at S8 of the liver dome that is c/w old granuloma.
      • There is a mass lesion in left adrenal gland, measuring 1.8 cm in size, -2 HU at non-enhanced CT and 42 HU at portal venous phase images.
        • Adenoma of left adrenal gland is highly suspected.
        • Follow up is indicated.
      • Abdominal aorta shows atherosclerosis andectasia 2.2 cm.
      • A renal cyst measuring 0.8 cm in left upper pole is noted. Please correlate with sonography.
      • There is a small soft tissue nodule in RML of the lung, measuring 3 mm in size at lung window setting (Srs:302 Img:7).
        • Follow up chest CT 6 months later is indicated.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N2 (N_value) M:M0 (M_value) STAGE:III(Stage_value)

[surgical operation]

  • 2022-11-10
    • Surgery
      • radical subtotal gastrectomy with D2 dissection
      • HIPEC with Oxalip (300mg/M2) at 42 degree C 60 mins
    • Finding
      • distal gastric cancer with multiple LN alpable
      • peritoneal seeding+
      • serosa++

[chemotherapy]

  • 2023-03-13 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2400mg 3880mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-17 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 625mg NS 250mL 2hr + fluorouracil 2400mg 3770mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-03 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 625mg NS 250mL 2hr + fluorouracil 2400mg 3770mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-20 - oxaliplatin 60mg/m2 90mg D5W 250mL 2hr + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2000mg 3200mg NS 500mL 46hr + [docetaxel 30mg/m2 20mg + cisplatin 30mg/m2 20mg + gentamicin 20mg + sodium bicarbonate 1400mg] IP 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-11-10 - oxaliplatin 300mg/m2 510mg IP 1hr (HIPEC)

==========

2023-01-04

Based on the available lab data, serum Ca levels are stably lower than the normal range. If PTH secretion is insufficient to act on kidney, bone, and intestines, hypocalcemia may occur (hypoparathyroidism). No PTH lab data available. As the serum albumin concentration is also below normal, the low calcium level could also be due to a reduction in serum albumin levels.

Even when potassium supplements are taken intermittently, serum K readings remain below normal range since December 2022. An acute increase in hematopoietic cell production is associated with potassium uptake by the new cells and this may lead to hypokalemia. Administration of vitamin B12 or folic acid to treat a megaloblastic anemia or use of granulocyte-macrophage colony-stimulating factor (GM-CSF) to treat neutropenia are the most common scenarios in which this occurs.

2022-12-20

  • Cancer multidisciplinary team meeting (2022-12-06) concluded the treatment for the case: arrange further CCRT and keep IP C/T.
  • This patient is admitted for mFOLFOX chemotherapy as arranged. Based on lab data (2022-12-19), the chemotherapy was not contraindicated.
  • There were low levels of albumin (3.1g/dL 2022-12-19) and prealbumin (13.85mg/dL 2022-11-21). They might indicate a short-term impairment in energy intake and the effectiveness of nutritional support.
  • As a diagnosis item, mixed hyperlipidemia is listed, however no associated medication is prescribed, and recent lab data show that triglyceride levels have returned to normal.
    • 2022-11-21 Triglyceride (TG) 109 mg/dL
    • 2022-11-14 Triglyceride (TG) 111 mg/dL
    • 2022-11-08 Triglyceride (TG) 156 mg/dL

700978784

230313

[diagnosis] - 2023-03-12 admission note

  • Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma]
  • Unspecified B-cell lymphoma, lymph nodes of head, face, and neck
  • Type 2 diabetes mellitus with diabetic nephropathy

[edu opinion] - 2023-03-12 admission note

History - Orbital lymphoma more commonly presents in the middle-age and the elderly. - Slowly progressing, and typically painless.

Signs - Conj: the typical lesion is salmon or flesh-pink color - Orbit, eyelid: when palpable, the masses are firm. - Lacrimal gland: an “S-shaped” mass due to the lateral location of the lacrimal gland - Proptosis - Ptosis and decreased levator function may indicate superior orbital and levator muscle involvement, and motility should also be measured if the patient complains of diplopia. - Signs are more commonly unilateral

Symptoms - Many lesions are asymptomatic but depending on the location of the mass, patients can complaint of exophthalmos, pain or diplopia, as well of conjunctival, eyelid, orbital or lacrimal gland mass.

Differential diagnosis - Benign lymphoproliferative lesions - Lymphoid hyperplasia - Systemic lymphoma - Metastasis - Amelanotic melanoma - Epithelial tumors - Inflammatory and infectious lesions - Orbital pseudotumor - Cavernous hemangioma    

[past history]

  • DM
  • Hyperlipidemia
  • Mucosa‐associated lymphoid tissue (MALT) lymphoma over kidney and urinary system s/p radiotherapy 

[allergy]

  • NKDA

[exam findings]

  • 2023-03-09 2D transthoracic echocardiography

(145 - 47) / 145 - M-mode (Teichholz) = 68 - Prominent concentric LV hypertrophy and mild RV hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; moderately dilated LA. - Dilated LV with normal LV and RV systolic function. - Aortic valve sclerosis and mild aortic root calcification; mild MR; mild PR.

  • 2023-03-07, 2022-12-20 ECG
    • Normal sinus rhythm
    • Moderate voltage criteria for LVH, may be normal variant
  • 2023-02-21 Patho - bone marrow biopsy
    • PATHOLOGIC DIAGNOSIS
      • Bone marrow, iliac creast, biopsy — Free from lymphoma involvement
    • Immunohistochemical stains:
      • MPO: positive for myeloid series
      • CD71: positive for erythroid series
      • CD61: positive for megakaryocytes
      • CD34 and CD117: positive for blast
      • CD20: positive for B-cell
      • CD3: positive for T-cell
  • 2023-02-17 Patho - colon biopsy
    • Polypoid colonic lesion, cecum, biopsy — Non-specific chronic colitis
  • 2023-02-17 SONO - nephrology
    • Chronic renal parenchymal disease, mild to moderate degree
    • Right renal cysts
  • 2023-01-27 CT - chest
    • Indication:
      • Unspecified B-cell lymphoma, lymph nodes of head, face, and neck
      • Type 2 diabetes mellitus with diabetic nephropathy
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 2.5 mm lung window,5 mm soft-tissue window slice thickness)
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Minimal interstitial infiltration over both lungs is found.
        • Patent airway is found.
        • There is no evidence of destructive bone lesion.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Mild left hydronephrosis and hydroureter is found.
        • Right renal stone is found.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
    • IMp: Minimal interstitial infiltration over both lungs
  • 2023-01-20 Patho - stomach biopsy
    • Stomach, low body and antrum, biopsy— chronic gastritis with intestinal metaplasia and Helicobacter infection
    • Stomach, cardia, biopsy— inflammatory polyp with Helicobacter infection
  • 2023-01-18 Whole body PET scan
    • Glucose hypermetabolism in the left orbital fossa (Deauville score 5), compatible with lymphoma with tumor recurrence.
    • Glucose hypermetabolism in bilateral mediastinal and bilateral pulmonary hilar lymph nodes (Deauville score 4-5), tumor recurrence should be considered, suggesting biopsy for further investigation.
    • Glucose hypermetabolism in a lymph node in the right retromolar region (Deauville score 4) and in the gastric region (Deauville score 4), the nature is to be determined (reactive or recurrent nodes, or other nature ?), suggesting follow-up.
    • Increased FDG uptake in the rectal region, the nature is to be determined also, suggesting colon fibroscopy exam. for investigation.
    • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    • B-cell lymphoma s/p treatment with tumor recurrence, rc-stage II at least, by this F-18 FDG PET scan.
  • 2023-01-02 Patho - soft tissue nontumor/mass/lipoma/debridement
    • PATHOLOGIC DIAGNOSIS
      • Orbital, left, biopsy — Small B-cell lymphoma, compatible with extranodal marginal zone lymphoma
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Small B-cell lymphoma, compatible with extranodal marginal zone lymphoma, composed of small to medium-sized, slightly irregular nuceli with abundant pale cytoplasm and monocytoid appearance
      • Pathologic Extent of Tumor: To adjacent adipose tissue
      • Additional Pathologic Findings: None identified
      • Immunophenotyping: CD3(-), CD20(+), CD5(-), CD23(focal+), CD43(-), Cyclin D1(-)
  • 2022-12-20 Nasopharyngoscopy
    • polyp over right middle meatus, mucopus over right inferor meatus and left chona, polyp over nasopharynx, fair vocal fold movement
  • 2022-12-14 CT - orbits
    • With and Without contrast CT of the bilateral orbital cavities showed
      • An irregular-margined soft tissue lesion, about 38.7mm, with attachment to the anterior aspect of the left IR muscle. Mild enhancement was noted.
      • The anterior and lateral bony walls of right maxillary sinus were thickened.
      • The mucosal thickening in the bilateral ethmoidal, sphenoidal and right maxillary sinuses with destruction of the medial wall of the right maxillary sinus. Some calcified spots within the right maxillary sinus were noted.
    • IMP:
      • Suspected inflammatory tumor in the left orbital cavity or hemangioma (less likely).
      • Suspected infectious process or tumor in the right maxillary sinus.
  • 2022-12-14 Nasopharyngoscopy
    • smooth nasopharynx, oropharynx, hypopharynx
    • nasal polyp over right middle meatus, no obvious mucopus noticed
    • post-nasal dripping over nasopharynx
  • 2018-10-31 SONO - abdomen
    • Diagnosis
      • Fatty liver,mild to moderate
      • Suspected renal cysts,bil
      • Pancreas not shown
      • Suboptiaml examination of liver due to Poor echo window
    • Suggestion
      • OPD follow up
      • Follow liver function test and AFP
      • Small liver lesion may be masked by bowel gas, especially liver dome

[consultation]

  • 2022-12-14 Ear Nose Throat
    • Q
      • Pain noted around left eye, no blurring of vision
      • Redness +, Swelling +, Local Heat +
      • Past History: DM, HTN
      • Surgical history: Denied
      • Drug allergy: Denied
    • A
      • S
        • Left eye pain and periorbital swelling for 2 months
        • Phx: type 2 DM, dyslipidemia, gout
        • no visual loss, diplopia, facial pain, epistaxis, foul smelling, epistaxis, nasal obstruction, rhinorrhea
      • O
        • Local finding: bilteral pale and boggy inferior turbinates
        • Scope:
          • smooth nasopharynx, oropharynx, hypopharynx
          • nasal polyp over right middle meatus, no obvious mucopus noticed
          • post-nasal dripping over nasopharynx
        • CT: sinusitis over bilateral sphenoid sinus and right maxillary sinus, mass lesion over left infra-orbital region
      • A
        • Impression: Right maxillary sinusitis
      • P
        • Nasonex for right side sinusitis
        • Survey and management of right eye lesion as ophthalmalogist suggested
        • ENT OPD f/u a week later
        • Well education
        • if diplopia, visual loss noticed, back to ER soon
  • 2022-12-14 Ophthalmology
    • Q
      • Pain noted around left eye, no blurring of vision
      • Redness +, Swelling +, Local Heat +
      • Past History: DM, HTN
      • Surgical history: Denied
      • Drug allergy: Denied
    • A
      • S: left periorbital swelling for 1-2 month, no BV, no diplopia, no pain
        • PHx: DM, hyperlipidemia, ophx denied, nka
      • O
        • WBC 6740, CRP 0.8
        • BCVA OD 0.6x-1.75/-2.25x75 OS 0.6x-3.0/-1.0x100
        • PT: 15/18 mmHg
        • pupil: 3mm+/+, 3mm+/+, no rapd
        • palpation : no tenderness
        • Hertel exophthalmometer: 12>–120–<16
        • EOM: mild limitation at lower left gaze os
        • conj: mild chemosis os
        • K: cl ou
        • AC: deep and clear ou
        • LenS: NS + ou
        • F’d: no infiltration, no whitish nor lelvated lesion, no vessel compromise , macula ok, no break ou
      • A: orbital tumor with proptosis, os cause to be determied, lymphoma?
      • P:
        • please consult ENT for sinus lesion
        • explain to the patient, the lesion might be benign or malignant, further survey is needed
        • inform the risk of disesae progression and IOP elevation, if difficulty on opening eye and progressive pain, come back to ER asap
        • opd f/u on W2

[chemoimmunotherapy]

  • 2023-03-13 - rituximab 375mg/m2 674mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID D2-6
    • [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D2
  • 2023-02-21 - rituximab 375mg/m2 674mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID D2-6
    • [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D2

[assessment]

  • On 2023-03-12, a self-paid G-CSF filgrastin 150ug SC was administered due to leukopenia (WBC count of 2.73K/uL, marked with asterisks in the following table) observed on the same day. The event occurred approximately 3 weeks since the patient’s first R-CHOP treatment started on 2023-02-21. This is longer than the usual 1-2 week timeframe for WBC nadir after chemotherapy. However, it cannot be entirely ruled out that there may be other unidentified factors that are affecting the patient’s WBC count.
    • 2023-03-13 WBC 7.91 x10^3/uL
    • 2023-03-12 WBC 2.73 x10^3/uL *
    • 2023-03-03 WBC 4.72 x10^3/uL
    • 2023-02-19 WBC 3.89 x10^3/uL
    • 2023-02-03 WBC 6.99 x10^3/uL
    • 2023-01-12 WBC 9.84 x10^3/uL

701455299

230310

[exam findings]

  • 2022-12-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (82 - 26) / 82 = 68.29%
      • M-mode (Teichholz) = 68.4
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
  • 2022-11-14 Patho - breast simple/partial mastectomy
    • Diagnosis:
      • Breast, right, partial mastectomy — Invasive carcinoma of no special type, grade 2
      • Skin, right breast, partial mastectomy — Negative for malignancy
      • Lymph node, SLN, right axilla, SLNB — Negative for malignancy (0/2)
      • AJCC 8th edition pathology stage:pT1cN0(if cM0); Anatomic stage IA; AJCC prognostic stage IA
    • Gross Description
      • Procedure
        • Partial mastectomy
      • Lymph node sampling (if lymph nodes are present in the specimen)
        • Sentinel lymph node(s)
      • Specimen laterality
        • Right
      • Sections are taken and labeled as:
        • F2022-533FSA1-2: margins,
        • F2022-533FSB: SLN,
        • F2022-533A1-8: tumor and skin,
    • Microscopic Description
      • For Invasive Carcinoma
        • Histologic type: Invasive carcinoma of no special type
        • Size of invasive carcinoma (mm): 15 mm
        • Histologic grade (Nottingham histologic score): grade II (score7)
        • Extent of tumor (required only if the structures are present and involved)
        • Skin involvement: Absent
        • Chest wall invasion deeper than pectoralis muscle: Absent
      • For Ductal Carcinoma In Situ
        • Tumor size (mm): 6 mm
        • Nuclear grade: 2
        • Architectural pattern: Comedo and Non-comedo
        • Tumor necrosis: Present
      • Margins:
        • Negative, Closest margin (7 mm from closest margin)
      • Nodal status: Negative
      • No. examined: 2
      • No. macrometastases (>2 mm): 0
      • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells):0
      • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
      • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
        • In the Breast: N/A
        • In the Lymph nodes: N/A
      • Immunohistochemical Study: Reference: S2022-17911
  • 2022-11-11 Frozen Section
    • Margin, right breast, frozen section — Free
    • SLN, axilla, right, frozen section — Negative for malignancy (0/2)
  • 2022-11-11 Lymphoscintigraphy
    • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the right breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the right axilla.
    • IMPRESSION: Probably a sentinel lymph node at the right axillary region.
  • 2022-10-25 Tc-99m MDP whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the maxilla, lower T-spine, some L-spines, bilateral shoulders, sternoclavicular junctions and hips in whole body survey.
    • IMPRESSION:
      • Increased activity in the lower T-spine and some L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
      • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2022-10-24 CT - chest
    • Indication: Malignant neoplasm of unspecified site of right female breast, Unspecified lump in breast
    • MDCT (256-detector rows, GE Revolution, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images and axial slab MIP images, and oblique coronal reconstructed images of the Rt breast shows:
      • Lungs: normal appearance of bilateral lungs.
      • Mediastinum and hila: no enlarged LN or mass.
        • the trachea and main bronchi are normallly identified without endobronchial lesion.
      • Vessels:
        • the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
        • Chest wall and visible lower neck: an enhancing nodular lesion with mild lobulated contour (15mm in longest dimension) in inferior central aspect of Rt breast. multiple low density ovalm or round shaped lesions within the breast too measuring up to 3.1cm. no enlarged LNs in axilla.
      • Visible abdominal-pelvic contents: diffuse wal thickening of distal half body and fundal part with sessile luminal nodular lesions of the gall bladder.
        • unremarkable of the liver, spleen, both adrenal glands, pancreas, kidneys, uterus, U-bladder, and small and large bowels.
        • no enlarged lymph node. no ascites.
      • Visualized bones: unremarkable.
    • Impression:
      • Rt breast tumor (15mm) and multiple cysts.
      • Gall tumor.
  • 2022-10-17 Patho - breast biopsy (no need margin)
    • DIAGNOSIS:
      • A. Breast, right, nipple, core biopsy — Fibroadenoma
      • B. Breast, right, 6 o’clock, core biopsy — Invasive carcinoma, no special type, NST.
        • IHC stains: ER (+, 90%, strong intensity), PR(+, 5%, strong intensity), Her2/neu: negative(score=0), Ki-67(10 %), p53 (15-20%).
    • MICROSCOPIC DESCRIPTION:
      • A. Section shows fragments of breast tissue with fibroadenoma.
      • B. Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • 2022-10-17 SONO - breast
    • Treatment: core needle biopsy
    • Suggestion and Plan:
      • Right breast 6’region tumor, suspected malignancy, suggest biopsy.
      • Right nipple region cystic tumor, suspected intraductal papilloma, suggest biopsy.
      • Multiple bilateral breast cysts.
    • BI-RADS:
      • Category 4c: highly suspicious abnormality-biopsy should be considered.
  • 2022-10-17 Mammography
    • Indication: breast lump was noted during regular healthy examination.
    • No previous mammography is available for comparison.
    • Mammography of bilateral breasts with craniocaudal (CC) and mediolateral oblique (MLO) views shows:
      • Composition: The breast tissue is heterogeneously dense, and this may decrease the sensitivity of mammography.
      • Multiple oval nodules with obscured margin at bilateral breasts, suggest ultrasound correlation.
      • An irregular mass shadow at right lower central breast, 6’ region, superimposed with microcalcifications and associated with mild architectural distortion. Suggest ultrasound correlation and may consider biopsy.
      • No enlarged axillary lymph nodes.
    • Final assessment:
      • BI-RADS category 0, Need additional imaging evaluation.
      • Suggest ultrasound correlation for bilateral breast masses, especially right 6’ region mass.

[consultation]

  • 2022-11-11 Rehabilitation
    • Q
      • This 43 y.o lady denied systemic disease, op history on contraceptive for 10 years. 5 months before admission, noted solid tumor on 7 o’clock of right breast. Futher investigation was done. Right breast biopsy showed invasive carcinoma no special type, NST. IHC stains: ER (+, 90%, strong intensity), PR(+, 5%, strong intensity), Her2/neu: negative(score=0), Ki-67(10 %), p53 (15-20%).
        • 2022/10/17 Mamography : BI-RADS category 0, Need additional imaging evaluation.
        • 2022/10/17 Breast sono : 1. Right breast 6’region tumor, r/o malignancy, suggest biopsy. 2. Right nipple region cystic tumor, r/o intraductal papilloma, suggest biopsy.3. Multiple bilateral breast cysts.
        • 2022/10/24 Chest + Abd CT : Rt breast tumor (15mm) and multiple cysts. Gall tumor.
        • 2022/10/25 Bone scan : Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • She is admitted for partial masmectomy + SLND possible ALND.
      • We need your expertse opinion and set up rehabilitation program for post masmectomy and axillary lymph node dissection.
    • A
      • Physical examination
        • 2022/11/10 14:15 T/P/R: 36.5 degree celsius / 66bpm / 17bpm BP:118/56mmHg
        • Consciousness: clear
        • Cognition: intact
        • MP: RUE/RLE: 5/5, LUE/LLE: 5/5
        • Functional status: ID
        • ADLs: ID
        • Hand and arm circumference (R/L,cm):
          • Elbow joint above 5cm 23/23.5
          • Elbow joint below 5cm 21/21
      • Imp
        • Breast, right Invasive carcinoma, no special type, NST. IHC stains: ER (+, 90%, strong intensity), PR(+, 5%, strong intensity), Her2/neu: negative(score=0), Ki-67(10 %), p53 (15-20%).
        • Unspecified lump in breast
      • OP: right partial masmectomy + SLND possible ALND on 2022/11/11.
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation (passive ROM, massage, therapeutic exercise) and home program education
        • Goal: Functional ability ID, maintain ROM, prevent post-OP complications

[surgical operation]

  • 2022-11-11
    • Surgery
      • partial mastectomy and SLNB
    • Finding
      • right 6/1 tumor, about 1.5cm in diameter, frozen: margin free
      • SLNB: negative of malignancy, 0/2
    • Procedure
      • Under ETGA, we harvested the SLNB under gamma-detecter assisted. The frozen section showed negative of malignancy. Then we performed wide excision for right breast tumor. Then frozen section of margin showed negative of malignancy. After one J-vac drain was left, then we closed the wound layer by layers.

[chemotherapy]

  • 2023-02-20 - fluorouracil 500mg/m2 790mg NS 100mL 30min + epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 500mg/m2 790mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-30 - fluorouracil 500mg/m2 790mg NS 100mL 30min + epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 500mg/m2 790mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-03 - fluorouracil 500mg/m2 790mg NS 100mL 30min + epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 500mg/m2 790mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-12 - fluorouracil 500mg/m2 790mg NS 100mL 30min + epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 500mg/m2 790mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-03-10

  • Currently, there are no observed leukopenia symptoms. However, the time serial data of the WBC count showed a downtrend, with the nadir (marked with an asterisk in the following table) indicating a obvious decrease in accordance with the treatment cycle. To avoid over-suppressing the recovery of WBC, it may be beneficial to consider reducing the dose of epirubicin.
    • 2023-03-08 WBC 7.12 x10^3/uL
    • 2023-03-02 WBC 0.79 x10^3/uL *
    • 2023-02-16 WBC 7.56 x10^3/uL
    • 2023-02-09 WBC 1.13 x10^3/uL *
    • 2023-01-30 WBC 5.90 x10^3/uL
    • 2023-01-12 WBC 2.27 x10^3/uL *
    • 2023-01-03 WBC 5.95 x10^3/uL
    • 2022-12-20 WBC 2.23 x10^3/uL *
    • 2022-12-12 WBC 4.79 x10^3/uL
    • 2022-10-22 WBC 5.16 x10^3/uL

2023-02-20

  • The WBC count reached its lowest point approximately 7-10 days after the previous chemotherapy treatment in this patient, as indicated by the time relationship between the chemotherapy dates and the lab data recorded at this hospital.

  • Epirubicin can cause neutropenia (in 54% to 80% of patients; with grades 3/4 in 11% to 67%; nadir occurring at 10 to 14 days and recovery by day 21) and leukopenia (in 50% to 80% of patients; with grades 3/4 in 2% to 59%). ref: UpToDate

  • The prophylactic administration of G-CSF after chemotherapy may be considered around one week after treatment. Another option to consider is to moderately reduce the dose of epirubicin.

  • Cyclophosphamide use may lead to hemorrhagic cystitis, which can cause pyelitis, ureteral disease (ureteritis), and hematuria. Therefore, please closely monitor for any signs of these possible adverse reactions. Mesna can be used for the prevention of cyclophosphamide-induced hemorrhagic cystitis in cancer patients. Patients who have difficulty emptying their bladders are at a higher risk of developing bladder toxicity. If there is a clinical concern, a bladder ultrasound should be performed, and if there is a high post-void residual, the use of mesna is also appropriate for such patients.

701443048

230309

[exam findings]

  • 2023-01-09, 2022-12-13, -12-06, -11-22 CXR
    • Increased infiltration over RLL. May be active infection.
    • S/P port-A catheter insertion.
    • S/P tracheostomy.
    • S/P N-G tube insertion.
  • 2022-11-03 Patho - colon biopsy
    • Distal transverse colon, biopsy — Ulcer
  • 2022-11-01 PD-L1 IHC 28-8
    • PD-L1 Immunostaining Result
      • Tumor cell (TC) staining assessment: TC < 1%
      • Percentage of 28-8 expressing tumor cells (%TC): 0%
  • 2022-10-21 MRI - nasopharynx
    • Indication: Malignant neoplasm of tongue, unspecified
    • Findings
      • invasive tumors with heteorogeneous enhancement in the bilateral oropharynx, posterior tongue, oral tongue, mouth floor, left buccogingical mucosa, the mendible, left pterygoid plates, lower lip with the largest axis, about 111mm.
      • enlarged lymph nodes in the bilateral submandibular spaces
      • a nodular lesion about 25mm in the left thyroid gland.
    • IMP: invasive oral cavity cancer, in progression.
  • 2022-10-18 Patho - colon biopsy
    • Large intestine, descending, biopsy —- ulcer with non-specific colitis
  • 2022-10-06 Nasopharyngoscopy
    • Granulation over mouth floor, left gingival sulcus, left tonsillar fossa, tongue base (almost contacted lingual side of epiglottis), bulging of R posterior phayrngeal wall, cystic formation? over R AE fold, fair vocal cord movement
  • 2022-10-05 CT - abdomen
    • History: Recurrent squamous cell carcinoma of tongue, cT4aN0M0, stage IVA
    • Findings:
      • There is distension with fluid and gas collection of the entire colon. please correlate with clinical condition.
      • A renal cyst measuring 1.5 cm in right middle pole is noted.
      • There minimal effusion in right posterior basal CP angle.
  • 2022-10-03 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
      • PEG insertion site (wound) at AW of lower body, without presence of the PEG tube, suspected buried bumper syndrome
      • Bilious substance in stomach
      • Oral cancer
    • Suggestion
      • No bloody substance or active bleeder in UGI tract. Please survey other bleeding source, such as LGI bleeding.
      • Consider CT scan to confirm the location of the PEG. Remove the PEG tube and then revision should be done If buried bumber syndrome or migration of PEG is confirmed.
  • 2022-09-12 ECG
    • Sinus tachycardia
    • ST & T wave abnormality, consider inferior ischemia
    • ST & T wave abnormality, consider anterolateral ischemia
  • 2022-08-12 Patho - gingival/oral mucosa biopsy
    • Labeled as “left lower gingiva”, incisiaonal biopsy — squamous cell carcinoma.
    • IHC stains: p16 (-), CK5/6 (+), p40 (+).
  • 2022-08-10 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed hot areas in the mandible, and increased activity in the skull base, bilateral sternoclavicular junctions, shoulders, and S-I joints, in whole body survey.
    • IMPRESSION:
      • Hot areas in the mandible, the nature is to be determined (dental problem, cancer with local bone involvement, or other nature ?), suggesting further evaluation and follow-up with bone scan in 3 months.
      • Suspected benign lesions in the skull base, bilateral sternoclavicular junctions, shoulders, and S-I joints.
  • 2022-08-09 MRI - nasopharynx
    • Oropharyngeal Cancer (p16-) Staging Form
    • For Oropharyngeal Carcinoma (p16-)
        1. PRIMARY TUMOR:
        • T4 : Moderately advanced or very advanced local disease
          • T4a : Moderately advanced local disease: Tumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible
        1. REGIONAL LYMPH NODES:
        • N1 : Metastasis in a single ipsilateral lymph node, 3 cm or smaller in greatest dimension and ENE(−)
        1. DISTANT METASTASIS:
        • M0 : No distant metastasis (in this study)
    • AJCC 8th edition Staging status: T4aN1M0
  • 2022-08-08 SONO - abdomen
    • incomplete exam of liver
    • pancreas obscured

[consultation]

  • 2023-03-09 Family Medicine
    • Q
      • For hospice care for pain control and and aromatherapy and lymphatic massage
      • This is a 41-year-old male Fillipino patient, he had squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino. However, recurrent squamous cell carcinoma of tongue and was admitted for palliative chemotherapy. immunotherapy with OPDIVO and CCRT at our hospital since 08/16/2022 (The treatment process has been listed in detail in the progress note). ECOG: 3. However, anemia, hypoalbuminemia and mild electrolyte imbalance and swelling of face were noted. We need your help for combined hospice care for pain control and and aromatherapy and lymphatic massage, Thanks !!
    • A
      • 41 y/o gentleman advanced tongue cancer
      • pain control now
        • Fentanyl 2 large Q3D, Oxynorm (5) 2# q4H, MXL (60) 1# Q12H
      • VAS 5~ 7
      • may add lyrica for neuropathic pain
      • adjust morphine as required
      • Our sahre care would follow up.
  • 2023-03-07 Nephrology
    • Q
      • For severe hyponatremia and unbalance electrolye
      • Because of severe hyponatremia, we need your help, Thanks!!
    • A
      • We visited the patient at the bedside and evaluated his condition. His consciousness was clear, speech was coherent, no respiratory distress, no convulsions and no focal neurological symptoms were noted, and his four limbs were not edematous. He denied having drunk excessive free water or urinated in larger amount than usual.
      • His blood test showed a steep decline in serum Na levels over the course of hospitalization, but we require more data to determine the nature of hyponatremia.
        • 2023-03-06 Na (Sodium) 109 mmol/L
        • 2023-02-27 Na (Sodium) 126 mmol/L
        • 2023-02-24 Na (Sodium) 129 mmol/L
        • 2023-02-20 Na (Sodium) 132 mmol/L
      • Our advices are as follows
        • Adequate hydration with isotonic saline, and avoid 3% hypertonic saline unless patient exhibit severe neurological symptoms
        • Monitor serum Na at least Q12H, changes in serum Na levels should not exceed 4-6mEq/L within 24 hours or osmotic demyelination syndrome (ODS) may develop
        • Monitor urine output amount and neurological symptoms
        • Check serum osmolality, TSH, fT4, ACTH (8am), Cortisol (8am)
        • Check urine osmolality, Na, Cre
      • Please feel free to contact us should you require further assistance.
  • 2023-02-27 Ear, Nose, and Throat
    • Q
      • For nasal bleeding management.
      • This 41-year-old Philippine male patient was a case of recurrent squamous cell carcinoma of tongue, cT4aN1M0, stage IVa.
      • MRI revealed tumor had involved to posterior pharyngeal walls. We need your help for nasal bleeding management. Thanks.
    • A
      • S
        • L nasal bleeding even after bosmin gauze compression
        • a case of Recurrent squamous cell carcinoma of tongue, cT4aN1M0, stage IVA with cuffed-tracheostomy (Rota)
      • O
        • Left anterior nasal bleeding
        • trismus and oropharynx invisible, but no blood noticed from oral cavity
        • scope can not be performed due to active bleeding even under bosmin gauze
        • no more bleeding after merocel packing over left common meatus
      • A
        • Left epistaxis
      • P
        • no more bleeding after merocel packing over left common meatus
        • suggest abx usage for merocel insertion
        • may contact us for merocel removal 5-7 days later
  • 2023-02-21 Infectious Disease
    • Q
      • For severe leukocytosis
      • This is a 41-year-old male Fillipino patient, he had squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino. However, recurrent squamous cell carcinoma of tongue and was admitted for palliative chemotherapy. immunotherapy with OPDIVO and CCRT at our hospital since 08/16/2022. ECOG: 3. However, anemia, hypoalbuminemia and mild electrolyte imbalance were noted.
      • Because of severe leukocytosis (CRP:12.19, WBC: 17680) and sputum culture revealed Pseudomonas aeruginosa 2+ and Achromobacter xylosoxidans 2+, we need your help, Thanks !!
  • 2023-01-12 Cardiology
    • Q
      • For severe hypertension
      • This is a 41-year-old male Fillipino patient, he had squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino. However, recurrent squamous cell carcinoma of tongue and was admitted for palliative chemotherapy. Immunotherapy with OPDIVO and CCRT at our hospital since 2022-08-16. ECOG: 3. However, Anemia . hypoalbuminemia and mild electrolyte imbalance were noted . Because of severe hypertension recently, we need your help, Thanks !!
    • A
      • S
        • This 41 y/o male patient is a case of squamaous cell tongue cancer s/p OP and C/T with recurence. He was admitted for palliative chemotherapy. He also had previous history of bronchial asthma and no longer attack in the previous 2 years. High BP was recorded after hospitalization. Now we are consulted for adjusting anti-HTN medications.
      • O
        • BP: 160190/80110+ mmHg, HR:80~110 BPM
        • Current anti-HTN medications: olmetec 1# BID use
        • 20221024 EKG: sinus tachycardia
        • 20230111 BUN/CR:12/0.55, ALT:8, K:3.1
      • Suggestion:
        • Please add adapin (nifedipine 30mg) 1# QD and nebilet (nebivolol 5mg) 1/2 # QD for better BP and HR control.
        • If elevated BP is still recorded 3~5 days later, then push up adapin to 1 # BID, and push up nebilet to 1# QD if no bronchial asthma happens after nebilet treatment.
        • Change olmetec to micardis (telmisartan) 1# QD if above treatment is unsatisfactory for BP control.
  • 2022-11-22 Radiation Oncology
    • Q
      • For radiation therapy
      • This is a 41-year-old male Fillipino patient , he had squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino. However, recurrent squamous cell carcinoma of tongue and was admitted for palliative chemotherapy and imunotherapy.
        • Anti-neoplastic therapy:
          • Palliative chemotherapy with #3 Erbitux 400mg/M^2 + #2a 90% TPF (Taxotere 36mg/M^2, Cisplatin 36mg/M^2, 5-Fu 900mg/M^2, Leucovorin 90mg/M^2) on 2022/09/07 - 2022/09/09.
          • Palliative chemotherapy with #4 Erbitux 400mg/M^2 + #2b 60% TPF (Taxotere 24mg/M^2, Cisplatin 24mg/M^2, 5-Fu 600mg/M^2, Leucovorin 60mg/M^2) on 2022/09/30 - 2022/10/02.
          • Palliative chemotherapy with #5 Erbitux 250mg/M^2 + #3a 70% Taxotere 28mg/M^2 on 2022/11/01.
          • Palliative chemotherapy with #6 Erbitux 250mg/M^2 + #3b 70% Taxotere 28mg/M^2 on 2022/11/11.
          • Immunotherapy with #1 OPDIVO 160mg on 2022/11/07. 2022/11/22.
    • A
      • S: For palliative radiotherapy due to recurrent left tongue cancer.
      • O
        • PI: This is a 41-year-old male Fillipino patient, he had squamous cell carcinoma of left oral tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Philippines. Because of recurrent squamous cell carcinoma of tongue, he was admitted for palliative chemotherapy and immunotherapy.
          • Previous RT Hx (2021-11-15 ~ 2021-12-31, St. Luke’s Medical Center, Phippines): 6000cGy/30 fractions of the (GTVp+0.1cm+ entire tongue, base of tongue, alveolar ridge, epiglottis, bilateral retrostyloid, level IB, II, III, IV, V, and modified level VI and left level IA nodes, + margins), 7000cGy/35 fractions of the [(GTVp(heterogenous enhancing mass, left hemitongue extending to the right side) + margin), + prechemotherapy level IIA, bilateral; level IB, right]+ margin] + margin.
        • ECOG: 3
        • PE: oral cavity: protruding tumor mass over anterior tongue border and low gum; poor hearing function; on oxygen inhalation.
        • MRI (2022-08-09): stage T4a(5.3cm, right tongue base; left tonsillar fossa, oropharyngeal wall), N1(right level I, single lymphadenopathy)M0.
        • Bone scan (2022-08-10): Hot areas in the mandible, the nature is to be determined (dental problem, cancer with local bone involvement, or other nature ?)
        • Pathology (S2022-13232, 2022-08-16): Labeled as “left lower gingiva”, incisiaonal biopsy — squamous cell carcinoma. IHC stains: p16 (-), CK5/6 (+), p40 (+).
        • CXR (2022-10-07): No cardiomegaly. No active lung lesion. Normal bony contour. S/P port-A catheter insertion.
        • MRI (2022-10-21): 1. invasive tumors with heteorogeneous enhancement in the bilateral oropharynx, posterior tongue, oral tongue, mouth floor, left buccogingical mucosa, the mendible, left pterygoid plates, lower lip with the largest axis, about 111mm. 2. enlarged lymph nodes in the bilateral submandibular spaces. 3. a nodular lesion about 25mm in the left thyroid gland. Imp: invasive oral cavity cancer, in progression.
      • A:
        • Squamous cell carcinoma of left oral tongue, stage cT3N0M0, stage III, s/p partial glossectomy on 2015/07.
        • Squamous cell carcinoma of left oral tongue, stage cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy and definitive radiotherapy in Philippines, with progression, s/p palliative chemotherapy and immunotherapy.
      • P: Palliative radiotherapy is indicated for this patient with the following indicators: tumor progression
        • Goal: pallaition
        • Treatment target and volume: tumor over left oral tongue to low gum and peripheral involved area
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 3000cGy/15 fractions
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be arranged.
  • 2022-10-28 Thoracic Surgery
    • Q
      • This 41-year-old Philippine male patient was a case of recurrent squamous cell carcinoma of tongue, cT4aN1M0, stage IVa. MRI revealed tumor had involved to oropharyngeal walls. However, he had suddened onset severe dyspnea and stridor were found. Acute respiratry failure were highly suspected, we need your for tracheotomy tube insertion. Thanks !!
    • A
      • The patient had buccal ca. s/p CCRT with fibrotic neck
      • Progressive dyspnea noted since last night
      • Tracheostomy may be considered but very high risk of life threatening
      • Consult ANE Dr for evaluation
      • Prepare ICU bed
  • 2022-10-12 Dermatology
    • Q
      • However, patient complained of itching skin lesion suspected fungal infection in right inguinal was noted for a while. We need your expertise and further management. Thanks !!
    • A
      • The patient had sufferred from erythematous to blackwish palques over bilateral inguinal area with staellite active borders.
      • Under the impression of intertrigo eczema with seocndary candidiasis infesation.
      • The following sugeetion:
        • Zalain (sertaconazole) 1 tube topical bid use over large area of invloved area
        • Please keep the affected area dry and clean, add Mycomb (nystatin, triamcinolone, neomycin, gramicidin) 1 tube topical bid use on the active scaling lesions of bilateral inguinal area.
  • 2022-10-03 Gastroenterology
    • Q
      • However, blood stool since 2022-10-02 was noted. Anemia (Hb: 7.9) and tachycardia this morning. Because of suspected GI bleeding. We need your further evaluation and suggestion. Thanks !!
    • A
      • S
        • The 41-year-old man has left tongue cancer, cT3N0M0, stage III, s/p glossectomy and chemotherapy at Philippines. Due to further treatment of recurrent left tongue cancer, he transfered to Taiwan for further management. He just received chemotherapy, finished on 2022-09-30 but bloody stool with tarry was noted. Therefore, we are consulted for further management.
      • O
        • PE
          • conscious: clear
          • chest: smooth breath pattern under room air
          • abdomen: soft and flat
          • extremity: warm
        • Lab
          • Hb: 10.8 -> 7.9
          • Plt: 515k -> 542k
        • 20221003 EGD
          • Diagnosis:
            • Reflux esophagitis LA Classification grade A
            • Superficial gastritis
            • PEG insertion site (wound) at AW of lower body, without presence of the PEG tube, r/o buried bumper syndrome
            • Bilious substance in stomach
            • Oral cancer
          • Suggestion:
            • No bloody substance or active bleeder in UGI tract. Please survey other bleeding source, such as LGI bleeding.
            • Consider CT scan to confirm the location of the PEG. Remove the PEG tube and then revision should be done If buried bumber syndrome or migration of PEG is confirmed.
      • Impression
        • Tarry stool with blood clot, lessly like Upper GI tract bleeding by 20221003 EGD, need to rule out Lower GI tract bleeding
      • Suggestion
        • Due to the patient unable oral intake and dysfunction PEG, please use Ducolax 2PC BID + Cleanse enema, then arrange Colonscopy
        • If massive bleeding again or unstable hemodynamic status, please arrange CTA or TAE
        • Due to PEG dysfunction, after bleeding subsided, discuss with GS for further management.
  • 2022-09-28 Infectious Disease
    • Q
      • This 40-year-old male Fillipino patient who sufferred from recurrent squamous cell carcinoma of tongue, cT4aN1M0, stage IVA and under process in palliative chemotherapy treatment. Leukocytopenia, anemia, hypoalbumin and electrolyte imbalance were noted during this chemotherapy course.
      • Current problem: his central line culture showed GNB, we need your further evaluation and suggestion. Thanks !!
    • A
      • S: The patient’s condition was as your description.
      • O: 2022-09-25 B/C: GNB
      • Suggestion:
        • Antibiotics with finibax 500mg iv q8h for GNB sepsis is suggested.
        • DC tapimycin
        • Please remove or exchange the CVP
        • Check CXR
  • 2022-09-07 Metabolism and Endocrinology
    • Q
      • However, his thyroid function showed T3 46.195ng/dl, T4 4.076, free T4 1.388 and TSH 1.3. We need your further evaluation and suggestion. Thanks !!
    • A
      • S
        • This 40-year-old male, with past history of squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino, was admitted due to recurrent squamous cell carcinoma of tongue and for palliative chemotherapy. We were consulted for abnormal TFT.
      • O
        • HR: 119
        • Possible related medication: Thyroxine 50 mcg 1# QDAC for 2 months until now (according to his family)
        • AST/ALT: 50/85
        • BUN/Cr: 13/24
        • Na: 137, K: 3.7
        • TSH/FT4: 1.300/1.388
        • T3: 46.195
        • ATPO, ATG, TSH receptor Ab: unavailable
        • ACTH/Cortisol: unavailable
        • ECG: sinus tachycardia (8/8)
      • A
        • Sick euthyroid syndrome
        • R/I radiation related primary hypothyroidism
      • Suggestions
        • Keep thyroxine 50 mcg 1# QDAC as before
        • Check ATPO, ATG in the next lab
        • Recheck TSH/FT4 2 weeks later or Meta OPD follow, including thyroid ultrasound
        • Contact us if needed. I’d like to follow up this patient.
  • 2022-08-12 Gastroenterology
    • Q
      • However, his Anti-HCV (+) and value showed 1.20 were noted. We need your further evaluation and suggestion. Thanks !!
    • A
      • check Bil(D), a-Fetoprotein, HCV RNA PCR (quantitative)
      • Well explained to the patient low incidence of HCV reactivation during or after chemotherapy according to previous reports
      • GI OPD f/u for treatment

[chemoimmunotherapy]

  • 2023-03-09 - methotrexate 30mg/m2 50mg NS 100mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-02-21 - pembrolizumab 200mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-02-16 - docetaxel 32mg/m2 50mg NS 100mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-02-09 - docetaxel 32mg/m2 50mg NS 100mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-01-31 - pembrolizumab 200mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-01-30 - methotrexate 30mg/m2 50mg NS 100mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-01-03 - cetuximab 250mg/m2 420mg 1hr + cisplatin 40mg/m2 70mg in saline 0.9% 500mL 2hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-28 - nivolumab 3mg/kg 160mg in saline 0.9% 100mL 1hr
    •                 diphenhydramine 30mg + granisetron 1mg
  • 2022-12-20 - cetuximab 250mg/m2 420mg 1hr + cisplatin 40mg/m2 70mg in saline 0.9% 500mL 2hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-09 - nivolumab 3mg/kg 160mg in saline 0.9% 100mL 1hr
    •                 diphenhydramine 30mg + granisetron 1mg
  • 2022-12-06 - cetuximab 250mg/m2 400mg 1hr + docetaxel 40mg/m2 60mg in saline 0.9% 100mL 1hr
    • dexamethasone 4mg + granisetron 1mg
  • 2022-11-24 - cetuximab 250mg/m2 400mg 1hr + docetaxel 28mg/m2 45mg in saline 0.9% 100mL 1hr
    • dexamethasone 4mg + granisetron 1mg
  • 2022-11-22 - nivolumab 3mg/kg 160mg in saline 0.9% 100mL 1hr
    •                 diphenhydramine 30mg + granisetron 1mg
  • 2022-11-10 - cetuximab 250mg/m2 400mg 1hr + docetaxel 28mg/m2 45mg in saline 0.9% 100mL 1hr
    • dexamethasone 4mg + granisetron 1mg
  • 2022-11-07 - nivolumab 3mg/kg 160mg in saline 0.9% 100mL 1hr
    •                 diphenhydramine 30mg 
  • 2022-11-01 - cetuximab 250mg/m2 400mg 1hr + docetaxel 28mg/m2 48mg in saline 0.9% 100mL 1hr
    • dexamethasone 4mg + granisetron 1mg
  • 2022-09-30 - cetuximab 250mg/m2 400mg 1hr + docetaxel 24mg/m2 40mg in NS 100mL 1hr + cisplatin 24mg/m2 40mg in NS 300mL 3hr + [leucovorin 60mg/m2 100mg + fluorouracil 600mg/m2 1000mg] in NS 1000mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2022-09-07 - cetuximab 250mg/m2 400mg 1hr + docetaxel 36mg/m2 60mg in NS 150mL 1hr + cisplatin 36mg/m2 60mg in NS 300mL 3hr + [leucovorin 90mg/m2 160mg + fluorouracil 900mg/m2 1600mg] in NS 1000mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-08-23 - cetuximab 250mg/m2 440mg 1hr + docetaxel 36mg/m2 60mg in NS 150mL 1hr + cisplatin 36mg/m2 60mg in NS 300mL 3hr + [leucovorin 90mg/m2 160mg + fluorouracil 900mg/m2 1600mg] in NS 1000mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-08-16 - cetuximab 400mg/m2 700mg 1hr + docetaxel 36mg/m2 60mg in NS 150mL 1hr + cisplatin 36mg/m2 60mg in NS 300mL 3hr + [leucovorin 90mg/m2 160mg + fluorouracil 900mg/m2 1600mg] in NS 1000mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg

==========

2023-03-09

[assessment - appetite stimulant]

  • The patient reached his lowest recorded weight of 52.6kg on 2023-01-13, before slightly increasing to 54.6kg on 2023-02-24. The patient is currently receiving nutrition through a nasogastric tube and it is recommended to provide sufficient calories, protein, and other nutrients.

  • Previously in another pharmacist note, megestrol was recommended as an appetite stimulant, but if the patient cannot tolerate it and there is still a need for an appetite stimulant, Pilian (cyproheptadine 4mg/tab) might be also considered as an off-label alternative for decreased appetite due to chronic disease. The recommended dosage for Pilian is an initial 2mg four times per day for one week, followed by 4mg four times per day.

    • ref:
      • Cyproheptadine is an effective appetite stimulant in cystic fibrosis. Pediatr Pulmonol. 2004;38(2):129-134. doi:10.1002/ppul.20043
      • Long-term trial of cyproheptadine as an appetite stimulant in cystic fibrosis. Pediatr Pulmonol. 2005;40(3):251-256. doi:10.1002/ppul.20265
  • Quetiapine might then be considered as a last resort to increase weight, but it comes with the cost of dyslipidemia.

[assessment - pain control]

  • MXL (morphine 60mg/cap) 1# Q12H, fentanyl transdermal patch 50ug/h 2# Q3D, OxyNorm (oxycodone 5mg/cap) 2# Q4H have been properly prescirbed to deal with the backgroud pain.

  • NG tube OxyNorm administration: pour the small granules out of the OxyNorm capsules, dissolve them in drinking water, and pass them through the feeding tube.

  • If the patient still experiences breakthrough pain with a high VAS score, the addition of PRN morphine might be considered.

2023-02-10

  • HGB 11.3 g/dL 2023-02-09 <- 6.5 g/dL 2023-02-06, in this case, anemia has been mitigated.

  • Platin- and taxel-based treatments have been administered to the patient.

    • Cisplatin-induced neuropathy was more similar to neuropathy in patients receiving oxaliplatin than in those receiving paclitaxel. The cisplatin and oxaliplatin groups exhibited the coasting phenomenon and more prominent upper extremity symptoms than lower extremity symptoms during chemotherapy administration weeks. In contrast, paclitaxel-treated patients did not, on average, exhibit the coasting phenomenon; additionally, lower extremity symptoms were more prominent during the weeks when paclitaxel was administered. ref: Cisplatin-associated neuropathy characteristics compared with those associated with other neurotoxic chemotherapy agents (Alliance A151724) [published correction appears in Support Care Cancer. 2021 Nov;29(11):7129-7130]. Support Care Cancer. 2021;29(2):833-840. https://doi.org/10.1007/s00520-020-05543-5
    • Cisplatin-induced peripheral neuropathy (CIPN) is a frequent serious dose-dependent adverse event that can determine dosage limitations for cancer treatment. CIPN severity correlates with the amount of platinum detected in sensory neurons of the dorsal root ganglia (DRG). After cisplatin-induced DNA damage, p21 appears as the most relevant downstream factor of the DDR in DRG sensory neurons in vivo, which survive in a nonfunctional senescence-like state. ref: Cisplatin-induced peripheral neuropathy is associated with neuronal senescence-like response. Neuro Oncol. 2021;23(1):88-99. https://doi.org/10.1093/neuonc/noaa151
  • 2020 ASCO guidelines suggest that clinicians may offer duloxetine to patients with chemotherapy-induced peripheral neuropathy, and 2020 joint ESMO/EONS/EANO guidelines recommend duloxetine for treatment of neuropathic pain in this setting. ref: Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325. https://doi.org/10.1200/jco.20.01399

    • Duloxetine for adult patients with chemotherapy-induced peripheral neuropathy: Oral initial 30 mg once daily for 1 week, then 60 mg once daily. Ref: Effect of duloxetine on pain, function, and quality of life among patients with chemotherapy-induced painful peripheral neuropathy: a randomized clinical trial. JAMA. 2013;309(13):1359-67. doi:10.1001/jama.2013.2813 https://doi.org/10.1001/jama.2013.2813
    • There is Cymbalta (duloxetine 30mg/cap) available in the stock. According to the patient’s lab results of 2023-02-09, his liver and kidney function have not deteriated, so no dose adjustment is required. Cymbalta 1# QD is recommended to mitigate his neuropathy.
  • The platinum agents cisplatin and carboplatin are used both as single agents and to form the backbone for most combination regimens to treat metastatic and recurrent head and neck cancers. Although carboplatin is often considered to be less systemically effective than cisplatin in head and neck cancer, there is little direct evidence. Carboplatin may be preferred in some cases since it is associated with less neurotoxicity, nephrotoxicity, ototoxicity, and nausea and vomiting compared with cisplatin, although carboplatin causes more myelosuppression.

    • Compared to TPF (docetaxel, cisplatin, fluorouracil) induction chemotherapy, CT (carboplatin, paclitaxel) induction chemotherapy had at least similar if not better LRC and PFS in patients while having less renal toxicity. Thus, CT induction chemotherapy may benefit patients with locally advanced HNSCC by facilitating adequate chemoradiation regimens that enhanced disease control. ref: Comparison of carboplatin-paclitaxel to docetaxel-cisplatin-5-flurouracil induction chemotherapy followed by concurrent chemoradiation for locally advanced head and neck cancer. Oral Oncol. 2014;50(1):52-58. https://doi.org/10.1016/j.oraloncology.2013.08.007

[duplicate note]

  • As the note has already been responded to, please disregard this duplicate note generated by the system.

2023-01-30

  • Since the patient has lost more than 10kg of body weight over the past 5 months (64.4kg 2022-09-17 -> 52.6kg 2023-01-13), possibly as a result of tumor-induced cachexia, it is recommended that the patient consume more and/or receive more intensive nutritional support. The addition of some appetizers, such as megestrol, might be beneficial.

  • Metoclopramide has been prescribed. The use of Emend (aprepitant) for antiemetic effect might be considered if nausea and/or vomiting is observed.

701472893

230309

[exam findings]

  • 2023-03-01 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with myeloproliverative neoplasm and see description
    • The sections show normocellular marrow (30%). The M/E ratio about 2:1 in MPO and CD71 immunostains. Increased numbers of small to enlarged CD61+ megakaryocytes with occasional hyperchromatic nuclei, arragned in loose clusters are present. No left shift of myeloid series and erythroid precursors. A few CD34+ and/or CD117+ immature cells in interstitium, account for <3% of nucleated cells can be found. Loose network of reticulin with many intersections (MF-1) in reticulin stain. The finding is compatible with myeloproliferative neoplasm. The differential diagnosis including prefibrotic/early primary myelofibrosis and essential thrombocythemia. Suggest bone marrow smear evaluation, genetic study and clinic correlation.
  • 2023-03-01 CT - brain
    • Indication: Thrombocythemia with dizziness, R/O CVA
    • IMP: No evidence of intracranial lesion.
  • 2023-02-24 CT - abdomen
    • CC: abdominal pain, diarrhea once and vomit > 3 times since last night
      • no fever, headache (+), no family had similar symptom
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There are multiple hyperdense lesions in the stomach, duodenum, and small intestine that may be food materials.
        • please correlate with clinical condition.
      • There are two poor enhancing lesion 2 cm and 1.8 cm in the uterus that may be myomas. In addition, there is a cystic lesion 2.1 cm in left adnexa that may be left ovarian cyst.
        • Please correlate with GYN. sonography.
      • Others
        • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidneys.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • Impression:
      • There are two poor enhancing lesion 2 cm and 1.8 cm in the uterus that may be myomas.
      • In addition, there is a cystic lesion 2.1 cm in left adnexa that may be left ovarian cyst.
      • Please correlate with GYN. sonography.

[consultation]

  • 2023-02-08 Ear Nose Throat
    • Q
      • This 43-year-old woman patient is a case of Thrombocythemia with dizziness. Now, for evaluate ear examine of dizziness. Thank you.
    • A
      • S:
        • intermittent Vertigo for 1 month
        • when lying down and getting up from the bed in the morning and at night?
        • Duration: 50 mins
        • First attack: this time
        • Headache(+) for 1 month
        • Tinnitus(-), Hearing loss(-), aural fullness(-)
        • N/V and abdominal pain since last Thursday, improved now nausea or vomiting now, but still intermittent vertigo and headache
        • PHx: denied
        • Allergy: denied
      • O:
        • Ear drums: intact
        • No spontaneous, positional , positioning nystagmus
        • Finger nose finger : ok
        • Romberg test : ok
        • Tandem gait : ok
        • Dix-Hallpike test: Bil negative
        • Supine roll test: Bil negative
      • A: Vertigo, cause?
        • central origin can’t be ruled out
      • P:
        • Please rule out central lesion due to thrombocythemia
        • Brain image study: had arranged
        • Treat thrombocythemia as your expertise
        • may consider diphenidol and nicametate citrate
        • ENT/Neuro OPD f/u

700070871

230307

{Diffuse large B-cell lymphoma, stage IV, with bilateral lung and adrenal gland metastasis. triple hit, IPI:4}

[diagnosis] - 2022-08-04 Discharge diagnosis

  • Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
  • Diffuse large B-cell lymphoma, stage IV, with bilateral lung and adrenal gland metastasis. triple hit, IPI:4.
  • Acute respiratory failure post intubation on 111-06-16
  • Pneumonia due to Pseudomonas and Oxacillin-resistant Staphylococcus aureus (ORSA)
  • Anemia, unspecified
  • Gastrointestinal hemorrhage, unspecified
  • Diarrhea, postive of stool GDH
  • Chronic viral hepatitis B without delta-agent
  • Constipation, unspecified
  • Other forms of stomatitis
  • Port-A catheter insertion 2022/6/30
  • Fistulotomy and debridement on 2022/8/3

[exam findings]

  • 2023-01-27 CT - chest
    • Indication
      • Dyspnea, unspecified
      • Secondary malignant neoplasm of unspecified lung
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 2.5 mm lung window,5 mm soft-tissue window slice thickness)
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • No evidence of pulmonary embolism nor aortic dissection is found.
        • MInimal dense opacity over right lower lobe, left lower lobe and left peripheral lung is found.
        • No evidence of bilateral pleural effusion.
        • Calcified coronary arteries is found.
        • Dense calcified lymph nodes at mediastinal and both hilar region is found.
      • Visible abdomen:
        • Splenomegaly and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
        • The GB is well distended without soft tissue lesion
        • Suggest clinical correlation
    • Imp:
      • MInimal dense opacity over right lower lobe, left lower lobe and left peripheral lung is found.
      • Calcified lymph nodes at mediastinum and bilateral pulmonary hilum.
  • 2023-01-12 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (97 - 33) / 97 = 65.98%
      • M-mode (Teichholz) = 65
    • Adequate LV systolic function with normal resting wall motion
    • Mild MR and mild TR
    • LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
  • 2023-01-11, 2022-12-05 CXR
    • multiple nodules in both lungs, in regression
  • 2023-01-11 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
  • 2023-01-11 Spirometry
    • normal standard spirometry
    • negative BDT (back diffusion technique)
    • normal DLCO (diffusing capacity of the lungs for carbon monoxide)
  • 2022-10-25 CT - neck
    • Indication:
      • triple hit, diffuse large B-cell lymphoma with bilateral lung and adrenal gland metastasis, Lugano stage IV, IPI score: 4, High risk group, PS:1
    • Head and Neck CT with and without IV contrast administration shows: (Comparison: 2022/07/03 CT)
      • Head and Neck
        • A large mass lesion, can be confluent LAPs, in right middle low lateral neck.
        • Regressed size from 95x80x60 mm to 77x57x37 mm (RL-AP-CC). [CC: Cranial-caudal; RL: Right-left; AP: Anterior-Posterior]
        • After IV contrast administration shows well or heterogenous enhancement of the mass or LAPs with central necrosis.
      • Thorax:
        • Presence of multiple lung nodules/masses.
        • One enlarged LN in right paratracheal space, seems with central necrotic change. With unknown size change, not scanned on last CT study, 2022/07/03 CT.
        • Several LAPs in AP window and pretracheal space.
      • Abdomen and pelvis:
        • One enlarged LN in anterior part of celiac root. With unknown size change, not scanned on last CT study, 2022/07/03 CT.
        • No evident other abnormal enlarged lymph node in paraaortic space or iliac chain.
    • IMP: Decreased right neck LAPs when compared with 20220703 CT as mentioned above.
  • 2022-08-03 Patho - fissure/fistula
    • Anus, fistulotomy — Anal fistula with abscess
    • Section shows piece(s) of cutaneous-colonic junctional tissue with one fistula surrounded by abscess composed of debri and diffuse acute as well as chronic inflammation.
  • 2022-07-31 CXR
    • a mass shadow in over the Rt neck, in regression
    • multiple nodules in both lungs, in regression
  • 2022-07-26 PET
    • Mildly increased FDG uptake in a large focal area in the right neck, compatible with lymphoma of low FDG uptake.
    • Mildly increased FDG uptake in multiple lymph nodes on both sides of the diaphragm as mentioned above and Increased FDG uptake in multiple focal areas in bilateral lung fields. Lymphoma can not be ruled out. Please correlate with other clinical findings for further evaluation.
    • Mildly increased FDG uptake in the bone marrow of bilateral thighs. The nature is to be determined (bone marrow hyperplasia? lymphoma of low FDG uptake?). Please also correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in the intestine and both kidneys. Physiological FDG accumulaiton may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2022-07-21 Patho - intestine
    • Large intestine, ICV, biopsy —- ulcer with non-specific colitis
    • Small intestine, terminal ileum, biopsy —- ulcer with chronic inflammation
  • 2022-07-21 SONO
    • Right neck heteroechoic tumor with some necrosis
  • 2022-07-03 CT
    • No evidence of intracranial hemorrhage.
    • A large mass (8.1cm) at right neck.
    • Some patchy densities at bil. upper lungs.
  • 2022-06-24 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (95.9 - 33.9) / 95.9 = 64.65%
      • M-mode (Teichholz) = 64.7
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Mild to moderate tricuspid regurgitaition and mild mitral regurgitation
    • Dilated LA and IVC; mildly thick IVS and LVPW (IVC = inferior vena cava; IVS = interventricular septum; LVPW = left ventricular posterior wall)
    • Mild pulmonary hypertension
  • 2022-06-23 Patho - bone marrow biopsy
    • Bone marrow, biopsy — No evidence of lymphoma involvement and see description.
    • The sections show normocellular marrow (35%). M/E ratio = 4:1. The myeloid cells show maturation. The megakaryocytes are increased in number with a few small megakaryocytes. No focal lymphoid aggregation. Scattered CD34+ and/or CD117+ immature cells, account for 3% of marrow cells can be found. There is no evidence of lymphoma involvement in CD3 and CD20 immunostains. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2022-06-21 Patho - lymph node region resection
    • Tissue, neck, right, incisional biopsy — Diffuse large B cell lymphoma, GCB
    • Immunohistochemical stain profiles: CD20(+), CD3 (focal+ at background T-cells), Bcl-2(+), Bcl-6(+), MUM-1(-), CK(-), CD56(-), CD10(+), Cyclin D1(-), C-MYC(+).
  • 2022-06-17 Patho - lymphnode biopsy
    • Labeled as “Right neck lymph node”, SONO guided biopsy — B cell lymphoma, high grade.
    • IHC stains: CK (-), CD56 (-), CD3 and CD20: a predominant B cell sub-population, Bcl-2 (+), bcl-6(+), MUM-1(-), Ki-67: 95%, CD10 (-), cyclin-D1 (equivocal), CD23 (-), CD30 (-), C-myc (+, focally >30%), a pattern, in favor of diffuse large B cell lymphoma, double-expressor.
  • 2022-06-16 CXR
    • Diffuse nodular lesions at both lungs is found.
  • 2022-06-16 CT - neck
    • Neck lymphadenopathy with lung meta and extensive lymphadenopathy, suggest biopsy.
  • 2022-06-16 CT - lung
    • Huge right neck lymphadenopathy with bilateral lung meta, adrenal meta and mediastinal, bilatral axillary and paraaortic lymphadenopathy, please check neck, oral pharyngeal region for primary tumor.
  • 2022-06-16 CXR
    • Patch density at bil. lungs.

[consultation]

  • 2023-02-13 Vascular Surgery
    • Q
      • This 53 year old male is a case of triple hit, diffuse large B-cell lymphoma with bilateral lung and adrenal gland metastasis, Lugano stage IV, IPI score: 4, High risk group, PS:1
      • Will prepare autoPBSCT this time, we need your expertise for hickman insertion on 2023/02/16, thanks.
    • A
      • For BMT preparation, insertion of perm-cath will be scheduled on 20230216. Thanks for your consultation.
  • 2023-02-13 Oral and Maxillofacial Surgery
    • Q
      • This 53 year old male is a case of triple hit, diffuse large B-cell lymphoma with bilateral lung and adrenal gland metastasis, Lugano stage IV, IPI score: 4, High risk group, PS:1
      • Will receive autoPBSCT on 20230224, we need your expertise for oral examination, thanks
    • A
      • after examining the intraoral condition and taking radiographic study, no pathology was noticed neither hopeless tooth was noticed
      • Plaque deposition over upper dentition was noticed.
      • Plan:
        • Teach him how to reinforce oral hygiene
  • 2022-11-21 Vascular Surgery
    • Q
      • A case of triple hit, diffuse large B-cell lymphoma with bilateral lung and adrenal gland metastasis, Lugano stage IV, IPI score: 4, High risk group, PS:1
      • will receive PBSC harvest on 20221206 ~ 20221209, we need your expertise for double lumen insertion on 20221205, thanks
    • A
      • I have had the pleasure of involving with the patient’s care. In brief, He is a 53 year old male seen in consultation for opinion regarding treatment options for double lumen cath insertion for PRBC harvest access.
      • The pt’s hx/Dx was noted for Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
      • Lab/CXR reviewed.
      • SUGGESTION & PLAN:
        • D/L insertion will be arranged on R’t side on 2022/12/05 under LA 8AM
        • please prepare a 16cm D/L (double lumen catheter) to bring to OR.
  • 2022-08-01 Colorectal Surgery
    • Q
      • The 53 y/o neck diffuse large B cell lymphoma case s/p R-DA-EPOCH at MICU. Due to a carbuncle over left buttock without discharge for 2-3 days. PS was consulted and who assessment of abscess just located nearby anus and it is likely anal fistula with anal abscess, so we need your help. Thanks!
    • A
      • We’ll go to see the patient tomorrow morning
  • 2022-08-01 Reconstructive and Plastic Surgery
    • Q
      • The 53 y/o neck diffuse large B cell lymphoma case s/p R-DA-EPOCH at MICU. Due to a carbuncle over left buttock without discharge for 2-3 days, so we need your help for management. Thanks!
    • A
      • abscess just located nearby anus
      • it is likely anal fistula with anal abscess
      • plan and suggestion:
        • please consult CRS for this problem
        • sitz bath with warm water after stool passage
  • 2022-06-24 Gastroenterology
    • Q
      • For HBV evaluation
      • This is a 53 years old man, a case denided Diabetes, Hypertension or heart disease history. This time, he suffered from shortness of breath was noted since today. right neck swelling for 6 months. so he went to ER for help. At ER, conscious clear, vital sign showed BP:163/91mmHg; HR:139; BT:36.3; RR:20; SPO2:88%, follow up Lab data showed leukocytosis (wbc:16930 CRP:11.55). chest films revealed diffuse nodular lesions at both lungs is found. chest CT revealed huge right neck lymphadenopathy with bilateral lung mets, adrenal mets and mediastinal, bilatral axillary and paraaortic lymphadenopathy, please check neck, oral pharyngeal region for primary tumor.Because of dyspnea, desaturation progression, emergent intubation with ventilator support and then transfer to ICU for further care.
      • After admission. B cell lymphoma was diagnosis. HbsAg(-), Anti-Hbc reactive. We sinecerely need your help. Thanks a lot.
    • A
      • O
        • Abdominal echo: nil
        • ALT:15 , BUN:20, Cr:0.45
        • HBsAg(-), Anti-HBsAb:(-), Anti-HBc:(+), Anti-HCV(-)
      • Impression
        • Resolved HBV infection
        • Diffuse large B cell lymphoma, triple hit, IPI:4, stage IV
      • Suggestion
        • We will prescribe Baraclude 0.5mg QD (GFR>50 QD, GFR 30-49 QOD, GFR 15-29 Q3D, GFR<15 or HD QW)
        • Arrange abdominal sonography after transfer to general ward
        • Regular/close monitor liver function
        • Avoid hepatic toxic agent if possible (or adjust dose), simplify medication
  • 2022-06-23 Hemato-Oncology
    • Q
      • For B cell lymphoma evaluation
    • A
      • Impression:
        • Diffuse large B cell lymphoma, triple hit, IPI:4, stage IV
        • Acute respiratory failure s/p intubation on 20220617
        • Bilateral lung pneumonia, sputum culture yeild Pseudomonas aeruginosa on 20220617
      • Suggestion:
        • Bone marrow aspiration and biopsy for further staging. Arrange PET after remove endo.
        • We had well explaint to his brother and will arrange R-COP for cyto-reduction. Please watch for tumorlysis syndrome
        • Check HbsAg, AntiHCV, Anti Hbc
        • We may take over this case after remove endo with stable condition.
        • Thanks for your consultation. If there is any problem, please feel free to let us know
  • 2022-06-20 Anesthesiology
    • Q
      • For pre-op evaluation
    • A
      • Condition: Stable V/S Cons. clear, previous walking ok but now weakness and tired, no dyspnea, chest tightness or leg edema, fighting with ventilator
      • EKG: ST
      • CXR: a huge mass shadow in over the Rt neckmultiple nodules and several large massses of variable sizes in both lungs due to metastases. Cardiomegaly, Tortous aorta with calcification, Osteopenia, Senile fibrotic change
      • Neck CT: Neck lymphadenopathy with lung meta and extensive lymphadenopathy, suggest biopsy
      • Lung CT: Huge right neck lymphadenopathy with bilateral lung meta, adrenal meta and mediastinal, bilatral axillary and paraaortic lymphadenopathy, please check neck, oral pharyngeal region for primary tumor.
      • Airway: adequate open
      • ASA3
        • NOTE: AMERICAN SOCIETY OF ANESTHESIOLOGY PATIENT CLASSIFICATION STATUS
          • ASA I
            • Normal healthy Pt
          • ASA II
            • Pt with mild systemic disease; no functional limitation–eg, smoker with well-controlled HTN
          • ASA III
            • Pt with severe systemic disease; definite functional impairment–eg, DM and angina with relatively stable disease, but requiring therapy
          • ASA IV
            • Pt with severe systemic disease that is a constant threat to life–eg, DM + angina + CHF; Pts have dyspnea on mild exertion and chest pain
          • ASA V
            • Unstable moribund Pt who is not expected to survive 24 hours with or without the operation
          • ASA VI
            • Brain-dead Pt whose organs are removed for donation to another
          • E
            • Emergency operation of any type, which is added to any of the 6 above categories, as in ASA II E
      • Plan:
        • High risk of aspiration, sepsis, shock
        • Anes. plan and risk was told to him at bedside and brother at door of SICU
        • Resucitation will be procedured if emergence condition.
        • We will arrange ETGA
        • Correct underly dx as your expertise.
        • Follow onetouch q6h when nil per os if DM or high risk of hypoglycemia
  • 2022-06-20 ENT
    • Q
      • For A huge indurated mass (over 10cm in largest dimension) with partial skin erosion (2*2cm) over right lateral-posterior neck without tendeness.
    • A
      • CT: right neck lymphadenopathy with bilateral lung meta, adrenal meta and mediastinal, bilatral axillary and paraaortic lymphadenopathy
      • PE:
        • Oral: N-P
      • Scope: unable to evaluate due to saliva pooling
      • Imp: R neck lympahdenopathy with metastasis, origin?
      • Plan:
        • Arrange excisional biopsy for tissue proof on 20220621 On call.
  • 2022-06-16 Oral and Maxillofacial Surgery
    • Q
      • shortness of breath was noted since today
      • right neck swelling for 3 month
      • Hx of NIL
    • A
      • This is a 53-year-old male who felt a little hard to breath and went to our ER for help
      • PMH: denied
      • S: I felt a little hard to breath
      • O: BP:163/91; P:139; T:36.3; R:20;
        • Con’s: E4V5M6
        • SpO2:88%
        • Extraoral finding:
          • mass (width 4 fingers, length 9 fingers) over his right neck was noted (it was so small 3 months ago)
      • A: tumor of right neck
      • P:
        • Physical exam and explain the findings to the patient.
        • Consult Hemato-Oncology for further survey
  • 2022-06-16 ENT
    • Q
      • shortness of breath was noted since today
      • right neck swelling for 3 month
      • Hx of NIL
    • A
      • O
        • Local finding:
          • No stridor but shortness of breath
          • Fair oral cavity and oropharynx
          • A huge indurated mass (over 10cm in largest dimension) with partial skin erosion (2*2cm) over right lateral-posterior neck without tendeness.
        • Portable nasopharyngoscopy: smooth nasopharynx, oropharynx and hypopharynx; patent airway through subglottic level; no vocal palsy.
        • Neck and Chest CT Report: A huge solid mass measuring up to 12cm in greatest dimention over right posterior-lateral neck with partial liquid component, along with bilateral multiple pulmonary/mediastinal nodular/mass lesion.
      • Impression:
        • Suspect malignancy, pulmonary origin with multiple metastasis should be primarily considered.
      • Plan:
        • Closely monitor airway condition.
      • Suggest consult Chest Physician or Hemato-oncologist for further evaluation and management.

[surgical operation]

  • 2022-12-05
    • Surgery
      • D/L insertion (RIJV approach, 16cm)  
  • 2022-08-03
    • Surgery
      • Fistulotomy and debridement
    • Finding
      • Inflammation and swelling over left perianal region with much pus was drained. Debridement and irrigation using H2O2 was done.
  • 2022-06-21
    • Surgery
      • Incisional biopsy of right neck mass
    • Finding
      • Right neck indurated mass, measuring up to 12cm in greatest dimention

[chemoimmunotherapy]

  • 2022-12-19 - rituximab 375mg/m2 600mg 8hr D1 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-6 + etoposide 50mg/m2 80mg 24hr D2-5 + doxorubicin 10mg/m2 15mg 24hr D2-5 + vincristine 0.4mg/m2 0.5mg 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg D6 (R-DA-EPOCH)
    • premed - dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + acetaminophen 500mg PO D1 + granisetron 2mg D1-6
  • 2022-11-21 - rituximab 375mg/m2 600mg 8hr D1 + methylprednisolone 500mg 1hr D2-6 + etoposide 40mg/m2 63mg 1hr D1-5 + cisplatin 25mg/m2 39mg 18hr D1-5 + cytarabine 2000mg/m2 3160mg 2hr D6 (R-ESHAP)
  • 2022-10-25 - rituximab 375mg/m2 600mg 8hr D1 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-6 + etoposide 50mg/m2 80mg 24hr D2-5 + doxorubicin 10mg/m2 15mg 24hr D2-5 + vincristine 0.4mg/m2 0.5mg 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg D6 (R-DA-EPOCH)
    • premed - dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + acetaminophen 500mg PO D1 + granisetron 2mg D1-6
  • 2022-09-16 - rituximab 375mg/m2 600mg 8hr D1 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-6 + etoposide 50mg/m2 80mg 24hr D2-5 + doxorubicin 10mg/m2 15mg 24hr D2-5 + vincristine 0.4mg/m2 0.5mg 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg D6 (R-DA-EPOCH)
    • premed - dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + acetaminophen 500mg PO D1 + granisetron 2mg D1-6
  • 2022-08-18 - rituximab 375mg/m2 600mg 8hr D1 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-6 + etoposide 50mg/m2 80mg 24hr D2-5 + doxorubicin 10mg/m2 15mg 24hr D2-5 + vincristine 0.4mg/m2 0.5mg 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg D6 (R-DA-EPOCH)
    • premed - dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + acetaminophen 500mg PO D1 + granisetron 2mg D1-6
  • 2022-07-11 - rituximab 375mg/m2 600mg 6hr D1 + prednisolone 60mg/m2 5mg/tab 19tab BID D1-5 + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 10mg/m2 15mg 24hr D1-4 + vincristine 0.4mg/m2 0.5mg 24hr D1-4 + cyclophosphamide 750mg/m2 1200mg D5 (R-DA-EPOCH)
    • premed - dexamethasone 4mg D1 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D1 + famotidine 20mg D1
  • 2022-06-23 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1260mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 tmg/tab 10tab BID D1-6 (R-COP)
  • G-CSF
    • Granocyte (lenograstim 250mg SC) 2022-11-04, -05, -07 (20221104 OPD)
    • Granocyte (lenograstim 250mg SC) 2022-11-01, -02, -03 (20221023 IPD)
    • Granocyte (lenograstim 250mg SC) 2022-09-26, -27, -28 (20220926 OPD)
    • Granocyte (lenograstim 250mg SC) 2022-09-20, -21, -22 (20220913 OPD)
    • Granocyte (lenograstim 250mg SC) 2022-08-30, -31, -09-01 (20220830 OPD)
    • Granocyte (lenograstim 250mg SC) 2022-08-24, -25 (20220818 IPD)

[problem list / assessment / plans]

Problem 1# triple hit, diffuse large B-cell lymphoma with bilateral lung and adrenal gland metastasis, Lugano stage IV, HCT-CI score: 0, IPI score: 4, High risk group, PS: 1 Assessment: autoPBSCT on 2023/02/24 (D0)

Plan

  • Blood transfusion with LPRBC (ZhaoGuang) and LRP (ZhaoGuang) for anemia and thrombocytopenia (In this context, “ZhaoGuang” refers to a leukocyte reduction process in which blood products such as LPRBC and LRP are exposed to ultraviolet light to inactivate leukocytes. This is done to reduce the risk of transfusion-related reactions and complications.)
  • Nincort and Mycostatin 5ml QID for mucositis
  • PPN with Oliclinomel was administered for poor appetite from 3/2
  • AutoPBSCT on 2023/02/24(D0),infusion time 10:11AM-10:17AM;10:19AM-10:26AM, (12/6 CD34: 5.49x10^6/kg and 12/5 CD34: 4.05x10^6/kg, total 9.54x10^6/kg)  
  • Baktar 2tab QD for PJP prevention
  • Prophylaxis antibiotivcs with Cravit 1.5tab from 2/16-23,antifungas with Fluconazole 300mg QD IVD from 2/16-23,then shifted to Tienam,Targocid from 2/24-3/2 then shifted to Zyvox from 3/2(D6) and Mycamine from 2/24(D12),pending blood culture
  • Conditioning regimen for autologous PBSCT with BuCyE was administered on 2023/2/17-22
  • Adequate hydration
  • Oral surgerist was consulted for oral examination
  • CVS was consulted for Hickman insertion on 2/16
  • closely monitor clinical condition  

==========

2023-03-07

[assessment - Improvement in WBC Count Trend Observed]

  • Today (2023-03-07) marks the 11th day since autoPBSCT. Based on recent lab data, there is a noticeable upward trend in WBC count over these two days, indicating a return to the normal range.
    • 2023-03-07 D11 WBC 4.87 x10^3/uL
    • 2023-03-06 D10 WBC 2.51 x10^3/uL
    • 2023-03-05 D 9 WBC 0.91 x10^3/uL
    • 2023-03-04 D 8 WBC 0.28 x10^3/uL
    • 2023-03-03 D 7 WBC 0.04 x10^3/uL
    • 2023-03-02 D 6 WBC 0.01 x10^3/uL
    • 2023-03-01 D 5 WBC 0.01 x10^3/uL
    • 2023-02-27 D 3 WBC 0.01 x10^3/uL
    • 2023-02-26 D 2 WBC 0.02 x10^3/uL
    • 2023-02-24 D 0 WBC 0.11 x10^3/uL
    • 2023-02-22 D-2 WBC 1.16 x10^3/uL
    • 2023-02-20 D-4 WBC 1.22 x10^3/uL
    • 2023-02-16 D-8 WBC 1.08 x10^3/uL

2023-02-15

[preparation and administration of mesna]

  • Mesna can be dissolved in 0.9% normal saline (NS) or 5% dextrose in water (D5W).

  • As the patient weighs 60kg, the scheduled (since 2023-02-21) dose of mesna is 12mg/kg, which means that 720mg of mesna should be dissolved in the aforementioned solvent no less than 50mL (final concentration no more than 20 mg/mL).

  • To ensure optimal administration, it is recommended that the injection lasts for no less than 30 minutes.

700378861

230306

[exam findings]

  • 2023-03-01 SONO - chest
    • Pleural effusion, minimal, bilatera
    • Consolidation, LLL and RLL
  • 2023-02-27, -02-25, -02-23, -02-20, -02-17 CXR
    • S/P nasogastric tube insertion
    • S/P CVP line insertion from left jugular vein and the tip located at SVC.
    • Atherosclerotic change of aortic arch
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Linear and nodular infiltration over both lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Borderline cardiomegaly
  • 2023-02-23 KUB
    • Fecal material store in the colon.
    • Ascites is highly suspected. Please correlate with sonography.
  • 2023-02-22 CT - brain
    • Indication: Myelodysplastic Syndrome
    • IMP: No evidence of intracranial lesion.
  • 2023-02-22 SONO - abdomen
    • GB wall thickening, possibly secondary to hepatitis or ascites
    • Parenchymal renal disease
    • Left renal cyst
    • Ascites
    • Pleural effusion
    • suboptimal echo window
  • 2023-02-17 MRI - L-spine
    • Indication: Myelodysplastic Syndrome. bilateral lower limbs weakness
    • Impression:
      • Degenerative spinal and disc disease.
      • Favor intramuscular hematomas in right psoas muscle.
  • 2023-02-08 SONO - chest
    • Symptoms:
      • Internal jugular vein narrowing or thrombosis.
      • Peripheral vein narrowing
    • Indication:
      • Risky in bleeding, thrombosis, vessel narrowing.
    • Clinical Diagnosis
      • COVID-19 pneumonia with ARDS.
      • MDS with severe pancytopenia
    • Echo Diagnosis
      • Right side
        • Internal jugular vein and common carotid artery confirmed by echo probe compression, Doppler velocity detection.
        • Internal jugular vein compress: lumen narrowing, velocity increasing.
        • Internal jugular vein lumen narrowing and velocity increase during inspiration.
        • Cross-sectional probe: lumen area: 0.66cm in diameter
        • Thrombosis: No
  • 2023-02-02 CT - abdomen
    • History and indication: SOB
    • IMP: Ground glass opacities at bil. lungs. Some LNs at mediastinum. Pericardial and pleural effusion.
  • 2023-01-12 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
      • diverticulum : the second portion of duodenum
    • Suggestion
      • PPI therapy
      • OPD follow-up
  • 2021-09-30 Patho - bone marrow biopsy
    • PATHOLOGIC DIAGNOSIS
      • Bone marrow, biopsy — Compatible with myelodysplastic syndrome with excess blasts (MDS-EB-1)
      • MICROSCOPIC EXAMINATION
        • The sections show normocellular marrow (25%). M/E ratio = 2:1 in CD71 amd MPO stains. The megakaryocytes are not remarkable.
        • Slightly increased CD138+ mature plasma cells (5%) in interstitium.
        • Increased CD34+ blasts, account for 9% of marrow cells. Only few CD117+ immuture cells. the finding is compatible with myelodysplastic syndrome with excess blasts (MDS-EB-1). Suggest further bone marrow smear evaluation and clinic correlation.
  • 2019-08-12 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (119 - 37) / 119 = 68.91%
      • LVEF = 69
      • M-mode (Teichholz) = 69
    • Normal LV systolic function with normal wall motion.
    • Normal LV diastolic function.
    • Normal RV systolic function.
    • Mild MR; mild TR; mild PR.
    • No vegetation was found by TTE.
    • Flat IVC, consider hypovolemia.
  • 2019-08-11 CT - abdomen
    • Indication: Suspected liver abscess.
    • Impression:
      • No intraabdominal abscess
      • Left renal cyst
      • Prominent pancreatic tail

[consultation]

  • 2023-02-24 Nephrology
    • Q
      • For Hyernatremia evaluation
      • The 63-year-old man had past history with MDS with RAEB s/p vidasa. This time, he was visited ER due to dyspnea and progressed since 20230202, the chest film manifasted bilateral ground glass opacity with severe pneumonia patch noted. Abomen CT showed left renal cyst and pleural effusion with pericardial. He was admited due to bilateral lung pneumonia with respiratory failure s/p intubation and COVID-19 infection.
      • The lab showed Hyernatremia, Na (blood): 160 -> 163 -> 171 mmol/L, Na (urine): 32 mmol/L, K (blood): 2.5 -> 3.2 mmol/L, K (urine): 18.8 mmol/L, Osmolality (blood): 340mOsn/kg, Osmolality (urine): 236mOsm/kg, Urine SG: 1.006, U/O: 2807.3+ lossml/day(2023/02/20), 1560ml/day(2023/02/21), so we need your help for Hyernatremia evaluation, thanks a lot!!
    • A
      • Patient seen with history reviewed. We are consulted for hyernatremia.
      • pitting edema 2+
      • Lab
        • 2023-02-22 Na(Urine) 46 mmol/L
        • 2023-02-22 Urine osmolarity 281 mOsm/Kg
        • 2023-02-22 Na (Sodium) 171 mmol/L
        • 2023-02-21 Na (Sodium) 163 mmol/L
        • 2023-02-20 Na (Sodium) 160 mmol/L
        • 2023-02-17 Na (Sodium) 141 mmol/L
        • 2023-02-13 Na (Sodium) 141 mmol/L
        • 2023-02-22 BUN 40 mg/dL
        • 2023-02-20 BUN 32 mg/dL
        • 2023-02-17 BUN 31 mg/dL
        • 2023-02-13 BUN 45 mg/dL
      • U/O
        • 2023-02-20 U/O 2807+loss
        • 2023-02-21 U/O 1560
      • Impression
        • hypernatremia, suspected osmotic diuresis
      • Suggestion
        • estimated free water deficit: 8.5L
        • correct hypernatremia with adequate free water (in diet and IVF), since pleural effusion and pitting edema were noted
        • monitor sodium level closely, sodium level decrease should not exceed 8mmol/L/d
        • record I/O
  • 2023-02-20 Infectious Disease
    • Q
      • For antibiotic evaluation
      • The 63-year-old man had past history with MDS with RAEB s/p vidasa. This time, he was visited ER due to dyspnea and progressed since 2023/02/02, the chest film manifasted bilateral ground glass opacity with severe pneumonia patch noted. Abomen CT showed left renal cyst and pleural effusion with pericardial. He was admited due to bilateral lung pneumonia with respiratory failure s/p intubation and COVID-19 infection.
      • The lab showed leucopenia, pancytopenia due to MDS, Lenograstim and Tapimycin, Mycamine for blood culture: Candida, sputum culture: PDR-K. oxytoca, so we need your help for antibiotic evaluation, thanks a lot!!
    • A
      • keep present antibiotic Rx, and adjust to culture data later
      • monitor CRR
  • 2023-02-08 Gastroenterology
    • Q
      • After admission, he received ventilator support, empiric antibiotics with Tapimycin and Cravit was prescribed for pneumonia treatment, Decan 6 mg IVD QD (2/2-2/10) and DC Remdisivir due to liver failure. LPRBC and LRP were tranfused for anemia and pancytopenia. We need your expert to evaluate his condition and give us advise with hepatitis. Thank a lot
    • A
      • B (-) C (-)
      • Impression
        • Abnormal liver function test, resolving, r/p sepsis related, r/o shock liver (The liver function test was abnormal but it is improving. This could be related to the recent sepsis the patient had and we need to rule out shock liver.)
      • Plan:
        • Arrange abdominal sonography when transfer to a general ward after isolation
        • Check Anti HAV IgM
        • Regular/close monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALP
        • Avoid hepatic toxic agent if possible (or adjust dose), simplify medication
        • Silymarin 1#~2# TID (The National Health Insurance will reimburse when the levels of GOT and GPT are greater than or equal to twice the normal values.)

[chemotherapy]

  • 2022-05-10 - Vidaza (azacitidine) 230mg SC
  • 2022-01-17 - Vidaza (azacitidine) 260mg SC
  • 2022-01-10 - Vidaza (azacitidine) 260mg SC
  • 2021-12-13 - Vidaza (azacitidine) 260mg SC
  • 2021-12-06 - Vidaza (azacitidine) 260mg SC
  • 2021-11-15 - Vidaza (azacitidine) 260mg SC
  • 2021-11-08 - Vidaza (azacitidine) 260mg SC

[assessment]

  • The patient’s renal function has declined, as evidenced by a decrease in creatinine clearance based on Cockcroft-Gault formula to 33mL/min as of 2023-03-06.

    • 2023-03-06 Creatinine 2.37 mg/dL
    • 2023-03-03 Creatinine 1.79 mg/dL
    • 2023-02-27 Creatinine 1.54 mg/dL
    • 2023-03-06 eGFR 29.54
    • 2023-03-03 eGFR 40.84
    • 2023-02-27 eGFR 48.58
  • In patients with a CrCl between 25 and 50 mL/min, a recommended dose of 1g Q12H for meropenem is advised, compared to the intended dose of 1g Q8H.

  • By the way, there is no dosage adjustment necessary for any degree of kidney dysfunction for micafungin use. And there are no dosage adjustments for nystatin provided in the manufacturer’s labeling for patients with kidney Impairment.

700701354

230306

{Squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence. Squamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0.}

[lab data]

  • HBsAg 2022-06-04 Reactive, Value 4.62 S/CO
  • Anti-HCV 2022-06-04 Nonreactive, Value 0.10 S/CO
  • Anti-HBc 2022-06-04 Reactive, Value 7.96 S/CO
  • Anti-HBc IgM 2022-06-04 Nonreactive, Value 0.12 S/CO

[exam findings]

  • 2023-02-22 CT - chest
    • Squamous cell carcinoma of upper to middle esophagus, cT3N3M0 stage IVA for esophageal cancer follow-up
    • MDCT (128-detector rows, iCT Philips,was performed with 0.625 0.5 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Comparison was made with previous CT dated on 2022/11/07
      • Lungs: basal segmental consolidation and volume loss of LLL. long subpleural lines at RLL, may be fibrosis.
        • extensive ground-glass opacity at RML and centrilobular nodular opacities at RUL.
      • Mediastinum and hila: s/p left main bronchial stenting.
        • asymmetric wall thickness with luminal dilatation of upper to middle third thoracic esophagus, seem in progression as compared with CT on 2022/08/08. enlarged subcarinal LNs in visceral space, in progression
        • filling defects in pulmonary arteries (distal main, intrapulmonary lobar and segmental/subsegmentsl branches)
      • Heart: normal in size of cardiac chambers.
      • Pleura: small Lt-sided effusion.
        • opacification of veins in the chest wall and mediastinum
      • Visible abdominal contents:
        • normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
        • no enlarged lymph node.
      • Visualized bones: unremarkable.
    • Impression:
      • proression of esophageal cancer with regional LN metastasus and newly developed pulmonary embolism and LLL consolidation/volume and pleural effusion as compared with CT on 2022/11/07
  • 2023-02-21 ECG
    • Sinus tachycardia
    • Incomplete right bundle branch block
    • Septal infarct, age undetermined
    • Inferior injury pattern
    • ACUTE MI / STEMI
  • 2023-02-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 25) / 93 = 73.12%
      • M-mode (Teichholz) = 73
    • Normal LV filling pressure; possibly impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; mildly dilated aortic root.
    • Sinus tachycardia.
  • 2023-02-19, -02-02 ECG
    • Sinus tachycardia
  • 2023-01-26 Laryngoscopy
    • Findings
      • left nasal cavity and left middle meatus clear, smooth nasopharynx, epiglottis and bi arytenoid mild edema, no gross tumor found at hypopharynx, small airway
    • Conclusion
      • hypopharyngeal cancer s/p CCRT, no evidence of local tumor recurrence via scope exam
      • supraglottic swelling
  • 2023-01-20 CXR
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Left hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2023-01-09 Esophagogastroduodenoscopy, EGD; Endoscopic Retrograde CholangioPancreatography, ERCP
    • Findings
      • Supraglottic swelling and posterior hypopharynx ulcer was noted.
      • A stricuture was noted at posterior hypopharynx. The regular EGD scope could not be inserted into esophageal inlet.
      • Using guidewire(Jagwire Revolution 0.025in x450cm) and balloon dilatation with CRE ballooin (15-18 mm, 3 ATM) was performed under fluroscopy.
      • After dilatation, the regular EGD scope still could not be inserted pass through the stricture due to the angulation at the stricture site.
    • Diagnosis
      • Hypopharyngeal stricture, s/p endoscopic balloon dilatation
    • Suggestion
      • Repeat CRE balloon dilatation
  • 2023-01-08 CXR
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Linear fibrosis or discoid atelectasis in LLL of the lung?
  • 2022-12-30 CXR
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-12-27 Laryngoscopy
    • Findings
      • right nasal cavity and left middle meatus clear, smooth nasopharynx, epiglottis and bi arytenoid mild edema, no gross tumor found at hypopharynx, yellowish sputum accumulation at bi hypopharynx, patent airway but small
    • Conclusion
      • hypopharyngeal cancer s/p CCRT, no evidence of local tumor recurrence via scope exam
      • supraglottic swelling
  • 2022-12-19 SONO - abdomen
    • probable liver parenchymal disease
    • pancreas obscured
    • spleen not seen: obscured?
  • 2022-12-19 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal inlet stricture, s/p endoscopic balloon dilatation
    • Suggestion
      • Suboptimal effect of the balloon dilatation was noted in this procedure.
      • Repeat dilatation is indicated.
  • 2022-12-13 Patho - stomach biopsy
    • Stomach, mid-body, PW, biopsy — inflammatory polyp. No H.pylori present
  • 2022-12-12 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal inlet stricture, suspected cancer stenosis s/p CRE balloon dilatation
      • C/W esophageal cancer, 20cm to 35cm below incisor
      • Gastric polyp, mid-body, PW, s/p biopsy, suspected adenoma
      • Superficial gastritis & hiatus hernia
      • Reflux esophagitis LA Classification grade A
    • Suggestion
      • Arrange CRE balloon dilatation again and placement of esophageal stent on 20221219.
  • 2022-12-06 CT - brain
    • Imp: No brain nodule or metastasis. Mild cortical brain atrophy.
  • 2022-12-05 Esophagography
    • Esophagography revealed obstruction of cervical esophagus with chocking.
  • 2022-12-01 CXR
    • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
  • 2022-11-29 Laryngoscopy
    • hypopharyngeal cancer s/p CCRT, no evidence of local tumor recurrence via scope exam
  • 2022-11-16, -11-04, -10-19, -09-30 CXR
    • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Lung volume decrease of left lower lung is suspected.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-11-07 CT - chest
    • residual subsegmental atelectasis at basal segments of LLL.
    • suspect progression of esophageal tumor as compared with CT on 20220808.
  • 2022-11-02 SONO - neck (lymph node)
    • Findings
      • Multiple LNs in left middle and left lower neck, with size up to 0.4cm in length at left.
      • No abnormal fluid collection.
    • Imp
      • Multiple small left neck LNs.
  • 2022-10-24 MRI - larynx
    • Remarkly regressed right hypopharyngeal tumor.
    • Multiple abnormal enlarged lymph nodes in left low neck and supraclavicular fossa were noted, suggest check sonography.
    • Severe artifacts at left upper face,neck and oral cavity was noted, this can mask details.
    • Highly suspected regrowth of upper thoracic esophageal tumor/CA, was noted.
  • 2022-09-22 Laryngoscopy
    • Findings:
      • right nasal cavity and left middle meatus clear, smooth nasopharynx, epiglottis and bi arytenoid mild edema, mucus coating on supraglottis and bi hypopharynx, no gross tumor found at hypopharynx
    • Conclusion:
      • hypopharyngeal cancer s/p CCRT, no evidence of tumor recurrence
  • 2022-09-07, -09-02 CXR
    • Atherosclerotic change of aortic arch
    • Lung volume decrease of left lower lung is suspected.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-09-05 ECG
    • Sinus tachycardia
    • Rightward axis
    • Borderline ECG
  • 2022-08-25 Laryngoscopy, Stroboscopy
    • hypopharyngeal cancer s/p CCRT
  • 2022-08-08 CT - chest
    • Findings
      • Lungs: residual atelectasis at basal segments of LLL. normal appearance of LUL and Rt lung.
      • Mediastinum and hila: s/p left main bronchial stenting. decrease wall thickness and luminal dilatation of lower third esophagus compared with CT on 20220604. small LNs in visceral space.
      • Pleura: trace Lt-sided effusion or thickening or nodule.
    • Impression:
      • Regression of lower third esophageal tumor as compared with CT on 20220604. LLL basal segmental atelectasis.
  • 2022-08-02, -07-04 CXR
    • Atherosclerotic change of aortic arch
    • Lung volume decrease of left lower lung is suspected.
  • 2022-07-07 Abdomen - standing (diaphargm)
    • Left hemi-diaphragm elevation is noted, which may be due to left lower lung volume decrease .
  • 2022-06-23 CXR
    • Lt pleural effusion and consolidation and volume loss over Lt lower lobe
    • post Lt main bronchial stent placement, with expansion of atelectatic left lung
  • 2022-06-15 CXR
    • Lt pleural effusion and consolidation and volume loss over Lt lower lobe
  • 2022-06-13 CXR
    • regression Lt pleural effusion and consolidation and volume loss over Lt lower lobe
  • 2022-06-08 CXR
    • Atherosclerotic change of aortic arch
    • Lung volume decrease of left lower lung is suspected.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
    • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
  • 2022-06-08 Bronchoscopy
    • Nasal mucosal lesion, favor mucocele
    • Orolaryngeal wall tumor invasion
    • Endobronchial tumors invasion of whole left main bronchus, combined with severely external compression with LM near-total obstruction.
  • 2022-06-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (30 - 4) / 30 = 86.67%
    • Normal LV systolic function with normal wall motion.
    • Normal LV diastolic function.
    • Normal RV systolic function.
    • Aortic valve calcificaiton with no AS and AR; mild MR; trivial TR.
    • LV chamber obliteration and flat IVC, consider hypovolemia.
  • 2022-06-04 CT - CTA, chest
    • CTA of chest revealed:
      • Wall thickening of subcarinal esophagus. Left pleural effusion. Partial consolidation at left lung. A patchy density at RLL.
      • S/P jejunostomy.
      • Hyperplasia of left adrenal gland.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Wall thickening of subcarinal esophagus. Left pleural effusion. Partial consolidation at left lung. A patchy density at RLL. No evidence of pulmonary embolism.
  • 2022-05-26 Electrocardiogram, EKG
    • Incomplete right bundle branch block
  • 2022-05-25 Nasopharyngoscopy
    • Scope: smooth NPx, oropharynx
    • post. pharyngeal wall ulcerative lesion s/p biopsy, wound healed
    • saliva and mucus pooling, aspiration+
  • 2022-05-05 Patho - larynx biopsy
    • Labeled as “Hypopharyngeal lesion”, punch biopsy — squamous cell carcinoma.
    • IHC stains: CK5/6 (+), p40 (+), p16 (+, >70%).
    • Specimen submitted in formalin consists of 2 piece(s) of tan, irregular tissue measuring 0.2 x 0.2 x 0.1 cm.
  • 2022-05-02 Miniprobe Endoscopic Ultrasound
    • Diagnosis
      • Esophageal cancer, upper to middle esophagus, EUS estimated stage: at least T3NxMx with suspicious hypopharyngeal involvement
      • Gastric polyp, body, PW, s/p biopsy
      • Reflux esophagitis, LA grade A
      • Hiatal hernia
      • Superficial gastritis, body
    • Suggestion
      • suggest consult ENT for biopsy of hypopharynx lesion
      • Pursue pathology report
  • 2022-05-02 Nasopharyngoscopy
    • smooth nasopharynx and oropharynx;
    • small whitish lesion over left pyriform sinus;
    • bulging over right pyriform sinus;
    • posterior hypopharyngeal wall ulcerative lesion;
    • fair vocal cord movement.
  • 2022-04-29 Tc-99m MDP whole body bone scan
    • Mildly increased activity in the lower C-spine, some T- and L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2022-04-28 MRI - brain
    • No evidence of brain metastasis.
    • Mild general brain atrophy.
  • 2022-04-28 Abdominal Ultrasonography
    • Diagnosis
      • Hepatic lesion, S3, 1.22cm, suspected falciform ligament or hemangioma
      • Suspected calcified spot, left kidney
    • Suggestion
      • Please correlate with other image study for liver lesion
  • 2022-04-19 Whole body PET scan
    • Glucose hypermetabolism involving the middle portion of the esophagus and an adjacent lymph node, compatible with recurrent/residual esophageal malignancy with an adjacent lymph node metastasis. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in some right neck level II lymph nodes, a left submandibular lymph node, a left supraclavicular lymph node and a right paratracheal lymph node. The nature is to be determined (inflammatory process? metastases of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism involving the posterior pharyngeal wall of the hypopharynx. Hypopharyngeal malignancy should be considered.
    • Glucose hypermetabolism in a left neck level II lymph node and a left neck level IV lymph node. Metastatic lymph nodes may show this picture.
  • 2022-04-13 Patho - esophageal biopsy
    • Esophagus, 25 to 28 cm, biopsy — Squamous cell carcinoma, moderately differentiated
    • The specimen submitted consists of multiple small pieces of gray-tan soft tissue, labeled esophagus, 25 to 28 cm, measuring up to 0.2 x 0.1 x 0.1 cm. All for section and labeled S2020-05275 FS.
    • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and subtle stromal invasion. Keratin formation is evident.
  • 2022-04-09 CT - lung/mediastinum/pleura
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Soft tissue mass at middle to lower third esophagus up to 7.5cm in length is found. Esophageal cancer is considered. In comparison with CT dated on 2021-08-27, the lesion progressed.
        • Small lymph nodes are found at AP window and paratracheal region.
        • The lung fields are clear.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • Suggest clinical correlation
    • Imp:
      • Suspected recurrent/residual esophageal cancer at middle/lower third esophagus with progression.
      • Mediastinal lymphadenopathy
  • 2021-08-30 Patho - esophageal biopsy
    • Esophagus, middle, 25 to 30 cm, biopsy — High-grade dysplasia (severe dysplasia)
    • The sections show high-grade (severe) dysplasia, composed of squamous epithelium with hyperkeratosis, parakeratosis, acanthosis, cellular atypia and atypical mitotic figures. Changes extend to upper-third of the epithelium. Suggest closely follow up.
  • 2021-08-27 CT - lung/mediastinum/pleura
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Calcified coronary arteries is found.
        • The lung fields are clear.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
        • There is no evidence of esophageal wall thickening.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
        • Suggest clinical correlation
    • Imp: no evidence of esophageal wall thickening in the study.
  • 2020-12-29 Patho - esophageal biopsy
    • Esophagus, middle, biopsy — high-grade dysplasia
    • Microscopically, it shows high-grade dysplasia with aacanthosis and dysplastic change of the epithelial cells.
  • 2020-12-29 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade AEsophageal lesion, middle esophagus s/p biopsy (B)
    • Superficial gastritis, antrum
    • Gastric polyp, GC of body s/p biopsy (A)
  • 2019-11-13 CT - mediastinum
    • Comparison: prior CT dated on 2017/11/27
      • Chest
        • No enlarged LNs in the mediastinum, supraclavicular fossa, and hilars.
        • Normal appearance of visible thoracic aorta, central pulmonary arteries, and cardiac chmabers.
        • No pleural effusion or nodule.
        • There is no soft tissue mass or enhanced wall thickening along the course of the esophagus and esopho-gastric juncntion.
        • A tiny subupleural nodule at LUL. normal appearance of the LLL and Rt lung.
        • Unremarkable of the chest wall.
      • Visible abdomen
        • Unremarkable of the liver, spleen, pancreas, both kidneys, GB, and adrenal glands.
        • No enlarged LN.
        • No ascites in the abdominal cavity.
      • Visible bones
        • Mild marginal spurs of multiple vertebral bodies.
    • Impression:
      • esophageal cancer,T2N2M0, s/p compeleted CCRT with no obvious recurrent tumor or luminal narrowing based on this CT study.
  • 2018-07-03 Bone densitometry - hip
    • Hip BMD performed by DXA revealed:
      • Hip, BMD is 0.660 gms/cm2, about 1.5 SD below the peak bone mass (78%) and 0.6 SD below the mean of age-matched people (89%).
    • IMP: osteopenia
  • 2017-11-27 CT - lung/pleura, chest and upper abdomen
    • Findings
      • Chest:
        • No enlarged LNs in the mediastinum, supraclavicular fossa, and hilars.
        • Normal appearance of aorta, pulmonary arteries, and cardiac chmabers.
        • No pleural effusion.
        • There is no soft tissue mass or enhanced wall thickening along the course of the esophagus and esopho-gastric juncntion.
        • Two tiny subupleural nodule at LUL srs5 img10
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys, GB, and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • No ascites in the abdominal cavity.
    • Impression:
      • esophageal cancer, T2N2M0, s/p compeleted CCRT without obvious recurrent tumor or luminal narrowing based on CT study.
  • 2017-03-06 CT - lung/pleura, chest and upper abdomen
    • Findings
      • Chest:
        • No enlarged LNs in the mediastinum, supraclavicular fossa, and hila.
        • Normal appearance of aorta, pulmonary arteries, and cardiac chmabers.
        • No pleural effusion.
        • There is no soft tissue mass or enhanced wall thickening along the course of the esophagus and esopho-gastric jucntion.
        • Two tiny subupleural nodule at LUL
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
        • Suggest clinical correlation
    • Impression:
      • esophageal cancer, T2N2M0, s∕p compeleted CCRT without obvious recurrent tumor or luminal narrowing based on CT study.

[consultation]

  • 2023-02-21 Cardiology
    • Q
      • This 61-year-year-old male has the medical history of low third esophageal cancer (SCC, cT2N2M0) s/p CCRT in 2013 and HBV carrier without follow up.
      • Chemotherapy with Docetaxel + Leucovorin + Fluorouracil + Cisplatin was started on 2022/12/21. C2D1 for Docetaxel + Leucovorin + Fluorouracil + Cisplatin was on 2023/01/09. C2D15 chemotherapy with Docetaxel + Leucovorin + Fluorouracil + Cisplatin was on 2023/01/09.
      • This time, he suffered from intermittent and progressive chest tightness and chest pain for 2 day. He denied fever, chills, abdominal pain, or dysuria. He visited our ER for management. During ER, vital sign showed BP:114/69, PR:122, BT:36.7 degree Celsius, RR:20. Lab data showed negative cardiac enzyme abnomality, but CRP was elevated. CXR showed focal increased density in the right lower lung field. Under the impression of pneumonia, he was admitted for further management.
      • He complatins chest pain, chest tightness, short of breathing, 12 lead EKG: II, III, aVF ST elevate, follow-up right side 12 lead EKG showed acut MI/ STEMI, so we need your help, thanks a lot!!
    • A
      • The patient was examined and hx was reviewed.
      • O
        • nsp chest tightness and chest pain;
          • aggravated productive cough with wheezing+ in recent days;
        • CxR: elevated L’t diaphragm, suspected LLL consolidation;
        • 2D echo showed preserved LV systolic function; no evidence of segmental asynergy.
      • Imp
        • Sinus tachcyardia, possibly due to underlying infection (possibly L’t pneumonia); no evidence of STEMI now.
      • Suggestion
        • Treat L’t pneumonia and bronchospasm firstly.
        • Check thyroid function for tachycardia survey.
  • 2023-01-09 Gastroenterology
    • Q
      • For esophagus balloon dilation
      • This 60-year-year-old male has the medical history of low third esophageal cancer (SCC, cT2N2M0) s/p CCRT in 2013 and HBV carrier without follow up. He was found esphagus relapse and suspicious hypopharyngeal involvement by PES was done on 2022/04/13 and nasopharyngoscopy 2022/05/02.
      • He received 6 courses CCRT with PF from 2022/06/02 ~11/04. Radiotherapy from 2022/05/30~7/27.
      • This time, he was admitted for exam and chemotherapy on 2023/01/08.
      • He under went CRE balloon dilatation again on 2022/12/19 which showed esophageal inlet stricture.
      • Thus we need your expertise for his balloon dilatation at this admission. Thanks a lot!
    • A
      • 60M, A case of 1) Squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence. 2) Squamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0. 3) Squamous cell carcinoma of the middle third esophagus. We are consulted for CRE balloon dilatation.
      • S+O:
        • conscious status: clear
        • HEENT: dysphagia, including drinking water
        • chest: smooth breath sound
        • abdomen: soft and flat
        • Lab
          • WBC: 4700
          • Hb: 11
          • Plt: 208
          • AST/ALT: 30/26
          • INR: 1
          • PT: 10.3
        • EGD(2022/12/19):
          • Esophageal inlet stricture, s/p endoscopic balloon dilatation
      • A:
        • Esophageal squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence.
        • Esophageal inlet stricture
        • quamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0.
      • P:
        • We will arrange EGD for endoscopic balloon dilatation evaluation.
  • 2022-12-13 Thoracic Surgery
    • Q
      • He underwent jejunostomy surgery on 2022/05/06 by doctor Hsieh. The patient complaint about redness around Jejunostomy with leakage recently. We need your help for further evaluation. Thank you very much.
    • A
      • Dear Dr. Wan, I will visit the patient and educate about wound care. Thanks for your consultation!!
  • 2022-12-02 Gastroenterology
    • Q
      • The patient was unable to swallow even water. We need your help for further evalution of esophageal stent. Thank you very much.
    • A
      • Image
        • 2022/11/07 - asymmetric wall thickness and luminal dilatation of upper to middle third thoracic esophagus, seem in progression as compared with CT on 8/8. small LNs in visceral space
      • Impression
        • Dysphagia, suspicious obstruction of recurrent esophageal cancer
      • Suggestion
        • Please arrange Esophagography first to evalute the level of esophagus obstruction, then contact us for further management about esophageal stent placement
        • We would arrange EGD for tthis patient.
  • 2022-11-07 Rehabilitation
    • A
      • Assessment
        • Squamous cell carcinoma of upper to middle esophagus, cT3N3M0 stage IVA
        • Squamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0
        • Carrier of viral hepatitis B
        • constipation
        • Dysphagia due to esophageal tumor progression
      • Plan
        • The patient is not suitable for swallowing training
        • Food and water cannot pass down the esophagus, they will go back retrogradely and cause aspiration or choking
  • 2022-07-08 Dental Clinic
    • Q
      • For dental evaluation and management
      • This is a 60-year-old man with past history of esophageal cancer (SCC, T2N2M0) lower third post CCRT in 2013 and HBV carrier without follow up. This time he has suffered from progressive dysphagia and weight loss of 8 kg in 1 month. In hematology OPD, chest CT was arranged and showed suspected recurrent/residual esophageal cancer at middle/lower third esophagus with progression and mediastinal lymphadenopathy. He was extracting the teeth (14, 27, 28, 38, 45), and he received CCRT with PF. The family request consult dentistry for dental evaluation and management. Thanks a lot.
    • A
      • #11-#13 The dental bridge is loose, it is recommended to use interdental brushes to maintain oral hygiene.
      • A diagnostic certificate issued by an oral and maxillofacial surgery department is required.
    • 2022-06-09 Infectious Disease
      • A
        • Assessment
          • Consultation for Mepem antibiotic
          • 60-year-old esophageal cancer male patient has received recent chemotherapy
          • High fever yesterday afternoon despite Cravit use for left lung pneumonia.
          • Aspiration pneumonia is the first impression.
          • Sputum culture normal flora only.
          • Cravit is replaced by Mepem yesterday evening.
        • Suggestion:
          1. Continue Mepem for one week first.
          1. Check blood culture report, repeat sputum culture.
    • 2022-06-08 Family Medicine
      • Q
        • The patient and family request to combine hospice care (NHI card annoted DNR), so we need your help, thanks a lot!!
      • A
        • 60 y/o gentleman advanced esophageal cancer. admitted for CCRT
        • Our share care would follow up.
    • 2022-05-26 Thoracic Surgery
      • Q
        • This 60 y/o man with past history of esophageal cancer (SCC, T2N2M0) lower third post CCRT in 2013 and HBV carrier without follow up.
        • Recurrent upper to middle esophagus squamous cell carcinoma, cT3N3M0 stage IVA status post jejunostomy and port-A catheter implantation on 2022-05-06.
        • The patient’s jejunostomy was done under your servise on 2022-05-06. This time, he was admitted due to acute epiglottitis. After admission, antibiotic with Cravit was given. The patient suffered from cold sweating and palpitation while G-tube feeding, and some yellowish discharge from jejunostomy for 4-5 days. NPO was told since last night. We request your consultation for further evaluation.
      • A
        • I have visited the patient and educated about care of jejunostomy. Thanks for your consultation!!!
    • 2022-05-10 Oral and Maxillofacial Surgery
      • Q
        • This is a 60-year-old man with past history of esophageal cancer (SCC, T2N2M0) lower third post CCRT in 2013 and HBV carrier without follow up. This time he has suffered from progressive dysphagia and weight loss of 8 kg in 1 month. In hematology OPD, chest CT was arranged and showed suspected recurrent/residual esophageal cancer at middle/lower third esophagus with progression and mediastinal lymphadenopathy.
        • Upper GI panendoscpope showed one lumen-obstructive tumor was noted from 25 to 30 cm and biopsy was done. Pathology revealed moderately differentiated squamous cell carcinoma. He was referred to our CS OPD. PET scan revealed a glucose hypermetabolic lesion involving the middle portion of the esophagus and an adjacent lymph node, compatible with recurrent/residual esophageal malignancy with an adjacent lymph node metastasis.Endoscopic biopsy proved Esophageal squamous cell carcinoma at middle/lower third esophagus. However, his EUS showed Esophageal cancer, upper to middle esophagus, EUS estimated stage: at least T3NxMx with suspicious hypopharyngeal involvement.
        • We consult ENT Dr. Lan for hypopharynx lesion, nasopharngoscopy biopsy show squamous cell carcinoma.
        • After admission, we arranged WBBS, brain MRI, abd. sono, EUS and bronchoscope, for cancer work-up. On 2022-05-06, he underwent feeding jejunostomy + port-A insertion. We kept nutrition supplement with jejunostomy feeding since 2022-05-07 and increased calories gently. We also consulted ONCO and for further manegement.
        • Impression: upper to middle esophagus squamous cell carcinoma,cT3N3M0 stage IVA and hypopharynx squamous cell carcinoma.
        • We need to consult you for for pre-RT dental evaluation and management.
      • A
        • This is a 60-year-old man suffered from upper to middle esophagus squamous cell carcinoma, cT3N3M0 stage IVA and hypopharynx squamous cell carcinoma. We were consulted for Pre-radiotherapy dental evaulation
        • O:
          • Hopeless teeth of tooth 14, 27, 28, 38, 45
          • Poor oral hygiene with full mouth gingivitis.
        • P:
          • Explain the finding to patient and his son.
          • Please prescribed Cefa 1g IV Q8H for prophhylaxis.
          • We were arranged further extraction for him .
          • OPD follow up.
    • 2022-05-09 Radiation Oncology
      • The patient’s history was reviewed and patient was examined.
      • S:
        • For radiotherapy due to recurrent esophageal carcinoma and hypopharyngeal carcinoma.
        • PI: The patient was a case of low third esophageal cancer (SCC, cT2N2M0) s/p CCRT in 2013 and HBV carrier without follow up. He suffered from progressive dysphagia since 2021 with body weight loss of 8 kg in 1 month. After a series of work-up, the impression was upper to middle esophageal squamous cell carcinoma, cT3N3M0 stage IVA and hypopharynx squamous cell carcinoma. On 2022-05-06, he underwent feeding jejunostomy + port-A insertion. Nutrition supplement with jejunostomy feeding since 2022-05-07 and increased calories gently.
        • Family history: (father: esophageal cancer).
        • Cancer site specific factors: Alcohol (quit); Smoking (quit); Betel nut (quit).
        • Personal Hx: DM(-); HTN(-); HBV(+)
      • O:
        • ECOG: 1
        • PE: neck and bil SCF: neg.
        • Pathology (2013-02-01; S2013-01656): Esophagus, esophagocardiac junction to 32 cm below incisor, biopsy — squamous cell carcinoma.
        • Esophagography (2013-02-22): lower esophageal cancer.
        • CXR (2013-02-18): neg.
        • Chest CT (2013-02-08): Soft tissue mass at lower third esophagus near EG junction up to 5*3.55cm with central necrotic part is found. There is no evidence of mediastinal LAP, however, some lymph nodes (3-4) around EG junction is noted. Esophageal cancer at lower third esophagus. T2N2M0 in the study. Stage IIIa.
        • PET scan (2013-02-20): Glucose hypermetabolism lesion in the esophagus, L/3, probably primary esophagus malignancy; hypermetabolism lesion in the right subcarinal region of mediastinum, probably reactive node or malignancy with lymph nodes metastasis. Staging: TxNxM0.
        • RT (2013-3-11 ~ 2013-4-15): 4500cGy/25fractions of the low third esophageal tumor to peripheral lymphatic area.
        • CT scan of mediastinum (2013-07): resolution of intraluminal mass in lower third of esophagus; post treatment change involving M/3 esophagus?
        • Pathology (S2021-11415, 2021-08-31): Esophagus, middle, 25 to 30 cm, biopsy — High-grade dysplasia (severe dysplasia).
        • CT scan of lung (2022-04-09): Suspected recurrent/residual esophageal cancer at middle/lower third esophagus with progression. Mediastinal lymphadenopathy.
        • UGI pandendoscopy (2022-04-13): One lumen-obstructin tumor was noted from 25 to 30 cm, s/p biopsy*8 (A). Lugol solution was applied. Area of sliver color sign was noted at 23-25cm. Biopsy was done. (A). One depressed lesion with loss of vasculature was noted at hypopharynx. Diagnosis: Esophageal cancer, s/p biopsy (A) + (B). Hypopharynx lesion, suspected metastatic lesion
        • Pathology (S2022-06234, 2022-04-14): Esophagus, 25 to 28 cm, biopsy — Squamous cell carcinoma, moderately differentiated
        • PET (2022-04-19): 1. Glucose hypermetabolism involving the middle portion of the esophagus and an adjacent lymph node, compatible with recurrent/residual esophageal malignancy with an adjacent lymph node metastasis. 2. Mild glucose hypermetabolism in some right neck level II lymph nodes, a left submandibular lymph node, a left supraclavicular lymph node and a right paratracheal lymph node. The nature is to be determined (inflammatory process? metastases of low FDG uptake?). 3. Glucose hypermetabolism involving the posterior pharyngeal wall of the hypopharynx. Hypopharyngeal malignancy should be considered. 4. Glucose hypermetabolism in a left neck level II lymph node and a left neck level IV lymph node. Metastatic lymph nodes may show this picture.
        • CXR (2022-04-27): a focal Rt-sided convexity of the azygoesophageal recess interface, raise suspicious of esophageal tumor. Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch. Clean lung fields based on plain image. Normal shape and size of heart. Marginal spurs of multiple vertebral bodies of T-L spine due to spondylosis. Normal appearance of both hila
        • MRI of brain (2022-04-28): No evidence of brain metastasis. Mild general brain atrophy.
        • Abd sono (2022-04-28): Hepatic lesion, S3, 1.22cm, suspected falciform ligament or hemangioma. Suspected calcified spot, left kidney.
        • Bone scan (2022-04-29): no evidence of bone metastasis.
        • Miniprobe EUS for UGI (2022-05-02): 1. Esophageal cancer, upper to middle esophagus, EUS estimated stage: at least T3NxMx with suspicious hypopharyngeal involvement. 2. Gastric polyp, body, PW, s/p biopsy. 3. Reflux esophagitis, LA grade A. 4. Hiatal hernia. 5. Superficial gastritis, body.
        • Operation (2022-5-6): Feeding jejunostomy + port A
        • Pathology (S2022-07892, 2022-5-9): Labeled as “Hypopharyngeal lesion”, punch biopsy — squamous cell carcinoma. IHC stains: CK5/6 (+), p40 (+), p16 (+, >70%).
      • A:
        • Squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence.
        • Squamous cell carcinoma of the hypopharynx, p16 (+).
      • P:
        • Radiotherapy is indicated for this patient with the following indicators: recurrent esophageal carcinoma and hypopharyngeal carcinoma.
        • Goal: curative (if double primary), or palliation (if metastatic chypopharyngeal carcinoma).
        • Treatment target and volume: hypopharyngeal tumor, bilateral neck, to recurrent esopharyngeal tumor area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: probably 5000cGy/25 fractions of the esophageal tumor, bilateral neck, and 7000cGy/35 fractions of the hypopharyngeal tumor to involved neck nodal lesions (if hypopharyngeal carcinoma is 2nd primary).
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 10:30, 2022-05-11.
        • Please consult Dental department for pre-RT dental evaluation and management.
    • 2022-05-05 Hemato-Oncology
      • Impression:
        • Recurrent upper to middle esophagus squamous cell carcinoma, cT3N3M0 stage IVA
        • Hypopharynx tumor suspect SCC s/p biopsy, pending pathology
      • Suggestion
        • For recurrent esophagus cancer, SCC, systemic therapy is indicated (such as 5-FU/capecitabine + oxaliplatin[self-paid]/cisplatin) or clinical trial if available
        • Schedueled feeding jejunostomy + port-A had arranged
      • Thanks for your consultation. We will discuss with patient. If there is any problem, please feel free to let us known
    • 2022-05-02 ENT
      • A
        • Local finding: fair oral cavity and oropharynx
        • Scope: smooth nasopharynx and oropharynx; small whitish lesion over left pyriform sinus; bulging over right pyriform sinus; posterior hypopharyngeal wall ulcerative lesion; fair vocal cord movement.
        • Impression: hypopharyngeal malignancy cannot be ruled out
        • Plan: Biopsy for tissue proof may be required.

[surgical operation]

  • 2022-10-26 Removed port-A and insert new one. Revision of jejunostomy.
  • 2022-06-13 Tracheal stent inseriton.
  • 2022-05-06 Feeding jejunostomy

[radiotherapy]

  • 2022-05-30 ~ 2022-07-27 - 5000cGy/25 fractions (15MV and 6MV photon) of the hypopharyngeal tumor to bilateral neck, and 7000cGy/35 fractions of the reduced hypopharyngeal tumor to bilateral involved neck nodal area.

[chemoimmunotherapy]

  • 2023-02-02 - docetaxel 40mg/m2 65mg NS 200mL 1hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 400mg/m2 690mg NS 250mL 2hr + fluorouracil 1000mg/m2 1735mg NS 500mL 24hr D1-D2 + cisplatin 40mg/m2 65mg NS 500mL 4hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL] D1 + NS 500mL 2hr (after cisplatin) D3
  • 2023-01-09 - docetaxel 40mg/m2 70mg NS 200mL 1hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-D2 + cisplatin 40mg/m2 70mg NS 500mL 4hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL] D1 + NS 500mL 2hr (after cisplatin) D3
  • 2022-12-20 - docetaxel 40mg/m2 70mg NS 200mL 1hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-D2 + cisplatin 40mg/m2 70mg NS 500mL 4hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL] D1 + NS 500mL 2hr (after cisplatin) D3
  • 2022-12-01 - docetaxel 40mg/m2 70mg NS 200mL 1hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-D2 + cisplatin 40mg/m2 70mg NS 500mL 4hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL] D1 + NS 500mL 2hr (after cisplatin) D3
  • 2022-11-04 - cisplatin 75mg/m2 130mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
  • 2022-09-30 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
  • 2022-09-02 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
  • 2022-08-02 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
  • 2022-07-04 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
  • 2022-06-02 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)

[note]

  • Esophageal and Esophagogastric Junction Cancers NCCN guidelines version 4.2022, 20220907
    • DEFINITIVE CHEMORADIATION (NON-SURGICAL) p51
      • Fluorouracil and cisplatin
        • Cisplatin 75-100 mg/m2 IV on Day 1
        • Fluorouracil 750-1000 mg/m2 IV continuous infusion over 24 hours daily on Days 1-4
        • Cycled every 28 days for 2 cycles with radiation followed by 2 cycles without radiation
      • ref: Minsky BD, Pajak TF, Ginsberg RJ, et al. INT 0123 (Radiation Therapy Oncology Group 94-05) phase III trial of combinedmodality therapy for esophageal cancer: high-dose versus standard-dose radiation therapy. J Clin Oncol 2002;20:1167
    • PERIOPERATIVE CHEMOTHERAPY (Only for adenocarcinoma of the thoracic esophagus or EGJ) p50
      • Fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) - (4 cycles preoperative and 4 cycles postoperative)
        • Fluorouracil 2600 mg/m2 IV continuous infusion over 24 hours on Day 1
        • Leucovorin 200 mg/m2 IV on Day 1
        • Oxaliplatin 85 mg/m2 IV on Day 1
        • Docetaxel 50 mg/m2 IV on Day 1
        • Cycled every 14 days
      • ref: Al-Batran S-E, Homann N, Pauligk C, et al. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastrooesophageal junction adenocarcinoma (FLOG4): a randomised, phase 2/3 trial. Lancet 2019;393:1948-1957.
  • Concurrent Chemoradiotherapy with Docetaxel, Cisplatin, and 5-fluorouracil Improves Survival of Patients with Advanced Esophageal Cancer Compared with Conventional Concurrent Chemoradiotherapy with Cisplatin and 5-fluorouracil. J Cancer. 2018;9(16):2765-2772. Published 2018 Jul 16. doi:10.7150/jca.23456
    • All patients underwent chemotherapy and radiotherapy concurrently.
    • In the CF-RT group, cisplatin (70 mg/m2) was administered via intravenous drip infusion on day 1, and 5-FU (700 mg/m2) via continuous intravenous drip infusion on days 1-5.
    • In the DCF-RT group, docetaxel and cisplatin (both 50 mg/m2) were administered via intravenous drip infusion on day 1, and 5-FU (500 mg/m2) via continuous intravenous drip infusion on days 1-5.
    • Patients underwent 2 cycles of chemotherapy during radiotherapy when no deterioration in overall health or occurrence of adverse events was verified.
    • Patients with severe neutropenia were immediately administered granulocyte-colony stimulating factor (G-CSF).

==========

2023-03-06

  • 2023-03-05 lab data CRP 5.25mg/dL.

  • 2023-03-05 sputum gram’s stain result showed:

    • G(+) Cocci 3+: There is a high amount of gram-positive cocci bacteria present in the sample being analyzed.
    • GNB 3+: There is a high amount of gram-negative bacilli bacteria present in the sample being analyzed.
    • Neutrophil/LPF <10 and/or Epithelial cell/LPF >25: This may indicate that the sample was not collected properly and that there is a risk of contamination.
  • As the staining results may suggest a possibility of contamination, it may be necessary to collect a new sample.

  • Moxifloxacin with an antibacterial spectrum encompassing both aerobic gram-negative and gram-positive strains, as well as anaerobic bacteria, can be used for pneumonia, community-acquired, outpatients with comorbidities and inpatients as an alternative agent. It is not recommended to be used in patients with risk factors for P. aeruginosa (ATS/IDSA [Metlay 2019]; File 2020). Based on the normal liver and kidney function lab results on 2023-03-05, the current dosage of 400 mg once daily is appropriate and does not require any adjustments.

2023-02-02

  • Lab data on 2023-02-01 were grossly normal. There is no problem with the active prescription, except for the anticipated less effective use of Boren-C by tube-feeding.

2023-01-09

[tube feeding]

  • Broen-C (bromelain + L-cysteine) is an enteric-coated tablet designed to prevent the destruction of the bromelain enzyme by gastric juice.

  • Bromelain is sensitive to extreme conditions such as high temperature, gastric proteases in stomach juice, high acidity, and organic solvents, and thus, reduces its functionalities and bioavailability. Its instability under such stress conditions reduce its enzymatic activity, decrease its health benefits, and limit its pharmacological applications. ref: Mala T, Anal AK. Protection and Controlled Gastrointestinal Release of Bromelain by Encapsulating in Pectin-Resistant Starch Based Hydrogel Beads. Front Bioeng Biotechnol. 2021;9:757176. Published 2021 Oct 29. doi:10.3389/fbioe.2021.757176

  • There are no other drugs in the inventory that contain bromelain.

2022-12-19

  • It has been arranged on 20221219 for a CRE (controlled radial expansion) balloon dilatation and placement of an esophageal stent due to obstruction of cervical esophagus.
  • Medication is sometimes responsible for clogged feeding tubes. To prevent clogs and other related issues, there are general tips for giving medication through a feeding tube:
    • Administer each medication separately.
    • Stop the feeding and flush the tube with water before and after medication administration.
    • Crush only those medications which are immediate-release. Sustained-release and enteric-coated medications don’t dissolve well and may not absorb properly when crushed.
    • Use liquid medications when available.
    • Dilute liquid medications to prevent clogging and gastrointestinal upset, like diarrhea.

2022-12-12

[tube feeding]

  • Except for Broen-C, all oral medications in the active prescription can be administered by nasogastric tube.
  • In order to prevent the bromelain enzyme from being destroyed by gastric juice, Broen-C (bromelain + L-cysteine) is designed as an enteric-coated tablet.

2022-12-02

  • As a result of the CT result obtained on 2022-11-07, it appears that the esophageal tumor has progressed. It was then decided to change the regimen from [cisplatin + fluorouracil] to [docetaxel + leucovorin + fluorouracil + cisplatin], which was initiated during this hospitalization.
  • Neither a non-trivial adverse reaction nor an issue with the active prescription have been observed.

2022-12-01

[tube feeding]

  • With the exception of Boren-C, all other drugs in the active prescription can be administered via nasogastric tube.
  • As an enteric-coated tablet, Boren-C is designed to prevent gastric acids from destroying its key ingredient, bromelain enzyme.

2022-10-03

  • The underlying condition HBV is currently being managed with Vemlidy (tenovofir) without any problems.

2022-09-30

[tube feeding]

  • Broen-C (bromelain + L-cysteine) is an enteric coated tablet that should not be administered through a nasogastric tube. Right now, there is no single ingredient bromelain item in stock, however, Actein (acetylcysteine 200 mg/pk) has also been prescribed and may act in part as cysteine.

2022-09-05

[tube feeding]

  • As Harnalidge (tamsulosin 0.4mg PO QDAC) is not intended for use with nasogastric tubes, it is recommended to replace it with Urief (silodosin 8mg PO QD).
  • Broen-C (bromelain + L-cysteine) is formulated as an enteric coated tablet and is not intended for nasogastric tube feeding. Currently, there is no single ingredient bromelain item available in inventory, however, Actein (acetylcysteine 200mg/pk) is available and could partially serve as cysteine.

2022-06-06

  • Initially diagnosed in 2013, this patient now suffers from recurrent esophageal squamous cell carcinoma of cT3N3M0 stage IVA. He has begun receiving CCRT since late May 2022.
  • Additionally, the patient carries viral hepatitis B, which is treated with Vemlidy (tenofovir alafenamide) 25mg PO QDCC.

700081806

230303

[exam findings]

  • 2023-02-27 Patho - gingival/oral mucosa biopsy
    • Bone, chin, removal — Osteitis and osteonecrosis
  • 2022-09-20 MRI - nasopharynx
    • Indication: Recurrence SCC of mandibular gingiva
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
    • Pulse sequences:1. Precontrast: sagittal and axial, coronal T1WI, coronal T2WI images, axial T2WI 2. Post contrast: axial, coronal T1WI. Slice thickness: 3-5 mm
    • Comparison: 2022/05/13 MRI
      • Post fat-containing flap reconstruction surgery with clips/sutures retention and/or bony defect at left mandible, bucco-gingival region.
      • No evident abnormal enlarged lymph node in the visible neck.
      • No obvious abnormal enhancement after contrast medium administration.
      • No obvious gingival nodule or mass was found, though early shallow lesion is hard to be defined on this study.
  • 2022-09-19 PD-L1 IHC (28-8 pharmDx Assay, Agilent/Dako)
    • Tissue blocks/unstained slides received labeled as: S2022-15310
    • TC >= 1% and < 5%
    • Percentage of PD-L1 expressing tumor cells (%TC): 1%
  • 2022-09-12 Patho - soft tissue biopsy / simple excision (non lipoma)
    • Skin lesion, chin, frozen and excision — Squamous cell carcinoma, moderately differentiated
    • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated characterized by solid tumor nests show enlarged, pleomorphic nuclei infiltrate in the stroma with keratin formation.
  • 2022-09-09 CT - facial bone
    • Indication
      • SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I)
      • SCC of left lower gingival (T1N0M0 stage I) s/p OP with tongue flap .
      • SCC of lower lower gingival (T4N0M0 stage IV) s/p OP with fibula flap reconstruction
      • During CCRT
      • The STSG wound of left fibula region was healing in progress .
      • Multiple ulceration of left floor of the mouth
      • A little swelling of chin region .
    • Protocol: 2.5mm slice thickness, axial scan and coronal/ sagittal reconstruction
    • Without contrast fical bone CT showed
      • The neck airway was unremarkable.
      • Suspicious a break at the metallic plate of the left posterior mandible.
      • Post-operation change at left buccal region, mandile and maxilla.
      • No neck LAP
    • IMp: suspicious a break at the metallic plate of the left posterior mandible.
  • 2022-07-19 PD-L1 IHC (28-8 pharmDx Assay, Agilent/Dako)
    • Tissue blocks/unstained slides received labeled as: S2022-09325A1
    • Tumor cell (TC) staining assessment: TC < 1%
  • 2022-06-09 Patho - oral cancer (wide excision without lymph node)
    • PATHOLOGIC DIAGNOSIS
      • Mandibular gingiva, left, wide excision — Squamous cell carcinoma
      • Lymph nodes, llevel 3, right, LN dissection — Negative for malignancy (0/1)
      • Bone, mandible, segmental mandibulectomy — Involved by carcinoma and free margin
      • Pathology stage: rpT4aN0(cM0); Stage IVA
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure(s): Wide excision + segmental mandibulectomy + LN dissection
      • Specimen Type:
        • Main location: Left mandibular gingiva
        • Lymph node dissection: Yes, right level III
      • Specimen Integrity: intact
      • Specimen Size: 7.2 x 4.2 x 3.5 cm with skin 3.9 x 3.2 cm, mandible bone, 7.2 cm in length, and three teeth
      • Tumor Site: Mandibular gingiva; Laterality: Left
      • Tumor Focality: Single focus
      • Tumor Size: 2.0 x 1.0 x 0.8 cm
        • Depth of Invasion: 8 mm
      • Mucosal Surface : Ulcerated
      • Gross Tumor Extension: Tumor invades bone
      • Representative parts are taken for section and labeled: A1= tumor + anterior margin of mouth floor, A2= tumor + upper lip, A3= tumor + mouth floor, A4= tumor + buccal mucosa, A5= tumor + skin, A6= lower lip, A7= posterior area of molar, A8= mandible bone. B= level 3 lymph node. F2022-00263 FSA= mouth floor, left, FSB= mouth floor, right
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Squamous cell carcinoma
      • Histologic Grade: G2 (moderate differentiated)
      • Microscopic Tumor Extension: To mandible bone
      • Margins: Margins free, Distance from closest margin: 0.5 cm (anterior margin of mouth floor)
      • Lymph-Vascular Invasion: Not identified
      • Perineural Invasion: Not identified
      • Neck Lymph Nodes: Negative (0/1)
        • Number of LN examined: 1 (right level 3)
        • Number of LN metastasis: 0
      • Mandibule bone margin: Free of tumor
      • Surgical margins received for frozen section, including mouth floor, right and mouth floor left: Free of tumor
  • 2022-05-13 MRI - nasopharynx
    • Indication:
      • SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I)
      • SCC of left lower gingival s/p OP with tongue flap .
      • A ganuloma like mass was noted of left commisure region with bleeding tendancy s/p CO2 laser surgery on 2022/04/25. Pathology report: SCC
    • Imaging protocol: 3-5mm slice thickness; coronal T1 & T2, sagittal T1, axial T1 & T2FS & DWI/ADC, axial and coronal T1FS+C images
    • Neck MRI without/with Gadolinium-based contrast enhancement shows:
      • magnetic suceptibility artifacts from dental prosthesis obscure the image details in oral cavity.
      • postoperative change at left buccal region, left neck, and left submandibular space.
      • ill-defined enhancing mass lesion (largest diameter about 3.3cm) at left lower gingiva and oral commisure, with invasion to mandibular bone causing cortex destruction and bone marrow signal change, and probably also invasion to left inferior alvealar nerve. T4a disease is compatible.
      • no enlarged cervical lymphadenopathy.
    • Impression:
      • Recurrent left lower gingival cancer, image staging favor T4aN0.
      • Postoperative change at left buccal region and left neck.
    • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage) : T:T4a(T_value) N:0(N_value) M:____(M_value) STAGE:IVA(Stage_value)
  • 2022-05-10 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a faint hot spot in the midline lower frontal area of the skull and increased activity in the mandible, sacrum, bilateral shoulders and right sternoclavicular junction in whole body survey.
    • IMPRESSION:
      • Increased activity in the mandible. The nature is to be determined (dental problem? malignancy with local bone invasion?). Please correlate with other clinical findings for further evaluation.
      • Mildly increased activity in the sacrum. Degenerative change may show this picture.
      • A faint hot spot in the midline lower frontal area of the skull. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders and right sternoclavicular junction, compatible with benign joint lesions.
  • 2022-04-25 Patho - gingival / oral mucosa biopsy
    • Oral cavity, left lower gingival, incisional biopsy — moderately differentiated squamous cell carcinoma
    • Microscopically, section shows moderately differentiated squamous cell carcinoma consisting of nests and sheets of non-keratinizing tumor cells in infiltrative growth pattern with squamous differentiation and areas of dyskeratosis. The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
    • Immunohistochemical stain reveals p16(-).
  • 2021-11-15 Patho - gingival/oral mucosa biopsy
    • PATHOLOGIC DIAGNOSIS
      • Tumor, left lower gingiva, wide excision — Squamous cell carcinoma
      • Resection margins, ditto — Tumor present at one of peripheral margins
      • Lymph node — N/A
      • AJCC Pathologic staging — pT1, if cN0 and cM0, stage I
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure(s): wide excision
      • Specimen Type:
        • Main location: left lower gingiva
        • Other part(s) included: N/A
        • Lymph node dissection: NO
      • Specimen Integrity: Intact
      • Specimen Size: 1.0 x 0.7 x 0.4 cm
      • Tumor Site: left gingiva
      • Tumor Focality : solitary
      • Tumor Size: 0.4 cm
        • Tumor thickness (for pT1 and pT2 tumors only): 0.1 cm
      • Mucosal Surface: ulcerative tumor
      • Gross Tumor Extension (specify) : can not be assessed
    • MICROSCOPIC EXAMINATION
      • Histologic Type: squamous cell carcinoma
      • Histologic Grade: G2, moderately differentiated
      • Microscopic Tumor Extension: 0.1 cm
      • Margins: tumor present at one of peripheral margins , < 0.1 cm from base
      • Lymph-Vascular Space Invasion: absent
      • Perineural Invasion: absent
      • Neck Lymph Nodes: N/A
      • Immunohistochemistry: CK5/6(+), P63(+), P53(+) and P16(-) for tumor
  • 2021-11-12 MRI - nasopharynx
    • History:
      • Squamous cell carcinoma of left buccal mucosa ,pT1N0M0 post of operation (2012)
      • Squamous cell carcinoma of left upper gingiva, pT1N0(cM0) post of operation (2017)
      • A verrucous like mass was noted of left lower gingival about 0.5 cm in diameter. Pathological report: Squamous cell carcinoma in situ at least.
    • Imaging protocol: 3-5mm slice thickness; coronal T1 & T2, sagittal T1, axial T1 & T2FS & DWI/ADC, axial and coronal T1FS+C images
    • Neck MRI without/with Gadolinium-based contrast enhancement shows:
      • magnetic suceptibility artifacts from dental prosthesis obscure the image details in oral cavity.
      • postoperative change at left buccal region, left neck, and left submandibular space.
      • the primary lesion at left lower gingiva is not obviously seen in this image study. No mandibular bone invasion is noted.
      • no enlarged cervical lymphadenopathy.
    • Impression:
      • Left lower gingival cancer, image staging favor T1N0.
      • Postoperative change at left buccal region and left neck.
    • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage) : T:T1(T_value) N:0(N_value) M:M0(M_value) STAGE:I(Stage_value)
  • 2021-11-04 Patho - gingival/oral mucosa biopsy
    • Gingiva, left lower, incisional biopsy — Squamous cell carcinoma in situ at least
    • The sections show squamous cell carcinoma in situ at least, composed of squamous epithelium with hyperkeratosis, parakeratosis, acanthosis, keratin pearls, marked cellular atypia and atypical mitotic figures. Changes involving the whole thickness of the epithelium. No stromal component can be found, and squamous cell carcinoma can not be excluded. Suggest excision.
  • 2021-04-24 MRI - nasopharynx
    • Indication: SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I). follow up.
    • IMP: C/W left buccal cancer s/p operation without recurrence. Stationary as compared with MRI on 20190907.
  • 2021-04-06 Patho - fissure/fistula
    • Anus, fistulotomy and hemorrhoidectomy — hemorrhoid and consistent with anal fistula
  • 2020-04-07 Whole body PET scan
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2019-09-07 MRI - nasopharynx
    • For oral cancer follow up. SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I)
    • IMP: C/W left buccal cancer s/p operation, without recurrence. Stationary as compared with MRI on 20190126.
  • 2019-01-26 MRI - nasopharynx
    • For oral cancer follow up. SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I)
    • IMP: C/W left buccal cancer s/p operation, without recurrence. Stationary as compared with MRI on 20180629.
  • 2018-06-29 MRI - nasopharynx
    • bilateral neck LNs, stationary.
  • 2017-12-20 MRI - nasopharynx
    • prominent buccal mucosa in the right inferior buccal region. Nature? bilateral neck LNs, stationary.
  • 2017-08-09 MRI - nasopharynx
    • Left buccal CA, post OP with neck LNs dissection. No tumor recurrence. Small bilateral neck LNs, stationary.
  • 2017-05-04 Surgical pathology Level VI
    • PATHOLOGIC DIAGNOSIS
      • Gingiva, upper, left, wide excision — Squamous cell carcinoma
      • Lymph nodes, level V, left neck, dissection — No metastatic carcinoma (0/3)
      • Pathology stage: pT1N0(cMx)
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure(s): Wide excision + neck dissection
      • Specimen Type:
        • Main location: Left upper gingiva
        • Other part(s) included: Bone of left maxilla
        • Lymph node dissection: Yes (specify): Left neck level V
      • Specimen Integrity: Intact
      • Specimen Size: 3.5 x 2.4 x 2.0 cm
        • Additional dimensions (maxilla bone): 3.0 x 1.5 x 1.0 cm
      • Tumor Site: Left upper gingiva
      • Tumor Focality: Single focus
      • Tumor Size: Greatest dimension: 0.5 cm
        • Additional dimensions (if available): 0.5 x 0.3 cm
        • Tumor thickness (for pT1 and pT2 tumors only): 3 mm
      • Mucosal Surface: Intact
      • Gross Tumor Extension: To subepithelial connective tissue
      • Representative parts are taken for section and labeled as: A1= anterior palatal, A2= palatal gingiva, A3= posterior buccal, A4= superior buccal, A5= anterior buccal, A6= bone, B= level V LN, C= left maxilla bone.
      • The specimen received for frozen section consists of four pieces of gray red soft tissue, labeled cheek mucosa, maxillary site, anterior margin, posterior margin; measuring 0.6 x 0.4 x 0.3 cm, 0.7 x 0.5 x 0.4 cm, 0.4 x 0.3 x 0.2 cm, 0.5 x 0.3 x 0.2 cm; respectively. All for paraffin section and labeled as: S2017-06679FS.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Squamous cell carcinoma
      • Histologic Grade: G2 (Moderately differentiated)
      • Microscopic Tumor Extension: To subepithelial connective tissue
      • Margins: Free, Distance from closest margin: 3 mm (superior buccal margin)
      • Lymph-Vascular Invasion: Not identified
      • Perineural Invasion: Not identified
      • Neck Lymph Nodes:
        • Ipsilatera (specify)l: level V
        • Number examined: 3
        • Number involved: 0
      • Left maxilla bone: Free of tumor
      • Margins for frozen section, including cheek mucosa, maxillary site, anterior margin, posterior margin: Free of tumor
  • 2017-04-29 MRI - nasopharynx
    • Left buccal CA, post OP with neck LNs dissection. No tumor recurrence. Small bilateral neck LNs, stationary.
  • 2017-04-26 Whole body bone scan
    • No evidence of bone metastasis.
    • Suspected benign lesions in the lower frontal area of the skull, maxilla, mandible, sacrum, bil. shoulders, elbows, and knees.
  • 2017-04-19 Surgical pathology Level IV
    • Left maxilla, biopsy — Squamous cell carcinoma IHC stain p16 (-)

[consultation]

  • 2022-06-24 Radiation Oncology
    • A
      • A: Squamous cell carcinoma of the left mandibular gingiva, stage rpT4aN0(cM0), Stage IVA; s/p operation (Wide excision of the malignant tumor of left mandibular gingiva plus segmental mandibulectomy. Intermaxillary fixation. Complicated extraction of tooth 31, 41, 42. Left fibula osseocutaneous free flap reconstruction. STSG (16*5cm) from the left thigh for wound closure of the left calf).
      • P: Radiotherapy is indicated for this patient with the following indicators: stage rpT4aN0(cM0)
        • Goal: curative
        • Treatment target and volume: left mandibular gingiva tumor bed, peripheral, to bilateral neck
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5000cGy/25 fractions of the left mandibular gingiva tumor bed, peripheral, to bilateral neck, and 6000cGy/30 fractions of the left mandibular gingiva tumor.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his family. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2022-06-30.

[radiotherapy]

[chemoimmunotherapy]

  • 2023-03-03 - cetuximab 250mg/m2 400mg 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-16 - cetuximab 250mg/m2 400mg 2hr + docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 200mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-01-16 - cetuximab 400mg/m2 700mg 2hr + docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 200mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-26 - docetaxel 40mg/m2 70mg NS 150mL + cisplatin 32mg/m2 60mg NS 150mL 3hr + leucovorin 80mg/m2 150mg & fluorouracil 800mg/2 1500mg NS 1000mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2022-12-12
  • 2022-11-21
  • 2022-11-11
  • 2022-10-18
  • 2022-10-11
  • 2022-09-27
  • 2022-09-19
  • 2022-08-16
  • 2022-08-09
  • 2022-07-26
  • 2022-07-19

[assessment]

  • Lab data

    • 2023-03-03 CRP 3.90 mg/dL
    • 2023-02-27 CRP 0.34 mg/dL
    • 2023-02-23 CRP 0.68 mg/dL
    • 2023-02-16 CRP 0.57 mg/dL
    • 2023-03-03 WBC 20.65 x10^3/uL
    • 2023-02-27 WBC 1.34 x10^3/uL
    • 2023-02-23 WBC 1.67 x10^3/uL
    • 2023-02-16 WBC 5.48 x10^3/uL
    • 2023-03-03 HGB 10.4 g/dL
    • 2023-02-27 HGB 7.3 g/dL
    • 2023-02-23 HGB 8.2 g/dL
    • 2023-02-16 HGB 8.8 g/dL
    • 2023-03-03 PLT 198 x10^3/uL
    • 2023-02-27 PLT 210 x10^3/uL
    • 2023-02-23 PLT 230 x10^3/uL
    • 2023-02-16 PLT 249 x10^3/uL
  • According to recent lab results, there is no longer leukopenia observed, but instead an overboosted WBC count accompanied by an elevated CRP reading (G-CSF administered on 2023-02-27). Please be aware of any signs of infection or inflammation. Anemia has gradually improved, and there is no observed thrombocytopenia.

  • The patient received injectable Amsulber (ampicillin + sulbactam) from 2023-02-23 to 2023-03-02 and has been taking oral Soonmelt (amoxicillin + clavulanic acid) since 2023-03-03. However, there has been no recent culture result available for the patient.

  • The laboratory results from 2023-02-28 also showed 4+ stool occult blood, which could be a possible cause of the anemia. It would be beneficial to rule out gastrointestinal bleeding before discharging the patient.

700052706

230302

[exam findings]

  • 2023-02-14 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a hot spot in the inferolateral aspect of right orbital area of the skull, some faint hot spots in bilateral rib cages and increased activity in the maxilla, mandible, middle T-spines, some L-spines, bilateral shoulders, bilateral sternocalvicular junctions, hips and knees in whole body survey.
    • IMPRESSION:
      • In comparison with the previous study on 2022/08/18, the lesions in the middle T-spines are slightly more evident. Degenerative change in slightly more severe status is more likely. Please correlate with other imaging modalities for further evaluation.
      • No prominent change is noted in other bone lesions.
  • 2023-02-13 SONO - abdomen
    • mild fatty liver (incomplete exam of liver)
    • fatty infiltration of pancreas
  • 2023-02-01 Patho - gingival/oral mucosa biopsy
    • Labeled as “right mandibular gingiva near tooth of #43”, incisional biopsy — squamous cell carcinoma.
    • IHC stain: p16 (-).
  • 2023-01-20 MRI - nasopharynx
    • History: previous MRI showed an enlarged lymph node (14 mm) at right surpaclavicular fossa. He had received a series of operations on 2022-09-09 at the right buccal mucosa, retromolar trigone area and soft palate.
    • Without- and with-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed using the protocol: pre-contrast coronal T1WI and T2WI (thickness=3 mm, gap=1 mm), sagittal T1WI (thickness=4 mm, gap=1 mm), and axial T1WI and T2WI with FS (thickness=5 mm, gap=1 mm), and post-contrast coronal T1WI with FS (thickness= 3 mm, gap=1 mm) and axial T1WI with FS (thickness=5 mm, gap=1mm) show:
      • Post-operation change at bilateral buccal regions, with flap reconstruction at left part of palate and buccal region.
      • S/P lymph node dissection on both sides of the neck.
      • No abnormality at nasopharynx, oropharynx, hypopharynx and larynx.
      • A 14-mm lymph node at right supraclavicular fossa, and a 7.5-mm one at left supraclavicular fossa. Stationary as compared with MRI on 20220817.
      • Atrophy with fatty degeneration of left parotid gland.
      • New lesions with diffuse heterogeneous enhancement along right pterygopalatine fossa and pterygoid muscles and temporalis mcsules near right pterygoid plate. Abnormal enhancement also noted along post-operated right posterior buccal region. D/D: recurrence or inflammatory process.
    • IMP:
      • C/W oral cancer s/p treatment, with highly suspicious recurrence along right pterygopalatine fossa and pterygoid plate.
      • Bilateral supraclavicular lymph nodes, stationary as compared with MRI on 20220817.
  • 2022-09-19 PD-L1 IHC (28-8 pharmDx Assay, Agilent/Dako)
    • PD-L1 Immunostaining Result, S2022-15256A1
      • Tumor cell (TC) staining assessment: TC >= 1% and < 5%
      • Percent of PD-L1 expression in tumor cells (TC): 1%
  • 2022-09-12 Patho - oral cancer (wide excision without lymph node)
    • Diagnosis
      • Buccal mucosa, right, wide excision —- Squamous cell carcinoma, moderately differentiated, AJCC 8th edition: pStage I, pT1Nx(if cM0)
      • Buccal mucosa, right, posterior tumor margin, re-excision —- Mild dysplasia
      • F2022-00419
        • FsA: Palatoglossal fold, resection margin, biopsy — Negative for malignancy
        • FsB: Oropharynx, resection margin, biopsy — Negative for malignancy
        • FsC: Posterior margin, resection margin, biopsy — Severe dysplasia, at least
        • FsD: Upper posterior margin, resection margin, biopsy — Negative for malignancy
        • FsE: Inferior posterior margin, resection margin, biopsy — Negative for malignancy
        • FsF: Middle inferior margin, resection margin, biopsy — Negative for malignancy
        • FsG: Anterior margin, resection margin, biopsy — Negative for malignancy
        • FsH: Inferior tumor margin, resection margin, biopsy — Negative for malignancy
    • Microscopic examination
      • Histologic Type: Squamous cell carcinoma,
      • Histologic Grade: G2: Moderately differentiated,
      • Microscopic Tumor Extension: (specify) submucosa
      • Margins (obtained from the main resection specimen): …
      • Lymph-Vascular Invasion: not identified
      • Perineural Invasion: not identified
      • Neck Lymph Nodes: not received
      • Extranodal extension: not received
      • Additional Pathologic Findings: The posterior tumor margin reveals focal residual squamous epithelium with mild dysplasia.
      • F2022-00419 Sections of the 8 specimens show squamous mucosa and salivary glands without malignancy. Severe dysplasia is seen in posterior margin specimen.
  • 2022-08-18 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a hot spot in the inferolateral aspect of right orbital area of the skull, some faint hot spots in bilateral rib cages and increased activity in the maxilla, mandible, middle T-spine, some L-spines, bilateral shoulders, bilateral sternocalvicular junctions, hips and knees in whole body survey.
    • IMPRESSION:
      • In comparison with the previous study on 2017/11/14, the lesions in some L-spines are slightly more evident. Degenerative change in slightly more severe status may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Other bone lesions are either stationary or a little less evident, possibly more benign in nature.
  • 2022-08-17 MRI - nasopharynx
    • C/W oral cancer s/p treatment without evidence of recurrence. Stationary as compared with MRI on 20220304.
  • 2022-08-17 SONO - abdomen
    • renal cyst, bilateral
    • most pancreas masked by gas
  • 2022-08-03 Patho - gingival/oral mucosa biopsy
    • Labeled as “right buccal mucosa”, incisional biopsy — verrucous carcinoma with high grade dysplasia.
    • IHC stain: p16 (-).
  • 2022-03-04 MRI - nasopharynx
    • C/W oral cancer s/p treatment without evidence of recurrence. An enlarged lymph node (14 mm) at right surpaclavicular fossa. Stationary as compared with MRI on 20210715.
  • 2021-07-15 MRI - nasopharynx
    • C/W oral cancer s/p treatment without evidence of recurrence. An enlarged lymph node (14 mm) at right surpaclavicular fossa. Stationary as compared with MRI on 20200916.
  • 2020-09-16 MRI - nasopharynx
    • post-OP change in left maxilla floor, hard palate, upper bucco-gingival regions.
    • No local tumor recurrence.
    • No neck LAP.
  • 2020-08-30 CT - abdomen
    • dilated small bowels. suspected small bowel ileus
  • 2020-03-09 MRI - nasopharynx
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows: (comparison: 2019/10/18 MRI)
      • Post fat-containing flap reconstruction surgery with clips/sutures retention and/or bony defect of left maxilla floor, hard palate, upper bucco-gingival region. No obvious focal mass or nodule, stationary.
      • Post LNs dissection with clips retention with metallic artifact and/or soft tissue or muscle defect, left.
      • Post resection of left submandibular gland.
      • No evident abnormal enlarged lymph node in the visible neck.
      • Presence of thick fluid accumulation and thickened mucoperiosteum in the bilateral paranasal sinuses.
      • No obvious abnormal enhancement after contrast medium administration.
    • Impression:
      • Stationary post OP change in left maxilla floor, hard palate, upper bucco-gingival regions. No local tumor recurrence. No neck LAP.
  • 2019-10-22 Surgical pathology level VI
    • Pathologic Diagnosis
      • Buccal mucosa, right, wide excision — Squamous cell carcinoma
      • Resection margins, the same as above and frozen section — Free of tumor invasion
      • Lymph node, submandibular and submental gland, dissection — Free of tumor metastasis (0/5)
      • Lymph node, superficial Level II, the same as above — Free of tumor metastasis (0/2)
      • Lymph node, parotid area, dissection — Free of tumor metastasis (0/1)
      • Lymph node, Level III, dissection — Free of tumor metastasis (fat only)
      • AJCC Pathologic staging — pT1N0Mx, at least stage I.
    • Microscopic Examination
      • Histologic Type: Squamous cell carcinoma
      • Histologic Grade: G1: Well differentiated
      • Microscopic Tumor Extension: 0.35 cm in thickness
      • Margins: Free, less than 0.1 cm from base, 0.1 cm from posterior margin, 0.6 cm from anterior margin, 0.5 cm from superior margin and 0.5 cm away from inferior margin
      • Lymph-Vascular Space Invasion: absent
      • Perineural Invasion: Present
      • Neck Lymph Nodes: free from tumor metastasis (0/8)
      • Salivary gland, submandibular and submental gland LN: chronic sialoadenitis
  • 2019-10-18 MRI - nasopharynx
    • Post-operation change without evidence of recurrence. No evidence of right lower buccogingival lesion based on this study.
  • 2019-10-02 Surgical pathology level IV
    • Right buccal mucosa, biopsy — Squamous cell carcinoma, well differentiated.
    • IHC stain: p16 (-)
  • 2019-05-02 MRI - nasopharynx
    • CC: He is an oral cancer patient and received 3 cycles of induction chemotherapy followed by cancer operations and CCRT. CCRT ended on 2018-02-01. He complains of dry mouth and pain at his left lower lip area occasionally. The patient became anxious and sought medical attention at both Shuang Ho Hospital and Far Eastern Memorial Hospital, where they received cryotherapy treatment (2018-11-01).
    • Cancer Site-Specific Factors
      • Betel nut chewing [present]: 20 nuts per day, for the past 20 years.
      • Smoking [present]: 20 cigarettes per day, for the past 20 years.
      • Alcohol consumption [none].
    • Indication:
      • S: He is an oral cancer patient and received 3 cycles of induction chemotherapy followed by cancer operations and CCRT. CCRT ended on 2018-02-01.
      • O: cheilis of both oral commissure combined with fungus infection are noted. leukoplakia of the right palatoglossal fold is still present after injection treatment. chronic abnormal erythymatous lesion on the inner surface of lower lip near left oral commissure are still noted.
      • A: SCC of left maxillary gingiva with bone invasion (cT4aN1M0 before) (2017/11/17 OP) (pT4aN0M0)
      • P:
        • check BUN and creatinine before MRI examination
        • arrange MRI with contrast to evaluate undermining tumor status
    • IMP
      • Post OP in left maxilla floor, hard palate, upper bucco-gingival regions. No local tumor recurrence. No neck LAP.
  • 2018-11-01 MRI - nasopharynx
    • Post flap reconstruction surgery in left maxilla floor, hard palate, bucco-gingival regions. No local tumor recurrence. No neck LAP.
  • 2018-03-06 MRI - nasopharynx
    • Post flap reconstruction surgery in left maxilla floor, hard palate, bucco-gingival regions.
  • 2017-11-20 Surgical pathology level VI
    • Pathologic Diagnosis
      • Gum, left upper, wide excision — Squamous cell carcinoma, moderately differentiated, with invasion to maxillary sinus, s/p induction chemotherapy
    • Microscopic Examination
      • Histologic Type: Squamous cell carcinoma, s/p induction chemotherapy; The immunohistochemical stain of p16 is negative.
      • Histologic Grade: G2: Moderately differentiated
      • Microscopic Tumor Extension: (specify) maxillary sinus
  • 2017-11-14 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a hot spot in the inferolateral aspect of right orbital area of the skull, some faint hot spots in bilateral rib cages and increased activity in the left aspect of the maxilla, middle T-spine, bilateral shoulders, bilateral sternocalvicular junctions, hips and knees in whole body survey.
    • IMPRESSION:
      • Increased activity in the left aspect of the maxilla. Malignancy with local bone invasion should be watched out. Please correlate with other clinical findings for further evaluation.
      • Increased activity in the middle T-spine. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • A hot spot in the inferolateral aspect of right orbital area of the skull and some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, bilateral sternocalvicular junctions, hips and knees, compatible with benign joint lesion.
  • 2017-11-13 MRI - nasopharynx
    • Indication: SCC of left maxillary gingiva with bone invasion (cT4aN2bM0)
    • Impression:
      • Residual left maxillary gingiva tumor with bone involvement, in regression
      • compared with previous brain MRI study.
      • paranasal sinusitis.
      • no cervical enlarged LNs.
  • 2017-08-14 Nerve Conduction Velocity, NCV
    • The NCV study showed (1) Prolonged distal motor latency and slowing of sensory nerve conduction velocity in bilateral median nerves. (2) Slowing of motor nerve conduction velocity in left ulnar nerve across elbow. (3) Decreased CMAP amplitude and slowing of motor conduction velocity in left peroneal nerve. (4) Decreased SAP amplitude in left ulnar nerve.
    • The F wave study showed prolonged latency in all sampled nerve of lower limbs. The H reflex showed prolonged latency of left side. The above findings suggest bilateral lumbosacral polyradiculopathy and entrapment neuropathy of bilateral median nerves at the wrist and left ulnar nerve across elbow. Advise careful clinical correlation.
  • 2017-08-12 MRA - brain
    • Indication: SCC of left maxillary gingiva with bone invasion
    • Impression:
      • Essential normal brain MR study.
      • Left chronic paranasal sinusitis

[chemotherapy]

  • 2023-02-22 - cetuximab 250mg/m2 460mg 2hr + docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + [leucovorin 100mg/m2 180mg + fluorouracil 1000mg/m2 1800mg + NS 1000mL] 22hr D2 (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-15 - cetuximab 400mg/m2 740mg 2hr + docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + [leucovorin 100mg/m2 180mg + fluorouracil 1000mg/m2 1800mg + NS 500mL] 22hr D2 (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2022-08-30 ~ 2023-02-09 - UFT (tegafur + uracil) KUFT01 2# BID
  • 2017-10-26 ~ 2017-11-16 - UFT 2# BID

[assessment]

  • Leukopenia was observed in the patient, with a count of 1.97 K/uL, on 2023-02-27. This occurred 5 days after the patient received the second cycle of chemoimmunotherapy (cetuximab + TPF).
  • This patient also took UFT from 2022-08-30 to 2023-02-09. As UFT has been discontinued for some time, it is less likely to be the cause of the recent leukopenia.
  • According to the National Health Insurance medication reimbursement regulations, patients with malignant diseases who have experienced leukopenia (less than 1000/uL) or neutropenia (ANC less than 500/uL) after receiving chemotherapy are eligible to use short-acting granulocyte colony-stimulating factor (G-CSF) injections, such as filgrastim or lenograstim.
  • Self-paid G-CSF may be considered by the patient as an option to rapidly increase his white blood cell count.

700280118

230302

[exam findings]

  • 2023-02-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (132 - 56) / 132 = 57.58%
      • M-mode (Teichholz) = 58
    • Dilated LV, Ao
    • Adequate LV, RV systolic function with normal wall motion
    • Thick LVPW, Impaired LV relaxation
  • 2023-01-13 SONO - right knee
    • Right knee joint fluid. The differential diagnosis includes, but is not limited to hemarthrosis, gouty arthropathy.
  • 2023-01-03 Patho - bone marrow biopsy
    • PATHOLOGIC DIAGNOSIS
      • Bone marrow, biopsy — Myelodysplastic syndrome with excess blasts (RAEB-1)
      • Immunohistochemical stains:
        • MPO: positive for myeloid series
        • CD71: positive for erythroid series
        • CD61: positive for megakaryocytes
        • CD117: positive for blast
        • CD34: positive for blast
        • CD138: positive for plasma cell
      • Histochemical stain:
        • Reticulin: increased reticulin fibers
    • Microscopically, the sections show pictures as follows:
      • Hypercellularity for his age >90%
      • M/E ratio about 2-3/1, proliferation with left shift maturation of myeloid and erythroid series
      • Proliferative megakaryocytes with nuclear dysplasia and clustering, accompanied by grade 2 (MF-2) reticulin/collagen fibrosis
      • Increased blast (5-9%)
      • Scater distribution of plasma cells
      • Myelofibrosis and osteosclerosis
      • According to all above histopathologic findings, it is suggestive of myelodysplastic syndrome with excess blasts, compatible with RAEB-1 and myelofibrosis. Please correlate with clinical and bone marrow smear findings for conclusive diagnosis.
  • 2022-12-28 SONO - abdomen
    • Splenoemgaly
  • 2022-07-25 Patho - stomach biopsy
    • Stomach, lower body, biopsy — Chronic erosive gastritis, Helicobacter Pylori: NOT present
  • 2022-07-25 SONO - abdomen
    • splenomegaly, mild to moderate
    • pancreas almost not shown
  • 2022-07-25 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A
    • Gastric ulcer, multiple, shallow, lower body, s/p biopsy
    • Hiatal hernia
  • 2022-06-17 Patho - gingival/oral mucosa biopsy
    • Labeled as “right buccal mucosa”, excisional biopsy — verrucous hyperplasia, involving un-oriented and unspecified excisional side margin.
  • 2021-11-01 MRI - nasopharynx
    • History: a tongue cancer at the right side was noted and he had received cancer surgeries on 2021-07-07. suspected SCC of right floor of mouth (cT2N2bM0)
    • Indication:
      • S: He is cheek cancer (2016-09) and tongue cancer (2017-03). He finished 3 cycle of induction chemothrapy followed by surgery to remove oral cancer (2016-06).
      • O: Toothace due to gingivitis of residual teeth and residual roots of #22 is noted. red color change on the left palatlglossal fold is noted.
      • A:
        • Verrucous carcinoma of right tongue border (2017-03-15)
        • SCC of left buccal mucosa, lower gingiva and retromolar area, size about 5 cm with suspicous lymph node involment and skin invasion near oral commissure (cT3N1M0 preChemo) (2016-06) (pT2N0M0 postChemo)
      • P:
        • BUN and creatinine before the MRI examination
        • arrange MRI examination to evaluate the underming tumor status
    • Impression:
      • Post OP at right tongue and mouth floor, no obvious focal residual mass
      • Post OP at left bucco-gingival region with neck LNs dissection.
      • No local tumor recurence.
      • No neck LAP.
  • 2021-07-08 Patho - oral cancer (wide excision + lymph node)
    • Oral cavity, right mouth floor, wide excision — Well differentiated squamous cell carcinoma
  • 2021-06-03 Patho - gingival/oral mucosa biopsy
    • Labeled as “right floor of mouth and tongue”, incisional biopsy — Squamous cell carcinoma, well differentiated.
    • IHC stains: CK5/6 (+), p40 (+), p16 (-).
  • 2021-05-19 Tc-99m MDP bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral shoulders, S-I joints, hips, right knee, and left ankle.
  • 2021-05-18 MRI - nasopharynx
    • Post OP at left bucco-gingival region with neck LNs dissection. No local tumor recurence. No neck LAP.
    • No obvious discernible right mouth floor lesion. Stationary and hard to define right tongue or mouth floor tumor? after comparing with 2020/02/11 MRI, need clinical correlation. (revised on 2021/06/10)
  • 2021-02-11 MRI - nasopharynx
    • Post-operation change without evidence of recurrence. Stationary as compared with MRI on 20190402.
  • 2020-02-05 Patho - gingival/oral mucosa biopsy
    • Right floor of mouth? biopsy — Verrucous hyperplasia. Please excise entire lesion for further patholoigcal evaluation.
  • 2019-04-02 MRI - nasopharynx
    • Post-operation change without recurrence. Stationary as compared with MRI on 20180828.
  • 2018-10-02 Surgical pathology level IV
    • Oral cavity, right, buccal mucosa, laser remove — Verrucous carcinoma — margin free
  • 2018-08-28 MRI - nasopharynx
    • Post flap reconstruction surgery at left bucco-gingival region with neck LNs dissection. No tumor recurence.
  • 2018-01-03 MRI - nasopharynx
    • Post flap reconstruction surgery at left bucco-gingival region with neck LNs dissection. No tumor recurence.
  • 2017-06-22 MRI - nasopharynx
    • Post flap reconstruction surgery at left bucco-gingival region with neck LNs dissection. No tumor recurence.
  • 2017-03-15 Surgical pathology level IV
    • Tongue, right border, wide excision —- Verrucous carcinoma
    • Pathology stage: pStage I, pT1 Nx (cMx)
  • 2017-01-03 MRI - nasopharynx
    • Post flap reconstruction surgery at left bucco-gingival region with neck LNs dissection. No tumor recurence.

[consultation]

  • 2021-06-23 Hemato-Oncology
    • Q
      • This is a 51-year-old male who had medical history of squamous cell carcinoma of left bucco-gingival region with retromolar extension and possible anterior skin invasion, cT4aN1M0 status post induction chemotherapy and surgery, ypT2N0M0 in 2016 and several cancer surgeries for verrucous carcinoma of tongue and right buccal mucosa thereafter. He didn’t return to OPD follow-up until this time with a painless malignant tumor with firm texture on the right floor of mouth and ventral tongue. After thorough tumor work-up, he was diagnosed with squamous cell carcinoma of right floor of mouth, cT2N2bM0. This time, he was admitted for surgical intervention. However, his platelet count was lower than average (50x10^3/uL) without any underlying known cause and coagulation defiency. Therefore, we need your expertise for further survey of idiopathic thrombocytopenia.
    • A
      • The 51 y/o male, a pt of L bucco-gingival SCC wt retromolar extension and possible anterior skin invasion, cT4aN1M0 s/p post induction chemotherapy and surgery, ypT2N0M0 in 2016 and several cancer surgeries for verrucous carcinoma of tongue and right buccal mucosa, was noted to have thrombocytopenia just before Op in June 2021.
      • The definite diagnosis of thrombocytopenia is to be under further investigation.
      • Image
        • Abd sono (20210520): splenomegaly.
      • Lab data
        • Hb (20210622):15.6, MCV:95.0, MCHCL34.5, plt:50K, WBC:3600
        • Hb (20210517):15.9, MCV:96.0, MCHC:34.6, plt:51K, WBC:4270
        • LFT & RFT (20210622): normal
        • HBsAg & antti-HCV (20210519): negative.
      • Dx: Thrombocytopenia, cause ? R/I splenomegaly related R/I idiopathic thromcytopenic purpura (ITP) R/I autoimmune related
      • Medical advice:
        • By Tracing his medical history, thrombocytopenia has been noted recently in May & June 2021.
          • Abd CT (20210520) showed splenomeagly. Splenomegaly related thrombocytopenia seems to be likely cause of thrombocytopenia.
        • May check Rheumatoid factor & ANA to exclude possible autoimmune dz. But autoimmune dz very rarely occurs in male pt. 
          • By clinical pictures, hematologic dz, TTP with toxic S/S, or DIC by infection were less likely to be the causes of thrombocytopenia of this pt. 
          • Splenomegaly related thrombocytopenia seems to be likely cause of thrombocytopenia if RF & ANA show negative.
        • If RF or ANA shows positive, may consult rheumatologist for further Tx. Tx of underlying autoimmune Dz may improve thrombocytopenia or may try prednisolone 1mg/kg/day for 2 weeks. If no response, splenectomy or IVIG or immunosuppressant (eg: Azathioprin, cyclophosphamide or Vincristine ) may be tried.
        • The current platelet count 50 K/uL is safe for this pt if no trauma happens. If platelet count requirement for Op is above 100K /uL, may consider platelet transfusion wt single donor ( pheresis ) platelet transfusion which is more effective to elevate platelet count & may less induce autoAb that will cause poor response to next platelet transfusion in the future.
          • But it is hard for pt wt splenomegaly related thrombocytopenia to elevate plt count by plt transfusion.

[chemotherapy]

  • 2023-03-01 - Vidaza (azacitidine) 75mg/m2 150mg SC D1-7

  • 2023-02-02 - Vidaza (azacitidine) 75mg/m2 150mg SC D1-7

  • 2021-05-17 ~ 2021-07-05 UFT (tegafur + uracil) KUFT01

[assessment]

  • Lab data

    • WBC
      • 2023-03-01 WBC 21.51 x10^3/uL
      • 2023-02-27 WBC 3.45 x10^3/uL
    • HGB
      • 2023-03-01 HGB 7.4 g/dL
      • 2023-02-27 HGB 9.3 g/dL
    • PLT
      • 2023-03-01 PLT 16 x10^3/uL
      • 2023-02-27 PLT 3 x10^3/uL
      • 2023-02-26 PLT 7 x10^3/uL
      • 2023-02-24 PLT 17 x10^3/uL
      • 2023-02-22 PLT 12 x10^3/uL
      • 2023-02-19 PLT 6 x10^3/uL
      • 2023-02-17 PLT 4 x10^3/uL
      • 2023-02-15 PLT 1 x10^3/uL
      • 2023-02-14 PLT 2 x10^3/uL
      • 2023-02-13 PLT 1 x10^3/uL
      • 2023-02-12 PLT 1 x10^3/uL
      • 2023-02-11 PLT 1 x10^3/uL
      • 2023-02-10 PLT 1 x10^3/uL
      • 2023-02-09 PLT 1 x10^3/uL
      • 2023-02-09 PLT 1 x10^3/uL
      • 2023-02-08 PLT 7 x10^3/uL
      • 2023-02-08 PLT 3 x10^3/uL
      • 2023-02-07 PLT 2 x10^3/uL
      • 2023-02-06 PLT 1 x10^3/uL
      • 2023-02-04 PLT 3 x10^3/uL
      • 2023-02-03 PLT 1 x10^3/uL
      • 2023-02-02 PLT 2 x10^3/uL
      • 2023-02-01 PLT 3 x10^3/uL
      • 2023-01-30 PLT 5 x10^3/uL
      • 2023-01-18 PLT 6 x10^3/uL
      • 2023-01-16 PLT 7 x10^3/uL
      • 2023-01-13 PLT 10 x10^3/uL
      • 2023-01-11 PLT 9 x10^3/uL
      • 2023-01-10 PLT 6 x10^3/uL
      • 2023-01-08 PLT 5 x10^3/uL
      • 2023-01-06 PLT 3 x10^3/uL
      • 2023-01-05 PLT 5 x10^3/uL
      • 2023-01-03 PLT 15 x10^3/uL
      • 2023-01-02 PLT 7 x10^3/uL
      • 2022-12-31 PLT 7 x10^3/uL
      • 2022-12-27 PLT 9 x10^3/uL
      • 2022-12-27 PLT 7 x10^3/uL
      • 2022-07-13 PLT 15 x10^3/uL
      • 2022-03-29 PLT 24 x10^3/uL
      • 2021-07-12 PLT 44 x10^3/uL
      • 2021-07-09 PLT 74 x10^3/uL
      • 2021-07-07 PLT 125 x10^3/uL
      • 2021-07-06 PLT 153 x10^3/uL
      • 2021-07-05 PLT 77 x10^3/uL
      • 2021-06-22 PLT 50 x10^3/uL
      • 2021-05-17 PLT 51 x10^3/uL
  • According to the lab data on 2023-03-01, leukopenia has improved in the patient. However, anemia is still progressing, and blood transfusion might be necessary.

  • Erythropoiesis-stimulating agents (ESAs) have been recommended as an effective treatment option for lower-risk MDS, including biosimilar epoetin alfa. ref: Epoetin alfa for the treatment of myelodysplastic syndrome-related anemia: A review of clinical data, clinical guidelines, and treatment protocols. Leuk Res. 2019;81:35-42. doi:10.1016/j.leukres.2019.03.006

  • In addition to leukopenia and anemia, the patient has been experiencing thrombocytopenia for years with no substantial improvement. Therefore, increased risk of bleeding should be carefully monitored and managed.

  • Thrombocytopenia is a significant problem in myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Eltrombopag, a thrombopoietin receptor agonist, has shown potential clinical activity in MDS and AML clinical trials. Studies have shown that eltrombopag is well tolerated and clinically effective in both low-risk and higher-risk MDS and AML patients. ref: Eltrombopag reduces clinically relevant thrombocytopenic events in higher risk MDS and AML. Lancet Haematol. 2018;5(1):e6-e7. doi:10.1016/S2352-3026(17)30229-6

  • There was another study evaluated the safety and efficacy of Eltrombopag in low to intermediate risk myelodysplastic syndromes (MDS) patients. The primary efficacy endpoint was hematologic response at 16-20 weeks, and 44% of the patients responded. The safety profile was consistent with previous studies, and Eltrombopag was effective in restoring hematopoiesis in these patients. ref: Eltrombopag monotherapy can improve hematopoiesis in patients with low to intermediate risk-1 myelodysplastic syndrome. Haematologica. 2020;105(12):2785-2794. Published 2020 Dec 1. doi:10.3324/haematol.2020.249995

701201523

230302

[diagnosis]

  • Small cell B-cell lymphoma, lymph nodes of head, face, and neck
  • Relapsed small lymphocytic lymphoma involving multiple lymph nodes as of bil. neck, axillary regions, mediastinum, peritoneal cavity, pelvi cavity, retroperitoneum and bil. inguinal regions ,Lugano stage IV, PS:1
  • Essential (primary) hypertension
  • Chronic viral hepatitis B without delta-agent

[exam findings]

  • 2022-12-12 ECG
    • Sinus rhythm with 1st degree A-V block
  • 2022-11-25 CT - chest
    • Lymphadenopathy at left lower neck. Statioanry.
    • Lymphadenopathy at mesenterric and paraaortic region. In progression.
  • 2022-07-29 CT - chest
    • Extensive lymphadenopathy at bilateral lower neck, axillary, and mesenterric region. Stationary in size.
  • 2022-04-15 CT - chest
    • Lymphadenopathy at left supraclavicular region and bilateral axillary region, paraaortic and mesenterric region. In regression.
  • 2022-01-06 CT - chest
    • Lymphadenopathy at bilateral thoracic inlet and axillary, mediastinal and abdominal paraaortic and paracaval region. In regression.
  • 2021-10-19 CXR
    • Atherosclerotic change of aortic arch.
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2021-10-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (74 - 19) / 74 = 74.32%
      • M-mode (Teichholz) = 74
    • Normal LV systolic function with normal wall motion.
    • Normal LV diastolic function.
    • Normal RV systolic function.
    • Aortic valve sclerosis with no AS and AR; mild MR; moderate TR; mild PR.
  • 2021-10-06 CT - chest
    • advanced malignant lymphoma involving both sides of diaphgram, stationary as compared with previous CT study on 2021/04/13
  • 2021-04-13 CT - chest
    • advanced malignant lymphoma involving neck both sides of diaphgram, seem stationary as compared with previous CT study on 2020/12/22
  • 2020-12-22 CT - chest
    • advanced malignant lymphoma involving neck, axillary regions, mediastinum, and abdomen (both sides of diaphgram), stationary as compared with previous CT study on 2020/07/15
  • 2020-07-15 CT - chest
    • advanced malignant lymphoma involving neck, axillary regions, mediastinum, and abdomen (both sides of diaphgram), stationary as compared with previous CT study on 2019/12/05
  • 2019-12-17 Surgical patholgoy Level IV
    • Clinical diagnosis: Lymphoma, other named variants, LN of head face and neck;
    • Pathological diagnosis:
      • Bone marrow, iliac, biopsy — Lymphoma involvement.
      • IHC stains: CD3 and CD20 show monoclonality. CD5 (+), CD23 (+).
    • Microsopic description
      • Section shows one piece of bone marrow with 50% cellularity and M:E ratio of approximately 5:1. There is a predominant subpopulation of small lymphoid cells.
      • IHC stains: CD3 and CD20 show monoclonality. CD5 (+), CD23 (+), compatible with clinical history of small lymphocytic lymphoma.
  • 2019-12-05 CT - abdomen
    • Enlarged LNs at bil. neck, axillary regions, mediastinum, peritoneal cavity, pelvi cavity, retroperitoneum and bil. inguinal regions c/w lymphoma.
  • 2019-11-01 PET
    • There was mildly or faintly increased FDG uptake involving multiple lymph nodes (SUVmax early: 1.10, delay: 1.15) including multiple bilateral neck, bilateral supraclavicular and axillary lymph nodes, some mediastinal, abdominal and bilateral inguinal lymph nodes. There was increased FDG uptake in the nasopharynx (SUVmax early: 1.94) and stomach (SUVmax early: 2.84, delay: 1.79).
    • IMPRESSION:
      • Mild or faint glucose hypermetabolism involving multiple lymph nodes as mentioned above. Lymphoma of low FDG uptake involving multiple lymph nodes on both sides of the diaphragm should be watched out. Please correlate with other clinical findings for further evaluation.
      • Mild glucose hypermetabolism in the nasopharynx and stomach. The nature is to be determined (inflammatory process? other nature?). Please also correlate with other clinical findings for further evaluation.

[chemoimmunotherapy]

  • 2023-03-01 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2023-01-06 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2022-12-13 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2022-03-08 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2022-02-08 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2022-01-03 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2021-12-07 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2021-11-09 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2021-10-19 - rituximab 375mg/m2 490mg NS 470mL 8hr D1 + [cyclophosphamide 750mg/m2 780mg NS 250mL 0.5hr + vincrestine 1.4mg/m2 1.8mg NS 50mL 10min] D2 + prednisolone 60mg/m2 30mg BID PO D2-6 (R-COP Q3W, Endoxam 20% off due to age)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2

[assessment]

  • This patient with Small cell B-cell lymphoma was treated with a total of six cycles of R-COP regimen from 2021-10 to 2022-03. However, during regular CT follow-up on 2022-11-25, progression of lymphadenopathy was observed in the mesenteric and paraaortic regions. As a result, the patient was rechallenged with R-COP from 2022-12 onwards.

  • The lab results from 2023-03-01 indicated that there were no notable abnormalities in the patient’s liver and kidney functions or blood cell counts. And the TPR panel revealed that the patient’s vital signs and blood pressure were stable.

  • Entecavir is prescribed to suppress the replication of the hepatitis B virus with no issue.

700207892

230301

[present illness] - 2023-02-27 admission note

  • The 44 year old woman has history of
    • Renal stone /p ESLW once and /p URS on 2018
    • Small lymphocytic lymphoma / chronic lymphocytic leukemia with bone marrow involvement, Lugano stage IV under Leukeran (chlorambucil) 2mg 1# qd treatment on 2021/05 ~ 2022.

[past history]

  • medication history:
    • small lymphocytic lymphoma/ chronic lymphocytic leukemia with bone marrow involvement, Lugano stage IV, ECOG:  1
  • operation history:
    • Renal stone s/p ESLW and URS
    • anal fissure and mixe dhemorhroids s/p operation
    • right thigh intramascular abscess s/p debridement                    

[allergy]

  • NKDA     

[family history]

  • no family history of DM, CAD, CVA and cancer

[exam findings]

  • 2022-10-13 Patho - abscess
    • Labeled as “right thigh soft tissue”, clinical history of chronic lymphocytic leukemia, debridement — chronic inflammation.
    • IHC stains: CD3 and CD20 show no predominant sub-population.
  • 2022-10-08 MRI - lower extremity
    • Indication: Small lymphocytic lymphoma / chronic lymphocytic leukemia with bone marrow involvement, Lugano stage IV
    • MRI of lower extremity without/with Gadolinium-based contrast enhancement shows:
      • swelling of right anterior thigh muscle (mainly rectus femoris) with a rim-enhancing intramuscular mass lesion (about 3.1x2.4x4.5cm) with central necrosis. Marked adjacent subcutaneous fat stranding and superficial fascial fluid collection is noted. An intramuscular abscess is first considered. Suggest follow up after treatment to exclude lymphoma involvement.
      • clustered enlarged inguinal lymph nodes.
      • no abnormal bone marrow edema nor hyperemia.
    • Impression:
      • Favor an intramuscular abscess (about 3.1x2.4x4.5cm) at right anterior thigh. Suggest follow up after treatment to exclude lymphoma involvement.
  • 2022-08-23 Patho - fissure/fistula
    • Anus, PIS — Anal fissure
  • 2022-08-12 Abdomen - standing (diaphragm)
    • There is hepatosplenomegaly. please correlate with clinical condition
  • 2022-06-29 CT - abdomen
    • Indication: intermittent, whole abdominal dull pain for 3 days
    • IMP:
      • no evidence of free abdominal air.
      • a nodular lesion, about 14mm, in the spleen. Nature?
  • 2022-06-04 CT - brain
    • Clinical information: Cranial CT scans from the vertex to the mid-maxillary level were performed without i.v. contrast injection.
    • Impression:
      • The brain shows normal grey and white matter attenuation without evidence of focal lesion. There is no intracranial hemorrhage seen.
      • The size of the lateral and third ventricles appears normal.
      • The posterior structures including the brain stem, cerebellum and CP angles look normal.
  • 2021-05-27 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Small lymphocytic lymphoma / chronic lymphocytic leukeima
    • The sections show hypercellular marrow (>90%) for her age with small lymphocytes proliferation. Immunohistochemistry of CD20(+), CD3(-), CD5(+), CD23(+), Bcl2(+), CD34(-), CD61 showed adequate megakaryocyte, CD71 showed mild decreas of erythroid series and MPO showed decreased myeloid series. Clinical correlation is advised.
  • 2021-05-25 CT - abdomen
    • Lymphoma in paraaortic, iliac and pelvic cavity, inguinal regions. Progression.
    • Splenomegaly with splenic nodule, progression, suspected lymphoma.
  • 2021-01-05 CT - abdomen
    • Splenomegaly.
    • Lymphadenopathy at paraaortic and mesenterric region. Stable.
  • 2020-09-25 CT - abdomen
    • Lymphoma S/P C/T show stable disease.
  • 2020-07-01 Whole body PET scan
    • Glucose hypermetabolism in bilateral cervical lymph nodes, bilateral axillary lymph nodes, pelvis, and bilateral inguinal lymph nodes, lymphoma should be the first considered.
    • Glucose hypermetabolism in bnilateral palatine tonsils, reactive change resulting from locoregional inflammation may show such a picture.
    • Lymphoma (if proved), stage III at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2020-06-12 Patho - lymphnode biopsy
    • Lymph node, right inguinal, excision —– Small lymphocytic lymphoma / chronic lymphocytic leukemia
    • Histology type: B-cell neoplasms: B-lymphoblastic lymphoma/leukemia
    • Immunohistochemical stain profiles: CD20(+), CD3(-), CD5(+), BCL2(+), CD23(+), CD43(+), SOX11(-), Cyclin D1(-), BCL6(-), CD10(-). The Ki-67 is about 15%.
  • 2020-06-12 CT - abdomen
    • Lymphoma is highly suspected.
    • The differential diagnosis include metastases.
  • 2020-06-10 Patho - bone marrow biopsy
    • clinical diagnosis: D72.829 Elevated white blood cell count, unspecified
    • Bone marrow, iliac, biopsy — B cell lymphoma.
    • IHC stains: CD34: 1%; MPO: approximaltely: 10%; LCA (+, 80-90%); CD20: a predominant monoclonal subpopuation. CD3: few.
    • Additional IHC stains: bcl-2 (diffuse +++), bcl-6 (-), CD23 (+++), cyclin-D1 (-).
    • The IHC pattern is that of a small lymphocytic lymphoma / chronic lymphocytic leukeima.
    • Section shows one piece of bone marrow with 60-70 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes and a predominant subpopulation of small round blue cells. Megakaryocytes are adequate in number. B cell lymphoma.
  • 2020-06-09 CXR
    • A nodular opacity projecting in the left upper lung is suspected that may be left 1st rib cartilage calcification or true lesion? Follow up is indicated. Otherwise, Please correlate with CT.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.

[chemoimmunotherapy]

  • 2023-02-27 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1450mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2023-01-30 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2023-01-04 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2022-12-13 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2022-11-07 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2021-05-26…2021-07-04 - Leukeran (chlorambucil 2mg/tab) KLEUK BID PO

[G-CSF]

  • Granocyte (lenograstim) CGRAN01
    • 2022-11-29 ~ 2022-11-30 250ug SC 2022-11-17 IPD
    • 2022-08-27 ~ 2022-08-26 250ug SC 2022-08-12 IPD
  • G-CSF (filgrastim) CGCSF01
    • 2023-02-27 150ug SC 2023-02-27 IPD self-paid
    • 2022-08-12 300ug SC 2022-08-12 IPD

[assessment]

  • It is recommended avoiding the administration of filgrastim from 24 hours before to 24 hours after the administration of cytotoxic chemotherapy, due to the potential sensitivity of rapidly dividing myeloid cells to the cytotoxic effects of chemotherapy.

  • Filgrastim was administered on 2023-02-27 and chemotherapy is scheduled to be administered on 2023-03-01, with one day in between. Our administration pattern for the patient helps to uphold this principle without an issue.

700853234

230301

[exam findings]

  • 2023-02-27 CXR
    • small Lt hemithorax, decreased pulmonary vascularity, and small hilum, due to fibrotic and bronchiectatic change
    • extensive mixed consolidation and hazy increased opacity over Rt lower lung zone
    • pathological compression fracture of multiple vertebral bodies
    • compression fracture of L2 vertebral body priop vertebroplasty
  • 2023-02-07 Tc-99m MDP whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the skull, multiple C-, T- and L-spines, bilateral multiple ribs and bilateral pelvic bones.
    • IMPRESSION: The scintigraphic findings suggest multiple bone metastases.
  • 2023-02-03 MRI - spine
    • Diffuse bony metastases involving C2-T12 vertebral bodies and bilateral ribs. LUL lesion, suspected metastases.
    • Diffuse bony metastases involving vertebral column (T10-S1) and iliac bones. Recent compression fratucre of L1 vertebral body, pathologic? S/P VP at L4 vertebral body.
  • 2023-02-03 ECG
    • Sinus tachycardia with Premature atrial complexes
  • 2023-02-01 T-spine AP + Lat
    • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture(s).
    • Presence of thoracic-lumbar spinal kyphosis, mild.
  • 2023-02-01 KUB + L-spine Lat
    • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
    • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture(s).
    • Post percutaneous vertebroplasty of the visible lumbar or thoracic spine at L4.
  • 2022-09-21 CT - abdomen
    • History: abdominal pain and cramp for 1 m. poor appetite. diarrhea but small amount 3-4/day. blood stool (-).
      • 20220426 colonoscopy: R/O A-colon cancer with obstruction. pathology: Signet-ring cell carcinoma
      • 20220504 CT:T4bN2aM0, cSTAGE:IIIC
      • 20220511 S/P right hemicolectomy:Advanced A-colon CA wt peritoneal seeding, pT4aN2bM1c , stage IVC
    • Indication: A-colon cancer S/P C/T for FU
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • S/P right hemicolectomy
      • There is minimal ascites in the cul-de-sac.
      • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left lower pole.
      • Prior CT identified two confluent cystic dilatation lesion in LUL and LLL of the lung are noted again, stationary.
        • Bronchiectasis are highy suspected.
      • Others
        • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • S/P right hemicolectomy.
      • There is no evidence of tumor recurrence.
  • 2022-09-21 CXR
    • Fibrosis of left upper lung is noted. Please correlate with clinical history to rule out old inflammatory process.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-05-12 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Ascending colon, right hemicolectomy — Signet-ring cell carcinoma
      • Resection margins, bilateral, ditto — Free of tumor
      • Lymph node, mesocolic, dissection — Tumor metastasis (14/18) with extracapsular extension (7/14)
      • Appendix, right hemicolectomy — Appendiceal wall invasion
      • Omentum tissue, ditto — Signet-ring cell carcinoma
      • AJCC pathologic stage — pT4aN2bM1c, stage IVC
    • MACROSCOPIC EXAMINATION
      • Operation procedure: right hemicolectomy
      • Specimen site: Ascending colon, terminal ileum and appendix
      • Specimen size: (a) A-colon: 22.5 cm in length, up to 5.2 cm in diameter with some omentum tissue, (b) Terminal ileum: 6.5 cm in length, 2.7 cm in diameter; (c) Appendix: 3.4 cm in length, 0.3 cm in diameter
      • Tumor size: 6.9 x 4.8 cm
      • Tumor location: 15 and 6.5 cm away from bilateral resection margins
      • Tumor appearance: protruding mass
      • Depth of invasion grossly: visceral peritoneum
      • Representative sections as A1: ileum + colonic margin, A2: appendix, A3: tumor + radial margin, A4-A6: tumor + serosal layer, A7-A8: tumor, A9-A12: lymph nodes, A13: omentum nodules
    • MICROSCOPIC EXAMINATION
      • Histology: signet-ring cell carcinoma with abundant mucin production
      • Histology Grade: G3, poorly differentiated
      • Depth of invasion: visceral peritoneum
      • Angiolymphatic invasion: present
      • Perineural invasion: present
      • Discontinuous extramural tumor extension: not identified.
      • Circumferential (radial) margin of rectosigmoid: involved
      • Lymph node metastasis, mesocolic: tumor metastasis (14/18)
      • Lymph node metastasis, IMA / SMA: N/A
      • Extranodal involvement: Present (7/14)
      • Pathological TNM Stage: pT4aN2bM1c
      • Type of polyp in which invasive carcinoma arose: N/A
      • Omentum tissue: tumor deposition
      • TNM descriptors: N/A
      • Tumor regression grading S/P CCRT: N/A
      • Appendix: appendiceal wall invasion
  • 2022-05-10 CT - chest
    • post infectios or inflammatory fibroticalcified change of lungs
    • with bronchiectasis/bronchiolitis and volume loss especially left lung.
  • 2022-05-10 Flow volume chart
    • mild restrictive impairment
  • 2022-05-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (74 - 15) / 74 = 79.73%
      • M-mode (Teichholz) = 79.5
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Mild MR, TR and PR
  • 2022-05-04 CT - abdomen
    • History: abdominal pain and cramp for 1 m. poor appetite. diarrhea but small amount 3-4/day. blood stool (-).
      • 20220426 colonoscopy: R/O colon cancer with obstruction at hepatic flexture. pathology: Signet-ring cell carcinoma
    • Indication: colon cancer, hepatic flexure for staging
    • Findings:
      • There is asymmetrical wall thickening with whole layer involvement and irregular outer margin at the ascending colon, ileo-cecal valve and terminal ileum, measuring 7.5 cm in length. The adjacent omentum shows fatty stranding and suspicious soft tissue nodules.
        • Adenocarcinoma of the ascending colon with direct invasion the adjacent omentum (T4b) is highly suspected.
        • In addition, There is are four enlarged nodes in the adjacent mesocolon (N2a).
      • There is minimal ascites in the cul-de-sac.
      • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left lower pole.
      • There are two confluent cystic dilatation lesion in LUL and LLL of the lung that may be bronchiectasis? Please correlate with chest CT.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)
  • 2022-04-26 Patho - colon biopsy
    • Colon, hepatic flexure, biopsy — Signet-ring cell carcinoma
    • Section shows pieces of colonic tissue with invasive signet-ring cells.
    • The immunohistochemical stains reveal CK7(-) and CK20(+), EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
    • Please correlate with the clinical presentation and image study to exclude other primary origin.
  • 2022-04-26 Colonoscopy
    • Suspected colon cancer, hepatic flexure, s/p biopsy
    • Suspected lumen stricture, hepatic flexure
    • Mixed hemorrhoid
  • 2018-02-12 MRI - L-spine
    • Recent compression fracture of L4 vertebral body
    • Mild central HIVD, L3-L4.
    • Disc bulge with fissure of posterior annulus, L4-L5
    • Disc bulge with tear fissure, L2-L3.

[surgical operation]

  • 2022-05-11
    • Surgery: Right hemicolectomy        
    • Finding: large A-colon cancer withmesentary LN enlargement R/O Omental carcinomatosis and tumor seeding on viceral peritoneum
  • 2018-02-13
    • Diagnosis: L4 compression fracture
    • PCS code: 64160B

[chemoimmunotherapy]

  • 2022-10-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3170mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-09-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 535mg NS 250mL 2hr + fluorouracil 2400mg/m2 3220mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-08-22 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 535mg NS 250mL 2hr + fluorouracil 2400mg/m2 3235mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-08-03 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2400mg/m2 3240mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-07-18 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2400mg/m2 3240mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-06-27 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-06-09 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

[assessment]

  • A blood transfusion may be considered in light of the patient’s HGB level of 8.6 g/dL, PLT count of 31K/uL, and 4+ stool occult blood in 2023-02-28 lab results.

  • The sputum culture result 2023-02-28 revealed the presence of 1+ gram-positive cocci and 2+ gram-negative bacilli. Levofloxacin has been prescribed appropriately to target and treat these strains.

701462331

230301

[present illness]

  • The 72-year-old men has had history of
    • Hypertension for more than 5 years under regular medication treatment at CGMH
    • Coronary artery disaeae post stent for more than 10 years under regular medication treatment at CGMH
    • Gallbladder stone
    • Hyperlipidemia for more than 5 years under regular medical treatment at CGMH
    • Right clavicle fracture s/p plating, union on 2003/10/27
    • Diagnosis lung cancer in ECKH (En Chu Kong Hospital) 2022/11/23, status post Tarceva (erlotinib) since 2022/11/25, change to Giotrif (afatinib) since 2022/12/08.

[past history] - 2023-02-25 admission note

  • Hypertension for more than 5 years under regular medication treatment at CGMH.
  • Coronary artery disaeae post stent for more than 10years under regular medication treatment at CGMH.
  • Gallbladder stone.
  • Hyperlipidemia for more than 5 years under regular medical treatment at CGMH.
  • Right clavicle fracture s/p plating, union on 2003/10/27.
  • COVID-19 infection on 2022/06     

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, mental diseases or asthma.
  • No members of the family with diabetes.   

[exam findings]

  • 2023-02-25 - CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2023-02-01 CT - chest
    • Indication: Lung adenocarcinoma with lung to lung mets, cT4N3M1a, TTF-1 (+)
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.625 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Comparison was made with previous CT )other hospital) dated on 2022/11/16
      • Lungs: diffus reticular and small nodules opacities over both lungs, with subpleural ground glass opacity over Rt lower lobe.
      • Mediastinum and hila: extensive lymphadenopathy in the visceral space and left anterior prevascular space and both hila/ small calcifiecations are noted, may be sequela of previous TB infection
        • extensive coronary arterial calcification.
      • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: trace Rt-sided effusion.
      • Chest wall and visible lower neck: small LNs at Lt supraclavicular fossa.
      • Visible abdominal contents: gall bladder stone (20mm).
        • no focal lesion in visible portion of liver, spleen, both adrenal glands, pancreas, and both kidneys.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression: RLL cancer with lung to lung (hematogeneous, lyphaphatic routes) and mediastinal-hilar LNs metastases in regression compared with CT on 2022/11/16, and suspect RLL fibrosis extensive 3V-CAD
  • 2023-02-01, -01-19, -01-05, 2022-12-22, -12-01 CXR
    • There are multiple nodular opacities projecting at both lung that are c/w lung to lung metastases after correlate with CT.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2022-12-01 Patho - lung transbronchial biopsy
    • Lung, RB7a, TBLB — adenocarcinoma, moderately differentiated
    • Sections show acinar glandular cells infiltrating in a fibrotic stroma. The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for the diagnosis.
  • 2022-12-01 Cell Block
    • Indication: multiple metastatic lung nodules, ADC proved by CGMH, but origin unknown
    • Result: Malignancy
    • Smears and cell block show clusters of pleomorphic tumor cells. The immunohistochemical stains reveal CK(+), TTF-1(+), and Calretinin(-). The results are consistent with meatstatic adenocarcinoma from lung. Please correlate with the clinical presentation.
  • 2022-12-01 Bronchoscopy
    • Chronic rhinitis with post-nasal drip
    • Multiple mucosa anthrocosis change
    • No any visible endobronchial lesion
    • RB7 para- and peribronchial lesion, s/p TBLB.

[medication]

  • 2022-12-08 ~ undergoing - Giotrif (afatinib 30mg/tab) KGIOT03 QDAC
  • 2022-11-25 ~ 2022-12-?? - Tarceva (erlotinib)

[assessment]

  • Based on the patient’s medication history of erlotinib followed by afatinib, it can be inferred that the disease is likely positive for EGFR exon 19 deletion or L858R, S768I, L861Q, and/or G719X mutations.

  • The patient had Grade 1 diarrhea which responded well to Smecta treatment (bowel movement of 3 times each day on 2023-02-27 and 2023-02-28). Additionally, the patient also experienced Grade 2 dermatitis and onychomycosis, which are currently being treated externally with tetracycline. If severe or prolonged diarrhea is not responding to antidiarrheal agents, GILOTRIF should be withheld to prevent dehydration and renal failure. In addition, GILOTRIF should be discontinued for life-threatening cutaneous reactions. Severe bullous, blistering, and exfoliating lesions occurred in 0.2% of patients. Severe and prolonged cutaneous reactions also require withholding of GILOTRIF.

  • After ground glass opacity was detected in bilateral lower lungs on the chest X-ray 2023-02-25, and G(+) Cocci were identified from sputum culture 2023-02-26, the afatinib treatment was temporarily suspended until the lung symptoms were relieved.

  • The current prescription is without any issue.

700838300

230224

[diagnosis] - 2023-02-23 admission note

  • Invasive carcinoma, no special type of right breast cT1bN0M0, stage IA, IHC stains: ER (+), PR(+), Her2/neu: (-).
  • Malignant neoplasm of unspecified site of right female breast
  • Mastodynia
  • Essential (primary) hypertension
  • Insomnia, unspecified
  • Constipation, unspecified

[past history] - 2022-12-08 admission note

  • The patient has history of hypertension under medication treatment.
  • history of operation: s/p bilateral mammoplasty.
  • G2P0SA2
  • Breast feeding (-)
  • menarche : 13y/o
  • menopause: y/o
  • Hormone therapy: (+) due to In Vitro Fertilization
  • Family history of breast cancar: NIL       

[lab data]

  • 2022-08-29 HBsAg Negative
  • 2022-08-29 HBsAg Value 0.524
  • 2022-08-29 Anti-HCV Negative
  • 2022-08-29 Anti-HCV Value 0.0352
  • 2022-08-29 Anti-HBc Nonreactive
  • 2022-08-29 Anti-HBc-Value 0.19 S/CO
  • 2022-06-29 Anti-ENA Scl-70 Ab <0.6 EliA U/ml
  • 2022-06-29 Anti Jo-1 antibody <0.3 EliA U/ml
  • 2022-06-29 Anti-ENA SS-A(Ro) <0.3 EliA U/ml
  • 2022-06-29 Anti-ENA SS-B(La) <0.3 EliA U/ml
  • 2022-06-29 ANA Negative

[exam findings]

  • 2022-12-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 22) / 89 = 75.28%
      • M-mode (Teichholz) = 76
    • Normal chambers sizes
    • Normal LV and RV systolic function.
    • Typical mitral valve prolapse ( anterior leaflet); mild PR.
    • poor apical echo window due to previous mammloplasty procedure.
  • 2022-12-10 CT - chest
    • Indication: Invasive carcinoma, no special type of right breast cT1bN0M0, stage IA, IHC stains: ER (+), PR(+), Her2/neu: (-).
    • Chest CT with and without IV contrast ehnancement shows:
      • S/p port-A placement with its tip at Superior vena cava.
      • s/p op. over right axillary region is found. Some fibrotic mass like lesion at op region. Regional lymph nodes are also found.
      • Calcified dot at uncinate process of the pancreas is found.
    • Imp:
      • Right axillary soft tissue mass with lymph nodes.
      • Calcified dot at uncinate proces of the pancreas.
  • 2022-10-05 Pap Smear Test (for cervical cancer screening)
    • Atypical squamous cells (ASC-US)
  • 2022-08-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (72.1 - 26.8) / 72.1 = 62.83%
      • M-mode (Teichholz) = 62.8
    • Normal AV with no AR
    • Normal MV with no MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, trivial TR, normal IVC size
  • 2022-08-11 Patho - breast biopsy
    • PATHOLOGIC DIAGNOSIS
      • Tumor, right breast, frozen+ partial mastectomy —- Invasive carcinoma of no special type
      • Resection margins, frozen section — Free, closest 0.2 cm at upper side of 1 o’clock margin
        • 12 o’clock margin, recut — Free of tumor invasion
      • Skin, ditto — Free of tumor invasion
      • Lymph node, R’t axillary SLN, frozen section — Tumor metastasis (2/4) without extracapsular extension (0/2)
        • Lymph node, R’t level I, dissection — Free of tumor metastasis (0/14)
        • Lymph node, R’t level II, dissection — Free of tumor metastasis (0/7)
      • Cyst, R’t chest wall, excision — Epidemal cyst
      • AJCC Pathologic Anatomic Stage — pT1cN1a, if cM0, stage IIA; Prognostic Stage — Stage IA
    • MICROSCOPIC EXAMINATION
      • Histologic type: Invasive carcinoma of no special type with focal ductal carcinoma in situ, low grade
      • Size of invasive carcinoma: 1.1 x 0.9 cm
      • Histologic grade (Nottingham histologic score): Grade I (score 5) including (A) Tubule formation: score 2; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1]. Besides, focal ductal carcinoma in situ, low grade arranged in cribriform pattern is also noted
      • Margins: Free, closest 0.2 cm away from upper side of 1 o’clock, 2.6 cm from 12 o’clock, 1.1 cm from 3 o’clock, 2.6 cm from 9 o’clock, 2.4 cm from 6 o’clock and 0.5 cm from base
      • Nodal status:
        • R’t axillary SLNs: Tumor metastasis (2/4) without extracapsular extension (0/2)
        • R’t level I: Free of tumor metastasis (0/14)
        • R’t level II: Free of tumor metastasis (0/7)
      • Treatment Effect: N/A
      • Lymphovascular space invasion: present
      • Perienural invasion: Not identified
      • Immunohistochemistry: Please refer to S2022-11514
  • 2022-08-11 Frozen Section
    • Margins, right breast, frozen section — Free, closest margin 0.3 cm at 12 o’clock and 0.2 cm at upper side of 1 o’clock margin
    • Sentinel lymph nodes, right axilla, ditto — Tumor metastasis (2/4)
  • 2022-08-11 Lymphoscintigraphy
    • Finding
      • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the right breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the right axilla.
    • Impression
      • Probably a sentinel lymph node at the right axillary region.
  • 2022-07-28 Tc-99m MDP whole body bone scan with SPECT
    • Mildly increased activity in lower L-spines. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Some faint hot spots in the anterior aspect of bilateral rib cages and increased activity in the nasal bon. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral elbows, hips and knees, compatible with benign joint lesions.
  • 2022-07-25 SONO - abdomen
    • Calcified spots in the liver.
    • Liver cysts.
    • Gallbladder stone.
  • 2022-07-18 Patho - breast biopsy
    • Breast, right, 1/3 tumor, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (+, 100%, strong intensity), PR(+, 100%, strong intensity), Her2/neu: negative(score=1+), Ki-67(<10 %), p53 (<10%).
  • 2022-06-28 SONO - breast
    • Diagnosis
      • Bil. fibroadenomas as described
      • Suspected right breast tumor (#2)
      • S/P bil. mammoplasty
    • Suggestion
      • tissue study
    • BI-RADS:
      • suspicious abnormality, biopsy should be considered
  • consultation
    • 2022-08-16 Dermatology
      • Q
        • For dermatitis
        • This 41 y/o female a case of right breast cancer. She underwent right partial mastectomy + ALND on 20220811. She has noted dermatitis at forehead, without itch. We need your expertise for dermatitis evaluation and treatment.
      • A
        • The patient had sufferred from facial and scalp erythematous papules
        • Under the impression of seborrheic dermatitis
        • The following sugeetion:
          • Topysm lotion 2 bot. topical bid use on the scalp lesions.
          • Rinderon-V cream 1 tube topical bid use on the facial and post-aucurial area.

[surgical operation]

  • 2022-08-11
    • Surgery
      • right partial mastectomy and ALND (axillary lymph node dissection)
      • tumor excision
    • Finding
      • right 1/3 tumor, about 1cm in diameter
      • SLNB (sentinel lymph node biopsy): positive of malignancy, 2/4
      • epidermoid cyst over right chest wall, LIQ, no infection

[chemoimmunotherapy]

  • 2023-02-23 - doxorubicin 60mg/m2 95mg NS 100mL 10min + cyclophosphamide 600mg/m2 945mg NS 500mL 1hr (AC, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-31 - doxorubicin 60mg/m2 95mg NS 100mL 10min + cyclophosphamide 600mg/m2 950mg NS 500mL 1hr (AC, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-28 - doxorubicin 60mg/m2 94mg NS 100mL 10min + cyclophosphamide 600mg/m2 940mg NS 500mL 1hr (AC, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-08 - docetaxel 75mg/m2 115mg NS 250mL 1hr + cyclophosphamide 600mg/m2 945mg NS 500mL 1hr (post-Op adjuvant TC)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-17 - docetaxel 75mg/m2 118mg NS 250mL 1hr + cyclophosphamide 600mg/m2 900mg NS 500mL 1hr (post-Op adjuvant TC)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-26 - docetaxel 75mg/m2 118mg NS 250mL 1hr + cyclophosphamide 600mg/m2 900mg NS 500mL 1hr (post-Op adjuvant TC)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-09-23 - docetaxel 60mg/m2 90mg NS 250mL 1hr + cyclophosphamide 600mg/m2 900mg NS 500mL 1hr (post-Op adjuvant)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • G-CSF (granulocyte colony stimulating factor)
    • 2022-12-17, -18, -19 (20221217 OPD)
    • 2022-11-26, -27, -28 (20221126 OPD)
    • 2022-11-20, -21, -22 (20221117 IPD)
    • 2022-10-29, -30, -31 (20221026 IPD)
  • Low WBC data points
    • 2022-12-17 WBC 1.29 *10^3/uL
    • 2022-11-26 WBC 2.59 *10^3/uL
    • 2022-10-04 WBC 1.34 *10^3/uL

==========

2023-02-24

  • The most common sequelae, or aftereffects, of axillary lymph node dissection (ALND 2022-08-11) are arm lymphedema, numbness, and limited shoulder mobility.

  • For patients with lymphedema (ie, International Society of Lymphology - ISL stage I, II, III), there is a recommendation to measure blood pressure in the contralateral arm, particularly in any setting in which blood pressure is being closely repeatedly or continuously monitored.

  • The effectiveness of these treatments in patients with established breast cancer-associated lymphedema (BCAL) is summarized below.

    • For patients with mild lymphedema (ISL stage I), it is suggested physiotherapy in the form of manual lymphatic drainage and compression garments, rather than more intensive therapy. Manual lymphatic drainage (MLD) is a massage-like technique that is typically performed by specially trained physical therapists, but a self-help maneuver (simple lymphatic drainage) has also been used for mild cases. Light pressure is used to mobilize edema fluid from distal to proximal areas.
    • For patients with moderate-to-severe lymphedema (ISL stages II to III) and no contraindications, it is suggested intensive physiotherapy, usually in the form of complete decongestive therapy, rather than less intense therapy. Complete decongestive therapy (CDT) refers to a two-phase (treatment phase, maintenance phase) multicomponent technique that is designed to reduce the degree of lymphedema and to maintain the health of the skin and supporting structures.
    • Patients with severe lymphedema (ISL stage III) may also benefit from intermittent pneumatic compression (IPC) in addition to CDT. IPC (also called sequential pneumatic compression) devices employ a plastic sleeve or stocking that is intermittently inflated over the affected limb. Most pneumatic compression pumps sequentially inflate a series of chambers in a distal-to-proximal direction.
  • This (2023-02-24) morning, there was a decrease in blood pressure by 10mmHg resulting in a reading of 96/57, which should be noted. If the blood pressure continues to decrease, the administration of Concor (bisoprolol 5mg) may be suspended.

  • No medication reconciliation issues were found during this hospital stay, and the recently prescribed drugs disclosed in the NHI PharmaCloud System have been accurately prescribed as self-carried items that cover the patient’s underlying conditions.

2022-12-09

  • 2D transthoracic echocardiography performed on 2022-12-19 and 2022-08-29 did not demonstrate deteriorations in heart function.

2022-11-18

  • Docetaxel has been associated with adverse dermatologic reactions: Alopecia (56% to 76%, can be permanent), dermatological reaction (20% to 48%; severe dermatological reaction: 5%), nail disease (11% to 41%). There have also been reports of adverse reactions associated with cyclophosphamide: Alopecia, changes in nails, dermatitis, erythema multiforme, erythema of skin, hyperhidrosis, palmar-plantar erythrodysesthesia, pruritus, skin abnormalities related to radiation recall, skin blister, skin rash, skin toxicity, Stevens-Johnson syndrome (Assier-Bonnet 1996), toxic epidermal necrolysis (Sasak 2016), urticaria (Thong 2002).
  • It is not recommended to immediately reduce the dose of chemotherapy once a mild adverse reaction has been observed in order to gain expected therapeutic effect. Skin symptoms are currently treated with drugs prescribed by dermatologists.
  • The underlying conditions of hypertension, constipation, mastodynia, and insomnia are all appropriately treated with appropriate medication without a problem.

2022-10-06

  • A rise in serum creatinine has been observed over the last three months, while the patient has been taking several NSAIDs, including Tonec (aceclofenac), Arcoxia (etoricoxib), and Volna-K (diclofenac). If NSAIDs are required for myositis and/or mastodynia, the renal function should be routinely monitored.
    • 2022-10-04 Creatinine 0.70 mg/dL
    • 2022-09-23 Creatinine 0.64 mg/dL
    • 2022-08-10 Creatinine 0.55 mg/dL
  • For this patient with ER(+), PR(+) and HER2(-) breast cancer, the current adjuvant chemotherapy might be followed by endocrine therapy (e.g., aromatase inhibitor or tamoxifen).

700851656

230224

[exam findings]

  • 2023-02-17 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-02-17 ECG
    • Normal sinus rhythm
    • Minimal voltage criteria for LVH (left ventricular hypertrophy), may be normal variant
    • Borderline ECG
  • 2022-09-23 SONO - nephrology
    • chronic parenchymal renal disease
  • 2022-01-28 Merchant view (patella 45 0) Rt
    • No lateral subluxation or lateral tilting of the patella
    • Patellofemoral osteoarthritis
    • Sperner classification: 4
  • 2022-01-28 Knee Rt standing AP and Lat views
    • Severe osteoarthritis of right knee with valgus deformity
    • Ahlback calcification: grade 4
  • 2021-11-04 Patho - colorectal polyp
    • Mid transverse colon, polypectomy — Tubular adenoma, low grade
    • Proximal transverse colon, polypectomy — Tubular adenoma, low grade
  • 2021-07-02 SONO - nephrology
    • chronic parenchymal renal disease
    • distended urinary bladder
  • 2021-06-28 CT - abdomen
    • Bilateral kidney atrophy
    • Lumbar spondylosis
  • 2020-12-24 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Duodenal ulcer scars, bulb
      • Superficial gastritis, antrum, s/p CLO
      • Reflux esophagitis LA Classification grade A
    • Suggestion
      • PPI use
      • Pend for CLO
  • 2020-08-01 SONO - abdomen
    • Diagnosis
      • liver parenchyma disease
      • gallstones, GB wall thickening
      • suspect renal parenchyma disease
    • Suggestion
      • correlate with kidney echo
  • 2020-07-30 CXR
    • Increased bilateral lung markings.
    • Cardiomegaly.
    • Intimal calcification of thoracic aorta.
  • 2020-07-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 45.4) / 104 = 56.35%
      • M-mode (Teichholz) = 56.3
    • Dilated LA
    • Adequate LV,RV systolic function with normal wall motion
    • LV hypertrophy, Impaired LV relaxation
    • Mild MR, TR, AR, PR
    • Mild Pulmonary HTN
  • 2020-07-28 CXR
    • Mild increased infiltration in both lungs
    • No pleural lesion
    • Borderline enlarged cardiac sihoutte
  • 2020-05-08 SONO - nephrology
    • chronic parenchymal renal disease
  • 2020-04-30 CXR
    • Increased bilateral lung markings.
    • Borderline cardiomegaly.
    • Intimal calcification of thoracic aorta.
  • 2020-04-30 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Left ventricular hypertrophy
    • Nonspecific ST abnormality
    • Abnormal ECG

[assessment]

  • Based on the available lab data in HIS5, the patient’s HGB level has been consistently below the lower limit of normal since May 2020. The most recent HGB level recorded on 2023-02-23 was 7.4g/dL. It is recommended to closely monitor the patient’s ability to oxygenate.

  • For patients with chronic kidney disease-related anemia (2023-02-07 Ferritin 731.6ng/mL), the initiation of epoetin alfa or its biosimilars is generally recommended when Hb levels fall below 10 g/L, according to the Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. Reference: KDIGO clinical practice guideline for anemia in chronic kidney disease, published in Kidney Int Suppl in 2012;2(suppl):279-335.

  • Please evaluate if the detected bacteriuria (2023-02-24 lab result) indicates an asymptomatic UTI or not. Asymptomatic bacteriuria is common, but most patients with asymptomatic bacteriuria have no adverse consequences and derive no benefit from antibiotic therapy. With few exceptions, nonpregnant patients should not be screened or treated for asymptomatic bacteriuria.

701296927

230224

{not completed}

[diagnosis]

  • K-ras wild type Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum, of the Descending to sigmoid colon with LNs and right upper lung metastases, pT4aN2bM1, stage IV.

[past history]

  • Denied history of Hypertension        

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer

[exam findings]

  • 2023-01-02, 2022-12-20, -12-15 Abdomen - Standing (Diaphragm)
    • Ascites is noted.
    • S/P clips projecting at RUQ and LMQ abdomen, and pelvis.
    • Spondylosis of the L-spine is noted.
    • 2023-01-02 Partial Small bowel obstruction with partial resolving is suspected. Follow up is indicated.
    • 2022-12-20 Partial Small bowel obstruction is suspected. Please correlate with CT.
    • 2022-12-15 Small bowel obstruction is suspected. Please correlate with CT.
  • 2022-12-14 CT - abdomen
    • CC: Abd fullness for 2+ weeks, poor appetite,
    • Past History: Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum of the Descending to sigmoid colon with LNs and right upper lung metastases, pT4aN2bM1, stage IV, hemicolectomy at TSGH on 2021-05-13.
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is massive ascites and soft tissue lesions in the omentum and mesentery.
        • Carcinomatosis is highly suspected. Please correlate with ascites cytology.
      • There is suggestive tumor seeding in splenic flexure colon, causing marked dilatation of the proximal colon and small intestine.
        • Tumor seeding in the splenic flexure colon induce mechanical colonic obstruction is highly suspected. Please correlate with clinical condition and colonoscopy.
      • There are multiple metastatic nodes in the celiac trunk, para-aortic space and para-cava space that are c/w metastatic nodes.
      • There are two kissing poor enhancing lesions in S4/8 of the liver that are c/w liver metastases.
      • Abdominal aorta shows atherosclerosis, aneurysm 3.2 cm and mild intramural thrombus formation.
      • A calcification 7 mm in S4 liver is noted that is c/w old granuloma.
      • There are several renal stones on both kidney and the largest one measuring 0.6 cm in right middle pole.
        • There are several renal cysts on both kidney and the largest one measuring 1.1 cm in size at right upper-middle pole.
      • S/P LAR with autosuture retention over the sigmoid colon.
      • S/P cholecystectomy.
      • Others
        • There is no focal abnormality in the biliary system, pancreas, and spleen.
        • The IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
    • Impression:
      • Carcinomatosis is highly suspected. Please correlate with ascites cytology.
      • Tumor seeding in the splenic flexure colon induce mechanical colonic obstruction is highly suspected. Please correlate with clinical condition and colonoscopy.
      • Multiple metastatic nodes in the celiac trunk, para-aortic space and para-cava space.
      • Two metastases in S4/8 of the liver.
  • 2022-12-14 KUB
    • Increased air in distended loops of small bowel over abdomen and pelvicr ,could be adhesive or mechanical ileus.
    • Abdominal ascites
    • Surgical clips over the abdomen
  • 2022-12-14 ECG
    • Sinus tachycardia
    • Possible Septal infarct, age undetermined
    • Abnormal ECG
  • 2022-10-14 Anoscopy
    • Stool color: normal
    • Rectal mucosa: normal
    • Anal canal: abnormal
    • Impression: 2022-05-20 DRE/anoscopy: mixed morrhoids with perianal skin erosion(+)
  • 2022-10-01 CT - abdomen
    • Colon cancer s/p operation. Increased soft tissues at left abdominal cavity suspected tumor seeding.
    • A poor enhancing nodule (1.1cm) at pancreatic tail.
  • 2022-06-13 CT - abdomen
    • Very faint soft tissue nodule at left subphrenic region about 0.74cm in largest dimension.In comparison with CT dated on 2022-03-11, the lesions are stationary.
    • s/p cholecystectomy
    • s/p LAR.
  • 2022-03-21 Anoscopy
    • Hemorrhoid and anterior anal fissure
  • 2022-03-11 CT - abdomen
    • Two soft tissue nodules in LUQ omentum measuring 8 mm and 5 mm that may be post-operative change.
    • The differential diagnosis include tumor seeding but less likely.
  • 2022-02-21 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed faint hot spots in the left rib cage, and increased activity in the maxilla, mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, and knees, in whole body survey.
    • IMPRESSION:
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in the left rib cage, maxilla, mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, and knees.
  • 2021-12-06 CT - abdomen
    • Colon cancer s/p operation. No evidence of tumor recurrence.
    • Wall edema of colon r/o colitis. Focal small bowel ileus.
  • 2021-08-26 CT - abdomen
    • Colon cancer s/p operation. No evidence of tumor recurrence.
  • 2021-06-10 Whole body PET scan
    • Glucose hypermetabolism in multiple abdominal bilateral paraaortic lymph nodes, compatible with metastatic lymph nodes.
    • Glucose hypermetabolism in some left supraclavicular lymph nodes. Metastatic lymph nodes should be watched out. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar lymph nodes and in a small focal area in the upper lobe of right lung. The nature is to be determined (inflammatory process? other nature such as metastases?). Please follow up other imaging modalities for further evaluation.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.

[consultation]

  • 2022-12-21 Orthopedics
    • Q
      • The patient is an 63-year-old man with a history of K-ras wild type Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum, of the Descending to sigmoid colon with LNs and right upper lung metastases, pT4aN2bM1, stage IV, Hypertension.
      • He presented with left knee painful since yesterday, progression when movement. Suspect OA knee.
      • Follow-up knee bil. x-ray today. We need your further evaluation and management.
    • A
      • S: 63 male
      • Dx: Left knee OA, grade II
      • O
        • No open fracture
        • Intact N/V
      • Plan:
        • OPD f/u
        • Pain management with pain killers
        • RICE (Rest, Ice, Compression, and Elevation)
  • 2022-01-04 Infectious Disease
    • Q
      • The 61 y/o man has watery diarrhea per day for 2-3 weeks and went to PoJen General Hospital for colonscopy /p biopsy. Thus, he sent to TSGH for future management and D- and Sigmoid PD adenocarcinoma with invading to the visceral peritoneaum, pT4aN2b, stage IIIC at least, lymphovascular invasion (+), perineural invasion (+) (LN met 11/16 and 5/11) at least post hemicolectomy at TSGH by GS Chan DChung on May 13, 2021.
      • port-A insertion on 2021-06-09. PET was performed on 2021-06-11 which showed There was increased FDG uptake in some left supraclavicular lymph nodes (SUVmax early: 8.27, delay: 10.54), in a small focal area in the upper lobe of right lung (SUVmax early: 3.30, delay: 5.38), in bilateral pulmonary hilar lymph nodes (SUVmax early: 4.86, delay: 6.77) and in multiple abdominal bilateral paraaortic lymph nodes (SUVmax early: 7.50, delay: 13.69). Besides, there was increased FDG accumulation in both kidneys and bilateral ureters. Radiotherapy with 4500cGy/25 fractions were done. Under the diagnosis of Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum, of the Descending to sigmoid colon with LNs and right upper lung metastases, pT4aN2bM1, stage IV.
      • He received chemotherapy with
        • C1D1 FOLFIRI on 2021/06/11-13.
        • C1D15 Avastin plus FOLFIRI on 2021/06/25-27.
        • C2D1 Avastin plus FOLFIRI on 2021/07/12-14.
        • C2D15 Avastin plus FOLFIRI on 2021/07/27-29
        • C3D1 Avastin plus FOLFIRI on 2021/08/10-12
        • C3D15 Avastin plus FOLFIRI on 2021/08/23-25.
        • => Followed CT of abdomen on 2021/08/26 which revealed Colon cancer s/p operation. No evidence of tumor recurrence.
        • C4D1 Avastin plus FOLFIRI on 2021/09/06-09/08
        • C4D15 FOLFIRI on 2021/9/27-29.
        • C5D1 Avastin plus FOLFIRI on 2021/10/12-14.
        • C5D15 Avastin plus FOLFIRI on 2021/10/26-28.
        • C6D1 Avastin plus FOLFIRI on 2021/11/10-12.
        • C6D15 Avastin plus FOLFIRI on 2021/11/23-25
      • RT 4500cGy/25 fractions at primary tumor bed, peripheral, to regional lymphatic including pelvic area started from 2021/11/11.
      • clostridium difficileGDH as well as Toxin A/B, which showed GDH and Toxin A/B all positive on Dec,2021 although cultural results showed no infection signs.
      • He was admitted for scheduled chemotherapy this time, however still severe diarrhea and clostridium difficileGDH andToxin A/B, which still showed GDH and Toxin A/B all positive. we need your expertise for further management,thanks
    • A
      • The patient’s condition was as your description.
        • RT 4500cGy/25 fractions at primary tumor bed, peripheral, to regional lymphatic including pelvic area started from 2021/11/11.
        • clostridium difficile GDH as well as Toxin A/B, which showed GDH and Toxin A/B all positive on Dec, 2021.
      • Clostridium difficile associated diarrhea was impressed.
      • Suggestion:
        • Vancomycin 125 mg po qid is suggested for 10 days.
        • Please keep contact isolation
  • 2021-09-06 Radiation Oncology
    • A
      • A: Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum, of the Descending to sigmoid colon, AJCC pathological staging pT4aN2b(cM0), stage IIIC at least, s/p operation.
      • P: Radiotherapy is indicated for this patient with the following indicators: D-S colon cancer, stage pT4aN2b(cM0), stage IIIC, wth visceral peritoneum invasion and tumor focal attach to the nearest circumferential margin.
        • Goal: curative
        • Treatment target and volume: primary tumor bed, peripheral, to regional lymphatic including pelvic area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions.
        • The patient’s family is going to apply the details of medical records. I would like to view those including preoperative CT scan image to clarify the tumor location and then make a decision.
        • RTC: in one week

[radiotherapy]

[chemoimmunotherapy]

  • 2023-02-23 - ramucirumab 8mg/kg 400mg NS 250mL 1hr + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4560mg NS 500mL 46hr (Cyramza + FOLFOX, Q2WK)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-02-03 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-01-15 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-30 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-16 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-06-13 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • … … ..

  • 2022-03-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • … … ..

  • 2021-06-11 - irinotecan 180mg/m2 310mg D5W 250mL 90min + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2800mg/m2 4830mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL

==========

2023-02-24

  • There is a possible trend towards leukopenia as the patient’s WBC count has gradually decreased over time.

    • 2023-02-23 WBC 3.44 x10^3/uL
    • 2023-02-10 WBC 2.83 *10^3/uL
    • 2023-02-03 WBC 3.09 *10^3/uL
    • 2023-01-27 WBC 4.43 *10^3/uL
    • 2023-01-15 WBC 4.05 *10^3/uL
    • 2023-01-12 WBC 5.79 *10^3/uL
    • 2022-12-29 WBC 5.29 *10^3/uL
    • 2022-12-26 WBC 7.99 *10^3/uL
  • The patient’s HbA1c levels have slowly increased and warrant attention.

    • 2023-02-20 HbA1c 6.1 %
    • 2022-12-06 HbA1c 5.8 %
    • 2022-09-05 HbA1c 5.7 %
  • Diarrhea seems to have improved as there was no bowel movement recorded on 2023-02-23.

  • The medications recently prescribed for the patient are in accordance with the records in the NHI PharmaCloud System, and have been correctly prescribed as self-carried items during this hospital stay to cover his underlying conditions. No issues related to medication reconciliation have been identified.

2023-01-16

  • Based on the records, bowel movements were 2, 2, 1 over the past three days. No further diarrhea has been observed; loperamide might not be continued. (The drug has not been refilled after the original prescribed expired.)
  • Blood sugar levels remain at 90 mg/dL, they are in good control.

700174936

230223

[past history]

  • Medical history:

    • Heart: hypertension and dyslipidemia for 10+ years under medical control
    • Other medical:
      • Insomnia, but does not use sleeping pills
      • Asymptomatic gallbladder stones
  • Surgical: operation for endometriosis x3, 10+ years ago (open abdominal x1 + hysteroscopic x2)

  • Menstrual history: G0P0, Last menstrual period:2022/8/2

    • Menarche at the age of 13 years old
    • Menstrual cycle:Duration/Interval:7-14days/28days
    • Amount: moderate —> changed to menstruation 1 time per year for the past 3 years
  • Has regular Pap smear examination (most recent 2022/08/03)

[allergy]

  • NKDA         

[family history]

  • Mother had hysterectomy, but the patient doesn’t know why
  • Mother has thalasemia anemia and hypertension

[exam findings]

  • 2022-12-30 - CT - abdomen
    • History: Left ovary cancer of clear cell carcinoma s/p Laparoscopic hysterectomy + BSO + bilateral pelvic lymphadenectomy on 2022/09/22, pT1aN0; stage IA; FIGO stage IA
    • MD CT (iCT 256 slices) of the chest, abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • S/P hysterectomy
      • Severe fatty liver, grade 5, is noted.
      • The gallbladder shows stones and mild wall thickening. please correlate with clinical condition.
      • There is a soft tissue enhancing lesion in left adrenal gland, measuring 1.3 x 0.9 cm in size, that may be adenoma. please correlate with clinical condition.
      • Others
        • There is no focal abnormality in the biliary system, pancreas, spleen & both kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • Impression:
      • S/P hysterectomy
      • Severe fatty liver, grade 5, is noted.
      • The gallbladder shows stones and mild wall thickening. please correlate with clinical condition.
      • Left adrenal adenoma is highly suspected. please correlate with clinical condition.
  • 2022-10-19 Gynecologic Ultrasonography
    • Suspected LT skin sub? cyst: 16mm x 11mm
    • ATH + BSO
  • 2022-09-23 Patho - uterus (with or without SO) neoplastic
    • PATHOLOGIC DIAGNOSIS
      • Ovary, left, BSO — Clear cell carcinoma
      • Lymph nodes, pelvic, bilateral, BPLND — Negative for malignancy (0/15)
      • AJCC 8 th edition, Pathology stage: pT1aN0; stage IA; FIGO stage IA
    • MACROSCOPIC EXAMINATION
      • Procedure: Laparoscopic hysterectomy + BSO + BPLND
      • Specimen Size:
        • Multiple pieces, up to 7.5 x 2.2 x 0.5 cm (Lt ovary, received for frozen section), multiple pieces up to 2.5 x 2.0 x 1.5 cm (Lt ovary), 5.5 x 1.2 x 0.7 cm (Lt tube), 4.5 x 3.2 x 2.5 cm (Rt ovary), 4.5 x 1.5 x 0.9 cm (Rt tube), 12.0 x 7.0 x 5.0 cm and 100 gm (uterus)
      • Specimen Integrity
        • Right ovary: Capsule intact
        • Left ovary: Fragmented
        • Right fallopian tube: Serosa intact
        • Left fallopian tube: Serosa intact
      • Tumor Site: Left ovary
      • Ovarian Surface Involvement: Absent
      • Fallopian tube Surface Involvement: Absent
      • Tumor Size: Cannot be assessed (about 5-6 cm in dimension)
      • Lymph Nodes: Four groups including left iliac, left obturator, right iliac, right obturator
      • Representative parts are taken for section and labeled as: F2022-00449FS and A1-A3, A4, A6 = left ovary, A5 = left tube. S2022-16185A = left iliac LNs, B = left obturator LNs, C = right iliac LNs, D = right obturator LNs, E1 = cervix, E2-E7 = uterine corpus, E8-E9 = endometrium, E10-E11 = right ovary, E12 = right fallopian tube, F1-F2 = left ovary.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Clear cell carcinoma
      • Histologic grade: High-grade
      • Implants: Not identified
      • Other Tissue/Organ Involvement: Not identified
      • Peritoneal Fluid: Not submitted
      • Regional Lymph Nodes: All lymph nodes negative for tumor cells
        • number of lymph node examined: 2 (left iliac), 7 (left obturator), 1 (right iliac), 5 (right obturator)
        • number with metastases >10 mm: 0
        • number with metastases 10mm or less: 0
        • number with isolated tumor cells (<=0.2mm): 0
      • Pathologic Stage
        • Primary Tumor: pT1a (tumor limited to one ovary)
        • Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
        • Distant Metastasis: Not applicable
      • FIGO Stage: Stage IA
      • Lymphovascular invasion: Absent
      • Perineural invasion: Absent
      • Additional Pathologic Findings:
        • Cervix: Chronic cervicitis with squamous metaplasia
        • Endometrium: Endometrial polyp with endometrial hyperplasia
        • Myometrium: Leiomyoma and adenomyosis
        • Ovary, right: Endometrosis
        • Fallopian tube, left: Unremarkable
        • Fallopian tube, right: Hydrosalpinx and hemosalpinx
  • 2022-09-22 Frozen Section
    • Ovary, left, frozen section — Malignant, clear cell carcinoma can be considered
  • 2022-09-21 ECG
    • Marked sinus bradycardia
    • Septal infarct, age undetermined
    • Nonspecific ST abnormality
  • 2022-08-20 Gynecologic Ultrasonography
    • Suspected LT ovarian mass with (papillary 24x23mm)
    • Uterine myoma
  • 2022-08-03 Mammography
    • Impression: Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
    • BI-RADS: Category 1: negative. - annual screening.

[surgical operation]

  • 2022-09-22
    • Surgery
      • Diagnosis: Left ovarian tumor suspected malignancy for staging surgery.    
      • Operation: Laparoscopic gynecologic oncology staging surgery (Laparoscopic hysterectomy + BSO + bilateral pelvic lymphadenectomy)   - Finding
      • Left ovarian tumor, suspected malignancy.
      • Frozen: clear cell carcinoma
      • Uterus: irregular shape due to multiple uterine myomas with size 9x8cm, there was dense adhesion with bladder, peritoneum due to previous endometriosis surgery before, adhesiolysis was performed smoothlt.
      • LOV: 6x7x5xcm , capsule intact , smooth surface, with yellowish mucus fluid content and necrotic tissues found within the ovary .
      • ROV: 3x3x2 cm , grossly normal
      • Fallopian tube: bilateral grossly normal
      • CDS: invisible due to tumor mass occupied
      • Ascites: bloody , about 10 ml
      • Bilateralpelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • Omentum: not seen
      • Liver: grossly normal & smooth
      • Appendix: grossly normal.
      • After the operation, check the bleeder and spray the arista on both pelvic lymph nodes lesion
      • Estimated blood loss: 300 ml
      • Blood transfusion: nil
      • Complication: nil  

[chemoimmunotherapy]

  • 2023-02-22 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-01-30 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-12-28 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-12-07 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-11-14 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-10-21 - paclitaxel 175mg/m2 260mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL

==========

2023-02-23

  • The patient exhibited severely elevated blood pressure of 228/122 at 19:17 on 2023-02-22, which should be noted as it indicates that her blood pressure was unstable.
  • The patient’s 2023-02-22 lab results showed generally normal readings, and she is tolerating the treatment well.
  • The active prescription for the patient’s underlying conditions, including hypertension, chronic viral hepatitis B, and hypomagnesemia, has been prescribed without an issue.

2022-10-24

  • The patient has just undergone her first treatment with paclitaxel/carboplatin and her TPR and blood pressure are stable.
  • The active prescription does not present a problem.

701468007

230223

[past history] - 2023-02-22 admission note

  • The patient had no systemic diseases, including endocrine、CNS、CV
  • history of operation:
    • s/p abdominal total hysterectomy (ATH) for 20+ y/o ago
    • s/p Urethovesicopexy
    • s/p bilateral cataract
    • s/p rectal biopsy on 2023/02/01
    • s/p L’t port-A on 2023/02/15
  • Denied recent traveling history
  • Blood transfusion history: NIL
  • Occupational function (premorbid):OK。
  • Regular medications or herb:no            

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[lab data]

  • 2023-02-12 HBsAg Nonreactive
  • 2023-02-12 HBsAg (Value) 0.44 S/CO
  • 2023-02-12 Anti-HBc Reactive
  • 2023-02-12 Anti-HBc-Value 7.26 S/CO
  • 2023-02-12 Anti-HCV Nonreactive
  • 2023-02-12 Anti-HCV Value 0.11 S/CO

[exam findings]

  • 2023-02-03 MRI - pelvis
    • CC: She sufferred from constipation for 2 months. This time, anal pain and anal bleeding after defecation developed recently. Digital examination: swelling anorectal region, 7 o’clock rupture.
      • 20230117 sigmoidoscopy: perianal swelling and extensive ulcerative lesion over 6-8 o’clock. Suspected anorectal ulcer
    • MR Imaging of the abdomen was performed on a 1.5 T superconducting magnet and phase arrayed body coil. Patient kept in supine position.
    • Scanning protocol:
      • Axial plane: spin echo T1WI, diffusion weighted images, Non-Fat-saturation FSE T2WI, and HASTE T2WI
      • Coronal and sagittal plane: Non-Fat-saturation FSE T2WI,
      • Dynamic study: Fat saturated T1WI with IV Gd-DTPA 0.1mmol/Kg and images were obtained at 70 second.
    • Findings:
      • There is circumferrential asymmetrical wall thickening at the rectum and aus, with right lateral exophytic growing measuring 4 cm in size. The cranial-caudal dimension of the rectal lesion is measured about 8 cm in length.
        • The fat plane between this mass and right levator ani muscle shows obliteration that is c/w direct invasion.
        • In addition, the rectal mass shows poterior extension to the perineum.
        • Squamous cell carcinoma of the anorectum with right levator ani muscle invasion (T3) is highly suspected.
        • Please correlate with biopsy.
      • There are five enlarged nodes in the perirectal space and sigmoid mesocolon that are c/w regional metastatic nodes.
        • The largest one measuring 1.3 cm.
        • In addition, There are several enlarged nodes in bilateral inguinal area that are also c/w regional metastatic nodes (N1a).
      • Others
        • There is no focal lesion in the urinary bladder and vaginal.
        • There is no evidence of ascites.
        • The visible artery and vein show unremarkable finding.
    • IMP:
      • Squamous cell carcinoma of the anorectum with right levator ani muscle invasion is highly suspected. Please correlate with biopsy.
      • According to American Joint Committee on Cancer (AJCC) staging system, 9th edition for anal cancer: T3N1aM0, stage:IIIC
  • 2023-02-02 CT - abdomen
    • History and indication: anorectal ulcer
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of rectum with adjacent tissue invasion, regional LAP and perforation. Colonic diverticula.
      • Some calcifications in bil. breasts.
      • Hyperplasia of left adrenal gland.
      • Some LNs at bil. inguinal regions.
      • S/P hysterectomy. Suspected left ovary cyst (1.8cm).
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • Addendum Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N1a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2023-02-02 Patho - colon biopsy
    • Anorectum, biopsy — squamous cell carcinoma, moderately differentiated
    • Section shows pieces of squamous mucosa with invasive squamous cell carcinoma.
    • The immunohistochemical stains reveal CK5/6(+), p40(+), CDX2(-), and CD56(-). The results are supportive for the diagnosis.
  • 2023-01-31 ECG
    • Sinus rhythm with Premature atrial complexes
    • Left axis deviation
    • Right bundle branch block
  • 2023-01-17 Sigmoidoscopy
    • Findings
      • 30cm to S colon, diverticulosis of S colon.
      • perianal swelling and extensive ulcerative lesion over 6~8 o’clock.
    • Diagnosis
      • anorectal ulcer, easily bleeding, pt complain better
    • Suggestion
      • repeat 1 month later.
    • Complication
      • No immediate complication
  • 2023-01-13 CXR
    • Cardiomegaly is noted.
  • 2023-01-13 ECG
    • Normal sinus rhythm with sinus arrhythmia
    • Left axis deviation
    • Right bundle branch block
    • Abnormal ECG

[SOAP]

  • 2023-02-10 Radiation Oncology
    • CCRT is indicated but old age. CT-simulation will be arranged on 20230215. Plan to deliver 45 Gy/ 25 fx to the pelvis (including inguinal, int & ext iliac lymphatic drainage area). Then boost the anal tumor and LAPs to 54 Gy/ 30 fx.

[chemotherapy]

[assessment]

  • The use of 5-fluorouracil/mitomycin or capecitabine/mitomycin in combination with radiation for the treatment of anal cancer was considered (2023-02-10). A population-based study found that capecitabine/mitomycin and fluorouracil/mitomycin given concurrently with radiation achieved similar disease-free survival (DFS) and anal cancer-specific survival (ACSS). As such, substituting capecitabine for infusional 5-FU may be a viable option for patients and healthcare providers who prefer to avoid the potential complications and inconvenience of a central infusional device. (Reference: “A comparison between 5-fluorouracil/mitomycin and capecitabine/mitomycin in combination with radiation for anal cancer.” J Gastrointest Oncol. 2016;7(4):665-672. doi:10.21037/jgo.2016.06.04)

  • The mitomycin and fluorouracil with concurrent radiation (FUMIR) regimen was ultimately chosen for the patient. There are multiple variations of this regimen. The standard administration of 5-FU involves a continuous infusion over 4 days, specifically on Day 1-4 and 29-32. (ref: Mitomycin and Fluorouracil With Concurrent Radiation (FUMIR) Regimen for Anal Cancer. Hosp Pharm. 2013;48(6):464-469. doi:10.1310/hpj4806-464). Due to the patient’s advanced age, a 3-day infusion was utilized during this hospitalization, with a weekend break in between.

  • Lab results 2023-02-22 revealed that the CBC, WBC DC, Na, K, liver and kidney function were grossly normal, indicating no significant abnormalities.

  • In the review of systems section of the admission note (2023-02-22, yesterday), it was documented that the patient had been experiencing constipation for a period of two months, as well as anal bleeding with pain. The prescription of sennoside has been appropriately made. If anal bleeding persists, the addition of tranexamic acid may be considered as a potential treatment option.

  • A summary of the compatibility of mitomycin with various intravenous solutions is listed as following: mitomycin is not compatible with D5W, Dextrose 3.3% in sodium chloride 0.3%, and Dextrose 5% in water. Compatibility with D10W, D5LR, D5NS, 1/2NS, D5W-1/2NS and Ringer’s Injection is untested. IV compatibility with Normal saline (Sodium chloride 0.9%) is variable; Lactated Ringer’s Injection, Sodium chloride 0.4%, Sodium chloride 0.6%, and Sodium lactate 1/6 M is compatible.

700348666

230221

This patient passed away at 10:19, 2022-11-03.

701470008

230221

[lab data]

2023-06-26 CMV viral load assay Target not detecetedIU/mL
2023-06-19 CMV viral load assay Target not detecetedIU/mL
2023-06-12 CMV viral load assay Target not detecetedIU/mL

2023-03-14 CMV IgM Nonreactive
2023-03-14 CMV IgM Value 0.57 Index
2023-03-14 CMV_IgG Reactive
2023-03-14 CMV_IgG Value 393.8 AU/mL

2023-02-16 FLT3-D835 Undetectable
2023-02-15 BCR/abl Undetectable
2023-02-15 PML-RARA Undetectable
2023-02-13 FLT3/ITD Undetectable
2023-02-13 NPM1 Undetectable

2023-02-04 Anti-HBc Nonreactive
2023-02-04 Anti-HBc-Value 0.21 S/CO
2023-02-04 Anti-HBs 1.78 mIU/mL
2023-02-04 Anti-HCV Nonreactive
2023-02-04 Anti-HCV Value 0.09 S/CO
2023-02-04 HBsAg Nonreactive
2023-02-04 HBsAg (Value) 0.36 S/CO
2023-02-04 Anti-HBc IgM Nonreactive
2023-02-04 Anti-HBc IgM Value 0.10 S/CO

[exam findings]

  • 2023-07-03 Patho - bone marrow biopsy
    • Bone marrow, iliac bone, biopsy — Compatible with AML with partial remission at least, see description
      • Immunohistochemical stains:
        • MPO: positive for myeloid series
        • CD117: negative for blast
        • CD34: positive for blast
        • CD61: positive for megakaryocyte
        • CD71: positive for erythroid series
        • CD68: positive for monocyte
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consisted of one strip of bone marrow tissue measuring 2.2 x 0.2 x 0.2 cm in size, fixed in B-5 solution. Grossly, it was tan in color and bony hard in consistence. All embedded for sections after short decalcification.
    • MICROSCOPIC EXAMINATION
      • Hypocellularity for her age, 30%
      • M/E ratio about 1.5/1, largely normal maturation of myeloid and erythroid series
      • Adequate megakaryocytes with focal mononucleation and hyposegmentation
      • Some scatter large nucleated cells, which IHC shows CD34(-) / CD117(+) / CD68(+/-, equivocal), maybe residual blast or erythroid precursor
      • According to all histopathologic finding, it is compatible with acute myeloid leukemia with partial remission at least. Clinical or smear correlation is needed for conclusive diagnosis due to histologic limitation. Closely follow up.
  • 2023-02-09 CXR
    • Enlargement of cardiac silhouette.
  • 2023-02-06 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with acute myeloid leukemia with maturation
    • The sections show hypercellular marrow (95%). M/E ratio = 3:1 in CD71 immunostain. The marrow space is partially replaced by a population of medium to large-sized immature cells with round to oval nucleus and prominent nucleoli.
    • IHC, increased CD34+ and or CD117+ blasts, constitue 40% of marrow cells. Most blasts are also positive for MPO and a few blasts are positive for CD68. The finding is compatible with acute myeloid leukemia with maturation. Suggest bone marrow smear evaluation and clinic correlation.
  • 2023-02-06 Gynecologic Ultrasonography
    • EM: 6.7mm.
  • 2023-02-02 CXR
    • Increase bilateral lung markings.

[MedRec]

  • 2023-07-06 Progression Note
    • Problem #1: Acute myeloid leukemia, 46,XX[20], status post induction chemotherapy with I3A7 on 2023/02/13-19, consolidation chemotherapy with hige dose Ara-C on 2023/04/12-15, 2023/06/02-05
      • Assessment: pending for bone marrow biopsy
    • Plan:
      • Followed bone marrow aspiration and biopsy on 2023/7/3 and pending
      • Family meeting on 2023/07/06 10:30, explained the current condition and further chemotherapy, alloPBSCT
      • closely monitor clinical condition
    • Medical team explained the current changes in the patient’s disease and future treatment direction:
      • The patient was diagnosed with Acute Myeloid Leukemia in 2023-02. Induction chemotherapy (I3A7) was given from 02/13 to 02/19. A follow-up bone marrow biopsy on 02/24 showed partial remission. Starting from 04/11/2023, the patient has been receiving consolidation treatment (High dose Ara-C) in two courses.
      • The initial white blood cell count was 100,000, indicating a poorer prognosis. The recent bone marrow biopsy during this hospitalization showed that complete remission has not yet been achieved. We discussed the subsequent treatments and the possibility of allogeneic peripheral blood stem cell transplant.
      • The patient’s sister will have HLA-ABC DR DQ typing performed for compatibility matching.
      • We explained and presented the consent form for matching from the Tzu Chi Stem Cell Registry.

[consultation]

  • 2023-02-06 Obstetrics and Gynecology
    • Q
      • This is a 29-year-old female with history of GERD. She denied systemic diseases, operation history or allergic history. She is ADL independent. This time, she suffered from abdominal distension for 1 months, accompanying with exertional dyspnea and bilateral lower limb edema for 5 days. Her dyspnea exacerbated during walking, and relieved during resting. She denied fever, chills, shortness of breath, dysuria, or abdominal pain. She visited local clinic first, and lab data revealed severe leukocytosis (92720) and anemia with HgB: 4.7. Then, she was transfered to Cardinal Tien Hospital. In order of further examination and survey, she was transfered to our ER due to leukocytosis, suspected leukemia. During ER, her vital sign showed BP:132/72, PR:123, BT:35.9 degree celsius, RR:18. Lab data showed severe leukocytosis (103.39 10^3/uL), anemia (HgB: 4.9 g/dL), thrombocytopenia (PLT: 52 10^3/uL). KUB and CXR showed negative findings. LPRBC 2U was transfused for her anemia.
      • Under the impression of anemia and abdominal distension, suspected acute leukemia, she was admitted for further hematological survey.
      • We strongely need your expertise for ceasing menstrural period due to severe thrombocytopenia (20230206 PLT: 78000/ul). Thank you very much.
    • A
      • S/O
        • SEX(+), LMP:2022/12/18 (moderate amount. irregular period, duration: 3~5 days)
        • NDKA
        • PHx: denied GYN history or family history GYN history. 2022/09 covid-19 infection.
        • Medication or hormone use: denied any hormone use before.
        • CC: for leukemia treatment.
        • PV: no lifting pain. clear discharge.
        • TVS (transvaginal ultrasound):
          • Uterus: AFV, 81X40 mm
          • EM:6.7 mm
          • ROV:27x12 mm
          • LOV:16x15 mm
      • Suggestion and plan:
        • Check pregnancy test. (Irregular menstrual cycle. )
        • Leuplin 3M 11.25 mg syringe SC ST for 1 dose
        • For long-acting Leuplin, one dose can last for three months, and at most two doses can last for six months. Patients have been informed that each dose will cost about TWD 10000 at their own expense.
        • The patient has been taught that Leuplin takes time to act, if there is still menstruation or heavy bleeding this month, oxytocin and transamin can be used (please contact obstetrics and gynecology).

[chemotherapy]

  • 2023-07-07 - [fludarabine 30mg/m2 46mg NS 500mL 30min + cytarabine 2000mg/m2 3000mg NS 500mL 4hr] D1-5 (FLAG Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-5
  • 2023-06-02 - cytarabine 3000mg/m2 4500mg NS 500mL 4hr Q12H D1-4 (HD Ara-C Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] Q12H D1-4
  • 2023-04-12 - cytarabine 1500mg/m2 2190mg NS 500mL 3hr Q12H D1-4 (HD Ara-C Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] Q12H D1-4
  • 2023-02-13 - idarubicin 10mg/m2 14mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 145mg NS 500mL 24hr D1-D7 (idarubicin/cytarabine 3+7 Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3

CYTARABINE (ARA-C) HIGH DOSE - Consolidation chemotherapy for AML in remission — https://nssg.oxford-haematology.org.uk/myeloid/protocols/ML-4-cytarabine-ara-c-3g-m2.pdf

ACUTE MYELOID LEUKAEMIA - CYTARABINE (3000mg/m2) — https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/AML/Cytarabine3000.pdf

==========

2023-07-07

  • In this hospital stay, the patient’s chemotherapy regimen has been augmented with the addition of fludarabine. I prepared information sheets for the patient on fludarabine and cytarabine and brought them to the ward. I visited her around 13:20 on 2023-07-07. Both the patient and her mother were present; the patient was standing and seemed to be reaching for something, and I observed that she was in good spirits. I highlighted the key points and potential side effects on the medication sheets with a colored marker, verbally informed both of them, and asked them to let our medical team know as soon as possible if they notice any suspected adverse drug reactions. I also left them with the contact information for the medication consultation window for their future reference.
  • During the visit, the patient’s mother asked about the results of the bone marrow biopsy performed on 2023-07-03. I informed her that questions regarding the patient’s condition and treatment strategy should be addressed to the attending physician. It is up to Dr Gao to disclose this information to the patient’s family as clinically necessary.

2023-02-11

  • Dr. Wan asked how long the stability of cytarabine lasts this morning. After calling the original supplier, the manufacturer said that the physical and chemical stability can be longer, but the microbiological stability is as shown in the package insert.
  • The content of this article “An 1H NMR study of the cytarabine degradation in clinical conditions to avoid drug waste, decrease therapy costs and improve patient compliance in acute leukemia” (Anticancer Drugs. 2020;31(1):67-72. doi:10.1097/CAD.0000000000000850) is the result of using Ara-C test instead of Cytosar.

700057920

230220

  • diagnosis - 2022-11-03 discharge
    • recurrent cholangiocarcinoma measuring 0.7 cm in S4, 0.9 cm in S8 and 1.2 cm in S3 of the liver are suspected. Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, aortocaval space, and mesentery, stage IV
    • Intrahepatic bile duct carcinoma status post laparoscopic S6-7 resection on 2020/09/30. ECOG:0, stage IV
    • chronic viral hepatitis B without delta-agent
    • liver cirrhosis, HBV related. Child A
  • exam findings
    • 2022-11-14 Ascites tapping
      • 2700mL
    • 2022-11-01 PTCD (Percutaneous Transhepatic Cholangial Drainage) revision
      • Obstruction of the PTCD catheter.
      • Revision of the catheter smoothly.
    • 2022-10-26 CT - abdomen
      • History and Indication:
        • 20080128 CT: HCC in S6 S/P partial segmentectomy
        • 20200826 AFP and CEA: normal, MRI:HCC 4.8 cm in S7 is suspected.
          • The differential diagnosis include cholangiocarcinoma and neuroendocrine carcinoma.
        • 20201002 Liver, S6-7 resection: cholangiocarcinoma
          • pT1aNx; Stage IA at least
        • 20220330 CEA, CA199, and AFP: normal.
      • IMP:
        • Recurrent cholangiocarcinoma in S4 of the liver S/P C/T shows stable disease.
        • Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, and aortocaval space S/P C/T show stable disease.
          • Multiple metastatic nodes in the mesentery S/P C/T show partial response.
        • Carcinomatosis is highly suspected.
          • Please correlate with ascites cytology.
          • In addition, there is marked increased the volume of the ascites.
          • please correlate with clinical condition.
    • 2022-09-26 Endoscopic Retrograde CholangioPancreatography, ERCP
      • diagnosis
        • Failed to reach major papilla
        • CBD stricture s/p PTCD
        • Duodenal stenosis, proximal 2nd portion and SDA
        • Duodenitis and duodenal tumor with ulcer
      • suggestion
        • PPI
    • 2022-09-05 KUB
      • S/P PTCD catheter implantation via left lobe IHD approach and the tip located at S2/3 IHD?
      • Fecal material store in the colon. -Mild ascites is suspected. Please correlate with sonography.
    • 2022-08-24 CT - abdomen
      • Recurrent cholangiocarcinoma in S4 of the liver S/P C/T shows partial response.
      • Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, and aortocaval space S/P C/T show partial response.
        • Multiple metastatic nodes in the mesentery show progressive disease.
      • Carcinomatosis is highly suspected.
        • Please correlate with ascites cytology.
    • 2022-06-15 CT - abdomen
      • One recurrent cholangiocarcinoma measuring 1.6 cm in S4 of the liver is suspected.
      • Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, aortocaval space, and mesentery S/P CT show partial response.
      • There is ascites in the abdomen and pelvis with smuddgy appearance at the perihepatic omentum area.
      • Please correlate with ascites cytology to R/O carcinomatosis?
    • 2022-05-09 Endoscopic Retrograde CholangioPancreatography, ERCP
      • Failed Cholangiography due to inablity to reach major papilla
      • CBD stricture s/p PTCD
      • Duodenal stenosis, proximal 2nd portion and SDA
      • Duodenitis and duodenal tumor with ulcers
    • 2022-04-29 Percutaneous Transhepatic Cholangiography and Drainage, PTCD
      • Dilatation of the biliary tree (by US images).
      • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree smoothly.
      • No procedure-related complication during the whole procedure.
    • 2022-04-28 SONO - abdomen
      • Diagnosis
        • Liver tumor, c/w recurrent cholangiocarcinoma, S3 and S7
        • Dilated CBD & bilateral IHD
        • Lymphadenopathy at pancreatic head area
        • Splenomegaly, moderate
        • Ascites, left retroperitoneal
      • Suggestion
        • ultrasound follow up ascites.
    • 2022-04-22 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • Liver tumor, c/w recurrent cholangiocarcinoma, S3 and S7
        • suspicious,subphrenic abscess or biloma , S7 area.
        • Prominent bilateral IHD and MPD
        • suspiciosu, Renal stone, right
        • lymphadenopathy at pancreatic head area
        • Splenomegaly, moderate
        • Ascites, left retroperitoneal
        • CBD, GB, pancreatic body masked
      • Suggestion
        • ultrasound follow up ascites.
    • 2022-04-20 Patho - lymphnode biopsy
      • Lymph node, hepatic hilum, EUS FNB — Compatible with metastatic cholangiocarcinoma
      • The sections show a picture of adenocarcinoma, composed of nests and cords of large pleomorphic neoplastic cells with focal glandular differentiation. Extensive tumor necrosis and moderate neutrophil infiltration are present.
      • IHC shows: CK7(+, focal), CK20(-), Arginase-1(-) and Hepatocyte(-). The finding is compatible with metastatic cholangiocarcinoma.
    • 2022-04-20 Patho - liver biopsy needle/wedge
      • Liver, EUS FNB — Adenocarcinoma, poorly differentiated, compatible with cholangiocarcinoma, recurrent
      • The sections show a picture of adenocarcinoma, composed of nests and cords of large pleomorphic neoplastic cells with focal glandular differentiation. Tumor necrosis, hemorrhage, and neutrophil infiltration are present.
      • IHC shows: CK7(+, focal), CK20(-), Arginase-1(-) and Hepatocyte(-). The finding is compatible with recurrent cholangiocarcinoma.
    • 2022-04-20 Endoscopic Ultrasonography, EUS
      • Diagnosis
        • Hepatic tumor, S4, s/p CH-EUS and FNB, suspect cholangiocarcinoma
        • Lymphadenopathy, hepatic hilum, s/p CH-EUS and FNB, suspect metaplastic lesion
        • Ascites
      • Suggestion
        • pursue pathological result
    • 2022-04-01 CT - abdomen
      • Three recurrent cholangiocarcinoma measuring 0.7 cm in S4, 0.9 cm in S8 and 1.2 cm in S3 of the liver are suspected. Please correlate with MRI.
      • Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, aortocaval space, and mesentery.
    • 2022-01-03 CT - abdomen
      • Liver tumor s/p operation with a biloma formation (3.5x7.9cm). A LN (1.5cm) at hepatic hilar region.
    • 2021-10-15 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • post partial right hepatectomy.
        • Calcified spot of liver, S4/7 area.
        • GB, pancreatic body and tail masked by gas.
        • Left hepatic lobe hypertrophy
        • Much colon gas.
      • Suggestion
        • semi-annual ultrasound follow up.
    • 2021-07-19 SONO - abdomen
      • Diagnosis
        • Liver cirrhosis
        • Status post S6/7 liver segmentectomy
        • Hepatic calcified spots
        • Fatty pancreas
      • Suggestion
        • keep follow up
    • 2021-04-30 CT - abdomen
      • History and Indication: FL + HCC + HBV , normal LFT
        • 20080128 CT: HCC in S6 S/P partial segmentectomy
        • 20200826 AFP and CEA: normal, MRI:HCC is highly suspected.
          • The differential diagnosis include cholangiocarcinoma and neuroendocrine carcinoma.
        • 2020/10/02 Liver, S6-7 resection: cholangiocarcinoma
          • pT1aNx; Stage IA at least
      • IMP:
        • S/P near total right hepatectomy. There is no evidence of tumor recurrence.
        • Biloma in right surgical margin shows decreasing in size to 4 x 2.2 cm.
    • 2021-02-25 Hearing Test
      • Tymp bil type A
      • ART bil WNL
      • PTA:
        • Reliability FAIR
        • Average RE 11 dB HL, LE 13 dB HL
        • bil normal to mild SNHL
      • SRT RE 10 dB HL, LE 10 dB HL
      • WDS RE 96 % at MCL, LE 96 % at MCL
    • 2021-02-03 SONO - abdomen
      • Diagnosis
        • Liver cirrohis
        • Propable post op related biloma, right lobe
        • C/w post liver segmentectomy
      • Suggestion
        • keep follow up
    • 2020-12-30 Patho - soft tissue
      • Labeled as “an erythematous nodules with heat and itching on left chest for 1 months -> suspected cutaneous metastasis of HCC or cholangiocarcinoma”, skin biopsy — marked perivascular lymphocytic inflammation.
      • IHC stains: CD3 and CD20: no predominant subpopulation. No metastatic carcinoma.
    • 2020-12-09 SONO - abdomen
      • Diagnosis
        • C/w post liver segmentectomy
        • Propable post op related bilioma,right lobe
        • Poor assessment of biliary tract and PV
        • Pancreas not shown
        • Suboptimal examination of liver due to poor echo window
      • Suggestion
        • OPD f/u
        • Please correlate with other image
        • Follow liver function test and AFP
        • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
    • 2020-11-09 CT - abdomen
      • Impression: Liver tumor s/p operation with a biloma formation (3.5x7.9cm). No evidence of tumor recurrence.
    • 2020-10-02 Patho - liver partial resection
      • PATHOLOGIC DIAGNOSIS:
        • Liver, S6-7, segmental hepatectomy — Intrahepatic cholangiocarcinoma
        • Pathologic Staging: pT1aNx; Stage IA at least
      • MICROSCOPIC EXAMINATION
        • Histologic Type: Intrahepatic cholangiocarcinoma
        • Histologic Grade: Poorly differentiated (G3)
        • Tumor Growth Pattern: Mass-forming
        • Tumor Necrosis: Present
        • Tumor Extension: Tumor confined to hepatic parenchyma
        • Large Vessel Invasion: Not identified
        • Small Vessel Invasion: Not identified
        • Perineural Invasion: Not identified
        • Pathologic Staging (pTNM): Stage IA at least (pT1aNx)
        • Margins
          • Parenchymal Margin: Free, 2.5 cm from closest margin
          • Hepatic Capsule: Involved by invasive carcinoma
        • Additional Pathologic Findings: None identified
        • Hepatitis (specify type): Hepatitis B
        • Ishak Modified HAI Grading: Score=2 (interphase hepatitis=0/4, confluent necrosis=0/6, focal necrosis=0/4, portal inflammation=2/4) (Corresponding Metavir A1, mild activity)
        • Ishak Staging: F2 (Corresponding Metavir F2, periportal fibrosis)
        • Fatty Change: Present (<5%)
        • IHC: Hepa-1(-), Arginase-1(-), CK7(+), CK19(+), CD56(-)
    • 2020-09-21 Visceral Angiography 2 vessels
      • DSA of celiac trunk and common hepatic artery with post-angiography CTAP study via right common femoral artery puncture revealed:
        • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
        • Liver cirrhosis.
        • Patency of portal vein.
        • A hypervascular tumor at right hepatic lobe. A marginal enhancing nodule at S4 of liver r/o hemangioma. Some vascular blushes at right hepatic lobe r/o vascular shunting.
        • Post-angiography CTAP images also revealed a perfusion defect (5.9cm) at right hepatic lobe.
        • No procedure-related complication during the whole procedure.
      • IMP: Right liver tumor (5.9cm), HCC is first considered. Left liver hemangioma (1.1cm).
    • 2020-09-21 SONO - abdomen
      • Diagnosis
        • Liver tumor, nature?
        • Parenchymal liver disease
        • HCC s/p S5 resection
      • Suggestion
        • Please follow sonography in 3-6 mon
        • Please check tumor, hepatitis markers and LFTs q3-6 mon
    • 2020-08-26 MRI - abdomen
      • History and Indication: FL + HCC + HBV , normal LFT and AFP
        • BWL 8 kg in 6 mon after exercise
        • 20080128 CT: HCCs in S6 S/P partial segmentectomy
        • 20200826 AFP and CEA: normal
      • Findings:
        • There is a well-defined, mild heterogeneous mass 4.8 x 3.5 cm in S7 of the liver. The main tumor shows hypointensity on T1WI, moderate hyperintensity on T2WI, and marked hyperintensity on DWI. During dynamic study, this tumor shows contrast enhancement in arterial phase and contrast washout in portal and delayed phase images.
          • The central area shows even higher intensity than the peripheral main tumor on T2WI and contrast enhancement in delayed phase images.
          • HCC is highly suspected.
          • The differential diagnosis include cholangiocarcinoma and neuroendocrine carcinoma.
        • S/P partial resection of S6 liver.
        • There are one enlarged node in hepatoduodenal ligament measuring 3 x 1.3 cm and several enlarged nodes in celiac trunk area, showing bright on DWI that may be metastatic nodes.
          • The differential diagnosis include benign reactive nodes.
    • 2020-07-28 Hearing Test
      • Reliabilty Fair
      • PTA
        • R’t: 13 dB HL
        • L’t: 11 dB HL
      • Bil WNL except L’t 8k Hz
      • Tymp
        • Bil Type A
      • ART
        • Bil WNL.
  • surgical operation
    • 2020-09-30
      • Surgery
        • S6-7 resection
        • laparoscope IOE
      • Finding
        • 5.5 x 5.0 x 5.0 cm well define tumor at S7
  • chemoimmunotherapy
    • 2022-11-22 - nivolumab 100mg 1hr + oxaliplatin 80mg/m2 140mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4370mg 46hr
    • 2022-11-02 - nivolumab 100mg 1hr + oxaliplatin 80mg/m2 140mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 725mg 2hr + fluorouracil 2400mg 4370mg 46hr
    • 2022-10-11 - nivolumab 100mg 1hr + oxaliplatin 80mg/m2 140mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4380mg 46hr
    • 2022-09-05 - nivolumab 100mg 1hr + oxaliplatin 80mg/m2 140mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4380mg 46hr
    • 2022-08-16 - nivolumab 100mg 1hr + oxaliplatin 70mg/m2 120mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4380mg 46hr # The chemotherapy Q2W shift to Q3W due to neutropenia.
    • 2022-07-27 - nivolumab 100mg 1hr + oxaliplatin 70mg/m2 120mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4360mg 46hr
    • 2022-07-08 - nivolumab 100mg 1hr + oxaliplatin 70mg/m2 120mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4360mg 46hr
    • 2022-06-13 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2200mg 3990mg 46hr
    • 2022-05-23 - fluorouracil 225mg/m2 400mg 24hr D1-3
    • 2022-05-16 - fluorouracil 225mg/m2 400mg 24hr D1-5
    • 2022-05-10 - fluorouracil 225mg/m2 400mg 24hr D1-3
    • 2022-05-04 - fluorouracil 225mg/m2 400mg 24hr D1-3

==========

2023-02-20

  • The recently prescribed drugs that were disclosed in the NHI PharmaCloud System have been appropriately prescribed during this hospital stay.
  • No medication reconciliation issues have been found in the patient.

2022-11-22

  • The HGB level was 7.7 g/dL on 2022-11-21, and a transfusion of LPRBC 2U is scheduled.

700545433

230220

{DLBCL}

[diagnosis] - 2022-07-31 discharge diagnosis

  • Diffuse large B-cell lymphoma, lymph nodes of multiple sites
  • Diffuse large B cell lymphoma, Non-germinal center type,multiple lymph nodes on both sides of the diaphragm as mentioned above and multiple focal areas in bilateral lung fields involvement,Lugano stage IV,IPI score:4,PS:2
  • Hypertension
  • Type 2 diabetes mellitus without complications
  • Hyperlipidemia

[lab data]

  • 2022-07-18 Amikacin <2.5 ug/mL
  • 2022-06-02 HCV RNA-PCR Target Not Detected IU/mL
  • 2022-06-01 EB VCA IgM Negative Ratio
  • 2022-06-01 EB VCA IgM Value 0.2
  • 2022-06-01 HBsAg Nonreactive
  • 2022-06-01 HBsAg (Value) 0.67 S/CO
  • 2022-06-01 Anti-HCV Reactive
  • 2022-06-01 Anti-HCV Value 2.98 S/CO
  • 2022-06-01 Anti-HBc Nonreactive
  • 2022-06-01 Anti-HBc-Value 0.18 S/CO
  • 2022-05-30 EB VCA IgG Positive Ratio
  • 2022-05-30 EB VCA IgG Value 7.2 Ratio
  • 2022-05-30 EBNA-IgG Positive Ratio
  • 2022-05-30 EBNA-IgG Value 2.5 Ratio
  • 2022-05-30 HSV 1 IgM Negative Ratio
  • 2022-05-30 HSV 1 IgM Value 0.18 Ratio
  • 2022-05-30 HSV 2 IgM Negative Ratio
  • 2022-05-30 HSV 2 IgM Value 0.04 Ratio
  • 2022-05-27 MTBC PCR NOT DETECTED
  • 2022-05-27 MTBC PCR Value <131 CFU/ml
  • 2022-05-26 CMV IgM Nonreactive
  • 2022-05-26 CMV IgM Value 0.21 Index
  • 2022-05-26 CMV_IgG Reactive
  • 2022-05-26 CMV_IgG Value 1701.6 AU/mL
  • 2022-05-26 HIV Ab-EIA Nonreactive
  • 2022-05-26 Anti-HIV Value 0.04 S/CO

[exam findings]

  • 2023-02-15 Whole body PET scan
    • There was increased FDG uptake in soft tissue in the upper and middle abdomen (SUVmax early: 18.32, delay: 27.37), and in the right lobe of the liver (SUVmax early: 17.88, delay: 26.98). In addition, increased FDG accumulation was also noted in bilateral kidneys and colon.
    • IMPRESSION:
      • The old lesions of glucose-hypermetabolism in bilateral neck and supraclavicular lymph nodes, bilateral axillary lymph nodes, mediastinal lymph nodes, pelvic lymph nodes, bilateral inguinal lymph nodes, and in multiple focal areas in bilateral lung fields disappear or come to very faint compared with the previous study on 2022-06-02.
      • However, old lesions of glucose-hypermetabolism in the upper and middle abdomen (Deauville score 5) become more evident, and there are several new lesions of glucose-hypermetabolism in the right lobe of the liver (Deauville score 5) in this study.
      • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
      • Diffuse large B-cell lymphoma s/p treatment with dissociated response to current therapy, by this F-18 FDG PET scan.
  • 2023-02-13 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a hot area in the sternum, and increased activity in the maxilla, mandible, some C-, T- and L-spine, sacrum, bilateral shoulders, S-I joints, hips, and knees, in whole body survey.
    • IMPRESSION:
      • A hot spot in the sternum and increased activity in the maxilla, the nature is to be determined (post-traumatic change, lymphoma or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in the mandible, some C-, T- and L-spine, sacrum, bilateral shoulders, S-I joints, hips, and knees.
  • 2023-02-10 Patho - liver biopsy needle/wedge
    • liver, CT-guided biopsy — Diffuse large B-cell lymphoma
    • The sections show a picture of diffuse large B-cell lymphoma with following features:
      • Specimen: Liver
      • Procedure: CT-guided biopsy
      • Tumor site: Liver
      • Histologic type: Diffuse large B-cell lymphoma
      • IHC: CD3(-), CD20(+), CK(-), and CD56(-)
  • 2023-02-01 CT - abdomen
    • History and indication: abdominal pain
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A poor enhancing lesion (4.0cm) in pancreatic body with SMA, splenic artery and splenic vein invasion. Some LNs at mesentery. A poor enhancing tumor (4.0cm) at right hepatic lobe.
      • Wall thickening of rectum.
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • A poor enhancing lesion (4.0cm) in pancreatic body with SMA, splenic artery and splenic vein invasion suspected malignancy. Liver and LNs metastases.
      • Wall thickening of rectum. Suggest coloscopy study.
  • 2023-01-30 KUB
    • Spondylosis of the L-spine is noted.
  • 2023-01-28 KUB
    • Calcified dot(s) is found at right paravertebral region, ureter stone(s) is most likely.
    • Stool impaction at the abdominal cavity is noted.
    • Phlebolith at pelvic cavity is also found.
  • 2023-01-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (39 - 13) / 39 = 66.67%
      • M-mode (Teichholz) = 66.7
    • Dilated aortic root
    • Concentric LV hypertrophy
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • AV sclerosis with mild AR, mild MR, TR and PR
    • No regional wall motion abnormalities
  • 2023-01-26 ECG
    • Normal sinus rhythm
    • Septal infarct, age undetermined
    • Abnormal ECG
  • 2023-01-26 KUB
    • Compression fracture of L2.
    • Stool retention in the bowel.
    • Atherosclerosis of the aorta.
  • 2023-01-18 KUB + AP & lat. LS-spine
    • Mild compression fracture of L1 vertebral body
    • Atherosclerosis of abdominal aorta and bilateral common and external iliac arteries.
  • 2023-01-02 CT - chest
    • Indication: malignant lymphoma in both sides of diaphram with lung involvement suspected LUL cancer with lung to lung metastases and distant lymph nodes metastases or double cancer lymphoma and LLL cancer with lung to lung metastases
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Comparison was made with previous CT dated on 2022/09/04
      • Lungs: stationary of reticular opacities at Lt lung and a small noodule at RUL-S2 compared with CT on 2022/09/04.
        • mild paraspinal fibrosis of RLL, stable.
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels:
        • mild calcified plaques of the LAD coronary artery.
        • Aorta: normal caliber, moderate atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers. minimal calcified aortic valves.
      • Pleura:no effusion.
      • Chest wall and visible lower neck: no enlarged lymphadenopathy.
      • Visible abdominal contents:
        • stationary residual of lymphadenopathy in mesentery root compared with CT on 2022/09/14.
        • normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
        • no bowel wall thickening in visible colonic segments and small bowel.
    • Impression:
      • post treatment change in lung and a a RUL 3mm nodule, and minimal residual small LNs at mesentery rootm as compared with CT on 2022/09/14
  • 2022-10-03, -07-14 CXR
    • Few nodular opacity projecting in both lung show mild resolving?
    • Spondylosis of the T-spine
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
  • 2022-09-14 CT - chest
    • near complete resolution of an irregular soft-tissue mass at LLL and multiple nodules in both lungs and significant regression of lymphadenopathy in both sides of diaphgram as compared with CT on 2022/05/30
  • 2022-07-29 ECG
    • Normal sinus rhythm
    • Septal infarct, age undetermined
    • Abnormal ECG
  • 2022-07-12 KUB
    • Radiopaque spot(s) at right renal region suspected renal stone(s).
    • Radiopaque density in left paraspinal portion suspected U/3 ureter stone.
    • Degeneration and spondylosis of L-S spine.
  • 2022-07-11 CT - brain
    • Brain atrophy.
  • 2022-06-30 ECG
    • Normal sinus rhythm
    • Anteroseptal infarct, age undetermined
    • T wave abnormality, consider lateral ischemia
  • 2022-06-28 CXR
    • Few nodular opacity projecting in both lung show mild resolving?
    • Spondylosis of the T-spine
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2022-06-02 Patho - lung wedge biopsy
    • Lung, side?, CT-guide biopsy —- diffuse large B cell lymphoma
    • Sections show alveolar lung tissue with infiltration of large pleomorphic tumor cells.
    • The immunohistochemical stains reveal CK(-), CD3(-), and CD20(+). The Ki-67 is about > 90%. The results are supportive for diffuse large B cell lymphoma.
  • 2022-06-02 Whole body PET scan
    • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm as mentioned above.
    • Prominently increased FDG uptake in multiple focal areas in bilateral lung fields. Lymphoma should be considered first.
    • Mildly to moderately increased FDG uptake in two focal areas in the region about left lobe of the thyroid gland. The nature is to be determined (some kind of benign or malignant thyroid lesion? lymphoma?). Please correlate with other clinical findings for further evaluation.
  • 2022-06-01 2D transthoracic echocardiography
    • Concentric LV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Aortic valve sclerosis.
    • Dilated aortic root and proximal ascending aorta (35 mm).
    • Prominent epicardial and pericardial fat.
  • 2022-05-30 CT - lung/mediastinum/pleura
    • malignant lymphoma in both sides of diaphram with lung involvement suspected LUL cancer with lung to lung metastases and
    • distant lymph nodes metastases or double cancer lymphoma and LLL cancer with lung to lung metastases, suggest tissue sampling.
  • 2022-05-30 SONO - abdomen
    • mild to moderate fatty liver (suboptimal exam of liver)
    • fatty infiltration of pancreas
  • 2022-05-27 Patho - lymph node region resection
    • Labeled as “Right level Ib lymph nodes”, excision biopsy — diffuse large B cell lymphoma. Non-germinal center type.
    • IHC stains: CD3 (focal +), CD20 (diffuse +), bcl-2 (diffuse +), bcl-6 (+, > 30%), MUM-1 (+, 90%), CD15 (+), CD30 (-), CD10 (-), c-myc: (+, <10%), Ki-67: 90%.
  • 2022-05-25 CXR
    • Multiple nodular opacities over both lungs. Suggest check CT scan to rule out metastases.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2022-05-16 Patho - lymphnode biopsy
    • Lymph nodes, L’t neck level V, excisional biopsy — Extensive coagulative necrosis with atypical B-cell proliferation
    • The large lymph node shows extensive, ring-like coagulative necrosis, 70-80% (unlikely geographic necrosis) with some nuclear debris, ghost cells, histiocytes and a few neutrophils as well as medium or large-size atypical lymphocytes in central, non-necrotic area. No granuloma is found. Immunohistochemistry of CK(-), CD3(+, scatter), CD20 (+) at subcapsular area and (-) at central area, CD68(+, scatter) and CD30(-). The three small lymph nodes show reactive change due to normal distribution of B and T-cell. The histopathologic finding and IHC stains is inconsistent with Kikuchi lymphadenitis, but infectious lymphadenitis or malignant lymphoma can not be excluded entirely due to suboptimal specimen with extensive necrosis. However, serology analysis (EBV or others) and repeat lymph node excision is advised for further evaluation. Closely follow up.
  • 2019-09-16 Knee Bilat. standing
    • Osteoarthritis change of both knees with joint space narrowing and marginal spur formation, more severe on right side. Osteopenia of visible bones.
  • 2019-01-26 CT - abdomen
    • Focal ileus of small and large bowel.
    • Wall thickening of gastric antrum. Distention of stomach.
  • 2019-01-24 SONO color transcranial, carotid phonoangiograph, CPA
    • Minimal atherosclerosis in bilateral CCA bifurcations.
    • Adequate total VA flow volume (107 ml/min).
    • Poor bilateral temporal windows for transcranial insonation.
    • Increased RI in bilateral VA, indicating distal stenosis.
    • Increased PI in right VA, indicating distal stenosis.

[consultation]

  • 2023-02-15 Psychosomatic Medicine
    • Q
      • The 77 y/o female patient with history of DM, HTN, hyperlipidemia. Under the diagnosis of Diffuse large B cell lymphoma, Non-germinal center type, multiple lymph nodes on both sides of the diaphragm as mentioned above and multiple focal areas in bilateral lung fields involvement, Lugano stage IV, IPI score:4, PS:2.
      • She received the C1 chemotherapy R-COP on 2022/06/08. C2 R-CHOP (Epirubicin 80mg/m2) on 2022/06/29-30. C3 R-CHOP (Epirubicin 80mg/m2) on 2022/07/29-30. C4 R-CHOP (Epirubicin 80mg/m2) on 2022/08/18-19. C5 R-CHOP (Epirubicin 80mg/m2) on 2022/9/11-12. C6 R-CHOP (Epirubicin 80mg/m2) on 2022/10/3-4.
      • The patient reported feeling very down lately, with physical discomfort and a lack of energy throughout the body. It has consulted with a psycho-oncologist who suggested a referral.
    • A
      • Psychiatric impression:
        • Acute depressive state
        • r/o adjustment recation with depressive features
        • r/o persistent depressive disorder, current major depressive episode
      • Symptoms and course:
        • This is a 77 y/o female patient admitted under the diagnosis of: Diffuse large B cell lymphoma, Non-germinal center type. We were consulted for her recent depressed mood.
        • According to the patient herself and the care-giver, since she was diagnosed of the disease about 1+ year ago, she had frequently visited the hospital with multiple treatment courses, that she developed depressed mood, preoccupied over her unfortunate, negative thinking, hopeless feelings. She claimed transient suicide ideation but not prominent without plan or attempt. When she was at home, she would try to relax herself and her mood would improve.
        • However, this admission, she suffered from greater pain, that she got more dysphoric with poor appetite, and also occaisonal sleep disturbance at night, sleepiness in the daytime.
      • Suggestion:
        • Suicide risk assessment: low to moderate: denied current ideation, without plan or attempt, care-giver(+), chronic disease
        • Provide psychoeducation for suicide prevention, and emotion catharsis, the patient and care-giver could understand
        • Brintellix (vortioxetine 10mg) 1# HS for the depressed mood
        • Arrange PSY OPD f/u
  • 2022-07-14 Infectious Disease
    • Q
      • The 77 y/o woman has diffuse large B cell lymphoma stage IV, who was admitted for neutropenic fever. Due to B/C yield Staphylococcus haemolyticus, so we need your help for antibiotic assessment. (20220714 WBC 14000/uL under GCSF 300 mcg treatment) Thanks!
    • A
      • Assessment:
        • Neuropenic fever with S. haemolyticus bacteremia
        • UTI
      • Suggestion:
        • Recommend antibiotic Rx with Targocid or Vancomycin + Amikin 500mg iv Qd
        • Check B/C from Port-A, if positive, may arrange echocardiography to rule out Infective Endocarditis (IE)
        • Monitor CRP
  • 2022-06-02 Radiation Oncology
    • Q
      • The 76 y/o female, she has right neck mass post biopsy and report showed diffuse large B cell lymphoma. Due to lung suspect a tumor, so we need your help for biopsy. Thanks!
    • A
      • This is a case of lung masses, suspected lung cancer or lymphoma. CT-guided biopsy is indicated. Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.
  • 2022-06-01 Gastroenterology
    • Q
      • The 76 y/o female, she has right neck mass post biopsy and report showed diffuse large B cell lymphoma. Due to postive of HCV, so we need your help. Thank you.
    • A
      • O
        • ALT 82
        • bil(t) 0.23
        • HbsAg(-)
        • anti-HbcAb(-)
        • anti-hcv ab(+)
        • abdominal echo: mild to moderate fatty liver(suboptimal exam of liver), fatty infiltration of pancreas
        • CT: normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
      • P
        • Check HCV viral load
          • If HCV RNA is detected, check HCV genotyping, and then discuss about treatment of direct antiviral agent.
        • Regular/close monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALP
        • Well explained to the patient low incidnece of HCV reactivation during or after chemotherapy according to previous reports
        • GI OPD f/u for treatment
  • 2022-06-01 Hemato-Oncology
    • Q
      • for diffuse large B cell lymphoma
      • This is a 76 y/o female patient with history of DM, HTN, hyperlipidemia. This time, she came to our hospital due to right neck mass noted for 3 months. Other painful LNs were also noted at R’t level V , L’t level V and Bil. axillary, R’t inguinal region. Neck CT was done and revealed a nodular lesion (28mm) and another small one over right submandibular region, favor enlarged nodes. Also, due to lab data when admission showed elevated WBC and CRP, infection doctor was consulted, and antibiotic with ceftriaxone and Amikacin were suggested. Blood culture was also done and grew K.p. Abd. sono was done, and there’s no liver abscess noted.
      • She received right level Ib lymph nodes excision on 20220526, and the pathology showed diffuse large B cell lymphoma. She also received lung CT due to bil. lung nodules noted by CXR. Chest CT revealed an irregular soft-tissue mass (40 mm) at LLL, multiple nodules of variable sizes throughout both lungs, extensive lymphadenopathy in para-aortic region and mesentery root. Malignant lymphoma in both sides of diaphram with lung involvement or LUL cancer with lung to lung metastases and distant lymph nodes metastases or double cancer lymphoma and LLL cancer with lung to lung metastases were impressed. Therefore, we need your expertise for further evaluation and management.
    • A
      • Impression:
        • Diffuse large B cell lymphoma, non-germinal center type, triple hit, IPI score:3 (age, stage, extranodal)
        • Suspected LLL cancer with lung to lung metastases
      • Suggestion:
        • Arrange LLL lung CT guide biopsy for suspected lung cancer with lung to lung meta
        • Arrange PET scan for lymphoma work up, bone marrow is indicated
        • Check CEA, SCC, HbsAg, Anti Hbc, Anti HCV
        • Arrange Port A insertion
        • Arrange 2D heart echo
  • 2022-05-26 Infectious Disease
    • Q
      • According to the blood culture on 20220525 revealed GNB. General infection can not be rule out. We request your consultation for further management.
    • A
      • A patient of DM, HTN, hyperlipidemia. High fever developed and GNB sepsis was noted. In series of patients with immune-deficient fever, infection has been identified as the cause of the fever in 60% or more of cases. In at least some cases, however, the diagnosis has been presumptive, based on a favorable clinical response to antimircobial therapy, rather than on the result of definitive tests. Infection caused by pyogenic bacteria are the most common cause of fever. The generally respond well to antibiotic therapy, whether or not the etiologic microorganism is isolated. Anti-microbiologic coverage with parenteral Rocephin 2.0 gm qd or Fortum 1.0 gm q8h +- plus AMK 500 mg qd is recommended. The antimicrobial regimen can be modified once the results of the culture and susceptibility tests are available.

[chemoimmunotherapy]

  • 2022-08-18 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + epirubicin 80mg/m2 130mg 10min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 6tab BID D2-6 (R-CHOP)
  • 2022-07-29 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + epirubicin 80mg/m2 130mg 10min D2 + prednisolone 60mg/m2 5mg/tab 6tab BID D2-6 (R-CHOP, vincristine not available then)
  • 2022-06-29 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + epirubicin 80mg/m2 130mg 10min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 6tab BID D2-6 (R-CHOP)
  • 2022-06-08 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 6tab BID D2-6 (R-COP)

701182757

230220

[exam findings]

  • 2023-02-17 SONO - chest
    • left lower lung consolidation
    • left side pleural thickening with trivial amount of pleural effusion, no thoracentesis wad done due to high risk
  • 2023-02-09, -02-02 KUB
    • Scoliosis of L-spine with convex to left side.
    • Fecal material store in the colon.
    • Calcified uterine fibroid in rihgt middle pelvis.
    • Ascites is highly suspected. Please correlate with sonography.
  • 2023-02-02 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Scoliosis of the T-spine with convex to right side.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Linear and nodular opacities on right lung are noted. please correlate with clinical condition or CT.
  • 2023-01-04 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • S/p port-A placement with its tip at Superior vena cava.
    • Right pleural effusion is found.
  • 2022-12-26 Lower leg RT
    • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography.
  • 2022-12-26 L-spine AP+Lat. (including sacrum)
    • S/P nasogastric tube insertion
    • scoliosis of L-spine with convex to left side
    • Ueterine fibroid is noted.
  • 2022-12-26, -12-22, -12-15, -12-12, -12-08, -12-06, -12-05, -12-03 CXR
    • S/P nasogastric tube insertion
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
    • Linear infiltration on both lung are noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2022-11-29 CT - abdomen
    • Clinical history: 75 y/o female patient with follicular lymphoma.
    • With and without contrast enhancement CT of abdomen - whole:
      • Diffuse multiple enlarged lymph nodes in the mediastinum, bilateral neck, right axillar regions, paraaortic regions and mesentery, progression
      • Paraspinal and prevertebral soft tissue with necrosis (T9-12 levels), could be due to lymphoma post treatment.
      • Focal soft tissue in right abdominal wall.
      • There are uterine tumors, some with dense calcifications, suspected uterine myomas.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • Diffuse right pleural thickening.
    • Impression:
      • Diffuse right pleural thickening.
      • Diffuse lymphoma (from neck to chest and adomen) with progression.
      • Uterine tumors some with calcifications, suspected myomas.
  • 2022-11-29 SONO - chest
    • Right thorax: partial lung consolidation was noted; no pleural effusion
    • Left thorax: no pleural effusion.
  • 2022-11-28 CXR
    • S/P nasogastric tube insertion
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Linear infiltration over right lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, Please correlate with CT.
  • 2022-11-08 SONO - chest
    • Right thorax: minimal amount pleural effusion; thoracocentesis was not performed.
  • 2022-11-07 CXR
    • S/P nasogastric tube insertion or S/P ventricular-peritoneal shunt insertion ?
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • There is scoliosis of the T-spine with convex to right side.
    • Right pleura effusion.
  • 2022-11-04 Peripheral Vascular Test - vein, lower limbs
    • Clinical diagnosis: edema
    • Doppler study: (N = Normal, A = Abnormal, T = Thrombus)
      • Lower limbs R_CFV R_SFV R_PV R_PTV R_SV L_CFV L_SFV L_PV L_PTV L_SV
      • Spontaneous signal N N N N N T T A T T
      • Respiratory changes N N N N N T T A T T
      • Cough response N N N N N T T A T T
      • Compression study N N N N N T T N N N
    • Report:
      • Right side:
        • SVC: 13.7 mmHg ; 15.1 mmHg ;
        • MVO/SVC: 100 % ; 99 % ;
        • Average MVO/SVC: 99 %
      • Left side:
        • SVC: 2.4 mmHg ; 4.5 mmHg ;
        • MVO/SVC: 100 % ; 98 % ;
        • Average MVO/SVC: 99 %
      • Thrombus at L’t CFV, SFV, PV, LSV
      • Varicose vein : None
    • Conclusion:
      • C/W acute to subacute DVT involved the left CFV, PFV, proximal SFV and proximal LSV with partial recanalization. The left middle to distal SFV, left popliteal vein and left PTV were patent with loss of respiratory change and cough response due to upstream outflow venous obstruction.
      • There was no evidence of DVT detected at right leg deep venous system.
      • The right saphenofemoral venous junction (LSV) and bilateral saphenopopliteal venous junction (SSV) were competent without venous reflux.
      • The measured MVO/SVC ratio at right leg was 99%, indicated no venous stenosis or obctruction at right iliofemoral venous system.
      • Although the measured MVO/SVC ratio at left leg was 99%, the SVC at left leg was very low, compatible with outflow venous obstruction.
  • 2022-11-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (53 - 9) / 53 = 83.02%
      • M-mode (Teichholz) = 83
    • Septal and RV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis.
    • Mild aortic root calcification with sessile atheromas.
    • Prominent epicardial fat.
  • 2022-11-02 CTA - chest
    • Indication: suspected Pulmonary embolism
    • Findings
      • Chest:
        • Pulmonary embolism at both sides of the main pulmonary artery and its branches more on right side is found.
        • Right pleural effusion is found.
        • Calcified coronary arteries is found.
        • Right pleural thickening is found and consolidation over right lower lobe is found.
        • Lymphadenopathy at right paratracheal region is found.
        • S/p port-A placement with its tip at Superior vena cava.
      • Visible abdomen:
        • The GB is well distended without soft tissue lesion
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
    • Imp: Pulmonary embolism at both sides of the pulmonary artery.
  • 2022-11-02 SONO - chest
    • pleural effusion, minimal, right
    • consolidation, RLL
  • 2022-10-31 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Abnormal QRS-T angle, consider primary T wave abnormality
  • 2022-10-31 CXR
    • Consolidation in right lung
    • Right pleural fluid
  • 2022-10-17 MRI - brain
    • Indication: consciousness disturbance suspected brain mets
    • Findings
      • Generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
      • The interhemispheric fissure is centered on the midline.
      • Sella and pituitary are normal. The parasellar structures are unremarkable.
      • There are no abnormalities in the cerebellopontine angle areas on both sides.
      • There are no abnormalities in the calvarium.
      • A left temporal base tumor mass up to 15 mm, DDx: meningioma or lymphoma?
      • Well and heterogenous enhancement after contrast administration was noted of this tumor mass.
    • Imp:
      • Brain atrophy.
      • A left temporal base tumor mass, DDx: meningioma or lymphoma?
  • 2022-10-14 CT - abdomen
    • History and indication:
      • 20190604 PET: Lymphoma in right paraspinal retroperitoneal space
      • 20190613 CT; Soft tissue tumors (up to 4.6x10.6cm) at spleen, right paraspinal region and retroperitoneum. follicular lymphoma s/p C/T & R/T.
    • FINDINGS - Comparison: prior chest CT dated 2022/09/27.
      • Prior CT identified diffuse and marked thickening of Rt parietal and visceral pleura (involving hemidiaphgram) is noted again, mild increasing in size.
        • In addition, prior CT identified enlarged LNs in the paratracheal space and subcarinal space are noted again, increasing in size that is c/w progressive disease.
      • Prior CT identified left middle paraspinal soft-tissue mass around the descending thoracic aorta and thickening of Rt pericardium is noted again, stationary.
      • Prior CT identified lobulated enhancing soft tissue tumors in right paraspinal area (right lower medial pleura space and right erector spinal muscle) are noted again, stationary.
      • Uterine tumors with some calcifications (up to 3.8cm) suspected myomas and fibroids.
      • Small renal cysts (up to 5mm).
      • Atherosclerosis of the aorta and coronary arteries.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, and pancreas.
        • There is no ascites.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion in the mesentery and omentum.
    • IMP:
      • Prior CT identified diffuse and marked thickening of Rt parietal and visceral pleura (involving hemidiaphgram) is noted again, mild increasing in size.
        • In addition, prior CT identified enlarged LNs in the paratracheal space and subcarinal space are noted again, increasing in size that is c/w progressive disease.
      • Prior CT identified lobulated enhancing soft tissue tumors in right paraspinal area (right lower medial pleura space and right erector spinal muscle) are noted again, stationary.
  • 2022-10-03 Patho - pleural/pericardial biopsy
    • Pleura, right, decortication — high grade B-cell lymphoma (please see microdescription)
    • Specimen submitted in formalin consists of multiple tissue fragments measuring up to 7.5 x 3.2 x 0.2 cm. Representative sections are taken and labeled as A1-3.
    • Sections show fibroadipose tissue with diffuse infiltration of intermediate to large size lymphoid cells.
    • The immunohistochemical stains reveal CD3(-), CD20(+), BCL2(+), BCL6(+), CD10(+), cMYC(+), and MUM1(-). The Ki-67 is about 70%. The results are in favor of Grade 3B follicular lymphoma or GCB type diffuse large B-cell lymphoma.
  • 2022-09-28 Cell block
    • Right pleural effusion: Suggestive of lymphoma involvement
    • 7 cc red cloudy pleural effusion
    • The smears and cell block show small to intermediate size of lymphocytes with cleaved nucleus and nucleoli. According to clinical information and cytomorphologic findings, it is suggestive of follicular lymphoma involvement.
  • 2022-09-27 CT - chest
    • Indication: Recurrent follicular lymphoma with right lung pleural effusion
    • Findings - Comparison was made with previous CT dated on 2022/09/20
      • diffuse and marked thickening of Rt parietal and visceral pleura (nvolving hemidiaphgram) with residual loculated effusion s/p pigtail drain placement (its pigtail segment is within lung parenchyma).
      • lungs compressive Rt lung volume loss (especially RML and RLL).
        • a subpleural lobular consolidation at S6 and minimal ground-glass opacities at basal segments of LLL.
      • Mediastinum and hila: enlarged LNs the visceral space especially subcarinal space and left middle paraspinal soft-tissue mass around the descending thoracic aorta.
        • small pericardial effusion and thickening of Rt pericardium.
      • Vessels:
        • extensive calcified plaques of the LAD and LCX coronary arteries.
        • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
        • Heart: normal in size of cardiac chambers.
      • Visible abdominal-pelvic contents: .
        • several small bilateral renal cysts.
        • unremarkable of the liver, spleen, both adrenal glands, pancreas, and no enlarged lymph node. .
        • Extensive atherosclerotic change of the abdominal aorta.
    • Impression:
      • recurrent follicular lymphoma with pleural, lung, hemidiaphgram, and descending aortic involvment, and mediastinal LAP.
      • regression of Rt pleural effusion with loculations, and malposition of pigtail drain.
  • 2022-09-26 Cell block
    • Suggestive of lymphoma involvement
    • 12 cc red cloudy right pleural effusion
    • The smears and cell block show mainly B lymphocytes with small to intermediate size of atypical lymphocytes with cleaved nucleus and nucleoli.
    • Immunocytochemistry shows CD20(+), CD3(-), Bcl-2(+), Bcl-6(+, focal) and CD10(+, focal) for lymphocytes. According to clinical information and cytomorphologic findings, it is suggestive of follicular lymphoma involvement.
  • 2022-09-20 CT - abdomen
    • Clinical history: 75y/o female patient with Recurrent follicular lymphoma at para-spinal region, Lugano stage II. Owing to poor appetite suspected peritonal seeding related.
    • Findings
      • Diffuse lobulated tumors in the pleura and pleural effusion with collapsed right lung, progression as compare with CT study on 2022-07-22.
      • R/O bilateral renal cysts, <1cm.
      • Unremarkable change of the liver, spleen, pancreas.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
      • There are uterine tumors, some with dense calcifications, up to 4cm, suspected uterine myomas.
    • Impression:
      • Progression of right plueral tumors and pleural effusion, right lung collapse, could be due to recurrent lymphoma with progression.
      • Uterine tumors, suspected uterine myomas.
  • 2022-09-16 MRI - T-spine
    • Indication: recurrent follicular lymphoma with low back pain
    • Findings
      • Abnormal enhancement in T10 and T11 vertebral body (esp T10), para-aoritc soft tissue lesions, right paraspinal soft tissue lesion at T9-12 levels, left paraspinal soft tissue lesionat T6-7 levels, and intraspinal lesion causing spinal cord compression at T7-10 levels (most severe at T10), indicating metastases.
      • Right massive pleural effusion.
      • End-plate degeneraiton, disc collapse with general bulging, posterolaterla osteophytes and enlarged facets causing diffuse spinal canal stenosis and neuroforaminal narrowing at at C2-3-4-5-6-7-T1.
      • No intramedullary lesion.
    • IMP: Bony metastases at T10 and T11 vertebral body and bilateral paraspinal metastases (left T6-7 and left T9-12) with intraspinal invasion and cord compression (T7-10).
  • 2022-09-16 CXR
    • Atherosclerotic change of aortic arch
    • There is scoliosis of the T-spine with convex to right side.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-09-13 Abdomen, standing (diaphragm)
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Scoliosis of L-spine with convex to left side
    • Fecal material store in the colon.
  • 2022-08-16 Whole body PET scan
    • Glucose hypermetabolism involving the upper abdominal right paraaortic area, pleura of right lower lung field, right paraspinal area and adjacent T10 spine. Recurrent lymphoma may show this picture.
    • A glucose hypermetabolic lesion in the wall of the descending aorta. The nature is to be determined (lymphoma? inflammatory process?). Please correlate with other clinical findings for further evaluation.
  • 2022-08-02 Patho - omentum biopsy
    • Pathologic diagnosis
      • Para-spinal tumor, CT-guided biopsy — Follicular lymphoma, compatible with recurrence
    • Macroscopic description
      • Operation procedure: CT-guided biopsy
      • Topology: Para-spinal tumor
      • Specimen size and number: one strip of tumor tissue measured 0.5 x 0.1 x 0.1 cm in size
    • Microscopic description
      • Histology type: follicular lymphoma
      • Histology description: B-cell lymphoma characterized by proliferative small lymphoid cells.
      • Immunohistochemistry shows CK(-), CD3(-), CD20(+), Bcl-2(+), CD10(+), Bcl-6(+), CD23(+) and Cyclin-D1(-) for tumor. According to all histopathologic findings and past history, it is compatible with recurrent follicular lymphoma.
  • 2022-07-22 CT - abdomen
    • Prior CT identified lobulated enhancing soft tissue tumors in right paraspinal area (right lower medial pleura space and right erector spinal muscle) are noted again, mild increasing in size.
  • 2022-01-24 CT - abdomen
    • History and indication: Follicular lymphoma grade I, lymph nodes of head, face, and neck
    • Impression:
      • Stationary condition of spleen lesions.
      • Total regression of retroperitoneal tumors.
      • Mild progression of right paraspinal lesions.
  • 2021-08-09 CT - abdomen
    • Stationary condition of spleen lesions.
    • Total regression of right paraspinal and retroperitoneal tumors.
  • 2021-02-19 CT - abdomen
    • Follicular lymphoma of right paraspinal area and retroperitoneal space s/p C/T & R/T show complete response.
    • Follicular lymphoma of the spleen s/p C/T & R/T show near complete response.
  • 2020-09-07 CT - abdomen
    • Much regression of spleen lesions.
    • Total regression of right paraspinal and retroperitoneal tumors.
  • 2020-03-03 CT - abdomen
    • Much regression of spleen, right paraspinal and retroperitoneal tumors.
  • 2019-12-31 CT - abdomen
    • Much regression of spleen, right paraspinal and retroperitoneal tumors.
  • 2019-12-12 MRI - C-spine
    • Indication:
      • 72 y/o, a pt of follicular lymphoma stage II Dx in May 2019 at TaiAn Hospital, s/p definitive C/T wt R-COP or R-CHOP IV Q3W x 6 finishing in Oct 2019 and R/T (15 frac) to paraspinal tumor bed from 20191113 to 20191203 by Dr JingMin Huang.
      • 20191203: right distal hand numbness for yrs with recent deterioration; neckpain also noted; clumsiness over rigth UE with weakness / eaasily lost holding things; no night pain
    • IMP:
      • Cervical spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, esp C7-T1 with right HIVD and compressive myelopathy.
  • 2019-09-04 Whole body PET scan
    • Glucose hypermetabolic lesions in the abdomen as mentioned above with extension to the right lower back region come to significantly less prominent compared with the previous study on 2019/06/04, indicating partial response to current therapy.
    • Mild and symmetric glucose hypermetabolism in bilateral pulmonary hilar regions, probably inflammatory process or physiological uptake of FDG.
  • 2019-06-13 CT - abdomen
    • Soft tissue tumors (up to 4.6x10.6cm) at spleen, right paraspinal region and retroperitoneum.
  • 2019-06-04 Whole body PET scan
    • Glucose hypermetabolic lesions in the abdomen as mentioned above with extension to the right lower back region, compatible with malignancy such as lymphoma. Please correlate with other clinical findings for further evaluation.
    • Mild and symmetric glucose hypermetabolism in bilateral pulmonary regions. Inflammatory process is more likely.

[consultation]

  • 2022-11-17 Rehabilitation
    • A
      • Assessment
        • Follicular lymphoma, stage II s/p chemotherapy
        • Pleural effusion in other conditions classified elsewhere
        • Shortness of breath
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation programs
        • Goal: recondition, improve endurance and muscle strength
  • 2022-11-04 Cardiology
    • Q
      • Consultation for management of pulmonary embolism.
      • This is a 75 year-old female patient with history of follicular lymphoma at para-spinal region, Lugano stage II, s/p definitive C/T wt R-COP or R-CHOP regimen finishing in Oct 2019 & R/T (15 fr) to paraspinal tumor bed completed in Dec 2019. This time, she was admitted due to dyspnea for 3 days. She appeared in general weakness and fatigue.
        • CXR done in ER : right-sided pleural effusion; however, chest echo showed only minimal fluid; therefore, tapping was not done.
        • PE : bilateral coarse breathing sound, swollen and cold left lower limb. SpO2 was able to be maintined by nasal cannula 3L for now.
        • Lab data : leukocytosis with neutrophilic predominance
        • WBC: 19.4 K
        • Neutrophil: 90%
        • D-dimer: >10000
        • NT-proBNP: 1896
        • Chest CTA was done on 20221102, which showed pulmonary embolim.
      • We have started 3 days of SC enoxaparin from 11/3, and have arranged lower limb Doppler sonography and cardiac echo. We need your expertise for this patient’s pulmonary embolism management.
    • A
      • This is a 75 year-old female patient with history of follicular lymphoma at para-spinal region, Lugano stage II,
      • This patient suffered from lobulated pleural effusion, s/p VATS decortication + close drainage. at 2022/09. According to this patient, she suffered rom dyspnea and also ntoed to have left lower limb swelling for 1~2 months. Currently, her left lower limb showed no obvious erythema or swelling or edema, however, the diameter was obvious larger than right side. She had history of cancer and also in semi-bedridden status.
        • Chest CT: right side pulmonary embolis, possible some small pulmonary embolism at left upper lobe branch, no RA dilatation
      • Impression:
        • compatible with pulmoanry embolism, beween submasive(trop-I) to low risk, suspected left chronic DVT related
      • Suggestion:
        • agree with Clexane Q12H use, ( BW 47kg, Creatine 1.10)
          • May transition to NOAC after 1 week of clexane injection
          • e.g. Apixaban 5mg 1# BID or Edoxaban 60mg 1# QD or Rivaroxaban 15mg 1# BID (EINSTEIN–PE study, higher dose and may go with higher bleeding risk in this patient)
        • Due to left lower limb swelling was noted, but clinical condition not favor acute DVT, may consider chronic DVT or may-thurner syndrome or retroperitoneal fibrosis
          • => please arrange lower limb echo (for DVT survey) and echocardiography (for pulmonary embolism PEPSI score)
        • This patinet had higher risk for recurrence (bed-ridden / cancer) and may consider long term NOAC use
          • If other cause was worry, may consider search for autoimmune and coagulation profile ( but might not change clinical decision)
          • => protein C/ protein S, anti-phospholipid antibody syndrome profile, C3,C4, lupus anticoagulant
  • 2022-10-18 Radiation Oncology
    • A
      • S: For radiotherapy due to high grade follicular lymphoma with brain metastasis.
        • PI: The patient suffered from change of personality during admission. Brain MRI (2022-10-17) showed a left temporal base tumor mass, suspicious meningioma or lymphoma? For radiotherapy.
      • A: Follicular lymphoma of the spleen, right paraspinal region and retroperitoneum, stage II, s/p chemotherapy, with partial response, s/p radiotherapy, with tumor progression including brain metastasis.
      • P: Radiotherapy is indicated for this patient with the following indicators: brain metastasis.
        • Goal: palliation
        • Treatment target and volume: brain
        • Technique: 2D and VMAT/IGRT
        • Preliminary planning dose: 1400cGy/7 fractions of the whole brain, and 3000cGy/15 fractions of the metastatic brain tumor.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy was already started at 1330, 2022-10-18.
  • 2022-10-06 Infectious Disease
    • Q
      • The 75 y/o woman has recurrent follicular lymphoma with right pleural effusion malignant. Due to rectal swab showed VRB, so we need your management.
    • A
      • Hx review as mentioned above and Lab data check
      • Suggestion:
        • May stop Targocid, shift to zyvox for this immunocompromised pt with increasing CRP
        • repeat B/C, monitor CRP
  • 2022-10-05 Psychosomatic medicine
    • Q
      • The 75 y/o woman has recurrent follicular lymphoma with right pleural effusion malignant. Due to several delirum with aggressive behavior, so we need your management. Thanks!
    • A
      • Psychiatric impression:
        • Acute agitated state
          • suspected adjustment reaction
          • suspected acute delirium
          • suspected dementia with BPSD
        • Depressive disorder
      • Symptoms and course:
        • This is a 75 y/o female patient with underlying lymphoma with right pleural effusion admitted for palliative C/T s/p 20220930 VATS decortication, and was just tranferred out from ICU at 20221005 afternoon. According to the patient, her family and side information collected:
        • Upon visit, she showed clear consciousness, alert, but very guarded and defensive attitude, irritable mood, angry, hostile attitude towards the medical team and her family. Speech were rather coherant and relevant, no obvious psychosis were noted currently.
        • Orientation:
      • Suggestion:
        • Anxicam 0.5amp IM/ Bini-U 0.5amp IM PRNQ6H if severe agitation
        • Add Utapine 1# HS, and give utapine 1# PRNHS if still irritable and sleep disturbance. Keep the xanax 1# BID for anxious mood.
        • Close monitor the vital signs, respiratory patterns after the PRN injection and medication, regularly follow up EKG
        • Further survey and treat her possible physical condition: infection, pain, urine retention…
        • Acute intervention, suicide risk assessment: moderate: denied past suicide idea or attempt; fair family support and accompany, but now in great distress and anger, impulsive
        • Suicide prevention is adviced.
  • 2022-09-29 Thoracic Surgery
    • Q
      • The 75 y/o woman has recurrent follicular lymphoma, least stage III. Due to right pleural effusion with loculations, so we need help for chest tube insertion assessment. Thanks!
    • A
      • I have visited the patient and reviwed the images. I will arrange right VATS decortication this week. Thanks for your consultation!!
  • 2022-09-17 Neurosurgery
    • Q
      • The 75 y/o woman has recurrent follicular lymphoma with bony metastases at T10 and T11 vertebral body and bilateral paraspinal metastases (left T6-7 and left T9-12) with intraspinal invasion and cord compression (T7-10). We need your help for surgycal intervention. Thanks!
    • A
      • suggest medication treatment for the recurrent follicular lymphoma with bony metastasis first.

[chemotherapy]

  • 2022-11-30 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + bendamustine 70mg/m2 100mg NS 250mL 90min D1-3
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + acetaminophen 500mg PO

==========

2023-02-20

[tube feeding]

  • Keppra: In this hospital, there is a liquid form of Keppra oral solution (levetiracetam 100mg/mL, 300mL per bottle) that is suitable for tube feeding.

  • OxyNorm: Pour the small granules out of the OxyNorm (oxycodone 5mg/cap) capsules, dissolve them in drinking water, and administer them through a tube feeding.

  • OxyContin: OxyContin (oxycodone 10mg controlled-release tablet) is a long-acting formulation. Grinding the tablet will destroy the controlled-release design and cannot maintain long-lasting effects. Its use is not recommended for tube feeding.

2022-10-06

[drug interaction]

  • Morphine (8mg IVD PRNQ6H currently) is contraindicated when used concurrently with monoamine oxidase inhibitors (MAOIs, linezolid 600mg IVD Q12H currently).

  • There is a possibility that monoamine oxidase inhibitors may enhance the adverse/toxic effects of morphine. Please monitor any possible adverse reactions carefully.

700936681

230216

{Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and Rt retropharyngeal LAP metastasis s/p concurrent chemoradiotherapy on 2012/9/17 s/p 2nd PF on 2012/11/30}

[past history]

  • Hepatitis B carrier
  • Acoustic neuroma
  • NPC
  • Liver metastasis s/p SBRT on 20180209
  • R/I recurrence of NPC by surgical excision at TuCheng ChangGung Hospital on 2022-01-21 by vice president Dr. Wei FuQuan.
    • Pathology: Brain, CP angle, Rt, carcinoma, metastatic.
    • Positive: AE1/AE3, EMA, p40; negative EBV, Hep-par-1, PR, S100; Ki67 100%.
    • Plan: Refer to LK-CGMH for evaluation of proton therapy.

[exam findings]

  • 2023-01-06 MRA - brain
    • History: This 53 years old male patient had past history of hepatitis B carrier; suffered from right abducens palsy with right tinnitus and head heaviness for months and progressively deterioration.
    • With- and without-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial FLAIR images and axial DWI; using 4 mm thickness for sagittal section and 5 mm thickness for the others) revealed
      • an multi-lobulted extraaxial tumor, about 29.7mm, in the right IAC and right CPA with invasion to the right pons. Severe perifocal edemea was noted. Due to rapid progression, malignent change was considered.
      • post-OP change in the right occipital lobe and right cerebellar hemisphere.
    • IMP: an extra-axial tumor with intra-axial invasion in the right IAC and right CPA
  • 2023-01-06 CXR
    • Tortous aorta with calcification is noted.
    • Emphysematous change over both lungs.
  • 2022-10-04 MRI - brain
    • Clinical information: Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and Rt retropharyngeal LAP metastasis s/p CCRT
    • Findings:
      • Still presence of the enhancing lesions at right CP angle and IAC, associating with perifocal edema in right cerebellum, as compared with MRI on 2022/07/07.
      • Mildly dilated ventricles.
      • Moderate periventricular small vessel disease. NO acute ischemic infarct.
  • 2022-07-07 MRI - brain
    • Indication: Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and Rt retropharyngeal LAP metastasis s/p CCRT PF
    • Without- and with-contrast multiplanar MRI studies of the brain (including axal and coronal T1WI, axial and sagittal T2WI, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) reveal:
      • Regressive change of the enhancing lesion at right CP angle and IAC, associating with perifocal edema in right cerebellum, as compared with MRI on 20220315.
      • General enlargement of ventricles and cisterns, indicating general brain atrophy.
      • Multiple small well-defined FLAIR-hyperintensities at deep cerebral white matters, indicating leukoaraiosis.
      • Post-operation change at right sub-occipital neck.
      • No abnormal intensity at nasopharynx.
    • IMP: Right CPA/IAC tumor s/p treatment, with residual lesion. Suggest close follow-up.
  • 2022-03-18 ENT Hearing Test
    • PTA
    • Reliability FAIR
    • Average RE >120 dB HL; LE 55 dB HL.
    • RE profound SNHL
    • LE mild to profound SNHL
  • 2022-03-17 MRI - nasopharnyx
    • Right IAC and CPA tumor, stationary as compared with MRI on 20223015. Metastatic LAP with ENE at right neck.
  • 2022-03-15 MRI - brain
    • Right CP (cerebellopontine) angle and IAC (internal auditory canal) mass, regressed size and perifocal edema, when compared with 20220108 MRI.
    • Mild Brain atrophy with bilateral periventricular ischemic/aging white matter change.
  • 2022-01-08 MRI - posterior fossa, brain stem
    • A multi-lobuled lesion in the right IAC and right CPA with severe mass effect on the right brain stem, marked increase in size.
  • 2022-01-03 Tc-99m MDP whole body bone scan
    • A hot spot in the left aspect of the maxilla, the nature is to be determined (dental problem or other nature?), suggesting follow-up with bone scan in 3-6 months for investigation.
    • Suspected benign lesions in the mandible, some C-, T- and L-spine, right sternoclavicular junction, bilateral shoulders, S-I joints, and hips.
  • 2021-10-06 SONO - abdomen
    • There are several hepatic cysts in right lobe and the largest one measuring 1 cm in size at segment 8.
    • A renal cyst 1.35 cm on right kidney middle pole is noted.
  • 2021-06-30 MRI - posterior fossa, brain stem
    • Right CP angle and IAC mass, slightly regressed size DDx: Neuroma, meningioma or metastasis.
    • Mild Brain atrophy with bilateral periventricular ischemic/aging white matter change.
  • 2020-12-30 MRI - brain
    • Tumor at right CPA and IAC. Mild enlargement as compared with MRI on 20201126. Suspected metastasis. Meningioma or Schwannoma is less likely.
  • 2020-11-26 SONO - abdomen
    • Right liver cysts and calcification. Left renal cyst and bil. renal stones.
  • 2020-11-26 MRI - nasopharynx
    • C/W NPC s/p treatment without local recurrence, but with a metastatic lesion involving right IAC and CPA
  • 2020-04-15 SONO - abdomen
    • There are several hepatic cysts in right lobe and the largest one measuring 1.08 cm in size at segment 8.
    • A renal cyst 1.27 cm on right kidney middle pole is noted.
  • 2020-04-15 MRI - nasopharynx
    • C/W NPC s/p treatment without evidence of recurrence. An enhancing lesion in right IAC and cochlea. Suspected post-RT neuropathy. Metastasis is unlikely. Stationary as compared with previous MRIs.
  • 2019-09-26 MRI - liver, spleen
    • Post RT change of right lobe liver.
    • Hepatic simple cysts.
  • 2019-05-20 MRI - nasopharynx
    • C/W NPC s/p treatment with complete remission and no evidence of recurrence. Stationary as compared with MRI on 20190108.
  • 2019-05-20 SONO - abdomen
    • Liver cysts.
    • Right renal stone.
    • Right renal cyst.
  • 2019-01-08 MRI - nasopharynx
    • Right NPC, post CCRT. No evidence local recurrent tumor. No neck LAP.
  • 2019-01-08 SONO - hepatobiliary
    • There are several hepatic cysts in right lobe and the largest one is measured about 0.91 cm in size at segment 8.
    • A renal cyst 1.33 cm on right kidney middle pole is noted.
  • 2018-09-05 Whole body PET scan
    • In comparison with the previous study on 20180118, the glucose hypermetabolic tumor in the liver dome had disappeared in this study, suggesting response to current treatment.
    • Glucose hypermetabolism in the right alveolar process of the maxilla had been stationary since the previous study, suggesting benign conditions such as dental inflammatory lesion.
    • Moderate glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, reactive change in response to locoregional inflammation may show such a picture. Please correlate with clinical findings and keep follow-up, however, to exclude the possibility of more significant clinical problems.
  • 2018-08-21 MRI - upper abdomen
    • Liver metastasis in segment 4/8 dome Status post R/T with inflammatory fibrosis is highly suspected.
  • 2018-05-21 CT - abdomen
    • Much regression of liver dome lesion.
  • 2018-01-24 CT - abdomen
    • A poor enhancing nodule (1.7cm) at liver dome c/w metastases.
  • 2012-07-12 Pathology
    • Nasopharynx, right: Non-keratinizing carcinoma, undifferentiated (WHO-2B).

[consultation]

  • 2023-01-31 Rehabilitation
    • Q
      • Brain MRI on 2023/01/06 showed an extra-axial tumor with intra-axial invasion in the right IAC and right CPA. Now, he was admitted for concurrent chemoradiotherapy. This time, for evaluate “limb and bedside rehabilitation exercises”
    • A
      • Physical examination
        • 2023/01/31 13:10 T/P/R: 35.8℃ / 84bpm / 20bpm BP:145/89mmHg
        • Body weight: 56.2
        • Consciousness: clear
        • Cognition: intact, oriented, could follow orders
        • Speech: no aphasia, no obvious dysarthria
        • Swallowing: oral diet
        • Sphincter: urinary and stool continence
        • MP: RUE/RLE: 3/2-3, LUE/LLE: 3/2-3
        • Functional status: could sit up under modA with fair-poor sitting balance
        • BADL: needs mod assistance
        • MRS: 4 (need follow-up)
      • Assessment
        • Malignant neoplasm of nasopharynx
        • Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and right retropharyngeal LAP metastasis s/p concurrent chemoradiotherapy on 2012/9/17 s/p 2nd PF on 2012/11/30, local relapse of right IAC and right CPA tumor s/p chemotherapy with PF4 from 2022/03/18~2022/09/29 for 7 cycles, local relapse of extra-axial tumor with intra-axial invasion
        • Fever
        • Chronic viral hepatitis B without delta-agent
        • Gout
      • Plan
        • Rehabilitation programs: Bedside first PT, OT rehabilitation programs
        • Goal: Ambulation with/without device ID, BADL ID
  • 2023-01-19 Family Medicine
    • Q
      • Brain MRA on 2023/01/06 showed an extra-axial tumor with intra-axial invasion in the right IAC and right CPA. Now, under brain tumor radiotherapy, for combined care need your evaluate. Thank you.
    • A
      • 63 y/o gentaleman advanced NPC for brain palliative RT .
      • Our share care would follow up.
  • 2023-01-09 Radiation Oncology
    • Q
      • This 63-year-old man patient is a case of Nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and right retropharyngeal LAP metastasis s/p concurrent chemoradiotherapy on 2012/9/17 s/p 2nd PF on 2012/11/30, local relapse of right IAC and right CPA tumor s/p chemotherapy with PF4 from 2022/03/18~2022/09/29 for 7 cycles, local relapse of extra-axial tumor with intra-axial invasion.
      • This time, General weakness and difficulty in urinating for one week and vomiting after excercis for three days. Brain MRA on 2023/01/06 showed an extra-axial tumor with intra-axial invasion in the right IAC and right CPA. Now, for evaluate brain tumor radiotherapy. Thank you.
    • A
      • S
        • This 63-year-old man patient is a case of nasopharyngeal carcinoma, cT4N1M0, stage IV, involving right nasopharynx, longus colli muscle, foramen ovale, foramen lacerum and cavernous sinus, and encasing right ICA and right retropharyngeal LAP metastasis s/p concurrent chemoradiotherapy (72 Gy/36 fx) on 2012/9/17 s/p 2nd PF on 2012/11/30, local relapse of right IAC and right CPA tumor s/p SRS (14 Gy) on 2020/12/31 s/p surgical resection on 2022/1/21, s/p chemotherapy with PF4 from 2022/03/18~2022/09/29 for 7 cycles, local relapse of extra-axial tumor with intra-axial invasion. This time, progressive general weakness and difficulty in urinating for one week and vomiting after exercise has been noted for three days. Brain MRA on 2023/01/06 showed an extra-axial tumor with intra-axial invasion in the right IAC and right CPA.
        • Previous RT: as above; s/p SBRT to single liver metastasis on 2018/2/09.
      • O
        • General Condition-ECOG: 2.
        • PE, 2023/01/09: No neck or SCF LAPs. General motor weakness; on bed ambulation.
        • Pathology, 2022/01/21: Rt CP angle, metastatic carcinoma.
        • Images:
          • Brain MRI, 2023/01/06: a multi-lobulated extraaxial tumor, about 29.7mm, in the right IAC and right CPA with invasion to the right pons. Severe perifocal edema was noted. Due to rapid progression, malignant change was considered. Post-OP change in the right occipital lobe and right cerebellar hemisphere. IMP: an extra-axial tumor with intra-axial invasion in the right IAC and right CPA
          • CXR, 2023/01/06: No lung metastasis; no pneumonia.
          • EBV DNA titer, 2022/11/16: Equivocal.
      • Diagnosis: Nasopharyngeal carcinoma, cT4N1M0, stage IV, s/p concurrent chemoradiotherapy on 2012/9/17 s/p 2nd PF on 2012/11/30, local relapse of right IAC and right CPA tumor s/p SRS on 2020/12/31 s/p surgical resection on 2022/1/21, s/p chemotherapy with PF4 from 2022/03/18~2022/09/29 for 7 cycles, local relapse of Rt CP angle tumor with invasion to the right pons; ECOG =2.
      • Plan: Palliative RT to Rt CP angle tumor for 4400cGy/20 fx is suggested for locoregional control. CT simulation was arranged on 2023/01/10, 09:30am. Possible radiation toxicity (white matter injury and pons injury) is told. Diet education is given. Poor prognosis is expected due to limited radiation dose.

[surgical operation]

  • 2022-01-21 at TuCheng ChangGung Hospital

[radiotherapy]

  • 2018-01-30 ~ 2018-02-09 - 5000cGy/5 fractions (6 MV photon) to metastatic tumor at liver dome
  • 2012-07-31 ~ 2012-09-17 - CCRT was performed on 2012/07/31, 2012/08/07, 2012/08/14, 2012/08/21, 2012/08/28, 2012/09/04, 2012/09/11. RT completed on 2012/09/17.

[chemotherapy]

  • 2023-02-03 - cisplatin 40mg/m2 65mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 (cisplatin weekly CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-01-27 - cisplatin 40mg/m2 65mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 (cisplatin weekly CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-01-18 - cisplatin 40mg/m2 65mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 (cisplatin weekly CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-01-12 - cisplatin 40mg/m2 65mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 (cisplatin weekly CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-09-29 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
    • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-08-30 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
    • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-08-04 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
    • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-07-08 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
    • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-05-25 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
    • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-04-22 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
    • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-03-18 - cisplatin 80mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 22hr D1-4 (PF Q4W adjuvant)
    • dexamathasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2023-02-16

  • Cisplatin is assciated with the potential hematologic and oncologic side effects as the following (ref: UpToDate)
    • Anemia may occur in up to 40% of patients receiving the treatment.
    • Leukopenia may occur in 25% to 30% of patients, with the lowest levels (nadir) typically occurring between days 18 and 23 of treatment. White blood cell counts typically recover by day 39. The incidence and severity of leukopenia may be related to the dose of the treatment.
    • Thrombocytopenia may also occur in 25% to 30% of patients, with the lowest levels (nadir) typically occurring between days 18 and 23 of treatment. Platelet counts typically recover by day 39. The incidence and severity of thrombocytopenia may be related to the dose of the treatment.
  • Reducing the dosage of cisplatin (which is dose-dependent) can alleviate thrombocytopenia. Although the patient’s decrease in neutrophils and hemoglobin is not as significant as the decrease in platelets, platelet transfusions may trigger immune responses, infections, and other complications. Therefore, a balance between the expected therapeutic effect and adverse reactions should be sought while considering treatment options. One possible approach is to first reduce the cisplatin dosage to a level where the patient’s platelet count can still recover, and then proceed with further consideration.

2023-01-26

  • Recent lab data showed a significant downward trend in PLT, indicating that the patient has developed thrombocytopenia. Please closely monitor the patient for any signs of bleeding.
    • 2023-02-13 PLT 45 *10^3/uL
    • 2023-02-10 PLT 59 *10^3/uL
    • 2023-02-03 PLT 81 *10^3/uL
    • 2023-01-27 PLT 128 *10^3/uL
    • 2023-01-18 PLT 260 *10^3/uL
    • 2023-01-12 PLT 292 *10^3/uL
  • Actively bleeding patients with thrombocytopenia should be transfused with platelets immediately to keep platelet counts >50K/uL in most bleeding situations including disseminated intravascular coagulation (DIC), and >100K/uL if there is central nervous system bleeding. (ref: Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology. Br J Haematol. 2009;145(1):24-33. doi:10.1111/j.1365-2141.2009.07600.x)

2022-08-05

  • The patient had a marginally high uric acid level (2022-07-05 7.7 mg/dL) prior to last chemotherapy, which could be followed up in order to determine the need for an uric acid lowering drug (e.g. febuxostat).
  • EBV DNA PCR results on 2022-01-17 indicated equivocal 120 copies/mL, which could be updated as well.
  • There is no issue with active prescriptions.

2022-04-25

  • For nonkeratinizing and/or undifferentiated histology, consider testing for EBV in tumor and blood. The EBV DNA load may reflect prognosis and change in response to therapy.
  • Stereotactic proton radiosurgery might be effective in treating brain metastases. reference: Proton Stereotactic Radiosurgery for Brain Metastases. https://pubmed.ncbi.nlm.nih.gov/29976494/
  • 5-Fu plus cisplatin has been the current regimen since 2022-03-18. PD-1 inhibitors (e.g. pembrolizumab or nivolumab) might be an additional treatment option for cancers that are recurrent, unresectable, or metastatic (without surgery or radiation therapy).
  • Chronic viral hepatitis B is managed with Baraclude (entecavir) currently.

700143756

230214

[diagnosis] - 2023-01-16 admission note

  • Synchronous cancer in the cecum and rectosigmoid colon, cT4aN2aM0, stage IIIC with partial obstruction and reginal lymph node metastasis s/p chemotherapy with FOLFOX from 2022/10/24 and status post robotic low anterior resection on 2022/12/20
  • Malignant neoplasm of sigmoid colon
  • Chronic viral hepatitis B without delta-agent
  • Hypokalemia
  • Constipation, unspecified
  • Cachexia
  • Insomnia, unspecified
  • Anemia due to antineoplastic chemotherapy

[past history]

  • Denied history of Hypertension, DM, asthma, cancer.
  • Denied any operation, accident and other medical history.                    

[allergy]

  • NKDA                     

[family history]

  • Father: colon cancer.
  • Mother: brain cancer.

[lab data]

  • 2022-08-23 Anti-HBc Reactive
  • 2022-08-23 Anti-HBc-Value 7.67 S/CO
  • 2022-08-23 Anti-HBs 1.00 mIU/mL
  • 2022-08-23 HBsAg Reactive
  • 2022-08-23 HBsAg Value 23.83 IU/mL

[exam findings]

  • 2023-01-03 CXR
    • staple line and hazy areas of increased opacity over Lt upper lung zone due to post op change
    • marginal spurs of multiple vertebral bodies due to spondylosis.
  • 2022-12-22 CXR
    • S/P Port-A infusion catheter insertion.
    • Right subphrenic air.
    • Presence of ileus.
    • S/P left side chest tube insertion.
    • S/P operation.
    • Right subcutaneous emphysema.
  • 2022-12-20 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, rectum, robotic low anterior resection —- Adenocarcinoma, moderately differentiated, s/p CCRT
      • Resection margins: circumferential: involved
      • Lymph node, mesocolic, dissection —- Negative for malignancy (0/15)
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: ypStage IIB, ypT4aN0(if cM0)
      • F2022-00614 Lung, LUL, wedge resection —- Negative for malignancy
    • Gross Description:
      • Operation procedure: robotic low anterior resection
      • Specimen site: rectum
      • Specimen size: 8.8 cm in length
      • Tumor size: 4.1 cm in length, annularly ulcerated
      • Tumor location: 2.7 cm and 2.0 cm away from the two resection margins, respectively
      • Depth of invasion grossly: visceral peritoneum
      • Mucosa elsewhere: congestion
      • Macroscopic Tumor Perforation: Not identified
      • Macroscopic Intactness of Mesorectum (if applicable): Complete
      • Sections are taken and labeled as: A1: colon, non-tumor; A2-6: tumor; A7-10: lymph node, mesocolic; B: proximal cutend; C: distal cutend.
      • F2022-00614 - The specimen submitted in fresh consists of a piece of lung tissue, measuring 9.3 x 2.0 x 1.4 cm and weighing 8g. On cutting, a fibrotic and calcified nodule measuring 0.5 x 0.4 x 0.3 cm is seen and 0.5 cm away from the resection margin. The parenchyma elsewhere is congested. The nodule is all for section in a cassette for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: resection margin; X2: lung, near nodule; X3-4: lung.
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades the visceral peritoneum (including tumor continuous with serosal surface through area of inflammation)
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Involved
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Tumor Budding: Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: tubulovillous adenoma
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes: 0/15
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): y (posttreatment)
          • Primary Tumor (pT): pT4a: Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
          • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
          • Distant Metastasis (pM): if cM0
      • Additional Pathologic Findings (select all that apply): None identified
      • Tumor regression grading S/P CCRT: Modified Ryan scheme: Tumor regression score: 2, Residual cancer with evident tumor regression, but more than single cells or rare small groups of cancer cells (partial response).
      • F2022-00614 - Sections show lung with a calcified and fibrotic nodule. No malignancy is seen.
      • Addendum: The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2022-12-19 CXR
    • Ground glass opacity in left lung.
  • 2022-12-19 Frozen Section
    • Preliminary diagnosis: Lung, LUL, biopsy — Calcified fibrotic nodule
  • 2022-12-19 ECG
    • Moderate voltage criteria for LVH, may be normal variant
    • Nonspecific T wave abnormality
  • 2022-11-29, -11-24 KUB
    • S/P intrauterine contraceptive device retention over the pelvis
    • Fecal material store in the colon.
  • 2022-11-24 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (92 - 19) / 92 = 79.35%
      • M-mode (Teichholz) = 79
    • Indeterminated LV filling pressure and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Suspected bicuspid aortic valve with mild to moderate aortic stenosis (AVA= 1.45 cm2 by Doppler method); mild AR; mild MR; mild TR and mild PR.
    • Dilated aortic root and proximal ascending aorta ( 34 mm) with mild calcification.
  • 2022-11-22 CXR
    • Solitary pulmonary nodule at LLL.
  • 2022-11-22 CT - abdomen
    • History and indication: A case of RS cancer s/p CCRT
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Stable condition of R-S colon cancer and LAP. Some nodules in bil. lungs.
      • Wall thickening of cecum.
      • Small liver and renal cysts.
      • Atherosclerosis of aorta, iliac arteries.
      • An IUD in the pelvic cavity.
    • IMP:
      • Stable condition of R-S colon cancer and LAP. Some nodules in bil. lungs.
      • Wall thickening of cecum.
  • 2022-11-22 Colonoscopy
    • Rectosigmoid cancer partial obstruction s/p CCRT
    • The scope can’t pass through due to lumen narrowing
  • 2022-10-17 Bronchodilator Test
    • Rectosigmoid cancer partial obstruction s/p CCRT
    • The scope can’t pass through due to lumen narrowing
  • 2022-08-30 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2022-08-29 ECG
    • Normal sinus rhythm
    • Minimal voltage criteria for LVH, may be normal variant
    • Nonspecific ST and T wave abnormality
  • 2022-08-29 CXR
    • Atherosclerotic change of aortic arch
    • Tortuosity of thoracic aorta
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2022-08-17 CT - abdomen
    • History: 76 y/o female
      • 20220726 FOBT positive at Far Eastern Polyclinic of Far Eastern Medical Foundation
      • 20220810 colonoscopy: An annular tumor mass obstructs the lumen at this level about 10-15 cm from the anal verge and the scope cannot pass through this stenotic lesion.
      • 20220816 pathological result: adenocarcinoma
    • Indication: Sigmoid colon cancer for staging
    • Findings:
      • There is segmental lobulated wall thickening measuring 6 cm in length and 1.8 cm in the maximal wall thickness at the rectal-sigmoid colon with irregular contour and lumen narrowing that is c/w adenocarcinoma (T4a) of the rectal-sigmoid colon with partial obstruction.
        • The fat plane between sigmoid colon lesion and the uterine cervix area shows obliteration that may be tumor invasion or attachment? Please correlate with MRI.
        • In addition, There are four enlarged nodes in left perirectal space that may be metastatic nodes (N2a).
      • Another lobulated soft tissue mass-like lesion in the cecum and proximal ascending colon is suspected.
        • Please correlate with colonoscopy to R/O Synchronous cancer.
      • There is a well-defined poor enhancing lesion 6 mm at S8 dome of the liver that may be cyst?
        • The differential diagnosis include metastasis?
        • However, it is too small to characterize. Follow up is indicated.
      • There is a well-defined ovoid-shaped poor enhancing lesion at right inguinal area, measuring 2.3 x 1.3 cm in size and 5HU in CT density.
        • Benign reactive node or cystic lesion is highly suspected. Please correlate with sonography.
      • There is a small nodule 4 mm at LUL of the lung.
        • Follow up is indicated.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)
  • 2022-08-11 Patho - colon biopsy
    • DIAGNOSIS: Intestine, large, RS colon, 10-15 cm from anal verge, biopsy — adenocarcinoma
    • Description: The specimen submitted consists of 4 pieces of tissues measuring up to 0.4 x 0.3 x 0.1 cm in size, fixed in formalin. Grossly, they are brownish and elastic. All for section.
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, tumor necrosis and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • NOTE: IHC stain for MSI will be followed.
  • 2022-08-10 Colonoscopy
    • Findings
      • Using Olympus CF-H260AL, endoscopic examination of rectum and colon was done and the scope is placed up to the level of RS junction. An annular tumor mass obstructs the lumen at this level about 10-15 cm from the anal verge and the scope cannot pass through this stenotic lesion. Bx x 4 done. Internal hemorroid is noticed.
      • Internal hemorrhoid was noted.
    • Diagnosis
      • Colon cancer, RS junction s/p Bx
      • Internal hemorrhoid
      • Incomplete CFS exam

[consultation]

  • 2022-11-25 Thoracic Surgery
    • Q
      • This is a 76 year-old woman who denied having any history. According the patient, she suffered from mucous stools was pink like, abdomen flatulence, and difficult defecation since half year ago. And she came to the local clinic (Far Eastern Polyclinic), the fecal occult blood test positive noticed, so referred to our GI OPD for further assessment.
      • Colonscopy (2022/08/10) showed: 1. Colon cancer, RS junction s/p Bx. 2. Internal hemorrhoid. Abdomen CT showed: 1. Adenocarcinoma of the sigmoid colon with suspicious uterine cervix invasion is suspected. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T4a(or4b)N2aM0, stage:IIIC. 2. Synchronous cancer in the cecum and proximal ascending colon is suspected on 2022/08/17. The RS colon biopsy — adenocarcinoma.
      • The radiotherapy starts from 2022/08/26, RT finished on 2022/10/12. CCRT with 5-FU (Covorin 20mg/m2, 5-Fu 225mg/m2) QW, (C1) on 2022/9/1-2022/9/2, 2022/9/5-2022/9/7, 2022/09/22-2022/09/23, 2022/09/26-2022/09/28. Chemotherapy with FOLFOX (Oxalip 85mg/m2, Covorin 400mg/m2, 5-Fu 400mg/m2、5-Fu 2400mg/m2) was given on 2022/10/24(C1D1), 2022/11/07(C1D15). Surgery will be arranged on 20221207 or later.
      • Due to CT image (2022/11/22) showed some nodules in bil. lungs, we need your consultation for evaluation. Thanks a lot!!!
    • A
      • LUL nodule was noted. I will arrange VATS LUL wedge resection.

[surgical operation]

  • 2022-12-19
    • Surgery
      • Robotic low anterior resection        
    • Finding
      • Advanced rectal cancer s/p CCRT with anterior pelvic peritoneal invasion
  • 2022-12-19
    • Surgery
      • VATS LUL wedge resection.
    • Finding
      • One small nodule was noted over LUL, size about 0.5cm in diameter.
      • Frozen section: benign lesion.
      • One 20 Fr. straight chest tube was inserted via left 6th ICS.

[radiotherapy]

  • 2022-08-26 ~ 2022-10-06 - 5040cGy/28 fractions (15 MV photon) to rectosigmoid tumor, LAPs and cecal tumor.

[assessment]

  • 2023-12-13 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (w/o 5-FU bolus)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-01-16 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-11-07 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-10-24 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-09-26 [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 225mg/m2 330mg NS 100mL 10min] D1-3 (CCRT)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-3
  • 2022-09-22 [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 225mg/m2 330mg NS 100mL 10min] D1-3 (CCRT)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-2
  • 2022-09-05 [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 225mg/m2 330mg NS 100mL 10min] D1-3 (CCRT)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-3
  • 2022-09-01 [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 225mg/m2 330mg NS 100mL 10min] D1-2 (CCRT)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-2

==========

2023-02-14

  • A leukocytopenia event was observed (2023-02-02 WBC 1.86K/uL, Neutrophil 42% => ANC 780/uL) and the previously scheduled chemotherapy was cancelled on that day. FOLFOX is being administered without a 5-FU bolus this time. It is important to monitor the patient’s WBC count to determine whether leukocytopenia recurs.

2023-01-17

  • Except for urticaria, the underlying conditions listed in the problem list are appropriately treated with corresponding medications.

  • As a premedication, a single shot diphenhydramine is used in the current chemotherapy regimen, however, the newer, second generation H1 antihistamines are recommended as first-line therapy for urticaria. These newer drugs are minimally sedating, are essentially free of the anticholinergic effects that can complicate use of 1st generation agents, have few significant drug-drug interactions, and require less frequent dosing compared with first-generation agents. It is recommended to initialize a 2nd generation antihistamine at standard therapeutic dose:

    • cetirizine, 10mg once daily
    • levocetirizine, 5mg once daily
    • fexofenadine, 180mg once daily
    • loratadine, 10mg once daily
    • desloratadine, 5mg once daily

2022-09-26

  • The CT of the abdomen on 2022-08-17 revealed possible synchronous cancer (rectal-sigmoid colon, cecum, and proximal ascending colon), a liver S8 dome lesion, and a LUL nodule.
  • Patients with synchronous colorectal carcinoma have a higher proportion of microsatellite instability cancer than patients with a solitary colorectal carcinoma. Also, limited data have revealed that in many synchronous colorectal carcinomas, carcinomas in the same patient have different patterns of microsatellite instability status, p53 mutation and K-ras mutation. (ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4051920/ ). Pathology (2022-08-11) IHC MSI results (for the rectal-sigmoid colon specimen) are not yet available.

701334097

230214

{not completed}

[exam findings]

  • 2023-02-08, -02-05, -01-31 CXR

    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Pleura effusion of right and left costal-phrenic angle S/P pigtail catheter implantation at right CP angle?
    • 2023-02-08 - Patchy consolidation of both lung zone are noted. please correlate with clinical condition to R/O Bronchopneumonia.
    • 2023-02-05 - Linear infiltration over both lung zone are noted. please correlate with clinical condition.
    • 2023-01-31 - Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2023-02-05 CT - brain

    • Brain atrophy
  • 2023-02-03 MRI - brain

    • No evidence of intracranial lesion.
  • 2023-02-03 Electroencephalography, EEG

    • This is an abnormal EEG suspecting bilateral central epileptogenic activities intermittent diffuse slow waves at bilateral central and temporal area
    • A few sharpy contour waves or spikes over bilateral central area.
    • Please correlate clinially
  • 2023-02-03 Peripheral Vascular Test - vein, lower limbs

    • No evidence of deep vein thrombosis at bilateral lower limbs (by color flow filling, direct compression, and distal augmentation response)
    • Bilateral long saphneous vein engorgement (from thigh to leg), left side more severe; connecting to bilateral engorged posterior tibial veins by perforator veins at leg level
    • 2022-01-06 Patho - colon segmental resection for tumor
      • pathology diagnosis
        • Rectum, Hartmann’s operation – Adenocarcinoma, moderately differentiated
        • Resection margins, Hartmann’s operation – Free of carcinoma
        • Lymph nodes, mesocolorectal, Hartmann’s operation — Metastatic adenocarcinoma (1/12)
        • Specime labeled pelvic tumor margin, biopsy — Necrosis and granulation tissue and free of carcinoma
        • T-colon colostomy, closure of colostomy — Free of carcinoma
        • Pathology stage: ypT3N1a(cM0); Stage IIIB
      • microscopic examination
        • Histology: Adenocarcinoma
        • Histology Grade: Moderately differentiated
        • Depth of invasion: Perirectal soft tissue
        • Angiolymphatic invasion: Not identified
        • Perineural invasion: Present
        • Tumor cell budding: Intermediate
        • Circumferential (radial) margin of rectum: Uninvolved, 2 mm from the margin
        • Lymph node metastasis, mesocolorectal: Metastatic adenocarcinoma (1/12)
        • Extranodal involvement: Absent
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • Primary Tumor (pT): ypT3 (Tumor invades pericolorectal tissues)
          • Regional Lymph Nodes (pN): ypN1a (one regional lymph node positive)
          • Distant Metastasis (pM): cM0
        • Type of polyp in which invasive carcinoma arose: Not identified
        • Additional pathologic findings: None identified
        • Tumor regression grading S/P CCRT: Partial response (score 2)
        • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
        • Specime labeled pelvic tumor margin: Necrosis and granulation tissue, and free of carcinoma
        • T-colon colostomy: Free of carcinoma
    • 2021-12-28 CT - abdomen, pelvis
      • Rectosigmoid colon cancer, size decreased.
      • Decreased size of pericolic lymph nodes.
      • Status post T-colostomy.
      • Right hydronephrosis and hydroureter.
      • Tiny subpleural nodules (<0.5cm) at basal LLL. Suggest close follow up.
    • 2021-12-28 Colonoscopy
      • compatible with colon cancer, 8cm AAV, with near lumen obstruction.
    • 2021-09-16 CT - abdomen, pelvis
      • Imaging stage: T3N2aM0, stage IIIB
  • lab data

    • 2022-02-24
      • All RAS mutation not detected
      • BRAF mutation not detected
  • surgical operation

    • 2022-01-05
      • surgery
        • Hartmann’s operation and closure of T-loop colostomy
      • finding
        • Advanced rectal cancer obstruction s/p CCRT and the tumor was firmly fixed to the pelvic cavity , clinically can’t be resected completely
    • 2021-09-17
      • surgery
        • T loop colostomy        
      • finding
        • Rectal cancer with obstruction, cT3N2aM0 stage IIIB
        • RUQ stoma with stent
  • radiotherapy

    • 2021-09-28 ~ 2021-11-04 - pelvis: 45 Gy/ 25 fx. R-S colon tumor and LAPs: 50.4 Gy/ 28 fx
  • chemoimmunotherapy

    • 2022-02-22 ~ undergoing - FOLFOX plus bevacizumab
    • 2021-11-29 ~ 2022-02-07 - FOLFOX
    • 2021-10-04 ~ 2021-11-01 - 5-Fu + LV (CCRT)

==========

2023-02-06

  • 2023-01-23 urine culture found Candidas abicans 50000 colony count CFU/cc. Treatment of candidemia and invasive candidiasis in nonneutropenic patients could be an echinocandin (1. caspofungin 70 mg IV loading dose, then 50 mg IV daily; 2. micafungin 100 mg IV daily; 3. anidulafungin 200 mg IV loading dose, then 100 mg IV daily. Items 2 and 3 are not necessary to be dose adjusted for any degree of kidney impairment and they are available in this hospital.) is recommended as initial therapy. (ref: https://www.uptodate.com/contents/image?imageKey=ID%2F87676)

  • 2023-01-13 anaerobic culture of the perineuim was found to contain Bacteroides thetaiotaomicron 3+ that was sensitive to metronidazole and ampicillin/sulbactam. It is not necessary to adjust dose for metronidazole if CrCl is greater than 10, while for ampicillin/sulbactam, CrCl is greater than 30. Keep metronidazole use is recommended.

  • If Keppra (500mg Q12H) is not demonstrated to be effective for seizure control, valproate (no dosage adjustment necessary if CrCl >= 10 mL/min) or carbamazepine (no dosage adjustment necessary for kidney impairment) might be added.

    • Depakine (valproic acid) is available in tabet, oral solution and injection forms.
    • Carbamazepine might cause hyponatremia, which might be a desired side effect to mitigate the patient’s hypernatremia (2023-02-05 Na 152 mmol/L).

2023-01-30

[compatible solutions to mitigate hypernatremia that do not rely on saline]

Following is a list of the selected injectable medications in the active prescription and their compatibility with non-saline-based solutions according to MicroMedex.

  • Benamine (diphenhydramine hydrocholoride)
    • D5W (Dextrose 5% in water)
      • IV compatible
    • D10W (Dextrose 10% in water)
      • IV compatible
    • D5LR (Dextrose 5% in lactated Ringers)
      • IV compatible
  • Flucon (fluconazole)
    • D5W (Dextrose 5% in water)
      • IV compatible
    • D10W (Dextrose 10% in water)
      • IV not tested
    • D5LR (Dextrose 5% in lactated Ringers)
      • IV not tested
  • Furosemide
    • D5W (Dextrose 5% in water)
      • IV compatible
    • D10W (Dextrose 10% in water)
      • IV compatible
    • D5LR (Dextrose 5% in lactated Ringers)
      • IV compatible
  • Metronidazole
    • D5W (Dextrose 5% in water)
      • IV compatible
    • D10W (Dextrose 10% in water)
      • IV not tested
    • D5LR (Dextrose 5% in lactated Ringers)
      • IV not tested

Use potassium supplements if necessary

  • Potassium phosphates
    • D5W (Dextrose 5% in water)
      • IV compatible
    • D10W (Dextrose 10% in water)
      • IV compatible
    • D5LR (Dextrose 5% in lactated Ringers)
      • IV not compatible

2022-04-08

  • Having been firmly embedded in the pelvic cavity, the tumor could not be surgically resected fully (2022-01-05).
  • The patient receives FOLFOX since 2021-11-29 (plus bevacizumab since 2022-02-22) s/p T loop colostomy (2021-09-17) and CCRT (late Sep to early Nov 2021).
  • According to laboratory data reported on 2022-04-06, there were no obvious abnormalities; however, elevations in ALT (60 U/L) and AST (64 U/L) should be addressed, as these two readings had been normal prior to the this last examination.
  • As metoclopramide is one of the potentially hepatotoxic drugs, some silymarin as supplementation might be an optional add-on to mitigate the potential hepatotoxicity.

701277175

230213

  • diagnosis - 20230105 admission note
    • Malignant neoplasm of unspecified site of left female breast
    • Left breast invasive carcinoma with left axillary LN enlargement and bone metastasis, ER (+), PR (-), Her2 (+), stage IV, PS 1
    • Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes
    • Secondary malignant neoplasm of bone
  • exam finding
    • 2022-10-17 CT - chest
      • Indication: left breast invasive carcinoma with left axillary LN enlargement and BONE Metases ER (+), PR (-), Her2 (+), stage IV, PS 1
      • MDCT (128 256-detector rows, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows: (Comparison was made with previous CT dated on 20220702)
        • Lungs: s/p RUL operative with septal line and surrounding opacity along the interalobar fissures, and septal thickening and subpleural edema along minor fissure. septal line and septal thickening at RML too.
          • there is subpleural and reticulation at basal segments of RLL.
      • Impression:
        • post op change in RUL and RML, in regression as compared with previous CT on 20220702.
        • suspect early fibrosis in RLL.
    • 2022-07-05 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2022/02/11, no prominent change is noted in the previous faint hot spots in the skull, anterior aspect of bilateral rib cages, right S-I joint and bilateral iliac bones, suggesting stable condition.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • 2022-07-04 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Reflux esophagitis LA Classification grade A(minimal)
        • Superficial gastritis, body, s/p CLO test
        • Gastric erosions, antrum
        • Gastric polyps, fundus and AW site of high body, r/o fundic gland polyps
        • Duodenal shallow ulcer, bulb, AW site
      • Suggestion
        • Pursue CLO test result
    • 2022-07-02 CT - chest
      • S/P mastectomy at left side
      • S/p port-A placement with its tip at SUPERIOR VENA CAVA
      • post op. change over right upper lobe
    • 2022-06-20 Abdomen - standing (diaphragm)
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
      • S/P Mastectomy, left.
    • 2022-06-14 MTBC (Mycobacterium tuberculosis complex) PCR
      • Undetectable
    • 2022-05-30, -05-27 CXR
      • Port-A catheter inserted into RA via right subclavian vein.
      • s/p right chest tube in place, its tip directed superiorly projecting over 5th rib
      • extensive hazy areas of increased opacity over Rt upper lung zone
    • 2022-05-27 Patho - lung wedge biopsy
      • DIAGNOSIS:
        • A: Lung, RML, wedge resection — organizing pneumonia
        • B: Lymph node, right, group 7, dissection — negative for malignancy (0/1)
        • C: Lymph node, right, group 9, dissection — negative for malignancy (0/1)
        • D: Lymph node, right, group 11, dissection — negative for malignancy (0/3)
        • E: Lymph node, right, group 12, dissection — negative for malignancy (0/1)
        • F2022-00248: Lung, RUL, segmentectomy — Non-necrotizing granulomatous inflammation with organizing pneumonia
    • 2022-05-26 Pulmonary Flow Volume Loop
      • Normal ventilation
    • 2022-04-22 CT - lung/mediastinum/pleura
      • Chest CT with and without IV contrast ehnancement shows:
        • Chest:
          • S/P mastectomy at left side.
          • Spiculated nodule at right upper lobe up to 1.9cm in largest dimension is found. Another fissural based lesion at right middle lobe up to 1.4cm in largest dimension. In comparison with CT dated on 2021-12-17, the lesions are new. Suggest correlate with PET or other exam.
          • No evidence of bilateral pleural effusion.
          • S/p port-A placement with its tip at Superior vena cava.
        • Visible abdomen:
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • Non-specific bowel gas at abdominal cavity is found.
        • Imp:
          • S/P mastectomy at left side.
          • New spiculated nodule at right upper lobe and right middle lobe, the nature of the lesions should be further characterized or closely follow up. (mets is less likely but primary tumor or inflammation cannot be excluded.)
    • 2022-02-11 Tc-99m MDP whole body bone scan - In comparison with the previous study on 20210924, no prominent change is noted in the previous hot spots in the skull, anterior aspect of bilateral rib cages, right S-I joint and bilateral iliac bones, suggesting stable condition. - Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • 2022-01-20 Patho - breast simple/partial mastectomy
      • Breast, left, simple mastectomy (s/p chemotherapy) — No residual tumor
      • Pathology stage: ypT0N0(if cM0)
    • 2022-01-19 Lymphoscintigraphy
      • No sentinel lymph node in the left axillary region or left ant. chest wall is delineated throughout the whole study.
    • 2022-01-11 SONO - breast
      • Clinical left breast s/p C/T.
      • Right breast cysts and fibroadenomas. Suggest follow up.
      • BIRADS 6 - proven malignancy
    • 2021-12-17 CT - chest
      • No evidence of recurrent/residual tumor at both sides of the breast and other region.
    • 2021-09-24 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 20210427, the previous hot spots in the skull, anterior aspect of bilateral rib cages, right S-I joint and bilateral iliac bones are less evident. Bone metastases with some resolution may show this picture. Please correlate with other clinical findings for further evaluation.
      • Increased activity in the maxilla in stationary status. Dental problem and/or sinusitis may show this picture.
    • 2021-09-06 CT - chest
      • resolution of Lt breast tumor and metastatic axillary and supraclavicular lymphadenopathy as compared with CT on 20210423.
      • minimal paraspinal fibrosis in RLL of lung.
    • 2021-04-30 CT - brain
      • No intracranial lesion based on this study.
    • 2021-04-27 Tc-99m MDP whole body bone scan
      • Multiple hot spots in the skull, anterior aspect of bilateral rib cages and bilateral iliac bones. Bone metastases should be watched out if no definite traumatic event is noted. Please correlate with other clinical findings for further evaluation.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • 2021-04-26 Patho - lymphnode biopsy
      • Lymph node, left axilla, core biopsy — Invasive carcinoma, no special type, NST.
      • IHC stains (using block S21-6478): ER (+, strong intensity, 70%), PR(-), Her2/neu: positive(score=3+), Ki-67(50%), p53 (<5%).
      • Section shows fragments of tissue with irregular neoplastic ducts infiltration.
    • 2021-04-26 Patho - breast biopsy
      • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
      • IHC stains (using block S21-6477): ER (+, strong intensity, 70%), PR(+, weak intensity,5%), Her2/neu: positive(score=3+), Ki-67(80%), p53 (10%).
      • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
    • 2021-04-26 SONO - breast
      • Left breast tumors with axillary lymph nodes, suspected malignancy with lymph nodes metastasis.
      • BI-RADS5
    • 2021-04-23 CT - nect
      • Suspect left breast tumor with left axillary lymphadenopathy. Several small lymph nodes at left supraclavicular region.
      • Suggest further breast ultrasound correlation and tissue proof if needed.
  • surgical operation
    • 2022-01-19 Simple mastectomy and SLNB (Sentinel Lymph Node Biopsy)
      • No palpable and visible tumor over L`t breast UOQ.
      • Sentinel nodes biopsy was done
      • Simple mastectomy was done.
      • L’t big toe nail bed redness & loosen wit hpus discharge.
  • chemoimmunotherapy
    • 2023-01-05 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-10-18 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-09-18 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-08-22 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-07-25 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-06-20 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-04-27 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-04-01 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 130mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-03-10 - docetaxel 75mg/m2 120mg 2hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-02-16 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-12-28 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-11-25 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-11-02 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-10-05 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-08-27 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 120mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2021-07-29 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-07-02 - trastuzumab 600mg SC 5min D1 + pertuzumab 840mg 1hr D1 + decetaxel 75mg/m2 120mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2021-06-01 - docetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg
    • 2021-05-05 - docetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg
  • medication
    • Xgeva (denosumab) CXGEV01
      • 2022-09-01 120mg Q1M SC OPD
      • 2022-06-20 120mg ST SC IPD 2022-06-19
      • 2022-05-06 120mg Q1M SC OPD
      • 2022-04-01 120mg ST SC IPD 2022-03-31
      • 2022-02-25 120mg Q1M SC OPD
      • 2022-01-06 120mg Q1M SC OPD
      • 2021-12-02 120mg Q1M SC OPD

==========

2023-02-13

WBC returned to 5.05K/uL on 2023-02-12, neutropenia not observed.

2023-01-06

  • CT scan results from 2022-10-17 and bone scan results from 2022-07-05 indicate that the disease has remained non-progressive, indicating that the current regimen is still effective.
  • The lab results for 2023-01-05 were normal, and the vital signs during this stay in the hospital were stable.

2022-04-28

  • The patient was diagnosed with hormone receptor and Her2 positive breast cancer with bone mets. Mastectomy with SLNB was performed on 2022-01-19. Her chemoimmunotherapy with docetaxel began in May 2021, then trastuzumab and pertuzumab were added since July 2021.
  • She also received three denosumab injections for the bone mets on 2021-12-02, 2022-01-06, and 2022-02-25. Tc-99m MDP scan on 2022-04-22 showed that bone mets were stable.
  • The lab results of 2022-04-27 revealed no noticeable abnormalities. No issue with current prescription.

700380439

230210

[diagnosis] - 2022-12-02 admission note

  • Malignant neoplasm of lower third of esophagus
  • Bacteremia
  • Other specified bacterial agents as the cause of diseases classified elsewhere
  • Gastro-esophageal reflux disease with esophagitis
  • Secondary malignant neoplasm of other specified sites
  • Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
  • Urinary tract infection, site not specified
  • Enterococcus as the cause of diseases classified elsewhere
  • Cardiomegaly
  • Rheumatic disorders of both mitral and tricuspid valves
  • Gastritis, unspecified, without bleeding
  • Pneumonia due to Pseudomonas

[past history]

  • denied systemic diseases
  • hyperthyroidism years ago? without follow up and medicine
  • SCC of esophagus of middle to lower third esophagus with gastric involvement, ycT3N1M1, stage IVB.   

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-02-10 CT - abdomen
    • History: esophageal cancer S/P C/T
      • 20210118 chest CT:interval regression of esophageal tumor and metastatic LN at Rt supraclavivular fossa, but new regional metastatic mediastinal LAP, progression of retroperitoneal LAP and lung metastases, new hepatic metastasis, as compared with CT on 2022/10/28.
    • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is newly-developed massive ascites and omentum cake that is c/w carcinomatosis.
        • Please correlate with ascites cytology.
        • In addition, There are newly-developed ill-defined poor enhancing masses on both hepatic lobes that are c/w liver metastases.
      • Prior CT identified multiple lung metastases are noted again, mild increasing in size that is c/w progressive disease.
      • Prior CT identified metastatic nodes in the gastrohepatic ligament, celiac trunk and para-aortic space are noted again, mild increasing in size that is c/w progressive disease.
      • Prior CT identified regional metastatic node in right lower para-esophageal mediastinum 2 cm is noted again, mild increasing in size to 2.5 cm.
      • There are several renal cysts on both kidney and the largest one measuring 2 cm in size at right umiddle pole.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery.
    • Impression:
      • Carcinomatosis and liver metastases (newly-developed).
      • Multiple lung metastases show progressive disease.
      • Metastatic nodes in the gastrohepatic ligament, celiac trunk and para-aortic space show progressive disease.
      • Metastatic regional node shows progressive disease.
  • 2023-01-18 CT - chest
    • Indication: esophageal cancer, S/P chemotherpaycheck chest C.T.
    • MDCT (128-detector rows, iCT Philips,was performed with 0.625 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Comparison was made with previous CT dated on 2022/10/26
      • Lungs:
        • extensive, bilateral, upper lobes predominant, destructive centrilobular emphysema and subpleural paraseptal emphysema/bulla, in the lungs.
        • Multiple randomly distributed pulmonary nodules of varying sizes
        • due to metastases. reticular opacities at LLL and lingula.
      • Mediastinum and hila: a new necrotic lymphadenopathy in Rt paraesophageal region, subcarinal space.
        • Diffuse wall thickening from middle to lower third esophagus, in regression.
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: no effusion or nodule.
      • Chest wall and visible lower neck: regression mestatatic LAP at Rt supraclavicular fossa..
      • Visible abdominal contents: s/p percutsneous gastrostomy.
        • interval increase in size metastatic lymphadenopathy at para-aortic region near celiac trunk, with invasion to the pancreas.
        • multiple small hepatic cysts and small metastatic tumors are found. several small bilateral renal cysts.
    • Impression:
      • interval regression of esophageal tumor and metastatic LN at Rt supraclavivular fossa, but new regional metastatic mediastinal LAP, progression of retroperitoneal LAP and lung metastases, new hepatic metastasis, as compared with CT on 2022/10/28.
  • 2023-01-02 CXr
    • A nodular opacity projecting in the left lower lung is suspected. Please correlate with CT.
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
  • 2022-11-02 Patho - esophageal biopsy
    • Labeled as “lower esophagus”, biopsy — Ulcer.
    • IHC stains: CK highlights surface squamous mucosa. P40 (-).
    • Section shows surface squamous mucosa, abundant cell debris and acute inflammatory exudates.
  • 2022-11-02 Patho - esophageal biopsy
    • Stomach, PW of upper body, biopsy — Ulcer, H pylori NOT present.
    • Section shows benign gastric mucosal tissue and ulcer debris with chronic inflammation. H. pylori NOT present.
    • NOTE: Since malignancy is clinically suspected, further work up or repeat biopsy might be considered.
  • 2022-11-02 SONO - abdomen
    • Liver cyst, both lobe
  • 2022-11-02 Miniprobe Endoscopic Ultrasound
    • Indication: Esophageal cancer, s/p CCRT, for restaging
      • Esophageal cancer staging
      • Symptoms: Nil
      • Dysphagia
      • Pre-EUS diagnosis: Esophageal cancer
    • Endoscopic findings:
      • With NBI-ME, no lesion nor brownish area was noted above epiglottis or at bilateral pyriform sinuses. With whitelight endoscopy, an easily touch-oozing scar was noted at 29cm below the incisors, causing luminal stenosis. The magnified endoscope could not pass through the stenotic site. With NBI-ME, non-specifc JES-IPCL pattern was noted over the scar and focal JES-IPCL B1 pattern was noted near the scar. We changed the scope to ordinary GIF scope and could pass through the stenotic site with resistance. A PEG tube was noted at AW of lower body. A healing ulcer with surrounding fold convergence was noted at PW of upper body, s/p biopsy(A). A kissing scar was noted at duodenal bulb. Chromoendoscopy with lugol solution showed circumferential LVL with pink-color sign from EC junction to 29cm below the incisors, s/p biopsy(B).
    • EUS findings:
      • With UM-2R, EUS showed 4th layer destruction, at least 3cm in length by miniprobe measurement. A 6.1mm hypoechoic lesion was noted near EC junction.
    • Diagnosis:
      • C/W esophageal cancer, middle to lower esophagus, EUS restaging at least cT3N1, s/p biopsy(B)
      • Gastric ulcer, PW of upper body, H2, Forrest III, suspected malignancy but improved, s/p biopsy(A)
      • PEG in situ
      • Duodenal ulcer scar, bulb
    • Suggestion:
      • Consider to correlate to other image studies and pursue pathology report
  • 2022-10-31 Tc-99m MDP whole body bone scan with SPECT
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, L-S junction, left sternoclavicular junction, bilateral shoulders, S-I joints, hips, and knees.
  • 2022-10-29 MRI - brain
    • Findings
      • mild dilated intraventricular and extraventricular CSF spaces
      • some white matter gliosis in the bilateral frontal lobes
    • IMP: no evidence of brain metastasis.
  • 2022-10-28 CT - chest
    • Indication: esophageal cancer
    • Findings
      • Chest:
        • Diffuse wall thickening from middle to lower third esophagus is found.
        • Severe Emphysematous change over both lungs is found.
        • Nodular lesion at subpleural region of right lower lobe up to 0.7cm and left lower lobe up to 0.5cm is found. These nodules are new.
        • S/p port-A placement with its tip at Superior vena cava.
        • Mild pericardial effusion is found.
        • No evidence of bilateral pleural effusion.
        • Lymphadenopathy at supraclavicular region is found. In regressionn.
      • Visible abdomen:
        • s/p gastrostomy. -Lymphadenopathy at retroperitoneum near celiac trunk is found. In enlargement. -The GB is well distended without soft tissue lesion -The liver, spleen, pancreas, both kidneys and adrenals are intact. -There is no evidence of paraarotic LAPs. -Suggest clinical correlation
      • Imp:
        • Severe COPD.
        • Esophageal cancer with regression.
        • NEw Right lower lobe and left lower lobe nodules. suspected lung meta.
        • Lymphadenopathy at supraclavicular region, in regression.
        • Lymphadenopathy at retroperitoneum, in enlargement.
  • 2022-10-28 Nasopharyngoscopy
    • Bil. few thick mucus and nasal cavity, suspected chronoic rhinosinusitis.
  • 2022-10-27 Body fluid cytology - bronchial washing
    • Atypia
  • 2022-10-27 Whole body PET scan
    • Glucose hypermetabolism involving the lower portion of the esophagus and cardia of the stomach, compatible with primary malignancy involving these regions.
    • Glucose hypermetabolism in multiple lymph nodes in the right lower neck, right paratracheal, precarinal, gastric cardiac and abdominal left paraaortic regions. Metastatic lymph nodes may show this picture.
    • A glucose hypermetabolic lesion in the segment IVb of the liver. Liver metastasis should be watched out.
    • Some glucose hypermetabolic lesions in bilateral lung fields. The nature is to be determined (inflammation? metastases?). Please correlate with other clinical findings for further evaluation.
    • Increased FDG uptake/accumulation in the left neck muscle, bilateral kidneys, ureters and colon. Physiological FDG uptake/accumulation may show this picture. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2022-10-27 Bronchoscopy
    • nasal mucosa chronic inflammation
    • No evidence of trachea or LLL bronchus invasion of esophageal cancer
    • COPD AE during scopy
    • Diffuse proximal airways mucus impaction
  • 2022-10-26 CXR
    • Increased lung volume and areas of hyperlucency and decreased upper lung vascular markings due to severe emphysematous change of both lungs upper lung predominance
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
  • 2022-09-16 CXR
    • Atherosclerotic change of aortic arch
    • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to suspected old inflammatory process.
  • 2022-08-10 KUB
    • S/P gastrostomy.
    • Radiopaque spot(s) at left renal region suspected renal stone(s).
    • Intact bony structure(s).
  • 2022-08-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (134 - 43) / 134 = 67.91%
      • M-mode (Teichholz) = 67.8
    • Dilated LV, Ao
    • Adequate LV, RV systolic function with normal wall motion
    • LV hypertrophy, Impaired LV relaxation
    • Mild MR, TR
  • 2022-08-01 Tc-99m MDP whole body bone scan with SPECT
    • Several faint hot spots in the right rib cage, and increased activity in some T- and L-spine, and L-S junction, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
    • Suspected benign lesions in the maxilla, left sternoclavicular junction, bilateral shoulders, and S-I joints.
  • 2022-07-30 CT - chest
    • Indication: esophageal tumor, lower esophagus
    • Findings
      • Chest:
        • Dilated upper esophagus with soft tissue occupying middle to lower esophagus about 10.3cm in largest dimension.
        • Lymphadenopathy at right lower neck, paratracheal, paraesophageal, gastric cardiac and retroperitoneal region.
        • There is no evidence of destructive bone lesion.
        • Severe Emphysematous change over both lungs.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Multiple hepatic cysts are found at both lobes of liver is found.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
      • Suggest clinical correlation
    • Imp:
      • Esophageal cancer at lower third esophagus and extensive lymphadenopathy. Suggest further treatment.
      • Severe Emphysematous change over both lungs.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-07-29 Patho - esophageal biopsy
    • Esophagus, 30-40 cm below the incisors, biopsy — Squamous cell carcinoma, moderately differentiated
    • Esophagus, 40-42 cm below the insicors, biopsy — Squamous cell carcinoma, moderately differentiated
      • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation and tumor necrosis are evident.
    • Stomach, cardia, biopsy — Squamous cell carcinoma, moderately differentiated
      • The sections show a picture of squamous cell carcinoma, composed of gastric mucosal tissue with nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation is evident.

[consultation]

  • 2022-10-28 ENT
    • Q
      • This 63-year-old man has squamous cell carcinoma of middle to lower third esophagus, with caria involvement, cT3N3M0, stage IVA. He underwent neoadjuvant CCRT and visited our oncologist OPD for regular follow-up. This time, he was admitted for cancer restaging. Due to nasal mucosa lesion noted during bronchoscope on 2022-10-27. Thus we need your professional evaluation and suggestion. Thank you very much.
    • A
      • Local finding via scope (PACS):
        • Bil. few thick mucus and nasal cavity, suspected chronoc rhinosinusitis
        • No obvious abnormal lesion was noted via this exam
      • Suggestion:
        • OPD f/u for his chronoc rhinosinusitis is enough
  • 2022-08-05 Radiation Oncology
    • A
      • A: Squamous cell carcinoma of the M-L/3 esophagus, with gastric involvement, stage cT3N3M0.
      • P: CCRT is indicated for this patient with the following indicators: esophageal cancer with gastric involvement, stage cT3N3M0.
        • Goal: palliation
        • Treatment target and volume: esophageal tumor, peripheral involved and regional involved nodal lesions.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5040cGy/28 fractions of the esophageal tumor, peripheral involved and regional involved nodal lesions.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-08-09.
  • 2022-08-02 Hemato-Oncology
    • Q
      • For CCRT surveillance
      • This is a 63 y/o male with history of hyperthyroidism (subclinical?) without medical treatment.
      • He was admitted for tumor work-up and treatment due to unintentional BW loss, esophageal and gastric tumor noted via PES on 20220728.
      • Pathological study showed squamous cell carcinoma. We sincerely need your expertise for CCRT evaluation and management.
    • A
      • This 63-year-old man was consulted and evaluated for esophageal cancer and CCRT
      • A:
        • esophagel cancer, with partial obstruction.
      • Recommendation:
        • CCRT is indicated for this patient
        • suggest port-A implantation and feeding jejumstomy for nutrition

[surgical operation]

  • 2022-08-08 laparoscopic gastrostomy and port-A implantation

[chemoimmunotherapy]

  • 2023-01-02 - pembrolizumab 200mg NS 100mL 30min + [NS 500mL 2hr + cisplatin 80mg/m2 130mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 800mg/m2 1300mg NS 500mL 24hr D1-D5
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-02 - pembrolizumab 200mg NS 100mL 30min + [NS 500mL 2hr + cisplatin 80mg/m2 130mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 800mg/m2 1300mg NS 500mL 24hr D1-D5
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-11-11 - pembrolizumab 200mg NS 100mL 30min + [NS 500mL 2hr + cisplatin 80mg/m2 130mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 800mg/m2 1300mg NS 500mL 24hr D1-D5
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-09-16 - [NS 500mL 2hr + cisplatin 75mg/m2 120mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-D4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-08-19 - [NS 500mL 2hr + cisplatin 75mg/m2 120mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-D4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-02-10

  • After the last round of chemotherapy (in early Jan 2023), he suffered from severe diarrhea for seven days and poor intake of food.
  • Chest CT images (2023-01-18) and abdomen CT images (2023-02-10) indicated that the disease is progressive.
  • A subsequent line treatment with paclitaxel 50 mg/m2 and carboplatin AUC 2 weekly for 5 weeks could be considered optionally.

2023-01-03

  • As part of the admission diagnosis, COPD with (acute) exacerbation is present, however, the Sp02 remains at no less than 94% according to vital sign records in this hospitalization.
  • Here are a few signs to watch for: diffuse wheezing, distant breath sounds, barrel-shaped chest, tachypnea, tachycardia, use of accessory muscles, brief and fragmented speech, inability to lie supine, profound diaphoresis, agitation, and an asynchrony between respiration and chest and abdominal movements.
  • In the event that exacerbations occur:
    • Inhaled beta agonist: Albuterol 2.5 mg diluted to 3 mL via nebulizer or 2 to 4 inhalations from metered dose inhaler (MDI) every hour for 2 or 3 doses; up to 8 inhalations may be used for intubated patients, if needed.
    • Short-acting muscarinic antagonist (anticholinergic agent): Ipratropium 500 micrograms (can be combined with albuterol) in 3 mL via nebulizer or 2 to 4 inhalations from MDI every hour for 2 to 3 doses.
    • Intravenous glucocorticoid (eg, methylprednisolone 60 mg to 125 mg IV, repeat every 6 to 12 hours).
  • A slightly low level of serum Na, K, and Mg was found in the 2023-01-02 lab result. Corresponding supplements were administered.

701463803

230210

[exam findings]

  • 2023-01-20 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, lower C-spine, middle and lower T-spines, some L-spines, bilateral shoulders, hips and knees in whole body survey.
    • IMPRESSION:
      • Increased activity in the lower C-spine, middle and lower T-spines and some L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
      • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
  • 2023-01-18 ECG
    • Possible Left atrial enlargement
    • Left axis deviation
    • Nonspecific T wave abnormality
  • 2022-12-30 SONO - abdomen
    • Findings:
      • The liver shows normal in size and echogenicity without focal lesion.
        • Portal vein flow: patent.
        • Bile ducts: not dilated.
      • The gallbladder appears normal in wall thickness and size.
        • There is no evidence of stone, polyp or sludge.
      • The pancreatic head and body shows normal in size and texture.
        • The pancreatic tail is obscured by overlying bowel gas.
      • The spleen shows normal in size and echogenicity without focal lesion.
      • Abdominal aorta and IVC show unremarkable finding.
      • There is no evidence of para-aortic lymphadenopathy or ascites.
      • Both kidney show normal echopattern and size.
        • There is no evidence of stone or hydronephrosis.
    • Impression:
      • Normal sonographic study of the hepatobiliary system.
  • 2022-12-23 Patho - breast mastectomy with regional lymph nodes
    • PATHOLOGIC DIAGNOSIS
      • Breast, left, modified radical mastectomy — Invasive carcinoma of no special type
      • Resection margin, breast, left, modified radical mastectomy — Free
      • Lymph node, level I and level II, left axilla, modified radical mastectomy — Metastatic carcinoma (1/12)
      • AJCC 8 th edition, Pathology stage: pT4bN1a(cM0); Anatomic stage IIIB; Prognostic stage IIIB
    • MACROSCOPIC EXAMINATION
      • Breast Size: 18 x 12 x 5.0 cm
      • Skin Size: 11.5 x 4.5 cm
      • Nipple: Not retracted
      • Tumor Size: 3.5 x 3.0 x 2.5 cm
      • Resection Margin: Free, 0.1 cm from the deep margin
      • Lymph nodes, left axillary: Level 1 and level 2
      • Representative parts are taken for section and labeled: A1=lateral margins, A2-A8= tumor, B1-B4= left axillary LN, level I, C= left axillary LN, level II
    • MICROSCOPIC EXAMINATION
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma: 3.5 x 3.0 x 2.5 cm
      • Histologic grade (Nottingham histologic score): Grade 2 (score= 6)
      • Skin involvement with ulcer: Present
      • Ductal carcinoma in situ: Present; Extensive DCIS: Negative
      • Margins: Negative; Closest margin (1 mm from deep margin)
      • Nodal status: Positive (level I 1/11; level II 0/1)
        • number of lymph node examined: 11 (level I), 1 (level II)
        • number with macrometastases (>2mm): 1 (level I)
        • number with micrometastases (>0.2~2mm and/or >200 cells): 0
        • number with isolated tumor cells (<=0.2mm and <=200 cells): 0
      • Extranodal extension: Not identified
      • Treatment Effect: No presurgical neoadjuvant therapy received
      • Lymphovascular invasion: Presnt
      • Perineural invasion: Present
    • IMMUNOHISTOCHEMICAL STUDY (at Kaohsiung Armed Forces General Hospital)
      • ER (Ab): Positive (90%, 3+)
      • PR (Ab): Negative
      • HER-2/Neu (Ab): Negative
      • Ki-67: 5%
  • 2022-12-21 CT - chest
    • Indication: Malignant neoplasm of central portion of left female breast
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lymphadenopathy at left axillary region is found.
        • Soft tissue mass at left breast up to 2.8cm is found.
        • Minimal atelectatic change at right middle lobe is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Left breast cancer with left axillary lymphadenopathy
  • 2022-12-21 ECG
    • Normal sinus rhythm
    • Left anterior fascicular block
    • Abnormal ECG
  • 2022-12-21 Spirometry
    • Mild restrictive ventilatory impairment
  • 2022-12-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (92.4 - 23.4) / 92.4 = 74.68%
      • M-mode (Teichholz) = 74.7
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild MR, TR
  • 2022-12-20 External Eye Photography
    • cataract

[chemotherapy]

  • 2023-02-10 - Endoxan (cyclophosphamide) 600mg/m2 836mg NS 500mL 1hr + Lipo-Dox (liposome doxorubicin) 35mg/m2 48mg dextrose 5% 250mg 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg + NS 250mL
  • 2023-01-19 - Endoxan (cyclophosphamide) 600mg/m2 823mg NS 500mL 1hr + Lipo-Dox (liposome doxorubicin) 35mg/m2 48mg dextrose 5% 250mg 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg + NS 250mL
  • package insert
    • Endoxan: WBC > 2500
    • Lipo-Dox: ANC > 1500

[assessment]

  • 2023-02-09 WBC 1.74 *10^3/uL, Neutrophil 52.4%, Band 0.0% => ANC 912/mm3 grade 3 neutropenia. In the case of grade 3 neutropenia, chemotherapy is not recommended.
  • If the patient’s granulocyte count needs to be increased within a short period of time, 250ug of Granocyte (lenogastin) or 150ug of G-CSF (filgrastim) is recommended for two or three consecutive days. However, please do not administer G-CSF in the period 24 hours before to 24 hours after administration of cytotoxic chemotherapy because of the potential sensitivity of rapidly dividing myeloid cells to cytotoxic chemotherapy.
  • It is suggested to closely monitor any signs of infection.

700702162

230206

[diagnosis] - 20230203 admission note

  • Intrahepatic bile duct carcinoma
  • Malignant neoplasm of larynx, unspecified
  • Cholangiocarcinoma s/p weekly chemotherapy with Gemzar/CDDP * 8 doses (4 cycles) in TP-VGH (last dose on 2022/06/09), PD with spleen metastasis, stage IV on 2022/06/23 s/p plliative chemotherapy with FOLFOX from 2022/08/12 ~ 2022/10/21 for 5 cycles with liver metastasis s/p Target therapy with Lenvatinib (self pay) from 2022/11/16
  • Chronic viral hepatitis B without delta-agent
  • Essential (primary) hypertension

[past history]

  • Larynnx cancer (SCC), stage Tis, diagnosis at Cardinal Tien Hospital s/p radiotherapy at NTUHon 2017-04 ~ 2017-06
  • HBV under HBs(+) noted 30+ y/o, Hepatitis flare 2012-04 ~ (HBVDNA 1.36*7iu/ml) HBs(+>250iu/ml) HBe(-) antiHBe(+). PegIFN (Roche), 2012-09-12 ~ NHI 2012/09/14 ~ 2013/01 ETV NHI 2013/01/04 ~, self-paid 4/wk 2016/01/05 ~
  • DM with diet control 60 y/o~
  • Hypertension regular Olmetec 20mg 1# po QD tx 55 y/o~
  • Vocal cord SCC 28 y/o Cardinal Tien Hospital post R/T NTUH 2017/04 ~ 06    

[allergy]

  • Naproxen (KNAPO02): skin rash
  • Trimethoprim, Sulfamethoxazole (KBAKT01): slight ???

[exam findings]

  • 2023-02-03 KUB
    • Scoliotic alignment of the lumbar spine is found.
    • Phlebolith at pelvic cavity is also found.
  • 2023-02-03 CXR
    • Nodular lesion at right central lung is found.
  • 2023-01-31 CT - abdomen
    • History and indication: Intrahepatic cholangiocarcinoma
    • Findings
      • Some hypodense lesions (up to 3.3cm) in liver. A small enhancing tumor (1.6cm) at liver dome with venous wash out pattern. S/P right hepatic lobe operation. Grade 4 fatty liver.
      • Multiple nodules in bil. lungs.
      • Wall thickening of A-colon. Minimal ascites.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Duodenal diverticulum.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • A recurrent tumor (1.6cm) at liver dome.
  • 2022-10-24 CT - abdomen
    • Indication:
      • Intrahepatic bile duct carcinoma with splenic mets s/p OP and RFA
      • Malignant neoplasm of larynx, unspecified
    • Abdominal CT with and without enhancement revealed:
      • Abdomen
        • s/p right hepatic op.
        • Several low density lesions scattered at both lobes of liver is found up to 3.53cm at S4. Liver meta is considered. In comparison with CT dated on 2020-08-10, progession of the tumors are found.
        • Lymphadenopathy at hepatic hilum, mesenterric region and gastrohepatic ligment and paraaortic region is found.
        • MInimal ascites is found.
        • The GB is well distended without soft tissue lesion
        • The urinary bladder is well distended without soft tissue lesion.
        • The spleen, pancreas, both kidneys and adrenals are intact.
      • Visible chest
        • Normal heart size.
        • The lung fields are clear.
        • No pleural effusion is found.
    • Imp: Multiple liver meta with lymphadenopathy in the abdominal cavity.
  • 2020-08-10 CT - liver, spleen, biliary duct, pancreas
    • History and indication: cancer F/U
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A small enhancing tumor (1.1cm) at liver dome with venous wash out pattern. S/P right hepatic lobe operation. Grade 4 fatty liver.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Duodenal diverticulum.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • No abnormal density at bilateral basal lungs.
    • IMP:
      • A recurrent tumor (1.1cm) at liver dome. S/P right hepatic lobe operation. Grade 4 fatty liver.
  • 2020-06-03 Patho - liver partial resection
    • Diagnosis
      • Liver, S7, resection — Cholangiocarcinoma
    • Gross Description:
      • Procedure: S7 partial hepatectomy, 7 x 6 x 3 cm, 70 gms
      • Tumor Focality: Solitary
      • Tumor Site: Right lobe S7
      • Tumor Size: 2.2 x 2.0 x 1.8 cm , 2.0 cm away from closest margin
      • Non-tumorous part: cirrhotic
      • Gallbladder: size: not received.
      • Sections are taken and labeled as: A1-2: tumor with margins; A3-4: tumor; A5: non-tumor.
    • Microscopic Description:
      • Diagnosis: Intrahepatic cholangiocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Growth Pattern: Mass-forming
      • Tumor Extension: Tumor confined to hepatic parenchyma
      • Parenchymal Margin Uninvolved by invasive carcinoma
      • Bile duct Margin Uninvolved by invasive carcinoma
  • 2020-05-19 Visceral Angiography 2 vessels
    • DSA of celiac trunk, common hepatic artery and SMA with post-angiography CTAP study via right common femoral artery puncture revealed:
      • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
      • Patency of portal vein.
      • A faint enhancing tumor at right hepatic lobe.
      • Post-angiography CTAP images also revealed a perfusion defect (2.5cm) at right hepatic lobe. Left liver cyst (5mm).
      • No procedure-related complication during the whole procedure.
    • IMP: Right liver tumor, HCC is first considered.
  • 2020-05-15 CT - liver, spleen, biliary duct, pancreas
    • Indication:
      • 2015-08-14 HBV
      • 2020-05-12 US: susp tumor 17mm, > CT HBs(+) noted 30+y/o, HBe(-) antiHBe(+)
      • Vocal cord SCC 28y/o at Cardinal Tien Hospital and post R/T at NTUH 2017/4~6
      • FH: senior brother HBs + Cholangioca died 58y/o.
    • Findings:
      • There is an ill-defined hypodense mass lesion measuring 1.8 x 1.3 cm in S6 of the liver subcapsule area. During dynamic study, this mass shows mild contrast enhancement in arterial phase images and contrast washout in portal venous phase and delayed phase images.
        • HCC is highly suspected. The differential diagnosis include cholangiocarcinoma.
        • Please correlate with AFP and contrast enhanced dynamic MRI.
      • A hepatic cyst measuring 0.4 cm in S3 is suspected. Please correlate with sonography.
      • There is a diverticulum measuring 2.9 cm in the medial aspect of duodenum 2nd portion, near the ampulla of Vater area. Please correlate with clinical condition.
    • Imaging Report Form for Cholangiocarcinoma
      • Impression (Imaging stage): T:T1a (T_value) N:N0 (N_value) M:M0 (M_value) STAGE:IA(Stage_value)
  • 2020-05-04 SONO - abdomen
    • Diagnosis
      • Fatty liver, mild
      • Parenchymal liver disease, mild
      • Liver tumor, hypoechoic, nature indeterminate (1.7 cm, right lobe)
      • Suspected tiny GB polyps
    • Suggestion
      • Correlate with CT or MR
      • Check AFP
  • 2019-11-05 SONO - abdomen
    • Findings
      • Smooth liver surface. Small anechoic lesion about 0.5cm was noted at left lobe.
      • No gall stone. Small polyp about 0.2cm was noted on the gallbladder wall. No CBD dilatation.
    • Diagnosis
      • Liver cyst, left lobe
      • Gallbladder polyp
  • 2019-04-03 SONO - abdomen
    • Findings
      • Increased brightness, far attenuation and increased hepatorenal contrast
      • A few cysts were detected and the largest one 0.7 cm in size, was at S5
      • 2/3 pancreas was mask by bowel gas
      • Increased brightness of pancreas
    • Diagnosis
      • Fatty liver, mild
      • Fatty infiltration of pancreas
      • Liver cysts
  • 2018-09-19 SONO - abdomen
    • Findings
      • Increased brightness of echotexture. One 0.70cm anechoic cystic lesion with posterior enhancement at S5.
      • One 0.35cm hyperechoic lesion within GB lumen. No dilatation of CBD.
    • Diagnosis
      • Fatty liver, mild
      • Hepatic cyst, right
      • GB polyp
  • 2018-03-23 SONO - abdomen
    • Findings
      • Size normal; Surface smooth; Edge sharp; Vessel well-defined; Echotexture: increased hepatorenal echocontrast; One hypoechoic lesion about 0.8cm was found at the right anterior segment
      • One hyperechoic lesion about 0.4 cm in the GB; Normal GB wall thickness; No biliary tract dilatation
    • Diagnosis
      • Fatty liver,mild
      • Suspected liver cyst,right
      • Suspecetd GB polyp
      • Pancreas not shown
  • 2017-09-21 SONO - abdomen
    • Findings
      • bright echo appperance with increased hepatorenal contrast, mild
      • obliteration of portal tract; a 0.77-cm anechoic lesion at seg5
      • a 0.48-cm polyp in GB ; no biliary tract dilatation.
    • Diagnosis
      • mild fatty liver
      • liver cyst
      • GB polyp
  • 2017-03-22 SONO - abdomen
    • Indication: Hepatitis
    • Findings
      • Mildly bright liver echo comparing with renal cortex.
      • A 8-mm cyst in liver, right lobe.
      • A 6-mm polyp in GB. No biliary dilatation.
      • pancreas ~60% visible
    • Diagnosis
      • Mild fatty liver + Right Liver cyst
      • GB polyp

[consultation]

  • 2023-01-17 Dermatology
    • Q
      • This 64-year-old male patient has past history of 1) Larynnx cancer (SCC), stage Tis, diagnosis at Cardinal Tien Hospital s/p radiotherapy at National Taiwan University Hospital on 2017/04 ~ 2017/06; 2) HBV under ETV (4/wk) tx (self-paid), 3) Hypertension, he was regularly followed up at OPD. According for his statement, abdominal sonography on 2020/05/04 showed 1) Fatty liver, mild; 2) Parenchymal liver disease, mild; 3) Liver tumor, hypoechoic, nature indeterminate (1.7 cm, right lobe); 4) Suspected tiny GB polyps. Further Abdominal CT was perfromed on 2020/05/17 and revealed 1) HCCs 1.8 x 1,3 cm in S6 of the liver is highly suspected. The differential diagnosis include cholangiocarcinoma. Alpha-feto-protein (AFP) was 3.0ng/dl on 2020/05/04. Angio CT on 2020/05/15 also revealed a perfusion defect (2.5cm) at right hepatic lobe. Left liver cyst (5mm).
      • Cholangiocarcinoma s/p weekly chemotherapy with Gemzar/CDDP * 8 doses (4 cycles) in TP-VGH (last dose on 2022/06/09). Liver tumor biopsy on 2020/06/03 and pathology showed cholangiocarcinoma. PD in new lesion over spleen based on the findings of CT on 2022/06/24.
      • He was transfer to our hospital for further treatment. The patient has been informed again palliative chemotherapy with FOLFOX (Oxalip 85mg/m2 and 5HT3 are not covered by NHI) on 2022/08/12. Palliative chemotherapy with FOLFOX (Oxalip 85mg/m2 self pay, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) on 2022/8/12(C1D1), 2022/08/26(C1D15), 2022/09/13(C2D1), 2022/10/05(C2D15), 2022/10/21(C3D1). Abdominal CT on 2022/10/24 showed multiple liver metastases with lymphadenopathy in the abdominal cavity. Target therapy with Lenvatinib (self pay) from 2022/11/16. Now, he was admitted to ward for target therapy with Lenvatinib (self pay).        
      • For Lenvatinib related side effect of hand, we need your further evaluation and management.
    • A
      • The patient had sufferred from mutiple erythematous plaques with thick scales and erosion.
      • Under the impression of hand-foot syndrome after chemotherapy and target therapy.
      • The following sugeetion:
        • Tetracycline onit 2 tube topical bid use on the wound and erosive lesions first.
        • Sinphraderm cream (urea 100mg/gm) 1 tube topical QN use after body clean for skin mositurization and keratolytic effect.
        • If new erythema lesions development, consider Topysm cream (fluocinonide) 1 tube topical bid use for anti-inflammation.
  • 2020-05-18 Radiation Oncology
    • Q
      • for arrange angiography with CTAP (computed tomography arterial portography)
      • This 61 year-old male of DM, HBV.
      • Abdominal CT showed HCCs 1.8 x 1,3 cm in S6 of the liver is highly suspected. The differential diagnosis include cholangiocarcinoma. Please correlate with AFP and contrast enhanced dynamic MRI. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition, CT staging of HCC: T1N0Mx, Staging: I.
    • A
      • According to the clinical condition and imaging findings, angiography with CTAP study is indicated.

[chemotherapy]

  • 2022-10-21 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3
  • 2022-10-05 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-09-13 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-08-26 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-08-12 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

[medication]

  • Lenvima (lenvatinib) KLENV02
    • 2022-11-16 ~ undergoing 10mg QD
  • Baraclude (entecavir) KBARA01
    • 2022-11-02 ~ undergoing 0.5mg QDAC
    • 2020-08-21 ~ + 84 days 0.5mg QDAC

==========

2023-02-06

  • 2023-02-06 lab data showed low Na, low K, low Mg, low Ca in the blood, Nako No.5 electrolyte solution has been provided appropriately.
  • Due to the patient’s blood pressure level staying at 90/50 for the past two days, it is not necessary to lower his blood pressure further. Please temporarily hold the self-carried Olmetec (olmesartan).
  • Please follow up with the patient to determine whether the hand-foot syndrome is improving, if not, topical tetracycline, Sinphraderm (urea), and Topysm (fluocinonide) can be applied again.

2023-01-18

  • Because lenvatinib has a moderate to high emetic potential, the antiemetic agent metoclopramide has also been prescribed appropriately in combination with lenvatinib.
  • Lenvatinib’s dermatologic adverse reactions include: alopecia (12%), palmar-plantar erythrodysesthesia (27% to 32%), skin rash (14% to 21%). The developed hand-foot syndrome has been referred to a dermatologist and topical tetracycline, Sinphraderm (urea), and Topysm (fluocinonide) have been prescribed to mitigate the symptoms.
  • As the patient has a history of hypertension, and lenvatinib is also associated with hypertension (45% to 73%; severe hypertension: 3%), it is recommended that blood pressure be closely monitored.

700151650

230203

{not completed}

[exam findings]

  • 2023-02-02 Tc-99m MDP whole body bone scan
    • Mildly increased activity in the middle and lower T-spines, some L-spines and sacrum. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral wrists, hip and right knee, compatible with benign joint lesion.
    • No prominent bone abnormality was noted elsewhere.
  • 2023-02-02 SONO - chest
    • Echo diagnosis:
      • pleural effusion
    • Suggestion:
      • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
      • Check bleeding, if bleed from pig tail tube, please call Dr.
      • CxR follow up pig tail tube position.
  • 2023-02-01 Bronchoscopy
    • no endobronchial mass,
    • s/p bronchial washing via RML, sent for TB culture, TB PCR and cytology
  • 2023-01-31 SONO - thyroid gland
    • Normal size of the thyroid gland.
    • Some hypoechoic nodules (up to 0.67cm) in left thyroid gland.
    • Some LNs at bil. neck.
  • 2023-01-19 Cell block
    • PATHOLOGIC DIAGNOSIS
      • Positive for malignancy
      • Immunocytochemistry show TTF-1(+), CK7(+), Napsin-A(+), CK20(-) and CDX-2(-), compatible with metastatic pulmonary adenocarcinoma
      • The smears and cell block show lymphocytes, mesothelial cells and many hyperchromatic atypical epithelial clusters with focal tubular arrangement, compatible with metastatic adenocarcinoma.
  • 2023-01-19 SONO - chest
    • Echo diagnosis:
      • Pleural effusion
    • Suggestion:
      • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
  • 2023-01-18 CT - chest
    • Findings
      • lungs:
        • a spiculated tumor at mediobasal segment of RLL (31mm in axial dimension) invading adjacent pericardium.
        • partial atelectasis of RML.
        • innumberable randomly distributed pulmonary small nodules of varying sizes due to lung to lung metastases.
        • moderate Rt pleural effusion.
      • Mediastinum and hila:
        • extensive lymphadenopathy in the visceral space, with central necrosis in subcarinal LAP.
      • Aorta:
        • normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Heart:
        • normal in size of cardiac chambers.
        • mild calcified mitral annulus
      • Chest wall and visible lower neck:
        • suspect metastatic LAP aty Lt supraclavicular fossa.
      • Visible abdominal contents:
        • normal appearance of gall bladder.
        • a small Rt hepatic measurig 10mm.
    • Impression: RLL cancer T4N3M1a(E1)
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:M1a(M_value) STAGE:____(Stage_value)
  • 2023-01-17 CXR
    • diffuse miliary lesions in both lungs with xonsolidation and volume reduce over Rt lower lung zone and Rt pleural effusion, miliary tuberculosis or metastasis
    • Mild dextroscoliosis of the T-spine
    • Thoracic aortic arch calcified atheriosclerotic plaque
  • 2023-01-12 Merchant view (patella 45 0) Bil :
    • Lateral subluxation of the patella, Rt
    • Patellofemoral osteoarthritis
    • Sperner classification: 3, 3
  • 2023-01-12 Knee BIL standing AP and Lat
    • Moderate to severe osteoarthritis of both knees, Rt > Lt
    • Ahlback calcification: grade 4, 3
  • 2022-08-15 Peripheral Vascular Test - Vein, lower limbs
    • Significant venous reflux at left saphenofemoral junction with varicose change of left LSV from upper to lower leg level (Tortuous change at lower leg level). Slow venous return flow at left popliteal vein; atleast two perforator veins connecting the left PTV and LSV at left proximal to middle lower leg level were detected.
    • Slow venous return flow at left popliteal vein; atleast three perforator veins connecting the right PTV and LSV at right proximal to distal lower leg level were detected.
    • No evidence of venous thrombosis at bilateral lower limbs venous systems.
    • The ratios of MVO and SVC of bilateral legs were within normal limits.
  • 2022-08-02 ENT Hearing Test
    • Reliabilty Fair to Poor, 50dB
    • PTA
      • R’t : 73 dB HL, moderately severe to profound mixed type HL
      • L’t : 68 dB HL, moderately severe to profound SNHL
    • Tymp
      • R’t : Type A
      • L’t : Type As.
  • 2022-08-02 Nasopharyngoscopy
    • Findings
      • bil clear nasal cavity; smooth NPx, oropharynx, hypopharynx, no vocal lesion
      • a few whitish discharge coating on pharyngeal wall
    • Conclusion
      • chronic pharyngitis and rhinitis

701456943

230202

[diagnosis] - 2023-01-12 discharge note

  • Adenocarcinoma of rectosigmoid junction status post laparoscopic low anterior resection on 2022/11/03, pT3N2aM0(6/17), stageIIIB
  • Constiplation

[Past History]

  • DM under metformin
  • Adenocarcinoma of rectosigmoid junction status, cT3N2bM0, status post laparoscopic low anterior resection on 2022/11/03, pT3N2aM0(6/17), stageIIIB, LVI(+), PNI(-), CRM(-), EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+) , stageIIIC    

[Family History]

  • His mother had colon cancer and DM
  • His younger brother had colon cancer; one of his elder sister had lung adenocarcinoma; one of his elder sister had gastric cancer
  • He denied other systemic diseases

[lab data]

  • 2022-10-20 HBsAg (NM) Negative
  • 2022-10-20 HBsAg Value (NM) 0.424
  • 2022-10-20 Anti-HBs (NM) Positive
  • 2022-10-20 Anti-HBs value (NM) 197
  • 2022-10-20 Anti-HCV (NM) Negative
  • 2022-10-20 Anti-HCV Value (NM) 0.0365

[exam findings]

  • 2022-12-02 Anoscopy
    • Mixed hemorrhoids with congestion
  • 2022-11-04 All RAS + BRAF mutation
    • ALL-RAS:
      • Detected (KRAS codon 12 GGT>GAT, p.G12D)
    • BRAF:
      • There was no variant detect in the BRAF gene.
  • 2022-10-28 Patho - colon segmental resection for tumor
    • Diagnosis:
      • Intestine, large, RS colon, Laparoscopic low anterior resection — Moderately differentiated adenocarcinoma
      • Distal cut-end: Free
      • Proximal cut-end: Free
      • Lymph node, regiona, dissection — Metatstaic adenocarcinoma (6/17)
      • AJCC 8th edition pathology stage: pT3N2a(if cM0); AJCC stage IIIB
    • Gross Description:
      • Procedure: Laparoscopic low anterior resection
      • Tumor Site: RS colon
      • Tumor Size: 5 x 4 cm.
      • Macroscopic Tumor Perforation: Not identified
      • Macroscopic Intactness of Mesorectum (if applicable): Complete
      • Sections are taken and labeled as:A:distal cut end, B1-3:LNs, B4-10:tumor, C:proximal cut end
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Uninvolved
        • Distance of tumor from margin: 4 cm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Not identified
      • Tumor Budding:
        • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2)
        • Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose:Not identified
      • Tumor Deposits: Not identified
        • Specify number of deposits: N/A
      • Regional Lymph Nodes:
        • Number of Lymph Nodes Involved/Examined: 6/17
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply)
        • m (multiple primary tumors) r (recurrent) y (posttreatment)
          • Primary Tumor (pT)
            • pT3: Tumor invades through the muscularis propria into pericolorectal tissues
          • Regional Lymph Nodes (pN)
            • pN2a: Four to six regional lymph nodes are positive
          • Distant Metastasis (pM):
            • N/A
      • Additional Pathologic Findings (select all that apply): None identified
      • Ancillary Studies: Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
      • Comment(s): None
  • 2022-10-28 Sigmoidoscopy
    • Diagnosis
      • A fungating tumor lesion (3-4cm in size) is located at rectosigmoid junction (15cm AAV)
      • A middle rectal diverticulum
    • Suggestion
      • suggest operation
  • 2022-10-21 CT - abdomen
    • History: passage of bloody stool, change in bowel habit, decrased stool caliber for weeks. tumor of RS-colon at YongHe local clinics.
    • Findings:
      • There is segmental wall thickening of the recto-sigmoid colon, measuring 1.3 cm in the maximal wall thickness that is c/w adenocarcinoma (T3).
        • In addition, There are seven enlarged nodes in the perirectal space and sigmoid mesocolon that are c/w metastatic nodes (N2b).
      • There is a small poor enhancing lesion measuring 5 mm in S2 of the liver that may be cyst? Please correlate with sonography.
      • There is no focal lesion in both lung and mediastinum.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N2b (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)

[surgical operation]

  • 2022-10-03
    • Surgery
      • Laparoscopic low anterior resection     
    • Finding
      • A fungating 4-5cm tumor is located at RS-colon. Some adhesions over small bowel and S-colon mesentery was found, and adhesiolysis was done.    
      • Radical proctectomy (low anterior resection) with total mesorectal excision was carried out smoothly. Blood loss was about 30ml.    
      • Anastomosis was achieved using endo GIA 601+ 451/ green, + CDH-33 + TISSEEL 4ml. Air test is ok.     
      • A drain in pelvis, 4DF 3g was applied for prevent adhesions.  

[radiotherapy]

  • 2022-12-05 ~ 2023-01-13 - completed RT to the pelvis: 45 Gy/ 25 fx. The rectal tumor bed: 54 Gy/ 30 fx.

[chemotherapy]

  • 2023-02-01 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 2hr + fluorouracil 2400mg/m2 4100mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + metoclopramide 10mg
  • 2023-01-09 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 2hr + fluorouracil 2400mg/m2 4100mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + metoclopramide 10mg
  • 2022-12-19 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + metoclopramide 10mg
  • 2022-12-05 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + metoclopramide 10mg

[assessment]

  • The lab results (2023-02-01) were grossly normal.
  • Metformin (prescribed by a local clinic) is not included on the active medication list despite the fact that the patient has a history of diabetes.
  • If there are no contraindications, the addition of metformin is recommended to maintain stable blood sugar control.

700508887

230201

  • diagnosis
    • 2023-01-11 admission note - Acute lymphoblastic leukemia not having achieved remission
    • 2022-12-21 OPD assessment - MDS is considered with Karyotype: 45~46,XX,+1,der(1;16)(q10;p10)[cp7]/46,XX[7]
    • 2022-12-09 OPD assessment - MDS is considered
  • past history - 20230111 admission note
    • Myelodysplastic syndrome diagnosed on 2022-12-05 by BM biopsy
    • Hypertension for years, with medication (Aprovel) control and regular follow-up at Cardinal Tien Hospital
    • Hyperlipidemia for years, with medication (Livalo) control and regular follow-up at Cardinal Tien Hospital
    • Thrombocytopenia since 2015, and regular follow-up at Cardinal Tien Hospital
  • allergy
    • NKDA
  • family history
    • Mother: Hypertension.
    • Deny any cancer history
  • exam findings
    • 2023-01-11 CXR
      • Essential negative findings of the air way, mediastinum, heart, lungs, pleura, diaphragm and thoracic cage.
    • 2022-12-05 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy — Normal cellularity with presence of blasts; Suspicious for myelodysplastic syndrome
        • NOTE: Correlation with peripheral blood test, bone marrow smear, flow cytometry, molecular genetic study and clinical findings is recommended.
      • Microscopically, it shows normal cellularity for age (40%), 3:1 of M:E ratio and presence of trilineage marrowe component. Occasional megakaryocytes are seen. Blasts are highlighted by CD34 and CD117 (<20%).
      • Immunohistochemical stain reveals MPO (focal +), CD71(focal+), CD20(focal+), CD138(focal+), CD10(-) and TdT(-).
    • 2022-12-02 CXR
      • cardiomegaly; mediastinal widening

==========

2023-02-01

[potential drug interactions]

  • Flunarizine (patient-carried) is cocommitant with clonazepam, diphenhydramine, estazolam and fexofenadine currently.

  • According to the flunarizine product monograph (https://www.aapharma.ca/downloads/en/PIL/2021/Flunarizine_PM_EN.pdf), use of CNS depressants, including alcohol, should be avoided during treatment with flunarizine due to the risk of excessive sedation.

  • There is also an antivertigo preparation available in stock known as Nilasen (betahistine 24mg/tab), which has a lower risk of drug interaction than flunarizine and can be considered as a 1# daily dosage alternative.

2023-01-11

There is no specific pharmacist shift handover to follow in this patient.

[drug identification]

  • A request has been made for us to identify drugs for 3 items.
  • In total, 3 items have been identified as follows, with 0 item remaining unidentified.
    • Doxynin (doxycycline 100mg)
    • Welizen (famotidine 20mg)
    • Flamquit (diclofenac potassium 50mg)
  • These drugs will be sent back to ward by the in-hospital porter.

701352128

230201

[diagnosis] - 2023-02-01 discharge note

  • Gastric cancer with liver metastasis status post total gastrectomy with D2 and dissection, S2-3 left lateral segmentectomy, S6-7 partial hepatectomy and S4-8 alcohol injection on 2021-12-16, stage IV.
  • Chronic viral hepatitis B without delta-agent, 2022/12/23 Anti-HBc: postive

[lab data]

  • 2022-12-26 HBV-DNA-PCR Target Not Detected IU/mL
  • 2022-12-23 Anti-HBc Reactive
  • 2022-12-23 Anti-HBc-Value 4.82 S/CO
  • 2021-12-13 HBsAg Nonreactive
  • 2021-12-13 HBsAg (Value) 0.32 S/CO

[exam findings]

  • 2023-01-31 CT - abdomen
    • Clinical history: 70 y/o male patient with Gastric cancer (pathology showed poorly adenocarcinoma) with outlet obstruction.
    • Impression:
      • S/P total gastrectomy.
      • Ascites with pleural effusion and basal lung atelectasis, progression.
      • Minimal pericardial effusion.
  • 2022-10-12 CT - abdomen
    • History and Indication:
      • 20211206 Gastroscopy at Yonghe Cardinal Tien hospital: gastric cancer at the antrum induce gastric outlet obstruction.
      • 20211214 sono: A 1.7 cm hypoehcoic lesion at S2
      • 20211215 CT: gastric cancer & liver metas? cT4aN3aM1, csTAGE:IVB
      • 20211217 S/P total gastrectomy: pT4aN3bM1, pstage:IV
    • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings - Comparison: prior CT dated 2022/03/16.
      • There is ascites in pre-hepatic space, perisplenic space, and the pelvis.
        • S/P total gastrectomy.
        • S/P total resection of S2-3 and tumor enucleation of S6/7 of the liver.
      • Prior CT identified three ill-defined poor enhancing lesions on S4, S8, and S5 of the liver are not noted again that are c/w metastases S/P C/T with complete response.
      • Prior CT identified A small ground-glass opacity in RUL-RML of the lung measuring 5 mm in lung window setting is not noted again.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • There is ascites in pre-hepatic space, perisplenic space, and the pelvis.
  • 2022-06-23 CT - abdomen
    • History and indication: Gastric cancer with liver metastasis
    • IMP:
      • Gastric cancer s/p operation. Minimal ascites in pelvic cavity.
      • Much regression of liver lesions.
  • 2022-03-16 CT - abdomen
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • S/P total gastrectomy.
      • S/P total resection of S2-3 and tumor enucleation of S6/7 of the liver.
      • There are three ill-defined poor enhancing lesions on S4, S8, and S5 of the liver that may be metastases? The largest one measuring 1.1 cm in S4.
      • A small ground-glass opacity in RUL-RML of the lung measuring 5 mm in lung window setting is noted.
        • Primary lung cancer is suspected.
        • The differential diagnosis include Metastasis.
        • Follow up is indicated.
    • Impression:
      • There are three ill-defined poor enhancing lesions on S4, S8, and S5 of the liver that may be metastases? The largest one measuring 1.1 cm in S4.
      • A small ground-glass opacity in RUL-RML of the lung measuring 5 mm in lung window setting is noted.
        • Primary lung cancer is suspected.
        • The differential diagnosis include Metastasis.
        • Follow up is indicated.
  • 2021-12-20 Upper GI series
    • S/P gastrectomy. No evidence of contrast medium leakage.
    • Normal contour and mucosal pattern of the esophagus.
    • Right CVP inserted to SVC in position.
    • Compression fracture of spine.
  • 2021-12-17 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS
      • Liver, S2-3, partial hepatectomy — Metastatic adenocarcinoma, stomach origin
      • Liver, S6-7, partial hepatectomy — Metastatic adenocarcinoma, stomach origin
    • MACROSCOPIC EXAMINATION
      • Procedures: Partial hepatectomy of S2-3 and S6-7
      • Specimen Size: 12 x 5.0 x 4.0 cm and 130 gm (S2-3); 3.0 x 2.0 x 1.2 cm (S6-7)
      • Tumor Focality: Multiple; number: 3 (S2-3) and 1 (S6-7)
      • Tumor Site: S2-3 and S6-7
      • Tumor Size: 1.4 x 1.2 cm, 1.2 x 0.9 cm, 0.2 x 0.2 cm (S2-3), and 0.8 x 0.6 cm (S6-7), respectively
      • Large vessel involvement: Not identified
      • Non-tumorous part: Not cirrhotic
      • Sections are taken and labeled as: A1-A4= S2-3 tumors, B1-B2= S6-7 tumor
    • MICROSCOPIC EXAMINATION
      • Diagnosis: Metastatic gastric adenocarcinoma
      • Histologic grade: Poorly differentiated
      • Tumor growth pattern: Infiltrating
      • Tumor pseudocapsule: Absent
      • Tumor necrosis: Present
      • Parenchymal margin: Uninvolved by carcinoma
      • Vascular invasion: Present
      • Perineural invasion: Not identified
      • Non-neoplastic liver parenchyma: Mild lymphocytic portal
  • 2021-12-17 Patho - stomach subtotal/total (tumor)
    • PATHOLOGIC DIAGNOSIS
      • Stomach, total gastrectomy — Mixed tubular adenocarcinoma and poorly cohesive carcinoma
      • Margins, bilateral cutting ends, total gastrectomy — Free of tumor invasion
      • Lymph nodes, D2 LN dissection — Metastatic adenocarcinoma (46/60)
      • Omentum, omentectomy — Free of tumor invasion
      • AJCC Pathologic staging — pT4aN3bM1, stage IV
    • MACROSCOPIC EXAMINATION
      • Specimen type: Stomach, lymph nodes, omentum
      • Specimen size: (a) Stomach: 31.5 cm along the greater curvature and 16.0 cm along the lesser curvature (b) Omentum: 35 x 22 x 5 cm
      • Number of lesions: Solitary
      • Tumor site: Antrum to cardia, lesser curvature, 3.5 cm from distal margin
      • Tumor size: 12.5 x 11.0 cm
      • Tumor configuration: Ulcerative tumor
      • Representative sections as follows: A1= distal cut end, A2-A5= tumor with lesser curvature LNs, A6-A7= tumor at antrum, A8= tumor at body, A9-A10= tumor at fundus and cardia, B1-B2= omentum, C= esophageal margin, D1-D4= LN 1, E1-E2= LN 2, F1-F5= LN 4, G1-G2= LN 5, H1-H2= LN 6, I1-I4= LN 7,8,9,11,12a,16, J1-J2= LN 10, K1-K2= LN 14. F2021-00500FS= esophageal cut end received for frozen section
    • MICROSCOPIC EXAMINATION
      • Histologic type: Mixed tubular adenocarcinoma and poorly cohesive carcinoma (Lauren classification: mixed type)
      • Histologic grade: Poorly differentiation (G3)
      • Depth of tumor invasion: Tumor invades the serosa
      • Margins: All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin: <1 mm from radial margin
      • Perineural invasion: Present
      • Lymphovascular space invasion: Present
      • Regional lymph nodes: Metastatic adenocarcinoma (46/60) 8/8 (lesser curvature LNs), 0/1 (omentum LN), 12/14 (LN 1), 0 (LN 2), 14/14 (LN 4), 1/2 (LN 5), 4/5 (LN 6), 4/8 (LN 7, 8, 9, 11, 12a, 16), 0/1 (LN 10), 3/7 (LN 14) (Number of LN involved/Number of LN examined)
      • Extracapsular extension: Present
      • Omentum: Free of tumor invasion
      • Additional pathologic findings: Liver metastasis (S2021-18735)
      • Pathologic Staging: pT4aN3bM1, stage IV
      • IHC: HER2(Negative, score= 0)
      • Esophageal margin (including frozen section specimen): Free of carcinoma
  • 2021-12-15 CT - abdomen
    • History and Indication:
      • 20211206 Gastroscopy at Yonghe Cardinal Tien hospital: gastric cancer at the antrum induce gastric outlet obstruction.
      • 20211214 sono: A 1.7 cm hypoehcoic lesion at S2
    • Findings:
      • There is an ill-defined poor enhancing mass measuring 1.5 cm in S2 dome of the liver at portal venous phase images and suggestive enhancement in delayed phase images.
        • In addition, there are two lesions measuring 0.5 cm in S4 and 0.7 cm in S5, showing similar feature.
        • Metastases are highly suspected.
        • The differential diagnosis include hemangioma.
        • Please correlate with MRI.
      • There is wall thickening at the gastric antrum measuring 1.3 cm in wall thickness. Please correlate with gastroscopy.
        • In addition, there are seven enlarged nodes in the gastrohepatic ligament, celiac trunk, and hepatoduodenal ligament that may be metastatic nodes.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T4a (T_value) N:N3a (N_value) M:M1 (M_value) STAGE:IVB(Stage_value)
  • 2021-12-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (84.4 - 24.6) / 84.4 = 70.85%
      • M-mode (Teichholz) = 70.9
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • AV sclerosis with mild AR, mild MR, TR and PR
    • No regional wall motion abnormalities
  • 2021-12-14 Patho - stomach biopsy
    • Stomach, prepyloric antrum, biopsy— poorly differentiated adenocarcinoma with focal signet-ring cell differentiation
    • Microscopically, it shows poorly differentiated adenocarcinoma composed of proliferation of neoplastic cells arranged in solid to glandular architecture, and focal signet-ring cell diffferentiation.
  • 2021-12-14 SONO - abdomen
    • Hepatic tummor, nature to be determinated
  • 2021-12-14 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Suboptimal study due to much semi-fluid residue retention
      • Ulcerative tumor, preplyoric antrum and probable low body, s/p biopsy x6
    • Suggestion
      • Pursue biopsy result
  • 2021-12-13 Spirometry
    • normal spirometry

[consultation]

  • 2021-12-24 Radiation Oncology
    • Q
      • This 69 y/o male with history of gastric with liver meta then s/p total gastrectomy with LN D2+ dissection and S23 resection + S6-7 partial hepatectomy + S4-8 alcohol injection on 2021/12/16. Pathology showed Mixed tubular adenocarcinoma and poorly cohesive carcinoma. pT4aN3bM1, stage IV. after well improved of general condition and well oral intake, further management of CCRT will plaining. We need your help for RT evaluation. Thanks you!!
    • A
      • A: Mixed tubular adenocarcinoma and poorly cohesive carcinoma of the stomach, AJCC Pathologic staging — pT4aN3bM1, stage IV, with liver metastases, s/p total gastrectomy with LN D2+ dissection, S23 resection, S6-7 partial hepatectomy, S4-8 alcohol injection.
      • P: Radiotherapy is indicated for this patient with the following indicators: stage pT4aN3bM1
        • Goal: palliation
        • Treatment target and volume: gastric tumor bed, peripheral involved including regional lymphatic area
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the gastric tumor bed, peripheral involved including regional lymphatic area
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and would like to receive radiotherapy, The treatment planning of radiotherapy will be started at 8:30, 2022-01-10.

[surgical operation]

  • 2021-12-16
    • Surgery
      • total gastrectomy with LN D2+ dissection
      • S23 resection
      • S6-7 partial hepatectomy
      • S4-8 alcohol injection
    • Finding
      • gastric ca lesser curvature cardia to lowewr antrum with multiple LN enlarge
      • serosa+
      • seeding-
      • multiple liver tumor
      • S2-3 at least 3 nodle 0.2, 0.8 1.2cmS6-7 0.8cm
      • S6-7 0.8 cm
      • S4-8 0,8 x 0.6cm in deep central parancyhma

[radiotherapy]

  • 2022-01-19 ~ 2022-03-02 - 4500cGy/25 fractions (15 MV photon) of the gastric tumor bed, peripheral involved including regional lymphatic area.

[chemotherapy]

  • 2023-01-30 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4775mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-12-22 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4770mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-12-09 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4740mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-11-25 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4740mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-11-09 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-10-24 - oxaliplatin 85mg/m2 144mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4760mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-09-27 - oxaliplatin 85mg/m2 144mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4760mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-08-24 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-08-10 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-07-27 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-07-08 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-06-22 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-06-06 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-05-23 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-05-03 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-04-19 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-03-29 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-03-15 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-03-01 - fluorouracil 225mg/m2 380mg 24hr D1-2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-02-21 - fluorouracil 225mg/m2 380mg 24hr D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-02-14 - fluorouracil 225mg/m2 390mg 24hr D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-02-07 - fluorouracil 225mg/m2 390mg 24hr D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-01-24 - fluorouracil 225mg/m2 390mg 24hr D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-01-19 - fluorouracil 225mg/m2 390mg 24hr D1-3
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg

701460262

230201

[diagnosis] - 2023-02-01 discharge note

  • Malignant neoplasm of cervix uteri, unspecified
  • Squamous cell carcinoma, keratinizing, moderately differentiated of the uterine cervix, stage pT1a2 (III), with negative margin (HPV related), s/p laparoscopic assisted vaginal hysterectomy, with local recurrence.
  • Type II diabetes mellitus

[lab data]

  • 2022-11-29 HBsAg (NM) Negative
  • 2022-11-29 HBsAg Value (NM) 0.775
  • 2022-11-29 Anti-HBc Nonreactive
  • 2022-11-29 Anti-HBc-Value 0.19 S/CO
  • 2022-11-29 Anti-HCV (NM) Negative
  • 2022-11-29 Anti-HCV Value (NM) 0.0347

[exam findings]

  • 2022-11-21 MRI - pelvis
    • Clinical history: 42 y/o female patient with cervical CIN 3 and ov tumor said s/p hysterectomy in Keelung CGMH in 2020 , patho revealed cervical cancer (SCC, stage Ia2, patho Number S2020G-15625A), 2021 stump revealed VaIN 3 (S2021G-12951) -> local LASER was done. 2022/11/10 vaginal bleeding, suggest IVRT (intravaginal radiotherapy) if residual cancer tissues noted. next – ask the patient to bring the reports from previous hospital, + MRI + SCC + CEA check.
    • Impression:
      • S/P hysterectomy.
      • Recurrent tumors in the vaginal stump with colon and urinary bladder adhesion/involvement.
      • Cystic lesions, 2.35cm in left pelvic cavity.
  • 2022-11-10 Gynecologic ultrasonography
    • s/p ATH
    • Suspcted Rt Ovarian cyst
  • 2021-11-04 Pathology - vagina biopsy (Keelung CGMH)
    • S2021G-12951A: vagina biopsy — vaginal intraepithelial neoplasia III (VaIn III) — P16(+), suggestive high risk HPV infection.
  • 2020-10-29 Pathology (Keelung CGMH)
    • S2020G-15625A: uterus, cervix, laparoscopic assisted vaginal hysterectomy — squamous cell carcinoma, keratinizing, moderately differentiated, pT1a2, wth negative margin (HPV related)
  • 2020-10-26 Pathology (Keelung CGMH)
    • S2020G-15625: uterus, cervix, laparoscopic assisted vaginal hysterectomy — squamous cell carcinoma, keratinizing, moderately differentiated, pT1a1, wth negative margin (HPV related)

[surgical operation]

  • 2020 Laparoscopic Assisted Vaginal Hysterectomy, LAVH (Keelung CGMH)

[radiotherapy]

  • 2022-12-09 ~ - at 4500cGy/25 fractions (15 MV photon) of the pelvic area.

[chemotherapy]

  • 2023-01-30 - cisplatin 70mg/m2 115mg 4hr D1 + fluorouracil 1000mg/m2 1660mg 24hr D1 (CCRT)
    • dexamethasone 4mg D1 + diphenhydramine 30mg D1 + granisetron 2mg D1
  • 2022-12-15 - cisplatin 70mg/m2 115mg 4hr D1-4 + fluorouracil 1000mg/m2 1660mg 24hr D1-4 (CCRT)
    • dexamethasone 4mg D1 + diphenhydramine 30mg D1 + granisetron 2mg D1